What We Mean When We Talk About Suicide

Why would someone want to end their own life? For some people, it’s a bleak mystery. For those of us who have lost someone to suicide, it’s much more. It can put a rip in the fabric of our lives, threatening to unravel everything we know.

As a clinician, I sometimes find myself in conversation with someone who wants to end their life. I’m a mandated reporter, like a wide variety of service providers. This means I have an obligation to break the person’s confidentiality—the legally guaranteed privacy of what they talk about in therapy—in order to ensure their safety when it comes to risk of self-harm. I advise people of this the first time we meet. Because of the mandate, I set whatever my thoughts and values are regarding someone ending life and work to keep the other person as safe as I can.

When their safety is more assured, when the risk of acting on their thoughts of suicide is decreased, I ask them what suicide means.

In the discussion that follows, names have been changed and personal identification has been filtered out to protect confidentiality.

We each live a world of meanings. Often these meanings are unique to us—what my childhood meant to me might not be what yours did to you. In couples counseling, I’ve noticed that partners sometimes ascribe very different meanings to the phrase, “I love you.” The same is true with suicide. Sometimes just being able to get this material out of their head and into dialogue with an interested and receptive other person can make all the difference.

When I first met Dana, he was actively suicidal. He had a plan (to jump out of a window), the means (his apartment was on the sixth floor of his building), and a time frame (the next time one more thing in a never-ending series went wrong). I initiated an involuntary hold, and he was later hospitalized. And while he objected to this as it was being put in place, he was glad of it as his fearful and angry mood resolved.

Working with Dana, we discovered that he became overstimulated quickly when trying to complete tasks, and for this reason he would put them off or reject them completely. The crises that resulted from this strategy added to his sense of being overwhelmed and with nowhere to turn, of always being one step away from an absolute catastrophe. And while he was able to not think about things like paying his bills, he tended to ruminate about this imminent but unclear catastrophe. For him, suicide seemed like a way of getting free from the radio station of his anxious thoughts.

Even though suicide wasn’t the best—or, as it turned out, the only—way of “turning off the radio,” it suddenly made sense to both of us. Because of this, we were able to brainstorm some alternative ways for Dana to take breaks, as well as to focus on tasks for brief periods. And now that we knew what suicide meant to him, we were able to use the presence of those thoughts as a way of tracking overwhelm.

We each live a world of meanings. Often these meanings are unique to us—what my childhood meant to me might not be what yours did to you. In couples counseling, I’ve noticed that partners sometimes ascribe very different meanings to the phrase, “I love you.” The same is true with suicide. Sometimes just being able to get this material out of their head and into dialogue with an interested and receptive other person can make all the difference.

Ben was in his early 80s. When we met for our initial consultation, one of his first statements was, “I don’t want to live anymore.” While he didn’t discuss a plan or means (other than to note “if I had a pill I knew would work I’d have already taken it”) I knew he had access to medications. I frequently assessed him for risk of harm during our work together. And yet my honoring his feelings also seemed to relieve them. He told me about the loss of most of the people he loved, the isolation he lived with on a daily basis, and the shame and anger he felt at having to depend on a niece (not one of his favorite nieces, but the only one who lived in the same area) to take him to do his shopping and run his errands—“and always on her schedule, and making it clear she hasn’t got much time for me.” For Ben, suicide meant a clear way of declaring his independence and his rejection of what he identified as charity that seemed motivated by duty and by nothing like affection.

Because the idea, though not the action, of suicide could be tolerated in our conversation, Ben was able to articulate what it meant. From there we moved to imagining what it might be like to communicate some of what he was feeling to his niece, via role-playing. Often I was the niece, receiving a piece of his mind in the form of his legitimate feelings. But sometimes Ben was the niece, and to my presentation of grievances he was able to note he had a young family, he was concerned about his elderly uncle, and it was hard to balance everything. Eventually he began saying some of these things to the niece herself, and the result was their relationship deepened a bit and he experienced some relief from isolation.

Ted also talked about suicide at our first meeting, describing his stockpile of sleep and pain medications and his feeling he couldn’t see the value of keeping himself safe. I called 911 and made my report while he witnessed this. He was assessed as not sufficiently at risk for hospitalization. Perhaps inviting him to be present while I made the phone call helped to establish a good connection between us. He said he could tell I was trying to take care of him.

As our sessions continued, he described the verbal, emotional, and physical abuse he had experienced as a child (which formed the basis of a call to the Department of Children and Family Services and subsequent report). Feelings of worthlessness and guilt were triggered by his recent AIDS diagnosis. For Ted, suicide meant giving up a struggle he felt he could never win, which was to prove to the universe his life was worth preserving. Building on his witnessing me trying to get him hospitalized, we addressed his trauma, focusing on ways he could keep himself safe, not just in terms of suicide but in terms of choices about self-care, drug use, and companions. As he became more invested in keeping himself safe, he eventually surrendered his stockpile of meds to his pharmacy.

For someone living with severe illness, suicide sometimes means insurance against suffering. Chris told me, “I know if it gets too bad, I can just leave.” He also told me that knowing he could determine how much was too much helped him face severe illness and sometimes equally severe treatments. Bill, dealing with multiple opportunistic infections that weren’t responding to treatment, decided in consultation with his doctor to stop all medical intervention and go into palliative care, or hospice. In one of our last conversations, he explained to me that his decision meant death with dignity.

Joe, enraged to be losing control over his body and his mind, died by suicide. Ironically, two months later a new treatment protocol was made available that would have reversed many of the symptoms he found unendurable.

Now we come to another set of meanings related to suicide: those of the survivors.

I met Richard two weeks after Joe’s suicide. Even though Joe had told Richard in clear terms he “wasn’t going to stick around to see how bad it got,” Richard had still been shocked by his action. The grief he felt over the death of his husband was compounded by overwhelming levels of guilt. The guilt was so difficult Richard considered suicide himself, although he didn’t have a specific plan.

“What would that mean, if you killed yourself?” I asked him.

“That I failed to keep him alive,” he said bleakly. “That it was my fault.”

“So the meaning of his death is that you failed him?” Something about hearing it said back to him like this caught Richard’s attention. Gradually he began the work of separating his life from Joe’s, and the more challenging work of allowing Joe responsibility for his own death.

Bill was an intern to whom I provided clinical supervision at the community mental health agency where we both worked. One morning, I had to disclose to him that a woman who had been seeing him for depression had died by suicide over the weekend. Bill’s first reaction was shock, then denial. What surfaced then were feelings of responsibility, failure, and guilt. According to his religious orientation, he told me, suicide was a “sin.” Was he guilty because he hadn’t kept this woman alive? Was he now lost to the possibility of redemption?

We’re connected to each other in a network, even to people we’ve never met. Following Robin Williams’ death, many of the people I worked with were deeply shaken. Like the narrator in the poem Richard Cory, they questioned how much value could be found in their own lives if someone as accomplished and widely loved as Williams could end his. For weeks after the event, I found myself in conversations in which another person’s suicide was seen as a denial of meaning to the lives of people he’d never met. The need to identify and assert the value of continuing to live took on the aspects of a crisis for many people.

Sometimes the poets say it more simply and elegantly than psychotherapists. James Krusoe, in his book of poems on the suicide of an acquaintance, Notes on Suicide, describes this life, including its hardships, challenges, and even despair, as an inducement to keep living. “All this,” he asserts, “was just to keep you here.”

Sometimes, knowing what an action means frees us from the compulsion to complete the action.

If you are in crisis or considering ending your life—and particularly if you have developed a plan to end your life, gathered the means to carry it out, and decided on a time—please consider initiating hospitalization for yourself by going to any emergency room or by calling 911.

None of us knows what happens after this life. But as long as you stay in it, change remains possible.

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