Tuesday, December 20, 2011

Life and Death in Ireland

By Kevin Murphy MSc,
Psychoanalytic Psychotherapist,
Dublin, Ireland.

There’s been a great deal in the media recently about suicide and depression. In terms of the former, we have an alarmingly high incidence compared to our European partners. And the latter seems to be universally accepted as the root cause of the situation. Depression and suicide; they sit oddly with our reputation, and indeed our perception of ourselves, as a happy-go-lucky country that likes a drink and a laugh. So which are we: the country with an alarmingly high rate of suicide or the happy nation?
I ask that question not to confuse but to tease out something that has been a striking feature of some suicides according to reports in the mainstream media. Again and again you read the testimony of the people close to those who died in which they say that there was no sign that anything was wrong. They may even have been speaking to the person only hours before their final act and everything seemed ok. It is, on the face of it, an unnerving and puzzling aspect. What, if anything, are we to understand from it?
Well, let’s work our way back from the unavoidable fact of successful suicide. It begins with the painful truth that someone ends their own life. We can reasonably assume that this is not an easy thing to do. We can also reasonably assume that in order to do it one has to be consumed with a weight of negativity that is directed purely and solely towards oneself. Yes, there are cases where revenge against others can be a strong element but there is no getting away from the fact that the final act of ending life is directed against one’s own being, against the self. And when you further consider how instinctual it is to avoid danger and stay alive, we must also include a strong motivation to do it as being a key feature.
If we take these ideas and go back to my first point, then we have a picture of two contrary realities being lived out. One is an outward facing display of everything being alright, not giving a hint of any intention to end one’s life. And the other is an inner lived experience, and presumably a lonely one at that, characterised by a growing negativity towards oneself that will eventually end in death by one’s own hand. As an aside, it is interesting how this double positioning at the level of the individual matches a similar duality in terms of how we present as a nation: happy out but with a seemingly dark inner core. So why, in the case of those individuals who succeed in ending their own lives, is there no bridge between these two realities? Why does the inner come eventually to dominate and put an end to the outer? And why is there no route that might let human support, comfort and healing have a chance at creating some positive and far less drastic outcomes?
You don’t need a university degree in psychotherapy to understand that two realities being lived at the same time represent an enormous strain on any individual. It is a conflict, pure and simple. And this is happening at a time when there is great work being done to bring about awareness of depression and of the harsh reality of suicide for those left behind. There are free helplines, doctors, counsellors, psychiatrists, psychologists, psychotherapists, self help groups, as well as public campaigns and media debate of these issues. It seems there is one other feature we have to add to our picture so far. The people who give no hint of their anguish and who succeed in ending their own lives do not appear to reach out for these options.
What is it about depression, particularly depression that gets intolerably bad, that makes this action impossible for some? Is it simply the stigma of having it? We certainly have heard a lot about that in recent times. Is the admission that speaking about depression requires a step too far? It would certainly seem to be the case. The choice of constantly pretending that everything is fine is the choice that eventually leads to death for some. It gives us some idea of the grip this idea can have. The choice not to speak, to portray an acceptable, presentable face to the outside world, is so important in some people’s minds that it, in effect, accompanies them to the grave. What are we to make of that?
The person with suicidal depression is a person deep in sadness yet also deep in fear. This fear is twofold: firstly the depth of their depression must never be discovered by anyone else and, secondly, as a result it can never be fully accepted by the individual themselves. The sadness, on the other hand, is seen as a form of un-shiftable truth that cannot be undone, by anyone. It is a profound fatalism, if you like. They wonder how could it be fixed when it’s a problem of the mind and probably the very soul. ‘Who is qualified or able to get inside my mind and fix it? No one can do that. My situation will continue for as long as I can bear it.’ And that’s ultimately what life becomes, an endurance until it cannot be endured anymore.
You often hear people use the bits of information they have picked up from scientific circles or from the internet, or both. Depression is a case of chemicals in the brain; ‘my chemicals are out of balance’. But if that’s the case couldn’t a discreet prescription from a doctor solve that? Using the same logic, a supply of pills, which are essentially chemicals, could reinstall the missing chemicals and the problem should be solved?
Equally, you will often hear people say ‘Oh it’s genetic, my grandfather had it, and my own father, so it’s no surprise I have it too. No one can fix something that is hereditary.’ Here we see again how a seemingly reasonable explanation of an ailment, always a reassuring thing, can bring with it a hopeless fatalism at the same time. If something is in the DNA, that’s nice to know but it also implies it can’t be fixed. And in this way the depressive cycle is re-energised once again. If you are prone to profound sadness then this approach is guaranteed to get you there fast.

What we don’t hear said often enough is that growing up with people who have a sadness within them, and even the jolliest of people do, can make you sad as well. Outwardly it’s going to look exactly the same as a hereditary issue or a chemical imbalance, but in reality it’s not. Nor is it permanent.
A psychoanalytic understanding of how this profound sadness takes root is that it is based on an unshakeable sense of loss. Something has been lost to the person, something they can’t put their finger on or name or describe. The person suffering is conscious only of a profound loss at the very centre of their being.
Freud in a famous paper, written in 1915 and published two years later, compared melancholia (profound and potentially harmful sadness) with mourning, the first time anyone had done so, and argued convincingly that in mourning the person knows who has been lost to them but in melancholia, which is similar to a grieving process, they are unaware of what is lost. They are unaware usually because it happens at such an early age or because it has been worked on by our powers of repression. In his paper Freud makes a number of interesting points, essentially insights he gained from his clinical work, which are just as relevant today. But before I mention these let us consider seven important assumptions that are needed to make it easier to understand what he is saying. Firstly, and most obviously, we invest emotionally in those we love. This means part of us goes into our relationships and we suffer real pain when they are ended. Secondly, we identify, become ‘like’ the people we love. The verb ‘Identify’ comes from the Latin ‘to be the same as’. Thirdly, these connections can be sometimes broken and easily so. Fourthly, when we ‘lose’ a connection with someone as an object of our love, there is a painful internal surge of emotional energy as we pull back into ourselves and retreat from outer reality to our inner reality. Fifth, our human life is full of moments of loss – from birth, through weaning, through puberty, through broken or unhealthy relationships, through bereavement and so on – and to lessen the impact on us we incorporate into ourselves something of the lost object of our love. Sixth, this loss can happen for real or imagined reasons at any age of our life. Seven, we can start to quietly attack ourselves for being responsible for this painful loss.
So, what Freud pointed out was that in severe depression very often we don’t know what or who has been lost to us. But even if we know who has been lost to us, we are not sure exactly ‘what’ we have lost in losing them as love objects. Think of the number of people with complex or troubled relationships with family members or loved ones, for example, and how their thinking remains fixed on trying to solve it. We lose interest in reality around us because we are completely absorbed in trying to figure out this puzzle.
Unlike actual mourning, the person suffering profound sadness has an extra characteristic – ‘an extraordinary’ reduction in their confidence, self regard, self belief and self respect. When we mourn the loss of a loved one, the world becomes a ‘poor and empty’ place. When we are in profound depression, it is we ourselves who become ‘poor and empty’, no matter what outward trappings we have acquired. The person sees themselves as worthless, morally despicable and expects to be punished. In believing that a love object has been lost to them, a transformation has taken place whereby the person becomes something of the thing that was lost and becomes, in turn, the target for their own anger and negativity. The picture Freud paints of this kind of sadness is completed, he says, by a capacity for life threatening behaviour or, as he puts it, by ‘an overcoming of the instinct which compels every living thing to cling to life’. (Freud, S., Mourning and Melancholia, 1915, Standard Edition, Vol XIV, p.246.)
When all else has failed we try to return to the place where we began as infants, to a self-sufficient inner world that promises comfort. But in contrast to our first experience of it as infants, this time something of the disappointments we have encountered in reality return with us. Now it is not a nirvana but a more claustrophobic internal life plagued by guilt and condemnation and a puzzling sense of loss. It is interesting in Freud’s paper how he says this profound and potentially harmful sadness can arise not only as a result of real events but also from all those situations where we might feel slighted or neglected or disappointed. (p.251) Put another way, in profound depression the loss can be based on something real or imagined.
At an age before we even realise it, we build up a sense of ourselves through our interaction with others. This gives us an internal anchoring point, if you will. This is our ego ideal, the sense we carry within ourselves of who we believe we are and can be, not only in relation to significant others in our lives but also in the larger context of the world we live in. Whether there is trauma or not, but greater damage is done if there is trauma, it is astonishingly easy for us to pick up the message, ‘I have lost something important and so I will never be good enough to fix the sadness and unhappiness in me or others’. This simple message is very hard to shift once it becomes part of our self-belief system. It then becomes the template for all our other relationships, which is why people with profound depression get so little from their relationships and why, ultimately, their key relationships are not enough to help them fight the urge to end their own lives.
Because the person has difficulty forming a positive image of who they are, the business of engaging with others becomes problematic and consistently unsatisfying. It’s not about vanity either, more about survival. A positive ideal about ourselves is the thing that sustains us through difficult times. This ideal is created not in isolation but in the interplay with those around us whom we have loved, who have loved us and with whom we have been able to identify strongly and positively.

In the absence of indentifications with people like this – not unreachable idols but ordinary people subject to the ordinary imperfections of being human – those prone to severe depression substitute in a different kind of ideal, one without flaws that is based on perfection or infallibility. This is the dangerous one because a) it is impossible to attain and b) every failure in attaining it brings self punishment. The end result is a person for whom sadness and the unattainability of certain standards become central components in their lives, along with ever increasing self-punishment. How often do we hear of successful people die by suicide? It would seem that no amount of success can ward off the self punishment. In fact the person who dies by suicide is essentially carrying out the final act of punishment on themselves after a life, however long or short, of consistent internal punishment that they mistakenly believed they deserved.
These are weighty issues that do not often get an airing in public discourse. There is no easy cure and there is no quick cure. Medication can help and so too can psychotherapy. But psychotherapy requires people not just to talk but to give themselves permission to engage in a relationship, albeit a professional one. This second part is often the trickiest bit of the operation. Profound depression tells the sufferer that they are never going to re-find what they have lost and that they don’t deserve to re-find it. The need for another person in this context, especially a trained other, can often be seen as a further example of their own imperfection. Some prefer to remain suffering rather than see themselves in that light. But that is the very place where all humanity resides, in imperfection, in the potential to make mistakes and very often fall short of ideals. If someone suffering from profound depression can manage to allow themselves a leap of faith, to believe that going back through the route of a connection with another human being – the place where it all started – might help them re-find something of what was lost, then there is real hope that something positive can be achieved.