Psychoanalytic contributions to understanding suicide.

Transcription

1 Psychoanalytic contributions to understanding suicide. Faculty of Medical Psychotherapy Conference 6/04/2017 Dr Jessica Yakeley Dr William Burbridge-James

2 Suicide In the last 100 years two models have been proposed and found support. 1. Sociolgical studies of the epidemiology of suicide rates in various cultures 2. Psychoanalytic efforts to explain individual motivations. While psychoanalytic understanding is our focus we mention Durkheim who from a sociological perspective located suicide in a wider societal relational context linking with psychoanalytic understandings.

3 Durkheim "Le Suicide" 1897 Durkheim proposed the integration theory of suicide. As social integration decreases people are more likely to commit suicide. He analysed differences in suicide rates between Protestants and Catholics and found lower rates of suicide among Catholics. Theorised this was due to stronger social control and cohesion among Catholics.

4 Durkheim 1897 Distinguished 4 subtypes of suicide. 1. Egoistic suicide A prolonged sense of not belonging in a community; an experience of not having a 'tether ;- an absence giving rise to meaninglessness, apathy, melancholy, and depression. Suicide is the result of "excessive individuation" 2. Anomic suicide;- occurs when a person experiences disconnection from society and feelings of not belonging that result from weakened social cohesion: occur during extreme socio-economic and political upheaval, leading to confusion. 3. Altruistic Suicide:- occurs when overwhelmed by a group's goals and beliefs e.g. suicide bomber 4. Fatalistic suicide;- the opposite of anomic suicide, when a person is excessively regulated e.g. preferring to die than be a prisoner.

5 Suicide as a relational act (Stekel, 1910) 1910 symposium On Suicide I am inclined to feel that the principle of talion plays the decisive role here. Noone kills himself who has never wanted to kill, or at least wished the death of another.

6 Mourning and melancholia (Freud, 1917) Suicide results form internalised anger that had been originally directed at someone close to the person Mourning is impeded if ambivalence and hostility predominate towards the lost object, and a state of melancholia ensues Hated object is incorporated inside the self, which is then attacked as if it were the object Underlying suicide and acts of self- destruction is an attack upon the self that is unconsciously identified with someone whom the person has lost and therefore hated.

7 Melanie Klein Innate envy and destructiveness predominate in early life, giving rise to persecutory anxieties of annihilation and primitive defences, unconscious phantasies and an archaic superego, characterising the paranoid schizoid position Splitting and projection predominate and baby unable to integrate conflicting experiences. World divided between idealised good objects which are maintained internally, and bad ones which are persecutory and projected externally. This gradually develops into the more mature depressive position with integration of good and bad objects, tolerance of loss and ambivalence and feelings of guilt and mourning.

8 Kleinian understanding of suicide Inner world of suicidal person characterised by paranoid schizoid mechanisms Deep splits in inner world between part of the self in relation with idealised object, and part of the self felt to be bad and subject to terrifying cruel attacks Idealisation serves to protect good object from self s own cruel murderous wishes and the bad parts of the self become identified with part or whole of the body, which must be killed off.

9 Unconscious suicidal fantasies (Hale) Vary in their level of conscious awareness, and elaborate relationship between the self, the body, and significant others in the patient s life Revenge fantasy, to make others suffer for how they have maltreated the suicidal patient Self-punishment fantasy, dominated by guilt, where the surviving self is gratified by its sadistic treatment of its own body, in identification with the helpless submissive body.

10 Unconscious suicidal fantasies (Hale) Assassination fantasy, more common in psychotic patients, body is experienced as source of madness, which must be killed off so self survives: person is therefore acting in self-defence Dicing with death fantasy, the person is leaving the outcome of the their suicidal act to fate, an outside agent. Merging fantasy, underpins all other fantasies, suicidal wish to merge with an omnipotent mother to attain state of timeless bliss and to escape intolerable pain of living.

11 Addiction to Near Death (Joseph, 1982) Self-harming can become suicidal - urge to selfharm becomes compulsive and addictive Pull of individual by death instincts into a private place of violence, a no-mans land between life and death where the person is unreachable by others on the side of living Joseph s ideas pertinent to current era of Internet where suicidal person can hide in a secret arena with like-minded individuals where their fantasies may be rehearsed in virtual reality

12 Pathways to suicide (Hale) Pre-suicidal state - suicidal fantasies become more conscious and plans for the suicidal act are developed, usually triggered by a rejection or betrayal, and may last for hours or days (Ringel 1976) Confusional state provoked by final trigger, usually a rejection, often apparently innocuous Feelings and thoughts become fragmented, distinction between fantasy and reality blurred, more mature ego defence mechanisms fail. (the influence of alcohol and drugs)

13 Pathways to suicide (Hale) Unacceptable ideas and feelings come into consciousness which must be expelled immediately by primitive physical defences Body boundary now crossed and suicidal fantasy is translated into physical action Once this crucial border between mind and body is breached, the easier it becomes to discharge intrapsychic tension via a physical pathway.

14 The descent into Suicide (2004) IJPa 85(3): John T. Maltsberger Proposed a model for suicidal collapse of 4 interlocking aspects that can be moved in between or more than one maybe present as suicide nears. 1. Affective Deluge:- Desperation defined as a state of Anguish {excruciating mental distress} coupled with an urgent need for immediate relief, are seen as driving suicide. 2. Efforts to master affective flooding:-people may attempt to save themselves by frantically turning to others and then, for some, in a state of dissociation (depersonalisation + derealisation) making the decision to kill oneself offers a sense of control.

15 The descent into Suicide (2004) IJPa 85(3): John T. Maltsberger 3. Loss of control and disintegration:- people experience a sense of falling apart, intense horror and fear, feel completely overwhelmed, helpless and then despairing. Fragmentation of the self is portrayed in dreams act as alarm signals off failing self integrity. 4. Grandiose survival and body jettison:- desperate for relief people adopt omnipotent schemes for survival; splitting their mental and physical selves, and by killing their bodies they survive in their mind in another sphere.

16 The descent into Suicide (2004) IJPa 85(3): John T. Maltsberger Deluge of painful affect that can not be regulated of moderated Mental functions including self-object representation fail. Fears of self-disintegration become primary (annihilation anxiety) Grandiose and magical behaviour supervenes. Suicide reflects profound narcissistic collapse, loss of reality testing, self-fragmentation and ego failure.

17 Maltsberger, J.T., Buie, D.H. (1980). The Devices of Suicide Revenge, Riddance, and Rebirth. Int. R. Psycho-Anal., 7:61-72 Studied patients who successfully committed suicide a number of years ago and who were studied at the Massachusetts Mental Health Centre in Boston. They surveyed the principal purposes and fantasies expressed in suicide The destructive or hate causes come first:- divided into two groups. Malicious or revenge phantasies.. Riddance wishes, (the self representation splits and that the patient's body representation fuses with a representation of the intolerable object which underlie) fantasies of annihilation or destruction Death as Nothing: The oblivion of restful sleep equated with death (The Greeks believed Hypnos, the god of sleep, and Thanatos, that of death, were brothers). Rebirth Fantasises: - death as passage into a new world; - Failed identification with the comfort-giving mother renders a patient vulnerable to intolerable feelings of aloneness, and opens the way to extraordinarily intense feelings of helplessness. Death may itself become personified as the comfort-giving mother, as may that dark oblivion which waits beyond the grave.

18 Thank You. Jessica Yakeley,