THE
SUICIDAL
CHARACTER Donald A. Schwartz
Suicidal behavior is generally taken to be symptomatic in nature rather than egosyntonic. However, any behavior which comes to be used as a means of adaptation to the world long enough tends to become ego-syntonic. There are some suicidal people for whom suicidality has become a means of securing nurturance from the interpersonal world. The usual "crisis response" to suicidality reinfbrces such patients in their suicidal styles. Increased long-term risk becomes the price of shortterm nurturance. Specific alterations of treatment and management are indicated if such patients are to be helped to long-term survival. Behavior in general tends to be t h o u g h t of as either ego-alien or as egosyntonic. T h a t is, feelings or behaviors are seen as being either evidences of illness, symptoms, things not a part o f the normal self; or else they are experienced as "the way I am", a part o f the recognized self. But there is a point at which chronic symptoms begin to become a part o f the recognized self and symptomaticity shades into character structure. It is by such assimilation of the alienness o f experience that people come to see themselves as "nervous" or "sickly" or "sensitive" people rather than to experience egoalien anxiety, somatic distress or emotional hurt. In this more relativistic sense, experience or behavior may be ranged along a hypothetical continuum with symptomaticity at one end and characterology at the other. Suicidal ideas or impulses are generally experienced as alien events which arise in response to great anguish or dread, as final desperate ways of escape from the unbearable. Suicidal impulses are generally t h o u g h t to be acute and time-limited and approaches to suicide prevention are organized for the most part a r o u n d crisis responses. But suicidality, though it is most often symptomatic in nature, is also sometimes characterological. And suicidal character problems require a radically different approach from that used on symptomatic suicidal states. T h e approach used successfully with people in acute symptomatic states o f suicidality is not only ineffective with suicidal character problems; it is antitherapeutic. In fact it may well be that the suicidal character is an iatrogenic condition p r o d u c e d by such inappropriate response to what was initially symptomatic suicidality. Dr. Schwartz received his M.D. degree from Case Western Reserve University, Cleveland, Ohio in 1952. He is currently Adjunct Professor of Psychiatry at the UCLA School of Medicine and the UCLA Neuropsychiatric Institute. Reprint requests should be sent to Dr. Schwartz at UCLA-NPI, 760 Westwood Plaza, Los Angeles, California 90024. 64
PSYCHIATRIC QUARTERLY,VOL 51(1) 1979 0033-2720/79/1300-0064500.95
65 D. A. S C H W A R T Z
The Meaning of Suicidality Both demographic and conceptual distinctions are made between suicide attempts and completed suicides. These two kinds of acts appear to be the behaviors of two overlapping but by no means identical populations. Suicidal states of mind and suicide attempts which do not kill are generally taken to be behaviors which reflect mixed feelings, while fatal suicide acts are taken to be more unambivalently intended. There are exceptions, to be sure. An act which would be expected to produce a given result on the basis of all its characteristics may, nevertheless, produce an unexpectedly different result. Chance intervenes in all human events. An unambivalently suicidal person may be rescued by the merest chance and a clearly conflicted act may yet end fatally because of unforeseen happenstance. Nevertheless, outcomes do determine our ways of viewing motivation and the mere fact of survivorship following suicidal concern or behavior leads to the presumption that there was a mixture of intents. The title of a prominent book on suicide and suicide prevention, "The Cry For Help",* is meant to convey the authors' feelings "about the messages of suffering and anguish and the pleas for response that are expressed by and contained within suicidal behaviors." Implicit is the idea that suicidality is a means of seeking help and remedy from others. That concept has earlier support from a Supreme Court decision in which suicidal behavior was felt to be a (nonverbal) request for help. Justice Benjamin Cardozo is quoted as holding that "A cry of distress is a summons to rescue. ''2 Professional intervention in suicidal states is influenced gready by the hypotheses that suicidality is generally ambivalent and that suicidal behavior is a summons to rescue. In its most simplistic interpretation, that point of view might read, "The suicidal person wants to be dissuaded from the act." It is the position which holds that suicidal behavior conveys statements about one's helplessness, need for nurturance, and attitudes toward non-gratifying love objects. But however the conceptual matrix of the intervenor is worded, his or her response is generally marked by the rolebehaviors that characterize a parent: nurturance, protection and control. The suicidal person, having been heard to say that he/she needs to be parented in order to be saved for life, is generally responded to in the immediacy of the crisis with direct gratification of the professed need. The response is one which has been found empirically to be helpful to the vast majority of suicidal persons with whom one has the opportunity to intervene. Whether or not this parental response is always necessary in the crisis situation, it is certainly generally helpful. And certainly it is not harmful.
When is Parenting Harmful? But that is not always true. It is one of the general tenets of most psychotherapies that the therapist avoid becoming (much less seeking to
66 PSYCHIATRIC QUARTERLY
be) a substitute for the patient's own internal value systems. To be parental is to seek introjection into the internal value system, to aspire to membership in the patient's superego. Most of us now accept the impossibility of being a truly blank value screen as was once suggested to be a desideratum in classical psychoanalysis. But certainly most of us do not seek actively to replace the patient's values with our own, in other than unusual circumstances. Patients commonly deal with internal conflicts by projecting on to the therapist one side of such a conflict while acknowledging within themselves only the other side. The conflict can then be conceived of as taking place between the patient and the therapist. While the therapist may sometimes permit such a defensive maneuver to be carried out unchecked, it is more common to seek to confront patients with their projections and to get them to recognize both sides of the conflict as internal. One method by which therapists do this is in openly professing n o t to hold the views which the patients seek to ascribe to them. Suicide is one of the limiting conditions of such asserted neutrality. It is customary in dealing with suicidal persons to ally oneself with the side of the patient's conflict which is for living. This is consistent with the values and goals of medicine as a profession and with the general stance of most physicians and most others in the business of helping people. It is also a good method of denying our sadistic or destructive impulses toward patients, as transferred from significant figures in our own personal lives. But the tendency vigorously to ally oneself with the patient's drives toward continued life is carried out at the expense of the neutrality which the therapist would assert in other and less crucial conflicts dealt with in treatment. The therapist's alliance with life is often so vigorously espoused as to be asserted independently of the patient's own strivings in that direction. That is to say, the therapist (or professional or other person intervening with the suicidal person) may avoid discovering whether there is a conscious striving toward life within the patient with which the therapist may make alliance. Rather, the therapist may assert that she/he is for life, be damned to the patient! For the patient who is somewhat uncomfortable in dealing with an internalized conflict between living and dying, such an assertion by the therapist or others is a welcome invitation to project entirely the desire for life within the patient. Consequently, the patient may assert an unambivalent wish to die in response to the therapist's unambivalent wish that she/he live. Into such an interpersonal conflict there may intrude all of the transfeted rebellion against parental figures from the patient's past, thus investing the struggle over life with much rebellious torce that it did not originally possess. The therapist has relieved the patient of the need to attend to his/her responsibility for choosing whether to live or to die. The patient can be wholly for death. What ensues in such cases is often a prolonged struggle in which each side engages in a Vietnamese escalation of efforts to prevail. The patient finds ever more creative ways in which to fall toward death, while the therapist and other allies of the suicide prevention efforts
67 D. A. SCHWARTZ
respond with more and more desperate effbrts at catching the falling patient. Nurturance as a Secondary Gain
If the patient is a person with needs for mothering which are inadequately met in his or her life, a great danger exists with such struggles. In addition to the issue of life or death which is central to the stage on which suicidal dramas are played out, the need ~br nurturance becomes a sub-plot. The patient discovers that great attention and concern are expressed at moments of suicidal crisis; it is at such times that others seek to emphasize their concern and affection for the suicidal person. Non-suicidal moments may seem, by contrast, to be empty of caring and love. Subtly, the suicidal person may be invited to show the need for mothering by the expression of increased suicidality at times of special nurturant need. The suicidal impulse may gradually become the principal effective gateway to maternal care and love. As it does this, the suicidal impulse becomes, concomitantly, less of an ego-alien symptom and more of a characterological device for adaptation to the world. When this characterological development of suicidality becomes established in a patient who has successfully projected into the therapist the patient's own strivings toward life, as outlined in the preceding section of this paper, an explosive situation exists. Once such a process has become established, the patient is headed almost inexorably toward suicide. The projection into the therapist of the patient's wish to live is not a sufficient cause of such an eventuality without the concomitant shift of suicidality into the characterological mode. The projection of the wish to live into the therapist does not, of course, abolish it as a wish within the patient. The projection simply represents a disclaimer of its internal existence. But the defensive maneuver is not necessarily a permanent disavowal. Either as a result of changes in the patient and her/his relationships with external reality, or as a result of change in the degree of clinical illness or as a consequence of the treatment itself, the patient may come to acknowledge again the internal wish to live. As long as being suicidal means only wishing to die, it may yet be a symptom, still ego-alien, still capable of being rejected or modified. It is when being suicidal means more than only wishing to die that special danger is introduced. When being suicidal means success in coercing nurturance from a cruel world of others; when it has become a means of coping with the world more successfully; when it has, thus, lost the ego-alien quality that it had originally; that is when the danger of suicide in the long run becomes less of a risk and more of an inevitability. Recognition
Staff members of clinical facilities to whom this material is presented characteristically experience anxiety in considering it. They are frequently
68 PSYCHIATRIC QUARTERLY
faced by urgently suicidal cries for help and have generally learned that the standard crisis approach is a comfortable operating procedure to use in coping with such situations. It has generally not been suggested that the standard crisis response has adverse side effects. When they first consider that the use of this approach may actually increase ultimate suicide risk, their concern is mostly focused on the question, "How can we know whether the suicidal person we are confronting is characterologically suicidal?" The problem of recognition is easier than that of treatment. The suicidal character type is a person who is carrying out an adaptive maneuver with others whom she/he is training to respond as mother surrogates to her/his need for nurturance. Such patients will tend to turn characteristically to people who know them rather than going from facility to facility or person to person. The diagnosis of suicidal character types is made on the basis of behavior displayed over a period of time. One does not need to hesitate in applying the usual crisis approach to a newly seen suicidal patient. Nor need one fear the iatrogenic effect of such crisis succorance. Character problems are not created by one or a few events but by the systematic repetition of shaping experiences.
Treatment Strategyfor the Suicidal Character Acute symptomatic suicidal states should be responded to by prompt nurturant behaviors. The acutely suicidal person requires the assumption of responsibility for her or his life to be taken temporarily by others. Observation, companionship, even involuntary detention may be required. Since the suicidal state is so often a request about whether others care, those others need to respond behaviorally that they do care. That is the immediate need. Once this crisis is under control, then other measures may be taken to deal with underlying psychiatric illness or environmental stresses which may participate in the causation of the suicidal state. In acute symptomatic suicidal states such more definitive measures will generally exert a therapeutic effect in addition to that engendered by the mothering crisis response. As the stressful situation subsides, the crisis response may be withdrawn, and responsibility for living turned back to the previously suicidal person. In acute situations, no harm has been done. But in those who have developed the characterological form of suicidality, such responses reinforce the suicidal character and increase the likelihood that future needs for love and nurturance will produce another and perhaps more dangerous suicidal state. In such cases one will note a longitudinal worsening of suicidality, each succeeding crisis being more fearsome. Close observation will generally make evident the secondary gains and the adaptive nature of suicidality. In such cases, the response must be modified. Therapists and other helpers must not rush in without considering whether they will be over-reacting to the immediate need at the cost
69 D. A. SCHWARTZ
of increasing the suicidal characterology and the likelihood of ultimate suicide. Efforts must be made to alert the person to the fact that he or she is moving toward inevitable death. A long-range plan needs to be developed for the gradual relinquishment of the responsibility of others for the person's life and his/her own reassumption of that burden. And all this must be done with the recognition that characterologically suicidal people are truly suicidal; they are not play-acting. Immediate risks may not be ignored. It is only that they must be weighed against long-term risks. The latter concerns are generally not so fearsome in acute symptomatic suicidal states. In brief, the treatment of suicidal character states is a long-term undertaking, as is that of all character problems. It is unique only in that the consequences of neglecting it are more likely to be fatal than are those of neglecting treatment in the other characterological conditions that we see. There are a few rules of thumb to be kept in mind in addition to the general strategy outlined. Hospitalization of suicidal characters should be as brief as possible. Prolonged hospitalization fosters precisely the kind of dependency that promotes suicidal character formation. It is necessary to keep constantly before the patient the fact that others cannot guarantee her/his life: that they can only be supporters to the patient. The therapist or other professionals should beware feelings of challenge within themselves to outwit the patient's suicidal plots, to out-manipulate his or her cleverness at being suicidal. Power struggles are dangerous because they promote the development of an adversary system around suicidal decision-making in which the patient comes to be able to align him/herself entirely on the side of suicide because the professionals are aligned so massively on the side of living. Even when external controls must be temporarily increased at times of suicidal crisis, patient and professionals should try to keep in mind the longitudinal plan of gradually decreasing external protection and placing the life-death decision-making on the patient's shoulders. The emphasis in psychotherapy needs to be kept on seeking the internal motivations for life rather than attempting to replace them with external ones. Mental health professionals have their own problems with life-death issues, as reflected by their higher-than-average suicidality. It is a special danger that we may deal with our own anxieties over life and death by fighting out the battle with our patients. Finally, it is necessary to accept the fact that we cannot save all the lives which we come to touch therapeutically. There is a failure rate in suicide prevention. This is not to imply that we ought not to try as hard as possible to minimize that failure rate. But it is to say that we should not be so intent on eliminating it for the present that we inadvertantly come to increase it for the future. It may be more comfortable to feel that the patient has killed him/herself in spite of our most desperately valiant efforts to save him or her, even though by our desperation we have increased the statistical rate at which such inevitabilities occur.
70
PSYCHIATRIC QUARTERLY
REFERENCES 1. Farberow, Norman L. and Shneidman, Edwin S., Eds. The Cry For Help, New York, McGraw Hill, 1961, preface, p. xi. 2. Shneidman, Edwin S., Farberow, Norman L. and Litman, Robert E. The Psychology of Suicide, New York, Science House, 1970, p. 107.
SUICIDAL
CHARACTER Donald A. Schwartz
Suicidal behavior is generally taken to be symptomatic in nature rather than egosyntonic. However, any behavior which comes to be used as a means of adaptation to the world long enough tends to become ego-syntonic. There are some suicidal people for whom suicidality has become a means of securing nurturance from the interpersonal world. The usual "crisis response" to suicidality reinfbrces such patients in their suicidal styles. Increased long-term risk becomes the price of shortterm nurturance. Specific alterations of treatment and management are indicated if such patients are to be helped to long-term survival. Behavior in general tends to be t h o u g h t of as either ego-alien or as egosyntonic. T h a t is, feelings or behaviors are seen as being either evidences of illness, symptoms, things not a part o f the normal self; or else they are experienced as "the way I am", a part o f the recognized self. But there is a point at which chronic symptoms begin to become a part o f the recognized self and symptomaticity shades into character structure. It is by such assimilation of the alienness o f experience that people come to see themselves as "nervous" or "sickly" or "sensitive" people rather than to experience egoalien anxiety, somatic distress or emotional hurt. In this more relativistic sense, experience or behavior may be ranged along a hypothetical continuum with symptomaticity at one end and characterology at the other. Suicidal ideas or impulses are generally experienced as alien events which arise in response to great anguish or dread, as final desperate ways of escape from the unbearable. Suicidal impulses are generally t h o u g h t to be acute and time-limited and approaches to suicide prevention are organized for the most part a r o u n d crisis responses. But suicidality, though it is most often symptomatic in nature, is also sometimes characterological. And suicidal character problems require a radically different approach from that used on symptomatic suicidal states. T h e approach used successfully with people in acute symptomatic states o f suicidality is not only ineffective with suicidal character problems; it is antitherapeutic. In fact it may well be that the suicidal character is an iatrogenic condition p r o d u c e d by such inappropriate response to what was initially symptomatic suicidality. Dr. Schwartz received his M.D. degree from Case Western Reserve University, Cleveland, Ohio in 1952. He is currently Adjunct Professor of Psychiatry at the UCLA School of Medicine and the UCLA Neuropsychiatric Institute. Reprint requests should be sent to Dr. Schwartz at UCLA-NPI, 760 Westwood Plaza, Los Angeles, California 90024. 64
PSYCHIATRIC QUARTERLY,VOL 51(1) 1979 0033-2720/79/1300-0064500.95
65 D. A. S C H W A R T Z
The Meaning of Suicidality Both demographic and conceptual distinctions are made between suicide attempts and completed suicides. These two kinds of acts appear to be the behaviors of two overlapping but by no means identical populations. Suicidal states of mind and suicide attempts which do not kill are generally taken to be behaviors which reflect mixed feelings, while fatal suicide acts are taken to be more unambivalently intended. There are exceptions, to be sure. An act which would be expected to produce a given result on the basis of all its characteristics may, nevertheless, produce an unexpectedly different result. Chance intervenes in all human events. An unambivalently suicidal person may be rescued by the merest chance and a clearly conflicted act may yet end fatally because of unforeseen happenstance. Nevertheless, outcomes do determine our ways of viewing motivation and the mere fact of survivorship following suicidal concern or behavior leads to the presumption that there was a mixture of intents. The title of a prominent book on suicide and suicide prevention, "The Cry For Help",* is meant to convey the authors' feelings "about the messages of suffering and anguish and the pleas for response that are expressed by and contained within suicidal behaviors." Implicit is the idea that suicidality is a means of seeking help and remedy from others. That concept has earlier support from a Supreme Court decision in which suicidal behavior was felt to be a (nonverbal) request for help. Justice Benjamin Cardozo is quoted as holding that "A cry of distress is a summons to rescue. ''2 Professional intervention in suicidal states is influenced gready by the hypotheses that suicidality is generally ambivalent and that suicidal behavior is a summons to rescue. In its most simplistic interpretation, that point of view might read, "The suicidal person wants to be dissuaded from the act." It is the position which holds that suicidal behavior conveys statements about one's helplessness, need for nurturance, and attitudes toward non-gratifying love objects. But however the conceptual matrix of the intervenor is worded, his or her response is generally marked by the rolebehaviors that characterize a parent: nurturance, protection and control. The suicidal person, having been heard to say that he/she needs to be parented in order to be saved for life, is generally responded to in the immediacy of the crisis with direct gratification of the professed need. The response is one which has been found empirically to be helpful to the vast majority of suicidal persons with whom one has the opportunity to intervene. Whether or not this parental response is always necessary in the crisis situation, it is certainly generally helpful. And certainly it is not harmful.
When is Parenting Harmful? But that is not always true. It is one of the general tenets of most psychotherapies that the therapist avoid becoming (much less seeking to
66 PSYCHIATRIC QUARTERLY
be) a substitute for the patient's own internal value systems. To be parental is to seek introjection into the internal value system, to aspire to membership in the patient's superego. Most of us now accept the impossibility of being a truly blank value screen as was once suggested to be a desideratum in classical psychoanalysis. But certainly most of us do not seek actively to replace the patient's values with our own, in other than unusual circumstances. Patients commonly deal with internal conflicts by projecting on to the therapist one side of such a conflict while acknowledging within themselves only the other side. The conflict can then be conceived of as taking place between the patient and the therapist. While the therapist may sometimes permit such a defensive maneuver to be carried out unchecked, it is more common to seek to confront patients with their projections and to get them to recognize both sides of the conflict as internal. One method by which therapists do this is in openly professing n o t to hold the views which the patients seek to ascribe to them. Suicide is one of the limiting conditions of such asserted neutrality. It is customary in dealing with suicidal persons to ally oneself with the side of the patient's conflict which is for living. This is consistent with the values and goals of medicine as a profession and with the general stance of most physicians and most others in the business of helping people. It is also a good method of denying our sadistic or destructive impulses toward patients, as transferred from significant figures in our own personal lives. But the tendency vigorously to ally oneself with the patient's drives toward continued life is carried out at the expense of the neutrality which the therapist would assert in other and less crucial conflicts dealt with in treatment. The therapist's alliance with life is often so vigorously espoused as to be asserted independently of the patient's own strivings in that direction. That is to say, the therapist (or professional or other person intervening with the suicidal person) may avoid discovering whether there is a conscious striving toward life within the patient with which the therapist may make alliance. Rather, the therapist may assert that she/he is for life, be damned to the patient! For the patient who is somewhat uncomfortable in dealing with an internalized conflict between living and dying, such an assertion by the therapist or others is a welcome invitation to project entirely the desire for life within the patient. Consequently, the patient may assert an unambivalent wish to die in response to the therapist's unambivalent wish that she/he live. Into such an interpersonal conflict there may intrude all of the transfeted rebellion against parental figures from the patient's past, thus investing the struggle over life with much rebellious torce that it did not originally possess. The therapist has relieved the patient of the need to attend to his/her responsibility for choosing whether to live or to die. The patient can be wholly for death. What ensues in such cases is often a prolonged struggle in which each side engages in a Vietnamese escalation of efforts to prevail. The patient finds ever more creative ways in which to fall toward death, while the therapist and other allies of the suicide prevention efforts
67 D. A. SCHWARTZ
respond with more and more desperate effbrts at catching the falling patient. Nurturance as a Secondary Gain
If the patient is a person with needs for mothering which are inadequately met in his or her life, a great danger exists with such struggles. In addition to the issue of life or death which is central to the stage on which suicidal dramas are played out, the need ~br nurturance becomes a sub-plot. The patient discovers that great attention and concern are expressed at moments of suicidal crisis; it is at such times that others seek to emphasize their concern and affection for the suicidal person. Non-suicidal moments may seem, by contrast, to be empty of caring and love. Subtly, the suicidal person may be invited to show the need for mothering by the expression of increased suicidality at times of special nurturant need. The suicidal impulse may gradually become the principal effective gateway to maternal care and love. As it does this, the suicidal impulse becomes, concomitantly, less of an ego-alien symptom and more of a characterological device for adaptation to the world. When this characterological development of suicidality becomes established in a patient who has successfully projected into the therapist the patient's own strivings toward life, as outlined in the preceding section of this paper, an explosive situation exists. Once such a process has become established, the patient is headed almost inexorably toward suicide. The projection into the therapist of the patient's wish to live is not a sufficient cause of such an eventuality without the concomitant shift of suicidality into the characterological mode. The projection of the wish to live into the therapist does not, of course, abolish it as a wish within the patient. The projection simply represents a disclaimer of its internal existence. But the defensive maneuver is not necessarily a permanent disavowal. Either as a result of changes in the patient and her/his relationships with external reality, or as a result of change in the degree of clinical illness or as a consequence of the treatment itself, the patient may come to acknowledge again the internal wish to live. As long as being suicidal means only wishing to die, it may yet be a symptom, still ego-alien, still capable of being rejected or modified. It is when being suicidal means more than only wishing to die that special danger is introduced. When being suicidal means success in coercing nurturance from a cruel world of others; when it has become a means of coping with the world more successfully; when it has, thus, lost the ego-alien quality that it had originally; that is when the danger of suicide in the long run becomes less of a risk and more of an inevitability. Recognition
Staff members of clinical facilities to whom this material is presented characteristically experience anxiety in considering it. They are frequently
68 PSYCHIATRIC QUARTERLY
faced by urgently suicidal cries for help and have generally learned that the standard crisis approach is a comfortable operating procedure to use in coping with such situations. It has generally not been suggested that the standard crisis response has adverse side effects. When they first consider that the use of this approach may actually increase ultimate suicide risk, their concern is mostly focused on the question, "How can we know whether the suicidal person we are confronting is characterologically suicidal?" The problem of recognition is easier than that of treatment. The suicidal character type is a person who is carrying out an adaptive maneuver with others whom she/he is training to respond as mother surrogates to her/his need for nurturance. Such patients will tend to turn characteristically to people who know them rather than going from facility to facility or person to person. The diagnosis of suicidal character types is made on the basis of behavior displayed over a period of time. One does not need to hesitate in applying the usual crisis approach to a newly seen suicidal patient. Nor need one fear the iatrogenic effect of such crisis succorance. Character problems are not created by one or a few events but by the systematic repetition of shaping experiences.
Treatment Strategyfor the Suicidal Character Acute symptomatic suicidal states should be responded to by prompt nurturant behaviors. The acutely suicidal person requires the assumption of responsibility for her or his life to be taken temporarily by others. Observation, companionship, even involuntary detention may be required. Since the suicidal state is so often a request about whether others care, those others need to respond behaviorally that they do care. That is the immediate need. Once this crisis is under control, then other measures may be taken to deal with underlying psychiatric illness or environmental stresses which may participate in the causation of the suicidal state. In acute symptomatic suicidal states such more definitive measures will generally exert a therapeutic effect in addition to that engendered by the mothering crisis response. As the stressful situation subsides, the crisis response may be withdrawn, and responsibility for living turned back to the previously suicidal person. In acute situations, no harm has been done. But in those who have developed the characterological form of suicidality, such responses reinforce the suicidal character and increase the likelihood that future needs for love and nurturance will produce another and perhaps more dangerous suicidal state. In such cases one will note a longitudinal worsening of suicidality, each succeeding crisis being more fearsome. Close observation will generally make evident the secondary gains and the adaptive nature of suicidality. In such cases, the response must be modified. Therapists and other helpers must not rush in without considering whether they will be over-reacting to the immediate need at the cost
69 D. A. SCHWARTZ
of increasing the suicidal characterology and the likelihood of ultimate suicide. Efforts must be made to alert the person to the fact that he or she is moving toward inevitable death. A long-range plan needs to be developed for the gradual relinquishment of the responsibility of others for the person's life and his/her own reassumption of that burden. And all this must be done with the recognition that characterologically suicidal people are truly suicidal; they are not play-acting. Immediate risks may not be ignored. It is only that they must be weighed against long-term risks. The latter concerns are generally not so fearsome in acute symptomatic suicidal states. In brief, the treatment of suicidal character states is a long-term undertaking, as is that of all character problems. It is unique only in that the consequences of neglecting it are more likely to be fatal than are those of neglecting treatment in the other characterological conditions that we see. There are a few rules of thumb to be kept in mind in addition to the general strategy outlined. Hospitalization of suicidal characters should be as brief as possible. Prolonged hospitalization fosters precisely the kind of dependency that promotes suicidal character formation. It is necessary to keep constantly before the patient the fact that others cannot guarantee her/his life: that they can only be supporters to the patient. The therapist or other professionals should beware feelings of challenge within themselves to outwit the patient's suicidal plots, to out-manipulate his or her cleverness at being suicidal. Power struggles are dangerous because they promote the development of an adversary system around suicidal decision-making in which the patient comes to be able to align him/herself entirely on the side of suicide because the professionals are aligned so massively on the side of living. Even when external controls must be temporarily increased at times of suicidal crisis, patient and professionals should try to keep in mind the longitudinal plan of gradually decreasing external protection and placing the life-death decision-making on the patient's shoulders. The emphasis in psychotherapy needs to be kept on seeking the internal motivations for life rather than attempting to replace them with external ones. Mental health professionals have their own problems with life-death issues, as reflected by their higher-than-average suicidality. It is a special danger that we may deal with our own anxieties over life and death by fighting out the battle with our patients. Finally, it is necessary to accept the fact that we cannot save all the lives which we come to touch therapeutically. There is a failure rate in suicide prevention. This is not to imply that we ought not to try as hard as possible to minimize that failure rate. But it is to say that we should not be so intent on eliminating it for the present that we inadvertantly come to increase it for the future. It may be more comfortable to feel that the patient has killed him/herself in spite of our most desperately valiant efforts to save him or her, even though by our desperation we have increased the statistical rate at which such inevitabilities occur.
70
PSYCHIATRIC QUARTERLY
REFERENCES 1. Farberow, Norman L. and Shneidman, Edwin S., Eds. The Cry For Help, New York, McGraw Hill, 1961, preface, p. xi. 2. Shneidman, Edwin S., Farberow, Norman L. and Litman, Robert E. The Psychology of Suicide, New York, Science House, 1970, p. 107.
