ANP0010.1177/0004867414531151Australian & New Zealand Journal of PsychiatryBou Khalil

Viewpoint Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(6) 505­–506 DOI: 10.1177/0004867414531151

To be or not to let others be: Is it relevant to the mental health field?

© The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com

Rami Bou Khalil1,2,3

‘They let you down… but we will retaliate…’ and a day before the suicide bombing took place, he took to his social media personal page to say that ‘heaven has opened its doors to receive him’ (OTV, 2013). When treating patients suffering from mental disorders, suicide, as a phenomenon, has always been a major incident to prevent. Conventional knowledge indicates that the vast majority of those who commit suicide are suffering from some form of mental disorder; in most cases depressive illness, schizophrenia, substance misuse or, occasionally, personality disorder or adjustment reactions (Fairbairn, 1994; Hawton and Van Heeringen, 2000). However, there is evidence to suggest that the presence of a mental disorder in itself is not sufficient to give rise to an act of suicide and, in addition, some who kill themselves may not be mentally disordered at all (Fairbairn, 1994; Hawton and Van Heeringen, 2000). The problem with the medical approach for dealing with suicide events is that doctors in general and, more specifically, mental health professionals are not in agreement on whether to consider suicide itself as a disease or as a phenomenological manifestation of other diseases. In other words, should suicidal behaviours and thoughts be treated by treating the underlying mental disorder, or should these behaviours and thoughts be treated as clinical manifestations of an independent psychopathologic entity? To date, no clear consensus exists to enable mental

health professionals either (a) to consider suicidal behaviours as unchangeably corresponding to a complication occurring during the course of a mental disorder, or (b) to admit the existence of some suicidal behaviours and ideation in a person who does not present any other described disorders. As a corollary of this question, no clear consensus arbitrates as to whether humans who do not suffer from any mental disorder commit suicide as a response to a self-deliberated decision or in response to specific constraining conditions. Can a person who is considering committing suicide under specific constraining conditions still be considered not to suffer from a mental illness, even though he/she does not manifest any characterized specific mental symptoms? Close observation of some real-life types of suicide attempt may lead us to consider describing suicide behaviours and ideations along a dimension that parallels the classic spectrum, going from simple attention-seeking behaviours seen in patients suffering from a personality disorder, to the serious response to a severe major depressive disorder during which the patient determines to put an end to his or her suffering by committing suicide. On this parallel dimension, one of the most important motives for suicidal ideations and behaviours for a considerable subset of patients are those where the suicidal person not only aims to put an end to their own life, but also intends to give a meaning to their death in a way that contains its own dimension

of hetero-aggressiveness. Within this category of patients, we can find patients suffering from a characterized mental disorder, such as major depressive disorder, who commit suicide in a special way designed to make others, especially their loved ones, imagine the few seconds during which their death took place every time they come across the circumstances that make them recall it. With this perspective, one can understand the reason behind the fact that some patients choose to commit suicide in a public location that is difficult to access, despite the fact that they could have used easier means. Also within this category of patients we find ideologically militarized individuals, who are not necessarily suffering from a characterized mental disorder, but who voluntarily aim to commit suicide in a particular way to shock the largest proportion of people who see or hear about the suicide attempt. For example, self-immolation and self-induced starvation are provoking suicide behaviours that play a primary role in influencing public opinion. One of the most important objectives behind these behaviours is not death in itself, but the shock that this horrible means of death creates in the minds of others. Finally, in this 1Saint

Joseph University, Beirut, Lebanon Hospital of the Cross, Jalledib, Lebanon 3Hotel Dieu de France, Beirut, Lebanon 2Psychiatric

Corresponding author: Rami Bou Khalil, Psychiatric Hospital of the Cross, PO Box 60096, Jalledib, Lebanon. Email: [email protected]

Australian & New Zealand Journal of Psychiatry, 48(6)

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506 same category of patients, we find ideologically militarized individuals who are not necessarily suffering from a characterized mental disorder and who commit suicide in a manner that endangers the lives of other human beings. The most relevant example of this pattern is that of suicide bombers, who aim to take the lives of as many human beings as they can, to send a political, cultural or religious message. Again, the bomber’s death in itself is not the main objective behind the bombing so much as the terror that lies behind the massacre that the bombing provokes. Committing suicide while striking an enemy target is the result of a decision taken at the highest level in a community in a reaction to specific conditions. One of the best known historical examples of these acts is that of the Japanese Kamikaze attacks during World War II. In these attacks pilots would attempt to crash their aircraft into enemy ships. These attacks followed several crucial military defeats for Japanese forces, while the Japanese government remained reluctant to surrender. When feelings of hopelessness and helplessness are shared within a community, especially at the highest levels, and when the cultural and ideological approach is in favour

ANZJP Perspectives of self-destructive behaviours for the purpose of hetero-aggressiveness against enemies, suicide with the most extreme hetero-aggressive component, such as in Kamikaze or suicide bombing, can occur. It is in this context that the first suicide bomber in recent Lebanese history – quoted at the beginning of this manuscript – committed his suicide attack against the Iranian Embassy in Beirut in November 2013 (OTV, 2013). And it is this context that explains why the whole world is witnessing a spate of these auto- and hetero-aggressive behaviours since the bloodiest attacks that were launched on 11 September 2001 upon the USA. When the hetero-aggressive aspect of the pattern for suicide is taken into consideration, all forms of suicidal ideations and behaviours become enrolled in a spectrum of ‘suicide disorders’. This perspective enhances our ability to study and treat both essential facets of suicide, namely: when a person considers harming him/herself to stop the suffering he or she is living in; and when a person considers harming him/herself for the same reasons and/or to inflict their suffering on others. Moreover, when the conceptualization of suicide takes into consideration that it always occurs in severely stressful

surrounding conditions (relative to the suicidal person and regardless of whether these extremely stressful conditions exist in reality or not), all suicidal ideations and behaviours can be categorized under one category of disorders and should consequently be treated accordingly. Keywords Suicide bombing, auto-aggressiveness, depression, hetero-aggressiveness

Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

References OTV (2013) Iran embassy suicide bombers were Lebanese. Available at: http://www.yalibnan. com/2013/11/23/iran-embassy-suicide-bombers-were-lebanese-otv/ (accessed 11 January 2014). Fairbairn GJ (1995) Contemplating Suicide: The Language and Ethics of Self-harm. London: Routledge. Hawton K and Van Heeringen K (2000) The International Handbook of Suicide and Attempted Suicide. Chichester: John Wiley.

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To be or not to let others be: Is it relevant to the mental health field?

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