depressionI want to focus on two ideas about the nature of suicide among those of us suffering from uncontrolled pain (UP). It goes without saying that persons with pain (PWP) also suffer from depression. This depression can be the result of the multitude of losses from the onslaught of grueling, mindless pain. It is also well known among us that UP leads us to contemplate ending our lives to end monstrous pain.

When UP sets up shop in us and we think about ways to end the pain, it is logical that we see never waking up again and death as a permanent solution to an often impermanent hellish life of pain. When this takes root in a PWP’s mind the link between ending pain through death often becomes detached from reality: death will end pain permanently but it will also permanently end the person’s life. This nearly simpleminded notion is especially noticed in an adolescent and even young adult’s thinking. Strange as it may seem, in the deepest throes of pain and despair, the link between suicide and the permanent end of life becomes lost. For this person, suicide is a temporary solution, not an irreversible act.

This notion becomes less strange when we realize that the overwhelming attack of UP slowly but surely undermines our thinking. This isn’t just an emotional reaction to the pain but part of the notion that pain is, indeed, in our heads. Not that we are making it up, but that pain is not just a biological malady but a disease of the brain. By this, I mean that the battle with pain is largely fought through brain chemistry & biological structures. In short, pain by virtue of its nature, alters the topography of thought and emotion.

I won’t belabor this point other than to say that UP fundamentally alters our physical, mental and emotional landscape. I lay this out as the groundwork for the following discussion of the notion I’ve developed about an unconscious, yet powerful instigator of self destruction.

We all know the usual reasons for suicide. However, there is a deeply buried unconscious meaning that I’ve found both in those with severe mental illness and those of us who suffer from UP, including this writer. At the deepest level, I’ve experienced over my career with suicidal thinking of my patients and in my own multiyear long struggle with suicidal ideation which has gradually lead me to a possible motivator of suicide that remains largely, if not completely hidden from the PWP, caretakers and, in my case, a psychotherapist trained and experience in conversations with the unconscious.

For PWP, including those who suffer only from psychic pain, the idea of ending one’s life involves several obvious reasons, no less important for being conscious and not unconscious, that lead to self inflicted death. These are:

  • Ending the pain;
  • Ending all the burden and strains on caretakers, and;
  • The notion of regaining control not only of one’s life, but of one’s body. This is often unconscious yet of great importance.

Of course, that notion while seemingly important to that person is, in the end, the demented thinking of one under the onslaught of mindless pain. Yes, one regains control but only in the final moment of self destruction.

This tragic thinking needs to be confronted with the person who may only be dimly aware of its existence. This can be done either in therapy or with trusted caretakers. The individual will need help articulating this fantasy and then need help in examining it in the light of borrowed rationality. The open discussion of this fantasy while rendering it less harmful, paradoxically empowers the patient’s resilience as s/he is no longer in the throes of completely understandable but erroneous thinking.

The final, and in my experience, the most abyssal fantasy and consequently the most lethal notion submerged in an amorphous and cataclysmic idea: Suicide as reification of a “death foretold.” I’ll attempt to raise this prelinguistic thought into comprehensible language. I must warn, though, that in doing this we need to keep in mind that the moment we put something into language we necessarily deform the very notion we are describing as language is limited.

In uncovering in myself and others ideas of self-destruction a deeply held image, as it were, begins to take shape. This coalescing image doesn’t come out directly through the content of speech as much as it takes shape through the process of speech, through what is included and more importantly what is excluded. It comes through rumination, body language and what is expressed by the body outside the awareness of the individual and often the therapist.

With no more introductions, I will now reduce this process and its underlying fantasy. Suicidal ideation when openly and intuitively listened to and shaped by the nature of the relationship of both partners comes to this: The person’s suicidal ruminations and intentions are a reification (making something real, bringing something into being, or making something concrete) of something that has already happened-their death. The fantasies around self-destruction often tells the story of that which has already happened. The individual is in a prospective fantasy telling a story about what has happened but unthinkable. Only with time and an empathic relationship with another is this fantasy accessible.

When the patient is thinking of killing themselves, they are unconsciously describing what has already happened–their existential death. This includes all the small deaths (homicides) that accumulate over time as the painful illness cleaves off more and more of the person’s life:

  • Death of work life
  • Death of recreational activities
  • Death of their self-image, they often no longer recognize themselves
  • Death of dreams, their future aspirations have been forever altered
  • Death of relationships, in that their earlier relationships before the advent of pain are fundamentally changed
  • Death of intimacy. Their sex life after the introduction of pain is often killed, murdered by homicidal pain.

We people with pain have suffered our homicide at the hands of pain. The deeply held reification of our deaths implanted in our suicidal fantasy can ultimately kill us if this derangement of our deaths through suicide are not somehow confronted, dragged into the light and examined very closely. What this implies is the mourning of all the homicides already committed against nearly every aspect of our lives.

This reification is best revealed, understood and mourned through psychotherapy. I’m not sure in my own thinking of what form of therapy should be advanced here. My best suggestion is a combination of individual and conjunctive couples’s therapy. I suggest couples therapy as we PWP need desperately to be reconnected to the matrix of our heretofore sustaining relationships. Murder (our personal deaths) is not something that can be faced alone.

We need to uncover all the murders, all their fantasies, all the despair, all the loss; within this process there is life. As we confront all the deaths we’ve endured, we can not only reconnect with our damaged, murdered and deranged selves, but we can reconnect with the life we thought had already died. It hasn’t. We’re still here.

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