Is Suicide Really a Choice?

iceAfter multiple trips down the hall, I dumped the last bucket of ice into the bathtub, then topped it off with cold water.  Just a couple hours earlier, I had completed my first marathon in New York’s Central Park, finishing fifteen minutes north of three hours. My legs cramped badly in the last half-mile, and after returning to our hotel, my friend Michael and I thought it would be a good idea to do what the professionals do to expedite recovery: take an ice bath.

With his teasing encouragement to go first, I stepped into the tub and quickly sat down, immersing my body in the ice and water up to my neck… Jesus! I have always tried to avoid the cold, but the pain I encountered upon entering the tub was instantly and completely unbearable. I don’t really recall the specific nature of the pain, but the memory is vivid. I was filled with an all-consuming terror that I would not be able to get out of the water fast enough. In the next moment, I was thrashing in the water, desperate to escape the acute pain I was experiencing.

That type of reaction is hard-wired in all of us. Our immediate response to acute pain is physiological: our pupils dilate and eyelids widen, our heart rate and blood pressure spike, our breathing quickens. It is part of our body’s built-in defense system, and in a micro-second we are into fight-or-flight mode. I didn’t choose whether to exit the ice bath; my primal reaction was to simply GET OUT.

Last year, at the American Association of Suicidology annual board meeting, I challenged a friend of mine regarding the relative absence of survivors of suicide attempts at the meeting, and told him how incongruous I thought it was. “What if the American Cancer Association meetings lacked survivors of cancer?” I asked. He replied that such a comparison was inappropriate. “Individuals choose to die by suicide; no one chooses cancer.”

Perhaps we have all thought about suicide in this same way, but I’m not sure how helpful or even how accurate that frame actually is. In “A Darkness Visible,” one of our most skilled American authors, William Styron, expresses his frustration with finding the words to adequately convey the utterly crippling nature of his suicidal depression.

Depression is a disorder of mood, so mysteriously painful and elusive in the way it becomes known to the self — to the mediating intellect– as to verge close to being beyond description. It thus remains nearly incomprehensible to those who have not experienced it in its extreme mode.

Styron says that for those of us who have not experienced this kind of darkness, it is extraordinarily difficult to grasp how much like physical pain this anguish can be. Our more typical life experiences of disappointment and sadness, grief and loss, and the normal ups and downs of being human do not provide any accurate translation.

When my friend talked about choice, I relayed my experience with the ice bath. I told him I didn’t go through a decision-making algorithm on the benefits and drawbacks of leaving the tub, nor did I white-board potential solutions. Like any animal in pain, I instinctively bolted away from the source of it. No one needed to offer me the idea of exiting the tub, because that idea had already filled every neural pathway of my mind. (Many who have experienced psychic anguish are offended by the concept that someone who mentions suicide might give them an idea that they have not already had.)

My example references an acute pain, but extend that into a chronic day-over-day anguish that blinds the person to the possibility of a better day tomorrow. Perhaps people do not choose suicide so much as they finally succumb because they just don’t have the strength, supports, resources, hope, etc. to hold on any longer.

Recently, I have been offering a multiple choice question to audiences. Suicide is preventable:

A.  Never in Those Truly Intent on Suicide
B.  Sometimes, but Only in Advance of Acute Risk
C.  Always, but Only in Advance of Acute Risk
D.  Always, Even Up to the Last Moment

The idea that “suicide is a choice” is central to our disbelief that we could actually save everyone. But, we know we can extend and strengthen a person to hold on, even in spite of desperate pain.

Last year, I had the pleasure of meeting Major General Mark Graham and his wife Carol, who tragically lost two sons, Kevin and Jeff, in the military within seven months of one another. One died as a result of an IED in Iraq; the other was taken by suicide. You expect courage from leaders in the army, but I was so inspired by the choice this couple made to speak out about their pain and make themselves vulnerable in order to help and support others. Their choice demonstrates bravery to the tenth power.

In his appearances, Maj. General Graham speaks of Rabbi Kushner’s famous book “When Bad Things Happen to Good People,” in which the author highlights a study done regarding how much pain one can endure and for how long. Individuals were timed on how long they could hold their feet in a tub of ice water, first by themselves, and then with another individual in the room with them. The study found they could persevere almost twice as long when they were not alone. Kushner’s conclusion: “The mere presence of at least one caring person doubles the endurance of an individual.”

I think it’s a fair statement that almost no one chooses cancer. We simply would never frame someone’s struggle with such a disease in that fashion.  Why should suicide be any different? Yes, the individual did something: they pulled a trigger or they took an overdose. But I would argue that all of us react to pain, instinctively and immediately. The vast majority of us can only remain in a tub of ice water for so long. Imagine living day after day with extreme psychological pain and anguish.

Many of us have considered the phrase “committed suicide” as an inappropriate way to talk about the deaths of individuals who, despite their most tenacious efforts, could no longer endure unbearable pain. Perhaps Maj. General Graham has a better focus. I haven’t heard him talk about choice; he talks about sitting with the person in pain and helping them hold on. That’s even better.

*Note: Also, see my YouTube TED-style TALK at the 2014 National Council for Behavioral Health Conference in Washington, DC, “Everything we knew about suicide was wrong.”

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