Suicidality after a suicide attempt: A range of possibilities

4.1.1 Catharsis

In a paper initially presented in 1938, Zilboorg (1996) discussed the case of a female patient who showed remarkable improvement after an attempted suicide by hanging. He suggested that many suicidal people feel calmer and more serene shortly after a suicide attempt especially if it has been a medically serious one. He went on to develop the argument that the reason is that a highly charged emotional state, in this case aggression against the self, has been expressed or discharged. He likened this to a situation where a person who is very angry, and has been holding it in, erupts in a tirade or punches someone and then finds the anger has dissipated and the person is now calm. This view of a suicide attempt having a cathartic effect held considerable currency in decades past but has been less widely accepted in recent times. However Sarfati, Bouchard, and Hardy-Baylé (2003) have advocated for its continuing

relevance. They argued that a suicide attempt has a ‘resolving power’ (p.76), and went so far as to suggest that the seeking of this cathartic resolution of painful affect may contribute to the occurrence of repeat attempts. This is a similar argument to the more widely held view that non-suicidal self-harm (such as cutting) serves an emotional regulation function, releasing tension, anger and distress (Favazza, 1996).

4.1.2 The attempt as a gateway to further suicidality

Contrary to the position outlined above, Joiner (2002) has argued that a suicide attempt effectively opens a gateway to further suicidality. In this view a suicide attempt is a kind of rehearsal, a way of ‘working up to the act’ (Joiner, 2005, p.47). It reduces the fear, and the sense of danger and alarm, that is otherwise associated with self-injury and usually likely to prevent it. According to Joiner a suicide attempt also enables the person to learn more about how to do it. Joiner (2005) argued that the ability to enact lethal self-injury is acquired, and it is acquired through mental or physical rehearsal. This means that after a person has made one suicide attempt he or she has increased capacity to make another – but will do so only if the desire to suicide and the painful states that underlie such a desire are also present. Joiner (2002, 2005) argued that the theory of acquired capability is consistent with, and at least partially explains, the epidemiological findings that a suicide attempt is associated with elevated risk for further attempt or suicide. According to this view, the reason that many people who make one suicide attempt do not make another is because the desire for suicide is no longer present even though the capability is retained.

4.1.3 The attempt as disruptor of fantasy meanings of suicide

Another possibility may be that confronting the reality of a suicide attempt may create a shift in the underlying (at least partly unconscious) fantasy meanings of suicide, or of death. Alvarez (1971) may provide an example of this in what he says about his own suicide attempt, resultant coma and near death. He wrote that he expected something of death, some kind of solution: ‘a synoptic vision of life, crisis by crisis, all suddenly explained, justified, redeemed’ (p.235). But instead of ‘something overwhelming, an experience which would clarify all my confusions’, what he got was just ‘a denial of experience’ (p.234). Given his level of drunkenness at the time, it seems unlikely these ideas were particularly clear in Alvarez’s mind at the time he overdosed. They may only have become clear in retrospect, but he described using the refrain of wishing he was dead as a kind of mantra ‘to ward off devils’ (p.226) for a long time before his suicide attempt. He located this fantasy of the power and promise of death somewhere within an idealistic, over-sensitive, over-intense self which

somehow hadn’t quite grown up, and wrote that after (a rather slow) recovery from the suicide attempt, these aspects of his self were gone. He gradually emerged as ‘less theoretical, less optimistic [although he had been severely depressed], less vulnerable’ (p.234), and had accepted that there weren’t going to be any answers, even in death.

4.1.4 The attempt precipitates a change in life circumstances

The three possible effects of a suicide attempt outlined above (sections 4.1.1 to 4.1.3) concern a change within the person’s inner life or mental state. Another possibility is that a suicide attempt may result in a change to external life circumstances, which in turn may make a further attempt or subsequent suicide either more or less likely. In Joiner’s (2005) terms the external change may impact on desire for suicide. This could occur, for example, where a suicide attempt somehow results in removal or escape from entrapment within a toxic and/or violent relationship or family. More generally a first suicide attempt may result in a first offer of psychotherapy or other psychiatric treatment, which may over time lead to significant change. Any such change in external life circumstances could occur at the same time as one of the internal psychological changes discussed above.