The Psychodynamics of Suicide

Almost all states of health and disease result from interactions between individual and environmental factors (IOM, 2003), and suicide is perhaps an example of the interaction of multiple factors including psychological, biological, cultural and social factors. It draws upon a wide variety of disciplines and, whilst not discounting these contributions, my goal in this essay is to present suicide theory from a psychodynamic perspective. Given that the psychodynamic church is a ‘broad one’ (Davies & Burton, 1996), and word limitation, this essay is in no way comprehensive. Various psychodynamic viewpoints will be presented, together with some implications for therapy with my client.

Theory usually begins with definition. Thus, let me offer Shneidman’s definition of suicide:

The suicidal state is one in which an individual “cuts his throat and cries for help at the same time, and is genuine in both of these acts” (1996, p 49)    

A man, who we can refer to as "Michael", was referred for depression. His partner, Wendy, completed suicide eighteen months previously. Suicide by a close relative may well precipitate a suicide attempt by a partner. (Campbell & Hale 1991) Shneidman tells us that “the person who commits suicide puts his psychological skeleton in the survivor's emotional closet” (Shneidman 1999 p357).

When suicide is the problem of the hour, the analyst’s own working through of beliefs and attitudes may markedly influence the context of suicidal client interactions (Hillman, 1997 p17).  “We ought to know what we are treating” (Shneidman 1985 p116). The need to treat prompts the counsellor, even necessitates them, to understand the theory; to enable them to endure the storm of such a relationship.

Plato claimed that suicide is disgraceful and its perpetrators should be buried in unmarked graves, except when the self-killing results from shame at having participated in grossly unjust actions (Cooper 1997). Suicide under these circumstances can be excused but, according to Plato, it is otherwise an act of cowardice or laziness (1997). St Thomas Aquinas emphasised that suicide was not only unnatural and antisocial but also a mortal sin (Battin 1980). In psychodynamics suicide is not a sin, nor is it a crime. What is it? This is the topic to which I now turn.

Anyone left behind after someone close completes suicide is likely to spend much of the rest of their life wondering whether they should have survived (Sandler 1992). Pollock believed that what may seem to be an identification of the suicidal person with someone who is dead is likely to be ‘reflective of the wish to reunite with the one from whom the separation occurred’ (Pollock 1975, p 336).  In his first session Michael told his therapist:

It’s as if Wendy tore herself away from me, and I feel deeply wounded. I am an open wound, I am afraid I will bleed to death. But what does it matter, then I will be with her…

This dynamic was emphasised by Zilboorg who wrote that “the drive towards death, always with the flag of immortality in hand, carries with it the fantasy of joining the dead or dying or being joined in death” (1938 p19). Perhaps Michael saw his life as set on a course in which gratification of his fantasies was only possible through his death?

Jones and Jung recognised the importance of rebirth and reunion fantasises in suicidal clients. Jones suggested that such fantasies had as their prototype the wish to return to the mother’s womb (1964), while Jung and his followers emphasised the unconscious need for spiritual rebirth (1959).

The current revival of interest in the psychodynamics of suicide derives in part from the increasing realisation that assigning to a client a diagnosis of high-risk suicide is not in itself an explanation for suicide (McWilliams 1998). Psychodynamic viewpoints accept that it may be linked with a depressive state (e.g. Freud 1917, Klein 1975, Abraham 1970) and they have also considered the narcissistic aspects of the act (e.g. Grunberger 1990, Kernberg 1987). Theorists such as Shneidman have hypothesized that individuals seek death primarily to escape from intolerable emotional pain (1992, 1996). Many recognise the ‘violence inherent in the suicidal act’ (Campbell & Hale, 1991, p292) and the predominant view appears to be that it is an aggressive act (e.g. Freud 1920, Sandler 1992, Sneidman 1996, Fairbairn 1995), thus any attempt to understand suicide needs to also address the place of aggression within the human psyche.

For Freud, aggression “represents the ego’s original reaction to objects in the external world” (Freud, 1917, p. 252). His view of suicide derived from his observation in 1917 that depression is an attempt to regain, through introjection, a lost object (person or an ideal) that is both loved and hated (1917) [to introject is to incorporate characteristics of an object into one's own psyche unconsciously (Klein 1975)]. Freud hypothesized that intense identification with the lost object is crucial in understanding the suicidal person. Identification is defined as an attachment (bond), based upon an important emotional tie with another object (Jones 1953) or any ideal. This identification process establishes a “critical agency” (superego) (1953, p366). With relentless violence, the superego attacks the ego for failing to live up to the original object, leading to the internalisation of aggression, characteristic of melancholia.

According to Freud, when the ego cannot withstand the mercilessly violent attacks of the punitive superego, the sufferer may resort to suicide (1917).  [The ego serves as a mediator between the id’s desires and the superego’s ideals. The id seeks immediate gratification and is not concerned with reality. The superego acts as the conscience and pushes an individual to strive for perfection (1917)].  In essence, suicide according to Freud expresses a repressed wish to kill an ambivalently regarded lost love object and thus it is ultimately an act of revenge (1920). These feelings may be conscious as well as unconscious or expressed in dreams (1920).  Such an expression of revenge may have been in Wendy’s mind. Michael told his therapist that the week prior to her suicide she dreamed she had killed her mother.  Shortly before killing herself she told Michael that suicide would be a way of getting back at her parents.

In 1920 Freud introduced the concept of a separate aggressive drive which is operative from birth and which he linked to the death instinct. This destructive instinct aims to ‘undo connections and to destroy things...We may suppose that its final aim is to lead what is living into an inorganic state’ (Freud, 1920, p98.). He describes the interplay of the life instinct (Eros) and the death instinct (Thanatos). It is possible to observe the working of the pure death instinct when it is detached from the life instinct, as, for example, in the case of the melancholic in which the superego appears as "a pure culture of the death instinct." (Freud 1920 p 102). Some post-Freudian authors tried to dissociate themselves from their predecessor’s pessimistic views on the death instinct which is seen by them as “no longer a principal instigator of human tragedy“ (e.g. Kohut 1977, Bowlby 1984). The common opinion appears to be that “Freud’s musings” on life and death instincts were intended as philosophical speculation on biological forces in life in general, not as theoretical concepts meant to be applied directly to clinical phenomena” (Greenberg & Mitchell, 1983, p.141).

One therapist who did incorporate the death instinct into her clinical theory was Klein who did much to extend and develop it and emphasised how an infant’s earliest experiences (usually with the mother) can help him to modify his innate destructive tendencies  (Klein, 1975). She postulates that the death instinct starts the very moment we are born; an extremely painful and traumatic process that represents the struggle between life and death instincts (Klein, 1975). The Freudian concept of depression includes the mechanism of introjection. Suicide, from this point of view, is seen as directed against the introject.

Klein does not appear to openly question this theory but does not fully subscribe to it either. In her opinion, it is not only the introject that is responsible for suicide – external objects may also play an important part (1975).  In Kleinian theory, an object tends to be perceived either through its good or its bad aspects, even when the whole-object relationship is already established. While the loss of the whole object means the loss of love, the intrusion of the paranoid anxiety into the depressive state brings in with it the bad object (external or internal). Along with its good counterpart, it becomes one of the main characters in the unfolding drama. Suicide occurs as a result of the tragic, unresolved relationships between the ego, its introjects, and the external objects (Klein 1975).

The struggle between the ego and the superego, according to Fenichel, characterises only a certain type of suicide – suicide due to depression, which signifies the victory of the superego over the ego. Self-destruction can take either a passive or active form (1946). In the former, the ego is completely crushed, its worthlessness is proven. As the superego turns away from the ego, it leaves it without self-esteem and the ego, deprived of protective forces, has no choice but to let itself die (1946).

So, it seems one does not necessarily have to be depressed to complete suicide.   According to Bibring (1968), there is a decisive difference between the “ego killing itself” and the “ego letting itself die”. Only in the first case is the aggression involved. Giving up the struggle because one is tired and feels hopeless is not identical with self-destruction” (p.180). In Bibring’s opinion, self-destruction is inseparable from self-directed aggression but not from a depressive state of mind, which may or may not be accompanied by the feelings of self-hatred leading to suicide. Bibring also questions Freud’s emphasis on the punitive nature of the superego as a source of fatality (1968). 

He suggests that both depression and self-destruction more often than not originate within the ego itself. The latter develops frictions with the ego ideal which is regarded as part of the ego itself (1968). It is the ego’s inability to live up to its high standards and aspirations and a refusal to reconsider or modify them that usually leads to the tragic finale (1968). The ego dies not because it is attacked by a superior agency or, in Fenichel’s words, abandoned by it, but because it keeps holding on to unattainable and unrealistic goals, which makes it feel powerless and hopeless (Fenichel 1968). Thus, self-destruction due to depression is primarily an ego-phenomenon that “stems from tension within the ego itself, from an inner-systemic conflict” (Bibring 1968p.164). 

Why shame was the exception for Plato is not clear to me, but Lansky cites it as the key feature in many suicides (1997).  Goleman tells us: “shame is a master emotion, regulating the expression of other feelings.” (1987 p65).  Freud's work paid more attention to guilt but Lanski says that shame is often masked by “manifestations of conscious guilt” (1997 p231).  Recent theorists have focused on the role of shame in suicide (Kohut 1984, Lanski 1997, Malan 1976, Loader, 1998).  For, toilet-training became a troubling issue; most children his age were already past that stage.  Having been punished, shamed and ridiculed for something completely out of his control, it seems Michael may have suffered a long chain of narcissistic injuries. “When we understand narcissism not as love of the self, but as the love of the idealised image of the self, we become aware of the gravity of shame, self-hate, and alienation which needs to be present in order to kill the self”. (Kilpatrick 1948).

The possibility of suicide gives some people the illusion of mastery over a situation through the control of their living or dying (Jamison 2000).  Others may think the crisis has passed when in fact the opposite is true (Sandler 1992). Often, when the decision is made, relief and calm may follow (1987). Michael told his therapist:

 "I can’t believe I was so naïve as to believe Wendy was getting better.   She was stock-piling pills. Yet she seemed to ‘perk up’; our sex life became brilliant.  Now, of course, I realise she was relieved to have made her decision, and she would enjoy life in the knowledge that it would end at a time appointed by her."

Biven & Daldin hold that in self-destruction the person is not only avoiding unpleasure but actively seeking pleasure, and thus quite often pursuing sexual gratification (1993). 

The phenomenon of self-destruction in Menninger’s work, as well as in Freud‘s, is characterized by two major features: it is highly ambivalent, comprised of contradictory, mutually exclusive strivings and it is ubiquitous – worked into the fabric of everyday life (1966).  However, he refined Freud’s theory that anger directed against the self must conflate with the death instinct. He posits three components prerequisite to suicide: the wish to kill, the wish to be killed and the wish to die (the death instinct) (1966). 

Bowlby rejects Freud’s theory of the death instinct stating that it is “rooted in a non-evolutionary paradigm that bears no relation to modern biology” (Bowlby,1975, p.205) and, therefore, it would seem he also shuns the Kleinian approach that makes special accommodations for the death instinct in clinical work (Klein 1975).  Bowlby says the death instinct “has the effect, inimical to good practice, of directing attention away from a person’s real experiences, past or present, and treating him almost as though he were a closed system little influenced by his environment” (1975 p.205). In Bowlby’s theory, the environment comprised of relationships with real parents or caregivers becomes particularly important. It is responsible for the formation of a specific propensity to establish strong affectional bonds with others (Bowlby, 1975). This process is called attachment (of which he cites four types) and is viewed by Bowlby as a sin qua non of human development (1975). 

Suicide is understood as a postponed result of serious disturbances in early attachment that have been caused by loss, due to death or other unfortunate circumstances, of the caregiver (1975).  Michael suffered many losses in his life including his mother’s departure from the family home when he was three.  He was reunited with his mother when he was seven. “Early loss”, hypothesises Bowlby (1975), “…can sensitise an individual and make him more vulnerable to setbacks experienced later, especially to loss or threat of loss” (p.310). Early traumata shatter the psychological immune system and, therefore, chances are that the analogous traumatic events in adulthood may prove fatal (Mann 1998).

Bowlby’s approach served as the basis for neurobiological research in attachment that revealed disruptions in the hypothalamic-pituitary-adrenal stress-response system, and changes in the serotonin system associated with suicide (Schore 1994).  Particularly promising are the significant advances being made in our scientific understanding of the neurological basis of suicidal behaviour and the mental conditions associated with it (Ezzell 2003, Fonage 2004).

They have suggested that it is disturbances associated with the right brain that predisposes those afflicted to adolescent and adult suicide risk.  Nonetheless, certain questions about suicide seem to fall at least partially outside the domain of science.  Shneidman contends that, as an essentially psychological problem, understanding suicide itself - the thought process underlying it - necessarily requires research of persons, not brains.  Suicide, he asserts, "is an essentially mental process in the mind".(1996 p 18). I would suggest the truth is probably somewhere in the middle. Utilising only one of these views is, in my opinion, too reductionistic.

Bowlby’s hypothesis appears not to be just a product of speculation. Concerned with objectivity and scientific reliability of his theoretical apparatus, Bowlby bases most of his conclusions on empirical data.  Statistics he refers to show that people who suffered loss as children are prone to suicidal acts (1975). Even if they do not consciously attempt to take their lives, they are more likely to participate in hazardous sports or take part in other reckless behaviours (Fenichel 1946). 

Freud, too, makes it clear that many so-called “accidents” are often suicidal in nature (Freud, 1901).  Prior to Wendy‘s suicide, Michael, in a drugged state, ‘accidentally’ fell from Brighton Pier to the rocks below, and sustained a fractured skull. Could he have harboured an unconscious intention to kill himself?  At that stage in his therapy, Michael appeared to idealise his mother; thereby unconsciously denying to himself any knowledge of a deep-seated resentment which subsequently surfaced in the material.  His therapist is left wondering what ’sent him over the edge’ literally. 

Could it be that Michael (in the same vein as Wendy - described above) wanted to punish his mother for abandoning him by making his mother feel guilty?  Fenichel called this  “the love-blackmailing tendency “When I am dead the parents will regret what they have done to me and will love me again” (1946, p 291). The child”, says Stekel, “…wants to rob his parents of their greatest, most treasured possession: his own life” (Friedman, 1967, p.89). Adler adds that “in later years it is no longer the parents, but the teacher, or some beloved person, or society, or the world at large, that is taken as the object of this act of revenge” (Friedman, 1967 p.119).

Rosenthal (1993) introduces another perspective: an individual may deliberately engage in a gamble with some probability of death because, if he lives, his attempt will have sent a message – a cry for help – to a sympathetic observer. Thus, the perceived benefits of an unsuccessful suicide attempt may outweigh the chance of death. Farber notes there is also a convoluted form of sexual involvement in the excitement of gambling (Ferber 1962). By engaging in parasuicidal behaviours, people play with death, but sometimes “the game turns into the ‘real thing’ and the danger they tried to control overwhelms them” (Fenichel, 1946, p.382).  (Depending on who you read, Parasuicide can be defined as “an apparent attempt at suicide, commonly called a suicidal gesture, in which the aim is not death”  (Wikipedia encyclopedia)or,  “injuries undetermined whether accidentally or purposely inflicted (the Samaritans). Fenichel believes that sometimes suicide occurs accidentally despite the original intentions of the subject, whose morbid impulses, even though quite obvious and deliberate, may simply represent the attempts “to master guilt, depression or anxiety by activity” (1946 p.382).

Although intriguing, it is my view that this approach does not consider people who actually want to be dead, only people willing to take a risk of death in return for greater benefits in life. Although suicide and attempted suicide are related, since at least some people who don’t intend to succeed do, and some who intend to succeed don’t (Durkheim 1951), parasuicide is often regarded as a distinct phenomenon because the motivations of the people involved differ substantially (Kreitman 1969). If you play Russian roulette with a six-shooter, your odds of dying are one in six (Martin 1958); if you climb Mt. Everest (as my tutor is apt to do!) they're also about one in six (Simpson 1988). The former is a generally recognised form of suicide; what, then, is the latter? Yet, "Life is impoverished, it loses in interest, when the highest stake in the game of living, life itself, may not be risked.  It becomes as shallow and empty as, let us say, an American flirtation." (Freud 1920)

Klein interprets the accident of one of her client’s as an “unconscious suicidal attempt “(1975, p365). His self-destructiveness, she believes, was caused by the strong negative feelings he had developed towards his deceased mother as a defence against the pain of the loss. “Unconsciously he had reinforced his hatred and the feelings of persecution”, says Klein , “because he could not bear the fear of losing his loved mother” (p.367).  Could she have been describing Michael’s position?  Is it possible that there may have been a split in Michael; part of him unconsciously wanting to die whilst another part “maintains the fantasy of still being alive after the act of having successfully manipulated or punished” his mother (?[1]). 

A theme that appears to run through the varying psychodynamic meanings of suicide is the perception that some suicidal clients experience unconsciously and/or consciously, that they are already dead (Hinden 1982).  “The very life-style of some individuals seems to truncate and demean their life so that they are as good as dead”(McWilliams 1994 p118).  At the age of 11, Michael noted on a sheet of school notepaper, “reality is not pleasant."  It seems he may have used various ways to escape his situation ever since.  Dreams of death, dying, coffins, and burial are frequent in suicide, especially the young  (Raphling, 1970, Hindin 1982), who experience psychic (emotional) death in their attempts to bury their rage and despair (Hindin 1982). The preoccupation of some with death is often the climax of having felt emotionally dead for a lifetime (1982).

Individuals who have killed others have a suicide rate several hundred times greater than those who have not (Fairbairn 1995). As mentioned, some theorists have speculated that injuring others and injuring oneself are sometimes two sides of the same coin (e.g Freud 1917, Shneidman 1985, Abraham 1970, Jung 1959). Jung warned: “You ought to realise that suicide is murder since after suicide there remains a corpse exactly as with any ordinary murder. Only it is yourself that has been killed” (Nantis 2004).  Freud noted "suicides are sometimes committed to forestall the committing of murder… there is no doubt of it.  Nor is there any doubt that murder is sometimes committed to avert suicide" (Freud 1920, p213). 

One significant factor in Michael’s story was that he managed to create a distance between herself and the members of his family by migrating to this country from Ireland. Given the psychodynamic idea that suicide is ultimately based on aggression towards others,  one might thus speculate that he did this to keep his family safe from the effects of his own fury and murderous feelings.  Stekel tells us “No one kills himself who has never wanted to kill another, or at least wished the death of another” (Friedman, 1967, p.87).  Perhaps his reasons for coming to this country suggest that Michael had some awareness of his murderous feelings towards others and was thus concerned to mollify the effect of these. In Fenichel’s terms, he may have a harsh super-ego and the fantasy of suicide was, perhaps sacrificial in nature.

Trying to save lives of suicidal clients, writes Weisman, “is like preventing death and destruction during a hurricane; we nail down the furniture, tape up the windows, and hang on until the crisis is over” (1967 p.266).  And here one meets the question of the counsellor’s capacity to endure the storm of such a relationship.

To Be…?

Counsellors may be cast in, or may be tempted to play, the role of saviours, just as often as they are cast in the role of executioners (Asch 1980). Suicidal clients are amongst those who rely heavily upon projective identification,  both as a defence and as a means of communication (Malin & Grotstein, 1966). Hence, they can provoke very intense countertransference reactions within their counsellor (Maltsberger, 1989).  [“In projective identification parts of the self and internal objects are split off and projected into the external object, which then becomes possessed by, controlled and identified with the projected parts” (Segal, 1973, p. 27)].  Countertransference refers to specific, emotional and at least to some extent, unconscious responses of the therapist to the client (Racker 1968). The therapist must be aware of her countertransference reactions (Casement 1985) because if they remain unrecognised and become acted out, for example, in angry retaliation, they can be therapeutically undesirable and even destructive to the therapy (Ogden 1986). If she can take note and make sense of such responses, the countertransference can be a great aid in understanding the client.  (Heimann, 1950). 

Michael wanted to control his sessions; lingering and invariably pleading for ’a few minutes more’. In the countertransference, his therapist being cast into the role of Executioner; even considering his request. Dealing directly with thoughts of death can be disturbing for a Counsellor and provoke her own fears of death or failure, feelings of helpless despair, retaliatory anger, or impulses to act out, thus safe intervention requires considerable self-knowledge (Malts Berger & Buie 1980). Management of the boundaries became an important aspect of the Therapist’s work with Michael.  Langs conveys this very well when he says that ‘the therapist’s appropriate love is expressed by maintaining the boundaries’ (Langs & Searles, 1980, p. 130).  When his Therapist tried to explore Michael's demands with him, he became angry and accused her of withholding; she was not ‘responding to his cries’ for the feed he had been searching for (extra time).  Under guidance from her Supervisor, the Therapist interpreted that perhaps his demands were an example of his relational patterns in the past and that when she did not respond to his needs, he felt abandoned by her in the same way he did by his mother and by Wendy.  At the end of this session, he announced ‘I am able to leave you today’!

Since suicidal clients use their possible death as a way of relating to and controlling the therapist, the psychodynamics underlying their suicidal feelings can be seen in the transference (Joseph 1983).  It seemed Michael could experience his Therapist as the loving mother at times.  Often, it was a negative transference (Joseph 1983): he found in her the mother who abandoned him at such a young age, and it seemed that the prospect of facing this inner threat and pain of annihilation was so terrifying that he could only find ways of avoiding it.  His attempts to avoid reality in the therapeutic relationship by splitting and first of all idealising and then disparaging the therapy and his Therapist, were perhaps evidence of this.  He would undermine it by going to the pub first, coming in smelling of drink, arriving late. 

At times, in the countertransference, his Counsellor felt attacked but, with the support of her Supervisor, mostly did not retaliate.  It seemed that Michael was trying to provoke a rejection from her. Once satisfied that no one really understood or cared he could turn away from other people and destroy himself. His Therapist understood these aspects as revealing, in the transference, something of his inner world and the relationships that existed within it. By staying with him (empathy) and not retaliating (her hitherto unconscious feelings of resentment were located and managed through Supervision), she may have given him a new experience.  She will probably never know as his work took him away from the area after 18 months of therapy.  A powerful after effect of working with suicidal clients is  “an emptiness, a feeling of not knowing“ (Campbell & Hale 1991). The difficulties posed by such a therapeutic experience for the therapist working psychodynamically, with its strong emphasis on containing powerful feelings, can result in a state of inner turmoil (Bion 1967). His therapist is still processing this in her own therapy, but she feels she has much to thank Michael for; he offered her a working metaphor to aide her understanding of the issue of suicide; the contemplation of an end. 

Bion developed Klein’s ideas about the importance of the earliest mother-infant relationship as the medium through which the infant is helped to manage his destructiveness (Bion 1967).  For Bion the infant projects his un-containable fear, discomfort and anxiety into the mother, who acts as a container for the child's fears. By taking in the projections (identifying with them) and detoxifying them through her maternal reverie, she can offer them to her infant in a more manageable form. However, it is often the case that the mother is unable to do this (perhaps due to postnatal depression or her own poor mothering), which can be traumatic for the infant. These traumatic infantile experiences may then manifest in later life in an acute susceptibility to rejection and the suicidal client may experience minor rejections in life as catastrophic blows.  Therapeutically these dynamics may be reproduced, so that it is incumbent on the therapist to try to correct the emotional deficit - to become a container (Symington & Symington, 1996, p. 50), She can make the client’s temporarily unbearable life just enough better so that he can stop to think and reconsider, because “where acting out is, thought cannot be” (Young 1998). 

According to Jacobs (1998), the most difficult aspect of therapy with suicidal clients is to sustain the empathic relationship and “face the spectre of death with the client” (p.332). Empathy keeps people connected and “by maintaining connection, suicidal clients who are on the verge of losing their sense of self can find themselves through their ability to find others” (Jacobs, 1989, p.336), although the level of identification between counsellors and clients can only be possible as a result of the counsellor being in touch with her own death instinct.   Sandler adheres to the belief that people can be sincere in their repudiation of life and have every right to plan self-destruction, carry out their death wishes and make deadly mistakes, while assuming full responsibility for their actions (1992).  Suicide as a possible outcome can never be fully dismissed and the client’s longing for death as a relief or escape from his despair has to be always acknowledged. (Sandler 1992). It should be interpreted in an effort to escape from unbearable suffering. But, of course, there is no way of knowing how many suicides desperately wanted to live. Had there been someone to turn to, someone caring and understanding, they might have not chosen death. Perhaps Jacobs is right; a good method of understanding the patent’s true state of mind is through empathy, through “living” oneself into his experience and trying to provide him with the support he really needs, while respecting his will and withholding “help” he is not asking for (p221). 

So, in conclusion, the psychodynamic meanings given to the “painful and insoluble riddle of suicide” (Freud, 1920) can be conceptualised as responses to loss, separation, or abandonment. Rebirth and reunion fantasies may be seen as attempts to undo or deny such losses.  Feelings of rage that are repressed, suppressed or expressed as revenge may derive from the experience of loss. Self-punishment may express shame and guilt at having been responsible for a loss and the fantasy of rapprochement through atonement. Even numbness or deadness and the insistence that one is already psychologically dead may reflect determination not to live without the lost object (Freud 1917). In this sense, Freud’s insight into the relationship of abandonment, loss, and suicide (1917, 1920) has perhaps the most meaning and has stood the test of time, although others have developed this theory, and others still, disagree, as we have seen. His formulation of the death instinct continues to serve as one of the psychoanalytical theoretical constructs that has proved resistant to criticism by his adherents. (Freidman 1967).

Despite the Therapist’s best efforts, my client may still choose to complete suicide.  The most vulnerable therapists are those who need to see themselves as able to save any patient, which renders the possible suicide of a client narcissistically devastating (Meltsberger & Buie 1980). The Therapist is responsible for doing what she can “by living through the crises with the client and bearing some of the …uncertainty about his future” (Jacobs, 1998, p.335), then my client’s life is his responsibility.  While Jung would counsel clients to "hang on as long...as it is humanly possible…” (Jung 1959), for Lacan, the counsellor’s task is to enable the client’s  “own unique truth to emerge in the treatment, a truth that is absolutely different to that of the analyst . . .” (Evans, 1996, p. 39).  I would not dedicate my time to helping client’s make the unconscious conscious if I did not agree with Lacan, Freud, Bion and many others, that truth is better than lies, even truths that go against health, life, love and relatedness.