I 90

THE PSYCHODYNAMICS OF SUICIDE*

SIDNEY S. FURST
Professional Director
The Psychoanalytic Research and Development Fund, Inc., New York, N. Y.

MORTIMER OSTOW
Vice President
The Psychoanalytic Research and Development Fund, Inc., New York, N. Y.

T HE SCIENCES of sociology, anthropology, epidemiology, and demog-

raphy have contributed extensively to our knowledge of suicide
by delineating the milieu in which suicide occurs and by the study of
those environmental factors-cultural, social, economic, political, and
religious-which influence the prevalence of suicide.
These findings lend even more urgency to the question of the in-
dividual determinants that operate within the environment to produce
suicide-for surely suicide is a highly individual, personal act.
Sociologic theory, particularly that which prevailed at the turn of
the century, held that suicide reflects the impact of society on the in-
dividual. This view is now recognized as inadequate, primarily because
it does not attempt to account for the fact that one person seeks self-
destruction while another, in similar circumstances and with equal
provocation, does not. Thus while external conditions and group pat-
terns operate as inhibiting or encouraging factors, it has become clear
to all students of the problem that suicide is essentially a personal re-
action. As such, it can be accounted for only in terms of intrapsychic
events that constitute the essential, final pathway to the suicidal act.
In his recent book, Suicide, a Sociological and Statistical Study,
Louis Dublin1 writes: "The suicidal drive in the last analysis is from
within the individual, rather than from without. Suicide is the terminal
act in a complicated psychic drama, the final response of a person to
his own needs, desires, and circumstances. External events may pre-
cipitate that act, and in certain circumstances such as mass suicide in
the face of persecution, may dictate it. Countless persons faced with
*Read before the 28th Annual Conference of the Public Health Association of New York held
at The New York Academy of Medicine, May 12, 1964.

Bull. N. Y. Acad. Med.

 THE PSYCHODYNAMICS OF SUICIDE I 9I

what appear to be the same provocations, do not commit suicide.

The primary impulses which lead to suicide lie hidden in the depths
of the individual's personality."
Viewed as the end product of a series of psychic events it becomes
apparent that suicide is not an illness but a symptom that may occur
in the course of any of several types of mental illness: depression, either
neurotic or psychotic, schizophrenia, and hysteria.
Is suicide invariably the outcome of mental illness or can it occur
in the absence of psychic disorder? Some authors have designated the
term "normal suicide" for acts of self-destruction committed under
circumstances of extreme stress and hopelessness. Examples would in-
clude suicide among concentration camp prisoners and among those
suffering from painful and fatal disease. Closer examination of such
cases, we believe, would reveal that here we are dealing with individuals
who have reacted to shattering extrapsychic stresses with depression of
inordinate intensity. The fact that most concentration camp prisoners
and most sufferers from terminal, neoplastic disease do not attempt
suicide lends support to this view.
PSYCHIC MECHANISMS LEAD TO SUICIDE
THAT
The human psychic apparatus strives constantly to achieve pleasure
through the gratification of instinctual needs and to avoid pain. For
these purposes, it has access to a number of unconscious devices that
arrange for the matching of inner needs with the opportunities for
gratification provided by the environment. While innate instinctual
sequences are employed for these purposes by lower animals, humans are
able to create novel behavioral patterns by bringing great plasticity
and flexibility to bear upon the behavioral elements with which they
are endowed. Unfortunately, this flexibility may permit the mechan-
ism to miscarry, so that, operating in the face of certain combinations
of inner drives and external events, it may lead not to adaptation but
to suicide. Let us consider some of the more common instances of such
malfunction.
i) When an individual suffers severe pain, he bends every effort
to disengage himself from the source or, more precisely, from the
apparent source of the pain. The apparent source may be realistically
recognized as a frustrating object. On occasion, however, when the
actual object is not available for attack, the experience of pain may be
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 I 92 S. S. FURST AND M. OSTOW

blamed upon the organ of perception or upon the perceiving self. At

times, when the patient is so disturbed as to tolerate such illusions,
self-destruction may even seem to be equivalent to the destruction
of the object.
A patient discussing the thoughts and emotions that preceded a
serious suicide attempt said, "For a while I thought that by killing my-
self I'd make my mother sorry and guilty for the way she treated me.
But then I realized that that was ridiculous, because she'd probably
be glad if I was gone." I (S.F.) commented that her second thought
must have made the idea of suicide much less attractive. "Oh no,"
she replied, "I'd still be getting rid of her!"
2) Intolerable inner pain may be dealt with by the attempt to elimi-
nate the locus or site of the pain. Patients suffering from causalgia
often beg for the amputation of the painful member, and animals are
known to chew off their own diseased limbs. The offending part is
literally attacked and, if possible, destroyed. Severe depression is
characterized by intolerable, inner, psychic pain, and suicide may appear
to be a desirable means of eliminating it. The melancholic individual
wishes for death as a release from anguish. In less extreme form, this
accounts for banging of the head and similar attacks upon the self
commonly seen in cases of agitated depression.
3) A child knows that his helplessness and suffering will evoke
concern and care from his parents. Children whose demands for atten-
tion and care are unmet, have been observed to beat or harm themselves
in an effort to elicit concern and love. Suffering adults also may exploit
this method of obtaining a desired response from the loved individual
who represents a parent by injuring or even destroying themselves.
A 49-year-old man was evicted by his wife who declared that she
could no longer live with him because of his incessant, unreasonable
demands and his temper tantrums. When his urgent pleas for reconcilia-
tion were rejected he began to threaten suicide. This, too, did not have
the desired effect. One evening he remained at his office after hours, and
there took a huge dose of barbiturate. He was found dead the next
morning on the steps leading from his office to the street.
4) Similar in form, but differing in motivation from the mechanism
just mentioned, is another in which hostility and death wishes originally
directed toward an object come to be turned against the self. Since the
disappointing object is loved as well as hated, hostility against him can-
Bull. N. Y. Acad. Med.
 THE PSYCHODYNAMICS OF SUICIDE I93

not be directly expressed. Guilt arising from this hostility and an inhibi-
tion against killing in general both combine with the ambivalence to
deter overt attack. Here suicide presents itself as a method of discharg-
ing the aggression without physically injuring the object while still
taking revenge upon him, since the object is likely to hold himself
responsible for the death.
Here the motive for suicide is quite clearly revenge against the dis-
appointing object. In the mechanism mentioned above, namely hurting
oneself in order to compel care and attention, reconciliation, not aggres-
sion, is the motive.
5) Erotogenic masochism, as is well known, involves the sexual
wish to suffer pain or injury, or both. Freud,2 who studied this problem
extensively, came to the conclusion that primary erotogenic masochism
is derived from an imperfect fusion of the destructive or death instinct
with libido. This is confirmed by numerous case reports of masochists
who have died as a result of self-inflicted sexual mutilation. Here the
mechanism leading to suicide is seen to operate directly in the service
of a derivative of instinctual drives.
6) Finally, in discussing the role of instincts in relation to suicide,
mention must be made of the death instinct. Little is known about this
drive since it operates silently, that is, it gives rise to no unique, direct,
and obvious psychic representations. In fact, many psychiatrists and
psychoanalysts doubt the existence of a primary drive toward death.
Freud3 postulated a death instinct because he found that ultimately he
could not account for the insistent destructiveness of aggression, sadism,
and masochism in any other way. We have each observed individuals
who seemed irresistibly driven to self-destruction. They appeared to
be dominated by a primary force which operated independently of,
and above and beyond, any immediate considerations of gratification or
frustration of libidinal drives. We attribute these clinical states, which
very frequently terminate in suicide, to the operation of a death instinct.
Others disagree, arguing that one cannot assume such an entity unless
it can be demonstrated that its derivative aggressiveness presses con-
stantly for discharge without requiring any external trigger. We believe
that such a criterion cannot properly be applied since many instincts
do not become active without the operation of a trigger of some
kind. However, since psychic pain and distress are ever present to some
degree, they serve as a constant and ubiquitous trigger. From a practical
Vol. 41, No. 2, February 1965
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'9l.S
S. S. FURST AND M. OSTOW
USTADM SO

point of view, therefore, destructiveness presents itself everywhere,

creating mental illness among other manifestations and, often, suicide.
FANTASIES THAT FAVOR SUICIDE
Fantasy formation in essence is the result of the interplay between
psychic mechanisms on the one hand and important wishes and mem-
ories on the other. The form taken by the fantasy is determined by the
mechanisms, while the ideational content is contributed by the wishes
and memories. The role of fantasies, both conscious and unconscious,
in determining human behavior and motivation, is too well known to
require elaboration. Of interest here are those which anticipate suicide.
Some of them are so consistently associated with suicide that they may
serve as indicators of concern with it.
I) Identification with a lost object. Identification occurs in indi-
viduals whose object relations are characterized by the need to feel the
same as-to be one with-the object. By identification, the distance
between subject and object is abolished. In sublimated form, identifica-
tion gives rise to feelings of loyalty. When a love object with whom
one has identified dies, or when there is a strong wish to identify with
one who is dead, suicide may present itself as a means for reestablishing
sameness, for reuniting the fates of subject and object. The fantasy of
identification in death with lost objects probably accounts for most of
the so-called "anniversary suicides," and, to a certain extent, for the
unusual prevalence of suicide in certain families. A patient who had lost
his father, grandfather, and two brothers by suicide and was himself
suicidal reported the suicide of yet another brother with the terse
remark, "This is the way we do it." Here we see not only identification
in death, but identification in the manner in which one dies.
2) Rebirth. The fantasy of being reborn, of "starting all over
again" occurs, at one time or another, almost universally. It is par-
ticularly prominent and clinically significant at the beginning of recov-
ery from acute episodes of schizophrenia and from melancholia. Com-
monly, a patient who wishes to die will attempt to make death more
acceptable by persuading himself that it is a preliminary to rebirth,
that is, that death will bring not only relief but repair and renewal.
The patient seems to say, "After I end this life, I can begin a new one."
As a resident at the New York State Psychiatric Institute, which over-
looks the Hudson River in the vicinity of the George Washington
Bull. N. Y. Acad. Med.
 THE PSYCHODYNAMICS OF SUICIDE I 95

Bridge, I (S.F.) encountered three patients with precisely the same

fantasy: "I will escape from this place, run out on the bridge, jump off
and drown, and later come out alive and new on the other side."
It is not surprising, therefore, that most religions which hold forth
the promise of an afterlife which is, in effect, a rebirth, deny this reward
to those who would gain it by suicide.
3) Reunion with mother. The regressive wish to be reunited with
the giving, protecting mother of earliest infancy finds expression in the
fantasies of many deeply disturbed individuals. The patient longs for
an ideal state, characterized by passivity, helplessness, and the relative
absence of disturbing stimuli arising from within or from without. In
the unconscious death may be endowed with these qualities. At times
the fantasy assumes the form of wishing to return to mother's body and
to live there. The formal resemblance between the image of inhabiting
mother's body and the state of being interred makes the wish to die
more compelling. Thus the wish to return to a very early anaclitic rela-
tionship becomes the bearer of the wish to die. An increase in the
intensity of the wish to return to mother in this way, for example,
occasioned by frustration or disappointment in object relations, brings
with it an increase in suicidal danger.
4) Escape. To those suffering the misery of depression or psychosis,
death may appear to be a release from suffering. Although this idea may
occur at any age, it is probably more common among older, depressed
individuals who have become preoccupied with the thought that they
have lost all that is important to them, and that life is therefore no
longer worth living.
Ancient and elegant documentation of this fantasy is found in the
Book of Job. Reduced from great wealth to poverty, bereft of all his
children, his body covered with boils, Job says (3: 20-22):
Wherewith is light given to him that is in misery,
And life unto the bitter in soul-
Who long for death, but it cometh not
And dig for it more than for hid treasures,
Who rejoice unto exultation,
And are glad when they can find the grave.
5) Splitting of the self-image. In predisposed individuals intense intra-
psychic pressures may induce a defensive splitting of the self-image,
commonly into a "good" and a "bad" self. The former image is ego
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196 S. S. FURST AND M. OSTOW

syntonic, the latter ego alien. This splitting may give rise to a number
of consequences. Depersonalization is a common result of splitting. In
melancholia the image of the self is often divided into two portions.
The "bad" fragment remains within the ego and becomes the target of
the melancholic's relentless, punitive superego with which the "good"
fragment identifies. The patient may speak of a demon clawing away
at his insides. The resulting inner pain and tension may be so great as
to lead to suicide in a desperate attempt to eliminate one of the pro-
tagonists. The associated fantasies indicate that either the harsh punitive
superego or the unacceptable "bad self" may be the primary target of
the suicidal impulse.
In an attempt to ward off a threatened breakthrough of poorly re-
pressed, incestuous wishes, a young woman moved out of her parents'
home. Shortly thereafter she became depressed and reported the follow-
ing dream: "My father and I are standing at the window of our old
apartment with loaded shotguns. We are waiting for 'another me' to
emerge from the entrance of a building across the street. Finally, the
'other me' comes out, and we fire. I awake in terror."
6) Autoscopy. Actually this last example relates to a similar phe-
nomenon of waking life, autoscopy. Here the patient describes encoun-
tering an image of himself while awake. The image may be an hallu-
cination, an illusion, or a vivid fantasy. More than 6o years ago Rank4
suggested that in adult life the double appears as a harbinger of death.
This hypothesis is supported in a paper by one of us (M.O.) on the
metapsychology of autoscopic phenomena,5 in which several auto-
scopic phenomena are reported, including the following.
While walking home from an analytic hour, a depressed patient felt
weary and stopped to lean against a tree. He felt that he wanted to
stay there, and at the same time he could visualize an image of himself
continuing to walk home. "I wanted just to stand there, and let another
part of me carry on." When questioned, he said, "Yes, I wanted to die."
About a week later the same patient reported another autoscopic
incident. As he sat alone in his room reading, it seemed to him that
''another one of me goes to the medicine closet and takes an overdose
of sleeping pills."
In the first autoscopic incident it is the observing self who is to die
while the observed image goes on living. In the second, the roles are
interchanged.
Bull. N. Y. Acad. Med.
 THE PSYCHODYNAMICS OF SUICIDE I 97

7) Revenge. Finally, and perhaps best known, are the fantasies in

which suicide represents the ultimate act of revenge aimed at a dis-
appointing object, or a real or imagined persecutor. Here, in effect,
suicide is homicide which has been turned against the self. The inter-
play between murderous impulses and suicidal drives and, in particular,
the mechanisms whereby one is interchanged with the other, were not
understood until Freud formulated his theory of sadism in Mourning
and Melancholia in I917,6 by which time the vicissitudes of aggression
were more clearly recognized. Freud postulated that in pathologic
depression the subject identifies with a hated and loved object. The
identification, or psychic incorporation, expresses the love. When, as a
result of loss, disappointment, or rejection, the love turns to hate, the
tendency to suicide may become overwhelming. By destroying him-
self, the subject also destroys the object, who is inside him and yet
remains united with him. If, in addition, there is guilt toward the object,
suicide becomes even more appropriate and compelling. For then, in a
single act, not only is the object destroyed, but the guilty self is justly
punished for hatred and murder.
The jilted lover or the deserted spouse who dies at his own hand
may perhaps leave a note which not only names the target of the
suicide, but states that the motive was revenge. "You made me do this
-and my blood shall be on your hands forever," read one such note.
With regard to the determinants of suicide just discussed, it should
be added that they are not mutually exclusive. Generally, one or more
mechanisms and one or more fantasies which express the mechanisms
may exist. Suicide therefore is usually an overdetermined act. In fact,
the likelihood of a serious attempt and a fatal outcome increases directly
with the degree to which the impulse to suicide is overdetermined.
MECHANISMS OF SUICIDE IN VARIOUS DISEASE ENTITIES
From the hypothesis that suicide is the product of mental disorder,
one may infer a corollary, namely that the mechanism of the suicide
will relate to and derive from the psychodynamic pattern of the dis-
order which generated it.
Typically, in schizophrenia and hysteria, the dynamic problem
centers around the need to disengage from a pain-provoking object.
The object gives rise to pain instead of pleasure either because he rejects
and disappoints, or because he represents a forbidden temptation.
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SO

The schizophrenic's need to detach himself from objects finds ex-

pression in his fantasies of world destruction. He exchanges perceiver
and percept and so destroys the world by destroying himself. The para-
noiac may kill himself in order to avoid falling into the hands of his per-
secutors. When we recall that the persecutors in paranoia were orig-
inally loved homosexual objects, we see that his suicide is determined
by the need to prevent the breakthrough of repressed, unacceptable
impulses. The suicide committed at the height of homosexual panic, in
the absence of a delusionary system, is of course similar and more
transparent.
A usually passive young man was hospitalized following a vicious,
unprovoked assault on his father. His initial warm, friendly feelings for
his male therapist unaccountably changed to dislike and then to aver-
sion. He became convinced that his doctor was harming rather than
helping him, and his anxiety in the latter's presence rapidly increased
to the point of panic. When his repeated demands for a change of
therapist went unheeded, he managed to escape from the hospital and
promptly threw himself under a passing truck.
For the hysteric, the tempting but forbidden object is usually an
incestuous one. As often as not, the detachment must be effected from
one who has become the psychic representative of the parent or sibling.
In reality, the object involved may be a spouse, child, or friend. Much
of the marital and family discord suffered by hysterics is attributable
to this need to disengage. If severe enough, it may leave suicide as the
only solution.
A man was carrying his beloved daughter around his apartment. As
he passed an open window, he suddenly threw the baby out, and then
jumped after her.
The psychodynamics of pathologic depression have been touched
upon several times in this discussion, and classical theory requires only
brief recapitulation here. Both normal and pathologic depression are
precipitated by a loss. In normal depression (mourning) the ties to the
lost object are gradually severed and, when this task is completed, the
subject is free to reach out for new objects. In pathologic depression
this does not occur because the lost object has been both loved and
hated. The aggression now gives rise to guilt, which makes it impossible
to dissolve the ties, and enforces the continued identification with the
object. The psychicly incorporated image-the introject-cannot be
Bull. N. Y. Acad. Med.
 THE PSYCHODYNAMICS OF SUICIDE I 99

eliminated. The relentless self-accusation and self-depreciation of the

melancholic thus are directed not only at himself but, more significantly,
at the hated introject. This, as well as the resulting inability to undo
the loss by turning to new objects, gives rise to the feeling of emptiness
and severe inner pain characteristic of depression. The ensuing suicidal
impulses may therefore be triply determined. The guilty self is to be
punished; the tormenting introject will finally be eliminated; and the
inner pain will be abolished. It is this overdetermination that makes
suicide such a serious threat in pathologic depression.
Following the death of his wife, a 58-year-old man became de-
pressed. Instead of abating with the passage of time, his morbid state
deepened. He was unable to return to work, shunned friends and
relatives, and spent most of his time brooding and weeping. When
forced to visit a psychiatrist, he first spoke of how close he and his
wife had been, how they had done everything together (they had no
children), and of his feeling that he could not go on without her. Later
his verbal productions dealt almost exclusively with occasions when he
had mistreated or failed her. In a delusional way he insisted that he had
not done all he could for her in her terminal illness and therefore was
responsible for her death. For this he could never forgive himself. To
the feeling that life was no longer worth living was added the convic-
tion that he did not deserve to live. Despite intensive psychotherapy
and pharmacotherapy his condition continued to deteriorate. Arrange-
ments for hospitalization were made, but on the morning of his sched-
uled admission he was found dead in his apartment.
Finally, mention should be made of suicides that occur in conse-
quence of pathologic influences but in the absence of any clear-cut
diagnostic entity. Typically these stem from a real or imagined rejec-
tion at the hands, of an object who was relied upon to fulfill needs for
emotional support. Here the patient feels the loss of the object just as
an infant would feel abandonment by its mother. Elements of resent-
ment and revenge may play a role, but the prime determinant is the
feeling of helplessness and panic at the prospect of facing life alone.
The husband of a mild, passive, middle-aged woman stayed out late
one night without notifying her. Unable to locate him, she feared
desertion, was overwhelmed by separation anxiety and, at the height of
her panic, impulsively swallowed a bottleful of pills. Until this time she
had shown no signs of organized, clinically definable psychopathology.
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THE PSYCHOLOGY OF THE SUICIDAL Acr

We have concerned ourselves to this point with the psychology of
suicidal motivation. In this final section, the psychology of the suicidal
act itself will be briefly discussed.
Suicidal acts are rightfully evaluated in terms of seriousness of intent.
As is well known, the range is quite broad. At one extreme is the un-
happy teenager who swallows five aspirin tablets and, at the other, the
melancholic who leaps from the top of a skyscraper. The degree of
seriousness is determined by two factors: i) intensity of the motivation
and the extent to which it is overdetermined; and 2) the degree to
which the urge to self-destruction is diluted by the presence of libidinal,
life-preserving energies.
We suspect that no suicidal act is completely conflict-free, that is,
totally devoid of any urge to live. Even in extreme cases it is present,
and it weakly and ineffectually opposes the destructive forces.
Conversely, the significance of the most benign suicidal gesture
should not be underestimated. The facts that the idea did occur and
that the gesture was made betrays the existence of the tendency to self-
destruction. Under more adverse circumstances the latter might easily
be activated in more urgent form and with serious consequences.
The method chosen for accomplishing the suicide is a relative indi-
cator of seriousness of intent. Thus, other conditions being equal, a bit
of iodine spells lesser motivation than does jumping from heights.
More important is the fact that the method chosen is usually related
symbolically to the fantasy that underlies the suicidal impulse. How he
does it tells us a great deal about why he does it.
In general, the unconscious seems to believe that the punishment
should fit the crime. The patient generally chooses a method of dying
which represents either an extreme variant of or the opposite of the
fantasied crime for which he punishes himself.
For example, in his dreams and fantasies the male homosexual will
see himself shot or stabbed to death. This image represents the carrying
of his wish to be attacked by another man's penis, to a lethal extreme.
It is also the converse of an associated wish, to attack another man with
a lethal penis. Such an individual, if he is bent on suicide, will stab or
shoot himself, or arrange, for example, by exposing himself to danger
and by provoking attack, to be stabbed or shot by someone else.

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 THE PSYCHODYNAMICS OF SUICIDE 2 0 I

Similarly, for many phobics, Oedipal guilt is associated with fan-

tasies of climbing or flying too high, or of phallic erection under
improper circumstances. The retaliatory punishment involves falling
from heights, being pushed down, or jumping, and these then are pre-
ferred modes of suicide for such individuals. The depression which
antecedes the suicide is associated with feelings of a drop in self-
esteem, of humiliation, and of being "brought low."
For some individuals the sensation of heavy breathing, which is
associated also with sexual excitement, becomes an erotic experience.
XWhen the threat of loss of control of erotic impulses creates anxiety
and, with it, breathlessness, the latter is accompanied by the specific
fear of suffocating. Hanging is a preferred mode of suicide among such
individuals. Drowning represents not only suffocation, but also rejoin-
ing mother, by immersion in what becomes literally a fluid matrix.
Taking an overdose of medication is, in effect, death by the inges-
tion of poison. Psychoanalytic investigation of individuals who have
attempted or later committed suicide by poisoning leaves little doubt
that the act stemmed from disappointment in an anaclitic or dependent
relationship. It is as if the suicide's final words are to the effect: "You
are a bad mother. You were supposed to care for me and feed me well,
but you fed me poison."
Those individuals who find sexual excitement in smelling the love
object, as the infant detects and enjoys its mother by her smells, prefer
the inhalation of poisonous gases as a mode of suicide. Since the
strongest odor of childhood is the fecal odor, such individuals are prone
to fixation at the anal phases of psychosexual development. They are
likely to enjoy fantasies of identifying with the lost mother or mother-
surrogate by the fantasy of incorporating her by inhalation. Therefore
just as the oral individual, disappointed in feeding by the mother, will
poision himself, the anal individual, disappointed by her absence, or
rather by the absence of her odors, will inhale poisonous gases.
Cutting oneself is the favored mode of suicide among those individ-
uals who deal with excessive sexual excitement with fantasies of cutting
the genitals, their own or their partner's. Another form of cutting, less
physical, is detaching oneself psychically from the love object or from
an offending organ, as in hysteria, or from the entire world of reality,
as in catatonia.
In addition to discrete suicidal acts, there are the slow or partial
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S. S. FURST AND M. OSTOW

suicides. Included here are alcoholism and other addictions, compulsive

gambling and, in certain circumstances, unnecessary heroism. In an-
other category are those suicides in wvhich the agent is projected onto
the outside. Death is made to appear as though it came from without,
or by chance. Russian roulette in its various forms is one. Life-endan-
gering occupations or acts are another. Here one thinks of the race-car
driver, the bullfighter, and the stunt man. Serious accident-proneness is
a third and more common category. When a friend asks the reckless
driver, "What are you trying to do-kill yourself?" he may be more
rhetorically correct than he suspects. In each instance a relation exists
between mode of self-destruction and motivating fantasy, and it is
specifically determined.
Fortunately, all suicidal acts do not terminate in death-and this
brings up, a final question. What can be said about the psychology of
the aftermath of a suicide attempt?
The reactions of would-be suicides to their failures fall into two
rather distinct categories. In one there is depression and disappoint-
ment in the discovery that the attempt has failed. A deeply depressed
patient, in speaking of a recent suicide attempt said, "I suppose it's
like tennis; you don't get it right at the first attempt. With practice,
though, you improve, and finally succeed." Needless to say, this re-
action carries a highly unfavorable prognosis.
The second type of reaction encountered is essentially the con-
verse of the first. There is elation and a feeling of reprieve from a situ-
ation of danger. The failure may come to represent the gratification of
the wish to be rescued, and may be accompanied by the feeling of
being reborn. In some instances, the suicidal intent, or even the suicidal
act itself, may be denied. Though more favorable prognostically, the
elation following failure is usually short-lived. Unless corrective mea-
sures are taken, the intra- and extrapsychic factors which motivated
the first attempt may well reassert themselves with undiminished in-
tensity-bringing with them renewed danger.
THERAPY
A discussion of the treatment of the would-be suicide lies beyond
the scope of this paper. Obviously, though, since suicide is not a dis-
ease in itself, but a manifestation of disease, it is the latter which must

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 THE PSYCHODYNAMICS OF SUICIDE 2 0 3

be treated. Generally, perhaps usually, the evolution of the illness to

the point at which suicide presents itself as an irresistible attraction
may be prevented or at least retarded by psychoanalysis when the
latter is undertaken early enough and, to a lesser extent, by the less
thoroughgoing psychotherapy. When psychoanalysis or psychotherapy
fails, or when the patient fails to present himself for treatment until
the disease is too far advanced to be subject to such influences, the
newer drugs can now often be used to exert some control over an
otherwise desperate situation. The proper use of these agents is diffi-
cult, requiring experience, patience, ingenuity, and courage, and their
power is only relative and far from permanent. Moreover, while they
may correct a regressive process at an advanced phase of illness, they
cannot combat the illness itself nor undo the pathogenic process. Their
most elegant use in the individual case is to provide relief while the
analyst works to get hold of the disease process and to interfere with
its unremitting progress and destructive tendency. Such intensive and
refined care can be made available only to a few, so that for the large
majority of suicidal patients, major reliance must be placed upon these
powerful medications.
Electroshock therapy exerts a more powerful and speedy thera-
peutic influence than the energizing drugs, but the latter can be used
over an extended period of time when necessary, whereas the former
is necessarily limited to relatively brief, circumscribed courses.
SUMMARY
Suicide, when it occurs, is the outcome of a disease process which
has prevailed for a considerable period of time previously. The factors
which bring it about are essentially two. First, there is a drive to
destructiveness, which Freud saw as the manifestation of a death in-
stinct or a set of death instincts. Second, there is a set of mechanisms
that normally function to increase by several orders of magnitude the
flexibility and plasticity of instinctual behavior but which, when the)T
miscarry under the influence of disease, serve to reflect destructive in-
stincts away from external objects and back upon the self.
In this brief essay, we have tried to enumerate and describe some
of the more common of these mechanisms. Furthermore, these mech-
anisms operate unconsciously, but they achieve representation in con-
scious or preconscious thought by creating fantasies. The fantasies
Vol. 41, No. 2, February 1965
 20 4 S. S. FURST AND M. OSTOW

seem to explain or justify the suicide and also to make it more attrac-
tive or, at least, less frightening. We have listed, described, and illus-
trated some of the more common of these fantasies too.
Of course, the mechanisms which lead to suicide constitute in each
case a portion of the repertoire of instinctual mechanisms of each in-
dividual. Since it is this same repertoire which determines the form of
the antecedent illness, we can expect to find a relation between the
psychodynamics of this illness and the mechanisms and fantasies of
suicide which evolve. We have tried to spell out a few of these re-
lations.
When the mechanisms and fantasies that we have here described
appear in the course of an illness, we must alert ourselves to the possi-
bility of suicide. And when they disappear, we may infer that the
danger of suicide has receded.
Finally we have drawn attention to a corollary of our discussion,
namely, that the treatment of the suicide complex is the treatment of the
underlying disease. Since definitive psychoanalysis, which is still our most
effective, long-range therapy, is a slow and inefficient procedure at best,
even when applied early in the course of the illness, since the same is true
in even greater degree of the lesser psychotherapies, and since patients
seek assistance in their struggle with suicide only relatively late in the
course of illness, the newer drugs and, in a few instances, electroshock
therapy have offered welcome assistance in the management of the suicide
threat. While practical considerations may limit treatment to these
chemical and electrical modalities, the psychiatrist must realize that their
influence is symptomatic and usually temporary. Unless psychoanalysis,
or one of the psychotherapies, taking advantage of the respite offered
by these other procedures, succeeds in retarding the pathogenic proc-
ess, the suicide threat will recur time after time.
REFERENCES
1. Dublin, L. Suicide: a Sociological and Imago 3. Cited by Freud in The Un-
Statistical Study. New York, Ronald canny, Standard Edition XVII, London,
Press, 1963. Hogarth Press, 1953.
2. Freud, S. (1924) The economic problem 5. Ostow, M. The metapsychology of auto-
of masochism, Standard Edition XIX, scopic phenomena, Int. J. Psychoanal.
London, Hogarth Press, 1961. 41:619-25, 1960.
3. Freud, S. (1920) Beyond the pleasure 6. Freud, S. (1917) Mourning and melan-
principle, Standard Edition XVIII, Lon- cholia, Staiidard Edition XIV, London,
don, Hogarth Press, 1955. Hogarth Press, 1957.
4. Rank, 0. (1897) Der Doppelganger,

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