Psychotherapy

It might be thought perhaps that this incident represented ancient feeling and that a similar condition in the modern times would not have a corresponding effect. It so happens that something similar has been tried. In some of the cities of South Central Europe in which the suicide rate is almost the highest in the world, it was decided about a generation ago by the Church authorities of the towns that suicides would not thereafter be buried in the cemeteries near the bodies of those who died in the regular course of nature, but must be interred in a separate portion reserved for themselves. Strange as it may seem, just as in the case of the young women of Milesia, this proved a great deterrent to suicide. The suicide rate was reduced one-half the next year.

As a matter of fact, it only takes some reasonably forceful countervailing notion to set a train of suggestions at work that will prevent suicide. If those contemplating suicide are made acquainted with some of these curious facts we know, then the notion of suicide loses more than half its terrible attraction by being stripped of all of its supposed inevitableness. Almost any motive that attracts attention, even apparently so small a thing as disgrace after death, makes these people realize the littleness and the cowardice of the act.

Favoring Factors.—Psychic Contagion.—A prominent factor in suicides that must constantly be borne in mind is the influence of example or, as we have come to call it learnedly in recent years, psychic contagion. It is discussed more in detail in the chapter on Psychic Contagion, but its place here must be emphasized. It has often been noted that certain peculiar suicides are followed by others of the same kind. If a special poison has been used, others obtain it and put an end to their lives in that way. Even such horrible modes of death as eroding the jugular vein by drawing the neck backward and forward across a barbed-wire fence have been imitated. If the story of jumping off a high building is told with lurid details, special care has to be taken in permitting unknown people to go up to the same place for some time afterwards. The imitative tendency is evidently a strong factor. Plutarch's story of the young women of Milesia brings this out, and it has been noted all down the centuries.

In any discussion of the prophylaxis of suicide the effect of newspaper descriptions of previous suicides must be looked upon as very important. The influence of suggestion of this kind on people who have been thinking for some time of suicide is very strong. There comes to them the impelling thought that the suicide's miseries are over and they wish they were with him. From the wish to the resolve and then to the deed itself are only successive steps when suggestion is constantly prodding the unfortunate individual. If we are going to reduce the suicide rate materially or, indeed, keep it from increasing beyond all bounds, this question must be squarely faced. Accounts of suicides are not news in the ordinary sense of the word and while they might find a place for legal and other purposes in a few lines of an obituary column, the present exploitation of them by the papers makes them a constantly recurring source of strong suggestion to go and do likewise. These suggestions come to persons already tottering on the edge of disequilibration in this matter, and it is like tempting children to do things that they know are wrong, but that look irresistibly inviting when presented under certain lights. The very fact that their death will produce a sensation and will give them so much space in the newspapers attracts many morbidly sensation-loving people. Physicians must work as much for this prophylaxis as we have for the prevention of infectious diseases.

Child Suicides.—Probably the worst feature of the suicide statistics of recent times in all countries is the great increase of self-murder among children. Arthur MacDonald in discussing the "Statistics of Child Suicide"55 has shown that there is a special increase of young suicides everywhere. In France there are nearly five times as many suicides at the end of the nineteenth century as there were at the beginning of it. In England there is almost as startling an increase. Though the statistics are not as well kept, child suicide has increased not only in proportion to the increase of suicide among adults, but ever so much more. In Prussia the condition is even worse.

The French child suicide rate is especially interesting and disheartening. In the Paris Thesis for 1906 Dr. Moreau discusses the subject of suicide among young people and shows how rapid has been the growth of the number of such suicides in the last 100 years. The first statistics available for the purpose that, in his opinion, are exact enough to furnish a basis for scientific conclusions, are from 1836 to 1840. Altogether during that period in France there were 92 suicides under the age of seventeen years, 69 of whom were boys and 23 girls. In 1895 this number had increased to such a degree that in a single year there were almost as many suicides (90) as there had been in five years, only fifty years before. In 1895 the proportion of suicides less than ten years of age was a little more than one in twenty of the total number of suicides in France. There are countries in Europe in which the suicide rate among such children is even higher than it is in France. In every country it has gone on increasing and the awful thing is that the suicide rate is increasing more rapidly among children than it is among adults, though among adults it doubles every twenty years.

Causes at Work .—The causes for the increase in suicide among children were pointed out even by Esquirol, the great French psychiatrist, nearly a century ago. They are the same to-day, only emphasized by the conditions of our civilization. He attributed it to a false education which emphasizes all the vicious side of life, makes worldly success the one object of life, does not properly prepare the child for constancy in the midst of hardships, nor make it appreciate that suffering is a precious heritage to the race, that has its reward in forming character and fixing purpose. He thought that there were two very serious factors for the increase of suicide among children not usually realized. They were in his time literature and the theater. He said: "When the theater presents only the triumphs of crime, the misfortunes of virtue, when the books that are in common circulation because of the low price at which they are issued, contain only declarations against religion, against family ties and duties towards our neighbor and society, then they inspire a disdain of life and it is no wonder that suicide rapidly increases even among the very young." He was commenting on the case of a child of thirteen who had hanged himself, leaving this written message: "I bequeath my soul to Rousseau and my body to the earth."

Cowardice of Suicide.—Of course, the strongest motive for dissuasion from suicide is the utter cowardice of the act. As a rule, the man who contemplates suicide is not a sufferer from inevitable natural causes, but one who for some foolish act has put himself into what seems to him an intolerable position out of which escape without disgrace is impossible, and he is afraid to face the consequences of his own acts. It is from the fear of mental worry and of the condemnation of others rather than from any dread of physical suffering and pain that men commit suicide. The suicide leaves those who are nearest and dearest to him to face the battle of life alone, with all the handicaps that have been created by their foolishness. Running away in battle is as nothing compared to the cowardice of the suicide. The deserter is deservedly held in deepest dishonor, and if there is some little pity for the suicide, it is because of the supreme foolishness of his act and the feeling that it only can have been dictated by some defect of mental equilibrium. A frank recognition of these conditions in their real significance probably will do more than anything else to make the prospective suicide realize the true status of his act better than anything else.

Men sometimes seem to persuade themselves that it is a brave thing thus to face death. The shadowy terrors of what may come after death are too little realized to deter a man from his act when compared with the real disgrace that he is so familiar with and that he has often witnessed in actual life. It is the man, as a rule, who has most condemned others when something has gone wrong, who has found no sympathy in his heart for the slips of his fellows, who discovers no courage in himself when he has to face disgrace. He does not realize that for most men there are so many extenuations of any evil that a man may do, that the large-minded man is ready to forgive and eventually to forget almost anything that happens. "To know all is to forgive all," and the more we know of men the readier we are to forgive them. Little men do not forgive and cannot forget the failings of their fellows and they think that everyone else looks upon men's failings in the same way. It is only the small, narrow man who contemplates suicide as a refuge from disgrace, and the fact that he can complacently plan the abandonment of others not only to the disgrace which he himself is not ready to face, but to all the suffering consequent upon it, is the best proof of his littleness of soul. The utter pusillanimity of suicide is the best mental antidote for the temptation to it.

Besides, the thought that deterred Hamlet may well be urged:

                                          There's the rub;  For in that sleep of death what dreams may come.  When we have shuffled off this mortal coil,  Must give us pause;       . . . who would fardels bear,  To grunt and sweat under a weary life;  Cut that the dread of something after death.—  The undiscovered country, from whose bourn  No traveller returns.—puzzles the will;  And makes us rather bear those ills we have.  Than fly to others we know not of?

It is sometimes said that this is the argument of a coward, but such cowardice is as reasonable as the dread of touching a wire that may be carrying a high charge of electricity. Besides it is only such an argument that will properly suit the man who, in his cowardice, is ready to let others bear the brunt of his disgrace, flying from it himself.56

There has sometimes been an erroneous tendency to confuse suicide and heroism, but Chesterton, in "Orthodoxy,"57 has well expressed the difference:

A soldier surrounded by enemies, if he is to cut his way out, needs to combine a strong desire for living with a strange carelessness about dying. He must not merely cling to life, for then he will be a coward, and will not escape. He must not merely wait for death, for then he will be a suicide, and will not escape. He must seek his life in a spirit of furious indifference to it; he must desire life like water and yet drink death like wine. No philosopher, I fancy, has ever expressed this romantic riddle with adequate lucidity, and I certainly have not done so. But Christianity has done more: it has marked the limits of it in the awful graves of the suicide and the hero, showing the distance between him who dies for a great cause and him who dies for the sake of dying. And it has held up ever since above the European lances the banner of the mystery of chivalry: the Christian courage, which is a disdain of death; not the Chinese courage, which is a disdain of life.

The feature of incidents in life that bring with them disgrace and punishment which needs to be insisted on for those to whom the thought of suicide comes, is that the sensation which the revelation of such acts causes is but a passing phase of present-day publicity, and that after all it is not even a nine-days' wonder, but a two- or three-days' wonder, and then it is forgotten and replaced by something else. The facing of the condemnation for the moment may seem an extremely severe trial. The world's blame, however, is largely a bogey, a dread that is phantom-like and that disappears, or at least diminishes, to a great degree as soon as it is bravely faced. Besides, as practically every man who has been carrying around a guilty secret with him for years is free to confess, there is an immense sense of relief once the worst is known. At last the effort at concealment, the nervous tension, the fear of the moment of exposure are all past and a new set of thoughts can be allowed to come. Those may be unpleasant and yet they are not so bad as the dread of discovery that hung over the unfortunate. If a man can be braced up to meet exposure, usually he will find in a very few days that there are sources of consolation that make it much easier for him to live than he thought possible before.

Real Suffering a Tonic.—Probably the best remedy for a man or a woman who talks of suicide and seems to fear lest the temptation should overcome them is, if possible, to give them an opportunity to see some real suffering. I have on a number of occasions had the opportunity to note the effect on a discouraged man or woman of the sight of a cancer patient suffering severely, yet bearing the suffering patiently, wishing that the end might come, yet ready to wait until it shall come in the appointed order of nature. Suffering, like everything else, becomes much more bearable with inurement to it. The old have learned the lesson of not only not looking for pleasure in life, but of being quite satisfied with their lot if no pain comes to them, and they even grow to consider that they have not much right to murmur if their pain is not too severe. It is not among those who have to suffer severe pain that one finds suicides as a rule. It is true that young, strong, healthy persons who suddenly find that pain is to be their lot for a prolonged period may grow so discouraged and moody over it as to take their lives. The patients that I have seen suffering from incurable diseases have expressed no desire at all that their life should be shortened, except during the paroxysms of their pain, unless they feel that they are a serious burden on others when they may express the wish to be no more.

Euthanasia.—Every now and then there is a discussion in the newspapers of the justifiableness of euthanasia, that is, the giving of a pleasant death to those who are known to be incurably ill and who are doomed to suffer pain for most of what is left of their existence. The question usually discussed is whether patients have the right to shorten their own existence and then, also, whether their physician might have the right or, even as some people say, the duty, to lessen human suffering by abbreviating existence for such incurable cases. The discussion has always seemed to me beside the realities of things, because physicians do not see many patients, I might almost say any patients, who really want to shorten their lives or would want to have them shortened. I have known many physicians die of cancer, but very seldom is it that one tries to shorten his own existence, or that even his best friend in the profession would consider that he was justified in doing this for him. This, it seems to me, should be the test of the problem. It is true that not infrequently, in the midst of their paroxysms of pain, patients wish they were dead, but there come intervals of surcease from discomfort to some degree at least that make life quite livable for a time again and even occasionally there is real happiness in these intervals, deep, human, natural happiness in heroic forbearance and example.

We can recall AEsop's fable of the old man who, gathering wood for the fire in the winter that he needed so much, finds the burden of his labor and the wood too much for him and calls loudly for death to come to him. Promptly Death makes his appearance and asks what the old man wants. "Oh! nothing," is the reply; "only I would like you to help me to carry this bundle of sticks." This is the attitude of mind of practically all who have grown old in suffering. They have learned to bear with patience, and that patience gives even something of satisfaction. After all, it is not so often the pleasant things in life that we look back on and recall with most satisfaction as the difficulties and trials. Virgil said long ago, "Forsan et hoc olim meminisse juvabit"—perhaps at some future time we shall recall these, our trials and pains, with pleasure. It is the conquering of difficulty that means most for men and even the standing of pain is not without an aftermath, if not of pleasure, at least of broad human satisfaction. When we talk about euthanasia, then, it would be well to ask some of these old people whether they want it or not. Seldom will the answer be found to be that which is so often presumed, by those in good health and strength, to be inevitable under such conditions.

Physicians have all seen incurable cancer patients who were approaching their end inevitably and with the fatal termination not far off, have hours and days of alleviation of suffering and even of enjoyment that made up for the prolongation of life almost in the midst of constant agony. The distinguished New York surgeon who had the pleasure a few years ago of listening once more to his favorite singer and fairly seemed to get renewed life from the inspiration of her voice and who for days after had the pleasant consciousness of smooth running life in improvement so characteristic of convalescence, is a typical example of what may happen under such circumstances. I shall not soon forget Dr. Thomas Dunn English, the well-known author of "Sweet Alice, Ben Bolt," saying at an Alumni dinner of the University of Pennsylvania, that, like Bismarck, he used to think that all the joys of life's existence were in the first eighty years of life, but of late years he had found that many of them were also in the second eighty years of life. He was at the time 83. He made the most joyous and happiest speech on that occasion. He was quite blind, was almost deaf, had been reported dying some months before, and had gone through prolonged suffering, yet he was by his cheeriness and whole-hearted gaiety on that occasion a joy and inspiration to all the younger men at the table.

Dread of Suicide.—There are patients who come to the physician worked up because they fear they may commit suicide. Every now and then the thought comes to them that some time or other they will perhaps throw themselves out of a window, or be tempted to drop in front of a passing train, or over the side of a steamboat, or impulsively take poison. Some nervous people become quite disturbed by these thoughts. Every physician is sure to have some patients who must be reassured, every now and then, that they are not likely to commit suicide. Their nervousness over the fear of this may serve to make them supremely miserable and it evidently becomes the doctor's duty to reassure them. It is not difficult to do this, as a rule, provided the physician will be absolutely confident and unhesitating in his declaration that there is no danger that they will commit suicide, since it has almost never been known that patients who dread it very much and, above all, those who dread it so much that they take others into their confidence in the matter, take their own lives. The very fact that the thought produces so much horror and disturbance in them is the best proof that they will not impulsively do anything irretrievable in this way.

Prof. Dubois has discussed this subject in his usual thoroughly practical way and his words serve as an authoritative confirmation of what has been already said, though as a matter of fact the expressions and experience of nearly every nervous specialist thoroughly justify the position here assumed. Besides, it must be realized that this confident assurance is the best possible prop that doubting patients can have with regard to the actions they dread, and by positive declarations the physician will accomplish more than in any other way.

There are patients who are subject to strange obsessions. They are afraid that they will throw themselves out of the door of a car, or climb over the parapet of a bridge. They are afraid that they will throw their relatives out of a window, or will wound somebody with a knife or a gun. There are some with a strong impulse to open their veins. But if there is a certain attraction in such things, it is really a phobia. It tends to make one shrink back and not to act.

Nothing quiets these patients like the frequently repeated statement that they will not do anything. It is necessary to show them the vast distance there is between the impulse toward suicide and murder and the phobia which, however distressing it may be, is a safeguard. One must keep at this education of the mind with imperturbable persistence and use the most forceful and convincing arguments that one can think of to correct the judgment of his patient, in order to make the strings of moral feeling and reason vibrate in unison.

It is through lack of courage and perseverance that we err in the treatment of these psychoneuroses. We wait too long to distinguish the morbid entities that bear on a certain etiology or a different prognosis. We do not see clearly enough the bond which unites these different affections.

It may seem to some physicians as though they would be assuming too much responsibility in giving patients such positive assurance that their dreads will not be fulfilled, but as a matter of fact the experience of physicians is quite sufficient to justify the confident statements here suggested. It is true that occasionally a person who afterwards commits suicide talks the matter over and hints at the possibility of taking his own life. He does not, as a rule, speak of it with dread, however, but as one of the alluring solutions of his difficulties that he sees ahead of him. He is much more likely to write a letter to his physician telling him that all his arrangements are made and that by the time this letter reaches him he will be already dead. The prospective suicide is usually quite secretive about this purpose, not only to friends, lest he should be prevented from accomplishing it, but even with his physician, in whom he has had absolute confidence and to whom he has told practically everything else. The patients who fear the possibility of committing suicide, who tell how much they dread the horror of it, and who rush to consult the physician to help them against themselves, show by the very fact the unlikelihood of action on their part.

The Physician and Suicide.—By mental influence, then, the physician may lessen the tendency to suicide in the individual and in the community. To do this is to save suffering and to help in the solution of one of the most serious social problems in modern times. It can only be accomplished by a sympathetic attitude towards the whole subject and a tactful understanding of each individual case. Every effort in the matter, however, is well worth while, for there is no more hideous blot on our modern civilization than the startling increase of suicide. It is particularly important to bring about improvement in this regard among young suicides, and fortunately it is here that the influence of the physician for good is likely to be most felt. The saving of life is the noblest part of the mission of the physician and nowhere, perhaps, can this be accomplished more successfully than with regard to some of these patients whom a rash resolution, due to a momentary fit of depression and a sense of suffering exaggerated out of all proportion to their actual pain, is hurrying out of life.

CHAPTER IV

GRIEF

Grieving would seem at first glance to be one of the conditions for which the physician, especially if the etymology of the name of his profession be taken strictly, should not be called upon to minister, nor his remedies be expected to relieve. Grief is usually supposed to be due to moral ills and, therefore, at most to come under the care of the alienist, with the feeling that even he can accomplish very little for what is an affective rather than a true mental disorder. There is no doubt at all, however, that grieving, especially in the excess that shows it to be pathological, is always associated with certain physical and mental conditions for which the physician can accomplish much. Indeed more often than not the physical condition of the grief-stricken person is a prominent factor in the production of the state of feeling which causes grief to be exaggerated, while, on the other hand, this state of mind itself reacts upon the physical being so as to make it more sluggish in all its functions, and as a consequence a vicious circle of cause and effect is formed affecting unfavorably both the mental and physical conditions. It is when patients are run down in health that grief becomes extremely difficult or apparently impossible to bear and grief itself still further brings about a deterioration of health that makes the mind's reactionary power against its gloomy feelings still weaker than they were.