Choice

I'd been thinking about this topic off and on and, up until now, there were two things that hadn't come together. One was knowing what I'd want to say about it. I've seen a lot of opinions out there, and it seems like it's a question a lot of people feel very strongly about. I also wasn't sure where I cane down on it, and I'd at least need to be clear on that. The other thing was the willingness to potentially upset some folks with my opinion. Well, as recently I seem to have been struck with hoof-'n'-mouth disease, it seems like as good a time as any. So, here we go. The topic for today is choice and how it relates to suicide.

Before I get into it, I want to start with a disclaimer. I know that some people who get really caught up in this question are the ones who're dealing with losing a loved one to suicide. In that case, they've got a total pass on it in my opinion, at least for however long they're dealing with the loss & grief. They're not the ones who I have a harder time dealing with. I get how those questions don't leave folks alone, how there's that burning need to know, one way or other, if choice is the deciding factor. It's other folks who I have a harder time dealing with around this issue.

Some people say that it's certainly a matter of choice. People choose what they do (or don't do), what they say, where they go. Our legal system is based on that, that people are responsible for what they choose and do. That's why, at least technically, suicide is the one crime for which someone simply CANNOT be charged if they pull it off, but theoretically could be charged if they tried and failed. That idea of choice is why it takes going through a rather intense process to get someone involuntarily committed to a mental institution, at least for any length of time, or to be force-medicated. There's some evidence to back up the idea that choice is certainly involved in suicide, like the following:

• People decide how they're going to kill themselves (or at least try), and they choose different means. Some of it depends on what they can get access to. However, almost everyone has access to a sharp knife/blade, a length of wire or rope, and chemicals or drugs that are highly toxic, especially if taken internally. People in similar circumstances don't always take the same approach. Ergo, there's an element of choice.
  
  
• Maybe the strongest piece of evidence has to do with how long folks who attempt or commit suicide were depressed and hurting beforehand. While with some it's an impulsive, spur-of-the-moment act, with most there's some degree of consideration and deliberation. Despite feeling hopeless, they hang in there for awhile before acting, sometimes for a long time. The reasons they do so vary, but regardless it points to the choice to act or not act.

Other people say that it's not a matter of choice; it's a matter of mental illness. Research over the last several decades has shown substantially higher rates of suicide in those with major mental illnesses, such as major depressive disorder, bipolar disorder, schizophrenia, and some of the personality disorders. There's a reason those are called “major mental illnesses.” People say and do things they wouldn't ordinarily when they suffer from those conditions. There is a legal defense of insanity that points to the idea of someone who's suffering from severe enough mental illness not knowing what they did. There's also evidence for the idea that it's about mental illness:

• As mentioned above, the suicide rates are dramatically higher for those who're diagnosed with serious mental illness. In some cases, going back and reading over journals or correspondence suggests that people who hadn't been diagnosed with major mental illness likely would have been. For example, there's been some studies suggesting people with borderline personality disorder have suicide rates roughly 400% that of the “average” people.
  
  
• One of the symptoms of depression is a sense of pessimism and hopelessness, the idea things just won't get better. That goes along very well with the concept of suicide, where it's taking a permanent exit from one's circumstances or life. People usually value at least some things in their lives enough to stay around for, even in hard circumstances. Getting to the point of not valuing anything enough to keep trying is pretty outside of what's considered “normal.” And that's part of how mental illness is defined.
  
  
• When treatment for major mental illness is provided and followed through with, the rates of suicides and suicide attempts go down significantly. That's been seen enough times to be able to say that it's not just a fluke or accident. There's something to it.

So, there's evidence on both sides of this debate. Which one wins? How hard do people press their points, either reinforcing their evidence and position or undermining that of the “other side”?? Some people get pretty...intense about this. I think a lot of that's because people either have personal investment in it, or see the money tied up in it....or both. Regardless, the arguments/discussions get pretty heated at times, and on both sides there are people who are insisting they have The Right Answer!

The problem is, I've been coming to believe that they're asking the wrong question.

I don't think it's a black-and-white, yes-or-no kind of issue. Is suicide chosen or not? I think that's the wrong question. I think that it's more an issue of how much of choice and how much of mental illness play in...and how they interact. Is it possible to choose to not act toward ending one's life? I think so. However, that doesn't say anything at all about HOW HARD THAT CHOICE CAN BECOME. I think that's where the mental illness comes in. It makes it harder and harder to see the options that might be there, or to believe they'll help/work. For anyone who's experienced significant pain over an extended period of time, they'll also get it how that just wears a person down, saps energy and resolve, slowly takes the color out of the world. It's one of the reason why prescription pain medications are some of the most widely abused drugs; people get to the point where they're willing to do damn near anything to make the hurting stop. In that case, it's a continuum of things people might do to get it to stop, with the ultimate end being suicide. 'Cause there's no coming back or other options after death. At least not in this life.

One of the things it helped me to do, when I accepted both are involved, was have more compassion for her pain and more respect for her strength. I'd gotten to read some of her journal files, the ones that weren't massively encrypted, and found out how long she'd been depressed and hurting. How long that had been weighing on her, dragging her down. And I also got to see how long she had gone on and chosen to keep going. She was thorough and thoughtful enough about killing herself, that there had to have been a good stretch of time where she was thinking about it AND DECIDING NOT TO DO IT, at least not then. And that kept getting more difficult. And she kept choosing to stay around, as long as she could. And when it finally hurt too bad to keep choosing to stay, it was because of the depression and anxiety and anger and everything else that robbed her world and her life of comfort, of color, of worth. Of hope.

Like I said in the beginning, I get how those who're still hurting and grieving focus on the one or the other. When you're hurting and empty and confused and scared and angry like that, it's too hard to look at bigger, more complicated questions. But it's ultimately not as simple as a yes-or-no, this-or-that kind of issue. Both play into it. And until we figure out how to deal with both, it's going to continue to be a problem that isn't going to change.

For me, being able to accept that I'd been asking the wrong question was another leg of the journey. A little farther down. A little closer to the way out.