Table of Contents
| Prologue | 3 |
| I | Buried Above Ground: An Introduction to Suicide | 9 |
| 1 | Death Lies Near at Hand: History and Overview | 11 |
| 2 | To Measure the Heart's Turbulence: Definitions and Magnitudes | 26 |
| Essay: This Life, This Death | 52 |
| II | Just Hope Has Gone: Psychology and Psychopathology | 71 |
| 3 | Take Off the Amber, Put Out the Lamp: The Psychology of Suicide | 73 |
| 4 | The Burden of Despair: Psychopathology and Suicide | 98 |
| 5 | What Matters It, If Rope or Garter: Methods and Places | 130 |
| Essay: The Lion Enclosure | 154 |
| III | Pangs of Nature, Taints of Blood: The Biology of Suicide | 161 |
| 6 | A Plunge into Deep Waters: Genetic and Evolutionary Perspectives | 163 |
| 7 | Death-Blood: Neurobiology and Neuropathology | 182 |
| Essay: The Colouring to Events: The Death of Meriwether Lewis | 213 |
| IV | Building Against Death: Prevention of Suicide | 233 |
| 8 | Modest Magical Qualities: Treatment and Prevention | 235 |
| 9 | As a Society: The Public Health | 264 |
| 10 | A Half-Stitched Scar: Those Left Behind | 290 |
| Epilogue | 309 |
| App | Resources for Information About Suicide, Mental Illness, and Alcohol and Drug Abuse | 315 |
| Notes | 319 |
| Acknowledgments | 415 |
| Index | 419 |
Reading Group Guide
1. Jamison writes, "My hope was to maintain an individual perspective—through an emphasis on the psychology of suicide and an extensive use of the words and experiences of those who seriously attempted to, or eventually did, kill themselves" [p. 20]. In other words, she attempts to write about her subject with an intimacy and immediacy that will engage the reader, despite the painful nature of her topic. How well does she succeed in what she sets out to do? How does this book change your thinking about those who kill themselves?
2. Jamison reports that the rate of suicide has tripled among young people in the past forty years, and that suicide is now the second leading cause of death among American college students. What are some of the forces in our society, according to studies Jamison cites, that might be causing this alarming trend? What point is Jamison making about the variety of styles and feelings expressed in suicide notes? Only one in four people who kill themselves, she says, is likely to leave a note. What in the state of a suicidal mind would account for this unwillingness to communicate their intentions?
3. In his suicide note, British painter Benjamin Haydon left a quote from Shakespeare's King Lear: "Stretch me no longer on this rough world" [p. 83]. If this is a feeling shared by most people who commit suicide, doesn't it seem entirely understandable, and forgivable, that they should end their lives? Why then have most societies been so insistent that suicide be considered a crime and a grave sin, involving forfeiture of property, exclusion from hallowed graveyards, etc.?
4. What is the cumulative effectupon you, as a reader, of the use of statistics throughout the book? Are you surprised, for instance, that while 30, 000 Americans die from suicide each year, 500, 000 make suicide attempts? How does Jamison bridge the gap between scientific studies and the emotion surrounding the issue of suicide?
5. Jamison tells with care and great empathy the tragic stories of Dawn Befano, Drew Sopirak, and Meriwether Lewis, among others. Do these stories successfully provide a window into the tumultuous and shattered minds of those who suffer from mood disorders? What makes them so compelling? Do you believe that these deaths were avoidable?
6. Jamison uses the story of the unknown woman who climbed into the lions' enclosure at the Washington Zoo to point out the urgent problems of the homeless mentally ill. She writes, "They make us uncomfortable, but not so uncomfortable that we protect or house, insure or tend or heal them" [p. 158]. Do you agree with Jamison that American society is irresponsible and cruel in its policies regarding the homeless mentally ill?
7. Jamison uses the examples of the Japanese volcano Mount Mihara, San Francisco's Golden Gate Bridge, and other popular sites for those who choose to end their lives, to illustrate the odd fact that suicide sometimes has a dramatic allure that can be contagious. Why do you suppose this is so? Do you think that young people are especially vulnerable to a "copycat" phenomenon in suicide?
8. How do you feel about the poem on pages 90-91, written by a fifteen-year-old boy who killed himself two years later? Does it seem predictive of his fate? Do you think this was a masked cry for help?
9. The story of Washington political figure John Wilson shows that the social stigma surrounding mental illness is still strong enough to put an end to political hopes. Is this bias justified? Should the public demand that those who hold public office be free of mental instability? Or is this a lingering prejudice that will eventually be outgrown?
10. Surgeon General David Sacher has said, "As a society, we do not like to talk about suicide" [p. 264]. Why, in a society which is so permissive and so open, should suicide, depression and related forms of mental illness be hard to talk about? To what degree does a sense of shame prevent the suicidal individual from seeking help? Do you agree with Jamison when she argues that educating the public about mental illness will bring about a change in thinking, treatment, and public policy regarding suicide?
11. Until the publication of An Unquiet Mind, Jamison had kept her own illness a secret. Had it been known, do you think she could have had a successful career as a professor of psychiatry, or that she would have been chosen to write an important standard textbook on the subject of manic depression? Would you consider the sacrifice of Jamison's own privacy ultimately worth the exposure, considering that she wants to save lives? Do you think that her books will have a definite effect in reducing the suffering of the mentally ill and the toll of suicide in this country?
12. Jamison points out that the field of psychiatry is turning ever more strongly towards pharmacological management and away from psychotherapy, and that "there remains a pervasive belief in many psychiatric and research quarters that medication by itself is sufficient to deal with serious mental illness" [p. 252]. What is the danger of trying to manage mood disorders solely through medication? What does Jamison suggest is the ideal approach to the treatment of these illnesses?
13. What do you think of psychiatrist Thomas Szasz's views on mental illness and suicide [pp. 253-54]? Was the court correct in making him pay damages to the wife of a patient of his who killed himself after Szasz instructed him to stop taking lithium? Should someone who holds such views be made to stop practicing medicine?
14. Jamison quotes the writer Joseph Conrad, who suffered from major depression and survived a suicide attempt, as saying: "Suicide, I suspect, is very often the outcome of mere mental weariness—not an act of savage energy but the final symptom of complete collapse" [p. 198]. Yet, as she points out, most people are able to survive the stresses of life without "complete collapse, " and others are not. Why is this so? How important a role does the biochemistry of the brain play in our response to life's troubles?
15. Josephine Pesaresi's description [pp. 301-302] of the response to her husband's suicide underscores the lack of real empathy that people often have for the survivors of people who kill themselves. Do you think that her family's sense of isolation was unusual? Do the immediate survivors of a person who kills himself or herself need a different kind of concern and care from the people around them than, say, the survivors of a death by cancer?
16. What does Jamison mean when she writes, in her epilogue: "I am by temperament an optimist, and I thought from the beginning that there was much to be written about suicide that was strangely heartening" [p. 309]?
17. Reflecting on the emotional toll it took to write this book, Jamison writes ruefully, "Mostly, I have been impressed by how little value our society puts on saving the lives of those who are in such despair as to want to end them. It is a societal illusion that suicide is rare. It is not" [p. 310]. The staggering fact is that "every seventeen minutes in America, someone commits suicide" [p. 309]. Does this book leave you with a new sense of what an urgent and tragic public health issue suicide is? Do you come away with some ideas about what can be done to save the lives of potential suicides?
Read an Excerpt
Summer evenings at the Bistro Gardens in Beverly Hills tended toward the
long and languorous. My friend Jack Ryan and I went there often when I
lived in Los Angeles, and I invariably ordered the Dungeness crab and a
scotch on the rocks. Not so invariably, but from time to time, Jack would
use the occasion to suggest we get married. It was an idea with such patent
potential for catastrophe that neither of us had much of an inclination to
take the recurring proposal with too much gravity. But our friendship we
took seriously.
This particular evening, having hooked and tugged out the last bits of
crab, I found myself edgily knocking the ice cubes around in my whisky
glass. The conversation was making me restless and uneasy. We were talking
about suicide and making a blood oath: if either of us again became deeply suicidal, we agreed, we would meet at Jack's home on Cape Cod. Once there,
the nonsuicidal one of us would have a week to persuade the other not to
commit suicide; a week to present all the reasons we could come up with for
why the other should go back on lithium, assuming that having stopped it
was the most likely reason for the danger of suicide (we both had
manic-depressive illness and, despite the better and often expressed
judgment of others, had a tendency to stop taking our lithium); a week to
cajole the other into a hospital; to invoke conscience; to impress upon the
other the pain and damage to our families that suicide would inevitably
bring.
We would, we said, during this hostage week, walk along the beach and
remind the other of all of the times we had felt at the end of hope and,
somehow, had come back. Who, if not someone who had actually been there,
could better bring the other back from the edge? We both, in our own ways
and in our own intimate dealings with it, knew suicide well. We thought we
knew how we could keep it from being the cause of death on our death
certificates.
We decided that a week was long enough to argue for life. If it didn't
work, at least we would have tried. And, because we had years of cumulative
experience with lifestyles of snap impetuousness and knew how quick and
final a suicidal impulse could be, we further agreed that neither of us
would ever buy a gun. Nor, we swore, would we under any circumstances allow
anyone else to keep a gun in a house in which we lived.
"Cheers," we said in synchrony, ice and glass clinking. We sealed our foray
into the planned and rational world. Still, I had my doubts. I listened to
the details, helped clarify a few, drank the rest of my scotch, and stared
at the tiny white lights in the gardens around us. Who were we kidding?
Never once, during any of my sustained bouts of suicidal depression, had I
been inclined or able to pick up a telephone and ask a friend for help. Not
once. It wasn't in me. How could I seriously imagine that I would call
Jack, make an airline reservation, get to an airport, rent a car, and find
my way out to his house on the Cape? It seemed only slightly less absurd
that Jack would go along with the plan, although he, at least, was rich and
could get others to handle the practicalities. The more I thought about the
arrangement, the more skeptical I became.
It is a tribute to the persuasiveness, reverberating energies and
enthusiasms, and infinite capacity for self-deception of two manic
temperaments that by the time the dessert souffles arrived we were utterly
convinced that our pact would hold. He would call me; I would call him; we
would outmaneuver the black knight and force him from the board.
If it has ever been taken up as an option, however, the black knight has a
tendency to remain in play. And so it did. Many years later -- Jack had
long since married and I had moved to Washington -- I received a telephone
call from California: Jack had put a gun to his head, said a member of his
family, and "put a bullet through his brain."
No week in Cape Cod, no chance to dissuade. A man who had been inventive
enough to earn a thousand patents for such wildly diverse creations as the
Hawk and Sparrow missile systems used by the U.S. Department of Defense,
toys played with by millions of children around the world, and devices used
in virtually every household in America; a Yale graduate and lover of life;
a successful businessman -- this remarkably imaginative man had not been
inventive enough to find an alternative solution to a violent,
self-inflicted death.
Although shaken by Jack's suicide, I was not surprised by it. Nor was I
surprised that he had not called me. I, after all, had been dangerously
suicidal myself on several occasions since our Bistro Gardens compact and
certainly had not called him. Nor had I even thought of calling. Suicide is
not beholden to an evening's promises, nor does it always hearken to plans
drawn up in lucid moments and banked in good intentions.
I know this for an unfortunate fact. Suicide has been a professional
interest of mine for more than twenty years, and a very personal one for
considerably longer. I have a hard-earned respect for suicide's ability to
undermine, overwhelm, outwit, devastate, and destroy. As a clinician,
researcher, and teacher I have known or consulted on patients who hanged,
shot, or asphyxiated themselves; jumped to their deaths from stairwells,
buildings, or overpasses; died from poisons, fumes, prescription drugs; or
slashed their wrists or cut their throats. Close friends, fellow students
from graduate school, colleagues, and children of colleagues have done
similar or the same. Most were young and suffered from severe illness; all
left behind a wake of unimaginable pain and unresolvable guilt.
Like many who have manic-depressive illness, I have also known suicide in a
more private, awful way, and I trace the loss of a fundamental innocence to
the day that I first considered suicide as the only solution possible to an
unendurable level of mental pain. Until that time I had taken for granted,
and loved more than I knew, a temperamental lightness of mood and a
fabulous expectation of life. I knew death only in the most abstract of
senses; I never imagined it would be something to arrange or seek.
I was seventeen when, in the midst of my first depression, I became
knowledgeable about suicide in something other than an existential,
adolescent way. For much of each day during several months of my senior
year in high school, I thought about when, whether, where, and how to kill
myself. I learned to present to others a face at variance with my mind;
ferreted out the location of two or three nearby tall buildings with
unprotected stairwells; discovered the fastest flows of morning traffic;
and learned how to load my father's gun. It was not the kind of education
one expected to receive in high school.
The rest of my life at the time -- sports, classes, writing, friends,
planning for college -- fell fast into a black night. Everything seemed a
ridiculous charade to endure; a hollow existence to fake one's way through
as best one could. But, gradually, layer by layer, the depression lifted,
and by the time my senior prom and graduation came around, I had been well
for months. Suicide had withdrawn to the back squares of the board and
become, once again, unthinkable.
Chillingly, although the privacy of my nightmare had been of my own
designing, no one close to me had any real idea of the psychological
company I had been keeping. The gap between private experience and its
public expression was absolute; my persuasiveness to others was
unimaginably frightening.
Over the years, my manic-depressive illness became much worse, and the
reality of dying young from suicide became a dangerous undertow in my
dealings with life. Then, when I was twenty-eight years old, after a
damaging and psychotic mania, followed by a particularly prolonged and
violent siege of depression, I took a massive overdose of lithium. I
unambivalently wanted to die and nearly did. Death from suicide had become
a possibility, if not a probability, in my life.
Under the circumstances -- I was, during this, a young faculty member in a
department of academic psychiatry -- it was not a very long walk from
personal experience to clinical and scientific investigation. I studied
everything I could about my disease and read all I could find about the
psychological and biological determinants of suicide. As a tiger tamer
learns about the minds and moves of his cats, and a pilot about the
dynamics of the wind and air, I learned about the illness I had and its
possible end point. I learned as best I could, and as much as I could,
about the moods of death.
Copyright 1999 by Kay Redfield Jamison
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