You Don't Get to Go: On the Moral Obligation not to Kill Oneself

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I have a therapist again.  She lives in Florida.  We talk on the phone once every three weeks for 45 minutes.  (There was, apparently, a rule about teletherapists needing to be in the same state as their clients, but that appears to have been suspended by my insurance company. There was also an idea that one should speak to a therapist weekly, but that too is by the wayside. Once every 21 days you get to pour out your heart to Carlie in Orlando. Be bloody grateful.)

It’s been nearly 35 years since I first learned one of the most basic truths about our mental health system: the fastest way to get seen is to say you’re about to commit suicide.

This makes sense. All medical care rests on the principle of triage – the idea that the sickest and most vulnerable patients should get care first.  You treat a gunshot wound before you treat a broken wrist and so forth.  In psychiatric medicine, the fastest way to get to the front of the queue – and more often, the ONLY way to get any kind of medical attention – is to either be (or claim to be) actively suicidal.

I’m filled with despair, anxiety, and self-hatred

 “Are you having thoughts of suicide?”

Constantly.

“Do you have a plan? Do you intend to kill yourself in the very near future?”

I have a plan, but no, I don’t have permission to die. As bad as things are, I will not kill myself.  No matter what.

“Okay, that’s great.  Keep reminding yourself of that!  Go, you!  Remember people love you! Oh, and I think we can arrange to have someone call you back within the month. Is that okay?”

Plenty of battered veterans of the mental health system will recognize this exchange.

You won’t die from a broken wrist, but you still need treatment.

Since I was first hospitalized at 19, my mental breakdowns have unnerved and terrified my family.  I have genuinely attempted suicide three times, made ineffectual (if bloody and dramatic) suicidal gestures at least a dozen times, and been placed on temporary psych holds many other times because I was unable to promise I wouldn’t try to kill myself. 

Several years ago, I spent a week reading every study I could find on the adult children of fathers who had killed themselves.  I was looking, of course, for reassurance that if I did do this thing, my children might still thrive.  I was looking for stories of adaptability and resilience, for tales of well-adjusted adults who had easily come to terms with an early and traumatic loss.

As you might suspect, that’s not what I found.  I did read essays by adult children of suicidal dads, and though some clearly had found happiness, the pain invariably endured. I read that the risk of suicide increased exponentially among the survivors of a parent’s self-chosen death. 

I messaged a friend I knew whose dad had hanged himself when she was in high school.  She was the one who gave me the phrase that has become my mantra.  “You don’t have permission.” 

I want to choose my words carefully here, as I know that some of my readers have lost loved ones to suicide.

I find the idea of not having permission to be immensely helpful. It’s not that I’m a naturally rule-abiding sort; my life is filled with ample evidence to the contrary.  It’s that in the end, our autonomy is constrained only by love.  Obligation comes from the Latin verb ligare, meaning to bind.  Love is a tie that binds, as the old hymn reminds us.  Generally it binds us from not doing what we would do if we were not so well-loved.  We stay faithful rather than cheat, we go to work when we’d rather sleep in because our children need to eat, we keep showing up for this life even when we’re in complete despair.  We are bound by the thought of what would happen to those we love were we to loosen the knot, and slip ourselves free.

I’ve seen what infidelity, divorce, mental illness, poverty, and public humiliation can do to children.  My friends who’ve lived through the loss of a parent to suicide promise me that the pain is a thousand times worse than anything I have inflicted so far.

One of the most powerful country tracks of this past year is Vincent Neil Emerson’s Learning to Drown.

I'm barely a man and livin' hard
My father killed himself
And my mother hit the bar
Well, ain't it funny?
Ain't it funny how
The world'll set you free?

I spent my whole life wonderin' why I'm down
I don't feel easy if the blues don't come around
And my face don't look right without a frown
Well, if you can't swim, you better learn to drown

Emerson’s father really did commit suicide.

When the narrator of the song says he’s been set free, he makes it clear he’s adrift — barely surviving, wondering with bemused detachment when and how his own end will come. What loosened the bond and put him at such reckless liberty? His dad’s decision. I think of my own children, and imagine what pain I would permission in Heloise and David if I gave myself the freedom to opt out.

In another of this year’s best country songs, Amanda Shires takes up the same theme from a different angle: the wife and mother insisting that even if it’s wretched, what you want to be an option can’t be:

Between you and the kids
I’ve been lifting and cleaning
Feeding and bending for over 20 years now
We might be standing here
Looking at the end of our world
But there’s beauty in knowing
The closure you owe to your girls

And you don’t get to go
Out your own way
You don’t get to choose
So just spare me

I get a great deal of solace and resolve from country music.

In that famous soliloquy, the very young, self-absorbed, and very childless Hamlet debates suicide, and comes to the conclusion that the unknown beyond the grave — that “dread of something after death” is too scary. “Conscience makes cowards of us all,” says the young prince, but he who is not a parent might have different fears than they who have children. My great fear is not the life to come - mine is the horror of simply shifting my own immense pain onto my children, my wife, my family and my friends.

It is dangerous to tell someone you’re staying with them out of obligation. No one wants to be married to someone, say, who doesn’t enjoy the union at all, but feels compelled to honor a promise made long ago. I go back and forth on whether suicide is different. Part of me desperately wants acknowledgement that simply staying alive is frequently such grueling, tedious, stupendously numbing, exhausting work! The act of not only not dying, but actively showing up in spite of wanting to die, feels as if it should be regarded at least as vaguely heroic, if only because it feels so immensely difficult. On the other hand, your loved ones would prefer not to be saddled with a guilt trip; they’d so much rather you not only were willing to stay, but actively enjoyed your staying. Giving someone praise and recognition for not killing themselves is a bit like complimenting your wife for not screwing the hot poolboy who caught her eye. Shouldn’t promise-keeping just be a given? How needy and frail must one be to want constant praise solely for not hanging oneself? Better to neither ask nor expect.

And yet, it is still very hard to stay, even if I very much love the people who constitute my reasons for remaining.

My previous therapist asked me, “If you did have permission, would you go?” And I said that I would, but only if I could trust that the permission was granted with warmth and enthusiasm, not regret or grief or resignation. “That’s a tall order,” she commented, and I agreed it was so. The ties remain, and I stay, and I will make the best of my staying, even if it is not what I would have chosen.

In the absence of the freedom to do what I want most, I will make the joyful best of what I am permitted. That has to be good enough.