On suicide, depression and euthanasia

When the actor Robin Williams died recently – more specifically, killed himself – there was the usual outpouring of comments about suicide and the wider issue of depression. As ever, they came from a huge variety of perspectives and different levels and types of experience and expertise. This one, on Twitter, wasn’t atypical:

How is depression gonna keep robbing us of such beautifully talented people? The struggle is so real. RIP.

But something about it irritated me enough about it to make me want to write this blog post (and I’m sorry, but it’s a long one). I think it was the sense that “depression… robs us” – the general public – of the person who has killed themselves. That seems to be a rather common response to suicide – that it is those left behind who have been deprived of something, perhaps even by an unreasonability of behaviour on the part of the suicide-ee. And, without wishing to deny the extraordinary pain experienced by those whose loved ones kill themselves, the extent to which the friends and family of suiciders sometimes turn the spotlight on their own suffering, rather than on the pain that drove someone to take their own life, really pisses me off.

I don’t usual write about mental health and depression on this blog. That’s mainly because I am extremely wary of joining the large number of depression-memoir blogs out there. I respect the rights of those people who choose the blogosphere as a place to work through their mental health situations, but I don’t feel the need to join them. I don’t think I particularly hide the fact that I have a mental health diagnosis, but equally I don’t usually advertise it.

There is a tricky line to tread here. It feels to me that the stigma attached to mental illness means that there is almost a pressure for those regarded as ‘coping’ to be open about their situation, in order to break down those stereotypes and stigmatisations. Do we expect people with other medical conditions to do the same? Not usually. I can see the reason that this situation has developed, but I’m not 100% comfortable with it.

One of the reasons I am not wholly happy with talking about my own situation in this kind of environment is, sort of, illustrated in this excellent post by Jack Halberstam on the “neo-liberal rhetoric of harm, danger and trauma”. It describes a political situation in which comparatively privileged white, Western young people – often those who call themselves activists – have slithered into a swamp of competitive suffering, when anyone and everyone seems to want to come up with a reason why they are oppressed, in an ahistorical, ageographical, uncomparative discourse of ‘trigger warnings’ and public articulation of carefully cultivated pain. I’m not denying that privileged white Western people suffer – sometimes terribly. The idea that someone privileged cannot articulate their pain because there is always someone worse off is profoundly un-useful; the current slapdown of ‘first world problems’ is potentially damaging in all sorts of ways. But there is an extent to which it is applicable, and to which many of us seem to have lost much of our sense of proportion on these issues.

One example is an article which I have, unfortunately, lost the link for, but which put forward the idea that we need to differentiate between the everyday use of the word ‘depressed’ to mean a bit down/low/upset, and clinical depression as a serious medical condition. I came across this article, again, on Twitter, where someone was slamming it. I agreed that the article’s tone, which was fairly judgemental and black-and-white about the issue, was not necessarily helpful. But I do think that the writer had a point; that – as with those ‘trigger warning’ addicts – there is a tendency to see any period of low mood as abnormal, to medicalise it or to broadcast our own suffering as if it somehow validates us, makes us more worthy or more interesting or more important as people.

And that is not a useful situation, it seems to me, for those who do suffer from clinical, debilitating depression. People like Robin Williams, who may well go on to kill themselves because what is going on in their brain is no longer bearable to live with.

For the record, my own diagnosis is ‘severe acute recurrent depression’. What that means in everyday terms is that I can be fine for months or years, able to build a career, write books, appear assertive and independent to the world. But every so often, it all cracks, and this is where the difference between being ‘low’ or ‘unhappy’ and being clinically depressed comes out. It’s the intense physicality of depression, the sense of being physically grasped by something you cannot escape and which takes over your entire being. It’s not just something that happens in your head, or it can seem that way. My depression can include hallucinations or psychosis, from strange visual effects to nightmarish scenarios in which, for instance, I find myself crawling across the floor screaming because the black void inside me is trying to rip its way out through my skin.

One of the problems with depression is the lack of understanding – in science and in society – of the human mind. In scientific or medical terms, that means that the treatments for mental illness of all kinds tend to be very blunt instruments, and their prescription a very hit-or-miss affair. I’m extremely lucky; I have a very sympathetic doctor, and I respond well, and with limited side-effects, to one particular drug.

But I’m more interested in the way that this poverty of understanding manifests socially, in the fact that we don’t really have a clear sense of the relationship between ‘the mind’ (as a psychological, personal, philosophical entity) and ‘the brain’ (as an organ, like the liver or the heart). And that means that mental illness occupies a very different place in people’s fears and thoughts from any other illness, because it is so intimately tied up with our selves and who we are. It is possible to have something wrong with any other organ and it not be perceived as affecting who we are as people. But because mental illness by definition influences how we behave, those who we interact with – and possibly we ourselves – have trouble unpicking which behaviours are ‘us’, and which are ‘the illness’. It’s a profound philosophical challenge.

To loop back to the opening issue of suicide, though, the fact of this complex relationship between ‘self’ and ‘illness’ seems to me to become particularly difficult when it comes to the point of people with depression who kill themselves.

I suppose that if you completely deny the right of any person to choose the moment of their death there is no debate about what I am going to say. Suicide can never be considered. But in a society where the issue of euthanasia is increasingly debated and, perhaps, increasingly accepted, I think there is also a conversation that needs to be had around mental illness and suicide.

Many of the most beloved people in my life have categorically said that they would want to exercise their right to die if they were diagnosed with a serious terminal or debilitating condition such as MND. I assume they would also assert such rights if confronted with, for instance, metastatic cancer which resisted even the strongest opiates. Where might the fact of having a severe mental illness, of having to confront terrifying mental pain (and of spending even your ‘sane’ periods living in fear of its return), fit into this discourse?

Statistically speaking, the chances of my dying by suicide are fairly high, given my medical history. On the other hand, I have no current plans to exercise that choice, and I am told that I have some very well-developed mechanisms for extracting myself from a place where killing myself is likely. But is it so terrible that I actually find that statistical likelihood somehow comforting? Like someone with a severe physical condition, I see the potential to choose not to carry on as a valid one, not something positive per se, but something empowering that involves me in an active choice to determine the extent of my own suffering.

Many of the responses to suicide, however, suggest for me to make that choice is selfish. Again, if you refuse the possibility of euthanasia, then this is entirely consistent. If you don’t, however, why is self-euthanasia as a response to incurable and repeated mental suffering different from (self-) euthanasia as a reaction to other forms of disease? Is it partly because we acknowledge the physical nature of failures of every other organ, but not that of the brain? Because we cannot see depression on a scanner or try to excise it with scalpels, we find it hard to admit that, at least sometimes, it is also a physical disease, a matter of organs and tissue and chemicals – but one that happens to manifest in a way that is so intertwined with everything that makes us individuals, makes us ‘ourselves’, that it is impossible to unpick where we end and the disease begins. That is, for many people, existentially threatening.

Politically, this conclusion is one that I think poses some interesting political questions. Many ‘activist’ types (of the likes of those I’ve spent my adult life amongst) need to see depression as psychological rather than physical, partly because it fits into the idea that mental illness is a valid response to a fucked-up world (yes, in many cases it probably is) and because this also rejects the evil pharmaceutical industry as a possible cure (sorry, I don’t completely buy that one, although I fully admit that much of the pharmaceutical industry is, indeed, pretty satanic). It also fits in with the fact that psychiatric medicine has committed some terrible things in the name of supposedly ‘treating’ (controlling, eradicating, muting) people who don’t fit social norms (which it has).

But after 25 years, perhaps more, of depression, I feel I have a right to assert that I’m pretty sure that, for me, this is not a psychological issue. It’s a malfunction, something chemical, something that short-circuits every so often. The same way that someone with liver disease can avoid alcohol or a diabetic can control their diet, I can try to control elements of my mood and surroundings and that might lift a little of the likelihood of my losing it again. But that’s a matter of understanding the delicate balance of chemicals within the brain that constitute mood and feeling and emotion, not a non-physical model of mental illness. And for me, that also suggests that I have the right to make a considered choice about how long I stick it out.

I don’t have any neat wrap-up here. I’m sure there’s plenty that I’ve written that will make painful reading for those who know me, and which will piss off the kinds of people who need to loudly discuss their own moods in order to assert their personal suffering. But there are a bunch of things here that are on my mind (ha!) quite a lot, and which the Robin Williams case pushed out into the open. I hope that, if nothing else, they provide someone with food for thought.