Hegemonic Sanity and Suicide

You have heard the story before. A suicide attempt survivor, now a glowing picture of health, gives a detailed description of the moment when they woke up after their attempt (the more lethal or violent the attempt appears, the better). They were in a hospital bed, bathed in beautiful natural light, surrounded by the people who love them most, and they realized that their thinking was flawed. That they were broken before, but now they are whole and all of those unsolvable problems can actually be solved. All of their pain can be erased. They were sick, and if they are just compliant with medication and therapy, they can manage their disease.

You know this story because it is the story of the “good” suicide attempter. To be a “good” suicide attempter, one must recognize that their desire for suicide was a result of something broken in them, some disease or defect. “Good” suicide attempters wish they hadn’t attempted, and see their survival as a blessing or a miracle that gives them an opportunity to do better. They know that suicide is wrong, shameful, an inappropriate response. They know they should have asked for professional help sooner and that the pros would have saved them. They discredit their suffering, deep feelings of burdensomeness and isolation, because they were a result of illness or madness — some kind of state that left them unable to make informed choices about living or dying.

My first encounter with a “good” attempter was in It’s a Wonderful Life. George is planning to kill himself to save his business, and we get a tour of his life along with his guardian angel. George has had a series of misfortunes, and has always made the choice to do the right thing. His guardian angel tricks him into rescuing him instead of killing himself. George still wishes he had never been born. When his guardian angel grants his wish and shows him what life is like without him, he begs for his life back. Once George has made this shift in perspective, everything works out for him. The town saves his business and keeps him from being incarcerated, and all his problems are solved.

A more current example of this narrative is Kevin Hines. Kevin made a highly lethal suicide attempt that only thirty-six people have survived. He has built a career in suicide prevention telling the story of regretting his attempt, and his treatment and recovery. His survival is positioned as a miracle, and his story has inspired audiences all over the world to chant, “Be here tomorrow,” in unison. Kevin is a champion of “brain health” (you can even buy brain health swag on his website) and his personal mantra is: “Life is a gift, that is why they call it the present. Cherish it always.”

There is another narrative you know. It is the story of the “bad” suicide attempter. They are angry that they lived. They don’t want to go into treatment, and may even physically attack the people who give them medications, hospitalize them, put them in seclusion or restraints. They don’t take their medications. They have likely attempted suicide before, or will again. Perhaps their suicide attempt was about vengeance. They might be hearing voices or having visions or experiencing an extreme state. Perhaps they drink or use drugs and don’t have any intention of stopping. They’re called noncompliant, combative, manipulative. People might even claim they weren’t really suicidal; they just wanted attention.

Glenn Close’s character Alex Forrest in Fatal Attraction is the epitome of the “bad” suicide attempter. She is portrayed as using her suicide attempt as a manipulation. Instead of getting traditional mental health treatment following her suicide attempt, she stalks and terrorizes the man who was cheating on his wife with her. She is vengeful and violent, pouring acid on his car and boiling his pet rabbit in a pot on his stove. He comes to her apartment and nearly strangles her. Following the attack, Alex shows up at his home, clearly mad, wielding a knife, self-harming, and ranting about her resentment of his wife. Ultimately, her lover and his wife murder her.

In reality, some people’s experiences fit into these categories, but many people really land somewhere in between. But these narratives are powerful. As a suicide attempt survivor, I have felt immense pressure to tell my story the “good” way. I have done it many times, especially in efforts to avoid forced treatment or to be respected within the suicidology community. But I am not a good suicide attempter. Following my suicide attempt and a series of treatments that were utter failures, I made a series of decisions that put me squarely in the “bad” survivor category. I stopped therapy. After being told by the pros that I needed to adjust to the idea that I was disabled and would likely not be able to go to college, hold a job, or live on my own, I did all of those things. Mental health professionals proved themselves over and over to be unable to understand or interpret my experiences, even with the use of their own tools. My diagnosis history is like a tour of the DSM. With every new diagnosis, I got a new set of pills with a new set of side effects. The side effects were debilitating and horrifying. I quit taking them without the support of a psychiatrist because no psychiatrist would support me. The voices the psychiatrists had spent so much time trying to eradicate persisted through every round of medication, and I wanted them to stay. Suddenly, in my 20’s, I was the worst kind of suicide attempt survivor. A voice-hearing, un-medicated ex-patient who used substances, rarely slept, and had a tenuous connection to the reality that others were experiencing.

As a “bad” suicide attempter — a mad woman — my credibility was always suspect. Interactions with police and psychiatry landed me in involuntary holds a handful of times even though I wasn’t suicidal. I experienced restraint, seclusion, and forced medication. After becoming an ex-patient and committing to living in my madness, the only times I had real thoughts about suicide were during forced treatment.

I used to think there was something wrong with me that caused treatment to be such an utter failure. If being a “good” suicide attempter means you voluntarily go to the hospital and get treatment, and being a “bad” suicide attempter means you go to the hospital and get treatment involuntarily, it should follow that hospitalization prevents suicide, right?

Wrong. In a keynote presentation at the American Association of Suicidology in 2016, Dr. Marsha Linehan, the founder of DBT (a program implemented pervasively in inpatient settings), said that there is not “a single shred of empirical evidence showing that hospitalization prevents suicide.” A study published in JAMA Psychiatry found that for three months following psychiatric inpatient treatment, all patients — not just those who were admitted for suicidal thoughts/behaviors — experience suicide rates 100 times higher than the global suicide rate. Another study found that one-third of all suicides among patients with mental disorders occur within three months of discharge from an inpatient psychiatric unit. A third study found that rehospitalization predicted more severe suicide ideation among adolescents. In fact, suicide prevention generally has failed — the CDC reports that suicide rates have gone up more than 30% in half of the states in the U.S. since 1999.

Since we know “good” and “bad” suicide attempters are all funneled to hospitalization, and we know hospitalization increases people’s risk for suicide, our deep cultural investment in these narratives about suicide attempt survivors must come from somewhere else. I believe that this dichotomy is rooted in a cultural investment in a medicalized understanding of mental health experiences that systematically privileges sanity over madness.

The Preservation of Hegemonic Sanity

In Marxist philosophy, cultural hegemony is the domination of a culturally diverse society by the ruling class, who manipulate the culture’s beliefs, explanations, perceptions, values, and mores so that their imposed worldview is accepted as normative, universal, natural, and inevitable, as opposed to artificial social constructs that benefit only the ruling class. Hegemonic sanity systematically privileges people whose experiences and presentations align with the characteristics we have assigned to sanity and avoid the characteristics of madness. The practice of hegemonic sanity relies heavily on the medical model of mental health, and is reinforced and enacted through psychiatry and hospitalization (among other cultural institutions like media). Hegemonic sanity creates and is supported by epistemic injustice, which undermines the credibility of mad people’s testimonies of their experiences and makes them less inclined to believe their own experiences. Hegemonic sanity tells us that people who experience trauma, crisis, substance use, extreme/altered states or psychiatric diagnosis are afflicted by madness, a disease or defect that can be treated and managed. Because madness is constructed as a personal deficit, it is the individual that needs to assimilate to society, not society that needs to accommodate difference.

Our cultural investment in the narrative of “good” and “bad” suicide attempters seems to be rooted in the preservation of hegemonic sanity. Good suicide attempters are really just individuals who describe their experience in a way that validates hegemonic sanity. They recognize that the suicide attempt was a result of an illness, and comply with treatment. Not only do they comply with treatment — they get better! This affirms that there is something wrong with the individual that needs to be managed, and absolves the community of any responsibility to accommodate madness or prevent experiences that might lead to it.

“Bad” attempters, however, challenge the status quo. When we don’t “get better” and attempt again, when we don’t find usefulness in treatment and medication, when we point to things in our communities that cause our suffering instead of pointing at ourselves, we destabilize hegemony. We cause small hiccups in the system. The system’s response is to attack us. It pushes us into treatment, discredits our experiences, and tells our community we are volatile and dangerous. The more we resist, the more forceful the implements of hegemony will try to bend us to their will. Social condemnation gives way to “welfare” checks which lead to 72-hour holds, certifications, and incarcerations (particularly for people of color). And when we want to die to end our suffering or to escape the endless threats to our liberties, our continuing suicidal intensity is used as further evidence of our incompetence.

None of this ideology is rooted in reality. The CDC reported this year that its previous claims were wrong — more than half the people who die by suicide do not have a mental health condition. The same report details the many other factors that contribute to suicide, including relationship problems, recent past or impending crisis, criminal legal problems, loss of housing, and job/financial problems — all of which are not a result of personal illness or defect, but external factors. So suicidal people cannot be diagnosed by the very system that pathologizes their suicidal thoughts. That system has also failed to produce a reliable method of assessing people’s risk for suicide. And when that system does respond to suicidal thoughts, hospitalization actually increases the risk that a person will die by suicide. The mental health system’s “management” of suicidal people is, at best, an utter failure.

Despite the obvious failings of suicide prevention, hegemony reifies the narrative of the “good” and “bad” suicide attempter as a mechanism of ensuring sane privilege. The narrative is so powerful that we begin to understand our own experiences through that lens. Resisting this narrative is dangerous because it is punishable by isolation, imprisonment, abuse. Resisting this narrative may also mean killing ourselves.

An Anti-Sanist Approach to Suicide

When we begin to strip away the ideology of hegemonic sanity, we can more cogently address suicide. An anti-sanist approach to suicide creates space for madness. It never takes suicide off the table, and protects an individual’s right to make decisions about living and dying without forced intervention.

Implementing an anti-sanist approach to suicide does not mean that we do nothing for people who are suffering, but that we will not forcefully do anything. It requires us to shift from screening and assessing to exploring and understanding. Under this framework, when a person tells us they want to die, we can respond with, “tell me more… how did you get to this point?” We hold space for suffering. If the person wants us to, we can problem solve and adjust their environment to make it feel safer. We can ask what they need. And ultimately, we can trust them to know and make the choice that is best for them.