Ep. 205: Suicide with Dr. Drew (Durkheim et al) (Part One)

0:00 Mark: Our question for episode 205 is something like is suicide ever morally permissible? Or perhaps do we have any business morally evaluating suicide? And we read philosophical essays by Camus, Schopenhauer, Freud and Seneca, plus some of suicide by Emile Durkheim from 1897. Plus two multi author psychology articles from 2017, Risk Factors for suicidal thoughts, and a Meta analysis of 50 years of research and Annual Research Review, Suicide among Youth. For more information and links to many of these readings, please visit partiallyexaminedlife.com this is Mark Linsenmayer filled with thoughts about suicide, but no thoughts of suicide.

0:37 Seth: In Madison, Wisconsin, this is Seth Paskin, exhibiting risk behaviors but without predictability.

0:42 Wes: In Austin, Texas, this is Wes Owen, hanging in there. In Cambridge, Massachusetts, this is Dylan Casey.

0:49 Dr.: In Madison, Wisconsin, this is Dr. Drew Pinsky. I'm in Laguna Beach, California.

0:53 Mark: Hello, Drew.

0:54 Dylan: Hey, Drew.

0:54 Seth: Good morning.

0:55 Mark: Welcome back.

0:56 Dr.: Hey, guys. It is such a privilege. I gotta tell you, Mark, if it was any hint to my anxiety about this topic, the deluge of emails I sent you about the various details, I feel overwhelmed and unprepared.

1:09 Mark: So I think we probably all share that and I apologize to all of you. This is really a BYOB bring your own books episode.

1:17 Dylan: And Mark always brings a gigantic stack and tells us about it every day because he adds more to it. With love, Mark.

1:27 Dr.: With love.

1:28 Mark: We want to have a little bit of philosophy, a little bit of experimental psychology, a little bit of psychoanalysis, and that adds up to a lot. So, you know, everybody's bringing a different thing to the table. I don't expect us to cover or even bring up necessarily all the things, you know, I made it clear to folks that if they didn't read something that was totally fine, we did. To avoid just completely skipping over some of these authors altogether, I had an informal assignment. You know, each of us hosts was responsible for one of the short philosophy readings, so that we could just use those as wood for the fire to introduce that briefly when we get to it.

But by all means, let's. We can be pretty freeform about this. I like when Drew was on last time, it was adding some psychological depth to things that we'd already covered in previous episodes. Well, that's true to some extent here in that one of our very early episodes was on Camus on suicide. So we revisited that very shortly section of that reading. But other than that, I realized like, we really haven't covered this much before. So I felt like we should at least have the option drag out the heaps of books and see what people find interesting.

Drew, do you want to start or do you want to put it on us first and you can respond?

2:32 Dr.: I think I'm going to put it on you guys first because I feel like my job today is going to be mostly gadfly. Because I could not get out of my own way to embrace so much of the philosophical thinking on this topic because I have so much, you know, 30 years of clinical experience with actual humans attempting suicide. And that is so thoroughly colored my sense of what this is, that I found myself sort of frustrated and angry with some of the philosophy. So let me be the caboose on the comments.

3:04 Mark: All right, who else wants to start?

3:05 Seth: Then?

3:06 Dylan: I was in our little list of responsibilities was responsible for Seneca. And apropos of what Drew just said about the clinical question about suicide, and particularly related to things like depression and what we normally think of as people, people committing suicide out of either sadness or events in their lives. That whole category of thinking I was thinking in reading Seneca, because that question really isn't structured in Seneca that way. It has more to do with your living your life. And what I found myself wondering about is just what the notion of even mental health at all was for someone at year zero, which to first order, seemed like there wasn't one, except for maybe thinking that people were off.

But the notion that there would be something like genuine mental illness that would be contributing to someone's suicide. And the examples that he gives of suicide involve people seizing ending their lives as an act of freedom against harsh circumstances. You know, gladiators who choose to end their lives rather than face the gladiatorial arena, that sort of thing. For Seneca, you might also categorize is suicide as basically a end of life decision.

4:13 Dr.: I think it's in his writing where he makes one comment that is truly, to me, the most philosophical of all. The reading we did just one sentence that just cut to the core for me. He said, man should live as long as he ought, not as long as he he can. Which I thought was a very penetrating statement.

4:30 Mark: So that was from Moral Letters to Lucilius, letter 70. So there were 70 and 77 were the two that had to do with.

4:36 Dylan: Yeah, 70, which has the nice title on the proper time to slip the cable. So Seneca, possibly as a stoic, it's all about the question of living life. Well, you know, he has comments in letter 70. 7 On taking one's own life. There is no life that is not short. And another one from 77 it is. With life as it is with a play, it matters not how long the action is spun out, but how good the acting is. Makes no difference at what point you stop, stop wherever you choose, only see to it that the closing period is well turned. So this idea of what Drew referred to, that sort of pithy statement of how well you live one's life.

So for Seneca, it's choosing living or choosing dying. Both of them are an act of freedom. And that's. That's sort of the lens with which he views it. And also a corollary to that is life in and of itself isn't worth preserving on its own. And so that to me, again, in this sort of act of freedom, put me down the road of thinking about other decisions that people do for putting themselves in harm's way, whether it be battles or giving your life over to something else, whatever that may be, that the preserving of your life, regardless of circumstance, is not the point of things.

It's not worth it. And in that way, this question of what we would call, I guess, depression doesn't even factor in from Seneca's perspective, because your life was really, really unbearable for any number of reasons. It was perfectly reasonable and in fact admirable to take your life. He has like five or six examples of pretty extreme circumstances and actions that people take and how brave they were for doing so.

6:13 Dr.: And Mark, you framed this as is it morally permissible? And my understanding of the Stoics is that if you cannot achie a eudaimonic life, it's perfectly moral to kill yourself.

6:24 Mark: I think the one I pitched to you is just the second one. Do we have any business morally evaluating suicide? And Wes called me on that and said, you know, we should just use the simpler one, which is, is it morally permissible? That is what is most often debated in philosophy settings. I think, like you, Drew, I found some of that discussion a little beside the point. What interested me about this topic was considering it from the point of view of free will. That you could say, even if people under normal circumstances are making quality of life decisions using free will, if we want to say, you know, whatever compatibilist account we want to give to that, maybe we're underlyingly chemically determined, maybe we're underlyingly determined by our characters, but still we feel like this is a decision.

We regard other people as having made decisions, but we regard suicide as a mental illness. You don't make a decision to exhibit a symptom of a mental illness. So that was the question was, is even makes sense to ask about the moral permissibility of something if it's not actually a choice. If you say at any time, or at least a lot of the times when somebody chooses suicide, they're not really making a choice at all. It's the chemicals in an unusual way in their brain, have taken control of them and are making this decision that they would not make under other circumstances, just like if they were drunk.

7:32 Dr.: When Mark proposed the idea that we have to address this from the standpoint of free will and I thought about the compatibilist argument, I had a two word thought in my head as it pertains to this conversation. Oy vey. So I thought we should maybe agree to compatibilism and move on.

7:51 Wes: My objection to this whole idea that you put behavior in the category of mentally ill behavior under a different paradigm and say, well, this is all determined, and it's all determined by a kind of illness, a certain abnormality of brain chemicals, let's say, or something like that, and therefore we can't evaluate it morally. Well, we could say that about any action. We could say that all behaviors are the result of deterministic forces, things that determine our character and make us who we are, genetics, early environment, all of that stuff.

And we could say that no actions whatsoever can be morally evaluated. And really I just, I think all this is a continuum and there isn't this very strict dividing line between the so called mentally ill and the not mentally ill. You know, I think if there is such a thing as morality at all, all behavior falls into the category of something that can be morally evaluated. So even if someone is, say, homicidally disturbed, people don't cease to morally evaluate that behavior even if they know that that person is really, really messed up. And we talked about this a little bit in the Free Will episode, the Galen Strawson paper.

I think he's the one who brought up, you know, the case of a killer who had a really, really terrible childhood. You could shape this person into someone who is capable of something like that. So Yeah, I think Dr. Drew is right. We can agree to disagree. I'm not sure who's disagreeing or agreeing with what exactly, but compatibilism ultimately is the position. I accept, I accept to some extent the role of these deterministic forces. And yet I think we can think about human freedom as long as we're doing it in a sophisticated way. I think it's a real thing.

And also I think that we can morally evaluate behaviors if we're going to be in that mode of moral evaluation of behavior. It applies to all behavior. There isn't some domain subset that becomes immune to it when we use the phrase mental illness.

9:46 Dr.: Agreed.

9:47 Seth: So I'm not wearing it today, but I have a T shirt that says there is no God and we have no free will. I feel pretty strongly around that this should not be a compatibilist or determinist episode. But I will share my assignment with Schopenhauer. So let me first get to that and then I'll talk about what I think will be interesting. So Schopenhauer's point in his short paper called Studies in Pessimism on Suicide is just that the notion that suicide is a morally wrong or criminal act doesn't come along until you have monotheistic religion. So he mentions Pliny and the Ancients, which Dylan mentioned, and he says that the Bible doesn't even really have any strong evidence to suggest that suicide should be criminalized or thought of as morally wrong.

That it's something that was essentially invented by the church fathers. So he says, I think if you look in your heart, you'll see that it's not a criminal act either. But he says that doesn't mean I think it's a smart thing to do. He essentially says we want to distinguish between saying it's a crime versus saying it's a mistake. And what he means by that is that people commit suicide with a goal in mind. You don't commit suicide just for the sake of ending your life. You do it for the sake of achieving some outcome that you think will make your life better.

But there's a logical conundrum there in that the you that would be benefit from the alleviation of the suffering or whatever it is that you think death is going to free you from. When you kill yourself, you will not be there to sort of experience the benefit of having had that alleviated. He basically says that's my argument against it, but that I don't think it's a moral crime.

11:20 Wes: Yeah, it's a mistake because it thwarts our highest moral aim. Right. Which is actually to suffer.

11:26 Seth: Yes. Yeah. Schopenhauer was certainly not averse to suffering, at least as a philosophical construct. Perhaps in his own life. What struck me, and what I'll be interested in hearing from Drew about today is the paper about the risk factors. The takeaway for me about the Meta analysis of 50 years of study on risk factors is that they said in all the time that people have been studying risk factors, no one has successfully discovered a way to predict better than chance that somebody who has the risk factors will or will not actually make an attempt on their life.

And it made me question, if this is something that's really important to us as a society and really important to us as a mental health issue, why is that the case? And why is our predictive capability in our analysis of suicide so essentially poor for the last half century? And is it the same sort of thing where you look at the types of things that people care about in society? We don't put a lot of priority on addressing mental health issues in our homeless population. And is there a societal view that people who are suicidal are somehow less than or not worth the resources when we can spend another three quarters of a billion dollars over the next decade on improving, you know, breast cancer screenings to save an extra 25,000 people?

12:46 Mark: Just to throw out the citations there, that risk factors for suicidal thoughts. A Meta analysis of 50 years of research. That's Joseph C. Franklin et al. There's like 10 different authors on it, one of which is Matthew Nock. I will refer folks to the Very Bad Wizards interview with Matthew Nock over the summer here. But one of the responses, the other one that we read this annual research review, suicide among Youth by Christine B. Cha et al. Has some, you know, here are promising avenues for research. So maybe one way of answering Seth, why we haven't made progress in 50 years, but we might now is because we have smartphones now that they, that they propose, you know, that there are more and more studies of like getting real time, moment to moment.

Like, are you thinking suicidal thoughts now? Click yes on your smartphone. Are you, are you thinking now like I almost was thinking of a, a sci fi black mirror sort of scenario of everybody walks around with a digital number on their forehead that shows the likelihood that they're going to commit suicide so that everybody can, you know, that that's kind of the goal of current research.

13:42 Dr.: I have two thoughts. One is we do have one predictive finding and that is you can predict future suicide attempts based on past attempts. So somebody who makes attempts is somebody who's going to make attempts. So that's the only predictive thing we have. And then Seth asked, just that's a very, again, a penetrating question. And as I think about it, and this is what's troubled me about the whole topic, is that in medicine we think of suicide not as a phenomenon, not as a Diagnosis, but as a symptom. So to research suicide would be like researching fever.

And we don't worry so much about the symptom as much as the underlying condition. So what are the conditions predisposing to suicide, for instance? You know, one of the dirty little secrets on suicide is for sure it is unrelenting pain, that psychic pain that people are trying to escape. But for instance, in bipolar patients, they're more likely to commit suicide when they're manic than when they're depressed. So it's a protean phenomenon, suicide that is a symptom in different context addiction. And addiction has a wholly different set of manifestations.

And so we haven't really looked at suicide as the unifying phenomenon. We look at as a symptom of other illnesses.

14:57 Dylan: It sounds like you're saying that it is a symptom like fever is. And in fact, understanding it as its own phenomenon is wrongheaded in the sense that you wouldn't even expect to find a coherent set of metrics to describe suicide. Just like you wouldn't necessarily expect to find a coherent set of metrics to describe fever. Right, because it's a symptom. And what you need to do is you need to consider the different classes of conditions whose outcome results in suicide. To me, that's kind of clarifying, actually.

15:27 Dr.: Exactly.

15:28 Dylan: It's kind of clarifying because it makes like the discussion of other kinds of suicide where you say, well, is it really suicide if it's physician assisted suicide? In that realm seems to be a completely different set of questions that would be at play regarding suicide associated with bipolar disorder or suicide associated with PTSD or any of these other things, because you would understand it as a symptom of something or the endpoint of something that you really should be thinking about and analyzing in a different context.

15:57 Dr.: Well, in fact, advocates for physician assisted fill in the blank. They're asking that we please don't use the word suicide because it's not suicide. It's a physician assisted dignified death rather than a suicide per se. And one of the things, interestingly we have not done yet today is really define suicide.

16:14 Dylan: Well, yeah, but using that language is the same kind of thing that you would say, well, you know, murder is illegitimate killing. And in that realm, suicide means unjustified self harm. And so I need to come up with a different term that allows me to speak of ending one's own life or ending a life and separate out whether it's myself or someone else doing it. What context of ending a Life is acceptable.

16:41 Dr.: It's a bit of a slippery slope because there is an issue of temporality in all of this. In other words, most people that commit suicide do it because of intolerable psychic pain. I don't know if you've ever been around people that are in that kind of pain or ever experienced it yourself, but it often is something that you can not imagine suffering another minute, which is why we put them in a hospital for three days. And it passes. Temporally it passes. Though it might have been legitimate in that moment to escape the pain, it's illegitimate because they can't see the fact that the pain is going to get better.

So temporality sort of. I found myself thinking about Heidegger a lot during this whole process. I know we didn't do any reading with him, but I. And he doesn't write about it, which I found weird. The man that's being unto death, you know, all the time. I couldn't find any writing by him. And yet the issue of temporality seemed to keep coming into my thinking.

17:34 Seth: So, Drew, when you talk about putting people in the hospital and these things passing, I mean, that strikes me as suggesting are we differentiating between the psychic pain you describe, which has, let's call it waves and is temporal, tied to this temporality, versus the kind of stoic description of what could be a static or perpetual state of physical pain or I don't know what other things would classify for stoicism.

18:02 Dr.: Well, it's existential pain. Right. Life has no meaning. And I've never really encountered that person. I guess I kind of have. But when life has no meaning, eventually gets so painful that here we are back in that same state again. Wes, you would say that that's a very superficial sort of take on this. And that really from the Freudian perspective, it's about object destruction.

18:24 Wes: Right. I'm still thinking about the role of. Is it just pain? But yeah, the alternative idea, and this is the one, I guess this is a good time to present mourning and melancholia. So of course we associate suicide with depression, which Freud calls melancholia. But often, by the way, because Dr. Drew, when you were talking about the extreme emotional pain, that is really just a passing thing, I think suicide, is it highest among people with borderline personality disorder and other personality disorders.

18:53 Dr.: That's a loaded question. Borderlines are very self destructive because they're predominantly female. They're not as likely to commit to complete suicide.

19:01 Wes: Yeah. I just wanted to point out that people who are suicidal, they're often In a kind of chronic situation, even if the extreme, emotionally intense pain that might lead them to complete the act of suicide is temporary, they're usually undergoing a lot of chronic suffering. Just to give you the Freud's take on this mourning and melancholia, really, we're talking about depression, and he's using mourning as sort of the counterpoint to melancholia, where mourning might involve, for instance, the loss of a loved one, their death. And we go through this process where we gradually say goodbye to them by gradually saying goodbye to certain memories of them.

It's not an abrupt process. It involves sadness, it involves withdrawal, and eventually it runs its course. Melancholia, by contrast, and this is something where this idea of lost, Freud expands this idea to mean more than just the death of a loved one. It could be that we've been left by someone, it could be that someone has disappointed us, and it could also be that someone has disrespected or slighted us. It could be any number of things that happen regularly in human relationships that can become triggers for what you might call a melancholic reaction.

And that reaction is to, instead of going through this process of mourning, which is also a process of reality testing, according to Freud, where you come to terms with what you've lost, you sort of deny it up front, or you cut the object, you withdraw from the object, to use the psychoanalytic language up front, you cut it off consciously, but you maintain this unconscious tie to the object. And you do that by a process of identification. The ego becomes identified with the object. So the ego sort of becomes like a pacifier. You direct the libidinal energy that you might have directed outside yourself towards the loved one.

You're now redirecting at yourself as a substitute for the loved one. And that creates a situation in which the natural ambivalence towards love objects comes out. Because it's always a love hate relationship, except that it's no longer regulated the way it is normally in human relationships. You know, we can't just willy nilly express our dissatisfaction with people. We have to do it if we want to maintain a relationship diplomatically. And we have various ways in which that feeling is just regulated. The brakes are put on it. Not so with ourselves, to ourselves, we become a very easy target for self attack, for the hate side of the ambivalence to come out.

And this is something, when Freud thinks about depression, self hate and self attack, to him, those are the primary phenomena that define depression. So suicide isn't a big part of the paper, but it does come up. And the point that Freud wants to make is that it is an expression of aggression. It's not just that the suicidal person is suffering. And by the way, their suffering in the case of depression is primarily the result of self attack, of self hatred, but it's not just a result of that suffering. It's an expression of that self hate. It's an expression of an aggression that needs discharge.

And the aggression is not primarily towards the self, but towards the disappointing object with whom one has identified. So that's a very broad picture of what's going on in that paper. But yes, that does give an alternative to Drew, what you're talking about. That's another way of looking at this, which is that it's not just about the escaping pain and suffering, but it's about inflicting damage.

22:39 Mark: So I know that Freud is trying to give a scientific, mechanistic description of what's going on here, but you could also see him as a way, as sort of a double condemnation of the act that it is because it is really, you want to kill someone else and you're letting rage take you to the point of killing. It is criminal in that respect, but it's also stupid because you really want to kill someone else. You want to kill this external thing, but you've made a mistake and turned it inward.

23:06 Dr.: Yeah, you're somewhat misinterpreting the sense of object, though. Object is something in us, right, Wes?

23:12 Wes: It can be either. So there are self objects or there are internal objects. But it's both in the sense of other people are our objects to the extent that we are behaving towards them in ways that are patterned on our relationships with early objects. So, you know, the paradigmatic early object is the mother or other closest caretaker. And yes, we internalize those objects so that even when we're no longer directly relating to a mother as our object, we are relating to internalized versions of those. Is that what you meant, Drew?

23:48 Dr.: Well, I think when he used the term object, he doesn't mean other people in the world. He means something going on that we cathect from those things in the world and put in ourselves.

23:57 Wes: He defines this in three essays on Sexuality. And he defines object very vaguely as just the object of desire, Just whatever it is. And it is outside of us at this point, whatever it is that satisfies our libido, that allows our libido discharge. That's the object. But, yeah, I think you're right. As things get elaborated, we're Thinking of this as something psychically internal.

24:20 Dr.: Right. And the other thing about mourning and melancholy I thought was fascinating. When you try to distinguish between who completes mourning and who develops melancholia, he sort of throws up his hands and goes, you're just one of those people. You just get melancholia. You're just one of those guys.

24:32 Wes: Yeah, yeah. And, of course, there's a whole history after Freud of elaborations on this theory.

24:38 Seth: And.

24:38 Wes: Yeah. And through the object relations, I think, Drew, you were mentioning something related to object relations earlier. But there are lots of different ways to explain this in relation to the object. Suicide might even, for instance, involve a fantasy of merger with the object, a fantasy of this quiescent, desireless place in which one has destroyed all badness, even if that means destroying the self in order to, in fantasy, in this delusional fantasy, occupy a place, a state of ideal merger with an object. And there are all kinds of variations on this. This is in our optional article. One of the authors is Elsa Ronningstam of Harvard Medical School. It's a chapter from a textbook. Gives a very good overview on different psychoanalytic theories of suicide. But a lot of them are variations on this theme of relations to an object or internal objects.

25:33 Mark: And I like that all these. You know, that paper lists a bunch of different fantasies that could result in suicidal behavior. One of the other ones you recommended, Kate Friedlander's on the Longing to Die, is talking about somebody who really doesn't want to kill himself. He wants to gain sympathy. He has illusions about, you know, he kind of carelessly takes sleeping pills, but not enough to kill him. But it is kind of a dangerous amount because he has this fantasy that the mother who was one of the people he in real life resents, would swoop in and save him.

So the whole idea that in psychoanalysis you're trying to get rid of these illusions and as a way of treating suicides, because it's not that you've made a rational decision. My life is intolerable. It has an intolerable level of physical and. Or mental pain that is recurrent. And it's just not worth the effort on the utility calculation anymore. And the theory here seems to be that, at least in most cases, that's not the case. It's that there's something going on psychically that you don't understand. And you could come to understand, perhaps through treatment, not just, you know, give you a pill to make you feel better, but actually understand the psychic machinations that are going on and understand that you have made a mistake, that your feelings.

And people don't like to hear that their feelings could be mistaken. But that seems sort of fundamental to this approach that no, you don't understand yourself well enough. You think, you know, my life is terrible. I can't go on like, no, you don't actually understand. You need to get in therapy and figure out what's actually going on there.

26:56 Wes: Yeah, I think some of this goes back as Drew, you had mentioned. We'll have to talk more about the whole meaning of life thing because I think all of these are intimately related. I think the point is with Freud that it's not. Ultimately people can suffer a lot of pain and deprivation and not necessarily end up being suicidal. But. But there's a worse. You might still think of it as pain, but there's a worse. So for instance, someone might talk about the deprivation of not having relationships or not having a job or all sorts of circumstances in their life. If they talk about their suicidality, that's what they might talk about. But I think you have to be able to distinguish that person from other people who are in the same state, have the same level of relationship satisfaction and job satisfaction and all that stuff, and don't feel the same impulses.

27:47 Dylan: Wes, is this saying anything much different than there's a component of self loathing involved that distinguishes a symptom of suicidality regarding the pain and suffering involved as opposed to other cases.

28:02 Wes: So I was just going to say just relating it. So for instance, to Hegel and to Fonagy, some of this comes back to a need to be seen to have a part of oneself that recognizes an internal recognizer of your own existence, which I think is something that we associate with meaningfulness and a benevolent recognizer. So that relates to the internalization of objects and internalization of a self soothing function, of a self regulating function. All of those things I think are related.

28:35 Dr.: And I would just pile onto that. Just say what we're looking at is why do some people develop this symptom and some don't. I had a friend woke up middle of the night this week. I just happened to be talking to him. Developed acute suicidal ideation with intent. And he was not depressed. And he had no previous symptomatology and he couldn't understand where it came from. And everything was perfect in his life. Everything's great and he's happy. And he went to sleep happy, woke up acutely suicidal. Turned out he had a very severe endocrinological disturbance that he was not aware of.

Again, Just pointing out that the biology of suicide and the genetics of suicide figure into why one person developed these things and somebody else doesn't. So there's a dynamic aspect, what you described from Freud, like when you look back and go, why did you choose suicide? Why were you thinking about harming yourself? Well, there's the Freudian. That's one explanation. Another explanation, another contributing factor is, well, people in my family have committed suicide. There's a genetic component and there's a biological component which is massively complex sort of web that includes psychiatric neurobiological states, but also includes general body states.

People can get suicidality from biological states that are divorced from psychology.

29:48 Mark: So it seems like this frustration with, I guess, the difficulties of the psychoanalytic explanation is maybe what led scientists more to. Well, of course, that's still going on by therapists, but these. The experimental papers to just try to chart correlations. And it could be biological correlations, it could be geographical correlations, it could be any number of correlations. And I think the first one of those, perhaps. Let me throw out our final assigned author here, Emile Durkheim, in his 1897 book Suicide. So we read a few different sections of that, or at least I did.

A lot of the reason why Durkheim is interesting is just because he's basically inventing the science of sociology. And so he does say why it's distinct from psychology. I remember taking an intro sociology course my freshman year in college and reading some of this very book and thinking like, isn't this all just psychology? How can you even think that there. But he really thought that there were distinct sui generis sociological facts that you can just investigate. So he uses correlations. So he has charts of how many people in this country died by suicide in each year.

Are they male or female? Are they married or unmarried? What is their religion? And he just is looking at all these correlations and. And I guess part of what was innovative about him is he was very sensitive about how the various factors could interfere with each other. It seems like people are more suicidal when they get older. But it also seems that marriage insulates you to some degree when you're suicidal and older people are more married. So how do you separate those two things? Or even if you find a correlation, how do you figure out if there's a cause?

And so you have some very insightful discussions of his interpretations of ultimately where some of these correlations come down to. So, for instance, in this chapter two on egoistic suicide. Egoistic suicide, meaning sort of, I'm left to the devices of my own ego, as opposed to society giving me values and telling me what to do. That primitive societies, it's just entirely the society dictating the mores. And so he actually considers like what he calls altruistic suicide. People who sacrifice themselves for the group more or less, because that's what the group more say to do.

But in more developed societies, the that he's really concerned with egoistic suicide is going to be much more common. He ultimately, the way he starts to talk about this based on religion, like why are Catholics less likely than Protestants to kill themselves? And it's not just because Catholics have a stricter regimen against it. No, the Protestants have a very strict prohibition of it as well. It's just that his analysis of it at the time he was writing was that Protestants kind of leave you to put together your own religion, find your own path.

There's that emphasis on direct communication with God, whereas Catholics and even more so Jews taking a tradition and fitting themselves into it more that they don't have to figure out these things. So he generalizes from that and compares it to other things, compares it to, you know, this insulating effect that marriage has and says ultimately you get higher suicide rates when the society is not as coherent, when there's more of a breakdown, you don't have social supports, you don't know your role exactly. And then he distinguishes this egoistic suicide and altruistic suicide.

The third kind is anomic suicide, which is if you have a sudden shift in fortunes. So say you're used to a certain level of economic stability. Even if you're poor, it doesn't mean you're going to commit suicide. You could be poor in a lot of suffering. But if you suddenly have a shift, if you suddenly become poor, or even if you were poor and suddenly become rich, then that sense of dissociation also gives rise to a rise in suicide. So overall it's not having the social support. So one of the things that we thought was good in our recent episode, episode 200 on enlightenment, when you get to the point where you're thinking for yourself, this seems like a good thing.

But one of the things that comes to that is, well, if you think for yourself, then prohibitions against suicide or prohibitions against anything don't necessarily seem as strong. I guess a very Mendelssohn like way of tempering this. That also we talked about Mendelssohn in that episode Durkheim gives us is the examples of Jews who are very educated, but he says they use this education not to cast out on their own, but as ammunition for their faith. So it's not learning in itself, it's not enlightenment in itself that raises your risk of suicide, but it's enlightenment when it is not on par with what Mendelssohn calls civilization, with having a very firm idea of your place in the order of things.

Meaningfulness, ultimately. All right, so there's my little summary there. And you could see once he got those correlations going, that stretches all the way to the present of people trying to look at charts and find what types of people are more likely than others. And that's what a lot of the current science seems to have to do with.

34:32 Wes: Yeah, So I just wanted to supplement some of that and maybe read a few things, because I think some of this, the anomic part, I mean, it's really fascinating and Durkheim is a very pleasurable writer to read, by the way. The anomic part of it is just. Society performs this function of being able to regulate our impulses by telling us what we can and can't have. So the way we internalize our roles in society. So, for instance, if we think we have to get married and not cheat on our spouse, our sexual frustrations are to some extent contained. That's just the way things have to be.

But if we're a bachelor forever, the sky's the limit. Then our sexual frustrations become more urgent. There's no longer any raison d' etre for them to be curtailed in some way. So that's that part of it. And then the egotistical part of it. Part of this is that we have needs. We have social needs that are unlike animals, that are predicated on the process of socialization. We've internalized the mores of society. So, for instance, page 170. Indeed, the whole range of functions concern only the individual. These are the ones that are indispensable for physical life.

Since they are made for this purpose only. They are perfected by its attainment in everything concerning them. Therefore, man can act reasonably without thought of transcendental purposes. These functions serve by merely serving him. So these are like physical functions, eating and sex and things like that. Insofar as has no other needs, he is therefore self sufficient and can live happily with no other objective than living. This is not the case, however, with the civilized adult. He has many ideas, feelings and practices unrelated to organic needs.

The roles of art, morality, religion, political faith, science itself are not to repair organic exhaustion nor to provide sound functioning of the organs. All this supraphysical life is built and expanded not because of the demands of the cosmic environment, but because of the demands of the social environment. The influence of society is what has aroused in us the sentiments of sympathy and solidarity drawing us toward others. It is society which, fashioning us in its image, fills us with religious, political and moral beliefs that control our actions and to some extent create needs in us.

Right. So we've had certain needs created. And this goes back to this distinction between the cause of suicide being mere suffering, as in mere deprivation, which we might think of in its purest form as, you know, being without the things that sustain our bodies, to the social elaboration of that where our suffering is predicated on not having these social needs met, including having a certain comportment to others, awareness of us, to their recognition. That could be status, that could just be getting the love that we want, but also having that internalized comportment to ourselves.

So I think this all connects up to the meaning of life on the one hand and the psychological stuff on the other.

37:37 Dylan: I was just going to bring the notion of shame into there. That the social aspect of shame that comes with a self loathing that has to do with the way you're pictured by others.

37:51 Wes: Yeah, a fantasy of the way others see us. That's what's going on, I think.

37:56 Seth: So all of this talk is starting to ring a little theoretical to me. And I want to kind of get back to the notion that suicide is a symptom. And this idea about if we bring in the notion that it's a social ill, what is the empirical response? What's the tactical response to dealing with this? If it is because like a fever, you can treat a fever by just putting somebody in an ice bath, Right. Or you can give them pills and then the fever goes away. And you think to yourself, all right, well, maybe it was a virus that was causing it and if it doesn't come back, great, we've got immunity for the future. And if it does come back, then maybe there's some underlying cause that we need to treat.

38:36 Dylan: Just on this analogy, wouldn't we have to say that suicide is a symptom of sometimes and that there may be cases where it's not a symptom? I mean, in that way of thinking about it, it's always the case that suicide is a symptom of an underlying psychic illness. And therefore it's categorically not the case that you could have a rational choice in that way. This gets us back to the problem with the Term as being wrongful, self harm and stuff like that. When we cite the fact that more people die by suicide than car crashes in this country, that the gigantic majority is the aspect in which it's a symptom, but as a category, it gets muddied because that would predefine the scope, which seems to be not quite right in general.

39:30 Seth: Okay, Well, I mean, even if we were going to limit it to the scope of times in which it's a symptom, I mean, my point is that there's a tactical intervention that's required and then there's an acknowledgement that as a symptom, as Drew said earlier, it will recur. It's not simply something that will pass and that you'll gain immunity to. It's going to recur as a symptom and that the underlying causes need to be treated. The challenge, what I heard was that we don't have a good understanding, not necessarily of all the different risk factors, you know, potential causes, but how they interact with each other.

And the Franklin research paper was saying it's not that we can't identify all the risk factors, it's that we don't understand the way that they interact with each other in order to be able to a predict who's truly at risk and who's not, but also presumably how you could, if you understood the way they interacted, you have a better chance of a therapeutic intervention to address the causes. And so I thought what was being suggested was that there needs to be more of a modern, data driven, analytic, artificial intelligence kind of approach to looking at all these different symptoms and trying to identify the way in which they interact with each other so that we could correctly categorize and then identify and treat people who have different types of risk factors.

40:55 Dylan: Yeah, but this is a characteristic of risk factor in general. What that article is saying in the end is that we don't have a metric for suicide. We don't have a metric that can go prospectively and take things like risk factors. We can go backwards and say, yes, these kinds of things make it more likely, but in the end, we can't predict based upon you having those things better than a flip of a coin, the actual outcome. But that's going to be true of anything that is dominated by risk factors. Right, but the risk factor of a ball hitting the ground when you throw it up in the air is that it doesn't work the same way.

41:31 Dr.: Yeah. According to Durkheim, you just need to be Jewish or Catholic and married and boom, done.

41:37 Seth: Hey, I'm safe.

41:38 Mark: You know, this is one of the texts I came in here wanting to read. And when I raised this to Drew, he's like, well, all right. That's when we're operating from a point of ignorance. And now with subsequent research were coming from a better place. Did actually looking at some of the Durkheim change your mind on this or you think this is kind of irrelevant?

41:56 Dr.: Sociologists drive me crazy, and Durkheim in particular drives me crazy. But I like Wes, love his writing and I think he's brilliant. But to, you know, look at the behavior, say of an ant population and disregard completely what the pheromones and the biology of the ant, you just don't get the whole story. And it's all correlative, as you're saying. Seth keeps issuing us a challenge here, and we're not rising to it because I don't think it is answerable now. But Seth, I will tell you that the direction research is going is trying to look at these risk factors, look at the underlying diagnoses, and really define with far greater accuracy the underlying neurobiology.

And then trying to look at things that are likely to affect treatment. For instance, paper just came out yesterday that was looking at certain kinds of depression, which inevitably the term suicide gets involved with that. But they're starting to parse out depression of other causes as opposed to depression in the setting of childhood trauma. And in the setting of childhood trauma you have many other phenomena operating, including, as Wes pointed out, personality disorders that can have self destructiveness as a feature of the disorder. So they're beginning to parse it out that way.

But your challenge I don't think we can rise to today. I don't think we have the answer.

43:13 Seth: Well, that's fair. But what is it going to take for us to put the resources on it to get that answer in contrast to where so much other money is being spent? The reason why this is of interest to me is that suicide in a family can function in the same way as like cancer. Cancer has a way of devastating individuals, but then devastating the families that those individuals are in for a variety of reasons. And I see this in my wife's family and friends. She had a cousin who committed suicide. She has several friends whose fathers committed suicide.

And it haunts, you know, it's like a specter that just hangs over especially Drew, when you're talking about genetic factors. Anytime we get a phone call from certain people in our circle, we don't know what's going to happen when we pick up the phone. And that kind of experience of living, I'm sure for the people involved, but also for the people in their circle, is really traumatic and anxiety inducing. And so, you know, these are people, obviously you can't make people go to therapy and some people can't afford it. And, you know, and all this.

But it's very, very difficult to be in the circle of somebody who's a potential risk when you aren't a professional and when you don't have the means to help them out all the time.