AT THE AGE of twenty-nine, I was in my last year as a registrar in psychiatry at the University of Padua in northern Italy. As was customary in that school at the time, I was assigned – for the first time – a newly appointed registrar, four years younger than me. My role was to guide him in his clinical and research developments. A more senior staff member was in charge of supervising both of us.
In those days, the Department of Psychiatry was deeply characterised by the psychoanalytical approach, and we were strongly encouraged to make a full immersion into the theories of Freud and his followers. However, my inclination was towards other theories. From a very young age, I'd been intrigued by the mind-body interaction, and I wanted to understand how the brain (cells, nerves and the like) could be the origin of feelings and thoughts. The possibility that negative emotions, or symptoms like depression and anxiety, may provoke alterations and diseases in the body fascinated me. I hoped that my choice of psychiatry could help clarify these issues.
In any case, with some reluctance, I started my psychoanalytical therapy/training. I must admit that, more than an expression of an authentic credo, it was a way of being accepted by the local psychiatric environment.
The young registrar was soon revealed to be very nice: intelligent and witty, always cheerful and ready to make fun of everything, he nonetheless seemed seriously motivated to become a researcher and shared my passion for the mind-body interface. Consequently, as two clandestine researchers – and as far away as we could get from our supervisor – we started a "forbidden" study of psychosomatics. At that time I had the firm conviction that certain people, characterised by a particular personality type and particular behaviours, were more exposed than others to the risk of myocardial infarction. The theories of an American scientist, Professor David Jenkins, appealed to me. He thought that there were two main patterns of behaviour, Types "A" and "B", which were associated with totally different predispositions to cardiac diseases: Type A the assertive, hard-driving, ambitious and aggressive, and Type B the relaxed, tolerant, contemplative and spiritually oriented. Intuitively, As were at risk, while Bs were relatively protected. In almost-hidden contact with Professor Jenkins, we started to study a population of survivors to verify whether their personalities and behaviours were in line with our expectations.
My young co-worker was the son of a well-known professor in the same Faculty of Medicine. Potentially being under special scrutiny because of this did not affect my audacity. On the contrary, the presence of an important family name fortified my determination in that very innocuous conspiracy against the psychoanalytical establishment. We know that universities should be flag-bearers of intellectual freedom, but we also know that this is rarely so. And even if our aim was merely to study something that interested us, side-effects of our deviant behaviour were to be feared. To reduce their impact, we also started some studies on psychoanalytical topics.
Of course, the cover-up lasted only l'espace d'un matin. We were not expelled (that would have been too much), but the strong antibodies the environment generated against us soon became very significant. We were not made part of mainstream initiatives, and we obtained only limited access to funding opportunities. Heresy has a price, as history teaches, and I learned later that our department was certainly not the only institution in which psychoanalysis was professed as a religious doctrine rather than treated as a science. Anyhow, that ridiculous discrimination cemented our cooperation, and transformed us from accomplices into friends.
ABOUT THREE YEARS after the beginning of our research on Type A behaviour patterns, the first paper appeared in a reputable medical journal, and other research followed over the next two years. As soon as I received a copy of the publication, I called my friend to invite him for a toast in celebration of our small achievement.
On the phone he said that he was very busy, but he would try to make time for a meeting over the weekend. I didn't hear from him, but paid no particular attention to that: he often disappeared for days with his girlfriend of the moment (he seemed to be a prodigious tombeur de femmes) and, without a formal contract with the department, he normally came only to see me and discuss our research projects. But two weeks without communication had never occurred before.
My concern did not last too long. One morning, Anna – a colleague with whom I shared a room at the institute – did not greet me with the usual "Ciao". Instead she said: "Have you heard?"
"Heard what?" I replied without particular apprehension.
"He killed himself. Didn't you realise how much that guy was suffering?"
In pronouncing the verdict sanctioning my perennial incompetence, Anna passed to me a copy of the local newspaper. A two-column article explained that my friend had shot himself at dawn with his father's pistol in a bushy area of the hills surrounding Padua. Apparently he had walked for quite a while before reaching the place.
I could not believe it. It must have been someone else, maybe with the same name and profession, but not him. My eyes full of tears, I read and reread the article. I refused to believe that my friend – my splendid, intelligent, brilliant friend – was the same person who had carried out this insanity. And, God, I did not see him suffering at all! How could Anna say something like that? Anna, who had continued to stare at me while I was frantically searching backwards in my memory files for some hints in justification of the senseless act, did her best to demolish me.
"What sort of psychiatrist are you going to be if you are not even able to understand the people around you?"
More than twenty years later, I still distinctly remember Anna's words. Indeed, I remember everything of that moment: the colour of the day, the dress she was wearing, the smell of Toscano cigars in the room (we smoked in hospitals then), the newspaper over my desk. And, of course, Anna's accusatory eyes.
The family of my young colleague and friend never sought any contact with me. They held a private funeral and never replied to my long, passionate letter. This made everything even more traumatic and painful. His death remains forever a mystery to me; the silence from the family was absolute. A few rumours suggested that he had been abusing drugs (cocaine? amphetamines?) or had been sick. But sick from what? He looked to me absolutely normal – and certainly happier than me, to be honest.
SUICIDE IS THE worst of all human tragedies. Not only does it often represent the epilogue to unbearable suffering for the person who commits it, but also it may be the source of incredible pain for those who survive the loss. It may constitute a life-changing experience. The most common reactions are disbelief, guilt, anger, anxiety and depression, but survivors may also experience fear of becoming crazy, fear of being predestined to suicide, and being stigmatised forever. Or they may simply feel that, without the lost person, life is meaningless, thus consider suicide – their own – as a possible way out. These psychological sufferances mark the existence of those left behind and, with different degree of intensity, may accompany them throughout their lives.
These conditions are far from rare. Based on World Health Organisation data there were approximately eight hundred and eighty thousand cases worldwide in 2003. It has been calculated that every year an average of four and a half million individuals have their lives deeply affected by a suicide. Given the fact that the scars from the event are present for life, the number of people who continue to live with the consequences of a suicide is enormous. Most struggle in search of explanations – something that may help them to recompose a more peaceful picture inside their hearts.
Since my friend's unexpected suicide, my life has been dedicated to studying and preventing suicidal behaviours. Having become a known expert, many people contact me in an effort to understand "what has happened". Parents who approach me after the suicide of children usually bring diaries, drawings and possessions belonging to the deceased, and sometimes a suicide note. They hope I might identify from this material useful elements to provide sensible explanations – why he (far more often than she) did it. When I ask whether there was any clue that may have predicted what happened, the answer is always more or less the same: "Nobody could have expected anything like that!"
How many people really know how to listen, and how many are willing to do so? Is it possible that many parents do not "have the ear", do not listen to their children? It seems that in a number of cases this is what occurs. Those parents were unable to pick up dangerous signals that could have been important warning signs. They did not pay enough attention to what was happening in the troubled lives of their sons and daughters, who shut the door on their young lives – leaving the parents, shocked and traumatised, to exchange accusations with each other and to look for ethereal culprits in contemporary society, empty of any value, materialistic, cynical. The family that educates, gives support and shelter to a child is the prime form of society for the developing individual. It is better to look inside first, and then eventually outside.
Obviously, society has responsibilities. This is undeniable. All researchers are aware of the negative influence of factors like unemployment, economic recession, individualism, separation and divorce, alcohol and drug abuse, criminal behaviour, secularisation, and so on. All these factors (and others) are important, but they merely provide what are called "epidemiological profiles" of suicidal people – which means that they simply aggregate those elements found most commonly in individuals who kill themselves.
But you cannot report this to the grieving families. They don't care about the increased participation of women in the labour force, or the lack of spirituality in society. They want specific, personalised answers. They want to understand why it happened, and why to them – the parents of a non-psychiatrically disturbed child.
This is another crucial point in suicide prevention. If a great number of suicides are affected by a psychiatric condition at the time of their death, there are also many in which there is no evidence of such an illness. Of course, these situations embarrass us most, because it would be very reassuring to think that suicide happens only to psychiatric patients. This way of considering suicide is unfortunate but deeply rooted. The Church had a role, permitting burial in holy soils only those suicide victims who were non compos mentis (i.e. mentally insane). This attitude has changed only recently. I am not saying that we don't have to fight psychiatric diseases to prevent suicide, but this would probably solve only a part of the problem.
Most people, at some stage in their lives, encounter difficult circumstances or personal crises. One in six considers suicide. Crisis intervention is crucial; once the crisis is overcome, subjects may regain control of their lives. Sometimes nobody intervenes – despite the fact that most suicidal people communicate, more or less directly, their intention to die. The fact that suicidal ideation is so widespread underscores the preoccupation about death that characterises society, which generally reacts with the denial.
Suicide is a very complex phenomenon ("The only serious philosophical problem", in the words of Albert Camus), and to be properly addressed it requires multiple remedies, including social and cultural changes.
During the more than two decades I have dedicated to the study of suicidal behaviour, many people have offered me their personal accounts of what happened to them. Probably, they just wanted me to understand better. Some have even said, "If you promise to read it, next time I'll bring with me the story of what I went through." And normally I promise.
At the beginning, I was just curious, then I realised that these scripts were incredibly important documents; spontaneous reports, untouched by the medical model of investigating. The stories are unique witnesses of tormented lives; amazing reports on what predisposed, fostered, and finally triggered the suicidal behaviour. In some it is difficult not to interpret the suicidal choice as coldly rational, but they are also evidence of the role of impulsivity, the influence of psychiatric conditions, and the terrible impact of stigma. Most often though they are excellent examples of life resurrection: wars that have finally been won, even if sometimes at a very high cost.