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Working in the Dark: Understanding the pre-suicide state of mind
Working in the Dark focuses on the authors’ understanding of an individual’s pre-suicide state of mind, based on their work with many suicidal individuals, with special attention to those who attempted suicide while in treatment. The book explores how to listen to a suicidal individual’s history, the nature of their primary relationships and their conscious and unconscious communications.
Campbell and Hale address the searing emotional impact on relatives, friends and those involved with a person who tries to kill themself, by offering advice on the management of a suicide attempt and how to follow up in the aftermath. Establishing key concepts such as suicide fantasy and pre-suicidal states in adolescents, the book illustrates the pre-suicide state of mind through clinical vignettes, case studies, reflections from those in recovery and discussions with professionals.
Working in the Dark will be of interest to social workers, probation officers, nurses, psychologists, counsellors, psychotherapists, psychoanalysts and doctors who work with those who have attempted suicide or are about to do so.
Campbell and Hale address the searing emotional impact on relatives, friends and those involved with a person who tries to kill themself, by offering advice on the management of a suicide attempt and how to follow up in the aftermath. Establishing key concepts such as suicide fantasy and pre-suicidal states in adolescents, the book illustrates the pre-suicide state of mind through clinical vignettes, case studies, reflections from those in recovery and discussions with professionals.
Working in the Dark will be of interest to social workers, probation officers, nurses, psychologists, counsellors, psychotherapists, psychoanalysts and doctors who work with those who have attempted suicide or are about to do so.
128 pages, Kindle Edition
Published March 16, 2017
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Displaying 1 - 8 of 8 reviews
June 21, 2024
A psychoanalytic take on suicide and how to manage suicidality in the room with a patient. Interesting vignettes, incorporating psychoanalytic theory in suicide fantasies and talking about the collusion of the therapist with the patient. Found it interesting and enriching to the therapeutic work.
September 26, 2024
In suicide, the unconscious fantasy often revolves around settling old scores from unfinished and unacknowledged battles of childhood. These are memories that reside in that part of the patient’s mind of which he is unaware and of which he has no understanding. Freud (1909) described these memories as ghosts which compulsively haunt the patient. ‘That which cannot be understood inevitably reappears; like an unlaid ghost that cannot rest until the mystery has been solved and the spell broken.'
The painful reality, which every therapist needs to come to terms with, is the fact that it is always within the patient’s power to kill themselves. [...] There may come a time in the therapy that the therapist has to communicate this reality to the suicidal patient. This statement to the patient in no way implies that the therapist does not care or condones suicide. On the contrary, it implies that the patient will only move on from the suicidal state of mind if the therapist can take the risk of letting the patient be responsible for his or her own life. Psychic change can only take place when the patient is free to act and the analyst is free to analyse. If either the patient or the analyst is operating under external pressure, coercion or moral blackmail, the best that can be hoped for is compliance rather than real permanent psychic change.
The word crisis has come to connote a situation with potential for danger; but the original meaning is broader – it is a turning point, a crossroads, a state of affairs in which a decisive change for better or for worse is imminent. The pre-suicide state of mind is a mind in crisis that is balanced between acting out a destructive fantasy or learning from the fantasy. Suicide may always remain an option for some suicidal individuals, but it is our belief that some resolution of the underlying conflicts will play a crucial part in reducing the suicidal potential.
February 28, 2026
except psychoanalysis terms, it is a good initial for this topic.
people who self-mutilate
will often tell you that they experienced the endorphin high before
cutting or burning themselves. This has two results: first, the physical
pain is not experienced, and second, the psychological experience is of
elation, sexual excitement and relaxation of superego control
the therapist must be aware
that if they take someone on for therapy following a suicide attempt and
after a gap, or referred “second hand” from another clinician, they may
be implicated in another suicide attempt. Indeed, this may be a necessary
part of the therapeutic process; a daunting prospect, but a real one. It
also emphasises the importance of continuity and reliability for the
suicidal individual
To establish the extent to which the patient can look inwards at the
reasons for his actions. Surprisingly, this is often much easier for
the patient in the disturbed state of mind immediately following a
suicide attempt. A helpful technique to encourage this process is
that of the action replay. In this, the patient is encouraged to give a
detailed account of the events leading up to the day of the suicide,
to the hour and then the actual minute. As the patient recalls the
details, both he and the therapist are often given much more direct
access to the affects and fantasies which motivated the act.
He was, in fact, in the midst of a narcissistic
regression sustained by the prospect of imminently fulfilling his merging
suicide fantasy. As far as the patient is concerned, he is already at peace
because he has crossed a rational barrier of self-preservation and now
positively identifies the assassin (his body) and has no doubt about
killing it. In a sense, a psychic homicide has already occurred.
The analyst was alerted to the existence of the
assassination fantasy by its enactment in Mr Adams’ neglect of his
body, slovenly dress and poor hygiene. In this way, the analyst was able
to bring Mr Adams’ assassination fantasy into the analysis
A decisive factor in a successful suicide attempt appears to be the
implied consent or unconscious collusion between the patient and the
person most involved in the psychic struggle’
Paraphrasing Asch (1980), implicit or explicit blackmail has
this message: ‘Unless you see me more often or cancel your holiday, I
will kill myself. I will commit suicide because you failed me. It will be
your fault. You will have driven me to it. You will have killed me’. The
danger in giving in to this demand is that it will endorse the fantasy that
someone else can completely take over responsibility for the patient’s
body, and in so doing sanction the abdication of responsibility for his
actions. The worker will have to find ways of making this aspect of the
fantasy clear to the patient, especially his wish to deny his own violence
towards his body and the sadistic use of it against others.
On the other hand, the suicidal individual may experience the
practitioner’s refusal to satisfy these demands as a rejection, as though
abandoning them to die. This is why blackmail must always be taken
seriously. Beneath the sadomasochistic dynamic may lay a terror that
the patient no longer feels safe in his own hands and is really asking for
protection against himself
Many suicidal
patients suffer from poor self-esteem, are severely self-critical and feel
themselves to be failures. An actual failure, for example getting sacked
or failing an examination, is a danger signal because it is experienced as
confirmation by the outside world of what the patient feels about himself.
Hope for rescue from outside is lost.
When the individual is in therapy the therapist inevitably and
necessarily becomes another person with whom the sadomasochistic
relationship exists and is likely to fail them either by abandonment or
humiliation.
We have found that suicidal individuals
experience even a minor rejection or disappointment as a catastrophic
blow to their self-esteem and psychic integrity, which then dramatically
undercuts their capacity to cope. As psychic defences are breached, the
body is felt to be at extreme risk. There follows a regressive longing to
merge with the primitive omnipotent caretaker. In this state, the
individual is vulnerable to re-experiencing primitive anxieties of
annihilation: either being engulfed by the object if they succeed in
merging, or being abandoned to starve if they are unsuccessful in getting
‘into’ the object
Conrad did not have a sufficiently satisfying affective
relationship with his mother, which left him in a state of narcissistic
depletion that was often felt in his body. ‘The absence of pleasurable
bodily experiences which can be registered at a psychic level creates an
unbridgeable gap or hole in the nascent sense of self that can only be
“covered over” by the use of [the] primitive defences of splitting and
projection’ (Schachter, 2014, p. 29). In Conrad’s case, this resulted in a
negative cathexis of his body, which he attached in several suicide
attempts.
When the ego is successful,
it enjoys the superego’s approval and protection. When the ego fails to
live up to the superego’s prescriptions or transgresses the superego’s
proscriptions, it experiences shame and guilt. We have often found that
death by suicide symbolises or re-enacts a sort of abandonment of the
ego by the superego. It is a situation similar to severe rejection by a
loving and protecting mother (Freud, 1923, pp. 53–58)
people who self-mutilate
will often tell you that they experienced the endorphin high before
cutting or burning themselves. This has two results: first, the physical
pain is not experienced, and second, the psychological experience is of
elation, sexual excitement and relaxation of superego control
the therapist must be aware
that if they take someone on for therapy following a suicide attempt and
after a gap, or referred “second hand” from another clinician, they may
be implicated in another suicide attempt. Indeed, this may be a necessary
part of the therapeutic process; a daunting prospect, but a real one. It
also emphasises the importance of continuity and reliability for the
suicidal individual
To establish the extent to which the patient can look inwards at the
reasons for his actions. Surprisingly, this is often much easier for
the patient in the disturbed state of mind immediately following a
suicide attempt. A helpful technique to encourage this process is
that of the action replay. In this, the patient is encouraged to give a
detailed account of the events leading up to the day of the suicide,
to the hour and then the actual minute. As the patient recalls the
details, both he and the therapist are often given much more direct
access to the affects and fantasies which motivated the act.
He was, in fact, in the midst of a narcissistic
regression sustained by the prospect of imminently fulfilling his merging
suicide fantasy. As far as the patient is concerned, he is already at peace
because he has crossed a rational barrier of self-preservation and now
positively identifies the assassin (his body) and has no doubt about
killing it. In a sense, a psychic homicide has already occurred.
The analyst was alerted to the existence of the
assassination fantasy by its enactment in Mr Adams’ neglect of his
body, slovenly dress and poor hygiene. In this way, the analyst was able
to bring Mr Adams’ assassination fantasy into the analysis
A decisive factor in a successful suicide attempt appears to be the
implied consent or unconscious collusion between the patient and the
person most involved in the psychic struggle’
Paraphrasing Asch (1980), implicit or explicit blackmail has
this message: ‘Unless you see me more often or cancel your holiday, I
will kill myself. I will commit suicide because you failed me. It will be
your fault. You will have driven me to it. You will have killed me’. The
danger in giving in to this demand is that it will endorse the fantasy that
someone else can completely take over responsibility for the patient’s
body, and in so doing sanction the abdication of responsibility for his
actions. The worker will have to find ways of making this aspect of the
fantasy clear to the patient, especially his wish to deny his own violence
towards his body and the sadistic use of it against others.
On the other hand, the suicidal individual may experience the
practitioner’s refusal to satisfy these demands as a rejection, as though
abandoning them to die. This is why blackmail must always be taken
seriously. Beneath the sadomasochistic dynamic may lay a terror that
the patient no longer feels safe in his own hands and is really asking for
protection against himself
Many suicidal
patients suffer from poor self-esteem, are severely self-critical and feel
themselves to be failures. An actual failure, for example getting sacked
or failing an examination, is a danger signal because it is experienced as
confirmation by the outside world of what the patient feels about himself.
Hope for rescue from outside is lost.
When the individual is in therapy the therapist inevitably and
necessarily becomes another person with whom the sadomasochistic
relationship exists and is likely to fail them either by abandonment or
humiliation.
We have found that suicidal individuals
experience even a minor rejection or disappointment as a catastrophic
blow to their self-esteem and psychic integrity, which then dramatically
undercuts their capacity to cope. As psychic defences are breached, the
body is felt to be at extreme risk. There follows a regressive longing to
merge with the primitive omnipotent caretaker. In this state, the
individual is vulnerable to re-experiencing primitive anxieties of
annihilation: either being engulfed by the object if they succeed in
merging, or being abandoned to starve if they are unsuccessful in getting
‘into’ the object
Conrad did not have a sufficiently satisfying affective
relationship with his mother, which left him in a state of narcissistic
depletion that was often felt in his body. ‘The absence of pleasurable
bodily experiences which can be registered at a psychic level creates an
unbridgeable gap or hole in the nascent sense of self that can only be
“covered over” by the use of [the] primitive defences of splitting and
projection’ (Schachter, 2014, p. 29). In Conrad’s case, this resulted in a
negative cathexis of his body, which he attached in several suicide
attempts.
When the ego is successful,
it enjoys the superego’s approval and protection. When the ego fails to
live up to the superego’s prescriptions or transgresses the superego’s
proscriptions, it experiences shame and guilt. We have often found that
death by suicide symbolises or re-enacts a sort of abandonment of the
ego by the superego. It is a situation similar to severe rejection by a
loving and protecting mother (Freud, 1923, pp. 53–58)
June 3, 2019
Emphasis on psychoanalysis and Freud. Not sure how helpful it is in practical terms for Crisis Prevention Intervention or addressing Suicidality. Depends on your theoretical orientation I suppose, however, if you are not knowledgeable about Freud's work not sure how helpful this would be for you.
December 28, 2023
I cannot in good conscience rate this book at more than 2, and that is why:
That's not the only paragraph that was a cause for my concern, albeit it is definitely the nail in the coffin.
As a psychologist and psychotherapy adept (studying the TFP approach) it's beyond my understanding to still in 2017 (!) write such crap in a book that actually didn't even need mentioning this point of view. It could have been easilly avoided, but
I guess someone felt the itch to share their believes. It could have been a great book.
This being said, I have learnt a lot of good stuff from this book, especially on the basics of why patients commit suicide and what to look out for. I can recommend some chapters.
In therapy with patients who were searching for sexual reassignment surgery (SRS), we found that several of them had displaced their impulses to mutilate themselves onto surgeons, so that one component of their fantasy was self-mutilation by proxy. Both the self-mutilator and those mutilating by proxy projected rage against the mother onto the body. Perhaps paradoxically, these patients who were pursing SRS often identified the surgeon with their mother who they felt hated their masculine body.
Alessandra Lemma's (2015) clinical work with patients who requested SRS found that beneath the delusion that gender could, in fact, be assigned' surgically through SRS, these patients had found a way of representing, unconsciously, the incongruity of the subject's gender identity.
That's not the only paragraph that was a cause for my concern, albeit it is definitely the nail in the coffin.
As a psychologist and psychotherapy adept (studying the TFP approach) it's beyond my understanding to still in 2017 (!) write such crap in a book that actually didn't even need mentioning this point of view. It could have been easilly avoided, but
I guess someone felt the itch to share their believes. It could have been a great book.
This being said, I have learnt a lot of good stuff from this book, especially on the basics of why patients commit suicide and what to look out for. I can recommend some chapters.
May 30, 2022
Deep, analytical understanding of the pre-suicidal state. Case studies included are helpful. I am glad the authors discuss the heavy emotional impact of this line of work, and am very grateful that experts like these exist to aid our understanding of a tragic phenomenon that has puzzled many a great mind for centuries. This book is not for the faint-hearted, however allows a healthcare professional working with distressed individuals a new perspective from experienced psychoanalysts. I wish I had read this years before.
July 28, 2022
Excellent and informative psychodynamic analysis of suicide, and to a lesser degree self-harm. Will come back and read this book again.
August 5, 2023
Interesting at points but very focussed on psychoanalysis and psychodynamic theory that wasn’t very well explained unless that’s your area of expertise
Displaying 1 - 8 of 8 reviews