One of the wards in the hospital in which I work is designated for patients who have poisoned themselves by deliberate overdose. We treat about 1,200 cases a year there, so each day I go to work firm in the conviction that by now I've heard everything that human foolishness, depravity, fecklessness, and cruelty have to offer by way of narrative. But each day my faith in the ability of human beings comprehensively to ruin their lives is renewed: not for nothing did Tolstoy write at the beginning of Anna Karenina that every happy family is happy in the same way, but every unhappy family is unhappy in its own way. Of course, it would be an exaggeration to call the social arrangements in which most of my patients live families, but still the point is made. Truly, the ways of human misery are infinite.
Let us take a snapshot of the ward, and examine the previous day's catch from the great ocean of unhappiness that lies all about us.
In the first of the six beds is a young woman of West Indian descent, aged 21, who has dyed her hair orange and painted her nails bright yellow. She tells me that she was once a nursery school teacher but then went "on the sick" with an illness about whose nature it would be indelicate to ask, since it is obviously wholly fraudulent—the product and not the precondition of receiving sickness benefits from the public purse. She has a terrific black eye and a large swelling on her forehead. She tells me that she took her overdose after her ex-boyfriend, aged 19, punched her.
"Why did he do that?" I ask.
"I phoned him," she replies. "He said he'd told me he didn't want me to phone him no more."
"So he came round and hit you?"
"Does he hit you often?"
"No," she replies. "Usually, he head-butts me."
In the next bed is a man in his fifties, a former graduate of our ward. Back then, he took to the pills because his brother—his best friend and virtually his only reliable social contact since his own divorce—had died. This time, however, the overdose was precipitated by an entirely different matter.
"Some gypsies was smashing my windows, so I got out my shotgun and shot one of them."
"Was he injured?" I ask.
"No, not serious. A bit in the leg, like. It was only homemade cartridges, see, a bit of powder and scrap metal."
"Are the police involved?"
After it happened, neither party to the transaction was particularly anxious to seek the protection or interference of the law.
"But now, presumably, you are afraid to return to your flat because they will come for you again, and it won't be only your windows they'll want to smash?"
I arrange for him to be admitted to the psychiatric hospital, the asylum of his choice.
In the next bed is a slender girl, aged 15. She wears bright red lipstick and tight-fitting clothes, binges on food and vomits after eating, and has cut her wrists on many occasions. She has taken her stepfather's anticoagulant pills, which he needs after his heart operation. She is a problem child and was brought to the hospital by her mother as one might deliver a sack of potatoes; her daughter's suicidal gesture had made her late for her bingo. Pouting and eternally on the verge of a temper tantrum, the child tells me that she does not want to return home.
"Because of your mother and stepfather?" I ask.
No, she says. She doesn't want to return home because she was raped three months ago somewhere in the public housing project where she lives, and since then graffiti have appeared there saying that she enjoyed being raped and that she's a "slag" (meaning, a girl of easier virtue than average when adjusted for age, social class, educational background, and so forth). This is a point of view with which her mother wholeheartedly agrees, and so the patient has decided to run away and live on the streets rather than return home.
She doesn't want to go to a municipal children's home either, and in this I can't entirely blame her. She says she wants to be found a foster family, but the social worker informs me that not only is this difficult to arrange in a hurry but that once any prospective family knows her history—her truancy from school, her bulimia, her wrist-cutting—it will not agree to take her. The only possible solution would be for her to live with her aunt (her mother's sister), where she lived once before and was so happy that she behaved herself. But her mother, exercising parental rights if not duties, has specifically forbidden that, precisely because, I surmise, she behaves well there. Her mother wants to be rid of her as much as she wants to be rid of her mother, but her mother also wants to maintain the fiction that this desire stems solely from her daughter's impossible conduct. In order to disguise her own contribution to the situation and her indifference toward her own offspring, it is imperative that no place be found for her daughter that is so agreeable that her behavior improves there.
An impasse results; and so my patient is like the Russia of the old proverb, in which all roads lead to disaster.
On to the next bed. Here is a man in his thirties, of powerful physique and malign countenance—an unfortunate combination, in my experience. He has taken an overdose of his wife's antidepressant pills, and it does not take Sherlock Holmes to deduce that he is the principal reason she needs them. He took the overdose after he pinned her against the wall by her neck, round which, he says, there are now bruises "no bigger than love-bites." She started it, he says, so it's her fault; she'd been giving him an earache about his drinking all day.
"I couldn't take no more, so I had to get out of the house, and she wouldn't let me go. So yes, I did pin her up against the wall." He shows me by mime how he did it. "Everyone's got their breaking point, even you."
He tells me that they argue constantly. "What about?" I ask.
"When I was in prison, she had an affair with a black man, who beat her up, and an abortion."
"How long were you in prison?" I ask.
"Long imprisonment doesn't do much for a marriage," I remark.
"Yeah, but I didn't ask her to lie down and open her legs, did I?"
"Are you staying with her, then?" I ask.
"She's got my children; they're the only thing I've ever had. If she takes them away from me, I'd have to go straight back to crime, because there's nothing else out there for me. I'd blitz the public and the police; they wouldn't know what happened to them. They don't mean no more to me than cockroaches. And I can tell you, I'd soon have money in my pocket, more than you'll ever have."
I point out that history suggests otherwise: he's already spent 16 years of his life in prison.
"Yeah, well this time I'll do something really big; there's no point in getting a three or a five." His eyes shine with the brilliant, hard light of the purest psychopathy. "I'm what this society and this government's made me. My father fucked me off to reform school when I was young, and all they learnt me was how to commit more crime. Well, now they've got what they want, so they'd better look out if they take my children from me."
There is not much point in continuing the conversation, so let us now progress to the next bed, which contains a thin 27-year-old woman of West Indian extraction who has drunk half a bottle of methadone. This she got from a friend, who got it from a friend (the person for whom it was actually prescribed is like a distant ancestor, whom only a diligent genealogist could be expected to uncover). She took the methadone to help her come down from crack cocaine, which she has been taking many times a day for two years. She lives at home with her mother and nine-year-old daughter.
"And the father of your daughter?" I ask delicately, as if I were inquiring about a history of venereal disease.
"I don't see him no more."
"Does he support your daughter in any way?"
"He comes to see her sometimes."
"When he feels like it."
The patient had been a secretary in a law firm until a boyfriend introduced her to crack.
"You didn't have to take it," I tell her.
"It was free," she replies.
"You mean, if I handed you 50 pills now, free of charge, you'd take them?"
"I would if I saw you take them, and they gave you a good time."
The free crack did not last forever, of course, and soon she had to pay for it. And having lost her job, the only way she could do so was by accepting what both the New England Journal of Medicine and The Lancet now call "sex work."
I ask her whether she currently has a boyfriend.
"He's in prison."
"Burglaries. He's out in two years."
Her mother, who looks after her daughter, arrives on the ward. She is in her fifties, dressed in a blue suit and wearing an old-fashioned hat with a veil and white gloves. As a person of the utmost respectability, a householder and a churchgoer who on Sunday speaks in tongues, she is deeply distressed by the dissolution of her daughter into vice and addiction, though she is at pains to disguise just how deeply. We soon dispatch the daughter to a drug rehabilitation center.
In the last of the six beds in the ward, an 18-year-old girl lies looking up at the ceiling. She took her overdose, she tells me, because she hates life. But in my experience people who hate life rarely take quite so much trouble over their appearance, from which I deduce that something more specific is bothering her. She has left home and gone to live with a friend. She took the overdose after a row with her boyfriend, ten years older than she, an ex-soldier dishonorably discharged from the army for smoking marijuana. She has been his girlfriend for nine months now (the whole of her semi-adult life), and so far she has not gone to live with him. But he is very jealous of her, wants to know where she is every minute of the day, accuses her of infidelity, searches through her things whenever she meets him, cross-examines her about her activities in his absence, and searches her purse. Though he has not yet hit her, he has been threatening at times. She is frightened now to go anywhere without him, for fear of his reaction. If they go out together, he never lets her out of his sight.
"Do you know about his previous girlfriends?" I ask.
"He was living with one, but she left him when she found out he was seeing someone else."
"What is your boyfriend interested in, apart from you?" I ask.
"Nothing, really," she replies.
"And what are your interests?" I ask again.
"I don't have any," she says.
She hates her poorly paid job, which requires no skill at all—not that she has any skill to impart. She left school as soon as she could, though I would estimate that she is of above-average intelligence, and in any case she never tried very hard to learn, because it was not socially acceptable to do so. In short, I tell her, she has always taken the line of least resistance, and as it says in Shakespeare, nothing will come of nothing.
"What should I do?" she asks me.
"Your boyfriend will imprison you," I tell her. "He will take over your life completely, and if you go to live with him he will become violent. You will spend several years being ill-treated and abused; eventually you will leave him, but you will not have been a victim. On the contrary, you will have been the co-author of your misery, because I have now told you what to expect, just as your parents and your friends have told you."
"But I love him."
"You are 18 years old. The law says you are an adult. You must make up your own mind. Here is my telephone number: ring me if you need help."
Our tour of the six beds is complete: nothing unusual or out of the ordinary today, just an average trawl of social pathology, ignorance of life, and willful chasing after misery. Tomorrow is another day, but the same tide of unhappiness will lap at our doors.
Attempted suicide—what is also known as "parasuicide" or "deliberate self-harm," in a vain effort to find the perfect scientific terminology—is the most common cause of emergency admission to the hospital in England among women and the second most common among men. There are more than 120,000 cases a year, and England boasts one of the highest rates of such behavior in the world. Its completed suicide rate, on the other hand, is rather low by international standards. I do not think this merely denotes a general comparative decline in technical competence among the English ("Made in England," after all, no longer indicates quality and reliability, but rather its reverse): it means only that many of those who attempt suicide don't intend to die.
It was not ever thus. Attempted suicide enjoyed, if that is quite the word, an explosive growth at the end of the fifties and the beginning of the sixties. Until then, to attempt suicide had remained a crime in England, and it had also remained a comparatively rare event. But something more than the liberalization of the laws was involved in the opening of the floodgates of self-poisoning, for the floodgates were opened throughout the rest of the Western world also. Within a few years, overdosing was as traditional as Christmas.
Suicide and attempted suicide have attracted the attention of sociologists, psychologists, and psychiatrists ever since the publication in 1899 of Emile Durk-heim's great work Suicide. Today, an academic discipline known as suicidology thrives. The great majority of the published work of these suicidologists is mathematical: their writings overflow with dense statistical tables correlating one factor (the unemployment rate, social class, income, even the phases of the moon) with the act of suicide or attempted suicide.
Try as one might to remember that a correlation does not mean cause and effect, the overall impact of this work is to suggest that, if only enough variables were examined, if only enough data were collected and analyzed with sufficient sophistication, the "cause" of suicide and attempted suicide would be found. The importance of what goes on in the minds of individual human beings is thus implicitly denied, in favor of vast impersonal forces that statistical regularities supposedly reveal and that supposedly determine people's behavior. Thus suicidology joins the other great intellectual movements of the twentieth century—Freudianism, Marxism, and more recently, sociobiology—in denying consciousness any importance in human conduct. On this view, thought is irrelevant to action; and, dimly apprehending the intellectual currents of their time, ordinary people actually begin to experience themselves as unable to affect their own behavior. Many patients have described to me how they took the pills because, like Luther posting his theses on the cathedral doors, they could do no other.
Nevertheless, statistical regularities do exist, and used sensitively they can provide insights into the minds of men. For example, the number of patients admitted to our ward declined precipitously during the first days of the Gulf War and during the European soccer championships. People were too absorbed for a time in affairs other than their own—albeit by the proxy of television—to contemplate suicide. The boredom of self-absorption is thus one of the promoters of attempted suicide, and being attached to a cardiac monitor for a time or having an intravenous infusion in one's arm helps to relieve it. I'm treated, therefore I am.
Patterns are also discernible in the daily flux of a busy overdose ward. There is, for example, the pre-court appearance overdose, precisely timed to preclude the appearance of the defendant in the dock and calculated to evoke sympathy for him when he finally does appear there, insofar as he now has a psychiatric history. Anyone with a psychiatric history, of course, must be of doubtful responsibility for his own actions and therefore can expect a correspondingly reduced sentence.
And then there is the pre-employment overdose. A surprising number of the unemployed who succeed at last in finding a job take an overdose on the evening before they start work: their non-attendance the following morning gets them the sack before they've even begun, and so they join the ranks of the unemployed once more.
And then again there are the young Indian women who take overdoses to avoid arranged marriages or the wrath of their fathers when they discover that, contrary to the community's code of conduct, their daughters have been courting men of their own choice, thus bringing ineradicable shame upon their families.
But patterns and statistical regularities by themselves tell us little unless we are prepared to search for their meaning, and that meaning is always to be found in the minds of men and women.
Why, then, do so many take to the pills? To swallow an overdose without seriously intending to die is a curious thing to do, after all, and is specific to modern Western, or Westernized, society. They don't do it in Senegal or Outer Mongolia.
A gesture in the direction of death, even though only a gesture, is still a powerful signal of distress. But in nine-tenths of the cases (in my experience) the distress is self-inflicted, or at least the consequence of not knowing how to live. The emotions that surround most overdoses are simultaneously in-tense and shallow.
In modern welfare states, the struggle for subsistence has been abolished. In Africa, where I have also worked, the poor engage in a cruelly demanding battle to obtain water, food, firewood, and shelter for the day, even in the cities. This battle automatically gives meaning to their existence, and another day lived without hunger in, say, Kinshasa, is a personal triumph of a kind. Survival there is an achievement and grounds for celebration.
This is not so in my city, in which subsistence is more or less assured, irrespective of conduct. On the other hand, there are large numbers of people who are devoid of either ambition or interests. They thus have nothing to fear and nothing to hope, and if they work at all it is in jobs that provide little stimulus. Without religious belief to imbue their existence with transcendental meaning from without, they can provide none for themselves from within.
What, then, is left for them? Entertainment and personal relationships. Entertainment, absorbed passively, informs them, through television and films, of a materially more abundant and more glamorous way of life and thus feeds resentment. A sense of their own nothingness and failure breeds powerful emotions—especially jealousy and the intense desire to dominate or possess someone else in order to feel fully in control of at least one aspect of life. It is a world in which men dominate women to inflate their egos, and women want children "so that I can have something of my own" or "someone to love and who'll love me."
Personal relationships in this world are purely instrumental in meeting the need of the moment. They are fleeting and kaleidoscopic, though correspondingly intense. After all, no obligations or pressures—financial, legal, social, or ethical—keep people together. The only cement for personal relationships is the need and desire of the moment, and nothing is stronger but more fickle than need and desire unshackled by obligation.
Unfortunately, the whims of two people rarely coincide, and thus the emotional lives of people—who, remember, have very little else to console or interest them—are repeatedly in crisis. They are the stars of their own soap operas. An overdose—with the secure knowledge that help is at hand—is often the easiest way to relieve the continued crises in their lives. The hospital is warm and welcoming, the staff sympathetic. In the world that I describe, where else can one turn? Parents are frequently hostile, and acquaintances are in the same boat.
Most overdosers—not all, of course—live in an existential void. Theirs are voices calling from an abyss—an abyss created in large part by the idea, peddled by generations of intellectuals, that material security and human relationships unconstrained by any kind of necessity would set mankind free, beyond the dreams of past unenlightened or less fortunate ages. To be or not to be? Overdosers opt for something in between the two.