MALTSBERGER ET AL.

SUICIDE FANTASY

Suicide Fantasy as a Life-Sustaining Recourse

John T. Maltsberger, Elsa Ronningstam, Igor Weinberg,

Mark Schechter, and Mark J. Goldblatt

Abstract: The suicide literature tends to lump all suicidal ideation together,
thereby implying that it is all functionally equivalent. However obvious the
claim that suicidal ideation is usually a prelude to suicidal action, some sui-
cidal daydreaming tends to inhibit suicidal action. How are we to distinguish
between those daydreams that augur an impending attempt from those that
help patients calm down?

Our professional literature tends to lump all suicidal ideation togeth-

er as though there were but one species of it (Jacobs, Baldessarini, Con-
well et al., 2003). Maris, Berman, and Silverman (2001) suggests that
suicidal ideas, transient or chronic, belong to a continuum of increasing
risk, moving forward from simple ideation to ideation coupled with
impulses, through actual suicide planning, and ultimately, sometimes
to suicidal action.
In fact, there are different kinds of suicidal ideation. There is the fa-
miliar, ominous suicidal rumination that precedes suicides and suicide
attempts. But we have also occasional benign suicidal daydreaming
unassociated with any impulse or intention to act. (These are very com-
mon in adolescence.) Suicide ideas may erupt as frightening, distress-
ing obsessional thoughts, but these are not generally associated with
dangerous suicidal states in the experience of most clinicians.
Indeed, suicidal ideation is so commonplace that taken alone it is a
poor predictor of impending action. The lifetime prevalence of suicide
ideation is reported to lie in the range of between 9 and 20% (Line-
han & Laffaw, 1982; Nock, Borges, Bromet et al., 2008), but on the basis
of clinical experience, we believe these numbers are too low. In fact,

John T. Maltsberger, M.D., Elsa Ronningstam, Ph.D., Igor Weinberg, Ph.D., and Mark
J. Goldblatt, M.D., Harvard Medical School and McLean Hospital, Belmont, MA. Mark
Schechter, M.D., North Shore Medical Center, Salem, MA.

Journal of The American Academy of Psychoanalysis and Dynamic Psychiatry, 38(4) 611–624, 2010
© 2010 The American Academy of Psychoanalysis and Dynamic Psychiatry
612 MALTSBERGER ET AL.

there is evidence that people forget about having entertained suicidal

ideas as time goes by (Goldney, Winefield, Winefield, & Saebel, 2009).
To understand the seriousness of suicidal ideation as a suicide predic-
tor in individual patients, it is essential to weigh suicide thinking with
the rest of patients’ histories and mental state examinations—that is, to
make a formal suicide risk assessment (Simon & Hales, 2006).
First we shall discuss suicidal fantasy as a self-soothing measure and
an aid to narcissistic cohesion. Following a discussion of this phenom-
enon, we can take up the kind of suicide ideation that is a prelude to
action, contrasting sustaining fantasy with the kind of thinking we find
in lethal suicide planning.

SUSTAINING SUICIDAL FANTASY

Recurring suicidal reveries can quiet patients down and stabilize tee-
tering self-cohesion. We may call them “sustaining suicidal fantasies”;
they are organizing and comforting in effect. They serve the structural
function of fortifying weakening narcissistic integrity.
Zelin, Bernstein, Heijn, and their colleagues (1983) identified and
studied 134 different sustaining reveries helpful in coping with painful
feeling states. They sorted these fantasies into ten groups. The items in
one group reflected efforts to remember or anticipate sensual pleasure;
in another, they represented coming closer into protection or fusion with
an idealized object (e.g., God). Other sustaining daydreams were om-
nipotent in nature, sadistic sometimes, occasionally murderous. Others
yet involved reveries of admiration and acclaim. There were others of
withdrawal to a safe place proof against hurt. One set involved fantasies
of being loved; another, conscious thoughts of sadness, suffering, and
deprivation. Men especially liked to daydream about winning compe-
titions, athletic or otherwise. Another set imagined making restitution
for harm done to others. Some relied on reveries of self-improvement.
Most of the fantasies described were reveries agreeable to the pa-
tients entertaining them, but only 12 of the 134 imaginings reported
seemed to have the potential for translation into immediate action. For
example, “the thought of being popular and well-liked” might not be
too easily achieved by immediate action. But of the nine dying and ill-
ness items, eight were notions capable of being put into immediate ex-
ecution, and most of those involved suicide.
Many persons, falling into comparatively mild states of loneliness,
unhappiness, or other distress are able to regulate themselves, that is,
to calm themselves down, and even feel better, by daydreaming. Some
quiet themselves with reveries of suicide. “The thought of suicide is a
 SUICIDE FANTASY 613

powerful comfort: it helps one through many a dreadful night,” Ni-

etzsche remarked (1886, p. 91). Gabbard (2003) reminds us of a Walker
Percy character who says,

They all think I’m going to commit suicide. What a joke. The truth of course
is the exact opposite: suicide is the only thing that keeps me alive. When-
ever everything else fails, all I have to do is consider suicide and in two
seconds I’m as cheerful as a nitwit. But if I could not kill myself—ah then,
I would. I can do without Nembutal or murder mysteries but not without
suicide. (Percy, 1961, pp. 194-195)

Ordinarily, we modulate fluctuations in mood automatically with-

out much conscious effort or expenditure of energy. The ordinary adult
has, through processes of internalization, appropriated self-soothing
and self-esteem bolstering capacities from good childhood experiences
with comforting caregivers. What others give in childhood becomes a
part of the adult’s mind and affords satisfactory mood regulation most
of the time. Some lonely adults may glance at photographs of others
they love, or have loved in the past, and keep such souvenirs near to
hand, as an aid to refresh and intensify helpful memories of those ab-
sent or lost.
Stressed normal adults may find their capacity for self-regulation in-
sufficient, but in the absence of significant psychopathology, temporary
states of milder narcissistic instability (anxiety, fluctuating self-esteem,
inadequate self-regard) usually can be relieved by exterior sustaining
resources—most commonly, other people whose support and reassur-
ance restores acceptably good balance (Maltsberger, 1986). If reassuring
others are absent, one may rely on memories of them. Some patients
invent suicidal daydreams for themselves that buttress shaky self-es-
teem. In that event, suicidal fantasies can have a positive narcissistic
function.

A 25-year-old man had been depressed for as long as he could remember.1

After two failed attempts to attend college, he gave up on building a pro-
ductive and independent life. Living with his parents, he daydreamed his
life away, fiddling at his computer, woolgathering about unrealistic career
plans. Isolated and depressed, but not especially agitated or anguished,
he elaborated complex suicidal scenarios, although he was never close to
putting them into action. He idealized suicide as the only way to escape
his passive misery and end his life on a high note. After he came into treat-

1. For all cases presented in this article, names have been changed and personal clinical
material disguised in order to preserve patient confidentiality.
614 MALTSBERGER ET AL.

ment, his depression improved, and he took a job. His self-esteem rose as
he began to make a few friends. Gradually he gave up suicidal daydream-
ing as a means for boosting his self-esteem; he no longer needed it.

Thinking can be understood as trial action—thinking before doing is

an imaginary trial of behavior before action (Bion, 1961; Kanzer, 1957;
Rappaport, 1959). Sustaining suicide fantasies often portray trial ac-
tions. The patient trying to stabilize himself with suicidal daydreaming
says to himself, “I can always kill myself if my suffering becomes too
great. I am not helplessly trapped, suicide is always there as a means of
escape, I am not helpless to cope with my misery.” The fantasy can give
the patient a sense of control and mastery. Trapped in prison he may
feel, but he reminds himself that he always has the key to get out, and is
therefore not helpless.2 Some patients grow frightened and angry when
suffering physical pain and bear the helplessness of it with difficulty.

A 45-year-old man suffered from severe chronic pain following an automo-

bile accident a few years earlier. He announced to his new therapist that
should the pain worsen and the prescribed medication not help he knew
he could kill himself to end the pain. “Not that I really want to die,” he
said. But it reassured him to know he had an escape route if things got too
bad. Focusing in therapy on the next steps in his life and growing in his
capacity to accept physical suffering more patiently, he thought less about
suicide. He no longer needed to daydream about it to feel better. After a
few years later he married and bought a new house with his wife.

In brief, trial action in thought is the opposite to acting out without

reflection.
The capacity to bear painful affect requires resignation and tolerance
for suffering—patients must resign themselves to suffering, at least for
a time. There are those who grow panicky when they cannot get away,
finding passive entrapment even worse than other depressive feelings
(Zetzel, 1970).

Elizabeth, a 40-year-old woman, physically abused as a child, came to psy-

chotherapy for depression. She had comforted herself for years with the
thought that if things got any worse “I could always kill myself.” Elizabeth
was troubled by the amount of time and energy she spent engaging in
suicidal thoughts, but felt that without them she would feel overwhelmed.

2. Seneca (62–65 A.D.) wrote that when the soul is trapped in the body, as one might be
in prison, the key for escaping is in the hand of the prisoner: suicide is always a way out.
See the Letters, especially numbers 58 and 70.
 SUICIDE FANTASY 615

After several years of therapy she announced that she was “ready to give
up suicide,” and that she could rely on other ways to soothe herself. Her
suicidal thoughts and fantasies did in fact diminish, and while she came
back to them from time to time, they no longer felt compelling or neces-
sary.

Even negative memories, perceptions, and experiences can some-

times be structured to strengthen self-cohesion. Valenstein (1973) ob-
served that some patients remain attached to negative experiences for
such purposes, and there is some empirical research to support this
viewpoint (Swann, 1996). Schafer (1984) proposed that idealization of
suffering, once incorporated into the ego ideal, invites the pursuit of
pain-inducing experiences. A masochistic ego-ideal of this nature may
lead to suicidal reveries that are narcissistically stabilizing.

Pamela, a 22-year-old college student, reported chronic suicidal ideation

since age 15. She gave herself over to suicide reveries every night as she
waited for sleep. How would others react, she wondered. Would they miss
her? Regret how they mistreated her? These thoughts were comforting and
eased her into sleep. Several months later as her depression improved, she
had new difficulty falling asleep because the fantasy of suicide was no
longer comforting. She had to search her mind for other warm thoughts to
enhance her drowsiness.

WHEN SUICIDE FANTASIES ARE REAL DANGER SIGNALS

Comparatively benign, even helpful suicidal daydreaming is a differ-

ent matter from the crisis of events that precedes a true suicide attempt,
and the essence of the difference lies not in the ideation itself, but in
the context wherein the ideation occurs. Suicide fantasies antecedent
to deadly action almost always occur in the context of a suicidal crisis,
whereas the helpful variety of fantasies do not.
Clinically the capacity to discriminate between a narcissistically
helpful suicidal reverie (one that promotes self-cohesion and relieves
distress) and suicidal thinking that signals impending suicidal action
is obviously important. One patient may daydream of suicide to quiet
down before falling asleep, but another may brood about suicide while
getting ready to do it. What are the differences between suicidal sus-
taining fantasies, and suicidal fantasies as antecedents to action? In the
former case, ideation and fantasy about suicide paradoxically serve to
mitigate hopelessness, provide self-soothing, relieve distress, and en-
hance self-cohesion. These operations serve to make suicidal action less
616 MALTSBERGER ET AL.

necessary. The therapist has this challenge: to bear the anxiety hearing
such fantasies may engender, trying over time to understand what they
mean, and what purposes they serve.
Most of the time, a true suicide crisis is marked by intolerable emo-
tional suffering of desperate proportions (Hendin, Maltsberger, &
Szanto, 2007). What are the characteristics of a suicide crisis? Typically
something of significance will have taken place to trigger a crescendo
of pain (a precipitating event). Behavioral indicators of crisis will ap-
pear (suicide threats may be made; patients may do things portraying
or hinting at an impending attempt, or they may lose emotional control
with outbursts, perhaps of rage or intense anxiety). These behavioral
indicators are signals that self-cohesion is being stretched beyond the
capacity for affective self-containment. Increasing recourse to alcohol
or drugs may occur, and deterioration of work or social functioning is
seen (Hendin, Maltsberger, Lipschitz, Haas, & Kyle, 2001). On the other
hand, those who are revisiting their sustaining suicide fantasies are not
“going to pieces.” Our point is this: the psychological meaning of a sui-
cidal fantasy cannot be inferred from the fantasy alone when it is taken
out of context. Who can say what a flame considered in isolation signi-
fies? Some fire is helpful, as when under a furnace. Other fire marks
imminent catastrophe, as when burning unconstrained in the walls of
a house. The following example reflects the experience of a patient in a
true suicide crisis.

An Iraq war veteran with posttraumatic stress disorder and major de-
pression suffered from flashbacks of combat experiences. He was a binge
drinker and had poor control over his temper. He had occasional suicidal
ideas but had made no attempts. After several months of verbal abuse, he
struck his wife when in a rage, and, announcing that was the limit, she left
him. In a final therapy session, he attributed his escalating suicidal ideas
and heightening mental anguish to the loss of his wife. He began to drink
more heavily, increasingly provoked quarrels with others, and shot him-
self in the head a few days later. (Maltsberger, Hendin, Haas, & Lipschitz,
2003)

In true suicidal crises, marked by fantasies of killing oneself that are

true preludes to action, there is usually evidence that the patient is liter-
ally going to pieces mentally. The loss of self-integration that occurs in
such crises is better captured by the German word Zusammenbruch than
in the English equivalent “nervous breakdown.” The German term de-
notes a loosening of mental integration—the mind is not holding to-
gether.
 SUICIDE FANTASY 617

The inner and the outer worlds threaten to become one, reality test-
ing fails, and overwhelming affect cripples the mind. Such crises are,
subjectively, apocalyptic experiences.

Turning and turning in the widening gyre

The falcon cannot hear the falconer;
Things fall apart; the centre cannot hold;
Mere anarchy is loosed upon the world,
The blood-dimmed tide is loosed, and everywhere
The ceremony of innocence is drowned. . . .
(Yeats, 1952, pp. 184-185)

Although the inner turmoil of suicide crises may not be obvious to

casual outward inspection, the subjective distress accompanying them
is so severe that it threatens to become insupportable and can impel
patients to kill themselves. This is usually discernable if the clinician is
careful about systematic mental state examination. The emotional dis-
tress of a suicide crisis makes patients desperate, although sometimes
the desperation may be strangely quiet. It may not be reflected in gen-
eral appearance and behavior.
We have long understood that suicide attempts are closely associated
with depression and anxiety. More recently it has become evident that
depression is especially worrisome when agitation is present, and other
fierce affects emerge. Depressions with motor agitation worry us very
much, of course, but even without motor signs, subjective agitation in
the mind (psychic anxiety) can be very ominous also, particularly when
intense (Koukopolous & Koukopolous, 1999).
Beyond ordinary experiences of depression, suicidal patients are
menaced by extreme feelings of hopelessness, abandonment, self-ha-
tred, rage, anxiety, and harrowing loneliness (Hendin, Maltsberger, &
Szanto, 2007). More than 80 years ago Freud (1926) proposed that in-
tense subjective distress (anxiety) beyond patients’ capacity for regu-
lation may damage the ego. Strictly speaking, we cannot tell whether
overwhelming affective desperation causes the other mental injuries
that accompany a suicide crisis, or is only correlated with them, but it
may be that the noxious flood of unremitting desperation forces self-
breakup. In suicidal crises, patients lose the capacity for regulating and
modulating affect. They kill themselves to escape it.
The association of severe hopelessness with suicide has been dem-
onstrated in long-term prospective studies (Beck, Steer, Kovaks, &
Garrison, 1985; Fawcett, Scheftner, Clark et al., 1987). Yet in view of
some recent reports that conflate hopelessness with other unpleasant
suicide-related feelings, a delimiting remark is in order here. Strictly
618 MALTSBERGER ET AL.

speaking, hopelessness is not a pure affect. It is a self-state associated

with a belief in which prominent unpleasant emotions are present. If
helplessness, which is indeed an affective experience, is to metamor-
phose into hopelessness, a cognitive operation, or judgment, must be
added. The reflecting self must conclude that there is no remedy for
the present condition of suffering. Overwhelmingly intense suffering
makes patients desperate. If the desperate self can find no remedy, then
hopelessness becomes synonymous with despair.
Freud (1926) understood that when traumatic situations arise where-
in the ego is unable to effect necessary changes to relieve intolerable
levels of distress, it falls into a state of helplessness. Prolonged help-
lessness in the face of intense suffering generates hopelessness, and,
sometimes, despair. In a largely forgotten but ingenious paper, Edward
Bibring (1953) discussed the ways in which helplessness gives rise to
hopelessness.

A 34 year-old noncommissioned military officer fell into a suicidal depres-

sion when his infant son was diagnosed with leukemia. To his mind, the
child’s illness proved him a failure as a father and as the protector of his
family. He told a psychiatrist he had suggested to his wife they kill them-
selves and their two children by immolation in the family car. His irri-
tability and dysphoria worsened; his work performance deteriorated; he
annoyed his supervisor and was in danger of losing his military career.
Faced with the likelihood of his son’s death and career failure, overcome
with anguish and despair, he was falling apart. He shot himself and died
in his garage.

What are the other phenomena of self-fracture that accompany flood-

ing with emotional anguish? The preceding example certainly illustrates
the worsening anguish that precedes giving way to despair—despair is
the abandonment of hope. It also shows, however, how cognition may
be affected in true suicide crises. Our officer who killed himself was
convinced his son’s illness was the result of a personal failure. To this
man, it was either paternal omnipotence (power against leukemia) or
paternal incompetence. The cognitive functions essential for thinking
and language (especially symbolic and abstracting capacities) are gen-
erally compromised in suicide crises, as they were in the example. The
judgment of suicidal patients is often disturbed; they misread the com-
munications and intentions of others. Edwin Shneidman (1985) referred
to “cognitive constriction”—dichotomous “all or nothing” and “either-
or” thinking wherein nuance and shades of meaning are lost. Baumeis-
ter (1990) described “cognitive deconstruction;” suicidal patients shift
toward less meaningful, integrated forms of thought. Awareness of self
 SUICIDE FANTASY 619

and thinking about the consequences of action become concrete. The

sense of personal identity fades.
Further, the synthetic function of the ego—its integrating and harmo-
nizing function—fails. Self-cohesion loosens. Patients cannot adequate-
ly tell the difference between themselves and the contents of their own
minds and the minds of others. Self and object representations break up
and become confused (Maltsberger, 2004).

A 42-year-old professor of Romance Languages developed a severe depres-

sion with profound suicide ideation and intent. A psychotic transference
to her psychiatric resident arose; she formed the conviction that he wanted
her to kill herself and “get it all over with.” Her affective suffering was
intense, her work had deteriorated to the degree she could not manage
academic duties. She spoke frequently of suicide and had to be confined in
a hospital. She was sure her family would be better off without her. Escap-
ing from the psychiatric unit she hid in a little used hospital washroom
and commited suicide by chloroforming herself. (Where she obtained the
chloroform was never discovered.)

Reality testing fails as the self breaks up. Functionally, at least, sui-
cidal patients are often deluded. Moved by the conviction of false be-
liefs, and propelled by mental pain, they swing into action, convinced
that others would be better off without them, or that others want them
dead. Some are convinced that in killing themselves they will live on in
a better afterlife (Maltsberger & Buie, 1980).
Finally, true suicide crises are usually marked by pathological de-
fensive postures. Many patients split off their feelings from conscious
awareness, that is, they dissociate. Combinations of projection, distor-
tion, and denial in the face of failed reality testing render many of these
patients functionally psychotic (Laufer & Laufer, 1989).

A 22-year-old law student quarreled with his girl friend and threatened
to kill himself. She told him she was sick of his threats and as far as she
was concerned he should go ahead and do it. He had been anxious and
depressed for several days, but now he became much worse. He decided
to kill himself. As soon as his decision was made, his mind became calm.
For the first time in weeks, he felt competent and collected. Very coolly he
drove to a high bridge and jumped off, feeling detached from himself, ob-
serving what was happening with the admiration of an onlooker. As soon
as he began to fall, the dissociation broke, and he began to scream in terror.
(Maltsberger, 2004, p. 656)

In concluding we acknowledge that the prolonged suffering associ-

ated with chronic narcissistic instability is corrosive in effect, especially
620 MALTSBERGER ET AL.

in the absence of satisfying and stabilizing exterior sustaining objects.

We do not propose, therefore, that sustaining reveries are always in-
nocuous; the psychotherapist should keep them under review, mindful
that with increasing affective suffering and other signs of crisis they are
capable of pernicious metamorphosis. Ordinarily, however, soothing
sustaining suicidal reveries are not more than trial actions in the mind.
When they become ineffective in helping a patient feel better and there
is a crescendo in suffering, they can alter and become a true signal of
true danger.
Occasionally a vulnerable patient who has remained more or less
stable for years, sometimes assisted by a sustaining fantasy, may be
precipitated into a suicide crisis by some external narcissistic shock
(Maltsberger, Hendin, Haas, & Lipschitz, 2003). When such a deterio-
ration occurs, the emerging suicidal plan may contain elements of the
old self-sustaining fantasies. We can sometimes see how these elements
turn into actual planning for suicide action.

A 50- year-old expert upholsterer, long employed in an interior decorat-

ing firm, privately struggled for years with the horrible memories of her
childhood. She had been sexually abused by her brother, neglected by
both parents, and humiliated by her father. She felt that her body and her
mind were hardly her own. Shy and seclusive, her attitude toward others
was quietly paranoid. She feared them and suspected they believed she
was contemptible. She feared being hurt and humiliated as in the past. To
heighten her sense of mastery and for self-protection, she relied on a sus-
taining suicide fantasy to the effect that she could always kill herself and
claim control over her body and mind if worse came to worse. Comforted
by these recurrent fantasies, she was outwardly a successful, highly func-
tioning individual. One day, she was suddenly verbally assaulted by an an-
gry client of the decorating firm. This volatile client flew into a rage about
an unsatisfactory minor detail of the patient’s work. She threatened to get
the upholsterer fired, shouted, and yelled profanities into her face. Easily
triggered, the patient spiraled down into a deep depression intermingled
with flashbacks of her past. The childhood memories of abuse flooded her
mind during the day while nightmares of being chased and hunted kept
her awake at night. Flooded by anguish and anxiety, she felt her mind was
going to pieces, and she made a suicide attempt a few days later.

CONCLUSION

We have proposed that a sustaining suicidal fantasy can be narcis-

sistically useful, serving a regulatory function that relieves mental an-
 SUICIDE FANTASY 621

guish and lessens hopelessness. In many instances they are transient,

sometimes they are recurrent, and they signal narcissistic instability,
often minor, but sometimes major.
When Tom Sawyer’s aunt unfairly blamed him for breaking a sugar-
bowl, knocked him to the floor, and angrily refused to apologize for it,
Mark Twain (1876) imagined a transient spell of narcissistic instability
in Tom. He described Tom’s soothing reverie of vengeful death, if not
outright suicide:

He pictured himself lying sick unto death and his aunt bending over him
beseeching one little forgiving word, but he would turn his face to the wall,
and die with that word unsaid. Ah, how would she feel then? And he pic-
tured himself brought home from the river, dead, with his curls all wet, and
his poor hands still forever, and his sore heart at rest. How she would throw
herself upon him, and how her tears would fall like rain, and her lips pray
God to give her back her boy and she would never never abuse him any
more! But he would be there cold and white and make no sign—a poor little
sufferer whose griefs were at an end. . . . (Clemens, 1876, pp, 25-26)

In contrast to Tom Sawyer, who quickly recovered, here is a case of

suicide in another adolescent boy whose fantasies were not for pres-
ent soothing, but were action plans to get out of an intolerable state of
mind.

Patrick was 17 with an adjustment disorder and dysthymia. His idealized

19 year old brother Matt had recently hanged himself in jail after arrest for
possession of illicit drugs, after which Patrick became subjectively very
distressed. Matthew had been the mother’s favorite; she told Patrick it was
he who should have died, not her beloved Matt. Patrick began wearing
Matt’s clothes and reported dreams of reunion with Matt to his psycho-
therapist. He increased his drug abuse and there was more than usual de-
linquent behavior. He threatened suicide and was admitted to a hospital
where after a few days he too hanged himself. (Maltsberger, Hendin, Haas,
& Lipschitz, 2003, p. 114)

Suicide ideation in the presence of affective distress always requires

systematic suicide risk assessment. Alone however, in the context of
mild and transient emotional suffering like Tom Sawyer’s, they need
not signal that an attempt is brewing.
622 MALTSBERGER ET AL.

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