This is a book about transforming depression and discovering a meaningful alternative to suicide that grew out of my painful personal experience, followed by many years of study and practice as a doctor, psychiatrist, and psychoanalyst. My interest in this field derives from several very unsettling events in my youth and early adulthood—personal bouts of depression, the suicide of my surrogate father, the realization that suicidal inclinations can be impossible to detect in others. I came to realize that no one is immune from the inclination toward suicide.

Years later, as I became aware that my first marriage was ending, I found myself in a suicidal rage, and had an out-of-body experience, with an inner voice telling me to leave the relationship. In this act beyond ego, I unwittingly found my soul and spiritual center and my Self had found me. I had been rescued but this did not mean I was spared the ensuing feelings of despair, helplessness and worthlessness. I felt a failure, but a psychiatrist who was also a family friend reminded me that I had failed at a marriage, but not at life. I was not a failure.

This episode left an indelible impression on me and my practice as a physician and analyst. My spontaneous out-of-body experience was an example of what I now call "egocide," the letting-go of a hurt and hurting dominant ego-image or identity. It is a sacrifice of the ego to the Self, a higher principle.

Egocide is the core strategy for transforming depression and the heart of this book. It represents an antidote to suicide, a way out of depression by affirming life rather than rejecting it. It is not a magic switch, turning a sad person instantly into a happy one—the grieving process must still be tackled—but it does allow transcendence of previous ego limitations and clears the way for an eventual transformation of one’s self-identity.

In this book, I use "ego" to represent an awareness of one’s conscious identity, and Self to represent one’s unique, personal being and expressions of self-esteem and self-realization. In my life I learned to use painting to vanquish depressive states and years after I began to do this, I discovered the shamanic roots of art therapy: A shaman often uses creative activities to overcome a life-threatening illness.

While I was a resident in psychiatry at the UC Medical Center in San Francisco, I became interested in tracking down and interviewing survivors of suicide jumps from the Golden Gate Bridge. I wanted to refine my egocide theory and make it more therapeutically useful. I posed two questions to the ten survivors I located: How had they handled the traumatic event of attempting suicide? And what had been the long-term effects of the event on their lives?

The survivors all described a common core feeling of aloneness, alienation, depression, rejection, worthlessness and hopelessness. They also all admitted to feelings of spiritual transcendence after their leap—feelings of unity with all things and oneness with all people. All of these people committed symbolic suicide, i.e. egocide. As they looked back, they realized they had planned their jump in a demoralized state in which they had defined their whole being in terms of a specific failing or negative self-image. Their experiences became the basis of a new paradigm for me and my patients.

The model I offer in this book presents a Bad News/Good News scenario of psychological development. The Bad News is that we all occasionally become depressed. For some, this is a dark abyss where they feel completely worthless, with little hope for the future. Suicide seems like the only solution. The Good News is that only a part of the ego has to die (or be killed). This egocide (Symbolic Death) can usher in a positive psychic transformation, or New Life. This model, therefore, has four aspects: Bad News, Good News, Symbolic Death and New Life. The Bad News operates on the ego level and is experienced as a wounding of the ego. If we endure and persist, it is followed by the Good News, that we are able to pick ourselves up. There is ascent after descent. The way to survive is to commit egocide (killing the negative ego) and shadowcide (killing the negative shadow). Together these equate to killing the false self, in a Symbolic Death. This Symbolic Death leads to a greater fall, which actually feels like death, the eternal void. It is a frightening transitional phase characterized by a death-rebirth struggle. In time, the individual contacts the center of the psyche, the Self, leading to a reorganization of the ego and the emergence of the true self (genuine being). The passage through the death-rebirth struggle leads to the final phase, New Life, in which the person feels reborn, with restored morale.

Two well-known examples of suicidally-depressed figures (with opposite results) are Elvis Presley and Betty Ford. Elvis had become inflated (emotionally and physically) and remained stuck in the "king" state. Betty, unlike Elvis, was able to admit that she was depressed and self-destructive, and reached out for help.

I have a Jungian perspective in this book, sharing Jung’s recognition that, during the time an individual is establishing an ego-identity, major aspects of the psyche are repressed or unconscious, e.g. the anima/animus (the contrasexual principle), the persona (the mask one wears, tied to social roles), the shadow (the unknown aspects of one’s psyche), and the Self (the center and totality of one’s being). Jung postulated the goal of his psychology as "individuation," i.e. a process toward achieving psychic wholeness through the symbolic death of the previous, dominating ego-identity and the emergence of a newly-reconstructed ego-Self identity. In his theory, Jung has a strong spiritual element, similar to what I discovered in my study of the bridge-jump survivors. Jung believed the spirit was integrally related to healing and to becoming fully human.

Just as spirit is a central component of healing, so, Jung felt, are archetypes—symbols, myths and motifs common to all human cultures throughout history. I have found that a patient’s recognition and recasting of archetypes via creative expression (specific arts or artistic productions) is an essential part of the transformation process. Jung encouraged his patients to confront these archetypal images through a technique he called active imagination, a kind of free-flowing, non-goal-oriented creative meditation. Drawing, painting, writing (prose and poetry), ceramics and dance are all methods my patients have used.

Death and rebirth themes are central to Jungian healing philosophy and analytical therapy. Egocide, as a process, has worked successfully in the Jungian analytical context even for people so depressed they were repeatedly in danger of committing suicide, as I illustrate later, from case histories.

This book is about self-healing. In this process, transcendence—rising above conflicting forces—is a necessary step in the transformation process. Transcendence affords an overview of what is going on. The next step, which is essential for real change, is to transform. This results from the union of opposites and leads to something new: A creative change. The egocide strategy I have used for 17 years, and it has consistently produced qualitative, life-enhancing change. It also has provided meaning in the lives of my patients.

Egocide is a process of illumination, a shining of light on hidden mysteries. It is about seeing into the darkness, discovering one’s personal, soul-nourished myth and then living this myth fully and with joy. Egocide is timely now, as a process, because we now have the potential to commit mass suicide, omnicide. But this can be prevented with the widespread use of the egocide process.

Theorists in psychology and psychiatry have numerous differences, but they all share a sense that depression is something negative—a disorder or disease. But I take a different view, seeing depression as a favorable affect linked to the quest for meaning. It can help a person adjust to a new reality and therefore has positive value. Jung, too, saw it as a positive force.

Depression can be regarded in many ways. For the psyche, it is a natural reaction to a disruptive situation and is essential for the psyche to adapt. It can also be regarded as a dark, underground process where seeds of new life germinate (if the soil of depression is properly nourished). George Engel sees depression operating as a biological conservation-withdrawal mechanism that is found in all life forms from plants and single-celled organisms to primates and humans.

In Western civilization, the trend has been to view all forms of depression as somehow shameful, e.g. the Roman Catholic Church regards sadness (tristitia) as one of the cardinal sins. Such attitudes make it hard for depressed people to give themselves time and space to understand their depression for what it truly is. But this they must do to complete their journey back to health.

I am suggesting that depression is an archetype that expresses itself in biological, psychological, social and existential/spiritual ways. It resembles the Chinese principle of yin/yang, an archetype of all existence as a balance of opposites. It manifests through the persona as a mood, is felt subjectively as an emotion, and on a deeper level, takes the form of an affect. Sometimes a person exhibits a lack of congruity among affect, emotion and mood, in the depressive disorder known as masked depression. In this situation, the individual manifests a false self. Eventually this mask of happiness and contentment develops cracks and the affect becomes evident. The false self has serious implications in regard to suicide.

Common to all cases of depression is a loss of morale. If morale can be restored, then recovery from the depression is much more likely. Loss of morale is generally associated with collapse of a person’s spirit, will or courage. In this state, an individual feels unable to cope with or extricate himself from difficult life situations. Restoration of morale involves the person’s quest for meaning, a life-regenerating meaning that can be the basis for new confidence in one’s self and in the future.

I take a holistic, or systems approach to understanding and treating depression. In such an approach there are four factor groups: biological, psychological, sociological, and existential/spiritual.

Biological factors that can contribute to depression include: low concentrations of certain monoamine neurotransmitters in the brain; imbalanced adrenal and thyroid systems; and genetic inheritance (especially with bipolar disorder, or manic-depressive illness).

Psychological causes vary with different schools: Freudians see the cause of depression as due to a blockage of libido. Jungians see it as a regression into an unconscious state, a "psychic death" accompanied by "loss of soul," for the purpose of integrating aspects of the past into consciousness, via a "renunciation of egohood." Steinberg uses a redemption model, wherein there is a death of the negative parental introjects and a rebirth of a "newly organized ego [that] represents a greater approximation to and reflection of the Self." The cognitive approach to depression, as offered by Aaron Beck, holds that it is not external events that lead to depression, but an individual’s internal representations of those events. John Bowlby has shown the special developmental importance of affectual bonding with the mother, or an early parental surrogate, in avoiding depression later in life.

Social factors include high levels of stress, particularly stress resulting from life events that significantly change a person’s social matrix (e.g. a change in job status, economic situation, or living conditions). Depressed patients have almost three times as many social stressors during the six-month period prior to the onset of their depression than normal controls do, according to many studies. Those groups more vulnerable to high stress levels—women, separated or divorced people, and adolescents—manifest more cases of depression.

Existential/spiritual factors—issues of soul—I consider to be central in any healing process, since the soul is the "seat of one’s emotional moral nature—of one’s feelings and love (Eros)..." The basis for my premise here is Friedrich Nietzsche’s statement: "[The person] who has a why to live can bear with almost any how." This is the same existential wisdom Viktor Frankl drew upon in creating his school of logotherapy, which is focused on the search for meaning. From his own experience in concentration camps, Frankl learned that virtually any amount of suffering can be endured if the sufferer can find meaning in it.

Jung agreed that "the psyche needs to know the meaning of its existence." Jung felt that a person’s progress toward wholeness (individuation) involves the development of meaning in his/her life and in contact with a higher force (the Self). I agree that overcoming depression does entail finding meaning in life and in one’s suffering. But depression can be overcome only with positive developments in all four factor groups. For example, if a man takes better care of his physical health (biological), and seeks therapy (psychological), life may seem more worth living (existential/spiritual), which may give him more incentive to meet outer life challenges (social).

Of the four factor groups, I believe the most promising factor in reversing depression is the existential/spiritual, because the most powerful healing emotion is what Jerome Frank calls expectant faith. Joy, inspiration and hope are healing agents in cases of depression and hope can be learned, because human beings have an innate propensity to search for light in any darkness. This propensity will produce the light of hope eventually, if the patient persists.

Depression, in sum, is a vast and varied terrain, a surround not only of suffering and despair but of great value and meaning.

Suicide is self-murder and only humans are capable of performing such an act. Rates of suicide are much higher in the Western world than in developing countries, particularly because Western societies contain more conflicts and complexities that intensify the intra-psychic conflicts in the potentially suicidal person.

Contemporary thinking about suicide derives from the classic 1897 study Suicide, by Emile Durkheim. He classified suicide into three categories: egoistic (when the individual is not properly integrated into society and feels lonely or cut off), altruistic (when an individual is so absorbed in a group that he voluntarily sacrifices his life for it, e.g. Arab terrorists, Japanese kamikaze pilots), and anomic (when an individual is unable to cope with sudden changes in his/her social situation, e.g. suicides after the 1929 stock market crash).

In modern America, teenagers are the group most at risk, in suicides of both the egoistic and anomic forms. Suicide is the ninth leading cause of death in the general population, but the third leading cause among teenagers. The rate for teen suicide is two and a half times higher than it was twenty years ago, and almost four times higher than thirty years ago. A teenager tries to commit suicide every 1.1 seconds and every 80 seconds one of these teens does, in fact, die.

Why this high rate of suicide among adolescents? Partly because this is the life stage when an individual’s child ego disintegrates and the newly emerging adolescent ego can make powerful contacts with the Self. Lacking adult ego defenses, the adolescent ego can also see the shadow better than adults can. Native American tribes recognized this capacity for double vision when they turned to adolescents for insights into the future.

Another cause may be the "Werther effect," named for the hero of Goethe’s The Sufferings of Young Werther (1774), who committed suicide in a romantic manner that subsequently inspired a wave of imitative suicides. Now, with the influence of the media, especially television, "copycat suicides" produce epidemics of teen suicides.

For a potential suicide to carry through the deed, depression (anger directed against the self) must conflate with the death instinct (according to Freudian theory). Karl Menninger refined this, to posit three components prerequisite to suicide: the wish to kill, the wise to be killed and the wish to die (the death instinct). There is also always a wish to be rescued, and this forms the basis for all suicide prevention and therapy. Donald Winnicott believes that suicide relates to an ambivalence about death: there is a wish to die along with a desire to explore what died long before, i.e. the true self. In these cases the false self has been confused with the true self and the person thinks the false self is real.

While Jung did not write directly about suicide, he clearly opposed it in multiple letters he wrote. He regarded it as a crime against the Self. He noted that "We live in order to attain the greatest possible amount of spiritual development and self-awareness... To interrupt life before its time is to bring to a standstill an experiment which we have not set up." He made it clear he would not condone "mercy killing" or euthanasia, but would counsel patients to "hang on as long...as it is humanly possible..."

Other Jungians see the contemplation of suicide as containing the "longing for spiritual rebirth" (Bruno Klopfer) or as "nature’s demand for a change in attitude or an increase in self-awareness which brings on the depressed state." (Jane Wheelwright).

I believe that those seeking to heal suicide-prone patients must put a premium on life, and particularly on hopefulness as an attitude about life. The therapist’s attitude toward suicide and death itself is also extremely important. I agree with the Hindu perspective that suicide is essentially bad karma and fundamentally out of step with nature. Doctor-assisted suicide violates the Hippocratic Oath to "Do no harm."

Although there is plenty of evidence to support the existence of a death instinct in the human psyche, there is little evidence of a suicide instinct. In fact there seems to be a suicide taboo in the human psyche parallel to the incest taboo. Very few myths and even fewer fairy tales incorporate suicide in them. Rather than suicide, the hero/heroine of these archetypal tales usually undergoes an ego-sacrifice, which leads to transformation and rebirth.

Artistic creativity after the act of egocide parallels the healing process of transformation. A suicide-like state often signals a potential movement of an individual away from an untenable mode of being or lifestyle, into a new, more rewarding mode.

Americans tend to equate successful medical treatment with "cure." But I tell my students that only hams are cured. In my opinion, to treat a person’s illness successfully means to effect a healing process in that person, which is related to integrity, to "make whole." Jungian analytical psychology, in particular, rarely seeks to "cure." Rather it aims at promoting a person’s individuation, the ongoing journey toward wholeness. Finding a cure implies a reductionistic approach to treatment, while individuation implies taking a multidimensional, holistic approach.

The most prevalent misconception about the treatment of depressed and suicidal persons is that they can be "cured" by medication alone. In double-blind studies, patients were given anti-depressant medications. Sixty to 70% who took them got better, but 30-40% of those given the placebo also got better. That is, they improved with no pharmaceutical agent. Clearly the most powerful medicine of all is "expectant faith," or hope.

There is minor depression (neurotic or dysthymia) and major (psychotic or melancholia). There are depressive symptoms (e.g. depressed mood, disinterest or lack of pleasure in life, loss of appetite and weight loss, insomnia, fatigue or loss of energy, sense of worthlessness and guilt, difficulty with thinking or concentrating, and thoughts of death and suicide). Major depression often leaves the patient unable to cope with normal life, and suffering with hallucinations or delusions. Clinically, the most important distinction among the various forms of depression is between unipolar and bipolar mood disorder (manic-depressive illness). Unipolar mood disorder is ten to twenty times more common than bipolar disorder.

Depression can also be related to the seasons, especially winter (Seasonal Affective Disorder, due to a deprivation of sunlight), and to alcohol use (with a mutual cause-effect process: overconsumption leads to depression, and depression can lead to more alcohol use). Light therapy can alleviate SAD, and spiritual/existential factors offer the greatest help with alcoholism. Jung saw the alcoholic’s craving for spirits as a thirst for wholeness and union with God (i.e. the Spirit).

How to tell if a person is at risk for suicide? The best predictor is a feeling of hopelessness. The next best is the presence of depression. The way to instill hope and dispel depression is via egocide, and the creative transformation of the self.

A high suicide risk is related to affirmative answers to four questions:

1. Do you feel that your world is narrowing and you are more alone and alienated than ever before?

2. Do you feel unable to express anger toward others and increasingly blame yourself for everything that goes wrong?

3. Do you feel hopeless?

4. Do you think of dying and of ways to kill yourself?

 

To help in assessing risk to self or significant others, here are the basic risk factors for suicide

• suicidal thoughts

• terminal behavior (e.g. giving away valuable possessions and acting as if one is not going to be around much longer)

• detailed suicide plan with a lethal method at hand

presence of psychosis (especially featuring delusions that involve suicidal thoughts)

• presence of an organic brain disorder or chronic disease, especially one which affects the brain, which could lead to poor judgment

• severe loss or threat of loss (e.g. death of a loved one, loss of a job, or advent of a serious illness)

• history of alcohol or drug abuse

• family history of suicide

 

Someone who suspects suicidal intentions in a friend or relative should take the following five steps:

• take the time to accept the distraught person and listen to what he or she has to say

• begin your inquiry with sensitive, open-ended questions related to depression and hopelessness

• if the person admits to depression and hopelessness, ask if he or she has thoughts of dying or ending his/her life

• if the person has thoughts about suicide, ask if he or she has any plans or means to carry out these thoughts

• if the person admits to having a plan and the means, ask "What is stopping you?"

 

If, from these questions, you determine a suicide risk is present, then you must decide whether inpatient or outpatient treatment is indicated. This is a thorny issues. Here are some rules of thumb: First, develop a collaborative partnership with a doctor. Second, outpatient treatment is indicated when the person is not psychotic or severely depressed; when he or she does not suffer from severe insomnia; when he or she is not acutely suicidal; when there is the presence of good social support; when the individual is hopeful about the future; and when the person has a stable relationship with his or her doctor.

Depression often goes undiagnosed. Primary-care physicians should evaluate every individual who seems sad and depressed for a clinical diagnosis of depression. If depression exists, the best situation to be in is a healing relationship with a doctor. The patient’s needs ought to determine all aspects of treatment, including all four factors mentioned earlier. All measures necessary must be taken to keep a person from committing suicide, while simultaneously providing a real human bond between patient and doctor. Hope, faith and love provide light at the end of the tunnel of depression. It has even been suggested that hope provides "suicide antibodies."

Depressive and suicidal states can be treated biologically, psychologically, socially and existentially. In the biological realm, there are somatic (electroconvulsive therapy), pharmacologic (MAO inhibitors and tricyclic antidepressants—Prozac, Paxil, etc; lithium carbonate, especially for bipolar forms of depression), phototherapeutic (full-spectrum light exposure) and diet therapies (elimination of caffeine and refined sucrose).

In the psychological realm, there are behavioral (positive reinforcement of behaviors not associated with depression), cognitive (changing how the patient thinks), interpersonal (focusing on current interpersonal relationships), psychoanalytic (focusing on transference, in a long-term process), and the systems approaches (considering the full range of causes, with the goal of transforming hopelessness into hope).

In the social realm, there are two forms of treatment: family and group therapies. Family therapy works to give the patient inner peace while achieving harmony with the outer environment. Group therapy provides support for the individual within a homogeneous group. This is similar to the kind of support provided by AA and NA. In both of these groups the spiritual element is at the center.

In the existential realm, treatment is built on two assumptions: that human nature is intrinsically flexible; and that life makes sense, and one’s attitude toward life creates meaning.

All treatments should be viewed holistically, with the patient as an individual guiding the therapy. For a severely depressed person, thoughts of meaninglessness approach hopelessness; he is cut off from many values and has little or no energy for living a full life. Hope is the internally generated medicine that taps into the archetype of the healer within.

If, in the first two years of life, we are accepted by mother and/or father, or a parental surrogate, we have a fundamental sense of self-acceptance on which we can rely forever after. With suicidal teens, this reservoir of love in their lives is lacking, reflecting our general culture’s increasing depersonalization. Depression cannot be resolved until a person finds and reconnects with his or her lost soul, so the candle of hope can be rebuilt. In the healing process, crying and laughter are powerful methods to relieve tension and restore balance. They can lead to what Arthur Koestler calls creative regeneration. Another powerful tool is involvement in creative expression—art therapy, based on active imagination. Creative products of active imagination, in fact, often stimulate resynthesis of fragmented parts of the ego.

My approach to treating depressed persons and those who want to kill themselves is novel. It involves egocide, transcendence and transformation. This model could be called, colloquially, a Commonsense Model, with the four components—Bad News, Good News, Symbolic Death and New Life—that were mentioned earlier.

Many famous people in history have made this healing journey through dark nights of the soul, enduring depression in order to transcend it and transform his or her life. Afterwards these individuals made vital contributions to bettering the lives of others. Abraham Lincoln, for example, suffered from recurring bouts of severe depression. The English philosopher, John Stuart Mill, became morbidly depressed at age 20, pushed himself through it and formulated an entirely different personal philosophy as a result of his experience. Likewise, William James, the founder of both American psychology and philosophy, suffered from depression to such an extent that he had to drop out of medical school. In each case, these individuals, by transcending their illness, became weller than well. They committed egocide, rather than suicide, and were able to transform their identities. This transformation is inherent in egocide because it is a humbling, as well as a healing act.

This transformation also occurred with all the bridge-jump survivors. Not one went on to commit suicide. Rather they all went through a transcendent experience after his or her suicide attempt, and their whole view of themselves (their ego-identity) changed dramatically.

I use "ego" here in the Jungian, not the Freudian, sense. Freud saw the ego as both conscious and unconscious. But Jung defines the ego as existing only in a conscious state, "the complex factor to which all conscious contents are related," and forming "the center of the field of consciousness." The ego rests on the unconscious and is influenced by subliminal memories and intrusions of the shadow.

The personal shadow is that which is repressed or unknown about oneself. It is typically projected on to other people and while it seems "unacceptable to one’s present ego image, it often contains unrecognized positive qualities needed for further individuation." This is because the shadow has both positive and negative poles, containing idealized traits that have been repressed (e.g. heroic, visionary, spiritual, noble qualities) and anti-social traits (e.g. hate, envy, lust etc.) Part of the healing process—the growth toward wholeness—involves assimilating the personal shadow.

The ego, as the center of consciousness, is concerned with personal image and identity. It is subordinate to the Self, which is the totality of the psyche, encompassing both the conscious and the unconscious. The ego tends to dominate the first half of life, as one creates a personal identity in the world. Often at mid-life a crisis occurs which can lead to a personal paradigm shift in which the ego is displaced from the center and the Self is recognized as the center. This is comparable to the socio-historical paradigm shift in the 17th century from the Ptolemaic to Copernican concept of the solar system. The Freudian view of the ego remains Ptolemaic. Jung took a Copernican view. In those who suffer severe depression, it becomes painfully clear that the ego is not the central element. As the dominant ego-image changes, the ego feels threatened with dissolution, but as the ego identity becomes more comprehensive, one achieves individuation.

The ego wears a mask, a persona, to relate to and interact with the outer world. The healthy ego functions independently from the persona and knows that it can choose or not choose to identify with persona roles. In unhealthy conditions the persona can be overly developed (causing insensitivity to the surrounding world), underdeveloped (causing hypersensitivity, or being thin-skinned); or the ego may identify too strongly with the collective, engendering a false self (e.g. the "organizational man").

In dreams and the Jungian practice of active imagination, both the ego and shadow are symbolically killed. For example, as an analysand goes through the process of withdrawing shadow projections and assimilating shadow contents, dreams of evil same-sexed figures often are common.

Adolescents want and need to psychically kill off their dominant ego-identity (which is tied up with parental introjects). Goethe extolled this process and claimed that he repeatedly chose to go through death-rebirth experiences (adolescent crises) throughout his life.

Even though this egocide lets only part of the ego die, it feels like total ego death. One feels dead and the experience requires a period of mourning. There are chaotic emotions, especially anger, that must be processed in the Symbolic Death. The result is a release of energy as the old ego-identity is transformed into New Life. The new ego-image, based on a deeper ego-Self connection, leads to better relationships with others.

A variety of researchers, studying the process of symbolic death and rebirth, have identified a series of stages associated with depressive illness. I have condensed these into the following table (See Next Page)

The fourth column of this table describes the behaviors likely in the analytic process. In Stage I, for example, you nearly always exhibit resistance and express a lot of rage and negativity. This behavior is to test your therapist, to be sure he or she can empathize with you. Be sure your therapist’s response is accepting and caring, for building trust with your therapist is essential for achieving "regression in the service of the ego."

In Stage I the primary task is to understand and work through complexes (conflicts) you have with your parents. This gets underway once the initial resistance has been overcome. As you acknowledge your strength and reinforce your positive ego image, you work on identifying negative introjects. This is the essence of what I call egocide. During the final part of Stage I you actually feel as if you are dying. The dying negative ego-image and false self are pulling your healthy ego into the sea of the unconscious to join them in Symbolic Death. This is a very powerful and difficult time in therapy.

In Stage II, you usually feel dead and are very dependent—a confirmation that your previous ego-identity is dead. There is a synergism with your therapist, who becomes a mother surrogate. There is a "regression in the service of the Self." You experience Good News, and begin to see light at the end of the tunnel. Your reconstituted ego (now including more of the shadow and contrasexual aspects of the psyche [animus/anima]) helps you contact your center, the Self. During Stage II the ego-Self axis develops and you begin working with the collective unconscious complexes and archetypes. At the end of Stage II, you begin to feel hopeful and less depressed, which ushers in the final stage of therapy.

In Stage III you separate from the therapist and experience a death-rebirth. You transcend the opposites within you by integrating them. Mandala images are common in this stage, in dreams and artwork, as the Self manifests. New Life is the culmination of this last stage, and signals self-realization. You feel now that life has meaning and purpose.

Jung called this three-stage process individuation, the healing journey toward wholeness. Carl Rogers postulated a similar concept in self-realization, akin to Abraham Maslow’s self-actualization. In each case, psychotherapy offers a container in which this difficult process can be more effectively handled, in the temenos, or sacred space affording privacy and relative security.

The egocide and transformation paradigm is very applicable to the group therapy setting, which is very effective in preventing suicide. Suicide Attempters Anonymous groups use three stages parallel to those I have outlined above for individual therapy: getting to know one another (resistance and building trust); catharsis and crisis (sharing and repeating of past behavior); working through and socializing together (action and resolution).

Egocide must not be regarded lightly: it is a soul-wrenching process that must be pursued with immense respect for the dangers involved. Your level of psychic pain needs to be monitored as carefully as possible. There is the danger that your entire ego could disintegrate, leaving you without an ego, i.e. psychotic. So this is a process best undertaken under the supervision of carefully trained persons.

Symbols are images infused with meaning—a meaning so profound and multidimensional that often we cannot translate it into words. Symbols inspire and motivate us in ways reason can’t and they give us the power to grasp, identify and control what reason can’t. They both alter our experience and permit us to shape our experience. The therapy by which an individual’s egocide is made to lead to a positive transformation relies heavily on the evocation of healing symbols.

At this point, three important concepts associated with egocide and transformation deserve further clarification: archetypes, transformation and active imagination. Archetypes are innate, affectively charged predispositions toward ideas and patterns of behavior that are common to all human beings. Jung regarded archetypes as intricate and fundamental parts of the Collective Unconscious. Paralleling Darwin’s theory of physical evolution, Jung’s theory of psychic evolution proposes that all of history is embedded within each individual psyche in the form of archetypes.

Archetype, as a term, encompasses both positive and negative possibilities, e.g. the kind, nurturing mother and the wicked, terrible mother. This theme of opposites, which is the cornerstone of Jungian psychology, also applies to the Self, the timeless center and totality of the psyche. The Self includes the affirming higher force as well as the dark side, or shadow; animus (masculine) and anima (feminine). This is comparable to the Taoists’ yang and yin. The Self, in other words, is the central archetype in the human psyche—the innate healing force that is within every individual and the key to the self-realization process, individuation.

As I use "transformation," it means to change the nature of our personality. If we grow up in the usual way, we introject our parental conflicts and characteristics. If we remain unaware of this and do nothing about it, we can evolve into a manifestation of our parents’ wises and not our true self. The Self is the force behind the Symbolic Death of the dominant ego-image and it facilitates the process of transformation that can lead to the manifestation of our true self. The most important archetype of transformation is the healing and centering Self archetype, commonly symbolized by a mandala (a balanced image of concentric circles or shapes, often used in meditation).

"Active imagination" is the Jungian term for a process of letting oneself go with the flow of the unconscious and then manifesting one’s insights in an artistic form or product. These products reveal the present "state of affairs" in the psyche and also have a therapeutic function in themselves.

Another innately therapeutic element is the doctor-patient relationship. While a doctor cannot "cure" a patient, his or her involvement in the healing process certainly helps.

A central element in an individual’s transformation is the union of opposites, preceded by a radical experience of opposites. Jung used the term enantiadromia—borrowed from Heraclitus—to describe this play of opposites in the course of events. William James notes how Tolstoy, in a morbid psychological state, was drawn to suicide and then an enantiadromia occurred. He confronted death and the pull toward ending his life, and then let go of the old false self and contacted a higher power (the Self) and felt the spiritual vitality of being reborn and at one with his true self.

Certain specific archetypes, or symbolic images, tend to recur repeatedly in depictions of transformations in the human psyche. These include: snakes or serpents (symbolizing fear of death, and in the snake’s shedding of its skin, Symbolic Death and New Life); the cross (symbolizing the union of opposites, in a quaternary); the uroboros (a snake curled up in a circle, swallowing its tail, representing death and rebirth); a journey to the netherworld and back (the "hero’s journey," à la Joseph Campbell, characterized by a departure, an initiation [confrontation with the shadow] and the return).

In my analytical practice, I ask patients to create their own spontaneous artistic productions to express their feelings, states of mind, visions and dreams. This does not require any special artistic skills but simply responding to their own active imaginations. In interpreting these artistic productions, I often find helpful a schema developed by Marion Woodman that attaches symbolic importance to different compositional spaces of a drawing or painting: The upper left quadrant is associated with the father; the upper right, with the future; the lower left, with the unconscious; the lower right, with the mother. This schema I find useful, but recognize it is only one of many ways to interpret drawings or paintings.

Art works developed during active imagination come from patients’ unconscious minds and therefore contain collective (archetypal) symbols and themes, as well as personal symbols and themes. Using active imagination to evoke and render these archetypes is a profoundly effective therapeutic technique. A therapist-client relationship of mutual trust assists the development of this process on an internal level, allowing for the healer within the client’s psyche to take charge and continue the process of self-healing.

I see the therapist’s role as one of offering acceptance, empathy, nurturance, gentle confrontation and guidance, rather than "curing." The egocide model discussed above sounds simple and direct but it is not. Like life itself, it resembles a series of advances and retreats, progressions and regressions, flux and stagnation. The false self gets pulled into the black hole of severe depression.

Rebecca began analysis as a 42-year-old mother of three children who had recently completed a Ph.D. She had long felt a call to the ministry but had twice been rejected for seminary training. Deeply troubled by these two rejections, she now sought meaningful work. Her marriage was strained but tolerable. In three years of therapy, Rebecca moved through all three stages of therapy, uncovered early childhood incest, as well as unethical treatment from another therapist. She left her church, gave up her original intentions of finding work as a counselor and became a teacher at a women’s college. Like many people involved in the process of egocide, Rebecca had to go through the egocide/transformation sequence multiple times on her soul journey.

Gary came to me as a 35-year-old professional dancer and college instructor, married, childless, with a casual student-like appearance. Underneath his casual, upbeat surface, he was depressed and stuck, complaining of a loss of soul, which he attributed to a lack of creativity and meaning in his life. He wanted to get back to the free spirit he remembered himself as being when he was in college. Like a typical puer aeternus (eternal boy), Gary declared he loved speed and power. He had been adopted as an infant and had mixed feelings about finding his biological mother. He and his wife lived in an open marriage with numerous infidelities on both sides. Gary had had a poor relationship with his adoptive father and had had a vasectomy, insuring he would have no children himself. One of his major tasks was to resolve his father issues, lest he remain a boy forever. During our work together, Gary repeatedly sought to stop therapy, which I saw as a form of resistance. Then he stopped recalling his dreams, which was a more subtle form of resistance.

His art therapy took the form of dancing, painting and writing, which was, in its early stages, full of images lacking groundedness, darkness and reality. This is typical of men who are stuck in a puer aeternus complex.

I worked with Gary for over two years, until I moved away from San Francisco. During our time together he worked on both parental complexes, identified and met his biological mother. He changed his career direction, after a major injury to his foot, away from performer toward choreography and dance instructor. Five years from the beginning of his therapy (two and a half with me, two and a half with another therapist), Gary has transformed his depression, held on to his soul, permanently separated from his wife, and has become a mentor to many people. He has also continued on his journey of individuation.

When Sharon began with me, she suffered from a self-destructive depression and borderline condition, along with ego-related deficits, rapid mood swings, and many inner conflicts. She was 26 years old and a new graduate students, married (to her second husband), and a veteran of a year of therapy in another state. She suffered from anorexia and a distorted body image. She was physically separated from her fatherlike husband, having moved away to enroll in a Ph.D. program. This move represented the painful beginning of her independent healing journey. She intended to follow a family script and study in a business-related field. Her realization that she didn’t want to do this was the impetus for her egocide and transformation.

One of Sharon’s most serious problems was an addiction to perfection, the product of her general sense of feeling worthless. She had a long history of suicide attempts, sparked by parental abandonment. My working diagnoses initially were: major depressive episode (acute), dysthymia (depressive neurosis, chronic), eating disorder (anorexia nervosa), and a possible borderline personality disorder (later confirmed by psychological testing).

Sharon began our work together preoccupied with fears of failure. She was in the Bad News phase of her therapy, trying to sort out her personal conflicts and alternately accepting and resisting my help. She was cut off from her true self, and feeling suicidal.

Five months into therapy I introduced her to the term egocide. She grasped the concept immediately and agreed that the negative ego parts identified with her mother and father must be symbolically killed if she were to be her own person and achieve individuation.

Seven months into our work, when Sharon began to find it hard to recall her dreams, I suggested art therapy, to put her back in touch with her unconscious. The ensuing paintings she created helped her let go of some negative aspects of he male-dominated ego-image, and she regressed in the service of positive ego, which is characteristic of Stage I.

But she was still suicidally depressed. We began to meet more frequently and I talked more about egocide, to help her construct a symbolic logic for the painful thoughts and emotions she was experiencing, so that she would respond to them in a symbolic way, by committing egocide instead of suicide.

After 18 months of therapy, Sharon regressed into a period of melancholia and anger that she transferred on to me. Again she was suicidal. In such a pass, Jung felt a patient needs a vision of transcendence arising from the union of conscious and unconscious contents. Sharon found this vision in the painting she did during active imagination of a maternal uroboros. She was clearly working to resolve a very negative mother complex.

Two months later, Sharon took a decided turn for the worse, drinking more alcohol than usual and falling into a deepening depression. She began to think life was pointless. When I went on vacation, she felt rejected and she regressed, once again, to a Stage I state of mind. She got involved in self-harmful and self-defeating behavior. From her artwork I concluded that, in this interval, she was confronting her false self or negative ego-image, as well as beginning to see herself as a reborn woman—the mother of her true self.

There followed a series of abrupt turn-abouts in her moods, reflected in her paintings. She was slowly killing her Inner Witch and giving birth to the creative Self

By the end of two years of therapy, Sharon was doing well in several areas of her life. She had some good friends, including one especially close friendship with a woman, which was a first for her. She finished up a Master’s degree, having done well in her courses. She had changed from a dependent daughter to an independent and assertive wife, leading her husband (who was not in therapy) to talk about his desire for a separation. To this Sharon replied she wanted a permanent separation.

At this point she actually committed egocide and went through Symbolic Death, as the persona roles and ego-images she had had disintegrated. She had reached a completely disorganized state of confusion and had to take an official leave of absence from her graduate work toward her Ph.D. She had now transitioned from Stage I to Stage II of her process.

Typical of this stage, Sharon felt dread, agony and a sense of being out of control—a dangerous set of feelings for one prone to severe depression and a history of repeated suicide attempts. Patients like Sharon, at this juncture, have a strong need to be contained and held in the temenos, and to be allowed to borrow some positive ego from the therapist. While this is not always the most difficult period of therapy, for Sharon it was. She flirted with suicide several times (by cutting herself). She was committed to the hospital after one of these attempts.

After four days in the hospital, Sharon decided to fully commit herself to the analytical process. Psychological tests done in the hospital revealed that she had a very high I.Q., was severely depressed, in a borderline state, and a high suicide risk. Once out of the hospital, Sharon decided to leave the negative, male-dominated Ph.D. program, feeling this part of her ego identity had to die and through this act, it did. She was still depressed and I added an anti-depressant to her therapy, to counteract her increasing depression and replace her self-treatment of choice (alcohol).

While I was on vacation, Sharon called and talked of committing suicide and I had her committed again to the hospital. Her husband had just served her with divorce papers. She was now two and a half years into analytical treatment.

She began to talk of her therapy and relationship with me in more positive terms around this time, as she moved into Stage III. She developed a clear self-Self connection, manifested by new and creative actions having to do with goals and relationships.

Three years after beginning therapy with me, Sharon got a job as a manager trainee in a bookstore and also began a new, positive relationship with a man. She was no longer thinking of giving up or wanting to die. She was more assertive and realized she was no longer into hiding things or feelings from the men in her life. Our last session was 37 months after we began and I had the sense I had been on a true healing journey with Sharon. She had crossed over the water of the unconscious and had successfully transformed negative introjects and shadow aspects of herself, as well as her own animus. She had created better relationships with her family and most importantly with herself, based on her union with a positive animus. Following her inner marriage, she had divorced her outer husband, thus freeing herself from a dependency that had been generated by her negative complexes. She felt better about herself as a result. She had transformed her false self into her true self by finding her lost soul (anima) and contacting the Self.

After a year’s work with a female analyst, Sharon went alone for two weeks to the Rocky Mountains on a spiritual quest—a sign of real change for a person in whom abandonment issues had been so large. This act suggests that Sharon had discovered an inner healer, so she no longer felt in danger of abandonment. She also no longer wants to abandon herself (i.e. suicide). She worked with Native American shamans, discovered the wolf as her totem animal, and is now in training to become a therapist, and has the potential to become an excellent one, living out the archetype of the wounded healer.

Paul’s story illustrates how endurance and healing through love are some of our best medicines. A mental health professional, Paul came to me in an acutely suicidal state. He had been seeing a psychiatrist for two years and was not being helped by large doses of tricyclic anti-depressants. He had been referred to me by an internist worried about his safety.

When he began therapy with me, Paul felt hopeless and worthless. He found no meaning in life. He suffered from low energy, insomnia, and a spastic colon. He also had panic attack symptoms from fears of impending doom. He also had several phobias around food, restaurants and chlorinated water.

Paul’s wife was also in therapy for depression and suicidal impulses. Two years earlier she had had bilateral mastectomies for breast cancer. Her father had killed himself four years before. She and Paul were in marital therapy as well.

Paul insisted his suicidal state was biological in origin. His mother, a health care professional, had a long history of psychiatric problems and suicide attempts. Paul also harbored much anger against his parents. His initial dream suggested a negative mother complex, but also a strong anima, connoting a potentially positive outcome for therapy.

I changed Paul’s medication, but he remained very depressed and angry, and had a delusion that he was destined to bear witness to the second coming of Christ, suggesting ego inflation and possibly a messianic complex. He tended to project his problems with his mother on to his wife. Meanwhile, his wife was distressed that she couldn’t be more supportive.

Two months into analysis, Paul had an especially meaningful dream.

This dream hinted that he was in the middle of Stage I, where the negative internalized images of his parents were being analyzed to death. The stage was being sent for egocide and transformation. A month later, his wife called me to tell me Paul had a suicide plan. I saw him immediately and he confirmed this. He refused hospitalization.

Then I introduced him to the concept of egocide, explaining that a negative part of his ego, in collusion with his shadow, was trying to overtake his whole being, and that this abnormal part, not his whole being, had to die. He readily grasped the concept and it helped to decrease his sense of desperation.

I saw Paul every day for a week. By not hospitalizing him, I was taking a chance—assuming that he would call me before attempting suicide. To deal with my self-doubts, I sought professional consultation. We made it through this crisis, but afterward, Paul was in agony and completely disorganized. He was unable to work, so I sent a note to his employer stating that he would be disabled for at least three months. My certifying that he couldn’t function finalized his ego death. He had committed egocide, not suicide.

I emphasized to Paul that it was now essential that he turn his death energy into creative products and prescribed that he draw his visions, dreams, and feelings at least once a week. At first he resisted, saying he couldn’t draw, but then agreed to do it.

His first drawing was of a spiral, a common image in the drawings of repressed and suicidal patients. Other subsequent dreams and drawings made me aware that we were in Stage II of the therapy.

At this point, Paul’s wife left him, unable to cope with his extreme depression, which was associated with killing off the negative mother within his psyche. At the same time, Paul was further upset because a woman colleague hanged herself. But Paul, significantly, was not suicidal.

In fact, he had enough new ego strength to go further into the collective unconscious. After five months of therapy, coming for two or three sessions a week, Paul drew an incubation image—a concept central to psychotherapeutic healing.

In the next phase, Paul started thinking of suicide again, but at this point he knew that such thoughts really meant that more negative ego and shadow parts had to die. He felt guilt-ridden as his dreams and drawings dealt with killing his mother and father. I explained that, in analyzing these negative parental complexes to death, he had committed psychic murder, thus freeing his true self.

Paul had analyzed to death his own personal neurotic parental complexes, but to have lasting results, he also had to resolve similar issues on the collective level, by going into deeper levels of the psyche. This caused him a great deal of anxiety. He felt disorganized and disintegrated: dead and dying. He struggled for nearly two months to find meaning in his life. He felt partly dead and partly alive. He could now talk with his two brothers; he no longer had panic attacks and his medication had been cut back. He also got a new job in the field of computers (a career change).

He wanted to stop therapy but I was empathic that this was not timely. He stuck with it and took up playing the guitar again, something he had not done since high school. Music is an ancient healing method.

As Paul entered Stage III, many positive changes were taking place in his life: He returned to work, moved into a new house and proceeded with his divorce. He became interested in Taoism, and began a spiritual quest, suggesting that he had made contact with the Self. He began to play bridge with his mother as his partner, for the first time in 10 years. He had no more symptoms of spastic colon. He established new relationships with women, and had no fears around food or restaurants.

Seventeen months into analytical therapy, Paul’s art indicated he was killing off his negative father complex. Other drawings indicated his new-found sense of wholeness. Two years into his therapy, Paul began a very gratifying relationship with a loving, creative woman, suggesting he had forged a meaningful inner connection with his anima (outer reality often being a mirror of an inner state).

Twenty-nine months after beginning his work with me, Paul obtained home movies of his childhood that his parents were going to throw out. Reviewing these movies turned out to be a very intense and painfully important part of his treatment, for he saw the reality of his deprived and difficult early childhood. As Paul discussed these movies, he realized he now accepted himself—wounds and limitations, as well as strengths.

Paul began to write songs around the theme of "soul-making" 38 months into therapy. He was intrigued by his idea of soul-making as a way to find his soul and he wanted to stay in therapy to work on separation from mother, which is the essential task of Stage III.

Then his depression returned. He developed insomnia, but was no longer suicidal. This phase lasted four months. His dreams dealt with the union of his masculine and feminine nature, and things began to improve. Paul talked about getting married and buying a new home. But then, in the next two months, he got increasingly depressed. He was hospitalized by a biologically-oriented psychiatrist and had tests done. He was put on synthroid, Asendin and Xanax. Paul decided to stop seeing me, which I understood as part of his process of separating from mother and his parental complexes.

My last contact with Paul, nine years after our first meeting, was by letter. He let me know he was doing very well in his work, and had gotten married to the loving woman he had been with when he left therapy with me. His depressive episodes were very infrequent and mild. He had not had any psychiatric treatment in four years and was no longer taking any medication. He had completely transformed his depression into creative work, living and loving.

The counterclockwise spiral—suggesting disintegration, regression, and collectivization—and the clockwise spiral—suggesting evolution, maturation and individuation—are emblematic of the nature of the transformation process.

Egocide allows us to transform depression and this transpersonal experience gives us hope. Seeing our lives as part of a larger human journey is also useful. In this perspective, crises are opportunities for transformation. Life provides us with three general crisis times: early, mid-life, and late-life.

In early life, the baby, through over or under-parenting, develops negative mother and father identifications. In adolescence, if the individual does not rebel and break from the parents, and their introjected egos, the stage is set for emotional disturbance and the creation of a false self.

The mid-life crisis is almost epidemic today. It is especially intense for the person who failed to resolve his or her true self vs. false self issues during adolescence. The goal in this mid-life crisis is individuation, the reclamation of the lost and unknown parts of oneself.

Late-life crises come when we have to renounce those family and work roles and ego images that we struggled so hard to attain over the years.

Crises also arise around times of the death or divorce of a life partner. Isolation and solitude allow the depressed person to go through a time of desolation in his or her own nigredo, or darkness. Out of this immersion in darkness comes the guiding light of the soul

Finally, egocide can be extended to encompass the collective, in the concept of world suicide, or omnicide. Jung emphasized that, on a personal or world scale, the issue of self-destruction begins and ends with the individual because "we are at war with ourselves." If we commit egocide and thus transcend the self-destructive complexes within ourselves, then we can begin to help make a positive difference on a collective level.

Egocide requires a paradigm shift, a shift that is a direct challenge to behavioral and ego psychologists, biomedically-oriented psychiatrists and individualists. It does accord well with Self psychology à la Jung, Rogers, Maslow and Kohut, since this school posits the Self, not the ego, as the center of the psyche.

There are striking parallels between egocide and its transformation paradigm and the process of developing psychic wholeness that is described in The Secret of the Golden Flower, a 1200-year-old Chinese work. This ancient source realized that a negative state of mind need not lead to suicide but can clear the way to New Life.

Each and every life has meaning, and everything depends on inner change. On these principles egocide is based.