A book to help us choose hopeBMJ 2023; 383 doi: https://doi.org/10.1136/bmj.p2727 (Published 17 November 2023) Cite this as: BMJ 2023;383:p2727
Years ago, when, for the first time, I heard of the suicide of a patient for whom I was responsible, I thought back to a story I learnt in primary school which had somehow become my personal benchmark for an intractable and unremitting sense of failure. I had learnt that in 1558, during the rule of Queen Mary Tudor, England had lost control of Calais which it had ruled for more than 200 years. Later that same year, Mary was dying and she is reported to have said: “when I am dead and opened, you shall find … Calais lying in my heart.” I immediately felt my patient’s name inscribed on my own heart and I still do.
Doctors are haunted by their failures and nothing feels more like a failure than the patient who deliberately ends his or her own life. A recent book by Christopher Dowrick is attuned to the depth of this feeling of failure among healthcare professionals, but he has been very careful in his choice of title. At no point does the book allude to “saving lives” but, by exploring the possibility of staying alive, he challenges all of us to do just that, purposefully including both sides of the healthcare relationship and fully aware that everyone can be confronted by despair. He was writing the book during those miserable doldrums of the covid lockdown and noted that:
Consistently between March and May , more than 10 per cent of us reported ‘thoughts that you would be better off dead or of hurting yourself in some way.’
He begins the book by describing five people in various states of misery and confronting suicidal thoughts: three are his own patients, but two turn out to be Leo Tolstoy and Gerard Manley Hopkins. This signals his declared intention to combine his longstanding commitment to good mental health with his belief in the healing power of literature. His epigraph from Matt Haig’s 2015 memoir Reasons to Stay Alive is telling:
Books are possibilities. They are escape routes. They give you options when you have none. Each one can be a home for an uprooted mind.
Both Haig and Dowrick understand that great writers possess a genius for choosing and using words that throw light on aspects of human experience that the rest of us sense, but are unable to articulate or really understand. When great writers have themselves experienced despair, their words can bring clarity and hope to those who read.
In the anguish of hopelessness, staying alive remains a choice which can be made, unmade and remade until the very last moment. Dowrick carefully examines the precise way in which Tolstoy describes the eventual suicide of Anna Karenina as she oscillates between hope and despair.
For me as a clinician and as a human being, Tolstoy’s message here is critical: even in the most desperate of circumstances, even if we are convinced that the whole world is against us, until that very last moment when the train actually rolls over us, the possibility of hope remains.
And, with hope, the possibility of staying alive.
Also in his novel Anna Karenina, Tolstoy creates the character of Konstantin Levin, and in doing so he seems to describe many of the circumstances of his own life, his own experience of desolation and hopelessness, and of finding of solace in doing. Dowrick writes:
The first way in which Levin (and Tolstoy) is able to stay alive is by doing rather than thinking.
When Levin thought about what he was and why he lived, he could find no answer and was driven to despair; but when he left off asking himself these questions, he seemed to know what he was and why he lived, for he acted and lived unfalteringly and definitely.
And Dowrick responds:
… our engagement in the ordinary activity of our everyday lives, our commitment to the circumstances in which we find ourselves, may be crucial to the existential preservation of the self.
When Levin does hard physical work, his suicidal thoughts recede and I am reminded of the constant refrain of the deeply unhappy protagonists in Chekhov plays: “we must work.”
For priest and poet Gerard Manly Hopkins, thoughts of suicide seem to be precipitated by intense loneliness when he is sent as a teacher to Dublin by his religious order. Simultaneously his exquisite, alliterative, and luminous poems become desolate, dark, and terrifying. Throughout his close reading of the poems, Dowrick admires Hopkins’ “absolute raw honesty”:
His ability to use form as a way of channelling and bearing witness to angst while refusing to explain it away or let it evaporate into abstract knowledge was as unparalleled in his time as it is in our own.
And then Dowrick gives us the lines with which Hopkins reaches the point of deciding to stay alive: lines with no less than six “nots”:
Not, I’ll not, carrion comfort, Despair, not feast on thee;
Not untwist – slack they may be – these last strands of man
In me ór, most weary, cry I can no more. I can;
Can something, hope, wish day come, not choose not to be.
As Hopkins slowly moves further away from his suicidal ruminations, Dowrick finds in his poems a fundamental:
… emphasis on care and kindness to the self in times of trouble.
For those of us caring for people considering suicide, whether family, friends, or health professionals, literary reading … enables us to overcome that first, sometimes immense hurdle, composed of ego-centricity, uncertainty, confusion and dread, …[and] become more able to turn towards suffering, become more curious about the person’s experience and intentionally become more present and engaged. … Bearing witness to suffering, giving the other person a sense of being understood and accepted, is the first essential step towards hope.
I can only scratch the surface of what this magnificent book has to give and I urge you to read its slim 140 pages for yourself. How much I wish that I had been able to read them before I had had any names inscribed on my heart. Yet the publishers have priced the book at a shocking £80 and as much as £25 for the eBook. They seem determined to ensure minimal sales and so reduce the contribution that this book could undoubtedly make to helping all of us to choose hope, and to stay alive.
Reading to Stay Alive
Tolstoy, Hopkins and the Dilemma of Existence
Anthem Press, 2022
Competing interests: none declared.
Provenance and peer review: not commissioned not peer reviewed.
If you're struggling, you're not alone. In the UK and Ireland, Samaritans can be contacted on 116 123 or email 988lifeline.org, or text HOME to 741741 to connect with a crisis counselor. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at www.befrienders.org.or . In the US, you can call or text the National Suicide Prevention Lifeline on 988, chat on