Why People Die by Suicide

Thomas Joiner

• Publisher: Harvard University Press
• Year: 2009
• ISBN:
  9780674970618
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

In the wake of a suicide, the most troubling questions are invariably the most difficult to answer: How could we have known? What could we have done? And always, unremittingly: Why? Written by a clinical psychologist whose own life has been touched by suicide, this book offers the clearest account ever given of why some people choose to die.Drawing on extensive clinical and epidemiological evidence, as well as personal experience, Thomas Joiner brings a comprehensive understanding to seemingly incomprehensible behavior. Among the many people who have considered, attempted, or died by suicide, he finds three factors that mark those most at risk of death: the feeling of being a burden on loved ones; the sense of isolation; and, chillingly, the learned ability to hurt oneself. Joiner tests his theory against diverse facts taken from clinical anecdotes, history, literature, popular culture, anthropology, epidemiology, genetics, and neurobiology--facts about suicide rates among men and women; white and African-American men; anorexics, athletes, prostitutes, and physicians; members of cults, sports fans, and citizens of nations in crisis.The result is the most coherent and persuasive explanation ever given of why and how people overcome life's strongest instinct, self-preservation. Joiner's is a work that makes sense of the bewildering array of statistics and stories surrounding suicidal behavior; at the same time, it offers insight, guidance, and essential information to clinicians, scientists, and health practitioners, and to anyone whose life has been affected by suicide.

1

WHAT WE KNOW AND DON’T KNOW ABOUT SUICIDE

The last compelling theory of suicide appeared approximately fifteen years ago. The number of other prominent and coherent theories in the decades or even centuries before that can be tallied on one hand. This is a strange state of affairs for a phenomenon that kills millions.

A new theory is needed that builds on existing models and provides a deeper account of suicidal behavior to explain more suicide-related phenomena. This is a very tall order, because the extent and diversity of facts related to suicide are intimidating and baffling. For example, suicide is far more common in men than in women … except in China. In the United States, there has been a recent increase in suicide among African-Americans—specifically, young black men. And yet, the demographic group at highest risk is older white men. Female anorexics, prostitutes, athletes, and physicians all have elevated suicide rates. A theory that can account for these diverse facts would be persuasive.

Such a theory would not only advance scientific knowledge, but deepen the understanding of suicidal behavior among clinicians who need to assess risk, intervene in crises, and design treatment and pre- vention protocols. It would also help those who have lost a loved one to suicide, who suffer much misunderstanding.

In this chapter, I describe some of my own clinical work and the supervision of others’ clinical work with suicidal patients. In the clinical literature, suicide is often described as an “urgent,” “vexing,” or “pressing” issue, one that preoccupies clinicians. Suicide is an urgent issue—it kills people—but urgency need not entail panic. Suicide can be understood in ways that resolutely point to clear clinical decisions … given, that is, a full explanatory model. My and others’ clinical experiences with suicidal patients will highlight how a comprehensive account of suicide would have reduced confusion and panic and facilitated clinical progress.

This chapter also touches on some of my scientific work on suicide. My research group is one of many that have produced new and important findings regarding suicide. The chapter will include some basic scientific findings on suicide produced by my and other research groups—facts that any compelling account of suicide must explain.

I also summarize existing models of suicide in this chapter—theoretical accounts that have been developed to explain some of these facts. One of the best ways to evaluate a theoretical model is the number of facts it can explain, and some of these models are more successful than others, as we shall see. My hope is that this book’s explanation of suicide will save people some of the misunderstandings my family and I went through, will refine clinicians’ approach to treating suicidal behavior, and will set a scientific agenda for the study of suicide. In the process, some interesting questions will be raised and addressed. For example, should family members tell the truth about the cause of death when a loved one has died by suicide? What constitutes a proper definition of suicide itself? How are we to understand the deaths of those who jumped from the World Trade Center towers’ upper floors on September 11, of the September 11 terrorists, and of those in mass suicides in cults? What protects most women from suicide, and yet, why do some very different subgroups of women—such as prostitutes and physicians—share similarly high suicide rates? Why are older, white men the demographic group in the United States most vulnerable to suicide? Why do suicide rates decrease in the United States during times of national crisis and decrease in a particular city when the city’s professional sports team is making a championship run? What are the constituent parts of the genuine desire for death? These and other questions will be raised and addressed throughout the book.

Notes from the Clinic

My first job after getting my doctorate was as an assistant professor of psychiatry at the University of Texas Medical Branch at Galveston. What a blessing this job was in many ways. I saw many psychotherapy patients and worked with skilled psychiatrists who taught me a lot about the biological bases of mental disorders. Biology appears to play some role in why people die by suicide, a fact I will address later in this book. But they also taught me something more—an attitude about suicide risk in patients that was neither dismissive nor alarmist. The alarmist position is perhaps the easiest to understand—this is the idea that whenever someone mentions suicide, it is a life-threatening situation and alarms should be sounded. This idea occurs in settings in which staff see relatively few people with serious mood disorders. In settings where serious mood disorders are common, people understand that suicidality is just part of the disorder; the majority of people who experience mood disorders will have ideas about suicide, and the vast majority will neither attempt suicide nor die by suicide. If 911 were called in each of these cases, a “cry wolf” scenario would quickly develop. Alarmists are making a mistake in conditional probability. Given the existence of a suicidal thought or behavior, they mistakenly estimate the probability of death or serious injury by suicide to be higher than it is.

Although alarmists make a mistake, it is not hard to see why they do. When people have ideas about suicide, it is quite true that risk is elevated compared to people who do not have suicidal ideas. Moreover, suicide is irreversible, and everything possible should be done to prevent it. Alarmists overreact, but they are doing so in the safe direction; “better safe than sorry,” they might say.

The alarmist problem is easy to notice in training clinics. Most of the pages I receive on my beeper are from therapists at the training clinic I direct who are worried that they should do more for a patient with suicidal symptoms. When I return the call, I ask a series of questions to see if the therapist is meeting the standard of care. In our clinic, meeting the standard of care is routine. And so I will then say, “Well, you’ve done everything I would’ve done; I wonder, what else is it that you think you’re supposed to do?” The answer is often, “I’m not sure, I just have this feeling that there’s something else I should do.” Then I’ll say, “Well, there’s not; but don’t lose that feeling, because it will ensure that you regularly do what’s best for patients; also, though, don’t let that feeling get out of hand, because it can burn you out, plus, ultimately these choices are not up to us, they’re up to patients.” Make no mistake, the standard of care is important—at times even life-saving—and therapists are expected to meet it rigorously, including involuntary hospitalization of the patient if needed. But beyond that, responsibility for life choices resides with patients. Therapists who see this are likely to enjoy their work more, to not be distracted by one patient when dealing with another, and, importantly, to enjoy their nonwork time as well.

The alarmist attitude is understandable but, especially if exaggerated, mistaken. Those who take a dismissive approach make a mistake in the opposite direction. They become blasé about suicidal behavior, often attributing it to manipulation or gesturing on the part of the potentially suicidal person. This problem is acute when it comes to the often misunderstood borderline personality disorder, which is characterized by a long-standing pattern of out-of-control emotions, interpersonal storminess, feelings of emptiness, and impulsive behaviors, including impulses toward self-injury. Some clinicians take a dismissive attitude toward patients with this disorder because they believe that these patients merely “gesture” suicide. In other words, they engage in suicidal behaviors, such as cutting themselves, but do not really intend to kill themselves; instead, they only intend to provoke or manipulate others. I wish this were true, but it is not—approximately 10 percent of patients with this disorder end up dying from their suicidal gestures (comparable to the rate for patients with mood disorders). The following quotation illustrates this misunderstanding:

The borderline patient is a therapist’s nightmare … because borderlines never really get better. The best you can do is help them coast, without getting sucked into their pathology … They’re the chronically depressed, the determinedly addictive, the compulsively divorced, living from one emotional disaster to the next. Bed hoppers, stomach pumpers, freeway jumpers, and sad-eyed bench-sitters with arms stitched up like footballs and psychic wounds that can never be sutured … Borderlines go from therapist to therapist, hoping to find a magic bullet for the crushing feelings of emptiness.¹

This characterization is demonstrably false. Patients with borderline personality disorder do get better. A persuasive study found that 34.5 percent of a sample of borderline patients met the criteria for remission at two years, 49.4 percent at four years, 68.6 percent at six years, and 73.5 percent over the entire follow-up. Only around 6 percent of those who remitted then experienced a recurrence.²

The dismissive attitude is dangerous for another reason. A main thesis of this book is that those who die by suicide work up to the act. They do this in various ways—for instance, previous suicide attempts—and all of these various ways have the effect of insulating people from danger signals. They get used to the pain and fear associated with self-harm, and thus gradually lose natural inhibitions against it. Clinicians’ dismissive attitudes have the potential to model a blasé attitude about self-harm. If clinicians blithely get used to suicidal behavior, their patients may vicariously do so as well.

The psychiatrists at my first job balanced the alarmist and dismissive positions very well. They clearly understood the danger and horror; in fact, most of them had had a patient who had died by suicide. They knew the standards of care for suicide risk assessment and the treatment of suicidal behavior, and they followed them faithfully. But they understood the limits of their interventions, they understood people’s ultimate autonomy, including their freedom to occasion their own death if they really were committed to doing so. My impression was that these psychiatrists did their job well during the day, and slept well at night.

Consider for example the case of Gayle (a false name). In retrospect, I understand Gayle’s situation clearly, but when I was seeing her, I was uneasy. She was the sort of patient who seemed potentially self-destructive. Indeed, she often fantasized about death by suicide, envisioning a particularly graphic means—severing her hand with a machete and bleeding to death (people have died in just this way, incidentally). She even owned a machete. This would be enough to concern any clinician, and I was no exception. I recommended that Gayle be hospitalized, so that she would remain safe while treatments for her substantial depression were started.

She refused hospitalization and also refused antidepressant medicines; she would agree only to psychotherapy. An initial question, then, was whether I should hospitalize her involuntarily. I had the sense that this would not be best, but I was having trouble putting my finger on exactly why she did not require hospitalization. After consultation with colleagues, I was reminded of some mildly reassuring facts. Gayle was around forty-five years old and had never attempted suicide. She had had plenty of time to have tried it, and yet had not. This is no guarantee. There are people who at age forty-five or even sixty-five attempt suicide for the first time and die. Still, the fact that she had not had previous experience with suicidal behavior was mildly reassuring. Her gender was another mildly reassuring factor—women are a lot less likely to die by suicide than are men. Also somewhat reassuring were her connections to life. There were things that she was proud of regarding her professional life, and more important, she was deeply connected to her young son. She spontaneously mentioned these things as I questioned her about suicide potential.

Gayle was also the rare person who clearly met criteria for a major depressive episode but who had an absence of depressed mood. In a study of young adults my colleagues and I conducted, this pattern was found to occur in only about 5 percent of those who were in a depressive episode. Recent work has shown lack of depressed mood to be a positive prognostic indicator among depressed people; that is, they tend to get better quicker and to have good outcomes.³

Throughout this book, I will argue that the acquired ability to enact lethal self-injury is crucial in serious suicidal behavior. People are not born with the developed capacity to seriously injure themselves (although they are born with factors, including certain genes, that may facilitate the future development of this capacity). In fact, if anything, they are born with the opposite—the knee-jerk tendency to avoid pain, injury, and death. That is, people have strong tendencies toward self-preservation; evolution has seen to that. Through an array of means described later, some people develop the ability to beat back this pressing urge toward self-preservation. Once they do, according to the theory laid out in this book, they are at high risk for suicide, but only if certain other conditions apply—namely that they feel real disconnection from others and that they feel ineffective to the point of seeing themselves as a burden on others. These factors, like the acquired ability to enact lethal self-injury, are covered in detail in later chapters of the book.

I now understand clearly why Gayle made me feel uneasy, but also why she was not at particularly high risk for suicide. She had acquired the ability to enact lethal self-injury. A main way that people develop this capacity is through previous suicidal behavior. As noted already, Gayle had not engaged in such behavior. What I believe led to her developing this capacity was a long history of severe substance abuse, which included many painful and provocative experiences (another way to gradually beat back the instinct to survive). Her substance abuse had ended; she had been clean for around eight years when I saw her. But her earlier experiences had left various residues.

This ability in Gayle was manifested by her having a clear and detailed suicide plan, but especially in her sense of calm and her lack of fear about the plan. These were the things that made me want to hospitalize Gayle. Nevertheless she was not at particularly high risk for suicide, and the reason involves two other factors that I believe are required for serious suicidal behavior—thwarted belongingness and perceived burdensomeness. Gayle had a fairly well-developed circle of friends and was very connected to her son. There was no evidence that she felt fundamentally disconnected from others, and plenty of evidence that her sense of belonging was very much intact. Similarly, Gayle was a particularly capable woman; for instance, even when depressed, she was the office’s top performer in her professional line of work. There was no evidence that she felt ineffective, certainly not to the point that she believed she burdened others.

Her sense of belonging and effectiveness buffered her, but it is important to note that this could have changed rapidly. People cannot develop the ability to lethally injure themselves quickly; the experiences that are required take time and repetition. By contrast, people can quickly develop views that they do not belong or that they are particularly ineffective. Thus, in a case like Gayle’s, suicide risk can quickly escalate. Repeated risk assessment is thus necessary in Gayle’s case (and is a safe clinical practice anyway).

The case of Sharon (a false name) is interesting by way of contrast. When questioned about suicide risk, Sharon articulated no plan at all. When pressed a little on the question, she made statements like, “I can’t imagine actually trying suicide, it’s just that I have the sense that I’d be better off dead.” Like Gayle, Sharon had never attempted suicide in the past, but unlike Gayle, she had no history of repeated painful and provocative experiences through which she might have acquired the ability to enact lethal self-injury. She thus did not have the setting condition for serious suicidal behavior, even though, as it turns out, she did have the other factors important in the current theory. That is, she felt she was a burden on others and felt disconnected from them. These feelings, combined with statements like, “I’d be better off dead” and with symptoms like sleep difficulty, clearly indicated a mood disorder, but her risk for suicide was slight. The thought never occurred to me that she should be hospitalized. Indeed, though she clearly had a mood disorder, it was of relatively moderate severity, and she remitted with less than two months of psychotherapy and stayed remitted for at least two years thereafter, which was the last time I contacted her.

The cases of Gayle and Sharon, especially when viewed through the lens of this book’s theory on suicide, are informative regarding suicide risk assessment. Generally speaking, someone like Gayle is at chronically elevated risk, at least to some degree, because the capacity for serious self-injury already is in place. All that is needed for Gayle to engage in serious suicidal behavior if she chooses is a quick change in her feelings of connection and effectiveness. Accordingly, routine assessment of risk status is required with someone like Gayle. By contrast, someone like Sharon is unlikely to engage in serious self-harm because she has not beaten down the instinct to live. Even if Sharon feels disconnected from others and ineffective, she lacks...