9.1 What Is Suicide?

Not every self-inflicted death is a suicide. A man who crashes his car into a tree after falling asleep at the steering wheel is not trying to kill himself. Thus Edwin Shneidman (2005, 1993, 1963), a pioneer in this field, defined suicide as an intentioned death—a self-inflicted death in which one makes an intentional, direct, and conscious effort to end one’s life.

suicide A self-inflicted death in which the person acts intentionally, directly, and consciously.

Intentioned deaths may take various forms. Consider the following examples. All three of these people intended to die, but their motives, concerns, and actions differed greatly:

Dave was a successful man. By the age of 50 he had risen to the vice presidency of a small but profitable investment firm. He had a caring wife and two teenage sons who respected him. They lived in an upper-middle-class neighborhood, had a spacious house, and enjoyed a life of comfort.

In August of his fiftieth year, everything changed. Dave was fired. Just like that. The economy had gone bad once again, the firm’s profits were down, and the president wanted to try new, fresher investment strategies and marketing approaches. Dave had been “old school.” He didn’t fully understand today’s investors—didn’t know how to reach out to them with Web-based advertising, engage them online in the investment process, or give his firm a high-tech look. Dave’s boss wanted to try a younger person.

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The experience of failure, loss, and emptiness was overwhelming for Dave. He looked for another position, but found only low-paying jobs for which he was over-qualified. Each day as he looked for work Dave became more depressed, anxious, and desperate. He thought of trying to start his own investment company or to be a consultant of some kind, but in the cold of night, he knew he was just fooling himself with such notions. He kept sinking, withdrew from others, and felt increasingly hopeless.

Six months after losing his job, Dave began to consider ending his life. The pain was too great, the humiliation unending. He hated the present and dreaded the future. Throughout February he went back and forth. On some days he was sure he wanted to die. On other days, an enjoyable evening or uplifting conversation might change his mind temporarily. On a Monday late in February he heard about a job possibility, and the anticipation of the next day’s interview seemed to lift his spirits. But Tuesday’s interview did not go well. He knew there’d be no job offer. He went home, took a recently purchased gun from his locked desk drawer, and shot himself.

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Shocking Comparison

Each year, more deaths in the United States result from suicide (38,364) than from motor vehicle crashes (33,687) (CDC, 2013).

Demaine never truly recovered from his mother’s death. He was only seven years old and unprepared for such a loss. His father sent him to live with his grandparents for a time, to a new school with new kids and a new way of life. In Demaine’s mind, all these changes were for the worse. He missed the joy and laughter of the past. He missed his home, his father, and his friends. Most of all he missed his mother.

He did not really understand her death. His father said that she was in heaven now, at peace, happy. Demaine’s unhappiness and loneliness continued day after day and he began to put things together in his own way. He believed he would be happy again if he could join his mother. He felt she was waiting for him, waiting for him to come to her. The thoughts seemed so right to him; they brought him comfort and hope. One evening, shortly after saying good night to his grandparents, Demaine climbed out of bed, went up the stairs to the roof of their apartment house, and jumped to his death. In his mind he was joining his mother in heaven.

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Additional Punishment

  • Up through the nineteenth century, the bodies of suicide victims in France and England were sometimes dragged through the streets on a frame, head downward, the way criminals were dragged to their executions.

  • By the early nineteenth century, most legal punishments for people who committed suicide (for example, confiscating their estates) were abolished across Europe and America.

  • In the United States, the last prosecution for attempted suicide occurred in 1961; the prosecution was not successful.

(Wertheimer, 2001; Fay, 1995)

Tya and Noah had met on a speed date. On a lark, Tya and a friend had registered at the speed date event, figuring, “What’s the worst thing that can happen?” On the night of the big event, Tya talked to dozens of guys, none of whom appealed to her—except for Noah! He was quirky. He was witty. And he seemed as turned off by the whole speed date thing as she was. His was the only name that she put on her list. As it turned out, he also put her name down on his list, and a week later each of them received an email with contact information about the other. A flurry of email exchanges followed, and before long, they were going together. She marveled at her luck. She had beaten the odds. She had had a successful speed date experience.

It was Tya’s first serious relationship; it became her whole life. Thus she was truly shocked and devastated when, on the one-year anniversary of their speed date, Noah told her that he no longer loved her and was leaving her for someone else.

As the weeks went by, Tya was filled with two competing feelings—depression and anger. Several times she texted or called Noah, begged him to reconsider, and pleaded for a chance to win him back. At the same time, she hated him for putting her through such misery.

Tya’s friends became more and more worried about her. At first they sympathized with her pain, assuming it would soon lift. But as time went on, her depression and anger worsened, and Tya began to act strangely. Always a bit of a drinker, she started to drink heavily and to mix her drinks with various kinds of drugs.

One night Tya went into her bathroom, reached for a bottle of sleeping pills, and swallowed a handful of them. She wanted to make her pain go away, and she wanted Noah to know just how much pain he had caused her. She continued swallowing pill after pill, crying and swearing as she gulped them down. When she began to feel drowsy, she decided to call her close friend Dedra. She was not sure why she was calling, perhaps to say good-bye, to explain her actions, or to make sure that Noah was told; or perhaps to be talked out of it. Dedra pleaded and reasoned with her and tried to motivate her to live. Tya was trying to listen, but she became less and less coherent. Dedra hung up the phone and quickly called Tya’s neighbor and the police. When reached by her neighbor, Tya was already in a coma. Seven hours later, while her friends and family waited for news in the hospital lounge, Tya died.

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While Tya seemed to have mixed feelings about her death, Dave was clear in his wish to die. Whereas Demaine viewed death as a trip to heaven, Dave saw it as an end to his existence. Such differences can be important in efforts to understand and treat suicidal persons. Accordingly, Shneidman distinguished four kinds of people who intentionally end their lives: the death seeker, death initiator, death ignorer, and death darer.

How should clinicians decide whether to hospitalize a person who is considering suicide or even one who has made an attempt?

Death seekers clearly intend to end their lives at the time they attempt suicide. This singleness of purpose may last only a short time. It can change to confusion the very next hour or day, and then return again in short order. Dave, the middle-aged investment counselor, was a death seeker. He had many misgivings about suicide and was ambivalent about it for weeks, but on Tuesday night he was a death seeker—clear in his desire to die and acting in a manner that virtually guaranteed a fatal outcome.

death seeker A person who clearly intends to end his or her life at the time of a suicide attempt.

Death initiators also clearly intend to end their lives, but they act out of a belief that the process of death is already under way and that they are simply hastening the process. Some expect that they will die in a matter of days or weeks. Many suicides among the elderly and very sick fall into this category. Robust novelist Ernest Hemingway was profoundly concerned about his failing body as he approached his sixty-second birthday—a concern that some observers believe was at the center of his suicide.

death initiator A person who attempts suicide believing that the process of death is already under way and that he or she is simply hastening the process.

Death ignorers do not believe that their self-inflicted death will mean the end of their existence. They believe they are trading their present lives for a better or happier existence. Many child suicides, like Demaine’s, fall into this category, as do those of adult believers in a hereafter who commit suicide to reach another form of life. In 1997, for example, the world was shocked to learn that 39 members of an unusual cult named Heaven’s Gate had committed suicide at an expensive house outside San Diego. It turned out that these members had acted out of the belief that their deaths would free their spirits and enable them to ascend to a “higher kingdom.”

death ignorer A person who attempts suicide without recognizing the finality of death.

Death darers experience mixed feelings, or ambivalence, about their intent to die, even at the moment of their attempt, and they show this ambivalence in the act itself. Although to some degree they wish to die, and they often do die, their risk-taking behavior does not guarantee death. The person who plays Russian roulette—that is, pulls the trigger of a revolver randomly loaded with one bullet—is a death darer. Tya might be considered a death darer. Although her unhappiness and anger were great, she was not sure that she wanted to die. Even while taking pills, she called her friend, reported her actions, and listened to her friend’s pleas.

death darer A person who is ambivalent about the wish to die even as he or she attempts suicide.

Death darers? A sky surfer tries to ride the perfect cloud, high above the hustle and bustle of the city below. Are thrill seekers daredevils searching for new highs, as many of them claim, or are some actually death darers?

When people play indirect, covert, partial, or unconscious roles in their own deaths, Shneidman (2001, 1993, 1981) classified them in a suicide-like category called subintentional deaths. Traditionally, clinicians have cited drug, alcohol, or tobacco use, promiscuous sexual behavior, recurrent physical fighting, and medication mismanagement as behaviors that may contribute to subintentional deaths. Obviously, these kinds of behaviors are dangerous in their own right. Moreover, researchers have found a correlation between regularly engaging in such behaviors and later attempts at suicide (Juan et al., 2011).

subintentional death A death in which the victim plays an indirect, hidden, partial, or unconscious role.

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In recent years, another behavioral pattern, self-injury or self-mutilation, has been added to this list—for example, cutting or burning oneself or banging one’s head. Although this pattern is not officially classified as a mental disorder, the framers of DSM-5 have proposed that a category called nonsuicidal self-injury be studied for possible inclusion in future revisions of DSM-5. People would qualify for this diagnosis if they intentionally injure themselves on five or more occasions over a one-year period, without the conscious intent of killing themselves (APA, 2013).

Self-injurious behavior is more common than previously recognized, particularly among teenagers and young adults, and it may be on the increase (Rodav, Levy, & Hamdan, 2014). Although the pattern is not well understood, it appears that the behavior becomes addictive in nature. The pain brought on by self-injury seems to offer some relief from emotional suffering, the behavior serves as a temporary distraction from problems, and the scars that result may document the person’s distress (Wilkinson & Goodyer, 2011). More generally, self-injury may help a person deal with chronic feelings of emptiness, boredom, and identity confusion. Although self-injury and the other risky behaviors mentioned earlier may indeed represent an indirect attempt at suicide (Victor & Klonsky, 2014), the true intent behind them is unclear, so, other than the MediaSpeak below, these behaviors are not included in the discussions of this chapter.

How Is Suicide Studied?

Retrospective analysis The very public retrospective analysis of the 1994 suicide of rock star Kurt Cobain, leader of the grunge band Nirvana, was given new impetus in 2002 with the publication of Journals—a collection of notebook pages in which Cobain had written about his thoughts and concerns, bouts with depression, and drug addiction during the final years of his life.

Suicide researchers face a major obstacle: the people they study are no longer alive. How can investigators draw accurate conclusions about the intentions, feelings, and circumstances of those who can no longer explain their actions? Two research methods attempt to deal with this problem, each with only partial success.

One strategy is retrospective analysis, a kind of psychological autopsy in which clinicians and researchers piece together data from the suicide victim’s past (Schwartz, 2011; Wetzel & Murphy, 2005). Relatives, friends, therapists, or physicians may remember past statements, conversations, and behaviors that shed light on a suicide. Retrospective information may also be provided by the suicide notes that some victims leave behind (Wong et al., 2009).

retrospective analysis A psychological autopsy in which clinicians piece together information about a person’s suicide from the person’s past.

However, such sources of information are not always available or reliable. Around half of all suicide victims have never been in psychotherapy (Stolberg et al., 2002), and less than one-third leave notes (Maris, 2001). Nor is retrospective information necessarily valid. A grieving, perhaps guilt-ridden relative or a distraught therapist may be incapable of objective recollections or simply reluctant to discuss an act that is so stigmatizing in our society (Kelleher & Campbell, 2011; Wurst et al., 2011).

Because of these limitations, many researchers also use a second strategy—studying people who survive their suicide attempts. It is estimated that there are 12 nonfatal suicide attempts for every fatal suicide (AFSP, 2014). However, it may be that people who survive suicide attempts differ in important ways from those who do not. Many of them may not really have wanted to die, for example. Nevertheless, suicide researchers have found it useful to study survivors of suicide attempts, and this chapter shall consider those who attempt suicide and those who commit suicide as more or less alike.

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MediaSpeak

Videos of Self-Injury Find an Audience

By Roni Caryn Rabin, The New York Times

YouTube videos are spreading word of a self-destructive behavior already disturbingly common among many teenagers and young adults—“cutting” and other forms of self-injury that stop short of suicide, a new study reports.

As many as one in five young men and women are believed to have engaged at least once in what psychologists call nonsuicidal self-injury. Now the behavior is being depicted in hundreds of YouTube clips—most of which don’t carry any warnings about the content—that show explicit videos and photographs of people injuring themselves, usually by cutting. They also depict burning, hitting and biting oneself, picking at one’s skin, disturbing wounds and embedding objects under the skin. Most of the injuries are inflicted on the wrists and arms and, less commonly, on the legs, torso or other parts of the body.

Some of the videos weave text, music and photography together, which may glamorize self-harming behaviors even more, the paper’s authors warn.

And the videos are popular. Many viewers rated the videos positively, selecting them as favorites more than 12,000 times, according to the new study, … whose authors reviewed the 100 most-viewed videos on self-harm.

Why do you think certain individuals decide to display their acts of self-injury online?

Stephen P. Lewis, assistant professor of psychology at the University of Guelph in Ontario and the paper’s lead author, calls the YouTube depictions of self-harm “an alarming new trend,” especially considering how popular Internet use is among the population that engages most in self-injury already: teenagers and young adults.

Self-mutilation online The self-inflicted knife wounds of this patient are evident. The phenomenon of self-injury is growing and now extends even to the Internet and social networks.

“The risk is that these videos normalize self-injury, and foster a virtual community for some people in which self-injury is accepted, and the message of getting help is not necessarily conveyed,” Dr. Lewis said. “There’s another risk, which is the phenomenon of ‘triggering,’ when someone who has a history of self-injury then watches a video or sees a picture, his or her urge to self-injure might actually increase in the moment.”

Only about one in four of the 100 most-viewed videos sent a clear message against self-injury, the paper’s analysis showed, and about the same proportion had an encouraging message that suggested the behavior could be overcome. About half the videos had a sad, melancholic tone, while about half described the behavior in a straightforward and factual manner.

About a quarter of the videos conveyed a mixed message about self-injury, while 42 percent were deemed neutral and 7 percent were clearly favorable toward self-injury. Only 42 percent of the videos warned viewers about the content.

February 22, 2011 “VITAL SIGNS; Behavior: Videos of Self-Injury Find an Audience” Rabin, Roni Caryn. From The New York Times, 2/22/2011 © 2011 The New York Times. All rights reserved. Used by permission and protected by the Copyright Laws of the United States. The printing, copying, redistribution, or retransmission of this Content without express written permission is prohibited.

Patterns and Statistics

Suicide happens within a larger social setting, and researchers have gathered many statistics regarding the social contexts in which such deaths take place. They have found, for example, that suicide rates vary from country to country (Kirkcaldy et al., 2010). South Korea, Russia, Hungary, Germany, Austria, Finland, Denmark, China, and Japan have very high rates—more than 20 suicides annually per 100,000 persons; conversely, Egypt, Mexico, Greece, and Spain have relatively low rates, fewer than 5 per 100,000. The United States and Canada fall in between, each with a suicide rate of 12.1 per 100,000 persons; England has a rate of 9 per 100,000 (AFSP, 2014; CDC, 2013).

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Religious affiliation and beliefs may help account for these national differences (Foo et al., 2014). For example, countries that are largely Catholic, Jewish, or Muslim tend to have low suicide rates. Perhaps in these countries, strict prohibitions against suicide or a strong religious tradition deter many people from committing suicide (Stack & Kposowa, 2008). Yet there are exceptions to this tentative rule. Austria, a largely Roman Catholic country, has one of the highest suicide rates in the world.

What factors besides religious affiliation and beliefs might help account for national variations in suicide rates?

Research is beginning to suggest that religious doctrine may not help prevent suicide as much as the degree of an individual’s devoutness. Regardless of their particular persuasion, very religious people seem less likely to commit suicide (Cook, 2014; Güngörmüş, Tanriverdi, & Gündoğan, 2014; Stack & Kposowa, 2008). Similarly, it seems that people who have a greater reverence for life are less prone to consider or attempt self-destruction (Lee, 1985).

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Deal Breaker

If clients state an intention to commit suicide, therapists may break the doctor–patient confidentiality agreement that usually governs treatment discussions.

The suicide rates of men and women also differ. Three times as many women attempt suicide as men, yet men succeed at more than four times the rate of women (AFSP, 2014; CDC, 2013). Around the world 19 of every 100,000 men kill themselves each year; the suicide rate for women is 4 per 100,000 (Levi et al., 2003).

Although various explanations have been proposed for this gender difference (Fiori et al., 2011), a popular one points to the different methods used by men and women (Stack & Wasserman, 2009). Men tend to use more violent methods, such as shooting, stabbing, or hanging themselves, whereas women use less violent methods, such as drug overdose. Guns are used in 56 percent of the male suicides in the United States, compared with 31 percent of the female suicides (CDC, 2014).

Suicide is also related to social environment and marital status (You, Van Orden, & Conner, 2011). In one study, around half of the individuals who had committed suicide were found to have no close personal friends (Maris, 2001), although they may be active on Internet and social networks. Fewer still had close relationships with parents and other family members. In a related vein, research has revealed that divorced persons have a higher suicide rate than married or cohabitating individuals (Roskar et al., 2011; Stolberg et al., 2002).

Finally, in the United States at least, suicide rates seem to vary according to race (see Figure 9-1). The overall suicide rate of white Americans is more than twice as high as that of African Americans, Hispanic Americans, and Asian Americans (AFSP, 2014; CDC, 2013). A major exception to this pattern is the very high suicide rate of American Indians, which is at least 20 percent higher than that of white Americans (Herne et al., 2014; SPRC, 2013; CDC, 2010). Although the extreme poverty of many American Indians may partly explain their high suicide rate, studies show that factors such as alcohol use, modeling, and the availability of guns may also play a role (Lanier, 2010). In addition to differences across racial groups, researchers have found that suicide rates sometimes differ within groups. Among Hispanic Americans, for example, Puerto Ricans are significantly more likely to attempt suicide than any other Hispanic American group (Baca-Garcia et al., 2011).

Figure 9.1: figure 9-1
Suicide, race, and gender
In the United States, American Indians have the highest suicide rates among both males and females.

Some of these statistics on suicide have been questioned. Analyses suggest, for example, that the actual rate of suicide may be 15 percent higher for African Americans and 6 percent higher for women than usually reported (Barnes, 2010; Phillips & Ruth, 1993). People in these groups are more likely than others to use methods of suicide that can be mistaken for causes of accidental death, such as poisoning, drug overdose, single-car crashes, and pedestrian accidents.

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