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.

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:

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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.

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 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 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 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.

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 (Juan et al., 2011).

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 proposed that a category called nonsuicidal self-injury be studied for possible inclusion in future revisions of the DSM (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). It appears that this 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 and boredom. 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 commentary in MediaSpeak, these behaviors are not included in the discussions of this chapter.

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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). 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 (Cerel et al., 2015). However, such sources of information are not always available or reliable (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.

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).

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. Yet there are exceptions to this tentative rule. Austria, a largely Roman Catholic country, has one of the highest suicide rates in the world.

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; Güngörmüs et al., 2014). Similarly, it seems that people who have a greater reverence for life are less prone to consider or attempt self-destruction (Lee, 1985).

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, 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).

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Suicide is also related to social environment and marital status (You et al., 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).

Finally, in the United States at least, suicide rates seem to vary according to race (see Figure 7.1). 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). 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).

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.