Why People Die By Suicide

by Thomas Joiner

  He had also had the opportunity to habituate to pain and provo-

  cation in general. People work up to the extreme act of death by sui-

  cide through various means. The clearest involves previous suicidal

  behavior. But other means are possible too—any activity that allows

  people to get used to pain and provocation can serve to reduce fear

  of injury in general and self-injury in particular. Crane had plenty of

  opportunities to habituate to pain and provocation. He could not

  control his drinking, and frequently had drunken episodes that in-

  volved physical fights or the destruction of property. He spent time

  in jail in three different countries. Crane also had perhaps hundreds

  of anonymous sexual experiences, picking up sailors at New York’s

  docks. Anonymous sex might qualify as a provocative experience if

  some of the experiences turned violent, which seems likely given his

  history of alcohol use and drunken violent behavior.

  Crane’s life and death are clear examples of some of the themes of

  this book. For instance, many people who die by suicide appear to

  engage in short-term practice—I noted for example that my dad cut

  his wrists before the lethal wound to his heart. By contrast, through

  years of frequent provocative and painful experiences, people like

  Crane do not need short-term practice; they just go. And in fact, wit-

  nesses described Crane as “vaulting” over the rail of the ship. Crane’s

  lifetime of pain and provocation left him with no hesitation about

  death by suicide.

  Another fact about Crane is important, and it is that he character-

  ized a relationship that intensified near the end of his life as “some-

  thing of a reason for living.” The relationship was with the wife of a

  friend—their marriage had neared its end, and in the wake of it, and

  in the wake of Crane’s many troubles, a deep relationship emerged.

  Crane was gay, and it is not clear whether or not this relationship was

  sexual, though it was intense enough that Crane entertained ideas of

  marriage. In the days before his death, there were serious disruptions

  The Ability to Enact Lethal Self-Injury Is Acquired ● 57

  in this relationship. Crane had developed the capacity for self-injury

  already, and used it once his one remaining close relationship ap-

  peared to be falling apart.

  I have pointed to two of the three key components of completed

  suicide regarding Crane’s death—acquired ability to enact lethal self-

  injury (the focus of this chapter) and thwarted belongingness (a

  focus of the next chapter). The third component—a deep sense of

  incompetence or ineffectiveness (also a focus of the next chapter)—

  can be detected as well. In the days before his death, he said to many

  people that he felt “utterly disgraced,” in part by his drunken behav-

  ior on the ship, but also by his long history of such behavior.

  The death by suicide of the actor Spalding Gray in early 2004 is

  still another illustration of some of these principles. Gray was last

  seen on January 10 in New York City and was reported missing on

  January 11. There were reports that a Staten Island Ferry worker be-

  lieved he saw Gray coming off the ferry on the night of January 9.

  This left Gray’s wife and brother with the fear that the January 9 ferry

  ride was a “dry run” to prepare for the next day’s suicide. Their fears

  were confirmed when Gray’s body was found in the East River two

  months later, on March 7.

  Gray had attempted suicide multiple times since a 2001 car acci-

  dent in which he was badly injured. In September 2003, Gray left a

  phone message for his wife saying goodbye and indicating his plan to

  jump from the Staten Island Ferry. His wife called police, who radi-

  oed the ferry; ferry workers found a dejected Gray and escorted him

  off the boat.

  His lethal attempt was different. Before Gray was found, his wife

  stated that if her husband’s disappearance involved suicide, it had a

  different character than previous attempts. His past attempts had al-

  ways involved a note telling her what he would do, where he would

  be, and so forth. For his lethal attempt, there was no note; he just

  suddenly disappeared.

  There are other aspects of Gray’s death that are instructive. As was

  58 ● WHY PEOPLE DIE BY SUICIDE

  mentioned, he was badly injured in a car accident approximately

  three years before his death; he sustained a severely broken hip as

  well as head injuries. The experience of having been injured—having

  to endure the pain; facing the fear of bodily damage—may have in-

  ured Gray to the pain and provocation of self-injury. Just as Hart

  Crane habituated to pain and provocation through an array of pro-

  vocative experiences, including previous suicidal behavior, Gray’s in-

  juries, combined with his subsequent suicide attempts, may have left

  him prepared to fully face down death on his final attempt.

  Gray’s wife reported that his depression, which had been severe

  and treatment-resistant following his car accident, seemed to have

  been lifting in the days and weeks prior to his death. A well-known

  piece of clinical lore cautions that there is a window of heightened

  suicide risk as people emerge from depression, perhaps because they

  have the energy and cognitive clarity to act on long-standing suicidal

  ideas. There are anecdotal reports that appear to support this possi-

  bility. For example, Alvarez noted that the poet Sylvia Plath experi-

  enced increased energy and artistic productivity during the period

  before her suicide.20 This possibility was also noted—memorably—

  by the psychologist Paul Meehl in his famous paper “Why I Do Not

  Attend Case Conferences,” in which he describes upbraiding a stu-

  dent. Meehl, incredulous, asks the student if he has never heard that

  a psychotically depressed patient is more likely to kill himself when

  his depression is lifting. The student says no.

  “Well you have heard of it now,” says Meehl. “You better read a

  couple of old books, and maybe next time you will be able to save

  somebody’s life.”21

  The diminution of fear through repeated self-injury is, accord-

  ing to my account, necessary for serious suicidal behavior to occur.

  Shneidman described the case of Ariel,22 a young woman with previ-

  ous suicidal behavior (e.g., an overdose) who went on to attempt to

  burn herself to death. Her plan was to fill a gallon jug with gasoline,

  The Ability to Enact Lethal Self-Injury Is Acquired ● 59

  douse the inside of her parked car and herself with the gasoline, and

  then strike a match. She wrote, “I remember kind of shaking when I

  was getting the jug because I think I was a bit afraid.” Fear thus sur-

  faced even in Ariel, a woman who was clearly resolved to die by sui-

  cide. Ariel did strike the match, and was terribly burned. She sur-

  vived, but a few years later, died from natural causes.

  To be competent at and courageous about anything, one must

  have experience with it—the more experience, the more compe-


  tence and the more courage. The implications of continued experi-

  ence with provocative or painful stimuli, such as self-harm, are far-

  reaching.

  First, with repeated exposure, one habituates—the “taboo” and

  prohibited quality of suicidal behavior diminishes, and so may the

  fear and pain associated with self-harm. Second, and relatedly, oppo-

  nent processes may be involved. Briefly, opponent process theory23

  predicts that, with repetition, the effects of a provocative stimulus

  diminish, and the opposite effect, or opponent process, becomes

  amplified and strengthened. For example, with repeated use, the eu-

  phoric effects of heroin (the “a” process) weaken, and the aversive

  effects of withdrawal (the opponent process) increase; similarly, with

  repetition, the fear-inducing effects of skydiving (the “a” process)

  diminish, and the exhilarating effects of the opponent process are

  amplified. Skydivers become more competent and more courageous

  with skydiving practice and experience increasing reinforcement

  (e.g., exhilaration).

  So may suicidal people become more competent and courageous

  with repeated practice at suicidal behavior, and may even experience

  increasing reinforcement. Indeed, as will be expanded on later, many

  patients report that self-harm has calming and pain-relieving ef-

  fects—they self-injure because it distracts them from even deeper

  emotional pain, or because it makes them feel alive, or because it

  brings their inner world back into harmony with the world at large.

  60 ● WHY PEOPLE DIE BY SUICIDE

  What is the evidence that, through practice and the attendant ac-

  crual of competence and courage regarding suicide, people “work

  up” to the ability to enact lethal self-injury and may even find sui-

  cidal behavior increasingly rewarding? The several anecdotal exam-

  ples described in this chapter are consistent with this view, but anec-

  dotal evidence, by itself, is not particularly persuasive. If the view

  espoused here is true, what facts should be empirically demonstra-

  ble? In the following sections, several lines of research are described

  that, considered together, suggest that this viewpoint has merit.

  Multiple Suicide Attempts

  Alvarez wrote, “It is estimated that a person who has once been to

  the brink is perhaps three times more likely to go there again than

  someone who has not. Suicide is like diving off a high board: the first

  time is the worst.”24 Indeed, if past experience with suicidality facili-

  tates future suicidality, such that it becomes more serious and more

  lethal, people with multiple past suicide attempts should be demon-

  strably different from others, even including those with one past sui-

  cide attempt. My colleagues and I compared 134 current suicide

  ideators, 128 people who had recently made their first suicide at-

  tempt, and 68 people who had recently attempted suicide for at least

  the second time (i.e., multiple attempters). We compared the three

  groups on an array of symptom and personality indices. It should

  be noted that patients in all three groups were in crisis—they had

  either recently attempted suicide or ideated about it to the point that

  a mental health professional became concerned—and so the three

  groups did not differ in terms of why they were included in the study.

  All were suicidal in one way or another. A unique feature of this

  study was the comparison of multiple attempters to one-time at-

  tempters. The three groups did not differ with regard to age, so any

  differences among them were not likely age-related.

  And there were differences among them. As compared to those

  The Ability to Enact Lethal Self-Injury Is Acquired ● 61

  with suicidal ideas and those with one attempt, multiple attempters

  experienced more intense suicidal symptoms, such as desire to die,

  plans to attempt, resolve to die, intensity and duration of suicidal

  ideation, and so forth. This was the case on both self-report and cli-

  nician-rated scales of suicidality, which is important because the two

  data sources do not always agree (when they do, confidence in the

  results is higher). There were also differences on some personality

  variables, such as hostility. Even though all participants were in a

  suicidal crisis, multiple attempters stood out from others in terms

  of the severity of their suicidality as well as some features of their

  personality.25

  They had more past practice at suicide, and thus had moved fur-

  ther along the trajectory toward serious suicidal behavior than the

  others. Their position on this trajectory is indicated by the severity of

  their current suicidal symptoms. Other research groups, too, have af-

  firmed this pattern of findings.26

  What does the association between past suicide attempts and cur-

  rent suicidality mean? For example, it is possible that repeated sui-

  cidal behavior occurs simply because of an ongoing, chronic mood

  disorder. To rule out explanations like these, studies need to first doc-

  ument that an association between past and current suicidality exists,

  but also document that it persists when variables like chronic mental

  disorders are accounted for.

  In fact, several studies have shown that past suicidal behavior con-

  fers risk for later suicidality, including death by suicide, taking into account other key variables like mood disorders, for example. One

  study compared those who died by suicide to living controls. Sui-

  cides and controls were matched for presence and severity of mental

  disorders (also for gender and age), so any differences between the

  groups were not likely to be attributable to one group having more

  psychopathology than the other group. One of the main variables

  that distinguished those who died by suicide from living controls was

  62 ● WHY PEOPLE DIE BY SUICIDE

  a significant past history of deliberate self-harm.27 In a similar study,

  past attempts comprised a significant predictor of later death by sui-

  cide, even taking into account several other powerful predictors, such

  as presence of mood disorders.28 In these studies, multiple attempt

  status conferred risk to death by suicide, even beyond the effects of

  other powerful predictors, a finding quite consistent with the current

  conceptualization that people may “work up” to death by suicide

  through repeated episodes of deliberate self-harm (as well as through

  other means, noted later).

  Similarly, Boardman and colleagues compared those who died by

  suicide to controls who had died from other causes; cases and con-

  trols were matched for age and sex. Among the variables that distin-

  guished deaths by suicide from other deaths was a past history of de-

  liberate self-harm as well as a history of past criminal charges or

  contact with the police. Those who died by suicide had more sig-

  nificant histories of past self-harm and more police contact.29 The

  finding on criminality and legal contact is interesting; deliberate self-

  harm is the clearest means to habituate to self-injury, but not the
r />   only way. As will be expanded on later, other provocative experiences,

  including those associated with police contact (e.g., assault; injury

  from recklessness or substance abuse), may serve as well.

  A study following 529 mood-disordered patients over fourteen

  years found a similar pattern. Thirty-six participants died by suicide

  and 120 attempted suicide during the study. Among the variables

  that differentiated those who died by or attempted suicide from

  those who had no suicide attempt were history of previous attempts,

  impulsivity, and substance abuse.30 As with the previous finding on

  police contact, this result on substance abuse and impulsive behavior

  as precursors to suicidality is consistent with the view that an array

  of provocative experiences lays the groundwork for future self-injury.

  Another finding from this study was intriguing: Assertiveness was

  found to be a predictor of later suicidality among these mood-

  The Ability to Enact Lethal Self-Injury Is Acquired ● 63

  disordered patients. This finding on assertiveness as a predictor of

  suicidality squares with the current view that serious suicidality re-

  quires the accrual of a kind of courage or strength.

  My colleagues and I have recently conducted two studies that sup-

  port the conclusion that past suicidal behavior is related to future

  suicidal behavior in a fundamental and important way. We tried to

  take the same approach as some past investigators in that we assessed

  the relation of past suicidal behavior to later suicidality, again ac-

  counting for other key predictors. That is, we wanted to show that past and future suicidal behavior were related directly, as opposed to being associated simply because they are both related to a third thing,

  like a chronic mood disorder or personality disorder (this is known

  as “the third variable problem” in some research circles). The title of

  our paper included the phrase “the kitchen sink,” denoting our at-

  tempt to include as many “third variables” as we could think of. This

  paper included four different studies. A representative list of third

  variables would include: The demographic variables of age, marital

  status, and ethnicity; family history of suicide, depression, bipolar

  disorder, and alcohol abuse; personal history of legal trouble as an

  adult and as a juvenile; current and past diagnoses of depression and