Why People Die By Suicide

by Thomas Joiner

  The “resolved plans and preparations” category was made up of

  the following symptoms: a sense of courage to make an attempt; a

  sense of competence to make an attempt; availability of means to and

  opportunity for attempt; specificity of plan for attempt; prepara-

  tions for attempt; duration of suicidal ideation; and intensity of sui-

  cidal ideation. It is worth noticing that this category explicitly in-

  cludes indicators emphasizing courage and competence regarding

  The Ability to Enact Lethal Self-Injury Is Acquired ● 79

  suicide, which, according to the view proposed here, are reflective of

  the acquired ability to enact lethal self-injury.

  The “suicidal desire and ideation” category was comprised of the

  following symptoms: reasons for living; wish to die; frequency of

  ideation; wish not to live; passive attempt; desire for attempt; and

  talk of death/suicide. This factor does not include content related to

  courage, competence, and the like, but rather, emphasizes thwarted

  desire to live and reasons for death. In the next chapter, it will be ar-

  gued that thwarted desire to live can be understood in terms of feel-

  ing a burden on and disconnected from others. Thwarted desire to

  live is of course important in suicidality, but in an important sense, it

  is less clinically worrisome than the “resolved plans” category.

  Although the presence of symptoms corresponding to either cate-

  gory is of clinical concern, the symptoms of “resolved plans and

  preparations” are, relatively speaking, of more concern than the symp-

  toms of “suicidal desire and ideation.” And crucial to the predic-

  tion that serious suicidal symptoms should become more and more

  prominent with repeated suicidal experience, “resolved plans and

  preparations” was significantly more related than “suicidal desire and

  ideation” to status as a multiple suicide attempter.68

  A subsequent study reached similar conclusions regarding attempt

  status as well as eventual death by completed suicide. Specifically, my

  colleagues and I studied several hundred current suicide ideators,

  who were evaluated regarding their “worst-point” suicidal crisis, and

  then who were followed for many years.69 The “worst-point” was de-

  fined as a past suicidal crisis that was the most severe in the respon-

  dent’s life. In this study, as in the earlier reports, the distinction be-

  tween “resolved plans and preparations” (which includes courage

  and competence regarding suicide) and “desire for death” (the less

  serious dimension) was emphasized, in that respondents rated their

  “resolved plans” and their “desire for death” with regard to their

  worst-point crisis.

  80 ● WHY PEOPLE DIE BY SUICIDE

  According to the model proposed in this book, people who have

  experienced severe episodes of suicidality in the past (particularly

  if the episode involved loss of fear and other “resolved plans and

  preparations” phenomena) may be most at risk for severe suicidality

  in the future, and possibly even death by suicide. Our results con-

  formed to this view: The “worst-point resolved plans and prepara-

  tions” symptoms were the strongest predictor of suicide attempts

  during the follow-up period, and the only significant predictor of eventual death by suicide in the sample; the “suicidal desire and

  ideation” symptoms were not associated with later death by suicide.

  Consistent with these findings, a separate eighteen-year follow-up

  study found that planfulness regarding episodes of deliberate self-harm represented a significant risk factor for later completed sui-

  cide.70 Planfulness requires competence, which in my model is a key

  aspect of the acquired capability for lethal self-injury.

  That fearlessness and accrued courage and competence regarding

  suicide—key indicators of the “resolved plans and preparations” fac-

  tor—are implicated in severe suicidality is a central assertion of the

  present theory. In this connection, it is of interest to recall the four-

  teen-year prospective study of several hundred mood-disordered pa-

  tients mentioned earlier.71 Assertiveness was found to be a predictor

  of severe suicidality during the fourteen-year follow-up period. My

  model is perhaps the only theory of suicide that is compatible with a

  relation between assertiveness and suicidality.

  My colleagues and I analyzed notes written by those who died by

  suicide as well as those who attempted and survived72 using a soft-

  ware program called Linguistic Inquiry and Word Count (LIWC).73

  The program divides text into its components—for example, ten-

  dency to use action verbs, words denoting negative emotion, and so

  on. Among the clearest variables that differentiated notes by those

  who died by suicide from notes by those who attempted suicide and

  survived were indices related to assertiveness, specifically anger com-

  The Ability to Enact Lethal Self-Injury Is Acquired ● 81

  bined with confidence. The combination of anger and confidence

  bears some similarity to the combination of courage and resolution

  of ambivalence regarding suicide.

  Another aspect of the “resolved plans and preparations” category

  should be noted. In addition to indicators related to courage and

  competence regarding suicide, the factor also involved intense, vivid,

  and long-lasting ideation about one’s death by suicide. People who

  experience this say that they can see their death by suicide very

  clearly in their mind’s eye—it is as if they are watching a clear and

  vivid video of their own death by suicide. In this context, it is an

  interesting possibility that courage and competence regarding sui-

  cide may develop mentally as well as behaviorally. That is, vivid and

  long-lasting preoccupation regarding one’s suicide may represent a

  form of mental practice. To the extent that one rehearses for suicide,

  whether actually or mentally, suicide potential is increased. The con-

  cept of mental rehearsal may be helpful in understanding those who

  die by suicide on their first attempt—studies have found rates of

  first-attempt completed suicide as high as 50 percent.74 Mental prac-

  tice may facilitate suicide completion among those attempting it for

  the first time.

  Shneidman’s case example of Beatrice illustrates this aspect of

  mental practice. She says, “For the next two years . . . every night, be-

  fore fading off to sleep, I imagined committing suicide. I became ob-

  sessed with death. I rehearsed my own funeral over and over, adding

  careful details each time.”75 Beatrice later planned her suicide for

  three months, and tried to die by self-cutting; she survived.

  In 1992 and 1993, musician Kurt Cobain obsessively watched a

  videotape of the suicide of R. Budd Dwyer, a Pennsylvania state of-

  ficial who died at a live press conference (that Dwyer himself had

  called) by putting a gun in his mouth and firing.76 This may have

  represented a form of mental practice for Cobain’s 1994 death by a

  similar method.

  82 ● WHY PEOPLE DIE BY SUICIDEr />
  David Reimer, mentioned earlier and described in the book As

  Nature Made Him: The Boy Who Was Raised as a Girl, said that in

  eighth grade, when he was living as a girl, he “kept visualizing a rope

  thrown over a beam.”77 He would have continued experience with

  suicidality as well as numerous other provocative experiences, and at

  age thirty-eight, died by suicide.

  A study of over 3,000 patients at risk for suicide, thirty-eight of

  whom subsequently died by suicide, provides some indirect evidence

  regarding mental practice.78 Of the factors that predicted death by

  suicide, an important one was “contemplation of hanging or jump-

  ing.” Through mental rehearsal of violent death by suicide, these

  patients may have acquired more of the ability to enact lethal self-

  injury.

  Also relevant here is the concept of aborted suicide attempts, de-

  fined as an event in which an individual comes close to attempting

  suicide but does not do so and thus sustains no injury. Barber and

  colleagues interviewed 135 psychiatric inpatients, and over half re-

  ported at least one aborted suicide attempt.79 Intent-to-die ratings

  for aborted suicide attempts were similar to those for actual suicide

  attempts, indicating that aborted attempts can have severe quali-

  ties—qualities that could potentially produce habituation and prac-

  tice effects. Moreover, patients who reported aborted attempts were

  nearly twice as likely to have made an actual suicide attempt as pa-

  tients with no aborted attempts. Practice regarding suicide may oc-

  cur in the absence of actual suicidal behavior, either through mental

  rehearsal or through aborted suicide attempts.

  One additional reason to worry about the accrual of courage

  about suicide relates to the concept of cognitive sensitization. Cog-

  nitive sensitization occurs when one undergoes a provocative experi-

  ence, and subsequently, images and thoughts about that experience

  become more accessible and easily triggered. As applied to suicid-

  ality, as suicidal experience accumulates, suicide-related cognitions

  The Ability to Enact Lethal Self-Injury Is Acquired ● 83

  and behaviors may become more accessible and active.80 The more

  accessible and active these thoughts and behaviors become, the more

  easily they are triggered (e.g., even in the absence of negative events),

  and the more severe are the subsequent suicidal episodes. My col-

  leagues and I have documented that, in fact, as episodes of suicidality

  increase, their relation to external triggers decreases, and their sever-

  ity increases.81

  Vicarious Habituation: The Example of Guns in the Home

  As the example of aborted suicide attempts shows, there are multiple

  ways that people may habituate to dangerous stimuli. One way is

  through habituating to danger by observing someone else do so, or

  by repeatedly being exposed to cues associated with danger. The ex-

  ample of Kurt Cobain’s obsessively watching a videotaped suicide

  was mentioned earlier, as was his gradually increasing interest in

  guns. Guns in the home are an issue in this regard.

  First, let me disclose that I am not a huge fan of guns—I don’t

  own one myself—but neither do I have strong feelings against gun

  ownership. Regardless of one’s viewpoint on this topic, there ap-

  pears to be an undeniable association between the presence of guns

  in a home and suicides occurring in that home. For example, a study

  across twenty-one countries documented this association very

  clearly.82 In twelve countries, another study found that the percent-

  age of households with guns was strongly associated with the over-

  all mortality rate from guns in children aged 0–15 years, including

  death by suicide.83 An association does not prove a causal connection

  between presence of guns and suicide, but the association is consis-

  tent with the possibility that having guns around acquaints people—

  renders them fearless—about a potentially lethal stimulus.

  Brent and colleagues did an interesting study on whether families

  with a depressed adolescent follow recommendations to remove

  guns from the house. Of families advised to remove firearms from

  84 ● WHY PEOPLE DIE BY SUICIDE

  their homes, 26.9 percent did so. Interestingly, the decision to keep

  a gun, even when advised not to, was associated with the father’s

  psychopathology as well as marital dissatisfaction.84

  Repetition May Reinforce Suicidal Behavior

  The singer Pink, who has numerous body piercings and tattoos, said

  in the December 2003 issue of Jane magazine, “I took out my tongue ring when I was 21 and regretted it a week later. I like putting holes in

  my body. It’s addictive, it’s pain to know you’re alive.”85 The evidence

  summarized so far suggests that habituation and practice effects may

  be implicated in the escalating trajectory toward serious suicidality.

  In addition to habituation and practice, the theory put forth here

  suggests that repeated suicidality may engage opponent processes,

  such that not only do people habituate to self-injury, they also come

  to experience it as increasingly rewarding, similar to the way Pink re-

  ported that “putting holes” in her body is addictive.

  Many people appear to share Pink’s perspective. There is clear and

  consistent evidence that a primary motive for self-injury is relief,

  and that people find self-injury rewarding, at least in the immediate

  period following the incident. This may seem hard to imagine, but

  recall the example of skydiving. In a way, flinging yourself out of

  an airplane makes no more sense than cutting the side of your arm—

  indeed skydiving deaths occur every year. Why do people do this,

  then? The first time they skydive, they feel some of the thrill and

  exhilaration of it, and a large dose of the fear of it. But as they

  keep doing it, encouraged by the thrill and exhilaration, the pri-

  mary process of fear fades, and the opponent process of exhilaration

  strengthens.

  So it goes with self-injury. As people continue to do it, the primary

  process of pain fades, and the opponent process amplifies. What is

  the opponent process? As noted earlier, according to patients who

  self-harm, it is relief because it distracts from even deeper emotional

  The Ability to Enact Lethal Self-Injury Is Acquired ● 85

  pain, or because it makes them feel alive, or because it brings their

  inner world back into harmony with the world at large.

  Several studies support this idea.86 These findings appear to impli-

  cate what is called negative reinforcement (i.e., the self-injury is rein-

  forcing because it stops or reduces noxious experiences). However,

  positive reinforcement (i.e., the self-injury is reinforcing because it

  induces positive feelings) may be operative as well—for example, in a

  study of female psychiatric inpatients with borderline personality

  disorder (a main feature of which is repeated self-harm), patients

  rated various dimensions of their self-injury experiences. Results re-

  vealed significant mood elevation
as a consequence of self-injury

  among these patients.87 Many patients report that although negative

  reinforcement (i.e., relief) is a primary motive for self-injury,88 other

  motives exist, including positive reinforcers such as fascination with

  the injury and reaffirming the ability to feel89—or, in Pink’s words,

  “pain to know you’re alive.”

  To my knowledge, however, only one study has directly evaluated

  whether the rewarding properties of self-injury increase with repeti-

  tion. Participants who frequently engaged in self-injury were com-

  pared to those who infrequently did so, with regard to responses

  to a self-mutilation imagery task. In response to the imagery task,

  those in the frequent self-injury group reported more relief and

  more reductions in anxiety and sadness as compared to the infre-

  quent group.90 As people continue to engage in self-injury (or un-

  dergo other provocative experiences), they change. Self-injury loses

  its painful and fear-inducing properties and may even begin to gain

  rewarding properties. As this occurs, the main barrier to suicide

  erodes.

  The Psychological Merging of Death and Life

  To this point, the argument has been made that those prone to seri-

  ous suicidal behavior have reached that status through a process of

  86 ● WHY PEOPLE DIE BY SUICIDE

  exposure to self-injury and other provocative experiences. As this

  process unfolds, fear of death and pain on self-injury decreases. As

  reviewed above, certain scientific facts seem to support this view.

  Little has been said so far about how potentially suicidal people

  view death (except that they come not to fear it). When someone is

  far along the trajectory toward suicide, when they have acquired the

  ability to enact lethal self-injury, what is their view of death? Though

  there are very few scientific data on this point, anecdotal and case

  summary data suggest that people who are near death by suicide

  view death in a very peculiar way—namely, that death is somehow

  life-giving.

  For most people, the notion that death is life-giving or nurturing

  is not only irrational but very disturbing. Suicidal people appear to

  see it differently, however. For example, in Shneidman’s case study of

  Ariel, she stated, “We were in this old cemetery, and what was inter-

  esting and unique about this cemetery is that it is very old and the