Why People Die By Suicide

by Thomas Joiner

Relate to Each Other?

  My model assumes that two psychological conditions are necessary

  to the will to live, effectiveness and connectedness. If one is intact, so

  is the will to live. Numerous theorists have articulated aspects of this

  assumption in a variety of ways. William James, with regard to those

  who do not feel a sense of belongingness, wrote, “to those who must

  confess with bitter anguish that they are perfectly isolated from the

  soul of the world . . . [contributing to society] may not prove such an

  unfruitful substitute. At least, when you have added to the property of

  the race, even if no one knows your name, yet it is certain that, with-

  out what you have done, some individuals must needs be acting now

  in a somewhat different manner. You have modified their life; you are

  in real relation with them . . . And is that such an unworthy stake to set up for our own good, really?”101 James is claiming that effectiveness can be sustaining, even in the context of failed belongingness.

  The emphasis on feeling effective and connected is reminiscent

  of the famous dictum that mental health involves satisfying work

  and love.102 Much of the material reviewed above is consistent with

  the assumption that effectiveness and connectedness are the key in-

  gredients of the will to live. In fact, a recent study is consistent with

  this assumption. Researchers used several scales from the Minnesota

  Multiphasic Personality Inventory (MMPI), administered in early

  adulthood, to predict later death by suicide. Numerous scales were

  examined, but the only two that could discriminate those who died

  by suicide from depressed living controls and from non-depressed

  living controls were related to burdensomeness and low belong-

  ingness—the scales were “self-blame” and “social introversion.”103

  The Desire for Death ● 135

  Incidentally, the Atlanta Journal-Constitution reported that on July 7, 2004, a man threatening to jump off a bridge onto the northbound

  lanes of interstate I-75/I-85 (which combine in downtown Atlanta)

  brought all northbound interstate traffic to a halt. This was the sixth

  such incident from March to July 2004 in Atlanta. What is the psy-

  chological experience of someone who feels isolated and ineffective

  enough to threaten suicide, and then within minutes, has an audi-

  ence of very concerned emergency personnel and has shut down a

  big part of a large city’s transportation, affecting thousands of peo-

  ple? One wonders whether the rush experienced by having such an

  effect (affecting the city) and belonging (concern of a crowd of

  emergency personnel) allays the initial suicidal desire.

  One also wonders if any of the attempted suicides in Atlanta oc-

  curred on a Monday. My guess is that they did not, because the six

  people in Atlanta did not seem resolved to die by suicide; Monday is

  the day of the week on which most people actually die by suicide.104

  There are multiple reasons why this is so, including people with-

  drawing from weekend substance abuse. But it is interesting to spec-

  ulate that for the person wracked by feelings of burdensomeness and

  low belongingness, Monday may be especially difficult. The upcom-

  ing week may be perceived as a further challenge to one’s effective-

  ness, and whatever belongingness one could manage over the week-

  end may be disrupted by a return to the work week.

  However, some questions about the roles and interrelations of per-

  ceived burdensomeness and failed belongingness remain. For exam-

  ple, it could be argued that, to feel a burden on others, one must feel

  connected to them; thus, burdensomeness implies belongingness.

  This of course would pose a problem for the view proposed here that

  the co-occurrence of burdensomeness and thwarted belongingness

  lays the groundwork for suicidal desire. In reply, to perceive oneself

  as a burden on others (whether on family or society) requires only a

  minimal connection to them. To view oneself as a member of a fam-

  136 ● WHY PEOPLE DIE BY SUICIDE

  ily or of a society is all that is required to feel a burden on them.

  Therefore, only the complete absence of any ties whatsoever to others

  might prevent one from feeling a burden, even if one feels ineffective.

  An assumption of the present view is that human nature in general,

  and the need to belong in particular, are such that virtually no one

  experiences no ties whatsoever to others.

  Of course, it is likely that feeling disconnected could affect feel-

  ings of effectiveness, and vice-versa. For example, low feelings of ef-

  fectiveness may threaten belongingness. In a relevant study, research-

  ers led participants to believe that their partner perceived a problem

  with their relationship. In response, those lower in effectiveness en-

  gaged in behaviors that reduced relationship closeness, whereas those

  higher in effectiveness did not. In this study, low effectiveness facili-

  tated low belongingness.105

  According to the model described here, serious suicidal behavior

  requires the desire for death. The desire for death is composed of

  two psychological states—perceived burdensomeness and failed be-

  longingness. On belongingness, recall the example of the man who

  left a note in his apartment that said, “‘I’m going to walk to the

  bridge. If one person smiles at me on the way, I will not jump.” The

  man jumped to his death. On burdensomeness, recall the study that

  genuine attempts are often characterized by a desire to make others

  better off, whereas nonsuicidal self-injury is often characterized by

  desire to express anger or punish oneself. Examples like these sup-

  port the direct involvement of failed belongingness and perceived

  burdensomeness in the desire for death. Either of these states, in iso-

  lation, is not sufficient to instill the desire for death. When these

  states co-occur, however, the desire for death is produced; if com-

  bined with the acquired ability to enact lethal self-injury, the desire

  for death can lead to a serious suicide attempt or to death by suicide.

  WHAT DO WE

  MEAN BY SUICIDE?

  HOW IS IT

  DISTRIBUTED

  IN PEOPLE?

  4

  In the previous chapter, I asserted that those who desire suicide die by

  suicide only if they can. Those who can die by suicide will die only if

  they want to. But who can? Those who have acquired the capability to

  enact lethal self-injury. Who wants to? Those who perceive that they are

  a burden on loved ones and that they do not belong to a valued group or relationship. There are relatively large numbers of people who desire

  suicide, and large numbers of those who have developed the capacity for

  suicide. But there are relatively few people in the dangerous convergence

  zone—those who are at greatest risk for serious suicidal behavior.

  The components of the model have some interesting relation-

  ships to each other. The interrelations of burdensomeness and low

  belongingness have been discussed, but what of the associations be-

  tween acquired ability for suicide, on the one hand, and burden-

 
; someness and low belongingness, on the other hand? In fact, there is

  evidence that social isolation may lead to increases in pain tolerance.

  Researchers have shown that the pain threshold of mice increases af-

  ter thirty days of isolation.1 Sensory deprivation increases the pain

  threshold in people as well.2

  137

  138 ● WHY PEOPLE DIE BY SUICIDE

  Those who desire suicide:

  Those who are

  Perceived burdensomeness

  capable of suicide

  +

  Failed belongingness

  Serious attempt or death by suicide

  Just as isolation may lead to the ability to bear increased pain,

  behaviors that increase the pain threshold may lead to isolation.

  Provocative behaviors, like self-injury, can be off-putting. These be-

  haviors can also lead others to perceive one as a burden. In one

  study, a majority of the significant others of those who had re-

  cently attempted suicide reported that their support of the patient

  represented a burden to them.3 If people who engage in self-harm

  are ostracized and viewed as a burden because of it, their sense of

  belongingness may diminish and their sense of perceived burden-

  someness may increase. In a number of ways, then, components of

  the model presented here may feed each other. Any one of the com-

  ponents could be viewed as an entry into a process whereby all

  three components, and thus high risk for serious suicidal behavior,

  escalate.

  Any persuasive explanation of suicide should shed at least some

  light on the existing data, including prevalence; the clustering and

  “contagion” of suicide; and the associations of suicide with age, gen-

  der, race, neurobiological indices, mental disorders, substance abuse,

  impulsivity, and childhood adversity. The present model may also

  contribute to the resolution of long-standing dilemmas in the field

  of suicide research, treatment, and prevention, and explain some

  What Do We Mean by Suicide? ● 139

  puzzling suicide-related facts. For example, what constitutes a proper

  definition of suicide itself? Are mild suicidal ideation and lethal sui-

  cidal behavior located at different points along the same underly-

  ing continuum, or are they categorically different phenomena? The

  model may help us think about what we mean by suicide.

  Definitions of Suicidal Behavior

  A man is discovered dead in his car, which has veered off the road

  and slammed into a tree. There are no skid marks and alcohol is in

  his system, though not at levels exceeding the legal limit. Family and

  friends state that he has been somewhat despondent over the disrup-

  tion of a romantic relationship, but generally doing well. Is this a sui-

  cide or an accident?

  A woman ingests half a bottle of pills and then immediately tells a

  family member what she has done. She is rushed to the hospital,

  where she initially recovers, and she confides that she did not mean

  to die. Complications arise due to the overdose, however, from which

  she later dies. Is this a suicide?

  An adolescent pricks the side of her wrist with a pin, barely draw-

  ing blood, and then immediately tells her mother what she has done.

  Is this a very mild version of the same type of behavior by which

  people die by suicide, or is this behavior qualitatively different than

  more serious forms of suicidal behavior?

  As these examples show, defining suicidal behavior is not always

  straightforward. Indeed, the definition and classification of various

  forms of suicidality have been a vexing and long-standing issue.4 The

  questions have centered on whether suicidality represents a true con-

  tinuum, ranging from mild and fleeting suicidal ideation all the way

  on up to death by suicide,5 or whether some forms of suicidality are

  categorically different from others (e.g., a medically lethal attempt

  with stated intent to die as distinct from mild ideation).

  140 ● WHY PEOPLE DIE BY SUICIDE

  A complete answer to this question requires a program of research

  involving a statistical technique called taxometrics.6 This technique is

  complicated, but its main point is to differentiate categorical, either-

  or phenomena, like biological gender, from qualitative, dimensional

  continua (like temperature). This program of research needs to be

  done, but to date, awaits its steward.

  Until then, another approach to solving problems like this is

  through theory development, and in this regard, the current model

  provides some perspective. In one sense, the theory identifies a cut-

  point along the continuum of suicidal symptoms; namely, the point

  at which, for a given individual, suicidal ideation or behavior further

  engages habituation and opponent processes. This point varies from

  individual to individual, depending on the degree to which the indi-

  vidual has previously acquired the capability for lethal self-injury.

  In another sense, however, the current theory suggests that any cut-

  point may be deceiving, because burdensomeness and failed belong-

  ingness may be on the relatively less serious side of any line (because

  they constitute suicidal desire, the less serious aspect of suicidality),

  yet they are nevertheless key contributors to serious suicidal behav-

  ior, according to the current model. Whether suicidality represents a

  true continuum, ranging from mild and fleeting suicidal ideation all

  the way on up to death by suicide, or whether categories are involved

  (for example, medically damaging versus ideation), is a question that

  future research will have to resolve.

  Is Killing Oneself Always Suicide?

  Another complicated issue regarding definitions involves those who

  clearly caused their own deaths, but who may not be classified as

  having died by suicide. The terrorist attacks of September 11, 2001

  brought this issue into stark focus. First, there were people on the

  upper floors of the World Trade Center who jumped to their deaths.

  What Do We Mean by Suicide? ● 141

  At least fifty people died in this way, and the actual number is proba-

  bly closer to two hundred.7 Did they die by suicide?

  According to the New York medical examiner, they did not. All

  September 11 deaths at the World Trade Center were classified as ho-

  micides. Had even one person survived from the upper floors from

  which people jumped, perhaps a case for suicidal elements could be

  made, but no one from those floors survived. These people presum-

  ably realized that death was imminent, and chose one form of death

  over another.

  Moreover, if these deaths contained suicidal elements, the demo-

  graphic profile of suicide, for example regarding gender, should cor-

  respond to the profile of people who jumped from the World Trade

  Center. Overall, three times as many men as women died in the di-

  saster. For deaths due to jumping to conform to suicide demograph-

  ics, then, the ratio of men to women who died by jumping would

  need to approximate twelve to one (i.e., the 3:1 ratio of male to fe-

  male deaths in the disaste
r combined with the 4:1 preponderance

  of male suicides in the United States). To my knowledge, specific

  information on proportion of men and women who died in this way

  is not available; anecdotal impressions from photographs, however,

  suggest that, among those whose gender was identifiable, the ratio of

  men to women was substantially less than 12:1. Classifying these

  deaths as suicides therefore seems arguable at best.

  Still, the case can be made that these deaths technically were sui-

  cides, and if so, the current model should have something to say

  about them. The situation on the upper floors of the World Trade

  Center forced people to make horrible probability calculations (to

  the degree that people under duress were even capable of such calcu-

  lations)—jumping meant a quick end to suffering and certain death;

  not jumping meant a minuscule chance of survival at the cost of

  near-certain death by more painful means. Who would cling to this

  142 ● WHY PEOPLE DIE BY SUICIDE

  minuscule chance of survival? By the logic of the current model,

  there are two possible answers—those who wished to jump but

  could not because they were unable to enact lethal self-injury, and

  those whose desire to live was enormously strong—enough so to risk

  intense pain and suffering in exchange for even the smallest chance

  to live.

  Second, there were the terrorists themselves. Did they die by sui-

  cide? As I have stated in Chapter 1, according to dictionary defini-

  tions (e.g., “the act of killing oneself intentionally”), they did. Their

  views appeared to have been that their self-sacrifice was for their so-

  ciety’s greater good, which, in his classic work on suicide, Durkheim

  might have characterized as altruistic suicide. Here again, however,

  classifying these deaths as suicides seems quite arguable. The terror-

  ists themselves would almost certainly have described their actions

  as those of martyrs or casualties of holy war,8 especially since Islam

  views suicide as a serious sin.9

  Still, some might characterize these deaths as suicide, and if they

  were, how does the current model understand them? It is clear that

  suicide terrorists and bombers work up to the act, going through

  months and sometimes years of training and preparation for the

  act; in this way, they are consciously and deliberately attaining the