The idea that well-meaning prevention efforts can backfire and in-
crease the behavior they try to prevent is not unheard of. For exam-
ple, researchers evaluated an eating disorder prevention program in a
sample of college women who were in their freshman year.19 The in-
tervention involved peers who had recovered from eating disorders
describing their experiences and providing educational information
about eating disorders; a control group who did not receive this in-
tervention was also assessed. Results suggested that the intervention
backfired: Those who received it had slightly more symptoms of eating disorders than did controls. In fact, I recently saw a specific ex-
ample of this at the clinic I direct. A girl who was dissatisfied with
her body but who had no frank symptoms of an eating disorder saw
a prevention film at her school. The film discussed various aspects
of eating disorders, including self-induced vomiting. According to
the girl, the film produced in her the thought that “I’d like to try that
to see if it helps me feel better about my body.” Over the ensuing
months, she developed a serious eating disorder, including self-
induced vomiting multiple times per day.
A mild kind of backfiring has even been detected in some suicide
222 ● WHY PEOPLE DIE BY SUICIDE
prevention studies. For example, in an evaluation of a school-based
suicide prevention program, it was found that the program increased
relevant knowledge among girls, but that boys reported increased
hopelessness and maladaptive coping responses upon exposure to
the prevention program.20
The model of suicidal behavior developed in this book is intended as
a comprehensive theory of suicidal behavior, not as a clinical de-
scription or as prelude to the introduction of some clinical tech-
nique. Nevertheless, one of the main benefits of a thoroughgoing
theory is the clarification and illumination of clinically important
and sometimes vexing topics. Indeed, a theory that has nothing to
say about such things could rightly be viewed as suspect.
The theory developed here has substantive things to say about sui-
cide risk assessment, crisis intervention, treatment, and prevention.
Each of these areas is informed by the insight that those who do not
desire death will be unlikely to pursue it. Therefore, reduced percep-
tions of burdensomeness and lowered feelings of belongingness rep-
resent key targets for clinical interventions from risk assessment on
through to prevention. The acquired ability to enact lethal self-injury
is important too, but its relatively static quality makes it a target
mostly in risk assessment and intensive psychotherapy, and not as
much in crisis intervention or in prevention.
THE FUTURE OF
SUICIDE PREVENTION
AND RESEARCH
7
In this book’s opening chapter, I mentioned my own three connec-
tions to suicide—as survivor of my dad’s death by suicide, as clini-
cian, and as scientist. As perhaps has become clear in the previous
chapters, the topic has become mostly scientific and professional for
me, with the agenda of prevention and relief of suffering through the
culmination of the slow labors of scientific understanding.
But it’s still personal too. When I hear misinformation or ludi-
crous claims, like masturbation and nail biting as relevant to suicide,
or the description of a depressed person as “a cognitive-emotionally
retarded adult child,” it’s personal. Or when I am reminded that to-
morrow, and the day after that, and the day after that, around 2,500
families worldwide will go through what my family went through, it’s
personal. And when people scramble to prevent death by lightning
strike or death by bicycle accident on the Golden Gate Bridge, and
yet are reticent about preventing death by suicide, it’s personal.
And when friends and family looked me in the eye and expressed
genuine sympathy and sadness about my dad’s death—and when
others did not do this—that was, and remains, personal. On this im-
223
224 ● WHY PEOPLE DIE BY SUICIDE
portant point of support to those who have lost a loved one to sui-
cide, I think my model has a few insights. The main contribution of
the book, I hope, is to provide people with an understanding of
death by suicide; despite the tragedy, shock, and pain of it, there are
tractable and comprehensible reasons that people die by suicide,
just as there are tractable and comprehensible reasons that people die
by heart disease or cancer. My model emphasizes perceived burden-
someness and a perceived sense of low belongingness. It is painful for survivors to understand that their loved ones, lost to suicide, perceived these things about themselves; but it is helpful, I think, to un-
derstand that these were perceptions, not realities that should be
blamed on survivors.
Indeed, if one insists on a special quality to the tragedy of suicide,
this is it. These perceptions were lethal, but were changeable through
proper treatment (as described in the previous chapter). In general, I
believe that death by suicide should be viewed as death by any other
means—a tragedy with painful and shocking though not mysterious
or stigmatizing properties. Still, the process of death in some cancers,
for instance, is simply not reversible with current treatments; that the
process of death by suicide is reversible and yet so often is not re-
versed is a horrible tragedy.
Though my model has a few insights for those who have lost a
loved one to suicide and for those who wish to support them, the
model is mostly gainsaid by common sense on this point. My advice
is to act like my Uncle Jim and my high school friends did for me:
just act right. Look survivors in the eye, express sadness and sympa-
thy, be there for them, support them, check in with them every so of-
ten, just as you would anyone who has lost a loved one. If you want
to recommend a reliable resource for information, education, lists
of support groups, and so forth, recommend www.suicidology.org, the
website of the American Association for Suicidology, or www.afsp.org,
the website of the American Foundation for Suicide Prevention. No
The Future of Suicide Prevention and Research ● 225
lying, no tiptoeing around the subject, no whispering. And if you in-
sist—wrongly, I believe—that suicide is a special case, not like other
deaths, then that should make you more, not less, compassionate.
The confluence of the personal and the scientific has informed the
model I developed in this book. My dad did not possess many of the
characteristics that the public mind attributes to those who die by
suicide—he was not timid or retiring; not prone to emotional out-
bursts or anger; not prone to substance abuse. He was generally an
optimistic and hopeful character, though his periodic depressions
tempered this. He had bipolar II disorder, but among the group of
people with this disorder, I would estimate that my dad was in the
top
one or two percentiles in terms of functioning and accomplish-
ment, and in the bottom half in terms of symptom severity. If you
were looking at the charts of a hundred patients with bipolar II dis-
order, knowing that approximately ten may die by suicide in the en-
suing years and trying to estimate risk for suicidal behavior based on
symptoms and functioning, I do not think you would include my
dad among the ten or even fifty most likely to die by suicide.
Yet he did. Why? By now, my answer should be familiar. Through-
out his life, he had experiences and injuries that facilitated his acqui-
sition of the ability to enact lethal self-injury. I mentioned several of
these experiences in the opening chapter. Two others occur to me. In
the late 1940s, he survived a hurricane. He told me that the wind
blew the rain through the walls of the cinder block structure where
he was, and his older brother later told me a similar story. In 1989,
there was something wrong with one of my kidneys, and I needed to
have surgery to have my kidney removed. My dad spent hours with
me in the hospital as I recuperated, far more time than anyone else.
This is a reflection of his caring nature, but also, I think, of his toler-
ance of pain and suffering—even that of his child. Add these experi-
ences to all the others, and it is not hard to see why he had developed
the capacity for lethal self-injury—he had numerous chances for ha-
226 ● WHY PEOPLE DIE BY SUICIDE
bituation. He was as stoic a person in the face of pain as anyone I
have met.
This makes suicide an option, an option that will only be accessed
when the desire for death is present. My dad’s desire for death, I be-
lieve, developed in the context of his losing touch with his profes-
sional identity, his marriage, and his church. He tried to compensate,
for example, by visiting African-American churches, but his efforts
were not sufficient. What he needed was to form new and deep
friendships and to suffer the pain of rebuilding his professional iden-
tity. These things were beyond him, as they are to many men, partic-
ularly white men in their fifties and older. I believe this is a main rea-
son that this demographic is at highest risk for death by suicide.
My theory is not only about my dad, however. It is intended to be
comprehensive but succinct: to have at least something to say about
all deaths by suicide worldwide, across cultures, by employing three
simple concepts. I have attempted not only to explain facts, but also
to produce new understanding with new ideas. For example, the
erosion of fear and the attendant ability to tolerate and indeed en-
gage in lethal self-injury may set into motion still other psychological
processes that are important in suicidality; namely, the merging of
death with themes of vitality and nurturance. Only when people
have lost the usual fear and loathing of death do they become capa-
ble of construing it in terms related, ironically, to effectiveness and
belongingness. Only those who desire death and have come not to
fear it can believe that through death, their need to belong and to be
effective will be met. Past researchers and theorists have remarked on
attraction to death among suicidal people—my theory specifies the
conditions under which it happens, as well as why it happens.
Where Do We Go From Here?
My theory leads to some as yet unanswered questions and suggests a
number of avenues for future research. For example, do the reward-
The Future of Suicide Prevention and Research ● 227
ing properties of self-injury actually increase with repetition, as
predicted in this theory? Is it defensible to view effectiveness and
connectedness as the two key ingredients of the will to live? How are
we to discriminate lethal, stable forms of burdensomeness and dis-
connection from less pernicious, more temporary forms? In cul-
tures in which an interdependent view of the self is the norm, is dis-
connection more painful than burdensomeness, and in cultures in
which an autonomous, individualist view of the self is the norm,
is burdensomeness more painful than disconnection? What are the
precise kinds of self-harm and other provocative behaviors that pro-
duce habituation and engage opponent processes? Are mechanisms
like cognitive sensitization and cognitive deconstruction compatible
with habituation and opponent processes?
Other directions for future research should be mentioned too. A
basic but quite important agenda for future work involves measure-
ment technology for each of the three main components of the
model presented here. Reliable and valid self-report and clinician-
rated measures would obviously benefit research on the model (as
well as benefit clinical risk assessment). My students and I have a
start on this; here are some of the items we are using to assess the
three components of the model. The items are rated on a one-to-five
scale. For belongingness, “These days I am connected to other peo-
ple”; “These days I feel like an outsider in social situations” (this one
is reverse scored); and “These days I often interact with people who
care about me.” For burdensomeness, “I give back to society” (reverse
scored); “The people I care about would be better off if I were gone”;
and “I have failed the people in my life.” For acquired ability to enact
lethal self-injury, “Things that scare most people do not scare me”; “I
avoid certain situations (e.g., certain sports) because of the possibil-
ity of injury” (reverse scored); and “I can tolerate a lot more pain
than most people.”
A longitudinal study assessing acquired capability for self-harm,
burdensomeness, and failed belongingness at baseline, with periodic
228 ● WHY PEOPLE DIE BY SUICIDE
assessments for changes in burdensomeness and belongingness, as
well as for the development of suicidal behavior, would be of interest.
In a study like this, it might be predicted that the combination of
burdensomeness and failed belongingness should predict increases
in suicidal desire, though it should not predict increases in the re-
solved plans and preparations factor unless the acquired capability
for self-injury is also present.
The various conditions and processes that lead up to the develop-
ment of pernicious forms of burdensomeness and belongingness
deserve study too. It has already been mentioned that one can poten-
tially lead to the other, and that provocative experiences and behav-
iors (e.g., repeated self-harm) can lay the groundwork for their de-
velopment as well (e.g., through ostracization). Recurrent or chronic
forms of mental disorders also seem likely to produce serious threats
to the need to belong and to be effective.
By the logic of the current model, those who, through various
means (especially deliberate self-injury), have acquired the ability for
significant self-harm should be demonstrably different from others
in many ways. In fact, as was reviewed earlier, extan
t data appear to
support such differences. More research on this topic would be of in-
terest, for example, in the area of neurobiology. Studies are needed
on the neurophysiology and neuroanatomy of the acquired capabil-
ity for lethal self-injury. Comparison of those who have acquired the
capability for self-harm to those who have not on magnetic reso-
nance imaging (MRI) and other scanning technologies may illumi-
nate specific brain processes and areas that are implicated (for exam-
ple, serotonin-related processes in the ventral prefrontal cortex, an
area implicated in impulsivity).1 The self-aggression paradigm de-
scribed earlier, in which people self-administer shock,2 may be useful
in testing the present theory, especially with regard to the acquired
ability to enact lethal self-injury. One prediction would be that those
with substantial histories of provocative behaviors would self-ad-
minister more shock as compared to others.
The Future of Suicide Prevention and Research ● 229
Psychological autopsy studies would also be useful tests of the the-
ory presented here. These studies involve detailed interviews of rela-
tives and reviews of documents regarding those who have recently
died by suicide, as compared to those who have died by other means.
Aspects of the three variables emphasized here—acquired capability
for suicide, burdensomeness, and low belongingness—should all be
demonstrable in such studies. A psychological autopsy that shows lit-
tle evidence of one or more of these variables in those who have died
by suicide would represent a grave challenge to the present theory.
Theorists and scientists who work on suicide are often asked why
they have chosen their field of study. Isn’t the topic morbid and de-
pressing? My answer is probably predictable by now—there is noth-
ing depressing about working to prevent and relieve the kind of suf-
fering that my dad, my family, and millions of others go through.
This alone is enough of a reason to study suicide.
But there are other reasons still. Artists and writers, for example,
have long understood that the dysfunctional and moribund can in-
form us about human nature, including what is positive and good.
Extreme states and conditions, including suicidal crises, have the
potential not only to illuminate the nature of those experiencing
Why People Die By Suicide Page 29