Why People Die By Suicide Read online

  WHY PEOPLE DIE BY SUICIDE

  WHY

  PEOPLE

  DIE

  BY

  SUICIDE

  Thomas Joiner

  Harvard University Press

  Cambridge, Massachusetts, and London, England

  This book is dedicated to those who

  have lost someone to suicide, and

  especially to those who have been

  supportive of survivors like me,

  including, for example, my friends

  from high school, who did all the

  right things.

  Copyright © 2005 by the President and Fellows of Harvard College All rights reserved

  Printed in the United States of America

  First Harvard University Press paperback edition, 2007

  Library of Congress Cataloging-in-Publication Data

  Joiner, Thomas E.

  Why people die by suicide / Thomas Joiner.

  p. cm.

  Includes bibliographical references and index.

  ISBN-13 978-0-674-01901-0 (cloth: alk. paper)

  ISBN-10 0-674-01901-6 (cloth: alk. paper)

  ISBN-13 978-0-674-02549-3 (pbk.)

  ISBN-10 0-674-02549-0 (pbk.)

  1. Suicide.

  2. Suicide victims—Psychology.

  3. Suicide victims—Family relationships.

  4. Children of suicide victims.

  I. Title.

  HV6545.J65 2005

  616.85′8445—dc22

  2005051347

  CONTENTS

  Prologue: Losing My Dad

  1

  1

  What We Know and Don’t Know about Suicide

  16

  2

  The Capability to Enact Lethal Self-Injury Is Acquired

  46

  3

  The Desire for Death

  94

  4

  What Do We Mean by Suicide? How Is It Distributed

  in People?

  137

  5

  What Roles Do Genetics, Neurobiology, and Mental

  Disorders Play in Suicidal Behavior?

  172

  6

  Risk Assessment, Crisis Intervention, Treatment,

  and Prevention

  203

  7

  The Future of Suicide Prevention and Research

  223

  Epilogue

  231

  Notes

  235

  Works Cited

  243

  Acknowledgments

  267

  Index

  271

  WHY PEOPLE DIE BY SUICIDE

  LOSING MY DAD

  PROLOGUE

  In 1990, close to a million people died by suicide worldwide. My dad

  was one of them.

  Of course my dad’s death has deeply affected both my feelings

  about suicide and my understanding of it. My feelings about suicide

  stem partly from people’s reactions to my dad’s death. Some friends

  and family reacted in ways that I still treasure—the sorts of things

  that make you proud to be human. Others’ reactions were not quite

  up to this very high standard.

  My intellectual understanding of suicide evolved along a different

  track than my feelings. Informed by science and clinical work, I came

  to know more than most about suicide—on levels ranging from the

  molecular to the cultural. But here too, my dad’s death never left me,

  for the simple fact that I could evaluate theories and studies on sui-

  cide not only by formal professional and scientific criteria, but also

  by whether they fit with what I know about my dad’s suicide. As I

  will point out, a nagging fact about my dad left me unsatisfied with

  existing theories of suicide and pushed me to think in new ways

  about his death and about suicide in general. All of this will become

  1

  2 ● WHY PEOPLE DIE BY SUICIDE

  clear throughout the book, but first, let me turn to the details of my

  dad’s suicide.

  In Atlanta in the early morning hours of August 1, 1990, my dad

  was sleeping, or trying to, in the bed that was mine as a teenager.

  He wasn’t sleeping with my mom; I think his snoring had become

  too much of a problem. I was a graduate student in Austin, Texas at

  the time.

  It was summer, so my dad must have been alternately cold and hot

  in that bed—cold when the air conditioning kicked in (because the

  vent was right next to the bed), hot when it turned off (because that

  room was not well insulated). My dad rose from the bed. I wonder if

  he made some silent gesture, like putting his hand against the wall

  that separated my old bedroom from his old bedroom, where my

  mother lay asleep. He walked past the room he had shared with my

  mom, and then past my younger sisters’ rooms, where they lay asleep.

  Here again, did he hesitate as he passed their rooms, I wonder? Was

  he prepared with a cover story in case my mother or sisters woke up

  and asked him where he was going?

  He went downstairs. Before going out the door, he must have

  pulled open a drawer or two in the kitchen, looking for a large knife.

  Or maybe he got the knife from his fishing tackle in the garage. It

  surprises and distresses me even now when I can’t remember or

  never knew a key detail like this about my dad’s death.

  He walked outside, got into his van, and drove a half-mile or so to

  the lot of an industrial park. He prepared no note. At some point be-

  fore dawn, he got into the back of the van and cut his wrists. His self-

  injury escalated from there—the cause of death from his autopsy re-

  port is “puncture wound to the heart.” These details remain very

  painful for me, but they are important—as will become clear, people

  appear to work up to the act of lethal self-injury. They do so over a

  Prologue: Losing My Dad ● 3

  long period of time, by gradually accumulating experiences that re-

  duce their fear of self-harm; and they do so in the moment, by first

  engaging in mild self-injury as a prelude to lethal self-injury.

  My dad’s body was not discovered until about 60 hours after his

  death, which necessitated a closed casket funeral. So the last time I

  saw my dad was in June of 1990 when I joined the family on a beach

  trip. We fished and talked about the NBA finals and a large stock deal

  my dad was proud to have recently pulled off. We played board

  games in the van on the way home—the same van in which my dad

  died. I am still stunned to think that six weeks later he would leave

  the house and walk away from us forever. He never said goodbye to

  my mother, my sisters, or me.

  In the months before his death, my dad had parted ways with the

  company in which he had formed his professional identity and, in-

  deed, much of his identity as an adult. The position with this com-

  pany was one of influence, and after leaving, he struggled to regain

  his former feeling of effectiveness. I think this struggle was exacer-

  bated by some callous and self-serving behaviors by those remaining

  at the company, who my dad believed were friends.
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  The first family member I saw after my dad was found was my

  Uncle Jim, my dad’s older brother. He met me at the gate at the At-

  lanta airport. He must have been heartbroken and incredibly con-

  fused about how his very successful little brother could have sud-

  denly died by suicide. He shouldered this shocking burden and put

  it aside, at least for a while, to pay attention to how I was feeling

  and, in the days following, to how my mom and sisters were feeling.

  Jim didn’t understand much about suicide—I think he would have

  said that himself—but some people don’t require understanding in

  order to act right. They just let compassion take over; that’s what my

  Uncle Jim did.

  The relation of understanding suicide and “acting right” about it is

  interesting to explore. In thinking back over people’s reactions to my

  4 ● WHY PEOPLE DIE BY SUICIDE

  dad’s death, my sense is that no one understood it, really. To some

  people, like my Uncle Jim, understanding didn’t matter and wasn’t a

  barrier to acting with real generosity of spirit. To others, the lack of

  understanding seemed an insurmountable barrier, so that instincts

  toward compassion were short-circuited. They were caught up in

  their minds about how to understand this shocking death and what

  to say to me and my family. One contribution of this book, I hope, is

  to provide understanding, so that those who need it in order to un-

  leash their caring and generosity will have it.

  Ironically, those whose reactions were the least helpful were those

  who might have known better—those who, unlike my Uncle Jim, got

  tripped up by intellectual lack of understanding. All that was needed

  was eye contact and phrases like, “Man, I’m real sorry about what

  happened to your dad,” as well as a willingness to interact with me

  like I was the same person they always knew. My friends from high

  school all did this by instinct, both at the time of my dad’s death and

  in the weeks and months following. For instance, at my parents’

  house after my dad’s funeral, one of my high school friends told a

  story about how his girlfriend had recently “dropped him like a

  rock.” The phrase probably is not very funny to read, but there was

  something about his tone and facial expression that was extremely

  funny—I’m sure that was the first time I had laughed in the several

  days since my dad died. As another example, a few weeks after my

  dad’s death, I went to dinner with a girl I had admired very much in

  high school, but with whom I had lost touch. She was among the first

  people I told about the exact details of my dad’s death, and her un-

  derstanding and composure encouraged me to talk to others.

  By contrast, my peers and professors in psychology—yes, psy-

  chology of all things—struggled to get it right. A girlfriend seemed

  more concerned about tainted DNA (“suicide’s genetic, right?”) than

  about how I was coping. Peers and professors ignored my dad’s death

  altogether. One professor, a psychoanalytically oriented clinical su-

  Prologue: Losing My Dad ● 5

  pervisor of mine, was particularly inept and seemed unable to say

  anything at all in response to my dad’s suicide. He tried to hide his

  inability behind a psychoanalytic stance of neutral silence, but never

  was that charade more apparent and more pitiful. These people, I

  think, needed to intellectually grasp suicide before they could do

  anything else . . . and since they couldn’t grasp it intellectually—few

  can—their otherwise good hearts were hampered. It is also possible

  they were just too scared to deal with the topic. I hope this book frees

  good hearts in those with a need for intellectual understanding and

  steels those who need courage to help the bereaved.

  Among my psychology peers and professors, there were people

  who, like my Uncle Jim, just did what was right. A different psycho-

  analytic supervisor was among the most understanding and helpful

  of anyone I encountered in the difficult days and weeks following

  my dad’s death. A week or two after my dad’s death, still another per-

  son, my professor Jerry Metalsky, paused as we were working on a

  manuscript, looked me in the eye, and said with real feeling, “I’m just

  so sorry about what happened to your dad.” These simple words

  choked me with tears at the time, and can still bring tears to my eyes

  to this day.

  One of my peers, Lee Goldfinch, found my parents’ phone number

  in Atlanta and called me, as it turned out, on the day of my dad’s fu-

  neral. This alone set him apart, but as we talked for a few minutes

  about what happened and how my family and I were doing, Lee wept

  in a very quiet and selfless way. That brief conversation with Lee rep-

  resented one of the times in my life that I have felt most understood,

  most listened to.

  Some experiences within my family exacerbated the pain of my

  dad’s death. Just as some of my psychology peers and professors

  struggled for understanding and thus couldn’t quite hit the right

  note, some in my family faced the same difficulty. For example, one

  relative counseled another to tell others that my dad died from a

  6 ● WHY PEOPLE DIE BY SUICIDE

  heart attack. The instinct to lie about suicide is not rare. In one study,

  44 percent of those bereaved by suicide had lied to some extent about

  the cause of death, whereas none of those dying from accidents or

  natural causes lied.1

  Indeed, those who die by suicide will occasionally advise in suicide

  notes that others lie about their deaths. Edwin Shneidman2 gave this

  example: “Please take care of little Joe because I love him with all of

  my heart. Please don’t tell him what happened. Tell him I went far

  away and will come back one of these days. Tell him you don’t know

  when.” This example shows why it is not rare and why it is under-

  standable that people sometimes lie about suicide.

  Lying about suicide is just one form of misunderstanding it. An-

  other, more pernicious form is blame, and in this regard, my own ex-

  periences were quite mild—I am aware of no one who blamed my

  mother, my sisters, or me for my dad’s death. Unfortunately, others

  are forced to go through this particular form of hell. In Shneidman’s

  case example of Ariel, Ariel’s father had died by self-inflicted gunshot

  wound in what was very likely a suicide (but there was some possibil-

  ity of the death being an accident). Ariel wrote, “Well, my aunt . . .

  told me that I had killed my father, and he had committed suicide

  because of me.” Almost exactly three years after her father’s death,

  Ariel herself nearly died by setting herself on fire.

  Misunderstanding and even taboo about suicidal behavior are

  rampant. Karl Menninger3 said, “So great is the taboo on suicide that

  some people will not say the word.” The staff of the magazine that

  promotes prominent research at my university wanted to run a story

  on my suicide research. They pondered featuring the work on the

  ma
gazine’s cover, but decided against it—they could not imagine

  prominently displaying the word “suicide,” although they ran the ar-

  ticle itself.

  These same attitudes are common among family members of

  those who engage in suicidal behavior. Decades ago, Menninger,4 in

  Prologue: Losing My Dad ● 7

  describing relatives’ reactions to the hospitalization of depressed and

  potentially suicidal patients, commented, “Patients committed to our

  care in the depth of a temporary depression in which they threatened

  suicide would begin to improve, and relatives thereupon would seek

  to remove them, utterly disregarding our warning that it was too

  soon, that suicide was still a danger. Frequently they would ridicule

  the idea that such a thing might be perpetrated by their relative.”

  Menninger collected a large file of newspaper clippings reporting the

  deaths by suicide of such patients.

  I understand why people tiptoe around suicide or even lie about it

  outright. This has never been clearer to me than when my oldest son,

  Malachi (named after my dad’s ancestor who was the first in our

  family to come to America), asked me why my dad was not alive. He

  was three years old at the time. Luckily, I had anticipated this ques-

  tion, but I thought I’d have another two or three years to think about

  my answer. I took a deep breath and said something like, “Well, you

  know how people can get sick, like when you have a cough or your

  stomach hurts. People can get sick like that in their bodies, and they

  can also get sick in their minds, sometimes very sick. My dad got very

  sick like that in his mind; he got to where he was so sad and lonely

  that he didn’t want to live anymore. When people feel like this for a

  long time, they sometimes think about hurting themselves or even

  killing themselves. That’s what my dad did.”

  Malachi’s reaction was similar to the many times he had learned a

  surprising fact about nature from me. With the same sense of inno-

  cent surprise, not tinged much at all with negative emotion, he said,

  “You mean he killed him self? ” much as if he were saying, “You mean there are fish that can taste things with their skin? ” (which there are and which we had just read about). I answered (to the first question),

  “Yes, he did. That can happen sometimes when people feel so sick in

  their minds.”

  I was ready for fallout. For example, I imagined what I would say

  8 ● WHY PEOPLE DIE BY SUICIDE