Why People Die By Suicide Read online

  in suicide among African-Americans—specifically, young black men.

  And yet, the demographic group at highest risk is older white men.

  Female anorexics, prostitutes, athletes, and physicians all have ele-

  vated suicide rates. A theory that can account for these diverse facts

  would be persuasive.

  Such a theory would not only advance scientific knowledge, but

  deepen the understanding of suicidal behavior among clinicians who

  need to assess risk, intervene in crises, and design treatment and pre-

  16

  What We Know and Don’t Know about Suicide ● 17

  vention protocols. It would also help those who have lost a loved one

  to suicide, who suffer much misunderstanding.

  In this chapter, I describe some of my own clinical work and the

  supervision of others’ clinical work with suicidal patients. In the clin-

  ical literature, suicide is often described as an “urgent,” “vexing,” or

  “pressing” issue, one that preoccupies clinicians. Suicide is an urgent issue—it kills people—but urgency need not entail panic. Suicide

  can be understood in ways that resolutely point to clear clinical deci-

  sions . . . given, that is, a full explanatory model. My and others’ clini-

  cal experiences with suicidal patients will highlight how a compre-

  hensive account of suicide would have reduced confusion and panic

  and facilitated clinical progress.

  This chapter also touches on some of my scientific work on sui-

  cide. My research group is one of many that have produced new and

  important findings regarding suicide. The chapter will include some

  basic scientific findings on suicide produced by my and other re-

  search groups—facts that any compelling account of suicide must

  explain.

  I also summarize existing models of suicide in this chapter—theo-

  retical accounts that have been developed to explain some of these

  facts. One of the best ways to evaluate a theoretical model is the

  number of facts it can explain, and some of these models are more

  successful than others, as we shall see. My hope is that this book’s ex-

  planation of suicide will save people some of the misunderstandings

  my family and I went through, will refine clinicians’ approach to

  treating suicidal behavior, and will set a scientific agenda for the

  study of suicide. In the process, some interesting questions will be

  raised and addressed. For example, should family members tell the

  truth about the cause of death when a loved one has died by suicide?

  What constitutes a proper definition of suicide itself? How are we to

  understand the deaths of those who jumped from the World Trade

  Center towers’ upper floors on September 11, of the September 11

  18 ● WHY PEOPLE DIE BY SUICIDE

  terrorists, and of those in mass suicides in cults? What protects most

  women from suicide, and yet, why do some very different subgroups

  of women—such as prostitutes and physicians—share similarly high

  suicide rates? Why are older, white men the demographic group in

  the United States most vulnerable to suicide? Why do suicide rates

  decrease in the United States during times of national crisis and de-

  crease in a particular city when the city’s professional sports team is

  making a championship run? What are the constituent parts of the

  genuine desire for death? These and other questions will be raised

  and addressed throughout the book.

  Notes from the Clinic

  My first job after getting my doctorate was as an assistant professor

  of psychiatry at the University of Texas Medical Branch at Galveston.

  What a blessing this job was in many ways. I saw many psychother-

  apy patients and worked with skilled psychiatrists who taught me a

  lot about the biological bases of mental disorders. Biology appears to

  play some role in why people die by suicide, a fact I will address later

  in this book. But they also taught me something more—an attitude

  about suicide risk in patients that was neither dismissive nor alarm-

  ist. The alarmist position is perhaps the easiest to understand—this

  is the idea that whenever someone mentions suicide, it is a life-

  threatening situation and alarms should be sounded. This idea oc-

  curs in settings in which staff see relatively few people with serious

  mood disorders. In settings where serious mood disorders are com-

  mon, people understand that suicidality is just part of the disorder;

  the majority of people who experience mood disorders will have

  ideas about suicide, and the vast majority will neither attempt sui-

  cide nor die by suicide. If 911 were called in each of these cases, a

  “cry wolf ” scenario would quickly develop. Alarmists are making a

  mistake in conditional probability. Given the existence of a suicidal

  What We Know and Don’t Know about Suicide ● 19

  thought or behavior, they mistakenly estimate the probability of

  death or serious injury by suicide to be higher than it is.

  Although alarmists make a mistake, it is not hard to see why they

  do. When people have ideas about suicide, it is quite true that risk is

  elevated compared to people who do not have suicidal ideas. More-

  over, suicide is irreversible, and everything possible should be done

  to prevent it. Alarmists overreact, but they are doing so in the safe di-

  rection; “better safe than sorry,” they might say.

  The alarmist problem is easy to notice in training clinics. Most of

  the pages I receive on my beeper are from therapists at the training

  clinic I direct who are worried that they should do more for a patient

  with suicidal symptoms. When I return the call, I ask a series of ques-

  tions to see if the therapist is meeting the standard of care. In our

  clinic, meeting the standard of care is routine. And so I will then say,

  “Well, you’ve done everything I would’ve done; I wonder, what else is

  it that you think you’re supposed to do?” The answer is often, “I’m

  not sure, I just have this feeling that there’s something else I should

  do.” Then I’ll say, “Well, there’s not; but don’t lose that feeling, be-

  cause it will ensure that you regularly do what’s best for patients;

  also, though, don’t let that feeling get out of hand, because it can

  burn you out, plus, ultimately these choices are not up to us, they’re

  up to patients.” Make no mistake, the standard of care is impor-

  tant—at times even life-saving—and therapists are expected to meet

  it rigorously, including involuntary hospitalization of the patient if

  needed. But beyond that, responsibility for life choices resides with

  patients. Therapists who see this are likely to enjoy their work more,

  to not be distracted by one patient when dealing with another, and,

  importantly, to enjoy their nonwork time as well.

  The alarmist attitude is understandable but, especially if exagger-

  ated, mistaken. Those who take a dismissive approach make a mis-

  take in the opposite direction. They become blasé about suicidal be-

  havior, often attributing it to manipulation or gesturing on the part

  20 ● WHY PEOPLE DIE BY SUICIDE

  of the po
tentially suicidal person. This problem is acute when it

  comes to the often misunderstood borderline personality disorder,

  which is characterized by a long-standing pattern of out-of-control

  emotions, interpersonal storminess, feelings of emptiness, and im-

  pulsive behaviors, including impulses toward self-injury. Some clini-

  cians take a dismissive attitude toward patients with this disorder be-

  cause they believe that these patients merely “gesture” suicide. In

  other words, they engage in suicidal behaviors, such as cutting them-

  selves, but do not really intend to kill themselves; instead, they only

  intend to provoke or manipulate others. I wish this were true, but it

  is not—approximately 10 percent of patients with this disorder end

  up dying from their suicidal gestures (comparable to the rate for pa-

  tients with mood disorders). The following quotation illustrates this

  misunderstanding:

  The borderline patient is a therapist’s nightmare . . . because border-

  lines never really get better. The best you can do is help them coast,

  without getting sucked into their pathology . . . They’re the chroni-

  cally depressed, the determinedly addictive, the compulsively di-

  vorced, living from one emotional disaster to the next. Bed hoppers,

  stomach pumpers, freeway jumpers, and sad-eyed bench-sitters with

  arms stitched up like footballs and psychic wounds that can never be

  sutured . . . Borderlines go from therapist to therapist, hoping to find

  a magic bullet for the crushing feelings of emptiness.1

  This characterization is demonstrably false. Patients with border-

  line personality disorder do get better. A persuasive study found that 34.5 percent of a sample of borderline patients met the criteria for

  remission at two years, 49.4 percent at four years, 68.6 percent at six

  years, and 73.5 percent over the entire follow-up. Only around 6 per-

  cent of those who remitted then experienced a recurrence.2

  The dismissive attitude is dangerous for another reason. A main

  thesis of this book is that those who die by suicide work up to the act.

  What We Know and Don’t Know about Suicide ● 21

  They do this in various ways—for instance, previous suicide at-

  tempts—and all of these various ways have the effect of insulating

  people from danger signals. They get used to the pain and fear asso-

  ciated with self-harm, and thus gradually lose natural inhibitions

  against it. Clinicians’ dismissive attitudes have the potential to model

  a blasé attitude about self-harm. If clinicians blithely get used to sui-

  cidal behavior, their patients may vicariously do so as well.

  The psychiatrists at my first job balanced the alarmist and dismiss-

  ive positions very well. They clearly understood the danger and hor-

  ror; in fact, most of them had had a patient who had died by suicide.

  They knew the standards of care for suicide risk assessment and the

  treatment of suicidal behavior, and they followed them faithfully. But

  they understood the limits of their interventions, they understood

  people’s ultimate autonomy, including their freedom to occasion

  their own death if they really were committed to doing so. My im-

  pression was that these psychiatrists did their job well during the day,

  and slept well at night.

  Consider for example the case of Gayle (a false name). In retro-

  spect, I understand Gayle’s situation clearly, but when I was seeing

  her, I was uneasy. She was the sort of patient who seemed potentially

  self-destructive. Indeed, she often fantasized about death by suicide,

  envisioning a particularly graphic means—severing her hand with a

  machete and bleeding to death (people have died in just this way, in-

  cidentally). She even owned a machete. This would be enough to

  concern any clinician, and I was no exception. I recommended that

  Gayle be hospitalized, so that she would remain safe while treatments

  for her substantial depression were started.

  She refused hospitalization and also refused antidepressant medi-

  cines; she would agree only to psychotherapy. An initial question,

  then, was whether I should hospitalize her involuntarily. I had the

  sense that this would not be best, but I was having trouble putting

  my finger on exactly why she did not require hospitalization. After

  22 ● WHY PEOPLE DIE BY SUICIDE

  consultation with colleagues, I was reminded of some mildly reassur-

  ing facts. Gayle was around forty-five years old and had never at-

  tempted suicide. She had had plenty of time to have tried it, and yet

  had not. This is no guarantee. There are people who at age forty-five

  or even sixty-five attempt suicide for the first time and die. Still, the

  fact that she had not had previous experience with suicidal behavior

  was mildly reassuring. Her gender was another mildly reassuring fac-

  tor—women are a lot less likely to die by suicide than are men. Also

  somewhat reassuring were her connections to life. There were things

  that she was proud of regarding her professional life, and more im-

  portant, she was deeply connected to her young son. She spontane-

  ously mentioned these things as I questioned her about suicide po-

  tential.

  Gayle was also the rare person who clearly met criteria for a major

  depressive episode but who had an absence of depressed mood. In a

  study of young adults my colleagues and I conducted, this pattern

  was found to occur in only about 5 percent of those who were in a

  depressive episode. Recent work has shown lack of depressed mood

  to be a positive prognostic indicator among depressed people; that is,

  they tend to get better quicker and to have good outcomes.3

  Throughout this book, I will argue that the acquired ability to en-

  act lethal self-injury is crucial in serious suicidal behavior. People are

  not born with the developed capacity to seriously injure themselves

  (although they are born with factors, including certain genes, that

  may facilitate the future development of this capacity). In fact, if any-

  thing, they are born with the opposite—the knee-jerk tendency to

  avoid pain, injury, and death. That is, people have strong tendencies

  toward self-preservation; evolution has seen to that. Through an ar-

  ray of means described later, some people develop the ability to beat

  back this pressing urge toward self-preservation. Once they do, ac-

  cording to the theory laid out in this book, they are at high risk for

  suicide, but only if certain other conditions apply—namely that they

  What We Know and Don’t Know about Suicide ● 23

  feel real disconnection from others and that they feel ineffective to

  the point of seeing themselves as a burden on others. These factors,

  like the acquired ability to enact lethal self-injury, are covered in de-

  tail in later chapters of the book.

  I now understand clearly why Gayle made me feel uneasy, but also

  why she was not at particularly high risk for suicide. She had ac-

  quired the ability to enact lethal self-injury. A main way that people

  develop this capacity is through previous suicidal behavior. As noted

  already, Gayle
had not engaged in such behavior. What I believe led

  to her developing this capacity was a long history of severe substance

  abuse, which included many painful and provocative experiences

  (another way to gradually beat back the instinct to survive). Her sub-

  stance abuse had ended; she had been clean for around eight years

  when I saw her. But her earlier experiences had left various residues.

  This ability in Gayle was manifested by her having a clear and de-

  tailed suicide plan, but especially in her sense of calm and her lack of

  fear about the plan. These were the things that made me want to hos-

  pitalize Gayle. Nevertheless she was not at particularly high risk for

  suicide, and the reason involves two other factors that I believe are

  required for serious suicidal behavior—thwarted belongingness and

  perceived burdensomeness. Gayle had a fairly well-developed circle

  of friends and was very connected to her son. There was no evidence

  that she felt fundamentally disconnected from others, and plenty of

  evidence that her sense of belonging was very much intact. Similarly,

  Gayle was a particularly capable woman; for instance, even when de-

  pressed, she was the office’s top performer in her professional line of

  work. There was no evidence that she felt ineffective, certainly not to

  the point that she believed she burdened others.

  Her sense of belonging and effectiveness buffered her, but it is im-

  portant to note that this could have changed rapidly. People cannot

  develop the ability to lethally injure themselves quickly; the experi-

  ences that are required take time and repetition. By contrast, people

  24 ● WHY PEOPLE DIE BY SUICIDE

  can quickly develop views that they do not belong or that they are

  particularly ineffective. Thus, in a case like Gayle’s, suicide risk can

  quickly escalate. Repeated risk assessment is thus necessary in Gayle’s

  case (and is a safe clinical practice anyway).

  The case of Sharon (a false name) is interesting by way of contrast.

  When questioned about suicide risk, Sharon articulated no plan at

  all. When pressed a little on the question, she made statements like,

  “I can’t imagine actually trying suicide, it’s just that I have the sense

  that I’d be better off dead.” Like Gayle, Sharon had never attempted