Why People Die By Suicide Page 5
laced with cyanide and sedatives at the behest of leader Jim Jones. In
the Heaven’s Gate event, which caused the deaths of thirty-nine peo-
ple (two additional cult members died by suicide in the months fol-
lowing), people died by ingesting high doses of phenobarbital mixed
with vodka at the behest of leader Marshall Applewhite.
Mass suicide in cults raises difficult definitional issues—are these
really examples of suicide or are they examples of mass homicide
perpetrated by delusional and psychopathic people like Jones and
Applewhite? A compelling theory of suicide should be able to ad-
dress this question, as well as other difficult questions. A complete
theory would also have something to say about the array of other
well-established facts about suicide, only some of which were
touched on above. The influence of age, mental disorders, and other
factors on suicide all need to be incorporated. In later sections of the
book, I will describe such a theory. This book’s theory of suicide ac-
complishes something new: It is not only consistent with but illumi-
nates the wide array of well-documented facts on suicide. But first, I
will summarize existing theories.
Existing Theories of Suicide
The theory put forth in this book places me in competition with nu-
merous other theorists, past and present. In one sense, that is the na-
What We Know and Don’t Know about Suicide ● 33
ture of science and scholarship. In another sense, however, I am
much more a collaborator than a competitor with other theorists.
This is also the nature of science and scholarship. Although we pay
tribute to the achievements of past theorists, we must also point out
ways in which their work needs to be expanded and modified to pro-
vide a more comprehensive and accurate explanation of why people
die by suicide. The remainder of this chapter focuses on the high-
lights of some of the more compelling theories of why people die by
suicide.
In the preface to his book Man Against Himself, Karl Menninger7
wrote, “to have a theory, even a false one, is better than to attribute
events to pure chance. ‘Chance’ explanations leave us in the dark; a
theory will lead to confirmation or rejection.” Although there have
been persuasive and careful theories, compared to other areas of sci-
ence, even compared to other areas of psychopathology research,
theorizing on suicide has been somewhat slow. The dominant theo-
ries can be counted on one hand (not necessarily using all the
fingers). The last major theoretical statement appeared in 1990, and a
century-old theory still has a lot of influence.
That theory was put forth by the French sociologist Emile
Durkheim in his 1897 book Le Suicide. The theory emphasizes col-
lective social forces much more than individual factors. In
Durkheim’s theory, the common denominator in all suicides is dis-
turbed regulation of the individual by society. He was concerned
with two kinds of regulation: social integration and moral regula-
tion.
Regarding social regulation, a curvilinear, U-shaped relationship
between individuals’ degree of integration in society and that soci-
ety’s suicide rates is hypothesized; too much or too little integration
are both bad things, according to Durkheim. Low integration—
something that in later chapters of this book will be referred to as
low belongingness—leads to an increase in a type of suicide that
34 ● WHY PEOPLE DIE BY SUICIDE
Durkheim labeled “egoistic.” His idea was that we need something
that transcends us, and he felt that the only thing that is transcendent
enough is human society. When it breaks down, people feel purpose-
less and become desperate, and suicide rates go up.
Too much integration, according to Durkheim, is also associated
with more suicide, but of a different type, namely “altruistic” sui-
cides. Excessive societal integration leads people to lose themselves
and to commit to a larger goal. Self-sacrifice is a defining aspect of
this kind of suicide; self-sacrifice bears some similarities to the
concept of perceived burdensomeness, which will be emphasized in
my account of why people die by suicide. In Durkheim’s view, when
individuals are so integrated into a social group that individuality
fades, they become willing to sacrifice themselves to the group’s in-
terests.
Regarding moral regulation, “anomic” suicide is caused by sudden
changes in the social position of an individual, mainly as a result of
economic upheavals. The idea is that any abrupt change in the regu-
latory function of society or its institutions on people’s behavior is
likely to increase suicide rates. Because society loses its scale, people’s ambitions are unleashed but cannot all be satisfied, leaving a lot of
unhappy people.
Durkheim contrasted anomic suicide to “fatalistic” suicide, which
occurs among those with overregulated, unrewarding lives, such as
slaves. Of the four types of suicide discussed by Durkheim, fatalistic
suicide receives the least attention, perhaps because he viewed it as
relatively rare.
One of Durkheim’s goals was to study social forces, often to the
exclusion of other factors, of which he was at times dismissive. He
did not deny, however, that individual conditions like mental disor-
ders are relevant to suicide. But he did claim that most such factors
are insufficiently general to affect the suicide rate of whole societies,
What We Know and Don’t Know about Suicide ● 35
and thus should not be emphasized by sociologists. It is notable that
these days many sociologists study individual factors as well as social
forces.
It is remarkable, too, that a theorist who could be dismissive of the
role of genes and of mental disorders in suicide is still influential, be-
cause there is absolutely no doubt that genes and mental disorders—
and much else at times marginalized by Durkheim—are involved in
suicidal behavior. Why, then, is he still influential? He was the first to
attempt a fully empirical sociology, and he was the first to attempt a
systematic, comprehensive, coherent, and testable theory of suicide.
Second, he was right about some things. As I show in Chapter 3, he
anticipated my model’s emphasis on social disconnection as a major
source for the desire for suicide. Through his emphasis on altruistic
suicide, he also anticipated my theory’s inclusion of perceived bur-
densomeness as a key precursor to serious suicidal behavior, though
we differ on the details. Third, Durkheim had little competition for
decades. The first half of the twentieth century was dominated by
psychoanalysis, and to be blunt, it is difficult to think of a lasting
contribution to the understanding of suicide from this perspective.
It is easy, however, to think of many examples in which psychoana-
lytic theories have been obstacles to understanding. For example, the
most well-known view of suicide from a psychoanalytic perspective
view, Harry Stack Sullivan8 noted examples in which suicides were
carried out in a hateful or spiteful way toward others. It certainly is
the case that some suicides are arranged spitefully, but the majority
are not. My dad, for example, died away from the house in a manner
such that he was likely to be discovered by police personnel. I think
he believed that this would be easier on us, and I think he was right.
It is hard to detect the spite here. Hostility or aggressiveness is a com-
mon part of the background of those who die by suicide, but as I will
36 ● WHY PEOPLE DIE BY SUICIDE
demonstrate in Chapter 2, there is a way to understand this that is
more plausible and consistent with scientific evidence than “hostility
turned inward.”
As another example, Menninger (1936) was persuaded that mas-
turbation has an important connection to suicide. He stated, “It has
been observed that suicidal attempts sometimes follow the interrup-
tion of an individual’s habitual auto-erotic activities . . . the mecha-
nisms by which the suicide is precipitated are the same: the mastur-
bation occasions a heavy burden of guilt, because in the unconscious
mind it always represents an aggression against someone. This guilt
demands punishment and as long as the auto-erotic practices are
continued, the punishment is bound up in the satisfaction, since
masturbation is imagined by many to be a grave danger to health,
and to one’s life both in this world and the hereafter.”9 Menninger
continues by postulating that when masturbation is interrupted, the
needed punishment is no longer “bound up in the satisfaction,” and
suicide results as a form of self-punishment. On this view, suicide is a
“violent form of sexual preoccupation.”10 Later in the same book,
Menninger claims that nail-biting is similar to masturbation.11
These examples show that Durkheim had little real competition
as a theorist for decades. Incidentally, I do not blame Menninger,
Sullivan, and others for their misperceptions—had I been working in
the 1930s I would have seen the world through a similar lens. I feel
much less charitably, however, toward those who perpetuated these
mistakes into the following decades and less charitably still to the few
who promulgate these theories today.
Viable theories of suicide other than Durkheim’s began to emerge
in the latter half of the twentieth century. One of the most promi-
nent theorists is Edwin Shneidman. Shneidman was influenced by
Henry Murray, who focused on the nature of psychological needs
and the consequences of having those needs thwarted. Shneidman’s
views on suicide can be described as centering on thwarted psycho-
What We Know and Don’t Know about Suicide ● 37
logical needs—a general approach that I borrow from in the devel-
opment of my model of suicidal behavior.
Shneidman12 wrote, “In almost every case, suicide is caused by
pain, a certain kind of pain— psychological pain, which I call
psychache. Furthermore, this psychache stems from thwarted or dis-
torted psychological needs.” For Shneidman, psychache—defined as
general psychological and emotional pain that reaches intolerable in-
tensity—is a proximal cause of suicide. That is, whatever earlier risk
factors are at play, they operate through increasing psychache, which
in turn predisposes to suicidality.
Incidentally, in his enormous Anatomy of Melancholy, first pub-
lished in 1621, Robert Burton invoked a similar concept. Speaking of
suicidal individuals, he said, “These unhappy men are born to mis-
ery, past all hope of recovery, incurably sick; the longer they live, the
worse they are, and death alone must ease them.” Burton also im-
plied a stable, perhaps biological cause to suicide—an excess of
“black bile”—and at another place in the Anatomy, Burton labels
black bile as suicide’s “shoeing horn.”
In addition to psychache, Shneidman13 identified lethality as a key
ingredient of serious suicidality. Lethality is clearly related to the
concept emphasized in this book of the acquired ability to enact
lethal self-injury. An emphasis on psychache, too, is compatible with
my approach; perceived burdensomeness combined with failed
belongingness constitutes psychache.
“Psychache about what in particular?” we might ask. The an-
swer, taken from Shneidman’s 1996 The Suicidal Mind 14 and adapted
from Murray’s work in the 1930s, is a list of thwarted needs: abase-
ment, achievement, affiliation, aggression, autonomy, counterac-
tion, defendance, deference, dominance, exhibition, harm avoid-
ance, inviolacy, nurturance, order, play, rejection, sentience, shame-
avoidance, succorance, and understanding.
I believe that Shneidman’s answer is too general, because most of
38 ● WHY PEOPLE DIE BY SUICIDE
us identify with one or more of these thwarted needs from time to
time. What in particular, we are then led to wonder, are people feeling psychache about? I believe the answer to this question is per-
ceived burdensomeness and failed belongingness.
Of all the people who experience psychache, we might then ask,
why do only a minority die by suicide? Shneidman15 is aware of this
issue, and captures it very well when he states, “What my research
has taught me is that only a small minority of cases of excessive psy-
chological pain result in suicide, but every case of suicide stems from
excessive psychache.” This suggests that psychache is necessary but
not sufficient for suicide. There must be an additional factor, there-
fore, that differentiates those with psychache who die by suicide from
those with psychache who do not.
The additional factor, according to Shneidman, is lethality. What
constitutes lethality and how it develops are subjects I address in
Chapter 2.
My theory does not replace concepts like psychache with brand
new concepts—psychache is rather viewed as a generalized form of
perceived burdensomeness and failed belongingness. My theory
strives to improve upon, not replace, Shneidman’s and others’ defini-
tions and inter-relations, and to articulate when they are most likely
to result in serious suicidal behavior. The model I present is thus
intended to provide an account of suicide that incorporates the
strengths of major existing models, but goes beyond them to develop
a framework that is at the same time conceptually more precise and
epistemically broader, explaining more suicide-related facts.
My work rests on the shoulders of theorists like Shneidman and
Aaron T. Beck. Beck and colleagues’ cognitive perspective on sui-
cidality emphasizes the role of hopelessness.16 Hopelessness for Beck
plays the role of psychache for Shneidman.
Impressive data support the view that hopelessness is involved in
suicidality. For example, Beck and colleagues17 studied a group of 207
What We Know and Don’t Know about Suicide ● 39
/>
patients hospitalized for suicidal ideation. Over the course of the
next decade, fourteen patients died by suicide. Of several variables
assessed, only hopelessness predicted eventual death by suicide. In
this study, hopelessness was measured using a twenty-item scale with
possible scores ranging from zero to twenty; a score of ten or more
on the hopelessness scale correctly identified 91 percent of those who
later died by suicide. Beck and colleagues18 extended their work to a
group of 1,958 psychotherapy outpatients, seventeen of whom even-
tually died by suicide. High scores on the hopelessness scale again
predicted later death by suicide, correctly identifying sixteen of the
seventeen who later died by suicide. Those with high hopelessness
scores were eleven times more likely to die by suicide as compared to
patients with lower hopelessness scores.
However, an emphasis on hopelessness cannot tell the whole story
(an issue that Beck and colleagues understand well). What in partic-
ular are suicidal people hopeless about? If hopelessness is key, why
then do relatively few hopeless people die by suicide? In my view, the
reply to the first question is burdensomeness and failed belonging-
ness, and the reply to the second is that hopelessness is not sufficient;
hopelessness about belongingness and burdensomeness is required,
together with the acquired capability for serious self-harm.
An emphasis on hopelessness places negative thoughts and styles
of thinking front and center in explaining risk for suicide. From a
similar perspective, Beck19 has also argued that previous suicidal ex-
perience sensitizes suicide-related thoughts and behaviors such that
they later become more accessible and active. The more accessible
and active the thoughts and behaviors become, the more easily they
are triggered, and the more severe are the subsequent suicidal epi-
sodes.20 In one sense, this account shares similarities to the current
model in that both perspectives propose psychological mechanisms
underlying an escalating course of suicidal behavior over time. The
difference between the models has to do with the nature of the pro-
40 ● WHY PEOPLE DIE BY SUICIDE
posed psychological mechanisms—the mechanism in Beck’s view is
cognitive sensitization—that is, with repetition, suicide-related