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The Why of it All

By their own hands, more than 30,000 Americans die every year. Each death commonly leaves a wake of grief and empty guesses.

by Robert Pool

It’s the question that haunts almost everybody who has lost a loved one to suicide: Why?

Why leave this world and everything in it, knowing you’re never coming back? Why say a permanent goodbye to everyone who loves you? Why choose death over life?

Why?

The question hits Thomas Joiner on two levels—where he lives and where he works. As FSU’s Bright-Burton Professor of Psychology, Joiner has made the study of suicide his career. He also lost his own father to suicide 14 years ago.

He reconciled his loss years ago, but his academic interest in mood disorders in grad school at the Univesity of Texas-Austin gradually brought him face-to-face with the essential enigma of suicide—the ‘why’ question.
Soon, Joiner set his sights on understanding why anyone would kill himself or herself. The quest has produced some remarkable insights into the question of whether it’s possible to predict which people are most at risk for suicide. And, of course, why they are.

Frankly, Joiner has built a reputation for himself as an expert in a subject that most people would prefer not to think about. His resumé is packed with honors and awards, such as the Shneidman Award for Excellence in Suicide Research, awarded by the American Association for Suicidology (yes, there is such a thing), and he is regularly asked by journalists and lawyers for his opinions on suicide-related issues.

In late September, for instance, city officials in St. Petersburg, Florida, called on Joiner when the city was trying to block the rock group Hell on Earth from holding a concert in which a terminally ill person planned to kill himself on stage to publicize the need for physician-assisted suicide. Joiner suggested that the event might lead to copycat suicides and, furthermore, that the prearranged nature of the act might push the terminally ill patient to go through with the suicide despite last-minute reservations. Many people who plan suicide back away at the last minute, Joiner noted. The city won the case, and a judge issued an injunction barring the group from holding the concert. Later, when the band announced it would hold the concert and suicide at a secret location and broadcast them over the band’s Web site, the judge barred that as well.

But the suicide work that Joiner believes will be his most important contribution is a theory that explains suicide far better than anything proposed before. The acid test for any theory of suicide is whether it can specify why some troubled people kill themselves while others with very similar problems never even try, and Joiner believes he can do just this. If he is correct, psychologists should be able to use this new understanding to more accurately pick out those at risk of suicide and intervene before they can hurt themselves.

It was 1990 when Joiner’s father killed himself. At the time, Joiner was a graduate student in psychology in Texas.

“It was very tough,” he acknowledges, adding, “but I don’t believe that it was the main source of my interest in suicide.”

Instead, he says, the questions raised by his father’s suicide dovetailed well with the sorts of questions he had already been asking himself in his psychology studies.

“I started off trying to explain social and relationship problems in people with mood disorders, and a lot of mood-disordered people have suicidal ideas that are triggered interpersonally, for instance, by rejection or by loneliness. So it was a natural evolution of interest to begin studying suicide.”

“This field is underdeveloped, under-funded, younger and less mature than even something like the study of mood disorders.” Amazingly enough, even though more than 30,000 Americans kill themselves each year, relatively few psychologists have studied the topic directly, he said.

Joiner sees one reason for this neglect being that psychologists have traditionally seen suicide as part of a larger problem—depression and other mood disorders. But even if psychologists understood mood disorders—which they don’t, says Joiner—that would not mean they understood suicide. Millions of people suffer from mood disorders, and only a small percentage of those kill themselves, Joiner said. Furthermore, some of those who commit suicide are not suffering from any mood disorder.

A second reason that suicide has gotten relatively little attention from psychologists, Joiner suggests, is the stigma and fear associated with it.

“Rational people get irrational when they talk about things like this,” he says, and even psychologists may find themselves unconsciously avoiding the subject of suicide.

Over the past decade or so, however, this neglect has begun to fade. A growing number of psychologists have begun turning their attention to the question of why people kill themselves, bringing to bear a whole new suite of cutting-edge tools, including techniques from molecular biology and genetics, sociology, anthropology, even economics. They have brought new insights and new energy to what had been a very quiet, slow-moving area of psychology. Joiner is one of these young guns.

Traditionally, Joiner explains, there have been two major schools of thought on suicide. One follows the teachings of Edwin Shneidman, a prominent “thanatologist,” or suicide researcher, at UCLA, and the man for whom the award that Joiner received was named.

“Shneidman writes that suicide is the result of intractable emotional pain,” Joiner says.

This pain, which Shneidman calls “psychache,” gets so bad that a person prefers death over life. Shneidman further claims that most people who commit suicide can be put into one of five groups characterized by different needs, such as the need to be loved, the need to belong, and the need to strike first.

By contrast, another well-known suicide researcher—psychologist Aaron Beck of the University of Pennsylvania—and his followers have focused on hopelessness. Known as the “grandfather of cognitive therapy,” Beck, now an emeritus professor at Penn’s med school, believes that the most important thing in explaining suicide is to understand the mental states that lead people to simply give up.

Joiner grants that both these schools of thought have a piece of the truth, but he believes that they’re both missing something.

“Lots of people who are in incredible pain or who are very hopeless never try suicide,” he notes. “Also there are people who kill themselves without a lot of pain or hopelessness, so it seems that there is a lot more to it. I’ve taken a shot at what I think is a full explanation,” he says.

That shot begins with what Joiner believes is a fundamental fact about suicide that most people overlook or misunderstand.

“Most of the work on suicide that has been done to date assumes a weakness of will or of character on the part of the person committing suicide,” he says. “But suicide is actually about a kind of strength.”

Self-preservation is a basic human instinct, Joiner points out. People try very hard to avoid things that will harm them or cause pain. The thought of, say, cutting or asphyxiating oneself is very upsetting and difficult to contemplate for most people. And that, Joiner says, is precisely why relatively few people commit suicide out of all of those who think about it.

“There’s actually a large number of people who express a desire for death—about 85 percent of mood-disordered people experience substantial suicidal ideas, for instance—yet very few of them will do anything to hurt themselves and even fewer will do anything that causes truly serious damage.

“People who actually kill themselves,” he says, “have (obviously) managed to beat down the survival instinct and the fear of pain and suffering.”

With this in mind, Joiner has proposed that people who kill themselves are marked by three characteristics that distinguish them from people who might wish to be dead but never actually commit suicide:

  • The ability to hurt themselves—and, in particular, to hurt themselves enough and in such a way that it is fatal;
  • A sense that one is a burden on one’s loved ones, and;
  • A lack of any sense of belonging to a group or a relationship that has some value.
  • Joiner said that a person who does not possess all three of these characteristics is unlikely to commit suicide, no matter how depressed or hopeless he or she feels. On the other hand, people who are in great emotional pain, who feel hopeless about the future, and who do have these three characteristics are at a very high risk for suicide.

    The first characteristic is the most deceptive, Joiner said, even though at first glance it seems obvious. After all, if someone commits suicide then he or she must certainly have had the ability to inflict serious self-harm. But that is seeing the issue with the value of hindsight. It gets much trickier to look at it prospectively. Which potentially suicidal people actually have the ability to kill themselves, and how can anyone tell ahead of time?

    The answer, Joiner says, is that some people over time develop the ability to suppress their survival instinct—to hurt themselves- and they do it in certain characteristic ways. In essence, they must habituate themselves to pain and to the idea of injury.

    Some do it via failed suicide attempts. A large number of people who kill themselves have had previous suicide attempts that didn’t work, and typically the attempts build in severity with each new try. A person might start, for instance, with a shallow cut on an arm, then later a deeper cut, and still later perhaps a drug overdose, until the survival instinct can be ignored enough to inflict fatal damage.

    But not everyone who commits suicide has to work up to it.

    “About 40 percent of all deaths by suicide are first attempts,” Joiner says. “These people must habituate by other means.”

    Victims find various ways to do that.

    “Any set of behaviors where you get hurt a lot can lead people to habituate,” Joiner says. This includes drug abuse and “any lifestyle that regularly leads to serious injury.”

    A professional racecar driver, for instance, goes to work knowing that on any given day he could end up critically injured or even dead. Although the driver is not seeking to hurt himself, driving a car into a turn at top speeds demands that one ignore the self-preservation instinct to a certain degree.

    That is not to say that racecar drivers are more suicidal than anyone else. Many people, Joiner explains, develop the capacity to hurt themselves without actually having any desire to. But a racecar driver would be more able to act on suicidal thoughts than someone who had never gotten inured to the idea of self-injury.

    Another way to habituate oneself to pain and injury, Joiner believes, is to see those things in other people. Physicians, for example, regularly see people with serious injuries and who are in great pain, and this, Joiner says, makes them more capable of injuring themselves. This explains, Joiner claims, why physicians have a higher suicide rate than the general population. Male physicians have suicide rates that are 1.5 to 3 times as high as men in general, and women physicians kill themselves 3 to 5 times as often as women in general. The effect is greater for women, Joiner suspects, because women in the general population are less likely than men in the general population to be in jobs or to have hobbies that habituate them to pain and injury.

    Joiner’s theory predicts a number of facts about suicide, such as the higher suicide rate among physicians, but it was designed to explain these details. The true test will be whether the theory predicts things about suicide that doctors and researchers had not already noticed, and that is what Joiner is testing now.

    The theory predicts, for instance, that people who feel themselves to be a burden on their family would be more serious about committing suicide. They would employ more lethal means in their attempts, and they would be more likely to be fatal. To test this, Joiner and FSU colleagues looked at 40 suicide notes, half written by people who did indeed kill themselves and half written by those who attempted suicide but failed.

    Those whose notes indicated a strong sense of “my loved ones will be better off when I’m gone” were indeed significantly more likely to succeed in their attempts and also more likely to choose a more lethal approach—gunshot and hanging, for instance, versus cuts or a drug overdose. On the other hand, Joiner found no relationship between the hopelessness a person expressed in the suicide letter and the lethality of the suicide attempt. In short, the sense of being a burden appears to have been a more important factor in the suicide than a feeling of hopelessness.

    A great deal of work remains to be done to test Joiner’s theory and to extend and refine it, but if it holds up as Joiner believes it will, it offers great hope to those in the fight against suicide.

    “Tomorrow there are eighty families in the United States alone who will lose someone to suicide,” Joiner says.

    He dreams of helping bring that number down so that fewer of us will be left in the pain of wondering why a loved one chose death over life.



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