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Across human history and across cultures, what has been the most stigmatised of human behaviours? What behaviour is condemned by Islam and Christianity, for example? It is not the keeping of human slaves, which occurred through the last thirty centuries at least, usually with approval of many segments of society. Slavery was hardly viewed with condemnation by the Bible, for instance (if you doubt this, check Leviticus 25:44-46, or if you prefer the New Testament, Ephesians 6:5). And it is not murder, as this has been defended on a mass scale as necessary and good by many political regimes, often with the support of their respective populations and with easy comfort available from religious texts. For example, it is recommended in Deuteronomy that heresy should be met with immediate murder, including, explicitly, when the heretic is one’s own daughter or son.
If not human slavery or murder, even of one’s own child, what then? A plausible answer to this question is suicide. The topic has created revulsion and disgust across cultures and time. The Koran (4:29) dictates, “Do not destroy yourselves,” and suicide is haram – very strictly forbidden – in the hadith (collected sayings by and anecdotes about the prophet Mohammed). Since the fourth century, Christian scholars have been unanimous in their condemnation of suicide, which was termed “the sin against the Holy Ghost” (why specifically against that aspect of the Trinity is confusing). Indeed, according to George Minois’s History of Suicide, some theologians from the fourth century onward have argued that Judas Iscariot was more damned for his suicide than for his betrayal of Jesus (p. 235) – a betrayal, incidentally, that Jesus himself arranged, at least according to one interpretation of the recently discovered gospel of Judas.
No doubt influenced by these early Christian attitudes, Dante wrote in the Inferno that the seventh circle of hell contained those who died by suicide. “If e’er the frenzied soul the body quit, from which by its own will it separates, the Minos sends it to the seventh pit” (Canto VIII). Even below the burning heretics and the murderers stewing in a river of hot blood (excepting, one supposes, the murderers of heretics), the souls of those who die by suicide grow in the shape of warped, poisonous thorns. On Judgement Day, those not condemned to hell will have their bodies and souls reunited in paradise, but the bodies of those who die by suicide will hang from the thorns for eternity.
But surely attitudes have progressed since Dante’s time. Perhaps so in some quarters, but people still say and think shocking things about suicide decedents. Those who have recently lost a loved one to suicide are stunned by many things following their loss, including the profound change in their address books – once trusted friends fall away after ignoring a loved one’s suicide or after saying hurtful and appallingly glib things like “It was God’s will.” Of the many survivor anecdotes that have touched and moved me over the years, a memorable one came from a powerful Southern man who had been “comforted” by hearing that his son’s death by suicide was God’s will. In reaction, he thundered in his drawl: “It was NOT God’s will that my precious son shot himself in the head.” Good for him that he said that; I wish I had said more such things (though I said some, no doubt) in reaction to the inanities I heard after my dad’s death by suicide. In Shakespeare’s Hamlet, Ophelia has died, and a priest would deny her full funeral rites because she died by suicide. Her brother responds, “I tell thee, churlish priest, a minist’ring angel shall my sister be, when thou liest howling.” Most people bereaved by suicide can identify with this sentiment.
A May 2007 case in Oklahoma involved the family of a young woman who had died from a gunshot wound to the head. It was not clear if the wound was self-inflicted or not, but the family felt determined to show that it was not, and to have an insurance company pay death benefits. A judge decided that the insurance company’s lawyer did not adequately demonstrate the manner of death as suicide, and ordered them to pay the family (which they would have had to do anyway, as long as the death by suicide occurred more than two years after the policy was initiated. That is the standard policy, at any rate). The family’s lawyer was quoted as saying, “It wasn’t about the money … This is about clearing a daughter’s name of the stigma of having committed suicide.”
Really? It’s more about clearing a stigma than about finding the woman’s actual killer?
Psychiatrists and psychologists – highly trained, doctoral-level mental health professionals – sometimes whisper about or panic about or skirt around the issue of suicide, an aversion that has always puzzled me, and one that strikes me as similar to a surgeon being afraid of blood. I know about this too: I’m a clinical psychologist who specialises in the understanding and treatment of suicidal behaviour. Why this profound stigma? For any stigma, the usual ingredients are fear and ignorance. If suicide is special in the degree to which it is stigmatised – and I and others believe it may be – then it is simply because the fear and ignorance are so great. Stigma about suicide should be reduced, of course, and it is a point of this book to do so, but I think it should be reduced via a decrease in ignorance, not in fear. I would prefer to leave the fear of death by suicide more or less intact. Fear can be quite healthy, and its absence can be deranged. Some of the most consistently fearless people are the most dangerous and disturbed.
Fear of injury and death, and of self-injury and self-inflicted death in particular, is natural and normal. Fear is self-preservation’s substrate. In his biography of Jack London, Alex Kershaw described the author thus: “He was aware that mankind’s terror has always been its most basic emotion … it has far deeper roots than love, tracing back to the days before history, when man was just another wild, frightened savage” (p. 125).
The self-preservation instinct is hard-wired and strong, and, as Voltaire understood centuries ago, relevant when it comes to understanding suicidal behaviour. Voltaire wrote of the death by suicide of the Roman orator Cato, “It seems rather absurd to say that Cato slew himself through weakness. None but a strong man can surmount the most powerful instinct of nature.” Centuries earlier still, the Jewish historian Flavius Josephus understood this as well; he wrote that suicide “is contrary to the instincts shared by all living things.” This view is found as well in Camus’ The Myth of Sisyphus, in which he states, “The body’s judgement is as good as the mind’s, and the body shrinks from annihilation.” The simple but compelling idea that occurred to Voltaire, Josephus, and Camus is that one must first grapple with one of nature’s strongest forces – self-preservation – before one dies by suicide.
Based in part on this insight, I developed a new theory of suicidal behaviour (in the 2005 book Why People Die by Suicide). In my view people die by suicide because they have both the ability and the desire to do so. This may seem glib or superficial, and if things were left here, it would be. What is the ability to die by suicide and in whom and how does it develop? What is the desire for suicide, what are its component parts, and in whom and how do they develop?
Self-preservation is a powerful enough instinct that few can overcome it by force of will. The few who can have developed a fearlessness of pain and death, which they acquire through a process called “habituation.” Formally, habituation is defined as “a response decrement due to repeated stimulation.” Less formally, it can be defined as “getting used to something.” In his Memoirs from the House of the Dead, Dostoevsky wrote, “Man is a creature who can get used to anything, and I believe that is the best way of defining him.”
Getting used to pain, injury, and death – becoming fearless about it – is, according to my theory, a prerequisite for serious suicidal behaviour. People get used to such things by having repeatedly experienced them, often through previous self-injury, but other painful experiences serve too. A corollary to this view is that the self-preservation drive – the fear of pain, injury, and death – protects people from death by suicide (which is why this fear should remain more or less intact). This corollary is supported time and again by cases of people who report that they genuinely desired to die by suicide, but that their bodies would not allow it (e.g., people have cut at their veins for hours, only to eventually surrender to their bodies’ ability to clot the wounds).
Who desires suicide? I believe that when people hold two specific psychological states in their minds, simultaneously and long enough, they develop the desire for death. These two states are the perception that one is a burden and the sense that one does not belong, which in this book and elsewhere call perceived burdensomeness and a sense of low belongingness. Perceived burdensomeness is the view that one’s existence burdens family, friends, and society. This view produces the idea, “my death will be worth more than my life to family, friends, or society.” This same mental calculation motivates those who die in their homes by self-inflicted gunshot wounds as well as those who leave their homes to blow up themselves and others as an act of religious martyrdom. It also motivates insects that self-sacrifice under certain conditions (e.g., when they are infected with a parasite that will destroy an entire colony) – conditions under which their death will be worth more than their life to their genes (which reside in other insects spared the infection). It further characterises a scenario that NASA has been contemplating regarding a flight to Mars. When should care be withheld from a critically ill astronaut who is using up previous resources like oxygen and water and thereby endangering the rest of the crew on the very long trip between Earth and Mars? In May 2007, the New York Times quoted a bioethicist on this question, who said, “There may come a time in which a significant risk of death has to be weighed against mission success. The idea that we will always choose a person’s well-being over mission success, it sounds good, but it doesn’t really turn out to be necessarily the way decisions always will be made.” That is, an astronaut’s death may be worth more than his or her life to the mission. That the same calculation appears to apply to insects as to astronauts on their way to Mars – what pre-eminent psychologist Paul Meehl would have terms “a damn strange coincidence” – lends some credence to this perspective, I think.
This point of view can be misconstrued, however, and it is very important to me that it not be. Emphasis should be placed on the term perceived in “perceived burdensomeness.” The message is that this is what suicidal people perceive, not what suicidal people actually are. The perception of burdensomeness, though mistaken, can prove lethal. The distinction between actual and perceived burdensomeness does require emphasis. To see this, consider that in December 2004, a member of the British parliament in the House of Lords advocated that elderly people not only have the right but the obligation to kill themselves rather than become “a nuisance.”
In addition to perceived burdensomeness, the other important psychological state in my model of suicidal behaviour is the perception that one does not belong – the feeling that one is alienated from others and not an integral part of a family, circle of friends, or other valued group. Two striking examples of the connection between belonging and suicidal behaviour have resulted from studies of two very different populations. A study in Norway involved approximately a million women who were followed for fifteen years. Over 1,000 of the women died by suicide during those years. A key finding of the study was that women with children had lower suicide rates than those with no children. The more children, the more dramatic the effect: Women with six or more children had one-fifth the risk of suicide as compared to other women (Hoyer & Lund, 1993).
Let us pause to ponder this last sentence. Women whose stress levels must be extreme – they had at least six children! – had one-fifth the risk. Not one-half or one-third, but one-fifth. How can women with high stress levels nevertheless have had markedly reduced suicide rates? My answer is that they were protected by the sense of belonging inherent in having a lot of children.
A similar logic applies to identical twins, who have, on average, slightly higher rates of mental disorders than the rest of the population. Mental disorders constitute a clear risk factor for suicidal behaviour. (The reason why twins have slightly higher rates of mental disorders is not entirely clear, but it may have something to do with the neurobiological consequences of sharing a womb.) Yet twins have lower rates of suicide than others. Why would a group with a clear risk factor for suicide nevertheless experience low suicide rates? A sense of belonging, inherent in twinship, offers a protective benefit.
My theory asserts that when over a sustained period people believe that they do not belong and that they burden others, they lose their desire for life. Put somewhat differently, the theory argues that contributing and connecting are necessary for the will to live, and that their joint thwarting is sufficient to produce the desire to die. This view is consistent with an array of conceptual frameworks, including Sigmund Freud’s, which, among other things, emphasised instinctual aspects of drives toward love and work. This view is also consistent with approaches ranging from Henry Murray’s work in the 1930s on various psychological needs to twenty-first-century social psychology’s work on loneliness, as, for example, summarised in Loneliness, John Cacioppo’s 2008 book.
There exists a staggeringly diverse collection of facts about suicide, as well as the perversions of truth that have sprung up around this collection. Using my theory as a guide and unifying thread, I hope to expose myths, shatter misunderstandings, and encourage real understanding of suicide, though leaving a healthy fear of it intact. Of course, my theory is not the only theory of suicidal behaviour, but I have chosen it as a guiding framework for this book because its combination of specificity and comprehensiveness allows it to shed light on a wide array of suicide-related phenomena, and because it is empirically supported (Van Orden et al., 2008) and conceptually compatible with other leading frameworks (e.g., Shneidman, 1996).
Three chapters follow: one on the suicidal mind, one on suicidal behaviour, and one on causes, consequences, and sub-populations. In each of these chapters, eight or nine myths or misunderstood topics are described and then debunked, dispelled, or simply explained, as the case may require. The ones that I view as myths are printed within quotation marks (e.g., “Suicide’s an easy escape, one that cowards use”); misunderstood topics are stated without quotation marks and more dispassionately (e.g., suicide and genetics).
These myths and misunderstandings will serve as ways to teach and explore a diverse collection of facts about suicide, facts that I think deepen understanding of suicide, death, and the will to live – and thus of human nature itself. Taking on myths and misunderstandings has some potential to backfire, it should be acknowledged, by inadvertently reifying the very notions one wants to dispel. But “truth will out,” and I trust that this process will allow us to compassionately understand suicide for what it is: A profound and fearsome human tragedy. It is a tragedy because it has tractable causes that can be understood and thus counteracted (but currently are not, at least not enough); it is fearsome because it requires a forsaking of our basic nature as self-preserving creatures, because it kills a million people a year worldwide, and because no one should have to die alone in a mess in a hotel bathroom, in the back of a van, or on a park bench, thinking incorrectly that the world will be better off. Like any dangerous and lethal thing that causes human suffering, suicide needs to be understood so as to manage and allay its fearsomeness – survivors deserve this understanding (not to mention compassion). So do those who have died by suicide; we honour them by understanding and combating their cause of death. Dispelling myths and misunderstandings about suicide seems to me a good place to start.