Understanding and Overcoming the Myths of Suicide
Understanding and Overcoming the Myths of Suicide
Myths about suicide abound in the therapeutic setting. They often inhibit the ability of clinicians (and families) to assess the severity and magnitude of a patient’s suicide risk. This special report discusses some of those myths. In Why People Die by Suicide,1 I argued that a kind of fearlessness is required to face voluntarily the daunting prospect of one’s death, and that doing so necessarily involves a fight against ancient, ingrained, and powerful self-preservation instincts. In Myths About Suicide,2 I used the framework developed in the previous book to contend that death by suicide is neither impulsive, cowardly, vengeful, controlling, nor selfish.
Impulsivity myths
The tragic death of a Florida television news reporter in 1974 illustrates the fallacy that suicide is an impulsive, spur-of-the-moment whim, much like casting off peanut shells at the ballpark. In July of that year, the reporter was covering the story of a shooting that had happened the day before. When the reporter called for the news station’s video footage of the scene, the tape jammed. She shrugged and stated, “In keeping with Channel 40’s policy of bringing you the latest in blood and guts, and in living color, you are going to see another first—an attempted suicide.” She extracted a gun from beneath her desk and shot herself behind the right ear. She was rushed to a local hospital, but died 14 hours later.
The usual reaction to this tragic tale beyond shock and horror was to dwell on the seemingly impulsive nature of the act and ask, “How could the reporter have known that the tape would jam?” However, the reporter’s behavior leading up to her suicide dispels the idea that she acted impulsively:
• For years, she openly told her family that she felt depressed and suicidal
• Four years before her death, she attempted suicide by overdose and frequently discussed the incident subsequently
• Weeks before she died, the news station granted her request to cover a story on suicide; and during one interview, she asked a police officer for details on self-inflicted gunshot wounds
• One week before, she told a colleague that she had bought a gun and joked with him about killing herself on the air
• On the day of her suicide (or possibly even before), she had put the gun in a bag that she brought to the set daily
• Finally, she had prepared news copy for a fellow reporter to read about her suicide after the fact
The news reporter’s death illustrates that her suicide was premeditated. Death by suicide is extremely fearsome and daunting, and thus requires considerable thought, planning, and resolve. To consider her death impulsive is to assign primacy to that spur-of-the-moment decision as to precisely when to pull out the gun, instead of focusing on the many factors that led up to that planned moment.
In the book An Unquiet Mind,3 Kay Redfield Jamison discusses her own experience with suicidal behavior and describes how it actually works: “. . . for many months I went to the 8th floor of the stairwell of the UCLA hospital and, repeatedly, only just resisted throwing myself off the ledge. . . .” Contemplating suicide is a signature of serious suicidal behavior. Jamison’s months-long thought process and behaviors counter the notion of spontaneous death by suicide.
The suicide of President Bill Clinton’s childhood friend and White House adviser Vince Foster was of this sort. Despite wildly irresponsible speculation to the contrary, Foster died of a self-inflicted gunshot wound. Foster snuck a gun out to his car in an oven mitt; he drove to a secluded area of a park, and he shot himself. To imagine that Foster’s death was impulsive is to ignore all of the facts in what was by far the most investigated suicide in history (multiple Congressional inquiries and forensic investigations were conducted). It is also to ignore the character of Vince Foster; he was a well-organized, thoughtful, and deliberate person. No one who knew him would have described him as impulsive.
Foster’s friends and family were stunned by his death; it seemed “out-of-the-blue.” However, death by suicide can both shock loved ones and be planned for weeks, months, or even years. This is because of the human capacity, quite spectacular in some cases, for privacy and secrecy. Except in works of fiction, I have never encountered a death by suicide that was truly impulsive. Many clinicians have mistakenly deemed suicidal deaths impulsive merely because they seemed to be “out-of-the-blue.”
Suicide note myths
Foster did not leave a suicide note, a factor that spurred conspiracy theories on cause of death. To my knowledge, no study has reported a rate of note leaving among suicide decedents to exceed 50%. Moreover, most studies find rates between 0% and 40%4; a reasonable average rate would be approximately 25%.
Why are suicide notes so rare? Some have reasoned that because impulsivity is involved in suicidal behavior, suicidal persons often kill themselves before they have a chance to write a note. There are problems with this viewpoint, however. A major problem is that it draws on the distinct myth that dying on a whim is common. Another problem is the lack of empirical support that compares those who leave notes with those who do not. If it were true that note leavers are much less impulsive than those who do not leave notes, then this distinction should be easy to demonstrate in forensic studies that examine the lives, characteristics, and personalities of decedents. This difference has not been clearly demonstrated.
The relative rarity of suicide notes reveals the state of mind of those about to die by suicide. To say that persons who die by suicide are lonely at the time of their deaths is a massive understatement. Loneliness, combined with alienation, isolation, rejection, and ostracism, is a better approximation. Still, it does not fully capture the suicidal person’s state of mind. In fact, I believe it is impossible to articulate the phenomenon, because it is so beyond ordinary experience. Notes are rare because most decedents feel alienated to the point that communication through a note seems pointless or does not occur to them at all.
Diagnostic myths
Friends and family who have been surprised by a suicide often consider it to be deeply selfish. This is understandable because the bereaved are often convinced that the decedent did not consider the impact of his or her death on those left behind. However, those who die by suicide certainly do consider the impact of their deaths on others; but to them, death is a positive rather than a negative outcome. This is wrong, but nevertheless, it is the view of the person who attempts suicide.
Still another reason to question whether selfishness is involved in suicidal behavior involves the associations of various aspects of psychopathy to suicidal behavior. In its description of psychopathy, DSM-IV includes aggressive behavior and reckless, out-of-control disregard for others and for rules and norms. Another aspect of psychopathy—evidently to be emphasized more in DSM-5 and included in Hervey Cleckley’s classic 1941 book, The Mask of Sanity5—describes psychopaths as controlled, callous, sometimes charming con men. They also demonstrate marked emotional detachment (ie, low anxiety; fake or shallow emotions; immunity to guilt and shame; and incapacity for love, intimacy, and loyalty).
In the current DSM, psychopaths are considered out of control but not necessarily unfeeling. Cleckley psychopaths are very much in control and very much unfeeling, except, that is, when it comes to themselves. One cannot be a Cleckley psychopath and not be selfish—it is part of the core of the syndrome; but on the basis of DSM, one can be a psychopath and not be selfish. In short, one group is selfish to the core; the other, less so.
If selfishness is key to suicidal behavior, it stands to reason that the group more prone to suicidal behavior should be the Cleckley psychopaths, but it is not. Genuine suicidal behavior is quite rare in this group.
Seasonal myths
Another common myth that even some professionals harbor is that death by suicide peaks around the winter holidays. In fact, far from peaking, the winter holidays represents a low point in suicide rates,6 possibly because it is a time of togetherness.
My research group hypothesized that seasonality and suicidality are associated at least partly because of seasonal fluctuations in togetherness.6 Consider a large college campus in this regard. Campuses provide numerous activities for belonging; anyone who doubts this should check out a nearby university’s online master calendar. Universities offer many social, cultural, academic, athletic, and other events—many of them free of charge. Perhaps partly as a function of this high level of belonging inherent in these events, suicide rates of college students are relatively low compared with their same-aged peers not at college.6
Opportunities for togetherness are thus high on college campuses, but they are not uniform throughout the calendar year. During a standard academic year (the fall and spring semesters, roughly from September to May), most schools are clearly in session, and chances for social engagement abound through classes, dormitory and apartment life, sports, and so on. However, summer activities continue but they ebb considerably. Therefore, it is conceivable that students’ sense of belonging may be lower during the summer than during active semesters. We found that suicidal ideation was higher in the summer months than during the regular academic year, and we reasoned that this association might be partly explained by fluctuations in opportunities for socializing.6
Slow suicide myths
A final collection of myths involves the notion of slow suicide, by which a person engages in unhealthy behaviors despite knowing that these behaviors may ultimately lead to death. Genuine suicidal behavior involves a rather clear intent to die, not to do something else like smoking or taking drugs because they like it. Consider, for example, smoking. By the logic of smoking as slow suicide, we should have witnessed a most remarkable decrease in the suicide rate in the past half century, as smoking rates plummeted; alas, we have not. People know smoking puts them at risk, but they smoke anyway—not because they intend to die—but because they like it. They are willing to take the risks because of how much they enjoy smoking. Addicts continue to use drugs even though they have been told and understand that continued use might kill them; but because they like “doing” drugs, the risks do not matter.
Therapeutic implications
I articulated these perspectives in Why People Die by Suicide1 and Myths About Suicide,2 which encompass risk assessment, therapeutics, and suicide prevention. In addition to marked warning signs, such as talking about suicide and planning for it, the books discuss clinically severe agitation, insomnia, and nightmares (these latter 3 are themselves not considered acute risk factors in some clinical settings). Noting a patient’s fearlessness of death, perceived burdensomeness, and accelerating alienation may improve risk assessment.
Myths About Suicide concludes with the following excerpt:
We need to get it in our heads that suicide is not easy, painless, cowardly, selfish, vengeful, self-masterful, nor rash; that it is not caused by breast augmentation, medicines, “slow” methods like smoking or anorexia, or as some psychoanalysts thought, things like masturbation; that it is partly genetic and influenced by mental disorders, themselves often agonizing; and that it is preventable (eg, through means restriction like bridge barriers) and treatable (talk about suicide is not cheap and should occasion treatment referral). And once we get all that in our heads, at last, we need to let it lead our hearts.
Therapeutic regimens and prevention protocols that target and acknowledge these factors should be given serious consideration.
References
References
1. Joiner T. Why People Die by Suicide. Cambridge, MA: Harvard University Press; 2005.,
2. Joiner T. Myths About Suicide. Cambridge, MA: Harvard University Press; 2010.
3. Jamison KR. An Unquiet Mind. New York: Alfred A. Knopf; 1995.
4. Joiner TE, Pettit JW, Walker RL, et al. Perceived burdensomeness and suicidality: two studies on the suicide notes of those attempting and those completing suicide. J Soc Clin Psychol. 2002;21:531-545.
5. Cleckley H. The Mask of Sanity. St Louis: CV Mosby Co; 1941.
6. Van Orden KA, Witte TK, James LM, et al. Suicidal ideation in college students varies across semesters: the mediating role of belongingness. Suicide Life Threat Behav. 2008;38:427-435.
Rather than "myth about suicide"this article would be better titled "Stuff I don't believe about suicide"; no data of any quality is presented, just a couple of anecdotes. If the author really believes that these are "myths," then he ought to present some rigorous, objective data, not argument by assertion.
How do you reconcile the fact that most suicides are not impulsive with the theory that bridge barriers are preventative?
To the editor: Dr. Thomas Joiner notes, in "Understanding and overcoming the myths of suicide"(Jan.2011, p. 20) that "death by suicide is neither impulsive, cowardly, vengeful, controlling nor selfish." I would agree that suicide is not always or only characterized by those traits, but is Dr. Joiner willing to concede that it is, at some times and with some persons, any one of those? For instance, at least one study has suggested that the time interval between the decision to die and the act may be as little as five minutes, and murder-suicides are often extremely close in time; whether that is "true" impulsivity seems a quibble. Most clinicians have seen, I suggest, not just imagined mythically, the other traits in their practices. I seem to recall that Leston Havens suggested that suicide occurs within "a web of cause and chance;" perhaps that is a richer, more accurate and less mythic picture. Thomas G. Gutheil, MD Harvard Medical School 617-734-9519 gutheiltg@cs.com
Phil, Too often the decision to suicide is a 51-49 vote in favor of self-destruction. When in that 51% for state of mind, the individual may seek out a way to kill himself, but in all likelihood it is in a way they have thought of before. Think of a predator lying in wait for prey. The predator attacks with intent, but to an external viewer, why the predator singles out one victim or another seems random. JJ
To the Editor: In my opinion the issue is way more complex than this paper presents. Most patients with depression have some kind of suicidal ideation but only some will attempt suicide. A number of patients (for instance many of those with comorbid personality disorders) report a suicide plan but never carry it out. Someone attempts suicide right after visits when they have denied any suicide intention. I do not want to say that it is always impossible to predict suicide but there are cases when it actually is, even if we locked in a hospital all patients with some suicidal ideation. I am copying below the conclusions of my paper (based on data ) "Suicide attempts and ideation in patients with bipolar I disorder. "J Clin Psychiatry. 2004 Apr;65(4):509-14. http://www.ncbi.nlm.nih.gov/pubmed/15119913 'In some cases, suicide risk is transient and may be preceded by a period of severe suicidal ideation that lasts only a few minutes or hours. In such cases, mental health professionals are unable to predict suicide attempts.' Andrea Fagiolini, MD Chairman and Residency Training Director Department of Mental Health University of Siena School of Medicine Viale Bracci 1, Siena, 53100 Italy
Thanks to the Times for publishing this article for us to digest and consider. I believe that the unspoken issue here is how to engage and successfully treat a person who comes to treatment with expressed suicidality. Hidden suicidality is a norm, and must be clinically sensed and then exhumed without shaming and treated. I don't believe anybody has cornered the market on how to do that. Suicidality has many meanings, all idioscyncratic, in my experience. Clinicians often get incredibly uncomfortable talking about suicidality in depth with their patients and with their colleauges. The medico-legal climate is one where clinicians are burdened, in part appropriatey, with the responsibility to somehow help people not suicide. No clinician who has experienced the suicide of a patient is emotionally untouched from that event. Suicide rates amongst psychiatrists and allied professions are high enough as to make clear that our professions might be particularly burdened by suicidal patients and yet it is a burden that must be borne. It is not consolation, if my memory is correct, that dentists have a higher, if not the highest suicide ratesof health professionals. Current psychiatric training that focuses on psychopharmacologic approaches to treatment and cognitive behavioral therapy as mainstays of clinical intervention leave recent psychiatry graduates relatively bereft of the skills and emotional seasoning required to explore detailed fantasies of suicide as part of an outpatient psychotherapy. Repeated hospitalization of people with chronic suicidality without intensive inpatient psychotherapy of some length deprives people of what they need and create "revolving door"hospital admissions. Non-psychiatrists who are not trained in psychodynamic therapies and the use of countertransference are similarly burdened. This article appropriately describes myths about suicide, but as has been pointed out, sometimes the mythical story fits. Until the mental health professions work with suicidality as a symptom with psycodynamic meaning desperate for exploration, rather than as a behavior to be assessed by an "instrument" the current climate of "mystery" about why people suicide will remain the focus of our attention. "Why" is the question everybody asks. What we don't more specifically ask is "Where does it hurt?" Traveling "through the looking glass" with our patients, entering the place where they are in pain, and sitting down to talk about it is not mysterious. It is just plain painful. Tolerating the pain is part of what must happen for clinicians as they model tolerating the pain for their patients. Richard A. Chefetz, M.D., private practice, Washington, D.C.
Dr. Joiner This is a great report; but, I disagree with the point about selfishness and suicidal indivdiuals. To compare a suicidal individual with a psychopathy isn't reasonable. People with suicidal ideas are overly focused on themselves; therefore, they are self-centered and selfish.
Dear Colleagues,
Thank you for reading and commenting on this article. It is my hope that interchanges such as this might spark fresh, productive ideas. If so, the next step is to ask oneself, as Dr. Gutheil is fond of saying, "Has anyone ever written about this?"
What follows are my thoughts on this piece. Beginning with strengths, the piece sets out to reduce stigma re: suicide - a very noble goal. It addresses an issue that is greatly misunderstood by the lay public in all manner of detrimental ways. It also brings the entire issue of suicide "out of the darkness"- again, very noble (see: http://www.outofthedarkness.org/).
My apprehensions include essentially what my colleagues have commented on here. In essence, that suicide is multiply determined, and therefore very complex. It cannot be defined in broad brush strokes, as it is also a highly personal and individually nuanced behavior. As others have noted, in some cases it may be the product of long deliberation, while in others it may assume an episodic or transient struggle.
I may be misreading, but the piece seems to lose some clarity around the subject of psychopathy. This highly researched construct may be discussed here a bit inaccurately. Further, there are numerous research articles indicating that both psychopathy and ASPD are risk factors for suicide, esp. in the correctional setting. (See: Swogger M, Conner K, Meldrum S, Caine E: Dimensions of psychopathy in relation to suicidal and self-injurious behavior. J Pers Dis, 2009; 23: 201-10; and Douglas K, et al.: Relation of antisocial and psychopathic traits to suicide-related behavior among offenders. Law Hum Beh, 2008; 32: 511-25).
While I am in agreement with the author that suicide is not "cowardly" or "selfish," I cannot so quickly dismiss both the research and clinical data/experience suggesting that there is sometimes a psychological component (among many others, depending on the individual) of anger/vengefulness, which in turn suggests control. I am certainly not suggesting that this is at play in all suicides, or even a majority - but that is my point - this is a complex human behavior. In addition, clinical experience has also informed that some individuals, when questioned about their self-destructive behavior in the setting of a trusting therapeutic alliance, will admit to a "death wish" behind their behaviors. Whether this is "slow suicide" or not is too difficult to say, especially because the term has no clearly defined parameters. Finally, I am unaware of any psychoanalytic literature over the past several decades stating that suicide is linked to masturbation.
I am glad that this piece raised the issue of suicide and "impulsivity." Just as the nomenclature in suicidology continues to stymie, I believe the (mis)use of this unclear term has created confusion. I have found "impulsivity" to be used and conceptualized differently by different authors. It's most common definition, "acting swiftly without forethought," presents problems. As Joiner notes, I don't think many in the field contend that a person abruptly commits suicide "on a whim." If this is what he means by "impulsive," then I agree. The problem is that this is not how I see the term being used in the literature. One must contrast the notion of "Dying on a whim" with the chronic contemplation of suicide culminating in an unconstrained, desperate attempt to "escape" psych-ache. The confusion comes from how the term is used, and whether one is referring to that final, unconstrained (sometimes aggressive) act, and the mindset required to suppress the survival instinct.
As commenters noted, there is compelling research associating impulsivity, aggression and risk taking with suicide. (See: Deisenhammer E, et al.: The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt? J Clin Psych, 2009; 70: 19-24; and Roy A: Family history of suicide and impulsivity. Arch Sui Res, 2006; 10: 347-52). But again, this may represent a particular subgroup, and cannot be expected to apply to "all" suicides. I am aware that many studies use tools such as the Barratt Impulsivity Scale, yet close investigation suggests it may not be used consistently between investigators.
At some point, the field of suicidology needs to come together to rigorously define terms/definitions. Even if we don't get it right at the outset, this will be preferable to trying to chart the waters without a reliable compass.
Respectfully,
James Knoll, MD
Editor-in-chief
Psychiatric Times
I can agree with Dr. Joiner's premise because I have been there myself.
Oretha Ogwotu states "People with suicidal ideas are overly focused on themselves; therefore, they are self-centered and selfish". Let me tell you the thought that enables suicide. "they'd be better off without me". Such is the low ebb of self esteem. I have been in mental pain for 3/12 years following an MVA where I sustained permanent and painful injury. Sometimes, for 10 minutes to a few hours I seriously want to shut the door (on my lifetime). My family love me and I them and the thought that tempts me to break the rational barrier is "they'd be better off". Then I tell myself this is not rational and that they would hurt maybe forever in their lifetime. Is suicide selfish? I don't think so. It is the harsh judgements of Oretha Ogwotu who have NO understanding that create the deep well of thought "no one gives a sh*t" that enables the final act of selflessness. Susee S
Response to Sue Slater: My judgment is not harsh, but you need to understand that everyone is not like you. Actually I do know what it's like to want to die. I am a suicidal survivor. I never had good family support, my family was very dysfunctional and I had a very unhappy childhood. I was told by my mom that I was an unwanted child. So I didn't have people in my life that showered me with love and attention as you do. So family members were never in my mind when I made the decision to live or die.
I am a nurse practitioner that tried to find something medically wrong with my father because he wanted something to be wrong with him. Never found anything. I treated him for depression with multiple meds that he stopped taking. He was in my office with nausea vomiting one week before he shot himself. At first I blamed myself for not being able to help him. I was shocked that he did this but not surprised. I believe he was suffering and wanted to end it. Mental illness is a disease just like cancer. People are looked upon differently if they are diagnosed with a mental health problem. It is my belief both professionally and personally that if someone wants to take their life, they will. Medical intervention might prolong the time period but when they think the moment is right they will do it anyway. I believe also it is premeditated and spur of the moment. They have planned it for a long time and do it on the spur of the moment. I sympathized with those of you that have lost family members. To me the healing is a ongoing journey and time is the only thing that does aide in the healing but the scar is always there.
As a mental health professional and the executive director of a community mental health clinic I have had many experiences of suicidality in clients as well as myself. I have made several attempts at killing myself, each time putting more thought and planning to the act. I was in such pain with this "cancer of the soul" that I needed permanent relief. At one pont I did leave notes to my young children, explaining how they would be much better growing up without me. The closest I came was a 3 day coma. I have recovered but I do occasionally contemplate suicide, at which point I know I need a helpful booster shot. I am retired now and my life holds a measure of tranquility.
The author addresses many of the misconceptions about suicide. As a longtime sufferer of treatment resistant recurrent major depression, I have spent most of my life under depression's darkness. Not always suicidally-severe, but dark enough that life provides very little joy.
Despite continued efforts to improve, year after year of leaden lethargy pass. Is this a life worth living? Evaluating that question often brings suicide to mind.
We euthanize our pets when they are suffering. Why not ourselves?
"You are here to enable the divine purpose of the universe to unfold. That is how important you are!"
- Eckhart Tolle
In the print edition of _Psychiatric Times_, this article was next to the article on substance abuse and suicidality. So in Dr. Joiner's cases, there is no impulsive suicidality; yet, for those abusing street drugs, there clearly is.
While I appreciate Dr. Joiner's clarity of thought, he errs greatly when he quotes from his own book that suicide is not "cowardly." On the contrary, I can think of no more self-absorbed, self-righteous, and cowardly act than the taking of one's own life, which does not belong to oneself anyway.
Slow suicide by smoking: Don't you think that might be a metaphor?
Extremely important article. I have felt the depths of depression as well & at times I felt it would be better for my family if I weren't living. I strongly knew that I was dragging them down with me. Thank goodness for mood stablizers & antidepressants! I work & live a relatively normal life now because of science.
I wanted to add something that was very helpful to me during my extreme battle with chemical imbalance. (Calling myself deeply depressed was depressing in itself). I used a mantra ~I choose to live~ I may feel like the depression is taking over, but I choose to live. ~ Over & over I would repeat this & call for help from my husband. I promised him I would always call if I had suicidal feelings. He dropped everything to help me. Thank God for marriage! By putting the mantra into the present tense it helps the brain to be "in the now" so to speak. When sick with a cold, I still use positive mantras ~ I am healing~ Our bodies are marvelous machines & are set to heal.
The phenomena of suicide, due to its multifunctional causes, one approach may not answer all the questions.
Psychoanalytical approach with spiritual coloring would be the best not only to understand the phenomena but also to prevent it.
Dr.Ghorpade
consultant Psychiatrist
This is a soothing balm to me as I am the child of a father who committed suicide 3 months before I was born. I can feel compassion for him and less alienation from him knowing that he was not ruthlessly selfish or crazy impulsive. I do believe he was long suffering and I thank you for the gift of this view into his psyche.