Suicide: Thoughts and Questions
Suicide is the act of intentionally causing one’s own death. While that sounds straight-forward, it is not.
As we shall see, there is conflicting opinion and information about what constitutes suicide. Our cultural and individual views of suicide are varied, as are our opinions of those who engage in the act. Some who die by suicide are championed and honored, and may be made into folk heroes, while others are mourned, and some despised.
We’re clear about a number of things associated with suicide, but unclear about its actual causes. We are also at a loss to accurately identify why, given identical circumstances, some people will choose suicide while others will not.
So, let’s look at some of the numbers, methods, causes, types, and views of suicide, and the range of interventions that may help prevent it.
- In the United States, almost 43,000 die by suicide each year; that’s an average of 118 suicides per day.
- Females attempt suicide three times as often as males, while men are successful in their suicide attempts four times more often than women.
- The elderly have a 25% success rate (one death for every four attempts), while younger people have a 4% success rate (one death for every 25 attempts). White males over 85 years of age commit suicide at four times the rate of the general population (51/100,00 vs. 12.6/100,000).
- Finally, Whites and Native Americans/Native Alaskans have the highest suicide rates (14.7/100,000 and 10.9/100,000, respectively) while we see far lower rates in Hispanics, Asians, & Blacks (6.3, 5.9, & 5.5 per 100,000, respectively)
How dependable are all these numbers? Well, they’re the best we have and they are invaluable for comparative purposes. That being said, there are probably many suicides that go unreported, or that are reported as accidents, when in fact they are suicides.
There is a pervasive question about the definition of suicide. If someone overdoses six times, and continues to shoot dope, is their eventual overdose death an accident or a suicide? If someone voluntarily ceases to take in food or fluids, is their death one of natural causes or suicide? If someone intentionally drives their car into a concrete wall, is their death listed as an accident or suicide? You can see how these issues confound, and probably reduce, the number of recorded suicides.
There is tremendous variation, worldwide, in how people take their own lives. Hanging is the most common method of suicide worldwide, intentional pesticide poisoning the second most common method, followed by jumping, drowning, firearms and car exhaust in no particular order.
In the United States, half of all suicide deaths are by firearms, 27% are by suffocation, 16% are by poisoning, and 7% by other causes.
We have no information about the number of suicides, nationally or internationally, by overdose, VCNH (voluntary cessation of nutrition and hydration), or the cessation of or taking excess prescription medication. This is largely due to the high likelihood of these deaths being reported as accidents rather than suicides.
Causes and Associations
While there is a long list of factors associated with suicide, there is little evidence that any one of these factors actually directly cause suicide. The current belief is that most likely a combination of several of these factors, occurring simultaneously, outweighs the individual’s coping resources, and leads to a suicide attempt. The associated or contributory factors include:
- Prior attempts – People who attempt suicide once are more likely to try a second time than those who have not
- Both treated and untreated mental disorders – People living with depression, bipolarity, schizophrenia, PTSD, or borderline personality are more likely than the general population to attempt suicide
- Vanity – When someone who took pride in something like their appearance or wealth or prestige loses that something – perhaps through a disfiguring accident – they may consider suicide
- Loneliness, grief and loss, disconnection, and substance abuse – These four factors often occur together, can be seen in both adolescents and the elderly, and greatly increase the risk of suicide
- Hopelessness – Suicide becomes a more attractive option when there is a no hope that a situation will change. This can occur with a reality-based lack of hope (there is no hope that this terminal cancer can be cured) or a perceived lack of hope (this bullying will never end)
- Suffering – physical, emotional, spiritual, financial – Especially when the suffering lacks meaning, and/or is perceived as unending and unalterable.
- Humiliation – Often, but not always, related to adolescent bullying, cyber-bullying, and shaming
- Impatience – Understanding a solution for the situation may evolve over time, but being unwilling to stay alive until that time, e.g., a high school junior who is being cyber bullied and knows it will end after graduation when he/she goes away to college, but being unwilling to endure their senior year as a victim, and so suicides
- Impulsiveness – When there are no brakes (no pause) between an idea and acting on that idea – this is common in those who lack maturity, such as adolescents and/or practicing addicts and alcoholics
- Disappearing or absent informal social support system – An informal social support system, at any age, is essential to being able to cope with challenges and difficulties; without such a support system, loneliness looms large and there are no perspectives, views or solutions other than our own
- Identity crisis – Not having the coping tools or the willingness to seek help in dealing with a sudden or emerging change in identity, e.g., widowhood, discovering one is adopted, a change in body image related to amputation, colostomy, etc., or experiencing a change in sexual or gender identity
- Being a burden and/or to avoid being a burden – More common in the elderly, where an elder does not want to create a financial and/or care-giving burden for their family
- Avoidance (eviction, nursing home placement, treatment) – Suicide as the extreme response to an often sudden and certainly unwanted displacement or disease treatment, e.g., an elder who’s unwilling to undergo chemo therapy and just “ends it,” or a teen who commits suicide when told by their parents that they’re moving cross-country next month
- Meaninglessness and/or an inability to contribute – A life devoid of meaning, worth, value, or purpose can lead to a spiraling depression, from which one may not be able to see that they have anything to offer others or the world
- Belief that suicide is the honorable action – This is a fairly pervasive value (across cultures) that can make suicide a more attractive option (see “Types” below)
- Decreased/disappearing Quality of Life, Functional Integrity – These are common drivers of suicide in the elderly, but a perceived lack of Quality of Life, coupled with a belief that such Quality is unattainable, can lead to a consideration of suicide as a preferable option
- Invisibility and/or impotence – This is another pair that seems to be seen primarily in the elderly and in adolescents – the perception of being unseen by others (invisibility), and having no power (impotence) to alter their visibility
- Diminished or absent resilience – While we all encounter setbacks and challenges (illness, grief, accidents, rape, incest, incarceration, bullying, firing, loss of dreams, loss of love, etc.) in our lives, some seem more able to pick themselves up, dust themselves off, and move forward, while others seem unable to move beyond it
- Belief that “they” will be better off without me – An absolute and usually inaccurate certainty that the world and one’s friends and family will be far better off without them, and suicide becomes the vehicle to remove oneself from those people and the world
- Pain that exceeds one’s coping resources – This is really at the core of most of the above factors, and is often coupled with an unwillingness to ask for help
There are many views of suicide, and they are reflected in the language people employ when speaking about the topic. Sadly, they are often simple and dismissive statements about a highly complex problem, and which frequently lack compassion and provide little solution. They include:
- I’m not hurting anyone but me – Expressed by the person about to suicide, and reflective of a belief in #19, above
- Selfish/selfless – weak/strong – cowardly/courageous – Those left behind may view the person who committed suicide as selfish, weak, and/or cowardly while the person who attempts or commits suicide may view themselves as selfless, strong, and/or courageous
- Permanent solution to a temporary problem – While this may technically be true, the person who commits suicide finds the pain of their problem – be it temporary or permanent – unbearable, and this statement negates that truth
- Sin – Some view suicide as a mortal sin, and as disrespectful to God
- 9/11 – The people in the Twin Towers, in New York on 9/11, who jumped to their deaths, did not want to die. Rather, they saw jumping out the windows as a less painful alternative than being consumed by a wall of flame. In many mental health circles, this has become a metaphor for suicide – the person does not want to die, but cannot imagine enduring the pain of the issue with which they’re struggling, so suicide is chosen simply as the less painful option
- Mixed messages – When we denigrate as “weak, selfish or cowardly” someone who commits suicide and then champion “Thelma and Louise” for driving off the cliff or make a folk hero out of Dr. Kevorkian for assisting patients with their suicides, it sends a confusing and mixed message about whether suicide is a good or bad, right or wrong, acceptable or unacceptable behavioral choice. Also, the championing of certain suicides may embolden someone who is considering suicide to go ahead and commit suicide.
- Assisted Suicide – Whether called assisted suicide, medical aide in dying or death with dignity, family members helping someone who is suffering end their life, is more common than you might think
- Mass Suicide – While rare, mass suicides do occur, and have usually been linked to members of a cult committing suicide at the same time, in the same way, at the direction of the cult leader
- Homicide/suicide – Most common in elderly couples, where one member kills the other to end their disease-related suffering, and then takes their own life. We also see this pattern in many terrorist attacks where the terrorist kills as many people as they can, and then commits suicide
- Suicide pacts – This type of suicide occurs almost solely in adolescents, and involves an agreement between a romantic couple or a group of friends to all end their lives on a specific day and time; it is devastating to the families, school, and community, and may foster copy cat suicides in others
- Altruistic Suicide – For the good of others (family, tribe, etc.) In times of famine, elder Eskimos reportedly would wander away from their tribe, into the woods, to die and avoid slowing the tribe’s hunting and being a burden. This has not occurred since 1939. Reports of these elder Eskimos being placed on an ice floe and set adrift are pure myth. Today, people with major illnesses, who believe they might become a financial and/or care-giving burden to their families, sometimes consider and may engage in a suicide attempt to avoid imposing that burden.
- Honor Suicide – A type of suicide performed to either avoid dishonor (Harakiri or Seppuku – a Japanese ritual suicide by disembowelment) or to die honorably for a country or cause (Banzai – Japanese human wave suicide attacks sure to end in death, and Kamikaze – suicidal attacks by Japanese military aviators).
- Martyr Suicide – Terrorists
- Attentional Suicide – Suicide performed to make a statement about and bring attention to a perceived wrong or injustice, e.g., Buddhist monks practicing self-immolation over the Vietnam War
- Punishment suicide – A type of suicide seen most often, though not exclusively, in adolescents, and which involves taking one’s life to punish or hurt someone (a lover or parent) who committed some offending act, real or imagined
Given the range of types, views, and causes identified above, it is easy to see how difficult it is to come up with meaningful solutions to the suicide problem. Psychotropic medication may help the person living with schizophrenia or depression, rehab may help the person whose life is spiraling because of substance abuse, while neither of those will help with an honor suicide or punishment suicide.
Therapeutic approaches (CBT, DBT, EMDR, and talk therapy) might help with punishment suicide or altruistic suicide, but be useless with martyr suicide.
There are numerous national, regional, and local suicide prevention hotlines, but there is no clear evidence that they either help or hurt. That being said, they provide meaning for the volunteers who work there, an opportunity for a caller to hear a friendly voice who may say those two amazingly powerful words – “me too” – while creating a sense of connection and reduced aloneness. And, if they save even one life, they are certainly worth including in the arsenal of suicide prevention.
Programs aimed at reducing or preventing bullying and cyber-bullying can help reduce that as a driving cause of suicides. Palliative care programs that reduce patient and family suffering can help reduce suicides related to physical pain and suffering.
As I said earlier, there is no single intervention that works to reduce or prevent all types of suicide. Perhaps the most valuable things we can do include:
- Normalizing the experiencing of suicidal thoughts and assuring people that they usually pass, and do not have to be acted on
- Increasing opportunities for connection, as suicide usually grows out of isolation and a perceived loneliness
- Teaching people of all ages coping skills, because at the bottom of most, if not all, suicides is the factor of one’s pain – physical, emotional, or spiritual – outstripping their ability to cope with it.
I’m sure this article provided a greater appreciation of the complexity of this issue, and am less sure that it identified ways to prevent the various forms of suicide. If you’re willing to share, I want to hear if you’ve ever been suicidal, and if so, how you were able to keep from acting on the thought. I’d love to see your feedback in the Comments section below.
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