Why People Die by Suicide: Review and Notes

Recently, a very distant acquaintance – I infer, from Facebook – died by suicide. Because I was not close to this person and am not close to any of our mutual friends, my curiosity surrounding the circumstances of this surprising departure is thwarted and I remain fairly troubled regarding the whole thing (possibly since this recent pregnancy and birth made me more attuned to matters not just of life but of death – pregnant women and new mothers are not really allowed to talk about this, though I can’t be the only one). I decided to deal with this anxiety by reading a book recommended by my friend Sarah who I consider an expert on suicide.

Why People Die by Suicide by Thomas Joiner offers a simple and empirically-grounded theory of why suicide happens. Obviously, people who commit suicide are evidently both willing and able to kill themselves. To fulfill the “able to kill oneself” condition, suicide victims have to work up to lethal self-harm and/or become habituated to pain and “provocative” experiences. This can include violent and otherwise hardening experiences over a lifetime, like injuries, fights, incarceration, cutting, and more. It can also include a string of discrete suicide attempts, or escalating efforts at the time of suicide attempt (like non-lethal shallow cuts followed by deeper life-threatening ones). After all, it is the obvious norm for living things to try to go on living. Overriding this default instinct is not something that can happen especially quickly or easily.

Wanting to die is probably more common than being able to kill oneself. At any given time, plenty of people are quite unhappy and lacking in will to live (if temporarily), but most of them lack the ability to inflict lethal self-harm as described above. What seems to make people want to die, according to Joiner, is a sense of failed belongingness and perceived burdensomeness. These reflect some of the most basic of human needs: to care for others and be cared for by them, to have found a social place in the world, to contribute in some way.

Many people who think about suicide have no real ability to go through with it, at least not yet (this would have been my depressed and anxious teenage self). And most people who have extensive experiences with pain and danger have no desire to die anyways. But inhabiting the overlap of these categories on a Venn diagram is dangerous. When people who have acquired the capacity for lethal self-harm come to feel like they don’t belong and are even dragging others down, they are at heightened risk of completing suicide.

Mental health professionals do well to sort their patients into these rough groups, to avoid exaggerating the suicide risk of those with just a bit of suicidal ideation, and to avoid overlooking or discounting those who need emergency suicide prevention support. Since we don’t really know how to reduce people’s capacity for lethal self-harm once they have acquired the relevant life experiences, efforts should probably focus on getting genuinely suicidal people to more positively reassess how they belong socially and how they contribute to the world.

I am unfortunately not well-positioned to know whether Joiner has made use of a wide breadth of important existing research on suicide, and I don’t know if the studies he does cite were well-conducted. But as long as something isn’t deeply off in these ways, I find Joiner’s theory persuasive and useful as a lens through which to continue to think about suicide.

As an overarching explanation of suicide that’s light on specific, substantive claims, the Joiner theory is actually consistent with a wide range of current and potential work about how exactly the capacity for self-harm develops, and when and why people feel burdensome or like they don’t belong. It would take a good amount of research showing that suicide victims/attempters are characteristically well-integrated socially, feel useful to the world, and lack previous experiences with self-harm or pain in order to disprove Joiner. I doubt any such research is forthcoming.

Joiner’s theory also helps to explain various disparate facts about suicide. Suicide is relatively uncommon, especially as compared to the prevalence of depression, because the capacity for lethal self-injury is rare. It also explains why older white men have a high suicide risk – they become vulnerable when their social lives experience attrition without renewal (it’s harder to make friends as a guy, and men are more likely to be distant from their children) and/or the displacement from a breadwinner role easily produces perceived burdensomeness.

The weakest portion of Why People Die by Suicide is its discussion of the evolutionary roots of suicide. Joiner acknowledges the argument that when a person is actually quite burdensome to kin, it may be evolutionarily advantageous even from that individual’s point of view to commit suicide, thereby freeing her kin to reproduce more successfully — with a good chunk of the deceased’s genes still along for the ride. Joiner ultimately dismisses this theory of why people commit suicide, rejecting it as offensive, unknowable about the past, and in any case no longer true now (if it ever was).

Whether any one person’s suicide was or would be beneficial for her, from an evolutionary standpoint, in fact depends entirely on the circumstances. It is probably more likely that ritualized, norms-bound suicide-like practices (elderly eskimos on ice floes, widows on funeral pyres) serve evolutionary goals more than private, individual, pathological suicide. Norms about when a member should excuse herself from the group actually play to belongingness and prosociality, by outlining how good members give back via the ultimate sacrifice, when necessary. This type of norm can spare people from having to deliberate, possibly repeatedly, whether they (and their families) would be better off if they died. I would not be surprised if such norms have had a meaningful part to play in group and individual selection under certain limited historical conditions, though the possibility is indeed unpleasant to countenance.

The semi-evolutionary question I keep coming back to in my thoughts about suicide goes unanswered in Why People Die by Suicide, unfortunately. I want to know why suicidal people’s perceptions of their belongingess and burdensomeness are so dramatically detached from reality. How can it be that so many genuinely burdensome people live among us, dramatically encumbering their families (possibly including family members of reproductive age) while well-loved, employed people sometimes develop the nebulous but motivating sense that they are too much of a burden on others and call it quits? How can the actually burdensome often remain so oblivious while the not-actually-burdensome become so tortured by the prospect?

Something similar could be at work with belongingness, because friendship may not be a reciprocal property. As a possible form of “emotional self-defense,” we do not reliably recognize when our “friendships” are one-sided or merely aspirational. This means that plenty of people may in fact fail to belong, but they don’t realize it (and therefore it does not heighten their risk for suicide).

This brings me to what was supposed to be a hopeful part of the book, but which I found poignant in not a great way. One study found that an extremely minor intervention seemed to keep suicidal people from completing suicide. The population studied was a fairly large group of patients who had just been hospitalized for depression or suicidality, but who refused follow-up treatment following discharge. Patients in the treatment group received a letter from the hospital just checking in at least 4 times per year for 5 year, the control group received no further contact. Although the letters weren’t form letters, per se, they are nothing special – for example: “Dear John, it has been some time since you were here at the hospital, and we hope things are going well for you. If you wish to drop us a note we would be glad to hear from you.”

The treatment group (letter receivers) experienced a lower rate of suicide in those five years following discharge than did the control group (no letters). That’s sort of great — such a small intervention apparently boosted troubled patients’ sense of belongingness and may have literally saved their lives. On the other hand, it is close to absurd that such a minor gesture would make a statistically significant difference. The hospital administrators who printed and sent those letters don’t and can’t actually provide ongoing social resources for the discharged patients, instead their letter just appealed to some caringness detector in the patients’ ancient group-dwelling brains. The experiment attempted a kind of perceived belongingness hijacking, and it worked.

For suicide to be socially useful and a capacity worth keeping around (if mostly dormantly) in a species, it should strike genuine outliers to the group, who take more than they give, but people are are terrible judges of these qualities in themselves. What mechanism would ever correct for excessive suicides (those of people whose belongingness/burdensomeness perceptions were false)? Suicidality is only partially genetic (i.e. heritable), people who complete suicides can and do leave children behind, and (now more than ever before) the surviving children are not likely to themselves fail to reproduce due to their parent’s suicide. Then again, people who have the strong urge to kill themselves even when they are members of a group in good standing just are defective, on some level. I have only half-baked thoughts here. Your comments are welcome.

To bring things around to the introduction and my reasons for reading the book, I now understand that the suicide of my acquaintance could not really have happened randomly. The psychological preconditions of suicide don’t emerge out of nowhere (barring extremely extenuating circumstances). I would be more morbidly satisfied if I knew the details, but at least now I trust that they exist.

This realization is of some consolation to me, an uninvolved bystander, but I’m sure it would be extremely painful for those close to her to make — that the deceased’s capacity for self-harm, sense of failed belongingness, and perceived burdensomeness were creeping up as some amount of time went by, and that at least the latter two might have been ratcheted back fairly quickly, quickly enough to save her, with the right crisis interventions.

Joiner’s academic mission is personal, too — his own father died an ugly, self-inflicted death when Joiner was a young adult, and Joiner remains deeply pained over the loss. I am thankful that he has done his best to uncover the truth about suicide. The emerging picture that suicide is a preventable condition (related to failed belongningess and perceived burdensomeness) and not a mystery existentialist curse is either hope-inspiring or devastating, depending on whether and how you’ve been touched by suicide, or maybe both.

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