WHY PEOPLE DIE BY SUICIDE
WHY
PEOPLE
DIE
BY
SUICIDE
Thomas Joiner
Harvard University Press
Cambridge, Massachusetts, and London, England
This book is dedicated to those who
have lost someone to suicide, and
especially to those who have been
supportive of survivors like me,
including, for example, my friends
from high school, who did all the
right things.
Copyright © 2005 by the President and Fellows of Harvard College All rights reserved
Printed in the United States of America
First Harvard University Press paperback edition, 2007
Library of Congress Cataloging-in-Publication Data
Joiner, Thomas E.
Why people die by suicide / Thomas Joiner.
p. cm.
Includes bibliographical references and index.
ISBN-13 978-0-674-01901-0 (cloth: alk. paper)
ISBN-10 0-674-01901-6 (cloth: alk. paper)
ISBN-13 978-0-674-02549-3 (pbk.)
ISBN-10 0-674-02549-0 (pbk.)
1. Suicide.
2. Suicide victims—Psychology.
3. Suicide victims—Family relationships.
4. Children of suicide victims.
I. Title.
HV6545.J65 2005
616.85′8445—dc22
2005051347
CONTENTS
Prologue: Losing My Dad
1
1
What We Know and Don’t Know about Suicide
16
2
The Capability to Enact Lethal Self-Injury Is Acquired
46
3
The Desire for Death
94
4
What Do We Mean by Suicide? How Is It Distributed
in People?
137
5
What Roles Do Genetics, Neurobiology, and Mental
Disorders Play in Suicidal Behavior?
172
6
Risk Assessment, Crisis Intervention, Treatment,
and Prevention
203
7
The Future of Suicide Prevention and Research
223
Epilogue
231
Notes
235
Works Cited
243
Acknowledgments
267
Index
271
LOSING MY DAD
PROLOGUE
In 1990, close to a million people died by suicide worldwide. My dad
was one of them.
Of course my dad’s death has deeply affected both my feelings
about suicide and my understanding of it. My feelings about suicide
stem partly from people’s reactions to my dad’s death. Some friends
and family reacted in ways that I still treasure—the sorts of things
that make you proud to be human. Others’ reactions were not quite
up to this very high standard.
My intellectual understanding of suicide evolved along a different
track than my feelings. Informed by science and clinical work, I came
to know more than most about suicide—on levels ranging from the
molecular to the cultural. But here too, my dad’s death never left me,
for the simple fact that I could evaluate theories and studies on sui-
cide not only by formal professional and scientific criteria, but also
by whether they fit with what I know about my dad’s suicide. As I
will point out, a nagging fact about my dad left me unsatisfied with
existing theories of suicide and pushed me to think in new ways
about his death and about suicide in general. All of this will become
1
2 ● WHY PEOPLE DIE BY SUICIDE
clear throughout the book, but first, let me turn to the details of my
dad’s suicide.
In Atlanta in the early morning hours of August 1, 1990, my dad
was sleeping, or trying to, in the bed that was mine as a teenager.
He wasn’t sleeping with my mom; I think his snoring had become
too much of a problem. I was a graduate student in Austin, Texas at
the time.
It was summer, so my dad must have been alternately cold and hot
in that bed—cold when the air conditioning kicked in (because the
vent was right next to the bed), hot when it turned off (because that
room was not well insulated). My dad rose from the bed. I wonder if
he made some silent gesture, like putting his hand against the wall
that separated my old bedroom from his old bedroom, where my
mother lay asleep. He walked past the room he had shared with my
mom, and then past my younger sisters’ rooms, where they lay asleep.
Here again, did he hesitate as he passed their rooms, I wonder? Was
he prepared with a cover story in case my mother or sisters woke up
and asked him where he was going?
He went downstairs. Before going out the door, he must have
pulled open a drawer or two in the kitchen, looking for a large knife.
Or maybe he got the knife from his fishing tackle in the garage. It
surprises and distresses me even now when I can’t remember or
never knew a key detail like this about my dad’s death.
He walked outside, got into his van, and drove a half-mile or so to
the lot of an industrial park. He prepared no note. At some point be-
fore dawn, he got into the back of the van and cut his wrists. His self-
injury escalated from there—the cause of death from his autopsy re-
port is “puncture wound to the heart.” These details remain very
painful for me, but they are important—as will become clear, people
appear to work up to the act of lethal self-injury. They do so over a
Prologue: Losing My Dad ● 3
long period of time, by gradually accumulating experiences that re-
duce their fear of self-harm; and they do so in the moment, by first
engaging in mild self-injury as a prelude to lethal self-injury.
My dad’s body was not discovered until about 60 hours after his
death, which necessitated a closed casket funeral. So the last time I
saw my dad was in June of 1990 when I joined the family on a beach
trip. We fished and talked about the NBA finals and a large stock deal
my dad was proud to have recently pulled off. We played board
games in the van on the way home—the same van in which my dad
died. I am still stunned to think that six weeks later he would leave
the house and walk away from us forever. He never said goodbye to
my mother, my sisters, or me.
In the months before his death, my dad had parted ways with the
company in which he had formed his professional identity and, in-
deed, much of his identity as an adult. The position with this com-
pany was one of influence, and after leaving, he struggled to regain
his former feeling of effectiveness. I think this struggle was exacer-
bated by some callous and self-serving behaviors by those remaining
at the company, who my dad believed were friends.
Uncle Jim, my dad’s older brother. He met me at the gate at the At-
lanta airport. He must have been heartbroken and incredibly con-
fused about how his very successful little brother could have sud-
denly died by suicide. He shouldered this shocking burden and put
it aside, at least for a while, to pay attention to how I was feeling
and, in the days following, to how my mom and sisters were feeling.
Jim didn’t understand much about suicide—I think he would have
said that himself—but some people don’t require understanding in
order to act right. They just let compassion take over; that’s what my
Uncle Jim did.
The relation of understanding suicide and “acting right” about it is
interesting to explore. In thinking back over people’s reactions to my
4 ● WHY PEOPLE DIE BY SUICIDE
dad’s death, my sense is that no one understood it, really. To some
people, like my Uncle Jim, understanding didn’t matter and wasn’t a
barrier to acting with real generosity of spirit. To others, the lack of
understanding seemed an insurmountable barrier, so that instincts
toward compassion were short-circuited. They were caught up in
their minds about how to understand this shocking death and what
to say to me and my family. One contribution of this book, I hope, is
to provide understanding, so that those who need it in order to un-
leash their caring and generosity will have it.
Ironically, those whose reactions were the least helpful were those
who might have known better—those who, unlike my Uncle Jim, got
tripped up by intellectual lack of understanding. All that was needed
was eye contact and phrases like, “Man, I’m real sorry about what
happened to your dad,” as well as a willingness to interact with me
like I was the same person they always knew. My friends from high
school all did this by instinct, both at the time of my dad’s death and
in the weeks and months following. For instance, at my parents’
house after my dad’s funeral, one of my high school friends told a
story about how his girlfriend had recently “dropped him like a
rock.” The phrase probably is not very funny to read, but there was
something about his tone and facial expression that was extremely
funny—I’m sure that was the first time I had laughed in the several
days since my dad died. As another example, a few weeks after my
dad’s death, I went to dinner with a girl I had admired very much in
high school, but with whom I had lost touch. She was among the first
people I told about the exact details of my dad’s death, and her un-
derstanding and composure encouraged me to talk to others.
By contrast, my peers and professors in psychology—yes, psy-
chology of all things—struggled to get it right. A girlfriend seemed
more concerned about tainted DNA (“suicide’s genetic, right?”) than
about how I was coping. Peers and professors ignored my dad’s death
altogether. One professor, a psychoanalytically oriented clinical su-
Prologue: Losing My Dad ● 5
pervisor of mine, was particularly inept and seemed unable to say
anything at all in response to my dad’s suicide. He tried to hide his
inability behind a psychoanalytic stance of neutral silence, but never
was that charade more apparent and more pitiful. These people, I
think, needed to intellectually grasp suicide before they could do
anything else . . . and since they couldn’t grasp it intellectually—few
can—their otherwise good hearts were hampered. It is also possible
they were just too scared to deal with the topic. I hope this book frees
good hearts in those with a need for intellectual understanding and
steels those who need courage to help the bereaved.
Among my psychology peers and professors, there were people
who, like my Uncle Jim, just did what was right. A different psycho-
analytic supervisor was among the most understanding and helpful
of anyone I encountered in the difficult days and weeks following
my dad’s death. A week or two after my dad’s death, still another per-
son, my professor Jerry Metalsky, paused as we were working on a
manuscript, looked me in the eye, and said with real feeling, “I’m just
so sorry about what happened to your dad.” These simple words
choked me with tears at the time, and can still bring tears to my eyes
to this day.
One of my peers, Lee Goldfinch, found my parents’ phone number
in Atlanta and called me, as it turned out, on the day of my dad’s fu-
neral. This alone set him apart, but as we talked for a few minutes
about what happened and how my family and I were doing, Lee wept
in a very quiet and selfless way. That brief conversation with Lee rep-
resented one of the times in my life that I have felt most understood,
most listened to.
Some experiences within my family exacerbated the pain of my
dad’s death. Just as some of my psychology peers and professors
struggled for understanding and thus couldn’t quite hit the right
note, some in my family faced the same difficulty. For example, one
relative counseled another to tell others that my dad died from a
6 ● WHY PEOPLE DIE BY SUICIDE
heart attack. The instinct to lie about suicide is not rare. In one study,
44 percent of those bereaved by suicide had lied to some extent about
the cause of death, whereas none of those dying from accidents or
natural causes lied.1
Indeed, those who die by suicide will occasionally advise in suicide
notes that others lie about their deaths. Edwin Shneidman2 gave this
example: “Please take care of little Joe because I love him with all of
my heart. Please don’t tell him what happened. Tell him I went far
away and will come back one of these days. Tell him you don’t know
when.” This example shows why it is not rare and why it is under-
standable that people sometimes lie about suicide.
Lying about suicide is just one form of misunderstanding it. An-
other, more pernicious form is blame, and in this regard, my own ex-
periences were quite mild—I am aware of no one who blamed my
mother, my sisters, or me for my dad’s death. Unfortunately, others
are forced to go through this particular form of hell. In Shneidman’s
case example of Ariel, Ariel’s father had died by self-inflicted gunshot
wound in what was very likely a suicide (but there was some possibil-
ity of the death being an accident). Ariel wrote, “Well, my aunt . . .
told me that I had killed my father, and he had committed suicide
because of me.” Almost exactly three years after her father’s death,
Ariel herself nearly died by setting herself on fire.
Misunderstanding and even taboo about suicidal behavior are
rampant. Karl Menninger3 said, “So great is the taboo on suicide that
some people will not say the word.” The staff of the magazine that
promotes prominent research at my university wanted to run a story
on my suicide research. They pondered featuring the work on the
ma
gazine’s cover, but decided against it—they could not imagine
prominently displaying the word “suicide,” although they ran the ar-
ticle itself.
These same attitudes are common among family members of
those who engage in suicidal behavior. Decades ago, Menninger,4 in
Prologue: Losing My Dad ● 7
describing relatives’ reactions to the hospitalization of depressed and
potentially suicidal patients, commented, “Patients committed to our
care in the depth of a temporary depression in which they threatened
suicide would begin to improve, and relatives thereupon would seek
to remove them, utterly disregarding our warning that it was too
soon, that suicide was still a danger. Frequently they would ridicule
the idea that such a thing might be perpetrated by their relative.”
Menninger collected a large file of newspaper clippings reporting the
deaths by suicide of such patients.
I understand why people tiptoe around suicide or even lie about it
outright. This has never been clearer to me than when my oldest son,
Malachi (named after my dad’s ancestor who was the first in our
family to come to America), asked me why my dad was not alive. He
was three years old at the time. Luckily, I had anticipated this ques-
tion, but I thought I’d have another two or three years to think about
my answer. I took a deep breath and said something like, “Well, you
know how people can get sick, like when you have a cough or your
stomach hurts. People can get sick like that in their bodies, and they
can also get sick in their minds, sometimes very sick. My dad got very
sick like that in his mind; he got to where he was so sad and lonely
that he didn’t want to live anymore. When people feel like this for a
long time, they sometimes think about hurting themselves or even
killing themselves. That’s what my dad did.”
Malachi’s reaction was similar to the many times he had learned a
surprising fact about nature from me. With the same sense of inno-
cent surprise, not tinged much at all with negative emotion, he said,
“You mean he killed him self? ” much as if he were saying, “You mean there are fish that can taste things with their skin? ” (which there are and which we had just read about). I answered (to the first question),
“Yes, he did. That can happen sometimes when people feel so sick in
their minds.”
I was ready for fallout. For example, I imagined what I would say
8 ● WHY PEOPLE DIE BY SUICIDE