The “resolved plans and preparations” category was made up of
the following symptoms: a sense of courage to make an attempt; a
sense of competence to make an attempt; availability of means to and
opportunity for attempt; specificity of plan for attempt; prepara-
tions for attempt; duration of suicidal ideation; and intensity of sui-
cidal ideation. It is worth noticing that this category explicitly in-
cludes indicators emphasizing courage and competence regarding
The Ability to Enact Lethal Self-Injury Is Acquired ● 79
suicide, which, according to the view proposed here, are reflective of
the acquired ability to enact lethal self-injury.
The “suicidal desire and ideation” category was comprised of the
following symptoms: reasons for living; wish to die; frequency of
ideation; wish not to live; passive attempt; desire for attempt; and
talk of death/suicide. This factor does not include content related to
courage, competence, and the like, but rather, emphasizes thwarted
desire to live and reasons for death. In the next chapter, it will be ar-
gued that thwarted desire to live can be understood in terms of feel-
ing a burden on and disconnected from others. Thwarted desire to
live is of course important in suicidality, but in an important sense, it
is less clinically worrisome than the “resolved plans” category.
Although the presence of symptoms corresponding to either cate-
gory is of clinical concern, the symptoms of “resolved plans and
preparations” are, relatively speaking, of more concern than the symp-
toms of “suicidal desire and ideation.” And crucial to the predic-
tion that serious suicidal symptoms should become more and more
prominent with repeated suicidal experience, “resolved plans and
preparations” was significantly more related than “suicidal desire and
ideation” to status as a multiple suicide attempter.68
A subsequent study reached similar conclusions regarding attempt
status as well as eventual death by completed suicide. Specifically, my
colleagues and I studied several hundred current suicide ideators,
who were evaluated regarding their “worst-point” suicidal crisis, and
then who were followed for many years.69 The “worst-point” was de-
fined as a past suicidal crisis that was the most severe in the respon-
dent’s life. In this study, as in the earlier reports, the distinction be-
tween “resolved plans and preparations” (which includes courage
and competence regarding suicide) and “desire for death” (the less
serious dimension) was emphasized, in that respondents rated their
“resolved plans” and their “desire for death” with regard to their
worst-point crisis.
80 ● WHY PEOPLE DIE BY SUICIDE
According to the model proposed in this book, people who have
experienced severe episodes of suicidality in the past (particularly
if the episode involved loss of fear and other “resolved plans and
preparations” phenomena) may be most at risk for severe suicidality
in the future, and possibly even death by suicide. Our results con-
formed to this view: The “worst-point resolved plans and prepara-
tions” symptoms were the strongest predictor of suicide attempts
during the follow-up period, and the only significant predictor of eventual death by suicide in the sample; the “suicidal desire and
ideation” symptoms were not associated with later death by suicide.
Consistent with these findings, a separate eighteen-year follow-up
study found that planfulness regarding episodes of deliberate self-harm represented a significant risk factor for later completed sui-
cide.70 Planfulness requires competence, which in my model is a key
aspect of the acquired capability for lethal self-injury.
That fearlessness and accrued courage and competence regarding
suicide—key indicators of the “resolved plans and preparations” fac-
tor—are implicated in severe suicidality is a central assertion of the
present theory. In this connection, it is of interest to recall the four-
teen-year prospective study of several hundred mood-disordered pa-
tients mentioned earlier.71 Assertiveness was found to be a predictor
of severe suicidality during the fourteen-year follow-up period. My
model is perhaps the only theory of suicide that is compatible with a
relation between assertiveness and suicidality.
suicide as well as those who attempted and survived72 using a soft-
ware program called Linguistic Inquiry and Word Count (LIWC).73
The program divides text into its components—for example, ten-
dency to use action verbs, words denoting negative emotion, and so
on. Among the clearest variables that differentiated notes by those
who died by suicide from notes by those who attempted suicide and
survived were indices related to assertiveness, specifically anger com-
The Ability to Enact Lethal Self-Injury Is Acquired ● 81
bined with confidence. The combination of anger and confidence
bears some similarity to the combination of courage and resolution
of ambivalence regarding suicide.
Another aspect of the “resolved plans and preparations” category
should be noted. In addition to indicators related to courage and
competence regarding suicide, the factor also involved intense, vivid,
and long-lasting ideation about one’s death by suicide. People who
experience this say that they can see their death by suicide very
clearly in their mind’s eye—it is as if they are watching a clear and
vivid video of their own death by suicide. In this context, it is an
interesting possibility that courage and competence regarding sui-
cide may develop mentally as well as behaviorally. That is, vivid and
long-lasting preoccupation regarding one’s suicide may represent a
form of mental practice. To the extent that one rehearses for suicide,
whether actually or mentally, suicide potential is increased. The con-
cept of mental rehearsal may be helpful in understanding those who
die by suicide on their first attempt—studies have found rates of
first-attempt completed suicide as high as 50 percent.74 Mental prac-
tice may facilitate suicide completion among those attempting it for
the first time.
Shneidman’s case example of Beatrice illustrates this aspect of
mental practice. She says, “For the next two years . . . every night, be-
fore fading off to sleep, I imagined committing suicide. I became ob-
sessed with death. I rehearsed my own funeral over and over, adding
careful details each time.”75 Beatrice later planned her suicide for
three months, and tried to die by self-cutting; she survived.
In 1992 and 1993, musician Kurt Cobain obsessively watched a
videotape of the suicide of R. Budd Dwyer, a Pennsylvania state of-
ficial who died at a live press conference (that Dwyer himself had
called) by putting a gun in his mouth and firing.76 This may have
represented a form of mental practice for Cobain’s 1994 death by a
similar method.
82 ● WHY PEOPLE DIE BY SUICIDE
David Reimer, mentioned earlier and described in the book As
Nature Made Him: The Boy Who Was Raised as a Girl, said that in
eighth grade, when he was living as a girl, he “kept visualizing a rope
thrown over a beam.”77 He would have continued experience with
suicidality as well as numerous other provocative experiences, and at
age thirty-eight, died by suicide.
A study of over 3,000 patients at risk for suicide, thirty-eight of
whom subsequently died by suicide, provides some indirect evidence
regarding mental practice.78 Of the factors that predicted death by
suicide, an important one was “contemplation of hanging or jump-
ing.” Through mental rehearsal of violent death by suicide, these
patients may have acquired more of the ability to enact lethal self-
injury.
Also relevant here is the concept of aborted suicide attempts, de-
fined as an event in which an individual comes close to attempting
suicide but does not do so and thus sustains no injury. Barber and
colleagues interviewed 135 psychiatric inpatients, and over half re-
ported at least one aborted suicide attempt.79 Intent-to-die ratings
for aborted suicide attempts were similar to those for actual suicide
attempts, indicating that aborted attempts can have severe quali-
ties—qualities that could potentially produce habituation and prac-
tice effects. Moreover, patients who reported aborted attempts were
nearly twice as likely to have made an actual suicide attempt as pa-
tients with no aborted attempts. Practice regarding suicide may oc-
cur in the absence of actual suicidal behavior, either through mental
rehearsal or through aborted suicide attempts.
One additional reason to worry about the accrual of courage
about suicide relates to the concept of cognitive sensitization. Cog-
nitive sensitization occurs when one undergoes a provocative experi-
ence, and subsequently, images and thoughts about that experience
become more accessible and easily triggered. As applied to suicid-
ality, as suicidal experience accumulates, suicide-related cognitions
The Ability to Enact Lethal Self-Injury Is Acquired ● 83
and behaviors may become more accessible and active.80 The more
accessible and active these thoughts and behaviors become, the more
easily they are triggered (e.g., even in the absence of negative events),
and the more severe are the subsequent suicidal episodes. My col-
leagues and I have documented that, in fact, as episodes of suicidality
increase, their relation to external triggers decreases, and their sever-
ity increases.81
Vicarious Habituation: The Example of Guns in the Home
As the example of aborted suicide attempts shows, there are multiple
ways that people may habituate to dangerous stimuli. One way is
through habituating to danger by observing someone else do so, or
by repeatedly being exposed to cues associated with danger. The ex-
ample of Kurt Cobain’s obsessively watching a videotaped suicide
was mentioned earlier, as was his gradually increasing interest in
guns. Guns in the home are an issue in this regard.
First, let me disclose that I am not a huge fan of guns—I don’t
own one myself—but neither do I have strong feelings against gun
ownership. Regardless of one’s viewpoint on this topic, there ap-
pears to be an undeniable association between the presence of guns
in a home and suicides occurring in that home. For example, a study
across twenty-one countries documented this association very
clearly.82 In twelve countries, another study found that the percent-
age of households with guns was strongly associated with the over-
all mortality rate from guns in children aged 0–15 years, including
death by suicide.83 An association does not prove a causal connection
between presence of guns and suicide, but the association is consis-
tent with the possibility that having guns around acquaints people—
renders them fearless—about a potentially lethal stimulus.
Brent and colleagues did an interesting study on whether families
with a depressed adolescent follow recommendations to remove
guns from the house. Of families advised to remove firearms from
84 ● WHY PEOPLE DIE BY SUICIDE
their homes, 26.9 percent did so. Interestingly, the decision to keep
a gun, even when advised not to, was associated with the father’s
psychopathology as well as marital dissatisfaction.84
Repetition May Reinforce Suicidal Behavior
The singer Pink, who has numerous body piercings and tattoos, said
in the December 2003 issue of Jane magazine, “I took out my tongue ring when I was 21 and regretted it a week later. I like putting holes in
my body. It’s addictive, it’s pain to know you’re alive.”85 The evidence
summarized so far suggests that habituation and practice effects may
be implicated in the escalating trajectory toward serious suicidality.
In addition to habituation and practice, the theory put forth here
suggests that repeated suicidality may engage opponent processes,
such that not only do people habituate to self-injury, they also come
to experience it as increasingly rewarding, similar to the way Pink re-
ported that “putting holes” in her body is addictive.
Many people appear to share Pink’s perspective. There is clear and
consistent evidence that a primary motive for self-injury is relief,
and that people find self-injury rewarding, at least in the immediate
period following the incident. This may seem hard to imagine, but
recall the example of skydiving. In a way, flinging yourself out of
an airplane makes no more sense than cutting the side of your arm—
indeed skydiving deaths occur every year. Why do people do this,
then? The first time they skydive, they feel some of the thrill and
exhilaration of it, and a large dose of the fear of it. But as they
keep doing it, encouraged by the thrill and exhilaration, the pri-
mary process of fear fades, and the opponent process of exhilaration
strengthens.
So it goes with self-injury. As people continue to do it, the primary
process of pain fades, and the opponent process amplifies. What is
the opponent process? As noted earlier, according to patients who
self-harm, it is relief because it distracts from even deeper emotional
The Ability to Enact Lethal Self-Injury Is Acquired ● 85
pain, or because it makes them feel alive, or because it brings their
inner world back into harmony with the world at large.
Several studies support this idea.86 These findings appear to impli-
cate what is called negative reinforcement (i.e., the self-injury is rein-
forcing because it stops or reduces noxious experiences). However,
positive reinforcement (i.e., the self-injury is reinforcing because it
induces positive feelings) may be operative as well—for example, in a
study of female psychiatric inpatients with borderline personality
disorder (a main feature of which is repeated self-harm), patients
rated various dimensions of their self-injury experiences. Results re-
vealed significant mood elevation
as a consequence of self-injury
among these patients.87 Many patients report that although negative
reinforcement (i.e., relief) is a primary motive for self-injury,88 other
motives exist, including positive reinforcers such as fascination with
the injury and reaffirming the ability to feel89—or, in Pink’s words,
“pain to know you’re alive.”
To my knowledge, however, only one study has directly evaluated
whether the rewarding properties of self-injury increase with repeti-
tion. Participants who frequently engaged in self-injury were com-
pared to those who infrequently did so, with regard to responses
to a self-mutilation imagery task. In response to the imagery task,
those in the frequent self-injury group reported more relief and
more reductions in anxiety and sadness as compared to the infre-
quent group.90 As people continue to engage in self-injury (or un-
dergo other provocative experiences), they change. Self-injury loses
its painful and fear-inducing properties and may even begin to gain
rewarding properties. As this occurs, the main barrier to suicide
erodes.
The Psychological Merging of Death and Life
To this point, the argument has been made that those prone to seri-
ous suicidal behavior have reached that status through a process of
86 ● WHY PEOPLE DIE BY SUICIDE
exposure to self-injury and other provocative experiences. As this
process unfolds, fear of death and pain on self-injury decreases. As
reviewed above, certain scientific facts seem to support this view.
Little has been said so far about how potentially suicidal people
view death (except that they come not to fear it). When someone is
far along the trajectory toward suicide, when they have acquired the
ability to enact lethal self-injury, what is their view of death? Though
there are very few scientific data on this point, anecdotal and case
summary data suggest that people who are near death by suicide
view death in a very peculiar way—namely, that death is somehow
life-giving.
For most people, the notion that death is life-giving or nurturing
is not only irrational but very disturbing. Suicidal people appear to
see it differently, however. For example, in Shneidman’s case study of
Ariel, she stated, “We were in this old cemetery, and what was inter-
esting and unique about this cemetery is that it is very old and the