thoughts and behaviors become favored—whereas the mechanisms
in my view involve habituation, or getting used to the fear and pain
involved in self-injury. This in turn leads to an acquired ability for se-
rious suicidality, which, when combined with burdensomeness and
disconnection, produces high risk for suicide. These mechanisms are
not mutually exclusive and thus may operate jointly, incidentally. For
example, thoughts of burdensomeness and failed belongingness may
very well become sensitized in just the way Beck described.
My friend and colleague Roy Baumeister21 proposes an escape the-
ory of suicidal behavior that describes a sequence of steps leading up
to serious suicidal behavior. First, an individual experiences a nega-
tive and severe discrepancy between expectations and actual events.
For example, a businessperson may have imagined that a deal was
going to be extremely profitable, but it costs the business dearly. He
blames himself rather than chalking up the failure to bad luck or to
vacillations in the market. An aversive state of high self-awareness
develops, which produces negative affect. The businessperson be-
comes preoccupied by and often dwells on his personal inadequacies,
which leads to feelings of distress, sadness, and worry. He attempts to
escape from negative affect, as well as from the aversive self-aware-
ness and the discrepancy between expectation and outcome. This is
accomplished, according to Baumeister’s theory, by retreating into a
numb state of “cognitive deconstruction.” In this state, meaningful
thought about the self, including painful self-awareness and failed
standards, is replaced by a lower-level awareness of concrete sensa-
tions and movements, and of immediate, proximal goals and tasks.
The businessperson no longer thinks of the failed venture and its im-
plications for the future; rather, he focuses on the concrete task of
driving to the liquor store or watching television. An important con-
sequence of the state of cognitive deconstruction is reduced inhibi-
What We Know and Don’t Know about Suicide ● 41
tions, which contribute to lack of impulse control in general and lack
of impulse control for suicidal behavior in particular. The business-
person drinks a bottle of liquor and contemplates suicide.
Shneidman22 agrees that cognitive deconstruction is an important
sign of impending lethality, stating that “the most dangerous word in
all of suicidology is the four-letter word only. ” When people are in the lower-level state of focusing on the concrete, their ability to see
alternatives is compromised. When suicide is seen as the only option, that for Shneidman indicates increasing lethality and for Baumeister
is a sign that a state of cognitive deconstruction has developed.
There are compatibilities between Baumeister’s account and the
one developed in this book. For example, perceived burdensomeness
and failed belongingness can be seen as the results of disappointed
expectations; expectations that are internally attributed and thus as-
sociated with severe states of negative affect. The state of cognitive
deconstruction is not a part of the current model, but one could
imagine that perceived burdensomeness and failed belongingness are
painful enough to produce such a condition. To the degree that cog-
nitive deconstruction, perhaps facilitated by perception of burden-
someness and failed belongingness, produces disinhibition, it could
lead to repeated provocative experiences (including self-harm) and
thus could produce the processes emphasized here that lead up to the
acquired ability to enact lethal self-injury.
Marsha Linehan23 has theorized that biological deficits, exposure
to trauma, and the failure to acquire adaptive ways of tolerating and
handling negative emotion all contribute to suicidal behavior. Self-
injury, according to her view, is an attempt to regulate emotions—an
attempt that becomes necessary because more usual emotion regula-
tion mechanisms have broken down or never developed adequately.
Emotion dysregulation is a core problem in suicidal behavior, ac-
cording to this viewpoint. Parameters of emotional dysregulation
would include rapid onset, high intensity, and slow recovery, espe-
42 ● WHY PEOPLE DIE BY SUICIDE
proposed to lead to efforts to moderate the intense and painful feel-
ings, often through deliberate self-harm.
Based on this theoretical work, Linehan has developed a psycho-
therapy for suicidal behavior and for borderline personality disor-
der. The treatment is called Dialectical Behavior Therapy or DBT;
it includes an array of techniques geared toward changing self-
destructive ways of regulating emotion (cutting, for example) to
more constructive ways of regulating emotion (seeking counsel and
support from a trusted friend, for example). Linehan and colleagues
have conducted impressive studies supporting the treatment’s effec-
tiveness.
Emotional dysregulation can be viewed as a prime source leading
to the acquired capability to enact lethal self-injury. Those who
are dysregulated are likely to face an array of provocative situations
(e.g., physical altercations), many of them caused, at least in part, by
dysregulation itself. Moreover, the interpersonal strains associated
with emotional dysregulation are likely to contribute to feelings of
disconnection and ineffectiveness. The current framework and
Linehan’s model are thus quite compatible; she has identified pro-
cesses that can be viewed as relatively distal in the causal chain lead-
ing up to suicidal behavior; the processes, in turn, may lay the
groundwork for the relatively more proximal factors emphasized
here.
Though the theories of Durkheim, Shneidman, Beck, Baumeister,
and Linehan are the most prominent and influential explanations of
suicidal behavior, there are others that are of some interest. For ex-
ample, some have contended that economic theory can explain some
suicides. Changes in suicide rates vary detectably with changes in the
economy such that downturns are associated with higher rates, up-
turns with lower rates. However, this kind of theorizing essentially
reduces to sociological and psychological questions of why economic
What We Know and Don’t Know about Suicide ● 43
changes affect individuals in this way; the theorists summarized in
this chapter all have answers, as do I, which I describe in the chapters
that follow.
A more interesting and very provocative view was described by
Charles Duhigg in Slate Magazine on October 29, 2003. Duhigg sum-
marized the work of Dave Marcotte, a professor of public policy at
the University of Maryland, who analyzed the economic conse-
quences of attempted suicide. Marcotte’s premise is that those think-
ing of suicide face not two, but three alternatives—to not attempt, to
attempt but survive, and to attempt and die. Marcotte was particu-
larly interested in
those who attempt but survive, because this could
be an economically costly action (injury, medical bills, possibly per-
manent disability) but conceivably carries benefits too (increased ac-
cess to help and increased social support). Marcotte’s results indi-
cated that those who attempt suicide and survive subsequently see an
increase in income of around 20 percent as compared to those who
consider but do not attempt suicide. Among those who engage in
near-lethal attempts, the subsequent increase in income was over 35
percent.
How can this be? As Duhigg points out, attempted suicide is asso-
ciated with increased access to medical care and familial social sup-
port. He states, “Doubters may ask why the depressed don’t seek out
resources earlier. But studies have demonstrated that psychological
and familial resources become “cheaper” after a suicide attempt: It is
difficult to find free medical care when you are sad, but once you try
to kill yourself, it’s forced on you.”
The danger of viewpoints like this should be pointed out. Any
analysis that encourages suicidal behavior in any way—particularly
in ways that romanticize or glorify it, or make it seem easy and nor-
mative—has potential negative consequences for public health. Still,
an understanding of factors that promote suicidal behavior can steer
the way to interventions that prevent it. In this regard, a straightfor-
44 ● WHY PEOPLE DIE BY SUICIDE
ward conclusion of Marcotte’s economic analysis of attempted sui-
cide is that increased access to mental health care should lower the
rate of attempted suicide. Good mental health care will treat condi-
tions that lead to suicidal behavior but also, according to Marcotte’s
analysis, will remove the inducement of increased care that currently
is associated with suicidal behavior.
Though this is not a serious model of suicide, and there are those
who would question whether it is a serious model of anything, a cer-
tain set within the academic humanities—the deconstructionists, in-
fluenced by people like Jacques Derrida and Jacques Lacan—might
question whether all the pain and hopelessness associated with sui-
cide exist at all. Derrida is famous for the claim that “il n’y a pas de hors-texte” (there is nothing outside the text), and further, what is inside the text is, according to deconstructionists, but a heartless
concatenation of arbitrary linguistic codes. What is left for the de-
constructionist, then, is a constant questioning of the very existence
of reality and meaning—including the reality of emotional pain. Try
telling that to a suicidal person. In fact, David Kirby, an eminent poet
and Florida State University English professor, may have tried this as
a graduate student. He reports, “There was a bar . . . that served
twenty-cent highballs on Wednesday nights; penny-wise grad stu-
dents would moisten their clay there, shoulder to shoulder with the
more routine customers. Once I explained to a morose regular that
life was worth living, that even though his wife had left him and his kids had turned out to be disappointments and he’d just been laid off
from his job, none of that mattered because the human mind was, so,
uh, mental.”24 The regular appeared not to have been consoled, and
interestingly, at least as far as I can tell, Kirby did not grow up to be a deconstructionist.
In the time it takes to read this chapter, one or two people in the
United States have died by suicide, and many more have died world-
What We Know and Don’t Know about Suicide ● 45
wide. Just now, family members, police, or paramedics are discover-
ing their bodies. Their loved ones are embarking on an intensely
painful journey that involves not only sudden loss, but the poten-
tial for misunderstanding and confusion. I know about this journey
from every possible angle—I lived it myself; I have seen it in patients
and others; and I have studied it scientifically. I’ve told my sons why
they don’t have a grandfather, and I’ve told professional audiences
why and how serotonin-system genes may be involved in suicide.
People who have lost a loved one to suicide often bond together in
support groups—in fact, this is a healthy form of assortative relating
(in contrast to pernicious forms discussed earlier in this chapter).
These groups do a world of good for people. In some of these circles,
there occasionally arises a feeling that people who have not lost a
loved one to suicide could not possibly understand it. I sympathize
with this view, mainly because of the confusion and misunderstand-
ings that can complicate death by suicide, but ultimately, I don’t
share this sentiment. Given the right framework, anyone can under-
stand—indeed, everyone needs to understand if real progress on sui-
cide is to occur. By the same token, there is a feeling in some scien-
tific circles that nonscientists cannot possibly understand suicide in
any fundamental way because it is so complex, with factors ranging
from the molecular to the cultural levels. Here too, I sympathize but
disagree. A full account of suicide will no doubt be complex, but a
main point of science is to render the complex accessible.
THE ABILIT Y
TO ENACT
LETHAL SELF-INJURY
IS ACQUIRED
2
Existing theories of suicide illuminate some important facts and
concepts, but they also leave key questions unanswered. If emotional
pain, hopelessness, emotional dysregulation, or any variable is cru-
cial in suicide, how then to explain the fact that most people with any
one of these variables do not die by or even attempt suicide? How do
we make sense of the anecdotal and clinical evidence suggesting that
there are people who genuinely desire suicide but do not feel able to
carry through with it? What are the ingredients for the genuine de-
sire for suicide?
The ability to enact lethal self-injury is acquired through particu-
lar kinds of experience that I will describe in this chapter (genetics
and neurobiology are also important). Though the fact has been ne-
glected by theorists and researchers, those who repeatedly attempt
suicide emphasize how very difficult it is. On reflection, this is as it
should be—of course it is difficult to overcome the most basic in-
stinct of all; namely, self-preservation. How do people do it? This
chapter will show that it is no easy matter, and that it is impossible to
do without previous experiences that allay the fear of self-injury, in-
46
The Ability to Enact Lethal Self-Injury Is Acquired ● 47
ure people from the pain of self-injury, and build knowledge that fa-
cilitates self-injury.
According to the overall explanation of suicide presented in this
book, the acquired capability to engage in serious self-injury is but
one precursor to attempted suicide or death by suicide. There are
many people who, through an array of provocative experiences, have
become fearless, pain-tolerant, and knowledgeable about dangerous
beh
aviors, and yet who have no desire whatsoever to hurt themselves.
Those who do have the desire, coupled with the ability, are viewed as
at high risk for serious suicidal behavior. Chapter 3 explores the con-
stituents of the genuine desire for death. Drawing on diverse litera-
tures, the case is made that people desire death when two fundamen-
tal needs are frustrated to the point of extinction; namely, the need
to belong with or connect to others, and the need to feel effective
with or to influence others. When both these needs are snuffed out,
suicide becomes attractive but not accessible without the ability for
self-harm.
Working Up to the Act of Suicide
On February 1, 2003, the space shuttle Columbia disintegrated as it flew over the western United States, finally showering down over East
Texas and Louisiana in thousands of pieces. All seven crew members
were killed. The cause was a dense, dry, brownish-orange piece of
foam weighing about 1.7 pounds, 19 inches long and 11 inches wide.
The foam, traveling 545 miles per hour, hit Columbia’s left wing,
causing what investigators now know was a significant breach.
Foam strikes had happened before. For example, Atlantis was hit in 1988, causing such damage that an astronaut said “the belly looked
as if it had been blasted with shotgun fire.” William Langewiesche, in
the November 2003 issue of Atlantic Monthly, wrote, “Over the years foam strikes had come to be seen within NASA as . . . a problem so
48 ● WHY PEOPLE DIE BY SUICIDE
familiar that even the most serious episodes seemed unthreatening
and mundane.”1 One of the members of the panel investigating the
accident said, “The excitement that only exists when there is danger
was kind of gone—even though the danger was not gone.” Foam
strikes were routinely designated by NASA officials as “in-flight
anomalies,” but even this weak designation was removed in Octo-
ber 2002, just months before Columbia’s doomed mission. Key NASA
administrators decided against getting in-flight satellite images of
Columbia’s left wing, in part because their sense of danger about
foam strikes had eroded over the years due to repeated experience
with them.
What does this have to do with suicide? A key point of this book
is that when people get used to dangerous behavior—when they lose