bipolar disorder; and scores on indices of depression, hopelessness,
problem-solving difficulties, borderline personality symptoms, drug
dependence symptoms, alcohol dependence symptoms, and nega-
tive life events. Each of these variables has a resilient association with
suicidal symptoms, and to account for all of them simultaneously
would make it difficult for the association between past and future
suicidality to remain.
Nevertheless, across all four studies, the relation of past to future
suicidality persisted, even when this impressive list of suicide-related
variables was statistically accounted for. Essentially, this rules out the
possibility that repeated suicidal behavior simply occurs because of
an ongoing mental disorder. Rather, according to my view, it occurs
64 ● WHY PEOPLE DIE BY SUICIDE
because one instance of suicidal behavior lays the groundwork for
later instances, and it does so specifically through the accrual of fear-
lessness and competence.
In this “kitchen sink” study, we also tried to determine if any other
variable besides past suicidality displayed this resilient relation to
current suicidality. To do this, we conducted comparison analyses in
which, for example, we examined the association between current di-
agnosis of major depression and current suicidal symptoms, and
then examined this same association accounting for the list of other
key variables, now including past suicidality. In no case did any other
variable besides past suicidality display a resilient relation to current
suicidality. The bottom line was that there is something special about
the relation of past to future suicidality—it is hard to explain it away.
And I believe that something special has to do with the escalating
trajectory of lethality fuelled by habituation and opponent processes.
Incidentally, another aspect of this paper was that the four studies
involved diverse participants: young adults in the United States with
clinical levels of suicidality, U.S. undergraduates, mood-disordered
Brazilian outpatients, and an older adult psychiatric inpatient sam-
ple from the United States. Conclusions from the study are strength-
ened by the convergence of results across multiple and diverse sam-
ples.31
Another of our studies involved a similar approach, but focused
especially on childhood physical and sexual abuse. The framework
developed in this book is that repeated painful experience may lay
down the ability to enact future lethal self-injury; childhood physi-
cal and sexual abuse may constitute pathways by which this occurs.
Again, the most direct pathway from past provocative experience to
current suicidality is past self-injury. Less direct ways to habituate to
pain and provocation and thus to potentially acquire the capability
for serious self-injury include involvement in violence, either as per-
petrator or victim. It is in this last connection that childhood sexual
The Ability to Enact Lethal Self-Injury Is Acquired ● 65
and physical abuse may serve as a means to habituate to pain and in-
jury and thus to facilitate later self-injury.
Childhood physical abuse and certain forms of childhood sexual
abuse may be more closely linked to acquisition of lethality than
other forms of abuse (i.e., neglect or verbal abuse) because they are,
on average, more physically painful than the other forms of abuse.
Painful forms of childhood sexual abuse are more associated with
suicidality than less painful forms.32 On the other hand, as will be
made clear in the next chapter, the desire for death is also very im-
portant in serious suicidal behavior. I believe that the desire for death
stems from feeling a burden on loved ones and others, and feel-
ing disconnected and alienated from others. To the degree that any
form of abuse facilitates either lethality (through habituation to pain
and provocation) or desire for death (through increased feelings
of burdensomeness or disconnection), it should, according to the
model, constitute a risk for later suicidal behavior. Childhood physi-
cal and sexual abuse may particularly confer risk because they are
both painful and imply burdensomeness and disconnection.
Our study analyzed data collected in the National Comorbidity
Survey, which was a large project on the occurrence of mental disor-
ders and associated variables in U.S. adults. As part of the survey,
data were collected on childhood experiences of various forms of
abuse and on suicidal behavior. Our analyses showed that some
forms of abuse were more linked to subsequent suicidality than were
other forms; specifically, the effects for childhood physical abuse and
sexual abuse on later suicidal behavior were relatively pronounced
and similar to one another, and exceeded effects for molestation and
verbal abuse. Other researchers have reported similar findings. For
example, in a representative study, researchers interviewed over 3,000
female adolescent twins and found that childhood physical abuse
was one of the factors most associated with a suicide attempt his-
tory.33
66 ● WHY PEOPLE DIE BY SUICIDE
A link between abuse and suicidality is consistent with many pos-
sible explanations. For example, genetically transmitted personality
traits (like impulsivity) or disorders (like personality disorders) could
simultaneously explain a parent’s abusive behavior and a child’s sub-
sequent suicidal behavior, with no need to invoke a contributory link
between abuse and suicidality. However, judicious choice of which
other variables to account for can, at least to a degree, rule out many
explanations. For example, an association between abuse and sui-
cidality accounting for a parent’s impulsivity or personality disorder
would, to a degree, rule out the explanation that both parental abuse
and child suicidality are a result of shared impulsivity or personality
symptoms.
In fact, that is exactly the approach we took. Specifically, we statis-
tically accounted for such variables as the respondent’s mental disor-
ders, the respondent’s parents’ mental disorders, and family-of-ori-
gin variables like divorce and poverty. Even after accounting for all of
these variables, there was an association between childhood sexual
and physical abuse and later suicidality. Viewed within this book’s
framework, the reason for this association is that abuse habituates
people to pain and provocation and thus lowers their resistance to
self-injury; abuse also sends messages regarding low self-worth and
alienation from others, which, as will be argued in Chapter 3, can fa-
cilitate the desire for death.
The studies on those who attempt suicide multiple times and on
the vigorous association between past and future suicidality (even
accounting for “kitchen sink” variables) are consistent with the view
that people habituate to self-injury and thereby gain the ability to en-
act increasingly severe suicidal behaviors. As a complement to these
studies, it would be persuasive if it could be shown that the more
people attempt suicide, the more dangerous and the more intent on
dying they become. In fact, increasing lethality and intent in those
with past suicidal behavior have been documented in several studies.
The Ability to Enact Lethal Self-Injury Is Acquired ● 67
For example, in one study, fifty adults were interviewed the morn-
ing following a self-harm incident. Some of the patients had harmed
themselves numerous times before; for some patients this was their
first self-harm incident. These researchers compared those whose
self-injury was their first to those who had harmed themselves be-
fore. Those who had engaged in repeated self-injury reported that
their current episode of self-harm was more aggressive and poten-
tially more lethal than first-time self-injury patients; moreover, pa-
tients in the repeat group showed more intent to die than did the
first-time group.34 A similar study assessed 500 patients after an epi-
sode of self-injury. Just after the incident, the patients completed a
measure evaluating their intent to die during the self-harm inci-
dent. The patients were then followed for five years. Those patients
with high scores on the baseline intent-to-die measurement were the
most likely to die by suicide during the five-year follow-up interval.35
Studies like this square with the view that some people get on an es-
calating trajectory toward serious suicidal behavior, and that past
self-injury, as well as other painful and provocative experiences, can
accelerate movement along this trajectory.
Paul H. Soloff and colleagues conducted a similar study assessing
the effect of previous suicidal behavior on the extent of medical
damage from a person’s most serious suicide attempt. These re-
searchers examined patients with major depression alone, border-
line personality disorder alone, or both disorders. In this study, the
number of previous suicide attempts was a strong predictor of the
extent of medical damage resulting from the most serious lifetime
suicide attempt.36 This is consistent with the view that experience
with suicidality—or other provocative and painful experiences—is
necessary before people can inflict serious physical damage on them-
selves. Overall, this pattern of findings suggests that escalating sever-
ity of suicidality is furthered by earlier episodes of self-injury.
In summary, those who attempt suicide multiple times experience
68 ● WHY PEOPLE DIE BY SUICIDE
more severe suicidal symptoms, including more medically damaging
self-injury and higher rates of eventual death by suicide. Many of the
reviewed studies documented an association between past and sub-
sequent suicidal behavior, even accounting for other powerful vari-
ables like presence of mental disorders generally or mood disorders
in particular. It is therefore unlikely that this association can be fully
explained with reference to aspects of mental disorders like hopeless-
ness, mental pain, and impaired coping. Rather, there appears to be
a meaningful and fundamental relation between past and future
suicidality, and according to the present view, this relationship in-
volves habituation and opponent processes. Multiple suicide at-
tempts are viewed here as the most important (but not the only) way
that, through habituation and opponent processes, people acquire
the ability to enact lethal self-injury.
Pain, Injury, and Suicide
As has been mentioned previously, past self-injury is the most pow-
erful and dangerous way to acquire lethality. According to the pres-
ent theory, however, it is not the only means. There should be high
rates of suicidality in people who have repeatedly experienced and
thus habituated to injury and pain, even if not through self-harm
per se.
If an association of this sort were clear, it would support the the-
ory, but only somewhat. Other explanations may also adequately de-
scribe the relation between repeated exposure to pain and suicidality.
Studies relevant to my theory of lethality will be reviewed first, and
then studies that address some competing explanations will be noted
too. Partly because of the abundance of competing explanations, this
material is among the most speculative included in this chapter.
The famous philosopher of science Sir Karl Popper wrote in his
1959 Logic of Scientific Discovery, “We usually accord to the first corroborating instances far greater importance than to later ones: once a
The Ability to Enact Lethal Self-Injury Is Acquired ● 69
theory is well corroborated, further instances raise its degree of cor-
roboration only very little. This rule however does not hold good
if these new instances are very different from the earlier ones, that
is if they corroborate the theory in a new field of application.”37 My
theory of suicidal behavior has, so far, been consistent with emerg-
ing facts. For example, because those who regularly tattoo or pierce
themselves have numerous chances to habituate to pain, I would pre-
dict an association between tattooing and piercing and suicidal be-
havior. In a study comparing people who died by suicide to people
who died in accidents (matched for gender, race, and age), those who
died by suicide were more likely to have tattoos.38 There are many
suicide (for example, both tattooing and suicide may be associated
with substance abuse). It is an intriguing if speculative interpreta-
tion, however, that eventual suicide victims have obtained courage
regarding suicide partly via painful and provocative experiences such
as tattooing.
Menninger mentioned another possible way to habituate to pain
and provocative experiences, namely, compulsive submission to mul-
tiple surgeries.39 And, in fact, women who engage in repeated self-
injury have more surgeries than controls.40 Patients with Body
Dysmorphic Disorder (a condition characterized by obsessions with
one’s imagined ugliness) have both high rates of surgery (usually
cosmetic surgery to correct imagined defects) and high rates of
suicidality.41
On June 14, 2004, the Associated Press filed a report entitled,
“Doctors Remove Rods From Man’s Stomach.” On a bet from his
drinking buddies, Huynh Ngoc Son, twenty-two, swallowed three
metal construction rods, each around seven inches long. About a
month later, Son went to the hospital complaining of serious stom-
ach pains, and doctors quickly saw the problem in X-rays of his
stomach. Surgeons removed the rods, and apparently Son is doing
70 ● WHY PEOPLE DIE BY SUICIDE
well, with no permanent damage to his stomach. It is experiences like
these that lay down the ability to enact lethal self-injury. Should Son
develop the desire for suicide, he would likely be at high risk, because
he has developed the ability to do extreme things to his body.
David Reimer, described in John Colapinto’s 2000 book As Nature
Made Him: The Boy Who Was Raised as a Girl, died by suicide at the age of thirty-eight. Reimer, born a boy, was badly injured as a baby in
a botched circumcision. He was raised as a girl thereafter, including
estrogen treatments that induced breast growth, though this identity
clearly did not suit him. Bravely, he insisted that he revert to his true
identity in adolescence, and this meant numerous painful surgeries.
As Colapinto states, David “underwent a double mastectomy, an in-
tensely painful procedure that left him in agony for weeks after-
ward.”42 Later, he underwent a procedure to construct a penis from
muscles and skin from the inside of his thighs; during the following
year, he was hospitalized eighteen times for blockages and infections
associated with this procedure. Soon after this, he attempted sui-
cide twice within one week, both times involving an overdose of his
mother’s antidepressant medicines. A second procedure to improve
the earlier surgery to create a penis was a twelve-stage operation that
took three surgeons thirteen hours to perform. Apart from these
painful experiences, Reimer’s most satisfying job was in a slaughter-
house. These and many other painful and provocative experiences
may have facilitated Reimer’s later suicide.
Based on the perspective proposed here, one would predict that
those prone to suicide have witnessed, experienced, or engaged in
more violence than others, because violence exposure would be one
way to habituate—either directly or vicariously—to pain and provo-
cation. Research has borne out this prediction. A representative study
compared fifty persons attempting suicide with fifty nonsuicidal psy-
chiatric patients and with fifty nonpsychiatric control patients at-
tending a heart clinic (here, as in so many of these studies, groups
The Ability to Enact Lethal Self-Injury Is Acquired ● 71
were matched for age, sex, and social class). Suicidal patients had ex-
perienced an array of violent episodes to a significantly higher degree
than either control group.43 Conner and colleagues surveyed next-of-
kin and other respondents close to people who had died in the last
year (by suicide and by other means). Respondents indicated that
those who had died by suicide more frequently threatened and at-
tempted violence in the last year, as compared to accident victim