Myths About Suicide
Thomas Joiner, Ph.D.
The Robert O. Lawton Distinguished
Professor of Psychology
Department of Psychology
Florida State University
joiner@psy.fsu.edu
Suicide may just be the most
stigmatized of human
activities – it is even more
stigmatized than appalling
things like slavery and murder
– and therefore a powerful
mythology has arisen around
it.
The stigma can be
seen in many ways:
Bereaved
experience a change
in their address
books, as people
they thought they
could count on
avoid them.
So let’s just do away with
stigma, right?
Not only is it not easy, but
stigma = fear + ignorance
Some things in nature should be feared,
do deserve a healthy dose of respect
Fears are wired into us, and this wiring
can be sensitive
Moreover, the lack of fear
characterizes some of our most
deranged and dangerous
individuals.
Further still, in my book Why
People Die By Suicide, I argued
that the loss of fear – at least of
physical pain, physical injury,
and death – removes a barrier to
suicide, and is therefore
dangerous.
Cobain was temperamentally
fearful – afraid of needles, afraid of
heights, and, crucially, afraid of
guns. Through repeated exposure,
a person initially afraid of needles,
heights, and guns later became a
daily self-injecting drug user,
someone who climbed and dangled
from 30 foot scaling during
concerts, and someone who
enjoyed shooting guns.
Regarding guns, Cobain initially felt
that they were barbaric and wanted
nothing to do with them; later he
agreed to go with his friend to shoot
guns but would not get out of the car;
on later excursions, he got out of the
car but would not touch the guns; and
on still later trips, he agreed to let his
friend show him how to aim and fire.
He died by self-inflicted gunshot
wound in 1994 at the age of 27.
Mental disorders,
which spur death by
suicide, are forces
of nature, and thus
deserve our respect
and even fear (but
not our
resignation).
Let’s Leave Fear Be
Stigma = fear + ignorance
Decreasing Ignorance via
Dismantling of Myths
Many myths about suicide
are so ingrained that we may
not be able to reduce
ignorance until we undo these
myths.
Categories of Myths
Myths about the suicidal mind
Myths about suicidal behavior
Myths about the nature of
suicide
Myths About the Suicidal Mind
MYTH: Suicide is primarily about
– Cowardice – MYTH!!!
– Weakness – MYTH!!!
– Revenge – MYTH!!!
– Selfishness – MYTH!!!
– Self-Control – MYTH!!!
– Impulsivity – MYTH!!!
Myths About Suicidal Behavior
MYTH: Suicide is primarily
characterized by
– Note leaving – MYTH!!!
– “Slow” forms of suicide (e.g., smoking) –
MYTH!!!
– “Rational” suicide – MYTH!!!
– A cry for help – MYTH!!!
– Complete resolve and intent to die –
MYTH!!!
Myths About the Nature of Suicide
MYTH: Suicide is
– Limited to humans – MYTH!!!
– Not seen in young children – MYTH!!!
– Caused by things like breast
augmentation – MYTH!!!
– More common in winter – MYTH!!!
Myths About the Suicidal Mind
MYTH: Suicide is primarily about
– Cowardice – MYTH!!!
– Weakness – MYTH!!!
– Revenge – MYTH!!!
– Selfishness – MYTH!!!
– Self-Control – MYTH!!!
– Impulsivity – MYTH!!!
Sketch of the Theory
Those Who
Desire Suicide
Perceived
Burdensomeness
Those Who Are
Capable of Suicide
Thwarted
Belongingness
Serious Attempt or Death by Suicide
Suicide Requires Fearlessness;
Cowardice Will Prevent It
Death by any means – including
suicide – is fearsome and daunting.
We are self-preserving creatures, wired
in our cells and souls to fear death.
Even intently and deeply suicidal
people are subject to this fear, as we
will see.
Suicide Requires Fearlessness;
Cowardice Will Prevent It
The fearlessness is specifically
about physical pain, physical
injury, and death, and this
fearlessness is distinct from
concepts like courage, bravery,
and heroism.
Why I Jumped by Tina Zahn
In the midst of a recurrent, very severe
(at times near-catatonic) postpartum
depression, Zahn decided to jump off a
bridge near Green Bay, Wisconsin.
She fled relatives in her car, who called
police. Police clocked her at 120 mph.
Still, she is ambivalent, some signs of
which show up in the following video.
The Documentary The Bridge
Photographer saves
someone who is pondering
jumping from the Golden
Gate Bridge.
Here too, behavioral
indicators of ambivalence.
Incident at Train Tracks
Person balks at the last
moment, thus saving her
life.
Meriwether Lewis (of Lewis &
Clark fame)
From Stephen Ambrose’s biography of
Lewis, Undaunted Courage:
– Lewis paced for several hours (agitation), as
others could hear him all night as the floorboards
creaked.
– Two self-inflicted gunshot wounds, neither fatal.
– Servants found him “busily cutting himself from
head to foot.”
– Lewis said to servants, “I am no coward, but I am
strong, it is so hard to die.” He died a few hours
later.
Hesitation Wounds
What are they?
Virtually everyone who dies by self-
inflicted knife wound has hesitation
wounds around the site of the lethal
injury.
Why do even intently suicidal people
hesitate (and some are saved during
hesitation)? They hesitate because
they feel fear.
Suicide in Anorexia Nervosa
Mortality is extremely high in anorexic
women (SMR = ~60).
It is an under-appreciated fact that,
should an anorexic patient die
prematurely, the cause of death is more
likely to be suicide than complications
arising from compromised nutritional
status.
Suicide in Anorexia Nervosa
There are at least two possible
accounts of the high association
between AN and suicide. In one view,
anorexic women die by suicide at high
rates because they are unable to
survive relatively low lethality
attempts and/or they may be less likely
to be rescued after an attempt due to
their socially isolated status.
Suicide in Anorexia Nervosa
In another view, informed by my
theory of suicidal behavior, anorexic
women die by suicide at high rates
because their histories of self-
starvation habituate them to pain and
inure them to fear of death, and they
therefore make high lethality attempts
with high intent-to-die.
Suicide in Anorexia Nervosa
We pitted these two accounts against
each other, in a study of 239 women
with AN, followed over ~15 years.
9 died by suicide, the leading cause of
death among the sample.
Of these 9, were they mostly highly
lethal methods or not?
Suicide in Anorexia Nervosa
The least lethal method: Ingestion of 12
oz. of a household cleaning product,
along with an unknown amount of a
powerful sedative and alcohol (BAC =
0.16%). Cause of death was gastric
hemorrhaging due to hydrochloric acid
in the cleaning product.
– 911 (intently suicidal feel fear too).
– Might Bitrix have prevented this?
Myths About the Suicidal Mind
MYTH: Suicide is primarily about
– Cowardice – MYTH!!!
– Weakness – MYTH!!!
– Revenge – MYTH!!!
– Selfishness – MYTH!!!
– Self-Control – MYTH!!!
– Impulsivity – MYTH!!!
Myths About the Suicidal Mind
The Impulsivity Myth
– Three instructive incidents
• Christine Chubbuck
• David Foster Wallace
• Skydiving incident
Christine Chubbuck
MYTH: She died by suicide
impulsively, on live TV, while
reporting the local news.
Christine Chubbuck
TRUTH: She died by suicide on live TV,
while reporting the local news, after a very
long process of planning and deliberation.
Christine Chubbuck
Suicide attempt four years before
her death.
Frequent talk of suicide.
Asked police officer about lethality
of wound site.
A week before death, bought a
gun.
Christine Chubbuck
Days before death, she “joked”
with colleague about shooting
herself on the air.
Day of death, stowed gun in prop
bag, and brought it to the
newsdesk.
Christine Chubbuck
TRUTH CONTINUED: One aspect of
her death contained an impulsive
element, the basis on which her death
has been misunderstood.
David Foster Wallace
Severe major depressive
disorder, very well
controlled for nearly 20
years by MAOI.
David Foster Wallace
When illness was well
controlled, he did his life’s
work, including Infinite Jest
(all 1104 pages of it), work
which in part won him a
MacArthur fellowship.
David Foster Wallace
MYTH: He died
by suicide
impulsively; in a
brief window of
time when his wife
left their house, he
impulsively died
by hanging.
David Foster Wallace
TRUTH: He made
the disastrous
decision to go off of
MAOI, could not
get illness back
under control, and
died by suicide over
a year later.
Intently Suicidal People Know
That Death Is Difficult to Enact
Many documented cases of
people who take planful
steps to prevent their
bodies from reacting and
saving them (e.g., binding
hands before death by
hanging).
Skydiving Incident in New York
State
MYTH: Man went with
friends to take pictures as
the friends skydived; he
impulsively jumped to his
death from the plane.
Skydiving Incident in New York
State
TRUTH: Man was not
friends with others; had asked
pilot if he could board and
take photos the week before;
had asked others their
preference between jumping
from a building vs. a plane.
Sources of the Impulsivity Myth
Empirical link (correlation and
causation).
“Out of the blue” appearance.
May ease bereavement.
Myths About the Suicidal Mind
MYTH: Suicide is primarily about
– Cowardice – MYTH!!!
– Weakness – MYTH!!!
– Revenge – MYTH!!!
– Selfishness – MYTH!!!
– Self-Control – MYTH!!!
– Impulsivity – MYTH!!!
Misunderstanding Suicide as Selfish
Suicide “is generally prompted
by the most sordid and
unworthy selfishness. It is a
crime which sacrifices
everything on the altar of
individual feeling.” Samuel
Miller, 1805, Presbyterian
minister.
Sketch of the Theory
Those Who
Desire Suicide
Perceived
Burdensomeness
Those Who Are
Capable of Suicide
Thwarted
Belongingness
Serious Attempt or Death by Suicide
Perceived Burdensomeness
Essential calculation:
“My death is worth more
than my life to my loved
ones/family/society.”
Perceived Burdensomeness:
Empirical Evidence
Many studies to date have directly
tested this view; all support it.
– For example, we trained raters to evaluate actual
suicide notes regarding the following dimensions:
perceived burdensomeness; hopelessness; and
generalized emotional pain. Unknown to the raters,
half of the notes were from people who died by
suicide, and half were from people who attempted
suicide and survived. The notes from those who died
by suicide contained more perceived burdensomeness
than notes from attempters; no effects were found
regarding hopelessness and emotional pain.
Joiner et al. (2002). Perceived burdensomeness and suicidality: Two
studies on the suicide notes of those attempting and those completing
suicide. Journal of Social & Clinical Psychology, 21, 531-545
Perceived Burdensomeness:
Empirical Evidence
Other research too has supported
this link.
– For example, Brown, Comtois, & Linehan
(2000) reported that genuine suicide attempts
were often characterized by a desire to make
others better off, whereas non-suicidal self-
injury was often characterized by desires to
express anger or punish oneself.
Brown, M.Z., Comtois, K.A., & Linehan, M.M. (2002). Reasons
for suicide attempts and nonsuicidal self-injury in women with
borderline personality disorder. Journal of Abnormal
Psychology, 111, 198-202.
Perceived Burdensomeness:
Anecdotal Evidence
Among the Yuit Eskimos of St.
Lawrence Island, to become too sick,
infirm, or old may threaten the
group’s survival (i.e., burden the
group); the explicit and socially
sanctioned solution to this problem is
ritual suicide. The ritual is graphic,
often involving the family members’
participation in the shooting or
hanging of the victim
Perceived Burdensomeness:
Anecdotal Evidence
Burn victim: "I felt my mind slip back
into the same pattern of thinking I'd had
when I was fourteen [when he
attempted suicide]. I hate myself. I'm
terrible. I'm not good at anything.
There's no point in me hanging around
here ruining other people's lives. I've
got to get out of here. I've got to figure
out a way to get out of my life."
Misunderstanding Selfishness
Confusing selfishness with
cognitive constriction.
–Car crash incident.
–“Suicide is painless”
incident.
Misunderstanding Selfishness
“Persons of great dignity and pride
may find it necessary to destroy
their own lives under circumstances
in which those with a shallower
scope of feeling can adjust with
only moderate damage.”
–Hervey Cleckley, 1941, The Mask
of Sanity.
Speaking of Cleckley
What is the most selfish mental disorder?
“Cleckley psychopathy” (cf. DSM-5
proposed revision).
In what disorder do virtually no suicides
occur? “Cleckley psychopathy.”
- prisoner video
Speculations on the Suicidal Mind
An inward gaze of bemused
resignation and resolution.
Speculations on the Suicidal Mind
Speculations on the Suicidal Mind
Death and Life Merging
Cobain: “I am my own
parasite.”
Plath: “The woman is perfected./ Her
dead/Body wears the smile of
accomplishment…/her bare/ feet seem to
be saying: / we have come so far; it is
over.”
Categories of Myths
Myths about the suicidal mind
Myths about suicidal behavior
Myths about the nature of
suicide
Myths About Suicidal Behavior
MYTH: Suicide is primarily
characterized by
– Note leaving – MYTH!!!
– “Slow” forms of suicide (e.g., smoking) –
MYTH!!!
– “Rational” suicide – MYTH!!!
– A cry for help – MYTH!!!
– Complete resolve and intent to die –
MYTH!!!
Suicide Notes
MYTH: Those who die by suicide
usually leave a note.
TRUTH: Note-leaving is rare;
approximately 20% of people who die
by suicide leave a note.
Why Are Suicide Notes Rare?
Alienation/isolation.
Misery makes it hard to think straight
and thus hard to write anything,
especially something as momentous as
a final goodbye.
It’s not impulsivity – we already dealt
with that, and, carefully planned deaths
with no note are common.
Suicide Note Excerpts
“I will give you $5000, that’s what I figured
I owe you. I left your contract and listings
on the desk;”
“Please call the police before you open the
door, I have shot myself;”
“Police, my car keys are in my pocket.
Please drive my car home. My daughter
needs it to drive back-and-forth to work;”
“You have my permission to withdraw all
my savings etc. to pay off bills.”
Suicide Note Excerpts
The commonality?
– Concrete
– Cognitively Constricted
Compare to “Suicide is painless,” a
fake note.
Myths About Suicidal Behavior
MYTH: Suicide is primarily characterized
by
– Note leaving – MYTH!!!
– “Slow” forms of suicide (e.g., smoking) –
MYTH!!!
– “Rational” suicide – MYTH!!!
– A cry for help – MYTH!!!
– Complete resolve and intent to die – MYTH!!!
“Slow” Suicide
“Slow” Suicide
Why did Farley (and so many
others, famous and lesser known
alike) continue very extensive use
of drugs that he had been told and
understood may well kill him? It
was not be because he liked death,
it was because he liked drugs – he
liked them so much that the risks
be damned.
“Slow” Suicide
Why do people who
know they should not
smoke anymore do so
anyway, at great risk to
their lives? It is not
because they like death,
it is because they like
smoking.
“Slow” Suicide
Why do anorexic women persist in
their behavior despite everyone
advising them not to? It is not
because they want to die, but
rather, they are “dying to be thin.”
- video
“Slow” Suicide
Crucial concept is intent.
Suicidal people intend to die
(though they retain ambivalence,
as we have seen).
Smokers, anorexics, etc., intend
other things.
Myths About Suicidal Behavior
MYTH: Suicide is primarily
characterized by
– Note leaving – MYTH!!!
– “Slow” forms of suicide (e.g., smoking) –
MYTH!!!
– “Rational” suicide – MYTH!!!
– A cry for help – MYTH!!!
– Complete resolve and intent to die–
MYTH!!!
“Rational” Suicide
“in the large proportion
of cases, if not the
majority, suicide is
committed by sane
people.” John Gray,
1871, American
Journal of Insanity.
But what did he mean
by “sane?”
“Rational” Suicide
By “sane,” he meant non-psychotic.
His view is thus compatible with
mine: Virtually everyone, very
close to 100%, who dies by suicide
has a mental disorder or subclinical
variant thereof at the time of death.
“Rational” Suicide
If “virtually everyone” is defined as
greater than 90%, there is wide
consensus on this point.
It is the remaining 10% or so that
are in question. Some feel that
some “rational” suicides occur in
this subset; I believe this subset all
have mental disorders.
“Rational” Suicide
What is a “partial syndrome” or
“subclinical variant” of mental
disorders?
Consider this case example:
– Insomnia
– Suicidal ideas
– Feelings of sadness
“Rational” Suicide
Imagine further that the
insomnia is noticed by the
spouse but brushed off and
dismissed because the person
says “it’s nothing.” The suicidal
ideas and feelings of sadness are
not disclosed to anyone.
“Rational” Suicide
The person dies by suicide, leaving a
note saying, “For the record, I do
not have a mental disorder.”
Did he though?
And will the family believe his was a
“rational” suicide (and that it was
impulsive by the way)?
Myths About Suicidal Behavior
MYTH: Suicide is primarily characterized
by
– Note leaving – MYTH!!!
– “Slow” forms of suicide (e.g., smoking) –
MYTH!!!
– “Rational” suicide – MYTH!!!
– A cry for help – MYTH!!!
– Complete resolve and intent to die – MYTH!!!
The “Cry for Help” Myth
Consider this statement, which contains a
certain truth, but also may be misinterpreted
to indirectly perpetuate the myth: “While in
most suicide cases people have given verbal
or behavioral clues that they intend to take
their lives, suicide researchers agree that
most people expressing verbal threats will
not in fact attempt it” (Timmermans, 2006,
p. 184).
The “Cry for Help” Myth
The first part of the sentence is clear and right on
target: When people give off clues about their
impending suicide, it is a serious situation indeed.
The second part of the sentence, read closely and
literally, is true as well: Of all the people who
experience the desire for suicide, even to the point
of voicing it to others, only a proportion go on to
actually die. This is quite right, just as it is quite
right that, of all the people who experience severe
chest pain, only a proportion (and a pretty small
proportion at that) will go on to die from a heart
attack.
The “Cry for Help” Myth
A key point is that, in the case of severe chest pain,
it is relatively rare for the reaction to be “he’s
faking!” or “she’s just trying to get attention!”
Indeed, most people would find these reactions
cruel, rightly. And this despite the fact that a
sizable proportion of chest pain scenarios actually
are false alarms, with the discomfort caused by
anxiety, a panic attack, esophageal problems, and
so forth. In the case of suicide threat, it is common
for the threat to be dismissed, and an under-
appreciated fact is that this represents playing with
fire, just as ignoring or dismissing chest pain can
be.
The “Cry for Help” Myth
Gene from “The Bridge”
Myths About the Nature of Suicide
MYTH: Suicide is
– Limited to humans – MYTH!!!
– Not seen in young children – MYTH!!!
– Caused by things like breast
augmentation – MYTH!!!
– More common in winter – MYTH!!!
Perceived Burdensomeness: Self-
Sacrifice Across Species
Fire ants.
Pea aphids.
Lions.
Spiders
…. even bacteria and a palm tree.
– Slime mold video
Perceived Burdensomeness: Self-
Sacrifice Across Species
In several types of bacteria,
there are cells that produce
chemicals that kill both
themselves and those genetically
unrelated to the “suicidal”
bacterium.
Strengthening Belongingness
New CDC vision: Promote connectedness
– The degree to which a person or group is
socially close, interrelated, or shares resources
with other persons or groups
• Between individuals
• Between individuals/families and community
organizations
• Among community organizations and social
institutions
Those Who
Desire Suicide
Perceived
Burdensomeness
Those Who Are
Capable of Suicide
Thwarted
Belongingness
Serious Attempt or Death by Suicide
100
Number of Daily Suicides
90
80
70
60
1972 1976 1980 1984 1988
Missing 1978 1982 1986 Missing
February 22 (1972-1989)
Going Back to Answer
Questions: Suicide Terrorists
It is clear that suicide terrorists and
bombers work up to the act, going
through months and sometimes years of
training and preparation for the act; in
this way, they are consciously and
deliberately attaining the capability for
lethal behavior.
Suicide Terrorists & Bombers
Moreover, they do
appear to use a
kind of calculation
related to
burdensomeness
(i.e., their death is
worth more to
their community
than their life).
Suicide Terrorists & Bombers
Their sense of belongingness,
however, seems quite high – another
reason, from the perspective of the
current model, to view their deaths as
other than suicides, and many Muslim
clerics concur that self-martyrdom
and suicide are distinct (Kelsay,
2002).
Suicide Terrorists & Bombers
Even here, however, the current view has
something to contribute. It is possible that
death and life merge for suicide terrorists,
such that they view death as a way to
belong, and to belong more fully than by
anything they could do in life. In fact, in
his book entitled My Life is a Weapon,
Reuter (2004) identifies belonging in the
memories of family and society at large as
perhaps the prime motive for suicide
terrorists.
Suicide Terrorists & Bombers
Japanese kamikaze pilots can be viewed
similarly. Axell and Kase (2002)
published excerpts from the pilots’ “how-
to” manual. One excerpt read, “Just
before the collision it is essential that you
do not shut your eyes for a moment so as
not to miss the target. Many have crashed
into the targets with wide-open eyes. They
will tell you what fun they had.”
Suicide Terrorists & Bombers
A subsequent passage entitled
“The moment of the crash” read,
“You are two or three meters from
the target. You can see clearly the
muzzles of the enemy’s guns. You
feel that you are suddenly floating
in the air. At that moment, you see
your mother’s face.”
Suicide Terrorists & Bombers
Also like the suicide bombers, high
belongingness seemed to characterize the
deaths of Kamikaze pilots. A relevant
excerpt from their manual read, “Remember
when diving into the enemy to shout at the
top of your lungs: “Hissatsu!” (“Sink
without fail!”) At that moment, all the
cherry blossoms at Yasukuni shrine in
Tokyo will smile brightly at you.”
Suicide Terrorists & Bombers
According to my model, one
interpretation of this is that the
pilots’ need to belong has become
met by death. Another
interpretation, of course, is that
their elevated sense of
belongingness is a reason to define
their deaths as other than suicides.
Thank you for your attention
joiner@psy.fsu.edu
Jackson Pollock’s Blue Poles (1952)
Jackson Pollock’s Blue Poles (1952)
This work was conceived and
begun in the midst of a serious,
alcohol-related suicidal crisis, and
eventually sold for more than $2
million – at the time, only works
by Rembrandt, Velazquez, and da
Vinci had sold for more.
Jackson Pollock’s Blue Poles (1952)
Poetic and
romantic, right?
Wrong: Pollock
spent months
undoing and
redoing the work
of the night of the
crisis.
Jackson Pollock’s Blue Poles (1952)
Pollock’s career was cut short
when he died in an alcohol-related,
single car crash in Springs, New
York on August 11, 1956 at the age
of 44. One of his passengers also
died.
Barriers to Risk Assessment
Prodromality
Unaware/Latent Risk
Deceit/Demand
Characteristics
Distillation of Risk Factors
Talking about/planning suicide
(safety planning)
Agitation (benzos)
Insomnia (sleep hygiene)
Nightmares (rescripting)
Marked social withdrawal (list of
300).
– Motivational Interviewing
Nightmares
I could be bound in a nutshell
And count myself a king of infinite
space
were it not that I have bad dreams.
- from Hamlet
Distillation of Risk Factors
Two others to consider (but
less strongly):
–Humiliation
–Anger (marked increase)
Distillation of Risk Factors
What’s not listed?
–Sluggishness
• Hopelessness
• Depression
Charting
Quod non est in actis,
non est in mundo
(roughly, that which is
not recorded did not
happen).
Informed Consent
“If you’re presenting with some form of
suicidality (i.e. suicidal thinking or a suicide
attempt), it’s important to recognize the risks
inherent in treatment, as well as a decision not
to seek treatment. Randomized controlled
trials for the treatment of suicidality have
found re-attempt rates during treatment as
high as 47%, with a number of experimental
treatments significantly reducing the rate of
subsequent attempts by as much as half. The
risk of a suicide attempt during treatment is
greatest for those who have made multiple
suicide attempts (i.e. two or more)…”
Fascinating and Provocative
Approach
“I tell my patients certain actions
are evil - and if you do this - if
you kill yourself or someone else
- I'm going to come after you and
drag you out of hell.”
- quoted (anonymously) from an eminent
psychiatrist.
Fascinating and Provocative
Approach
“My patients - to a man and woman - are both
astonished that a psychiatrist would make a
judgment about good and evil in the present
day and are comforted that someone cares
enough about them and their life to try to do
everything possible to protect and sustain it.
The point is usually being made in the midst
of therapeutic planning and I back it up with
my availability to them during the crisis and
its resolution that has prompted their sense of
despair. Try it, you'll like it.” - quoted
(anonymously) from an eminent psychiatrist.
An empirically validated
treatment for resolving suicidal
behavior (cont.)
“Assume a virtue if you have it not,
for use can almost change the stamp
of nature.”
- From Shakespeare’s Hamlet
An empirically validated
treatment for resolving suicidal
behavior (cont.)
“Change your behavior, change your
brain.”
- From a study on how behavior therapy
for OCD leads to MRI-documented
brain changes.
Thank You!
joiner@psy.fsu.edu