I never claimed to be an expert on suicide, but I had been trained with some screening criteria. It wasn’t much more than, “Here are the things to look for, and here’s what you do,” but it seemed like enough. I found out it wasn’t enough when our son, Alexander Hedlund, died by suicide. He didn’t have any of the markers I was told to look for. He was facing the loss of a shipmate and was sad because of it, but nothing indicated that he would end his life.
Through the process of understanding what happened, I was pointed to Thomas Joiner’s work, Why People Die by Suicide. It was eye opening and confusing at the same time. A lot of what he says makes sense – and it still doesn’t explain Alex’s suicide.
The key to Joiner’s work is his Interpersonal Theory of Suicide. The theory says that, for suicide to occur, you must have three components in place. The first is an apathy towards self-harm. Having trained to be a rescue diver in the Coast Guard, he had been trained to do painful things in the service of the mission. The second component is a belief that you’re a burden to others. We had no indication that Alex felt this way, as he was mentoring others, completing schooling, working on his house, etc. In short, we didn’t see anything leading us to believe he would think that he felt like a burden. The final component is a lack of connectedness. Alex was one of seven children. He spoke to several of his siblings the weekend before taking his own life. He spoke with both his mom and I multiple times on the date of his death.
He confided in us that he had recently started drinking – as a result of the shipmates’ death – after 11 months of sobriety. He knew we wouldn’t approve but felt safe enough to tell us and to reach out to get some help processing how he felt.
It would be easy for me to dismiss Joiner’s theory for the causes of suicide except for two key things. First, his work is well researched. He points to numerous studies that he and his colleagues have performed as well as the research of others. He ticks a major credibility marker for me, because too few people do solid research.
Second, while his theory doesn’t explain Alex’s death, it feels like it’s possible that Joiner is materially correct in his theories of suicide, but that it’s not exactly right.
The Prevalence of Suicide
The statistics aren’t good – but they’re not bad enough to garner focused attention. The round number for suicide is 10-15 people per 100,000 per year. Some countries have more and some less. Men are three times as likely to commit suicide than women, while women are more likely to attempt it unsuccessfully. Men’s attempts are more lethal – due in not so small part to the use of firearms as a more lethal approach to suicide.
Suicide lands around 10th in terms of top causes of mortality in the United States and other countries. It’s enough to make the top ten list but not necessarily enough to create a focused effort to address it. Part of that, however, may be a result of the stigma against mental illness.
Mental Health Stigma
For centuries, suicide was a major sin in Christianity and Islam. While Islam maintains the prohibition against suicide, the Catholic church – and many other forms of Christianity – recognize suicide as a mental health illness. Despite the redefinition of suicide from a sin to an illness, it’s not dramatically changed the overall feelings about mental health.
Mental health isn’t something that people readily accept. While it’s okay for us to have high blood pressure, high cholesterol, diabetes, and a host of other comorbidities, we do not, from a societal standpoint, accept people who are struggling with depression – much less those who attempt to take their own lives.
We know that 80% of our healthcare costs are driven by behavioral issues, but we don’t want to acknowledge this fact. (See Change or Die for more.) It’s easier to believe that our lack of willpower is a weakness rather than accepting it as a skill that we must master. (See Willpower for more.) So instead of people getting our compassion and support when they manifest a mental illness, we shun them and avoid them.
Joiner believes that nearly all those who commit suicide could be diagnosed with a mental illness. Whether this is true or not misses the point that mental health is implicated in suicide.
Complicating matters in the case of suicide is our prohibition against speaking of death. While a fear of death seems embedded in nearly all we do, we actively avoid thinking about it, as The Worm at the Core so thoroughly explains. We feel uncomfortable when we face our own mortality – something that having compassion for suicide survivors – both those who attempted and their families – forces us to confront.
For me, being willing to confront death as a potentially better choice than living can occur only in situations of extreme pain when it’s believed there’s no hope of relief or that the world is better off without them. The second reason aligns squarely with Joiner’s concept of burdensomeness.
On the other side, Joiner explains that hopelessness isn’t enough. If everyone who was momentarily hopeless committed suicide, we’d have a lot fewer people on the planet. I believe strongly that hope is the most powerful force in the universe. It drives the placebo effect, and if you believe Greek legend, it can survive all the evils of the world. (See Warning: Psychiatry Can Be Hazardous to your Mental Health for more on the placebo effect and Pandora’s Box for the role of hope in Greek mythology.)
Hopelessness drives Martin Seligman’s learned helplessness concept and can be a major source of depression. (See The Hope Circuit for more about learned helplessness.) On the other side, researchers like Snyder explain how to generate hope in The Psychology of Hope. He explains that hope is a cognitive function – not an emotion – and that it’s created from waypower and willpower. Waypower is understanding how to move forward.
Mind the Gap
It started with anger, a passing comment that anger is disappointment directed by the Dalai Lama. The ball started to unwind, and it became apparent that one of the biggest sources of emotional distress was the gap between expectations and observed reality. Disappointment is the judgement that the experiences you’re having don’t meet your expectations. It became apparent that it wasn’t just anger that could result from the disappointment. It could also lead to burnout. These ideas are at the very core of what we teach in the Extinguish Burnout materials.
The problem isn’t the disappointment but what can happen in a mind when that disappointment is seen as personal, global, and forever. In these conditions, the gap becomes a psychological pain – one that too many people try to escape through a suicide attempt.
The problem with suicide is often the time horizon – or how people see time. It happens along two dimensions.
First, with any kind of pain or stress, our thinking is constrained to what can be done to alleviate the immediate pain – regardless of long-term impacts. In intense pain – of any kind – it doesn’t matter what the costs are later if it solves the immediate issue. This isn’t a bad thing per se. It allowed our ancestors to survive in a world where long-term planning was a luxury they couldn’t often afford. However, it does mean that all of us struggle to maintain a broad perspective both in terms of scope and time whenever we’re in pain.
Second, we tend to believe that the pain we’re feeling will continue into the infinite future. We believe that we’ll always feel loss and grieve at the same intensity as we do today. However, this simply isn’t true. No number of studies about how we adapt to pain will convince us that pain, in many if not most cases, does really get smaller over time. This is certainly true of psychological pain and often is true of physical pain as well when we take actions to resolve it.
The primary actor in the “Who done it?” of suicide may be constrained thinking – this idea that the person considering suicide doesn’t consider all the options. Instead of looking for all the alternatives and deciding which is best, they stop when they discover that suicide may solve their immediate pain.
Gary Klein in Sources of Power makes it clear that we make sequential decisions. We don’t evaluate everything; we often pick the first thing that works. Barry Swartz in The Paradox of Choice explains that, often, choosing an option that satisfies the criteria is adaptive. However, when it comes to a decision as final as a suicide attempt, a different, more deliberate, and broader strategy would be more appropriate.
This is exactly the kind of decision that Daniel Pink’s work in Drive explains that we’re unable to do. Stress constrains our thinking and makes it harder for us to break free of cognitive fixedness. That is, we tend to believe that things are the way that we see them, and they can’t change. Quoting an old experiment, he explains that if you tell folks to affix a candle to a wall given only the candle and a box of tacks, they can discover that the box the tacks are in can be fixed to the wall with the tacks, and the candle can be set in the box. But if you give them even a mild incentive for quick completion (thus creating mild motivation to complete the task quickly), they take substantially longer – if they can complete the task at all. The problem was, at the core, the person defined the box for the tacks as the container for the tacks and therefore not useful in holding a candle.
The suicidal person’s box is that suicide is the only answer. There is no way to address their psychological pain, and therefore suicide is the only viable solution. This is, of course, not truth, but it’s their truth. It’s the belief system that drives them towards self-harm.
The correlation between depression and suicide is well established. However, the mechanisms of that correlation are not clearly known. There are many theories, but no single, well-defined answer. One of the known factors in depression is that depressed people continuously rate themselves lower than their non-depressed peers.
One of the challenges is that depressed people may be rating themselves more accurately, but it’s not an accurate rating that is important. What’s important is what’s useful. Thomas Gilovich in How We Know What Isn’t So
explains that we all believe we’re better than we are. However, this perception may be far from getting us in trouble. It may be that our optimistic bias of our own capabilities protects us from the damages of depression.
Free Medical Care
There’s a problem with our medical system that isn’t immediately apparent but can be seen when you begin to look at the system itself. (See Thinking in Systems for more about how to view things this way.) What most people don’t know – but those who are struggling do – is that you can’t be turned away from an emergency room. If you wait until a problem is life-threatening, you’ll get the help you need – regardless of your ability to pay.
It’s an important safety net, but it comes as a cost. Those who are unable to access preventative care – either in medical or psychological terms – get caught by this safety net. Emergency rooms are swamped with people who are unable to pay and therefore have no other mechanism to get the life-giving care they need. It often frustrates the workers as they see the same people over and over again. If those people simply got the right preventative care, a great number of resources would be saved.
Emergency rooms are necessarily expensive to operate. They require professionals who are highly skilled, access to expensive diagnostic equipment, and other resources that are simply expensive to maintain. Thus, when people access the emergency room when they don’t need to, they drive the overall cost of healthcare up.
This shows up in suicide as a problem, because people are unable to get either the medical or psychological care they need prior to a suicidal event. It’s only after a failed suicide attempt that medical and psychological care will be forced upon the suicide event survivor. That’s great for them, but simultaneously a tragedy for those whose suicide attempt was successful.
Of course, making free medical and psychological care available pre-suicide attempt doesn’t solve the whole problem. We still must persuade those who struggle with suicidal thoughts to pursue care, but at least it would be available if they could be persuaded to get it.
Death as Life Giving
One of the curious comments contained in the book is that suicidal people begin to see death as life giving. While literally this cannot be the case, it creates questions about how suicidal people might feel more in control of their destiny because they’ve initiated their own death.
Another idea that may generate the perception that death is life giving is that it’s not life giving directly, but the freedom from pain may cause them to feel as if they could be more alive – paradoxically, by dying.
Joiner’s model focuses on connectedness; that I’ll cover shortly. It’s necessary to introduce the concept of belonging as a larger, overarching concept. We have a fundamental need to feel like we belong. In The Deep Water of Affinity Groups, I share how our need to feel like a part of a group causes us to make decisions that may be costly to us but help shore up areas of our self-esteem that may not be what we want them to be.
Ideally, we want people to feel personally connected. We want one-on-one intimacy that makes us feel truly seen and heard. However, we can’t ignore the fact that we often use belonging as a proxy for these connections.
The degree to which people are connected isn’t something that’s easy to quantify. On the one hand, David Richo explains in How to Be an Adult in Relationships that we should receive no more than 25% of our emotional needs from one person. On the other, you have Intimacy Anorexia, where people seem incapable of connecting with others in a deep and meaningful way. While marriage conveys a variety of health benefits, it can be challenging too. John Gottman explains in The Science of Trust how “sliding door” moments can make the difference.
Some of those “sliding door” moments can help us form friendships that last a lifetime, as we step in to help someone at just the right time. They’re eternally grateful, and at some point in the future, they step in to help you. The result is a connection that lasts over time.
The impact of these long-term connections creates challenges and opportunities. Challenges because the loss of someone whom you care deeply for can lead you to intense grief, and because we’re rarely able to articulate those people for whom we have these deep connections when pressed for a quick list. They may be the people for whom you have deep respect, admiration, and connection – and at the same time, they are likely not the people you speak with every week.
You can call it self-worth, self-esteem, self-efficacy, or self-concept. Though these concepts are slightly different, they all amount to the way that you see yourself. It’s about the value that you see in yourself and what the world will lose when you’re gone.
Joiner frames the conversation in terms of burdensomeness, but I wonder if the real core of this isn’t the balance of self-worth and perceived burdensomeness.
Everyone leans on others at times. When I’m sick, my wife takes the brunt of my relative helplessness. I know this and that, at times, I’ll support her when she’s ill. I don’t perceive myself as a perpetual burden to her or the family – though if I did, that would be a problem.
There are, of course, different ways that we can feel like we’re a burden to others. It could be a financial drain, an emotional drain, or a physical one.
Strangely – supporting my argument above – children, and particularly college-age children, rarely see themselves as a financial burden – at least not to the point of committing suicide. The belief that, ultimately, they have value or will generate value or simply have internal self-worth seems to provide at least some buffer against suicide. Despite this buffer, the changes in life situation make suicide the second leading cause of death for college-age students. (Studies vary on specific ages but cluster around 18-22.) Even buffered by self-worth, this time of fundamental transitions is dangerous.
The final aspect of Joiner’s model is self-harm, which includes tattoos and piercings up to cutting and previous suicide attempts. What’s harder to quantify is those people who have learned to push themselves into and through pain. High performers who have learned to allow themselves to feel some pain so that they can achieve peak performance. (See The Art of Learning for an example.)
Reconstituting a Model
I don’t have a formulation for a suicide model that makes Alex’s death make sense. I don’t think Joiner’s model covers it. However, I can say that it went a great way towards helping me understand Why People Die by Suicide.