Myths About SuicideRichard Balon, MD
Wayne State University, Detroit, MI, USA
By Thomas Joiner. Cambridge, MA: Harvard University Press; 2010; ISBN 978-0-674-04822-5; pp 288; $25.95 (hardcover).
Suicide, as Thomas Joiner points out in the Introduction to his book on myths about suicide, is the most stigmatized of human behaviors (p 1). It is a behavior condemned and forbidden by Christianity and Islam—condemned, interestingly, much more than murder or slavery (pp 1-2). It is stigmatized, feared, and skirted around by almost everybody. Suicide has also been storied by many myths that have been perpetuated by the media, by many clinicians, and even by many famous or not-so-famous psychiatrists. These myths have contributed to our fears and ignorance. Thomas Joiner, a well-known suicide researcher, attempts to address the stigma and ignorance of suicide by dispelling these myths in this small volume. The reader should note that Joiner is not only an accomplished suicide researcher, he is also familiar with suicide on a personal level—both his father and maternal grandfather committed suicide.
The book is divided into an Introduction and 3 large chapters. The most important point emphasized in the Introduction is the notion held by Joiner (and others, eg, Voltaire, Flavius Josephus, and Albert Camus) that suicide is not necessarily a sign of weakness, as one of the most powerful instincts—that of self-preservation—must be overcome.
The other important point of this section is Joiner’s theory of suicidal behavior. In his view, people die by suicide because they have both the ability and the desire to do so. He also postulates that “when people hold two specific psychological states in their minds simultaneously and long enough, they develop the desire for death. These two states are the perception that one is a burden and the sense that one does not belong.” He calls these 2 states “perceived burdensomeness” and a “sense of low belongingness” (pp 5-6).
To support his hypothesis, the author points to data from studies showing that women with children had lower suicide rates than those with no children, and the fact that although identical twins have higher rates of mental illness that are frequently associated with suicide, they have lower rates of suicide than other groups.
The first chapter, “The suicidal mind,” dispels 9 myths: “Suicide’s an easy escape, one that cowards use,” “Suicide is an act of anger, aggression or revenge,” “Suicide is selfish, a way to show excessive self-love,” “Suicide is a form of self-mastery,” “Most people who die by suicide don’t make future plans,” “People often die by suicide on a whim,” “You can tell who die by suicide from their appearance,” “You have to be out of your mind to die by suicide,” and “Suicide terrorists and others subvert the need to belong.”
The author addresses the myths and questions that plague the minds of survivors, family members, friends, and health professionals (p 12). He emphasizes that suicide is not an act of cowardice or anger. The text is rich—as is the rest of the book—with a diverse collection of facts, stories, and study data, all very interesting, informative, and persuasive. For instance, how many of us know much about hesitation wounds in those who die by self-inflicted knife wounds, illustrative of the fearsome, hesitant quality of taking one’s life?
Another interesting discussion touches on the implication of aggression in suicide—Joiner postulates that the regular experience of aggression (not necessarily being aggressive oneself) habituates one to injury in general and self-injury in particular (p 32). This notion may help to explain the higher suicide rates among physicians, who otherwise have many protections against death by suicide. However, by seeing pain and injury regularly, they may be inured to it and are thus more capable of enacting their own death (p 33).
Joiner also believes that, in addition to the 95% of those who die by suicide who are thought to have a diagnosable mental disorder at the time of their death, the remaining 5% are probably experiencing subclinical variants of mental disorders. Another interesting fact, among many in this part of the book, was the study finding that drinking in the mother is predictive of the child’s suicidal behavior.
The second chapter, “Suicidal behavior,” addresses myths about suicidal behavior, and attempts to explain what does and what does not count as suicidal behavior (p 111). The 8 myths discussed in this part include “The death scene shows that the cause of death was not suicide,” “Most people who die by suicide leave a note,” “Suicide behavior and contagion,” “If people want to die by suicide, we can’t stop them,” “It’s just a cry for help,” “Hospitalization as a treatment for suicidal behavior,” “‘Rational’ suicide,” and “‘Slow’ suicide.”
Some of the important areas of discussion in this part include the incorrect notion that mentioning suicide in a clinical screening situation will plant suicidality in the minds of patients, or the discussion of a study on people who were restrained from jumping from Golden Gate Bridge—most of them lived long after being restrained and some died of natural causes. The interesting debunking of slow suicide uses 2 well-known deaths: the comedian Chris Farley and the musician Kurt Cobain.
The last part, “Causes, consequences, and subpopulations,” focuses on 8 myths: “Animals don’t die by suicide” (some do), “Young children do not die by suicide” (again, this is not true), “Young ones (and others) should be lied to about deaths by suicide” (wrong strategy), “Suicide and genetics” (the genetic risk of suicide seems lower than usually cited), “Breast augmentation causes suicide” (it does not…many associations in research studies are misinterpreted as causative), “Medicines cause suicidal behavior” (Joiner takes a strong stand against this, discussing a 26-country study showing that an increase in sales of one selective serotonin reuptake inhibitor pill per capita was associated with a decrease in suicides of about 5%), “Sleep and suicidal behavior” (there is a definite connection between sleep problems and the whole spectrum of suicidal behavior), and “Suicidal behavior peaks around the Christmas holidays” (it does not—it peaks in the spring or maybe in the summer, but nor around winter holidays; it also peaks earlier in the week, especially on Mondays).
The Conclusion emphasizes that we need “to get it in our heads that suicide is not easy, painless, cowardly, selfish, vengeful, self-masterful…” and all of those things discussed in the 25 myths covered in this book,” and that “…it is preventable (eg, through means restrictions like bridge barriers) and treatable… And once we get all that in our heads at last, we need to let it lead our hearts” (p 272).
This is a very interesting, thoughtful, moving, powerful little book that contains a wealth of information. It is clearly written by an author who has mastered this area very well. It reminds me of the powerful Jamison book on suicide.1 I would recommend this book to all psychiatrists and other mental health professionals, as we all deal with suicide and the myths surrounding it. It would be a good book for all psychiatry residents to read. And as far as the general public—many, if not all, could benefit from reading such a powerful book, rather than playing video games or exploring new technological devices. Probably a futile desire on my part.
- Jamison KR. Night falls fast. Understanding suicide. New York, NY: Alfred A. Knopf; 1999.
Annals of Clinical Psychiatry ©2010 Quadrant HealthCom Inc.