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Suicide

Suicide

I. Social AspectsJack D. Douglas

BIBLIOGRAPHY

II. Psychological Aspects (1)Edwin S. Shneidman

BIBLIOGRAPHY

III. Psychological Aspects (2)Norman L. Farberow

BIBLIOGRAPHY

I. SOCIAL ASPECTS

Suicide has been an object of fundamental concern to Western men of all cultural periods, though the importance given to suicide itself, as well as the degree to which it has entered into other concerns, has varied greatly from one period to another. “Suicide,” said Goethe, “is an incident in human life which, however much disputed and discussed, demands the sympathy of every man, and in every age must be dealt with anew” ([1811-1833] 1908, vol. 2, p. 125).

This is not to say that suicide has failed to interest people in other cultures but, rather, that the reasons have usually been different. In feudal Japan, for instance, suicide was an ultimate act of honor, redemption, or union. In the Western world, however, suicide has always been regarded as fundamentally problematic. Possibly because suicide in the West has nearly always been interpreted as voluntary self-destruction, with no element of social constraint or obligation, philosophers from Plato to Camus have used it as a starting point for reflection on the eternal problems of human existence. Indeed, ambivalence toward the fact of his own existence is one of Western man’s most persistent characteristics; life and death, the relation of man to man, and the relation of man to himself have been subject to continual questioning, and suicide has been seen as relevant to all of these. In such a climate of thought, it is not surprising that neither settled opinion nor emotional consensus has ever been reached concerning the nature of suicide.

Early writings . Early Western writers on suicide were primarily concerned either with its desirability (including its honorability) or with its morality. But all of them, whether Greek, Roman, Jew, or Christian, were concerned to some degree with the particular facts of actual cases of suicide. Most importantly, from our point of view, they implicitly assumed that before one could properly judge the actor in the case, one had also to know his intentions, the situation in which he found himself, and the nature and outcome of his actions.

After the normative arguments against suicide by Augustine, the Council of Aries, and the Council of Bourges, there is little evidence that the normative evaluation of suicide was considered to be very problematic until the seventeenth century. But there remained the cognitive problem of deciding which set of facts concerning intentions, situations, and actions should be imputed to the category of suicide. Most important to Christian thinkers was the problem of categorizing “martyrs”: were they suicides or not? This cognitive problem was to be just as difficult for sociologists in the twentieth century as for theologians in the fifth century (see Halbwachs 1930).

The nineteenth century . The fundamental forms of thought about suicide, including the implicit assumptions that suicide must be studied as a form of normative action and that suicide is connected with the problem of man’s relation to God and man’s relation to man, were all part of the literary and common-sense background of sociological thought about suicide in the nineteenth century. But there were many other, more specific influences on these nineteenth-century works.

Almost all of the many works on suicide in the eighteenth and nineteenth centuries included extensive and detailed considerations of the historical cases, the literary examples, and the philosophical treatments of suicide. The works of Appiano Buona-fède, Louis F. Bourquelot, Carl F. Stäudlin, Albert des Étangs, Pierre J. C. Debreyne, Alexandre Brière de Boismont, and Alfred Legoyt, to mention but a few, were greatly concerned with such sources. Among the literary, philosophical, and historical influences on the developing sociology of suicide, three can be singled out as most important.

(1) Knowledge of the high frequency of suicide among the upper classes in ancient Rome, and of the honorableness of suicide among the Romans, led to the idea that suicide is fundamentally a matter of social custom. According to Voltaire and other thinkers of the Enlightenment, suicide in a society where suicide is neither the custom nor positively valued or expected was due to a failing, weakness, or disease. This background assumption helped to produce both the psychological theory that suicide is caused by insanity (or character weakness, or disequilibrium), a theory of great influence even today (Dahlgren 1945; Achille-Delmas 1932; Deshaies 1947), and the sociological theory that suicide is caused by a failure of the normative control of individuals by society (Brière de Boismont 1856; Morselli 1879; Durkheim 1897; Cavan 1928).

(2) In the eighteenth century, suicide became a focal point in the ethical argument between the philosophes and the church supporters. Largely as an outgrowth of this struggle, the relation of religion to suicide became a leading concern of the nineteenth-century sociologists. Specifically, this tradition of thought was largely responsible for the explanations of the great statistical increase in suicide in nineteenth-century Europe in terms of meaninglessness of life, lack of discipline, self-centeredness, moral disorganization, and materialism. These developments are dealt with more fully below.

(3) Death, especially death by suicide, was a favorite theme in the literature of the romantic movement. Indeed, the most important contribution of this literary tradition to the developing sociology of nineteenth-century Europe was probably that it helped to focus attention on suicide. Largely because of its treatment in literature, suicide was seen by the educated public as a fundamental social problem. Nineteenth-century Europeans, especially the French, were as frightened of la manie du suicide (as Tissot [1840] called it) as twentieth-century Americans are of juvenile delinquency and the Mafia. But the literary concern with suicide also provided the core of certain very important, specific “theoretical” explanations. Of fundamental importance was the prime romantic symbol of an isolated, lonely hero of a poetic (or intellectual) bent who wanders far from human society in search of the impossible and, failing of the impossible, becomes increasingly melancholy and enamored of eternity. The idea that self-imposed isolation produces “melancholy,” and thence suicide, was hardly novel; indeed, Robert Burton’s seventeenth-century treatise, The Anatomy of Melancholy, had carefully documented its classical sources. But this prime symbol of romanticism contained the most unclassical ideas of both egoism and anomie. Indeed, the romantic image of suicide seems to have been so much the mythical model which the sociologists of suicide had in mind that both Morselli ([1879] 1882, p. 297) and Durkheim (1897) had a strong tendency to treat egoism and anomie as almost identical. It is even possible to specify the work of Chateaubriand, especially as treated by Briére de Boismont (1856, pp. 39-40), as the major source of Durkheim’s idea of anomie suicide (Douglas 1965, pp. 20-26).

Some of the fundamental ideas about suicide which the sociologists inherited from history, philosophy, literature, and common sense became the cores of the various sociological theories of suicide. There were other influences on these theories which will be described later. But the sociologists of the period were dependent upon these nonscientific and, most importantly, nonempirical sources for their ideas about suicide as a specific phenomenon. Though this is somewhat less true today, the sociological study of suicide is in substantially the same condition.

The definition of suicide

A great number of different definitions of suicide have been proposed by the students of suicide during the first two hundred years of the term’s general use. Almost all of these definitions have included, to varying degrees and in various combinations, one or more of the following conceptual dimensions: (a) the initiation of an act that leads to the death of the initiator; (b) the willing of an act that leads to the death of the wilier; (c) the willing of self-destruction; (d) the loss of will; (e) the motivation to be dead (or to die, or to be killed) which leads to the initiation of an act that leads in turn to the death of the initiator; (f) the knowledge of an actor concerning the relations between his acts and the objective state of death; (g) the degree of central integration of the decisions of an actor who decides to initiate an action that leads to the death of the actor; (h) the degree of firmness or persistence of the decision to initiate an act that leads to the death of the initiator; (i) the degree of effectiveness of the act in producing death. (For a detailed presentation of the various definitions, see Schneider 1954, pp. 9-59; for an analysis of the definitions of suicide, see Douglas 1965.)

The great profusion and confusion of definitions of suicide have been very largely the result of combining an abstract, a priori approach to defining the concept with an assumption of “verbal realism” —i.e., the assumption that if the same name is in fact used to refer to a set of phenomena, then that set of phenomena must in fact have some shared property that is designated by the shared word. Durkheim and almost all other sociologists and psychologists who have attempted to carefully define suicide, have assumed that one should arbitrarily define the concept to fit his scientific methods and his theoretical purposes but that the definition should not differ too much from common usage (Durkheim [1897] 1951, pp. 41-42). Durkheim further assumed that the most common definition of suicide was that of death caused by an action initiated by the actor with the intention of causing his own death. Since, however, teleology is anathema to positivists, Durkheim decided that intentions are too “intimate” to yield valid information and that, consequently, “knowledge” by the actor of the deadly consequences of his actions should be the fundamental factor in deciding that a death is a suicide, even if the consequences are relatively uncertain (ibid., pp. 43-46).

Unfortunately, Durkheim’s definition of suicide was quite irrelevant to his work on suicide. As Maurice Halbwachs most astutely argued, Durkheim was almost totally dependent on the official suicide statistics for his data, so the only definition that really mattered was that (rather, those) which the officials had in mind when they categorized the causes of deaths. Since Halbwachs believed that one could not know what definitions these officials used, he concluded that sociologists must be satisfied with no definition at all (Halbwachs 1930). Actually, the coroners and doctors who do the categorizing seem generally to be firm believers in the common-sense theory of teleology. Moreover, the laws governing the certification of cause of death very generally specify “intention” as necessary for a classification of suicide. Benoit-Smullyan (1948) has also pointed out that since Europeans do not generally consider self-sacrifices to be suicides, Durkheim’s “altruistic suicides” would not be included in the official statistics on suicide. Consequently, it seems clear that Durkheim’s definition of suicide was not so much irrelevant to his data as it was a complete distortion of the meaning of the data.

With the exception of Halbwachs’ work, the published sociological works on suicide since Durkheim’s Suicide have generally assumed that Durkheim’s definition is best; they have even failed to note Halbwachs’ valid criticism of it. They have, however, also either implicitly assumed “intention” to be a necessary factor, or else they have totally avoided the problem. The result has been both confusion and a failure to recognize the problems involved in defining suicide. The sociology of suicide is in obvious need of a system of categories which will describe the observed phenomena that are significant in terms of a theory of suicide. Such descriptive categories must be worked out in partial independence of the theories in order to aid their development, but they must also be worked out in partial dependence on developing theories. However, the first critically important thing for sociologists to do is to make direct observations of the empirical phenomena which are called suicide in any society, so that definitions will be relevant and so that the meanings of the data will be known to the theorists.

Official statistics on suicide

Largely because of the rapid acceleration in statistics-keeping in eighteenth-century Europe, the systematic recording and tabulating of suicides had become standard practice in many of the governmental regions of Europe by the first quarter of the nineteenth century. The basic ideas of “moral statistics,” especially the fundamental idea that a given incidence of a phenomenon such as suicide is regularly associated with a given population, had been clearly formulated in the eighteenth century, certainly by 1741, when Johann Peter Süssmilch published his famous treatise on the “divine order” underlying demographic phenomena. The traditions of “political arithmetic,” of studying racial and national character, and of comparative studies of suicide rates were synthesized by Adolphe Quetelet (1835) in order to produce his “average man” theory of suicide rates. Quetelet’s fundamental idea was that each stable “social system” produces a stable, average personality type about which the individual personalities tend to cluster. The average man, therefore, has a given, stable probability of committing suicide in a given period of time.

Quetelet’s probabilistic theory was specifically intended to explain the observed regularity (or order) in the official suicide statistics. This regularity, which was first observed for the different nations of Europe, seemed to the moral statisticians to be a remarkable demonstration of the deterministic, lawlike nature of the actions of individuals. Since the seventeenth century, Europeans had believed suicide to be more frequent in some nations than in others. The French considered suicide to be as English as gambling (they seem to have believed that more Englishmen preferred death to life because the fog made living so unworthwhile), though Voltaire thought this impression was due to more newspaper coverage of suicide in England. But before the nineteenth century, the explanations of these (assumed) regular differences in suicide frequencies always involved the assumption that the individual will was the ultimate cause of the action. In the early nineteenth century both the psychiatric theory that all suicides are insane (and, therefore, do not cause their own actions) and the direct comparison of national suicide rates (without any real consideration of the individuals who committed the actions) combined to eliminate the individuals (or wills, or personalities) from consideration as possible causes of suicide. Quetelet’s early work on the comparisons of social rates of suicide (work that gained much support from the researches of Gustave F. Étoc-Demazy and Andre M. Guerry) was quickly given a metaphysical basis by the English positivists, especially by Henry Thomas Buckle. This largely eliminated Quetelet’s variable of average personality; the direct comparison of other external, objective data (such as geographical-ecological distributions and marriage rates) with suicide rates was now an established method with a metaphysical justification, that of positivistic determinism.

Largely because of the vast influence of Brière de Boismont’s great work on suicide (1856), based primarily on case studies of 4,595 suicides, including 1,328 suicide notes (a source of data first used by Guerry as early as 1833), and 265 attempted or planned suicides, the more important works on suicide by Wagner (1864) and Morselli (1879) did not deny causal significance to various individual factors, such as motives. They did, however, consider the comparative analysis of officially computed suicide rates to be necessary for establishing causes of suicide “. . . such as the most positive mode of psychological study would fail to discover in the individual” (Morselli [1879] 1882, p. 10). Durkheim’s sociologistic theory of suicide proposed that suicide rates are a sine qua non of the sociological study of suicide, and the great influence of his Suicide (the first edition of which appeared in 1897, although it was not translated into English until 1951) quickly made the statistical approach almost identical with the sociological approach, especially in the United States. Indeed, Kruijt (1960) and others have recently assumed the two to be totally identical.

Validity of official data . Since sociologists have relied almost exclusively on the official statistics and coroners’ reports on suicide for the data from which to develop and test theories of suicide, the question of the validity of the official data is absolutely critical in any evaluation of these sociological works. Throughout the nineteenth century most students of suicide were highly critical of the official statistics on suicide. Esquirol (1838), Brière de Boismont (1856), Legoyt (1881), Strahan (1893), and many others believed the official statistics grossly underestimated the actual number of suicides. Even Morselli (1879) most emphatically warned against the dangerous misuse of suicide statistics. But the sociologists, especially Durkheim (who included very little consideration of the value of his data in Suicide), consistently assumed that the evidence was good enough for the kinds of positivistic (i.e., objective, by definition) analyses they wanted to make. In general, they argued that (a) the stability of the statistics shows that there are no significant errors in them and (b) there are no good reasons to conclude that there are consistent biases in the data, i.e., the errors cancel each other out.

The first argument is based on the mistaken assumption that errors cannot be patterned or stable. Buckle (1857-1861, p. 18) even noted that the frequency of incorrectly addressed letters is extremely stable from year to year without noting the obvious implication for stable suicide statistics. Though contemporary sociologists (especially Americans) who have used the official records on suicide rarely have explicitly considered their value as evidence, they seem generally to have assumed that the second argument given above is correct. The most fundamental reasons for denying the validity of the argument, and therefore the adequate validity of the statistics, are as follows.

(1) It seems quite likely that the official categorizers of suicide in different nations, states, and cities have used different abstract and operational definitions of suicide. We have noted above that the formal definitions of suicide by the students of suicide have varied greatly and in a most complex fashion. But there have been some consistent differences in definitions between groups, such as those between the psychiatrists, the psychologists, and the sociologists. Why would one not expect to find similar consistent differences in the abstract and operational definitions of suicide used by different groups of official categorizers of causes of death? A coroner of a large city who will categorize a cause of death as suicide only if a suicide note is found clearly will produce results consistently different from those of a coroner in another city who uses a different rule-of-thumb definition, such as that there must be an eyewitness report, a clearly perceptible motive, etc. Only “verbal realism” can lead one to assure a priori that the coroner in Lapahaw, Georgia, applies the word “suicide” in a fashion substantially similar to the way the word is applied by the coroner in Los Angeles, California.

(2) It also seems most plausible to assume that there are consistent differences in the abstract and operational definitions of the terms of the different definitions, such as “cause,” “responsible,” “sane,” “death,” and “intention.” For example, some official agencies will not categorize the cause of death as suicide if death occurs three days after the injurious act; and it is worth observing here that all bureaucracies create ad hoc rules of thumb in order to effectively apply general policy to their own particular problems.

(3 ) A great deal of evidence has been presented by Herman Krose, Georg von Mayr, Halbwachs (1930, pp. 19-39), and Achille-Delmas (1932) which has shown both that (a) there are consistent differences in the administrative practices of dealing with suicide (and related categories) and that (b) changes (hence, differences) in administrative practices regarding suicide produce immediate and highly significant changes in suicide rates. Two brief examples are instructive. Halbwachs (1930, pp. 33-34) found that, though a ruling in 1866 made certification of cause of death by a doctor or public health official obligatory throughout France, in fact almost all rural deaths escaped certification; certification of cause of deaths in public places was made by police officials, and certification by family doctor was universally acceptable. He also found that a reform in the Prussian Bureau of Statistics in 1883 produced a 20 per cent stable increase in the suicide rate, beginning in 1884 (Douglas 1965, pp. 259-377).

These and other facts strongly suggest that the relationship between statistical organizations and the suicide rates they produce is subject to the following principle: other things being equal, suicide rates vary directly with the degree of professional medical training of the categorizers, the average rate of man-hours devoted to “cause of death” categorization, and the independence of the categorizers from “interested parties” (for which see below). This general principle leads us to expect, among other things, that (a) urbanization and suicide rates will vary directly; (b) both industrialization and the wealth of populations will vary directly with suicide rates (a possible explanation of the great increase in suicide rates of Europe in the nineteenth century and of developing nations today); and (c) periods of general disorganization or reorganization, such as wars, will produce decreases in suicide rates (because the officials are fewer and have more important things to do). And, in general, these predictions are strongly supported.

(4) The most important set of “other things” that are not equal, and which we must expect to cause great biases in official statistics on suicide, are the various social meanings of suicide, especially as they relate to approval or disapproval. Because of his positivist philosophy, his peculiar theory of “social pathology,” and his theory of “juridical norms,” Durkheim assumed that all groups in Europe were equally against suicide. With the partial exception of the works of Halbwachs (1930) and Cavan (1928), almost all sociological theories of suicide since Durkheim have implicitly assumed the normative definitions of suicide to be both invariant and highly negative. This is a totally fallacious and most unfortunate assumption. In his brilliant study of French attitudes toward suicide, Albert Bayet (1922) conclusively demonstrated that over a long period of time there was a consistently far more negative (even horrified) attitude toward suicide on the part of the “simple,” uneducated population (largely rural) than on the part of the more educated, upper-class population. Such patterned differences in the normative meanings of suicidal actions might produce different frequencies in actual (or real) suicidal actions, but they would seem far more likely to produce differences in the frequency and strength of attempts to conceal suicide both by the suicidal individual and by his significant others. Moreover, one would expect that the more a primary group has to lose from having one of its members socially categorized as a suicide, the greater will be the frequency and strength of attempts to conceal suicide. These two factors make up what can be called a group coefficient of attempted concealment of suicidal actions. We must also expect, however, that different groups will have different coefficients of success in such attempts, the major determinants of which would seem to be degree of social influence and degree of social integration of the group (or individual) making the attempt at concealment. Obviously, these two coefficients could produce many biasing effects on official statistics, the most likely of which seems to be that, given a certain degree of negative normative definition of suicidal action, the degree of social integration of the suicide’s primary group into the general community will vary directly with the coefficient of attempted concealment and with the coefficient of success in attempted concealment. This means, of course, that official statistics on suicide will tend to be biased in such a direction that they will support an integration theory of suicide, such as Durkheim’s.

(5) Over half a century before the publication of Durkheim’s Suicide, Jean-Étienne Esquirol (1838) had established that some methods of committing suicide make valid categorization of the cause of death more difficult. Since, moreover, there seem to be patterned variations between social categories in suicide methods, we must expect biases in official statistics from this source. For example, women use barbiturates and gas far more frequently than do men. Suicides by barbiturates and gas are very difficult to distinguish from accidents. Since such doubtful cases are almost always categorized as “accidental” or “accidental suicide,” we must expect bias in the direction of lower official suicide rates for women.

Two conclusions regarding the official statistics on suicide seem justified: (a) we have little specific, systematic knowledge about the means employed by different statistical bureaus to arrive at these figures; (b) what knowledge we do have about these figures and the means of arriving at them strongly supports our arguments that they are highly biased in certain directions. In general, at the present time there seems to be no adequate justification for using official statistics on suicide to build or test a scientific theory of suicide. There seems to be every reason for not using them (Douglas 1965, pp. 259-377).

Sociology and the official data . Almost every published theory of suicide that has been called sociological has depended on the official statistics on suicide for its testing. This means, of course, that the testing of these theories is subject to all of the biases of the official statistics and therefore cannot generally be accepted.

But this does not necessarily mean that the theories of suicide are themselves wrong. All the so-called sociological theories have been general abstract theories which the authors believed to be applicable to a great variety of social behavior—for instance, to all deviant behavior. These theorists have never derived their general theories from the official statistics, still less from any actual observations of cases of suicide. On the other hand, they have always known from the beginning most of the patterns of suicide shown by the official statistics, so that they have been able to select (no doubt unconsciously) just those patterns for consideration in the testing stage which their theories can “predict.” In spite of rhetorical disclaimers that any such bias exists, the fact remains that all published sociological theories of suicide have been supported at a high level of statistical significance by “tests” using the official statistics on suicide. Moreover, since all of these works after Durkheim’s Suicide have included only the most perfunctory consideration of alternative theories for explaining the same data, there is at present no justification for considering any one theory better than any other, unless one were to consider sophistication of argument an acceptable criterion, in which case Durkheim would hold the field unopposed (Douglas 1965, pp. 112-259).

Major theories of suicide

Durkheim’s sociologistic theory. In Suicide Durkheim was, of course, primarily concerned with proving by demonstration that sociology is a scientific discipline sui generis. The work was a polemic in a great ideological war; and as Halbwachs has said (1930, p. 3), its argumentative power has made it convincing (though, I would add, only to those already convinced of its general position). To achieve his goal of demonstration, Durkheim made use of the mass of published material on suicide statistics, the many statistical relations already established between suicide rates and social relations by the flourishing school of “moral statisticians,” and the methods of analysis developed by Bertillon and many others. Earlier sociologists, especially Morselli (1879), had considered “society,” and in particular the morals of a society, to be the most important cause of a given suicide rate. It was from these previous works that Durkheim took his specific ideas, such as “egoism” and “lack of moral restraint,” about what caused suicide rates to vary. But previous theorists, with the major exception of Quetelet, had proposed multifactored explanations; Durkheim proposed a general synthesis. In general, he took his notion of statistical relations and methods from the moral statisticians and, like many of the moral statisticians before him, turned to the romantics, and the psychologists whom they had influenced, for his fundamental causal variables. Durkheim’s own contribution was to translate “egoism,” “need for an external, moral authority,” and similar psychological variables into “social” (or cultural) variables which he finally reduced to the two opposing moral dimensions of egoism-altruism and anomie-fatalism.

Unfortunately for Durkheim’s ambitious program, Suicide (1897) is an extremely uneven work. The theory presented in Books 1 and 2 is for the most part extremely positivistic, relating external (or “objective”) variables to other external variables. In Book 3, however, the theory is radically different: internal variables are related both to each other and to external variables. The positivistic version is the one usually given primacy by American sociologists (see, for example, Gibbs & Martin 1964); but the later version is the more considered, developed, and tenable theory. The core of the latter is very simple, though its presentation is confused by Durkheim’s penchant for multiple terms (e.g., “disintegration,” “disorder,” “disequilibrium,” “lack of unity or cohesion”), petitio principii, and lack of conceptual clarity. He assumes that for all societies there is some optimal equilibrium or integration of egoism-altruism, on the one hand, and anomie-fatalism, on the other. Any change in the relative strengths of these ideas (or forces) will produce an increase in “social disintegration,” which will lead in turn to an increase in the suicide rate and in the particular type of social relation associated with the “force” that is on the increase. Hence, there is a statistical relation between suicide rates and the incidence of different types of social relations.

The critical flaw in the work is the lack of any means of measuring these forces of egoism, anomie, etc., either independently of each other or independently of a change in suicide rates. Yet Durkheim assumed that these were the fundamentally important variables: any change in suicide rates or social relations meant to him that one or more of the forces was increasing relative to the others. But how did he determine which force was increasing? We must conclude that he inferred it from the associated changes in social relations, and that, for the most part, he assumed he knew from common sense what these changes meant. Unfortunately, the concrete examples Durkheim gives us will not support the notion that his common sense was superior, as a scientific instrument, to anyone else’s (Douglas 1965, pp. 7-112).

The major contribution of Durkheim’s Suicide was its grand conception of the general nature of sociological theory. Durkheim’s intentions in this work went much too far beyond the possibilities of the theory and data of his day—and of ours.

Halbwachs’ theory of suicide. The work of Maurice Halbwachs (1930) began as a supplement to Durkheim’s Suicide but became a radical re-orientation of sociological theory. Halbwachs concluded that Durkheim, in spite of his extensive use of replicative analyses, had overlooked the high degree of overlap of the variables he found to be related to suicide rates. The only fundamentally significant independent relation, Halbwachs argued, is between suicide rates and the degree of complexity of a society: thus, the rural style of life (or sociocultural system) is simpler than the urban and therefore has a lower suicide rate. But Halbwachs also rejected Durkheim’s sociologism. He maintained that there is a complementary relation between the motives imputed to suicides and social situations of isolation. To support his theory, Halbwachs presented the most extensive and thorough analysis of official statistics in all of the sociological literature. As we have already said, however, it seems clear that there is a fundamental bias in the official statistics in the direction of underestimating rural rates (Douglas 1965, pp. 195-209).

Social disorganization theories . Unlike almost all other recent sociological works on suicide, the various “ecological” works on suicide have been done quite outside the tradition initiated by Durk-heim. Ruth Cavan’s Suicide (1928), the first of these works, was predominantly influenced by Morselli. Most ecological studies of suicide have relied heavily on some form of social disorganization theory. Various population variables, such as high mobility and complexity, are hypothesized as the causes of a relative lack of effect of social values on behavior (this being the meaning that “social disorganization” usually has for these writers), which in turn is hypothesized as the cause of suicide and similar deviant acts.

The social disorganization approach to suicide involved certain extreme assumptions which have more recently been shown to be clearly unacceptable. For one thing, it assumed cultural homogeneity of values and behavior patterns, that is, it was taken for granted that all of the many ethnic groups of cities like Chicago shared the same values and behavior practices with regard to any form of “deviance,” such as suicide was thought to be. An extensive literature has attacked this assumption when applied to delinquency, and Bayet (1922) has amassed enough evidence to prove that attitudes toward suicide may vary considerably even in a nation with a supposedly homogeneous culture. The social disorganization approach also assumed that cultural values are the only social meanings that determine rates of suicidal actions. But there is no evidence whatsoever in favor of this assumption—and, indeed, it was contradicted by Cavan’s own arguments concerning the importance of spite and other purely personal motives in causing suicide (Cavan 1928).

Cavan’s work, the earliest of the significant ecological works on suicide in America, did not involve the so-called ecological fallacy (for which see Robinson 1950). In fact, Cavan clearly recognized the fundamental principle involved in this fallacy, even to the extent of criticizing the statistical arguments of Morselli and Durkheim in terms of it (1928, p. 289). Realizing what was needed in order to avoid this fallacy, she did attempt to provide evidence regarding individual cases of suicide. In general, she argued that social disorganization causes individual disorganization, and that the latter manifests itself in patterns of increasing inability to cope with crisis situations. In an attempt to demonstrate the validity of this theory, she presented lengthy selections from the personal documents of two individuals who committed suicide. Though it seems clear now that the attempted demonstration involves an imposition of the general category of “individual disorganization” upon the statements of the individuals, it is also clear that Cavan’s work, which was followed in most important details by that of Schmid (1928), involved more consideration of real cases of suicide than any other sociological work to appear before the later 1960s. Moreover, her material on the case of Marion is still among the best available on real cases of suicide (see the discussion in Douglas 1965, pp. 140-167, 471-483).

Recent sociological theories . Most of the recent sociological theories of suicide have been formulated ostensibly within a Durkheimian content, yet most of them are psychosocial theories that are actually quite different from Durkheim’s.

The one theory that actually seems to be socio-logistic in the Durkheimian manner is that proposed by Gibbs and Martin (1964). This theory, although derived from far too simple an interpretation of Durkheim’s Suicide, is true to its positiv-istic aspect in rejecting any consideration of real cases of suicide and in attempting to relate official statistics on official categories (such as marriage) to official statistics on suicide. The basic idea of the theory is that the more socially integrated (or less “conflictful”) a set of statuses (such as age, race, marital status), the more frequently that set of statuses will be occupied by members of the society and the less frequently it will be associated with suicide. This whole approach suffers from all of the weaknesses already detected in Durkheim’s and from some important additional ones. Thus there is almost no consideration of the real-world (as opposed to official) social meanings of statuses, whereas Durkheim did at least make use of well-informed common sense to provide him with social meanings for the status categories he was interested in analyzing. In addition, the “testing” of the theory involved the analysis of only four of the truly immense number of statuses in our society, and all four of these are the standard categories used in analyses of official data on suicide, so that any sociologist making an analysis of the relations between these categories and suicide rates knows what the relations are before he begins (Douglas 1965, pp. 121-135).

Most of the other recent theories of suicide that purport to be sociological—the most significant is that of Henry and Short (1954)—include psychological variables. They almost all agree that socio-economic status change (or “reverse of fortune,” as Brière de Boismont called it) is the basic sociological cause of suicide, but each proposes a different personality theory (frustration-aggression theory, self theory, loss-of-meaning theory, etc.) to explain why some few individuals commit suicide when confronted with a given status change and almost all others do not. The basic problem is that status change is “significantly” related to an immense number of things. These statistical works never involve any demonstration that other factors are not causing both the supposed cause and the suicide. They rarely include consideration of the many alternative, conflicting theories that purport to explain the same official statistics. They generally involve careful arrangement and choice of data so that statistically “significant” results can be obtained. For example, in the work by Henry and Short (1954), social classes in America are dichotomized into high and low, an arrangement which completely obscures the U-functional relationship almost always found to exist between socioeconomic status and official suicide rates in the Western world. Moreover, theoretical argument in these works is frequently quite divorced from statistical analysis; in some cases, the two can be related only through the addition of many ad hoc assumptions (see, for instance, the analysis of Henry & Short 1954 in Douglas 1965, pp. 209-229). In some of these works, changes in the population bases for the official suicide statistics were actually not taken into consideration. For example, some of the most important analyses made by Henry and Short were for periods during which new states were being added almost each year to the U.S. Death Registration Area. This fact had led Dublin and Bunzel (1933) to use only the original Death Registration Area, but Henry and Short completely overlooked the whole problem.

However, a few of these psychosocial works, as this mingling of psychological and sociological approaches can be called, have introduced valuable new orientations into the study of suicide. Thus Breed’s interviews of the surviving families of individuals who committed suicide (1963) have finally introduced into sociology a research method long established in psychiatry. This method has moved sociologists one step further toward direct observation of real-world cases of suicidal events. Indeed, it has shown them that henceforth they must consider the effects of a suicide on others as part of the suicide phenomenon. The case studies reported by psychologists (Deshaies 1947; Schneider 1954) and the sociocultural studies of suicide made by a few anthropologists and psychiatrists (Devereux 1931; Hendin 1964) make clear what should have been obvious to sociologists long ago: suicidal actions are socially meaningful actions, and individuals commit them in order to communicate something to themselves and others about themselves and about others. Even an individual whose primary goal is a state of nonbeing will not commit suicide unless he can do so in such a way as to communicate, to himself and possibly to others as well, just the right meanings. The empirical study of suicidal actions as socially meaningful— cognitively, affectively, and normatively—opens new directions of highly fruitful research and theory (Douglas 1965, especially pp. 377-543).

Only the most comprehensive observation and description of the everyday actions and statements relevant to suicide are likely to result in scientifically useful empirical and theoretical generalizations concerning suicidal actions as socially meaningful actions. Systematic analyses of existing case studies have, however, already resulted in some very important generalizations concerning the social meanings of suicidal actions in the Western world. The best attempt to generalize about suicide in this way for a non-Western society is by Devereux (1931); there are some important contributions to such an approach in other works (see, for instance, Bohannan 1960).

Perhaps the most important high-level generalization about suicide that can be made at this time is that the situated meanings of suicidal acts are often very different from their abstract meanings. In other words, the meaning of a suicidal act for those who are directly involved with it will very rarely be the same as the meaning it has for those who are not so involved, and will certainly not be the same as for the individual who, by committing suicide, is trying to communicate something (Douglas 1965, pp. 406-440). This finding has two fundamental implications for all investigation of the social meanings of suicide and, perhaps, for all of sociology. First, it is not possible to predict or explain specific types of social events, such as suicide, in terms of abstract social meanings, such as values favoring suicide. Second, it is not possible to study the situated social meanings of suicide, which are most important in its causation, without reference to actual instances of suicidal acts with which the individuals to be questioned have been directly involved. This generalization leads one to question the value of any method for investigating any realm of social action if it attempts to abstract members of society from the involvements of their everyday lives.

This does not imply that there are no patterns of meanings common to all the events that members of a society call “suicide” or “suicidal.” When one looks at the meanings imputed to particular suicidal actions, one does find that certain general features tend to recur. Most importantly, any suicidal action is usually believed to mean something fundamental about the self of the individual committing it, or about the situation (especially the persons involved) in which he committed it, or about both of these. Whether the specific meanings realized will be directed to the actor’s self or to his situation will depend on the imputations of causality made by the various persons in the situation: will they see the individual as the cause of his own actions—that is, as “responsible” for them —or will they see him as having been caused (”driven”) to do them by circumstances (loss of job, family trouble, etc.)? The individual committing the suicidal action often attempts to place one of these two general constructions upon the action by pointing out in some way the external cause that is to be “blamed” for his suicide.

There is no one meaning or set of meanings that can be imputed to all (or even most) suicidal actions. Just what meanings are imputed in each case will depend on (1) the intentions of the various actors; (2) the socially perceived ways in which the actions are committed; (3) the specific patterns of suicidal meanings that are realized; (4) the argument processes before, during, and after the suicidal actions. It should be clearly noted that whether or not actions are socially categorized as “suicidal” depends on precisely the same sort of process. The obvious example is that of individuals who with various ends in mind (avoiding embarrassment to their families, loss of insurance money, or disgrace to themselves), arrange suicides that are designed to be taken for accidents.

It is probably not possible for individuals to construct any meanings they please for their actions, though individual creativity does extend the limits immensely, and all cases include imponderable idiosyncrasies. However, the limits remain. There are, first of all, various criteria of plausibility of motives, or rationality, though it is very likely that in some instances individuals intend their actions to be considered implausible or irrational. Second, a relatively few patterns of situated meaning play important parts in most interpretations of particular suicidal actions, and it therefore seems likely that individuals take these patterns into consideration when attempting to construct the meanings of their actions for others. The most common patterns of this sort in the Western world are those involving such motives as the search for help (Sacks 1966), sympathy, escape, repentance, expiation of guilt, self-punishment, and “seriousness” (Douglas 1965, pp. 440-511).

Much careful description and analysis in this area remain to be done (ibid, pp. 511-540). However, the basic problems and the most appropriate methods for solving them now seem clear, and there is great promise of rapid development in both the empirical and the theoretical study of suicide.

Jack D. Douglas

[See also Deviant behavior; Integration, article onsocial integration; Sociology, article onthe early history of social research; and the biographies ofDurkheim; Halbwachs; Quetelet.]

BIBLIOGRAPHY

Achille-Delmas, FranÇois 1932 Psychologie pathologique du suicide. Paris: Alean.

Bayet, Albert 1922 Le suicide et la morale. Paris: Alean.

BenoÎt-Smullyan, Émile 1948 The Sociologism of Émile Durkheim and His School. Pages 499-537 in Harry Elmer Barnes (editor), Introduction to the History of Sociology. Univ. of Chicago Press.

Bohannan, Paul (editor) 1960 African Homicide and Suicide. Princeton Univ. Press.

Breed, Warren 1963 Occupational Mobility and Suicide Among White Males. American Sociological Review 28:179-188.

BriÈre de Boismont, Alexandre 1856 Du suicide et de la folie suicide. Paris: Baillière.

Buckle, Henry Thomas (1857-1861) 1913 The History of Civilization in England. 2d ed. 2 vols. New York: Hearst.

Cavan, Ruth S. 1928 Suicide. Univ. of Chicago Press.

Dahlgren, Karl G. 1945 On Suicide and Attempted Suicide. Lund (Sweden): Universitets Bokhandel.

Deshaies, Gabriel 1947 La psychologie du suicide. Paris: Presses Universitaires de France.

Devereux, George 1931 Mohave Ethnopsychiatry and Suicide. Washington: Government Printing Office.

Douglas, Jack D. 1965 The Sociological Study of Suicide: Suicidal Actions as Socially Meaningful Actions. Ph.D dissertation, Princeton Univ.

Douglas, Jack D. 1966 The Sociological Analysis of Social Meanings of Suicide. Archives européennes de sociologie 7:249-275.

Douglas, Jack D. 1967 The Social Meanings of Suicide. Princeton Univ. Press.

Dublin, Leonard I.; and Bunzel, Bessie 1933 To Be or Not to Be: A Study of Suicide. New York: Smith & Haas.

Durkheim Émile (1897) 1951 Suicide: A Study in Sociology. Glencoe, 111.: Free Press. → First published in French.

Esquirol, Jean-ÉTIENNE D. (1838) 1845 Mental Maladies. Philadelphia: Lea & Blanchard. → First published as Des maladies mentales considérées sous les rapports médical-hygiéniques et médico-legal.

Gibbs, Jack P.; and Martin, Walter T. 1964 Status Integration and Suicide. Eugene: Univ. of Oregon.

Goethe, Johann Wolfgang Von (1811-1833) 1908 Poetry and Truth From My Life. 2 vols. London: Bell. → First published in German.

Guerry, AndrÉ M. 1833 Essai sur la statistique morale de la France. Paris: Crochard.

Halbwachs, Maurice 1930 Les causes du suicide. Paris: Alean.

Hendin, Herbert M. 1964 Suicide and Scandinavia: A Psychoanalytic Study of Culture and Character. New York: Grune.

Henry, Andrew F.; and Short, James F. JR. 1954 Suicide and Homicide: Some Economic, Sociological and Psychological Aspects of Aggression. Glencoe, 111.: Free Press.

Kruijt, Cornelius S. 1960 Zelfmoord: Statistich-sociologische verkenningen. Suicide: Sociological and Statistical Investigations. Assen (Netherlands): Van Gorcum. → Contains a summary in English.

Legoyt, Alfred 1881 Le suicide ancien et moderne. Paris: Droiun.

Morselli, Enrico (1879) 1882 Suicide. New York: Appleton. → First published in Italian.

Quetelet, Adolphe (1835) 1842 A Treatise on Man and the Development of His Faculties. 2 vols. Edinburgh: Chambers. → First published in French.

Robinson, W. S. 1950 Ecological Correlations and the Behavior of Individuals. American Sociological Review 15:351-357.

Sacks, Harvey 1966 The Search for Help: No One to Turn to. Unpublished manuscript.

Schmid, Calvin F. 1928 Suicides in Seattle, 1914 to 1925: An Ecological and Behavioristic Study. University of Washington, Publications in the Social Sciences, Vol. 5, no. 1. Seattle: Univ. of Washington Press.

Schneider, Pierre-B. 1954 La tentative de suicide. Neuchâtel (Switzerland): Delachaux & Niestlé.

Sthahan, Samuel 1893 Suicide and Insanity. London: Sonnenschein.

SÜssmilch, Johann P. (1741) 1788 Die göttliche Ordnung in den Veränderungen des menschlichen Geschlechts, aus der Geburt, dem Tode und der Fort-pflanzung. 3 vols. Berlin: Verlag der Buchhandlung der Realschule.

Tissot, Joseph 1840 De la manie du suicide et de l’esprit de révolte: De leur causes et de leur remèdes. Paris: Lagrange.

Wagner, Adolf H. G. 1864 Die Gesetzmässigkeit in den scheinbar willkuhrlichen menschlichen Handlungen vom Standpunkte der Statistik. Part 2. Statistik willkuhrlichen Handlungen. Hamburg (Germany): Boyes & Geisler.

II. PSYCHOLOGICAL ASPECTS (1)

The clear definition and meaningful classification of various suicidal phenomena are fundamental to advancements in the treatment, prevention, and investigation of self-destruction in man. The purpose of this article is to present some new conceptions of suicidal phenomena, first by identifying current confusions and then by proposing a taxonomic scheme that attempts to embrace many of the diverse aspects of self-destructive behavior.

Definition

As a beginning, a straightforward definition of suicide might read: “Suicide is the human act of self-inflicted, self-intentioned cessation.” At least five points are to be noted in this brief definition: (1) it states that suicide is a human act; (2) it combines both the decedent’s conscious wish to be dead and his actions to carry out that wish; (3) it implies that the motivations of the deceased may have to be inferred and his behaviors interpreted by others, using such evidence as a suicide note, spoken testimony, or retrospective reconstruction of the victim’s intention; (4) it states that the goal of the action relates to death, rather than to self-injury, self-mutilation, or inimical or self-reducing behaviors; and (5) it focuses on the concept of the cessation of the individual’s conscious introspective life. (An explication of the concept of “cessation” may be found in Shneidman 1964.)

Difficulties of definition. Assuming the validity of the definition of suicide cited above—that a human being, with the intention of stopping his life, inflicts upon himself the equivalent of a mortal wound—the meaning would seem clear enough if it were stated that a certain individual had “committed suicide.” On the other hand, confusions of meaning arise immediately if a specific individual is labeled as “suicidal.” Although suicide seems to be not too difficult to define, suicidal phenomena are, in fact, very complicated. Some of the current confusions relating to the term “suicidal” may be listed as follows.

(1) The word “suicidal” is used indiscriminately to cover different categories of behavior. For example, one cannot be sure whether it is being used to convey the idea that an individual has (a) committed suicide, (b) attempted suicide, (c) threatened suicide, (d) exhibited depressive behavior with or without suicidal ideation, or (e) manifested generally self-destructive or inimical patterns. Of recent writers, Stengel and Cook (1958) especially have emphasized the importance of differentiating specifically between data on attempted suicide and data regarding individuals who have committed suicide. But the fact remains that the classification of suicidal behavior currently most common in everyday clinical and research use is a rather homely, supposedly common-sense division: in its barest form it implies that all humanity can be divided into two groupings, suicidal and nonsuicidal; and then, with seeming meaningfulness, it divides the suicidal category into subgroups of committed, attempted, and threatened. Although this elaboration is more sophisticated than the suicidal-versus-nonsuicidal view of life, it remains neither theoretically nor practically adequate for understanding or treatment.

(2) There is constant confusion in respect to the temporal dimension of suicidal acts. One sees the word “suicidal” used to convey the information that an individual was self-destructive (or manifested behavior in any of the other categories listed immediately above), is currently self-destructive, or will be so. This obviously contains confusions among statements that are postdictive (relating to the past), “paridictive” (relating to the more-or-less present), and predictive (relating to the future). Most diagnoses of individual “suicidality” are post hoc definitions in that they refer to those cases in which an individual is labeled as “suicidal” only after he has committed suicide. Statistics on suicide are, of course, based primarily on post hoc definitions of suicide. The primary difficulty in all such cases lies in determining whether or not the individual actually intended to kill himself. The case of the individual who writes a suicide note and then shoots himself is fairly clear, but many cases of death are unclear or equivocal as to mode of death. For example, in the case of an individual who “jumps or falls” from a high place or who is found dead of barbiturate poisoning, the question is often raised whether the case was suicidal or accidental. The coroner’s traditional concern has been with assessing whether God (natural and accidental deaths) or man (suicidal or homicidal deaths) is responsible. The term “suicide” as used by coroners in the certification of death is a medicolegal term and includes, as a sine qua non, the concept that the person played a major role in bringing about his own demise, that is, that it was his intention to die. It should be obvious that statistics on suicide can be greatly influenced (in any city or country) by the manner in which these equivocal deaths are labeled.

(3) There are confusions relating to the characteristics of suicidal behaviors. In many past and current investigations of self-destructive behaviors, several different dimensions of behavior have unfortunately been thrown together. (If one were, for example, studying homicidal phenomena, it is unlikely that he would fail to differentiate among homicides committed on the highway, in the bedroom, during armed robberies, on the field of battle, etc.—and yet a comparable lack of discrimination has been characteristic of many studies of suicidal phenomena.) These issues also relate to the phenomenologic and semantic confusions in the use of the word “suicidal.” Some individuals who “die by their own hand” do not necessarily “commit suicide.” That is to say, they do not, in their own minds, kill themselves or seek death. Instead of fleeing into a vaguely conceptualized “death,” they behave so as to escape from aspects of life. For some the concept of death, or final cessation of being, does not enter into their thinking. They rather indulge in either a planned or a momentary impulsive act—and termination of life is the result. Then we say that they have “committed suicide,” whereas such an individual might conceivably have left a note which states that “. . . all I did was to swallow those pills ... I just wanted some relief at that moment. . . . The tension was so great I had to do something. ... I did not know what I was doing or what would happen. ... It was a gamble. ... I was desperate.. . .” Operationally, it would seem that the key characteristics of suicidal behaviors do not lie in the differences in method (shooting, sedation, cutting, hanging) but rather in the differences in the individual’s life phase, in the lethality of his acts, and in his intention vis-à-vis death, as indicated below in (4), (5), and (6), respectively. That is, it may very well be that the confusions listed above in (1), (2), and (3) might, in large measure, be avoided by making the very distinctions suggested in the subsequent paragraphs.

(4) Many confusions arise because each individual’s attitudes toward his own death are biphasic: that is, any adolescent or adult, at any given moment, has (a) more or less long-range, pervasive, relatively habitual orientations toward his own death. These characterological orientations are an integral part of his total psychological make-up and reflect his philosophy of life, need systems, aspirations, identifications, conscious beliefs, etc. And he is also capable of having (b) relatively short-lived, acute, fairly sudden shifts of his orientations toward his own death. Indeed, this is what is usually meant when one says that an individual has “become suicidal.” It is therefore crucial in any complete assessment of an individual’s orientations toward his own death to know both his habitual and his current (today’s) orientations. Failure to make this distinction is one reason why many current efforts to relate “suicidal state” to psychological test data or to case-history data have been barren and confusing. For individuals in their “normal” (usual for them) state, their habitual and their current orientations toward their own demise will be the same; for individuals who are acutely disturbed, their current orientations toward their demise will often reflect this perturbation. “Being suicidal” involves being disturbed, although not necessarily psychotic.

(5) Popular accounts of “suicidal” behaviors often focus on the method used (for example, wrist cutting) or on the precipitating cause (ill health, losing money) without regard for one of the key dimensions in the assessment of suicidal behavior, namely lethality. The primary clinical goal of any suicide prevention agency is to keep people out of the coroner’s department. Thus, an individual’s unhappiness, perturbation, loneliness, alcoholism, schizophrenia, homosexuality, depression, etc., are relevant in suicide prevention primarily as they bear on the assessment of his lethality potential. To say that an individual has “threatened” suicide or has “attempted” suicide is relatively uninformative without some indications of the potentialities of a lethal outcome with which the threat or attempt was made. Recently, at the Suicide Prevention Center in Los Angeles specific procedures have been evolved for the rapid assessment of the lethality of an individual’s suicidal potential (see Litman & Farberow 1961; Tabach-nick & Farberow 1961).

(6) The most obfuscating confusions relating to suicidal phenomena may occur if the individual’s intentions in relation to his own cessation are not considered. “Suicide” also has an administrative definition. In the United States (and most of the countries reporting to the World Health Organization), “suicide” defined from the point of view of the coroner or vital statistician is simply one of the four modes of death, the others being natural, accidental, and homicide (N-A-S-H). This traditional fourfold classification of all deaths leaves much to be desired. Its major deficiency is that it emphasizes relatively adventitious details in the death (that is, whether the individual was invaded by a lethal virus or a lethal bullet, which may make little difference to the deceased) and, more important, it erroneously treats the human being as a Cartesian biological machine rather than appropriately treating him as a psychosocial organism, thus obscuring the individual’s intentions in relation to his own cessation. Further, the traditional N-A-S-H classification of deaths completely neglects the concepts of contemporary psychology regarding intention and purpose, the multiple determination of behavior, unconscious motivation, etc.

Much of the problem arises because of a confusion between methods and purpose. Although it is true that the act of putting a shotgun in one’s mouth and pulling the trigger with one’s toe is almost always related to lethal self-intention, this particular isomorphic relationship between method and intent does not hold for most other means, such as ingesting barbiturates or cutting oneself with a razor. Individuals can attempt to attempt suicide, attempt to commit suicide, or attempt to be nonsuicidal. Cessation intentions may range all the way from deadly ones, through the wide variety of ambivalences, rescue fantasies, cries for help, and psychic indecisions, all the way to clearly formulated nonlethal intention in which a semantic usurpation of a “suicidal” mode has been consciously employed.

Deaths classified by intention. As a way out of this impasse it is suggested that all deaths—in addition to their being labeled as natural, accidental, suicide, or homicide—also be designated as intentioned, subintentioned, or unintentioned (Shneidman 1963).

Intentioned deaths. An intentioned cessation is one in which the deceased played a direct, conscious role in his own demise. The death was due primarily to the decedent’s conscious wish to stop his conscious life and to his actions in carrying out that wish. In this category would be individuals who seek their own demise, initiate or participate in their own demise, or take calculated risks where the odds are critically unfavorable to their survival, as in Russian roulette, where the individual bets his life on the objective probability of as few as five out of six chances that he will survive.

Subintentioned deaths. Subintentioned deaths are those in which the deceased played an important indirect, covert, partial, or unconscious role in his own demise. The death is suspected to be due in some part to the actions of the decedent which seemed to reflect his unconscious wishes to hasten his death, as evidenced by his own carelessness, foolhardiness, neglect of self, imprudence, resignation to death, mismanagement of alcohol or drugs, disregard of life-saving medical regimen, brink-of-death patterns, etc. This concept of subintentioned death is similar in some ways to Karl Menninger’s concepts (1938) of chronic suicide, focal suicide, and organic suicide, except that these relate to self-defeating ways of continuing to live, whereas the notion of subintentioned death relates to ways of stopping the process of living.

In terms of the traditional N-A-S-H classification of modes of death, it is important to note that some instances of all four types can be found in the category of subintentioned deaths, depending upon the particular details of each case. There is a growing literature on the role of the individual in his own natural, accidental, suicidal, or homicidal death. Subintentioned deaths involve what might be called the psychosomatics of death, that is, cases in which essentially psychological processes—like fear (including fear of voodoo), anxiety, derring-do, hostility, withdrawal, etc.—seem to play some role in exacerbating the catabolic or physiological processes which bring on termination, as well as those cases in which the individual seems to play an indirect, largely unconscious role in inviting or hastening his own demise [see Psychosomatic Illness; see also Gengerelli & Kirkner 1954; Macdonald 1961; Weisman & Hackett 1961; Weiss 1957; Wolfgang 1959].

It can be noted that the subintentioned death implies more than ambivalence toward wanting to be dead and wishing to be rescued (the to-be-or-not-to-be inner dialogue ) found in practically every suicide. It rather reflects the active indirect (largely unconscious) participation of the individual in hastening his own demise.

Unintentioned deaths. Unintentioned deaths are those in which the deceased played no significant psychological role in his own cessation. The death was due entirely to failures within the body or to assault from without (by a bullet, a blow, a steering wheel, etc.) in a decedent who, rather unambivalently, wished to continue to live. Such a person at the time of his death is, as it were, going about his business (even though he may be lying in the hospital) with no conscious intention or strong drive in the direction of effecting or hastening his demise. What happens is that something from the outside—outside of his mind— happens to him. This lethal “something” may be a cerebral vascular accident, a myocardial infarction, some malfunction, some catastrophic catabolism, some invasion—whether by bullet or by virus—which he did not, in any part, himself generate. “It” happens to “him.”

Practical applications. A practical application of the above schematization of death in terms of the individual’s intention has been made since 1960 in Los Angeles. This procedure, labeled the “psychological autopsy” (Curphey 1961; Litman et al. 1963), has been used in those cases that are equivocal as to mode of death. The procedure consists of the use of especially adapted interview techniques to generate psychological information about the deceased. Survivors, friends, and professional acquaintances of the deceased are interviewed. Clues are sought, especially in relation to the prodromal aspects of suicide. A judgment is made along traditional lines (for example, probable suicide, probable accident, probable natural cause, suicide-accident undetermined, suicide-natural undetermined, etc.). An additional judgment is also made in terms of the intentioned, subintentioned, and unintentioned categories. Although one would, a priori, expect all suicidal deaths to be intentioned and all natural, accidental, and homicidal deaths to be unintentioned, the findings in the Los Angeles procedures indicate that the relationship between traditional modes of death and types of intention is a complicated one, with the crucial role occupied by subintentioned deaths.

It might be protested, inasmuch as the assessments of these intentioned states involve the appraisal of unconscious factors, that some workers (especially lay coroners) cannot legitimately be expected to make the psychological judgments required for this type of classification. To this, one answer would be that medical examiners and lay coroners make judgments of this nature every day of the week. The fact is that in the situation of evaluating a possible suicide, the coroner often acts (sometimes without realizing it) as psychiatrist and psychologist and as both judge and jury in a quasi-judicial way. This is because certification of death as suicide does, in itself, imply some judgments of reconstruction of the victim’s motivation or intention. Making these judgments is an inexorable part of a coroner’s function. It might be much better for these psychological dimensions to be made explicit and for an attempt, albeit crude, to be made to use them, rather than for these psychological dimensions to operate on an unverbalized level.

Theoretical and taxonomic positions

We now turn from our consideration of the definitional problems of suicide to a brief historical resume of the major theoretical and taxonomic positions in relation to suicidal phenomena.

Durkheim and other sociological positions . In this century (or at least since 1897, the date of the publication of Durkheim’s Le suicide) there have been two major approaches to the definition and understanding of suicide: the sociological and the psychological. The former historically is identified primarily with Émile Durkheim, French sociologist (1897). Durkheim was interested not so much in suicidal phenomena per se as he was in the explication of his own sociological method. He used the analysis of suicidal phenomena as the occasion to work out four types of factors in suicide—altruistic, egoistic, anomic, and fatalistic—but discussed only the first three.

There are studies generally classified as “sociological” (in the sense that they present statistical or ecological data, but not in the sense that they follow Durkheim’s interest in explaining the variety of man’s moral commitments to his society) which are worthy of note, among them Sainsbury (1955) and Stengel and Cook (1958) in England, and Dublin (1963) in the United States. Dublin’s book, especially, furnishes the student with an encyclopedia of statistical information about suicide phenomena.

Freudian and other psychological positions . The psychological approach is identified primarily with Freud, who is generally acknowledged to have first stated comprehensive psychological insights into suicide. Freud’s conceptualization of suicide (1917a; 1917b) was that of a primarily intra-psychic phenomenon, stemming from within the mind, primarily the unconscious mind, of the individual. In one of his formulations Freud envisaged suicide as being the result of a process wherein feelings of love and affection which had originally been directed toward an internalized love object had become, as a result of rejection and frustration, angry, hostile feelings; however, because the object had become internalized and part of the self, the hostile feelings were then directed toward the self. Thus suicide, from a psychoanalytic point of view, might be described as murder in the 180th degree.

The classical Freudian approach not only tended rather systematically to ignore social factors but also tended to focus on a single complex or psychodynamic constellation. But we now know that individuals kill themselves for a number and variety of psychologically felt motives: not only hate and revenge, but also dependency, shame, guilt, fear, hopelessness, loyalty, fealty to self-image, pain, and even ennui. Just as no single formula or pattern can be found to explain all human homosexuality or prostitution, so no single psychological pattern is sufficient to contain all human self-destruction. (For a comprehensive review of this topic, see Litman 1967.)

Synthesis—the concept of self. The synthesis of the psychological position, with its clinical emphasis on the individual internal drama within the single mind, and the sociological position, discussed in the previous article, remains to be accomplished. A recent study bearing on this point (Shneidman & Farberow 1960) emphasized the interplay between both the social and psychological factors as mutually enhancing roles in each individual’s suicide. This finding is consistent with that of Halbwachs (1930), whose position—unlike that of his mentor, Durkheim—was that the “social” and “psychopathological” explanations of suicide are complementary rather than antithetical. A synthesis of these two lies in the area of the “self,” especially in the ways in which social forces are incorporated within the totality of the individual. In understanding suicide, one needs to know the thoughts and feelings and ego functionings and unconscious conflicts of an individual, as well as how he integrates with his fellow man and participates morally as a member of the groups within which he lives.

Taxonomic positions . Not many classifications of suicidal phenomena have been proposed. Durk-heim’s classification distinguished between anomic, egoistic, and altruistic suicide (1897). To this can be added Menninger’s classification of the sources of suicidal impulses, namely the wish to kill, the wish to be killed, and the wish to die (1938). Menninger also classified subsuicidal phenomena into chronic suicide (asceticism, martyrdom, addiction, invalidism, psychosis); focal suicide (self-mutilation, malingering, multiple accidents, impotence and frigidity); and organic suicide (involving the psychological factors in organic disease). A composite listing of other rubrics would include the following: suicide as communication; suicide as revenge; suicide as fantasy crime; suicide as unconscious flight; suicide as magical revival or reunion; suicide as rebirth and restitution. A classification of suicidal types in terms of cognitive or logical styles has been proposed (Shneidman 1961). This classification, which stemmed from the logical analysis of suicide notes, divides the thinking styles of suicides into three types: logical, catalogical, and paleological.

Thus, in general, we see that the term “suicidal” is a broad one, starting from a base line of the individual who consciously and advertently takes his own life, through those individuals who by virtue of their unconscious mechanisms hasten their demise, through those individuals who indulge in partial or focal or chronic suicide, and perhaps even to those many individuals who by their own daily inimical acts truncate and diminish the full scope of their potential self-actualizations.

A concluding note concerning the current professional status of suicide prevention: Since 1955 there has been a marked spurt in interest in suicide prevention activities. In the United States, in 1958, there were 3 suicide prevention centers; in 1960, there were 5; in 1964, 9; in 1965, 15; and in 1967, 40. A Center for Studies of Suicide Prevention was established within the National Institute of Mental Health (NIMH) in 1966. A new multidisciplinary profession, suicidology—the scientific and humane study of human self-destruction—has come into being; special training courses in suicidology are offered at Johns Hopkins University.

Edwin S. Shneidman

[See alsoDeath. Other relevant material may be found in Psychoanalysis; Self concept; Medical care; and in the biography of Durkheim.]

BIBLIOGRAPHY

The bibliography for this article is combined with the bibliography of the article that follows.

III. PSYCHOLOGICAL ASPECTS (2)

The continuum of suicidal activity comprises total self-destruction (death); self-injury (but non-lethal), including crippling, maiming, painful and nonpainful activities; threats and other verbalized indications of intention toward self-destruction or self-injury; feelings of despair, depression, and unhappiness (which may not include thoughts of self-injury, but frequently do); and thoughts of separation, departure, absence, and relief and release. Somewhere within this continuum the thought or impulse becomes translated into action. The clinical impression is that once the psychological defenses against suicidal activity have been breached and the action has occurred, the possibility for further future acting out when emotional tension and strain recur is facilitated. It seems likely also that increasingly serious behavior results, possibly because of feelings of guilt or of feelings that such behavior is necessary in order to communicate with equivalent impact. The factor that determines the behavior remains puzzling. Perhaps the controls developed through coping mechanisms and defense patterns, brought to bear at different levels of dysfunctioning (Menninger 1963), play a crucial role, and the intensive study of these might provide the understanding necessary for suicide prevention for different individuals in various suicidal situations.

Characteristics of the suicidal person . The identification of the suicidal person is not especially difficult once the process has begun. Most persons considering self-destruction will identify themselves by communicating this tendency either behaviorally or verbally long before any specific act occurs. The typical suicidal person will generally reveal all or most of the following characteristics: (1) ambivalence—the desire, either conscious or unconscious or both, to live and to die, present at the same time; (2) feelings of hopelessness and helplessness, futility, and inadequacy to handle problems; (3) feelings of either physical or psychological exhaustion, or both; (4) marked feelings of unrelieved anxiety or tension, depression, anger, and/or guilt; (5) feelings of chaos and disorganization with inability to restore order; (6) mood swings, for example, from agitation to apathy or withdrawal; (7) cognitive constriction, inability to see alternatives, limitation of potentialities; (8) loss of interest in usual activities, such as sex, hobbies, and work; (9) physical distress, such as insomnia, anorexia, psychasthenia, and psychosomatic symptoms.

Prediction of lethal behavior . The more difficult problem is the evaluation of the suicidal person in terms of the relatively immediate potentiality of lethal acting out. The suicidal crisis presents the professional person with the need for quick appraisal. A schedule, evolved from experiences in the Suicide Prevention Center in Los Angeles, lists the following criteria used in evaluation of the emergency situation (see Litman & Farberow 1961). (1) Age and sex: older white males generally have the highest suicidal potentiality; a young female, on the other hand, is usually less lethally suicidal. (2) Suicidal plans: specificity about time, place, and method, plus the means for carrying out a plan, indicate high suicidal danger; vague, diffuse talk by a nonpsychotic about dying indicates that the situation is less serious. (3) Resources: external sources of support and interest, such as family, relatives, friends, physician, or hospital, are helpful; when the patient’s resources are exhausted the suicidal potentiality rises. (4) Prior suicidal behavior: a past history of suicidal behavior indicates greater present danger, and the seriousness of the prior suicide attempt adds an additional important consideration. (5) Onset of suicidal behavior: the acute suicidal crisis may be more immediately serious but also more amenable to intervention. The chronically suicidal person, especially the alcoholic or borderline schizophrenic, who presents repeated feelings of depression, is the more serious long-term therapeutic problem. (6) The medical situation: many patients visit physicians with minor physical complaints which are in reality indications of severe depression. Studies (Motto & Greene 1958; Robins et al. 1959; Dorpat & Ripley I960; and Shneidman & Farberow 1961) have indicated that more than 50 per cent of the patients who had committed suicide had seen their physicians within three months prior to their deaths. (7) Loss of a loved one: where death, separation, quarrel, or divorce from someone close has recently occurred, the suicidal potentiality is increased. (8) Communication: if communication still exists between the patient and others the suicidal risk is lowered; when the communication breaks and the person withdraws the danger increases. (9) Reaction of the referring person: if interest and concern about the patient continue, this is helpful. If, however, the referring person is angry, rejecting, and attempting to rid himself of responsibility, the potentiality is increased.

Psychological theories

The psychological theories have been summarized by Jackson (1957), who divided them roughly into nonpsychoanalytic and psychoanalytic.

Nonpsychoanalytic formulations . The nonpsychoanalytic formulations refer to “exhaustion” causing restriction of the field of consciousness so that an “organic depression” occurs; failure of adaptation; a disturbance of balance of will to live from a dynamic fixation of infantile attachment; infantile protest and hostility against harsh, restraining figures; narcissism in a rigid personality; compensations for homicidal impulses against members of the immediate family; and spite in children.

Psychoanalytic formulations . Most of the psychoanalytic theories stern from two of Freud’s theoretical contributions: his elaboration of the dynamics of depression in Mourning and Melancholia (1917b) and his postulations of the death instinct in Beyond the Pleasure Principle (1920). Depression, and consequently suicide, occurs as a result of strong, aggressive urges directed against an introjected object formerly loved but now hated. Menninger (1938) adopts the concept of a death instinct and elaborates it by postulating three elements in suicide: a wish to kill, a wish to be killed, and a wish to die. Zilboorg (1936; 1937) considers suicide a way of thwarting outside forces and one method of gaining immortality. O’Connor (1948) adds the feeling that the person achieves omnipotence by a return to early power narcissism. Palmer (1941) suggests that arrested psychosexual development as a result of the unavailability of important figures at crucial stages is the basic mechanism. Garma (1943) stresses the loss of an important love object, suicide being used to recover it. Bergler (1946) describes the introjec-tion suicide, aggression against guilt feelings; hysteric suicide, unconscious dramatization of how one does not want to be treated; and the miscellaneous type, such as paranoid schizophrenics reacting to voices. Farberow (1961), in the collection The Cry for Help, summarizes his contributors’ several theoretical approaches to suicide. To the formulations already presented above, some of his contributors add frustrated dependency; longing for spiritual rebirth and seeking to re-establish contact with the self by destruction of the ego; strong inferiority feelings and veiled aggression in dependent individuals with “pampered life style”; a depressive, hateful type of personality structure developed from interpersonal experiences; alienation and feelings of disparity between idealized self and real self; and the person’s attempts to validate his self according to his own “constructions.”

Contributing factors

From the variety of theories and multitude of factors in suicide, it is apparent that suicidal phenomena are both widespread and complex. They reflect common sociological roots and influences and, at the same time, express singular personal experiences and impulses. A psychology of suicide must take as many such factors as possible into account if understanding is to be attained. A single schema encompassing the major factors which enter into the understanding of any suicidal event can, as yet, be only a desirable goal. The following factors are necessary considerations in any comprehensive overview of suicidal behavior.

Sociological background . It is obvious that any event needs to be viewed in the setting within which it occurs, but suicide especially has varying significance when it takes place in such widely different countries as, for example, Denmark, Italy, Japan, or the southern part of the United States. National differences are further compounded by racial, religious, and economic factors. Similarities and specific differences will be found. Studies of suicide in some of the tribes of east Africa (Bohannan 1960) and in aboriginal tribes of central India (Elwin 1943) have shown motives remarkably similar to those of Western cultures, for example, domestic strife or loss of social status, as well as features specific to these tribes, such as intervention by the gods or bewitchment by ghosts.

Fluctuations of economic status or the changing political scene influence suicide. For example, suicide has varied with economic depressions, as when the rate soared in the United States during the depression of the mid-1930s and dropped markedly during the war years of the 1940s. An investigation by Arkun (1963) of the suicide rates in Turkey during the periods from 1927 to 1946 (after sweeping social reforms) and 1950 to 1960 (after World War n) showed startling changes in rates which, during the earlier period, could be attributed to the upheavals in the culture of Turkey and especially to the change in the role of women because of the reforms of Ataturk. Japan’s suicide rate has always been high; but whereas in ancient times the traditions of hara-kiri and seppuku were prominent, today much of the suicide rate is contributed to by a younger age group, such as students in universities who are faced with failure or fear of it (Iga 1961).

Cultural background . Cultures often surround death with taboos and rituals which illustrate feelings about death and dying and which include attitudes toward suicide. Myths and folklore illustrate some of the attitudes, as in the history of the Vikings and the tales of Valhalla, and contribute to the condemnation or condoning of suicide.

The culture may also determine interpersonal relationships that influence the occurrence of suicide. Hendin (1964) examines the “Scandinavian suicide phenomenon” and arrives at an explanation for the high suicide rates in Denmark and Sweden in contrast to those in Norway by a determination of the “psychosocial characteristics.” Using psychoanalytic methods, he finds differences in the psychodynamic constellations of the three countries, such as in dependency aspects, attitudes toward performance and accomplishment, handling of aggression and guilt feelings, relationships between the sexes, methods of discipline, and other dynamic features.

Individual demographic characteristics . Epidemiological aspects of suicide, such as age, sex, nationality, race, religion, marital status, education, financial status, have all been studied exhaustively for various countries (Dublin 1963). Where the individual falls in respect to each of these provides immediately invaluable information about the suicidal person. Important to include here also is the physical and mental status of the individual. A chronic, debilitating, or possibly fatal illness such as emphysema, cardiac disease, or cancer, or a recurrent mental illness which hospitalizes the individual for several months every two or three years will obviously influence the individual suicide (Farberow et al. 1963; Shneidman et al. 1962).

Psychological factors . It is within the psychological factors that the core of the problem of understanding suicide is met. These factors include not only the current personality status and psycho-dynamic constellations of the individual in question but also the motivations for his suicidal behavior, the reasons why his actions, thoughts, or feelings lead him to suicide. The categorization of motivations into interpersonal and intrapersonal factors seems to offer a meaningful classification of many of the various phenomena. The distinction is arbitrary, of course, for it is practically impossible for a suicide to occur without both types of relationships being involved. Nevertheless, one or the other aspect will often predominate.

Interpersonal motivations in suicide occur when the suicidal person attempts by his behavior either to bring about an action on the part of another person or persons or to effect a change in attitude or feeling within another person or persons, or both. The suicidal behavior can thus be seen as a means to influence, persuade, force, manipulate, stimulate, change, dominate, reinstate, etc., feelings or behavior in someone else. The other person is most often someone who has been in a close relationship, such as spouse, fiancee, or member of the family. Infrequently, the object of the behavior is more generalized, and it may be society itself.

Interpersonal motivations can be found, of course, in all ages but are usually predominant in the younger and middle-aged groups. A typical example is that of the girl between the ages of 20 and 25 who is reacting with strong feelings of rejection to a quarrel with a loved one or to divorce or separation. Her emotional state is one of agitation, dependency, immaturity, poor judgment, and impulsivity. Her suicidal behavior is used to express anger or feelings of rejection and to force a change in the rebuffing person or to arouse guilt feelings in him. Much of the behavior is still verbal, some is impulsive acting out, and most of it contains an “appeal” element (Stengel & Cook 1958).

Less often the aim is the expiation of or the need to express the guilt the person feels for having done something either imaginary or real in the relationship with another person. Ambivalence about dying is relatively low, inasmuch as the person, despite the fact that he is engaging in suicidal behavior, does not usually wish to die.

Intrapersonal motivations appear most often in older persons and thus in situations in which ties with others have dissipated. The individual’s action seems aimed primarily at expressing the pressures and stresses from within and at fulfilling important needs in himself. The typical person is a male aged 60 or over who has recently suffered the death of a loved one, whose physical condition has deteriorated so that there is illness or pain, or whose children are married and so live their own separate lives. There are intense feelings of loneliness, feelings of not being needed any longer, of no longer being able to work effectively, perhaps because of physical condition, or of feeling that life has been lived and holds no more. The mood is often depressed, withdrawn, and physically and emotionally exhausted. There may be strong need for expiation and for atonement stemming from excessive feelings of guilt. An important dynamic is the need to maintain “psychological integrity” (Appelbaum 1963) or self-esteem or self-concept, even by the paradoxical act of self-destruction. Ambivalence is again low inasmuch as the person, if he embarks on a suicidal course, usually does so with full intent to die. [See Aging, article onpsychological aspects.]

Some cases of suicide occur in which it is difficult to distinguish whether interpersonal or intra-personal motivations are predominant. Rather it seems that each is equally present, although perhaps not always in the same strength at the same time. A typical example is a middle-aged person, the precipitating suicidal stimulus is the death of a loved one, separation, divorce, loss of job, loss of status, or sometimes a crippling, debilitating illness. Such a person is generally depressed, anxious, frustrated, and sometimes agitated, showing poor judgment and disorganization which will sometimes extend to psychotic or near-psychotic proportions. Marked symptoms of frustrated dependency, hostility, and aggression, perhaps because of rejection or masochism, and the two elements “appeal” and “ordeal” are readily seen (Stengel 1956). The ordeal element is especially apparent in the greater ambivalence about dying and the marked tendency to leave survival up to fate, destiny, or chance. Suicidal attempts are usually more lethal, but there are also more provisions for rescue, both conscious and unconscious.

Importance of work. Work takes on special significance for this group. Often with premature dissolution of relationships in the middle-aged group, work becomes the principal source of self-significance and self-esteem. The nonpersonal aspects of the work itself, rather than the people involved with whom interaction on the job occurs, become important. So long as the person is able to function in his job and to lose himself in its details, there is sufficient defense against suicidal impulses. For the very severely and chronically depressed person, work may provide a cover for the feeling of emptiness and void from which he is continually trying to escape. The routine of work keeps him busy and prevents him from thinking about himself. Not to work provides him with time during which he is free to think about himself and to feel useless and empty. Once the work is lost, perhaps through some personal difficulty, physical crisis, or enforced retirement, a crucial defense seems to be breached and suicidal impulses will burst through.

Can any suicide be entirely intrapersonal? One suggestion has been that this may occur only in the psychotic. However, the problem may well be only one of understanding on the part of the observer. The psychotic may be reacting entirely on an interpersonal basis but in a bizarre or devious process which simply is not comprehended by others.

Feelings about death and the afterlife. Most often the individual simply reflects the prevailing attitudes of his culture about suicide, death, or life after death. However, the individual may arrive at his own conceptualizations, which may vary markedly. Convictions of eternal peace after death, of the possibility of reunion with a deceased loved one, visions of hell-fire and brimstone, or of pain and unmitigated suffering, belief in the supernatural, or faith in magic may be key factors in an individual’s suicidal behavior.

Communication . Seen as a communication process, suicidal behavior often achieves clearer perspective. In most instances, the suicidal activity occurs at the end of a long train of events that have finally led the person to the decision that life is no longer worth living. Accompanied by many communications along this course, the suicidal act itself then becomes a communication which may have many meanings and much significance. The communication in suicidal behavior can be grouped under five headings. (1) Form: the communication may be verbal, including written, or nonverbal and behavioral. (2) Directness or indirectness: the communication may be straightforward and clear, or disguised and indirect. Withdrawal, giving away prized possessions, remarks about not needing articles, fantasies of death, burial, or rescue from dangerous situations may occur. (3) Substance or content: the communication may contain expressions of affect, either fixing or expiating guilt or blame, explanations of the suicidal act, or instructions and directions to survivors, as in wills and suicide notes (Shneidman & Farberow 1957a; Tuckman et al. 1959). (4) Object of the communication: in most interpersonal situations, the communication is directed to a specific person or persons; in intrapersonal motivations it is more often directed to society in general. (5) Purpose: the communication may be overt or indirect in aim. Sometimes it is a cry for help, a plea to be stopped or to be rescued, a means for expression of hostility and hate, a final fixing of blame, a way to cause shame or arouse guilt, or a way to assume blame, absolve others, and expiate one’s own guilt.

Countersuicidal controls

The factors that mitigate against suicide are as important as those that influence toward it. In many instances, the fact that self-destruction is not chosen as the way out of seemingly unbearable situations—as in the concentration camps of Germany, or when the individual is subject to continuous pain and discomfort in the terminal stages of cancer—impresses the observer. The controls may be external or internal.

External controls . External controls refer to all the controls that society may bring to bear on an individual to keep him conforming and alive, such as taboos, religion, myths, mores, group and subgroup identifications, marriage, family, children. Also significant are the actions of others toward the individual. Indications of support, understanding, interest, and concern, especially on the part of the “significant other” but also by hospital and professional personnel, may be the essential preventive factor.

Internal controls . Internal controls may stem from the ideals, standards, morality, conscience, or feelings of responsibility of the individual. In addition, the ego structure of the individual may provide him with flexibility, adaptability, independence, and feelings of self-esteem which will permit him to endure severe emotional stress. Or he may be more vulnerable because of rigidity, overdependence, and poor self-concept.

Psychology of the survivors

The suicide has great impact on the survivors, regardless of whether it had predominantly interpersonal or intrapersonal motives. These reactions generally vary directly in intensity with distance of relationship with the suicidal person. Among the group in a close relationship, the spouse, children, family, relatives, close friends, or therapist, a variety of feelings and reactions may be aroused. These may include (1) strong feelings of loss, accompanied by sorrow and mourning; (2) strong feelings of anger for (a) being made to feel responsible, or (b) being rejected in that what was offered was refused; (3) guilt, shame, or embarrassment with feelings of responsibility for the death; (4) feelings of failure or inadequacy that what was needed could not be supplied; (5) feelings of relief that the nagging, insistent demands have ceased; (6) feelings of having been deserted, especially true for children; (7) ambivalence, with a mixture of all the above; (8) reactions of doubt and self-questioning whether enough was attempted; (9) denial that a suicide has occurred, with a possible conspiracy of silence among all concerned; and (10) arousal of one’s own impulses toward suicide.

Among those in a more distant relationship, such as neighbors, employer or fellow employees, the hospital, or society, the reactions may also be those of (1) anger because of (a) a feeling that the suicidal person has rejected his social and moral responsibilities, or (b) being made to feel responsible, or (c) an implied accusation of not enough concern, interest, or caring about its members and fellow man; (2) guilt that not enough was offered to make the person want to live; (3) rejection, resulting from the suicidal person’s obvious choice to do without them; and (4) uneasiness, manifested by a vague need for self-examination to determine what was wrong or to rationalize the discomfort away.

Norman L. Farberow

[See alsoDeath. Other relevant material may be found in Depressive disorders; Medical care; and in the biography of Durkheim.]

BIBLIOGRAPHY

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Dublin, Louis I. 1963 Suicide: A Sociological and Statistical Study. New York: Ronald.

Durkheim, ÉMILE (1897) 1951 Suicide: A Study in Sociology. Glencoe, 111.: Free Press. → First published in French.

Elwin, Verrier 1943 Maria Murder and Suicide. Oxford Univ. Press.

Farberow, Norman L. 1961 Summary. Pages 290-321 in Norman L. Farberow and Edwin S. Shneidman (editors), The Cry for Help. New York: McGraw-Hill.

Farberow, Norman L.; and Shneidman, Edwin S. (editors) 1961 The Cry for Help. New York: McGraw-Hill. → Contains a bibliography on suicide, 1897-1957, on pages 325-388.

Farberow, Norman L.; SHNEIDMAN, E. S.; and Leonard, C. V. 1963 Suicide Among General Medical and Surgical Hospital Patients with Malignant Neoplasms. U.S. Veterans Administration, Medical Bulletin No. 9. Washington: Veterans Administration.

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Freud, Sigmund (1917b) 1959 Mourning and Melancholia. Volume 4, pages 152-170 in Sigmund Freud, Collected Papers. International Psycho-analytic Library, No. 10. London: Hogarth; New York: Basic Books. → Authorized translation from the German under the supervision of Joan Riviere. The first English edition was published in 1925.

Freud, Sigmund (1920) 1950 Beyond the Pleasure Principle. Authorized translation from the 2d ed., by C. J. M. Hubback. International Psycho-analytic Library, No. 4. New York: Liveright. → First published as Jenseits des Lustprinzips. A paperback edition, translated by James Strachey, was published in 1959 by Bantam Books.

Gahma, Angel (1943) 1944 Sadism and Masochism in Human Conduct: Part 2. Journal of Clinical Psycho-pathology and Psychotherapy 6:355-390. → First published in Spanish.

Gengerelli, Joseph A.; and Kirkner, Frank J. (editors) 1954 The Psychological Variables in Human Cancer, A symposium presented at the Veterans Administration Hospital, Long Beach, California, October 23, 1953. Berkeley: Univ. of California Press.

Halbwachs, Maurice 1930 Les causes du suicide. Paris: Alean.

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Iga, Mamoru 1961 Cultural Factors in Suicide of Japanese Youth With Focus on Personality. Sociology and Social Research 46:75-90.

Jackson, Don D. 1957 Theories of Suicide. Pages 17-21 in Edwin S. Shneidman and Norman L. Farberow (editors), Clues to Suicide. New York: McGraw-Hill.

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Litman, Robert E. 1967 Sigmund Freud on Suicide. Unpublished manuscript.

Litman, Robert E.; and Farberow, Norman L. 1961 Emergency Evaluation of Self-destructive Potentiality. Pages 48-59 in Norman L. Farberow and Edwin S. Shneidman (editors), The Cry for Help. New York: McGraw-Hill.

Litman, Robert E. et al. 1963 Investigations of Equivocal Suicides. Journal of the American Medical Association 184:924-929.

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Menninger, Karl A. 1938 Man Against Himself. New York: Harcourt.

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National Institute OF Mental HealthBulletin of Suicidology. → Published since 1967.

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Suicide

Suicide

Definition

Suicide is defined as the intentional taking of one's own life. Prior to the late nineteenth century, suicide was legally defined as a criminal act in most Western countries. In the social climate of the early 2000s, however, suicidal behavior is most commonly regarded and responded to as a psychiatric emergency.

Description

Suicide is considered a major public health problem around the world as well as a personal tragedy. According to the National Institute of Mental Health (NIMH), suicide was the eleventh leading cause of death in the United States in 2000, and the third leading cause of death for people between the ages of 15 and 24. About 10.6 out of every 100,000 persons in the United States and Canada die by their own hands. There are five suicide victims for every three homicide deaths in North America as of the early 2000s. There are over 30,000 suicides per year in the United States, or about 86 per day; and each day about 1900 people attempt suicide.

The demographics of suicide vary considerably within Canada and the United States, due in part to differences among age groups and racial groups, and between men and women. Adult males are three to five times more likely to commit suicide than females, but females are more likely to attempt suicide. Most suicides occur in persons below the age of 40; however, elderly Caucasians are the sector of the population with the highest suicide rate. Americans over the age of 65 accounted for 18 percent of deaths by suicide in the United States in 2000. Geographical location is an additional factor; according to the Centers for Disease Control and Prevention (CDC), suicide rates in the United States are slightly higher than the national average in the western states, and somewhat lower than average in the East and the Midwest.

Race is also a factor in the demographics of suicide. Between 1979 and 1992, Native Americans had a suicide rate 1.5 times the national average, with young males between 15 and 24 accounting for 64% of Native American deaths by suicide. Asian American women have the highest suicide rate among all women over the age of 65. And between 1980 and 1996 the suicide rate more than doubled for black males between the ages of 15 and 19.

Causes & symptoms

Causes

Suicide is a complex act that represents the end result of a combination of factors in any individual. These factors include biological vulnerabilities, life history, occupation, present social circumstances, and the availability of means for committing suicide. While these factors do not "cause" suicide in the strict sense, some people are at greater risk of self-harm than others. Risk factors for suicide include:

  • Male sex.
  • Age over 75.
  • A family history of suicide.
  • A history of previous suicide attempts.
  • A history of abuse in childhood.
  • A local cluster of recent suicides or a local landmark associated with suicides. Examples of the latter include the Golden Gate Bridge in San Francisco; Sydney Harbor Bridge in Australia; St. Peter's Basilica in Rome; the Eiffel Tower in Paris; Prince Edward Viaduct in Toronto; and Mount Mihara, a volcano in Japan.
  • Recent stressful events: separation or divorce, job loss, bankruptcy, upsetting medical diagnosis, death of spouse.
  • Medical illness. Persons in treatment for such serious or incurable diseases as AIDS, Parkinson's disease, and certain types of cancer are at increased risk of suicide.
  • Employment as a police officer, firefighter, physician, dentist, or member of another high-stress occupation.
  • Presence of firearms in the house. Death by firearms is the most common method for women as well as men as of the early 2000s. In 2001, 55% of reported suicides in the United States were committed with guns.
  • Alcohol or substance abuse. Mood-altering substances are a factor in suicide because they weaken a person's impulse control.
  • Presence of a psychiatric illness. Over 90% of Americans who commit suicide have a significant mental illness. Major depression accounts for 60% (especially in the elderly), followed by schizophrenia, alcoholism, substance abuse, borderline personality disorder, Huntington's disease, and epilepsy. The lifetime mortality due to suicide in psychiatric patients is 15% for major depression; 20% for bipolar disorder; 18% for alcoholism; 10% for schizophrenia; and 5-10% for borderline and certain other personality disorders.

Neurobiological factors may also influence a person's risk of suicide. Post-mortem studies of the brains of suicide victims indicate that the part of the brain associated with aggression and other impulsive behaviors (the frontal cortex) has a significantly lower level of serotonin, a neurotransmitter associated with mood disorders. Low serotonin levels are correlated with major depression. In addition, suicide victims have higher than normal levels of cortisol, a hormone produced in stressful situations, in the tissues of their central nervous system. Other research has indicated that abuse in childhood may have permanent effects on the level of serotonin in the brain, possibly "resetting" the level abnormally low. In addition, twin studies have suggested that there may be a genetic susceptibility to both suicidal ideation and suicide attempts which cannot be explained by inheritance of common psychiatric disorders.

Some psychiatrists propose psychodynamic explanations of suicide. According to one such theory, suicide is "murder in the 180th degree" that is, the suicidal person really wants to kill someone else but turns the anger against the self instead. Another version of this idea is that the suicidal person has incorporated the image of an abusive parent or other relative in their own psyche and then tries to eliminate the abuser by killing the self.

Diagnosis

When a person consults a doctor because they are thinking of committing suicide, or they are taken to a doctor's office or emergency room after a suicide attempt, the doctor will evaluate the patient's potential for acting on their thoughts or making another attempt. The physician's assessment will be based on several different sources of information:

  • The patient's history, including a history of previous attempts or a family history of suicide.
  • A clinical interview in which the physician will ask whether the patient is presently thinking of suicide; whether they have made actual plans to do so; whether they have thought about the means; and what they think their suicide will accomplish. These questions help in evaluating the seriousness of the patient's intentions.
  • A suicide note, if any.
  • Information from friends, relatives, or first responders who may have accompanied the patient.
  • Short self-administered psychiatric tests that screen people for depression and suicidal ideation. The most commonly used screeners are the Beck Depression Inventory (BDI), the Depression Screening Questionnaire, and the Hamilton Depression Rating Scale.
  • The doctor's own instinctive reaction to the patient's mood, appearance, vocal tone, and similar factors.

Treatment of attempted suicide

Suicide attempts range from well-planned attempts involving a highly lethal method (guns, certain types of poison, jumping from high places, throwing oneself in front of trains or subway cars) that fail by good fortune to impulsive or poorly planned attempts using a less lethal method (medication overdoses, cutting the wrists). Suicide attempts at the less lethal end of the spectrum are sometimes referred to as suicide gestures or pseudocide. These terms should not be taken to indicate that suicide gestures are only forms of attention-seeking; they should rather be understood as evidence of serious emotional and mental distress.

A suicide attempt of any kind is treated as a psychiatric emergency by the police and other rescue personnel. Treatment in a hospital emergency room includes a complete psychiatric evaluation; a mental status examination ; blood or urine tests if alcohol or drug abuse is suspected; and a detailed assessment of the patient's personal circumstances (occupation, living situation, family or friends nearby, etc.). The patient will be kept under observation while decisions are made about the need for hospitalization.

A person who has attempted suicide can be legally hospitalized against his or her will if he or she seems to be a danger to the self or others. The doctor will base decisions about hospitalization on the severity of the patient's depression; the availability of friends, relatives, or other social support; and the presence of other suicide risk factors, including a history of previous suicide attempts, substance abuse, and psychosis (loss of contact with reality, often marked by delusions and hallucinations ). If the attempt is judged to be a nonlethal suicide gesture, the patient may be released after the psychiatric assessment is completed. According to CDC figures, 132,353 Americans were hospitalized in 2002 following suicide attempts while 116,639 were released following emergency room treatment.

Related issues

Survivors of suicide

One group of people that is often overlooked in discussions of suicide is the friends and family left behind by the suicide. It is estimated that each person who kills him- or herself leaves six survivors to deal with the aftermath; thus there are at least 4.5 million survivors of suicide in the United States. In addition to the grief that ordinarily accompanies death, survivors of suicide often struggle with feelings of guilt and shame as well. They often benefit from group or individual psychotherapy in order to work through such issues as wondering whether they could have prevented the suicide or whether they are likely to commit suicide themselves. The American Foundation for Suicide Prevention (AFSP) has a number of online resources available for survivors of suicide.

Assisted suicide

One question that has been raised in developed countries as the average life expectancy increases is the legalization of assisted suicide for persons suffering from a painful terminal illness. Physician-assisted suicide has become a topic of concern since it was legalized in the Netherlands in 2001 and in the state of Oregon in 1997. It is important to distinguish between physician-assisted suicide and euthanasia, or "mercy killing.". Assisted suicide, which is often called "self-deliverance" in Britain, refers to a person's bringing about his or her own death with the help of another person. Because the other person is often a physician, the act is often called "doctor-assisted suicide." Euthanasia strictly speaking means that the physician or other person is the one who performs the last act that causes death. For example, if a physician injects a patient with a lethal overdose of a pain-killing medication, he or she is performing euthanasia. If the physician leaves the patient with a loaded syringe and the patient injects himself or herself with it, the act is an assisted suicide. As of early 2005 assisted suicide is illegal everywhere in the United States except for Oregon, and euthanasia is illegal in all fifty states.

Media treatment of suicide

The Centers for Disease Control and Prevention (CDC) sponsored a national workshop in April 1994 that addressed the connection between sensationalized media treatments of suicide and the rising rate of suicide among American youth. The CDC and the American Association of Suicidology subsequently adopted a set of guidelines for media coverage of suicide intended to reduce the risk of suicide by contagion.

The CDC guidelines point out that the following types of reporting may increase the risk of "copycat" suicides:

  • Presenting oversimplified explanations of suicide, when in fact many factors usually contribute to a person's decision to take their own life.
  • Excessive or repetitive local news coverage.
  • Sensationalizing the suicide by inclusion of morbid details or dramatic photographs.
  • Giving "how-to" descriptions of the method of suicide.
  • Describing suicide as an effective coping strategy or as a way to achieve certain goals.
  • Glorifying the act of suicide or the person who commits suicide.

Alternative treatment

Some alternative treatments may help to prevent suicide by preventing or relieving depression. Meditation practice or religious faith and worship have been shown to lower a person's risk of suicide. In addition, any activity that brings people together in groups and encourages them to form friendships helps to lower the risk of suicide, as people with strong social networks are less likely to give up on life.

Prognosis

The prognosis for a person who has attempted suicide is generally favorable, although further research needs to be done. A 1978 follow-up study of 515 people who had attempted suicide between 1937 and 1971 reported that 94% were either still alive or had died of natural causes. This finding has been taken to indicate that suicidal behavior is more likely to be a passing response to an acute crisis than a reflection of a permanent state of mind.

Prevention

One reason that suicide is such a tragedy is that most self-inflicted deaths are potentially preventable. Many suicidal people change their minds if they can be helped through their immediate crisis; Dr. Richard Seiden, a specialist in treating survivors of suicide attempts, puts the high-risk period at 90 days after the crisis. Some potential suicides change their minds during the actual attempt; for example, a number of people who survived jumping off the Golden Gate Bridge told interviewers afterward that they regretted their action even as they were falling and that they were grateful they survived.

Brain research is another important aspect of suicide prevention. Since major depression is the single most common psychiatric diagnosis in suicidal people, earlier and more effective recognition of depression is a necessary preventive measure. Known biological markers for an increased risk of suicide can now be correlated with personality profiles linked to suicidal behavior under stress to help identify individuals at risk. In addition, brain imaging studies using positron emission tomography (PET) are presently in use to detect abnormal patterns of serotonin uptake in specific regions of the brain. Genetic studies are also yielding new information about inherited predispositions to suicide.

Another major preventive measure is education of clinicians, media people, and the general public. In 2002 the CDC, the National Institutes of Health (NIH), and several other government agencies joined together to form the National Strategy for Suicide Prevention, or NSSP. Education of the general public includes a growing number of medical and government websites posting information about suicide, publications available for downloading, lists of books for further reading, tips for identifying symptoms of depressed and suicidal thinking, and advice about helping friends or loved ones who may be at risk. Many of these websites also have direct connections to suicide hotlines.

The National Institute of Mental Health (NIMH) recommends the following action steps for anyone dealing with a suicidal person:

  • Make sure that someone is with them at all times; do not leave them alone even for a short period of time.
  • Persuade them to call their family doctor or the nearest hospital emergency room.
  • Call 911 yourself.
  • Keep the person away from firearms, drugs, or other potential means of suicide.

KEY TERMS

Assisted suicide A form of self-inflicted death in which a person voluntarily brings about his or her own death with the help of another, usually a physician, relative, or friend.

Cortisol A hormone released by the cortex (outer portion) of the adrenal gland when a person is under stress. Cortisol levels are now considered a biological marker of suicide risk.

Euthanasia The act of putting a person or animal to death painlessly or allowing them to die by withholding medical services, usually because of a painful and incurable disease. Mercy killing is another term for euthanasia.

Frontal cortex The part of the human brain associated with aggressiveness and impulse control. Abnormalities in the frontal cortex are associated with an increased risk of suicide.

Psychodynamic A type of explanation of human behavior that regards it as the outcome of interactions between conscious and unconscious factors.

Serotonin A chemical that occurs in the blood and nervous tissue and functions to transmit signals across the gaps between neurons in the central nervous system. Abnormally low levels of serotonin are associated with depression and an increased risk of suicide.

Suicide gesture Attempted suicide characterized by a low-lethality method, low level of intent or planning, and little physical damage. Pseudocide is another term for a suicide gesture.

Resources

BOOKS

Alvarez, A. The Savage God: A Study of Suicide. New York: Random House, Inc., 1972. A now-classic study of suicide written for general readers. The author includes a historical overview of suicide along with accounts of his own suicide attempt and the suicide of his friend, the poet Sylvia Plath.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. Washington, DC: American Psychiatric Association, 2000.

"Depression." In The Merck Manual of Geriatrics, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

"Psychiatric Emergencies." In The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

"Suicidal Behavior." In The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

"Suicide in Children and Adolescents." In The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

PERIODICALS

Friend, Tad "Letter from California: Jumpers." New Yorker, 10 November 2003. http://newyorker.com/printable/?fact/031013fa_fact. A journalist's account of the Golden Gate Bridge in San Francisco, the world's leading location for suicide.

Fu, Q., A. C. Heath, K. K. Bucholz, et al. "A Twin Study of Genetic and Environmental Influences on Suicidality in Men." Psychology in Medicine 32 (January 2002): 11-24.

Plunkett, A., B. O'Toole, H. Swanston, et al. "Suicide Risk Following Child Sexual Abuse." Ambulatory Pediatrics 1 (September-October 2001): 262-266.

Soreff, Stephen, MD. "Suicide." eMedicine, 3 September 2004. http://www.emedicine.com/med/topic3004.htm.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007. (202) 966-7300. Fax: (202) 966-2891. http://www.aacap.org..

American Association of Suicidology. Suite 408, 4201 Connecticut Avenue, NW, Washington, DC 20008. (202) 237-2280. Fax: (202) 237-2282. http://www.suicidology.org.

American Foundation for Suicide Prevention (AFSP). 120 Wall Street, 22nd Floor, New York, NY 10005. (888) 333-2377 or (212)

Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control (NCIPC). Mailstop K60, 4770 Buford Highway, Atlanta, GA 30341-3724. (770) 488-4362. Fax: (770) 488-4349. http://www.cdc.gov/ncipc.htm.

National Institute of Mental Health (NIMH). 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513 or (886) 615-NIMH. www.nimh.nih.gov.

OTHER

American Academy of Child and Adolescent Psychiatry (AACAP). Teen Suicide. AACAP Facts for Families #10. Washington, DC: AACAP, 2004.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. "Suicide Contagion and the Reporting of Suicide: Recommendations from a National Workshop." Morbidity and Mortality Weekly Report 43 (22 April 1994): 9-18. http://www.cdc.gov/mmwr/preview/mmwrhtml/00031539.htm.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Suicide: Fact Sheet. http://www.cdc.gov/ncipc/factsheets/suifacts.htm.

National Institute of Mental Health (NIMH). In Harm's Way: Suicide in America. NIH Publication No. 03-4594. Bethesda, MD: NIMH, 2003. http://www.nimh.nih.gov/publicat/NIMHharmsway.pdf.

National Suicide Hotline: (800) 273-TALK (1-800-273-8255).

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Suicide

Suicide


The word suicide covers a wide range of behaviors, including (1) completed suicide; in which the individual dies as a result of the self-destructive act; (2) attempted suicide, in which the individual survives the act; and (3) suicidal ideation, which refers to the individual thinking about and planning suicidal behavior, but not putting these thoughts into action.

A controversy exists over the term attempted suicide. Because many of the individuals who survive a suicidal action did not intend to die (for example, they may have intentionally taken only half of a lethal dose of a medication), some scholars object to the term. Europeans suggested parasuicide as an alternative, especially for suicide attempts of low lethality, but in recent years the terms self-injury and self-poisoning have become popular.


The Epidemiology of Suicide

Completed suicide rates vary widely by nation. According to the latest figures available from the World Health Organization, rates in the 1990s ranged from thirty to forty per 100,000 per year for Belarus, Estonia, Hungary, Kazakhstan, Latvia, Lithuania, Russia, Slovenia, and the Ukraine to zero to five per 100,000 per year for Armenia, Greece, and Thailand. National rates of attempted suicide are not available, but it is estimated that there may be eight to ten attempts at suicide for every completed suicide.

Completed suicide rates are higher in men than in women in every country except for mainland China, where the female suicide rate exceeds the male suicide rate (Phillips, Liu, and Zhang 1999). However, in every nation, female rates of attempted suicide exceed those for men in the small samples that have been studied.

Completed suicide rates rise with age in men, but in women the peak age for suicide varies with the level of economic development in the nation. Female suicide rates peak in middle age in the most developed nations, but in young women in the least developed nations (Girard 1993). In general, attempted suicides are younger than completed suicides.

In the United States, whites and American Indians have the highest completed suicide rates, whereas Filipino Americans have the lowest rates. African Americans, Chinese Americans and Japanese Americans have intermediate rates (Lester 1998). These ethnic differences in the United States match those in other nations. For example, in Zimbabwe and South Africa, whites have higher completed suicide rates than blacks, and Philippine suicide rates are lower than the rates in China and Japan.


Theories of Suicide

Research into why individuals become suicidal has identified psychiatric disturbance as the strongest predictor of future suicidality. In particular, depression, both unipolar and bipolar, is associated with the greatest suicidal risk, and even in schizophrenics and substances abusers, both groups with high rates of suicide, depression is the strongest predictor of which individuals in those groups will complete suicide (Maris, Berman, and Silverman 2000). Among the components of depression, the cognitive component, which has been called pessimism and hopelessness by Aaron Beck and his colleagues (1979), is a more powerful predictor than the somatic components of depression (such as loss of appetite) or the mood symptoms (such as guilt).

Suicidal individuals are found to have experienced a high level of stress for a long period of time, and often have an increasing level in the time leading up to their suicidal action. In addition, suicidal individuals are found to have few resources, and the resources that they have are often unavailable (Lester 2000). For example, the people available to turn to for help may be resented by the suicidal person, or the resources may be hostile toward the suicidal person.

The family plays a critical role in each of these factors. Physiological and psychological theories of psychiatric disorder stress the role of the parents, either in passing on the genes for the disorder (in physiological theories) or in creating a pathological home environment (in psychological theories) (Maris, Berman, Silverman 2000). Family members are often the cause of much of the stress that suicidal individuals experience, and they are the resources that may be unavailable to the suicidal individual.

Sociological theories of suicide attempt to explain the suicide rates of cultures or regions. They have focused on the role of social disorganization (social integration and social regulation in Durkheim's theory—see below) or in the opportunity to blame others for one's misfortunes rather than oneself (Henry and Short 1954). For example, African Americans have been oppressed by the racism in U.S. society and so have a clear source of blame for their misery, whereas white Euro Americans have been the oppressors. African Americans have higher murder rates whereas whites have higher suicide rates, in line with this argument.


Marital Status and the Family

Marital status has a strong association with rates of completed suicide. Suicide rates are higher in the divorced and widowed than in single people, who in turn have higher suicide rates than married people. This protective effect of marriage on suicide is stronger for men than for women, although it is found for both men and women (Gove 1972).

The strong association of divorce with suicide is found at the societal level as well as at the individual level. For example, nations with higher divorce rates have higher suicide rates, U.S. states with higher divorce rates have higher suicide rates and, within nations, years with higher divorce rates have higher suicide rates. This association is probably the most robust association found in suicidology. The associations between marriage rates and suicide rates and between birth rates and suicide rates are not as consistent, although they do tend to be negative associations more often than positive associations.

These associations fit well with the classic sociological theory of suicide proposed by Emile Durkheim (1897). Durkheim proposed that suicide would be common where the level of social integration—the extent to which the members of a society are bound together in social networks—was high (leading to altruistic suicide) or low (leading to egoistic suicide), and where the level of social regulation—the extent to which the behaviors and desires of the members of the society conform to social rules and norms—was high (leading to fatalistic suicide) or low (leading to anomic suicide).

Modern sociologists have argued that altruistic and fatalistic suicide are rare in modern societies and that it is hard to measure social integration separately from social regulation ( Johnson 1965). Thus, they propose that suicide varies inversely with the level of social integration/regulation.

The association between divorce rates and suicide rates has two interpretations. Composition theory argues that because suicide rates are higher in divorced individuals, societies with a greater proportion of divorced people will necessarily have a higher suicide rate.

However, looking at the United States, divorce rates are strongly associated over the states with interstate migration rates, alcohol consumption, and low church attendance. Thus, these variables form a cluster of related social indicators, and they perhaps tap some broad, abstract quality of society: perhaps social disorganization is an appropriate term. This broad social characteristic has an effect on all of the members of the society, not just the divorced, the alcohol abusers, or the migrants.

Christopher Cantor and Penelope Slater (1995) found that the suicide rate in Queensland, Australia, was highest for men who were separated, as opposed to men who were single, married, divorced, or widowed. For women, the divorced had the highest suicide rate. The increase in the suicide rate in separated men was greater in those who were younger (age 15–19) than in those who were older (over the age of 55). These results suggest that the time during the breakdown in the marriage may be more stressful for men than for women, whereas the state of divorce may be stressful for both men and women.

The higher rate of suicide in widows as compared to those married of the same may be because bereavement increases the risk of suicide or because widows and widowers who are prone to suicide are less likely to get remarried. Some old data from Brian MacMahon and Thomas Pugh (1965) indicate that it is bereavement—and not differential remarriage rates—that is the factor responsible. However, research (for example, a study by Arne Mastekaasa [1993] in Norway) also indicates that, once age is taken into account, the higher suicide rate in the widowed as compared to the divorced is no longer found.

Even though those who are married have lower suicide rates than those in other marital statuses, Walter Gove (1972) has documented that marriage is more beneficial for men than for women, in that the reduction in the suicide rate (and also in rates of psychiatric disturbance) is greater for married men than for married women.


The Protective Effect of Children

The presence of children appears to have a protective effect with regard to suicide. In a study of a large sample of women in Norway, Georg Hoyer and Eiliv Lund (1993) obtained a sample of almost one million single and married women in Norway in 1970 and identified which of them had completed suicide by 1985. They found that unmarried women had a higher suicide rate than married women without children for those aged twenty-five to sixty-four, but not for those over the age of sixty-four. Thus, marriage appeared to reduce the suicide rate in women.

Hoyer and Lund also found that married women with children had lower suicide rates than married women with no children for all age groups. Thus, the presence of children further reduces the risk of suicide in women above and beyond the protective impact of marriage per se. Furthermore, the more children, the lower the suicide rate of the married women.

This study is the best study on the topic reported hitherto, but it confirms the results of earlier studies on smaller samples and without such detailed analyses. For example, in Portugal women with children were found to have a lower suicide rate than childless women, and those with more than five children had the lowest suicide rate (de Castro and Martins 1987).

There is also some evidence that the presence of children reduces the severity of suicidality in suicidal women, for example, making attempted suicide relatively less common and suicidal ideation relatively more common.


The Disturbing Effects of Families

Although the presence of children may protect their parents from suicide, the parents may increase the risk of suicide in the children. Even sibling position may play a role, as Alfred Adler (1958) suggested, with completed suicide being less common in last-borns and attempted suicide less common in first borns (Lester 2000).

Although in general, having a spouse and children reduces the risk of suicide, family members can play a role in precipitating suicide. For example, often family members feel and express a great deal of hostility toward one another. In psychic homicide, an individual commits suicide in response to the conscious or unconscious murderous impulses for them (Meerloo 1962). The role of murderous desires of parents toward their offspring may play a greater role in adolescent suicides than in the suicides of older adults. Transactional analysis has proposed that suicidal individuals had parents who experienced these desires (such as "I wish you had never been born") during the baby's first year of life.

It is difficult to show these effects with research, but the hostility has been observed at the time of the suicidal behavior. For example, Milton Rosenbaum and Joseph Richman (1970) in their study of attempted suicides reported a mother's first statement to her 24-year-old son in the hospital, "Next time pick a higher bridge." Or a wife whose 70-year-old husband said to her, "If I had a gun, I'd shoot myself," replied, "I'll buy you a gun." He used pills a few days later instead. A father said to his 17-year-old daughter, "We'd all be better off if you were dead. At least we'd know where you are."

There are many features of family life that impact on suicidal behavior. Abuse of children, both physically and sexually, appears to result in an increase in later suicidal behavior as well as other psychiatric disorders and symptoms.

Loss of parents during childhood, especially between the ages of six and sixteen, increases the risk of suicide. David Lester (1989) found that exactly half of a sample of famous suicides, for whom detailed biographies were available, had experienced such loss, such as the poet Sylvia Plath whose father died of natural causes when she was eight. If the parent dies from suicide, then suicide is even more likely in the children.

In general, research finds that married couples in which one partner attempts suicide have poorer communication between each other and more destructive conflicts (such as avoiding discussion and fleeing the home), and that the suicidal partner is more psychiatrically disturbed (Lester 2000).

Suicidal behavior in family members increases the risk of suicide in other family members, perhaps because this indicates a greater acceptance of suicidal behavior as a solution to problems in that family, or perhaps because the occurrence of suicide in many family members indicates the presence of an inherited psychiatric disorder. In the Hemingway family, for example, Ernest's father completed suicide, and so did three of his six children (including Ernest, of course). It is likely that an affective disorder was passed down in this family, but also completing suicide in middle age when suffering from severe medical problems appears to have become a learned strategy in the family.

However, this copycat (or contagion) effect is also found in social groups. A suicide in an adolescent is occasionally followed by "imitation" suicides among his or her peers (Maris, Berman, and Silverman 2000), and in these cases inheritance does not play a role.


Helping Suicidal Individuals

The most common tactic for suicidal individuals is to treat the underlying psychiatric disturbance using medication and psychotherapy. In recent years, the increasing prescribing of antidepressants appears to have resulted in a decline in suicide rates (Isacsson 2000). In addition, effective psychotherapies have been devised for suicidal individuals (Linehan 1993), and many countries now have networks of telephone crisis centers, functioning twenty-four hours a day, seven days a week, for individuals to call during times when they are most distressed (Mishara and Daigle 2001).

However, because interpersonal factors are often involved in precipitating and maintaining the suicidality of people, family therapy is perhaps the most appropriate format for psychotherapy for suicidal individuals. Joseph Richman (1986) has been the leading advocate of this approach.


Problems for Survivors

Those who experience the suicide of a significant other are known as survivors. Survivors have great difficulty coping with the death, perhaps more so than those whose significant others die of natural causes. In some cases, it is the family members who discover the body of the suicide, often greatly disfigured by the suicide. For example, Leicester Hemingway, Ernest's brother, was only thirteen when he found his father dead from a firearm wound. Leicester was one of the three children who later completed suicide.

Furthermore, the grieving process after a suicide is different in significant ways from the grieving after natural deaths. There is more anger felt toward the suicide and guilt over what the survivors might have done to prevent the suicide. Group therapy is particularly helpful for survivors whether led by peers or by professionals (Farberow 2001).

In recent years, survivors have banded together to form organizations to help one another and to work for the prevention of suicide in general. There are survivor groups in many countries and, in some countries, in every region. In the United States, the American Association of Suicidology maintains a directory of these services and, inter-nationally, Befrienders International has services (usually under the name The Samaritans) in more than forty countries.


See also:Childhood, Stages of: Adolescence; Death and Dying; Depression: Adults; Depression: Children and Adolescents; Euthanasia; Grief, Loss, and Bereavement; Rape; Self-Esteem; Widowhood

Bibliography

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farberow, n. l. (2001). "helping suicide survivors." insuicide prevention: resources for the millennium, ed. d. lester. philadelphia: brunner-routledge.

girard, c. (1993). "age, gender, and suicide." americansociological review 58:553–574.

gove, w. (1972). "sex, marital status and suicide." journal of health and social behavior 13:204–213.

henry, a. f., and short, j. f. (1954). suicide and homicide. new york: free press.

hoyer, g., and lund, e. (1993). "suicide among womenrelated to number of children in marriage." archives of general psychiatry 50:134–137.

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johnson, b. d. (1965). "durkheim's one cause of suicide." american sociological review 30:875–886.

lester, d. (1989). "experience of personal loss and latersuicide." acta psychiatrica scandinavica 79:450–452.

lester, d. (1998). suicide in african americans. commack, ny: nova science.

lester, d. (2000). why people kill themselves, 4th edition.springfield, il: charles c. thomas.

linehan, m. m. (1993). cognitive-behavioral therapy ofborderline personality disorder. new york: guilford.

macmahon, b., and pugh, t. f. (1965). "suicide in the widowed." american journal of epidemiology 81:23–31.

maris, r. w.; berman, a. l.; and silverman, m. m. (2000).comprehensive textbook of suicidology. new york: guilford.

mastekaasa, a. (1993). "marital status and subjective well-being." social indicators research 29:249–276.

meerloo, j. a. m. (1962). suicide and mass suicide. newyork: grune and stratton.

mishara, b., and daigle, m. (2001). "helplines and crisisintervention services." in suicide prevention: resources for the millennium, ed. d. lester. philadelphia: brunner-routledge.

phillips, m. r.; liu, h. q.; and zhang, y. p. (1999). suicide and social change in china. culture, medicine and psychiatry 23:25–50.

richman, j. (1986). family therapy for suicidal people.new york: springer.

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other resources

american association of suicidology. (2002). available from http://www.suicidology.org.

world health organization. (2002). available from www.who.int.

DAVID LESTER

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"Suicide." International Encyclopedia of Marriage and Family. 2003. Encyclopedia.com. 25 Aug. 2016 <http://www.encyclopedia.com>.

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Suicide

Suicide

Definition

Suicide is defined as the intentional taking of one's own life. In some European languages, the word for suicide translates into English as "self-murder " Until the end of the twentieth century, approximately, suicide was considered a criminal act; legal terminology used the Latin phrase felo-de-se, which means "a crime against the self." Much of the social stigma that is still associated with suicide derives from its former connection with legal judgment, as well as with religious condemnation.

In the social climate of 2002, suicidal behavior is most commonly regarded and responded to as a psychiatric emergency.

Demographics of suicide

In the United States, the rate of suicide has continued to rise since the 1950s. More people die from suicide than from homicide in North America. Suicide is the eighth leading cause of death in the U.S., and the third leading cause of death for people aged 15 to 24. There are over 30,000 suicides per year in the U.S., or about 86 per day; each day about 1,500 people attempt suicide.

The demographics of suicide vary considerably from state to state. Some states, like Pennsylvania, have suicide rates that are very close to the national average; others, such as Connecticut, have significantly lower rates. However, other states have much higher rates than the national average. These variations are due in part to differences among age groups and racial groups, and between men and women. Males are three to five times more likely to succeed in their suicide attempts than females, but females are more likely to attempt suicide. Most suicides occur in persons below the age of 40; however, elderly Caucasians are the sector of the population with the highest suicide rate.

Race is also a factor in the demographics of suicide. Between 1979 and 1992, the suicide rate of Native Americans was 1.5 times the national average, with young males between the ages of 15 and 24 accounted for 64% of Native American deaths by suicide. Asian-American women have the highest suicide rate among all women over the age of 65. Further, between 1980 and 1996 the suicide rate more than doubled for African-American males between the ages of 15 and 19.

High-risk factors

Research indicates that the following factors increase a person's risk of suicide:

  • Male sex.
  • Age over 75.
  • A family history of suicide.
  • A history of suicide attempts.
  • A history of abuse in childhood.
  • Traumatic experiences after childhood
  • Recent stressful events, such as separation or divorce, job loss, or death of spouse.
  • Chronic medical illness. Patients with AIDS have a rate of suicide 20 times that of the general population.
  • Access to a gun. Death by firearms is now the fastestgrowing method of suicide among men and women. Nearly 57% of deaths caused by guns in the U.S. are suicides.
  • Alcohol or substance abuse. While mood-altering substances do not cause a person to kill himself/herself, they weaken impulse control.
  • High blood cholesterol levels.
  • Presence of a psychiatric illness. Over 90% of Americans who commit suicide have a mental illness. Major depression accounts for 60% of suicides, followed by schizophrenia , alcoholism, substance abuse, borderline personality disorder , Huntington's disease, and epilepsy. The lifetime mortality due to suicide in psychiatric patients is 15% for major depression; 20% for bipolar disorder ; 18% for alcoholism; 10% for schizophrenia; and 510% for borderline and certain other personality disorders.

Low-risk factors

Factors that lower a person's risk of suicide include:

  • a significant friendship network outside the workplace
  • religious faith and practice
  • a stable marriage
  • a close-knit extended family
  • a strong interest in or commitment to a project or cause that brings people together, including community service, environmental concerns, neighborhood associations, animal rescue groups, etc.

Suicide in other countries

Suicide has become a major social and medical problem around the world. The World Health Organization (WHO) reported that one million people worldwide died from suicide in the year 2000. That is a global mortality rate of 16:100,000or one death by suicide every 40 seconds. Since the mid-1950s, suicide rates around the world have risen by 60%. Rates among young people have risen even faster, to the point where they are now the age group at highest risk in 35% of the world's countries.

The specific demographics, however, vary from country to country. China's pattern, for example, is very different from that of most other countries. China has a suicide mortality rate of 23:100,000, with a total of 287,000 deaths by suicide each year. The rate for women is 25% higher than that for men, and rates in rural areas are three times higher than in cities. The means also vary; In China, Sri Lanka, and Turkey the primary means of suicide is ingestion of pesticides, rather than using guns.

Suicide in children and adolescents

The suicide rate among children and adolescents in the U.S. has risen faster than that of the world population as a whole. The suicide rate for Caucasian males aged 15 to 24 years has tripled since 1950; and it has more than doubled for Caucasian females in the same age bracket. In 1999, a survey of high school students found that 20% had seriously considered suicide or attempted it in the previous year. Of adolescents who do commit suicide, 90% have at least one diagnosable psychiatric disorder at the time of their death. Most frequently it is major depression, substance abuse disorder, or conduct disorder . Adolescents are particularly susceptible to dramatic or glamorized portrayals of suicide in the mass media.

Causes

Suicide is an act that represents the end result of a combination of factors in any individual. One model that has been used by clinicians to explain why people suffering under the same life stresses respond differently is known as the stress/diathesis model. Diathesis is a medical term for a predisposition that makes some people more vulnerable to thoughts of suicide. Components of a person's diathesis may include:

Neurobiological and genetic factors

Post-mortem studies of the brains of suicide victims indicate that the part of the brain associated with controlling agression and other impulsive behaviors (the frontal cortex) has a significantly lower level of serotonin, a neurotransmitter associated with mood disorders. Low serotonin levels are correlated with major depression. In addition, suicide victims have higher than normal levels of cortisol, a hormone produced in stressful situations, in the tissues of their central nervous system. Studies of the levels of other neurotransmitters in brain tissue are underway.

Other research has indicated that abuse in childhood may have permanent effects on the level of serotonin in the brain, possibly "resetting" the level abnormally low. In addition, twin studies have suggested that there may be genetic susceptibility in males to both suicidal ideation and suicide attempts which cannot be explained by inheritance of common psychiatric disorders. No twin studies of susceptibility to suicide in women have yet been reported.

History and lifestyle

Other components of a diathesis include:

  • Chronic illness
  • Traumatic experiences after childhood
  • Alcohol or substance abuse
  • High blood cholesterol levels.

Factors in the wider society

In addition to factors at the individual level, factors in the wider society have been identified as contributing to the rising rate of suicide in the United States:

  • Stresses on the nuclear family, including divorce and economic hardship.
  • The loss of a set of moral values held in common by the entire society.
  • The weakening of churches, synagogues, and other mid range social groups outside the family. In the past, these institutions often provided a sense of belonging for people from troubled or emotionally distant families.
  • Frequent geographical moves, which makes it hard for people to make and keep long-term friendships outside their immediate family.
  • Sensationalized treatment of suicide in the mass media. A number of research studies have shown that there is a definite risk of "contagion" suicides from irresponsible reporting, particularly among impressionable adolescents.
  • The development over the past century of medications that allow relatively painless suicide. For most of human history, the available means of suicide were uncertain, painful, or both.
  • The easy availability of firearms in the United States.

Treatment of attempted suicide

Researchers estimate that 825 people attempt suicide for every person who completes the act. Suicide attempts can be broadly categorized along a continuum that ranges from seriously planned attempts involving a highly lethal method that fail by good fortune, to impulsive or poorly planned attempts using a less lethal method. Suicide attempts at the lower end of the spectrum are sometimes referred to as suicide gestures or pseudocide.

A suicide attempt of any kind, however, is treated as a psychiatric emergency by rescue personnel. Treatment in a hospital emergency room includes a complete psychiatric evaluation, a mental status examination, and a detailed assessment of the circumstances surrounding the attempt. The physician will interview relatives or anyone else who accompanied the patient in order to obtain as much information as possible. As a rule, suicide attempts requiring advance planning, including precautions taken against discovery, and the use of violent or highly lethal methods are regarded as the most serious. The patient will be kept under observation while decisions are made about the need for hospitalization .

A person who has attempted suicide and who is considered a serious danger to him- or herself or to others can be hospitalized against their will. The doctor will base the decision on the severity of the patient's depression or agitation; availability of friends, relatives, or other social support; and the presence of other suicide risk factors, including a history of previous suicide attempts, substance abuse, recent stressful events, and symptoms of psychosis . If the attempt is judged to be a nonlethal suicide gesture, the patient may be released after the psychiatric assessment is completed.

Related issues

Survivors of suicide

One group of people that is often overlooked in discussions of suicide is the friends and family bereaved by the suicide. It is estimated that each person who kills him- or herself leaves six survivors to deal with the aftermath. On the basis of this figure, there are at least 4.5 million survivors of suicide in the United States. In addition to the grief that ordinarily accompanies death, survivors of suicide often struggle with feelings of guilt and shame as well. In spite of a general liberalization of social attitudes since World War II, suicide is still stigmatized in many parts of Europe and the United States. Survivors often benefit from group or individual psychotherapy in order to work through such issues as wondering whether they could have prevented the suicide or whether they are likely to commit suicide themselves. Increasing numbers of clergy as well as mental health professionals are taking advanced training in counseling survivors of suicide.

Assisted suicide

One question that has been raised in developed countries as the average life expectancy increases is the legalization of assisted suicide for persons suffering from a painful terminal illness. Physician-assisted suicide has become a topic of concern since it was legalized by recent legislation in the Netherlands (in April 2001) and in the state of Oregon. It is important to distinguish between physician-assisted suicide and euthanasia, or "mercy killing." Assisted suicide, which is often called "self-deliverance" in Britain, refers to a person's bringing about his or her own death with the help of another person. Because the other person is often a physician, the act is often called "doctor-assisted suicide." Euthanasia strictly speaking means that the physician or other person is the one who performs the last act that causes death. For example, if a physician injects a patient with a lethal overdose of a pain-killing medication, he or she is performing euthanasia. If the physician leaves the patient with a loaded syringe and the patient injects himself or herself with it, the act is an assisted suicide. As of 2002, assisted suicide is illegal every where in the United States except for Oregon, and euthanasia is illegal in all fifty states.

Media treatment of suicide

In 1989, the Centers for Disease Control (CDC) sponsored a national workshop to address the issue of the connection between sensationalized media treatments of suicide and the rising rate of suicide among American youth. The CDC and the American Association of Suicidology subsequently adopted a set of guidelines for media coverage of suicide intended to reduce the risk of suicide by contagion.

The CDC guidelines point out that the following types of reporting may increase the risk of "copycat" suicides:

  • Presenting oversimplified explanations of suicide, when in fact many factors usually contribute to it. One example concerns the suicide of the widow of a man who was killed in the collapse of the World Trade Center on September 11, 2001. Most newspapers that covered the story described her death as due solely to the act of terrorism, even though she had a history of depressive illness.
  • Excessive, ongoing, or repetitive coverage of the suicide.
  • Sensationalizing the suicide by inclusion of morbid details or dramatic photographs. Some news accounts of the suicide of an Enron executive in January 2002 are examples of this problem.
  • Giving "how-to" descriptions of the method of suicide.
  • Referring to suicide as an effective coping strategy or as a way to achieve certain goals.
  • Glorifying the act of suicide or the person who commits suicide.
  • Focusing on the person's positive traits without mentioning his or her problems.

Prevention

Brain research is an important aspect of suicide prevention as of 2002. Since major depression is the single most common diagnosis in suicidal people, earlier and more effective recognition of depression is a necessary preventive measure. Known biological markers for an increased risk of suicide can now be correlated with personality profiles linked to suicidal behavior under stress to help identify individuals at risk. In addition, brain imaging studies using positron emission tomography (PET) are presently in use to detect abnormal patterns of serotonin uptake in specific regions of the brain. Genetic studies are also yielding new information about inherited predispositions to suicide.

A second major preventive measure is education of clinicians, media people, and the general public. Public health studies carried out in Sweden have shown that seminars for primary care physicians in the recognition and treatment of depression resulted in a rise in the number of prescriptions for antidepressants and a drop in suicide rates. Education of the general public includes a growing number of CDC, NIMH, and other web sites posting information about suicide, tips for identifying symptoms of depressed and suicidal thinking, and advice about helping friends or loved ones who may be at risk. Many of these web sites have direct connections to suicide hotlines.

An additional preventive strategy is restricting access to firearms in the developed countries and to pesticides and other poisons in countries where these are the preferred method of suicide.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Eisendrath, Stuart J., MD, and Jonathan E. Lichtmacher, MD. "Psychiatric Disorders." In Current Medical Diagnosis & Treatment 2001, edited by L. M. Tierney, Jr., MD, and others. 40th edition. New York: Lange Medical Books/McGraw-Hill, 2001.

"Psychiatric Emergencies." Section 15, Chapter 194 in The Merck Manual of Diagnosis and Therapy, edited by MarkH. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2001.

"Suicidal Behavior." Section 15, Chapter 190 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2001.

"Suicide in Children and Adolescents." Section 19, Chapter 264 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories,1999.

PERIODICALS

Byard, R. W., and J. D. Gilbert. "Cervical Fracture, Decapitation, and Vehicle-Assisted Suicide." Journal of Forensic Science 47 (March 2002): 392-394.

Fu, Q., A. C. Heath, K. K. Bucholz, and others. "A Twin Study of Genetic and Environmental Influences on Suicidality in Men." Psychology in Medicine 32 (January 2002): 11-24.

Gibb, Brandon E., Lauren B. Alloy, Lyn Y. Abramson, and others. "Childhood Maltreatment and College Students' Current Suicidal Ideation: A Test of the Hopelessness Theory." Suicide and Life-Threatening Behavior 31(2001): 405-415.

Kara, I. H., and others. "Sociodemographic, Clinical, and Laboratory Features of Cases of Organic Phosphorus Intoxication in the Southeast Anatolian Region of Turkey." Environmental Research 88 (February 2002): 82-88.

Mancinelli, Iginia, MD, and others. "Mass Suicide: Historical and Psychodynamic Considerations." Suicide and Life-Threatening Behavior 32 (2002): 91-100.

Phillips, M. R., X Li, and Y. Zhang. "Suicide Rates in China, 1995-99." Lancet 359 (March 9, 2002): 835-840.

Plunkett, A., B. O'Toole, H. Swanston, and others. "Suicide Risk Following Child Sexual Abuse." Ambulatory Pediatrics 1 (September-October 2001): 262-266.

Vieta, E., F. Colom, B. Corbella, and others. "Clinical Correlates of Psychiatric Comorbidity in Bipolar I Patients." Bipolar Disorders 3 (October 2001): 253-258.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007.(202) 966-7300. Fax: (202) 966-2891. <www.aacap.org>.

American Association of Suicidology. Suite 310, 4201 Connecticut Avenue, NW, Washington, DC 20008. (202) 237-2280. Fax: (202) 237-2282. <www.suicidology.org>.

National Institutes of Mental Health (NIMH). NIMH Public Inquiries: (800) 421-4211. <www.nimh.nih.gov>.

OTHER

Befrienders International. <www.befrienders.org>.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Programs for the Prevention of Suicide Among Adolescents and Young Adults; and Suicide Contagion and the Reporting of Suicide: Recommendations from a National Workshop. MMWR 1994; 43 (No. RR-6). <www.cdc.gov/ncipc>.

Mann, J. John, MD. "The Neurobiology of Suicide." Mental Health Clinical Research Center for the Study of Suicidal Behavior, Columbia-Presbyterian Medical Center, New York. <www.afsp.org>.

National Suicide Hotline: (800) SUICIDE (800-784-2433).

Rebecca J. Frey, Ph.D.

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Suicide

SUICIDE

Among industrialized countries that provide statistics on suicide, nearly all report that suicide rates rise progressively with age, with the highest rates occurring for men age seventy-five and older. In the United States in 1997, older white males age eighty-five and older had a rate of 65.4 per 100,000. This latter rate is almost six times the rate of all ages combined. Reviewed here is the available research evidence on correlates and risk factors in later life suicidal behavior, and suggested opportunities for prevention.

Demographic correlates and methods of later life suicide

U.S. data on completed suicides by sex, age, race, marital status, and method are based on vital statistics information gathered by the Centers for Disease Control and Preventions National Center for Health Statistics, with each state reporting from death certificates. From this data source we know that increased age among persons sixty-five and older is associated with higher rates of suicide. Also, older adults as a group are more likely to use a firearm as a suicide method compared to the total U.S. rate; 70 versus 60 percent. In terms of demographic correlates of suicide deaths, male sex, white race, older age, and unmarried status are associated with higher rates of suicide.

Older suicide victims are more likely to have lived alone than younger suicides. However, older adults are also likely to be those members of the population who live alone, so the potency of living arrangement as a risk factor for suicide is not clear. A correlate associated with living arrangement is marital status. The suicide rate for unmarried older adults is higher than the suicide rate for married older adults. For older men, the suicide rate for those who are divorced or widowed is much higher when compared with older females or with their married counterparts (Buda and Tsuang).

Psychological status and life events associated with later life suicide

In the absence of adequate prospective studies, the psychological autopsy (PA) method has been used to reconstruct a detailed picture of the victims psychological state prior to death, including psychiatric symptomatology, behavior, and life circumstances during the weeks or months before death. This includes interviewing knowledgeable informants, reviewing available clinical records, and comprehensive case formulation by one or more mental health professionals with expertise in postmortem studies. The PA method has been used to provide an inclusive, well-defined sample of all persons who die by suicide within a defined catchment area, region, or population. One of the most striking and consistent findings of the PA method is that psychiatric disorder and/or substance use is present in about 90 percent of all suicides, with affective disorder as the most common psychopathology, followed by substance use and schizophrenia (Conwell and Brent).

When compared to younger suicide victims, older victims are more likely to have had a physical illness, and to have suffered from depression that is not comorbid with a substance disorder (Conwell and Brent). The type of depression found in the majority of later life suicides is usually a first episode of depression, uncomplicated by psychoses or other comorbid psychiatric disorders, and, ironically, is the most treatable type of late-life depression. Such age-related patterns have appeared in reports from a number of countries including the United States, Finland, and the United Kingdom.

Although substance use is less frequent among elderly suicides, there is some evidence that among the young old, alcohol may be a correlate. For men with early onset alcoholism who have survived to their fifties and sixties, the combination of continued alcohol abuse and burn out among their social support network may be lethal. Murphy and his associates described that for older male alcoholics, loss of the last social support can be a pivotal event in suicide risk (Murphy, Wetzel, Robins, and McEvoy). How current, as well as past alcohol abuse, lowers the threshold for suicidal behavior in later life requires further systematic examination. Although it is often assumed that medication misuse (e.g., benzodiazepine dependence, psychotropic medication with alcohol abuse) is a risk for late life suicide, there is little published information on this topic.

Despite high rates of dementia and delirium in later life, few studies have found these diagnoses to be risk factors for suicide (Conwell and Brent). Controlled PA studies are needed to determine what other factors in combination with mental and physical disorders are related to risk for later life suicide.

The PA has been used to explore possible personality traits that may increase risk for later life suicide (Duberstein). Duberstein used an informant-based personality inventory measure to examine possible personality traits among older and younger suicides, relative to age- and sex-matched controls. The inventory measured five general personality traits: neuroticism, extroversion, openness to experience, agreeableness, and conscientiousness. Suicides were found to have higher neuroticism scores than normal controls, and older suicide victims had lower openness to experience scores than both younger suicides and normal controls.

Hopelessness, a set of beliefs related to lack of anticipated positive outcomes about the future, has also been examined in the context of later life suicide. A prospective investigation of a retirement community found a single item asking about hopelessness was related to later completed suicides (Ross, Bernstein, Trent, Henderson, and Paganini-Hill).

Suicide intent has also been examined in older adult suicide victims. Using the PA method, older adults were found to be more intent compared to younger suicide victims (Conwell, Duberstein, Cox, Herrmann, Forbes, and Caine). That is, older adults were more likely to have avoided intervention, taken precautions against discovery, and were less likely to communicate their intent to others. Moreover, older men, in particular, were less likely to have had a history of previous attempts.

The PA method has also been used to examine patterns of health services use among suicide victims. Health services for older adults who later suicided was typically available, and used. A number of reports indicate that approximately 70 percent of older suicide victims had seen a primary health care provider within a month (Conwell). In contrast, few older adult suicide victims have had a history of mental health care.

Neurobiological correlates of late life suicide

Postmortem brain tissue studies of suicide victims have found that the sertonergic systems (presynaptic and nontransporter nerve terminal binding sites) had reduced activity (Mann). Although there is optimism about new refinements and applications of neurobiological, brain imaging, and candidate gene markers to identify high risk individuals, there are currently no specific biological markers for suicidal behavior. With regard to older adults, it is conceivable that a neurobiological vulnerability to suicide might be modulated by age-related changes in neurobiological systems (Schneider). The consistency of increased suicide risk with age and male sex across nations also suggests a possible neurobiological process. Decreased brain concentrations of serotonin, dopamine, norepinephrine and their metabolites (HVA, 5-HIAA); increased brain MAO-B activity; increased hypothalamic-pituitary-adrenal (HPA) activity; and increased sympathetic nervous system activity are associated with both depression and normal aging (Schneider). Although several reviews have examined the evidence for neurobiologic abnormalities among older suicide victims relative to controls, there are too few studies that included sufficient older subjects (older than sixty years) to draw any conclusions (Conwell and Brent). This is particularly true of the subgroup of the older adults most at risk: those eighty-five and older.

Suicide attempts in later life

There are currently no national surveillance data of suicide attempts in the United States. Using data from the National Institute of Mental Health Epidemiologic Catchment Area study of five communities, Moscicki and her associates found a much lower prevalence of lifetime suicide attempts for older adults than younger populations. For persons age sixty-five and older, the lifetime prevalence for suicide attempts was 1.1 percent. By comparison, the rate was 4 percent for persons age twenty-five to forty-four. Other community-based studies have estimated lower attempt to completion ratios for older, compared to younger, adults (e.g., Nordentoft et al.). These findings support Conwell and colleaguess 1998 report that older adults are more intent in their efforts to commit suicide.

Other information about attempted suicide in late life comes from studying the characteristics of older persons recently admitted to a hospital due to the attempt. Draper reviewed twelve studies of later life suicide attempts published between 1985 and 1994. Despite variation in sampling contexts and approaches to measurement, and lack of adequate control groups, he reported several consistent factors associated with attempted suicide in late life: depression, social isolation, and being unmarried. The degree to which physical health was a risk factor was unclear. In some studies it appeared to play a major role, while in another only about one-third of the patients identified health as a salient factor.

The relationship between hopelessness and suicide attempts in later life was examined by studying the course of hopelessness in depressed patients (Rifai et al., 1994). Patients who had attempted suicide in the past had significantly higher hopelessness scores than nonattempters during both the acute and continuation phases of psychiatric treatment. Moreover, a high degree of hopelessness persisting after the remission of depression in older patients appeared to be associated with a history of suicidal behavior. This study by Rifai and her associates also suggested that a high degree of hopelessness may increase the likelihood of premature discontinuation of treatment and lead to future attempts or suicide. One prospective study of older depressed inpatients followed over a year found that 8.7 percent attempted suicide (Zweig and Hinrichsen). Patients who attempted suicide were more likely to have an incomplete remission of depression, history of suicide attempts, and familial interpersonal strain compared to those who did not attempt within the one year follow-up.

Prevention strategies

Prevention strategies should follow the most potent risk factor findings. Since the majority of older adults use firearms as a means of suicide, some have proposed that reduction in access to firearms may be an effective, preventive measure. However, others have argued that substitution in suicide methods may minimize the potency of this prevention approach (1990).

Research findings of increases in intent with age suggest that older persons who are at risk for suicide may be more difficult to identify as being at imminent risk than is the case for younger persons. Thus, clinical intervention strategies that target individuals who are at high risk for suicide, as indicated by a variety of demographic and psychiatric variables, may be more effective for preventing suicide than interventions that solely target individuals with suicide ideation or behavior. The fact that the majority of older adults are seen in primary care settings within the month of their deaths, coupled with the finding that most later life suicide victims have had a late onset, depressive episode, suggests that detecting and treating depression in primary care may be an efficient way to prevent later life suicides.

Although the identification and adequate treatment of depression is proposed as the most promising research avenue when considering preventive interventions in late life suicide, there are a number of factors that work against these prevention efforts. Ageism works against out-reach efforts. Many health providers, family members, and older adults themselves believe that depression and suicidal ideation are part of the normal aging process. Prevention efforts will need to consider these issues in public education and provider training to advance efforts in increased detection and treatment of depression.

Jane L. Pearson

See also Depression; Euthanasia and Senicide; Suicide and Assisted Suicide, Ethical Aspects.

BIBLIOGRAPHY

Buda, M., and Tsuang, M. T. The Epidemiology of Suicide: Implications for Clinical Practice. In Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients. Edited by S. J. Blumenthal and D. J. Kupfer. Washington, D.C.: American Psychiatric Press, Inc., 1990. Pages 1737.

Conwell, Y. (1994). Suicide in Elderly Patients. In Diagnosis and Treatment of Depression in Late-Life. Edited by L. S. Schneider, C. F. Reynolds, B. D. Lebowitz, and A. J. Friedhoff. Washington, D.C.: American Psychiatric Association, 1994. Pages 397418.

Conwell, Y., and Brent, D. Suicide and Aging I: Patterns of Psychiatric Diagnosis. International Psychogeriatrics 7 (1995): 149181.

Conwell, Y.; Duberstein, P. R.; Cox, C.; Herrmann, J. H.; Forbes, N. T.; and Caine, E. D. Age Differences in Behaviors Leading to Completed Suicide. American Journal of Geriatric Psychiatry 6 (1998): 122126.

Draper, B. Attempted Suicide in Old Age. International Journal of Geriatric Psychiatry 11 (1996): 577587.

Duberstein, P. R. Openness to Experience and Completed Suicide across the Second Half of Life. International Psychogeriatrics 7 (1995): 183198.

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Moscicki, E. K.; OCarroll, P.; Rae, D. S.; Locke, B. Z.; Roy, A.; and Regier, D. A. Suicide Attempts in the Epidemiologic Catchment Area Study. Yale Journal of Biology and Medicine 61 (1988) 259268.

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Suicide

Suicide

DURKHEIMS STUDIES

AMERICAN DEMOGRAPHIC DATA

SUICIDE AMONG THE ELDERLY

TEEN SUICIDE AND THE FAMILY

PHYSICIAN-ASSISTED SUICIDE

INTERNATIONAL DEMOGRAPHIC DATA

OTHER MANIFESTATIONS OF SUICIDE

BIBLIOGRAPHY

Suicide can be the outcome of an individuals difficult and stressful experiences or a response to an unbearable situation. Sometimes suicide is complicated by drug and/or alcohol use. The scope of suicide includes all ages, classes, races, and sexes, although some groups are at more risk than others. Children or family members of those who have attempted or completed suicide are more likely themselves to attempt or complete suicide, as suicide has a ripple effect and can convey the idea that self-destruction is an acceptable solution to distress. Casualties of suicide, or those left behind, experience traumatic grief, guilt, shame, stress, and self-doubtsometimes keeping them from speaking of the event at all. Statistics of suicide are underrepresented and not always reliable because the action can be classified in some other way; legally, suicidal components must be established beyond a doubt. Additionally, it is sometimes difficult to categorize the intentionality of death.

Suicide rates are higher for those who suffer from depression or other psychiatric problems; use drugs or alcohol when depressed; suffer from physical, especially irreversible, illness; are divorced; have lost an important relationship through death or breakup; and live in certain areas. War combatants also face a high rate of suicide because of post-traumatic stress disorders. People with HIV/AIDS are at risk, with the decision of suicide based on the fear of loss of function or increase in suffering and the feeling of being isolated. In suicide by cop incidents, an armed suicidal individual forces a law officer to use deadly force resulting in death. Individuals name various other reasons for suicide, including as a means to reunite with the dead, a means to ensure rest and refuge, a way to take revenge, and a penalty for failure.

DURKHEIMS STUDIES

In 1897 the French sociologist Émile Durkheim (18581917) conducted a study of suicide in France. He found lower suicide rates among women, Catholics, Jews, and married people and higher rates among men, Protestants, wealthy people, and unmarried individuals. Based on the data, he argued that categories of people with strong social ties had low suicide rates, and that categories of people with the lowest social integration had the highest suicide rates. Durkheim believed that too much or too little integration or regulation (cohesion) was unhealthy for society and accordingly established four conditions that can lead to suicide: (1) altruism, or too much integration, a willingness to sacrifice the self for the groups ostensible interest (e.g., suicide bombers); (2) egoism, or too little integration (e.g., those not bound to social groups left with little guidance); (3) fatalism, or too much regulation with no perceived way out of a situation (e.g., slaves); and (4) anomie, or too little regulation and no fulfillment of needs (e.g., those coping with the death of a spouse, economic depression, institutional failure, or wealth insufficient to provide happiness). Durkheim focused on anomie as an unhealthy and destructive pathological state for society, resulting in a milky-way-galaxy of choices for normative behavior (read normlessness) and a lack of social regulation.

AMERICAN DEMOGRAPHIC DATA

In the United States, suicide ranks eleventh on the list of causes of death. Suicides occur most often among white males, and the rate increases with age; older white males have the highest suicide rates in the nation. Females and nonwhite males reach their peak for suicide vulnerability earlier in adult life. Suicide is the third leading cause of death in the age group fifteen to twenty-four. Bad economic times are usually associated with an increase of suicide rates. Rates for Native Americans are the highest of any ethnic population in the nation.

Suicide rates tend to be higher in areas where people live far apart from each other; more densely populated states have lower suicide rates. Accordingly, the highest suicide rates are in the western states, with Wyoming and Alaska at the top of the list, although California is ranked as having one of the lowest rates. The middle and eastern states are ranked lower in suicide rates than the western states (with the District of Columbia and Massachusetts as the lowest), although Vermont, West Virginia, and Oklahoma are ranked as high. Most of the New England states are ranked as having the lowest rates of suicide.

SUICIDE AMONG THE ELDERLY

Since 1990, in the United States there has been an increase in suicide rates in individuals eighty-five years or older, although suicide in the elderly does not elicit the same response as it does in younger individuals. Elderly individuals are more likely to be socially isolated for a longer time before death and are more likely to experience physical illness, other sources of distress and depression, and loss of relationships, making them at higher risk for suicide. Elders are less likely to give warning signs of suicide.

TEEN SUICIDE AND THE FAMILY

Since the 1980s the general incidence of suicide has increased in the United States; the rate for those between the ages of fifteen and twenty-four has tripled. Although suicide among adolescents is seriously underreported, researchers generally consider it to be the second- or third-most common cause of death in that group. More than eight out of ten kids who threaten suicide attempt it; females make more suicide attempts, although more males complete suicide, with firearms or explosives the most common method of self-destruction. Half of all children who have made one suicide attempt will make another, sometimes as many as two a year until they succeed. The majority of suicide attempts are expressions of extreme distress and not merely bids for attention; this distress is often related to others prior to suicide. Additionally, some children who take their own lives are indeed the opposite of the rebellious teen. They are anxious, insecure kids who have a desperate desire to be liked, to fit in, and do well. Their expectations are so high that they demand too much of themselves, thereby condemning themselves to constant disappointment. A traumatic event (such as the loss of a valued relationship or a change of residence), which can seem minor viewed from an adult perspective, is enough to push children and adolescents over the edge into a severe depression. Alcohol and drug use are associated with heightened suicide risk in youth.

The role of the family is also a variable in teen suicide. Two-thirds of suicidal teens report poor relationships with their parents. Increased levels of suicidal behavior in adolescents is associated with certain family characteristics: rigid rules, poor communication, overbearing parents, and long-term patterns of family dysfunction such as alcoholism and mental illness.

PHYSICIAN-ASSISTED SUICIDE

In some cases an individual may be too incapacitated by illness to end his or her life without assistance. The ethics of physician-assisted suicide, or euthanasia, has been the subject of vigorous debate. Active euthanasia refers to direct action being used to end a life; passive euthanasia refers to not taking steps to prolong life or letting die. Some argue that active euthanasia respects the principle of individual autonomy and the right to self-determination, that its foremost concert is the patients well-being, and that it adheres to the physicians Hippocratic Oath to do no harm, where doing no harm means alleviating pain and respecting the wishes of a rational person. Many argue that a decision to kill oneself with the assistance of a physician is a private choice that society has no right to regulate; others argue that assisted suicide threatens the moral foundations of society.

INTERNATIONAL DEMOGRAPHIC DATA

Suicide rates vary from nation to nation, with Belarus, Estonia, Hungary, Kazakhstan, and the Russian Federation having the highest suicide rates in the world. Suicide rates for men are substantially higher in all countries and are also high for indigenous populations who have been exploited, discriminated against, and deprived of their previous cultural existence. China is undergoing a national suicide crisis, with 21 percent of the worlds population, 44 percent of the worlds suicides, and 56 percent of the worlds female suicides. Those in China at a higher risk of suicide live in rural areas or areas where the government has policies that have increased stress through the disruption of traditional family patterns. Some argue that this level of suicidal behavior has changed attitudes in China about suicide, with self-destruction coming to be seen as an acceptable action.

OTHER MANIFESTATIONS OF SUICIDE

Suicide can also occur as a group response to extreme situations, notable examples being the mass suicide at the Masada fortress in 73 CE by besieged Jews choosing death over defeat by the Romans; the Jonestown cults mass murder-suicides in Guyana in 1978; and the Heavens Gate cult suicides in southern California in 1997.

Suicide bombings by terrorist groups became a phenomenon in the late twentieth century. Terrorism constitutes random acts of violence or the threat of such violence as a political or religious strategy, and suicide bombing is one of these strategies. The attacks of September 11, 2001, show how self-destruction can be used as a weapon.

The act of suicide has been interpreted in many ways and given various meanings. In Christianity and Judaism, suicide is sinful and forbidden. Historically, many societies have viewed suicide as a crime and have enacted laws to regulate the act and punish those who attempt it. Those who attempt or commit suicide have often been seen as psychotic or mentally ill; by contrast, in some cultures suicide is viewed as an honorable and glorious death. Some approve of suicide when it is seen as the only option left to alleviate pain and suffering from severe illness. Freud understood suicide as a drive or death instinct; from an existentialist standpoint, suicide removes the necessary choice for authentic existence.

SEE ALSO Alienation; Alienation-Anomie; Assisted Death; Death and Dying; Depression, Psychological; Durkheim, Émile; Euthanasia and Assisted Suicide; Morbidity and Mortality; Native Americans; Suicide Bombers

BIBLIOGRAPHY

Beckerman, N. L. 1995. Suicide in Relation to AIDS. Death Studies 19 (3): 223234.

Brock, Dan W. 1994. Voluntary Active Euthanasia. In Contemporary Issues in Bioethics, 4th ed., eds. Tom L. Beauchamp and LeRoy Walters. Belmont, CA: Wadsworth.

Colt, George Holt. 1991. The Enigma of Suicide. New York: Summit.

Conwell, Y. 2001. Suicide in Later Life: A Review and Recommendation for Prevention. Suicide and Life-Threatening Behavior 31 (Suppl.): 3247.

Crosby, A. E., M. P. Cheltenham, and J. J. Sacks. 1999. Incidence of Suicide Ideation and Behavior in the United States, 1994. Suicide and Life-Threatening Behavior 29 (2): 131140.

Durkheim, Émile. 1951. Suicide. Trans. John A. Spaulding and George Simpson, ed. George Simpson. Glencoe, IL: Free Press.

Freud, Sigmund. [1917] 1959. Mourning and Melancholia. In Collected Papers. Trans. Joan Riviere, Vol. 4, 152172. New York: Basic Books.

Hendin, Herbert. 1995. Suicide in America, expanded ed. New York: Norton.

Kastenbaum, Robert. 2000. The Psychology of Death. 3rd ed. New York: Springer.

Kochanek, Kenneth D., et al. 2004. Deaths: Final Data for 2002. National Vital Statistics Report 53 (5). Hyattsville, MD: National Center for Health Statistics.

Leenaars, Anton A., and Susanne Wenckstern. 1991. Suicide Prevention in Schools. New York: Hemisphere.

Mancinelli, I., A. Comparelli, P. Girardi, and R. Tatarelli. 2002. Mass Suicide: Historical and Psychodynamic Considerations. Suicide and Life-Threatening Behavior 32 (1): 91100.

Minois, Georges. 1999. History of Suicide: Voluntary Death in Western Culture. Trans. Lydia G. Cochrane. Baltimore, MD: Johns Hopkins University Press.

Murray, Alexander. 19982000. Suicide in the Middle Ages. 2 vols. Oxford and New York: Oxford University Press.

National Household Survey on Drug Abuse. 2002. Substance Use and the Risk of Suicide Among Youths. http://www.oas.samhsa.gov/2k2/suicide/suicide.htm.

National Vital Statistics Reports: Deaths (2002). http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_10.pdf.

Osgood, Nancy J. 1992. Suicide in Later Life. New York: Lexington.

Pedahzur, Ami. 2004. Suicide Terrorism. Cambridge, U.K.: Polity Press.

Pellegrino, Edmund D. 1994. The Virtuous Physician and the Ethics of Medicine. In Contemporary Issues in Bioethics, 4th ed., eds. To m L. Beauchamp and LeRoy Walters. Belmont, CA: Wadsworth, 1994.

Phillips, M. R., H. Liu, and Y. Zhang. 1999. Suicide and Social Change in China. Medicine and Psychiatry 23 (1): 2550.

Rachels, James. 1994. The Distinction between Active Killing and Allowing to Die. In Contemporary Issues in Bioethics, 4th ed., eds. To m L. Beauchamp and LeRoy Walters. Belmont, CA: Wadsworth.

Reisman, David. [1961] 2000. The Lonely Crowd. New Haven, CT: Yale University Press.

Reuter, Christoph. 2002. My Life Is a Weapon: A Modern History of Suicide Bombing. Trans. Helena Ragg-Kirkby. Princeton, NJ: Princeton University Press.

Ryan Ashley Caldwell

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Suicide

SUICIDE

SUICIDE. When early modern authors and intellectuals considered the topic of suicide, they started out with one salient contrast in mind: Whereas the ancient Greeks and Romans had often approved of suicide, Christians did not. For many, this contrast illustrated the superiority of Christian thinking, but throughout the Renaissance and into the seventeenth century, some who admired the ancients drew a more nuanced set of conclusions. Thomas More's Utopia (1516), for example, presents voluntary euthanasia for the terminally ill in a favorable light, although More condemned suicide vigorously in other works. The bishop of Guadix, Antonio de Guevara, took inspiration from the heroic suicides of classical antiquity (for example, Cato, Diogenes, Zeno, Lucretia, Seneca) and praised the nobility of barbarians who did not overvalue life in this world. Similarly, Michel de Montaigne touched on the question of suicide repeatedly and in "A Custom of the Island of Cea" considered the topic at considerable length, thoughtfully assembling moral, religious, social, and legal views. Although he admired the deaths of the noble ancients, he was reluctant to give his blanket approval to all who sought to escape shame or pain through suicide, and in the end he thought one might kill oneself only as a last resort to avoid intense pain or torture.

Shakespeare's characters commit suicide with remarkable frequency (there are fifty-two cases in his plays), and Hamlet's soliloquy ("To be or not to be") dwells on the topic, presenting arguments both for and against (although ignoring specifically Christian objections), before concluding, famously, that the future was too murky to make self-murder a safe option. In other plays Shakespeare presents suicide as the result of tragic misunderstanding (Romeo and Juliet) or as grand examples of freedom or despair (Julius Caesar, Antony and Cleopatra, and Othello). In 1610 John Donne went further, arguing in Biathanatos that sometimes suicide was justified or at least excusable. He did not proceed, as others had, from the example of ancient worthies but specifically considered the Christian grounds for condemning suicide. In a nutshell, he concluded that suicide did not necessarily and always violate the laws of nature, reason, or God. Despite the daring independence of this view, Donne forbade the publication of his book, and it only appeared in print in 1647, sixteen years after his death. This fact illustrates the ongoing and deep anxiety early modern Christians felt about suicide as both a crime and as the result of despair, the ultimate sin. Usually Protestants and Catholics united to condemn "self-murder" and to depict the devil as the prime mover or inspiration for most cases of self-destruction. As a result, throughout early modern Europe, suicides were denied burial in hallowed ground and often suffered desecration of their corpses. The worldly goods of suicides were sometimes confiscated by the crown, as was the case in England and Scotland.

In the seventeenth and eighteenth centuries, however, this legal and moral position decayed, not so much because suicide became positively defensible but more commonly because it seemed increasingly to be the result of melancholy madness. Moralists and theologians had regularly made provision for a sort of insanity defense of suicide. They viewed both sin and crime as actions that proceeded from free and voluntary decisions; condemning actions one could not prevent or avoid did not seem to make moral sense. Indeed, Martin Luther had carried this point so far that he thought suicides were driven to their deaths by the devil, thus extinguishing human responsibility: "I have known many cases of this kind, and I have had reason to think in most of them, that the parties were killed, directly and immediately killed by the devil, in the same way that a traveler is killed by a brigand." Most theologians, however, understood the role of the devil as that of a tempter or seducer, and therefore left ample room for the harsh condemnation of suicide, as long as it seemed clear that the victim had acted deliberately, intentionally, or voluntarily.

THE SECULARIZATION OF SUICIDE

By the late seventeenth century, suicide began to seem so alien to right reason, so much the product of melancholy or delusion (what we might call acute depression), that coroners, villagers, pastors, and magistrates were prepared to grant decent (even if quiet) burials inside the churchyard. Townsmen and villagers alike might also (as in England and Scotland) unite to portray a suspicious death as the result of illness or accident in order to circumvent the crown's efforts to confiscate a victim's estate, a move that usually added to the burdens on local poor relief. Thus from about 1650 onwards, we can mark the "secularization of suicide," that is, the development of medical or other naturalizing explanations and excuses for suicide. This evolution of public sentiment was supplemented during the eighteenth century by the moral philosophizing of the Enlightenment. Montesquieu's Persian Letters (1721), for example, sharply criticized the condemnation of suicide. Voltaire went further and saw suicide as a question of liberty. It could not harm God or society, in his view, to exit the world when one could no longer enjoy life or contribute to the welfare of others. David Hume also defended an individual's absolute right to suicide. Despite hesitations and equivocations, however, many philosophes were drawn to the medical conclusion that suicide was usually the result of madness or bodily disturbances.

THE SOCIAL HISTORY OF SUICIDE

Broadly speaking, this array of opinions on suicide has been well known and well described for several generations. In recent years, scholars have renewed their attention to suicide and have made several noteworthy contributions, not so much to high religious or intellectual history, but to the sociology or social distribution and cultural understandings of suicide. In this work they have often taken inspiration from the foundational work of Émile Durkheim, Le suicide (1897), which tried to demonstrate that social dynamics account for almost all the statistical variations in suicide found in modern countries. Roughly stated, Durkheim held that higher rates of suicide were prompted by increasing conditions of social isolation, so that tight webs of social support served to protect populations from the effects of urbanization, individualism, migration, and other conditions of modernity. It seemed to make sense, from this point of view, that Protestants (as part of a "modern," "secularizing," and "individualizing" movement) should always and everywhere have higher rates of suicide than presumably more traditional and more socially cohesive Catholics. This schema has inspired a great deal of modern sociological investigation, and recently scholars have extended these efforts to the early modern period. However, one supreme difficulty has been that neither the numbers of suicides nor early modern populations were reliably recorded, making the calculation of a suicide rate (the number of suicides per 100,000 population) doubly problematic.

Suicide in Britain and Germany. After an extraordinary and energetic attempt to count the number of suicides in early modern England, for example, Terence Murphy and Michael MacDonald abandon the task of calculating the varying suicide rate from place to place and from time to time, turning instead to an examination of the varying meanings of suicide. In an excellent study of suicide in far northern Germany, Vera Lind draws similar conclusions, heaping criticism on those who have imagined that medieval or early modern rates of self-murder could be calculated unproblematically. In a vast and complex survey, Alexander Murray draws the same conclusion with respect to medieval Europe, but then curiously hazards the guess that whatever the medieval rate may have been, suicide became far more common in the sixteenth century.

Suicide in Switzerland. The most impressive recent attempt to scrutinize all the suicides in a fairly controlled population is Jeffrey Watt's study of early modern Geneva, where suicide remained rare until the end of the seventeenth century and then increased slowly in the early eighteenth century. After 1750, however, the rate jumped up by a factor of five or more, and it went even higher after 1780. Watt has been careful to count not only those cases regarded as suicide by the Genevan authorities, but to look for "disguised" suicides as well, deaths from falls or from drowning that may well have been self-inflicted even if contemporaries declined to label them self-murder. Watt's evidence is so rich and so complete that, at least for this city, a genuine suicide rate can probably be calculated. Recognizing a dramatic escalation after 1750 seems unavoidable. Rejecting an easy equation of Calvinism with higher rates of suicide, however, Watt points out that Geneva during the Reformation had promoted just as tight an integration of society as in any Catholic city or principality. Yet by the late eighteenth century, Genevans from top to bottom had grown more secular in their attitudes, abandoning belief in the devil and often in hell as well. These processes may have developed more quickly or more profoundly for men than for women, which might explain why the disproportion of male suicides became even more pronounced after 1750. On this reading, growing secularization accomplished more than just the decriminalization or medicalization of suicide; increasingly a more secular society relaxed its supportive web as well as its sanctions against self-killing. Taking one's own life became far easier to contemplate.

This finding runs counter to the conclusion of a study of suicide in Zurich, in which Markus Schär connects the rapidly escalating numbers of self-inflicted deaths in the eighteenth century not with increasingly secular attitudes but with the growth of acute religious despair among people who doubted that they could ever gain God's mercy. Oddly enough, however, both Watt and Schär agree in emphasizing the importance of religious and cultural changes, rather than social changes (such as demography, economy, and urbanization), as crucial stimulants to suicide.

THE EIGHTEENTH CENTURY

As far as eighteenth-century Europeans were concerned, England was the classic land of melancholy and suicide. In the absence of reliable comparative studies, it is not clear that this stereotype was fully deserved. It does seem certain, however, that suicide notes and newspaper publicity about recent suicides first proliferated in England, for reasons well explored by Murphy and MacDonald. In Germany, the popularity of Goethe's Sorrows of Young Werther (1774) led to a wave of widely publicized suicides supposedly inspired by the romantic death of that lovelorn protagonist. By the late eighteenth century suicide had been common enough that it seemed symptomatic of the cultural and social disruptions endured by nations undergoing rapid urbanization, industrialization, or secularization.

See also Death and Dying ; Madness and Melancholy ; Religious Piety .

BIBLIOGRAPHY

Bernardini, Paolo. Literature on Suicide, 15161815: A Bibliographical Essay. Lewiston, N.Y., 1996.

Donne, John. Biathanatos. Edited by Ernest W. Sullivan II. Newark, Del., and London, 1984.

Jansson, Arne. From Swords to Sorrow: Homicide and Suicide in Early Modern Stockholm. Stockholm, 1998.

Lind, Vera. Selbstmord in der frühen Neuzeit: Diskurs, Lebenswelt und kultureller Wandel am Beispiel der Herzogtümer Schleswig und Holstein. Göttingen, 1999.

Minois, Georges. The History of Suicide. Translated by L. Cochrane. Baltimore, 1999.

Murphy, Terence R., and Michael MacDonald. Sleepless Souls: Suicide in Early Modern England. Oxford, 1990.

Murray, Alexander. Suicide in the Middle Ages. 2 vols. Oxford, 1998, 2000.

Schär, Markus. Seelennöte der Untertanen: Selbstmord, Melancholie und Religion im Alten Zürich, 15001800. Zurich, 1985.

Watt, Jeffrey R. Choosing Death: Suicide and Calvinism in Early Modern Geneva. Kirksville, Mo., 2001.

H. C. Erik Midelfort

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MIDELFORT, H. C. ERIK. "Suicide." Europe, 1450 to 1789: Encyclopedia of the Early Modern World. 2004. Retrieved August 25, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3404901091.html

Suicide and Suicidal Behavior

Suicide and suicidal behavior

Definition

Suicide is the act of ending one's own life. Suicidal behavior are thoughts or tendencies that put a person at risk for committing suicide.

Description

Suicide, attempted suicide, and thoughts of committing suicide are, as of the early 2000s, growing problems among adolescents in the United States and much of the world. It is the third leading cause of death among 15 to 19 year olds in the United States and the sixth leading cause of death among 10 to 14 year olds. About 2 percent of adolescent girls and 1 percent of adolescent boys attempt suicide each year in the United States. Another 5 to 10 percent of children and teens each year come up with a plan to commit suicide.

Psychologists have identified the teenage years as one of the most difficult phases of human life. Although they are often seen as a time in which to enjoy life, hang out with friends, and perform other activities that adults would not usually do, the teenage period can be difficult. Many changes in the human mind take place during puberty . Apart from facing the onset of sexual maturity, teenagers must also make key decisions about their future, develop their identities, change schools, and meet new friends. They may have to cope with a wide range of personal and social challenges. Many young people have difficulty dealing with stress these experiences may elicit.

The most common reasons for suicide or suicidal behavior among children and adolescents involve personal conflict or loss, most frequently with parents or romantic attachments. Family discord, physical or sexual abuse, and an upcoming legal or disciplinary crisis are also commonly associated with completed and attempted suicide. Adolescents who complete suicide show relatively high suicidal intent, and many are intoxicated at the time of death. The most serious suicide attempters leave suicide notes, show evidence of planning, and use an irreversible method, such as a gunshot to the head. Most adolescent suicide attempts, though, are of relatively low intent and lethality, and only a small number of these individuals actually want to die. Usually, suicide attempters want to escape psychological pain or unbearable circumstances, gain attention, influence others, or communicate strong feelings, such as anger or love.

Suicidal behavior is rare in children prior to puberty, probably because of their relative inability to plan and execute a suicide attempt. Psychiatric risk factors, such as depression and substance abuse, become more frequent in adolescence , contributing to the increase in the frequency of suicidal behavior in older children. Some view the transition from primary to middle school as particularly stressful, especially for girls. Also, parental monitoring and supervision decrease with increasing age, so that adolescents may be more likely to experience emotional difficulties without their parents' knowledge.

Repeated suicide attempts are common, but rates vary. Follow-up studies ranging from one to 12 years found a re-attempt rate among adolescents of 5 to 6 percent per year, with the greatest risk within the first three months after the initial attempt. Factors associated with a higher re-attempt rate included chronic and severe psychiatric disorders, such as depression and substance abuse; hostility and aggression; non-compliance with treatment; poor levels of social skills; family discord, neglect, or abuse; and parental psychiatric disorders.

Highest risk

Four out of five teenagers who successfully commit suicide are male, but the average female teenager is prone to attempt suicide four more times during her teen years than the average male. White teenage males are more likely to commit suicide than other ethnic groups, but as of the early 2000s teenage suicide among blacks is also increasing. Teenagers who have unsuccessfully tried to commit suicide in the past are more likely to attempt suicide in the future. The odds increase after each failed attempt. There are two groups of teens that are at a particularly high risk for committing suicide: Native Americans, and gay, lesbian, bisexual, and transgendered teens.

In Native American, including Native Alaskan, youth ages 15 to 24 years, suicide is the second leading cause of death, according to a 2001 survey by the Bureau of Indian Affairs. The survey also showed that 16 percent of Native American youth attempted suicide in the preceding year. Among Native American high school students, suicide attempts were most associated with poor school performance, poor physical health, a history of family or friends who committed or attempted suicide, family problems, and physical and sexual abuse.

Gay and bisexual male teens, which represent about 10 percent of the male teen population, are six to seven times more at risk for attempting suicide than their heterosexual peers. Several surveys show gay and lesbian youth account for 30 percent of all suicides among teens, according to the U.S. Department of Health and Human Services. Yet most studies of teen suicide have not been concerned with identifying sexual orientation.

A 1997 study by the Massachusetts Department of Education found that 46 percent of high school students who identified themselves as gay, lesbian, or bisexual, had attempted suicide in the past year compared to 8.8 percent of their heterosexual peers. Of the gay, lesbian, and bisexual teens, 23.5 percent required medical care as a result of their suicide attempt compared to 3.3 percent of heterosexual students who attempted suicide.

Common problems

The following are common risk factors for teenage suicide:

  • Psychological problems: Depression, previous attempts at suicide, and having received psychiatric care in the past.
  • Personal failure: Unmet high standards set by the teen or parents, including failing grades in school or poor performance in sports.
  • Recent loss: Death of a close friend or family member, divorce , abandonment by a parent, pregnancy, and the breakup with a boyfriend or girlfriend.
  • Substance abuse: Abuse of alcohol and other drugs as forms of self-medication for overwhelming depression. A combination of depression, substance abuse, and lowered impulse control can lead to suicide or attempted suicide. Substance abuse in other family members can also lead to suicide.
  • Household guns: Easy access to a gun. Children of law enforcement officers have a much higher suicide rate because of the accessibility of guns in their houses. The most common method of suicide among teens is gunshot.
  • Violence: Violence against the teen either at home or outside the home, including physical, emotional, or sexual abuse, or bullying. Violence at home or against the youth teaches teens that the way to resolve conflict is through violence, and suicide is the ultimate act of self-violence.
  • Communication problems: The inability to discuss anger or other uncomfortable feelings with family members or friends. These feelings can include loneliness, rejection, and awareness of one's gay or bisexual sexual orientation.

Parental concerns

Parents who are concerned that their child is or may be suicidal should seek help immediately, such as from a psychiatrist, psychologist, or counselor. Therapists and counselors can listen to the child talk about his or her problems and may be able to suggest ways to cope which the teen will find useful.

There are a number of ways parents can help children and teens deal with loneliness, depression, and suicidal feelings. First, they can let the child do the talking, and listen carefully. They can let the child know they take his or her feelings and thoughts seriously. They can try to identify the root of the problem. Second, they can ask direct questions, such as "Are you thinking of committing suicide?" or "Are you thinking of ending your life?" Third, they can stay with the child. Parents should not leave their child alone if the child says he or she wants to commit suicide. By staying with the child, the parent may be protecting the child's life.

When to call the doctor

Many doctors recommend that teenagers be taken to a hospital immediately after they express the desire to commit suicide. At the least, immediate psychological help should be sought. There are many methods, both medical and psychological, of helping teenagers who consider committing suicide. Most teenagers who think of suicide believe their problems are too hard to solve or too embarrassing to talk about, so it is important for their helpers to show they are trustworthy and able to listen. Seeing a psychologist is widely recommended as well. A psychologist may be able to improve a teenager's vision of life by listening to the young person and conveying optimism regarding the future.

Doctors recommend that helpers not ask the teenager's reason for thinking of suicide; rather, helpers should listen and wait for the teenager to trust enough to talk openly about the problem. Helpers should, however, be understanding of the teenager's situation. Doctors also recommend that helpers not mention "reasons for living," as doing so might generate more depressing thoughts in the teenager.

There are many telephone hot lines available, on national, state, and local levels, to help teenagers who are considering suicide. Two national, 24-hour, toll-free suicide hotlines are: 8007842433 and 8009999999. Gay, lesbian, bisexual, or transgendered teens thinking of suicide can get help at 8008508078.

KEY TERMS

Puberty The point in development when the ability to reproduce begins. The gonads begin to function and secondary sexual characteristics begin to appear.

Transgendered Any person who feels their assigned gender does not completely or adequately reflect their internal gender, such as a biological male who perceives himself to be female.

Resources

BOOKS

Empfield, Maureen, and Nicholas Bakalar. Understanding Teenage Depression: A Guide to Diagnosis, Treatment, and Management. New York: Owl Books, 2001.

King, Robert A., et al. Suicide in Children and Adolescents. Cambridge, UK: Cambridge University Press, 2003.

Spirito, Anthony, and James C. Overholser. Evaluating and Treating Adolescent Suicide Attempters: From Research to Practice. New York: Academic Press, 2002.

Wallerstein, Claire. Need to Know: Teenage Suicide. Portsmouth, NH: Heinemann Educational Books, 2003.

PERIODICALS

Eckert, Tanya L., et al. "Adolescent Suicide Prevention: School Psychologists' Acceptability of School-based Programs." School Psychology Review (Winter 2003): 5776.

Fritz, Gregory K. "Prevention of Child and Adolescent Suicide." The Brown University Child and Adolescent Behavior Letter (September 2001): 8.

Norton, Patrice G. W. "Prevention Plan Reduces Teen Suicide Attempts." Clinical Psychiatry News (May 2004): 44.

Perlstein, Steve. "TeenScreen Flags Adolescents at Risk of Suicide." Clinical Psychiatry News (April 2004): 43.

Portes, Pedro R., et al. "Understanding Adolescent Suicide: A Psycho-social Interpretation of Developmental and Contextual Factors." Adolescence (Winter 2002): 805814.

ORGANIZATIONS

American Association of Suicidology. 4201 Connecticut Ave. NW, Suite 408, Washington, DC 20008. Web site: <www.suicidology.org>.

Suicide Awareness Voices of Education. 7317 Cahill Road, Suite 207, Minneapolis, MN 55424. Web site: <www.save.org>.

Yellow Ribbon International Suicide Prevention Program. PO Box 644, Westminster, CO 80036. Web site: <www.yellowribbon.org>.

WEB SITES

Columbia University. TeenScreen, 2003. Available online at <www.teenscreen.org> (accessed August 12, 2004).

"Depression and Suicide Page," 2004. Available online at <www.teenlineonline.org/helparchives/depression.htm> (accessed August 12, 2004).

Screening for Mental Health, Inc. "SOS High School Suicide Prevention Program", 2004. Available online at <www.mentalhealthscreening.org/sos_highschool/> (accessed August 12, 2004).

Ken R. Wells

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Wells, Ken. "Suicide and Suicidal Behavior." Gale Encyclopedia of Children's Health: Infancy through Adolescence. 2006. Encyclopedia.com. 25 Aug. 2016 <http://www.encyclopedia.com>.

Wells, Ken. "Suicide and Suicidal Behavior." Gale Encyclopedia of Children's Health: Infancy through Adolescence. 2006. Encyclopedia.com. (August 25, 2016). http://www.encyclopedia.com/doc/1G2-3447200556.html

Wells, Ken. "Suicide and Suicidal Behavior." Gale Encyclopedia of Children's Health: Infancy through Adolescence. 2006. Retrieved August 25, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3447200556.html

Suicide

SUICIDE.

The word suicide is a seventeenth-century English invention put together from Latin elements and meaning literally "self-slaughter," and from English the word spread to other European languages. An isolated scholar around 1179 had in fact coined a Latin word suicida, but it had not gained currency, and that fact highlights the question why so ancient an act should have had to wait so long for a name.

Taboo

One reason was taboo. People did not want to talk about suicide and, when they had to, used composite expressions like the medieval lawyers' "homicide (or felony) of oneself," or others, tinged with euphemism, like "to hasten death," "to die by one's own hand" (to quote from over a dozen expressions in classical Latin). A second reason, linked with the first, was an enduring difficulty in understanding the character of suicide. This is best seen in the history of a much older word, the Greek biaiothanatos. It literally meant "violent death" and included suicide along with deaths we would classify as accidents, like falling from a bridge, all of which were thought polluting, and had consequences for burial and for the dead person's status as a ghost. Although the Latinized successor-word, biothanatos, came increasingly to be confined to suicide, it still carried the old ambiguity as late as the twelfth century. The slowness of that discovery is confirmed by early legal texts, where rabbis, Christian canon lawyers, and commentators on the Koran all, in their turn, insist that it is intention that distinguishes suicideas if people did not know.

So the mere linguistic history of suicide already reveals a lot about how it was conceived. It suggests, further, that the taboo extended beyond the topic to the act of suicide, however vaguely distinguished. Religion absorbed the taboo, and in time gave it force and rationale. Already in Greek antiquity we find indignities attached to the burial of suicides, so understood. Similarly, as ideas of hell became better defined, we find suicides assigned to it, first (this time) in India.

Rationale

As for rationale, it drew on two kinds of source, divine and social. Around the sixth century b.c.e., Pythagoreans taught that we mortals are on sentry duty and bound to stay at our watch until relieved, an image that clearly implied man's obligation to superior powers, sovereign beyond death. The image would be absorbed by Plato and his innumerable readers, who in the later Roman Empire included Neoplatonists and Christians, both of whom used it, with other borrowings, to fortify their faintly equivocal traditions. For the Christian tradition had until then itself been uncertain. In the Bible, keen eyesight is needed to find suicide expressly forbidden (as perhaps in Gen. 9:5 or Exod. 20:13). And although most suicides in the BibleJudas the most notoriousare manifest villains, a "suicide guerilla" had slipped in among biblical heroes around the tenth century b.c.e., in the person of Samson (Judg. 16:1830), and was joined around 70 b.c.e. by another hero, Razias, who had killed himself after military defeat, in the Roman manner (2 Macc. 14:4346). The early church furthermore revered as saints certain women who had killed themselves to avoid rape. In the fourth century c.e., Christian opinion formers set about closing these loopholes, notably Pachomius (in respect of burial ritual) and Augustine (in argument). A few centuries later, Muslim commentators would do the same for the Koran, whose deficiencies in this particular were amply supplied by the Hadith (tradition).

A second main source for an antisuicide rationale was social. Aristotle had explained the Athenians' mutilation of suicides' corpses on the ground that a suicide had injured his polis (an argument to be seized on gratefully by Christian theologians in the later Middle Ages, when Aristotle became available in Latin). The Jews, for their part, told sympathetically (in Tobit, c. 200 b.c.e.) of a woman restrained from suicide by the thought that it would hurt her father. Even suicide-prone Roman Stoics could be restrained by consideration for their friends. Illiterates meanwhile expressed their social feelings on the subject by ideas about pollution of the community cemetery and bad weather. Finally, social considerations could express themselves on the vertical plane, from master to dependent. A Roman slave who killed himself robbed his owner, who might make him an example by maltreating the corpse. In early medieval Europewhen nearly everyone was someone else's dependentlords would punish an underling's suicide by confiscating the property. That prerogative gradually passed to monarchs. That suicide was in England classed as a felony until 1961 probably owed its origin to the defiance it had represented, in the early Middle Ages, to the king qua lord.

Justifications of Suicide

Condemnation of suicide, though widespread, has been far from universal. In all kinds of society, including preliterate kinds in Africa and America, communities with a suicide taboo can sometimes be found alongside others without. At least in more advanced cultures, two kinds of milieu have bred acceptance of suicide. One is military. In 1897 Émile Durkheim's classic, Suicide, recorded abnormally high rates among military officers. Durkheim ascribed this to the military ethos, on grounds that soldiers are familiar with weapons and death and set a high premium on honor. The same factors have operated throughout history. Greek and Roman warrior-heroes like Ajax or Brutusnot to mention their opposite numbers among Germanic opponents of Romewere remembered honorably as falling on their swords after defeat. Off the battlefield, in a political climate similarly based on honor, members of the same class might kill themselves to vindicate their honor, as Lucretia and Cato did, winning post-humous glory as martyrs, respectively to chastity and republicanism. In the most intensely militarized cultures, suicide can become an institution, as with the hara-kiri ("belly-cutting") ritualized by samurai in twelfth-century Japan, and the kamikaze of their twentieth-century successors, who piloted torpedoes and bombs. A more complex case is that of warriors fighting for Semitic monotheisms, which frown on suicide. That Jewish warrior-suicide Razias would set a dilemma for Christian commentators, while Muhammad's condemnation of suicide came to sit uneasily with the martial ethos of early Islam, which could at its most extreme produce an offshoot like the Shurat ("sellers of their lives for God"), who plunged into battle against patently overwhelming odds.

The second tolerant milieu has been philosophy. The classical Greek kind of philosophy, still thriving, tends to resist taboos unjustified by reason; and reason alone cannot easily justify the taboo on suicide, as Hamlet found. It may indeed resent it, since, lacking unquestionable evidence of sensation beyond death, reason suggests that an unhappy life with no prospects is best ended. This train of thought was formally inaugurated by the Cynic Diogenes in the fourth century b.c.e. and survived under the capacious blanket of Roman Stoicism, whose philosophers argued that, just as we may quit a banquet if it becomes tedious, so, under the same condition, we mayindeed must, to be rationalquit the banquet of life; what we do is in any case up to us and no cause for disgrace or punishment. Among lasting effects of this view was the systematic erasure from classical Roman law of any stigma on suicide as such. Around the fourth century c.e. came a change of mood, of which Augustine's arguments were less a cause than a symptom. The philosophical current only began reemerging in the Renaissance, and more fully in the eighteenth-century Enlightenment, when it targeted, in particular, ancient rituals that aimed to disgrace a suicide's memory, usually to the prejudice of his family. After a series of skirmishesincluding a pan-European scandal at the romanticization of suicide in Goethe's novel Die Leiden des jungen Werthers (1774; The sufferings of young Werther)philosophical tolerance completed its conquest of European law during the twentieth century.

Quite a different philosophical tradition has meanwhile recommended suicide of a very strictly defined type. The same ancient Sanskrit texts that condemned suicide done through passion have allowed those ascetics who have overcome passion to sever its last roots by parting from their bodies, by the least passionate method available (say, by drowning in a sacred river or by starvation). Traces of this view have been present in Mediterranean history, and condemnation of suicide by the Semitic religions may owe some of its force to a defensive reaction, against the doctrine of what one early Koran commentator calls the "Indian fools."

While suicides form a minute proportion of the population (0.03 percent per annum is a fairly high figure), a study of their circumstances, as Durkheim and his successors have demonstrated, throws otherwise inaccessible light on the lives of everyone else. In the same way, while suicide commands only a small proportion of moral and legal theory, it raises inexhaustible questions, both of the casuistical kind about suicide as such and also, through those, about life itself.

See also Christianity ; Cynicism ; Judaism ; Stoicism .

bibliography

Bohannan, Paul, ed. African Homicide and Suicide. Princeton, N.J.: Princeton University Press, 1960.

Durkheim, Émile. Suicide: A Study in Sociology. Translated by John A. Spaulding and George Simpson. 1952. Reprint, New York: Free Press, 1989.

Halbwachs, Maurice. The Causes of Suicide. Translated by Harold Goldblatt. London: Routledge and Kegan Paul, 1978.

McManners, John. Death and the Enlightenment: Changing Attitudes to Death among Christians and Unbelievers in Eighteenth-Century France. Oxford: Oxford University Press, 1981.

Murray, Alexander. Suicide in the Middle Ages. 2 vols. Oxford: Oxford University Press, 1998, 2000.

Stack, Steven. "Suicide: A Decade Review of the Sociological Literature." Deviant Behaviour 4 (1982): 4166.

Thakur, Upendra. A History of Suicide in India. Delhi: Munshi Ram Manoharlal, 1963.

Alexander Murray

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Suicide

SUICIDE

Suicide is defined as the act of deliberately taking one's own life. It occurs most often in response to a crisis such as a death or the loss of a relationship or job. During a crisis people experience a wide range of feelings, and each person's response to crisis is different. It is normal to feel frightened or anxious or depressed. If a person feels overwhelmed or unable to cope, he or she may try to commit suicide.

Almost all people who kill themselves either suffered from depression or had substance abuse problems. People who are lonely and isolated or who have histories of previous suicide attempts are also at greater risk for attempting suicide.

In 1996, approximately 31,000 people died of suicide in the United States. Suicide is the eighth leading cause of death overall, and the third leading cause of death among American teenagers. In Canada, suicide is second only to motor-vehicle accidents as a cause of death among adolescents.

The suicide rate is twice the murder rate among those aged 15 to 24, and it has increased dramatically in recent years. Each year, two thousand adolescents commit suicide in the United States. The highest suicide rates in the United States are found in white men over age 85. Men are more than four times as likely as women to die by suicide, yet women are more likely to make a nonlethal suicide attempt.

Suicide is a major public health problem. The need for a public health approach to suicide can be found in the African-American community, where the suicide rate among youths more than doubled between 1980 and 1995. Further, the number of suicides in the United States outnumbered homicides in 1995. Each year, firearms are used as many times for suicide as they are for murder. In some other countries, 71 percent of all firearm deaths are suicide.

Attempted and completed suicides result in enormous social, economic, and medical costs. Suicide is very disruptive to the quality of life of survivors and their families and friends. In 1995 it was estimated that in the United States each suicide attempt costs approximately $33,000. The cost of a completed suicide has been estimated at almost $400,000. These estimates were derived from factors including the expense of hospitalization, medication, and more general social costs.

Public health professionals have a major role to play in addressing the problem of suicide. Public health programs and policies can play a part before, during, and after completed or attempted suicides. First, public health programs are an important aspect of the prevention of suicide. Education campaigns can be used to increase knowledge and to change people's attitudes, beliefs, and values about suicide, and about people who may have attempted suicide. People may have distorted ideas about suicidal persons. For example, it is a myth that people who commit suicide never talk about it first. Most people provide important warning signs that can help to reduce the risk of suicide.

Health education can be combined with counseling or support programs. These programs can be provided by trained public health professionals or by peer counselors. For example, teenagers can be trained to provide counseling and support for other teens. Suicide awareness or prevention programs can be delivered in a variety of settings such as schools, churches, or in the community as a whole. They can also be delivered in psychiatric settings.

A second aspect of the prevention of suicide lies in judging or assessing a person's risk for suicide. Public health professionals such as nurses or doctors can help to prevent completed suicides by identifying people who may be thinking about or planning to try to commit suicide. They can also provide support through crisis or suicide-prevention counseling.

Public health can also play a valuable role during a suicide attempt. A suicide attempt is often a person's response to a crisis, or to a time when they feel overwhelmed or hopeless. Public health professionals can help during a suicide attempt through suicide-prevention counseling. This type of short-term counseling involves providing support and guidance to an individual who is suicidal. Its purpose is to decrease the person's emotional pain, to make sure that the person is safe, and to help develop a plan for coping. Sometimes suicide-prevention counseling includes connecting a person to community or health services. These services can then provide longer-term support.

Suicide prevention counseling is a valuable tool for public health. It is relatively low-cost, flexible, and simple to provide. A wide variety of health professionals, including doctors, nurses, psychologists, and social workers, can be taught to help people with suicide-prevention counseling techniques. These services can be provided in a wide variety of places or settings, including hospitals, community clinics, and telephone-based crisis centers or helplines. Suicide-prevention services provide an important link between the community and the formal health care system.

Public health professionals who work in suicide prevention and counseling are faced with a growing variety of issues and clients. Most communities are home to an increased number of people from a wide variety of cultural and ethnic backgrounds. There are also more older people in society. New issues that might trigger a suicide attempt include elder abuse, racism or discrimination, bullying, or gay bashing. Police officers, firemen, paramedics, and others are being trained to deliver on-the-spot suicide prevention counseling.

There is also a role for public health following a completed or attempted suicide. A suicide attempt or death can have a traumatic effect on the quality of life of survivors and their families and friends. Public health programs can provide important support services to survivors of a suicide attempt and their families.

Public health is only one important part of society's response to suicide as a health and social problem. There is also a role for law enforcement, the education system, the government, and the formal health care system in prevention, treatment, and follow-up to a suicide attempt.

Law enforcement (police officers) and public health professionals can cooperate to help suicidal persons. Police officers are often the first ones on the scene of a suicide attempt. They may act to prevent a suicidal person from hurting themselves (or someone else) through suicide prevention counseling. The may detain someone who is at high risk for suicide and refer him or her to appropriate public health resources.

Legislators can also help to address the challenges of suicide by creating policies or laws to support the development of public health programs and the training of public health professionals. They can also work to change society's attitude toward suicide and suicidal people. One example of this type of work is the fact that in many countries suicide is no longer illegal. Attempting suicide is seen as a mental health issue, not a crime. In 1999 the United States Public Health Service issued the first-ever Surgeon General's Report on Mental Health, as well as a Call to Action on Suicide Prevention, charting out this new approach to suicide.

The educational and health care systems also have a role to play in the prevention, treatment, and follow-up to a suicide attempt. Schools provide access to most young people and provide a place for delivering suicide prevention or awareness programs. They can also teach young people to recognize the warning signs of a potential suicide attempt in their friends, to provide peer counseling, and how to get immediate help and support. This is important because young people are at higher risk of attempting suicide than most adults.

The formal health care system (hospitals, clinics, doctor's offices) can play an important role in two main ways. First, people who are suicidal may come to an emergency room or a physician's office. In these cases, the health system serves as a "first-response" and crisis service. Second, once a person has been identified by a public health or law enforcement professional as suicidal, they may need to be hospitalized for a period of time. Health professionals can provide medications and further counseling or support to a suicidal person and their family.

Once a suicidal person is released from a hospital, public health professionals may make home visits or provide follow-up support through a community-based clinic. The prevention of suicide and the provision of support to people who are suicidal play an important and increasing role in the health of individuals, families, and communities. The most comprehensive national strategies on suicide have been developed by Finland, Norway, Australia, New Zealand, and Sweden.

C. James Frankish

Robbin Jeffereys

(see also: Crisis Counseling; Gun Control; Hotlines, Helplines, Telephone Counseling; Mental Health; School Health; Social Work; Violence )

Bibliography

Carter, C., and Baume, P. (1999). "Suicide Prevention: A Public Health Approach." Australian and New Zealand Journal of Mental Health Nursing 8:4550.

Harwitz, D., and Ravizza, L. (2000). "Suicide and Depression." Emergency Medical Clinics of North America 18:263271.

Lester, D. "Estimating the True Economic Cost of Suicide." Perceptual and Master Skills 80:746.

Office of the Surgeon General (1999). Mental Health: A Report of the Surgeon General. Washington, DC: U.S. Public Health Service.

Potter, L. B.; Powell, K. P.; and Kachur, S. P. (1995). "Suicide Prevention from a Public Health Respective." Suicide and Life Threatening Behavior 25:8291.

U.S. Public Health Service (1999). The Surgeon General's Call to Action to Prevent Suicide. Washington, DC: U.S. Public Health Service.

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Frankish, C. James; Jeffereys, Robbin. "Suicide." Encyclopedia of Public Health. 2002. Encyclopedia.com. 25 Aug. 2016 <http://www.encyclopedia.com>.

Frankish, C. James; Jeffereys, Robbin. "Suicide." Encyclopedia of Public Health. 2002. Encyclopedia.com. (August 25, 2016). http://www.encyclopedia.com/doc/1G2-3404000818.html

Frankish, C. James; Jeffereys, Robbin. "Suicide." Encyclopedia of Public Health. 2002. Retrieved August 25, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3404000818.html

Suicide

Suicide


Suicide rarely occurs before age ten, and although suicide rates for ten to fourteen year olds and adolescents greatly increased in the United States between the mid-1970s and the mid-1980s, suicide rates for children and adolescents are lower than for other age groups. Nevertheless, by the end of the twentieth century, suicide was the second greatest cause of death in adolescents, after (mainly automobile-related) accidents. In children age ten to fourteen suicide is the third leading cause of death, following unintentional injuries and malignant neoplasms. In the United States, males age ten to fourteen die by suicide three times more than females, and males age fifteen to nineteen have five times more suicides than females. The difference between male and female suicide rates may be explained by males being more vulnerable, or it may be due to their preferences for more lethal methods, particularly firearms: gunshot wounds are the leading cause of suicide deaths in the United States for all age groups. For each person who dies by suicide (a "completed suicide") there are an estimated 50 to 100 suicide attempts. When people under age eighteen are asked if they have ever seriously attempted suicide, at least one out of twenty say that they have.

The Historical Problem

The contemporary concern about adolescent suicide raises a complex historical problem. First, how new is the pattern? We know that adolescents and very young adults committed suicide in the past. In Germany in the late 1700s, the publication of Die Leiden des jungen Werthers (The Sorrows of Werter ), a novel by Johann Wolfgang von Goethe, presumably spurred some suicides in young men who were attracted to death by the prevailing romantic culture. Studies of suicide in England in the late nineteenth century also reveal some adolescent suicides. It is unclear how much the current patterns reflect new developments, as opposed to new levels of attention and concern.

To the extent that there is change, the question then arises: what might the causes be? A culture permeated with images of violence, but in which children rarely experience death directly, is sometimes held accountable. New tensions at school and in peer groups may be involved, sometimes complemented by drug use. Suicide is closely linked, of course, to psychological depression, which also seems to be on the rise among young people.

Children's Understanding of Suicide

Although young children (less than ten to twelve years) rarely die by suicide, contemporary children develop an understanding of suicide at an early age, and their conceptions of suicide may influence their behaviors later in life, when they experience the vulnerabilities of adolescence.

Research indicates that by age seven or eight most children understand the concept of suicide, can use the word suicide, and can name several common methods of committing suicide. Young children, as young as age five and six, can understand and talk about killing themselves, even if they do not understand the word suicide. Children by age seven or eight report that they have talked about suicide with other children, and most have seen at least one fictional suicide on television. These suicides usually occur in cartoons in which the villain takes his or her own life when he or she has lost an important battle and has no way to escape. Children also experience suicide attempts and threats in adult television programs, including soap operas and the news. Despite children's knowledge of and exposure to the subject, they receive little guidance about it from adults.

Children age five to twelve generally have quite negative attitudes toward suicide; they consider suicide something that one should not do and generally feel that people do not have a right to kill themselves. When there is a suicide in the family or in the family of their friends, children usually know about the suicide, despite parents' attempts to hide the facts by avoiding talking about it or explaining that the death was an accident. For example, in studies conducted in Quebec, Canada, by Brian L. Mishara, 8 percent of children said that they knew someone who committed suicide, but none of the children said that they were told about the suicide by an adult. Surveys of parents found that 4 percent of children have threatened to kill themselves at some time but these threats are rarely taken seriously or discussed.

Children at a young age are curious about understanding death, and although they know that one can commit suicide, their view of what occurs when someone dies may be very different from an adult's understanding of death. However, children learn fairly early (generally by age seven or eight) that death is finalthat someone who dies may not come back to life. Younger children often believe that people who have died are able to see, hear, feel, and be aware of what living people are doing.

Suicidal Behavior in Children and Adolescents

Suicide is a relatively rare event that results from a combination of risk factors, usually a precipitating event combined with access to a means of committing suicide and a lack of appropriate help. Suicide is generally understood to be the result of complex interactions between developmental, individual, environmental, and biological circumstances. Despite the complexity of factors that may result in suicidal behavior, it is possible to identify children at risk.

Depression is a major risk factor for suicide, although depression symptoms in children may be difficult to recognize and diagnose. In prepubescent children, symptoms may include long-lasting sadness, frequent crying for no apparent reason or, conversely, inexpressive and unemotional behavior, including speaking in a monotone voice. Other signs include difficulty concentrating on schoolwork, lack of energy, social withdrawal, and isolation. Children and adolescents who threaten suicide or become interested in the means of killing themselves, such as tying nooses or playing suicide games or trying to acquire a firearm, should be considered as potential suicide risks.

The best way to verify the risk of suicide is to ask direct questions of the child. They might include the following: "Are you thinking of killing yourself?"; "have you thought about how you would kill yourself?"; "do you think you might really commit suicide?" Many adults hesitate to ask such questions because they are afraid they might "put ideas" in a child's head. However, decades of experience indicate that talking about suicide cannot suggest suicidal behavior to children and can only help children express their concerns to an adult.

It is also important to ask suicidal children what they think will happen when a person dies. If the child indicates that they think someone can return from the dead or that being dead is like being alive, it may be useful to correct that impression and describe with some details what it means to die.

Children who have symptoms of depression or threaten suicide may benefit from help from a mental-health professional. It is also important to talk with a child or adolescent when there is a suicide in the family or in the school environment. Most children already have a good understanding of what occurred and do not feel that this is appropriate behavior. However, in the event that the child glorifies or trivializes a death by suicide or feels that the suicide victim is "better off" after dying, it is important to clarify what occurred and, if necessary, seek counseling or professional help. It is also important to help children express their feelings about a loss by suicide, even if they include "unacceptable" feelings such as being angry at the suicide victim for having abandoned them. It is important to communicate that suicide is a tragic event that is usually generally avoidable and certainly is not beneficial for anyone.

See also: Drugs; Emotional Life; Mental Illness.

bibliography

Bailey, Victor. 1998. This Rash Act: Suicide across the Life Cycle in the Victorian City. Stanford, CA: Stanford University Press.

Kushner, Howard I. 1989. Self-Destruction in the Promised Land: A Psychocultural Biology of American Suicide. New Brunswick, NJ: Rutgers University Press.

Maris, Ronald W., Alan L. Berman, and Morton M. Silverman, eds. 2000. Contemporary Textbook of Suicidology. New York: Guilford Press.

Mishara, Brian L. 1999. "Conceptions of Death and Suicide: Empirical Investigations and Implications for Suicide Prevention." Suicide and Life-Threatening Behavior 29, no. 2: 105108.

World Health Organization. 2001. Preventing Suicide: A Resource for Primary Health Care Workers. Geneva: World Health Organization.

Brian L. Mishara

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MISHARA, BRIAN L.. "Suicide." Encyclopedia of Children and Childhood in History and Society. 2004. Encyclopedia.com. 25 Aug. 2016 <http://www.encyclopedia.com>.

MISHARA, BRIAN L.. "Suicide." Encyclopedia of Children and Childhood in History and Society. 2004. Encyclopedia.com. (August 25, 2016). http://www.encyclopedia.com/doc/1G2-3402800393.html

MISHARA, BRIAN L.. "Suicide." Encyclopedia of Children and Childhood in History and Society. 2004. Retrieved August 25, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3402800393.html

Suicide

SUICIDE

The deliberate taking of one's own life.

Under common law, suicide, or the intentional taking of one's own life, was a felony that was punished by forfeiture of all the goods and chattels of the offender. Under modern U.S. law, suicide is no longer a crime. Some states, however, classify attempted suicide as a criminal act, but prosecutions are rare, especially when the offender is terminally ill. Instead, some jurisdictions

require a person who attempts suicide to undergo temporary hospitalization and psychological observation. A person who causes the death of an innocent bystander or would-be rescuer while in the process of attempting suicide may be guilty of murder or manslaughter.

More problematic is the situation in which someone helps another to commit suicide. Aiding or abetting a suicide or an attempted suicide is a crime in all states, but prosecutions are rare. Since the 1980s the question of whether physician-assisted suicide should be permitted for persons with terminal illnesses has been the subject of much debate, but as yet this issue has not been resolved.

The debate over physician-assisted suicide concerns persons with debilitating and painful terminal illnesses. Under current laws a doctor who assists a person's suicide could be charged with aiding and abetting suicide. Opponents of decriminalizing assisted suicide argue that decriminalization would lead to a "slippery slope" that would eventually result in doctors being allowed to assist persons who are not terminally ill to commit suicide.

The debate on physician-assisted suicide intensified after 1990 when Dr. jack kevorkian, a retired Michigan pathologist, began to attend many suicides. Kevorkian admitted to obtaining carbon monoxide and instructing persons who suffered from terminal or degenerative diseases on how to administer the gas so they would die. Despite the efforts of Michigan legislators and prosecutors to convict Kevorkian of murder, the pathologist, who was dubbed "Doctor Death," successfully fought the charges. Three murder charges were dismissed by Michigan courts, and in 1994 Kevorkian was acquitted of violating Michigan's assisted suicide law (Mich. Comp. Laws § 752.1021 et seq.). Despite Kevorkian's acquittals other assisted suicide advocates believe his methods have actually hurt the cause. In 1997 the U.S. Supreme Court held that neither the due process clause (washington v. glucksberg, 521 U.S. 702, 117 S. Ct. 2258, 138 L. Ed. 2d 772) nor the equal protection clause (Vacco v. Quill, 521 U.S. 743, 117 S. Ct. 2293, 138 L. Ed. 2d 834) of the fourteenth amendment includes a right to assisted suicide.

After four acquittals, Kevorkian was convicted in March 1999 of second-degree murder and delivery of a controlled substance by a jury in Pontiac, Michigan. Kevorkian administered a lethal injection in September 1998 to Thomas Youk, a 52-year-old man who suffered from amyotrophic lateral sclerosis, or Lou Gehrig's disease, a fatal neurological disorder that slowly disables its victims. Kevorkian performed the procedure on the CBS television program 60 Minutes amid great controversy.

At the time of his trial, Kevorkian represented himself, insisting that only he could explain to the jury that he did not intend to kill Youk but to end his suffering. The jury nevertheless reached a guilty verdict. Although he could have been sentenced to life in prison, he was sentenced to ten to 25 years in prison. He sought unsuccessfully for three years to appeal his conviction.

Kevorkian was not entirely alone in his crusade to legalize assisted suicide. In 1994, Oregon voters passed the Oregon Death with Dignity Act (DWDA), which allows physicians to prescribe lethal medication to Oregon residents who request it. The statute requires that the patient must be 18 years or older, must be able to make and communicate healthcare decisions, and have been diagnosed with a terminal illness that likely will result in death within six months. While physicians may make the prescription, patients must self-administer it, since the DWDA specifically prohibits "lethal injection, mercy killing, or active euthanasia." Oregon is the only jurisdiction in the world that has legalized physician-assisted suicide.

The Oregon legislature enacted the DWDA after residents voted in favor of the law twice, 51 percent in favor in 1994, then 60 percent in 1997. The law originally went into effect in 1994 but immediately was suspended by court injunctions pending legal challenges. After the Supreme Court rendered its decisions in Glucksberg and Vacco, the Ninth Circuit Court of Appeals lifted the injunction. The Oregon law went into effect on October 27, 1997.

Between 1998 and 2001, between 70 and 96 patients—the exact numbers are disputed—committed suicide under the act. In November 2001, U.S. attorney general john ashcroft issued a directive stating that physicians who prescribe lethal doses of drugs to end the lives of terminally ill patients would be subjected to criminal charges and have their medical licenses revoked or suspended. Ashcroft issued this directive pursuant to the Controlled Substances Act and reversed the position previously taken by former attorney general janet reno, who determined that the Oregon statute was outside the scope of the Controlled Substances Act. Members of Congress, including Senator Orrin Hatch (R-Utah) and Representative Henry Hyde (R-IL), also unsuccessfully sought to pass federal legislation that would have revoked the registration of Oregon physicians who participated in assisted suicide efforts.

In response to Ashcroft's order, the state of Oregon brought suit against the attorney general, seeking a permanent injunction to prevent him and the u.s. justice department from enforcing the directive. In April 2002, U.S. District Court Judge Robert E. Jones issued the injunction and also criticized Ashcroft for his handling of the directive. According to Jones, the Controlled Substances Act was not intended to override a state's decision concerning what constitutes legitimate medical practice, at least in the absence of federal law prohibiting such a practice. The judge also found that Congress never intended, through the Controlled Substances Act or other federal law, to grant blanket authority to the attorney general or the Drug Enforcement Agency to define what constitutes the legitimate practice of medicine.

The DWDA has strict requirements that are designed to prevent abuse of the act. Patients must make two verbal requests for lethal medication separated by at least 15 days, plus a written request. Two physicians must independently confirm that the patient has a terminal illness likely to result in death within six months and that the patient is capable to make and communicate healthcare decisions. If either physician believes the patient suffers from depression or any other psychiatric disorder, he or she must refer the patient for counseling. The prescribing physician must request, but not require, the patient to inform his or her next of kin of the suicide decision. The prescribing physician also must inform the patient of alternatives to suicide, including hospice care and pain control, and give the patient the opportunity to change his or her mind after the 15 day waiting period.

The strict DWDA requirements have not silenced its critics. Opponents in the medical community, including Physicians for Compassionate Care, believe that physician-assisted suicide is contrary to the profession's purpose—to promote health. Religious opponents, including the Roman Catholic Church, Mormons, and Christian fundamentalists, feel that suicide of any kind devalues life. Not Dead Yet, an organization of disabled persons, believes that states should instead enact legislation to improve access to health and hospice care, and the over-all quality of life, for terminally ill patients. Many opponents are concerned that poor or uneducated patients will be pressured by family members or the healthcare insurance industry to chose death over life with its medically expensive consequences.

To the supporters of physician-assisted suicide, the issue is a matter of personal autonomy and control. The Hemlock Society, an organization that supports physician-assisted suicide, claims that terminally ill patients must be allowed to end their lives voluntarily rather than suffer through the painful and disabling effects of a terminal illness.

cross-references

Death and Dying; Euthanasia; Patients' Rights; Physicians and Surgeons.

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suicide

suicide Current attitudes toward suicide derive from the debates of centuries long past. Aristotle condemned suicide on political grounds, arguing that the allegiance individuals owe to the state precludes them from taking their lives. Plato had likened the state to a parent in the Crito, a position which might seem to support a similar restriction of the individual's right to commit suicide. But Plato actually objected to self- destruction on religious grounds, claiming that human beings are the gods' possessions and risk punishment for daring to decide when to die. Nevertheless, a precedent for the right-to-die position may be found in the Phaedo, where Socrates argues against prolonging life at any cost.

The death of Socrates seemed to embody both reason and self control, qualities prized by the early Stoics, and euthanasia was practised among elderly members of the school. In theory, suicide was an option available to the Stoic at any time. In practice, however, only the first century statesman and philosopher Seneca glorified death to the point of advocating self-destruction as an end in itself. His own death at the command of the emperor Nero was entirely consistent with the principles he espoused. Witnesses described how he managed to stretch the event over the course of a full day, drinking wine and conversing with his friends while periodically opening his veins until he eventually bled to death. Seneca's willingness to end his career in cold blood earned the admiration of his contemporaries — and his was but one of the many heroic suicides that have come down to us from Roman antiquity. The legends of Lucretia, Cato, Brutus, Portia, Antony, and Cleopatra became models for the suicide of honour. To die for some higher ideal, for the sake of virtue, patriotism, or faith, as would become the case with the early Christians, was to make death a cause for celebration.

The Christian case against suicide was formally stated by St Augustine, who prohibited the act as a violation of the sixth commandment, ‘Thou shalt not kill’. But Augustine was actually ambivalent on the question of suicide, permitting it in instances where individuals behaved with divine sanction in ending their lives. This exception was necessary to allow for the voluntary sacrifice of Jesus, who freely chose to die on the cross for humanity's sins. In subsequent centuries the escape clause was widened to admit the martyrs of the early Church, whose sacrifices were essential to the mythology of medieval Christianity.

The Church policy regarding suicide that emerged during the Middle Ages was loosely based on Roman law. Picking up on ancient Greek traditions, the Romans had punished self- destruction, but only under certain conditions: when an individual killed himself to escape legal prosecution or in the case of a soldier or a slave. The act of suicide was not itself considered blameworthy. Rather, the suicide's civil status, combined with his presumed motivations — the cowardliness of the accused man who sought to pre-empt the law, the disobedience of the soldier or the audacity of the slave who disposed of a life that was not truly his — determined whether the act should be punished. (The legal status of Roman women was akin to that of the slave. An unmarried female was treated as her father's dependent; the pater familias held absolute power over his daughter's life. With marriage, this power was transferred to her husband.)

The Christian position was different. What made suicide a sin was its voluntary nature. Self- destruction was prohibited because it represented an individual's choice to do wrong, a deliberate challenge to divine authority. Following the publication of the Summa Theologiae of Thomas Aquinas, suicide came to be seen as a crime against society as well. Aquinas revived Aristotle's view of suicide as an act of political insubordination and also condemned self-destruction on the grounds that it went against the natural instinct for self-preservation. To the traditional religious objection, which served to deny the sinner a Christian burial, Aquinas thus added a provision which could be used to support the implementation of civil penalties against people who killed themselves. During the high Middle Ages, civil legislation against self-murder was enacted in the majority of Western European states. Under no circumstances were men or women permitted to sacrifice themselves without divine sanction or to place their needs above the needs of the community to which they belonged.

The Enlightenment brought into question the moral implications of self-destruction. For the eighteenth-century philosophes, the issue proved to be an effective weapon in their crusade against absolutism and the Christian religion. Voltaire and others revitalized the classical tradition in the name of rationalism and freedom, portraying Lucretius, Cicero, and Seneca — all advocates of the right to die — as early upholders of the secular cause. The Romantics turned self-destruction into a literary convention, further weakening the stigma attached to the act. Driven to despair by the death of their beloved or, worse still, loving and being loved by someone who belonged to another, countless characters in nineteenth-century fiction actively courted the solace which death alone could provide.

Suicide was decriminalized during the French Revolution, and neither Napoleon nor his monarchist successors reinstated the laws against it. And with the emergence of the psychiatric profession in the nineteenth century, the tendency to interpret the act as the inadvertent consequence of psychological problems, which could be diagnosed, treated, and cured, displaced the religious impulse to judge it in moral terms. Thus, while the Catholic Church continues to regard suicide as a sin, the modern inclination to attribute it to depression makes the deprivation of a religious funeral rare.

The greatest controversy today is over the question of assisted suicide. It is a felony to help someone commit suicide in Great Britain and in twenty-eight American states, but in neither country is it illegal to kill oneself. In effect, this means that only healthy people are allowed by the law to take their lives, since people who are seriously ill are often unable to kill themselves without assistance. Supporters of euthanasia aim to do nothing more than to decriminalize assisted suicide for the terminally ill, as has been done in the Netherlands. Opponents of the right to die range from Christian activists who invoke religious arguments against the taking of human life to physicians who think the need for assisted suicide would vanish with more effective strategies for pain management in the last months of life. On a policy level, some argue in favour of allocating limited health care resources toward people whose lives can be saved instead of prolonging the existence of someone already near death, particularly when that person no longer wishes to live. This line of argument has been criticized by those who envision the day when sick people will be hurried to their deaths for reasons of economic expediency.

Current thinking on suicide also owes much to the development of the social sciences, and to the work of Durkheim in particular. What distinguishes the sociological approach from the psychological is that it diminishes the importance of individual intentions in assessing the causes of suicide. Even the most private of human activities, the decision to end one's own life, turns out to be socially determined. Like other forms of collective behaviour, its incidence is governed by regular laws. To isolate the social factors conducive to high rates of self-destruction is the object of suicide prevention programmes today.

Lisa Lieberman

Bibliography

Kushner, H. I. (1989) Self-destruction in the Promised Land. Rutgers University Press, New Brunswick and London.
Lieberman, L. (2003) Leaving You: the cultural meaning of suicide. Ivan R. Dee, Chicago.


See also euthanasia.

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COLIN BLAKEMORE and SHELIA JENNETT. "suicide." The Oxford Companion to the Body. 2001. Encyclopedia.com. 25 Aug. 2016 <http://www.encyclopedia.com>.

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Suicide

SUICIDE

Suicide exists in all countries of the world and there are records of suicides dating back to the earliest historical records of humankind. In 2000 the World Health Organization estimated that approximately 1 million people commit suicide annually. Suicide is among the top ten causes of death and one of the three leading causes in the fifteen-to-thirty-five-years age group worldwide. In the United States, where suicide is the ninth leading cause of death (and where the number of victims is 50% higher than the number of homicides), the Surgeon General in 1999 issued a Call to Action to Prevent Suicide, labeling suicide "a significant public health problem."

Suicide is a tragic phenomenon that has preoccupied professionals from a variety of disciplines. Deaths by suicide have broad psychological and social impacts on families and societies throughout the world. On average, each suicide intimately affects at least six other people, and if the suicide occurs in the school or workplace it can significantly impact hundreds. Suicide's toll on the living has been estimated by the World Health Organization in terms of disability-adjusted life years, which indicates the number of healthy years of life lost to an illness or event. According to their calculations, the burden of suicide is equal to the burden of all wars and homicides throughout the world. Despite progress in controlling many other causes of death, suicide has been on the rise becoming one of the leading causes of death.

The taking of one's own life is the result of a complex interaction of psychological, sociological, environmental, genetic, and biological risk factors. Suicide is neither a disease nor the result of a disease or illness, but rather a desperate act by people who feel that ending their life is the only way to stop their interminable and intolerable suffering.

Despite the magnitude of social damage caused by suicide, it is a fairly rare event. Suicide rates of between 15 to 25 deaths per 100,000 population each year may be considered high. Most people who are seriously suicidal, even those who attempt suicide, rarely have a fatal outcome (although, in the United States, 500,000 people annually require emergency room treatment because of their attempts). For each completed suicide (a suicide that results in death) there are at least six or seven suicide attempts that result in hospitalizations and, according to community surveys, for each completed suicide at least 100 people report that they attempted suicide without being hospitalized as a suicide attempter. Furthermore, if one asks in a community survey if people seriously considered suicide, about one person in twenty-five says that they have done so.

Research shows that the vast majority, at least 80 percent, of persons who died by suicide had been or could be diagnosed as suffering from a mental disorder, usually mood disorders and depression. People who suffer from the mental disorders of depression and manic depression, alcoholism, or schizophrenia have between a 4 percent and 15 percent lifetime risk of suicide. These mental disorders do not "cause" suicide, but people with mental disorders are at much greater risk of committing suicide. For this reason, the diagnosis and treatment of mood disorders, alcoholism, and schizophrenia may prevent suicides.

Besides mental disorders, there are numerous other risk factors that help identify who is at greater risk of suicide. The most important risk factor is gender, with men in Europe and the Americas committing suicide about five times more than women even though women are more likely to attempt suicide. People with some physical illnesses have greater suicide risks. In most countries, men over the age of seventy-five have the greatest risk of suicide of all age groups. Those who live alone or are separated are more vulnerable to suicide, including divorced, widowed, and single people. Also at higher risk are individuals who have lost a job.

Various situational factors also increase the risk of suicide. Individuals who are exposed to suicide in real life or through the media have a higher like-lihood of suicidal behavior. Research on firearms and the availability of other means of suicide has shown that if a method is readily available a death by suicide is more likely to occur. For this reason control of firearms and reducing access to other preferred means of suicide, such as putting up barriers on bridges and getting rid of medications in the home of a suicidal adolescent, may help prevent suicides.

The crisis situation in which a person attempts or commits suicide is often precipitated by a stressful life event. Suicides are more likely to occur after an argument with family members or lovers following rejection or separation, financial loss and bereavement, job loss, retirement, or failure at school. Usually these events are "the last straw" for a suicidal person. They are generally not what caused the suicide but what resulted in an increased likelihood that the suicide would occur then.

People who consider suicide generally feel ambivalent about ending their own life. It is this ambivalence that leads desperately suicidal people to talk about their plans as they "cry for help." Telephone help lines, therapists, and friends strengthen the will to live of ambivalent people by helping them explore other options for changing their situation.

The psychoanalyst Edwin Shneidman described the mental state of suicidal individuals experiencing unendurable psychological pain and feelings of frustration. According to Shneidman, suicide is seen as the only solution to their problems, one that results in stopping intolerable feelings. Besides feeling ambivalent, suicide-prone individuals tend to have what he calls "constriction"rigid and persistent preoccupations with suicide as the solution to their problems. These individuals believe that the drastic option of ending their own life by suicide is the only way out unless others help break this pattern of constricted thought.

Many countries, including the United States, have created national suicide prevention programs that utilize a variety of strategies. These programs involve a variety of actions. Some prevention methods begin very early, teaching young children ages five to seven how to better cope with everyday problems. Other programs focus on teaching high school students how to better recognize signs of suicide in friends and how to obtain help. Actions also focus upon educating "gatekeepers," such as physicians, counselors, and teachers, who may come into contact with suicidal persons. The World Health Organization publishes resources on preventing suicide in its web site (www.who.org), and Befrienders International has extensive information on suicide and its prevention available in several languages at www.befrienders.org.

See also: Suicide Basics; Suicide Influences and Factors; Suicide over the Life Span; Suicide Types

Bibliography

Hawton, Keith, and Kees van Heeringen, eds. The International Handbook of Suicide and Attempted Suicide. New York: John Wiley and Sons, 2000.

Phillips, David P. "The Werther Effect: Suicide and Other Forms of Violence are Contagious." Sciences 25 (1985):3239.

Shneidman, Edwin. Suicide As Psychache: A Clinical Approach to Self-Destructive Behavior. Northvale, NJ: Jason Aronson, 1993.

World Health Organization. World Health Statistics Annual, 1995. Geneva: Author, 1996.

BRIAN L. MISHARA

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MISHARA, BRIAN L.. "Suicide." Macmillan Encyclopedia of Death and Dying. 2002. Encyclopedia.com. 25 Aug. 2016 <http://www.encyclopedia.com>.

MISHARA, BRIAN L.. "Suicide." Macmillan Encyclopedia of Death and Dying. 2002. Encyclopedia.com. (August 25, 2016). http://www.encyclopedia.com/doc/1G2-3407200271.html

MISHARA, BRIAN L.. "Suicide." Macmillan Encyclopedia of Death and Dying. 2002. Retrieved August 25, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3407200271.html

Suicide

SUICIDE

Suicide is a symptomatic act connected most frequently to the framework of depression and melancholy. Its etiology is varied and complex, since it is characterized by the collapse of the ego, along with self-reproach and a diminution or a loss of self-esteemand, at the same time, by a magic omnipotence which allows the annihilation of internal persecutors, as well as a manic feeling based on the denial of death itself. While suicide may appear to be a response to persecutory guilt, it is also a projection of this guilt onto objects as well as a liberation from their control through the death the subject has chosen for himself.

Suicide was discussed in the psychoanalytic literature as early as 1907, as recorded in the Minutes of the Vienna Psychoanalytic Society (Nunberg, Hermann, and Federn, Ernst, 1962-75), but it was a rather superficial discussion, centered on the fact that the differing choice of means by men and women reveals a primal sexual symbolism. From this came the formula that "suicide is the climax of negative autoeroticism" (Minutes, Vol. 1, February 13, 1907, p. 114). This should be understood in the context of the opposition between the ego instincts and sexual instincts in Freud's earliest theorization: "In suicide the life instinct is overwhelmed by the libido" (Vol. 2, April 20, 1910, p. 494).

In this approach, suicide, interpreted as a substitute for psychosis, seems linked both to an inability to tolerate reality and to autoerotic regression: "Suicide is an act of defense of the normal ego against psychosis" (June 6, 1907). Drive regression is equally central to Freud's ideas on the subject of the suicide of high school students; at school "Teachers. . . .must exercise a life-maintaining influence. [The function of] school is to give the child, in this stage of his detachment from his parents, a new footing within a larger relationship" (Vol. 2, April 20, 1910, p. 495). This should extend as far as not to "deny them the right to linger even in those phases of their development that seem vexing." There might well have been some evolution in Freud's thought here, especially if it is considered that, at the very beginning he insisted on the connection between neurasthenia, masturbation, and the risk of suicide. However, Freud also stressed that "in many cases it is the fear of incest itself that drives [children] to suicide" (p. 494), because of the enormous augmentation of their need for love at puberty; Freud went so far as to suggest, this being the case, that homosexuals make the best teachers, the worst being those whom the repression of their homosexuality has turned into sadists, pushing their students to suicide.

Later psychoanalytic thought on suicide followed the main ideas of Freud on the subject. First of all, in the depressive context, suicide was considered self-punishment for the desire to kill, primally directed toward another, as Freud himself stated in Totem and Taboo : "The law of talion, which is so deeply rooted in human feelings, lays it down that a murder can only be expiated by the sacrifice of another life: self-sacrifice points back to blood-guilt" (1912-13a, p. 154). Since then, the risk of self-mutilation or suicide with infantile or borderline personalities has been much emphasized (Kernberg, Otto, 1984); this risk is especially a factor during fits of rage following disappointments which are blamed on others; or else there is a risk of suicide because of failure to achieve success (guilt), or, even the failure of the cure (negative therapeutic reaction).

In fact, the idea that suicide is self-punishment for the desire to kill someone else cannot be understood completely apart from the process of melancholia, whereby the loved/hated object has been introjected within the ego and has become the target of the attack. More even than "self-punishment," suicide would be murder of the other within oneself. "Probably no one finds the mental energy required to kill himself unless, in the first place, in doing so he is at the same time killing an object with whom he has identified himself, and, in the second place, is turning against himself a death-wish which had been directed against someone else" (1920a, p. 162). Freud explained that "the ego is destroyed by the object."

The enigma constituted by suicide in relation to the self-preservative or ego instincts has also been approached in another way, through considering that it is accompanied paradoxically by a tentative intent to reappropriate vital energy, or, indeed, is even prompted by the fantasy of beginning a new life (Grinberg, León, 1983). Accordingly, suicide would result from a state of crisis dominated by the feeling that something must change. The person committing suicide "convokes death imaginally to assure himself paradoxically that life exists" (Triandafillidis, Alexandra, 1991). Ideal images of oneself and others can then survive, at the price of the death of the bad objects cluttering the ego.

The vital stakes involved in this symptomatic conduct have inclined authors not only to attempt to understand the suicidal mechanism, but also to describe its advance symptoms, evaluating the risk of suicide in order to decide on a therapeutic approach, especially in a care-giving institutional setting. León Grinberg (1983) emphasized suicidal premeditation and the fact that a suicidal plan follows the idea of suicide, which was at first only a way of dealing with anxiety. Continuing to the act of suicide depends on an "encounter," which might favor tipping the fantasy into reality. This author also examined factors of present or past vulnerability (feeling of culpability, narcissistic wound, loss of loved object, and so forth). Otto Kernberg (1984) emphasized the need for the therapist not to be fooled by an accentuation of the manic element; he stressed the seriousness of cases where "aggressiveness has infiltrated the grandiose Self," joined to an inability to enter into interpersonal relations and feel emotions. These considerations, however, concern psychotherapeutic strategies rather than the etiology of suicide.

Sophie de Mijolla-Mellor

See also: Bettelheim, Bruno: Bjerre, Poul; Great Britain; Morgenstern-Kabatschnik, Sophie: Rosenthal, Tatiana; Secret; Silberer, Herbert; Sokolnicka-Kutner, Eugénie; Stekel, Wilhelm; Tausk, Victor.

Bibliography

Freud, Sigmund. (1912-13a). Totem and taboo. SE, 13: 1-161.

Grinberg, León. (1983). Culpabilité et dépression. Paris: Les Belles Lettres.

Kernberg, Otto. (1984). Les trouble graves de la personnalité. Paris: Presses Universitaires de France.

Nuberg, Hermann, and Federn, Ernst. (1962-1975). Minutes of the Vienna Psychoanalytic Society. New York: International Universities Press.

Triandafillidis, Alexandra. (1991). La dépression et son inquiétante familiarité. Paris:Éditions Universitaires.

Further Reading

Laufer, M. (Ed.). (1995). The suicidal adolescent. Madison, CT: International Universities Press.

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Suicide

619. Suicide (See also Remorse, Self-Sacrifice.)

  1. Achitophel hanged himself when his advice went unheeded. [O. T.: II Samuel 17:23]
  2. Aegeus throws himself into the sea believing that his son, Theseus, has come to harm. [Gk. Myth.: Brewer Dictionary, 12]
  3. Ajax (the Greater) kills himself in rage over loss of Achilles armor. [Rom. Lit.: Aeneid ]
  4. Antigone imprisoned, kills herself in despair. [Gk. Lit.: Antigone ]
  5. Antony, Mark thinking Cleopatra is dead, he falls upon his sword. [Br. Lit.: Shakespeare Antony and Cleopatra ]
  6. Bart, Lily social climber takes poison when all her scheming comes to naught. [Am. Lit.: The House of Mirth in Hart, 385]
  7. Brand, Ethan acknowledging the unpardonable sin, throws himself into a lime kiln. [Am. Lit.: Hawthorne Ethan Brand in Hart, 261]
  8. Butterfly, Madama (Cio-cio-san) stabs herself when her American lover returns with his lawful wife. [Ital. Opera: Madama Butterfly in Osborne Opera, 192]
  9. Calista stabs herself on disclosure of adultery. [Br. Lit.: The Fair Penitent ]
  10. Cassandra commits suicide to escape the Athenians. [Fr. Opera: Berlioz, The Trojans, Westerman, 174]
  11. Charmian kills herself after mistress Cleopatras death. [Br. Lit.: Antony and Cleopatra ]
  12. Chuzzlewit, Jonas wicked murderer, found out, takes poison. [Br. Lit.: Dickens Martin Chuzzlewit ]
  13. Cleopatra kills herself rather than being led through Rome in defeat. [Br. Lit.: Shakespeare Antony and Cleopatra ]
  14. Compson, Quentin unable to prevent the marriage of his sister, he drowns himself on her wedding day. [Am. Lit.: Faulkner The Sound and the Fury in Magill I, 917]
  15. Deianira accidentally kills husband, Hercules; kills herself out of guilt. [Gk. Myth.: Kravitz, 76]
  16. Dido kills herself when Aeneas abandons her. [Rom. Myth.: Avery, 392393; Rom. Lit.: Aeneid ]
  17. Dobson, Zuleika Oxford undergraduates commit suicide when she spurns them. [Br. Lit.: Magill II, 1169]
  18. Eden, Martin disgusted by society snobbery, he drowns him-self. [Am. Lit: Martin Eden ]
  19. Ekdal, Hedvig heartbroken by her fathers rejection, puts a bullet through her breast. [Nor. Drama: Ibsen The Wild Duck in Magill I, 1113]
  20. Enobarbus kills himself for deserting Antony. [Br. Lit.: Antony and Cleopatra ]
  21. Erigone hangs himself in grief over fathers murder. [Gk. Myth.: Kravitz, 91]
  22. Evadne immolates herself on husbands funeral pyre. [Gk. Myth.: Kravitz, 100]
  23. Gabler, Hedda shoots herself upon realizing that she is in the power of a man aware that she drove another man to suicide. [Swed. Drama: Ibsen Hedda Gabler ]
  24. Goneril stabs herself when her murder plot is discovered. [Br. Drama: Shakespeare King Lear ]
  25. Hero grief-stricken when her beloved Leander drowns while swimming the Hellespont, she drowns herself. [Gk. Myth.: Brewer Dictionary, 450]
  26. Iseult (Yseult, Isolde) of Ireland arriving too late to save Tristram (Tristan) from death, she kills herself. [Medieval Legend: Brewer Dictionary, 913]
  27. Javert French inspector drowns himself to escape self-perpetuating torment. [Fr. Lit.: Les Misérables ]
  28. Jonestown in Guyana; scene of mass-murder and suicides. [Am. Hist.: Facts (1978), 889892]
  29. Julie, Miss compromised by a clandestine affair and thwarted in her plans to run away, she decides to kill herself. [Swed. Drama: Strindberg Miss Julie in Magill II, 675]
  30. Juliet stabs herself on seeing Romeo dead. [Br. Lit.: Shakespeare Romeo and Juliet ]
  31. Kamikaze WWII Japanese pilot corps plunge own planes into enemy ships in banzai attacks. [Jap. Hist.: Fuller, III, 618619]
  32. Karenina, Anna throws herself in front of approaching train. [Russ. Lit.: Anna Karenina ]
  33. Little Father Time solemn child hangs his foster-brothers and himself because of the familys misfortunes. [Br. Lit.: Hardy Jude the Obscure ]
  34. Loman, Willy crashes his car to bring insurance money to his family. [Am. Drama: Arthur Miller Death of a Salesman ]
  35. Mannon, Christine when her lover is killed she shoots herself. [Am. Drama: Eugene ONeill Mourning Becomes Electra ]
  36. Nickleby, Ralph learning that poor Smike is his own son, hangs himself. [Br. Lit.: Dickens Nicholas Nickleby ]
  37. Ophelia driven insane by Hamlets actions, she drowns herself. [Br. Drama: Shakespeare Hamlet ]
  38. Panthea kills herself upon death of lover, Abradates. [Gk. Lit.: Walsh Classical, 3]
  39. Paul deluded youth kills himself when his grandiose yearnings come to nothing. [Am. Lit.: Willa Lather Pauls Case]
  40. Phaedra Athenian queen drinks poison after confessing guilt. [Fr. Lit.: Phaedra, M agill I, 741742]
  41. Romeo thinking that Juliets sleep is death, he drinks poison. [Br. Lit.: Shakespeare Romeo and Juliet ]
  42. Rudolf, Archduke crown prince of Austria (18581889) died in suicide pact with his mistress at Mayerling. [Aust. Hist.: Colliers, XVI: 606]
  43. Saul falls on sword to avoid humiliation of capture. [O.T.: I Samuel 31:46]
  44. Sophonisba Carthaginian who took poison to avoid falling into Roman hands. [Rom. Hist.: Benét, 947]
  45. Suicide Club members wishing to die are chosen by lot, as are those who are to effect their deaths. [Br. Lit.: Stevenson The Suicide Club]
  46. Vane, Sibyl young actress kills herself after Dorians betrayal. [Irish Lit.: The Picture of Dorian Gray, Magill I, 746748]

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"Suicide." Allusions--Cultural, Literary, Biblical, and Historical: A Thematic Dictionary. 1986. Encyclopedia.com. 25 Aug. 2016 <http://www.encyclopedia.com>.

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Suicidal Behavior

SUICIDAL BEHAVIOR

The term suicidal behavior is understood to mean both suicidal equivalents not recognized as such (accidents, repeated risk-taking) and repeated suicide attempts whose chronic and unsuccessful nature certainly constitutes a real risk, but which are also acts of essentially relational significance.

The idea that accidents can be interpreted as unconscious suicide attempts appeared in Sigmund Freud's The Psychopathology of Everyday Life (1901b): "[I]n addition to consciously intentional suicide there is such a thing as a half-intention self-destruction [sic] (self-destruction with an unconscious intention), capable of making skillful use of a threat to life and of disguising it as a chance mishap. There is no need to think such self-destruction rare. For the trend to self-destruction is present to a certain degree in very many more human beings than those in whom it is carried out" (pp. 180-181). This essentially involves the person waiting for the occasion that will divert the forces of personal preservation, and there is thus a "meeting" between the event and the unconscious intention. Involuntary mutilations, which constitute a compromise between the self-destructive tendency and self-preservation, are also included within the framework of accidental suicidal behaviors.

Similarly, with regard to accidents that happen to babies, Melanie Klein spoke of suicide attempts with inadequate means, as if the infant did not yet have the ability to fantasize and premeditate its own death, and that it could only realize by unconsciously putting itself in danger.

In a letter to Freud dated 1 June 1911, Ernest Jones proposed a comparison between accidental suicide and "with the way in which the unconscious seizes on unassociated indifferent material in dream making" (1993 [1908-39], p. 105).

Systematic risk-taking requires a different psychic disposition. The idea of the possibility of death is present and even hypercathected, but at the same time denied in a megalomaniacal narcissistic affirmation. Death is thus "provoked" in the sense of a challenge that is also a relational challenge to those whose fantasized omnipotence cannot effectively protect the subject, the idealized parents. These situations are very common, especially during adolescence, and can involve the risk of accidents, but also toxic risks or even anorexia. Such risk-taking has a function similar to that of the ordalia, or trial by ordeal, in the sense that the subject expects to get from it an affirmation, if not of their own innocence, at least of their invulnerability. In the face of this excessiveness, the accident imposes a limit and brings the person into contact with reality, including that of the body's fragility.

Authors such as Philippe Jeammet and Elisabeth Birot who have studied suicide attempts in adolescents have emphasized the fact that the idea of death has an organizing function during adolescence. It can be noted that the idea of death is unavoidable at this age in conjunction with the obligation to renounce childhood, to which there is no possible return. The idea of death is linked to a sense of the ephemeralhence the ease during this period of identifying with romantic heroes (as seen in Freud's Manuscript N., 31 May 1897, regarding Goethe's hero Werther).

Beyond gambling with the idea of death, a suicide attempt can represent a way of trying to restore a lost identity (the prepubescent body of the anorexic) or a delusional identity. Similarly, the integration of the drives during adolescence, notably with respect to homosexuality, is a factor that can be conducive to suicidal behavior. Such behavior then appears in its relational significance, whether in the form of a threat, or even blackmail against those close to the subject, or a call for help when communication has broken down. Chronic suicidal behavior can have various etiologies; it remains the case that it cannot be dissociated from suicide proper, the potential for which is inherent in it.

Sophie de Mijolla-Mellor

See also: Suicide.

Bibliography

Freud, Sigmund. (1901b). The psychopathology of everyday life. SE,6.

Freud, Sigmund, and Jones, Ernest. (1993 [1908-1939]). The complete correspondence of Sigmund Freud and Ernest Jones, 1908-1939 (R.A. Paskauskas Ed.). London: The Belknap Press of Harvard University Press.

Garfinkel, Barry D.; Froese, A.; and Hood, J. (1982). Suicide attempts in children and adolescents. American Journal of Psychiatry, 139, 10, 1257-1261.

Jeammet, Philippe, and Birot, Elisabeth (Eds.). (1994)Étude psychopathologique des tentatives de suicide chez l 'adolescent et le jeune adulte. Paris: Presses Universitaires de France.

Further Reading

Hartmann, H. P., and Milch, W. (2000). Efficacy treatment of suicidal patients: Transference and countertransference. Progress in Self Psychology, 16, 87-102.

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De Mijolla-Mellor, Sophie. "Suicidal Behavior." International Dictionary of Psychoanalysis. 2005. Encyclopedia.com. 25 Aug. 2016 <http://www.encyclopedia.com>.

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suicide

suicide Commonly defined as the intentional killing of oneself. Émile Durkheim, in his classic study Suicide (1897), defined it as ‘every case of death which results directly or indirectly from a positive or negative act, accomplished by the victim himself which he knows must produce this result’. Controversially he did not require that the death must be intentional, arguing that intentions are hard to identify. Consequently he extended the definition, including for example heroic military deaths, where there is no chance of survival but no specific intention to kill oneself.

Durkheim chose to study suicide because it seemed to illustrate perfectly the necessity for and value of sociological explanation: a patently private, individual act, which was, none the less, subject to social forces and required a distinctively sociological explanation. He maintained that the tendency to suicide depended not on individual psychology or features of the physical environment, but on the nature of the individual's relation to society. Suicide as an individual action represented the failure of social solidarity and was indicative of the ineffectiveness of social bonds. He distinguished three main types of suicide according to causation. Altruistic and egoistic suicide depend on the individual's relations to social ideals and purposes. In altruistic suicide the individual is too strongly integrated into society—a society which encourages or even requires the individual to sacrifice his or her own life (as when a wife is expected to commit suicide on her husband's death). Conversely, in egoistic suicide the individual is insufficiently integrated into society, and so is not subject to the collective forces that prevent suicide—and, indeed, experiences an isolation and detachment conducive to it. Finally, anomic suicide depends on the social regulation of the individual's desires and ambitions. Where anomie—normlessness—is heightened in society, the individual's passions, ambitions, and appetites are increased to a level where they cannot find satisfaction.

Durkheim's analysis has been criticized on numerous grounds: for his definition of suicide and the mismatch between this definition and that embodied in the suicide statistics he employs to substantiate his argument; for his classification of types of suicide in terms of cause (so-called aetiological classification) which incorporates into the classification the very causal links he is seeking to establish; for his extreme polarization of social and psychological explanations (where complementarity should be assumed); and for using aggregate data to make inferences about individuals (the so-called ecological fallacy).

A major strand of subsequent sociological discussions concerns the limitations of official statistics of suicide. Jack D. Douglas, influenced by the work of interactionists and ethnomethodologists, argued in Social Meanings of Suicide (1967) that what was defined or treated as suicide differed from culture to culture, thereby calling into question cross-cultural and historical comparisons of suicide rates, or even data on suicide generated by different coroners. However, it does not follow that suicide statistics have no value in analysing the social causes of suicide; rather, that they need to be treated with exceptional care. One must assess the impact of social and cultural factors on the construction of suicide statistics as well as the tendency to commit suicide. Significantly, the tradition developed by Durkheim has continued, and a range of studies have provided some empirical support for his ideas and evidence of the impact of social factors (such as unemployment) on levels of suicide.

One important development has been the attention to attempted or parasuicide, frequently claimed to be a very different phenomenon from successful suicide, and representing a cry for help. However, some authors argue that the distinction between attempted and successful suicide is a matter of contingency, and it is wrong to exclude unsuccessful cases from the analysis.

The theoretical basis and empirical adequacy of Durkheim's explanation is most fully explored in Whitney Pope's Durkheim's Suicide (1976).

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GORDON MARSHALL. "suicide." A Dictionary of Sociology. 1998. Encyclopedia.com. 25 Aug. 2016 <http://www.encyclopedia.com>.

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suicide

suicide [Lat.,=self-killing], the deliberate taking of one's own life. Suicide may be compulsory, prescribed by custom or enjoined by the authorities, usually as an alternative to death at the hands of others, or it may be committed for personal motives. Depending on the time and place, it may be regarded as a heroic deed or condemned by religious and civil authorities.

Compulsory suicide may be performed out of loyalty to a dead master or spouse. Examples of this are suttee in India and the similar behavior expected of the dead emperor's favorite courtiers in ancient China. Such practices, now largely extinct, undoubtedly derived from the ancient and widespread custom of immolating servants and wives on the grave of a chief or noble (see funeral customs). Self-murder may also be enjoined for the welfare of the group; among pre-industrial peoples, the elderly who could no longer contribute to their own subsistence are an example. Finally, suicide may be offered to a favored few as an alternative to execution, as among the feudal Japanese gentry (see hara-kiri), the Greeks (see Socrates), the Roman nobility, and high-ranking military officers, such as Erwin Rommel, accused of treason. In traditional Japanese society, in certain situations suicide was seen as the appropriate moral course of action for a man who otherwise faced the loss of his honor. Self-killing may be practiced by peoples lacking a codified law of punishment; the Trobriand Islanders hurled themselves ceremonially from the tops of palm trees after a serious public loss of face. In these situations, the line between social pressure and personal motivation begins to blur.

In less traditional societies the causes of suicide are more difficult to establish. The problem has been approached from two different angles: the sociological, which stresses social pressures and the importance of social integration, and the psychoanalytic, which centers on the driving force of guilt and anxiety and the inverting of aggressive impulses. Recent studies have done much to dispel some of the myths surrounding suicide, such as the beliefs that suicidal tendencies are inherited, that suicidal tendencies cannot be reversed, and that persons who announce their intention to commit suicide will not carry out the threat.

Self-killing is expressly condemned by Judaism, Christianity, and Islam, and attempts are punishable by law in certain countries. Suicide was a felony in 11th-century England because the self-murderer was considered to have broken the bond of fealty, and the suicide's property was forfeited to the king. Suicides were interred on public highways with a stake driven through the heart; this practice was observed as late as 1823. In 1961, Great Britain abolished criminal penalties for attempting to commit suicide. Very few U.S. states still list suicide as a crime, but most states have laws against helping someone to commit suicide. A right-to-die movement has supported the principle of doctor-assisted suicide in certain cases (see euthanasia).

In the United States, suicide is the ninth leading cause of death. About twice as many women attempt suicide as men, but out of roughly 31,000 successful suicides in 1996, about four fifths were by men. A striking characteristic, which has concerned and baffled public health workers, has been the increase in suicides in the age group 10 to 14 years. In the period from 1980 to 1995, suicides in this age group rose from 139 to 330 per 100,000 individuals. Worldwide, suicide rates have been notably high in Russia, Hungary, and Finland.

Bibliography

See E. Durkheim, Suicide (1897, tr. 1951); R. Cavan, Suicide (1928, repr. 1965); E. Stengel, Suicide and Attempted Suicide (1965); J. Douglas, The Social Meanings of Suicide (1967); E. Shneidman, ed., Essays in Self-Destruction (1967); M. L. Farber, The Theory of Suicide (1968); E. A. Grollman, Suicide (1970); A. Alvarez, The Savage God (1972); J. Choron, Suicide (1972); D. Lester, Why People Kill Themselves (1972); G. Colt, The Enigma of Suicide (1991); P. Singer, Rethinking Life and Death (1994); H. Hendin, Suicide in America (new and enl. ed. 1995); K. R. Jamison, Night Falls Fast (1999).

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Suicide

Suicide. The deliberate taking of one's own life is condemned in all religions, although exceptions on the margins (death accepted or embraced for religious reasons) are usually made. In Judaism, there is no explicit condemnation in the Bible, but it came to be prohibited, partly on the basis of the sixth commandment (‘Thou shalt not kill’). However, suicide to avoid even greater offence (e.g. to avoid murder or idolatry) was regarded as praiseworthy: the reported suicides at Masada, to avoid falling into the hands of the Romans at the end of the Jewish revolt, 66–70, remained a model of martyrdom—see kiddush ha-Shem. Among Christians, martyrdom is commended in the pattern of Christ who laid down his life for others, but the deliberate taking of one's own life is condemned on much the same grounds as those of the Jews, but with an added sense of the wrong done to family and society at large. Suicides could not, until recently, receive Christian burial. The sense of compassion and support needed for those tempted to commit suicide led to the founding of the Samaritans by Chad Varah in 1953. Islam shares the same kind of attitude: martyrs (shahīd) are highly commended, but suicide (although barely mentioned in the Qurʾān: see 4. 29) is strongly condemned in ḥadīth.

In Eastern religions, the ambiguous border is not so much between martyrdom and suicide as between suicide and sacrifice. Among Jains, the religious relinquishing of the body is taken to a marked extreme in sallekhanā. In Buddhism, the propriety of suicide to benefit another is recognized. But the consideration of ahiṃsā (of doing no harm to a sentient being) makes suicide generally forbidden. Japanese hara-kiri (seppuku) was originally a social rather than specifically religious act, but its endorsement by Zen Buddhism gave it a religious support.

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JOHN BOWKER. "Suicide." The Concise Oxford Dictionary of World Religions. 1997. Encyclopedia.com. 25 Aug. 2016 <http://www.encyclopedia.com>.

JOHN BOWKER. "Suicide." The Concise Oxford Dictionary of World Religions. 1997. Encyclopedia.com. (August 25, 2016). http://www.encyclopedia.com/doc/1O101-Suicide.html

JOHN BOWKER. "Suicide." The Concise Oxford Dictionary of World Religions. 1997. Retrieved August 25, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O101-Suicide.html

suicide

suicide. Whereas in ancient Greece and Rome (for example, Socrates and Seneca) and in Japan (seppuku or hara-kiri) suicide was sometimes considered honourable, the Judaeo-Christian tradition and Islam have rejected the taking of one's own life as self-murder. God alone gives life and takes it away. But martyrdom, dying for a religious cause, blurs the distinction. Early Christian martyrs were almost theatrically suicidal as they went to death; mass suicide of Jews at Masada (ad 74) and at York (1190) and of cultic followers in Guyana (1978) also makes distinction difficult. Augustine (428), later church councils, and Aquinas condemned suicide as sinful and secular powers made it a crime. The custom of burying suicides in unconsecrated ground at crossroads, with stakes driven through their hearts to prevent their ghosts causing harm, ended in 1823 and property ceased to be confiscated (1870). Though no longer criminal in Britain (1961), suicide is still widely regarded as sinful. The issue is now ethically complicated by the advance of medical science, whereby the life of the elderly or terminally ill can be greatly extended to the detriment of themselves, relatives, and society. Meanwhile ‘living wills’ to prevent unnatural lengthening of life become more commonplace.

Revd Dr William M. Marshall

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JOHN CANNON. "suicide." The Oxford Companion to British History. 2002. Encyclopedia.com. 25 Aug. 2016 <http://www.encyclopedia.com>.

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suicide

su·i·cide / ˈsoōiˌsīd/ • n. the action of killing oneself intentionally: he committed suicide at the age of forty | gun control laws may reduce suicides. ∎  a person who does this. ∎  a course of action that is disastrously damaging to oneself or one's own interests: it would be political suicide to restrict criteria for unemployment benefits. ∎  [as adj.] relating to or denoting a violent act or attack carried out by a person who does not expect to survive it: a suicide bombing. • v. [intr.] intentionally kill oneself: she suicided in a very ugly manner.

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"suicide." The Oxford Pocket Dictionary of Current English. 2009. Encyclopedia.com. 25 Aug. 2016 <http://www.encyclopedia.com>.

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"suicide." The Oxford Pocket Dictionary of Current English. 2009. Retrieved August 25, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O999-suicide.html

suicide

suicide the action of killing oneself intentionally; a person who does this. The term is recorded from the mid 17th century, and comes ultimately from Latin sui ‘of oneself’ and caedere ‘kill’.

In Christian theology, suicide is regarded as a sin; it was also formerly a criminal act in the UK (see felo de se). A person who had killed themselves was regarded as someone whose ghost might walk; there was a traditional belief that this could be averted by a stake through the heart, or by the body's being buried at a crossroads. Suicides were also buried at the north side of a churchyard.

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ELIZABETH KNOWLES. "suicide." The Oxford Dictionary of Phrase and Fable. 2006. Encyclopedia.com. 25 Aug. 2016 <http://www.encyclopedia.com>.

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ELIZABETH KNOWLES. "suicide." The Oxford Dictionary of Phrase and Fable. 2006. Retrieved August 25, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O214-suicide.html

Suicide

Suicide

Who Commits Suicide?

What Factors Make People More Likely to Commit Suicide?

What Are the Signs That a Person Is Thinking of Committing Suicide?

Why Do People Commit Suicide?

If You Suspect Someone Is Suicidal

Resources

Suicide is the intentional taking of a persons own life.

KEYWORDS

for searching the Internet and other reference sources

Depression

As shocking as it may seem, in the United States every year there are more suicides than murders and twice as many suicides as deaths from acquired immunodeficiency syndrome (AIDS). Yet suicide gets far less press than murder or AIDS. Why? It may be because talking about suicide makes people very uncomfortable, because there are religious prohibitions against suicide, because suicide is thought of as a shameful act, or because many people simply cannot believe that someone they know and love could intentionally take his or her own life.

Who Commits Suicide?

Suicide is a complex act that results from many factors, not all of which are understood. It is not clear or predictable why the setbacks, losses, or difficulties that would lead one person to feel very unhappy may lead another person to be suicidal.

It is estimated that about 30,000 Americans die as the result of suicide each year, while about 20,000 people are murdered. Some experts, however, believe that the number of suicides is even higher. Many accidents, such as self-inflicted gunshot wounds or single-car crashes, actually may be unrecognized or unreported suicides. Although no official record is kept of suicide attempts, it is estimated that there are between 8 and 25 attempts for each completed suicide. Overall, suicide is the eighth leading cause of death in the United States.

Suicides are not spread equally throughout the population. Although more women than men attempt suicide, about four times more men die, because they use more lethal means. Men of European ancestry committed 72 percent of all suicides in 1997, while women of European ancestry accounted for about 18 percent of these deaths. The rate of suicide among people of Native American ancestry, especially young men ages 15 to 24, is particularly high. The suicide rate among men of African ancestry ages 15 to 19 doubled between 1980 and 1996. Age is another factor in suicide. After age 65, the rate of suicide among men of European heritage increases steadily as they get older. Men of European heritage who are older than 85 have a suicide rate that is six times the national average. The reasons for the different rates of suicide among people of different ethnic backgrounds, gender, and ages vary. Some factors include increased rates of alcoholism, poverty, loneliness, and violence for particular groups at a particular time of life.

Young people also have higher than average rates of suicide. Suicide is the third leading cause of death among people 15 to 24 years old. A 1997 survey found that 1 in 13 high school students said that they had attempted suicide. Meanwhile, the number of children ages 10 to 14 committing suicide has increased sharply during the past decade. The most common methods of committing suicide are by intentionally taking a drug overdose (prescription or over-the-counter medicines), inhaling carbon monoxide from car exhausts, or using guns.

What Factors Make People More Likely to Commit Suicide?

About 90 percent of people who commit suicide have a diagnosed psychiatric disorder. Depression and substance abuse (either alone or in combination) are the two most common disorders that play a part in suicide. This does not mean that everyone who has depression or an alcohol or drug problem will commit suicide. The majority of people with these problems are not suicidal.

People who are more likely to kill themselves also may:

  • have previously attempted suicide
  • live alone and have no social support network
  • have chronic (long-lasting or recurring) physical pain or a terminal (life-ending) illness
  • have a family history of suicide
  • be unemployed
  • be impulsive
  • keep a gun in the home
  • have spent time in jail
  • have experienced family violence, child abuse, or sexual abuse.

What Are the Signs That a Person Is Thinking of Committing Suicide?

It is a myth that people who talk about killing themselves do not do it. Four of five people who attempt suicide have given clues about their intentions before they acted on them. It is important to take seriously any talk about suicide or any indication that suicide is a possibility.

Some common warning signs that a person is thinking about suicide include:

  • talking about death or making suicide threats
  • making such statements asYou would be better off without meorIm no good to anybody(even if these are said jokingly)
  • having any of the symptoms or signs of depression
  • exhibiting major personality changes or unexplainable odd behavior
  • making a will or giving away cherished possessions
  • seeking isolation and becoming uncommunicative
  • being fascinated with death
  • taking a sudden interest in religion if previously not religious, or rejecting religion if previously devout.

Trained adults staff a suicide hotline. These crisis lines are entirely confidential, and can be called 24 hours a day, 7 days a week. Stock Boston

Why Do People Commit Suicide?

No one can explain why some people commit suicide and others do not. One theory is that suicide is an act of rage or anger. Another theory is that people may commit suicide because they feel they have no other choice. Hopelessness and distorted thinking may prevent a person from seeing solutions to their problems.

For a mentally healthy person, the idea that a person would have no choice except to seek death sounds absurd. But depression, substance abuse, and other mental illnesses, such as schizophrenia, alter the healthy mind. People with these problems may feel that they are in a deep, dark hole from which there is no escape and that life is so painful that there are no alternatives except death.

Researchers are finding that there may be inherited tendencies for depression, schizophrenia, alcoholism, substance abuse, and certain personality disorders. All of these problems can increase a persons vulnerability to suicidal thoughts when things go wrong. Some studies suggest that the brain chemistry of people who commit suicide is abnormal. Research is under way to examine the effects of certain medications that alter brain chemistry in a way that could decrease suicidal behavior.

If You Suspect Someone Is Suicidal

People who are thinking about committing suicide need professional help. They have usually sunk so deeply into their mental and emotional black holes that they may be unable to recognize that they are in trouble or to seek help on their own. It is important to pay attention when people talk about wanting to die and to take their words seriously. Having another person approach the subject directly is often a relief to them. It is sometimes thought that speaking to people about their possible wish to commit suicide willput thoughts in their heads.But people who talk about suicide often are already thinking about suicide.

Professional help is available through suicide prevention and crisis intervention centers, mental health clinics, hospitals and emergency rooms, family doctors, health maintenance organizations, mental health practitioners, and members of the clergy. When a person is possibly suicidal, it is a good idea to talk to another mature, responsible person and ask that person to join in helping to deal with the crisis. Many telephone books have community service sections that list suicide and mental health crisis hotlines. Immediate help can be obtained by calling emergency services (911 in most communities).

Other ways of possibly minimizing the risk of suicide include:

  • removing guns and ammunition from the house
  • locking up medications and alcohol
  • staying with the person, since suicide is an act most often performed alone
  • talking calmly, without lecturing, being judgmental, or pointing out all the reasons a person has to continue living.

Suicide places a heavy emotional burden on the survivors. People who have been close to someone who has attempted or completed suicide might consider mental health counseling to help them deal with their own emotions.

See also

Bipolar Disorder

Brain Chemistry (Neurochemistry)

Death and Dying

Depression

Substance Abuse

Therapy

Resources

Books

Cobain, Bev. When Nothing Matters Anymore: A Survival Guide for Depressed Teens. Minneapolis: Free Spirit Publishing, 1998. A guide to depression treatment and prevention. For ages 13 and up.

Crutcher, Chris. Chinese Handcuffs. New York: Bantam Doubleday Dell Publishing Group, 1991. A fictional account of teens dealing with suicide.

Hahn, Mary Downing. The Wind Blows Backward. New York: William Morrow and Co., 1994. A fictional account of teens dealing with suicide.

Organizations

American Psychiatric Association, 1400 K Street NW, Washington, DC, 20005. This professional organization provides online information on suicide (especially teen suicide) and depression at its website. Telephone 888-357-7924 http://www.psych.org

National Center for Injury Prevention and Control, Mailstop K65, 4770 Buford Highway NE, Atlanta, GA 30341-3724. The website of this organization provides up-to-date statistics and research findings about suicide. Telephone 770-488-1506 http://www.cdc.gov/ncipc

U.S. National Institute of Mental Health (NIMH), 6001 Executive Boulevard, Room 8148, MSC 9663, Bethesda, MD 20892-9663. This government agency conducts research on suicide and depression and provides information to the public through pamphlets and a website. Telephone 301-443-4513 http://www.nimh.nih.gov

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suicidal

su·i·cid·al / ˌsoōiˈsīdl/ • adj. deeply unhappy or depressed and likely to commit suicide: far from being suicidal, he was clearly enjoying life. ∎  relating to or likely to lead to suicide: I began to take her suicidal tendencies seriously. ∎  likely to have a disastrously damaging effect on oneself or one's interests: a suicidal career move. DERIVATIVES: su·i·cid·al·ly adv.

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"suicidal." The Oxford Pocket Dictionary of Current English. 2009. Encyclopedia.com. 25 Aug. 2016 <http://www.encyclopedia.com>.

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suicide

suicide (soo-i-syd) n. self-destruction as a deliberate act. assisted s. the act of helping a person to commit suicide by giving them the means (e.g. drugs) to do so, which is a criminal offence in England and Wales. attempted s. an attempt at self-destruction in which death is averted although the person concerned intended to kill himself (or herself). Compare deliberate self-harm.

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"suicide." A Dictionary of Nursing. 2008. Encyclopedia.com. 25 Aug. 2016 <http://www.encyclopedia.com>.

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suicide

suicide1 one who takes his own life. XVIII. — modL. suīcīda, f. L. suī of oneself; see -CIDE1.
So suicide2 taking one's own life XVII; see -CIDE2. Hence suicidal (-AL1) XVIII.

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T. F. HOAD. "suicide." The Concise Oxford Dictionary of English Etymology. 1996. Encyclopedia.com. 25 Aug. 2016 <http://www.encyclopedia.com>.

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T. F. HOAD. "suicide." The Concise Oxford Dictionary of English Etymology. 1996. Retrieved August 25, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O27-suicide.html

suicide

suicide Deliberate act of terminating one's own life.

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"suicide." World Encyclopedia. 2005. Encyclopedia.com. 25 Aug. 2016 <http://www.encyclopedia.com>.

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suicidal

suicidaladdle, paddle, saddle, skedaddle, staddle, straddle •candle, Coromandel, dandle, Handel, handle, mishandle, Randall, sandal, scandal, vandal •manhandle, panhandle •packsaddle • side-saddle •backpedal, heddle, medal, meddle, pedal, peddle, treadle •Grendel, Kendall, Lendl, Mendel, Rendell, sendal, Wendell •cradle, ladle •beadle, bipedal, credal, needle, wheedle •diddle, fiddle, griddle, kiddle, Liddell, middle, piddle, riddle, twiddle •brindle, dwindle, kindle, spindle, swindle, Tyndale •paradiddle, taradiddle •pyramidal • apsidal •bridal, bridle, fratricidal, genocidal, germicidal, homicidal, idle, idol, infanticidal, insecticidal, intertidal, matricidal, parricidal, patricidal, pesticidal, regicidal, sidle, suicidal, tidal, tyrannicidal, uxoricidal •coddle, doddle, model, noddle, swaddle, toddle, twaddle, waddle •fondle, rondel •mollycoddle •caudal, chordal, dawdle •poundal, roundel •Gödel, modal, yodel •crinoidal •boodle, caboodle, canoodle, doodle, feudal, noodle, poodle, strudel, udal •befuddle, cuddle, fuddle, huddle, muddle, puddle, ruddle •bundle, trundle •prebendal • synodal •antipodal, tripodal •citadel •curdle, engirdle, girdle, hurdle •dirndl

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suicide

suicidebackside, trackside •bedside • airside •Tayside, wayside •lakeside • stateside • graveside •quayside, seaside, Teesside •beachside • hillside • ringside •suicide • herbicide • regicide •fungicide • filicide • Barmecide •homicide •germicide, spermicide •tyrannicide • parricide •fratricide, matricide, patricide •uxoricide • countryside • infanticide •insecticide • pesticide • parasiticide •mountainside • Merseyside •Tyneside •dioxide, dockside, hydroxide, monoxide, oxide, peroxide •alongside •diopside, topside •broadside • downside • roadside •poolside • upside • nearside •fireside • Humberside • underside •genocide • waterside • riverside •silverside • overside •kerbside (US curbside) • Burnside

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