The Interpersonal Theory of Suicide
On the surface, suicide seems incomprehensible, contrary to our deepest instincts for survival. Losing a loved one to suicide often causes profound, unbearable anguish to those left behind, who question what they could have done differently to prevent this tragic loss. Yet suicide in the United States has climbed drastically in recent years. Let’s take a closer look.
The global suicide rate has fallen by a third since 2000, but the United States saw its rate increase by 33 percent from 1999 through 2017, from 10.5 to 14 suicides per 100,000 people; in 2017, there were 45,000 suicides, or about 127 people a day. Suicide ranks as the fourth leading cause of death for people ages 35 to 54, and the second for 10- to 34-year-olds. Why the sharp increase since 2006 in U.S. suicides? Hypotheses include:
- Access to firearms. Half the deaths involved a gun. A study of all 50 U.S. states by the Harvard School of Public Health showed a strong link between rates of firearm ownership and suicides, and guns have a much higher fatality rate than other methods—82.5 percent compared to the next most fatal method, drowning, at 65.9 percent. Easy access to an unlocked, loaded weapon is one reason U.S. deaths are higher than the global average; when guns are locked safely away, the suicide rate is lower.
- Cultural/or societal comfort with anger and expression of anger. What used to be considered a shockingly scary movie, such as Hitchcock’s Psycho, didn’t actually depict blood and guts. Now, however, have a culture where we have been desensitized to violence in entertainment of all kinds. A survey by the Classification and Rating Administration found that 80 percent of parents were most worried about films that contain graphic sex scenes compared with only 64 percent who were worried about graphic violence.
- Screens vs. real interaction. There is a clear association between screen-time (including social media and video games) and a higher chance of engaging in suicidal behavior. Kids or young adults who spend 5+ hours a day on screens have less time for activities that may be healthier, like socializing with others and getting adequate sleep.
- Disturbed sleep. Insomnia is a hallmark of suicide. Much research has shown “a statistical association between sleep disturbance and suicidal thinking, suicidal behavior, and suicide death.” And, while some might think depression causes insomnia, even controlling for that factor, “the relationship between sleep problems and suicide still stands.” Night after night of disturbed or limited sleep is draining.
- Opiates and other substance abuse. Being biologically and psychologically dependent on drugs takes us out of attunement with our natural biological signals arising from our brains that will protect us from self-harm, and substance abuse brings a host of medical, legal, financial, relationship, and other problems.
While some of these factors are difficult or slow to change, others can be more easily treated. For example, some treatments for sleep disturbance include better sleep hygiene, using cognitive-behavioral therapy for insomnia (CBT-I) to de-catastrophize insomnia, and stimulus control, in which you coach your mind to associate the stimulus of bed with sleep. For PTSD nightmares, imagery rehearsal therapy is the treatment of choice.
What suicides have in common
Suicide can seem unstoppable. When someone suffers from lifelong, hard-to-treat depression, for example, or a degenerative illness that drastically reduces the quality of life, some may believe we shouldn’t even try to stop them from suicide. And others think that if someone is determined to kill themselves, there is nothing you can do to prevent it. But when we take a deeper look at the commonality among people who kill themselves, we see there are clues about how to prevent suicide, giving us tools to reduce the risk of suicide.
Research over the past twenty years has shown that suicidal people are deeply ambivalent about taking their own life. Even the most suicidal person wavers in the final moments; even with the deadliest of methods, firearms, people flinch. You can’t understand the suicidal mind without understanding this ambivalent choice between life and death. As strong as is the desire for escape from anguish, the will to live is often equally strong. Even in the most suicidal person, there’s room to get a wedge in the door towards choosing life.
Suicide is not typically impulsive but well thought through. Premeditation, planning, and considerable thought about whether or not to kill themselves occur in the weeks, months, and sometimes years before a suicide. And while the final decision to take one’s life can happen in an instant, the mental preparation for the eventual suicide, in hindsight, can be seen when we look more closely at the sometimes subtle or hidden clues left behind.
About 70% of suicides express their intention to die before committing the act. The other 30% keep their wish to die hidden inside, so to survivors, it seems like their death came from out of the blue. Yet even those who don’t directly communicate their plans almost always leave a discernable trail that can be reconstructed after their death. This kind of psychological autopsy lets us reconstruct their mindset leading up to suicide.
The interpersonal theory of suicide proposed by Thomas Joiner describes three factors that, seen together in the same person, make them at greater risk of suicide.
- Perceived burdensomeness. The belief is that “my death will be worth more than my life to others.” This is a tragic and distorted misperception but feels very real to the person who believes it. Some of the components of burdensomeness are rejection, economic, physical.
- Low belonging/social alienation. Feeling alienated from others—having no sense of community or group identity—has a strong connection with suicidal behavior. National celebration and tragedy can both bring people together; suicide rates went down after 9/11, for example.
- Acquired ability to enact lethal self-injury. By repeatedly considering suicide, people weaken their instinct for self-preservation. It’s thought that “the capability for suicide is acquired largely through repeated exposure to painful or fearsome experiences. This results in habituation and, in turn, a higher tolerance for pain and a sense of fearlessness in the face of death.”
We can see that although suicide often seems senseless, there are patterns and wider explanations that put it in context, suggesting avenues for therapy.
The National Institute of Mental Health identifies signs and symptoms that someone may be thinking of suicide (for example, “Talking about feeling empty, hopeless, or having no reason to live”), as well as the most common risk factors (such as “Depression, other mental disorders, or substance abuse disorder), with other helpful information.