My dad was shot in Peckham. Which, if you’re going to get shot in Britain
today, appears to be the most likely place for it to happen. After a violent
altercation with another man in a pub, a car drew up alongside my father as
he walked home and a double blast from the weapon of choice, a shotgun,
shattered his kneecap – and his life.
This shooting took place in the Sixties and was to lead, partly, I now
believe, to his suicide 16 years later. Until recently I had never seriously
considered it a major factor in his death.
The change in the way I now look at my dad’s death comes because of a
compelling book, Why People Die by Suicide, by Thomas Joiner, the
Bright-Burton Professor of Psychology at Florida State University. He has
presented a cogent theory that he contends frames all suicides.
It’s a theory that seems to solve the how and the why of a mystery that has
been unresolved in my mind for 25 years. But Joiner’s book is made all the
more striking by what has, in part, driven him to produce it: the suicide of
his own father in circumstances uncannily similar to my dad’s.
In the middle of the night Joiner’s father drove his van to the car park of an
industrial estate and, just before dawn, climbed into the back, cut his
wrists and then pierced his heart with a large knife.
My dad, between 6am and 8am, took a large knife from the kitchen, got into the
bath at his new home in Peckham, South London, and cut his throat while my
mother, one of my sisters and myself lay sleeping in rooms a few feet away.
The details of my dad’s death are, even now, very painful to me and my family.
But the details, Joiner argues, are crucial.
Since my dad’s suicide I have spent the years largely burying it, rarely
discussing it, especially among those most affected by it: my family. Each
of us retreated into the cell of his or herself, nursing grief, guilt,
sometimes despair, anger, resentment and bafflement, which are, usually,
among the emotions for those whom Joiner calls “suicide survivors”.
Since his father’s death, which took place while he was away at college,
Joiner has dedicated his professional life to becoming an expert on suicide
– for the past 16 years as a scientist studying, researching and seeking
answers as to why people destroy themselves. He’s now one of the foremost
authorities on the subject.
“There’s an idea that suicide is a mode of death that stands apart from
others, but there are clear reasons why people die by suicide,” says Joiner.
“Just like heart disease, if you understand it, you can prevent it.”
Joiner’s theory is that those who kill themselves not only want to die, but
they have learnt to overcome the instinct for self-preservation. The desire
for death, he says, is composed of two psychological states: a perception of
being a burden to others (a belief that one has ceased to contribute in
useful ways to life), and a feeling of not belonging (social disconnection
and isolation expressing itself through a devastating sense of aloneness).
Neither of these states, on their own, is enough to instil the desire for
death, but together they produce a desire that can be deadly when combined
with the acquired ability to enact self-injury.
Suicide victims, Joiner says, “work up” to the act by getting used to danger,
fear and pain. They may do this in different ways. They engage in reckless
behaviour, cut or otherwise hurt themselves or make repeated suicide
attempts. Others may have a history of accidents or medical procedures and
still others become hardened vicariously. Physicians, for instance – who
have an elevated risk of suicide – are exposed daily through their work to
pain and suffering. Eventually, self-injury and dangerous situations become
unthreatening and mundane, according to Joiner, making suicide easier to
carry out.
“Some people think that those who commit suicide are weak,” Joiner says. “It’s
actually about fearlessness. You cannot do it unless you are fearless, and
this is behaviour that is learnt. The truth may be unsettling – it is about
fearless endurance of a certain type of pain. Perhaps this will demystify
and destigmatise suicide and perhaps even the mental disorders associated
with it.”
Joiner’s theory explains why seemingly disparate groups of people, such as
anorexics, athletes, prostitutes and doctors, have higher than normal rates
of suicide. The lifestyles of all of these people expose them to pain –
either their own or others – and can harden them against suffering.
Here’s where Joiner’s theory brings me back to my dad’s shooting when he was
aged 44. I believe now that it was part of the process that had inured him
to pain and injury. Two years after the shooting he had the leg amputated,
not because of the pain, which was acute still, but because it made it
difficult to sleep. He took the loss phlegmatically, I thought, although it
meant the end of his trade as a painter and decorator.
Before the last war my dad was set for a career as a professional footballer.
He twice broke his leg. As a gunner in the Navy, between the ages of 19 and
26, he saw brutal wartime action. He was tough, physically fearless,
confident, but prone to bouts of weekend pub drinking and possessed a quick
temper, although he was gentle with his family.
A year before his death my dad took early retirement from a clerical job. And,
more than I realised, coping with his disability had become worse. I suspect
now that he was probably suffering from a depression, undiagnosed, for the
last 12 months of his life. The first warning we got of that was when he
went to a park and took an overdose of sleeping tablets six weeks before his
death.
Joiner’s father had left the company that underpinned his adult
identity as a good provider and successful businessman and, in the grip of a
depressive episode, had gradually withdrawn from family and friends. A
former marine, his father had a tolerance for pain demonstrated in many
accidents that befell him.
About one million people kill themselves every year around the world. The
number in Britain was 5,671 adults (those under 15 not included) in 2005. To
put that last figure in proportion, compare it with UK road deaths: about
3,201 (in 2005). Yet when did you see a public information campaign aimed at
suicide prevention?
Suicide is the great taboo. Within my vision, as I write this, there are at
least two other close colleagues who are suicide survivors, but none of us
has ever spoken of it to each other. When asked how my dad died I often used
to answer, maybe implying judgment, that “his heart gave out”. One recent
study revealed that 44 per cent of suicide survivors lie about it, yet they
will tell the truth about other deaths, by accident or disease. After
Joiner’s book was first published his university was afraid to put the
subject and the word “suicide” on the cover of its magazine, though it ran
an article inside.
What Joiner’s theory gives, it seems to me, is a model to possibly head off
that period when mental illness can lead to a lethal conclusion.
With knowledge of Joiner’s theory we may, just possibly, have been able to
prevent my dad’s suicide. But it’s a big stretch. I know now that his
attempted suicide was merely miscalculation. The desperate method by which
he did destroy himself tells us that. It was the act of a man determined to
“succeed” where he had once failed. His attempt was not, as one doctor
inanely told me at the time, just a “plea for attention”.
White men present the highest risk group of all suicides in Western countries.
They kill themselves at a rate of 4 to 1 compared with women, though women
tend to attempt suicide more often. In the US, for instance, older white men
are most at risk of suicide (my dad was 62, Joiner’s 56 when they died).
Female lack of “success” is believed to be means-driven.
Men have more access to lethal ways of destroying themselves; and they become
more isolated than women.
Suicide is less likely among black men compared with white, probably because
of social support and religion within ethnic groups being stronger.
Critics of Joiner’s theory accuse him of overreaching in framing a theory to
fit all suicides, and that, while rigorously and scientifically researched,
his book is too loaded with heartfelt anecdotes about his father’s death.
Joiner tells me: “Either I am correct, in which case I am not overreaching by
definition, or I am not correct, in which case much can be learnt by
researchers showing exactly how I am wrong. It is rare, I suppose, for a
personal book to have much scientific value, but not impossible. The
creation of theories can come from anywhere, though the testing of theories
has to conform to the rules of science.”
In searching for answers to my dad’s suicide so many years after the event I
am motivated by thoughts about the future. My eldest and youngest sisters
have both been afflicted with serious depressive illness since our dad’s
death.
Thirteen days ago, in a depressive episode, my youngest sister took an
overdose of sleeping drugs. Only the timely intervention of my middle
sister, and later police, ambulance, A&E staff, and the Maudsley
Hospital team, prevented another tragedy befalling my family.
Joiner’s model, I believe, helped to alert me to the danger. Sadly, despite
repeated warnings from me that my sister was an imminent risk, there was a
lack of response and resources from some of the professionals connected with
her case. The fight is ongoing to prevent further harm.
During that crisis, her 25-year-old daughter asked me, searingly, if it was
inevitable that she too would suffer a mental illness similar to that of her
grandad, aunt and mother. The clinical response appears to be: possibly, but
not inevitably. While there is probably a genetic predisposition for mental
illness in my family, it is not preordained, but the odds are greater than
for those without this background.
A family history of suicide appears to contribute about a twofold increase in
risk. Approximately 95 per cent of people who die by suicide experienced a
mental disorder at the time of death. Yet most people with mental illness
neither attempt or commit suicide.
What I can confidently tell my niece is that a greater knowledge about suicide
may help to prevent others reaching a lethal end in the future. This is why
Thomas Joiner wrote his book. And why I wrote this piece.
— Why People Die by Suicide, by Thomas Joiner, published by Harvard
University Press, £16.95. The paperback edition will be published on October
26, £10.95.
How to prevent suicide: ‘Collect new friends and keep old ones – it’s
powerful medicine’
If you feel suicidal or you fear that someone you know is feeling that way get
professional help immediately. Call police and ambulance services if
necessary. There are also phone helplines, listed above, with trained
volunteers who will listen and help you.
Professional intervention during suicidal crises is the key to saving people,
says Professor Thomas Joiner. “Regarding prevention, I think the big thing
is to be aware of the risk factors in my theory [being a burden, a failure
to feel you belong, exposure to violence or pain] and to use them as warning
signs to urge and persuade people to access treatment and to adhere to it.
“Once people are stabilised in treatment, the theory suggests that the main
ways to keep the patient interested in life is to engage them socially and
to encourage activities that imbue a sense of contributing to others or to
society. Often people say ‘I can’t think of anything’. Marsha Linehan [a US
psychologist] has composed a list of activities people can do – hundreds of
things, which, collectively, have a power that surprises if people will only
commit to regularly trying them.
“I’m no advertising exec, but if I wanted to do a campaign to prevent suicide,
I might start with something like ‘Collect new friends and keep old ones –
it’s powerful medicine’. But accessing and adhering to treatment (either
cognitive behavioural psychotherapy and/or antidepressant medicines) are so
important that thinking about other things can be counterproductive at
times.”
In his book Joiner says that professionals who deal with suicidal crises would
do well to focus on a patient’s sense of being a burden and lack of
belonging. These elements are more amenable to short-term crisis
intervention than treating lethality.
Techniques such as symptom-matching in order of seriousness and the
development of a crisis-card can often take the the edge off intense
negative moods. Symptom-matching simply involves listing disruptive feelings
and emotions. The patient ranks these in terms of the most upsetting.
Concrete proposals are made (eg, treatment for insomnia, relaxation for
general distress, pleasant activities to combat depressive symptoms). These
are not intended to solve the problem or even change it much, but to take
the edge off the problem so that the patient is better able to tolerate the
crisis. Psychotherapy, which is focused on amending negative thoughts about
self, others and the future (cognitive therapy), is the leading treatment,
Joiner says.
Facts about suicide
— In the US men are approximately four times more likely than women to die by
suicide, whereas women are three times more likely than men to attempt
suicide.
— This pattern and ratio holds in most countries with the exception of
China where female suicide is slightly higher. In some Asian countries the
ratio drops but male suicide is still higher. The inferior position of
Chinese women is one explanation together with the great number of women
engaged in sports.
— Women who take part in vigorous athletic activity were at greater odds
of reporting suicidal behaviour than other women. There is evidence of
increased pain tolerance in women athletes, which would facilitate their
ability to enact self-injury.
— In most countries and cultures suicide increases with age. In the US
suicide is most common in those 65 or older.
— The feeling of being a burden seems more applicable to older people,
especially white men. One factor, Thomas Joiner believes, is the tendency of
this group not to replace their social connections as they age and lose
friends.
— Suicidal behaviour runs in families, which has to do with genetics and
neurobiology as well as genetically conferred personality traits such as
impulsiveness. Families share genes – and much else. The family
environment plays a role. Childhood adversity has been shown to be a risk
factor.
— There is a genetic component to suicidal behaviour, but it is too
complex to be accounted for by any one gene.
Contact if you need help
The Samaritans: 08457 909090; www.samaritans.org.uk
Sane: 0845 7678000; www.sane.org.uk
Mind: 0845 7660163; www.mind.org.uk
NHS Direct: 0845 4647; www.nhsdirect.nhs.uk
American Association for Suicidology: www.suicidology.org
Marsha M. Linehan: http://faculty.washington.edu/linehan
