Suicide and Self-Injury
Each year over 800,000 despairing people worldwide will elect a permanent solution to what might have been a temporary problem (WHO, 2014b). For those who have been anxious, the risk of suicide is tripled, and for those who have been depressed, the risk is quintupled (Bostwick & Pankratz, 2000; Kanwar et al., 2013). People seldom commit suicide while in the depths of depression, when energy and initiative are lacking. The risk increases when they begin to rebound and become capable of following through (Chu et al., 2016).
Comparing the suicide rates of different groups, researchers have found
- national differences: In Britain, Italy, and Spain, suicide rates have been little more than half those of Canada, Australia, and the United States. Austria’s and Finland’s are about double (WHO, 2011). Within Europe, people in the most suicide-prone country (Belarus) have been 16 times more likely to kill themselves than those in the least (Georgia).
- racial differences: Within the United States, Whites and Native Americans kill themselves twice as often as Blacks, Hispanics, and Asians (CDC, 2012).
- gender differences: Women are much more likely than men to attempt suicide (WHO, 2011). But men are two to four times more likely (depending on the country) to actually end their lives. Men use more lethal methods, such as firing a bullet into the head, the method of choice in 6 of 10 U.S. suicides.
- age differences: In late adulthood, rates increase, with the highest rate among 45- to 64-year-olds and the second-highest among those 85 and older (AFSP, 2015).
- other group differences: Suicide rates have been much higher among the rich, the nonreligious, and those single, widowed, or divorced (Hoyer & Lund, 1993; Norko et al., 2017; Okada & Samreth, 2013; VanderWeele et al., 2016, 2017). Witnessing physical pain and trauma can increase the risk of suicide, which may help explain veterans’ and physicians’ elevated suicide rates (Bender et al., 2012; Cornette et al., 2009). Gay, transgender, and gender nonconforming youth facing an unsupportive environment, including family or peer rejection, are also at increased risk of attempting suicide (Goldfried, 2001; Haas et al., 2011; Hatzenbuehler, 2011; Testa et al., 2017). Among people with alcohol use disorder, 3 percent die by suicide. This rate is roughly 100 times greater than the rate for people without alcohol use disorder (Murphy & Wetzel, 1990; Sher, 2006).
- day of the week and seasonal differences: Negative emotion tends to go up midweek, which can have tragic consequences (Watson, 2000). A surprising 25 percent of U.S. suicides occur on Wednesdays (Kposowa & D’Auria, 2009). Suicide rates are highest in April and May, and not (as commonly believed) over the winter holidays (Nock, 2016).
Social suggestion may trigger suicide. Following highly publicized suicides and TV programs featuring suicide, known suicides increase. So do fatal auto and private airplane “accidents.” One six-year study tracked suicide cases among all 1.2 million people who lived in metropolitan Stockholm at any time during the 1990s (Hedström et al., 2008). Men exposed to a family suicide were 8 times more likely to commit suicide than were nonexposed men. That phenomenon may be partly attributable to family genes. But shared genetic predispositions cannot explain why men exposed to a co-worker’s suicide were 3.5 times more likely to commit suicide compared with nonexposed men.
Suicide is not necessarily an act of hostility or revenge. People—especially older adults—may choose death as an alternative to current or future suffering, a way to switch off unendurable pain and relieve a perceived burden on family members. Suicidal urges typically arise when people feel disconnected from others and a burden to them, or when they feel defeated and trapped by an inescapable situation (Joiner, 2010; Taylor et al., 2011). Thus, suicide rates increase with unemployment during economic recessions (DeFina & Hannon, 2015; Reeves et al., 2014). Suicidal thoughts also may increase when people are driven to reach a goal or standard—to become thin or straight or rich—and find it unattainable (Chatard & Selimbegovic´, 2011).
In hindsight, families and friends may recall signs they believe should have forewarned them—verbal hints, giving possessions away, or withdrawal and preoccupation with death. To judge from surveys of 84,850 people across 17 nations, about 9 percent of people at some point in their lives have thought seriously of suicide. About 3 in 10 of those who think about it will actually attempt suicide (Nock et al., 2008). Only 3 percent of Americans die in that attempt (Han et al., 2016). In one study that followed people for up to 25 years after a first suicide attempt, some 5 percent died by suicide (Bostwick et al., 2016). One group of clinical psychologists summarized 50 years of research on suicide’s unpredictability: “The vast majority of people who possess a specific risk factor [for suicide] will never engage in suicidal behavior” (Franklin et al., 2017, p. 217).
But researchers continue to try to solve the suicide puzzle. Although most suicide attempts fail, the risk of death by suicide is seven times greater among those who have previously attempted suicide (Al-Sayegh et al., 2015). Each year, about 40,000 Americans will kill themselves—about two-thirds using guns. (Drug overdoses account for about 80 percent of suicide attempts, but only 14 percent of suicide fatalities.) States with high gun ownership are states with high suicide rates, even after controlling for poverty and urbanization (Miller et al., 2002, 2016; Tavernise, 2013). After Missouri repealed its tough handgun law, its suicide rate went up 15 percent; when Connecticut enacted such a law, its suicide rate dropped 16 percent (Crifasi et al., 2015). Thus, although U.S. gun owners often keep a gun to feel safer, having a gun in the home makes one less safe, because it substantially increases the odds of a family member dying by suicide or homicide (Kposowa et al., 2016; VPC, 2015; Vyse, 2016).
How can we be helpful to someone who is talking suicide—who says, for example, “I wish I could just end it all” or “I hate my life; I can’t go on”? If people write such things online, you can anonymously contact the safety teams at various social media websites (including Facebook, Twitter, Instagram, YouTube, and Tumblr). If a friend or family member talks suicide, you can
- listen and empathize;
- connect the person with your school psychologist or counselor, with (in the United States) the Suicide Prevention Lifeline (1-800-273-TALK) or Crisis Text Line (by texting HOME to 741741), or with their counterparts in other countries (such as the LifeLine App in Canada); and
- protect someone who appears at risk by seeking help from a trusted adult—a parent, a teacher, a school nurse or school counselor—or calling 911. Better to share a secret than to attend a funeral.
“ People desire death when two fundamental needs are frustrated to the point of extinction: The need to belong with or connect to others, and the need to feel effective with or to influence others.”
Nonsuicidal Self-Injury
Self-harm takes many forms. Some people may engage in nonsuicidal self-injury (NSSI), which is more common in adolescence and among females (CDC, 2009) (Figure 67.6). Such behavior, though painful, is not fatal. Those who engage in NSSI may cut or burn their skin, hit themselves, insert objects under their nails or skin, or self-administer tattoos. People who engage in NSSI tend to experience bullying, harassment, and other life stress (Liu et al., 2016; van Geel et al., 2015). They are generally less able to tolerate and regulate emotional distress (Hamza et al., 2015). They are often extremely self-critical and struggle to communicate, solve problems, and perform academically (Kiekens et al., 2016; Nock, 2010; You et al., 2015). Why do they hurt themselves? Reinforcement processes are at work (Bentley et al., 2014). Through NSSI they may
- find relief from intense negative thoughts through the distraction of pain.
- attract attention and possibly get help.
- relieve guilt by punishing themselves.
- get others to change their negative behavior (bullying, criticism).
- fit in with a peer group.
Figure 67.6 Rates of nonfatal self-injury in the United States
Self-injury rates peak higher for females than for males.
Does NSSI lead to suicide? Usually not. Those who engage in NSSI are typically suicide gesturers, not suicide attempters (Nock & Kessler, 2006). Nevertheless, NSSI is a risk factor for suicidal thoughts and future suicide attempts, especially when coexisting with bipolar disorder (Hawton et al., 2015; Runeson et al., 2016; Willoughby et al., 2015). If people do not find help, their nonsuicidal behavior may escalate to suicidal thoughts and, finally, to suicide attempts.