An Interview with Thomas Joiner, Ph.D. on Why People Commit Suicide
In this edition of the Wise Counsel Podcast, Dr. Van Nuys interviews Thomas Joiner, Ph.D., a clinical psychologist, professor of psychology and researcher of the troubling topic of suicide. Dr. Van Nuys became aware of Dr. Joiner after receiving a brochure for the annual conference of the American Association of Suicidology, which will take place in San Francisco, April 15-18, 2009, several weeks in the future at the time of this writing. Dr. Joiner will be speaking at this conference, and Dr. Van Nuys suggests that attendance there would be a good way for local mental health professionals to educate themselves on this important topic while earning continuing education credits necessary for continued licensure.
Dr. Joiner cites two motivations that drew him towards the study of suicide. As a young research psychologist, he saw career opportunity in the study of suicide, after realizing that though it was the most lethal symptom associated with major depression, it was also the least well studied aspect of that disorder. His father's suicide, which occurred in Dr. Joiner's third year of graduate school further reinforced his interest. He speaks about suicide in a very personal voice as a "foe to be defeated", and in an important way has been able to channel his grief in a professionally meaningful and societally beneficial manner.
Suicide is simultaneously a huge public health problem and also a rare event. In the USA approximately 30,000 people suicide each year. Across the world, 1,000,000 deaths a year by suicide are estimated. Suicide is highly associated with the occurrence of a variety of severe mental disorders such as Major Depression and Bipolar Disorder, Schizophrenia, Borderline Personality Disorder and Anorexia, but the fact remains that the vast majority of people who develop these disorders do not suicide (though they may frequently experience suicidal thoughts). It has not been possible to predict with great accuracy who is at risk for actual suicide and who is not, or to know how to offer protective interventions which can reduce the risk of suicide in vulnerable populations (beyond the need to treat the mental disorders which so exacerbate or create the suicidal conditions in the first place). Accordingly, Dr. Joiner's work has been focused on trying to improve our ability to predict who is at risk and to identify the best ways to prevent actual suicides from occurring.
Dr. Joiner has proposed a new theory of why people suicide which he believes is more accurate than previous formulations offered by writers like Edwin Schneidman, Ph.D. and Aaron Beck, MD. According to Schneidman's model, the key motivator which drives people to suicide is psychological pain. In Beck's understanding, the key motivator is the development of a pervasive sense of hopelessness. Dr. Joiner suggests that these are correct understandings but are also too vague to be useful for predictive purposes and not capable of offering a complete motivational picture.
Joiner proposes that there are three key motivational aspects which contribute to suicide. These are: 1) a sense of being a burden to others, 2) a profound sense of loneliness, alienation and isolation, and 3) a sense of fearlessness. All three of these motivations or preconditions must be in place before someone will attempt suicide. Psychological pain and a sense of hopelessness correspond roughly to Joiner's concepts of burdensomeness and alienation, and contribute to the content of much suicidal ideation. These are necessary but not sufficient preconditions for a suicide act, however. So long as a person remains fearful of death and the actions and consequences of the activities that will create death, the actual act of suicide is unlikely.
Joiner notes that the incidence of suicide increases linearly with age; the older you get, the more likely you are to suicide. If I (Dr. Dombeck) understand him correctly, the way he thinks about why this is so is because as people age they are also more likely to develop (based on various life experiences) the fearlessness which transforms the simple desire for death into a plan for action. Joiner talks about the heightened incidence of suicide in professions that deal daily with death and violence, such as people in the military and physicians.
Dr. Van Nuys asks Dr. Joiner whether genetics or a tendency towards "thrill seeking behavior" might play into who is at risk for suicide. Dr. Joiner reports that research has established that there is definitely a genetic contribution to suicide, but that it only can explain about 35% to 40% of the variance that goes into suicide. The research suggests that the major way that the genetic predisposition seems to express itself is by influencing how the neurotransmitter Serotonin functions within the brain.
Dr. Van Nuys asks Dr. Joiner to talk about the warning signs that suicide may be of concern. Dr. Joiner reports that the best predictive signs are often fairly clear but overlooked until hindsight provides the necessary context for interpreting them properly. People are at risk for suicide when they communicate about their desire to end their lives or to kill themselves. Other warning signs include dramatic mood changes, the combination of agitation and insomnia/sleeplessness, and the giving away of prized possessions.
The best and most effective way to prevent suicide from occurring is to treat the mental disorders that are almost certainly present and driving the situation. Generally, the best modern treatments for these various disorders will combine psychiatric medication with some empirically validated (e.g., scientifically "proven") form of psychotherapy such as cognitive behavioral therapy.
Family and friends can help a person who is considering suicide by being alert for warning signs (as mentioned above), and by patiently and persistently encouraging that person to get mental health treatment. Dr. Joiner mentions the (USA) National Suicide Prevention Lifeline (1-800-273-TALK) which makes crisis counselors available to people at risk for suicide and also concerned family and friends. Dr. Van Nuys notes that people are often at a loss for how to respond to grieving family members who have just sustained a loss due to suicide. There is something about suicide that leaves many people feeling paralyzed about how best to respond. Dr. Joiner encourages people to treat a loss by suicide just as they would any other death, which is to say, by offering support to the bereaved. The right thing to do is to show up at the funeral and offer condolences; to check in emotionally with the bereaved and offer support, and to stay in contact with the bereaved after the funeral. The wrong thing to do is to remain paralyzed.
Dr. Joiner goes over several myths associated with suicide and works to dispel them.
Suicide is not a cowardly act but rather one that takes great fearlessness to accomplish. By noting this he does not mean to romanticize suicide, but instead simply to represent it accurately.
Neither is suicide an instance of "anger turned inwards". From the suicidal person's perspective, killing one's self is frequently seen as an an altruistic act - the removal of a burden to others. Joiner does not buy into this self-perception of burdensomeness, but he does understand that this is how suicidal people tend to see their actions.
Another myth Joiner is concerned about is that antidepressant medications cause suicides. In Joiner's opinion, though there are cases where suicides have been linked to antidepressant use, this connection has been "overblown" by the media such that physicians are now increasingly afraid to prescribe antidepressants to suicidal patients. Joiner notes that the evidence is clear that antidepressant use on the whole decreases the incidence of suicides by the means of treating the mental disorders like depression that contribute to suicidal impulses.
Dr. Joiner notes that the research on suicide barriers for bridges like San Francisco's Golden Gate Bridge shows clearly that such barriers prevent suicides. There is no evidence to support the idea that suicidal people are determined to kill themselves and will simply go somewhere else to complete their suicide. In locations where barriers are in place, the overall rate of completed suicides decreases. He is strongly in support of a suicide barrier for the Golden Gate Bridge and sees as morally outrageous the argument that the barrier's construction should be delayed on account of expense or aesthetics.
In his closing remarks, Dr. Joiner hopes that listeners will offer compassion to suicidal people and their families, and that they will encourage (with patience and persistence) suicidal people to get mental health treatment for their symptoms. The combination of psychiatric medication and cognitive behavioral therapy (or other scientifically supported psychotherapy) is effective even though it can be a struggle to find the right combination of therapies to provide relief.
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About Thomas Joiner, Ph.D.
THOMAS JOINER grew up in Georgia, went to college at Princeton, and received his Ph.D. in Clinical Psychology from the University of Texas at Austin. He is Distinguished Research Professor and The Bright-Burton Professor in the Department of Psychology at Florida State University, Tallahassee, Florida. Dr. Joiner's work is on the psychology, neurobiology, and treatment of suicidal behavior and related conditions. Author of over 385 peer-reviewed publications, Dr. Joiner was recently awarded the Guggenheim Fellowship and the Rockefeller Foundation's Bellagio Residency Fellowship. He was elected Fellow of the American Psychological Association, and received the Young Investigator Award from the National Alliance for Research on Schizophrenia and Depression, the Shakow Award for Early Career Achievement from the Division of Clinical Psychology of the American Psychological Association, the Shneidman Award for excellence in suicide research from the American Association of Suicidology, and the Award for Distinguished Scientific Early Career Contributions from the American Psychological Association, as well as research grants from the National Institute of Mental Health and various foundations. He is editor of the American Psychological Association's Clinician's Research Digest, editor of the Journal of Social & Clinical Psychology, and incoming Editor-in-Chief of the journal Suicide & Life-Threatening Behavior, and he has authored or edited fifteen books, including Why People Die By Suicide, published in 2005 by Harvard University Press, and Myths and Misunderstandings About Suicidal Behavior, in press, also with Harvard University Press. Largely in connection with Why People Die By Suicide, he has made numerous radio, print, and television appearances, including write-ups in The Wall Street Journal, Men's Health, and The Times of London, a radio interview on the Leonard Lopate Show in New York, and two appearances on the Dr. Phil Show. He runs a part-time clinical and consulting practice specializing in suicidal behavior, including legal consultation on suits involving death by suicide. He lives in Tallahassee, Florida, with his wife and two sons.