S3E24 / Why Do People Die by Suicide? / Michael Anestis & Thomas Joiner

People die by suicide when they think they’re a burden on others, when they’re socially isolated, and when they have the ability to injure themselves lethally. Dying by suicide is really hard to do. It’s not an impulsive act. You need to have the knowledge and means to act on your feelings – with lethality.

Celine Gounder: Hi, everyone. Celine Gounder, here. I’m the host of “In Sickness and in Health.” We really appreciate all our loyal listeners and I’m hoping you can help us grow this community even more. If you like our podcast, tell a friend about it. The bigger we can grow this community the more episodes we can do, and the more ambitious our show can be. Thanks for listening. Now, here’s the show.

Celine Gounder: This episode of “In Sickness and in Health” talks about suicide. Please listen at your own discretion.

Thomas Joiner: Had I known what I know now, I would have been very worried about that. 

Michael Anestis: …focus on the most lethal and common method for suicide and you make it less deadly or less available for an attempt. In the US, that’s guns

Thomas Joiner: We lose close to 50,000 of our fellow Americans every year to this very preventable form of death. It’s just a shame.

Celine Gounder: Welcome back to “In Sickness and in Health,” a podcast about health and social justice. I’m Dr. Celine Gounder. This season we’re looking at gun violence in America.

Celine Gounder: We’ve spent the last several episodes talking about urban gun violence. Specifically, the killing of young black men. But homicide isn’t even half the picture when it comes to gun violence in America. Sixty percent of gun violence deaths in the U.S. … are suicides.

Celine Gounder: And it’s getting worse.

Celine Gounder: The suicide rate in the U.S. has been going up so much that it’s actually reduced the nation’s life expectancy. This is especially true for middle-aged, white men without a college degree — the same group most likely to own a gun.

Celine Gounder: But despite the increasing number of Americans impacted by suicide… it remains widely misunderstood. There are a lot of questions:

Celine Gounder: How can we prevent someone from taking their own life?

Michael Anestis: If they’re less able to act on it, that doesn’t solve their misery, but it keeps them alive so we have a chance to help them with that misery.

Celine Gounder: Is suicide impulsive?

Thomas Joiner: to believe that requires an understanding of human nature that is just so flawed.

Celine Gounder: And who is most at risk?

Michael Anestis: Gun ownership is a really strong predictor of death by suicide. Mental illness, not so much…

Celine Gounder: The fear and stigma around suicide makes it a hard issue to tackle in public health. But it’s not impossible.

Thomas Joiner: We need to grow up and face fears, and this is killing our loved ones, killing fellow Americans, killing people around the world and we need to grow up and do something about it.

Celine Gounder: Today on “In Sickness and in Health”: suicide and guns.

Celine Gounder: There’s a lot of misconceptions and clichés about suicide. So I want to start off with some basics.

Thomas Joiner: Hello.

Celine Gounder: Yes. Hi, is this Thomas?

Thomas: It is.

Celine: Hi, Thomas. It’s Celine Gounder calling. Is this still a good time to talk?

Thomas: This works, Celine. How are you?

Celine13: So I called Thomas Joiner.

Thomas Joiner: I’m a clinical psychologist. I’m the Roberto Lawton Distinguished Professor of Psychology at Florida State University. I study suicidal behavior.

Celine Gounder: Thomas told me he has always been fascinated with human nature. That’s part of what got him interested in psychology. That, and the opportunity to help people.

Thomas Joiner: …the reduction of misery is something that appeals to me. There’s a lot of unanswered questions… with regard to suicidal behavior.

Celine Gounder: And that was something Thomas had first hand experience with.

Thomas Joiner: I’ve lost loved ones, very close loved ones, to suicide… my dad, for instance…

Thomas Joiner: I really had no idea. I was very green at the time. I was a graduate student in clinical psychology, but clinically, woefully inexperienced. I would’ve seen something like this coming now with what I know now, but no, I didn’t see it then.

Celine Gounder: His father’s suicide wasn’t the only reason why Thomas decided to study suicide. But it showed him that the way people tend to think about suicide…. Didn’t match his dad’s story.

Thomas Joiner: …the clichés or things that people just mindlessly say about suicidal people, those things tend to not to apply to my dad at all. Things like, “suicide is a cowardly thing to do.” My dad was far from cowardly on the contrary, and there are other examples too of, “suicide is weak.” No, he wasn’t weak. Suicide is selfish. He wasn’t selfish. That was very eye-opening to see all that.

Celine Gounder: Thomas went on to develop something called the “Interpersonal Theory of Suicide.”

Thomas Joiner: The theory is, you can boil it down to three variables. The idea is that when these three things happen simultaneously in one person, well then that person is at risk for death by suicide. What are the three things?

Thomas Joiner: The first one, we’ve named “perceived burdensomeness.” That’s a mouthful, it’s also pretty obvious what that’s about. It’s the idea that you’re a burden on others. At least you feel that way. … That line of thinking leads people to think things like, “Everybody would be better off. I would be better off. My family would be better off if I were gone…

Celine Gounder: The second one is called “thwarted belongingness.”

Thomas Joiner: …that’s a long way of just saying you feel really lonely, isolated, alienated.

Celine Gounder: The third one is called capacity or capability.

Thomas Joiner: It has to do with the idea that death by suicide is intrinsically hard to do. It’s scary. It’s novel. It’s highly unusual. It’s often painful. When you think about things like that, to do something like that, you have to have a certain capacity to face fear, face pain… and not everybody has that capacity.

Thomas Joiner: So when those three things come together in the same person, that’s when they’re in that danger zone or very high risk, and many of those people who are in that zone either attempt or tragically die. That’s the theory, in a nutshell.

Celine Gounder: Thomas’s theory didn’t rely on old clichés. He also feels it better reflects what was going on with his father.

Thomas Joiner: Well, his fearlessness, let’s start there, was pronounced… he was a marine. He was a stoic person, not emotionally, but when it came to physicality. There are countless examples of him and me out in a boat, in the middle of the Gulf of Mexico, for example, fishing for huge fish, fish that were bigger than I was at the time. When you do stuff like that, physical hardships happen, and things like cuts to the hand, and things like that. That would happen, of course, and he would just be completely unfazed by that. His physical tolerance, his physical fearlessness was already– That was just a fact about him and had them for decades before his death. In the days and weeks before his death, his social isolation and social withdrawal were marked, and had I known what I know now, I would have been very worried about that.

Thomas Joiner: This is an interesting thing because it’s the sense of burdensomeness. Those three factors in the interpersonal theory, the three being burdensomeness, low belonging, and capacity for suicidal behavior. Burdensomeness can be the hardest to detect… When you withdraw socially, people can see that. When you’re physically a fearless person, people can often see that. When you’re feeling like you’re a burden, that can be a very interior experience. I think that was the case with my dad…

Celine Gounder: Thomas says that he had no idea his father was thinking about suicide. It seemed like it came out of nowhere. But that’s not how it is for the person thinking about suicide.

Thomas Joiner: I think there’s just rampant misunderstanding. The misunderstanding it goes along the lines that the usual narrative is somebody, all of a sudden, on a whim, out of the blue, decides on this and does it.

Thomas Joiner: My view is that these rarely, if ever… come out of the blue. Opportunity can happen quickly. Opportunities to act on a plan or act using a certain method, those can arise quickly. … That’s a different matter than it being impulsive. That’s opportunistic.

Celine Gounder: Thomas says suicide is simply too scary, too difficult to do on a whim. It takes years of experiences that prepare someone to be able to go through with something so final.

Thomas Joiner: …it’s rarely, if ever, in the moment, rather it’s years and decades before in which impulsive individuals… are having experiences that teach them physical hardship.

Celine Gounder: This is why suicide gets talked about sometimes as a “death of despair.” This is a phrase we also hear used to describe alcoholism, or opioid overdoses. This phenomenon is hitting middle-aged white people especially hard.

Celine Gounder: Thomas says alcohol and drug use and suicide are interconnected… just not in the way you might think. Take the idea that alcohol makes people impulsive. Someone gets drunk and then suddenly decide to end their life.

Thomas Joiner: That narrative seems very intuitive to the lay public, and actually to some mental health professionals. I think it’s badly mistaken.

Celine Gounder: For Thomas, it’s more about how alcohol or drug use increase someone’s capability for suicide.

Thomas Joiner: If you commit to a lifestyle of something like severe alcohol misuse — the same would apply to opioids use — when you reflect on that lifestyle, what it means is hardship. A lot of physical hardship. You get into accidents, you get arrested, you get sick. It also means alienating others around you. Loved ones, friends, coworkers. It also means job loss, which, in turn, has relevance for whether you’re contributing, whether you feel you are a burden on others, things like that.

Celine Gounder: In fact, Thomas did a study that found that 7 out of 10 people who died by suicide — including some alcoholics — had very little or no alcohol in their systems when they died.

Thomas Joiner: The role of alcohol misuse and other drugs affect lifestyle patterns. … They affect people’s jobs. They affect people’s tolerance to physical hardship, decades and years before the suicidal incident. What’s going on at the time in terms of whether they are high or drunk is actually missing the point.

Celine Gounder: All this isn’t to say that just alcoholics and drug users are at risk for suicide. Someone’s profession can just as easily… engender suicidal capability.

Michael Anestis: Some of the groups that we’ve seen that have higher capability… is in the military.

Celine Gounder: This is Mike Anestis. He’s a professor at the University of Southern Mississippi. We first spoke with Mike in episode 14 on the instrumentality of guns.

Michael Anestis: So ER docs I think have a similar situation to the military. In that on the one hand, you have a self-selection bias. Folks opt into that career knowing that they’re going to experience and see certain things — think about what ER docs are doing to people’s bodies, and what they’re seeing all day long. You think about how often they see death, and then think about how that might impact what they could do to their own bodies.

Celine Gounder: So, people’s experiences — from drug use to professions — build up a tolerance to hardship and pain… things that contribute to someone’s capability to end their life. But what about mental illness? What role does depression play when it comes to suicide risk?

Michael Anestis: One of the ways that we’ve tripped up a bit in the suicide prevention field is that we talked about suicide risk broadly, rather than looking at the difference between risk for thinking about suicide and risk for attempting or dying by suicide. And so mental illness, for instance, tells us a lot about thoughts of suicide, but almost nothing about suicidal behavior.

Celine Gounder: One of the reasons why mental illness isn’t as good an indicator as some might think is the stigma around seeking help. A CDC report on suicide found that many people who ended their life did not have a mental illness at the time of their death… or at least… they hadn’t been diagnosed with one.

Michael Anestis: It doesn’t mean they didn’t have a mental illness. It means they hadn’t been diagnosed with one. That tells us that people are not often engaging with the mental health care system, or telling us about their thoughts of suicide and thus been identified as at risk.

Celine Gounder: So if people aren’t seeking help for depression or other issues that can contribute to thoughts of suicide — things like isolation, feeling worthless — that means a diagnosis of mental illness… isn’t as good an indicator for who’s at risk for suicide as it may seem.

Michael Anestis: We’re not all that good at knowing the desire is present until someone has died.” …we are no better now predicting suicide risk prospectively than we were in 1950s. It’s just above chance.

Celine Gounder: But there is something else out there. Something much more reliable when it comes to predicting who’s at risk for dying by suicide. Gun ownership.

Michael Anestis: I do feel confident saying that firearm ownership and increasing rates of firearm ownership have played a unique and important role in the suicide rate in the United States.

Celine Gounder: Mike and his co-author, Claire Haussmann, looked at suicide data from the CDC. Then they looked at a bunch of variables to see if there was a correlation with suicide.

Michael Anestis: …we looked at CDC suicide rate data at the state level… we looked at gun ownership levels at the state level, and we considered every single possible confounder that we could think of. We entered into the same equation. What’s the median age? What’s the percentage of the population under the poverty line? …a college degree? …military veterans? … the mean elevation of the state above sea level… It’s a strangely robust relationship. …how many people in each state had depression? suicidal thoughts? substance use in the past year?

Michael Anestis: All of those things were important too, but firearm ownership was still significantly associated with… the suicide rate at the state level…

Celine Gounder: All those variables that Mike and Claire put into their equation? They predicted 95% of the difference in suicide rates between states. They weren’t missing much.

Michael Anestis: One of the misperceptions when I talk about that is people think I’m saying, “Well, mental illness doesn’t matter, and it’s just about the guns,” which I’m not saying it all. Mental illness absolutely matters. It tells us a lot about who’s thinking about suicide, and it’s vital that we focus on that too, but what it tells us is that mental illness does not explain away the gun association.

Celine Gounder: For regular listeners, this is nothing new. Just having a gun in the house — even if it’s supposed to be for self-protection — puts you at risk to die. This is part of the reason why Mike is arguing to shift the conversation about suicide prevention… toward reducing the ability to easily harm yourself.

Michael Anestis: We argue that we should find treatment or prevention approaches that focus on capability… The most obvious one that exists right now means safety.

Celine Gounder: Means safety boils down to making a common method of suicide more difficult to access or … at least… less deadly.

Michael Anestis: …the reality is owning a firearm dramatically increases the risk of death by suicide. Individuals in gun-owning homes have at least five times greater risk of death by suicide, and that risk goes up higher when the guns are stored unsafely. These are not debatable points. This is reality, and so our country needs to publicly and very clearly articulate the reality of the data and then promote approaches that are not a threat to the Second Amendment right now, because you’re not going to solve firearm suicide without firearm owners, and you’re not going to have firearm owners with you if the whole conversation is a debate about the Second Amendment.

Michael Anestis: …the most effective thing we can do would be on a national scale… insisting on safe storage of firearms and temporary removal in times of distress…

Celine Gounder: Thomas Joiner again.

Thomas Joiner: If that method, whatever it may be, can be made more safe, if it can be removed from the person’s presence, even by a little bit, even by an inch or a foot or a yard, those small differences can maybe translate into the difference between a lethal suicide versus not, a huge difference.

Celine Gounder: And that small act of prevention could save someone from ever attempting suicide again. Because suicide isn’t inevitable. Thomas points to people who went to the Golden Gate Bridge with every intention of jumping to their death… but were stopped.

Thomas Joiner: If that’s true, then most of them, nearly all of them should be dead… The actual truth is that very few of them are dead, way less than 10% have died… far less. In other words, the ones who are alive years and sometimes decades later… completely flatly contradicts this idea of inevitability. … means safety… works, it’s life-saving, and then the effects are lasting… A very important public health message that has a lot of promise to save a lot of lives.

Thomas Joiner: …we need to get this right, or else, we are going to bark up the wrong tree in terms of the intervention and prevention.

Thomas Joiner: This work is not about my dad anymore. This is about tomorrow, people are going to die, and I’d like to stop that.

Celine Gounder: Rates of suicide in the U.S. are on the rise. A lot of researchers are puzzling over why this might be. But meanwhile, tragically, too many Americans are dying by suicide. Half of those suicides… involve a gun. Yes, mental illness is a factor… It’s people who’re socially isolated… and who think they’re a burden on others. But it’s not just that. Lots of people feel that way… at least at some point or another. They don’t all die by suicide. It’s the people who have the fearlessness… the know-how… the practice… and the access to lethal means… who die by suicide. In this country… guns are by far and away the most readily available and deadly tools out there.

Celine Gounder: Next time we’re going to take a look at a very specific group of suicidal persons: mass shooters. Understanding that mass shooters are suicidal… and what sets them apart from others who take their own lives…  will help us prevent the tragedies that are dominating the news as of late. That’s next time on, “In Sickness and in Health.”

Celine Gounder: Today’s episode of “In Sickness and in Health” was produced by Zach Dyer and me. Our theme music is by Allan Vest. Additional music by The Blue Dot Sessions. If you enjoy the show, please tell a friend about it today. And if you haven’t already done so, leave us a review on Apple Podcasts. It helps more people find out about the show! You can learn more about this podcast and how to engage with us on social media at insicknessandinhealthpodcast.com. That’s insicknessandinhealthpodcast.com. I’m Dr. Celine Gounder. This is “In Sickness and in Health.”