History of suicidal behavior
Abstract: This paper is about the history of the definition of suicide and the beginning of suicidology. From the 1600s to present time, a compilation of where suicide in human history since was defined. Eminent psychiatrists and psychologists are talked about as they helped form the meaning and help for suicidal people. Some treatments are discussed as they pertain to suicidal behaviors. Discussion will also center around what it is to be suicidal and how it is addressed.
Suicide has been a human problem as long as man has existed. There has been documentation of a suicide note as far back as ancient Egypt (Ali & El-Mallakh, 2022). Each year, the suicide rate continues to grow in the world with more than 800,000 deaths (Gvion et al., 2021). Despite research that in this author’s opinion has gotten better, suicide remain elusive in prevention pathways (Shahnaz et al., 2020). In fact, there are so many interpretations of the definition of suicide and suicidal behavior, the nomenclature isn’t clear (O’Carroll et al., 1996; Silverman et al., 2007) In an example O’Carroll et al (1996) gives in their paper, a patient overdoses and then seeks help. To which the ED attending called it a suicidal attempt, the nurse called it a suicide gesture, another doctor called it a parasuicidal behavior as it was done while her therapist was on vacation. While also in this paper, O’Carroll et al mentions that Beck along with other suicidologists in 1974 broke down the terms to three, completed suicide, suicide attempt, and suicide ideas. This differs from Durkheim’s work that breaks suicide down into three categories, “altruistic”, “egoistic”, and “anomic” (Andriessen, 2007; Durkheim, 1997). Shneidman also broke down the work of Durkheim in his book, “Definition of Suicide” (Shneidman, 1985). He explore the concepts of the altruistic, egoistic, and anomic but added fatalistic as the fourth type of suicide. He mostly focused on suicide and the origin as he said that the word “suicide” didn’t appear until the mid-1600s. As he says, “In the etymological sense, it was not possible before 1635 to commit suicide. One could, of course, do harm to oneself…” (Shneidman, 1985, p. 7). The earliest definition of suicide goes back to 1651 by Walter Charleton when he said “to vindicate one’s self from …inevitably calamity, by sui-cide is not…a crime” (Shneidman, 1985, p. 10). There were also phrases in Latin that noted suicide such as “sibi mortem consciercere”, to procure one’s own death; “sui manu cadere”, to fall by one’s own hand; “vulnero me ut moriar”, to wound oneself in order to die, which refers to a suicide attempt that did not result in death (Shneidman, 1985). As Shneidman wrote for the Brittanica encyclopedia the definition of suicide is “the human act of self-inflicted, self-intentioned cessation” (Shneidman, 1985, p. 14) He goes on to say that Durkheim’s 1897 definition is as follows, “we may say conclusively: The term suicide is applied to all cases of death resulting directly or indirectly from a positive or negative act of the victim himself which he knows will produce this result” (Shneidman, 1985, pp. 14-15). Shneidman clearly presented his talk about suicide as a death by suicide and not a suicide attempt or other form of self-harming behavior such as cutting or burning oneself. Suicide is a multifaceted, multidisciplinary phenomenon that encompasses biological, sociological, psychological (interpersonal and intrapsychic), epidemiological, and philosophical (Leenaars, 2010). As Maris states, “Suicide is not one thing, but it is one word” (Maris, 2019, p. 3).
The care of suicidal people has not been good. Most psychiatrists dating to the mid-1800s thought that the institutionalization of these patients were necessary (Gnoth et al., 2018). Even Dr. Benjamin Rush in 1812 thought that if there was a temporary improvement to depressed people, they should be watched as it could mean they have made a decision to end their lives (Goldney, 2007).. The trouble in recent times has been finding a mental health professional to take on this population. In a study by Gvion et al, they found that some mental health professionals would rather refer out a suicidal adolescent than treat them (Gvion et al., 2021). This is sad considering one in five teens die by suicide a month after seeing a mental health professional (Gvion et al., 2021). It has also been stated that there is a 96.9% that throughout their careers, mental professionals will see someone with suicidal behaviors or ideation or death by suicide (Gvion et al., 2021; Jobes, 1995).
In 1956, Drs. Edwin Shneidman and Norman Farbarow wrote a paper on suicide notes that birthed the field of what is now suicidology (Shneidman, 2001). They later created the first suicide prevention center in Los Angelas in 1955 (Leenaars, 2010; Shneidman, 1985; Shneidman, 2001). In 1966, Dr. Shneidman went on to Washington, DC to head the NIMH (National Institute of Mental Health) and started the American Association of Suicidology (AAS). He would stay a part of the AAS organization until his death in 2009 (Pompili, 2009). His biggest contribution was creating the word “psychache”, which means intolerable mental pain (Shneidman, 1993). He believed that was the chief cause of suicide, no psychache, no suicide (Shneidman, 1993). One of his other major works was the commonalities of suicide. He listed ten statements that were common to suicide and listed them in Roman numerals as a sort of way listing the commandments of the Bible (Leenaars, 2010).
The treatment of suicidal people has come a long way since the 1800s where they would be locked away and sometimes forgotten. From being institutionalized to spending seventy-two hours on a psych unit is a big difference. The bodies of those that died by suicide suffered terrible fates, often becoming dismembered so their soul does not find their way home (Jamison, 1999). This all changed in the 1970s when suicide became legal (Jamison, 1999; Shneidman, 1985). With the way insurances are not allowing more than seventy-two hours in the hospital, the treatment approach seems to be focused more on outpatient care but due to legal laws such as involuntary commitment, patients may stay longer (Engleman et al., 1998). In the mid 1800s, a German psychiatrist named Wilheim Griesinger thought suicidal patient should be hospitalized and that no two suicidal patients should be together (Gnoth et al., 2018). Evidence for inpatient treatment is non-existent and Linehan (2015) has called it ineffective at reducing suicidal risk. Griesinger didn’t have a treatment back in the mid-1800s for suicidal patients (Gnoth et al., 2018) and there really is no treatment a hundred years later but with the new therapies of Cognitive Behavior Therapy in the 1960s (Beck & Dozois, 2011) and Dialectical Behavior Therapy in the 1980s (May et al., 2016) and the framework of CAMS, the Collaborative, Assessment and Management of Suicide by Dr. David Jobes (Jobes, 2006), there has been some remarkable treatment research in the management of suicidal behaviors. More theories have popped out in the last twenty years of research since the 1950s when suicidology was in its infancy. One of the theories is the Interpersonal Theory of Suicide developed by Dr. Thomas Joiner (Van Orden et al., 2010). It is predicated on the surmise that there is capability, desire, and want to die to attempt suicide (Bryan, 2022).
There has been a time when the countertransference of a suicidal patient was hate (Maltsberger & Buie, 1974) but now it tends to lean toward more empathic and supportive (Michel & Jobes, 2011). The Aeschi model has been around since at least 2010 and builds upon the therapeutic alliance as a respective and supportive listening of the patient’s narrative by the interviewer (Maltsberger, 2011). This model promotes the collaboration of therapist and patient and tries to eliminate the power dynamic of the therapist being the expert. It focuses on the patient being the expert as they have the lived experience to tell (Michel & Jobes, 2011).
Suicidologists have focused more recently on the suicide ideation to suicide attempt area of research. Another theory in the hopes of suicide prevention is the Three Step Theory which focuses on idea to action (Klonsky et al., 2021). It is an evidenced based theory with a promise of advancing suicide prevention. Step one is the combination of hopelessness and pain; step two is the suicidal desire exceeds the pain tolerance; step three is strong desire for suicide if capability is present (Klonsky et al., 2021). Acquired capability was first described in the Interpersonal Theory of Suicide by Joiner (Joiner, 2005; Klonsky et al., 2021). It is when the individual overcomes the fear of death and is ready to attempt suicide without fear of dying. Joiner suggests that the person overcomes this fear through life experience such as abuse, drug use, or other circumstances (Joiner, 2005; Klonsky et al., 2021). The causes of pain, hopelessness, disconnectedness, and capability for suicide will vary by the individual. It is a personal thing to think about ending your life and the reasons can be many.
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