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Suicidal Thoughts: Essays on Self-Determined Death
Reviewed by PETER M. GUTIERREZ
Am J Psychiatry 2009;166:1069-1070. doi:10.1176/appi.ajp.2009.09030305

edited by Max Malikow. Lanham, Md., Hamilton Books, 2008, 70 pp., $14.95.

In the introduction to this brief edited collection of essays on suicide, Malikow states that the purpose of the volume is to help readers better appreciate the complexities of suicide, not to debate the ethics of suicide. He further asserts that the essays are useful for professionals as well as laypersons, including those contemplating their own death by suicide. There are problems with both of these assertions. First, several of the essays directly or indirectly address ethical issues regarding the right of terminally ill or severely disabled individuals to choose how they die. Second, as one author discusses, the ways in which information about suicide is presented may increase the risk that a vulnerable individual exposed to it might decide that suicide is a good idea. This concern is raised about the risk to adolescents, but it applies to individuals of all ages. There is information in several essays regarding more or less lethal ways to attempt suicide, some of which is quite graphic. Other essays present arguments from the perspective of those in deep despair regarding why suicide is a desirable outcome. While there is no empirical evidence that discussing suicide with someone will lead them to engage in an act they would not have otherwise engaged in, there is ample evidence that glamorizing suicide can nudge vulnerable individuals toward suicide. It therefore seems more appropriate to introduce this book as a collection of thought-provoking essays most useful for those professionals interested in better appreciating the moral, ethical, and existential dilemmas inherent in one contemplating intentionally ending his or her life.

Rather than soliciting contributions for this book, Malikow combed through the published literature selecting excerpts from book chapters, newspaper and magazine articles, and other sources to create this collection. One result of this approach is a cross-sectional sampling of historical perspectives on suicide highlighting how the language used to discuss suicide, attitudes regarding those who are suicidal, and approaches to understanding suicide have changed over time. It also illustrates the problem of how best to talk about and describe suicide. A range of terms are used (e.g., “successful suicide”) that can contribute to the stigma associated with suicide. Other essays directly address the stigma issue and how to counteract it. The variety of definitions for suicide and suicide-related behaviors used in these essays is also quite broad, reinforcing the importance of adopting a consistent nomenclature when studying and writing about suicide. Unfortunately, although a comprehensive nomenclature was proposed by O’Carroll et al. in 1996 (1) and revised 10 years later (2, 3), the field has yet to decide whether to adopt that one or one of the few alternative systems that have been proposed.

Despite the lack of consistent language and the diverse backgrounds of the authors (e.g., scientists, physicians, and journalists), several consistent themes emerge in these essays. One is the intensely interpersonal nature of suicide. Multiple references are made to the concerns of the person contemplating suicide, or who has died by suicide, regarding the impact of their actions on others. Some do not want to leave a mess that must be cleaned up, others believe their loved ones will be better off without them, and one writes about her ability to hide her pain from others. A second is illustrations of Joiner’s interpersonal psychological theory of suicide, which posits that feeling like an unbearable burden on others (i.e., burdensomeness), believing that all or most meaningful interpersonal relationships have failed (i.e., failed belongingness), and habituating to painful experiences (i.e., acquired ability) combine to make lethal self-injury possible. The concepts of burdensomeness and failed belongingness appear in the largest number of essays, but several illustrate ways in which people can and do habituate to painful physical and psychological experiences, allowing them to overcome the basic human instinct for survival. Finally, in addition to the two essays written by Shneidman, his concept of psychache (i.e., unendurable psychological pain) (4) is well illustrated throughout the volume. These themes demonstrate that the complex and multiply determined nature of suicide can be meaningfully organized.

Malikow did not set out to present a collection of writings that answer the question of why people die by suicide, which is good because reading this book raises many questions in the reader’s mind. This book presents no new research findings regarding suicide or guidelines for intervening with those who are suicidal. It will not inform readers on how best to assess individuals for suicide risk. However, most readers will be affected by this book in some way and therefore will find it a worthwhile investment of time to read.

1.O’Carroll PW, Berman AL, Maris RW, Moscicki EK, Tanney BL, Silverman MM: Beyond the Tower of Babel: a nomenclature for suicidology. Suicide Life Threat Behav 1996; 26:237–252
 
2.Silverman MM, Berman AL, Sanddal ND, O’Carroll PW, Joiner TE: Rebuilding the Tower of Babel: a revised nomenclature for the study of suicide and suicidal behaviors, part 2: suicide-related ideations, communications, and behaviors. Suicide Life Threat Behav 2007; 37:264–277
 
3.Joiner T: Why People Die by Suicide. Cambridge, Mass, Harvard University Press, 2007
 
4.Shneidman E: Suicide as Psychache: A Clinical Approach to Self-Destructive Behavior. Northvale, NJ, Jason Aronson, 1993
 
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References

+The author reports no competing interests.

+Book review accepted for publication March 2009 (doi: 10.1176/appi.ajp.2009.09030305).

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References

1.O’Carroll PW, Berman AL, Maris RW, Moscicki EK, Tanney BL, Silverman MM: Beyond the Tower of Babel: a nomenclature for suicidology. Suicide Life Threat Behav 1996; 26:237–252
 
2.Silverman MM, Berman AL, Sanddal ND, O’Carroll PW, Joiner TE: Rebuilding the Tower of Babel: a revised nomenclature for the study of suicide and suicidal behaviors, part 2: suicide-related ideations, communications, and behaviors. Suicide Life Threat Behav 2007; 37:264–277
 
3.Joiner T: Why People Die by Suicide. Cambridge, Mass, Harvard University Press, 2007
 
4.Shneidman E: Suicide as Psychache: A Clinical Approach to Self-Destructive Behavior. Northvale, NJ, Jason Aronson, 1993
 
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