Some 12 years ago, on July 28, 1999, Surgeon General David Satcher, MD, PhD, joined Tipper Gore in releasing “The Surgeon General's Call to Action to Prevent Suicide,” a document1 that called for a national suicide-prevention strategy and announced 15 major recommendations around three principles:
Awareness: “We must promote public awareness that suicides are preventable … enhance resources in communities for suicide prevention programs and … reduce the stigma associated with mental illness that keeps many people from seeking the help that could save their lives.”
Intervention: “We must complete our work … on a National Strategy for Suicide Prevention … eliminate barriers in public and private insurance programs for provision of quality mental and substance abuse disorder treatments. We must institute training about suicide risk assessment, treatment, management and aftercare for all health, mental health, substance abuse and human service professionals … [and] develop and implement effective training programs … on how to recognize, respond to, and refer people who show signs of suicide risk …
Methodology: “We need to enhance research to understand risk and protective factors related to suicide … and increase research on effective suicide prevention programs, clinical treatments … and culture-specific interventions.”
Though much has been accomplished in the intervening years in all of these areas, public understanding about deaths due to suicide and the importance of suicide prevention as a public health issue languished until the Pentagon was forced to comment on rising suicide rates in the U.S. military some years ago. Since that time, the number of military deaths due to suicide has exceeded those from combat in Iraq and Afghanistan combined.
While these suicides are no more or less tragic than any of the other 35,000 suicides that occur annually in the United States (or the nearly one million that occur worldwide), they have proved to be much harder to dismiss or ignore, since they involve volunteers whom our society recognizes as selfless, courageous, and capable. It's impossible to ignore these deaths or to easily dismiss them with the suicide mythology and stigma of the past: that they were determined to end their lives and couldn't be helped, that their deaths should not be talked about or remembered, that their behavior was cowardly or shameful.
A nagging fact
Apart from the military sphere, many others, motivated by painful experience with suicide and its aftermath, have struggled and researched quietly to build a theoretical framework that applies broadly and helps clinicians make more timely and accurate assessments of risk.
Thomas Joiner, PhD, a professor of psychology at Florida State University, is one of those people. The 1990 suicide death of his father, a well-regarded and successful businessman, forced Joiner to confront “a nagging fact” that left him “unsatisfied with existing theories.”
The nagging fact, which he confronts in the prologue to his 2005 book, Why People Die by Suicide, was “the idea that suicide is a shameful act of weakness.” This idea did not square with his personal experience: “My dad was not weak in any sense of the word,” he asserts, noting that although the former Marine sergeant clearly suffered from a mood disorder (seen only in retrospect), he had a “stoic toughness about him that seemed to inure him to pain.” Joiner's search for a more precise understanding of suicide's causes led him to a theoretical framework for what has since become known as the “interpersonal theory of suicide.” This theory is built on three factors: a perceived sense of burdensomeness-that one has become ineffective or burdensome in the eyes of loved ones; a perception that one is isolated and no longer “belongs” or is needed; and an acquired capability to hurt oneself.