Indirect Suicide Awareness

Spring 2009

Final Research Essays

Article 8 of 12

Elizabeth Edkin

Have you ever found yourself questioning the actions of your family or friends? Do you worry that their behaviors are destructive to their health or a risk to their survival? Smoking, for instance, is one of the unhealthiest habits a person can have. Not only does it affect our lung capacity but the chemicals in cigarettes have been correlated with causing cancer. Many of us wonder why individuals insist on using cigarettes despite this well-known fact. The answer to that question may forever be unknown, but smoking is only one of many behaviors that have negative consequences to our health. Recently, psychologists have classified these types of behaviors into a category associated with suicide. This category is called indirect or subintentional suicide and unlike direct suicide in which a person takes his or her own life, subintentional suicide occurs when the actions or behaviors of a person indirectly causes their death. (Shneidman 21). There are many issues that lie behind this subject. The first would be the challenge of distinguishing between which life-threatening actions may fall into this category and which ones may simply be called accidents. Secondly, the level of intent behind those actions and the role consciousness plays when we involve issues such as psychological disorders like depression or addiction makes this topic difficult to understand and treat. However, while we acknowledge that in a sense, all human behavior affects a person’s life expectancy, a better understanding of indirect suicidal behavior is important because it will encourage individuals to lead safe and healthy lives as well as help create more effective support for treatable psychological issues. Awareness of indirect suicidal behavior will also make it easier for the public to recognize if their family or friends are victims of suicidal ideation. Overall this awareness will improve and more importantly save lives.

Defining Terms

In order to delve into the specifics on indirect suicide it is first necessary to address the definition from which it branches.  Suicide is a form of death. In pioneer suicidologist Edwin Shneidman’s book, Definition of Suicide, he classifies death into four categories: “Natural, Accidental, Suicide and Homicide -or NASH” (17). Of these four categories, suicide is by far the most problematic. Not only is it hard clearly define suicide, but it is difficult to detect when someone may be dealing with suicidal ideation. Psychologists dedicate lifetimes of study toward understanding the common causes of suicide and effective means of suicide prevention. However, many have noticed that a fine line exists between some accidental and suicidal deaths. Among these incidents, the majority of situations direct relate to everyday behavior and decisions of individuals.

For example, millions of fatal car accidents occur as a result of careless driving. Teenagers, or most inexperienced drivers, have a tendency to drive recklessly at dangerous speeds. Normally, the selfishness behind this decision does not change the fact that a crash is an accident, however, the theory of indirect suicide challenges this assumption. It makes us wonder what constitutes the line between an accidental death and indirect suicide. For example, if someone dies in a car accident as a result of speeding down the road, are they responsible for their death? Or was it simply an accident? Recently experts like Shneidman have found it necessary, in order to further and more effectively define suicide, to distinguish between accidental deaths and indirect suicide.

According to contemporary philosopher and writer, R.G. Frey (1980),  “Suicide is a death which occurs intentionally as a result of a person knowingly, and willingly placing himself in perilous circumstances” (qtd. in Shneidman 15). In other words, for an act to successfully fulfill Frey’s definition of suicide, it must contain three main aspects: will, knowledge and intention. This definition plays a large role in distinguishing an accidental death from a suicidal one. Many experts prefer to use this definition to refer to the term direct suicide rather than just suicide because unlike the indirect suicide, discussed earlier, a direct act must involve full consciousness, knowledge and intention of death.

To solve this issue, psychologists have invented the term indirect suicide to describe a circumstance in which the act or behavior does not fully involve all three of these characteristics. Smokers, for example, are aware that cigarettes may cause their death but they desire to smoke anyway. Although their intent is not fully focused on death, they are know that their actions pose serious threats to their health. Therefore, Shneidman introduces the term subintentional suicide as a synonym of indirect suicide. In his book he defines this term as, “behaviors that, while not consciously intended to end life, clearly jeopardize one’s health and longevity” (21). He also uses the definition: “The participation in self-destructive behaviors, putting life at risk, or disregarding canons of prudence and common sense” (21). Other behaviors that fall into this category include drinking alcohol, using drugs, participating in high-risk sports or activities, carelessly crossing a street or even not eating a healthy diet.

In essence, the difference between subintentional suicide and direct suicide lies in the intention behind an act. An article by psychologist Karl Andriessen titled, “Intention in the Definition of Suicide,” explains that, “intention distinguishes between accidental and suicidal behavior. Thus, it is essential in defining suicide to use a measurement scale for intention, such as the Suicide Intent Scale (SIS)” (Andriessen 534). Professionals rely on tools such as the SIS as a means of determining the level of intention behind an act. This becomes useful when we begin to discuss research on indirect suicide. The SIS helps professionals determine the amount of correlation between suicidal ideation and suicidal behavior. It also becomes useful when examining behaviors involving addiction, psychological disorders and high-risk activities. While these behaviors can often lead to a death that exhibits all aspects of direct suicide, many are placed into the subintentional category because they lack a high scale of intent to end one’s life.

Indirect Suicide

In an article on indirect suicide, researcher Brian Mishara states that, “indirect suicidal behavior is thus a matter of probabilities rather than certainties” (Mishara 136). By this he is saying that participating in these suicidal behaviors or failing to be cautious will not definitely end one’s life, however, the timing of a consequential death is unknown. A smoker may develop lung cancer and die at an early age, while we also hear stories of a person that has smoked for years yet continues to live a long, healthy life. Why then is such an uncertain subject important to the field of psychology and medical research?

As of the twenty first century, multiple studies have developed involving indirect suicidal behavior. Researchers Carol Garrison and colleagues conducted a survey among 3,283 American youths within the ages of twelve and fourteen. They determined that 2.46 percent of males and 2.79 percent of females engaged in "nonsuicidal physically self-damaging acts" (Garrison 346). The other 97% of these young people who engaged in these behaviors had more suicidal ideation, were more likely to have been suffering from a major depression, and had more frequently experienced recent misfortunes. The conclusion to this research stated that the children suffering with such circumstances were more likely to participate in indirect suicidal behavior. A discovery of such magnitude is shocking and distressing; children dealing with depression, trauma or stressful situations not only idealize about committing suicide, but they actually behave in ways that affect the length and quality of their lives at very young ages.

A similar study was also done among a much different age group. The researcher Yeates Conwell found that although suicide is rare in nursing homes, indirect self-destructive behaviors, such as refusing to eat or not taking life-sustaining medications, are commonplace (Conwell 157). Unlike the group of young people, the causes for these behaviors among the elderly are not associated with misfortunes. Rather, they may occur as a response to the individual’s expectation to die or as side effects of psychological issues such as Alzheimer’s disease, depression or denial. A review of this study by David Lester suggests that more elderly people die by indirect suicidal behavior than direct suicide (Lester, Why People Kill Themselves 183). Although these situations are common, they are still emotionally and ethically problematic.

According to The Ethics of Suicide, by psychologist Victor Cosculluela, “every living organism has a life-drive” (6). Cosculluela claims that suicide occurs when, “the life-drive is overpowered by some other drive, i.e., taking risks, escaping from pain, etc” (6). In this respect, we can make the connection that although these elderly subjects, or the young children do not intend to end their lives, they are putting their lives at risk to achieve some alternative state of mind. As these studies have shown, the motives behind such behavior are often a means of escaping pain or dealing with issues like stress. We can also apply this idea to psychological diseases such as depression and bipolar disorder or as discussed earlier, Alzheimer’s disease, which is common among the elderly. In a situation of manic depression, a person’s desire to escape pain and sadness will outweigh their desire to live. This can result in attempted direct suicide, or participation in self-destructive behavior such as drugs and alcohol.  With addiction, we see a similar situation.  In this case, the motive to use drugs or alcohol outweighs an addict’s desire to live a long, healthy life. According to The Ethics of Suicide, “the interruption or termination of the life-drive goes against our human instinct to preserve life; failing to do so is against our moral standards” (Cosculluela 7).

The Role of Psychological Illness and Addiction

It is vital to the analysis of this topic to discuss psychological illnesses because not only are they proven to be a cause of indirect suicidal behavior but they pose numerous limitations on recent studies. Earlier, the term “subintentional” was introduced to describe behavior related to indirect suicide, indicating that these types of behavior do not exhibit full intent toward death. However, intent is not the only factor that plays into suicidal behavior. For an act to be suicidal it must also reveal that a subject has the conscious knowledge to end his or her own life. (Shneidman 21). This restriction plays heavily into our topic when dealing with subjects affected by psychological disorders because individuals affected by illnesses such as depression are not always fully conscious of their behavior.

A psychological disorder is an illness of the mind. Due to chemical imbalances or abnormal hormone levels, they alter the way people interpret situations and control the ways in which they go about handling these situations (“Mental Health-Depression”). Based on these circumstances, depression also affects a person’s ability to make conscious decisions. So although people affected by these illnesses are aware of the fact that their decisions to refuse sleep, eat unhealthy, use drugs, or even attempt direct suicide physically harms their body, they are unable to control their behavior. Because of this, psychologists are hesitant to hold people with related disorders responsible for their actions. This factor of consciousness becomes a major implication when developing research on indirect suicidal behavior because it is nearly impossible to determine the level of consciousness of a subject at a certain point in time.

The same problem arises when we try to study the behavior of individuals dealing with addiction. WebMD, an online medical health journal, defines addiction as, “A chronic, often relapsing brain disease that causes compulsive drug seeking and use despite harmful consequences to the individual that is addicted” (Mental Health-Drug Abuse and Addiction). The definition of an addiction is important in understanding the role consciousness plays in any addictive behavior. According to this definition, an addiction is considered a disease in which a person’s mind and body become dependent on a specific drug or type or behavior. Because of the negative consequences drug and alcohol abuse have on one’s mind and overall health such as decreasing their life span or increasing their chance of developing a life-threatening illness, addictive behavior is certainly a form of indirect suicide.  However, researchers argue that it is difficult to incorporate addictive behavior in studies on indirect suicide because, “the abuse of nearly all addictive substances leads to changes in the structure and function of the brain. This affects self control and the ability to make decisions” (Mental Health-Drug Abuse and Addiction). Therefore, incorporating this behavior in research would not provide conclusive results because the behaviors may or may not involve conscious knowledge.

Nonetheless, the behaviors related to depression and addictions are still considered to be expressions of unconscious suicidal motivations (Gernsbacher 175). Psychologist Larry Gernsbacher speaks of these individuals in his book The Suicide Syndrome, claiming they lead "a suicidal lifestyle,” thus implying that their lifestyle will inevitably lead to premature death whether consciously intended or not. So although the study of those affected by psychological disorders may not provide evidence of how or why people participate in self-destructive behaviors, they do directly indicate subintentioned suicide.

In his book, Definition of Suicide, psychologist Edwin Shneidman does not completely argue this classification, but rather, he proposes another idea:
My own view is that all of these deleterious outcomes are more meaningfully called subintentioned deaths rather than one or another type of suicide. When we use the word suicidal to refer to anything which jeopardizes health or well being, we tend to rob the word of its more powerful and potentially more accurate meaning. (Shneidman 22).

I believe Shneidman makes an important point with this statement. He begins the argument by distinguishing suicide from death. This is important because while a person may participate in suicidal behaviors, their death is not considered suicide without conscious knowledge and the intent to die. This distinction is also important when considering addictions and depression. For instance, if an alcoholic dies of liver disease, although the user’s behavior exemplifies an intention that somehow caused him to die, he did not consciously and actively end his own life. Rather, the disease killed him. Therefore, Shneidman would call this a subintented death instead of subintended suicide. He claims that classifying this type of death as suicide takes away from the more “accurate” meaning of the suicide whereby a person, with intention, knowledge and full consciousness, directly ends his or her own life. While I accept that this is both accurate and meaningful in defining suicide and indirect suicide and classifying death into its respective categories, I do not believe the distinction between subintended suicide and subintended death diminishes the importance of acknowledging such behavior. Self-destructive and life-threatening behavior, whether committed with conscious intent or not, can lead to the untimely death of friends and loved ones.

Conclusion

Therefore, it is imperative that psychologists continue to research the types of people most commonly subjected to such behavior as well as possible causes or determining factors behind their motivation. Doing so would create a better understanding of the subject for use by other psychologists or medical experts attempting to treat related issues. It may also educate the general public about the seriousness of such behavior and at what extent to seek professional help for family and friends. Such research will make it possible to more easily recognize someone in danger of committing direct suicide. It may also enhance understanding toward causes related to suicide if studies also noted the extent to which subjects idealize about suicide.

Although it is obvious by now that life-threatening behaviors correlate with suicide, we must also acknowledge those that behave accordingly yet do not wish to alter or end their lives. While we may not need to urge them to seek medical help and we are unable to limit their freewill, despite attempts via government laws and age restricted products, there are certain actions we can take to try to improve their lives. While this paper has discussed some of the many behaviors that can hinder our life expectancy, there are also many that are proven to prolong life such as regular exercise, healthy eating habits, obeying a doctor’s orders or always using caution when driving a vehicle, which includes wearing a seatbelt or helmet.

By simply raising awareness of indirect suicidal behavior, continuing research based around it and supporting the practice of safe and healthy lives, we can positively affect the lives of individuals in a magnitude of ways. Not only would we enhance their quality of life, but it would also strengthen the amount of support and treatment available for those considering suicide. By encouraging these habits to friends and family, especially those susceptible to engaging in self-destructive behavior like young children or the elderly, we are not only promoting a healthy lifestyle but also providing hope and encouragement for individuals that may feel distress or neglect. As a wise person once said, “It’s the simple things in life that matter most” and, therefore, these simple actions will largely impact an individual’s decision to choose between life or death.

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Conwell, Yeates, Jane Pearson, and Evan G. DeRenzo. "Indirect Self-Destructive Behavior among Elderly Patients in Nursing Homes: A Research Agenda." American Journal of Geriatric Psychiatry 4, no. 2 (1996):152–163.

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