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Mixing the personal with the empirical, a scientist seeks to explain suicide

Why People Die by Suicide, By Thomas Joiner, Harvard University, 288 pp., $24.95

Thomas Joiner's book, ``Why People Die by Suicide," opens with a recounting of his father's gruesome death. Entitled ``Losing My Dad," the prologue details how a middle-age man crept from his house before dawn on a summer day in 1990, drove the family van to a deserted parking lot, and slit his wrists. When that act failed, he sunk a knife into his chest, puncturing his heart.

Focusing on human factors that set the stage for suicide, Joiner uses his father's death as a backdrop for presenting the theory that has earned him a formidable reputation as a suicide researcher. A named professor at Florida State University, he asserts a trio of factors, cumbersomely but evocatively labeled, that he contends frame all suicides.

The first is ``perceived burdensomeness," a belief that one has ceased to contribute in useful ways to life and has thus become a burden on others. Months before he died, Joiner's father had left the company that underpinned his adult identity as a good provider and successful businessman.

The second is ``failed belongingness," social disconnection and isolation expressing itself through a devastating sense of aloneness. In the thrall of a depressive episode, Joiner's father had gradually withdrawn from family and friends. Joiner takes pains to point out that his father's perceptions were faulty -- cognitive distortions typical of the deeply depressed that fan the anguish that drives suicidal states.

The third factor in Joiner's theory is the development of the capacity to perpetrate lethal self-injury. Joiner identifies the root and branch of this ability in repeated painful experiences that desensitize the individual to the ultimate injury. Among many examples he cites is his father's maneuvering a pleasure boat through a stormy sea. When the steering wheel snaps off, badly lacerating his hand, he continues to grapple with the shattered tiller, seemingly oblivious to the blood streaming from his hand.

Joiner's trio encompasses a satisfying logic that fits many suicide reconstructions and may aid suicide survivors whose postmortem tasks include making sense of what compelled a loved one to exterminate himself. But there is also the danger of seeking what one expects to find, without the one knowledgeable source available to confirm or deny.

Dead men tell no secrets. The story of a suicide thus becomes the narrative survivors construct from facts they deem valid. Survivors compile a narrative from the psychological and social details of a life. Just as it has become a truism that people who kill themselves are depressed, it can seem equally self-evident that they feel useless and disconnected at the moment of death, with a selective review of the data to prove it.

Unfortunately the suicide literature cannot even agree on a definition for suicide. Accidental deaths masquerade as true suicides, and deaths that may have been suicides are classified as accidents. People who afflict grievous harm on themselves claim they never intended death. People taking an extra dose of antibiotics truly believing it will kill them avoid the suicide label because their attempt is so objectively feeble.

It is the synergy and tension between Joiner's dual identity as suicide survivor and academic that imbues this book with both its power and a certain logical grandiosity. Joiner overreaches when he tries to stretch his theory to include all aspects of the phenomenon of suicide. He identifies the genesis of the ability to commit lethal self-injury -- the inuring to pain through repeated exposure to it -- in experiences as diverse as childhood neglect and repetitive self-cutting, submission to multiple tattoos , and service as a war correspondent. As a doctor, suicide researcher , and survivor of suicides both personal and professional , I simply cannot squeeze all the deaths I've known into his theoretical box. I also suspect a more personal agenda when heartfelt anecdotes from his father's life and death appear repeatedly amid academic material.

I by no means intend to dismiss the potent theory Joiner proposes. As a careful scientist, he tells reader s when he crosses from the empirically proven to the theoretically speculative, and proposes agendas for new research. While I do not believe one theory can fit all suicides, Joiner's ideas about belonging and burdensomeness are invaluable for survivors trying to come to terms with their loss and clinicians working to prevent such deaths. For the living, mattering in both work and love is critical to maintaining a vital grip on life. Eroded meaning in both dimensions is central to the stories of individuals like Joiner's father, who was withdrawing for months or years before his death.

Joiner is to be commended for a powerful effort to integrate science and personal tragedy. In an easily digestible style, he reviews the breadth of modern suicide scholarship -- biological, psychological, and social, and presents his integration clearly and forcefully. An extensive bibliography directs readers to additional resources.

Ultimately ``Why People Die by Suicide" is about Joiner's quest to understand his dad's suicide. Joiner bravely illumines how that death blew a crater in his assumptive world. Sixteen years later he tells us that sadness has supplanted heartsickness, and how he hopes his own example as researcher and a son will help to salve the pain of the 30,000 American families annually riven by suicide.

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