The term "suicide" is derived from the Latin "sui manu cadere", which means "to kill oneself by one's own hand". It is a taboo subject, often avoided, stereotyped and misunderstood in society. But what is suicide, what drives a person to commit the ultimate act of self-destruction, to end their life by their own hand? Is it a cultural phenomenon, an act of failure, an attempt to make a political or emotional statement, a desire to escape an inevitable crushing event, the result of mental illness or something else entirely? It is impossible to give a blanket answer to these questions, because every suicide story is very personal and the backgrounds are individual.
History is littered with famous people who chose death to escape the shame of dishonour, such as the Carthaginian general Hannibal Barkas or the last Egyptian pharaoh, Cleopatra VII. Many Japanese generals and samurai of the past also chose death by their own hands, perhaps for similar reasons. These and other tragic stories have been sung in song and immortalised in literature, theatre and film. Suicide is clearly a cultural phenomenon that touches and moves many people. It is therefore received and understood differently in various cultures.
In the German language, for example, there is the term "Selbstmord", which seems to equate the act of killing oneself with murder. This understanding of suicide goes back to the Christian teachings of the Middle Ages, which condemned suicide and the so-called "self-murderer" in the strongest possible terms. Suicide was considered a sin against God and was punished accordingly: family members of suicides could be dispossessed, and the "perpetrators" themselves were buried outside the cemetery boundaries in unhallowed ground. In the course of modern times, the view of suicide changed: the strict condemnation was gradually abandoned. Thanks to medical and scientific research into the phenomenon, which began in the 19th century, many previously unknown psychological and pathological backgrounds to suicide have been discovered.
Today, suicide is often referred to as "freitod" (meaning freely chosen death), suggesting that the end of life, brought about by one's own hand and voluntarily, is a free and largely autonomous decision on the part of the person concerned. This also includes the philosophical and, ultimately, legal debate about suicide or even physician-assisted suicide. The main purpose of this article is to look at suicide from a therapeutic point of view, and to show that suicide is often an act that is carried out almost out of inner compulsion, because there is seemingly no alternative for the person concerned, while to outsiders the way out may seem self-evident. Seen in this light, suicide has little to do with a free choice. It is therefore very important to discuss the path of suffering that can end in suicide, its causes and possible help to avoid a tragic outcome.
To avoid misunderstandings when dealing with suicidality, it is necessary to explain some basic terms. Four forms of self-destructive behaviour are described in professional literature:
Suicidal ideation: This term includes thoughts and ideas about suicide, but no specific plans to take one's own life.
Suicide attempt: A suicidal act that is aimed at killing oneself but does not result in death. Also unsuccessful/incomplete suicide.
Parasuicide: A suicidal act committed as a cry for help, but without the intention of leaving life.
Completed suicide: An act of suicide that has resulted in death. The actual intention is usually difficult or impossible to ascertain in retrospect.
There are also particularly distressing forms of suicide, such as extended suicide and murder-suicide. The former is a suicide that is preceded by the killing of intimates or family members, such as spouses and children. Murder-suicide describes the killing of random strangers, such as in a head-on collision between two vehicles deliberately caused by the suicidal person.
According to the German Federal Statistical Office, a total of 939,520 people died in Germany in 2019, 9041 of them by suicide. This corresponds to a rate of just under one per cent. This equates to more than 27 suicides per day or more than one suicide per hour. By comparison, 3046 people died in road accidents in the same year. Although the suicide rate in Germany has almost halved since 1980, more people still die from suicide than from road accidents, drug abuse, violence and AIDS combined.
Suicide as a cause of death is clearly male-dominated with a share of 75.7%. Over the past 40 years, the proportion of male suicides has risen steadily from 63.9% in 1980 to more than three quarters in 2019. The average age of people who died prematurely by their own hand in 2019 was 58.5 years. Women were slightly older than men. In general, the risk of suicide increases sharply with age for both sexes. However, this is particularly true for men in old age.
Suicide occurs in almost all age groups. Adolescents and young adults are also affected. Suicide is the most common cause of death in the 15-25 age group. However, in this age group, the number of attempted suicides is much higher than the number of completed suicides. Overall, the number of suicide attempts is 10 to 20 times higher than the number of completed suicides in all age groups.
The most common method of suicide is hanging, strangulation or suffocation, with a share of 45.1%. The second most common method is deliberate self-poisoning, usually with medicines or drugs. A distinction is generally made between 'hard' and 'soft' methods of suicide. The former have a much lower chance of survival and are much less likely to be found in time. Hard methods include hanging, shooting, deep cuts, jumping from great heights or jumping in front of trains and railways. Soft methods include poisoning of all kinds, including inhalation of exhaust fumes. There are gender differences in the methods used: men are significantly more likely to choose hard methods of suicide, resulting in a higher number of completed suicides among men than among women. These sober but moving figures paint a tragic picture and raise many questions, especially: what precedes the worst and how can it possibly be prevented?
Suicidal acts usually occur in times of crisis, when people see no other way out of a situation they feel is hopeless. The causes of suicide are many and varied and are mainly related to stressful life situations. These include: major strokes of fate such as death in the family or in a close personal environment, separation and divorce, heartbreak, loss of a job, prolonged unemployment, loneliness, serious illness and pain, loss of home and failure. Fortunately, most people can cope more or less well with stressful life events and rarely become suicidal. The situation is different for those who already have a mental illness, are vulnerable to developing one, or develop a mental disorder as a result of severe psychological stress. Statistics show that about nine out of ten people who take their own life have a history of mental illness. The risk of suicide is particularly high in cases of major depression: 15 to 20 percent of those affected take their own lives. Moreover, depression is the most common cause of suicide, accounting for about 60% of all suicides.
The following mental disorders are associated with an increased risk of suicide:
Depression (depressive episode, adjustment disorder with depressive reaction)
Alcohol dependence or long-term alcohol abuse
Drug or medication abuse
Schizophrenia and schizotypal disorders
Acute stress reactions and acute, including organic, psychoses
Post-traumatic stress disorder
Manic episodes and bipolar disorder
Eating disorders, particularly anorexia
Personality disorders, particularly borderline personality disorder
Multiple personality disorder
Other risk factors for self-harm and suicide include suicides in the immediate environment, such as family, friends and acquaintances. However, the negative impact of high-profile suicides should not be underestimated. Such widely publicised suicides by people who serve as role models for many are certainly capable of provoking imitation and triggering a real wave of suicides. The suicides of famous actors or popular musicians in the recent past, such as the guitarist and singer of the rock band "Nirvana", Kurt Cobain, the multi-award-winning actor Robin Williams or the frontman of the rock band "Linkin Park", Chester Bennington, are particularly worthy of mention. The increase in copycat suicides in certain populations following widespread media coverage is known as the Werther effect.
This contagious phenomenon is named after the novel "The Sorrows of Young Werther" by J. H. von Goethe, published in 1774. The protagonist of the novel experiences young love with a feeling of deep inner liberation, which he is unable to live out due to his bourgeois circumstances. This feeling turns into a feeling of captivity and overwhelming pain. As a way out, Werther invokes death, which he ultimately brings about himself. After the novel was published, there were a number of suicides by young men who either dressed like Werther or carried the book with them when they killed themselves. The connection was obvious.
The motives for suicide can be as varied and individual as the people who take their own lives. The information on motives comes from interviews with survivors of suicide attempts. The most common motives are summarised below:
Desire to change or end a situation that seems hopeless. Inability to endure prolonged suffering.
Cry for help.
Inability to release aggression due to disappointment or anger.
An attempt to escape an impending humiliation, indignity or conflict.
Revenge to show someone how far they have pushed the suicidal person.
Parasuicide as a means of manipulating others. This pattern of behaviour may be seen in emotionally unstable personality disorder of the borderline type.
The desire to join deceased family members or loved ones in the afterlife.
Suicide as a public display, especially to achieve political goals, e.g. hunger strike or public self-immolation.
Suicide as a consequence of severe symptoms of serious mental illness, e.g. major depressive disorder or paranoid schizophrenia, e.g. after being told by hallucinated voices to take one's own life, self-punishment as a consequence of complete devaluation of one's own person.
Suicide attempts and suicidal acts can occur either impulsively and unprepared in a state of emotional distress or, more commonly, as the result of a gradual development over a long period of time in the context of mental illness, which finally comes to a bitter end without external intervention. In more than half of the completed suicides, it is known from the environment that the person had seen a doctor or therapist in the six months before the suicide. This was usually because of a physical complaint. Usually they behave reservedly, hide their thoughts of death or make vague allusions that go unnoticed. This shows that "Freitod" is usually the result of a longer pathological process, which can be stopped or reversed if recognised in time. If suicidality is suspected, it is therefore very important to speak directly and openly to the person concerned. In most cases, such a confidential conversation is the first step towards healing and salvation.
According to classical psychiatric doctrine, suicide is the end of a pathological development. The inner psychological processes of this development were first described in detail in 1953 by the Austrian psychiatrist Erwin Ringel. He interviewed and examined more than 700 suicidal patients and formulated the presuicidal syndrome, a combination of three basic symptoms that are considered a sure sign of suicidality, regardless of the underlying physical or mental illness. These three features are constriction, reversal of aggression and death fantasies.
Constriction refers to at least one of the following areas:
In their social environment, people feel abandoned and isolated.
All thoughts are dominated by the personal situation, which is perceived as hopeless. There is little or no room for other thoughts.
Emotional life is limited to the current aspects of the problem. Feelings towards other people and situations are dulled and extinguished.
There is nothing left to live for. Life has no meaning.
According to Ringel, aggression reversal means that every suicidal person is deeply frustrated and dominated by aggression. However, they are unable to channel this anger outwards and thus vent it. This ultimately leads to the aggression being directed against the person.
Fantasies of death can take three distinct forms:
Passive death wish. The idea of being dead. This is not fantasising about the process of dying, but about the reaction that suicide will cause in other people.
Active death wish. Imagining killing oneself, but not yet having a concrete idea of how to do it.
Concrete plans to carry out the suicide, often thought out and planned in detail.
At first these fantasies are deliberately evoked. As they become more and more restricted, they are no longer produced voluntarily, and finally they take over and can take on the character of obsessive thoughts. It is only a small step from here to execution.
The symptoms described and their characteristics develop gradually, but are usually present at the same time immediately before the suicide attempt. Constriction is usually relatively easy to identify through specific questioning. Recognising the reversal of aggression is much more difficult. In order to determine the seriousness of the person's situation, another explanatory model is therefore used in practice, which divides suicidal behaviour and feelings into phases.
In 1968, the Swiss psychiatrist Walter Pöldinger defined three phases or stages of a suicidal course. They help the therapist to decide on the further course of action. The three stages and their main characteristics are presented below.
The contemplation stage. In this first stage, suicide is considered only as a possible solution to problems or conflicts. Such thoughts are often triggered by mental illness, especially depression. External factors such as suicides in the immediate environment or media reports in the sense of the Werther effect described above should also be mentioned in this context. Certain aspects of the personality structure, such as the inhibition of aggression, may play a decisive role in the further course of the illness. At this stage, people are still able to control their thoughts and actions.
The ambivalence stage. In this phase, the person's thoughts and feelings are dominated by an inner struggle between self-preserving and self-destructive forces. Thoughts of suicide may recur, only to be temporarily replaced by the desire to live. Characteristic of this stage are direct or indirect announcements of suicide in the form of hints, threats and predictions. These should be understood as calls for help and requests for contact. The still widespread idea that "those who talk about suicide do not commit it, and those who want to commit it do not talk about it" has not proved true in the past.
The decision stage. The person in this stage may appear calm and relaxed. To outsiders, the person who has recently been plagued by indecision may appear downright relieved and affectionate towards loved ones. This is a state of psychological emergency, often described as the 'calm before the storm'. The decision to leave life has been made and the preparations are usually complete. There is a critical risk that the person will attempt suicide within a very short time. A person in this phase must be admitted to a psychiatric hospital as soon as possible, either by voluntary self-admission or by forced admission by the police, the public order office or a court order. The legal basis is the Accommodation Act, which allows for compulsory admission in cases of acute danger to self or others.
In practice, the path from consideration to decision is rarely straightforward. In most cases, there are prolonged periods of persistent indecision, the development of which can be triggered or halted by various external factors. Sometimes suicidal thoughts and fantasies can lie dormant for years, only to be suddenly acted upon without any preparation. Sometimes suicide attempts are made impulsively, without thought or planning. In most cases, however, suicidal tendencies can be identified in advance, and there is some scope for helping those affected.
In the contemplation stage, the focus is on treating the underlying illness in which suicidality is a symptom or part of the clinical picture. In the case of depression, antidepressants are usually used and, depending on the indication and severity, other psychotropic drugs may also be used. In most cases, medical-psychiatric treatment is accompanied by psychotherapeutic treatment, either on an outpatient or inpatient basis. In the ambivalence and decision phase, crisis intervention is again the first step. People in the resolution stage should never be left alone, not even for a moment.
What should you do if you think you recognise some of the symptoms described in yourself or a relative, or if you suspect suicidal tendencies? If you are personally affected, see a doctor or therapist immediately or contact a suicide prevention hotline. Your GP can also help and refer you to a specialist if necessary. Be sure to tell your doctor about your symptoms and name them. If you are having suicidal thoughts or feelings, it is important to talk to your doctor openly about them. Such psychological phenomena are not to be taken lightly and should be medically evaluated as soon as possible.
If you suspect that someone close to you may be suicidal, talk to them directly, if you feel comfortable doing so. Do not leave them alone with their problem. Let them know that they are not alone and that you are there for them. Do not try to judge their thoughts and reasons: they may seem insignificant to you, but they are very serious to the person concerned. Do not do anything behind their back, tell them openly that you want to get help, be it from other relatives or professionals.
In general, suicide threats should always be taken very seriously: 80 per cent of people who have attempted suicide have made some form of threat. Many suicidal people long for human closeness, even if they do not necessarily realise it. It is important to support them, to take their grief seriously and not to comfort them lightly. Encourage them to see a doctor or therapist and convince them that they will not be able to cope without professional help. Doctors and therapists have specific expertise and can assess the seriousness of the situation and determine the next course of action by asking specific questions.
Suicidality is a very serious symptom of a severe illness and, in most cases, does not occur in isolation but in association with other clinically relevant physical and psychological phenomena. Once manifested, suicidal tendencies are unlikely to disappear on their own and therefore require professional medical treatment. Treatment for suicidal tendencies is worthwhile: Many people who have been saved in time and survivors of suicide attempts report that, under different circumstances, they would have reacted differently to their problem situation and found completely different solution strategies.
In addition, there are numerous offers of help on the internet. It is highly recommended to take a look at the website of the German Society for Suicide Prevention (unfortunately, available only in German), which offers a lot of relevant help information as well as nationwide telephone and electronic contact options for those affected.
Finally, please refer to another article on this blog that will help you distinguish between the different therapeutic professions in the field of psychology and find the right specialist for you: "Psychiatrists, psychotherapists, alternative practitioners and co. Who should I see?".
Important note: The treatment of suicidal patients is only permitted for alternative practitioners of psychotherapy on the condition that the patient is already being treated by a psychiatrist. This is justified by the fact that suicidal patients are usually indicated for treatment with psychotropic medication to stabilise their mood. In Germany, only doctors are permitted to prescribe and administer prescription drugs.
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