Suicide, perhaps the most obvious type of avoidable death at any age, is an intentional act that quickly results in death. However, there is a wide range of indirect suicidal behaviors in which death results gradually rather than immediately, and in which the degree of intentionality is less obvious than in an overt suicide attempt.
Defining Indirect Suicidal Behavior
Robert Kastenbaum and Brian Mishara, in their discussion of the concept of premature death and its relationship to self-injurious behavior, suggested that behaviors that shorten life are varied in form and widespread. They recognized that in one sense all human behavior affects a person's life expectancy. Some obvious examples of potentially life-shortening behavior include smoking cigarettes, taking risks when driving, and ignoring doctors' orders. On the other hand, life span can be prolonged by exercising regularly, eating well, using care when crossing the street, and driving an automobile in good condition equipped with air bags while always wearing a seat belt.
Indirect suicidal behavior is thus a matter of probabilities rather than certainties. Not taking one's heart medication or crossing the street carelessly will certainly increase the probability of a premature death. However, the timing of the occurrence of a subsequent heart attack is unknown; some people cross recklessly and live a long life, while others are hit by a car and die the first time they are not careful. Similarly, smoking cigarettes is clearly associated with a reduction in life expectancy, and most people know this, including smokers. However, as many smokers will point out, there is usually a case of a person someone knows who has smoked for decades and lived to old age.
Suicides are often deemed indirect where there is no immediate and clearly identifiable intentionality. The pioneer suicidologist Edwin Shneidman spoke of "subintentioned death" and "indirect suicide". He felt that orientations toward death, or "toward cessation," fall into four categories, which include intentioned, subintentioned, unintentioned, and contraintentioned. Suicide is by definition generally considered to be intentioned. Accidental deaths are unintentioned, and his category of "contraintention" includes people who feign death and threaten death. He specifies four groups of persons who have subintentional orientations.
First, there is the "death-chancer" who gambles with death by doing things that leave death "up to chance." Suicidal behavior in which there appears to be a calculated expectation for intervention and rescue are examples of this form of sub-intentional suicidal behavior.
The "death-hasteners" are individuals who unconsciously aggravate a physiological disequilibrium to hasten death. Death-hasteners may engage in a dangerous lifestyle, such as abusing the body, using alcohol or drugs, exposing themselves to the elements, or not eating a proper diet.
The "death-capitulators," by virtue of some strong emotion, play a psychological role in hastening their own demise. These people give in to death or "scare themselves to death." Shneidman includes in this category voodoo deaths and other deaths in which psychosomatic illness and higher risk of complications (e.g., high blood pressure and anxiety) increase the probability of an early death.
Shneidman's fourth and final category is the "death-experimenter," who does not wish consciously to end his or her life but who appears to wish for a chronically altered or "befogged" state of existence. This includes alcoholics and barbiturate addicts.
Interpretations by Freud and His Followers
Although Freud did not discuss indirect suicide, he developed the concept of the death instinct later in his life. It was his student Karl Menninger who elaborated on the concept of a death instinct, Thanatos, which he viewed as being in constant conflict with the opposing force of the life instinct, or Eros. According to Menninger, there is an inherent tendency toward self-destruction that may, when not sufficiently counterbalanced by the life instincts, result in both direct and indirect self-destructive behavior.
Norman Farberow expanded upon Menninger's theory and developed a classification system for what he called "indirect self-destructive behavior." Farberow felt that direct and indirect self-destructive behaviors differ in many ways. The impact of indirect self-destructive behaviors is most often long-term and frequently permanent, so that only the results are clearly apparent. Unlike direct suicidal behavior, indirect self-destructive behavior is not linked to a specific precipitating stress; hence this behavior is not sudden or impulsive. Unlike completed suicides and suicide attempts, indirect self-destructive behavior does not entail a threat to end one's own life; nor does it involve clear messages that indicate a death wish. Indirect self-destructive people are generally self-concerned and unable to invest much of themselves in a relationship with significant others. They are often alone and have limited social support systems. In contrast, the suicide attempts of the direct self-destructive are often related to the loss of a significant other.
Studies of Other Species
Humans are the only species who engage in intentional self-destructive behavior. Philosophers generally limit the possibility of voluntary and intentional self-destruction to the human race. Nevertheless, self-initiated behaviors that result in harm and death do occur in other species. These behaviors, while obviously self-destructive, do not have the characteristic of conscious decision-making that is unique to humans. Nevertheless, they may ultimately result in injury or death. Researcher Jacqueline Crawley and her colleagues present a review of ethological observations of self-sacrificing deaths in some animal species—usually in defense of territory.
Parental behavior may be at the core of many altruistic behaviors, with parents in many species performing some forms of self-sacrifice for the survival of their offspring.
When environmental conditions become stressful for animals, such as for those confined in zoos, self-mutilation and refusal to eat may result. Similarly, pets that are boarded at a kennel or have lost masters to whom they were very much attached may refuse to eat or may mutilate themselves. Crawley speculates that similar dynamics may explain the increased incidence of self-destructive behavior in humans who are imprisoned. More humane care in institutional settings can result in an elimination of self-destructive behaviors in animals. Crawley speculates that greater nurturing and caring behavior may similarly reverse many of the stress-related, self-injurious behaviors in humans.
Indirect suicidal behavior has been studied in several populations. For example, researchers Carol Garrison and colleagues conducted a survey of a community sample of 3,283 American youths in the range of twelve to fourteen years of age. They determined that 2.46 percent of males and 2.79 percent of females engaged in "non-suicidal physically self-damaging acts". Those 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 researcher Yeates Conwell and his collaborators 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. Reviews by McIntosh, Hubbard, and Lester suggest that more elderly persons may die from indirect suicide than from direct suicidal behavior.
Larry Gernsbacher, in his book The Suicide Syndrome, speaks of individuals who engage in what he calls "a suicidal lifestyle." He includes in this category alcoholics and drug addicts. These behaviors are considered to be expressions of unconscious suicidal motivations. Gernsbacher asks, "What better way for him to express his self-hatred than to destroy himself with alcohol? How could he more effectively express his vindictiveness than to inflict on those about him the consequences of his addiction? What better way to express his hopelessness than to drown his life in drink?"
In The Many Faces of Suicide: Indirect Self-Destructive Behavior, Farberow presents chapters by different authors on a wide variety of indirect suicidal behavior. The contributors discuss physical illnesses "used against the self," including self-destructive behavior in diabetics, "uncooperative" patients, self-destructive behavior in hemodialysis patients, spinal cord injury, and coronary artery illness. Several chapters are concerned with drug and alcohol abuse and their relationship to indirect self-destructive dynamics. Hyper-obesity and cigarette smoking are also analyzed as possible ways of increasing the probability of a shortened life. Similarly, gambling, criminal activities, and deviance are judged forms of indirect suicides. Criminals and delinquents often put themselves in situations where there is a high risk of a premature death. Finally, a variety of stress-seeking and high-risk sports activities draw on unconscious or sub-conscious motivations to risk death or to test one's ability to master death.
It may be that direct intentional acts that result in death (i.e., completed suicides) constitute only a small proportion of the various human behaviors that result in premature death. Perhaps these behaviors are, as Freud and Menninger hypothesized, the result of an intrinsic human proclivity to self-destruction that is locked in constant combat with an inherent motivation to preserve life at all costs. Perhaps indirect suicidal behavior is simply part of one's cultural baggage, with different societies encouraging or condoning certain forms of risky and dangerous activities, such as engaging in high-risk sports or having unprotected sex with a high-risk partner. Perhaps, as several research studies indicate, indirect suicidal behavior may be linked to treatable depression, stressful life events, and more obviously identifiable suicidal thoughts and intentions.
It is clear that indirect suicidal behaviors can decrease when the surrounding environment improves; for example, offering patients better treatment in a nursing home. Research in the twenty-first century indicates that it is important to be aware of indirect suicidal behavior and to understand it as a signal of treatable problems. Such vigilance cannot only improve lives, it can save them as well.