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Suicide Notes

From Night Falls Fast by Kay Redfield Jamison (Vintage, 2000)

"It would seem that nothing could be closer to the truth of suicide than notes and letters left behind by those who kill themselves, but this is not the case; our expectations of how we think people should feel and act facing their own deaths are greater than the reality of what they do and why they do it. Suicide authority Ed Shneidman, for example, in commenting on the disappointing banality of many suicide notes, lets slip his hope, a common one, that the last recorded moments of life will afford a deep or tragic view of dying: 'Suicide notes,' he writes, 'often seem like parodies of the postcards sent home from the Grand Canyon, the catacombs of the pyramids–essentially pro forma, not at all reflecting the grandeur of the scene being described or the dept of the human condition that one might expect to be engendered by the situation.'" (page 74)

What does it mean that my loved one did not leave me a note?

By Antoon A. Leenaars, Ph.D., C.Psych., Past President, American Association for Suicide Prevention, & First Past President, Canadian Association for Suicide Prevention & David Lester, Ph.D., President-Elect, American Association of Suicidology, & Past President, International Association of Suicide Prevention

One of the most frequent questions asked by survivors of a death by suicide is the very one asked of us here: “My loved one did not leave a note. What does that mean?” Not only is this a frequent question asked, but, although it may seem a simple question, it is a complex one. The asker is asking more then the surface meaning. We offer an evidence-based answer.

A Favorite Story

We will begin with a favorite story: Edwin Shneidman, a father of modern suicidology (and AAS, for that matter) does not know whether suicide was looking for him or he was looking for suicide. However, on a day in 1949, when he discovered 100’s of “genuine suicide notes," he was restless and looking for some niche in psychology. He had been working for the VA hospital in Los Angeles, and had been sent to the coroner’s office to obtain the files of two veterans who had died by suicide. Automatically, he opened the first file and found a suicide note. He wondered immediately if there was one in the second file. There was no note. As a researcher, he asked the question, “How common are suicide notes?” He wondered, “What can we learn from suicide notes?” It was our good fortune that the clerk who was assisting Shneidman, had collected on her own 100s of notes for years. She, too, had the same questions. With a little help from the VA, Dr. Shneidman obtained copies of the notes. (The copies are now stored at the senior author’s office). Were they bountiful, he thought? Here is verbatim what Shneidman (1991) wrote of that find:

"The fulcrum moment of my suicidological life was not when I came across several hundred suicide notes in a coroner’s vault while on an errand for the director of the VA hospital, but rather a few minutes later, in the instant when I had a glimmering that their vast potential value could be immeasurably increased if I did not read them, but rather compared them, in a controlled blind experiment, with simulated suicide notes that might be elicited from matched nonsuicidal persons.  My old conceptual friend, John Stuart Mill’s Method of Difference, came to my side and handed me my career" (p. 247).

In religion, we talk about Epiphanies and Epiphany moments. That the notes were “genuine” was an epiphanic moment for Shneidman. He had an autonomic reaction with the feeling, without verbalizing, that it was important to say “genuine” suicide note. Within a couple of months of saying “genuine” and then “simulated” and then eliciting simulated notes, and then calling Norman Farberow, he was beginning a discipline. He said, ‘oh boy, suicide notes, the golden road to suicide,’ and suicidology began. This dynamic duo in early suicidology answered some of the core questions about notes. They published their studies in a classic book in the field in 1957, Clues to Suicide. (We highly encourage the questioner to read this book). It is in this book that we find the first answer to the question asked. Twelve percent leave notes. Thus, it means little if your loved one does not leave a note. It is not common. In the 1950’s, it was, in fact, rare. By implication, it means little, if there is no note. But, allow us to go a little further. We want to be sure. What are the current rates of people leaving a note, after all, Ed’s study was 70 years ago. (As an aside, suicide notes from the 1950’s, 1980’s, and today, do not differ much.)

From recent reports, the answer is from about 18% to 37%. There is no absolute. Samples have varied greatly. There is no the verifiable estimate. Yet, the fact remains, it means little at the general level. Or, does it? (Of course, at the individual level, it always has meaning.)

Are People Who Die by Suicide and Left a Note Different from Those Who Die by Suicide and Do Not Leave a Note?

First, you must remember that we researchers deal with groups of people. We compare one group with another group and see if there are differences. In contrast, a particular individual may not fit conveniently into any “group” and so may differ from the average or from the norm.

Are people who die by suicide and left a note different from those who die by suicide and do not leave a note? Understanding the act of suicide and motives behind suicide behavior seems extremely important, and in order to do so; many researchers from around the world have used different methods to study suicide. Shneidman and Farberow (1957) have suggested the following avenues: national mortality statistics, retrospective psychological investigations (often called psychological autopsies), the study of nonfatal suicide attempts, and the analysis of documents (such as suicide notes). Suicide notes are, therefore, one route to scientific study.

Frederick (1969) has suggested the most accepted scheme for methods of note analysis; they are descriptive presentation, content analysis, classification analysis, and theoretical-conceptual analysis. Each of these approaches has had utility, although Frederick suggested that simple content analysis has limitations (see, for example, Ogilvie, Stone & Shneidman, 1969; they noted that the word “love” occurs frequently in suicide notes). Our question posed can be answered by classification analysis. Traditional classification schemes use demographic factors such as age, sex, marital status, educational level, employment status, and mental disorder (see, for example, Ho, Yip, Chiu, & Halliday, 1998). In 1960, a team in Philadelphia found that note writers and non-writers were similar in age, sex, race, marital status, employment, and suicidal history, but differed in the method used. A team in Los Angeles found no differences in these kinds of factors.

There have been more recent studies with large samples. For example, in Tasmania, Janet Haines, Christopher Williams and David Lester (2011) studied 1051 suicides and found many differences. Those who wrote a note were more often divorced, more often lived alone, were less likely to be under medical supervision or to have seen a doctor recently, and less often under psychiatric care. Note writers more often were in psychological distress (but not more often angry, sad, or withdrawn), less often confused or psychotic and more often hypochondriacs. The note writers killed themselves more often when in interpersonal conflict with others. They also used gas, firearms and poisons more as a method for suicide. Only 33% of the sample left a suicide note.

Based on the Tasmanian study, therefore, it seems that note writers are more often in the midst of interpersonal conflicts and, therefore, have more need to communicate to others. In contrast, those who do not leave a suicide note tend more often to be medically ill and under psychiatric care. Perhaps they assume that the reasons for their decision would be obvious to their significant others.

But these are simply the general differences. For example, although 37% of those who were not psychiatrically disturbed left a note, so did 26% of those who were psychiatrically disturbed. A difference, clearly, but not 100% versus 0%.

Ho and his colleagues (1998) developed the most widely used classification scheme; they studied suicides notes in Hong Kong. Ho’s scheme is largely based on forensic data that are gathered at postmortem investigation. They found that suicide notes written by young people were longer and richer in emotions than those written by older people. A similar classification scheme has been used in The United States (Callanan & Davis, 2009), India (Girdhar, Leenaars, Dogra, Leenaars, & Kumar, 2004), Mexico (Chavez, Paramo-Castello, Leenaars & Leenaars, 2006), Japan (Kubaware, H., Shiori, T., Nishimura, et al., 2006), and Turkey (Demirel, Akar, Sayin, Candansayar, & Leenaars, 2008). However, there are limitations in these studies. The data are not entirely consistent and differences in collection occur between researchers in different countries. There are also limitations in the generalizability of the findings. For example, unlike Ho’s finding, Demirel and the team from Turkey found the notes from the elderly longer. For a further example, Girdhar’s team from India found that many notes involved a specific instruction, mostly for care of the family; physical/psychological illness was the most frequently mentioned difficulty; whereas Chavez and her group from Mexico found little written about life’s difficulties and few specific instructions. In the U.S., Callanan and Davis (2006) noted only that note writers lived alone more often. Sometimes divorced people leave more notes; sometimes, married people leave more notes. Furthermore, a comparison of the great number of studies to date on note-writers with non-note-writers, has failed to find consistent results. Differences in demographic features like age and sex are also inconsistent (Chavez et al., 2006; Foster, 2003; Ho et al., 1998). The main finding to date, suicide note writers are essentially similar to suicides who did not leave notes. Therefore, once more we answer the question in the negative. It seems to mean little. Yet, our questions persist. The questioner is asking a deeper question than percentages and rates of notes. She is asking, “Why did my loved one die by suicide? Can suicide notes answer my question?” The answer: Yes.

What Do Suicide Notes Tell Us?

Within Frederick’s scheme, theoretical-conceptual analyses have given the best answer to date. Theory sorts out the question. Theory today has to be evidence-based, not armchair speculation. Thus, to answer the why, the senior author developed a theory of suicide, based on the person’s, who died by suicide, own words or narratives, the suicide note (Leenaars, 1988).

 Despite the call for, in the first formal study of suicide notes (Shneidman & Farberow, 1957), only a very few studies have utilized a theoretical-conceptual (thematic) analysis. To address this lack, over three decades ago, the senior author applied a logical, empirical analysis to suicide notes (see Leenaars, 1988). Theoretical analysis is conceptual; it looks at suppositions or a system of themes to explore the notes; for example, such concepts as pain, depression, and escape (Leenaars, 1988). (This is what our questioner is asking.) This is different from purely descriptive or content, that for example, counts how often the word ‘love’ appears, or classifications, that for example, examine whether men or women write more notes. Theoretical analysis provides us with meaningful conceptualizations regarding suicide, not necessarily the universal, but the most common or general. Suicide is, in fact, multi-determined and a theoretical-conceptual analysis allows us to empirically sort out the complexity (Shneidman, 1985). It answers our question. The theories of Freud, Beck, Shneidman, and other theorists offer an understanding of suicidal people and the suicidal person. Like Einstein in physics, these theorists answer our questions.

From decades of studies, an integrated multidimensional theory of suicide was proposed, consisting psychologically of intrapsychic (existing or taking place within the mind or psyche) and interpersonal clusters or themes. The intrapsychic clusters include unbearable psychological pain, cognitive constriction, indirect expressions (e.g., ambivalence, unconscious processes), inability to adjust (or psychopathology), and (vulnerable) ego. The interpersonal clusters include disturbed interpersonal relations, rejection-aggression, and identification-egression (or escape) (see Leenaars, 2004 for details).

Independent research on suicide notes (O’Connor, Sheeby, & O’Connor, 1999), investigation of suicidal Internet writing (Barak & Miran, 2005), and biographical studies of suicides (Lester, 1994) have supported the utility of the approach to note or any narrative analysis. Independent studies of inter-judge reliability (for example, O’Connor, Sheeby, & O’Conner, 1999) and over three decades of study by the senior author and colleagues show that, indeed, the percentage of inter-judge agreement has been satisfactory (> 85%). Reliability and validity have also been established in different countries: Australia, Canada, Germany, Hungary, India, Lithuania, Mexico, Russia, Turkey, United Kingdom, and United States. This is the most extensive cross-cultural evidence-based theory, and has direct implications for our question.

To answer the question why people kill themselves, suicide can be understood by the questioner from at least the following evidence-based commonalities or patterns.

Intrapsychic

1. Unbearable Psychological Pain

The common stimulus in suicide is unbearable psychological pain (Menninger, 1938; Shneidman, 1985, 1993). The suicidal person is in a heightened state of perturbation, an intense mental anguish. The person may feel any number of emotions such as boxed in, rejected, deprived, forlorn, distressed, and especially hopeless and helpless. The suicide, as Murray (1967) noted, is functional because it abolishes the painful tension for the individual. It provides a solution.

2. Cognitive Constriction 

The common cognitive state in suicide is mental constriction (Shneidman, 1985), i.e., rigidity in thinking, narrowing of focus, tunnel vision, concreteness, etc. The person is figuratively "intoxicated" or "drugged" by the constriction; the intoxication can be seen in emotions, beliefs, logic, and perception. This constriction is one of the most dangerous aspects of the suicidal mind.

3. Indirect Expressions 

Ambivalence, complications, redirected aggression, unconscious implications, and related indirect expressions (or phenomena) are often evident in suicide. The suicidal person is ambivalent. Not only is the ambivalence between love and hate but it may also be a conflict between survival and unbearable pain. Yet, there is much more. What the person is conscious of is only a fragment of the suicidal mind (Freud, 1917a/1974, 1917b/1974). 

4. Inability to Adjust (Psychopathology) 

People with all types of pains, problems, etc., are at risk for suicide. Psychological autopsy studies, consistent with studies of suicide notes (Leenaars, 1988), suggest that 40 to 90% of people (quite a range!) who kill themselves have some symptoms of psychopathology and/or problems in adjustment (Hawton & van Heeringen, 2000). Although the majority of suicides may fit best into mood spectrum classifications, (e.g., depressive disorders, bipolar/manic-depressive disorders), other emotional/mental disturbances have been identified (e.g., anxiety disorders, schizophrenic disorders [especially paranoid type], panic disorders, borderline personality disorders, and antisocial disorders [Sullivan, 1962, 1964; Leenaars, 1988]). Suicidal people see themselves as unable to adjust. They have the belief that they are too weak to overcome difficulties, and reject everything except death. 

5. Ego (Vulnerable Ego) 

The ego with its enormous complexity (Murray, 1938) is an essential factor in the suicidal scenario. The Oxford English Dictionary (OED) defines ego as "the part of the mind that reacts to reality and has a sense of individuality." Ego strength is a protective factor against suicide. Suicidal people frequently exhibit a relative weakness in their capacity to develop constructive tendencies and have likely been weakened by a steady toll of traumatic life events (e.g., loss, abuse) (Zilboorg, 1936). A vulnerable ego, thus, correlates positively with suicide risk. 

Interpersonal

6. Interpersonal Relations

The suicidal person has problems in establishing or maintaining relationships (object relations). There are frequently disturbed, unbearable interpersonal situations. The person's psychological needs are frustrated (Murray, 1938). Suicide appears to be related to an unsatisfied or frustrated attachment need, although other needs, often more intrapsychic, may be equally evident, e.g., achievement, autonomy, dominance, honor. 

7. Rejection-Aggression

Wilhelm Stekel first documented the rejection-aggression hypothesis in the famous 1910 meeting of the Psychoanalytic Society in Freud's home in Vienna (Friedman, 1910/1967). Loss and/or rejection are central to suicide; it is, in fact, often an unbearable narcissistic injury. This injury/traumatic event leads to pain and in some, self-directed aggression, and hate directed towards others (Shneidman & Farberow, 1957). Aggression is, in fact, a common emotional state in suicide.

8. Identification-Egression

Freud (1917a/1974, 1920/1974, 1921/1974) hypothesized that intense identification with a lost or rejecting person or, as Zilboorg (1936) showed, with any lost ideal (e.g., health, youth, employment, freedom) is crucial in understanding the suicidal person. Identification is defined as an attachment (bond), based upon an important emotional tie with another person (object) (Freud, 1920/1974) or any ideal. If this emotional need is not met, the suicidal person experiences a deep pain (discomfort). There is an intense desperation and the person wants to egress. Suicide is escape.

In concluding, the theory outlined may be useful to not only meet the survivor’s challenge on the question, “What does the suicide note mean?”, it tells us what we have learned from suicide notes. Yet, a further question is implied by our asker; she lives in the United States, and it can be asked, if the answer would be the same in India or Canada?

Does It Mean the Same That My Loved One Left No Note In The U.S. or Canada?

International studies are not only rare in the study of suicide notes, but suicide in general. There are only a few studies, for example, on suicide notes from different countries. Leenaars (1992) examined fifty-six suicide notes from Canada and the United States, whose writers were matched for age and sex (this was the first cross-cultural study of suicide notes). None of the intrapsychic or interpersonal aspects differed. Subsequently, studies from Germany (Leenaars, Lester, Wenckstern & Heim, 1994), United Kingdom (O’Connor & Leenaars, 2004), Hungary (Leenaars, Fekete, Wenckstern, & Osvath, 1998), Russia (Leenaars, Lester, Lopatin, Schustov, & Wenckstern, 2002), Australia (Leenaars, Haines, Wenckstern, Williams, & Lester, 2003), India (Leenaars, Girdhar, Dogra, et al., 2010), Mexico (Chavez, Leenaars, Chavez-de Sanchez, & Leenaars, 2009), and Turkey (Leenaars, Sayin, Candansayar, et al., 2010), supported this observation. Suicide notes are generally the same around the world, at least from our theoretical point of view. A few differences, however, were observed in some people: some people in collective cultural/social groups, such as India and Turkey, showed more indirect expressions, such as unconscious processes, redirected aggression, and dissembling (masking), than people from more individualistic cultural groups, such as the U.S. There are differences by age; younger people show more psychopathology. However, this is beyond space here to discuss. Yet, our main point: the theory has been empirically applicable to all people. Like our questioner, we all want to know the answer to the question. What does the person’s note say?

What Does It Mean That My Loved One Wrote a Note?

What does it mean that my loved one wrote a note? Erwin Stengel (1964), another great giant in the field, probably gave the best answer to our first question: “Whether the writers of suicide notes differ in their attitudes from those who leave no notes behind it is impossible to say. Possibly, they differ from the majority only in being good correspondents.  At any rate, the results of the analysis of suicide notes are in keeping with the observation.... common to most suicidal acts” (pp. 44-45). 

But let us leave “research” aside, and think about this question clinically. There are several ways that the person dying by suicide can express anger toward significant others– such as directly in the suicide note or by the circumstances of the act (which often traumatizes the survivors). So not writing a note is not a hostile act.

It may be that the individual is turned inward and concerned with himself or herself. Consideration for others is less relevant to them because they are so preoccupied with their own mental state and the decision that they are making. Perhaps in their anguish, they are unable to be considerate to others who might find a suicide note that explained the act comforting in some way– emotionally or intellectually. Pain, physical and mental, makes many of us focus inwardly and withdraw from others.

On the other hand, the content of a suicide note may be distressing to survivors. It may express anger and blame toward survivors. It may make survivors feel guilty for not responding better to the deceased. Many suicide notes do express love for the survivors and explain in reasonable way why they are making the decision, and these notes can be a comfort to the survivors. But such comfort cannot be guaranteed.

Some of you may know of Katie’s Diary, a book Lester (2004) edited with contributions from colleagues, analyzing the diary of a young woman who took her own life. Lester’s colleagues read Katie’s diary which extended over the last year of her life. You would think that they would be able to “understand” why Katie made that decision. But if you read the moving chapter by Silvia Canetto, a letter to Katie, you will see that even this diary of several hundred pages still left Silvia asking the question “Why?” A brief suicide note may, therefore, provide even less understanding.

A Final Story

Towards the end of Edwin Shneidman’s life, he believed that suicide notes were one golden source to the suicidal mind. We agree. Ed argued that not only is suicide multi-determined, the methods needed to understand the event needed to be equally diverse. Suicide notes are one royal road to understanding why people kill themselves. They are always bountiful for the reader; yet, the answer to the question posed is, “No, it does not mean a lot if there is no note." However, it is a golden source for that survivor of the death, but that is equally true for letters, emails, diaries, and other documents. Like any other personal document, the suicide note has a great deal of meaning if it is put within the context of the details of that person’s life. Yes, it is meaningful if your loved one leaves a note

Suggested Readings

Leenaars, A. (1988). Suicide Notes. New York: Human Sciences Press.

Leenaars, A. (2004). Psychotherapy with Suicidal People. New York: John Wiley & Sons.

Lester, D. (Ed.) (2004). Katie’s diary. New York: Brunner-Routledge.

Shneidman, E. & Farberow, N. (Eds.) (1957). Clues to Suicide. New York: McGraw-Hill.

Wilkinson, A. (Feb., 15, 1999). Notes left behind. The New Yorker, 44-49.

Comments

03/23/2013 at 10:41 PM
debbie procter
I have found this piece of writing most helpful and informative - and I will share the relevant parts with the family who lost someone very special - my connection was that the victim was my friend and we were very close for about 8 months in which time he helped me with a lot of things I needed to do. But I saw him deteriorate and I knew that there was nothing I could do - May he be resting in Peace. Thank you for posting this research Debbie
03/17/2013 at 10:14 PM
Michael
To Gord Mathison: I know this is a bit late, but I have only recently started to browse the net to find others who feel as I do. I have to say that the points you raised are similar to my own, and then I have many more reasons to die to add to this list. I wish we could talk because I am being persuaded by my lack of options that suicide is my only way.
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