IMR Press / JOMH / Volume 17 / Issue 4 / DOI: 10.31083/jomh.2021.098
Open Access Editorial
Understanding the phenomenon of suicide
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1 Department of Military Medicine, Faculty of Medicine, the Hebrew University of Jerusalem, 9190401 Jerusalem, Israel
J. Mens. Health 2021 , 17(4), 1–3; https://doi.org/10.31083/jomh.2021.098
Submitted: 22 February 2021 | Accepted: 1 March 2021 | Published: 30 September 2021
Copyright: © 2021 The Author(s). Published by IMR Press.
This is an open access article under the CC BY 4.0 license (https://creativecommons.org/licenses/by/4.0/).
Abstract

Background and objective: Suicidality and suicidal behavior have long been studied extensively, as they are considered the main cause of premature death throughout the world. Death by suicide seems to have always been part of human behavior. The earliest known report of a suicide was written 4000 years ago on papyrus. Still, despite the rich literature on the topic, prevention or prediction of suicide are still hard and sometimes impossible. To date, there is still no theoretical model that encompasses all possibilities of the phenomenon.

Material and methods: This study aim was to present studies of Professor Israel Orbach who was one of the pioneers in the research of suicide and a leading theoretician in the field of suicide.

Results: Studies point to numerous variables involved in suicidal behavior and in the suicidal act that the interaction between those variables promotes a destructive process that leads the individual to act in a self-harming manner. The research of mental pain and the inability to moderate it are the main contributions to the field of suicide, alongside with dissociation process which by its presence, increases the probability of suicidal behavior.

Conclusion: Numerous theories and models attempt to describe the process leading to the act of suicide, but the unknown is still larger. The fact that in most cultures suicide and suicidal behavior are still considered taboo, something to hide and be ashamed of, is a tragedy for the suicidal individual as well as his or her family, and other close people, as it impedes identification, treatment and prevention. It may be even more of a tragedy and harder to comprehend and accept, when the suicidal person is an otherwise healthy adolescent who has his whole life ahead of him or her. Therefore, any bit of new information and knowledge added to the field of suicidality is another layer in the understanding of the process, mechanism and dynamics of this subject and contributes to the improvement of prevention, treatment, and to assistance to those in distress and maybe help in stopping suicide from becoming a pandemic.

Keywords
Mental pain
Suicidal behavior
Suicide
Dissociation process
Israel Orbach

I would like to dedicate this special issue to the memory of Professor Israel Orbach from Bar-Ilan University, whom we lost in 2010. It has been my great privilege to have as my supervisor this great, world-renown researcher. He was a pioneer in the research of suicide and a leading theoretician in this field.

Throughout his professional life, Prof. Orbach managed to combine quantitative research and theoretical development of ideas, related to suicidal behaviors. According to him, the suicidal act is a combination of distal and proximal factors, of unbearable mental pain, inability to relieve that pain, and reaching a mental and physical state that makes it possible to act out the suicidal thoughts.

In one of his earliest studies [1], Prof. Orbach based his ideas on Shneidman’s theory of “psychache” and described the unbearable mental pain that may lead to suicide as being much more than the sum of negative feelings [2]. He defined mental pain as a trait characteristic linked to self-perception, similar to very dark mood and emotional suffering but much more, which under some circumstances, may lead an individual to view the only solution as being self-destruction [3]. The concept of self-destructive processes was a late development in Prof. Orbach theorizing and was based on the thought that the goal of suicide is to resolve highly distressing dilemma, by ceasing to exist - the existence of the self [4]. He further argued that the fear involved in this situation is that the currently highly distressing situation may even worsen in the future. The dominant emotion in such cases is helplessness and hopelessness accompanied by an attitude of ambivalence towards life. The logic accompanying the described state is dichotomous, black or white, and contains erroneous concepts of the world [1]. The aim of such self-destructive processes is to get a message across to other people and then disappear. Here the conflict is between separation or being engulfed by a significant other to the point of losing oneself, while the accompanying fear is abandonment and a fear of death and the accompanying emotions include loss, rejection, and estrangement. In his paper Orbach et al. [5], he defines four dimensions that constitute the basic attitude towards life and death. Those include attraction to life, repulsion by life, attraction to death and repulsion by death [5]. Thus, the attraction to life of people with suicidal tendencies is lower, while their repulsion by it is higher and they feel the opposite emotions regarding death [6].

Prof. Orbach asserted that the intensity of mental pain varies and can be measured. In cooperation with colleagues, he established the Orbach & Mikulincer Mental Pain Scale (OMMP), an assessment tool for the intensity of emotional to understand the contributing of mental pain to the suicidal process [7]. Yet, mental pain alone does not lead to suicidal behavior [8]. Only when the individual is unable and lacks the means to lessen the pain may he or she try to escape the pain through suicidal behavior [9]. This clinical understanding, prompted Prof. Orbach and his colleagues to create a second questionnaire aimed at assessing the regulation of mental pain [9]. This followed the understanding that not everyone who is considered at risk for suicide actually turns to suicidal behavior [10].

In his article named “Terror suicide: How is it possible?” he attempted to find an answer to the question of what causes people to commit a suicidal terror act and how this differs from other suicidal behaviors [11].

Next Prof. Orbach focused on the connection between physical and mental pain as contributing to the suicidal process. Already in the mid-nineties he discussed the association between tolerance for physical pain and suicidality [12,13]. However, the Body- Mind theory of the suicidal person and the suicidal scheme crystallized in later years [10,14].

One of the concepts that is identified with professor Orbach is that of physical dissociation. Dissociation manifests itself as, among others, avoidance of physical pain and indifference towards one’s self and one’s body. In stressful situations, such imperviousness to feelings may facilitate suicidal behavior [12]. Ultimately, physical dissociation, used repetitively as an escape mechanism from painful feelings, may become ineffective when needed during a stressful situation. Thus, the result may be a state of emotional severance and indifference as the customary coping mechanism for stressful situations [10].

As mentioned earlier, Prof. Orbach supervised my doctoral dissertation, which combined the concept of the above-described dissociation with the habituation component of Joiner’s interpersonal theory [15]. Habituation, currently the most prominent theory explaining the suicidal process, refers to a mental process that facilitates acquiring the capability for suicidal behavior. It results from repeated exposure to physically painful or fear-inducing experiences such as violence [15]. The two concepts of dissociation and habituation seem to complement each other. The mental pain and inability to moderate it is complemented by physical pain that results in the acquired ability to habituate to it. It should be noted, though, that dissociation and habituation do not in themselves, constitute reasons for suicide. Their mere presence does not cause a person to commit or attempt suicide. Their presence, however, increases the probability for suicidal behavior and thus, investigating them and gaining a better understanding of this mechanism is highly important to the understanding of the suicidal process as a whole and to its prevention. In this study we used a third clinical tool created by Orbach and his colleagues namely, evaluating whether solving a problem is perceived by a person as a threat or a challenge [16].

The concepts of dissociation and habituation in the context of suicidal behavior form the basis of many studies, and constitute a commonly used model to explain the suicidal mechanism in military soldiers who had been exposed to distressing combat situation [17-20].

Another great contribution by Prof. Orbach to the clinical field, maybe his greatest, is the idea of a therapist feeling empathy for the wish of death. According to him, therapy of a suicidal person is a voyage of experience and learning for both therapist and patient. Only a therapist who is able to feel empathy for the patient’s wish to die, yet is able to confront the self-destructiveness uncompromisingly, can travel with the patient into the darkest, most painful corners of the mind and help the patient rise from there to a place of hope for a new internal organization and learning of better strategies to cope with life’s obstacles [21].

Research constitutes of layers of knowledge built one on top of another, drawing on the previous ones and adding to them. Every new study adds another unique piece of knowledge and understanding to the subject at hand. This is especially true for a highly complex subject like suicidality - a phenomenon that seems to contradict human behavior and human nature; yet has been an integral part of it since ancient times. I cannot promise that you will find all the answers, or even some, in this special issue on suicide. But if the articles in this issue raise new questions or prompt you to go searching for novel approaches and new points of view on suicidal behavior, I feel I’ve succeeded.

Acknowledgment

Not applicable.

Funding

This research received no external funding.

Conflict of interest

The author declares no conflict of interest.

References
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