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Chapter One
Introduction
Rationale
Violent deaths (suicides, homicides, and accidents) are the leading cause of death of people aged 1-39 in the United States. More lives are lost to violent deaths during the first half of the normal life span than to heart disease, cancer, diabetes, or any other cause. In addition, violent deaths are the leading cause of expected life lost in this country. Overall, for all ages, violent deaths are the third leading cause of death, behind cardiovascular disease and cancer, respectively (Holinger, 1980). It is no exaggeration to suggest that this violent death aggregate represents a serious social and public health problem in the United States. The purpose of this book is to examine three aspects of this problem: the epidemiology of violent deaths; the self-destructive quality of violent deaths; and the potential for the prediction of violent deaths.
Scientists have long been interested in self-destructive tendencies among human beings. Most studies of self-destructiveness, however, have tended to concentrate only on suicide, that is, overt self-destructiveness (exceptions to this include Menninger, 1938; Farberow, 1979; Wolfgang, 1959; and clinical data and research on accidents; see Chapter 2). The organizing principle of this book involves a curiosity about the nature and degree of self-destructiveness among human beings, and particularly the role such self-destructiveness may play in suicides, homicides, and accidental deaths in populations. An attempt will be made to show that the patterns of violent deaths in populations are not random, but rather have understandable patterns; and that while the behavior of an individual may be unpredictable, the violent death patterns for populations may be predictable. Essentially, three issues are presented in this book: (1) the epidemiology (distribution and frequency) of violent deaths (suicides, homicides, and accidents); (2) the extent to which all forms of violent deaths reflect self-destructive tendencies; and (3) the prediction of violent death patterns for populations.
A variety of questions will be addressed by examining these three major issues:
1. What are the epidemiologic patterns of violent deaths in the United States? What are the age, race, and sex patterns for suicides, homicides, accidents (total), motor-vehicle accidents, and non-motor-vehicle accidents? How are the patterns for suicide, homicide, and accidents similar and how are they dissimilar?
2. How do epidemiologic patterns of suicide (overt self-destructiveness) relate to patterns for homicides and accidents? What are the epidemiologic trends for violent deaths when studied in aggregate?
3. What variables seem to correlate most closely with violent death patterns? Is there any way to predict the suicide rates and other violent death rates for specific age groups in specific populations?
The term "violent deaths" has been used here as elsewhere (Weiss, 1976) to refer to suicides, homicides, and accidental deaths. There are at least two reasons for studying these forms of death in aggregate as violent deaths. Webster's (1977) defines the term "a violent death" as "caused by force: not natural." Thus, the first reason relates to the sense that these causes of mortality are often considered to be "unnatural" as compared with, say, cancer or heart disease: They do not involve the deterioration of the body's internal organs, but are imposed from without. Second, clinical evidence suggests that homicides and accidents, as well as suicides, may be self-inflicted: the victim to some degree provokes his or her own death by being in the wrong place at the wrong time. The idea of risk taking is relevant here, people who take more risks being in greater danger of dying by accident or homicide. It should be stressed that homicide data, that is, deaths by homicide, refer to those who are killed, not to those who kill. One study of several hundred homicides (Wolfgang, 1959, 1968) demonstrated that about 25% of all homicides were provoked by the victim, and Wolfgang termed these "victim-precipitated homicides." Certainly a perpetrator is necessary in homicides and in some accidents, but in this book the focus is on the victim. Suicide, homicide, and accidents, in this framework, are seen as related in that all may represent some expression of self-inflicted mortality, with suicide being the most overt, and homicide and accidents being more subtle manifestations of self-destructive tendencies and risk taking.
In order to clarify this notion of viewing violent deaths as reflecting self-destructive tendencies, it is necessary to discuss briefly perception and consciousness. How is it that homicides and accidents, as well as suicides, can be conceived of as self-inflicted and self-destructive? It is most important to view the brain as an extremely powerful perceptual organ, the task of which is to perceive and organize stimuli. There is an increasing amount of evidence to suggest that the brain perceives far more than scientists initially thought it did. For instance, studies of so-called subliminal stimulation (stimuli whose registration is outside conscious awareness), negative hallucinations, and tachistoscopic data demonstrate the massive amount of stimuli that the brain does receive and process (Klein, 1959; Basch, 1975). Basch (1975) has noted that most current evidence suggests that all perception is unconscious, that is, outside conscious awareness. Then the important issue for study is why and under what conditions various unconsciously perceived stimuli are permitted to reach consciousness. For example, suppose a person trips over a crack in the sidewalk. Given the brain's enormous perceptual capacity, there can be little doubt that the crack in the sidewalk was perceived on some level. But the question arises: Why was this perceived information not permitted into consciousness to prevent the person from tripping? Similarly, suppose someone is making a sandwich in a familiar kitchen and bumps his head on the overhanging cabinets. Again, clearly the brain has perceived the cabinets and their distance from one's head. Yet such information is not permitted into conscious or preconscious awareness in order to stop the accident from occurring. One has only to consider the brain's magnificent capacity for evaluating and organizing stimuli such as distance and speed (e.g., all the perceptual elements that go into a baseball player's catching a difficult fly ball or hitting a difficult pitch) to appreciate the nature of the block or distortion of the information flow to consciousness. Freud, although using a somewhat different perspective, dealt with this problem of accidents being psychologically determined as early as 1901 (Freud, 1901).
How, then, does this issue of perception by the brain and admission of such perceptions into consciousness help toward an understanding of the nature of homicides and accidental deaths, as well as suicides? Several clinical vignettes will be presented to bring the above discussion on perception back into the realm of violent deaths.
Clinical Vignette: Homicide
A 27-year-old woman in the midst of severe marital problems began going to bars in an area of the city known for its high crime rate. Despite being beaten up one night in that neighborhood, and against the urgings of her parents and husband, she continued her evenings in that area. One morning she was found murdered in that neighborhood. Witnesses said she had become rather obnoxious and provocative with two men the night before who were then seen following her out of the bar.
Clinical Vignette: Accident
A 31-year-old woman whose business was not going well was driving home from a business meeting and got on to a two-lane highway which she thought was part of an expressway with all lanes going her way. The car she was behind, as well as a semitrailer up ahead in the lane next to her, both appeared to be moving in the same direction as she was. She pulled out to pass the slower-moving car ahead of her. As she was passing the car, she looked over and saw a horrified look on the driver's face. "This was the first time I realized that things were not quite right," she said. She looked ahead and then realized that the semi-trailer was coming toward her. She was hit by the truck, the car sheared in half, but she was not seriously hurt. However, the truck tipped over, failing on another car and killing the driver. About 4 years later, the same woman, now an insurance agent in the midst of a distressing divorce, was driving to an appointment when she ran a red light and hit one of the many cars which had begun to pull out into the intersection. She said she was sure the light had been green or that there had been no light. All witnesses said she ran a clearly visible red light. She later said she had not been wearing her contact lenses, a particularly risky omission, she admitted, given the amount of driving she does for her work. After dealing with the police and other driver, she canceled her appointment and began driving home (having put in her contact lenses). On the way home, driving on a two-lane highway with traffic moving in both directions, she moved out to pass a car ahead of her. She passed, but had not given herself enough time to get back into her lane before the oncoming cars reached her. The oncoming cars were forced to swerve onto the shoulder to avoid hitting her, and she was able to get back into her own lane without having another accident.
Clinical Vignette: Accident
A 30-year-old man who had been in analysis for several years and was becoming increasingly aware of his rage toward his mother went out jogging following an argument with her. Quite unusually, he slipped on some ice, hitting his head and causing a concussion. Later that evening he and his mother reconciled their differences primarily through the mother's attentiveness to the patient's injury. The next day the patient continued to be aware of his chronic rage at his mother and was increasingly anxious driving to work inasmuch as he felt certain he was going to be unable to control his car and would have an accident.
Clinical Vignette: Accident
The patient, a 36-year-old woman, became increasingly excited and over-stimulated as she and the man she was dating became closer to each other and, in short, more and more loving. She began feeling so excited that she could scarcely contain herself, describing the feeling as "too much of a good thing." Finally, the tension of her over-stimulation became intolerable, and one night she started drinking, sexually teased her male friend, and got into an argument with him which ended in door slamming; shortly thereafter she cut her legs severely while shaving.
In these vignettes, serious perceptual blocks or distortions led to death or severe injury. In the homicide case, the young woman did not allow herself conscious awareness (or, if she did have such awareness, chose not to act on it) of the realistic dangers of the neighborhood she was in or of the verbal warnings emphasizing the dangerousness of her actions. In the first accident vignette, the woman twice made severe perceptual distortions (seeing the semi-trailer as moving away rather than toward her and seeing a green rather than a red light), as well as engaging in serious risk taking in the second accident by not wearing her contact lenses which were necessary for accurate eyesight while driving. These vignettes also raise two other issues that are, for the most part, beyond the scope of this book, namely, the motivations and mechanisms that lie behind perceptual blocks and distortions and account for so many violent deaths; and the complex theoretical formulations used to explain perceptual blocks and distortions (such as repression, disavowal, splitting of the ego, and so on).
Purpose
The purpose of this book, then, is to address systematically the essential questions raised above. This work represents an attempt to look carefully at the data in an important area, that is, violence and violent deaths, which is often dominated by opinions rather than data. Furthermore, it is hoped that this endeavor will demonstrate that these data are comprehensible, that some sense can be made out of violent death patterns in populations.
This book focuses intentionally on the self-destructive perspective in examining suicides, homicides, and accidents. This is not to deny the importance of aggression or the existence of a perpetrator in homicides and some accidents; neither does it excuse the perpetrator of a homicide from responsibility. The decision to examine carefully the self-destructive perspective (e.g., the victim, risk-taking behavior) is merely a conscious choice to see if anything new can be learned or understood about violent deaths using such a microscopic focus. It appears that human beings generally tend to repress or disavow their self-destructive thoughts and impulses (e.g., consider society's abhorrence of suicide, even considering it a crime in some locations) and that the self-destructive perspective has not been adequately addressed by scientists. A second focus of the book is on the epidemiology of self-destructiveness rather than the intra-psychic motivation behind such a tendency. In other words, in this presentation the epidemiologic patterns are of most concern; the intra-psychic forces underlying such patterns (e.g., masochism, narcissism and grandiosity, perceptual distortions, issues in group psychology, etc.) will be the subject of future communications. Finally, the present work focuses on populations rather than individuals. The particular concern is on violent deaths in the United States, divided into categories of age, race, and sex. Intra-psychic, clinical data on violent deaths and self-destructiveness in individuals will be addressed insofar as they can aid in conceptualizing an understanding of violent death patterns in populations.
However, two large steps in the study of violent deaths may not yet be entirely possible; namely, a comprehensive theoretical understanding of the intra-psychic mechanisms underlying such ubiquitous self-destructiveness; and the understanding of self-destructiveness on a population, rather than an individual, level: Is there a qualitative difference in the patterns of violent deaths when one examines groups and larger populations as opposed to individuals? The first question must be answered primarily in the realm of psychoanalysis and clinical work with individuals. The second question involves the fields of sociology, psychiatric epidemiology, psychoanalysis, and clinical psychiatry. Most likely our under- standing of violent deaths in populations will arise from a hybrid of or communication among those disciplines. Gedo and Goldberg (1973) have cogently warned against inappropriately using metapsychological models derived from psychoanalytic data to explain phenomena in social psychology. However, adequate models do not yet exist for understanding violent deaths on population levels. This book attempts a small step in the direction of providing such conceptualizations.
The book is divided into five sections. Section I (Chapters 1-3) describes the rationale for and methodology of the study as well as providing a literature review. Section 11 (Chapters 4-8) is a straightforward presentation of the epidemiology of the suicide, homicide, and accidental death patterns in the United States, 1900- 1980. Section III (Chapters 9 and 10) utilizes the epidemiologic data to address the question of whether violent deaths reflect self- destructive tendencies. Section IV (Chapters I I and 12) examines specific variables that may aid in predicting violent death patterns. Section V (Chapter 13) summarizes the epidemiologic findings and examines the explanatory power of the self-destructive perspective. Readers interested primarily in the rationale and summary of the study would do best to look at Chapters I and 13. Those involved in epidemiology and interested in the more detailed descriptions of the violent death patterns of the United States, 1900-1980, could focus on Sections 11 and 111. Finally, those whose interest lies primarily in prediction and effective intervention may find Section IV of particular value.
Footnotes have been omitted. |
Violent Deaths in the United States: An Epidemiologic Study of Suicide, Homicide, and Accidents
