the columns The suicide bomber -- is it a psychiatric phenomenon?

Sir: Harvey Gordon's paper ( Psychiatric Bulletin , August 2002, 26 , 285-287) was refreshing on a worrying topic. I enjoyed the wide academic references to drive home an unemotional and rational argument. I was reassured by the conclusion that there was no need to apply a psychiatric analysis to

The 'suicide' bomber: is it a psychiatric phenomenon?
Although there is an association between suicide and suicidal behaviour and homicide and violence to others (van Praag, 2000), few, if any, major texts on suicide comment on the phenomenon of the 'suicide' bomber.However, the events in the USA of what Americans have now come to call '9/11', have left an enduring traumatic memory throughout the world.On the morning of 11 September 2001 four aeroplanes were hijacked and transformed from a means of mass transportation to a means of terror and destruction, killing a total of 233 passengers, 33 crew members and some 3000 people on the ground in the USA (Alexander & Swetnam, 2001).It is not clear whether all of the hijackers knew that they were on a 'suicide' mission because in only six cases were 'suicide' notes found (Jenkins, 2001).Indeed, the term 'suicide bombers' may be misleading because the main objective seems to have been not suicide but mass homicide, albeit carried out by means of self-destruction designed to inflict lethal harm on others.Those who planned and perpetrated the acts of 11 September 2001 would not conceptualise the acts as suicide but instead would perceive them as martyrdom, rationally underpinned by a legitimate struggle in a conflict of national and religious dimensions (Juergensmeyer, 2001).
Conventional teaching on suicide indicates that the vast majority of those who deliberately kill themselves are suffering at the time from some form of mental disorder, mostly depressive illness, schizophrenia, substance misuse or, in some cases, personality disorder or adjustment reactions (Hawton & van Heeringen, 2000).However, the presence of mental disorder in itself is not a sufficient basis for suicide, and some who kill themselves may not be mentally disordered at all (Fairbairn, 1995).Is the absence of commentary regarding 'martyrs' in psychiatric discourse a reflection of the fact that such behaviour is, in reality, unrelated to mental disorder, or is it an oversight that psychiatrists could study and develop further understanding of?
In the absence of any universally agreed definition of the term 'terrorism', one person's terrorist may be another's freedom fighter.According to some authors on the history of terrorism, suicide or self-sacrifice associated with terrorist violence is not a new phenomenon (Laqueur, 2001).In the 19th century, for example, owing to the limitations of firearms and knives, terrorists involved in such operations were usually caught and killed, or subsequently executed, such that they were virtually 'suicide' missions.Terrorists in some cases have committed suicide rather than being apprehended or tried.Such is said to have been the case with members of the Baader Meinhof gang in West Germany in the 1970s, although the death through hunger strike by Bobby Sands and other members of the IRA in the 1980s was also a reflection of what their supporters perceived as martyrdom (Lacqueur, 2001).
Simultaneous or contiguous 'suicide' and homicide has occurred in a military context, for example in the Second World War by Japanese kamikaze pilots who sacrificed their lives in the name of national honour (Littlewood, 1996).It is notable that in the Japanese context this only occurred towards the end of the war when Japan was losing, with the development of impending national dishonour and humiliation.As such, it could be postulated that by that time the Japanese collectively were subject to a developing mood of shame and despair.
More recently, over the past two decades, 'suicide' bombing incidents have been a component of conflict in the Middle East.Such incidents are not confined to the Middle East, but it is there that most media publicity has focused.There have been as many, if not more, such incidents related to the struggle by the Tamil Tigers against the Sinhalese in Sri Lanka and southern India, which remains one of the most underreported conflicts in the world (Laqueur, 2001).In the case of the Tamil Tigers, though of Hindu origin, their motives, though nationalistic, have not been essentially religious.Occasional use of 'suicide' bombing has also been part of Sikh nationalism in India and of Kurdish nationalism in Turkey.
Suicide is contrary to Islamic law (Chaleby, 1996); its frequency in Muslim societies is low (Racy, 1977), including in the Palestinian population (El-Sarraj, 1991).Espoused politically by the more fundamentalist wings of Islam, there is, however, no Islamic religious consensus that such acts of 'suicide' bombing are permitted (Cockburn, 1996).Clearly the prohibition in Islamic law against suicide is, in such instances, being overridden or reinterpreted as another factor, namely that of martyrdom, for which there are historical precedents in the acts of the Assassins in the 11th and 12th centuries (Taylor, 1991), the objectives of whom were the attainment of Islamic unity.
In the more modern context, the appearance of 'suicide' bombing in the Middle East can be dated from October 1983 when the Hizbu'llah in Lebanon, an Islamic Shi'ite group, killed 241 US marines in a 'suicide' attack (Saad-Ghorayeb, 2002).The Hizbu'llah's authorisation to undertake such a strategy was based on the issuing of an edict from Iran, rendering it religiously permissible.Such religious acceptance seems to have been based on the notion that Muslims were being oppressed in their own land by the perceived satanic forces of the USA and Israel.Hizbu'llah's use of 'suicide' bombing seems to have been partly a strategy to inflict damage on their enemy and partly a moral and religious imperative based on it being honourable to die for God's cause in the face of oppression.
In the context of the Israeli ^Palestinian conflict, the use of 'suicide' bombing as a strategy seems only to have been employed from 1994 (Rubin, 1999), it being noted that this was after the establishment of the Palestinian National Authority.Primarily used by Hamas and Islamic Jihad, which are organisations of Islamic fundamentalism, 'suicide' bombing has been used more recently also by the more mainstream secular Islamic groups.
There may be some characteristics that outline the Palestinian 'suicide' bomber, although these are based more on journalistic rather than professional psychiatric inquiry (Nolan, 1996).In the period of about 2 years from April 1994 until March 1996 there were 13 'suicide' bomb attacks in Israel that killed 131 people.The perpetrator would be described as either a terrorist or as a martyr, according to the political stance of the observer.He would be a young man aged 19^25 years who came from a devout Muslim family.He would be unmarried and the middle child of a large family and hence not usually the main wage earner on whom the family were dependent financially.Many would have lived in refugee camps, especially in Gaza, and may have had a father or brother killed in the Intifada.He may well himself have been subject to physical punishment.The journalist felt that the common elements were a sense of hopelessness, being too poor to study and being unable to find work, coming from a family of refugees with a strong sense of Palestinian identity.Recruits by Hamas or Islamic Jihad would have been told that through martyrdom they would find riches, including virgins, in heaven.Prior to the 'suicide' bombing, a celebration would be arranged, which would be videotaped for subsequent display in a form resembling a religious ritual to sanctify the martyr before his community.In subsequent years certain Arab countries gave sizeable donations to compensate the family of the martyr.Often the martyr's family only learn of the act after it has occurred.During the period of 8 years since the establishment of the Palestinian National Authority, 'suicide' bombings have continued, albeit with periods when Islamic Jihad and Hamas were prevented or persuaded to refrain from such acts (Rubin, 1999).The act of 'suicide' bombing, although an act by an individual, is one that usually occurs in a social or collective context, subject to ultimate sanction by sections of the community to which the individual is affiliated.
A senior Arab psychiatrist in Gaza, Dr Eyad El-Sarraj, in an unpublished study quoted in a British newspaper (Silver, 2001) concluded that religion was a crucial, but not the only, reason for the phenomenon of martyrdom, the other components being a need to identify with a symbol of power and a thirst for revenge.Being unable to win the conflict against the Israelis, the martyrs feel desperate, identify with the defeated Arab nation and turn themselves into bombs.Perceiving their fathers as being unable to protect them, said El-Sarraj, they seek an alternative that they perceive as dying for God's cause.
The profile outlined by Nolan (1996) and commented on by El-Sarraj (Silver, 2001), although still generally accurate, has to some extent altered more recently.Most frequently the 'suicide' bomber is a young unmarried male, but occasionally there have been older married men (Silver, 2002) and a few unmarried young women, although in the case of the women it is less clear that they have been sanctioned by an Islamic organisation (Reeves, 2002).Women, however, are no strangers to involvement in terrorist activities but are rare in the Islamic context, wherein social attitudes towards the role of women remain more paternalistic, albeit subject to transition (Alyahya, 1995).One author on terrorism (Juergensmeyer, 2001) has suggested that the preponderance of young unmarried males as 'suicide' bombers in the Israeli ^Palestinian conflict may be ascribed to their limitation of sexual outlets arising from high unemployment, the 'suicide' bombing being the equivalent of a massive explosive orgasmic catharsis.Such a psychoanalytically based explanation is probably untestable and is likely to be offensive to Muslims, yet quite why the 'suicide' bomber is promised 70 virgins needs also to be explained (Juergensmeyer, 2001).Certainly the reattainment of a sense of power and integrity by such violent means, the knowledge of the pain inflicted on the enemy and the attainment of a sense of some form of selfactualisation and recognition within the community probably help to explain the behaviour of the 'suicide' bomber.
The profile of the perpetrators of the events of 11 September 2001 represents a further development of the characteristics of the 'suicide' bomber (Alexander & Swetnam, 2001).Of the 19 involved, all were of Arab or Muslim origin, all were male but generally somewhat older than their Palestinian counterparts and all were of a higher level of academic attainment.It seems, therefore, that the nature of those involved in 'suicide' bombing is liable to evolve according to circumstances, although with nationalist and, at times, religious motivation being the most central.
Although terrorism throughout human history has been tragic, until relatively recently it has been more of an irritant than any major hazard.However, the existence of weapons of mass destruction now renders terrorism a potential threat to the very existence of human life (Hoge & Rose, 2001).Such potential global destruction, or globicide as one might call it, supersedes even that of genocide in its lethality.Although religious factors are not the only determinant of 'suicide' bombers, the revival of religious fundamentalism towards the end of the 20th century renders the phenomenon a major global threat.Even though religion can be a force for good, it can equally be abused as a force for evil.Ultimately, the parallel traits in human nature of good and evil may perhaps be the most durable of all the characteristics of the human species.There is no need to apply a psychiatric analysis to the 'suicide' bomber because the phenomenon can be explained in political terms.Most participants in terrorism are not usually mentally disordered and their behaviour can be construed more in terms of group dynamics (Colvard, 2002).On the other hand, perhaps psychiatric terminology is as yet deficient in not having the depth to encompass the emotions and behaviour of groups of people whose levels of hate, low self-esteem, humiliation and alienation are such that it is felt that they can be remedied by the mass destruction of life, including their own.

Declaration of interest
H.G. is Visiting Lecturer in Forensic Psychiatry at Tel Aviv University and an honorary member of the Israel Society of Forensic Psychiatry.He has close links with Palestinian colleagues and has lectured in Gaza and on the West Bank and has arranged educational placements in forensic psychiatry in Britain for Palestinian health professionals.