Between Clock and Bed - Munch
Between Clock and Bed - Munch
| This chapter reviews the efforts to explain suicidal behavior.
The earliest models used sin, crime and irrationality as models to explain.
While these motivated prevention efforts and provided some deterrence,
they lacked scientific justification and were never sufficient. In the
last 100 years two models have been proposed and found support. These are
the sociological studies of the epidemiology of suicide rates in various
cultures and the Psycho dynamic efforts to explain individual motivations.
The two innovators were Durckheim and Freud respectively. The loss of hope
and the role of meanings assigned to death are recent developments that
are achieving consensus. Some recent ideas are also discussed.
In the long history of suicidal behavior, the universal efforts to explain the problem of suicide have focused on two ideas: depression and mental illness. Plutarch in 400 BC offered depression as the cause. Merrian (1763) and Esquirol (1837) both believed suicidal death was a product of mental illness. While almost all health professionals have accepted these two explanatory models, neither one accounts for the false positives or false negatives, i.e. those with depression or mental illness who do not kill themselves, and those without either, who die from self injuries. The majority of victims in the USA are not known to be mentally ill, depressed nor even receiving psychotherapy. |
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In the last 100 years, two additional models have gained some consensus. The first is the orderly qualities of suicidal rates with what are now called epidemiological or social variables (Morselli, 1879; Masaryk, 1881; Durckheim 1897). "Le Suicide" was not translated into English until 1951. In it, Durckheim proposed the integration theory of suicide which relates death rates to the individual's acceptance of the influence of social purposes such as country, church, family, other causes etc.
He postulated two variables, social integration and social regutation to explain who would be likely victims. The first refers to the degree of acceptance of shared social beliefs. Those individuals who believe are prone to altruistic suicide while those who do not are vulnerable to egoistic suicide. The second variable refers to the degree of social control imposed by society on the individual's motives and feelings. Those who accept a highly regulated society are vulnerable to fatalistic suicide, while those who reject become anomic suicides. The majority of the people are in the middle of both dimensions and are less likely to die in a suicidal mode.
Henry & Short (1954) applied Durckheim's dimensions and status integration of suicide by looking at business data and degree of social regulation.
"The strength of external restraints ... varies positively with the strength of the relational systems and inversely with position in the status hierarchy." When external restraints are weak, aggression will be directed against the self. Gibbs & Martin (1964) tried to build on Durckheim and extend the status integration theory. "The suicide rate of a population varies inversely with the stability and durability of social relations within that population." They were relatively successful in their goal and stimulated efforts to replicate their findings with mixed results.
Sociologists like Goffman (1961), Douglas (1967), and Garfinkel (1967 questioned the Martin and Gibbs findings on the basis of the variability of social meanings from group to group, or time to time. For example Goffman pointed out that the reactions to the stigmatized are themselves factors in xplaining suicide. Douglas noted that the socially integrated could successfully hide a suicidal death by having it called accidental. Garfinkel writes that the coroner decisions are often reflexive; based on common conceptions and meanings, and thus shared expectations, which achieve internal consistency rather than validity. Phillips (1974) data revives suggestibility as an explanatory factor, which Durckheim had rejected.
Farber (1968) used some principals that moved towards a general theory of suicide. His starting premise is that "psychologically damaged personalities confronted by deprivational situations are most likely to commit suicide." He goes on to identify and analyze components of each. On the personality side he notes the role of hope and its loss, followed by a sense of competence which may be damaged in vulnerable people. On the deprivational side he emphasizes the availability of succorance, demands for interpersonal giving, and tolerance for suicide by the folkways of the victim's subculture. Farber views personality factors as playing a dual role both as actors and as a social surround for other actors. An increase in vulnerable personality types would create a multiplier effect on the number of victims in any society.
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The second model that has gained some consensus is the orderly qualities of behavior manifested by patients in psychotherapy who exhibit suicidal behavior. This was most explicitly proposed by Freud (1920). He had previously postulated a repetition-compulsion as an instinct which sought a return to an earlier state. This was an effective model for analyzing transference phenomena from childhood to present authority figures, but was insufficient to explain self injury motives. Freud now extended this compulsive return to an earlier state as a death drive which is equated with meanings such as achieving equilibrium, balance, nirvana or nothingness. Freud's later theory allowed for an explanation of suicidal behavior.
Menninger (1938) advanced Freud's explanation by noting the transitions from a wish to kill to its denial into a wish to be killed, and its further denial into the wish to die. Zilboorg (1936,1938) extended the psychoanalytical explanation by adding unconscious hostility to the love object, breakdown of the victim's family, and the inability to love another. While together these ideas have dominated individual care, psychotherapy and the thinking of mental health clinicians, these too ail to identify the majority of victims and to deal with the problem of false negatives and false positives.
Gibbs and Martin (1964) critique of psychological approaches is relevant
here. They found it inadequate because
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Implicit in all efforts to explain the problem of suicide is the assumption that death means the same thing to each person contemplating suicide. Such a premise is not supported by the very nature of individual differences. While relatively neglected, the relevance of death meanings to suicide have been noted by Wahl (1957), Hendin (1964), Douglas (1967), and Choron (1987, original in 1968).
Wahl statement is "one cannot truly understand the deeper dynamics of suicide until he comprehends its relationship to death and the unconscious significance and meaning death has for us."
Hendin stated "the suicidal patient's attitudes towards death, dying and afterlife must be known in order to understand his motivations".
Douglas (1967) reviewed the array of all possible definitions available to him at the time, and goes on to critique these. His major conclusion points to the tendency for definitions to be at least partially determined by everyday meanings used by officials and physicians as well as the public. He also notes that suicidologists before him have failed to consider the value of their respective ad hoc definitions to the development of a theory with explanatory advantages. He recommends the strategy of working with observations, descriptions, definitions, measurements and theory with each molding the other.
Douglas attempts to give operational social meanings to suicide by first describing death. The universal qualities of death are a permanent transformation of the substantial self from time-bound, space-bound, worldly, everyday meanings to timeless, infinite, and other worldly meanings. Death has its own meanings regardless of which mode or cause of death is contemplated.
Douglas goes on to note the four most common social meanings of suicide:
Choron has called attention to conscious and unconsciously held meanings for death and their relation to suicide promoting or suicide inhibiting behaviors. In particular, he raises the question of uniquely held beliefs e.g. a guilt ridden person would find eternal punishment in hell seductive, whereas for most people it would serve as a suicide inhibition. Choron goes on to urge therapists to discredit suicide promoting notions about death.
There are at least two additional and contemporary observations about death which emphasize the relevance of its meanings and which influence the occurrence of suicidal events. The first is Percy Bridgeman's (1947) writing about the moment of death. He notes that it cannot be experienced. A person can enjoy health, suffer illness, endure treatment and the dying process. However, there can be no sensory recognition of death because all physical processes cease. Sensory inputs can not occur and their subsequent evaluation by an aware person is impossible. In Bridgman's Perspective there is no way that any person can wake up after termination and say "Aha! Now I am dead".
This stopping of awareness has been called cessation (Shneidman, 1981), and from a scientific viewpoint, represents the end of the individual's psychological behavior. Religious and metaphysical perspectives suggest continuation past the point of termination as in immortality of the soul or more secular after death experiences. There is a great range of possibilities for individual preference. Any belief system about degrees of continuation after termination can be chosen. Consequently there exists a great variety of meanings assignable to personal futures after death occurs.
A second relevant observation is the current medical care of the terminally ill. The objective moment of death is no longer definable by physicians given the availability of life support technology. These permit the physical processes to continue with or without psychological awareness. The options for the patient and survivors have increased and bring the mixed blessings of difficult decisions at the worst of all possible times in the family faced with anticipatory grief. These issues are discussed more fully in Coming To Terms with Death (Cutter,1974, 1978).
The inability to experience death and medical limitations on recognizing the moment of death, have changed the dying process from relative simplicity to greater complexity. Where people used to die suddenly, at home, from random causes, they now die slowly, in strange places like a hospital, and from terminal illnesses with the individual imposing personal life styles on the quality of dying.
Suicidal behavior has emerged in this context as a way of achieving death with dignity. The goal is related to age, meanings assigned by participants, and the perception of the illness. These events tend to occur in a relatively public context. Death with dignity will be reviewed more fully in the chapter on high risk subgroups and the section on cancer.
These phenomena have revived an old iconoclasm about the right to commit and its opposite, the professional's right to intervene. Additional tensions have emerged with threats of litigation to the parties involved. These contemporary concerns build upon, long standing taboos about all aspects of suicidal events. The public information media's continuing emphasis on violent modes of death caters too, while aggravating attitudes of everyone towards the behavior of victims. This latter has been called the pornography of death by Gorer (1965) and compared to the return of repressed sexual impulses by myself (Cutter, 1974 p:9-10; 1988 p:178).
In the above context, efforts to explain death are not well received, be they philosophic or scientific. Instead, efforts to profess or publish serious thoughts about suicide do not reach the public in an objective manner, and fail to achieve consensus among the initiates.
Menno Boldt ( Crisis 9(2) 93-105, Nov 1988) has recently written that current thinking in prediction is impeded by the failure to deal with the meaning of suicide in the culture of the victim. The current trend is to think of suicide in some absolute sense, usually based on the coroner's definition, which makes for an interesting commentary on the ideas of Douglas, described earlier.
Efforts to explain the problem of suicide must start with explicit notions about the role of death meanings and its influence on the choice of suicide, especially when death wishes are most likely to occur.
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Over the last fifteen years, some recent developments in the science of suicidology have occurred that offer better explanations of the `why.' These will be reviewed briefly in the balance of this chapter.
Hopelessness as measured by Beck et al (1974) has emerged as a powerful and lethal factor in the context of clinical depression. Petrie & Chamberlain (1983) report that it is the key variable in predicting suicidal intent as measured by the Zung scale. They could not replicate Lineham & Nielsen's (1981) social desirability findings, and reject it as an obscuring issue. Dyer and Kreitman (1984) conclude that depression and intent are dependent on hopelessness. Drake and Cotton (1986) were able to identify suicidal status more effectively by use of hopelessness data. Beck (1985) has reported that items dealing directly with pessimism such as sense of failure, self dislike, and suicidal ideation, are more powerful in identifying the depressed patients who are at greatest risk for suicidal death.
Kobler & Stotland (1964) have applied the concept of hope, and its loss, to the dramatic increase of suicides in hospitalized psychiatric patients at a mental hospital. They were able to relate deterioration of staff optimism associated with leadership conflicts deriving from benefactors and administrators to professional people and members of the treatment staff. The hospital experienced three commits in one month after eight years of operation. They attribute the suicidal behavior to perception of pessimism in staff members.
Hopelessness relates to the future. It also reflects an increased readiness to die (Cutter, 1974). Measures that reflect readiness to die are discussed in chapter five. Others have attempted to measure time orientation because of its observed association with suicidal behavior. These are Yuffit & Benzies (1982), and Ganbzler (1968). Future orientations can reflect the loss of hope and become a viable clinical measure of intention to seek self injury. Self assessed future probability of survival are associated with risk of suicidal death (Motto 1988).
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Bachelor (1980) provides some clarifying ideas about suicide. He starts with the general explanatory model of suicide as problem solving behavior oriented to an objective. In his phrase "in order to...". This is in contrast to "because". He illustrates with the example of a person opening an umbrella order to avoid getting wet, because of a dislike for wet clothes. Self injury behavior occurs in order to solve an immediate need because of some strongly held belief system.
The time perspective on these two ideas is relevant. 'In order' to objectives relate to future behavior. 'Because ' motives are based on past experiences. There may be a practical value to the therapist in assisting potential victims who shift time frames. The professional response should vary accordingly. Thus clients who talk about suicidal behavior (in order to ...) as methods of achieving some immediate need reduction versus the (because) basis of their belief systems require correspondingly different interventions. The former, or problem solving, can be addressed by the more cognitive behavior modifications methods, while the latter or belief systems can be altered through the more dynamic processes of anamnestic history taking. In between, are transference behavior managed by psycho dynamic models.
Maris (1981), a sociologist, attempted to approach suicide with an integration of sociological, psychological, and psychiatric methods as well as existing knowledge. He looked at key concepts. These are lethal contingencies (lethality of planning), negative interaction, early traumatic relationships, abortive life stage transitions, multi problem families of origin, sex deviance, social mobility, drug use and alcoholism, hopelessness, depression and meanings of death.
Maris used the model of suicidal careers because it is always relevant to a victim's reaction to crisis and because these tend to be ignored. He reports that contributing concepts are identifiable early and continue through the history of the individual. Maris also makes the case for more priority in efforts attempting to explain the white older male suicide in America because results will have more generalizability to the young, female or black victims.
He cautiously coordinates his findings with reviews of the literature in a chapter titled: "towards a theory of suicide" which does not lend itself to a quick restatement as needed in this context. He offers five major conclusions. Suicide is directly related to the level of ones hopelessness and depression. Suicide is inversely related to satisfaction. Hopelessness, depression, and dissatisfaction are directly related to use of lethal methods. Hopelessness is directly related to depression, repeated life failures, and prolonged negative interactions with social isolation. The preceding are directly related to early traumas and to multi problem families of origin. Maris's findings are a tour de force of suicidology in both replications, synthesis and represent a major contribution to the advancement of all theories of the problem of suicide.
Stephens (1984) applied the vocabulary of motives tradition from sociology to an analysis of suicide notes and concludes that "motives can be viewed as social constructions ... which permit the individual and others to assign meaning and acceptability of the suicidal act".
Shneidman's efforts to explain suicide are long standing (1981). Lethality and perturbation are two aspects of suicide that provide new explanatory power. Aside from intention to die, the degree of self destruction imposed on the body of the victim is the most proximate cause of death, i.e. the lethality of the method chosen. Perturbation on the other hand, is the degree of distress or unbearable psychological pain, and therefore contributes the most to the search for relief, escape, etc. Shneidman puts these and an array of common characteristics together in an encyclopedic definition of suicidal behavior (1985).
"Currently, in the western world, suicide is a conscious act of self induced annihilation best understood as a multidimensional malaise in a needful individual who defines an issue for which the suicide is perceived as the best solution."
He devotes a whole chapter to explaining how he uses each word. Here it is sufficient to note he covers all the known bases, including the usually overlooked relevance of meaning of death.
Shneidman brings back the folk wisdom of suicide as a self serving act exclusively oriented to solving problems, escaping distress, reducing unendurable pain, and all this, through the achievement of cessation, or its experiential equivalent, change of awareness.
If read fully, his ten common characteristics, and their amplifications, give the reader an answer to the question of `why'. Is it enough? For the suicidologist it is at least heuristic. For the mental health professional it is interesting. For crisis personnel maybe, depending on how they translate the ideas into clinical practice. For the victim? Probably not at all.
Regardless, Shneidman's definition of suicide does contribute more operational focusing of research attention. Seasoned clinicians will be able to translate much of this into clinical wisdom, and for the next generation of health professionals. Its value for the potential victim today depends on how quickly this and existing knowledge is employed before the seductions of cessation allow victims to start a self injury event.
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Ellis (1988) has reviewed prior efforts to define typologies and classification systems in dealing with the explanation of suicide. He like Beck & Greenberg (1971) before him, documents the continuing lack of consensus and makes the analogy of the three blind men attempting to describe an elephant. Ellis offers a modest list of four categories to describe all aspects of suicide; descriptive, social, psychological, and teleological (why). These have the value of being more operational and with face validity. They seem credible to any reader and reflect a common denominator function apparent in the suicidology literature. The future value is to encourage more consensus in the scientific community. Many suicidologists can find their own ideas at least partially documented by Ellis's system, and can expect more support for their own writings because of common language. For example, the ideas I have used in the Suicide Prevention Triangle model are easily apparent in the following table.
Table 4
Comparison of Ellis with the triangle model
| Ellis | Triangle Model |
|---|---|
| Descriptive | Suicidal behaviour / lethality of plan What? |
| Situational | Social / external / Durckheim / stress When-Where? |
| Psychological / behavioural | Individual / internal / Freud / distress How? |
| Teleological | Problem of suicide / wish to die Why? |
Despite the significant past progress noted here the lack of consensus among suicidologists is discouraging with respect to the problem of suicide. Not because of diversity, but the lack of credibility in any one explanation, theory, or method of assessment. There is value in each of them, and together they allow younger suicidologists to reach for more. It is the absence of instant belief which can be subsequently mobilized into professional support and further applications to practice. In other areas of psycho pathology, psychologists have learned to be neutral, accepting of the client (with the full range of human misbehavior), able to deal with self hatred and extreme emotions, and to fulfill these duties with relative success. Individual professionals can learn to use existing models for the management of phobias, sexual dysfunction, delayed stress, even depression. However, when faced with client behavior that suggests self injury, the major resources are the models of depression and mental illness which are not immediately helpful. The newer ideas reviewed in this chapter can enhance intervention, but still do not go far enough to achieve treatment parity with other clinical problems. Any professional or gatekeeper, when faced with a continuing suicidal intent, falls back on personal notions of life and death to draw inspiration for further interventions. When these fail, there is an exit from the scene much like the victims. Patients are referred, hospitalized, and medicated. Some use the philosophy of "its up to you" (to choose or reject suicide) and make it the client's burden.
Much more is known now than in the previous generation, and there is much more awareness in American culture. The sad conclusion that it is not enough, simply documents the obvious. Improvement requires more focused effort by the scientific community. It also requires a greater awareness on the part of everybody in order to reach potential victims before they act. How to achieve these will be addressed in the last chapter.
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This chapter reviewed the efforts to explain the problem of suicide. Why do people choose to kill themselves? The early ideas of depression and mental illness while descriptive and generally accepted are inadequate to explain most suicidal events when judged by the resulting false positives and false negatives in clinical efforts to manage potential victims. The sociological perspective documents orderly qualities in suicidal death rates of countries, places, eras, and other epidemiological factors, but has not as yet yielded information that care givers can apply to populations at risk. Maris may be an exception in his use of suicidal careers and the replication of both sociological an psychological concepts, which supports their further application to potential victims.
The individual or psychological perspective, mainly building on psychoanalytical thinking, also provides an explanation that helps to identify and treat potential victims observed in psychotherapy. However, it too fails to improve outcomes in a testable fashion.
Theories reported in the last fifteen years have improved understanding of the problem. Ellis classification of suicidal behavior into four categories of descriptive, situational, psychological, teleological is useful as a means of developing more consensus among suicidologists.
The loss of hope has become increasingly prominent, and justly important, as an explanatory concept. Its measurement by Beck's pessimism scale, appears to identify the lethal element in depression. Shneidman's formulation of ten common aspects of suicidal behavior offers the promise of generating more operational measures to assess a greater variety of significant contributing factors. It immediate value is the enhancement of available wisdom in separating the many domains and layers of motivation implicit in an act of self injury.
Most of the past and present efforts, to explain the problem of suicide tend to ignore the meanings and values of death to the victim. Instead there is an assumption that physical termination and its psychological equivalent, cessation, have only one or two universal meanings. Even when variations are noted, these tend to be listed as collective categories such as unconscious hostility, escape or avoidance of pain, inability to love, significant loss, expiation of guilt, a cry for help, and so forth. It is not that these are in error, but rather that they fail to accommodate to cultural differences even within the USA. There is also the failure to consider individual differences of the most personally unique kind possible.
This review of current explanations while reflecting progress also documents the lack of consensus in so basic a question as why do people want to die? This is not surprising given the failure to achieve even minimal adoption of the more than 40 assessments methods reported in the scientific literature over the last 30 years. Still the variation among answers, when offered by suicidologists seems to be as diverse as that found in the victims, and documents again the great range of meanings assigned to death and the after life.
The suicidology literature supports the notion that all victims of self injury behavior are seeking to accomplish an objective of some kind, whether in their survivors, themselves, or both. Whatever this may be, the net effect is to alter the victim's own perceptions of existence. They do so through actions that are some variety of self injury behavior intended to accomplish cessation of awareness. The phenomena of para suicide share this in that the verbalizations, threats, gestures or self mutilations are also efforts to accomplish changes of perceived reality and subsequent awareness. In these behaviors the suicidal and parasuicidal victims appear to be assuming a continuation past the point of termination rather than cessation, even though they use words that suggest the latter.
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