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Suicide? #2

 

PART 2
The social construction of suicide

Scientific and quantitative methods are completely rejected by some Phenomenologists. J Maxwell Atkinson (1978) does not accept that a ‘real’ rate of suicide exists as an objective reality waiting to be discovered. According to Atkinson, behavioural scientists who proceed with this assumption will end up producing ‘facts’ on suicide that have nothing to do with the social reality they seek to understand. By constructing a set of criteria to categorise and measure suicide – in scientific language, by operationalising the concept of suicide – they will merely be imposing their ‘reality’ on the social world. This will inevitably distort that world.

As Michael Phillipson (1972) observes, the positivistic methodology employed by Durkheim and other researchers “rides roughshod over the very social reality they are trying to comprehend”. Suicide is a construct of social actors, an aspect of social reality. Official statistics on suicide, therefore, are not ‘wrong’, ‘mistaken’, ‘inaccurate’ or ‘in error’. They are part of the social world. They are the interpretations, made by officials, of what is seen to be unnatural death. Since, Phillipson argues, the object of Sociology is to comprehend the social world, that world can only be understood in terms of the categories, perceptions and interpretations of its members. Thus, with reference to suicide, the appropriate question for sociologists to ask is, in Atkinson’s words: “How do deaths get categorised as suicide?”

Atkinson’s (1971, 1978) research focuses on the methods employed by coroners and their officers to categorise death. His data are drawn from discussions with coroners, attendance at inquests in 3 different towns, observation of a coroner’s officer at work, and a part of the records of one particular  coroner.

He argues that coroners have a ‘common sense theory’ of suicide. If information about the deceased fits the coroner’s theory, they are likely to categorise the death as suicide. They consider 4 areas of evidence:-

  1. Suicide notes are recovered in around 30% of suicides – unfortunately there is no way of knowing if more may have been written but were destroyed by the families because of the accusations contained in them. (This point supports Douglas’ point that tightly-integrated families may misrepresent the circumstances of the death to avoid stigma.)
  2. Mode of death – some types of death being more typical of suicide than others. Road deaths are rarely interpreted as an indicator for suicide whereas drowning, hanging, gassing and drug overdose are more likely to be seen as such.
  3. Location/circumstances of death – coroners, according to Atkinson, believe that suicides are committed in places and circumstances where they will not be discovered and where the individual is certain the outcome will be successful. Death by gunshot is more likely to be defined as suicide if it occurred in a deserted lay-by than if it took place in the countryside during an organised shoot. In cases of gassing, a suicide verdict is more likely if windows, doors and ventilators have been blocked to prevent the escape of gas.
  4. Life history and mental conditions – coroners believe that suicide is often related to Depression brought on by significant events in the deceased’s life. A history of mental illness, a disturbed childhood and evidence of acute Depression are often seen as reasons for suicide.
    Chang, Gitlin & Patel support this kind of assumption, noting that a history of previous suicide attempts is the greatest predictor of eventual completion of suicide. Approximately 20% of suicides have had a previous attempt. Of those who have attempted suicide, 1% complete suicide within a year and more than 5% commit suicide after 10 years. In approximately 80% of completed suicides the individual had seen a physician within the year before their death, including 45% within the prior month. Approximately 25–40% of those who completed suicide had contact with mental health services in the prior year.
    A recent divorce, the death of a loved one or relative, a lack of friends, problems at work or serious financial difficulties are regarded as possible causes of suicide. This, as Atkinson (1978) acknowledges, is remarkably similar to Durkheim’s notion of social integration and hints at the PURPLE vMEME’s needs not being met.
    Referring to the case of an individual found gassed in his car, a coroner told Atkinson: “There’s a classic pattern for you – broken home, escape to the services, nervous breakdown, unsettled at work, no family ties – what could be clearer.” Thus, coroners’ views about why people commit suicide do appear to influence their categorisation of death.

Atkinson provides the following summary of the procedures used to categorise unnatural death. Coroners “are engaged in analysing features of the deaths and of the biographies of the deceased according to a variety of taken-for-granted assumptions about what constitutes a ‘typical suicide’, a ‘typical suicide biography’”, etc. Suicide can, therefore, be seen as an interpretation placed on an event – an interpretation which stems from a set of taken-for-granted assumptions.

Though he doesn’t consider himself a  Phenomenologist, Taylor’s (1989) study of ‘persons under trains’ – people who met their death when they were hit by tube trains on the London Underground – offers support for this viewpoint. Over a 12-month period he found 32 cases where there were no strong clues as to the reason for the death. No suicide notes were left and no witnesses were able to state that the victim jumped deliberately. In effect, it was impossible to say with any certainty whether a suicide had taken place or not. Nevertheless, 17 cases resulted in verdicts of suicide, 5 were classified as accidental deaths, and the remaining 10 produced open verdicts.

Taylor found that a number of factors made suicide verdicts more likely. People with a history of mental illness and those who had suffered some form of social failure or social disgrace were more likely to have their death recorded as suicide. When a person who had died had no good reason to be at the tube station, a suicide verdict was more likely.

Taylor also found that the verdict was strongly influenced by the witnesses who testified to the dead person’s state of mind. Where the witness was a close friend or family member, they tended to deny that the person had reason to kill themselves and to stress reasons why they might want to carry on living. Where the witnesses were less close to the person – eg: in one case their landlady – they were less likely to deny suicidal motives. This supports Douglas’ view that strong family integration may result in misinformation to the coroner in an attempt to avoid the stigma of a suicide verdict. It can also be seen as the work of a collective PURPLE/RED vMEME harmonic – trying to avoid bringing shame on the family and close friends.

Some support for Douglas’ explanation comes from a study by M W Atkinson, Neil Kessel & J B Dalgaard (1975) which compared the decisions made by English and Danish coroners on 40 uncertain causes of death. The Danes recorded more verdicts of suicide than their English counterparts. Atkinson, Kessel & Dalgaard attributed this to Denmark having a much more open attitude to suicide, with far less stigma attached.

Reliability and validity of coroner’s verdicts
The phenomenological view has serious implications for research that treats official statistics on suicide as ‘facts’ and seeks to explain their cause. Researchers who look for explanations of suicide in the social background or mental state of the deceased may simply be uncovering and making explicit the taken-for-granted assumptions of coroners. Atkinson found that coroners’ theories of suicide were remarkably similar to those of sociologists and psychologists. Since coroners use their theories of the cause of suicide as a means for categorising suicide, this similarity might be expected. The work of Douglas, Atkinson and Taylor casts doubt on the validity of coroners verdicts’ of suicide.

Phenomenological views have themselves been subject to criticism. Barry Hindess (1973) points out that the criticisms of suicide statistics advanced by Phenomenologists can be turned against the sociological theories of Phenomenologists themselves. If suicide statistics can be criticised as being no more than the interpretations of coroners, then studies such as that done by Atkinson can be criticised as being no more than the interpretation of a particular sociologist. Just as there is no real way of checking on the validity of the verdicts reached by coroners, there s no way of checking on the validity of the accounts of how coroners reach their decisions advanced by phenomenological sociologists.

Hindess, therefore, dismisses the work of such sociologists as being ‘theoretically worthless’, and he says of their work: “A manuscript produced by a monkey at a typewriter would be no less valuable.” If phenomenological views were taken to their logical conclusion, he argues, no Sociology would be possible and the attempt to understand and explain suicide would have to be abandoned.

For all such objections,it appears whether a death is classified as ‘suicide’ or not, is indeed very much open to interpretation. If the criteria for arriving at a verdict of ‘suicide’ are changed, then the number of such verdicts is likely to change too. Following changes in statistical recording and death registration, Meikle reports that coroners are currently giving more narrative verdicts, making causes of death more difficult to identify. For example, in Scotland in 2011 there were 889 suicides under the new guidelines and 772 under the old ones.

While the criteria for categorising ‘suicide’ can be queried with regard to validity, there is evidence to suggest coroners’ use of the criteria is fairly consistent, meaning their judgements have a good degree of reliability.

Brian Barraclough (1970) compared the correlations between suicide rates in 1950-1952 and 1960-1962 in regions in England & Wales where the coroner remained the same with regions where the coroner had changed. The correlations between the rates from the two periods did not differ depending on whether the coroner remained the same (r=0.45) or differed (r=0.49). Similarly, in a comparison between English & Welsh coroners and Scottish coroners, Olivia Ross & Norman Kreitman (1975) found no differences in the decisions made on a consecutive series of cases.

The key issues then, in establishing suicides appear to be the quality of the criteria for categorising suicide and the honesty of the family and close friends in presenting accurate information.

Psychological and biological factors
Durkheim’s study has been so influential that it seemed to make the study of suicide as a social phenomenon largely the preserve of sociologists. Perhaps unsurprisingly, critics – especially psychologists! –  point out that, apart from a passing acknowledgement to the effects of Depression, sociological theories generally ignore psychological and biological factors influencing suicide.

Yet the theories of Douglas and Baechler clearly have significant psychological elements in them.

Ironically, it is often overlooked that Durkheim did acknowledge that social factors influenced psychological states. He argued that, not only the behaviour of the individual was social, but also that the individual’s  internal world of feelings and mental states was socially produced – which accords with Susan Blackmore’s (1999) concept of the ‘self’ as the selfplex. Thus, Durkheim argued that the social isolation characteristic of Egoistic suicide resulted in apathy or Depression. Anomic suicide was associated with a much more restless condition of irritation, disappointment, or frustration. When lack of regulation meant that desires or ambitions got out of control, people became upset and frustrated by their inability to achieve them. Altruistic suicide, Durkheim posited, was generally accompanied by an energy and passion quite opposite to the apathy of egoism. Durkheim did not discuss the psychological state characteristic of Fatalistic suicide but it would seem to involve a mood of acceptance and resignation.

Psychologists often draw attention to biological factors as much as social ones.

Eg: Ramesh Arora & Herbert Meltzer (1989) found a relationship between violent suicide and elevated serotonin receptor density in the pre-frontal cortex. Similarly John Mann, Mark Underwood & Victoria Arango (1996) found that among suicide ‘completers’, those with increased numbers of pre-frontal cortex serotonin receptors had chosen more violent methods of suicide.

Brewer draws attention to the fact that men tend to use more violent means – shooting or hanging – whereas women tend to use methods like overdosing or self-poisoning. The result is that only about 1 in 25 suicide attempts by women succeed, meaning that men are much more the ‘completers’.

This gender difference is important because, during the 1990s, the suicide rate amongst young men doubled, making suicide the second most common cause of death for that age group after road accidents. Brewer cites the pressures on young men to move away from their home area in search of employment as a key factor, bringing the discussion back to Durkheim and social integration and the need of the PURPLE vMEME to find safety in belonging.

The gender difference is even more important in the early 21st Century because the number of young men taking their own lives is increasingly being matched by – and in some cases overtaken by – the number of middle-aged male suicides. Stephen Platt, a leading Samaritans researcher interviewed by Meikle, attributes the dramatic increase in middle-aged men killing themselves to social factors: “a perfect storm of challenges: unemployment, deprivation, social isolation, changing definitions of what it is to be a man, alcohol misuse, labour market and demographic changes that have had a dramatic effect on their work, relationships and very identity.”

However, a biological factor which may help explain more completers being men is the temperamental dimension of Psychoticism, attributable in large part to the male sex hormone, testosterone, according to Hans J Eysenck & Sybil B G Eysenck (1976). The impulsiveness, compulsiveness and tendency to violence all associated with Psychoticism may help explain male violent suicide.

In a totally-different dimension, David Phillips (1974) demonstrated that high-profile celebrity suicides are often followed by increased numbers of suicides amongst the general population. Such a phenomenon is probably more attributable to Social Learning Theory than any of Durkheim’s categorisations – or, for that matter, those of Douglas or Baechler.

Social Learning Theory may also help explain ‘copycat suicides’. Martin Veysey, Robie Kamanyire & Glyn Volans (1999) found that the average number of suicide attempts by self-poisoning with anti-freeze increased from 2 to 6 per month in the hospitals studied after a February 1997 episode of the BBC-TV drama Casualty featured a suicide attempt with anti-freeze. Casualty again appeared to have been copied according to a study by Keith Hawton et al (1999), covering 49 Accident & Emergency Departments. This time the TV programme had featured a paracetamol overdose. The researchers found the average general overdose rate in the week after broadcast had increased by 17% and paracetamol overdoses by 19%. The overall increase in the month after broadcast was 7% and 12% respectively. 25% of the survivors interviewed reported having watched the programme. Paul Siu Yip et al (2012) confirmed that, when detailed description of how to commit suicide by a specific means are portrayed in the media, this method of suicide may increase in the population as a whole.

Paul Andrews (2006) explained his findings, from a survey of 1600 American adolescents, that middle-born children were significantly more likely to make severe suicide attempts than their first-born or last-born siblings, in terms of parental investment. However, the middle-born’s attempts to extort increased investment from their parents by being a parasuicide can also be described in Baechler’s Ludic terms and  Taylor’s Appeal concept.

Ectopic and Symphysic suicides
From his 1989 study ‘persons under trains’, Taylor concludes that suicide figures are often distorted by such things as the narratives family and close friends tell and the assumptions made by coroners.

However, Taylor does not follow Phenomenologists in arguing that such problems make it impossible to explain suicide. Taylor’s own theory is not based upon statistical evidence but upon attempts to discover “underlying, unobservable structures and causal processes”. This type of approach is based upon a Realist conception of science.

Taylor (1990) also makes the point that most discussion of suicide omits the issue of parasuicides. Taylor finds that, when questioned, most would-be suicides are less a definite decision to end life and more of a gamble in which people leave the outcome to fate. If they survive, they were not meant to die; if they die, then that was fate (or God).

Taylor develops his theory as an attempt to explain the key features of different types of suicide and parasuicide revealed in case studies.

In his theory Taylor argues that suicides and suicide attempts are either ‘ectopic’ – they result from what a person thinks about themselves – or ‘symphysic’ – they result from a person’s relationship with others. Suicides and suicide attempts are also related either to certainty or to uncertainty – people are sure or unsure about themselves or about others. Thus, like Durkheim, Taylor distinguishes 4 types of suicide connected to diametrically- opposed situations. In Taylor’s theory. however, they are situations faced by particular individuals and not related so closely to the wider functioning of society.

The first two types of suicide in Taylor’s model are ‘ectopic’ or inner-directed.

Submissive suicides occur when a person is certain about themselves and their life; they believe their life is effectively over and see themselves as already dead. Taylor says, “The world of the submissive is one of constricting horizons, of closing doors, blind alleys and cul-de-sacs.” The terminally ill may commit submissive suicide. In other cases a person may have decided that their life is valueless without a loved one who has died. In this type of suicide the suicide attempt is usually deadly serious – the person is sure they wish to die.

There are some parallels with Baechler’s Escapist here and Douglas’ self-transformer. In Integrated SocioPsychology terms, the BEIGE vMEME has lost the will to carry on.

Thanatation is a type of suicide, or suicide attempt which occurs when a person is uncertain about themselves. The suicide attempt is a gamble which may or may not be survived, according to fate or chance. If the attempt does not result in death, the person learns that they are capable of facing death. In some cases the person may be exhilarated by the thrill of the risk taking and they may make several suicide attempts. Taylor gives as examples the novelist Graham Greene, who periodically played Russian Roulette with a revolver, and the poet Sylvia Plath, who deliberately risked death by driving her car off the road.

This thrill-seeking approach is symptomatic of the RED vMEME. The term Thanation implies a link to  Thanatos, the death drive of the Id, according to Sigmund Freud (1923b). Clearly it incorporates Beachler’s Ludic suicide.

The other two types of suicide are ‘symphysic’ or other-directed suicides.

Sacrifice suicides occur when a person is certain that others have made their life unbearable. The person who takes their own life often attributes the blame for their death to others so that they will feel guilty or will suffer criticism from other members of society. Eg: Taylor refers to a case in which a 22-year-old man killed himself because his wife was in love with his elder brother and she wanted a divorce. The man left letters making it clear that he felt that his wife and brother were responsible for his death.

The Sacrifice suicide could be attributed to the bitter zealotry of a RED/BLUE vMEME harmonic. Both Douglas and Baechler identify revenge as a suicide theme.

Appeal suicides and suicide attempts result from the suicidal person feeling uncertainty over the attitudes of others towards them. The suicide attempts are a form of communication in which the victim tries to show how desperate they are, in order to find out how others will respond. Suicide attempts may involve trying to persuade others to change their behaviour, or they may offer them chances to save the victim. Such attempts “combine the wish to die and the wish for change in others and improvement in the situation; they are acts both of despair and of hope”. Eg: a woman slashed herself with a bread knife in front of her husband after he had discovered her having sex with a neighbour. Her husband took her to hospital and she survived. She later said she was unsure whether or not she would bleed to death but wanted to show her husband how much she loved him and to appeal for forgiveness through her actions. In another case, a man took an overdose of barbiturates in a car parked in front of his estranged wife’s house. He left a note for his wife saying what he had done. However, a dense fog obscured the car and his wife did not see him when she returned to the house and therefore could not save him.

Taylor also refers to Marilyn Monroe’s death. She had rung her doctor before taking her fatal overdose; and, on previous occasions when she had rung him in an agitated state, he had come round to calm her  down. His failure to do so on this occasion removed any chance of discovery and rescue.

The desperation in Appeal suicides and suicide attempts can be seen as symptomatic of the PURPLE vMEME’s need to be accepted and safe in a context where close social integration is breaking down.

Taylor also extends Durkheim’s analysis by categorising successful parasuicides as ‘ordeal suicides’ which can be related to a profound sense of anomie while more purposive suicides, in his view, meet Durkheims’ Fatalistic criteria. Interestingly, Taylor supports Durkheim’s contention that Egoistic suicide results from individuals being too detached from society but posits that Altruistic suicide comes from being overattached to society. (In Egoistic suicide, then, PURPLE is weak and RED too strong; in Altruistic, PURPLE is too strong.)

Taylor’s theory helps to explain why some suicide victims leave notes and others do not, why some suicide attempts seem serious than others, and  why some take place in isolation and others in more public places. However, it is hard to test. It rests upon the meanings given to suicidal actions by those who take part in them.

Such meanings can be interpreted in different ways.

For those whose suicide attempts result in death, the meanings can only be inferred from circumstantial evidence, since they are no longer able to explain their motives. Individual suicides may result from a combination of motives, with the result that they do not fit neatly into any one category.

Interpersonal theory
Joiner’s (2005) Interpersonal Theory of Suicide has found its clearest expression so far in the work he has done with Kimberley van Orden and colleagues (Kimberley van Orden et al, 2010). While it largely ignores many social aspects of suicide and tends to fit a limited number of types of suicide, it nonetheless brings in factors which no other theory does. (According to Dokoupil, Joiner’s research was driven by the need to understand why his own father committed suicide.)

In particularly trying to understand why American middle-aged men commit suicide, Joiner identifies 3 characteristics which, where they overlap, create an imperative to kill yourself.

Graphic copyright © 2010 Kimberley van Orden et al/Psychological Review

The sense of ‘thwarted belongingness’ goes right back to Durkheim and reflects the fundamental needs of the PURPLE vMEME.

The perceived sense of burdensomeness as an explicit factor is new to theories on suicide – though Douglas’ Transformer and Baechler’s Oblative hint at it. Plus, it’s possible to conceived someone seeing themselves as unendingly burdensome ending up as a Fatalistic suicide.

Joiner claims that the factor of perceived burdensomeness explains why suicides increase with unemployment, debilitating illness, old age, etc, etc. This would seem to equate to the RED vMEME’s inability to accept shame. Not being able to look after yourself and your own needs but being dependent on others, depending on cultural context, may be just the unbearable situation RED can’t cope with.

Joiner considers whether the desire to avoid being a burden on others is actually adaptive and cites a number of species – from honey bees to lions – where ‘burdensome’ members of the group will sacrifice themselves for the good of the group rather than be a liability to it. This, of course, has strong echoes of Durkheim’s concept of Altruistic suicide.

Interestingly one suicide note Joiner looked at said simply: “Survival of the fittest. Adios. Unfit.”

In Joiner’s model, where a sense of burdensomeness crosses a sense of loneliness, then that is likely to bring about the desire for suicide. Where Joiner’s third factor overlaps with the desire for suicide, then some suicidal action will take place.

This third factor assumes access to the means to commit suicide – pills, firearms, rope for hanging, etc. But, more than that, it means the determination to go through with the action. Joiner actually refers this factor as ‘fearlessness’. Parasuicides he sees as not having quite enough fearlessness to make sure it happens. This kind of courage would require a RED/BLUE vMEME harmonic – the RED producing the sheer drive and the BLUE the sense that it’s the right thing to do…which means there can be no turning back.

The Interpersonal Theory is undoubtedly simplistic and limited in the types of suicide it can be applied to. Nonetheless, it is undoubtedly a powerful and highly innovative explanation for certain types of suicide.

Joiner’s theory, like Taylor’s, is far more a psychological than sociological one.

Types of suicide and suicide prevention
Clearly, from this review, there are many different types of suicide – and categorising a self-killing as a particular type of suicide – even ‘suicide’ at all! – is a testy business. Even so, understanding and categorising different types of suicide is essential if more of those types of suicide are to be prevented. To use Durkheim’s model, the Altruistic suicide has nothing in common with the Egoistic suicide. Therefore, completely different strategies need to be developed and implemented to reduce suicides of those 2 types.

If the despots of the Middle East had instituted programmes of social and economic reforms to reduce poverty and increase the distribution of wealth before 2011, maybe Mohammed Bouazizi wouldn’t have committed his Fatalistic suicide and maybe the so-called Arab Spring would never have happened or at least not in the revolutionary form it did?

If, in the West, people were encouraged to be kinder to each other and more responsible for each other, rather than more competitive and dismissive, might there be a reduction in Appeal suicide attempts?

Will the (slightly-)falling divorce rate in Western countries correlate with fewer Egoistic suicides, in which case should governments put more investment into marriage guidance and relationship counselling services?

Durkheim’s study, for all its flaws, sets the bar for the study of suicide. That there are queries about its methodology should not detract from the concepts Durkheim put forward – especially as at least one of his detractors, Douglas, has put forward a model with almost no empirical evidence. However, it says something for the quality of much of the research considered, that it almost all has face validity – ie: it is easy for lay people to match real-life examples to the theoretical models.

In all, we’ve probably got around 8 types of suicide, with some of them having sub-types. Research and theory should now concentrate on consolidating knowledge and understanding for the different circumstances and motivations which lead to self-killing so that more targeted strategies can be developed for helping would-be suicides step back from the proverbial precipice.

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