Models of Sensemaking and Suicide (and their challenges)

Note: the following paper explores concepts and ideas associated with Suicide. If this topic triggers distress, it may not be for you. If this paper does cause concern, within Australia you can contact Lifeline on 131114, or for outside of Australia, a list of support hotlines is listed HERE.

The longing to make sense of why people end their own lives leads to the development of models and/or frameworks. While such constructs cannot provide definitive nor complete answers, they can be helpful in making sense of complex, even wicked problems; in this case, suicide. A key argument of this paper is that while (all) models of comprehending suicide are imperfect, at the same time they may also be useful. This is the paradox established with (all) models of sensemaking and suicide.

Many models and frameworks that are developed, along with the academic literature that shape them, emerge from a reductionist and STEM based worldview. That is, one anchored in scientific measures and a search for empirical answers. While this is necessitated by the environment in which they are presented, as Tatz (2001) notes; “

As much as we may want to have a ‘science of suicide’, we can’t.” (p. ix).

It is this view that this paper will examine further, via an examination of models that are developed in pursuit of a ‘science of suicide’.

In doing this, a reflection on two specific models is included; Joiner’s Interpersonal Theory of Suicide (IPTS) model (2005) and O’Connor’s Integrated Motivational-Volitional (IMV) model (2018) in contrast, to contemplate the paradox that models of understanding suicide generate.

Before reviewing the models and offering a critique, the paper explores definitions and provides an historical perspective of suicide, before highlighting the importance of ontology and epistemology, in order to provide some context to the development of the Models. The paper then provides a synopsis of the IPTS and IMV models including key features and hypothesis, along with a brief review of the literature and commentary on the models. Finally, it concludes with thoughts on how both models may be strengthened, by forming a broader and more holistic, and hence less reductionist, understanding of suicidal.

Let’s begin by exploring the question, ‘what is suicide’?

A definition of suicide is contested. This is not surprising given that there are many different perspectives and influences that may shape how we explain suicide. As Silverman notes;

The terminology we use is often based on our training (Silverman & Berman, 2014b); theoretical, political, social, psychological, biological and religious perspectives; and the professional responsibilities to identify and count these behaviors in the first place (clinical, epidemiological, public health, research, etc.) (2016, p.12)

 When considering a definition of suicide, Goodfellow, Kolves and de Leo further suggest that;

A definition should be considered as a tool to posit a theory, and not the positing of the theory itself. Hence, a definition is not a theory: It describes elements that may ultimately constitute the components of the theory concerned. (2018, p.2).

Goodfellow, Kolves and de Leo (2018) provide 24 definitions of suicide, isolating four common features: agency, knowledge of a potentially fatal outcome, intent and outcome. (p.1). Of the four features, it is intent that Goodfellow, Kolves and de Leo (2018) spend the most time exploring.

In Joiner’s book Why People Die by Suicide, in which he articulates his theory, he dedicates all of Chapter 4 to the topic of intent asking questions such as “What do we Mean by Suicide?” and “How is it Distributed in People?” (p.137-171).

Throughout this Chapter, Joiner explores different examples of people seeming, at least initially, to die by suicide. However, due to the complex and multi-layered factors that lay behind the cited suicides, the notion of ‘intent’ becomes less clear. For example, Joiner (2005) cites people who died during the mass suicide event of Jonestown (p.145) and asks the question did they intend to die?

He includes other examples also, such as terrorists involved in the 2011 terror attacks in the United States of America and also of kamikaze pilots and suggests that; “Their views appeared to have been that their self-sacrifice was for their society’s greater good, which in his classic work on suicide, Durkheim might have characterized as altruistic suicide.” (p.142).

The question with such suicides may be, not so much was the intent to die, but was the intent of a higher order purpose, beyond their own death?

What other factors might be important to appreciate before we explore Joiner and O’Connor’s model?

All models and constructs are heavily influenced, often unconsciously, through their creators’ ontology.

For example, according to Weaver and Wright (2009), “For psychiatrists, self-murder is a medical problem” (p.3) and “For sociologists, suicide is a symptom of societal dysfunction” (p.3). Referring to Jung’s concept of archetypes in The Collective Unconscious (1959), Hillman (2016) suggests that; “All of us, no matter what the vocation, work from certain root-metaphors” (p.22). Hillman (2016) refers to four perspectives on suicide; sociological, legal, religious and medical points of view (p.22-32).

All four perspectives view suicidal differently and hence will influence the models developed. For example, in considering the (Christian) religious perspective, Hillman notes that:

…the American Council of Christian Churches passed a resolution condemning the Anglican position favouring repeal of the British laws on suicide (1961): Death by suicide ends all opportunity for repentance. Almighty God created life. It is His. Murder, including self-murder, is a transgression of His law. (2016, p.27)

In the eyes of many in the American Council of Christian Churches at the time, suicide could neither be understood nor explained in any other way other than as disobedience to God.

Contrastingly, van Hoof, cited in Maris, Ronald et. al. (2000) share the story of Lucrece who “was forced into sexual intercourse” (p.99) by the son of Rome’s seventh king and subsequently resolved that; “To save her reputation, Lucrece gave way, but afterward she called in her people, told them what had happened, and stabbed herself to death, thus preserving her honour and lending force to her words.” (p.99). Thus, to end life after such a defeat was the only means to gain respect (p.101).

The ontology of a person who explains suicide in this way is contrasted with a person whose ontology aligns with the American Council of Christian Churches in 1961. That is, they will develop different views and epistemological understandings of suicide.

Suicide is multifarious and, in many ways, mysterious to those who have not experienced it. Constraining its etiology neatly into (any) model is unavoidably restrictive, yet to some extent may also be helpful in sensemaking. In order to hold the paradox that models present, one’s epistemology needs to extend beyond a restrictive reductionist worldview. Sensemaking is an ongoing endeavour, and when one settles their understanding within the constraints of a model, the danger is that at the same time, sensemaking ends.

Joiner’s Interpersonal Theory of Suicide model of suicide (2005) lays bare his ontological journey.

In Why People Die by Suicide (2005) Joiner prefaces his intellectual understanding of suicide as evolving differently to his feelings:

“Informed by science and clinical work, I came to know more than most about suicide – on levels ranging from the molecular to the cultural.”… Of course my dad’s death has deeply affected both my feelings about suicide and my understanding of it” (p.1) and “the topic has become mostly scientific and professional for me, with the agenda of prevention and relief of suffering through the elimination of the slow labours of scientific understanding” (p.223).

Joiner’s background is in science, he is a clinician. Yet his experiences, particularly the loss of his father to suicide, have shaped and developed his ontological perspective of suicide. On this, Joiner notes that: “A new theory is needed that builds on existing models and provides a deeper account of suicidal behaviour to explain more suicide-related phenomena.” (p.16). He goes on to suggest that; “This is a very tall order because the extent and diversity of facts related to suicide are intimidating and baffling.” (p.16).

Joiner seems to be seeking a more holistic, rather than reductionist, understanding of suicide, however paradoxically, this is not entirely possible due to the limitations of a ‘science of suicide’, when trying to reduce its down into an assimilable model.

For Joiner (2005), three key factors lead a person taking his or her own life: simultaneous presence of thwarted belongingness, perceived burdensomeness and then, if these conditions are met, an acquired capability; to overcome the natural fear of death. Joiner attributes the first two factors as the desire to die. If these two factors are present, and the person is then able to overcome a fear of death, suicide is possible.  

In describing thwarted belongingness Joiner (2005) refers to eminent sociologist émile Durkheim when he describes that low belongingness “leads to an increase in a type of suicide that Durkheim labelled “egoistic”. His idea was that we need something that transcends us, and he felt that the only thing that transcendent enough is human society.” (p.33-34). Described in a simpler way, thwarted belongingness is a feeling of loss of social connectedness with others, which in turn may amplify feelings of loneliness.

Joiner describes that;

Those who view themselves as a burden on others have a negative self-image, feel out of control of their lives, and possess a range of negative emotions stemming from the sense that their incapacity spills over to affect others besides themselves. (2005, p.97).

Perceived burdensomeness is about a person’s perception of his or her self as a permanent burden to others. Combined with thwarted belongingness, a desire to die may emerge. In further describing this, Joiner notes;

I asserted that those who desire suicide die by suicide only if they can. Those who can die by suicide will die only if they want to. But who can? Those who have acquired the capability to enact lethal self-injury. Who wants to? Those who perceive that they are a burden on loves ones and that they do not belong to a valued group or relationship. (2005, p.137), (emphasis in original).

In describing ‘acquired ability’, Joiner (2005) refers to the suicide death of the celebrity Kurt Cobain, a popular musician who died after shooting himself with a gun. Joiner (2005) describes how Cobain “was temperamentally fearful – afraid of needles, afraid of heights, and afraid of guns.” (p.51). However, Cobain’s “repeated exposure and practice, a person initially afraid of needles, heights and guns later became a daily self-injecting drug user.” (p.51). He goes on describe that “Regarding guns, Cobain initially felt that they were barbaric and wanted nothing to do with them.” (p.51).

Joiner notes that;

In 1992 and 1993, musician Kurt Cobain obsessively watched a videotape of the suicide of R. Budd Dwyer, a Pennsylvania state official who died live at a press conference…by putting a gun in his mouth and firing. This may have represented a form of mental practice for Cobain’s 1994 by a similar method. (2005, p.81) 

Joiner’s theory of developing a capability to overcome fear combined with thwarted belongingness and perceived burdensomeness, support the conditions in which suicide is possible. However, his approach is not formulaic nor linear because these three factors may combine, yet not always lead to suicide.

How may an understanding of suicide through Joiner’s model ironically limit out understanding?

Joiner’s model has been significantly influential in the field of Suicidology, and is referenced heavily in the related literature, however this is not the first paper to offer a critique of the model. For example, Heidi Hjelmeland & Birthe Loa Knizek (2019) argue that;

In general, suicide researchers seem to agree that suicide is a complex, multifactorial phenomenon. With qualitative research currently burgeoning, it is also increasingly recognized that suicide is a highly contextual phenomenon (Hjelmeland & Knizek, 2016; White, Marsh, Kral, & Morris,2016). It is, therefore, surprising that a theory comprised by three internal/psychological factors only, is so extensively embraced rather than just ignored, rejected, or at least critiqued. (2019)

In demonstrating just how influential Joiner’s model has been in Suicidology, Hjelmeland & Birthe Loa Knizek (2019) provide the following table that outlines the proportion of publications referring to the IPTS model in main suicide research journals;

Source: https://www.tandfonline.com/doi/full/10.1080/07481187.2018.1527796

Such significant sightings are just one demonstration of the seduction in Suicidology toward reductionist thinking, where it is easier to attempt to reduce complex, wicked and perplexing challenges, such as suicide, into simplistic models, than to consider suicide from a more holistic, comprehensive and qualitative perspective. Hjelmeland & Birthe Loa Knizek (2019) offer that;

We cannot limit our study of something as complex and contextual as suicide “to ways of thinking that grew out of yesterday’s physics” (Bruner,1990, p. xiii). Suicide must be understood in a life-course perspective; not in terms of simplistic “proximal causes” but through the life-history with developmental and relational issues taken into consideration in the analysis. For this, we need qualitative research. (Hjelmeland & Knizek, 2016)

O’Connor’s Integrated Motivational-Volitional (IMV) model is another developed from a reductionist ontological perspective. For example, as O’Connor notes;

The guiding principle that led to the development of the IMV model was the desire to synthesize the extant evidence into a detailed theoretical framework that could make predictions about the factors that lead people to think about suicide and those factors which govern whether people act on their thoughts. (2018, p.2)

Based on three phases, the pre-motivational phase, the motivational phase and the volitional phase, O’Connor (2018) shares much in common with Joiner’s earlier developed model. The IMV model also refers to Joiner’s ideas of both thwarted belongingness and burdensomeness, then builds on these when considering the pre-motivational phase.  

Highlighting the appeal of representing theories as models, the IMV model is most often represented pictorially as included below:

Source: https://www.suicideresearch.info/the-imv

In doing this, it may be on the one hand helpful to ‘work through’ a model as a way of making sense of suicide, however, like all models, represented pictorially or otherwise, this also restricts our thinking and critical reflection.  The illusion that models may create is one of definitive answers, even to the most complex of questions and challenges.

One factor that appears to be missing in both Joiner and O’Connor’s models is both a social and a-rational understanding of a person and of suicide. Both models seem to concentrate on an individualist perspective of people, and allude to the ‘decision’ of suicide, as one made consciously and by an individual.

There is little reference in either model of the social psychological or the unconscious influences that may impact on the decision of a person to take their own life. What impact may this have on how we make sense of suicide?

While societal and environmental factors are considered in both models, individuals exist only as a social construct (Buber, 1969). The missing considerations in both models are that impacts that the social environment has on decisions (to suicide) and whether all such decisions are made consciously. Further exploration of the unconscious factors, that is those, that may only become obvious on reflection and with hindsight (and hence, may not be possible to ‘prevent’, although this will require an entirely separate meditation), would serve to enhance both models, if the aim is to make sense of suicide.

A more social and holistic, rather than individualistic perspective to sensemaking and suicide, could emerge when considering a social psychological perspective, reflecting on how our social arrangements and how we organise ourselves (Weick, 1979) for example, and how these may impact on people in our living and being together (Brenner, 2016) with each other. In considering this approach we may seek to understand how the political environment may ‘dehumanise’ people and lead them to have feelings such as thwarted belongingness and perceived burdensomeness.

We may also seek to explore how a world focused on consumerism, efficacy and positivism may impact people already feeling like they don’t belong and are of no-use to others. A capitalist world fixated on efficiency and in what Ellul (1964) describes as The Technological Society, only seeks to reinforce these factors.

While these factors may not easily fit into a model as they are more existential, philosophical and social psychological questions, nonetheless these may be helpful questions to ask if our quest is to make sense of suicide and its etiology.

On the question of a person making the decision to take his or her life made consciously, a more holistic perspective would surface if an exploration of the unconscious factors related to decision making (Plous, 1993) were included. That is, those factors that may only become obvious upon reflection and in hindsight. A consideration of the unconscious in decision making may serve to develop both Joiner and O’Connor’s models.

The usefulness and limitation of models and frameworks in understanding suicide is a paradox that must be held in making sense of suicide. If we were to accept this paradox, we may be able to better recognise and then support people showing signs of both thwarted belongingness and burdensomeness and not allow this to restrict our exploration of suicide. In doing this we may continue to learn more about suicide and its etiology.

About the Author:

Robert Sams is a student at Griffith University and the Australian Institute for Suicide Research and Prevention (AISRAP) currently completing the post-graduate Masters of Suicidology program. Rob is also has post-graduate qualifications in the Social Psychology of Risk (ACU) and an undergraduate degree in Health and Safety (University of Newcastle).

Rob has been involved with Lifeline, Australia’s eminent suicide prevention and crisis support service, since 2012 and authored his first book, Social Sensemaking in 2016. Rob has a particular interest in a community-led approach to suicide prevention and he proudly lives on the land of the Awabakal people in Newcastle, NSW.

This paper is adapted from a recent essay completed in Rob’s studies in Suicidology.

Twitter: https://twitter.com/rob_sams     LinkedIn: https://www.dhirubhai.net/in/robert-sams-6b171110/

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