Suicide and the Intolerable State of a Fragmented Self
Self murder: Suicide and the intolerable state of a fragmented self
Peter N. Chamberlain BA, BHSc (Hons)
School of Psychology and Discipline of Psychiatry
Submitted in partial fulfilment of the requirements for the combined degree of Master of Psychology (Clinical)/Doctor of Philosophy
November 2010 i | Suicide and the intolerable state of a fragmented self
ii | Suicide and the intolerable state of a fragmented self Declaration
This thesis contains no material which has been accepted for the award of any other degree or diploma in any university or any other tertiary institution and, to the best of my knowledge and belief, contains no material previously published or written by another person, except where due reference is made in the text.
I give consent for this copy of my thesis, when deposited in the Adelaide University Library, to be made available for loan and photocopying, subject to the provisions of the Copyright Act 1968.
I also give permission for the digital version of my thesis to be made available on the web, via the University’s digital research repository, the library catalogue, the Australasian Digital Theses Program (ADTP) and also through the web search engines, unless permission has been granted by the University to restrict access for a period of time.
I acknowledge that the copyright of my published work contained within this thesis (listed below) resides with the copyright holder of that work:
Chamberlain, P., Goldney, R., Delfabbro, P., Gill, T. & Dal Grande, L. (2009). Suicidal ideation: The clinical utility of the K10. Crisis, 30, 39-40.
Peter Chamberlain 12 November 2010
iii | Suicide and the intolerable state of a fragmented self Dedication
This thesis is dedicated to
Cynthia and Bernard Chamberlain,
and to
the memory of those who chose suicide to escape the intolerable burden of their psychological distress
iv | Suicide and the intolerable state of a fragmented self Abstract
Suicidal behaviour remains a serious public health issue worldwide despite the substantial literature on the subject and the development and implementation of prevention and intervention strategies. Notwithstanding the considerable contributions of researchers to date, suicidality is not fully understood and there remains a subgroup within the suicidal population whose behaviour cannot be adequately explained in terms of current understandings.
Consequently, this thesis applies Heinz Kohut’s (e.g. 1971, 1977) psychoanalytic theory of self psychology to the subject of suicidality. Specifically, it examines the relationship between individual differences in the cohesiveness of the construct of self and suicidal behaviour. Self psychology attributes primacy to the self in the human experience, and is essentially a theory of structural deficit in the self. The theory focuses on the enduring psychological effort to realise ones ambitions and maintain a healthy sense of self cohesion.
The research has a clinical emphasis and applies a mixed methods approach to data collection and analyses. Several epidemiological survey data sets are analysed to progress the central argument that individuals with a fragmented sense of self are vulnerable to suicidal behaviour. Additional data are also collected through the 2009
South Australian Health Omnibus Survey, the Australian National Epidemiological Study of Self Injury (Martin, Swannell, Harrison, Hazell, & Taylor, 2010), and several samples of convenience. The mixed method study collected qualitative and quantitative data from suicide attempters admitted to the emergency department of the Royal Adelaide Hospital and quantitative data from controls, resulting in the development of the Adelaide Self
Cohesion Scale (ASCS). The final study validated the measure with data from suicide attempters, suicidal ideators, and community controls.
v | Suicide and the intolerable state of a fragmented self The results of the research demonstrate that one’s sense of self is a core determinant for vulnerability to suicidal behaviour. The key suicidality findings are: (1) the significance of individual differences in the stability of self, and how this relates to early life experiences, (2) experiences of an incohesive sense of self is common in the suicidal, (3) trauma, as a risk factor, is best understood in terms of its proximity to one’s sense of self, and (4) sexual orientation is a more appropriate research variable than
biological sex in suicide research. In addition to providing a plausible explanation for
individual differences in the suicidal, this novel approach to suicidality also advances two
original concepts: the extension of Cannon’s (1929) fight-flight response, and the ASCS
for the measurement of self cohesion
The results of the findings in this dissertation have important implications for
understanding the unique role of one’s sense of self in determining an individual’s
vulnerability to suicidal behaviour. The consequences for clinical interventions and
prevention strategies, together with the limitations of the research and future directions,
are discussed.
vi | Suicide and the intolerable state of a fragmented self Acknowledgements
My sincere thanks to:
My supervisors: Associate Professor Paul Delfabbro and Emeritus Professor Robert Goldney for their insight, guidance and support. Their mentorship, complementary approaches to supervision, and access to funding, made the experience all the better. Paul’s humour and Bob’s graciousness have forever influenced my world view, and I am very grateful.
The South Australian Department of Health: For the postgraduate scholarship and access to epidemiological data. Associate Professor Anne Taylor and Ms Lora Dal Grande from the Population Research Outcomes Studies unit were particularly supportive.
The Emergency Department, Royal Adelaide Hospital: Dr Giorgina Kimber, Associate Professor Norman James, Mr Karl Haas and all the members of the mental health team for their accommodations and interest in my studies.
The University of Queensland: Professor Graham Martin for permission to access and analyse data from the Australian National Epidemiological Study of Self Injury. So too Ms Sarah Swannell, for her dialogue on the relationship between sexual orientation and self harm.
The participants: For their generous disclosures.
The academic and professional staff within the School of Psychology and Discipline of Psychiatry: For their tolerant and supportive responses to my many requests.
My peers: For their friendship and support; particularly Victoria, Kate, Ryan, Katie, Tracy, and especially Laura, for her statistical advice.
My family: For their love and encouragement, which warrant an honourable mention in despatches: Cynthia, Leigh, Melanie, Felicity and John, Tiffany and Michael, Joshua and Livia, Jude, Charlotte, Amos, and Jeannine.
Most importantly, Diane: For everything.
vii | Suicide and the intolerable state of a fragmented self Table of Contents
Declaration ...... iii Dedication ...... iv Abstract ...... v Acknowledgements ...... vii Table of Contents ...... viii List of Tables ...... xiii List of Figures ...... xv List of Appendices ...... xvi Preface ...... xvii
SECTION A: LITERATURE REVIEW ...... 1 Chapter 1: Suicide ...... 1 1.1 Introduction ...... 1 1.2 Historical Context ...... 2 1.3 Nomenclature ...... 5 1.4 Research in Suicidality ...... 7 1.4.1 Ideation as a Proxy ...... 7 1.5 Risk Factors ...... 9 1.5.1 Sex and Age ...... 10 1.5.2 Biological Factors ...... 11 1.5.3 Personality Traits ...... 12 1.5.4 Psychopathology ...... 13 1.5.4.1 Clinical Disorders (Axis 1) ...... 14 1.5.4.2 Personality Disorders (Axis 2) ...... 15 1.5.5 Social Factors ...... 16 1.5.6 Previous Suicidal Behaviour...... 17 1.6 Suicide Prevention ...... 18 1.6.1 Population Strategies ...... 18 1.6.2 Clinical Management ...... 19 1.7 Theories of Suicide ...... 22 1.7.1 Cry of Pain ...... 23 1.7.2 Psychache ...... 24 1.7.3 The Interpersonal-Psychological Model...... 25 1.7.4 Escape from Self ...... 27 1.8 Discussion ...... 31
viii | Suicide and the intolerable state of a fragmented self Chapter 2: Kohutian Self Psychology ...... 32 2.1 Introduction ...... 32 2.2 The Construct of Self ...... 38 2.3 Early Life Narcissistic Grandiosity ...... 40 2.4 Selfobjects ...... 42 2.5 Empathy ...... 43 2.6 Selfobject Transferences ...... 44 2.6.1 Mirroring: the need for applause ...... 46 2.6.2 Idealisation: the need for security ...... 49 2.6.3 Twinship/Alter Ego: the need to belong ...... 50 2.7 Self Fragmentation ...... 52 2.8 Disorders of the Self ...... 55 2.8.1 Devitalisation ...... 56 2.8.2 Preserving a Cohesive Self ...... 56 2.8.3 Forestalling Fragmentation...... 57 2.9 Applied Self Psychology: ...... 57 Chapter 3: The Construct of Self ...... 62 3.1 Introduction ...... 62 3.2 Identity ...... 66 3.3 Multiple Selves ...... 67 3.4 Conceptual History ...... 69 3.5 The Contemporary Self ...... 76 3.5.1 Reflexive Consciousness ...... 79 3.5.2 Interpersonal Being ...... 85 3.5.3 Executive Function ...... 90 3.6 Autobiographical Memory ...... 94 3.7 Contributions from Neuro-psychoanalysis ...... 99 3.8 Summary ...... 103 Chapter 4: Suicidal Behaviour, Self and Intolerable States ...... 105 4.1 Introduction ...... 105 4.2 Fight, Flight or Fragment? ...... 110 4.3 Summary of Section A ...... 124
SECTION B: QUANTITATIVE INVESTIGATIONS INTO THE RELATIONSHIP BETWEEN SELF AND SUICIDAL BEHAVIOUR ...... 125 Chapter 5: Individual Differences in Psychological Distress and Suicidality .... 125 5.1 Introduction ...... 125
ix | Suicide and the intolerable state of a fragmented self 5.2 Study 1: Psychological Distress and Suicidal Ideation ...... 126 5.2.1 Method ...... 126 5.2.1.1 Survey design and participants ...... 126 5.2.2 Measures ...... 127 5.2.3 Data analysis ...... 129 5.2.3 Results ...... 129 5.3 Study 2: Suicidal Ideation and the Experience of a Fragmenting Self ...... 131 5.3.1 Method ...... 131 5.3.1.1 Survey design and participants ...... 131 5.3.2 Measures ...... 131 5.3.3 Data analysis ...... 132 5.3.4 Results ...... 132 5.4 Discussion ...... 133 Chapter 6: Self, Trauma and Suicidal Behaviour ...... 136 6.1 Introduction ...... 136 6.2 Kohutian Trauma Theory...... 139 6.3 Method ...... 143 6.3.1 Survey Design and Participants ...... 143 6.3.1.1 Health Omnibus Survey ...... 143 6.3.1.2 IDACC Project ...... 145 6.3.2 Measures ...... 145 6.3.3 Data Analysis ...... 146 6.3.3.1 Health Omnibus Survey ...... 146 6.3.3.2 IDACC Project ...... 148 6.4 Results ...... 150 6.4.1 Health Omnibus Survey ...... 150 6.4.2 IDACC Project ...... 151 6.5 Discussion ...... 152 Chapter 7: Self, Sexuality and Suicidal Behaviour ...... 164 7.1 Introduction ...... 164 7.2 Method ...... 170 7.2.1 Survey Design and participants ...... 170 7.3 Measures ...... 171 7.4 Data analysis ...... 172 7.5 Results ...... 172 7.6 Discussion ...... 174
x | Suicide and the intolerable state of a fragmented self 7.7 Summary of Section B ...... 182
SECTION C: MEASUREMENT OF SELF COHESION AND THE RELATIONSHIP WITH SUICIDAL BEHAVIOUR ...... 183 Chapter 8: Measurement of the Self: Part 1 ...... 183 8.1 Introduction ...... 183 8.2 Phase 1: Suicide Attempters ...... 187 8.2.1 Method ...... 187 8.2.1.1 Participants...... 187 8.2.2 Measures ...... 188 8.2.2.1 Mini Mental State Examination ...... 188 8.2.2.2 Visual Analogue Scale: Self Harm ...... 189 8.2.2.3 Ruminative Response Scale ...... 189 8.3 Procedure...... 191 8.4 Phase 2: Healthy Controls and Ideators ...... 192 8.5 Method ...... 192 8.5.1 Participants ...... 193 8.5.2 Measures ...... 193 8.6 Results ...... 194 Chapter 9: Measurement of the Self: Part 2 ...... 195 9.1 Introduction ...... 195 9.2 Dominant Themes ...... 196 9.3 Themes Independent of Theory ...... 200 9.3.1 Non-empathic Childhood Environment ...... 200 9.3.2 Need for Love ...... 203 9.3.3 Inability to Intimately Connect ...... 205 9.4 Themes Relating to Theoretical Perspectives ...... 208 9.4.1 Mirroring: The need for applause ...... 208 9.4.2 Early Life Narcissistic Grandiosity ...... 209 9.4.3 Narcissistic Rage...... 209 9.4.4 Idealisation: The need for security ...... 210 9.4.5 Twinship/Alter Ego: The need to belong ...... 211 9.4.6 The Vertical Split ...... 212 9.4.7 Self Fragmentation ...... 212 9.5 Discussion ...... 213 Chapter 10: Measurement of the Self: Part 3 ...... 215 10.1 Introduction ...... 215
xi | Suicide and the intolerable state of a fragmented self 10.2 Rasch Analysis ...... 218 10.2.1 Analysis of Self Dimensions ...... 220 10.3 Rasch Analysis - Brooding Items ...... 224 10.4 Configuration of the ASCS ...... 227 10.5 Discussion...... 228 Chapter 11: Validation of the Adelaide Self Cohesion Scale ...... 236 11.1 Introduction ...... 236 11.2 Method ...... 237 11.2.1 Survey design and participants ...... 237 11.2.2 Measures ...... 238 11.3 Data Analysis ...... 239 11.4 Results ...... 239 11.4.1 Confirmatory Factor Analysis ...... 239 11.4.2 Univariate Analyses ...... 242 11.5 Discussion...... 243 Chapter 12: Concluding Discussion ...... 245 12.1 Chapter Overview ...... 245 12.2 Theoretical Review ...... 246 12.2.1 The Theory of Self Psychology ...... 246 12.2.2 The Construct of Self ...... 247 12.3 Fight, Flight or Fragment ...... 248 12.4 Primary Research Findings ...... 249 12.4.1 Individual Differences ...... 249 12.4.2 Self, Trauma and Suicidal Behaviour ...... 250 12.4.3 Self, Sexuality and Suicidality ...... 250 12.4.4 Self Cohesion ...... 251 12.5 Implications ...... 257 12.5.1 Clinical Implications ...... 257 12.5.2 Prevention Strategies ...... 257 12.5.3 Research Implications ...... 258 12.5.4 Implications for Self Psychology ...... 258 12.6 Methodological Considerations ...... 259 12.7 Future Research ...... 260 12.8 Concluding Comment ...... 260 References ...... 262 Appendices ...... 316
xii | Suicide and the intolerable state of a fragmented self List of Tables
Table 1.1: Suicidal intent and lethality associated with definitions of behaviour ...... 6
Table 3.1: Summary of various meanings attributed to the private and public self ...... 66
Table 3.2: Contemporary interpretation of James’ analysis of the empirical self ...... 71
Table 3.3: Summary of dominant control theories ...... 90
Table 5.1: The results of the univariate analysis for each of the K10 categories and the suicidal ideation score...... 129
Table 5.2: Results of the logistic regression indicating the likelihood of experiencing suicidal ideation in terms of levels of psychological distress ...... 129
Table 5.3: Results of the logistic regression indicating the likelihood of experiencing suicidal ideation in relation to the the frequency of experiences of self fragmentation as predicted by the theory of self psychology ...... 132
Table 6.1: Pattern and Structure Matrix for the HOS PAF with Oblimin Rotation ...... 146
Table 6.2: Pattern and Structure Matrix for the IDACC PAF with Oblimin Rotation ...... 148
Table 6.3: HOS logistic regression indicating the likelihood of experiencing suicidal ideation ...... 149
Table 6.4: IDACC logistic regression indicating the likelihood of experiencing suicidal ideation ...... 150
Table 7.1: Participant response rates and reasons for not taking part ...... 169
Table 7.2: Frequencies for sexual orientation, suicide attempt and suicidal ideation ...... 170
Table 7.3: Results of the logistic regression indication the likelihood of attempting suicide in terms of sexual orientation in compairson to heterosexuals ...... 171
Table 7.4: Results of the logistic regression indication the likelihood of experiencing suicidal ideation in terms of sexual orientation in compairson to heterosexuals ...... 162
Table 8.1: Participant demographic, method of attempt and mental health status ...... 190
Table 8.2: Demographics and psychological well being responses ...... 191
Table 10.1: Results for the suicide attempters: (#), MMSE, RSS and VASSH scores ...... 213
Table 10.2: Group response mean, standard error, and standard deviation for the original BSE dimensions ...... 214
Table 10.3: Group response mean, standard error, and standard deviation for the additional dimensions ...... 215 xiii | Suicide and the intolerable state of a fragmented self Table 10.4: Draft ASCS misfit items removed ...... 218
Table 10.5: Draft ASCS items retained ...... 219
Table 10.6: ASCS Self Dimensions: Rasch statistical summary ...... 220
Table 10.7: ASCS Brooding items: Rasch statistical summary ...... 223
Table 10.5: ASCS Brooding items: Rash item fit statistics ...... 223
Table 11.1: Age and sex composition for the participant samples ...... 238
Table 11.2: Age and sex composition for the suicidality group ...... 239
Table 11.3: Estimates for the ASCS ...... 240
xiv | Suicide and the intolerable state of a fragmented self List of Figures
Figure 1.1 Schematic representation of the Theory of Planned Behaviour ...... 8
Figure 1.2: The diathesis-stress model of suicidal behaviour ...... 10
Figure 1.3: Shneidman’s (1987) three-dimensional cubic model of suicide ...... 24
Figure 1.4: Joiner’s (2005) interpersonal-psychological theory of suicidal behaviour ...... 25
Figure 1.5: The causal process of Baumeister’s (1990) escape theory ...... 27
Figure 2.1: Schematic of the tripolar self ...... 45
Figure 2.2: A diagrammatic representation of the process of empathic selfobject transferences ...... 51
Figure 2.3: A diagrammatic representation of arrested development resulting from failed empathic transferences ...... 54
Figure 3.1: Schematic of social psychology’s contemporary understandings of self ...... 78
Figure 3.2: A common taxonomy of memory ...... 94
Figure 4.1: The stress response and development of allostatic load ...... 115
Figure 4.2: Four types of allostatic load ...... 116
Figure 4.3: Internal and external stressors ...... 119
Figure 6.1: A model of the postraumatic self ...... 158
Figure 7.1: Psychological mediation framework ...... 164
Figure 10.1: The person-item and item-person maps for the ASCS self dimensions ...... 221
Figure 10.2: The ASCS self dimensions non-uniform differential item function graph ...... 222
Figure 10.3: The item-person map for the ASCS brooding items ...... 224
Figure 10.4: The brooding items non-uniform differential item function graph ...... 225
Figure 10.5: A sample of adjective pairs from Section 1 of the ASCS ...... 226
Figure 11.1: CFA measurement of the ASCS ...... 241
Figure 12.1: The process of empathic self object transferences ...... 247
xv | Suicide and the intolerable state of a fragmented self List of Appendices
Appendix A: Information sheet: Mixed methods study ...... 316
Appendix B: Draft Adelaide Self Cohesion Scale ...... 318
Appendix C: Adelaide Self Cohesion Scale ...... 320
Appendix D: Information sheet: Validation of Adelaide Self Cohesion Scale ...... 322
Appendix E: Screen shot of LimeSurvey – participant view ...... 324
xvi | Suicide and the intolerable state of a fragmented self Preface
Suicide and the Intolerable State of a Fragmented Self
There are times in life when the question of knowing if one can think differently than one thinks, and perceive differently that one sees, is absolutely necessary if one is to go on looking and reflecting at all (Foucault, 1987, p. 8).
Suicide is arguably a uniquely human phenomenon, found almost universally throughout recorded history, and it attracts a plethora of historical and culturally contingent explanations. Referred to in earlier times as self murder, this seemingly senseless act appears to strike at the very heart of the human experience. As a result, all manner of social institutions and scientific disciplines have influenced perceptions and explanations of the behaviour. Researchers have made considerable progress toward identifying risk factors, introducing prevention strategies and developing intervention measures in response to the broad empirically-based consensus that the interaction between psychological distress and sociological issues is the principal cause.
Nevertheless, there remains a subgroup within the suicidal population whose behaviour cannot be adequately explained by contemporary psychological and sociological theories. Moreover, and provocatively, some accounts of suicide simply do not appear to completely capture the essence of why attachment to life was insufficient to insulate the person against acting out thoughts of death.
With psychopathology responsible for a significant proportion of suicidal behaviours, the question of how to differentiate between individuals suffering similar levels of psychological distress and their desire to die remains unanswered. It would be naïve to posit a single aetiology, because the evidence is irrefutable that suicide is not the homogenous construct that lay understandings implicitly assume it to be. Indeed, it is the heterogeneity of psychological circumstances that lie behind each completed act of suicide that continues to frustrate clinicians and researchers alike. Consequently, it is
xvii | Suicide and the intolerable state of a fragmented self this dearth of knowledge created by the considerable contributions of others that encourages this enquiry.
Inspired by Strozier’s (2001) biography of psychoanalyst Heinz Kohut and subsequent readings, the objective of this thesis is to determine whether the application of Kohut’s perspective can contribute further to understanding suicide. Specifically, it is the relationship between individual differences in the cohesiveness of the construct of self and suicidality that is the principal focus of this research. Personality is universally viewed as the primary defining characteristic of human individuality, the “putative nucleus” (Berrios & Markova, 2003, p. 9) referred to as the self. Intuitively it is understood to be responsible for, inter alia, the experience of general self-awareness and personal identity. Amongst the many other theorists interested in the construct of self such as Klein, Jung and Winnicott, Kohut figures predominantly for his theory of the self within the general psychodynamic paradigm developed by Sigmund Freud. Kohut, a qualified neurologist, introduced what he referred to as self psychology, which diverges
from the purist psychoanalytic emphasis on instinctive drives, which he considered
subordinate to self cohesion as the central fulcrum of the total personality. A cohesive self, he argued, is essential for psychological wellbeing and any deficits of cohesion result in fragmentation and ultimately psychopathology. Thus, it is through the paradigmatic lens of self psychology that suicide is examined.
The theoretical frame of reference addressed in this thesis is consistent with the classical Kohutian conceptualisation of disorders of the self. This restricted approach is by necessity, and does not imply a rejection of the contemporary theoretical self psychological perspectives and the considerable contributions of others since Kohut first articulated his theories. Self psychology is now too broad a school and Kohut’s original theories have been expanded in divergent directions and emphases, which are beyond the scope of this thesis (e.g. Bacal & Newman, 1990; Lichtenberg, 1989; Shane &
Shane, 1993) . Nevertheless, many post Kohutian contributions are included to elucidate the classical view. Moreover, it is acknowledged that Kohut’s original ideas do
xviii | Suicide and the intolerable state of a fragmented self not enjoy universal support, whether it is within self psychology (Gedo, 1988; Stolorow &
Atwood, 1992) or without (Rubovits-Seitz, 1988). Kohut’s theories are also not without their own assumptions, contradictions and leaps in logic, for these are characteristic of any emerging paradigm (Kuhn, 1962). Further compounding this was his preference for vagueness in terminology, and his tendency to illustrate by clinical example rather than by theoretical argument (Shane, 1992).
Psychology has a number of different approaches to explain the nature and function of the mind. Freud was the first to take the innovative approach of recognising personality as individual and complex processes of constantly seeking to adapt to the environment. These processes are viewed by the traditional psychoanalytic school as biologically driven internal conflicts which can result in maladaptive behaviour and psychological distress. Kohut begged to differ and suggested that psychopathology results from deficits in self cohesion because it interferes with the attempts to combat a devitalised self and maintain psychological wellbeing.
Although Freud is considered by many as the seminal thinker in the psychology of personality, the influence of psychoanalysis has given way to a discontinuity of disparate theoretic approaches such as the Humanistic and Existential, and the
Cognitive-Behavioural. Nevertheless, elements of psychoanalytic thought can be recognised in many of the contemporary understandings of what Wakefield (1992) refers to as the harmful dysfunction of the mind. However, psychoanalysis continues to be surrounded by controversy for its dependence on case-study qualitative data and the vocabulary it employs; recognised as the beginning of a science but not considered to be one (Breger, 2000). Accordingly, any reference to psychoanalytic theory may attract claims of redundancy and be dismissed as archaic knowledge, unsupported by empirical evidence. However, it can be the case, and it is the expectation of this critique, that through the reappearance and application of earlier knowledge, more will be revealed about the dynamics of suicide that may have been obscured by more recent theories.
xix | Suicide and the intolerable state of a fragmented self There are also other ingredients that constitute the self in as much as individual understandings of truth and knowledge, and the significance of the epistemological and ontological contributions are acknowledged. However, philosophical issues are largely omitted so as not to confound or distract from the argument. Nevertheless, philosophical discussion is included where necessary to provide clarity or context. This is particularly so in the chapter on the self, where an uncomfortable tension arises from the difficulty in incorporating a phenomenological construct into an empirical enquiry, and avoiding what
Lewis (2000) refers to as the “incredulous stare” (p.111). Embedded within the discussion that follows is the underlying assumption of the completeness of the self. It is noted because reference to disorders of the mind and the nuances of language may be interpreted as implying a dualistic perspective, which is not the case.
The thesis has a clinical emphasis and applies a mixed-methods approach to addressing the objectives discussed above. This research approach is taken because it converges different, but complementary, data collected on the same topic (Creswell,
2009; Creswell & Plano Clark, 2007), and is elaborated further in Chapter 8.
Nevertheless, to progress the central argument that individuals with a fragmented sense of self are vulnerable to suicidal behaviour, several epidemiological survey data sets are analysed. Specific data are also collected through the 2009 South Australian Health
Omnibus Survey, the Australian National Epidemiological Study of Self Injury (Martin et al., 2010), and psychology students from the University of Adelaide. The final two studies
include data from suicide attempters admitted to the emergency department of the Royal
Adelaide Hospital.
The structure of this dissertation is designed to bring together the subjects of
suicidal behaviour, self, and self psychology in a manner that provides meaning to the relationship between a subjective experience and an explicit act. To that end, the dissertation is presented in three sections. Section A is a literature review comprising four chapters. Chapter 1 provides context by way of a broad introduction to suicide and also includes a discussion of several theories relevant to the construct of self. Chapters
xx | Suicide and the intolerable state of a fragmented self 2 and 3 introduce the theory of self psychology, and the construct of self respectively.
Chapter 4 concludes the section with a discussion on the biological structures associated with stressors, and offers a hypothesis regarding the psychological burden of human executive functioning in the form of an extension of Cannon’s (1929) fight-flight response. Section B seeks to implicate the construct of self in suicidality and demonstrate the validity and utility of the theory of self psychology. Several quantitative studies are presented commencing with Chapter 5, which details two exploratory studies directed toward demonstrating a gap in the literature relating to individual differences within suicidality that might plausibly be explained by the theory of self psychology.
Chapters 6 and 7 continue the focus on self and suicidality by examining respectively the subjective experiences of trauma and sexual orientation. Section C develops and validates a measure of self cohesion and concludes the thesis. Chapters 8, 9, and 10 present a mixed method study and the development of the Adelaide Self Cohesion
Scale. The scale is validated in Chapter 11, and a final discussion is presented as
Chapter 12.
It is acknowledged that this is not an exhaustive examination of the relationship between self and suicidal behaviour. Although a great deal of information is covered in what follows, it is inevitable that as a result of the effort to be broadly inclusive within the limitations of this dissertation, many topics will not receive the attention they might otherwise attract.
Finally, this thesis is largely written in the masculine to avoid inconsistency with the considerable early psychoanalytic literature included, and is not intended in any way to present a gender bias.
xxi | Suicide and the intolerable state of a fragmented self SECTION A: LITERATURE REVIEW
Chapter 1: Suicide
Suicide
As for suicide [it is] a terrible but utterly natural reaction to the strained, narrow, unnatural necessities we sometimes create for ourselves (Alvarez, 1971, p. 272)
1.1 Introduction
Suicidal behaviour remains a significant social challenge worldwide despite considerable research into its aetiology and the multidimensional approaches to treatment and prevention. The World Health Organisation (WHO, 2009) reports that approximately one million people die from suicide annually, representing one death every 40 seconds. Moreover, the 60% increase in reported suicides over the last 45 years is alarming given the increasing focus on the subject. Internationally, the suicide rate is approximately 11 per 100,000, but rates vary considerably partly because of methodological issues relating to data collection. For example, the WHO reported national suicide rates ranging from 0.1 to 38.6 per 100,000. Prevalence rates also differ within countries as illustrated by the United States of America, where there is a frequently reported three-fold variation between the lowest and highest state rates
(National Institute of Mental Health, 2010). Several countries have not followed the international trend with Australia’s suicide rate, for example, reducing since 19971
(Goldney, 2006b). Nevertheless, suicide remains a leading cause of death (Australian
Bureau of Statistics, 2008). The Australian Senate (Community Affairs References
Committee, 2010) enquiry into the impact of suicide reported that over 2000 Australians die by suicide each year, and that over 60,000 people are estimated to attempt to take
1 This is addressed later in the chapter, but is generally attributed to prevention strategies restricting access to means.
1 | Suicide and the intolerable state of a fragmented self their own life. Notwithstanding the extent of the published data, the statistics are believed to be an underestimation of the actual suicide rate in the population (De Leo,
2010; Jobes, Berman, & Josselon, 1986; McPhedran & Baker, 2008).
Suicide stands in juxtaposition to the wider community assumption that life is worth living and that all self-destructive behaviours are irrational (Silverstein, 2000).
Indeed, Camus’ (1971) commented that “in a man’s attachment to life there is something stronger than all the ills in the world” (p. 14), yet his widely cited enigma remains a challenge: “[t]here is but one truly serious philosophical problem, and that is suicide.
Judging whether life is or is not worth living amounts to answering the fundamental questions of philosophy” (p. 11). Research has unequivocally demonstrated that suicidality is a complex behaviour that arises from psychological, biological, and environmental factors. However, as O’Connor and Sheehy (2000) emphasise,
“contemporary views on suicide do not exist in a historical vacuum” (p.1) and current
Western understandings differ substantially from those of the past. Shneidman (2001) observed that these historical changes in conceptualisation have focused predominantly around the locus of blame.
1.2 Historical Context
In the pre-Christian Greek and Roman civilisations, suicide was tolerated and frequently viewed as an ideal death. The act was lauded when it involved prominent members of the patriarchy who sought death for honourable reasons such as principle, grief or shame. Conversely, the act attracted moral condemnation when it involved members of the lower social classes, or involved cowardice or irreverence to the gods
(Shneidman, 2001). Minois (1998) noted that although early Christian scholars recognised “the grandeur” (p. 40) of suicides in classical antiquity, they also recognised a problem for Christian dogma: “if the Old Testament did not condemn suicide, if baptism removed all sin, and if suicide were allowed in order to avoid sin and hasten eternal life, then suicide, ideally through martyrdom, could become the obvious choice for Christian
2 | Suicide and the intolerable state of a fragmented self converts” (O'Connor & Sheehy, 2000, p. 3). Primarily through the contributions of Saint
Augustine, Christianity overcame this dilemma by applying the philosophy of Plato and the Pythorageans wherein life is considered God’s will. Accordingly, suicide was reframed and condemned as a rejection of God’s will, and therefore a crime against the
Church.
This remained the dominant view until the period of Enlightenment, which witnessed both philosophers and humanitarians seeking to position suicidal behaviour beyond the moral teachings of the Church. Indeed, Sym (1637) appears to be the first to record this shift in emphasis, by commenting that “[s]elf-murder is prevented, not so much by arguments against the fact; which disswades from the conclusion; as by the discovery and removall (sic) of the motives and causes, whereupon they are tempted to do the same: diseases are cured by removing the causes rather than of their symptoms”
(cited by Hunter & MaCalpine, 1963). Philosophers led the assault on the concept of sin with Rousseau and Hume, for example, seeking to implicate societal factors and decriminalise the act (Minois, 1998).
During the 19th century, the psychology of suicide became an increasing focus for medicine, although the contributions from that time have, until recently, remained in the shadow of Durkheim’s (1897/1958) sociological study Le Suicide (Goldney, Schioldann,
& Dunn, 2008). Suicide is now, for the most part, understood by reference to mental health and environmental factors rather than moral, religious or criminal determinations.
The move to the medical model, however, has not been without its critics, who argue that accompanying this conceptualisation is “a compulsory ontology of pathology” (Marsh,
2010, p. 4). Cawte (1998) contends that these criticisms are unwarranted as they appear to be directed towards the first half of the 20th Century, and do not appreciate the
“paucity of theoretical resources then available ... [and the difficulty in managing] grossly psychotic patients without neuroleptics” (p.24). Cawte attributes the public negativity about mental health generally, and the psy professions specifically, to Dr Henry
3 | Suicide and the intolerable state of a fragmented self
Maudsley2. Maudsley actively proclaimed that psychological distress reflected a weak and enduring constitution: “no mortal can transcend his nature: and it will be impossible to raise grapes from thorns or figs from thistles ... Suicide or madness is the natural end of a morbidly sensitive nature with a feeble mind” (cited by Cawte, 1998, p. 52). Szasz
(1979) takes a strong philosophical position in arguing that suicidal behaviour is not a medical problem at all, but rather a moral one, and that mental health practitioners are not justified in enforcing suicide prevention. Notwithstanding the criticisms directed toward the mental health professions, research into suicide now encompasses a variety of scientific disciplines, each maintaining different foci, and recognising that “a suicidal outcome is borne from a constellation of suicidogenic variables” (Fairweather-Schmidt,
2007, p. 2).
An historical legacy remains in the view that suicidality is abnormal behaviour, “an
unnatural feature of human kind” (Preti, 2007, p. 832). O’Connor and Sheehy (2000)
question whether suicide is indeed fundamentally abnormal, given the frequency of the
behaviour. Their argument centres on the criteria of what defines behaviour as
psychologically abnormal. Categorising behaviour as abnormal requires a comparison
with the behaviours of others, and interpreting the consequences of the behaviour for
others. Thus, abnormality is determined by norms, that is, “what is ‘right’, ‘proper’ or
‘natural’, and suicidal behaviour has often been regarded as an unacceptable breach of
these norms. But ‘unacceptable’ to whom?” (p. 5). Moreover, statistical definitions are
also problematic inasmuch as determining how far from the population mean can be
considered abnormal.
In reality it is often extremely difficult to construct dimensions for many kinds of
very important behaviours – friendship, honesty, love, trust, regret and so on –
that are fundamental to our social and personal interactions with others and that
are known to be implicated in many acts of suicide (p.6).
2 Dr Maudsley (1835-1918) is best known for London’s Maudsley hospital, and his role as editor for the Journal of Mental Science
4 | Suicide and the intolerable state of a fragmented self
Although several researchers have successfully applied ethological argument to pre-clinical models of suicidality (e.g. Goldney, 1980, 2001; Lester & Goldney, 1997), the behaviour itself is generally considered to be uniquely human. Nevertheless, interest remains in the legendary accounts of alleged animal suicide such as the Lemmings seemingly irresistible compulsion to self-destruction (Einsidler & Hankoff, 1979). Stoff and Mann (1997) refer to the stories of animal suicide as “frequently mythical ... and anthropomorphized to a degree” (p.3), or what Chitty (1996) refers to as “beautiful hypothesis, ugly facts” (p.1). Preti’s (2007) literature review of suicide among animals concluded that researchers “have not identified suicide in nonhuman species in field situations, despite intensive study of thousands of animal species” (p. 847). Animal suicide models rest on the analogy with learned helplessness, and it is meaningless to conceive atypical animal behaviour as analogous to suicidal behaviour in humans.
1.3 Nomenclature
The terminology surrounding suicidality is both varied and confusing as attempts are made to accommodate the problem of ‘intent’ (Cantor, 2000; Moscicki, 1995). The term parasuicide (Kreitman, 1977) was introduced to overcome the problem associated with the non-fatal behaviours subsumed under the term attempted suicide, such as self- injury or poisoning. For instance, behaviour understood to be attempted suicide may be premeditated or impulsive, and intended to end one’s life or elicit help, or a combination of both these intentions. Despite Kreitman’s claim that the term parasuicide avoids reference to the individual’s (unknown) intention, critics have argued that the term still suggests an underlying intent to die (e.g. Hawton & Catalan, 1987). O’Carroll et al.
(1996) attempted to address the issue by proposing a universal nomenclature, yet consensus has yet to be realised. For this reason, the terminology in this dissertation must first be clarified. Given the principal focus of this thesis is directed towards the relationship between self and suicidal behaviour, Shneidman’s (1985) solution-focused understanding of suicide has intuitive appeal. Suicide “is a conscious act of self-induced
5 | Suicide and the intolerable state of a fragmented self annihilation, best understood as a multidimensional malaise in a needful individual who defines an issue for which suicide is perceived as the best solution” (p. 22). Indeed, his concept of annihilation as an escape resonates with the principal hypothesis of this thesis in that some suicidal behaviour is directed toward evading the intolerable state of a fragmented self. Goldney’s (2008, p. 11) pragmatic definitions of suicidal behaviour are consistent with this emphasis and are the terms employed throughout this dissertation, Table 1.1 also refers:
a. Suicide – a self inflicted act resulting in death, albeit with varying suicidal intent. b. Attempted suicide – self-injurious behaviour with vary degrees of suicidal intent and lethality. c. Suicidal ideation – thoughts of self-injurious behaviour with variable suicidal intent but no lethality, and d. Self harm – deliberate non-fatal self injury with no suicidal intent.
Table 1.1 Suicidal intent and lethality associated with definitions of behaviour
Category Suicidal Intent Lethality
Suicide Variable – usually high Absolute
Attempted Suicide Variable Variable
Suicidal Ideation Variable Nil
Self-harm Nil Variable, usually low
Adapted from Goldney (2008, p.11)
The terms suicidality and suicidal behaviour also feature in the chapters that follow, and are used to encompass a range of behaviours from suicidal ideation through to completed suicide. Alternative synonyms will only be included when referencing sources that employ such terms.
6 | Suicide and the intolerable state of a fragmented self
1.4 Research in Suicidality
One of the most problematic challenges to conducting suicide research is that the very subjects of interest are, by definition, no longer alive. Moreover, Williams (1996) advocates suspicion of any argument that “assumes, a priori, that self-harm behaviour must always have suicidal intent, and that, if it is not found, then it is ‘latent’” (p. 150). As a consequence, research is limited to studies of completed suicide (e.g. psychological autopsies, suicide notes, epidemiological approaches) and those that, like this dissertation, focus on suicidal ideators or attempters. Although it is generally acknowledged that there is overlap between different suicidal behaviours, there are certain characteristics within suicide completers that differ from other suicidal behaviour
(Berman, Jobes, & Silverman, 2006); nevertheless, suicide attempters and ideators are considered suitable proxies. This follows the conceptualisation of suicidal behaviour as a continuum; that thoughts of suicide precede suicidal behaviour (Botega, 2005;
O'Connor & Armitage, 2003). Evidence for the concept of a continuum, and the validity of suicidal behaviour as a proxy for intent, comes from studies by Matheson (2000) and
O’Connor and Armitage (2003), who applied the Theory of Planned Behaviour (TPB)
(Ajzen, 1988) to examine the validity of the model within the domain of suicidality.
1.4.1 Ideation as a Proxy
The TPB evolved from the earlier Theory of Reasoned action (Ajzen & Fishbein,
1980). The assumption behind this cognitive theory is that most conscious behaviour is rational and goal-orientated (Connor & Armitage, 1998). Moreover, the TPB is also grounded in expectancy-value theory which posits that before deciding upon an action, individuals will consider the options available to them as well as the consequences
(Aizen, 2002, 2003), implying a causal relationship between attitudes and behaviour that is mediated by intentions. The TPB (Figure 1.1) holds that behaviour is directly related to
7 | Suicide and the intolerable state of a fragmented self behavioural intentions which are, in turn, influenced by three considerations (Ajzen,
1988).
NOTE: This figure is included on page 8 of the print copy of the thesis held in the University of Adelaide Library.
Figure 1.1 Schematic representation of the Theory of Planned Behaviour (Aizen, 2002). Note that Ajzen changed his surname to Aizen and both spellings appear in the literature
First, beliefs about the outcome of the behaviour, together with evaluations of these outcomes, produce an attitude towards the behaviour. Second, the beliefs about the expectations of others (about the behaviour) give rise to a subjective norm. Thirdly, beliefs about any factors that may either impede or facilitate the completion of the behaviour (e.g. resources and opportunity), as well as the strength of each of these beliefs, determines perceived behavioural control; that is, beliefs about the level of personal control over specified behaviour. According to the TPB, attitudes, subjective norms, and perceptions of control are, in turn, respective functions of intention and are also said to capture the motivational factors influencing behaviour. Additionally, Ajzen
(1998) proposed that individual perception of behavioural control is based on past experiences. This is consistent with the results of several studies which have indicated that past suicidal behaviour (including ideation) is a strong predictor of future suicidal behaviour (e.g. Joiner, 2002; Truant, O'Reilly, & Donaldson, 1991). Aizen (2002) theorised that the more positive the attitude and subjective norm, and the stronger the perceived control, the greater the intention will be to perform the behaviour. The model
8 | Suicide and the intolerable state of a fragmented self also allows for the capture of external factors that may be beyond the immediate control of the individual as these, in addition to intention, are likely to influence behaviour.
The results of both Matheson’s (2000) and O’Connor and Armitage’s (2003) studies supported the utility of the TPB. Matheson demonstrated that the model predicted suicidal intent with perceived behavioural control accounting for the greatest proportion of the variance. In a complementary study, O’Connor and Armitage applied an extended TPB, which included moral norms and anticipated effect. Their results demonstrated that people with a history of deliberate self-harm, in comparison to those who do not, “differentiate [in terms of] ... attitudes, subjective norms, self-efficacy, moral norms and anticipated effect” (p. 204). These contributions support several meta- analyses that have demonstrated the predictive power of behavioural intention (e.g.
Armitage & Connor, 2000; Sniehotta, Scholz, & Schwarzer, 2005) and the validity of applying “behavioural intention [i.e. suicidal ideation] as a proxy for actual behaviour, where such measures would be inappropriate or difficult to obtain” (p.198).
1.5 Risk Factors
Although the suicidal are not a homogenous group, they do share a number of characteristics that differentiate them from people who do not have suicidal experiences
(O'Connor & Sheehy, 2000). Known risk factors fall into three broad categories and often interact, developing into an amalgam of intolerable stressors: psychopathology, individual characteristics, and sociological factors. Typically, these experiences present as “a general sense of psychological pain and perturbation, dominated by relationship problems, internal upset, a sense of helplessness, issues related to self, and a situation specific compulsion to act” (Jobes et al., 2004, p. 109). Busch, Fawcett and Jacobs
(2003) reported that these experiences frequently manifest as severe anxiety and/or extreme agitation and are the most common factor precipitating inpatient suicides.
Moreover, emotional upsets, at least for those with a history of suicidal behaviour, appear to be experienced heterogeneously (O'Connor, Jobes, Lineberry, & Bostwick,
9 | Suicide and the intolerable state of a fragmented self
2010). That is, they are individual-specific and are best understood in terms of how the distress is experienced. Important as they are, none of the risk factors provide a sufficient explanation of suicidal behaviour (Goldney, 2008).
The diathesis-stress model (Figure 1.2) is helpful in terms of conceptualising the individual differences in protective factors and vulnerability to suicide. According to the model, the diathesis of longitudinal factors, which has the effect of raising or lowering an individual’s threshold to suicidal behaviour, is influenced by proximal stressors that can induce the behaviour. For example, contributing factors include religious beliefs, genetic and developmental factors, personality traits, interpersonal relationships and support systems (Cantor & Neulinger, 2000; O'Connor & Sheehy, 2000). Moreover, stressors that involve factors which exacerbate psychopathology almost inevitably result in a relationship loss or rejection (Goldney, 2008; Gunnell, Hardbord, Singleton, Jenkins, &
Lewis, 2004).
Societal Genetic Religious Personality Personal Biochemical Beliefs Traits Support Factors
Diathesis
Physical Illness Drugs Stress Alcohol Psychopathology
Interpersonal loss/rejection
Suicidality
Figure 1.2 The diathesis-stress model of suicidal behaviour adapted from Goldney (2008, p. 22).
1.5.1 Sex and Age
Bille-Brahe (1993) contends that biological sex and/or age are not, in themselves, antecedents for suicidality, but relate to specific life-periods wherein there is an greater
10 | Suicide and the intolerable state of a fragmented self likelihood of experiencing stressors that increase vulnerability to suicidal behaviour. For example, suicide amongst the elderly, compared to young adults, may relate to a higher proportion suffering serious health issues (Conwell, 2001). However, the evidence suggests that both sex and age influence risk factors for suicidality. For instance, the young have a greater propensity for suicidal behaviour and males, particularly older males, are more than four times likely to complete than females, whereas females make three times more attempts than males (De Leo, Hickey, Neuringer, & Cantor, 1999,
2001; O'Connor & Sheehy, 2000).
1.5.2 Biological Factors
Suicidal behaviours have been observed to run in families, suggesting an underlying biological predisposition (Träskman-Bendz & Mann, 2000). This is implicitly supported by evidence from family studies, which have revealed a higher risk of suicide for adopted individuals with a biological family history in comparison to adopted children with no family history (Roy & Janal, 2005; Roy, Rylander, & Sarchiapone, 1997).
Further, the rate of suicide is higher for monozygotic (genetically identical) twins than for those who are not (dizygotic) (Roy, Segal, Centerwall, & Robinette, 1991). Indeed, a family history of suicide doubles the risk of suicide even when familial psychiatric problems are controlled for (Qin, Agerbo, & Mortensen, 2003).
Gene studies have implicated the serotonin system which, in hyperarousal, leads to aggression, impulsivity and lethality in suicidal behaviour (Träskman-Bendz & Mann,
2000). Within this system, the transporter protein 5-HTT, the tryptophan hydroxylase
(TPH) gene, and the metabolite 5-hydroxyindoleacetic acid (5-HIAA) have been associated with suicidality (Davison & Neal, 2000; Mann, Brent, & Arango, 2001). The relationship between the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system (SNS) has also attracted interest, with van Heeringen (2003), for example, reporting higher levels of cortisol in suicide attempters. This relationship is the subject of an elaborated discussion in Chapter 4. Notwithstanding the significance of the
11 | Suicide and the intolerable state of a fragmented self role of biological and inherited determinants in suicidal behaviour, they lack specificity and can only increase an individual’s vulnerability and “do not inevitably lead to suicide
... even if there is a family history” (Goldney, 2008, p. 32).
1.5.3 Personality Traits
Personality traits are considered pivotal in terms of an individual’s vulnerability to suicidality. Regardless of whether they are accepted as psychological or diagnostic constructs, personality characteristics have attracted considerable attention because of their capacity to influence other risk factors implicated in the diatheses of suicidality. The most widely researched traits include hopelessness, impulsivity, cognitive rigidity, psychoticism, extraversion, and neuroticism:
a. Hopelessness refers to a system of negative cognitive schemas about the
future, and the belief that there is no escape from an intolerable situation, and
that the future will not bring relief (Beck, Kovacs, & Weissman, 1975; Williams
& Pollack, 2001). The relationship between hopelessness and suicidality is
well established in the literature (e.g. O'Connor & O'Connor, 2003; Smith,
2006) and appears to be a mediator between negative affect and suicidal
behaviour (Rudd, Rajab, & Dahm, 1994).
b. Impulsivity is frequently linked to suicidality with Williams (1997b) reporting
that 50% of suicide attempters had not considered suicide one hour
beforehand. Aggression is claimed to accompany impulsive behaviour, and is
often self-directed, covert and punitive, and associated with elevated levels of
guilt, shame and depression (Maiuro, O'Sullivan, Michael, & Vitaliano, 1989).
However, the roles of impulsivity and aggression in suicidality have been
questioned (Beautrais, Joyce, & Mulder, 1999; Goldney, Winefield, Saebel,
Winefield, & Tiggeman, 1997).
12 | Suicide and the intolerable state of a fragmented self
c. Cognitive rigidity refers to dichotomous thinking, which represents a
significant inflexibility in problem solving (Schotte & Clum, 1987). When faced
with challenging circumstances, suicidal people find difficulty in compromising
or modifying their expectations and perceive only a limited number of
available options (Williams & Pollack, 2001).
d. Psychoticism, Extroversion-Introversion, and Neuroticism-stability constitute
Eysenck’s (1981) three-factor-model of personality. Psychoticism refers to
personal dispositions such as a lack of empathy, egocentricity, cruelty,
insensitivity, hostility, and irrational mysticism (Eysenck, 1981; Kline, 1981).
Extraverts are typically gregarious, sociable, outgoing and spontaneous,
whereas Neuroticism is characterised by nervousness, moodiness, worry and
tension. In their review of the relationship between personality and suicidality,
Brezo, Paris and Turecki (2006) reported that all three factors effectively
predict either a history of suicide attempts, number of attempts, or risk of
suicidal ideation when, for example, anger, aggression and hopelessness are
present.
1.5.4 Psychopathology
All mental disorders, with the exception of dementia and intellectual disability, are associated with an increased vulnerability for suicidal behaviour (Harris & Barraclough,
1997; O'Connor & Sheehy, 2000). Indeed, Tanney (2000) reported that psychological autopsies revealed that over 90% of those who die by suicide had a recognisable psychiatric illness at the time of their death (e.g. Appleby, Cooper, Amos, & Faragher,
1999; Barraclough, Bunch, Nelson, & Sainsbury, 1974; Cavanagh, Carson, Sharpe, &
Lawrie, 2003). Furthermore, the results of Ernst et al.’s (2004) examination of the remaining 10% who appeared psychiatrically normal suggested an undetected underlying psychiatric process. Accordingly, the relationship between suicidality and psychopathology is discussed in terms of Axes 1 and 2 of the Fourth edition of the
13 | Suicide and the intolerable state of a fragmented self
Diagnostic and Statistical Manual of Mental Disorders – Text Revision (DSM-IV-TR)
(American Psychiatric Association, 2000).
1.5.4.1 Clinical Disorders (Axis 1)
The correlation between suicidality and clinical factors is well established in the literature. Affective disorders in particular have been a focus of interest, with Lönnqvist
(2000), for example, reporting that approximately 75% of people who die by suicide have a mood disorder. Maris (1991) estimated that 15% of severely depressed individuals are likely to take their own lives, however, this has since been downgraded to 3.5% (Blair-
West, Mellsop, & Eyeson-Annan, 1997). Moreover, people suffering from major depression, dysthymia, and bipolar disorder are 20, 12, and 15 times, respectively, at risk of suicidal behaviour in comparison to those with no mood disorder (Goldney, 2008).
Given the prevalence of depressive illness in the community, an estimated 40-50% reduction in suicidal behaviour has been suggested in the event that these could be eliminated (Beautrais, 2000; Goldney, Dal Grande, Fisher, & Wilson, 2003).
Notwithstanding the propensity for suicidal behaviour by those suffering depressive symptomology, other clinical factors have also been implicated.
Posttraumatic Stress Disorder (PTSD), for example, is significantly associated with suicidality (e.g. Barak et al., 2005), whereas the evidence is conflicting for the remaining anxiety disorders (Shaffer et al., 1996). Indeed, the evidence suggests heterogeneity in risk levels between the anxiety disorders, which are compounded by comorbidity with a mood disorder (e.g. Beautrais, Wells, McGee, & Browne, 2006; Sareen, Houlahan, Cox,
& Asmundson, 2005). For people with schizophrenia, however, the most serious of the symptoms is the “suicidal drive” (Bleuler, 1950, p. 488). For this population, there is a 30 to 40 times risk of suicidality in comparison to the general community, and approximately
10% of all patients with the illness will die by suicide (Cantor & Neulinger, 2000), although more recently Palmer, Pankratz and Bostwick (2005) have suggested that the lifetime risk of suicide is more likely in the order of 5%. Many of the risk factors for
14 | Suicide and the intolerable state of a fragmented self suicidal behaviour among patients suffering from schizophrenia are, like many other psychopathologies, associated with suicidality in their own right. For example, having a history of suicidal behaviour, suffering a recent loss, experiencing an affective or substance abuse disorder, increases vulnerability (Cantor & Neulinger, 2000).
In their meta-analysis of suicide as an outcome for mental disorders, Harris and
Barraclough (1997) reported that there is a significant association between substance abuse and suicidal behaviour, regardless of age. Confounding this relationship is that within this population the abuse frequently involves multiple substances accompanied by other risk factors such as comorbid psychopathology, physical health and/or social disadvantage (Cantor & Neulinger, 2000). Alcohol has a particularly strong association with suicidal behaviour, with up to 40% of alcohol dependent or abusing people attempting suicide and 7% dying by their own hand (Koller, Preub, Bottlender, Wenzel, &
Soyka, 2002). Similarly, the rates of suicidal behaviour among illicit and prescription drug abusers are many times greater than those in the general population. For example, the estimated risks for suicide for opioid use disorder, poly-drug and intravenous drug use are 14, 17, and 14 times, respectively, that of non-users (Harris & Barraclough,
1997; Joiner, Brown, & Wingate, 2005).
1.5.4.2 Personality Disorders (Axis 2)
“The stereotypical view of suicide is that it is the product of a deranged mind.
While this is a gross over-simplification, personality disorders are often associated with suicide” (O'Connor & Sheehy, 2000, p. 38). Bertolote et al. (2005), for example, reported that 15.2% and 13.1% of suicides by psychiatric inpatients and the general population, respectively, had diagnosable personality disorders. A large literature addresses
Borderline and Antisocial personality disorders, which are associated with 10% of all suicides. Borderline Personality Disorder (BPD) is characterised by “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity” (DSM-IV-TR, p. 710). The results of a longitudinal study examining Axes 1
15 | Suicide and the intolerable state of a fragmented self and 2 disorders, reported that their participants with BPD were more likely to attempt suicide than those with any other personality disorder. Moreover, 77.6% of those who attempted suicide also met the criteria for BPD (Yen et al., 2003; Yen et al., 2004).
Antisocial Personality Disorder (APD) is also characterised by impulsivity and “a pervasive pattern of disregard for and the violation of the rights of others” (DSM-IV-TR, p.
706). Although APD differs from BPD in terms of a reckless disregard for self or others, it is also associated with aggressiveness and non conformity with social mores. There is a paucity of statistical data on the rates of suicide for APD, although Fairweather-
Schmidt (2007, citing Garvey & Spoden, 1980), reported that 72% of individuals meeting the diagnostic criteria for APD attempted suicide.
1.5.5 Social Factors
Sociological explanations for suicide postulate that suicidality is the result of tension created by constraining social influences on the individual. Four types of suicide have been proposed to reflect the specific social interactions with individuals3: egoistic, altruistic, anomic, and fatalistic. Egoistic suicide is the result of marginalisation or isolation and can occur, for example, when one is isolated as a result of moving to a new area devoid of friends or family. The opposite of this is altruistic suicide, which can be an extreme act of social conformity such as the Japanese practice of hara-kiri. Anomic suicide is the result of perceptions of bitterness associated with estrangement from one’s environment, such as marital separation or the sudden loss of financial resources.
Suicide resulting from the belief that one has lost direction in, or control over, life is referred to as fatalistic.
Impaired proximal and distal social relationships are widely accepted as antecedents for suicidal behaviour. In particular, early-life intra and extra-familial adversity is a significant contributing factor in terms of vulnerability for suicidality (Donald,
Dower, Correa-Velez, & Jones, 2006; O'Connor & Sheehy, 2000). Beyond relationship
3 Although these have been attributed to Durkheim, some of the terms appear to have been in use prior to his contribution (Goldney & Schioldann, 2001; 2002; Goldney et al., 2008).
16 | Suicide and the intolerable state of a fragmented self issues are several social and environmental risk factors underlying suicidality, for example:
a. Marital status. Those who are legally classified as married are far less
likely to be suicidal (Goldney et al., 2003) in comparison to other forms of
relationships, and appears to be of equal benefit to both males and females
(Cantor & Slater, 1995).
b. Parenthood. The literature on the association between parenthood and
suicidality is sparse, however, there is some evidence that motherhood is
associated with reduced suicide (Cantor & Slater, 1995). Fatherhood also
appears to realise some benefit, although Qin, Agerbo, and Mortensen
(2003) suggest that the protective benefit is less than that provided by
motherhood.
c. Employment status. Suicidality occurs more frequently among the
unemployed, but how this status functions to impact on suicidal behaviour
remains unclear. O’Connor and Sheehy (2000) noted that reductions in
unemployment rates are not necessarily accompanied by declining suicidal
behaviour. The predominant explanation appears to be that unemployment
increases an individual’s exposure to stressful life events such as financial
hardship and social isolation, which in turn increases psychological distress
(Beautrais et al., 2006; Gunnell et al., 2004).
1.5.6 Previous Suicidal Behaviour
A history of suicidality is arguably the most effective predictor, and risk factor, for future suicidal behaviour (Borges, Angst, Nock, Ruscio, & Kessler, 2008). Indeed, Joiner et al.’s (2005) study demonstrated the significant influence of lifetime suicidal behaviour on future suicidality. After controlling for several suicidality-related variables, the association between past and current suicidal behaviour remained statistically significant. Furthermore, the results of Rudd, Joiner and Rajab’s (1996) examination of
17 | Suicide and the intolerable state of a fragmented self youth suicidality suggests that multiple attempters are a specific group with a heterogeneous personality, symptom, and risk profile.
1.6 Suicide Prevention
Preventing people from killing themselves is a daunting task given that most individuals experiencing suicidal behaviour do not die by suicide (Britton, Williams, &
Conner, 2008). Nevertheless, prevention is possible at an individual level given the opportunity for intervention. However, when applied strategically, the term ‘suicide prevention’ appears to ignore the heterogeneity of suicidality and may not be helpful.
Indeed, suicide reduction would appear to be a more appropriate strategic term in that it is an achievable goal and avoids the implicit rejection of a vulnerable person’s attraction to this method of coping with their distress. Notwithstanding this criticism, national prevention and clinical management strategies have been employed across the globe in an effort to reduce the personal, social and economic burdens associated with the behaviour.
1.6.1 Population Strategies
Reducing access to means has largely been demonstrated to be an effective strategy. In the UK, for example, replacing toxic coal gas with natural gas resulted in domestic gas suicides all but disappearing by 1990 (Kreitman, 1976; O'Connor &
Sheehy, 2000). Although reducing the packet size of paracetamol, and the introduction of blister packs for dispensing analgesics was not as encouraging as was first hoped
(Hawton et al., 1996; Lewis, Hawton, & Jones, 1997), more optimistic reviews have since been released reporting significant benefits (Hawton et al., 2009; Hawton et al., 2004).
Access to firearms remains a problem (Grossman et al., 2005), with suicide rates in the
United States of America lower in those states with stricter firearms legislation than those with where access is easier (Lester, 1989). In 1997 Australia introduced the National
Firearms Agreement (NFA) legislation in response to the 1996 Port Arthur Massacre.
18 | Suicide and the intolerable state of a fragmented self
The NFA extended the existing prohibition of handguns to include semi-automatic rifles and certain pump-action shotguns with the desired outcome of creating a safer society.
Simultaneously, the government implemented a ‘buyback’ scheme, which resulted in the destruction of over 600,000 firearms at a cost of approximately AU$500,000 (McPhedran
& Baker, 2008). The effectiveness of the scheme has been questioned, in terms of reducing firearm-related suicides, because suicide rates by other means have also declined steadily since that time (Klieve, Barnes, & De Leo, 2009). This has been attributed largely to national suicide prevention strategies and improvements in psychiatric care.
The Australian National Suicide Prevention Strategy (NSPS) was introduced in
2000 to overcome the indentified shortcomings of the National Youth Suicide Prevention
Strategy. The revised strategy had several objectives such as promoting resilience, reducing risk-factors and supporting evidence-based suicide prevention and good practice (Commonwealth Department of Health and Aged Care, 2000). Although the
2006 review of the NSPS recommended several changes (e.g. the strategy should be more targeted and directive), the Australian Bureau of Statistics (ABS) (2004b) reported that the age-standardised suicide rate for 2004 (4.3 and 16.8 per 100,000 for males and females respectively) was 6% lower than the corresponding rate for the previous year. It is important to note, however, that there is ongoing debate worldwide about the reliability and validity of suicide statistics (De Leo, 2010; Goldney, 2009). The ABS has responded to concerns that suicide is underreported and that the Australian mortality data are unreliable, by introducing changes to its cause of death recording process. Specifically, the new system allows coroners more time to finalise details of a death and introduces a revision process whereby the data can amended if necessary.
1.6.2 Clinical Management
The clinical management of suicidal behaviour is best discussed in terms of two broad approaches: the pharmacological and non-pharmacological (largely therapeutic).
19 | Suicide and the intolerable state of a fragmented self
1.6.2.1 The Pharmacological Approach
Medications are not prescribed to specifically prevent suicidal behaviour, but to treat any accompanying psychopathology. Moreover, this approach is generally limited to those circumstances when the suicidal behaviour is associated with a mental disorder for which there an established pharmacological treatment. The rationale behind this is the previously discussed association between psychopathology and suicidality. Whilst medications have been effective in decreasing the vulnerability to suicidal behaviour
(Hall, 2006; Malone & Moran, 2001) compliance is a common problem (van Heeringen et al., 1995). Moreover, because of the low base rate, it has been near impossible to mount randomised controlled trials to demonstrate the effectiveness of specific treatments (Goldney, 2005).
The use of some psychotropic medications has been controversial, particularly the effects of the selective serotonin-reuptake inhibitor (SSRI) antidepressants. SSRIs
have been claimed to trigger suicidality in vulnerable individuals (Healy, 2003; Teicher,
Glod, & Cole, 1990), although Healy acknowledged the difficulty in quantifying the risk.
However, the risk for suicide appears to be problematic for antidepressants generally,
particularly during the early stage of treatment when mood improvement is preceded by
relief from psychomotor retardation (Hall, 2006; Jick, Cole, Mesher, Tennis, & Jick,
1992). A similar emergence has been reported in non-pharmacological treatments for
depression such as Electroconvulsive Therapy (Mayer-Gross, Slater, & Roth, 1955;
Verkes & Cowen, 2000) and clinical psychotherapy (Bridge, Barbe, Birmaher, Kolko, &
Brent, 2005). Notwithstanding the controversy surrounding some medications, there is
considerable evidence that SSRI antidepressants, clozapine (antipsychotic), and lithium
(mood stabiliser) are effective in reducing suicidal behaviour (Goldney, 2008).
1.6.2.2 The Non-Pharmacological Approach
Within the non-pharmacological clinical approaches to suicide prevention, talking
therapies dominate. For example, cognitive therapy (Rudd, Joiner, & Hasan Rajab,
20 | Suicide and the intolerable state of a fragmented self
2001; Wenzel, Brown, & Beck, 2009), dialectical behaviour therapy (Linehan, Camper,
Chiles, Strohsak, & Shearin, 1987), solution focused therapy (Henden, 2008), and a person-centred approach (Leenaars, 2004) have all demonstrated some success in reducing suicidal behaviour. Notwithstanding the effectiveness of psychotherapeutic interventions, emergent suicidality is a common occurrence, particularly in the treatment of adolescent depression (Bridge et al., 2005). Although no single therapeutic approach is considered best-practice, they are all guided by similar structures and principles. In particular, all the aforementioned approaches include, to varying degrees, problem- solving techniques, which are considered important because “irrespective of the aetiology of your situation, the suicide attempt is a communication of problem-solving failure of some kind or another” (O'Connor & Sheehy, 2000, p. 129).
Britton, Williams and Conner (2008) noted, however, the tension that exists in therapy between respecting individual autonomy and protecting life. Individual autonomy, with few exceptions (e.g. Jobes, 1995; Linehan et al., 1987; Orbach, 2001), is frequently overlooked in the treatment process despite case studies suggesting that an individual’s sense of autonomy may affect both motivation for therapy and its outcome (Filiberti et al.,
2001). One evidence-based approach that recognises both the critical role of perceived autonomy and importance of problem-solving is the Collaborative Assessment and
Management of Suicidality (CAMS) (Jobes, 2000) clinical protocol. The CAMS clinical protocol is a pragmatic coalescence of several therapeutic approaches such as the cognitive, psychodynamic, behavioural, existential and humanistic. Regardless of the presence of comorbid psychopathology, CAMS specifically targets suicidality as the principal issue and emphasises the importance of “understanding and engaging the suicidal mind ...[in] a clinical alliance that enables the pair to get on with addressing the psychache4 that imperils the patient’s life” (Shneidman, 2006, p. x). “Ironically, the clinician’s ability to understand the viability and attraction of suicide as a coping option seems to provide the essential glue for forming a strong therapeutic alliance where more
4 Shneidman’s theory of psychache is discussed below.
21 | Suicide and the intolerable state of a fragmented self adaptive methods of coping can be evaluated, explored, and tested” (Jobes & Drozd,
2004, p. 75).
1.7 Theories of Suicide
Although there are many theories and proffered explanations for suicide, there is no single comprehensive theory that adequately accounts for the heterogeneity of the behaviour. The multidimensional and multidiscipline approach to suicidality has resulted in discrete explanations applying the “language and construct domains of a particular theoretical orientation or discipline” (Berman et al., 2006, p. 46). Consequently, the predominant theories of suicide fall within the broad categories of sociological, psychological and biological. Notwithstanding the divergent approaches to the subject, the following discussion is limited to an examination of several psychological theories that have particular relevance to the principal focus of this thesis: Williams’ (1996) ‘cry of pain’, Shneidman’s (1987) ‘psychache’, Joiner’s (2005) interpersonal-psychological model, and Baumeister’s (1990) ‘escape from self’. Williams’, Shneidman and Joiner’s contributions all relate, in some way, to self psychology’s concept of an intolerable state addressed in Chapter 2. The relationship between mental pain, self, and suicidality has been noted by others, with Orbach, Mikulincer, Gilboa-Schechtman, and Sirota (2003b), for example, referring to Bolger’s (1999) grounded theory analysis of emotional pain.
Bolger’s analysis concluded that the essence of emotional pain “is captured in the core category, The Broken Self, characterized by four properties including Woundedness,
Disconnection, Loss of Self, and Awareness of Self, and a set of visceral and spatial descriptors” (p.342). Baumeister’s (1990) escape from self hypothesis is given greater attention because of its focus on the construct of self. Importantly, these theories take the seemingly paradoxical view that the motivations behind suicidal behaviour are
“impulses towards preservation [rather] than self-destruction” (Williams, 1996, p. 150).
22 | Suicide and the intolerable state of a fragmented self
1.7.1 Cry of Pain
The cry of pain model replaces Farberow and Shneidman’s (1961) ‘cry for help’, and views suicidal behaviour as a response to stressful events that lead to a sense of entrapment: defeat, no escape and no rescue; that is, arrested flight. Williams (1996b;
Williams, Barnhofer, Crane, & Duggan, 2005) argues that a sense of entrapment is central to suicidality, and is generally experienced as a longer-term state because stressors are themselves often on-going. The three components of the model are:
a. Sensitivity to environmental cues that prompt humiliation or defeat. Some
people become sensitised to signals of defeat and are inclined to interpret
even neutral events as either a defeat or humiliation, which in turn result in an
overwhelming need to escape.
b. A sense of entrapment (no escape) arises from deficiencies in inter-
personal problem solving, which are closely associated with an
overgeneralised autobiographical memory. Suicidal people tend to be caught
at the general event summary level, which are necessary to “navigate through
the memory hierarchy” (Williams et al., 2005, p. 75). Using William’s
example; if asked to retrieve a specific event memory in response to the cue
‘sorry’, a suicidal person might comment that “I feel sorry for all the times I
have hurt my family” (p. 75). Although overgeneralised memory may initially
act as a protective measure by avoiding distressful memories, Pollack and
Williams (2001) reported a significant association between non specificity in
autobiographical memory and the severity of problem-solving deficits.
c. Projecting the sense of entrapment into the future results in a sense of
hopelessness. Moreover, the hopelessness is “a function of lack of positive
future, not an excess of negative future” (p. 76), and appears to be mediated
by high levels of social support.
23 | Suicide and the intolerable state of a fragmented self
1.7.2 Psychache
Shneidman (1987, 1993) coined the term ‘psychache’ to refer to the experience of psychological pain such as hurt, humiliation, shame and anguish, and the associated role of cognitive restriction. The theory holds that individuals have different thresholds for psychache, and escape is sought when the experience is subjectively perceived to be intolerable: “an insidious process whereby constricted dichotomous thinking leads the suicidal person into a desperate space” (Jobes & Nelson, 2006, p. 34). Although
Shneidman emphasised the precarious state of cognitive constriction, he differed from the cognitive models of suicide in that his focus was on the associated concept of perturbation. That is, “an anxious or distressed mental state [which] in the context of a completed or attempted suicide, ... is a measure of the extent to which a person is (or was) upset or disturbed” (APA, 2007, p. 692). Characteristically, this internal state of emotional upset necessitates panicked action directed toward relieving the psychache.
Shneidman’s (1987) cubic model of suicide (Figure 1.3) conceives suicidality as the consequence of three psychological constructs converging when each is at the maximum level of distress. Although Shneidman conceded that not everyone in the highly vulnerable (5x5x5) psychological space will commit suicide, he argued that every individual is in that space when they commit suicide. Holden, Mehta, Cunningham, and
McLeod (2001) responded to Shneidman’s (1992) challenge to operationalise psychache by developing the Psychache Scale. Concerned that Shneidman’s proposed construct of psychache may not “include the scope of meanings inherent in this experience [of mental pain]” (Orbach, Mikulincer, Sirota, & Gilboa-Schechtman, 2003a, p. 220), the
Orbach and Mikulincer Mental Pain Scale (OMMP) (Orbach & Mikulincer, 2002) extends
Shneidman’s understanding of psychache to a more comprehensive scale of mental pain than the Psychache Scale. The processes underlying the development of both scales support Shneidman’s emphasis on mental pain as a cause of suicidal behaviour.
24 | Suicide and the intolerable state of a fragmented self
Moreover, the authors of both scales utilise Baumeister’s (1990) theory of escape from the self (discussed below) to operationalise their models.
NOTE: This figure is included on page 25 of the print copy of the thesis held in the University of Adelaide Library.
Figure 1.3 Shneidman’s (1987) three-dimensional cubic model of suicide (pain-press- perturbation) with ratings on each axes from 1 (low) to 5 (high). The first axis is unbearable psychological pain, or psychache. Unrelenting psychological pressures (stress) is the second axis, with the third axis being perturbation. The particularly vulnerable (5x5x5) space is highlighted.
1.7.3 The Interpersonal-Psychological Model
Joiner’s (2005) interpersonal-psychological model of suicidal behaviour (Figure
1.4) is grounded in Baumeister and Leary’s (1995) concept of the “fundamental, and extremely pervasive” (Joiner, Hollar, & Van Orden, 2006, p. 179) human need to belong5.
Joiner’s model proposes that a person will not commit suicide unless he or she has the both the desire to die by suicide and the capacity to do so. Indeed, Joiner argues that the innate need to belong is so powerful that thwarting two interpersonally relevant states
5 Kohut’s (1977) theory of self psychology (Chapter 2) also recognises the fundamental human desire for interpersonal attachments, and the negative effects on the development and maintenance of self that can accompany efforts to achieve this.
25 | Suicide and the intolerable state of a fragmented self of mind (belongingness and perceived burdensomeness) is a proximal cause of suicidal desire6.
NOTE: This figure is included on page 26 of the print copy of the thesis held in the University of Adelaide Library.
Figure 1.4 Joiner’s (2005) interpersonal-psychological theory of suicidal behaviour
Perceived burdensomeness is the view that one is an unacceptable burden on family or friends, which produces the belief that death would serve them better than continued life. When thwarted belongingness or perceived burdensomeness results in a desire to suicide, the second, and most important, element of the model is the individual’s capacity to do so. The theory asserts that only a few are capable of taking their own life because the self-preservation instinct is an evolutionary driven “deep, ancient, and potent force” (Joiner & Van Orden, 2008, p. 81). The only people capable of
overcoming this barrier are those who have experienced sufficient pain and provocation
in their lives to have habituated to their aversion of deliberate self harm. Thus, the
capacity to commit suicide develops in response to these habituation experiences.
Central to Joiner’s argument is that capacity to enact lethal self-injury does not require
the desire to die, nor does it of itself, result in suicide. Only the rare conjunction of these
risk factors precedes a serious suicide attempt or death by suicide.
6 The theory proposes that suicidal ideation is an operationalised form of the construct of suicidal desire. That is, suicidal ideation is a variable used to describe the results of a suicidal scale, whereas suicidal desire is used to discuss the theory at the level of constructs (Van Orden, Witte, Gordon, Bender, & Joiner, 2008)
26 | Suicide and the intolerable state of a fragmented self
1.7.4 Escape from Self
Escape theory views some suicides as an attempt to escape from self, from the
“meaningful awareness of certain symbolic interpretations or implications of the self”
(Baumeister, 1990, p. 90). Originally conceived by Baechler (1979) and developed further by Baumeister (1990) who believed the Baechler model to be too rationalist and lacking clinical efficacy. The prevalence of escapist suicides is well documented in the literature (McAuliffe, Arensman, Keeley, Corcoran, & Fitzgerald, 2007; Pompili, Lester,
Lennaars, Tatarelli, & Girardi, 2008), and the results of the mixed methods study presented in Chapter 9 also demonstrate this.
Baumeister offers a cognitive and motivational explanation that is grounded in action identification theory (Vallacher & Wegner, 1985), attribution theory (Heider, 1954;
Kelly, 1972; Weiner, 1974), Pennebaker’s (1989) levels of thinking, self-awareness theory (Carver & Scheier, 1981), and self-discrepancy theory (Higgins, 1987). Jobes
(2006) noted the appeal of the theory in that “it captures two essential components of the suicidal struggle – the need for escape and the core importance of the self” (p.16).
Moreover, the validity of the theory has been demonstrated empirically (Dean & Range,
1999; O'Connor & Forgan, 2007).
Escape theory (Figure 1.5) is a causal process of six steps: (1) falling short of standards, (2) attributions to the self, (3) high self-awareness, (4) negative affect, (5) cognitive deconstruction, and (6) the consequences of deconstruction. The process will only result in suicide if each step produces a particular outcome. Baumeister applies the following example to elaborate: “If setbacks are handled with external attributions or if there is no awareness of self-discrepancies, then the process will not lead to a suicide attempt” (p.91).
27 | Suicide and the intolerable state of a fragmented self
Negative Life stress
Socially Prescribed Self-Orientated Perfectionism Perfectionism
Anxiety Depression
Hopelessness
Reasons for Living
Suicidal Behaviour
Figure 1.5 The causal process of Baumeister’s (1990) escape theory. Adapted from Dean and Range’s (1996, p. 416) proposed schematic
The first step is the individual’s belief that their current circumstances fall short of standards and this can be self-imposed or perceived as inflicted by a significant other.
This belief comes about by recent stressful life events, failures, unrealistically high expectations, or a combination of some or all of these stressors. Low expectations may not produce suicidal behaviour, but unrealistic expectations result in acute
disappointment when the experience falls short of them. Recent stressors are more
likely to have an influence as these are generally accompanied by an emotional crisis,
which later dissipates in response to effective coping strategies. The trigger is the extent
of the shortfall. Thus, suicidal behaviour may occur either because expectations are
unrealistically high and/or the stressor is particularly distressing. This is supported in the
literature, with the relationship between suicide and stressful life events well documented
(Conner, Phillips, & Meldrum, 2007). Moreover, suicidal patients also have greater
expectations than non-suicidal patients (Ellis & Ratcliff, 1986).
The next step involves responding to the shortfall in expectations by attributing
negative qualities to the self such as inadequacy or blameworthiness. Bonner and Rich
28 | Suicide and the intolerable state of a fragmented self
(1988) noted that self-blame fosters the core characteristics of suicidal people: a sense of worthlessness and rejection. Further, depression, hopelessness and suicidal ideation are more likely to be the experiences of those whose response to negative life events is self-attributive than those who do not do so. The third step of the escape theory is the development of a high state of awareness resulting from falling short of standards and self-blame. Here the self-focus is on incompetence, inadequacy, unattractiveness and guilt. Elevated self-awareness has been observed in suicide notes which can contain an unusually high number of self-references and first-person pronouns (Henken, 1976;
Lester, 2003b). Perfectionism is related to self-awareness and demonstrated to be associated with psychological distress (O'Connor & O'Connor, 2003) with self-orientated perfectionism characterised by unrealistic standards and self scrutiny, accompanied by an inability to accept flaws and failure (Hewitt, Flett, Sherry, & Caelian, 2006; Hewitt,
Flett, & Turnbul-Donovan, 1992). Socially prescribed perfectionism refers to the belief that others have unobtainable and unrealistic expectations which must be obtained for approval and acceptance.
The relationship between the fourth step, negative affect, and suicidal behaviour is well supported in the literature. For example, depression (Bolton, Belik, Enns, Cox, &
Sareen, 2008; Goldney et al., 2003), anxiety (Boden, Fergusson, & Horwood, 2007) or in comorbidity (Goodwin & Roy-Byrne, 2006; Simon et al., 2007). Negative affect arises as a result of the focus of self-awareness on negative events attributed to the self. The shift to the fifth step of cognitive deconstruction occurs in response to the dissonance created by the negative affect state.
Cognitive deconstruction is a subjective shift to less integrated and meaningful thoughts and awareness, bringing with it disinhibition and irrationality. Baumeister (1990) favoured the term deconstruction “because of its greater precision in suggesting the avoidance of constructive interpretations and the dismantling of integrative constructs”
(p.92). There are three components of focus: narrow time perspective focused on the present, action directed toward immediate rather than long-term goals, and an absolute
29 | Suicide and the intolerable state of a fragmented self focus on immediate emotions and cognitions. Hopelessness encapsulates this multi- component state in which suicidal people are unable to foresee a positive future and focus on the immediate circumstances (Beck et al., 1975; O'Connor & O'Connor, 2003).
The final step of escape theory presupposes four consequences of cognitive deconstruction: disinhibition, passivity, absence of emotions, and irrational cognitions.
Disinhibition refers to the absence of the strong desire to live, and the common inhibitions associated with suicidal behaviour (Bonnor & Rich, 1988; Tarter, Kirisci,
Reynolds, & Mezzich, 2004). Passivity is frequently observed in association with suicidal behaviour, whereby this population perceive their role as “passive victim rather than active murderer” (Dean & Range, 1999, p. 563). Consistent with self psychology,
Baumeister (1990) notes that the “self is typically associated with active striving and the quest for control” (p.92). Thus, adopting an attitude of passivity permits the avoidance of self awareness and meaning. The consequence of this is that whilst a passive approach will be made to important actions, a suicidal person may engage in seemingly mindless or impulsive behaviour.
The third consequence of the deconstructed state is the absence of emotions.
This is not supported in the literature, with labile affect more the norm for those engaging in suicidal behaviour (Lewis & Haviland-Jones, 2004; Shields, Hunsaker, & Hunsaker,
2005); although it is acknowledged that self-cutting behaviour has been associated with depersonalisation (Pao, 1969). Baumeister attempts to overcome this apparent anomaly by observing that feelings are kept out of awareness and therefore the presentation of absence of affect is simply superficial (Dean & Range, 1999). Vulnerability to irrational thought is the final consequence, with elements of previous steps also evident; the predominant being the removal of suicidal inhibitions. Suicidal psychiatric patients exhibit more dysfunctional attitudes and irrational cognitions than controls (Ellis &
Ratcliff, 1986) and a greater level of cognitive rigidity (Bonnor & Rich, 1988).
30 | Suicide and the intolerable state of a fragmented self
1.8 Discussion
In their examination of short-term outcome in well-being following suicidal behaviour, in terms of the conjoint effects of social perfectionism and positive future thinking, O’Connor and colleagues (2007) acknowledged the role of the self, though the focus was predominantly on socially prescribed perfectionism. The study employed
Baumeister’s (1990) escape theory and William’s (2001) cry of pain model which relate directly to the sense of self. Their results demonstrated that the best outcomes following a suicidal event were associated with clients who reported high positive future thinking and low social perfectionism. The authors concluded that Baumeister’s model should be refined as their data suggested that an individual’s view of the expectations of others, rather than self- imposed standards, is predominant in escapist suicidal risk. Although
Baumeister does not specifically address suicidal behaviour in a more recent contribution to the subject of self7 (Baumeister, 1998), he appears to have moved away from his earlier emphasis on unrealistically high expectations as the single destabilising influence on self experience as a trigger for suicidal behaviour. Nevertheless, the theory appears unique in its recognition of the broader construct of self as a core determinant in one’s vulnerability to suicidality.
Two consistent themes emerge from the theories discussed, and both complement Kohut’s emphasis on the importance of developing and maintaining a cohesive sense of self. The first is the experience of intolerable psychological pain from which the suicidal seek respite, even if it means ending one’s life. The second is that despite the subjective nature of the experience, suicidality is also intensely interpersonal.
The need for connectedness with another, and the role of positive relationships with significant others are fundamental tenets of self psychology, which is the subject of the following chapter.
7 This is discussed in Chapter 3
31 | Suicide and the intolerable state of a fragmented self
Chapter 2: Kohutian Self Psychology
Kohutian Self Psychology
You need other people in order to become yourself ... you cannot create the self ... it comes into being long before it is strengthened. In the process of psychoanalytic cure, we are always dealing, not with the creation of a self, but putting it in harmony, recreating its vitality, firming it (Kohut, 1985b, p. 238).
2.1 Introduction
For much of the twentieth century, psychoanalysis was the predominant approach to understanding psychopathology, but it has become less influential as the behaviourists, and more recently the cognitive school of thought placed greater emphasis on empirical data. At the same time, development of the Diagnostic and
Statistical Manual of Mental Disorders (DSM), currently in its fourth edition – text revision
(DSM-IV-TR), with its multiaxial approach to diagnosis, has resulted in theorists ascribing increasing importance to categories and the development of instruments for clinical assessment. Silverstein (2007) noted that self psychology represents one of the psychoanalytic theories that sought, inter alia, to reconcile the evolving categorical approach to assessment with Freud’s theories of personality structure and development.
Freud focussed on the unconscious and was influenced by the earlier observations of Mesmer, Charcot, and Bernheim (Millon, 2004). Classical psychoanalytic theory divides personality into three components: id, ego and superego.
The id is the reservoir for instinctual energy and encompasses basic biological needs such as food, water and sex. It is a subjective experience which cannot tolerate distressful increases in tension from either external or internal stimuli and discharges such tension by returning to a lower energy level. This impulsive, unchanging and powerful force is referred to as the pleasure principle for the id is “governed by a search for pleasure and immediate gratification” (Walker, Burnham, & Borland, 1994, p. 597).
32 | Suicide and the intolerable state of a fragmented self
The ego develops from the id in the second six months of life as the infant begins to distinguish itself from the environment. Unlike the id, the ego is regulated by the reality principle and acts to delay the discharge of tension until an appropriate object for the satisfaction of the need has been identified. Thus, the ego seeks to satisfy the id in a pragmatic manner that protects the individual from the consequences of indiscriminately responding to the pleasure principle. The ego perceives, acquires and remembers knowledge, and reasons. The superego emerges in the third to sixth year and is the equivalent of a conscience and ego-ideal, for it contains the cultural values and moral standards transmitted by the immediate family. Like the id, the superego represents the inner world of subjectivity and simply seeks to suppress the pleasure principle. The ego- ideal represents an image of the ideal individual, and this pushes the ego toward moral action, self-sacrifice and perfection. Consequently, the ego mediates between the divergent demands of the id and superego, and it is the ego that experiences psychological distress when reconciliation cannot be achieved.
Freud posited that the aetiology of all behaviour involved instinctual drives and that these drives were part of the unconscious. Instincts can be described in terms of four components: (1) source refers to some basic energy need such as food or water; (2) aim is the satisfaction or removal of the need and is homeostatic in nature; (3) the object is the means by which the need is satisfied, and energy may be used to satisfy the aim directly or indirectly. For example, sexual energy may be satisfied by engaging in sexual activity or displaced into other activities such as sport: (4) impetus is the strength or power that an instinct processes. While the ego experiences elevated levels of anxiety arising from the unresolved conflicts between the instinctual drives of the id and the
“strictures of the superego” (Walker et al., 1994, p. 598), defence mechanisms are activated to relieve the distress. These are common self-deceptive but adaptive mental strategies which effectively reduce anxiety but prevent the development of effective coping strategies (Underlid, 2007). For example, repression is a basic defence mechanism of forcing unacceptable impulses back into the unconscious, alienating from
33 | Suicide and the intolerable state of a fragmented self memory anxiety arousing traumatic, dangerous or embarrassing thoughts or desires.
Thus, Freud’s psychoanalytic formulations on personality development represented conflict models in which he emphasised regressions to, or fixations on, particular psychosexual stages of development. His work was significantly influenced by the
Victorian concern with sexuality generally (Lee & Martin, 1991). Freud observed that certain reactions to conflict did not result in neuroses and reasoned that although the asymptomatic reaction formations appeared different from their clinical presentations, their psychological foundations were indistinguishable. The Freudian view then is that personality development is an “asymptomatic form of conflict” (Silverstein, 2007, p.20).
Kohut’s (1978a) psychodynamic paradigm of self psychology evolved from his endeavours to develop a theoretical and therapeutic approach to the previously considered untreatable problem of pathological narcissism. His conclusions placed him at odds with the classical Freudian psychoanalytic school insofar as he located the development and maintenance of the self as the primary psychological objective of the human experience. In particular, instincts and drives are considered subordinate to the self and a level of healthy narcissism is conceptualised, and referred to as transformed
(from the archaic grandiose) narcissism, which Kohut (1985a) described as the ability of the self to deflect, rather than deny, a psychological wound; to reflect rather than to brood over the injury. Consequently, narcissism was no longer considered “pathological or obnoxious” but necessary for the development of the self (Kohut, 1985b, p.97). Adler
(1989) believes the reframing of narcissism is one of Kohut’s legacies to psychoanalysis.
In particular, the removal of the derogatory characterisation that condemned the narcissistic personality as egotistical to a redefinition that acknowledged “incompleteness and problems with poor self-worth” (p.764).
Kernberg (1975) noted that archaic narcissism in adults represents a defensive organisation that is, as with clients with Borderline Personality Disorder for example, characterised by the simultaneous appearance of contradictory self processes. “It is the image of a hungry, enraged, empty self, full of impotent anger at being frustrated, and
34 | Suicide and the intolerable state of a fragmented self fearful of a world which seems as hateful and revengeful as the patient himself” (p.233).
Tolpin (1986) is uncomfortable with the term “archaic” which, for her, carries pejorative overtones, preferring instead the term “phase appropriate selfobjects 8 of infancy”
(p.120), arguing that this provides greater clarity when referring to the function of narcissism in the maturating process of the developing sense of self 9. Within this acceptance of an adaptive function for transformed narcissism, or healthy self love, is the implicit rejection of a completely autonomous self, for it is within the selfobject (significant other) transferences and needs that transformed narcissism can contribute to the development of a cohesive sense of self. The term ‘cohesive’ was specifically applied to move from the classical focus on weak or strong ‘ego boundaries’ to an emphasis on cohesion of the whole self, and it is the self’s level of cohesion that is the issue in narcissism.
Although Freud (1957) had previously acknowledged the presence of normative narcissistic cognitions, he defined it in terms of an aspect of innate instinctive self preservation behaviour found in all living creatures, and ignored the possible potential role it might play in maintaining a cohesive sense of self. White and Weiner (1986) noted that Kohut’s differing perspective involved the psychological pursuit of a cohesive sense of self characterised by a stable self-concept, grounded in “tamed grandiosity and reliable ideals, and focused on the joyful experience of development” (p.12) (emphasis added). Importantly, in terms understanding narcissistic rage, Kohut (1971) rejected the
Freudian argument that aggression is an innate human characteristic, and instead argued that it is a regression to early life grandiosity brought about by an unresponsive environment. The power of narcissistic rage in giving rise to pathological behaviour cannot be understated. Indeed, Wolf (1988) emphasised this by noting that narcissistic rage:
8 Consistent with self psychology this is presented as one word. Selfobjects are significant others with whom we experience as a psychological part of our own sense of self. 9 In acknowledgement of the validity of Tolpin’s objection, “early life” replaces “archaic” in the discussion that follows.
35 | Suicide and the intolerable state of a fragmented self
arises when no self-assertion at all is possible, when the self feels absolutely
vexed, and mortified, that is, paralyzed while agitated to the extreme and in
deathly danger of losing its integrity. Such a self state is unbearable and must be
altered. The offending selfobject or the totally ashamed self must be made to
disappear, violently if necessary, even if the whole world will go up in flames
(p.79).
Self psychology is a theory of structural deficit in the self. It focuses on the
enduring psychological effort to realise ones ambitions and maintain a sense of
cohesion. This view differed from Freud’s drive-discharge theory which considers the
pathogenesis of psychopathology to be the result of unresolved conflicts and the
subsequent symptomatology as concealed attempts to gratify drives. The self is
attributed primacy within Kohut’s paradigm, along with the principle of self preservation,
which he defined as a precondition for selfobject love. Schneiderman (1997) explains
that a “healthy person is one who, despite the inevitable traumata of the developmental
years, has arrived at and preserved an integrated self involving the capacity for affection
and self-assertion” (p.417). To sharpen the distinction between his deficit approach and
classical psychoanalytical theory, Kohut (1977) introduced the concepts of Guilty Man
(Freudian) and Tragic Man (Kohutian). Here he appears to have been influenced by his
observation that the protagonists in the works of the popular European authors of the
nineteenth and twentieth century’s were dominated by the problems of the Guilty Man
who was characterised by neurotic conflict (Schulz, 2003). Kohut (1977) explains:
Man’s functioning should be seen as aiming in two directions. I identify these by
speaking of Guilty Man if the aims are directed toward the activity of his drives
and Tragic Man if the aims are toward fulfilment of the self. To amplify briefly:
Guilty Man lives within the pleasure principle; he attempts to satisfy his pleasure-
seeking drives, to lessen the tensions that arise in his erogenous zones …. Tragic
Man, on the other hand, seeks to express the pattern of his nuclear self; his
36 | Suicide and the intolerable state of a fragmented self
endeavours lie beyond the pleasure principle. Here, too, the undeniable fact that
man’s failures over-shadow his successes prompted me to designate this aspect
of negativity as Tragic Man rather than “self expressive” or “creative man” (p.132).
Consequently, self psychology challenged the fundamental psychoanalytic assumptions underlying what brings about change. Traditional analysis considers higher levels of insight and interpretation as the quintessential element of therapeutic change, whereas Kohut emphasised the creation of a new experience for the client within a positive selfobject relationship. Nevertheless, self psychology is grounded in depth psychology 10 and retains the psychoanalytic approach that personality deficits can be corrected by establishing new and permanent patterns or responses referred to as psychic structures (Lee & Martin, 1991). Atwood and Stolorow (1984) defined the process of structuralisation as the acquisition of “structures of experience [whereas a structure is an] enduring reorganisation of the subject field” (p.39). For self psychology, structure formation best occurs in response to empathy and attempts to repair empathic failures. Accordingly, disorders of the self represent deficits in self cohesion that obstruct efforts to maintain a buoyant sense of self by interfering with attempts to resist devitalisation, forestall fragmentation, or develop compensatory structures when the sense of self is threatened by destabilisation (Schneiderman, 1997; Silverstein, 2007).
Accordingly, in the applied sense, self psychology does not seek to make total or dramatic changes, but rather emphasises making “what is there more controlled, sensible, human [and] balanced” (Kohut, 1985c, p. 249). This approach recognises an underlying assumption within the paradigm that the direction of personality is one way, and that the critical self development experience of childhood cannot be recreated; all that is possible is to attempt to remedy “things that were left undone in that childhood or things that were not completely done” (p.249).
10 Depth psychology is “a general approach to psychology and psychotherapy that focuses on the unconscious mental processes as the source of emotional disturbance and symptoms, as well as personality, attitudes, creativity and life style” (American Psychological Association, 2007, p. 270)
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2.2 The Construct of Self
Kohut did not to attempt to formally define the self, and ostensibly accepted it as a priori in terms of the human experience. Indeed, Strozier (2001) reports that Kohut was not at all contrite about this omission as he considered the construct meaningless outside of the context of selfobjects. Notwithstanding the absence of a formal description, the construct is viewed within self psychology as a supraordinate concept that transcends the sum of its parts, and it is frequently expressed in language that takes the unhelpful direction of sophistic argument towards multiple selves. Reification of the sense of self is not supported within the theoretical framework espoused by Kohut, and
appears to be the unintentioned consequence of the inelegant language applied to
addressing such a complex and subjective experience. Basch (1991), in an effort to
undermine reification, reminds us that the term self is a collective noun that “subsumes
the hierarchy of information processing feedback cycles that adapt us to our environment
while assimilating the environment to our needs … and is one aspect of the ordering
function of the brain” (p.6). Nevertheless, Lee and Martin (1991) noted that for self
psychology, “the self … [is not] a completely individuated, absolutely independent being,
functioning in emotional isolation. The self is always in need of selfobjects” (p.102). The
construct is conceived of in two functional terms; the nuclear and the supraordinate self.
The nuclear self is the “core dimension of self process that defines experience” (Strozier,
2001, p.287), the foundation for the sense of individual difference, independent initiative
and perception, and the experience of body and mind being as one in time and space.
Self psychology holds that every child is born with an innate potential nuclear self, which
is either nourished or frustrated through the experiences of selfobject transferences.
This, in turn, serves as the motivating drive for the developing self by consolidating early
life grandiose fantasies as ambitions, internalising the qualities of the selfobject as
fundamental ideals, and developing skills and talents. Kohut (1985d) defined the nuclear
self as:
38 | Suicide and the intolerable state of a fragmented self
a specific psychic configuration available to introspection and empathy, ... the
representation of mind and body ... [that is] experienced as being continuous in
time, unitary and cohesive ... The specific self which fulfils two further conditions:
(1) It is the self which is the carrier of the derivatives of the grandiose-exhibitionist
self (i.e., the potential executor of the goals, purposes, and ambitions which are in
genetic-dynamic contact with the original aspirations of the grandiose-exhibitionist
self); and (2) it is the self which has its sights on values and ideals which are
descendents of the idealised parent imago (p.35).
The concept of the Kohut’s supraordinate self is defined by White and Weiner
(1986) as arising from the nuclear self as a result of “a cluster of responded to potentialities” (p.104). Thus, the construct is understood to be the result of transference experiences on the nuclear self, and is considered to be an amalgam of realised or responded to potentials developed in reaction to the environment, which becomes the
“enduring psychic configuration” (Kohut, 1977, p.177), the centre of individual personality.
The idea of a dichotomised self has been widely criticised within self psychology itself for being too materialistic and objectified, leading to reification through the inevitable temptation of viewing the interaction between the nuclear self and supraordinate self as if each have agency (Lee & Martin, 1991; Stolorow, Brandchaft, &
Atwood, 1987). Atwood and Stolorow (1984) attempted to resolve the issue, by proposing that the term “person” be applied when referring to the idea of the self as an agent. This simple delineation of the proposed functional roles of the self as (1) a psychological structure (nuclear self) and (2) an experiencing subject and agent who initiates action (supraordinate self), provided some clarity to this otherwise confusing concept. Stolorow, Brandchaft and Atwood (1987) took the argument further, defining psychological structure as an “organisation of experience” (p.17). Thus, the view of a
“fragmented self striving to restore cohesion [in which the agent “I” is transformed into a
39 | Suicide and the intolerable state of a fragmented self reified “it”, would be more accurately expressed as] … the person whose self experience is becoming fragmented strives to restore his sense of sense of self-cohesion” (p.19).
Accordingly, the italicised self referred to in this thesis embodies both the nuclear and supraordinate functions of the self. Notwithstanding the aforementioned dangers of reification of the self, Lee and Martin (1991) believe that this is not a significant issue for the concepts of a cohesive or fragmenting sense of self, “which are more easily conceived of as states of the self, on a continuum, with cohesion at one end and fragmentation at the other [and that] … perhaps more significantly, these concepts are supported by behavioural correlates” (p.186).
2.3 Early Life Narcissistic Grandiosity
Early life narcissistic grandiosity is essentially the starting point for the process of the development of psychic structure formation and a sense of self. Indeed, the transformation from the grandiose sense of self into a mature and cohesive sense of self is the primary developmental process of interest to self psychology. However, two essential issues need to be acknowledged before examining this developmental process further: engagement and optimal frustration. Beyond the genetically disposed behaviour to survive discussed in Chapter 1, we also have a repertoire of other innate behaviours, one of which is the capacity for engagement, which has been demonstrated in ethological studies (Meares, 1990), and well established within human developmental theory and research (Mazur, 2002). Thus, we are born for protoconversation (Trevarthen,
1974), that is, the ability and need for a reciprocal exchange between self and selfobject.
It is this innate behaviour that is lost in brain damage (Trevarthen & Aitken, 1994). The other necessary ingredient for self development is optimal frustration, which Kohut addressed in three ways. Most importantly, optimal frustration is the consequence of inadvertent, but inevitable, errors in transference experiences that evoke a previous experience but which result in a temporary disintegration of the self process; it is this process of self adaption that results in mature development.
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Early life narcissistic grandiosity is considered to be self soothing; a child’s response to the vagaries and frustrations that the often unwelcome realities of life frequently present. Even under the most ideal developmental circumstances, a child is faced with sufficient anxiety necessitating the development of a grandiose view of his own abilities (the grandiose self), and an unrealistic expectation of the capacity of his parents to care for him (the idealised parent imago). The role of grandiosity diminishes as the child comes to the realisation that the parents do not possess the attributes ascribed to them. The parents’ abilities are therefore subsequently reframed in terms of more normative understandings of their abilities. Early life grandiosity is particularly vulnerable to psychological insult and this frequently occurs through disappointments within the selfobject transference experiences. For Kohut, the role of the selfobject
(discussed below) therefore, is to minimise these disappointments for the child (or regressed adult) so that they can be accepted, and enable the child to gradually
“relinquish his omnipotent fantasies … while maintaining comfortable levels of self esteem” (Baker, 1979, p. 419).
Developing the ability to self soothe is considered essential to realising a cohesive sense of self because this is indicative of the capacity to cope with the absence of a selfobject and an ability to achieve self-restoration when faced with threats or trauma. For example, when faced with the unexpected physical, or emotional, absence of a parent because if illness, a child unable to self soothe might experience distress because of the absence is incongruent with their expectations of omnipotence. One reaction to such disillusionments is for the child to feel a sense of loss and shame, and to blame himself of being unworthy of parental love. For self psychology, the normative developmental process from early life narcissistic grandiosity to a mature and cohesive sense of self can only be realised through positive experiences with selfobjects.
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2.4 Selfobjects
Implicit within the theory of self psychology is the basic human need for recognition, which accompanies the development of a cohesive sense of self. This is achieved by positive transference experiences of acknowledgment within selfobject
(significant others) relationships. Selfobjects are those people who we incorporate as a psychological part of our own sense of self. Ornstein (1978a) best describes the role of the selfobject as “such [a person] is related in terms of specific phase appropriate needs of the developing self, without recognition of the separateness of the object and its own cent[re] of initiative” (p.60). That is, “psychological representations of others that are experienced as part of the self and that function, in a variety of ways, to support a person’s sense of liveliness and cohesiveness” (Galatzer-Levy & Cohler, 1990, p. 93).
Thus, the selfobject is valued for the internal functions and affective stability they provide and this role is significant during childhood development. Although the need for validation from a selfobject diminishes over a life time for those with a functionally cohesive sense of self, it nonetheless remains an essential self-maintenance factor. The subtle but distinguishing feature between selfobjects and others (objects) is that the latter are valued for who they are, functioning as autonomous and independent objects in our lives. However, the role of selfobject need not be restricted to animate objects.
Feldman and Johnson (1992) examined the selfobject function of weapons, concluding that these too can offer a “sense of power, omnipotence and mastery for the damaged self” (p.565). In so doing, the role of the weapon is analogous to an empathic selfobject response insofar as seeking to overcome disintegration anxiety by promoting a sense of control. Nevertheless, Kohut (1984) underscored the importance of the role of intimate transference in the development and maintenance of the self, by noting that “the most crucial emotional experience for human psychological survival and growth … [is] the attention of the selfobject milieu” (p.37). Basch (1991) places this in context by noting that, all through the selfobject’s intercession in the developmental process of the
42 | Suicide and the intolerable state of a fragmented self sense of self, the child learns functions that hitherto he has been unable to perform.
Kohut referred to this process as transmuting internalisation, which leads to the formation of psychic structure and reinforces a cohesive sense of self. However, when selfobjects fail to fulfil their role of nourishing the self, they can be seen as a threat to self cohesion and “must be eliminated” (Wolf, 1988, p. 78).
2.5 Empathy
Self psychology emphasises the role of empathic transference in the development and maintenance of the self and holds that selfobject failure to empathise results in a fragmented sense of self which underlies most psychopathology (Baker &
Baker, 1987). During the course of his theoretical development, Kohut attributed increasing significance to the role of empathy in the transference models he postulated.
In 1975, he formally expanded and finalised the definition of the construct, moving from the early-career view of it as simply an effective clinical method for data-gathering to:
a. The ability to recognise the self in the other.
b. The ability to expand the self to include the other “which constitutes a
powerful psychological bond between individuals, a bond that … perhaps
more than love …counteracts human kind’s destructiveness against fellow
creatures” (Lee & Martin, 1991, p.114), and
c. The psychological nutrient expressed to another as the “accepting,
confirming, and understanding human echo evoked by the self” (Lee &
Martin, p.114).
Strozier (2001) reports that, within self psychology, empathy came to be understood as a life force, “the self equivalent of libido” (p.330) and the absence of which is analogous to death.
From the moment when a man is born it is empathy, the wordless psychological
extension of the human environment to the baby which separates him from the
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inorganic world: from death, from the meaninglessness of solar systems, from
incomprehensible spaces, and from the ever more incomprehensible vastness of
endless time. ... It is this expansion of the self beyond the limits of the individual
which is the barrier to meaninglessness, to pessimistic despair (Kohut, 1978b, p.
667).
At first glance the significance given to empathy may appear all too similar to Carl
Rogers’ (1977, 1980) humanistic psychology developed earlier, to which Kohut could hardly claim authorship. Kahn (1985) attempted to address this issue by comparing the two, concluding that a “crucial similarity [exists in respect to] ... the nature of the psychotherapeutic “ambience” (p.903) whereby empathy is an important facilitator for developing personal growth, to which Roger’s deserves credit. Certainly, both were able to move beyond the classical emphasis on interpretation to positive regard within an empathic therapeutic relationship. Although Kahn and Rachman (2000) argue that the similarities between the two are not limited to the role of empathy, significant differences do remain, in particular the definition and primacy of self, time foci (past versus present), and Roger’s negative attitude toward classical psychoanalysis. Moreover, the relevance of psychic structures were rejected by Rogers who promoted a client-centred approach to therapy which focused on the here and now claiming his approach to be devoid of the mystery and myth of depth psychology (Rogers, 1977). Nevertheless, it is acknowledged that Kohut introduced Roger’s idea of empathy as a sine qua non for self psychology.
2.6 Selfobject Transferences
Central to Kohutian theory is the tripartite self, which recognises three selfobject transferences that contribute to the development, maintenance or restoration of an impaired sense of self: Mirroring (ambition pole), Idealisation (ideals pole), and
Twinship/Alter Ego (skills pole) which appears to reflect an early life need to feel human, and takes the form of a compensatory strategy to ensure the best possible relationship is
44 | Suicide and the intolerable state of a fragmented self achieved. Each is analogous to a self regulatory psychological strategy available to realise a cohesive sense of self. Thus, the presence of age-inappropriate transferences is often indicative of unmet selfobject needs, and symptomatic of a fragmented or fragmenting sense of self. Accordingly, these transference strategies are also employed by self psychology therapists as they engage with a client to restore a sense of self- cohesion. Notably, transmuting internalisation only occurs once adequate transferences have occurred in whatever combination that satisfies the transference need.
Although the transferences are examined separately in what follows, they are not necessarily mutually exclusive. Each is characterised by different lines of development from early life to mature forms. Kohut (1977) proposed the concept of the “tension arc”
(p.180), to acknowledge the psychodynamic interplay between each of the transferences in the pursuit of a cohesive sense of self and the subsequent development of skills and talents. Thus, by emphasising the significance of ambitions, ideals and personal skills,
Kohut advanced the concept of the nuclear self. The feelings of achievement that accompany the realisation of these core goals are not the result of the pleasure of discharging tension, but rather the joy of accomplishment. Importantly, these transferences need not be perfect to encourage the development of the intrapsychic structures that can reliably regulate a sufficiently functional sense of self. On the contrary, individual difference in transference need is recognised as paramount. What is prescribed is a “good enough” parental or selfobject transference for the experience to be positive. For example, what may be sufficient for one child may be quite inadequate for a sibling, suggesting that a consistent selfobject transference approach will inevitably fall short and this emphasises the significant role that empathy can contribute to the process. Equally, selfobjects themselves have their own selfobject transference experiences and this can influence their ability to participate positively as a selfobject to others. Further, selfobject transference needs continue throughout the life cycle and are often overlooked in geriatric interventions which seek to simply socialise and provide a sense of usefulness. Galatzer-Levy and Cohler (1990) posit that too often there is an
45 | Suicide and the intolerable state of a fragmented self eagerness to encourage the elderly to engage in the contemporary world by discouraging references to the past, and this may deny and invalidate individual transference needs relevant to these people. This is particularly terrifying for people in the early stages or dementia, because it “… deprives them of the [autobiographical] memories that solace, sooth, organise, and invigorate” (p. 100). Figure 2.1 illustrates the tripolar model for the development and maintenance of the self. Mirroring refers to the need for recognition and appreciation whereas idealisation and twinship recognises the need for security and a sense of belonging respectively.
Mirroring
Tension Arc Early Life Grandiosity: Idealisation Self Potential Self Tension Arc
Twinship
Figure 2.1: Schematic of the tripolar self, illustrating the transference options for the development and maintenance of the self.
2.6.1 Mirroring: the need for applause
Self psychology holds that infants have a genuine need for reassurance and appreciation in response to their endeavours, and that this need continues throughout life, albeit at a diminished level for people who experience a sense of self-cohesion.
Accordingly, embodied within the definition of the developmental stage of early life grandiose sense of self is the recognition of the legitimate role of narcissistic needs, which are considered as normal and adaptive in terms of providing a regressive defence
“against the too-early or too-abrupt disappointment in the omnipotent parent imago”
(White & Weiner, 1986, p.61). Nonetheless, Kohut (1971) recognised that although the narcissism associated with the grandiose sense of self can be the source of
46 | Suicide and the intolerable state of a fragmented self achievement, it can also give fuel to narcissistic rage. Narcissistic rage is the desire to regain control over the transference and is “characterized by an urge to revenge oneself, to undo an offense, and a driven-ness to accomplish these goals, which allow no respite to those affronted by a narcissistic injury” (White & Weiner, 1986, p.58). The target of this rage can be directed at the inadequate or absent selfobject, but when directed at the grandiose sense of self for the loss of control over the transference can become a source of psychopathology. Self directed narcissistic rage is viewed within self psychology as the final hope for an early life, or adult (who is unconsciously fixated at an age inappropriate phase), to repel somatic or psychological insult. Kohut (1972) hypothesised that some self-harming behaviour and suicides could be viewed as extreme examples of narcissistic rage directed against a deficient and therefore shameful sense of self. Consequently, suicides arising from narcissistic rage represent a failure of cathexis of the sense of self, and are not triggered by guilt, but rather by a tortuous sense of emptiness, deadening or shame. Or, as Feldman and Johnson (1992) suggest, these pathological behaviours are “…mobilised to fill “a hole” in the self, stabilising the self structure and preventing further fragmentation” (p.568).
Mirroring transferences, or appreciative responses such as ‘the gleam in a mother’s eye’, are considered essential to the positive development of a sense of self- cohesion. Mirroring back to the child a sense of self worth can be internalised and positively contribute to development of self respect. Baker and Baker (1987) note the importance of the mirroring being developmentally appropriate and genuine and offer the following example to elucidate. Throwing a ball would be a real accomplishment for a two year old, regardless of where it lands, and a joyous and reassuring mirroring response from the selfobject would be appropriate. A similar level of response to an eight year old would be inappropriate and unhelpful. Experiences of frustrations and failures are the processes of maturity, modulating and transforming the early life delusional grandiose sense of self by conditioning us to our own personal limits and those of others. As a result of these experiences, internal strategies are developed to
47 | Suicide and the intolerable state of a fragmented self allow for the tolerance of failure, and maintaining self esteem without undermining the pursuit of a realistically ambitious cohesive sense of self. Within this context, mirroring encourages and facilitates the early life demands for attention and perfection, leading to autonomous self-confidence and “a healthy self-object need for occasional, thoughtful appreciation and praise” (p.3).
The following two simple case vignettes illustrate “good enough” and pathogenic mirroring. Tolpin (1983) provides the first with the example of Mike, a five year old who was taught to ice skate by his parents. Serving as the needed selfobject, the parents provided the needed applause by way of delighted encouragement as he undauntedly moved on from the inevitable falls and failures that accompany learning a new skill.
Mike’s first public effort to skate without the presence of his parents left him crestfallen, and he returned home tearfully reporting that he had been unable to demonstrate how well he could skate because his legs kept collapsing. When his mother, in the expected responsive and supported manner of a selfobject, enquired what had happened in view of Mike’s earlier success, he explained it was because they were not there to watch him.
The encouraging presence of his parents was necessary for him to function adequately, but it is these unavoidable disruptions in the selfobject relationship, if kept within the context of an empathically responsive environment, that development of the self occurs.
Thus, for Mike, his sense of grandiosity was sustained, yet tempered. Baker (1979) provides the contrasting case of a young man who was failing at college. His father was critical of his acceptance into a prestigious college, commenting to his son as he left home on the first day “Just don’t come around here acting fancy and driving some big car” (p.4). Negative reflecting was a common experience for the young man, resulting in low self esteem and an inability to act assertively. This example of destructive mirroring is particularly salient as it also demonstrates the narcissistic vulnerability of the father, which prevented him from enjoying his son’s achievement, and participating in a positive selfobject transference experience.
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2.6.2 Idealisation: the need for security
The importance of idealising transference was recognised by Freud, who viewed it as a defence against libidinal drives (particularly aggression) that therapy sought to release through the repetition of past experiences. Unlike classical analysis, Kohut
(1971) interpreted idealisation as an attempt to overcome arrested transmutation from the grandiose self into a mature and cohesive sense of self. Wolf (1988) defines the self soothing nature of the transference as the “re-establishment of the need for an experience of merging with a calm, strong and good selfobject” (p.126). Notwithstanding the focus on selfobjects, idealising needs can be satisfied from other sources. Indeed,
Kohut (1971) believed that idealisation needs are the most prominent aspect of religious participation. God personifies all that is perfect, “whose function is to shore up, to hold together, sustain, to make harmonious, to strengthen, man’s self” (Strozier, 2001, p.328).
As with other transference needs, the external object (God) serves an internal self soothing function in the same manner as a selfobject.
The specific self development path for idealisation transference typically begins with a desire to merge with the idealised omnipotent selfobject. As the process matures so do the internal capacities of the self, with a corresponding reduction in transference needs. Thus, the idealised selfobject, or object, functions to facilitate the development of the capacity to control and channel libidinal and aggressive drives, and serves to assist the child establish productive life goals (Wolf, 1980). The following case vignette of Mr A from Kohut (1971) illustrates pathogenic idealising transference.
[Mr A had a] tendency toward feeling vaguely depressed, drained of energy, and
lacking zest with an associated drop in his work capacity and creativity during
periods when his mood had overtaken him. [His self was vulnerable, as]
manifested by his sensitivity to criticism, the lack of interest in him, or the absence
of praise from the people whom he experienced as his elders or superiors. Thus,
although he was a man of considerable intelligence who performed his tasks with
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skill and creative ability, he was forever in search of guidance and approval; from
the head of the research laboratory where he was employed, from senior
colleagues, and from the fathers of the girls whom he dated. He was sensitively
aware of these men and their opinion of him, attempted to get their help and
approbation, and tried to create situations in which he would be supported by
them. So long as he felt accepted and counseled and guided by such men, so
long as he felt they approved of him, he experienced himself as whole,
acceptable, and capable; and under such conditions he was indeed able to do
well in his work and to be creative and successful. At slight signs of disapproval
of him, however, or lack of understanding for him, or loss of interest in him, he
would feel drained and depressed, [and] would tend to become first enraged and
then cold, haughty, and isolated, and his creativeness and work capacity
deteriorated (p.57).
Kohut summarised the case by noting that Mr A was unable to feel adequately satisfied by living to his own standards and goals, and was only able to realise a heightened sense of self esteem by melding with others whom he admired and whose acceptance he craved. As with mirroring, the “good enough” parental or selfobject rule applies, as minor failures work in unison with success to ensure the mature development of the self. Baker and Baker (1987) apply the analogy of muscle development, “some resistance adds power and bulk. No challenge yields atrophy, and excess exhausts, or can even tear the muscle” (p.4).
2.6.3 Twinship/Alter Ego: the need to belong
Twinship is the final transference proposed by Kohut (1977) and transformed his original bipolar model into a tripartite understanding. Twinship-selfobject relationship refers to the need to relate to someone with similar interests and skills, a degree of likeness knowing that one is understood by someone similar to oneself:
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Within the context of the [twinship] transference, an outline will gradually come to
light of a person for whom the patient’s early existence and actions were a source
of genuine joy; the significance of this person as a silent presence, as an alter
ego or twin next to whom the child felt alive (the little girl doing chores in the
kitchen next to her mother or grandmother; the little boy working in the basement
next to his father or grandfather) will gradually become clear. (Kohut, 1984,
p. 204).
Kohut (1984) argued that the twinship experience represents the most fundamental sense of the human experience and begins in infancy, creating for the child a sense of belonging and participating that cannot be interpreted as a mirroring response or merger with idealised self objects. Wahba (1991) noted the frequent presence of envy in many twinship transferences suggesting that this could be understood as a fragmenting experience “resulting from the disrupted need to feel sustained by the experience of sameness or alikeness” (p.137).
The following case vignette is provided by White and Weiner (1986). John’s father had died before John’s birth and his depressed and withdrawn mother had been unable to provide adequate mirroring or idealisation experiences for him. He had been unable to idealise his grandfather who submitted publicly and unyieldingly to the sadistic behaviour of his wife, and developed a twinship relationship with him in lieu. John felt accepted and sustained by his grandfather’s warm mentoring of his literary interests and he became a successful editor. As with mirroring and idealisation, empathy and trust is essential for the experience to be positive and facilitate increasing autonomy and a cohesive sense of self. Accordingly, selfobjects serve to provide particular psychological functions that serve to establish and maintain a balanced, energised and cohesive sense of self. Figure 2.2 illustrates the process of empathic selfobjects and transferences within the development process of a healthy sense of self. However, when deprived of a needed selfobject response, or experiencing a failed selfobject transference or
51 | Suicide and the intolerable state of a fragmented self narcissistic insult, no matter how seemingly inconsequential to an observer, a sense of fragmenting self experience may result.
NOTE: This figure is included on page 52 of the print copy of the thesis held in the University of Adelaide Library.
Figure 2.2 A diagrammatic representation of the processes of empathic self object transferences (adapted from Kahn, 1985, p.900).
2.7 Self Fragmentation
Kohut (1984) noted that the sense of fragmentation or enfeebled depression “is the deepest anxiety man can experience” (p.16), a metaphor for the subjective state when “one no longer feels aspects of one’s self-experience to be coordinated or fitted together” (Shane, 1992, p. 216). Wolf (1988) went further, noting that “the experience of a crumbling self is so unpleasant that people will do almost anything to escape the
perceptions brought about by fragmentation” (p.39). Baker and Baker (1987) liken it to
the fear of death of one’s humanness, a psychological annihilation, which clients will
describe as the experience of being in space without oxygen, treading in ocean without
support and the ever present danger of sharks, or a sense of deadening. This
experience of fragmentation gives rise to the self (as an initiator of action) to respond in
52 | Suicide and the intolerable state of a fragmented self such a way to as to establish or restore a sense of coherence. Importantly, particularly in regard to this thesis, is that “even if the behaviour employed to ward off disintegrating anxiety is self-defeating or self-destructive, it is experienced by the individual as preferable to the sense of fragmentation” (p. 5) resulting from intolerable states.
Accordingly, psychopathology is viewed as analogous to crisis management seeking to restore a less vulnerable and cohesive sense of self. However, Silverstein (2007) noted that “fragmentation does not necessarily refer to an emergent psychotic reaction or to acute disruption of psychological functioning in the face of appreciable trauma” (p.115).
Instead, the experience of fragmentation can be understood as a sense of dissolution, of one coming apart.
Within the therapeutic relationship, Kohut (1971) also noted the difficulties in reaching the client’s narcissistic rage, grandiosity and fragmenting sense of self because of the defensive strategy of the vertical split. Classical psychoanalysis contributed the durable concept of defence mechanisms such as repression and denial, which are concerned with erasing desires, feelings and memories from conscious awareness.
Such processes are accepted as being commonly employed strategies within the human experience. Kohut referred to this as the horizontal split whereby the repressed memories are placed below the surface. The vertical split however, resulted from his recognition of another defence strategy he termed disavowal, which “isolates or sequesters mental contents rather than eliminates them from conscious awareness”
(Silverstein, 2007, p.249). Disavowal is a dimension of consciousness wherein one is aware of, and can acknowledge, particular behaviour, but is unaware they are experiencing disavowed states. Goldberg (1999, 2000) explained this further by noting that when particular mental phenomena contradict the predominant self-image they are segregated from, but not lost to, conscious awareness. This experience is distinct from the dissociative disorders, which are, unlike the vertical split, accompanied by distortions in reality awareness in the form of disruptions “in the usually integrated functions of consciousness, memory, identity, or perception” (DSM-IV-TR, 2000, p. 519). Goldberg
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(1995) considered promiscuity, eating disorders, and addiction to be indicative of vertical splitting, and stressed that not only was the behaviour in conscious awareness, but that those individuals often considered their own conduct as abhorrent. This self-abating behaviour is traditionally interpreted as a bid for attention in the hope of empathic responses from others, a “narcissistic component … unconsciously defending against the despair and rage of oedipal defeat” (White & Weiner, 1986, p.70). Within self psychology however, it is deemed to be a disavowal of the grandiose sense of self, an available compensatory strategy for dealing with an inadequate transference experience, whereby the client presents a false sense of invulnerability to psychological insult.
Clearly, the presence of age-inappropriate transference needs is indicative of the experience of a fragmenting sense of self. The emergence of the following examples is also seen as symptomatic of fragmentation and attempts to revitalise the self: brooding rumination (the inability to self-soothe), promiscuity and sexual perversion, Issues of sexual identity, and narcissistic rage (Chessick, 1985). Figure 2.3 illustrates the process of the experience of a fragmenting sense of self resulting from failed selfobject experiences which leave a self “vulnerable to narcissistic injury producing either withdrawal or frequent rage: sexual, aggressive or oral activities used by the fragmented self to soothe, stimulate or pull itself together; feelings of depression, boredom and emptiness in life” (Kahn, 1985, p.901).
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NOTE: This figure is included on page 55 of the print copy of the thesis held in the University of Adelaide Library.
Figure 2.3: A diagrammatic representation of arrested development resulting from failed empathic self object transferences (adapted from Kahn, 1985, p.901).
2.8 Disorders of the Self
The previously noted introduction of the DSM was accompanied by a delineation of symptomatologies foreign to psychoanalysis. In particular, the multiaxial approach emphasised diagnostic classifications whereas classical self psychology focused on reconceptualising personality disorders and neuroses as disturbances of self cohesion. van Heeringen (2001) recognised the need to move beyond the arbitrary structure of the
DSM to understand the aetiology of suicidal behaviour. Western, Shedler and Bradley
(2006) also referred to limitations in the dichotomising approach taken in the DSM, noting that most personality traits are not dichotomously distributed in nature, but are continuous which implicitly supports a neo psychoanalytic approach to diagnosis.
Moreover, Oldham (2006) also addressed the problematic nature of the DSM by examining comorbidity in diagnoses in the context of suicidality, suggesting, as an alternative approach, the three personality characteristics identified by Links and Kolla
(2005): perfectionism, impulsive aggression, and emotional dysregulation.
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Nevertheless, Silverstein (2007) provides a helpful rapprochement for self psychology that accommodates the different foci by addressing three deficit patterns that can undermine positive life experiences: devitalisation, preserving a cohesive sense of self, and forestalling fragmentation.
2.8.1 Devitalisation
Devitalisation represents deficient selfobject mirroring and is most apparent in
Schizotypal, Schizoid and Avoidant personality disorders. The consequence of failed mirroring experience, such as ignored or insufficient admiration or affirmation from a selfobject, undermines attempts to maintain a vigorous or cohesive sense of self. This is illustrated by entrenched averseness or distanced withdrawal, whereby people “conduct their lives by removing themselves from the painful rebuffs resulting from chronically ignored needs for admiration” (Silverstein, 2007, p.6). For example, children who have been unsuccessful in evoking a responsive selfobject environment ultimately retreat into themselves for self-gratification, “ushering in what will coalesce as a schizoid personality adaption” (p.77). This perspective is similar to Guntrip’s (1968) understandings of the schizoid personality and Winnicott’s (1965) concept of the false self.
2.8.2 Preserving a Cohesive Self
Attempts to preserve a buoyant sense of self relate to developing partially successful compensatory structures in an effort to “repair chronically injured self- cohesion deficits” (p.6). This strategy is common in Histrionic, Dependent, and
Antisocial Personality disorders, whereby attempts are made to restore an injured self through twinship or idealised selfobject transferences. For example, clients with
Dependent Personality Disorder are unable, or disinclined, to draw on their own resources, excessively relying on pleasing those on whom they seek support. Typically, the degree of dependence on others for self sustenance results in a vulnerability to feelings of abandonment, or a life preoccupied by the fear of selfobject abandonment.
56 | Suicide and the intolerable state of a fragmented self
2.8.3 Forestalling Fragmentation.
This final deficit pattern represents attempts to maintain a cohesive sense of self when threatened by destabilisation. Prominent in Borderline, Paranoid and Obsessive-
Compulsive disorders, this strategy is a response to the fear that an already fragile and brittle sense of self may fragment. Consequently, clients within this destabilised category seek to safeguard themselves against threats to their intactness that might re-expose them to experiences of a fragmenting sense of self.
Children whose early live experiences have lacked selfobject empathy and have left them feeling unprotected and vulnerable, “replace their disappointment in their caregivers with a prematurely acquired, hypervigilant attunement to protect their very survival” (Silverstein, 2007, p. 119). Silverstein is supported by Benedik’s (2008) examination of the relationship between identity diffusion and psychopathology, which demonstrated a statistically significant correlation between disturbances of self and different psychopathologies. The relationship between mental health and suicide
(Cavanagh et al., 2003; Cheng, Chen, Chen, & Jenkins, 2000; Goldney, 2006a), and personality disorders in particular (Links, Gould, & Ratnayake, 2003) is well established in the literature. However, inclusion of a self psychology interpretation of a relevant Axis
II disorder such as Borderline Personality would appear warranted at this point, to elucidate the theoretical perspectives hitherto addressed.
2.9 Applied Self Psychology:
Borderline Personality Disorder (BPD) is broadly defined as a “pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity” (DSM-IV-TR, p.706), and as such not all clients with BPD are the same
(Fuchs, 2007; Oldham, 2006). Indeed, a diagnosis of BPD requires the presence of any five of the nine criteria for the disorder, providing a range of combinations from which to determine whether the classification is appropriate. Oldham (2001, 2002) emphasises
57 | Suicide and the intolerable state of a fragmented self the individual variations within BPD by positing five subtypes: affective, impulsive, aggressive, dependent and empty; arguing that affective and impulsive clients are particularly vulnerable to suicidal and self-harming behaviour. Accordingly, like paranoid and obsessive compulsive disorders, BPD is a good example of a psychopathology in which affective stabilisation, impulse control and reality testing can be seriously undermined (Silverstein, 2007).
Kohut viewed BPD as a fragmentation-prone disorder in which the common and
“predominant organising principal is to: detect and counteract [the] perceived threats”
(p.117) of others: effectively a deficit state of pathological disturbances of self-structures preceding the development of a cohesive sense of self, or a pre-emergent condition
(Wolf, 1994). Unlike Narcissistic Personality Disorder, which is considered to represent transient fragmenting experiences within a relatively stable personality structure, BPD involves a greater level and persistence of destabilisation (Silverstein, 2007). The constant and intense tension state of the possible exposure to what Kohut (1971) referred to as disintegration products (e.g. narcissistic rage), is present in most disorders of the self and prominent in BPD (Kohut, 1978b). Thus, the principal objective appears
to be forestalling fragmentation of the self. Fuchs (2007) noted the inability of this
particular population to develop a cohesive self-concept, and the complete
preoccupation with their present affect state, “switching from one present to the next
…[and instead of repression] …their means of defence consists in a temporal splitting of
the self, that excludes past and future as dimensions of object constancy, bonding, commitment, responsibility and guilt” (p.379).
Moreover, he argues that BPD can be best understood in terms of the experience
of a fragmentation of the narrative self (refer to the discussion in Chapter 4). Briefly,
narrative identity theory implies a meaningful coherence between past experiences, the
present and future. Like self psychology, the role of the selfobject and positive selfobject
transferences is considered paramount. Fuchs (2007) approaches the process of the
relationship under the headings of impulsivity, splitting, identity and intersubjectivity.
58 | Suicide and the intolerable state of a fragmented self
Impulsivity and affect dysregulation are core symptoms of BDP whereby risk taking and highly unpredictable behaviour are common, together with an inability to regulate moods and affects (Clarkin & Posner, 2005). Further, their preoccupation with their momentary state means that their sense of self is often reduced to the present experience, and prevents a distancing from the present as they impatiently and continually seek to address emerging impulses such as anger, compulsion and self-mutilation. In terms of the self, the result is that this population does not have the ability to “draw on the experiences of the past in order to determine their own future by reflected decisions.
They miss the experience of agency or authorship of their life” (Fuchs, 2006, p.381).
The temporal phenomenon of splitting is unlike Kohut’s vertical splitting discussed earlier in this chapter in that it is concerned with the tendency to perceive the world in absolutes, artificially removing all the ambiguity of the human experience. Those suffering from BPD are unable to integrate the positive and negative characteristics into a coherent self experience and view themselves for example, as either completely good or bad; grandiose or immoral (Kernberg, 1975; Kernberg, Selzer, Koenigsberg, Carr, &
Appelbaum, 1989). The inability to simultaneously accommodate contradictory self representations results in a constant oscillation between the contradictions, and prevents the development of a “reflective position beyond their present state from which they could integrate divergent aspects of their …self experience” (Fuchs, 2006, p.382).
Fragmented identity is the result of impulsivity and splitting, which do not allow for the development of a sense of continuity over time. Rather, the experience for those with BPD is one of unending and repetitive affect states, creating a “… peculiar atemporal mode of existing” resulting in unstable self representations (Fuchs, 2006, p. 382). This population frequently change vocations, friends, and life goals; unable to commit to any enduring self-defining characteristics. Wilkinson-Ryan and Western
(2000) reported that although identity disturbance is associated with personality disorders generally, it is more prevalent in the majority of cases of BPD. Moreover, deficiencies in autobiographical memory have been noted leading to a sense of
59 | Suicide and the intolerable state of a fragmented self unauthenticity and incoherence (Levy, Meechan, Weber, Reynoso, & Clarkin, 2005;
Startup et al., 2001). Such experiences are referred to as dissociative in that the individual is unable to integrate cognitions, somatic perceptions and memory into a unitary and cohesive sense of self. This, in turn, can result in a discontinuous or fragmented sense of self experience. And finally, identity disturbances in BPD can also be conceived as a disorder of intersubjectivity.
Central to Kohutian self psychology is the view that selfobjects are essential to the development of a healthy and mature sense of self. Positive early life selfobject or implicit other (Fuchs, 2007) transference experiences such as mirroring create an emotional harmony that, when repeated frequently, are internalised as secure attachment behaviour (Bowlby, 1969, 1988) from which a cohesive sense of self can evolve. Tronick et al. (1998) referred to this as dyadically expanded states of consciousness, recognising the self organising nature of individual consciousness that
can be developed into “more coherent and complex states in collaboration with another
self-organising system” (p.290). Silverstein (2007) also noted that many sufferers of
BPD employ the strategy of fusing self and object as they attempt to address earlier
failed transference experiences. Such an amalgamation may be adaptive inasmuch as it
“reconstructs for such patients a semblance of a sense of self when there has been a
developmental failure to achieve self and object differentiation” (p.136). Within the BPD
population dysfunctional attachment patterns are common and considered to be the
result of adverse or traumatic transference experiences (Fonagy et al., 1996; Fuchs,
2007). Thus, the frequently observed fear of abandonment, feelings of emptiness,
expressions of rage, and a fragmenting sense of self may be explained in terms of failed
early transferences (attachments) resulting in the absence of trusting relationships.
Consequently, there is an inability to establish the necessary inner representations of
others for a coherent narrative of oneself to develop. “Hence, BPD may also be regarded
as a disorder of early social attunement and intersubjective temporality” (Fuchs, 2007,
p.383).
60 | Suicide and the intolerable state of a fragmented self
Individuals with BPD frequently exhibit profound and persistent instability in their sense of self. They often lead chaotic lives focussed in the present and characterised by attempts to forestall the experience of dissolution. The high prevalence of suicidal behaviour within this population is acknowledged in the literature, with studies demonstrating a strong association with affective instability and personality (Soloff,
Lynch, Kelly, Malone, & Mann, 2000; Yen et al., 2004). This supports Brown, Comtois and Linehan’s (2002) results, which revealed that women with BDP attributed their suicidal behaviour to excessive negative affect, though the reasons between self-harm and suicide attempt differed. Acts of self-harm were reported as intending to express anger, self-punish and generate normal feelings, whereas suicide attempts were altruistic in purpose, claiming to make others better off. Brown et al.’s comments provide a useful conclusion: “suicidal patients may need to develop relationships that are more effective” (p.201); implicitly acknowledging the positive role of ‘good enough’ selfobject transferences.
61 | Suicide and the intolerable state of a fragmented self
Chapter 3: The Construct of Self
The Construct of Self
One of the oddest events in the history of modern psychology is the manner in which the ego (or self) became side-tracked and lost to view … odd, because the existence of one’s own self is the one fact of which every mortal person – every psychologist included – is perfectly convinced (Allport, 1943, p. 451).
3.1 Introduction
The self would appear to be a universal human subjective experience, yet the construct continues to elude simple explanation and definition. Indeed, Popper and
Eccles (1977) noted the difficulty in authoring a discussion on the self, because to do so inevitably leads to essentialist questions about the meaning of self or consciousness which, in turn “degenerate into verbalism … [making] such discussions and definitions
… useless” (p.100). Zahavi (2003), amongst many, noted the absence of consensus on the definition of the concept of self, which is reflected in the divergent notions of the construct in contemporary discussions on the subject. Within the literature of the self,
definitions abound, such as Jung’s (1939) “the totality of the psyche in so far as it
manifests itself in an individual … but also the circumference that encloses
consciousness and the unconscious; it is the centre of this totality“ (p.96). Gallagher
(2000) offers “an intuition that there is a basic, immediate, or primitive ‘something’ that we are willing to call a self” (p.15). Or the unhelpful, epitomised in Stein’s circular and redundant assertion (as cited by Allport, 1943) that “a self is a self is a self” (p.452).
Olson (1999) posits that there is no problem in respect to defining the self as the
construct simply does not exist. Rather, he argues, discussions on the subject are
concerned with personal identity, semantics, cognitive psychology, or epistemology.
Nevertheless, embedded within the following discussion is the acceptance of the sense
of self as a valid construct and a uniquely human experience.
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The importance of language and the first-person pronoun has been emphasised for its role in facilitating the differentiation of self and other, and has long been recognised as one of the distinguishing characteristics of the human self-experience
(Erikson, 1968; James, 1890). Cavell’s (1987) contribution to understandings about the self and object relationships captures the complex dynamics in what might otherwise be assumed to be a simple matter:
For a creature who has learned to use [the term] “I” appropriately [he] must know
at least the following: I is not my proper name, but refers to its speaker whoever
he is, including you, when you are speaking for yourself; that you are not only
“you” for “me” but an “I” for you; that I am a “me” when I think of myself as the
object of your intentions, though when I am speaking to you I am an “I”; that for
you, I am “you”, when I am with you, though I am not when we are apart, and in
fact somebody else may then be playing “my” part for you; that for someone with
whom I am not present, I am a ‘she” or a “her”, as the one or ones I wish to
exclude or am excluding will be a third person or some singular or plural sort for
me, and with male or female if singular; that two or more of us can form a “we” in
which each of us is still an “I”; without losing, that is , our separate identities; and
similarly for “them” and “they”; that one can speak for himself can also speak to
and about others; and that there is a point of view from which I, too, am a third
person, one who can be spoken about (p.12) (emphasis added).
Although the universality of the sense of self enjoys broad and popular support, it is not without its critics. Dissent comes predominantly from within the humanities, particularly anthropology, wherein many argue that the self is an artefact of Western culture (e.g.
Shweder, 1985). In respect to the universality of the construct, Pinker (1994) observed that the “culture of anthropologists themselves makes one apprehensive about their leitmotif that anything goes ... [and it is this] attitude that guarantees that anthropologists will miss any universal pattern in human ways” (p.411). Nonetheless, several social
63 | Suicide and the intolerable state of a fragmented self psychologists have also argued that the construct is unique to the West. This is epitomised in Burkitt’s (1995) comment that the idea “of human beings as self-contained unitary individuals who carry their uniqueness deep inside themselves, like pearls hidden in their shelves, is one that is ingrained in the Western tradition of thought” (p.1).
Markus and Kitayama’s (1991) article on culture and self provides an ideal focus for a brief discussion on the subject for the response it elicited from anthropologist
Melford Spiro. Spiro (1993) objected to the authors’ casual referencing of Geertz (1984) in support of their view that the Western conception of self is “a rather peculiar idea within the context of world cultures” (p. 107). Spiro argued that, not only had the authors misinterpreted Geertz’s (1984) characterisation of the concept of the Western person, but they, like Geertz, conflate and confuse the self with other concepts such as personality, individual and self-representation. In his literature review that followed, which included Kohut’s (1977) contributions to understandings of the self, Spiro concluded that the characteristics attributed to the “Western self and those attributed to the non-Western
– are found, albeit in varying degrees, in the Western and non-Western self alike”
(p.145). Strawson (2005) takes a stronger position in respect to the universality of the sense of self by declaring that it “arises almost irresistibly from fundamental features of human experience and is in no sense a product of “Western” culture, still less a recent product of it, as some have foolishly supposed” (p.vi).
Notwithstanding the evidence supporting the universality of the construct, variations in the characteristics of the self have been reported in several disciplines; for example, psychology ( Gergen, 1993), sociology (Rosenberg, 1979), and again anthropology (Harris, 1989). Both Harris (1989) and Spiro (1993) allege that reported cultural variations have been overstated, or the result of studies confounded by the absence of a sufficient definition of self. Some degree of cultural variation in self should be expected in view of the acknowledged individual variations within the construct
(Allport, 1961; Beck, Brown, Steer, Kuyken, & Grisham, 2001; Kohut, 1972). We live our culture, so might our sense of self be influenced by it to some extent. Similarly, the
64 | Suicide and the intolerable state of a fragmented self
Budda’s interest in the self demonstrates that the construct is not simply a product of contemporary science. The Budda viewed the self as a source of suffering, and advanced the view that the frustrations of those who revolve around their sense of self are analogous to “a dog tied to a post” (cited by Carrithers, 2001). Accordingly, he advocated liberation by transcending these psychological frustrations to a state of non- self, that of enlightenment.
Current interest in the construct of self continues to be situated within the wider discourse of the phenomenological concern with consciousness. That is, the subjective experience and essence of our identity and mental state, which Nagel (1974) captured with his classic rhetorical question of “what is it like to be a bat?” Hume (1739/1898) was one of the first to formally recognise the difficulty of the subjective nature of self by commenting that “I can never catch myself at any time without perception, and never can observe anything but the perception” (p.569). Kant (1787/1990) took Hume’s position further, noting that you cannot perceive yourself directly but you can perceive the act of perceiving which is referred to as apperception. Thus, it is some of the activity of the self that is perceived rather than self.
Importantly, the experience of the self was never intended to be reified as a physical entity or viewed as a single dimensional “concept to be considered as semantically tantamount to changes in blood flow or test scores [and that] … selves live in the same realm as do [our] virtues, vices, beliefs and aspirations, and that is where they should remain” (Berrios & Markova, 2003, p. 10). Notwithstanding the continuing issues surrounding definition and explanation, considerable progress has been made in understanding the construct, including the cognitive and neurological processes of the self. However, in view of the absence of consensus, a review of the historical process that has given rise to present day understandings of the construct would appear warranted to gain some insight into the experience we intuitively understand to be our self. The intention is to operationalise the construct to make it meaningful within the
65 | Suicide and the intolerable state of a fragmented self context of this thesis. Before doing so, however, the term identity warrants definition to avoid the frequent and erroneous conflation with the construct of self.
3.2 Identity
For the purpose of this dissertation, self and identity are considered separate yet intimately related constructs. Baumeister’s (1986b) separation of the private and public self is applied for the purpose of differentiating the sense of self and identity respectively:
The public self is the self that is manifested in the presence of others, that is
formed when other people attribute traits and qualities to the individual, and that is
communicated to other people in the process of self-presentation. The private self
is the way the person understands himself or herself and is the way the person
really is – even if other people fail to recognise it (p. iv).
Thus, identity is a functional representation of self that is publically expressed in a manner influenced by environmental issues such as social conformity. Unlike the self, however, it is this recognition and accommodation of external expectations which in turn drive a functional definition and interpretation of the self that can be understood as identity (Baumeister, 1986a). Ashmore and Jussim (1997) attempt to avoid the
“amorphous, and changing phenomena that defy hard and fast definitions” of the two constructs by simply noting the distinction between the “self/identity as individual-level phenomena [and] self/identity as societal-level phenomena” (p.5). This idea follows
James” (1890) understandings of the self as knower and known. Identity theories dominate social psychology and anthropology, and focus primarily on the public self. For example, Tajfel and Turner’s (1979) Social Identity Theory, Role Theory (Linton, 1945;
Newcomb, 1943; Sarbin & Allen, 1950) and Heise’s (1979) Affect Control Theory.
The subtlety in the distinction between self and identity is well illustrated by
Peekay, the protagonist in Courtenay’s (1992) novel “The power of one”. This precocious and insightful young man, reflecting on his life and misunderstanding the
66 | Suicide and the intolerable state of a fragmented self reciprocal nature of relationship transference, considers his multiplicity of identities to be a camouflage in which he, chameleon like, was to others what they required him to be.
“To Doc a companion, to Mrs Boxall an enchantment … to Hymie a foil, to Singe “n Burn a product, and to [his] peers an idealised school boy, a winner and a great guy” (p.577).
Further, he believed he had become a mental medicant to those significant others in his life who were disempowering him by plundering “… [his] spirit with the gift of themselves”
(p.577). He failed to recognise the difference between his desire to be an independent person and the role others play in the process of developing a cohesive sense of self.
Table 3.1 is a summary of several meanings attributed to the constructs adapted from
Tedeschi (1986, p. 4).
Table 3.1 Summary of Various Meanings Attributed to the Private and Public Self
Private (Core Self*) Public (Identity*)
Phenomenological experience Observable behaviour
Acting only for self Acting as agent for others
Actor controls access to information regarding self Information about self not controlled by actor
Acting in the interest of a limited number of people Acting in the interest of the community
* Author’s additions
3.3 Multiple Selves
This treatise holds that self is a unitary construct11 and that there is insufficient evidence to support the notion of multiple selves. Baumeister (1998) acknowledges that the issue of unitary versus multiple selves remains unresolved (e.g. Lester, 2010;
Moldoveanu & Stevenson, 2001), but nevertheless argues that unity is one of the
11 Kohut does not appear to have addressed the subject of multiple selves. However, a single construct is consistently implied within all his publications and his theory of self psychology (e.g. Kohut, 1971, 1977).
67 | Suicide and the intolerable state of a fragmented self defining characteristics of self. Within the corpus frequent references are made to multiple selves and these generally fall within two categories: inadvertent attribution or intentional argument. The former is often the product of the combination of language construction and viewing parts of the self as agents (e.g. Showers & Zeigler-Hill, 2003).
The latter generally focuses around the controversial subject of dissociative identity disorder which will be addressed shortly. Lee and Martin’s (1991) concern with the reification of the self, and the commonly observed application of adjectives in conjunction with the term, prompted the comment:
The danger of seeing parts of the self as agents is present in Kohut’s concepts of
a nuclear (private) self and peripheral (public) self. Both refer to an area of
location of the self. The temptation is to view the peripheral self and the nuclear
self as interacting with each other as if they have agency. This kind of temptation
increases when the list of various “selves” increases. Reiser (1986), for example,
delineates five selves: the endangered self, the enraged self, the vulnerable self,
the grandiose self, and the mirroring self (p.230). And what about such well-
known concepts such as the true self, the false self, the disavowed self, and so
forth? They are often used as if they were entities rather than an authentic but
transient quality of the self. The danger of reifying and anthropomorphizing is less
with the concepts of the cohesive sense of self and fragmenting self. These are
more easily conceived as states of the self, on a continuum, with cohesion at one
end and fragmentation at the other (p. 186).
Although the arguments for multiple selves appear frequently in the literature of social psychology and anthropology (e.g. Ewing, 1990; Lester, 1992, 2003a; Rowan, 1990,
2010), it is within the disciplines of applied psychology and psychiatry that it has gained some voice, albeit not without controversy. Lilienfeld, Lynn and Lohr’s (2003) concern with the potential harm of pseudoscientific therapies resulted in, inter alia, Lilienfeld and
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Lynn’s (2003) examination of the contentious diagnosis of Dissociative Identity Disorder
(DID) (formerly Multiple Personality Disorder). Two of the diagnostic criteria for DID are the presence of two or more selves and that these recurrently take control of the person’s behaviour (DSM-IV-TR). Lilienfeld and Lynn concluded their review by claiming that the evidence does not adequately support the concept of multiple selves. They also noted with concern that “there is compelling evidence that a large proportion – perhaps even a substantial majority – of patients with DID exhibit very few or no unambiguous signs of this condition prior to psychotherapy ... [but] often develop unambiguous features of DID only after receiving psychotherapy” (p122). They also suggest that a plausible explanation for the alleged presence of multiple selves is the possibility of people seeking causality for their instability or psychopathology. Moreover, although certain behaviour may imply multiple selves, behaviour is not of itself sufficient evidence to support the concept. Baumeister (1998) concludes his discussion on multiple selves by commenting that the “concepts of multiple selfhood may be dramatic metaphors for discussing some phenomena ... but they do risk undermining the basic concept of self. Different people have different perspectives on the same self, and so there may be variations among the cognitive representations of the self ... but it is the same self” (p. 682).
3.4 Conceptual History
The concept of self dates back in recorded history to Plato and Aristotle
(Hartman, 1977; McCabe, 1994). However, the earliest specific views on the subject appear to have been proffered by Descartes in the seventeenth century, signalling the birth of rationalism (Magee, 1998). Cartesian dualism, as it later became known, was
Descartes” view of the bifurcation of human beings: subject and object, mind and matter.
He argued that the former, the soul (self), is a res cogitans (thinking substance), effectively an immaterial entity under the stewardship of God which observes representations of the world and responds accordingly. Eighteenth century philosophers
(as have the greater majority of those who followed) generally rejected this dualistic
69 | Suicide and the intolerable state of a fragmented self approach to body and mind, instead focusing their attention on two specific issues relating to the concept of self: the origin of our understandings about the intrinsic essence of self, and the question of whether memory is a valid explanation for the experience of continuity of self (Perkins, 1996).
The incorporation of the concept of self into early nineteenth century medicine was the consequence of the notion of cenesthesia, which is the awareness of all somatic sensations and the perception that the body state is the result of the sum of all these sensations (Berrios & Marková, 2003). Notwithstanding this wider acceptance of a more holistic view of self over the Dualist-Interactionist paradigm, Dennett (1992) still found it necessary to coin the derisive term Cartesian Theatre, to remind theorists that the erroneous view of a separation of mind and body remains a pervasive image amongst
“laypeople and scientists alike – even [after] ghostly dualism has been denounced and exorcised” (p.107). He describes Descartes” notion of the self as that of a material
homunculus, accommodated within the pineal gland, observing a screen on which all
sensory data is projected and against which all appropriate decisions are made, and the
body instructed accordingly.
Mill (1869) appears to be the first within psychology to note the multi dimensional
nature of the self, and its relationship with memory, positing that “[t]he phenomenon of
Self and that of Memory are merely two sides of the same fact 12… This succession of feelings, which I call my memory of the past, is that by which I distinguish my Self” (Mill,
1869). However, the earliest attempt to describe and account for the construct within psychology was made by William James (1890) who, in his chapter on the consciousness of self, construed the self-other differentiation as a distinguishing feature of the human experience. He also identified three constituents of the self: “The mutations of the self” (p.73), “The empirical self or me” (p. 291) and “The pure ego [self]” (p.329)
12 This quotation is frequently attributed to the first edition of Mill’s book dated 1829. This is incorrect as it did not appear until 1869 in the form of an Editor’s note in the “New Edition” in which Mill edited the first edition and included critiques from two academics.
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(emphases added). In doing so, he effectively recognised, respectively, the conative, cognitive and affective components of the experience.
The empirical self refers to the self as an object of perception and knowledge, and currently labelled self concept. This is divided into: constituents of the self, self- feelings (feelings and emotions aroused), and self-seeking (actions prompted). These are each addressed in terms of the material self (physical), social self (the impression given to others), and the spiritual self, which James (1890) referred to as our “inner or subjective being [and] … psychic dispositions” (p.296). Having identified and detailed the dimensions of the empirical self, he followed by addressing personal identity, which included the conflict and interaction between these various aspects of self. James” view of a multi-faceted self has been further developed and is widely accepted in contemporary psychology (Greenwald & Pratkanis, 1984). Nevertheless, the subject is frequently expressed and modelled in language suggesting dissociated multiple selves which, it will be asserted later, is not the case. Indeed, James (1982) initially argued that
“man has as many social selves as there are individuals who recognise him and carry an image of him in their mind” (p.179). Later, he retreated to a position of referring to identity wherein he proposed that there are as many social selves (identities) as groups or individuals who know him (Baumeister, 1998). Nevertheless, James, it could be argued, provided the space and impetus within psychology for theories of the mind and the concept of self. Greenwald and Pratkanis” (1984, p. 131) adaptation of James”
(1890; p. 329) matrix of the empirical life of self (Table 3.2) is more helpful than the original in as much as it is presented in contemporary vocabulary and includes the conative, cognitive and affective components of the experience. Indeed, this trilogy of components continues to be recognised as the principal structure of self.
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Table 3.2 Contemporary interpretation of James’ (1890) analysis of the empirical self.
NOTE: This figure is included on page 72 of the print copy of the thesis held in the University of Adelaide Library.
Reproduced from Greenwald and Pratkanis (1984).
Later, Freud focussed on the unconscious processes of the mind and was, according to Millon (2004), the first to map the complexities of the role of these intrapsychic processes that manifest in overt behaviour. He had much to say on the self as he developed his psychoanalytic theory of the mind, which posited that people are driven by unseen forces, those “… fundamental and omnipresent biological instincts, the most important of which are the sexual or life-propelling energies known as the libido”
(Millon, 2004, p. 262). His id-ego-superego theoretical model is perhaps his most well known paradigm for its capture of the “familiar conflicts between passion and reason, between selfish emotions and civilised control” (Breger, 2000, p. 272). Freud suggested that the id is a reservoir of hidden, uncontrollable and potentially destructive instincts which fuel the drive for life. In contrast, the superego is placed at the other extremity of the continuum, representing personal conscience, ambition and direction. The ego is the self, the conscious, reasoning and common sense arbitrator of the inevitable conflicts
72 | Suicide and the intolerable state of a fragmented self between the id and the superego. However, the original role of the ego as solely a mediating agency changed twice as Freud developed and reformulated his theories.
Guntrip (1968) noted Freud’s first shift to a position in which the ego was viewed as the “equivalent to the basic, primary, psychic self with ““the archaic inheritance” as it nucleus” (p.93). This was later abandoned and replaced with the narrower role of the ego as the malleable part of the self responding to the immediate environment’s requirement for conformity; for example, parental and pedagogic demands. Essentially, Freud settled on the position of multi-dimensionality in which the ego was viewed as a subordinate part of the self. Guntrip (1968) explains:
It would be legitimate to employ two terms, “self” and “ego”, and to use the term
“self” for the primary, total, “mental existence”, while “ego” stands for the more
restricted conscious “I” that we are familiar with. We could then speak of the “self”
as split into an “outer-reality ego” confirming to the pressures of the outer
environment, and an “inner-reality ego” owning the basic libidinal needs and
drives … [which can result in the dysfunction] … of the fundamental
psychosomatic unity or basic self … [when the egos encounter] mutually
incompatible experiences from its object-world” (p.95).
Notwithstanding the expressive and unique vocabulary employed within classical psychoanalysis, Freud forced the issue of self into a wider debate with many of his theories and terminology becoming common knowledge within the public domain. Millon
(2004) suggests that he “merely crystallized previously diffuse ideas of many of his many predecessors” (p.258) about the subject at that time. However, Freud’s emphasis on childhood experiences and the role they play in developing the self is frequently ignored by his critics. Freud’s psychogenetic hypothesis for example, postulates that early life events give rise to deeply entrenched defence systems that can dispose individuals to lifelong patterns of pathological adaptation. This general view of personality development
73 | Suicide and the intolerable state of a fragmented self has been widely embraced and is ubiquitous within contemporary developmental, clinical and neurological psychology.
Interest in the self attracted few adherents outside the psychoanalytic school until the mid twentieth century, when Allport (1943) argued for the acceptability of the concept in psychology. He recognised an intrinsic congruence within the complex and diverse psychological dimensions of the individual that went beyond psychoanalytic theory.
Allport (1943) lamented the “partial eclipse of self … [reasoning that this was the direct
result of the behavioural school’s positivist culture, which has] …engendered a
wholesome dislike for question-begging explanations … [and an intolerance of a theory
grounded in what is considered] … the unenlightening plane of dialectics” (p.452). His
review of the literature concerning the self concluded that eight conceptions of the
construct are paramount:
a. As a knower. The “experiencing agent” (Greenwald & Pratkanis, 1984,
p.132) corresponds to James” spiritual self.
b. As an object of knowledge. The bodily self, which James referred to as
the material self.
c. As primitive selfishness. Corresponds to James” material self-seeking
dimension.
d. As dominance drive. The “portion of the personality that demands status
and recognition” (Allport, 1943, p. 455).
e. As a passive organisation of mental processes. Allport’s (1943)
acknowledgement of the ego, which Freud considered to mediate between
the conflicting interests of the “id, super-ego, and external environment”
(p. 455).
f. As a fighter for ends. Corresponds to James” spiritual self-seeking
dimension and that of ego psychoanalytic theorists such as Hartmann
(1939) who argued the importance to the self of the development of the
74 | Suicide and the intolerable state of a fragmented self
future-time-perspective and “… such con-comitants as [the] delay of
gratification and anticipation of future events” (Henik & Domino, 1975, p.
557).
g. As a behavioural system. The Gestalt model of a core personality that
“avoid[s] thinking of the ego as a single unity, and prefers to regard it as
the variable set of forces that are aroused … [in response to circumstances
in] … relation to [the] environment” (Allport, 1943, p.457).
h. As the subjective organisation of culture. The acknowledgement that
the self is in part socially determined. Effectively “eradicating the artificial
Freudian distinction between ego and superego” (Allport, 1943, p. 459).
Later in his career, Allport (1961) revisited his earlier works including, inter alia, his concept of self, conceding a lack of progress by observing that “[t]he psychology of personality harbors an awesome enigma – the problem of self” (p.110). He subsequently stepped back from his earlier position in regard to the sense of self, suggesting in a gesture of capitulation that definition should remain an issue for philosophy. Moreover, he advocated a change of terminology to “proprium” to reflect a broader label to the sense of self beyond the limited definitions and multiplicity of selves or egos. The proposed proprium was intended to further discussion on the self as the centre of the psyche in the manner of Cooley (1909) and Kafka (1953). This was not embraced by researchers at the time and fell into obscurity.
Despite the advocacy of Allport and others (e.g. Kohut, 1972; Rogers, 1942), the construct continued to be denied credibility in mainstream psychology. Criticisms remained and followed the line that because the self is an intuitive experience, poorly defined, and arguably beyond measurement, it offered little to psychology (Skinner,
1974). This remained much the status quo until the latter half of the twentieth century when Greenwald and Pratkanis (1984), in their contribution to a review of the emerging discipline of social cognition, argued that “it seems time to conclude that the self has
75 | Suicide and the intolerable state of a fragmented self attained good standing in psychology” (p.133). Their conclusion may have been premature with Flanagan (2009) positing that the contemporary consensus “among philosophers and mind scientists ... [is] that the self is a forensic concept, not a scientific one, and therefore not a member of the ontological table of elements” (p.44). Rose
(1996), drawing on the works of Foucault (1967, 1988) and Deleuze (1990), argues that the “psy” disciplines, psychology in particular, have been instrumental in inventing the contemporary self; making visible and functional certain characteristics of people such
as their conduct and relations with others. Rose appears to be more concerned with
identity than self, though both are intimately connected. Notwithstanding the continuing
debate between academic disciplines regarding the experience of self, the construct
continues to be widely regarded as the core characteristic of personality and
fundamental to understanding the human experience.
3.5 The Contemporary Self
Contemporary understandings and empirical evidence of the self have come
predominantly from social psychology and the cognitive and neurological sciences (e.g.
Buckner & Carroll, 2006; Keysers & Gazzola, 2007). Kircher and David’s (2003)
adapted definition of the self is sufficient for the purpose of providing context against
which current understandings of the construct can be addressed. It acknowledges the
primary characteristics of self; the shared subjective experience encapsulated by the
theory of mind, time, authorship, memory and the sense of being a whole person:
the commonly shared [subjective human] experience, that we know we are the
same person across time, that we are the author of our own thoughts/actions,
and that we are distinct from the environment. It is the immediate, pervasive,
automatic feeling of being a whole person, different from others, constant over
time [with a past, present and future], with a physical boundary, the centre of our
experience (p.2).
76 | Suicide and the intolerable state of a fragmented self
One issue that warrants discussion before addressing the contemporary self is the power of negative valence over positive for the possible effect this might have on the development and maintenance of one’s sense of self. Baumeister, Bratslavsky,
Finkenauer and Vohs’ (2001) examination of the greater power of bad events over good noted that when equal measures of positive and negative are present, the psychological effects generally orientate towards the negative. “This may in fact be a general principle or law of psychological phenomena, possibly reflecting the innate predispositions of the psyche or at least reflecting the almost inevitable adaption of each individual to the exigencies of daily life” (p.323). Indeed, this pattern of positive-negative asymmetry affect (Mummendey & Otten, 1998) has been repeatedly confirmed within the cognitive field of impression formation (Anderson, 1965). Moreover, the effects of negative experiences take longer to diminish than positive experiences (Brickman, Coates, &
Janoff-Bulman, 1978). For example, marital satisfaction was better predicted by negative interactions than positive ones (Huston, Caughlin, Houts, Smith, & George,
2001). This is also the case for other relationships and interactions (Afifi & Burgoon,
2000).
Sexuality is also an important ingredient of self and the evidence is that good sexual experiences are often considered “the best and most intense positive experiences people have” (Baumeister et al., 2001, p.327). But negative sexual experiences such as childhood and adult sexual abuse, and sexual dysfunction can have long term deleterious effects on self (Christopher & Kisler, 2005; McCarthy, 1999). Similarly, abusive, violent and neglectful parents can harm child development. Significantly, even a single traumatic experience can have an enduring effect on psychological and physical wellbeing. Conversely, there is an absence of evidence that a single positive experience can have equally influential consequences or, more importantly, that it can invalidate a negative experience (Baumeister et al., 2001).
Scarr (1992) noted that exceptionally good parenting would not produce better development than an average environment, whereas a negative environment can inflict
77 | Suicide and the intolerable state of a fragmented self enduring negative consequences. Scarr’s position is similar to Kohut (1977), who argued that parenting does not have to be extraordinarily good, but simply adequate for each child’s individual needs. This view is analogous to Winnicott’s (1958) “good-enough mother”. Researchers examining cognitive and intellectual development have also revealed that negative environments negate the genetic heredity effect on intelligence
(e.g. Hart & Petrill, 2009; Rowe, Jacobson, & Van den Oord, 1999). Not surprisingly, information processing is more thorough for negative experiences than for positive events. Repressors are an exception to the rule in that they avoid unflattering information about self (Baumeister & Cairns, 1992). Taylor (1991) proposed a minimisation hypothesis which posited that memory has a positivity bias in that the processes of memory erase bad experiences. Whilst there has been supporting evidence for Taylor’s hypothesis, research suggests that memory biases dilute negative experiences of self, but not those relating to other people (Skowronski, Betz, Thompson,
& Shannon, 1991).
David, Green, Martin and Suls (1997) examined the relationship between personality traits, affect and common positive and negative life events. Their results suggested that negative events had a greater pervasive influence on affect than positive events. Negative events influenced both good and bad mood, whereas positive events only influenced good mood. This trend was also evident in respect to the two personality traits examined. Neuroticism, which is characterised by distress and negativity, influenced both good and bad mood. The positive and gregarious trait of extraversion, however, influenced only positive affect. This seemingly innate susceptibility to the influences of negative events appears to be yet another milieu for the developing sense of self. Baumeister et al. (2001) concluded by noting that:
The positivity of self-concept reflects the combined motivational effects of self-
protection (avoiding the bad) and self-enhancement (embracing the good). In
many cases, such as a simple desire to do well, these two motivations operate in
78 | Suicide and the intolerable state of a fragmented self
tandem. When they can be effectively separated, though, the weight of evidence
suggests that people are more motivated to avoid bad views of self than to claim
good ones” (p. 351).
Baumeister’s (1998) synopsis of psychology’s contemporary conception of self provides a useful framework for a discussion on the construct. Three prototypical patterns of the experience of self are addressed: reflexive consciousness, interpersonal being, and executive function (Figure 3.1).
Self Reference
Self-Awareness Reflexive Consciousness Self-Concept
Self-Esteem
Self-Views
Self-Presentation Self Interpersonal Being Interpersonal Consequences
Emotionality of Interpersonal Self
Control, Self-Efficacy, Autonomy
Executive Function Self Regulation
Self-Defeating Behaviour
Figure 3.1 Schematic of Social Psychology’s contemporary understandings of self; the three prototypical patterns of the experience and their respective underlying constructs.
3.5.1 Reflexive Consciousness
Reflexive consciousness refers to the ability to construct a concept of self through reflexive conscious attention. Indeed, Baumeister (1998) argues that the “capacity of the human organism to be conscious of itself is a distinguishing feature and is vital to selfhood” (p.683). Cavell’s (1987) reference to the term “I” presented earlier in this chapter is central to self awareness. Her contribution captures the subjectivity and
79 | Suicide and the intolerable state of a fragmented self complexity of the experience and again demonstrates that the self is not an object that can be perceived. Hume (1739/1898) noted the subjectivity of the experience when he commented that “I can never catch myself at any time without a perception, and never can observe anything but the perception” (p.534). Kant (1787/1990) went further, also positing that it is not only that one cannot perceive oneself directly; but rather, it is the act of apperception (perception of perception) through which we gain information about the self. In other words, self is deduced or inferred by reference to perception of some activity of the self. Thus, the self is always situated. For example, one can be aware of enjoying a conversation or driving your car, but you cannot be aware of self without some situation.
Research from the cognitive sciences has revealed that self-knowledge is not primarily sought for its own sake, but for the pragmatic adaptive benefit of maximising one’s relationship with the environment. Higgins (1996) argued that people construct a
‘self-digest’ with respect to their relation to the environment, and it is this self knowledge
base against which people self reflect. Baumeister (1998) noted that the implication of
Higgins’ position “is that the ‘me’ – the conceptions of self that the person has, and that
others have of him or her – is a construct, the result of cognitive processes, rather than a
real entity that exists in the world. These constructions are tentative inferences,
hypotheses, conclusions based on observations” (p.684).
Rogers, Kuiper and Kirker (1977) noted a self-reference effect whereby self-
information is processed more thoroughly, especially in memory, than other information.
Greenwald and Banaji’s (1989) study revealed that words cued by self-generated names
were more easily recalled than those cued by other-generated names. They attributed the
mnemonic benefits of self to the highly familiar and organised “polarised knowledge”.
More recently, Macrea, Moran, Heatherton, Banfield, and Kelly (2004) investigated the
neural processes that subserve self-knowledge. Their results of their event-related
functional magnetic resonance imaging (fMRI) offered a neural substrate for the self-
reference effect observed earlier, supporting the “ordinary theories” (p.651) of self such as
80 | Suicide and the intolerable state of a fragmented self those posited by Klien and Kihlstrom (1986) and Greenwald and Banaji (1989). Macrea et al. concluded that “the memorial advantage afforded to self-knowledge appears to depend on the additional recruitment of [the medial prefrontal cortex] MPFC” (p.651).
This appears to suggest that the process of self-reference is functionally separate from general semantic processing.
Self-awareness appears to be the essence of reflexive consciousness. Self- awareness theory (Duval & Wicklund, 1972) commenced with the view that self- awareness is binary in so far as it can be directed inward or outward. Moreover, it was considered to be an aversive state as awareness of self typically elicits a comparison with an internally or externally established standard. People will usually fall short of their self- expectations or standards, which in turn will invoke a negative affect. However, self- awareness has since been demonstrated to serve a paradoxical function: it need not be unpleasant and can be adaptive and beneficial, but when elevated is associated with several psychopathologies such as affective and personality disorders (e.g. Brown &
Dutton, 1995; Twenge, Catanese, & Baumeister, 2003; Wheeler, Morrison, DeMaree, &
Petty, 2007). Carver and Scheier (1981) reported that the comparative standard chosen is significant in terms of psychological distress. Indeed, self comparison to standards appears to be the most enduring and influential feature of self-awareness theory. Brown and Dutton (1995) noted that people typically consider themselves above average and comparisons to others or an average abstract can be beneficial in terms of psychological well being. However, when a comparison is made with unrealistic ideals, people may experience distress in the event they fall short (Baumeister, 1990; Higgins, 1987).
Self-awareness also has a motivational function. Duval and Wicklund’s (1972) original theory argued that motivation is directed toward either improving to meet a standard or escaping the aversive side of self-awareness. Greenberg and Musham
(1981) demonstrated that there are two sides to self-awareness. When participants performed counter-attitudinal behaviour designed to induce negative self attitudes, they avoided seating that faced mirrors. Mirrors made a person self-aware which was
81 | Suicide and the intolerable state of a fragmented self unpleasant for those whose behaviour was contrary to their standards. Conversely, when people behaved in a manner that exemplified their values they exhibited a preference to face the mirrors. Thus, people do not simply seek to avoid the aversive side of self- awareness, but may actually “seek out cues to increase self-awareness when they have reason to feel good about themselves” (Baumeister, 1998, p. 686). Nevertheless, escaping from self-focusing stimuli appears to be commonly employed strategy in dealing with psychological stressors. In fact, Baumeister’s (1990) Escape Theory of suicide discussed in Chapter 2 is based on the desire to escape the aversive side of self- awareness.
The need to escape has also been associated with self-awareness reducing effects of alcohol consumption (Hull, Levenson, Young, & Sher, 1983). Alcohol misuse is considered one of the contributing factors behind self-injurious behaviour as alcohol narrows attention to relatively concrete and unemotional stimuli (Steele & Josephs,
1990). This restricted focus replaces any negative aspects of self-awareness with attention directed to simple sensation and movement. Baumeister (1990, 1998) refers to this as deconstructing the self whereby the meaningful and elaborate constructions are abandoned for a more rudimentary and incohesive state of self-awareness. In this alcohol-induced altered self state, self injury appears to increase. Karch, Crosby and
Simon (2006) reported that alcohol is found in 33% of suicide attempters, exceeding by two to one the rate of other self altering substances such as amphetamines, opiates,
marijuana and cocaine. The results of Berman, Bradley, Fanning and McCloskey’s
(2009) study supported this theory of self-awareness by demonstrating that when self-
focused attention was experimentally enhanced for alcohol-intoxicated males, self-
injurious behaviour decreased. Escaping self-awareness, however, is not necessarily
maladaptive, whereas failing to do so can be. For example, Greenberg and Pyszczynski
(1986) showed that depression is associated with egocentric rumination. This has been
validated more recently, with studies revealing that people who respond to negative
mood, anger or anxiety with self-focused rumination, experience even greater depressed
82 | Suicide and the intolerable state of a fragmented self mood. Moreover, this state of elevated negative mood is accompanied by impaired attention and concentration, problem solving deficits, increased uncertainty, and negatively biased thinking which can result in continued rumination and behavioural paralysis (Lyubomirsky, Caldwell, & Nolen-Hoeksema, 1998; Nolen-Hoeksema, 2000;
Ward, Lyubomirsky, Sousa, & Nolen-Hoeksema, 2003).
Psychology’s approach to self-concept and self-knowledge includes all beliefs about the self regardless of whether these can be demonstrated to be true or false. It is worth emphasising an important corollary, namely, that only a fraction of self-knowledge can occupy awareness at any given time. This state of partial self-knowledge awareness is commonly referred to as the “phenomenal self” (Jones & Gerard, 1967) and is an important distinction in respect to operationalising the self. The functioning of a phenomenal self means that even contradictory beliefs about the self can coexist, for it is only the phenomenal self that would need to be internally consistent. Otherwise, the person could hold widely disparate views about self which in turn may be problematic if these beliefs were simultaneously activated. Baumeister (1998) emphasises that self- knowledge is not simply the result of “a dispassionate operation of cognitive processes”
(p. 688), but rather, the culmination of one or more of three common motivational forces.
The first is the appraisal motive which refers to a healthy curiosity about the self.
People seek to understand how others appraise them and have a preference for accurate feedback (Trope, 1982, 1986). The second motivation is self-enhancement (Trope, 1986) which reflects the common desire for favourable information about the self. For example, even though individuals seek to learn about the self, there is usually a strong preference for positive reinforcement from others such as being considered attractive, competent or morally good (Baumeister, 1998). Consistency is the third motive, whereby people wish to confirm their own beliefs about themselves. Studies have revealed that established self beliefs are resistant to change and people seek out confirmatory evidence; criticising, distrusting or rejecting contradictory information (Brown, Ganesan, & Challagalla, 2001;
Swann, 1987).
83 | Suicide and the intolerable state of a fragmented self
Self-esteem is “the degree to which the qualities and characteristics contained in one’s SELF-CONCEPT are perceived to be positive ... A high or reasonable degree of self-esteem is considered an important ingredient of mental health, whereas low-self- esteem and feelings of worthlessness are common depressive symptoms” (APA, 2007, p.
830)(emphasis in original). Indeed, people with low self-esteem are not simply negative about themselves, but “have a tendency toward floccinaucinihilipilification” 13 (Baumeister,
Campbell, Krueger, & Vohs, 2003, p. 7). The construct has attracted considerable interest in the literature, and research has revealed the importance of high levels of self-esteem to human functioning. For example, in comparison to people with negative self perceptions, those with high self-esteem are generally:
a. More persistent in the face of failure and after than those who have negative
self perceptions (e.g. Baumeister et al., 2003; Shrauger & Rosenberg, 1970).
b. Less likely to suffer psychosis (Smith et al., 2006), and
c. More likely to be happier and exhibit an adaptive level of grandiosity
(Baumeister et al., 2003; Freeman & Garety, 2003)
Although high self-esteem is strongly associated with happiness and a healthy sense of self (Lyubomirsky & Lepper, 2002; Shackelford, 2001), it is a heterogeneous category,
“encompassing people who frankly accept their good qualities along with narcissistic, defensive, and conceited individuals” (Baumeister et al., 2003, p. 1). Moreover, the popular view that high self-esteem is beneficial and enhancing it will bring about positive outcomes appears to be supported in the literature. However, Gerrard, Gibbons, Reis-
Bergan and Russell (2000) revealed an apparent paradox in that some adolescents often utilise a variety of self-serving defensive cognitive strategies that minimise the perceived consequences of their health behaviour. For example, smokers make higher estimates of prevalence of the behaviour than non-smokers. Such strategies appear to foster experimentation which, in turn, may lead to risk taking activities such as unsafe sex.
13 Defined as the “action or habit of estimating [everything] as worthless” (Brown, 2002, p. 985)
84 | Suicide and the intolerable state of a fragmented self
Though research on reflexive consciousness has labelled separately various functions or characteristics of self, they are not entirely discrete elements. For example, reflexive consciousness appears to be partly contingent on interpersonal connections.
3.5.2 Interpersonal Being
The second pattern of self is the interpersonal nature of the experience that appears to transcend lower order animals. Baumeister (1998) refers to Sartre’s (1957) expression “the look” to describe the subjective experience of knowing that when you are looking at someone, that person is looking at you. This understanding is encapsulated in the theory of mind (Premack & Woodruff, 1978) which posits that one can only prove the existence of his or her mind through the commonly shared human capacity for introspection. In this way, an individual “imputes mental states to himself and to others”
(p. 515). Kohut (1971, 1977, 1985b) emphasised the importance of positive relationships with significant others in the development and maintenance of the self. More recently,
Andersen and Chen (2002) proposed an interpersonal social-cognitive theory of self and personality termed the relational self. Like Kohut, Andersen and Chen’s theory embodies and gives prominence to the self-other relationship, arguing that the sense of self develops through the cognitive and social phenomenon of transference. Also complementing Kohut’s paradigm is the comment by Baumeister (1998) that “[s]elfhood cannot be achieved or constructed in solitude” (p. 701). Accordingly, interpersonal being is primarily focussed on the manner in which interpersonal relations develop and maintain the self.
Within the social environment, self-information is obtained by reflected appraisals which is the quintessential theme within Festinger’s (1954) social comparison theory
(SCT). Essentially, SCT posits that people have an innate drive to evaluate themselves against others. Thus, self-knowledge can only be gleaned through interpersonal processes which implicitly involve others (Baumeister, 1998); seeing ourselves as others see us, or what Cooley (1956) referred to as the looking-glass self. Nevertheless,
85 | Suicide and the intolerable state of a fragmented self reflected appraisal is unlike symbolic interactionism (Mead, 1934) which focuses on subjective social experiences and Baumeister (1998) argues that people are pragmatic actors who continually reflect the actions of other actors. For interactionists, the self
“emerges from human interaction that involves people trading symbols (through language and gesture) that are usually consensual, and represent abstract properties rather than concrete objects” (Vaughan & Hogg, 2002, p. 84). Thus, the development of self is attributed to predominantly observable external influences with little recognition of internal processes. The theory of reflected appraisal, however, emerged from research findings which have demonstrated that there is a greater correlation between self-concept and one’s belief about how we are perceived, than external influence. One of the consequences of this process is that discrepancies can arise between self-appraisals and reflected appraisals (Felson, 1989, 1993; Leary & Quinlivan, 2005). Baumeister (1998) notes that one of the causes for the discrepancy is that the “exchange of interpersonal evaluations is highly distorted” (p.701) by the desire to impress or avoid distressful responses. The other is self-deception whereby people filter and bias self-information, adapting it to complement existing beliefs and preferences. In an effort to construct a cohesive sense of self, people employ a variety of tactical strategies in response to these discrepancies. For example, some people may restrict their lives to a finite number of contexts so that the self is cued by context alone (Vaughan & Hogg, 2002), or revising
ones integrative autobiography to assimilate with a new self-identity (Greenwald &
Pratkanis, 1984).
The presentation of one’s self to others is perhaps the most conspicuous and
proactive method of interpersonal activity. “Part of the self exists outside, in the minds of
others: one does not have an identity unless it is validated by others, which means others
must recognise and acknowledge one’s self” (Baumeister, 1998, p.703). Hewitt et al.
(2003) reported that perfectionist self-presentation appears to involve self-promotional
and self-concealing strategies. For this population, self-promotion requires sensitivity
and attentiveness to the emotional state of others, whereas, concealment (non-display or
86 | Suicide and the intolerable state of a fragmented self non-disclosure) of imperfection requires elevated levels of self-monitoring. Both these defensive strategies are associated with self-concept that involves “nonveridical presentations of the self to others and with both self-related and interpersonal forms of distress that are not accounted for by other personality constructs or self-presentational styles” (p. 1320). Moreover, these maladaptive self-presentation strategies are related to prevarication, narcissism and delusions (Leary, 2004), eating disorders (Landa & Bybee,
2007) and suicidal behaviour (Apter & Ofek, 2001; O'Connor et al., 2007). Vohs,
Baumeister and Ciarocco (2005) argued that self-regulation is most likely to be intimately involved in effective self-presentation. The results of their study suggest that “effortful self- presentation depletes regulatory resources, thereby causing subsequent self-regulation to suffer ... when regulatory resources have depleted, self-presentations suffer” (p. 654).
But when there are adequate regulatory resources available, people engage in self- presentations that improve the likelihood of interpersonal acceptance. Two motivational forces appear important for self-presentation: influencing others as means of achieving rewards (e.g. acceptance), and establishing a self-identity (Baumeister, 1998). In respect to rewards, Jones and Pittman (1982) advanced a taxonomy of instrumental goals that are pursued in what Baumeister (1998) refers to as impression management:
a. Ingratiation is the strategy of convincing others that one has appealing
characteristic and therefore likeable.
b. Intimidation seeks to induce fear as a method of influencing others to achieve
a desired result.
c. Self-promotion invites respect by demonstrating one’s competence and
aptitude.
d. Exemplification presents high moral virtues as a method of convincing others
of one’s good character, and
e. Supplication is the victim strategy whereby others are induced into believing
that one is needy and dependent.
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In regard to constructing an identity, self-presentation can be paradoxical. People are not always driven by the ideals of the audience with whom they engage, particularly when a desired goal requires too great a divergence from self. On these occasions,
people may not seek to make an impression on others to establish an identity. Rather, to
avoid dissonance, they may claim fidelity to self and identity (e.g. personal philosophy)
and present themselves in a manner that they acknowledge will not achieve the desired
goal (Tice & Baumeister, 2001; Wicklund & Gollwitzer, 1982). Nevertheless, Baumeister
(1998) stresses that identity requires social validation and its proximal relationship with
self necessitates that any tension between the two is minimal.
Interpersonal consequences of self-views refers to the influence self exerts over
interpersonal relationships. This is especially evident in self-schemas which refer to the
cognitive structures that represent knowledge about a specific concept, including the
attributions and how these relate to each other (Markus, 1977; Markus, Kitayama, &
Heiman, 1996). Dubow, Huesmann and Boxer (2009) noted that a child’s developing self-
schema is influenced by the interactions with significant others. Of note is that during
middle childhood to adolescence these schemas and attributional biases appear to
crystallise, resist change, and control future behaviour (Dodge, 2006; Huesmann &
Guerra, 1997). For example, children exposed to racism or violence develop self-
schemas in which they take on similar self-attributions such as “I am more violent”
(Barber, 2008). Similarly, suicide attempters whose childhood experiences were
perceived as lacking acknowledgement or love had negative self-schemas (refer Chapter
8). Indeed maladaptive self-related cognitions influence a variety of behaviours, inter alia:
psychosis (e.g. Addington & Tran, 2009), depression and anxiety (Cukor et al., 2007),
female body image, sexuality and subjective well being (Donaghue, 2009), and childhood
aggressive behaviour (Dubow et al., 2009).
Emotions also play a significant role in motivating the development and
maintenance of interpersonal relationships. Baumeister and Leary (1995) demonstrated a
fundamental human motivation for interpersonal relationships, suggesting that “one
88 | Suicide and the intolerable state of a fragmented self function of emotion is to alert the self to changes in these relationships” (Baumeister,
1998, p. 710). Guilt and shame figure predominantly in what Baumeister refers to as the emotionality of interpersonal self. The difference between these two powerful emotions of self-condemnation appears to be a matter of self-reference: guilt condemns by reference to self whereas shame condemns the self (Lewis, 1971; Tangney, 1995), even vicariously (Lickel, Schmader, Curtis, Scarnier, & Ames, 2005). Shame is argued to be the more destructive because it is linked to pathological outcomes (e.g. Naso, 2007;
Sweetingham & Waller, 2007) brought about by condemnation of the complete self.
In contrast, guilt is not as destructive because it generally focuses on a relationship- specific issue or transgression and often has a reparative function (e.g. Forster, Grant, &
Idson, 2001; Schmader & Lickel, 2006). As with shame and guilt, embarrassment also appears to be a blend of self-evaluation and interpersonal concerns. Miller (1995) noted two predominant theoretical perspectives on embarrassment. The first emphasises concerns over how we are evaluated by others and the second refers to dealing with awkward and unpleasant social interactions. Miller concluded that although both perspectives demonstrated validity, it appears that concern over evaluation by others is the dominant cause of embarrassment.
The human experience is clearly one of interpersonal experiences in which the self develops through extensive social interactions. However, the self “is far from a passive receptacle of external influences. Rather, it actively transforms and incorporates what it receives from the interpersonal world ... [and is] shaped by the expectations and feedback from others” (Baumeister, 1998, p. 711). Strategies such as self-presentation seek to influence others in an effort to validate one’s sense of self. Baumeister concludes that the cognitive load brought about by these strategies impairs processing of external information and escalates internalisation processes that focus on self.
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3.5.3 Executive Function
The final prototypical pattern of the experience of self is executive function. This refers to the active function of exerting control over self and the environment in ways such as agency, control, decision making and choice. Undoubtedly, it is this comprehensive active functioning that is, in its totality and higher order, unique to the human experience.
The motivation for control appears to be one of the most fundamental and pervasive features of selfhood. Failure to establish control, or loss of it, can bring about conditions such as learned helplessness (Seligman, 1975) and, in turn, psychological issues such as dysfunctional emotion regulation, mood disorders, and impaired spatial learning and memory (e.g. Allan, Siegel, & Hannah, 2007; Song, Che, Min-wei, Murakami,
& Matsumoto, 2006; Weems & Silverman, 2006). Illusions of control, for example, underscore the significance of self as people do not simply wish to believe that control exists somewhere, but rather develop the belief that they have mastery over their environment (Langer, 1975). Though control has, to some extent, been demonstrated in lower order species, “such animals do not presumably cultivate illusions of control. The linking of control with the sense of self is indicated by the illusions of control” (Baumeister,
1998, p. 713). Understandably, research on locus of control 14 focuses on the capacity to regulate reinforcement. A summary of the dominant control theories is presented as
Table 3.3.
14 Locus of Control refers to the extent to which individuals believe that they can control events that affect them. For example, people with a high internal locus of control believe that events result primarily from their own behaviour and actions. Those with a high external locus of control believe that powerful others, fate, or chance determine events.
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Table 3.3 Summary of dominant control theories
Theory Distinctive definition of control
Locus of control Emphasises that beliefs about the power or capacity to regulate reinforcement revolve around two loci: internal (the capacity to regulate is a function of self) and external (the e.g. Rotter (1966), Langer capacity to regulate is not a function of self) (1975)
Learned helplessness Emphasises that if attributions about negative events are ascribed to causes that are e.g. Abramson et al. (1978), perceived as stable, global, and internal, emotional problems may result Rothbaum et al. (1982)
Self-efficacy Emphasises that the individual’s beliefs about their confidence in their competence to successfully execute behaviours to produce and regulate events in their lives are critical to e.g. Bandura (1982) emotional well-being
Perceived control Involves the individual’s perception of the capacity to regulate in each theory as distinguished from actual control. Moreover, it can involve the whole set of beliefs about the e.g. Connell (1985) power to regulate, which may or may not be based on actual control
Adapted from Weems and Silverman (2006
Deci and Ryan (1995) have proffered a theory of autonomy in which the emphasis is placed on agency; viewing the self as an initiator of action rather than a responder to events. Moreover, it is not simply deliberately responding to another, but rather a deliberate intentional act of the self. They argue that self-determination involves three intrinsically motivated pursuits by the self: competence, autonomy, and relatedness.
Competence satisfies the need to experience oneself as capable and effective, and understanding how to control the environment. Autonomy refers to the need for an internal locus of causality, “the feeling that one’s acts originate from within the self, as opposed to being controlled or directed by external forces” (Baumeister, 1998, p. 715).
Notably, the executive function of self is by nature active, and deliberate acts have greater potency than passive acts in terms of realising positive psychological and social outcomes
(Cioffi, 2003; Cioffi & Garner, 1996; Stutzer, Goette, & Zehnder, 2006).
Higgins (1996) argues for the “sovereignty of self-regulation” (p.1062), referring to the prominent role of self-regulation in understanding the nature of self. Self-regulation refers to “the exercise of control over oneself, especially with regard to bringing the self
91 | Suicide and the intolerable state of a fragmented self into line with the preferred (thus, regular) standards” (Vohs & Baumeister, 2004, p. 2).
Banaji and Prentice (1994) refer to this as self-improvement motivation whereby an effort is made to change the self to make it conform to its own ideals. Vohs and Ciarocco
(2004) remind us that as social creatures, the interrelatedness of intrapersonal self- regulation and interpersonal processes is paramount. Indeed, the human capacity to
“override, interrupt, and otherwise alter its own responses is one of the most dramatic and impressive functions of human selfhood, with broad implications for a wide range of behaviour patterns” (Muraven, Tice, & Baumeister, 1998, p. 774). Muraven, Tice and
Baumeister’s (1998) study of self-control as a limited resource demonstrated that a strength model of self-regulation provides a better explanation than the alternative models such as activation or priming (e.g. Bargh & Pietromonaco, 1982; Wyer & Skull, 1980). The strength model acknowledges that it takes strength to control or alter one’s responses and is implicit in the concept of willpower (Mischel, 1996).
The ability to exert emotional control begins in the first two years of life and is essential for the development of adaptive social behaviour, and thus a healthy sense of self. Moreover, secure early attachment styles appear to provide the most conducive environment for this to occur (Calkins, 2004). Impaired development in self-regulation, however, may be antecedent to psychopathology (e.g. Calkins & Fox, 2002). McCabe,
Cunnington and Brooks-Gunn (2004) noted the malleability of one’s capacity to self- regulate. For example, responsible parenting, quality early child care and education appear to facilitate self-regulation. In contrast, absent or excessively restrictive parenting, poor non-maternal-care experience or a low socioeconomic environment can inhibit behaviour and emotional regulation.
Notwithstanding the significance of developing an adaptive capacity for self- regulation, psychological distress can exhaust these finite regulatory control resources.
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This may result in ego-depletion 15 and subsequent self-defeating behaviour such as acquiescence to persuasion, which in turn is often accompanied by an increased vulnerability to maladaptive behaviour or psychopathology (Baumeister, Bratslavsky,
Muraven, & Tice, 1998). Marx, Heidt, and Gold’s (2005) literature review of sexual revictimisation (Cloitre, 1998) suggested that “unpredictable and uncontrollable” (p.83) childhood sexual abuse triggers a number of “specific unconditioned responses characterized by generalized fear and arousal” (p.83). In response, some forms of emotional regulation can bring about or perpetuate behaviour that in turn may be recognised by perpetrators as characteristic of weakness or vulnerability. Alternatively, some victims may respond by engaging in emotionally avoidant strategies such as substance abuse, promiscuity or dissociation, and thereby increasing their exposure to the possibility of revictimisation (Polusny & Follette, 1995). Baumeister and Heatherton
(1996) refer to this failure in self-regulation as mitigated acquiescence in that people do not simply seek to relinquish self-control but prefer self-deception to the exertion of self- regulation. Thus, the lack of self regulation, and the presence of self-defeating behaviour reflects some impairment in self because “when executive function has a clear grasp of its best interest, it nearly always pursues it” (Baumeister, 1998, p. 723).
To summarize the discussion thus far, the construct of self may be understood as the aggregate of all the prototypical patterns of self activity and experience: reflexive consciousness, interpersonal roles and executive function. These aspects of self are universal, albeit influenced by cultural mores and other environmental factors.
Nonetheless, two further issues relevant to the self warrant discussion: the role of autobiographical memory and the contributions from neuro-psychoanalysis in respect to the developmental neurobiological evidence for the construct.
15 The term ego-depletion (Muraven et al., 1998) refers to “a state in which one’s self-regulatory resources are diminished, and this diminishment is proposed to occur because acts of self-regulation and volition draw upon a single, limited intrapsychic resource” (Wheeler, Briñol, & Hermann, 2007, p. 150).
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3.6 Autobiographical Memory
The intimate and interdependent relationship between memory and self has been well established in the corpus since Mill (1869) claimed that they are essentially one and the same. Research has subsequently moved from Mill’s contention that the self is based on retrospective memory, and is now understood to include retrieval and reconstruction of the past in a manner that is, reciprocally, influenced by the self (e.g. Greenwald, 1980;
LeDoux, 2002; Schacter, Chiao, & Mitchell, 2003). Moreover, cognitive science research has demonstrated that human-experienced episodic memory is probably unique to our species (Suddendorf & Corballis, 2007; Tulving, 1985, 2005). Nevertheless, Tulving
(2005) draws attention to the point that uniqueness is not unique to the human species, and differences in conscious experience do not provide evidence for the myth of scala naturae.16 Accepting that consciousness is experientially different between species,
Tulving offers the following definition of episodic memory in respect to the human species:
Episodic memory is a recently evolved, late developing, and early deteriorating
brain/mind (neurocognitive) memory system. It is orientated to the past, more
vulnerable than other memory systems to neuronal dysfunction and probably
unique to humans. It makes possible mental time travel through subjective time –
past, present, and future. This mental time travel allows one, as an “owner” of
episodic memory (“self”), through the medium of autonoetic awareness, to
remember one’s own previous “thought about” experiences, as well as to “think
about” one’s own possible future experiences. The operations of episodic memory
require, but go beyond, the semantic memory system. Retrieving information from
episodic memory (“remembering”) requires the establishment and maintenance of
a special mental set, dubbed episodic “retrieval mode”. The neural components of
episodic memory comprise a widely distributed network of cortical and subcortical
brain regions that overlap with and extend beyond the networks subserving other
16 The concept of God’s natural hierarchical order of the universe; literally translated means “natural ladder”.
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memory systems. The essence of episodic memory lies in the conjunction of three
concepts – self, autonoetic awareness, and subjective time (p. 9).
Autobiographical memory is understood to be a subtype of episodic memory (e.g.
Arie, Apter, Orbach, Yefet, & Zalzman, 2008; Greenwald & Banaji, 1989; Tulving, 2005).
A schematic of a common taxonomy of memory systems locating autobiographical memory is presented as Figure 3.2.
NOTE: This figure is included on page 95 of the print copy of the thesis held in the University of Adelaide Library.
Figure 3.2 A common taxonomy of memory systems adapted from Suddendorf and Corballis (2007). Note that autobiographic memory is not simply a subtype of episodic memory but is also functionally associated with semantic memory (Addis & Tippett, 2004)
Nelson (1993) reported that autobiographical memory has its onset at about three and one half years, and then takes on a personal and social values in defining the self. The relative absence of memory prior to this time is frequently referred to as childhood (or infantile) amnesia (Freud, 1963). Autobiographical memory is experienced as a narrative,17 yet the memories retrieved are argued to be frequently inaccurate because
17 The narrative model attracts broad support but is by no means universal. The conflicting positions are detailed in Strawson’s (2005) comprehensive philosophical review on the theories regarding the nature of self .
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“the subjective process of constructing a life narrative is centrally related to self concept”
(Pillemer, 1998, p. 897). That is, life not how it was actually experienced, but rather “how it is interpreted and reinterpreted, told and retold” (Bruner, 1987, p. 31). Singer and
Salovey (1993) noted that one’s belief in the veracity of one’s self narrative is critical, commenting that our sense of self is determined as much from what we believed once happened as to what in fact did happen. Conway, Singer and Tagini (2004) offer a plausible conceptual explanation for the general issue of accuracy in respect to memory and self. They argue that coherence is a strong motivating force in memory directed towards ensuring consistency with current goals and self-concepts. “Thus, memory and central aspects of the self form a coherent system in which, in the healthy individual, beliefs about, and knowledge of, the self are confirmed and supported by memories of specific experiences” (Conway, 2005, p. 595). There is also a demand for correspondence whereby the memory system must deal with the contradictory demands for representing reality as this is experienced or in a manner that supports a cohesive sense of self (tactical self-deception). “When the self and autobiographical memory become disconnected ... so that memories no longer “ground” core beliefs of the self, then delusions and confabulations emerge” (p.565).
One universal finding in regard to autobiographical memory is the influence of parenting style in the construction of memory. Children whose parents engaged in elaborative talk, which refers to speaking about events in narrative terms such as where, when and with whom, recall significantly more self-information than those children who experienced pragmatic talk. Pragmatic parents refer to memory in instrumental terms such as retrieving information necessary for an activity at hand (e.g. where is the book?).
Elaborative talk provides for a more intimate relationship (and positive transference experiences) for both parent and child as “it is the basis for storytelling, constructing narratives about what mother and child did together in the there and then” (Nelson, 1993, p. 10). Indeed, autobiographical memory is grounded in the past and childhood and early adulthood autobiographical memories are critical for one’s sense of self (Addis & Tippett,
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2004). The absence of specificity (i.e. overgeneralised) is recognised as an impaired autobiographical memory (Williams, 1996, 1996a; Williams & Broadbent, 1986; Williams et al., 1996).
Bluck, Alea, Habermas and Rubin (2005) undertook a functional approach to memory which places an emphasis on memory utility. Their results complemented empirically untested theory (e.g. Pillemer, 1992) and extended the likely number of functions from three to four by identifying that the previously hypothesised singular social function may actually have two purposes.
a. Directive. The function of making sense of past memories and applying the
best “old information” (p.109) in order to direct present and future behaviour.
b. Self. This appears to focussed directly on self-continuity “and allows
individuals to have and maintain a biographical identity (e.g. McAdams, 2001)
and to be able to maintain a coherent self-concept across an entire lifespan
(Cohen, 1998), even in the face of developmental change and life events”
(p. 110). Conway (2005) refers to this function as the working self, arguing
that the purpose is to maintain coherence between short and long-term goals.
c. Social – Developing Relationships. Developing an understanding of
another in order to establish a new relationship, and
d. Social – Nurturing Relationships. Establishing, inter alia, empathy and
social bonding in existing relationships.
Thus, autobiographical memory appears to consolidate subjective experiences in a self-serving adaptive manner. Research has demonstrated that impairments in autobiographical memory are associated with changes in self. For example, Piolino et al.
(2006) reported a semantic-episodic dissociation in autobiographical memory in ageing participants that influenced self-perception. These effects are commonly observed in people with dementia (e.g. Addis & Tippett, 2004; Harrison, Therrien, & Giordani, 2005),
97 | Suicide and the intolerable state of a fragmented self traumatic brain injury (e.g. Williams, Williams, & Ghadiali, 1998) and mood disorders
(Williams & Scott, 1988). Moreover, poor autobiographical memory appears to be associated with an excess of childhood negative life experiences (Kuyken & Brewin,
1995) which are, in turn, correlated with suicidal behaviour later in life (Yang & Clum,
1996). In a follow up study, Yang and Clum (2000) concluded that the relationship between childhood stress and suicidal behaviour is mediated by impaired cognitive functioning resulting from childhood stressors. Williams (Williams, 1996, 1996a) and
Williams and Broadbent (1986) argue that negative childhood experiences lead to an atypical patterns of autobiographical retrieval which are characterised by sweeping generalisations. The absence of specificity may be related to the association of painful affect with these negative experiences. “Because these individuals lack a repertoire of specific personal memories to fuel their creative efforts, their interpersonal problem solving is faulty. This leads to hopelessness and, hence, to suicidal behavior” (Arie et al.,
2008, p. 23). Subsequent studies have supported Williams” model, confirming the relationships between suicidal behaviour, over-general autobiographical memory, and ineffective problem solving (e.g. Jollant et al., 2005; Pollock & Williams, 2001). More recently, Arie et al.’s (2008) study of adolescent and young adult suicide attempters
confirmed the relationship between childhood negative life events, repression,
generalised autobiographical memory, poor interpersonal problem solving and suicidal
risk.
Memory, especially autobiographical memory, is clearly an important element for
providing self-continuity and applying self-biased past knowledge to deal with the present
and the future. This appears to be exceptionally important for the development and
maintenance of relationships. Nevertheless, self is not simply autobiographical memory.
Research has been largely successful in identifying the neurological substrates
responsible for memory (e.g. Gilboa et al., 2005; Perry, Pollard, Blakley, Baker, &
Vigilante, 1995). The orbitofrontal system, especially the right prefrontal cortex, is of
particular interest for its role in integrating “past, present and future experiences, enabling
98 | Suicide and the intolerable state of a fragmented self adequate performance in behavioral tasks, social situations, or situations involving survival” (Lipton, Alvarez, & Eichenbaum, 1999, p. 356). Only relatively recently, however, has the biology of self attracted a significant focus for research.
3.7 Contributions from Neuro-psychoanalysis
Sacks (1984) commented that “Neuropsychology, like classical neurology, aims to be entirely objective, and its great power, its advances, come from this. But a living creature, and especially a human being is first and last ... a subject, not an object. It is precisely the subject, the living “I”, which is excluded from neurology” (p.164). The discipline of neuro-psychoanalysis, which comes under the broader umbrella of neuropsychology, seeks to address the exclusion to which Sacks refers. Schore (1997) describes this approach as a rapprochement between psychoanalysis, the subjective mind and the biological sciences. Neuro-psychoanalysis follows a dual-aspect monism philosophy recognising the objective (the neurological approach of observing the mind from the outside) and subjective (the psychoanalytic approach of viewing the mind from the inside) nature of mind. “Our brains, including mind, are made up of one stuff, cells, but we perceive this stuff in two different ways” (Solms & Turnbull, 2002, p. 56). Early efforts to identify the biological self were predominantly focussed on the conscious self
(e.g. Brothers, 1997; Popper & Eccles, 1977; Sperry, 1984). Nevertheless, increasing attention is now being directed toward unconscious processes and the plasticity of neurological structures.
Contemporary thought includes Damasio’s (2000) tri-level theory of self processes. First, the unconscious protoself which refers to the interconnected and transiently coherent collection of neural patterns representing the one’s current state.
Next is the core self, the familiar conscious subjective experience which is modified or produced when the protoself is altered. And finally, the autobiographical self as previously discussed. Damasio argues that there must be a core self to acquire an autobiographical self, but the converse is not true. Indeed, many examples have been recorded whereby
99 | Suicide and the intolerable state of a fragmented self people lose their autobiographical memory but not their core sense of self as a result of neurological insult or disease (e.g. Sacks, 1986).
LeDoux (2002) offers the synaptic self as an plausible explanation of the biological mechanisms that give rise to the sense of self. This theory proposes that “the self is created and maintained by arrangements of synaptic connections” (p.12). These connections respond to the influences of nature and nurture “by encoding who we are”
(p.4). It is Schore’s (e.g. 2000, 2002a, 2005) research, however, that appears relevant to this discussion for his contribution towards understanding the relationship between neuroscience and Kohut’s (1971) psychoanalytic theory of self psychology. A fundamental principle of self psychology is that, through transmuting internalisation resulting from selfobject transferences, the infant develops adaptive, drive-regulating and social integrating abilities that were previously performed by another. Consequently,
Schore’s particular focus has been on the role of attachment (selfobject transferences), and the development of the right hemisphere of the brain, herein after referred to as the right brain.
In respect to the neurology of self, Devinsky (2000) concluded his literature review by commenting that the right brain “dominates our awareness of physical and emotional self” (p. 69). Moreover, he noted that research has delineated the known functions of the right brain, which serve to:
a. Identify a corporeal image of self and it’s relation to the environment.
b. Distinguish self from non-self.
c. Recognise familiar members of a species, as well as other familiar organisms,
items and places.
d. Emotionally understand and react to bodily and environmental stimuli.
e. Recall autobiographical information.
f. Relate self to environmental reality.
g. Maintain a coherent, continuous, and unified sense of self, and
h. Relate self to the social group.
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Schore’s (2002a) own review reported that neuroscience has revealed that “the right hemisphere is specialized for generating self-awareness and self-recognition, and for the processing of self-related material ... [indicating] that self psychology is in essence a psychology of the unique functions of the right brain” (p. 447) (emphasis in original).
Sullivan and Dufresne (2006) made a corresponding comment that complex psychological regulatory processes are located in “the right hemispheric specialization in regulating stress- and emotion-related processes” (p. 55). Further evidence of right brain dominance in the attachment system comes from the functional magnetic resonance imaging and near-infrared spectroscopy studies of Lenzi et al. (in press) and Minagawa-Kawai et al. (in press) respectively. To that end, the ensuing discussion largely follows Schore’s (in press) outline of the evidence resulting from the “neuropsychoanalytic work on the interpersonal neurobiological origins of the self” (p.3).
In view of Kohut’s (1971) position that a defective self and an impaired regulatory structure result in psychopathologies, the environmental impact on the neurobiology of the developing self is especially relevant. No more so than the self-selfobject relationship, with Ovtscharoff and Braun (2001) commenting that, for newborns, this relationship not only serves to regulate homeostasis, but influences the synaptic connections during the development of functional brain circuits including the limbic system (see also Ziabreva,
Poeggel, Schnabel, & Braun, 2003). Considering that the emotion-processing limbic system myelinates in the first eighteen months at the time the related right brain is undergoing rapid maturation, attachment experiences substantially influence the limbic and cortical areas of the brain (e.g. Allman, Watson, Tetreault, & Hakeem, 2005;
Cozolino, 2002; Kinney, Brody, Kloman, & Gilles, 1988). Moreover, Papousek and
Papousek’s (1995) research into the biology of attachment suggests that developing communication skills is a particularly important development process in infancy (cited by
Schore, in press). This supports Kohut’s concept of empathic mirroring:
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Through visual-facial, auditory-prosodic and tactile-gestural communications,
[selfobject] ... and child learn the rhythmic structure of the other and modify their
behavior to fit that structure, thereby co-creating a specifically fitted interaction ...
the psychologically attuned mother synchronizes the spatiotemporal patterning of
her exogenous sensory stimulation with the spontaneous overt manifestations of
the infant’s oganismic rhythms (Schore, in press, p. 4).
Failures, or the absence of positive selfobject transferences severs (or inhibits the
development of) the attachment bond. The consequences are regulatory failure and
impairment in autonomic homeostasis. Indeed, the results of studies examining
impairments in dyadic attunement support Kohut’s argument that the selfobject simply
needs to be good enough to remedy any homeostatic imbalance (Beebe & Lachmann,
1994; Tronick, 1989; Winnicott, 1958). Thus, selfobjects serve as external regulators for
affective experiences, functioning beyond conscious awareness to maintain a cohesive
self (Schore, 2002a). Interestingly, empathy, another quintessential element for self
psychology, is also one of the intersubjective processes located in the orbital prefrontal
areas of the right brain (Bradshaw & Schore, 2007; Sullivan & Dufresne, 2006).
Attachment trauma alters the development of right brain functioning and thus the
self. A child’s response to traumatic experiences of attachment follows two separate and
sequential patterns: hyperarousal and dissociation (Schore, 2001, 2002b). In the initial
stage of hyperarousal, the previously safe refuge of the selfobject becomes a stressor,
activating the hypothalamic pituitary adrenal (HPA) stress-response axis. The
consequence is significantly elevated “somatic expressions of a dysregulated
psychobiological state of fear-terror” (Schore, in press, p. 8). This active state is
expressed in escalating levels of corticotrophin releasing factor creating a hypermetabolic
state in the brain. The later reaction of dissociation occurs when the child disengages
from the environment. “This parasympathetic dominant state ... is a primary regulatory
process” (p.8) of survival, and involves two vagal systems in the brainstem medulla
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(Porges, 1997). The ventral vagal system regulates cardiac output acts to foster the self- selfobject interaction and serves as a substrate for the development of social behaviour.
The dorsal vagal complex, however, is responsible for hyperarousal and pain-blunting dissociation. Thus, the ventral vagal complex promotes instantaneous and transitory activations, and the dorsal vagal complex seeks involuntary and prolonged vagal outflows. According to Porges, it is the immediacy of the transition from a state of sympathetic arousal to parasympathetic dissociation that creates the prolonged void states associated with pathological dissociative detachment.
Bromberg (2006) observed the association between right brain trauma and an incohesive sense of self, explaining it as:
a chaotic and terrifying flooding of affect that can threaten to overwhelm sanity and
imperil psychological survival ... The mind’s normal capacity for dissociation is
typically enlisted as a primary defence ... But the price for this protection is to
plunder future personality development of its resiliency and render it into a fiercely
protected constellation of relatively unabridgeable self states ... immune to the
potentially valuable input from other aspects of self (p. 33).
The evidence suggests that the developing brain is imprinted by both the overwhelming affective states associated with attachment trauma, and the regulatory defence strategy of dissociation (Schore, in press). Van Der Kolk et al. (1996) concluded that dissociation inhibits the integration of traumatic experiences into a cohesive sense of self. Schore
(2009) argues that this “self-depleting structure-altering cost of characterological dissociation is thus a central psychopathogenetic concept of both self psychology and neuroscience” (p. 11).
3.8 Summary
Despite the absence of consensus as to the definition and role of self, Kircher and
David’s (2003) contribution appears to be supported by the literature. To recapitulate:
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the commonly shared [subjective human] experience, that we know we are the
same person across time, that we are the author of our own thoughts/actions,
and that we are distinct from the environment. It is the immediate, pervasive,
automatic feeling of being a whole person, different from others, constant over
time [with a past, present and future], with a physical boundary, the centre of our
experience (p.2).
The self is uniquely human insofar as it is characteristically experienced by our species
(Baumeister, 1998). Moreover, the nature of self may be understood as the aggregate of three prototypical patterns of the experience. First is reflexive consciousness which refers to the conscious reflection that brings about self concept. Interpersonal functioning is the second pattern of selfhood whereby our interactions with others facilitates the development and maintenance of self. Third is executive function that is activated by emotion and motivated by the need for mastery over the environment; initiating, altering and directing behaviour. Autobiographical memory appears to play a significant role by functioning to make sense of past memories in a manner that that directs present and future behaviour, and provides a cohesive sense of self across one’s lifespan.
Additionally, it significantly contributes to the development and maintenance of relationships.
The evidence from neuro-psychoanalysis suggests that the right brain dominates the experience of self, with several researchers claiming that this evidence explicitly supports Kohut’s theory of self psychology. Moreover, childhood traumatic attachment
experiences and other traumatic experiences influence right brain development and
consequently the self.
The following chapter extends the discussion on traumatic experiences by
examining the relationship between suicidal behaviour, self and the biology of intolerable
states.
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Chapter 4: Suicidal Behaviour, Self and Intolerable States
Suicidal Behaviour, Self and Intolerable States
Whenever Richard Cory went down town The people on the pavement looked at him: He was a gentleman from sole to crown Clean favoured, and imperially slim. And he was always human when he talked: But still he fluttered pulses when he said, “Good-morning” and he glittered when he walked. And he was rich-yes, richer than a king, And admirably schooled in every grace: In fine, we thought that he was everything To make us wish that we were in his place. So on we worked, and waited for the light. And went without the meat, and cursed the bread; And Richard Cory, one calm summer night. Went home and put a bullet through his head. (Robinson, 1896)
4.1 Introduction
As previously noted, Kohut (1972) considered some self-harming behaviours and suicides to be extreme examples of narcissistic rage directed against a deficient and shameful sense of self. Within the literature, there is a paucity of attempts to apply self psychology to suicidality and, for those who have contributed, it has involved the traditional psychoanalytic method of explanation by reference to case studies.
Understandably, the dominant focus has been the selfobject relationship. Again, the selfobject is experienced as a part of the self and such relationships continue throughout life, sustaining, soothing and invigorating the sense of self. “Man lives in a matrix of selfobjects from birth to death. He needs selfobjects for his psychological survival, just as he needs oxygen in his environment for his physiological survival” (Kohut, 1980, p.
478). An empathic milieu is also important, which Kohut (1980) declared to be a “value neutral operation” (p.483), through which therapists can immerse themselves into the
“the patient’s inner life” (Ornstein & Kay, 1983, p. 333). In emphasising the role of
105 | Suicide and the intolerable state of a fragmented self empathy in relation to suicidality, Kohut (1984) argued that imbedded within classical psychoanalysis is a moral system that can undermine the efficacy of the therapist/client transferences, and exacerbate the client’s vulnerability. Kay (1989) summarises the classical psychoanalytic approach:
a. The therapeutic task is to make the unconscious conscious, and [encourage
the patient to accept responsibility by] ... facing the truth in the therapeutic
process [which] is brave and upstanding [however,] ... shrinking away from it,
as in the suicide’s refusal to examine introjected murderous impulses, is
cowardly and weak.
b. In harmony with the [protestant] work ethic that has dominated Western
civilization in recent centuries, it is good to work through life’s
disappointments and losses; not to do so, as in the case of the suicide,
means failing to do the work and is undesirable.
c. The unconscious knows nothing of time and change or birth and death.
Indeed man is supposedly unwilling to accept the truth about life and death
and about the endless succession of generations. These values are
especially understandable in the light of the strong feelings of vulnerability
and helplessness that are evoked in the therapist treating the severely
suicidal patient. (p.173).
Self psychology does not seek a moral position, nor does it view suicidal behaviour as a homogenous construct except insofar that it relates to the sense of self.
However, like traditional psychoanalysis, discussions within self psychology revolve around clinical examples that seek to explain rather than predict the psychopathology under review. Reiser (1984), for example, argues that narcissistic suicidal crises are not homogeneous entities and that self organisation, or more particularly a disordered or
106 | Suicide and the intolerable state of a fragmented self incohesive sense of self, is more associated with suicidal behaviour than for depression alone. Reiser appears to be the first within self psychology to extend the discussion on the relationship between self and suicidal behaviour beyond Kohut’s original contributions. He proposed five nuclear ‘selfs’ that are “prone to rapid fragmentation or sudden disintegration in the face of disrupted narcissistic homeostasis” (p.229).
a. The Endangered Self. This is seen primarily in schizoid and schizophrenic
conditions. “This tormented, primitively organized self is in perpetual conflict
between the wish for human contact, with its threat of engulfment and
annihilation of the self on one hand, and autism, with its terrible separateness
and isolation, on the other” (p.231).
b. The Enraged Self. A common characteristic of Borderline Personality
Disorder, the enraged self is often the consequence of an abused childhood.
This results in the formation of deeply ambivalent, hostile-dependent
relationships with a succession of selfobjects that replicate the original failed
parent-child dyad.
c. The Vulnerable Self. This refers to those whose sense of self might best be
described as chronically empty, unfulfilled, and needy. These people appear
to “function with an almost literal inability to establish self-object bonds ...
quietly, stealthily, at the very borders of humanity, they try to smuggle in
minimal human contact ... they are forever at risk and forever alone” (p.235).
d. The Grandiose Self. Narcissistic grandiosity is accompanied by elevated
dependence on selfobjects for applause, perfect empathy, and idealised
heroic behaviour. Failures in meeting these transference needs results in
“severe feelings of internal emptiness, rage, and pressure to act out, often in
extreme forms, to relieve the unbearable pain and tension of the
disintegrating self” (p.236), and
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e. The Mirroring Self. Reiser believes these people are particularly vulnerable
to suicidal behaviour. “The child of often exceptional gifts who functions like a
chameleon trapped upon a tapestry of bright and variegated color, a tapestry
whose threads are the emotional requirements of others ... in short,
indefatigable, infinitely adaptable, creative, ready-and-willing selfobjects for
any and all selfs who reach out to them and wish them to function in this role,
they are mirrors to us all” (p.239).
Reiser emphasised the existence of “a particularly poignant and mysterious type of disturbed self, the Mirroring Self, an affliction ... that too often leads unbearable inner pain and the compulsion to seek peace through the ultimate act of self-destruction”
(p.240). Each of these selves is characterised by varying levels of developmental arrest, narcissistic vulnerability and quite different dynamics within their selfobject transferences.
Reiser’s reification and multiplicity of the self again demonstrates the consequences resulting from the ambiguity of definition associated with discussions of the self; his delineation is better understood as self states that are vulnerable to fragmentation.
Moreover, he suggested that the self-harming behaviour evident in BPD is due to self fragmentation.
Abramowitz (1995) and Silverstein (2007) differ from Reiser (1984), positing that self harm (as opposed to suicide) is most likely an attempt to forestall a fragmenting sense of self. Precipitants of suicidal behaviour may be an expression of despair over the loss of a positive selfobject experience (Kohut, 1984), self states of envy or anger
(Kohut, 1971), loss of attachment (Ornstein, 1981), or the inhibition of self assertion
(Wolf, 1988). All of these authors have noted that those with a fragile sense of self are
particularly vulnerable to selfobject losses such as failed or inadequate transference
needs, which in turn can result in extreme helplessness, fragmentation and narcissistic
rage directed at the self. Hartmann and Milch (2000) reported that the vertical split is
108 | Suicide and the intolerable state of a fragmented self also evident in suicide ideators, with therapists frequently subjected to negative countertransference experiences as clients attempt to disavow their self-harming thoughts.
Accordingly, for those experiencing a defect in psychic structures that sustains a cohesive sense of self, one or two transference strategies may be employed to compensate for a sense of fragmentation. Kay (1989) examines idealisation, or more specifically de-idealisation, as one way to conceptualise some adolescent suicidal behaviour. Idealisation seeks to overcome absent or defective endopsychic structures and provides soothing by merging with the idealised omnipotent selfobject such as the omnipotent parent; in “[t]his way the self is experienced as complete” (p. 177). De- idealisation, however, can be particularly traumatic for the vulnerable self. Child development is generally accompanied by an increasingly complex and an accurate understanding of the characteristics of the principal selfobjects. Gradual de-idealisation facilitates the process of a developing self by permitting the acceptance of a selfobject with weaknesses and strengths. Some may experience traumatic de-idealisation in the form of an immediate and painfully distressing awareness of the fragility of the selfobject such as the unexpected revelation of parental infidelity. For the children whose parents, for their own sense of self, seek to be idealised, this can be particularly traumatic.
Hartmann and Milch (2000) argue that suicidal behaviour is a “final attempt to evoke a reaction of the selfobject, to experience one’s own efficacy, and to regulate the self state” (p.87). Selfobject transferences are bi-directional and positive experiences provide a sense of agency. Wolf (1988) noted a phenomenon in which the self is viewed as an actor acting upon the selfobject. However, Hartmann and Milch (2000) describe a process in the opposite direction in which the self is viewed as the recipient of the selfobject’s action. Consequently, failed transferences undermine one’s sense of agency and lead to a state of severe helplessness, a fragmenting sense of self and narcissistic rage. As discussed in Chapter 3, Baker and Baker (1987) liken this state to
109 | Suicide and the intolerable state of a fragmented self psychological annihilation, which gives rise to the self to respond in such a way so as to establish or restore a sense of coherence. “[E]ven if the behaviour employed to ward off disintegrating anxiety is self-defeating or self-destructive it is experienced by the individual as preferable to” (p.5) the sense of fragmentation resulting from intolerable states.
4.2 Fight, Flight or Fragment?
Evidence of the process of developing intolerable mental states and the accompanying sense of entrapment can be found within the corpus of the biological sciences. Moreover, several hypotheses have proposed effective evolutionary responses to environmental stressors that do, however, appear inadequate in dealing with psychological distress. What follows is an examination of the physiological processes and hypotheses that complement Kohut’s (1977, 1985b, 1985c) concept of fragmentation of the self that can result from the inability to establish a sense of personal cohesion or stability. This psychological sense of annihilation (Baker & Baker, 1987) is
argued to be so unpleasant “that people will do almost anything to escape” (Wolf, 1988,
p. 39). Indeed, escape appears to be a quintessential survival strategy that is directed
towards dealing with a stressful event and bringing about a return to the desired
homeostatic state once the crisis has past (Sapolsky, 1998).
In an unthreatening environment, animals and humans alike follow daily routines
and prepare for the predictable fluctuations in their lives by establishing and maintaining
adequate energy levels through nutritional intake. This homeostatic state ensures
physiological and behavioural stability during the inevitable changes during the life cycle
such as seasonal changes and reproduction (Cannon, 1929). When faced with a
stressor (Selye, 1956), however, the adaptive process of evolution has resulted in an
innate physiological response that maximises survival; the fight-flight response.
Physical stressors such as a predator typically generate a sympathetic nervous system
110 | Suicide and the intolerable state of a fragmented self response resulting in a rapid mobilisation of glucose, simple proteins and fats to fuel the body to meet the energy demands required to engage or escape. Elevated heart rate, blood pressure and breathing increase the distribution of nutrients. Digestion, reproduction and the immune system are inhibited whereas certain aspects of memory improve to maximise the body’s capacity to respond (Sapolsky, 1998). Indeed, adaption to a threat not only alters aspects of memory but also the mental state and cognitive level. “As the individual moves along the threat continuum – from calm to arousal to alarm, fear, and terror – different areas of the brain control and orchestrate mental and physical functioning. The more threatened the individual the more ‘primitive’ [or regressed] becomes the style of thinking and behaving” (Perry et al., 1995, p. 274).
Engel and Schmale (1972) postulated an additional phylogenetic mechanism of escape which they termed conservation-withdrawal. This refers to the “biological threshold mechanisms whereby survival of the organism is supported by processes of disengagement and inactivity vis à vis the external environment ... invoked either when input becomes excessive and beyond the organism’s capacity actively to cope or when available input becomes inadequate to meet needs” (p.57). This state of “toxic immobility” (p.62) also constitutes a mechanism for maintaining homeostasis and has been noted when infants have been separated from a selfobject (Bowlby, 1969; Harlow,
Harlow, & Suomi, 1971). The effect of positive transferences was not lost to Ironside
(1980) either in his examination of conservation-withdrawal within a theory of survival behaviour. Although he did not apply the language of self psychology, his discussion on the antecedents relating to individual differences in survivor behaviour noted that:
[The difficulty arises for those whose experiences in their] early years of
childhood and adolescence have been characterized by brutality: rigid, punitive,
and demanding control of expression of effect, feeding, and excretory behaviour.
But somewhere in the background of survivor patients have been loving,
111 | Suicide and the intolerable state of a fragmented self
consistently supportive figures or series of figures, to which actual retreat was
possible. As a defence, identification with the aggressive parent is common. The
training ground of the family seems to have provided an experience of tolerating
and surviving continuing extreme adversity with at least one external support
figure who could be internalized as a good object (p.173).
Thus, both active (fight-flight) and passive (conservation-withdrawal) escape responses are available when faced with a crisis. Stengel and Cook (1958), influenced by the then relatively recent ethological studies of Lorenz (1952) and Tinbergen (1952), interpreted some suicidal behaviour as an innate social releasing strategy; effectively functioning as an alarm signalling an appeal for help (Stengel, 1962). Similarly,
Henderson (1974) postulated that suicidal behaviour is care-eliciting behaviour in response to stressors. Goldney (1980) examined the utility of conservation-withdrawal theory in respect to attempted suicide, and concluded that this behaviour appears consistent with the idea that some suicidal behaviour may be self-preservative.
“Although it may initially appear paradoxical to seek biological analogies to self- destructive behaviour in man, the possibility that such an approach might be profitable is, paradoxically, suggested by a consideration of [Farberow and Shneidman’s (1961)] cry for help” (p.132).
In more recent times Sterling and Eyer (1988) introduced the formulations allostasis and allostatic load or overload to overcome the ambiguity of the term ‘stress’ and, like homeostasis, they considered to be endogenous systems responsible for maintaining somatic stability. The original concept of homeostasis posits a single optimum for any somatic measure, and that the body maintains that optimum by regulating appropriate physiological responses to any stressors. Allostasis takes this further insofar as it is considered a dynamic adaption to stressors that acknowledges that
“different circumstances require different homeostatic points” (Sapolsky, 1998, p. 7). In contrast to the narrow ranges of homeostatic systems such as body temperature, blood
112 | Suicide and the intolerable state of a fragmented self oxygen and pH level, allostatic systems have broader boundaries and purpose.
Allostatic systems enable people to cope with, inter alia, crowding, isolation, danger and infection (McEwen, 1998; McEwen & Seeman, 1999). In response to stress, the body activates an allostatic response that in turn initiates a complex adaptive physiological process that is terminated once the crisis has past. For example, the most common allostatic responses involve the sympathetic nervous system and the hypothalamic- pituitary-adrenal (HPA) axis. Briefly, activation of these systems releases catecholamines which in turn lead to the secretion of corticotrophin. Corticotrophin mediates the release of cortisol which is a corticosteroid hormone that, when elevated, creates a cascade of physiological responses to deal with a stressor. Some of the effects of this primary stress mediator are:
a. Increasing circulating glucose concentrations in the blood by counteracting
insulin (Freeman, 2004).
b. Stimulating gastric secretion (Soffer, Dorfman, & Gabrilove, 1961)
c. Inhibiting the loss of sodium which in turn augments potassium excretion to
bring the pH level to its most optimum for the immune enzymes (Muller,
Manning, & Riondel, 1958).
d. Inhibiting pain and creating a sense of euphoria (McAuley et al., 2009), and
e. Assisting epinephrine (adrenalin) develop memories of short-term emotional
events that should be avoided in the future (Newsholme & Leech, 1983).
Importantly, genetic factors do not account for all the individual variability in response to stress (Adler et al., 1994; Polmin, 1990). Further, individuals who develop inefficient stress mediating systems are more predisposed to inter alia, violence, impulse control disorders, psychosis and depression (Korte, Koolhaas, Wingfield, & McEwen, 2005).
Moreover, Perry et al. (1995) reported the impact of traumatic experiences on individual brain development, emphasising the adaptive nature of neurological processes. The
113 | Suicide and the intolerable state of a fragmented self developing brain organises and internalises stimuli in “a use-dependent fashion, the more a child is in a state of hyperarousal or dissociation, the more likely they are to have neuropsychiatric symptoms following trauma” (p. 271). Indeed, the capacity of neural systems to change in response to external and internal stimuli is the significant distinguishing feature of the brain that facilitates survival of an organism. However,
Glass and Singer (1972), in their examination of the effects of urban stress, noted that
“adaption is not necessarily beneficial to man. It is certainly one way of coping with environmental stress, but it is by no means an unequivocally effective strategy” (p.166).
van Heeringen (2003) and colleagues (van Heeringen, Audenaert, van de Wiele,
& Verstraete, 2000; van Heeringen et al., 2003) reported that suicide attempters have higher levels of cortisol which affects serotonin (5-HT) activity resulting in a significant decrease in 5-HT2a receptor binding index in the prefrontal cortex. Reward dependence and subsequently psychological resilience are also influenced by the serotonergic neurotransmission system (Cloninger, 1998; van Heeringen et al., 2003). Deakin’s
(1996) psychobiological concept of the social brain is helpful in illustrating the effect of decreased serotonergic activity. The social brain refers to the basolateral circuit which consists of the prefrontal and temporal cortices that function via two subsystems. The first is by way of feedback loops in close connection with the subcortical amygdala and hippocampus. This system is “thought to be involved in the processing of sensory information” (van Heeringen, 2003, p. 43). Deakin (1996) postulated that the primary purpose of the subsystem is adaption or tolerance to stressors, and dysfunction may result in a sense of subordination (lack of control), depressive cognitions and low self- esteem. The second subsystem is thought to involve “the (orbital) prefrontal cortex and amygdala which mediate approach or avoidance behaviour through dopaminergic and serotonergic 5-HT2a neuromodulation, respectively. Dysfunction of this system may become apparent through social anxiety and hopelessness and increase the diathesis for suicidal behaviour” (van Heeringen, 2003, p. 44).
114 | Suicide and the intolerable state of a fragmented self
van Heeringen (2001) referred to the particular clusters of characteristics associated with these two subsystems as the social interaction and behavioural inhibition components. The social interaction component recognises the association between suicidal behaviour and stressful life events. In particular, stressors can precipitate problems that undermine or threaten the capacity to integrate with the social environment in which one lives. This is common within interpersonal (selfobject or object transference) relationships. Within this domain, personality “is thought to be modulated
(at least partially) by the heritable temperamental dimension [referred to as] reward dependence” (p.44). Cloninger (1988) suggested that reward dependence is influenced by levels of serotonin. Low reward dependence has been demonstrated to be associated with increased stress responses that reflect a reduced psychological resilience to perceived stressors, with associated depressive ideation and sensitivity to signals of defeat (van Heeringen et al., 2000). In respect to the second subsystem of the basolateral circuit, Audenaert et al. (2001) reported decreased 5-HT2a receptor binding potential in the prefrontal cortex of self harming patients in comparison to controls. van
Heeringen et al.’s (2003) study demonstrated a correlation between the prefrontal 5-HT2a receptor binding potential and levels of hopelessness and harm avoidance. Harm avoidance is believed to reflect “biases in the regulation of anxiety or in behavioural inhibition when confronted with adverse stimuli” (p.45). Dysfunction in the second subsystem results in deficient problem solving (no escape) and deficient generation of positive future events (no rescue). Thus, allostatic load can result in physiological responses that increase the vulnerability to, or predisposition for, suicidal behaviour.
Figure 4.1 illustrates the cascading cause and effect that is triggered by primary stress mediators such as cortisol, leading to the adaptive process of allostasis that can be overloaded resulting in deleterious effects.
115 | Suicide and the intolerable state of a fragmented self
NOTE: This figure is included on page 116 of the print copy of the thesis held in the University of Adelaide Library.
Figure 4.1. The Stress Response and Development of Allostatic Load. The perception of stress is influenced by one’s experiences, genetics and behaviour. When the brain perceives an experience as stressful, physiologic and behavioural responses are initiated leading to allostasis and adaption. Over time, allostatic load can accumulate, and the overexposure to mediators of neural, endocrine, and immune stress can have adverse effects on various organ systems, leading to disease (McEwen, 1998, p. 172).
McEwen (1998; 1999) noted four situations associated with allostatic load: repeated hits from multiple novel stressors, lack of adaption, prolonged response due to delayed shut down, and inadequate response that leads to compensatory hyperactivity of other mediators. First are the most obvious responses to frequent stress such as elevated blood pressure which can trigger myocardial infarction in susceptible people.
Indeed, in primates, repeated elevations of blood pressure over extended periods accelerate atherosclerosis which increases vulnerability to myocardial infarction and acts with metabolic hormones to produce Type II diabetes. Second, repeated stressors of the same type result in a reduced ability to adapt and a prolonged exposure to stress hormones such as cortisol. Third, continued exposure to stressors inhibits the ability of
116 | Suicide and the intolerable state of a fragmented self the allostatic system to terminate responses, resulting in atrophy in the hippocampus which inhibits the HPA axis response capacity and impairs episodic, declarative and spatial memory. The fourth situation is that inadequate responses by allostatic systems trigger compensatory responses in others. For example, if cortisol secretion does not increase in response to a stressor, secretion of inflammatory cytokines increases, and these have been reported to be associated with depression (Berthold-Losleben,
Heitmann, & Himmerich, 2009) and suicidal behaviour (Lindqvist et al., 2009;
Wasserman, Wasserman, & Sokolowski, in press). Inflammatory cytokines are counter- regulated by cortisol and elevated levels result in autoimmune and inflammatory disturbances. Figure 4.2 illustrates this.
NOTE: This figure is included on page 117 of the print copy of the thesis held in the University of Adelaide Library.
Figure 4.2. Four Types of Allostatic Load. The top panel illustrates the normal allostatic response whereby a response is initiated by a stressor, sustained for an appropriate interval, and then turned off. The remaining panels illustrate four conditions that lead to allostatic load: 1. Repeated ‘hits’ from multiple novel stressors; 2. Lack of adaption; 3. Prolonged response due to delayed shut down; and 4. Inadequate response that leads to compensatory hyperactivity of other mediators (McEwen, 1998, p. 174).
117 | Suicide and the intolerable state of a fragmented self
Sunnqvist, Westrin, and Träskman-Bendz (2008) reported that, for suicide attempters, adverse life events in childhood produced long term vulnerability to allostatic load. For example, participants who reported sexual abuse or neglect during childhood had dysfunctional HPA activity and irregular levels of stress mediators such as cortisol.
This is consistent with other studies that have demonstrated a relationship between the
HPA axis and suicidal behaviour (Mann, 1998; Mann et al., 2001), childhood abuse and
neglect (De Bellis, 2005; Heim et al., 2000), perceptions of being unwanted by parents
(Ehnvall, Palm-Beskow, Beskow, & Ǻgren, 2005), and the trajectories of psychological
distress (Berk, 2009).
Perry, Pollard, Blakley, Baker, and Vigilante (1995) noted that, for children, in
particular, the trauma associated with adapting to a traumatic environment or event can
result in adaptive states, that if allowed to persist, will become maladaptive traits. This is
because the brain develops in response to the environment (Damasio, 1994; Perry et al.,
1995), and although experience can alter the mature brain, experience during the critical
periods of childhood organises the neurological systems. Further, adaptive responses
are age/development dependent. For example, temporary separation from a selfobject
might be traumatic for an infant, but not so for an adolescent. The converse can also be
true. Thus, persistent allostatic load resulting from failed selfobject transferences may
influence neural development resulting in an incohesive sense of self that continues into
adulthood. Indeed, Ryan and Deci (2000) argued that the “innate psychological needs
[for autonomy, competence and relatedness to others] are the basis for self-motivation
and personality integration leading to optimal psychological functioning” (p.68).
Moreover, supportive environments promote greater internalisation and integration
whereas a lack of connectedness or excessive subjugation disrupts these processes
resulting in distress and psychopathology. This realisation of the profound impact that
the environment can have on the developing brain no doubt prompted Perry et al. (1995)
to comment: “[p]ersistence of the destructive myth that “children are resilient” will prevent
millions of children ... from meeting their true potential” (p.286).
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Wingfield (2005) proposed two types of allostatic load/overload. Type I occurs when energy demand exceeds supply resulting in the flight-fight survival mode and is evident in most animal species. Type II allostatic load is peculiar to humans (and some animals in captivity) and “begins when there is sufficient or excess energy consumption accompanied by social conflict [or/] and other social dysfunction ... Curiously, type II allostatic overload does not trigger an escape response” (p.248). However, type II does trigger the fear response (Korte et al., 2005; Wingfield, 2005). Moreover, continued allostatic load inhibits the extinction of the fear response (Barr et al., 2003; Merali,
Anisman, James, Kent, & Schulkin, 2008); “escape from [which] is only possible when
[people] learn to change their behaviour and alleviate the negative social conditions”
(McEwen & Wingfield, 2003, p. 13). Thus, escape from type II allostatic load is not available by way of the innate physiological response mechanisms, though we are conditioned to expect this as a strategy of bringing about a stable state.
Gilbert (1989) termed the combination of perceived inability to escape and defeat as arrested flight and applied an ethological analogy. In their natural environment, birds seeking to establish their territory will engage in aggressive behaviour that results in the winner asserting authority and the loser seeking escape to another area. When caged however, the defeated bird cannot escape:
Its behaviour becomes entirely changed. Deeply depressed in spirit, humbled,
with drooping wings and head in the dust, it is overcome with paralysis, although
one cannot detect any physical injury. The bird’s resistance now seems broken,
and in some cases the effects of the psychological conditions are so strong that
the bird sooner or later comes to grief (Schjelderup-Ebbe, 1935, p. 966).
At first glance, this behaviour may be interpreted as conservation-withdrawal, yet in this case the consequences can be fatal. Price and Sloman (1987) demonstrated that this form of yielding behaviour in humans is likely to precipitate depression, which is relieved
119 | Suicide and the intolerable state of a fragmented self when escape is possible or exacerbated when it is not. Thus, a sense of defeat and a belief that escape is not possible may result in a sense of intolerable entrapment.
A complementing theory to arrested flight is Williams’ (1997a) Cry of Pain
hypothesis discussed in Chapter 1, which holds that humans have similar biological
scripts that can be triggered by psychological representations. Accordingly, “suicidal
behaviour represents the response (the “cry”) to a situation that has these three
components: defeat, no escape and no rescue”, real or imagined (Williams & Pollack,
2001, p. 78). Numerous studies have also noted the impaired problem-solving and
decision-making capacity of those engaged in suicidal behaviour (Jollant et al., 2005;
Williams et al., 1996). Research suggests that it is not simply problem-solving that
appears the issue, but rather the associated ability to access specific autobiographical
memory (Pollock & Williams, 2001). In particular, suicidal patients stop short of retrieving
specifics when recalling events. “It is possible that such patients suffer from a large
number of intrusive memories from the past, and have adopted a strategy of overgeneral
memory to regulate their emotion”, resulting in a sense of being trapped (Williams &
Pollack, 2001, p. 83). Thus, exposure or hypersensitivity to social signals that represent
these components are likely to trigger the primitive helplessness biological script
illustrated in Figure 4.3 below.
Stress: especially Escape Psychobiological defeat/rejection potential helplessness script
Social support - rescue factors
Judgement by individual: How stressful? How escapable? How much support available?
Affected by biases in information processing and memory deficit
Figure 4.3. Internal and external stressors (especially those that signal defeat, reversal, loss or rejection) combined with differences in a person’s ability to see a way of escaping
120 | Suicide and the intolerable state of a fragmented self or being rescued, causes the helplessness biological script to be activated. The strength of the activation of the script is moderated by information processing biases that affect the perceived aversiveness and likelihood of escape and rescue (Williams & Pollock, 2001, p.79).
Sapolsky (1998) noted the human propensity for worry and emphasised that stressors can also be the anticipation of something occurring; consequently, unlike less cognitively sophisticated species, we can activate allostasis simply by thinking about potential stressors:
Our human experience is replete with psychological stressors, a far cry from the
physical world of hunger, injury, blood loss, or temperature extremes. When we
activate the stress-response out of fear of something that turns out to be real, we
congratulate ourselves that this cognitive skill allows us to mobilize our defenses
early. And when we get into physiological uproar for no reason at all, or over
something we cannot do anything about, we call it things like “anxiety”,
“neurosis”, paranoia, or “needless hostility” (p.8)(emphasis added).
Caton (1986) argued that our evolutionary move to socialised urban environments has altered the cost-benefit reciprocities between individuals which has resulted in the nuclear family. Consequently, the “talents needed to operate [in] this highly artificial culture are indeed far from those that conferred fitness on the hunter- gatherer” (p.189). Glass and Singer (1972) demonstrated that urban environments produce unique stressors such as noise, shock and bureaucratic frustration which can have disruptive psychological and physiological after-effects depending on the cognitive circumstances in which the stressor occurs. Moreover, individual differences are also apparent in how people respond to stressors (Korte et al., 2005), which Sapolsky (1998) attributes to the differences in our “psychological filters” (p.227). Although the term is not elaborated on, the context in which it is applied is comparable to the sense of self.
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The desire for control and a sense of predictability also appear to be important ingredients in determining whether a stressor can manifest into psychopathology.
Indeed, research has demonstrated that the deleterious effects of stress arousal are significantly reduced if the subject believes they have control over the onset or termination of the aversive stimuli (Glass & Singer, 1972; Glass et al., 1973).
Heckhausen and Schultz (1999) argue that the need to control one’s environment is a universal characteristic of human behaviour that is not bound by culture or time. Indeed, they noted that striving for control has evolved into an innate behaviour because it facilitates those activities essential for survival such as foraging for food and seeking shelter. Moreover, research into the phylogenetic origin of higher-order functioning such as self-concept and language focuses on the idea of inclusive fitness (Haldane, 1955;
Hamilton, 1964a, 1964b). That is, the genetic composition most likely to ensure survival and reproduction; what Dawkins (1976) referred to as the selfish gene. Dawkins’ anthropomorphic analogy is that genes are selfish, and a person is simply a gene's survival machine. Graham (2002) clarifies this by noting that Dawkins did not mean that genes are directly involved in the struggle for survival. “Rather, genetic changes issue in phenotype changes. It is the phenotypes – whole persons, plants and so on – that struggle to survive and to propagate” (p.43). Success depends on genetic composition and it is the genetic structure that survives over the long term. Graham (2002) noted that inclusive fitness encompasses two strategies:
a. The number of offspring that an organism can directly produce and support
(classical fitness), and
b. Because close relatives have some replica genes, evolutionary success is
enhanced by promoting the production and survival of related individuals.
This in turn leads to behaviour which maximises their inclusive fitness rather
than individual fitness.
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Consequently, success largely depends on the individual’s and community’s ability to control the environment (Darwin, 1871; Durham, 1991; Mithen, 1996).
Clearly, the human experience is phylogenetically disposed to dealing with stressors in ways that enhance our survival in a manner that seeks to maintain a healthy homeostatic state. To that end, fight, flight or withdrawal are evolutionally developed survival strategies employed by many species to facilitate this. Similarly, survival is enhanced when one has a level of control over the immediate environment. However, when faced with type 2 allostatic load which is most commonly associated with humans and how we relate to each other, escape or control are not always available options.
This is particularly so for psychological stressors from which there is no easy retreat or strategy of engagement, leading to intolerable states and a fragmenting sense of self
(Kohut, 1977). Baumeister’s (1990) escape theory discussed in Chapter 2 offers an explanation about the process of retreat, in which suicidal behaviour is viewed as a chain reaction resulting from the belief that current circumstances fall short of unreasonably high expectations. Putting aside Baumeister’s emphasis on unreasonable expectations/falling short of standards as the motivating force in seeking to escape the self, the general theoretical process of escape is helpful in bridging the explanatory gap between a fragmenting sense of self and suicidal behaviour. To recapitulate, escape theory holds that there is a causal process from distress to suicidal behaviour. The process will only result in suicide if each step produces a particular outcome.
Considering that allostatic load in childhood can establish a long term vulnerability to stressors, and that transference stressors (real or perceived) give rise to a fear response, it is not an unreasonable extrapolation of the evidence to suggest that there would be a cognitive response (desire) to escape. Thus escape theory appears consistent with the phylogenetic desire to control one’s environment and escape the negative effects arising from psychological stressors.
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4.3 Summary of Section A
The literature review presented has provided a context for this dissertation, and operationalised the principal constructs of focus: suicide, self psychology, and self.
To recapitulate, Kohut’s theory of self psychology emphasises the role of self as the primary psychological objective of the human experience. This is achieved largely through positive early-life transference experiences with selfobjects. The self has been
argued to be the “putative nucleus” (Berrios & Markova, 2003, p.9) of one’s subjective
experience which, inter alia, facilitates the sense of being a whole person; distinct from
the environment and different from others. The proposed extension of Canon’s (1929)
fight-flight response emphasises the unique role of human executive functioning, which
locates suicidality within normative stress response-behaviours, albeit with dire
consequences.
The following section presents five studies, which apply several of the theoretical
concepts of self psychology to suicidal behaviour.
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SECTION B: QUANTITATIVE INVESTIGATIONS INTO THE RELATIONSHIP BETWEEN SELF AND SUICIDAL BEHAVIOUR
Chapter 5: Individual Differences in Psychological Distress and Suicidality
Individual Differences in Psychological Distress and Suicidality
Yet even in the case of severe depression, it is not the disorder itself which initiates the suicidal act, but the “owner” of the depression, the individual him or herself (Michel & Valach, 2001)
5.1 Introduction
The preceding section addressed, inter alia, the theory of self psychology and self, and concluded with a proposed psycho-physiological response to intolerable states.
However, in order for a theory to describe accurately (and predict) behaviour, it must be able to accommodate the multitude of contexts in which the behaviour is observed.
Accordingly, Section B presents several quantitative studies examining the relationship between self and suicidal behaviour. The current chapter details two exploratory studies directed toward demonstrating individual differences in suicidality that might plausibly be explained by the theory of self psychology.
Mental health is recognised as an important factor in the aetiology of suicidal behaviour (e.g. Cavanagh et al., 2003; Goldney, 2002). Indeed, Tanney (2000) reported that psychological autopsy studies from several different countries revealed that over
90% of suicides had a recognisable psychiatric illness at the time of their death. Major depression appears to be the most common form of psychological distress, occurring in
60–70% of suicides, whereas Schizophrenia, for example, is associated with up to 19% of suicides involving people under the age of 35 years (Appleby et al., 1999). Although psychological autopsies have been criticised for their sampling biases and confounding variables (Pouliot & De Leo, 2006), studies applying different methodologies have
125 | Suicide and the intolerable state of a fragmented self confirmed that psychological distress is associated with the major proportion of suicides.
For example, the results of follow up studies of mood disordered patients (Angst,
Stassen, Clayton, & Angst, 2002; Angst, Angst, Gerber-Werder, & Gamma, 2005) led the authors to conclude that suicidality “is a core symptom of depression and suicide is its most deleterious outcome” (Angst et al., 2005, p. 279). Indeed, Ernst et al. (2004) attempted to explain the 10% of completed suicides who, following psychological autopsy, appeared to be psychologically healthy. They concluded that although some people who committed suicide did not meet the DSM-IV-TR criteria for an axis 1 disorder, they probably had prodromal levels of distress that the process of the psychological autopsy failed to detect. Notwithstanding this strong association between psychological distress and suicidal behaviour, individual differences remain largely ignored. Consequently, the first exploratory study sought to answer the question ‘do all psychologically distressed people experience suicidal thoughts?’ Study 2 continues with an examination of whether Kohut’s (1977) intolerable state of a fragmenting self is a plausible explanation of some of the experiences of suicidal ideation.
5.2 Study 1: Psychological Distress and Suicidal Ideation
5.2.1 Method
5.2.1.1 Survey design and participants
The data for this study were collected through the South Australian (SA)
Monitoring and Surveillance System (SAMSS) from July 2002 to June 2007. The
SAMSS is a telephone monitoring procedure which monitors the trends of health related issues relevant to the South Australian Department of Health. Data collection is contracted to a specialist commercial research company employing trained interviewers.
The telephone interviews are conducted each month on a randomly selected sample of at least 600 South Australians using a Computer Assisted Telephone Interviewing (CATI) system. All households listed in the SA Electronic White Pages are eligible for selection.
A letter introducing the survey is sent to the selected household, and the person with the
126 | Suicide and the intolerable state of a fragmented self last birthday is chosen for interview; surrogate interviews are conducted for respondents aged less than 16 years. Up to ten calls are made to the household to interview the selected person, and non-respondents are not replaced. The data were weighted by age, gender, area (metropolitan/rural), and the probability of selection in the household to the most recent Australian Bureau of Statistics (2004a) data to ensure that the results were representative of the SA population (Taylor, Dal Grande, Gill, Fisher, & Goldney, 2007).
5.2.2 Measures
The level of psychological distress was measured by the 10-item Kessler K10
Psychological Distress scale (Kessler & Mroczek, 1994). The scale was developed as a population screen for anxiety and depressive disorders. The measure is frequently applied in epidemiological research in Australia to monitor the prevalence of psychological distress. Several studies have supported the internal consistency and validity of the instrument when it is used for this purpose (e.g. Furukawa, Andrews, &
Goldberg, 2002; Judd et al., 2005). Of particular interest is Baillie’s (2005) finding of “little evidence of predictive bias in the relationship between the K10 and CIDI DSM-IV diagnoses of anxiety and depressive disorders” (p. 747), positing that this relationship is the most significant justification for use of the K10 as an indicator of mental health status of populations. Moreover, the sensitivity and specificity of the K10 outperforms the
General Health Questionnaire (GHQ-12), which is the current de facto standard of mental health screening (Furukawa et al., 2002; Furukawa, Kessler, Slade, & Andrews,
2003). In particular, Furukawa et al. (2003) revealed that the K10 has better overall discriminatory power than the GHQ-12 in detecting affective disorders (p <0.001).
Scores below 10 are interpreted as indicating no psychological distress, whereas Low psychological distress is indicated by a score between 10 and 15, Moderate between 16 and 21, High between 22 and 29, and Very High between 30 and 50.
Suicidal ideation was measured independently on the basis of responses to four questions (D4, D5, D6 & D7) contained in the severe depression sub-scale of the 28-
127 | Suicide and the intolerable state of a fragmented self item General Health Questionnaire (GHQ-28) (Goldberg & Hillier, 1979). The GHQ-28 is a well established and reliable instrument that has been validated in the Australian population (Tennant, 1977). Moreover, Watson, Goldney, Fisher and Merritt (2001) extended its validation as a standardised method for comparing suicidal ideation in different populations. The participants were given the standard GHQ-28 instructions on replying to the questions about how they felt ‘over the last few weeks’:
1. Have you recently felt that life isn’t worth living?
2. Have you recently thought of the possibility that you might do away
with yourself?
3. Have you recently found yourself wishing you were dead and away
from it all?
4. Have you recently found that the idea of taking your own life kept
coming into your head?
Responses of ‘not at all’, ‘no more than usual’, ‘rather more than usual’, or ‘much more than usual’ were recorded for questions 1 and 3. Similarly, responses ‘definitely not’, ‘I don’t think so’, ‘has crossed my mind’, or ‘definitely has’ were recorded for questions 2 and 4. Each question was scored in a binary manner, with the negative responses (e.g.
‘not at all’) given a score of zero, and the positive responses a score of 1. The scores for were then added to give a suicidal ideation score ranging from zero to four.
The K10 was administered every month, whereas the four questions on suicidal ideation were only included every third month. Thus, the K10 data for the current study relates only to those months when suicidal ideation was also measured. This sample
(n = 11,456) was aged between 7 and 99 years (M = 38.56, SD = 22.53). Sex was equally represented with 49.2% males and 50.8% females.
128 | Suicide and the intolerable state of a fragmented self
5.2.3 Data analysis
Univariate and bivariate analyses of the data were conducted using SPSS
Version 15 applying a threshold significance level of .05.
5.2.3 Results
Psychological distress, in all categories, was detected in 9.9% (95% CI 10.6-11.4, n = 1132) of the respondents. The prevalence of suicidal ideation for the same participants was 5.1% (95% CI 5.0-5.9, n = 612). Refusals represented 10.7% of the sample with replacement interviews not permitted. The increasing psychological distress categories of the K10 were accompanied by an increasing percentage of respondents reporting suicidal ideation, together with increasing mean K10 scores. Over 52% of participants in the Very High category reported having suicidal thoughts (Table 5.1).
Table 5.1 The results of the univariate analysis for each of the K10 categories and the suicidal ideation score (from Chamberlain, Goldney, Delfabbro, Gill, & Dal Grande, 2009)
NOTE: This figure is included on page 129 of the print copy of the thesis held in the University of Adelaide Library.
A logistic regression was performed to determine if higher levels of psychological distress on the K10 were associated with a higher likelihood of suicidal ideation, and whether this relationship differed by sex. The Low category was set as the reference group. The model was statistically significant, χ² (3, n = 12884) = 1140.72, p < 0.001, indicating that it was possible to distinguish between participants reporting suicidal ideation and those who did not. The model explained between 9.4% (Cox and Snell R
129 | Suicide and the intolerable state of a fragmented self square) and 28.1% (Nagelkerke R squared) of the variance in suicidal ideation, and correctly classified 95% of cases. As illustrated in Table 5. 2, all of the K10 categories made a unique statistically significant contribution to the model. The strongest predictor of suicidal ideation was the Very High category of psychological distress, recording an odds ratio of 77, indicating that participants in this category were 77 times more likely to report suicidal ideation than those in the Low category. The Moderate and High categories recorded odds ratios of 4.4 and 21.1 respectively. When examined separately, sex was only a significant factor for the Very High category; males, were 104 times more likely to report experiencing suicidal ideation than those in the Low category,
χ² (3, n = 7154) = 613.29, p < 0.001, compared to 63 times for females, χ² (3, n = 5730)
= 550.38, p < 0.001.
Table 5.2 Results of the logistic regression indicating the likelihood of experiencing suicidal ideation in terms of levels of psychological distress (from Chamberlain et al., 2009)
NOTE: This figure is included on page 130 of the print copy of the thesis held in the University of Adelaide Library.
130 | Suicide and the intolerable state of a fragmented self
5.3 Study 2: Suicidal Ideation and the Experience of a Fragmenting Self
5.3.1 Method
5.3.1.1 Survey design and participants
The data for this study were collected in the 2009 Spring SA Health Omnibus
Survey (HOS) managed by the SA Department of Health. The HOS is used by government and commercial organisations on a user-pays basis, and is conducted at least once annually in exactly the same manner as the SAMSS described earlier. The sample (n = 3007) is well represented by both sexes (40.5% males, 59.5% females), and the age of the participants ranged from 15 to 98 years (M = 50.81, SD = 18.99).
5.3.2 Measures
The experiences of self fragmentation were measured by responding to the question ‘How often, if ever, have you experienced a distressing sense of personal fragmentation, coming apart or crumbling?’ 18 Responses of ‘never’, ‘rarely, ‘sometimes’,
‘often’, and ‘very often’, were attributed scores of 0, 1, 2, 3, 4, and 5 respectively.
Suicidal ideation was measured by one question from the Primary Care
Evaluation of Mental Disorders (PRIME-MD) (Spitzer et al., 1994): ‘In the last two weeks have you had thoughts that you would be better off dead or of hurting yourself in some way?’ The PRIME-MD has been applied in several health surveys as a measure of suicidal ideation (e.g. Goldney et al., 2003; Goldney, Fisher, Wilson, & Cheok, 2002).
The question ‘Are you currently receiving treatment for anxiety, depression, or any other mental health problem?’ provided a simple measure of current mental health status.
18 The interviewers were instructed that the question relates to a person’s sense of self. They were permitted to advise respondents that the researchers wished to know if the person experienced their sense of self as complete, cohesive and stable or coming apart/breaking up.
131 | Suicide and the intolerable state of a fragmented self
5.3.3 Data analysis
Univariate and bivariate analyses of the data were conducted using PASW
Version 17 applying a threshold significance level of .05.
5.3.4 Results
A sense of some level of personal fragmentation was detected in 43.2% (95% CI
0.45 – 0.49, n = 1352) of the respondents, whereas suicidal ideation was reported by
3.7% (95% CI 1.98 – 2.0, n = 106) of the participants. Diagnosed mental health issues were reported by 12.3% (95% CI 0.11 – 0.13) of the sample.
A logistic regression was performed to determine if greater frequencies of a sense of personal fragmentation were associated with a higher likelihood of suicidal ideation, and whether this relationship differed by sex. The never (experienced) category was set as the reference group. The model was statistically significant, χ² (4, n = 2888) =
213.85, p < 0.001, indicating that it was possible to distinguish between participants reporting suicidal ideation and those who did not. The model explained between 7.1%
(Cox and Snell R square) and 26.4% (Nagelkerke R squared) of the variance in suicidal ideation, and correctly classified 96.3% of cases. As illustrated in Table 5.3, with the exception of rarely, all of the frequencies of the experience made a unique statistically
significant contribution to the model. The strongest predictor of suicidal ideation was the
Very Often category of fragmentation, recording an odds ratio of 72, indicating that
participants in this category were 72 times more likely to report suicidal ideation than
those who had never experienced a sense of coming apart. The sometimes and often
categories recorded odds ratios of 11.53 and 58.81 respectively. Sex was not a
statistically significant factor.
132 | Suicide and the intolerable state of a fragmented self
Table 5.3 Results of the logistic regression indicating the likelihood of experiencing suicidal ideation in relation to the frequency of experiences of self fragmentation as predicted by the theory of self psychology
Frequency of Odds- Self B S.E. Wald df p (95% C.I.) Fragmentation Ratios
Rarely 0.60 .38 2.46 1 0.117 1.82 (0.86 – 3.83)
Sometimes 2.45 .32 58.60 1 <0.001 11.53 (6.16 – 21.55)
Often 4.07 .35 139.76 1 <0.001 58.81 (29.93 – 115.57)
Very Often 4.28 .53 65.43 1 <0.001 72.48 (25.67 – 204.62)
5.4 Discussion
The purpose of the current exploratory studies was to illustrate that, despite the considerable contributions of researchers to date, several issues surrounding suicidal behaviour are not yet fully understood. In particular, the focus was directed toward identifying a gap in the current literature wherein self psychology might provide a plausible explanation.
Study 1 sought to demonstrate the significance of individual differences in the relationship between psychological distress and suicidal ideation. The reported experiences of suicidal thoughts in the few weeks prior to the interview (5.1%), and psychological distress (9.9%) is consistent with other reports of similar populations (e.g.
Gili-Planas, Roca-Bennasar, Ferrer-Perez, & Bernardo-Arroyo, 2001; Goldney et al.,
2003). However, the results do suggest that the relationship between psychological distress and suicidality is not a sufficient explanation for suicidality. Although the vast majority of suicides are associated with mental health issues (e.g. Goldney, 2008; McGirr et al., 2007; Portzky, Audenaert, & van Heeringen, 2009) the reverse does not appear to be the case. That is, not every experience of psychological distress is accompanied by
133 | Suicide and the intolerable state of a fragmented self thoughts of self harm suggesting that individual differences are significant in terms of vulnerability to thoughts of self-harm.
As expected, the odds of experiencing suicidal ideation were related to higher levels of psychological distress. Furthermore, increases in the frequency of suicidal thoughts also accompanied increases in the K10 scores. Even those in the Moderate category had four times the rate of suicidal ideation than people in the Low category, and this increased to 21 and 77 times for the High and Very High categories respectively. In comparison to those in the Low Category, males are more likely to experience suicidal ideation than females when experiencing Very High levels of psychological distress, with odds ratios of 103 and 63 respectively. Yet, despite this significant association between psychological distress and suicidal ideation, only 52% of even the highly distressed
people (regardless of sex) experienced thoughts of self-harm. Clearly, such individual
differences suggest the influence of confounding dynamics beyond the explanations of
psychiatric illness or general psychological distress.
Study 2 examined whether people experiencing suicidal ideation also experience
a fragmenting sense of self. This experience appears relatively common, with 43% of
the participants acknowledging some level of a sense of coming apart. The increasing
likelihood of suicidal ideation associated with the increasing frequency of self
fragmentation is consistent with the theory of self psychology (Fuchs, 2007; Kohut, 1977,
1985b; Silverstein, 2007) and clinical observations (Gardner, 2000; Reiser, 1986;
Weisel-Barth, 2003). The finding that sex is not a significant factor is also important in
terms of understanding self within the paradigm of self psychology. One’s sense of self
is a very subjective construct resulting predominantly from early-life experience and,
although it is influenced by cultural mores such as sex roles, it does not appear to be
structurally determined by sexual anatomy.19
The strength of these studies lies in the large number of participants. However, there are potential limitations to the interpretation of these data. The primary limitation of
19 The relationship between biological sex and self are addressed in Chapter 8.
134 | Suicide and the intolerable state of a fragmented self both surveys is the exclusion of some socially disadvantaged members of the South
Australian population who are not contactable by telephone (e.g. homeless or cannot afford a telephone), and this may bias the results towards an underestimation of psychological distress and suicidal ideation, as these social determinants are significantly related to suicidal ideation (Taylor et al., 2007). Data gathering by telephone interview could also be questioned, but its validity has been demonstrated with face-to- face interviews (Taylor, Wilson, & Wakefield, 1998).
A further limitation for Study 2 is the question about the frequency of self fragmentation. The interpretation of the question was problematic for some respondents in a trial survey preceding the HOS, resulting in the provision of information to the interviewers to facilitate participant understanding. A trial survey always precedes the
HOS to identify issues that might prove to be problematic. The fragmentation question was initially given without context and several respondents were unsure as to what was being asked of them. This was overcome by including the statement: “The following question relates to your sense of self”. If the respondent still remained unsure, the interviewer would explain that “The self refers to how we see and understand ourselves as individuals and as part of groups such as families or friends. Or, put another way, our private identity that is only completely known to ourselves”. Nevertheless, the possibility remains that some confusion about the question may have influenced the results.
Nevertheless, the results identified a gap in the literature regarding the relationship between individual differences and vulnerability to suicidal behaviour.
Moreover, Kohut’s (1971, 1985c) understandings of a fragmenting sense of self are significantly related to thoughts of self-harm. Accordingly, the following chapter extends the examination of the association between the construct of self and suicidality by presenting two studies addressing the trauma theory of self psychology.
135 | Suicide and the intolerable state of a fragmented self
Chapter 6: Self, Trauma and Suicidal Behaviour
Self, Trauma and Suicidal Behaviour
As for suicide: the sociologists and psychologists who talk of it as a disease puzzle me now as much as the Catholics and Muslims who call it the most deadly of mortal sins. It seems to me to be somehow as much beyond social or psychic prophylaxis as it is beyond morality, a terrible but utterly natural reaction to the strained, narrow, unnatural necessities we sometimes create for ourselves. And it is not for me. Perhaps I am no longer optimistic enough. I assume now that death, when it finally comes, will probably be nastier than suicide, and certainly a great deal less convenient (Alvarez, 1971, p. 289).
6.1 Introduction
The relationship between trauma and suicide is well established in the literature
(e.g. de Zulueta, 2006; Goldney, Wilson, Dal Grande, Fisher, & McFarlane, 2000;
Seedat, Stein, & Forde, 2005), “along with the notion that the individual’s coping potential and available resources might mediate between traumatic events and the individual’s response” (Krysinska, Lester, & Martin, 2009, p. 103). This is particularly evident in the results of research examining the effects of childhood traumatic events (Sarchiapone et al., 2009) such as divorce (Hodge, 2006), physical and sexual abuse (Anderson,
Sachdev, Brodaty, & Trollor, 2007; Andover, 2007), and family history of suicide (Roy &
Janal, 2005). Despite this, trauma remains poorly defined, as does the frequently referred to construct of resilience, which is claimed to be the “basic ingredient to happiness and success” (Reivich & Shatté, 2002, p. 1).
Krysinska, Lester and Martin (2009) noted that the definition of trauma has changed in its emphasis over the numerous editions and revisions of the Diagnostic and
Statistical Manual of Mental Disorders (DSM). The current DSM-IV-TR (2000) defines trauma as “an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others ... [and] the person’s response involved intense fear, helplessness, or horror” (p.467)(emphasis added). These criteria
136 | Suicide and the intolerable state of a fragmented self differ from the original conception of a “recognizable stressor that would evoke significant symptoms of distress in almost anyone” (DSM-III, 1980, p. 238), which was extended to
“outside the range of usual human experience” in the DSM-III-R (1987, p. 250).
Notwithstanding the transient nature or the “current elastic definition of trauma” (Blum,
2003, p. 416) in the DSM, and the divergent understandings espoused in the literature, the traditional account of trauma as an external stressor resulting in “obligatory psychopathology” (Krystal, 1988, cited by Naso, 2008, p. 68) continues to be the dominant view.
According to Blum (2003), this limited approach conceptualises psychological trauma as a stimulus flooding of the ego which is simply a reference to the immediate traumatic situation, and neglects the residual state of a “persisting pathogenic internal condition” (p. 416). Notwithstanding these criticisms, there appears to be an increasing focus on the intra and inter-personal dynamics associated with the event. For example, in his endorsement of McAdams (1996) comment that traumatic experiences can damage self-perception, Hemenover (2003) emphasised the importance of “constructing a coherent life narrative that reflects and links together who we were, who we are now, and who we hope to become” (p. 1236). Similarly, Nishith, Mechanic, and Resick (2000) reported that prior interpersonal trauma (particularly those involving selfobjects and objects) significantly contributes to the manner and intensity of a response to a traumatic event.
Psychological resilience is often proffered as an explanation for individual difference in responses to traumatic events. Yet resilience has been described as “a poorly understood capacity of the human psyche” (Ornstein, 2003, p. 94), and it is frequently presented in the literature and the media as an inadequately defined explanation or therapeutic objective (e.g. Reivich & Shatté, 2002). Nevertheless, resilience researchers generally understand the construct to be the “process of overcoming the negative effects of risk exposure, coping successfully with traumatic
137 | Suicide and the intolerable state of a fragmented self experiences, and avoiding the negative trajectories associated with risks” (Fergus &
Zimmerman, 2005, p. 399).
Although resilience theory is attentive to risk exposure, the principal focus is on the strengths that reside within the individual, such as self-efficacy and coping skills
(Luthar, Cicchetti, & Becker, 2000; Tugade & Fredrickson, 2004). This approach appears to follow the contributions of Maslow (1954; 1965) and Rogers (1951), who directed their interests towards healthy development rather than psychopathology. Maslow noted that self-actualising (resilient) people are more able to realise their potential than those who are not. Stress or trauma, he commented, in a manner similar to Kohut’s (1974) process of developing a healthy sense of self, “will break people altogether if they are in the beginning too weak to stand distress, or else, if they are already strong enough to take the stress in the first place, that same stress, if they come through it, will strengthen them, temper them, and make them stronger” (Maslow, 1965, p. 23). This internal strength was also apparent to Rogers (1951), who included in his self-theory the basic propositions that a consistent conceptual pattern of self is formed in response to interactions with others, and behaviour is consistent with one’s concept of self. However, with very few exceptions (e.g. Staudinger & Fleeson, 1996), the construct of self is not attributed significance in the resilience literature, although frequent reference is made to several of the constructs underlying the three prototypical patterns of the experience discussed in
Chapter 4. For example, self-esteem (Cicchetti, Rogosch, Lynch, & Holt, 1993), self- efficacy (Karademas, 2005), and self-regulation (Nota, Soresi, & Zimmerman, 2005).
Given the paucity of research on the role of self in trauma and resilience studies, an examination of self-psychology’s trauma theory would appear warranted to determine whether this advances understanding of the relationship between self and suicidal behaviour.
138 | Suicide and the intolerable state of a fragmented self
6.2 Kohutian Trauma Theory
Self psychology’s theory of trauma emphasises the function of the self and selfobjects within the traumatic experience. This position is consistent with affect theory
(Tomkins, 1962), which acknowledges individual differences in traumatic responses, and the primacy of the role of self in relation to the body’s affect 20 system when the latter is
“in an excessive or prolonged state of excitation” (Lee & Martin, 1991, p.278). The somatic reactions to trauma may be experienced by, inter alia, perspiration, low blood pressure and muscular flaccidity. Psychologically however, elevated or prolonged stimulation of the affective system manifests with the shattering of “central organising fantasies 21 of self in relation to selfobject” (Ulman & Brothers, 1988, p. 295). Thus,
“trauma can be defined psychologically, therefore, as the shattering (Kohut’s fragmenting) of these fantasies” (Lee & Martin, 1991, p. 278) and destabilising self structures.
As previously noted, trauma is generally viewed as solely an objective event. This understanding is considered erroneous by self psychologists who argue, along the lines of traditional psychoanalytic theory, that trauma is more than simply an external stressor.
Bruer and Freud’s (1895) early contribution to trauma theory was their postulation that a traumatic response represented the psyche’s failure to metabolise the associated event.
For self psychology, however, trauma is a process involving overstimulation of the affect and cognitive systems and a subsequent fragmentation or collapse of the self. Ulman and Brothers (1988) commented that “in this shattering and subsequent faulty (defensive and/or compensatory) attempts to restore fantasies lies the unconscious meaning of the traumatic event” (p. xiii). Again, this is contrary to contemporary understandings that trauma is an objective unexpected catastrophic and intolerable event such as sexual assault. Undoubtedly, catastrophic events that are destructive, brutal, violent, tragic, or
20 Ulman and Brothers (1988) have extended trauma theory to include, and give emphasis to, the cognitive dimension of the traumatic experience. Although this divergences from the classical Kohutian view, it is does not have practical implications for the outcomes of this thesis. 21 The American Psychological Association (APA) defines fantasy as “any of a range of mental experiences and processes marked by vivid imagery, intensity of emotion, and relaxation or absence of logic” (APA, 2007, p. 368).
139 | Suicide and the intolerable state of a fragmented self represent a betrayal are by definition traumatic, and have a high probability of producing a traumatic response in the victim. However, whether or not traumatisation occurs depends largely on the internal state of the person experiencing the event (Kohut, 1977,
1984). Wolf (1995) argues that neither self nor trauma solely pertain to the subject or environment, but should be recognised as involving both. Complementing this position is
Monroe’s (2008) transactional definitions of stress which posit that both environmental and response components of stress determine outcomes.
The implication of self in the trauma process appears to be supported in the literature beyond the paradigm of self psychology. For example, Kilpatrick, Veronen and
Best’s (1985) study of female rape victims noted that the victim’s personality, or concept of self, played a pivotal role in respect to the intensity of the affect stimulation experienced. This appears to also be the case for males, with researchers suggesting that male rape victims may be particularly traumatised because of the socially constructed male role which, once violated, destabilises the man’s sense of self and sexual identity (Elliot, Mok, & Briere, 2004; Kimerling, Rellini, Kelly, Judson, & Learman,
2002). Similarly, the recovery trajectories of gay male sexual assault victims also appear to be positively associated with a cohesive sense of self (Gold, Marx, & Lexington,
2007). Moreover, victims who experience psychological distress, including interpersonal trauma prior to victimisation, tend to experience greater distress in response to a traumatic event (Bryant-Davis & Ocampo, 2005; Frazier, 2000; Nishith et al., 2000).
Lifton (1971) argued for the protean self in recognition of what he interpreted as extraordinary resilience in an age of self fragmentation. Named after Proteus, the Greek sea god of many forms, the protean self is viewed as an adaptive, fluid and multi-faceted sense of self that “emerges from confusion, from the widespread feeling that we are losing our psychological moorings” (p.1). Lifton’s research into the psychological causes and effects of the horrors of war, political violence and thought reform, led him to the view that the self is surprisingly resilient. Indeed, his studies of survivors of atrocities such as the Holocaust and Hiroshima (Lifton, 1968, 1986) concluded that trauma could
140 | Suicide and the intolerable state of a fragmented self lead to an emotional resilience if given appropriate intervention. He was impressed by the apparent resilience of many of the survivors, yet he may have, on occasions, mistaken stoicism for resilience. Complementing Lifton’s position was the popular assertion that suicide was a rare occurrence in the concentration camps (Bronisch, 1996;
Dublin, 1963). However, Lester (2004) revisited the subject and found such claims to be inaccurate, and estimated that suicide rates in concentration camps ranged from between 25,000 to 100,000 per year (see also Krysinska & Lester, 2008). Furthermore, in their study of aging Holocaust survivors, Barak et al. (2005) noted that this population was at increased risk of attempting suicide and more likely to receive a diagnosis of
PTSD. Nevertheless, they concluded that although “psychiatric illness is clearly a risk factor for suicide ... it is also an insufficient explanation” (p.704).
Kohut (1984) reported that detainees in the Nazi concentration camps during
World War II experienced a destruction of their sense of self. Herman (1992) also argues that one’s sense of self, or psychic structure, is dismantled by trauma (see also
Laub & Auerhahn, 1989). More recently, Walker and Dudley (2004) noted that trauma victims “frequently feel estranged from their pretraumatized selfhood” (p.112); their sense of self is shattered and there is an alienation from a selfobject or object with whom they feel they can no longer relate. Moreover, trauma can result in the invalidation and destabilisation of one’s self-efficacy and/or core beliefs (Naso, 2008; Nishith et al., 2000), although the consequences for the self appear to be mediated by age (Staudinger &
Fleeson, 1996). Nevertheless, Boulanger (2002) argues against conflating the consequences of trauma in childhood with those in adulthood:
When a child is overwhelmed by fear, contingent selves form as a protection
against fragmentation; the trauma is embodied in different self-states –
unwelcome, unfamiliar, but nonetheless part of personality. In childhood, trauma
becomes part of the self experience [the developing sense of self]; in adulthood, it
causes the collapse of the self. (p.49)
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Boulanger’s comments are consistent with Perry et al.’s (1995) neurological explanation of how psychological states become traits discussed in Chapter 5. Childhood trauma, particularly emotional, physical and sexual abuse, has a cumulative effect in terms of increasing one’s vulnerability to psychopathology and suicidal behaviour (Anderson, Tiro,
Price, Bender, & Kaslow, 2002; Andover, 2007; Sarchiapone, Carli, Cuomo, & Roy,
2007). Stolorow and Lachmann (1980), commenting on the pathological effects of incest, argue that childhood trauma involving selfobjects results in a “severe
‘developmental arrest’ in the psychic structuralisation of the incest survivor’s self- experience because these central organizing fantasies are repeatedly shattered and faultily resorted with each incestuous assault” (p. xiii).
Kohut’s process of structuralisation of the self (transmuting internalisation) is an acknowledged adaption of Freud’s (1917) idea of mourning whereby “the withdrawal of feelings from lost others occurs in a fractionated way, bit by bit” (Strozier, 2001, p. 199).
Kohut argued that the process of self development requires a developmental readiness for the formation of a structuralised self (Kohut, 1984). This is followed by optimal frustration with the selfobject that induces an emotional retreat and the internalisation of some function hitherto performed by the selfobject. This fractionalised process enables optimal internalisation whereby the child can relinquish functions of the omnipotent selfobject in a manner that can render the child vulnerable. Kohut maintained that traumatic early-life experiences, particularly those associated with the selfobject, interrupt the process of optimal internalisation. The consequence of these experiences is that the child remains obsessed with their early-life precepts of the selfobject and remains dependent on others “in order to replace functions of a segment of the mental apparatus which had not been established in childhood” (Kohut, 1971, p. 51). Moreover, the consequences of traumatic disruptions in the relationship with the selfobject are dependent upon the level of self structuralisation at the time of the experience. For example, very early disturbances result in the inability to establish a stable personality. In
142 | Suicide and the intolerable state of a fragmented self comparison, a core deficit in one’s capacity to idealise can be the result of a traumatic experience occurring when there is some cohesiveness in self structure. These people relentlessly seek out others to provide a soothing function that is beyond the capacity of their internal psychic structures. Thus, the purpose of the current study was to determine whether the self psychology theory of trauma has efficacy in understanding the relationship between suicidal behaviour and traumatic experiences. The study was exploratory in nature and intended to advance the primary argument of this treatise that some suicidal behaviour may be the response to the intolerable state of a fragmented sense of self.
6.3 Method
6.3.1 Survey Design and Participants
The data were gathered from two unrelated studies which, inter alia, administered the Posttraumatic stress disorder (PTSD) module of the Composite International
Diagnostic Interview (CIDI) (World Health Organisation, 1997): the 2004 South Australian
Department of Health Omnibus Survey (HOS) (Wilson, Wakefield, & Taylor, 1992), and the Identifying Depression as a Comorbid Condition (IDACC) project (Cheok, Schrader,
Banham, Marker, & Hordacre, 2003).
6.3.1.1 Health Omnibus Survey
The HOS is a client funded (user pays) survey that is conducted annually by the
South Australian Department of Health and allows organisations to share the cost of data collection. Each survey samples 4,400 households with 77% of the sample selected from the Adelaide metropolitan area, and the remainder representing rural areas with a population exceeding 1000, based on the current Australian Bureau of Statistics (ABS) census information. Within the selected areas, the ABS Collection Districts (CD) form the geographical basis of the sample frame with each CD comprising approximately 200 dwellings. Cluster sampling is applied whereby some, but not all, of the CDs are
143 | Suicide and the intolerable state of a fragmented self randomly included in the sample. Ten households are randomly selected from each of
440 CDs. Selection of a participant within each household is simply the person who was last to have a birthday (15 years or over). Selected persons are deemed non- replaceable and alternative household members are not invited to participate in the event the selected person is unavailable. A minimum of six approaches is made to each household before a selected person is considered a non-contact. Selections subsequently identified as hospitals, nursing homes, motels, hotels or other institutions were excluded from the survey. Reliability was monitored by way of re-interviews for selected questions conducted on a random 5% of each interviewers work. Data were weighted according to the aforementioned ABS census so that the sample composites reflected the South Australian population in terms of sex, age and geographic area.
An introductory letter was sent to each selected household, informing the occupants of the purpose of the survey and the intention to contact them by telephone.
The data were collected by an accredited commercial agency employing experienced interviewers using the Computer Assisted Telephone Interview (CATI) system. This system allows the immediate entry of the data collected from the interviewer’s questionnaire screen to the computer database. The CATI system enforces a range of checks on each response with most questions having a set of predetermined response categories, and automatically rotates the response categories to minimise participant bias. When open-ended responses were required, these were transcribed exactly by the interviewer.
The sample consisted of 3015 participants ranging from 15 to 96 years of age
(M = 48.71, SD = 18.71): 1256 males (41.7%) and 1759 females (58.3%). Ethics approval was provided by the South Australian Department of Health’s Human Resource
Ethics Committee.
144 | Suicide and the intolerable state of a fragmented self
6.3.1.2 IDACC Project
The IDACC project employed a longitudinal mixed method design
(quantitative/qualitative) that sought to identify depressive symptoms in hospitalised
(baseline) cardiac patients at three, six and 12 months post-discharge. The project also tested a General Practitioner (GP) focused intervention designed to improve the detection and management of depression (Wade, Cheok, Schrader, Hordacre, & Marker,
2005). For the purpose of the current study, the data were restricted to the baseline measurement results for the PTSD module of the CIDI.
Cardiac patients from four major hospitals in Adelaide, South Australia, were invited to participate after their first day of admission for unstable angina, myocardial infarction, arrhythmia, heart failure, angioplasty or coronary artery bypass graft surgery.
The PTSD module of the CIDI was one of several instruments administered to those who consented to participate, together with semi-structured face-to-face interviews.
Participants who were unable to complete the Center for Epidemiological Studies
Depression Scale (CES-D) because of language difficulties or cognitive impairment were excluded from the study. The participants ranged between 18 and 91 years of age (n =
4772, M = 64.01, SD = 12.92): 3005 males (63%) and 1767 females (37%). The IDACC project protocol was approved by the Human Research Ethics Committee for each of the participating hospitals.
6.3.2 Measures
Both studies sought a response from participants by questioning “Have any of following stressful or upsetting events happened to you?” The nine specific traumatic events (CIDI) were: “Direct combat experience in a war”, “Involved in a life-threatening accident”, “Involved in a fire, flood or natural disaster”, “Witness someone being badly injured or killed”, “Raped”, ‘sexually molested”, ‘seriously physically attacked or assaulted”, ‘threatened with a weapon, held captive, or kidnapped”, ‘tortured or the victim
145 | Suicide and the intolerable state of a fragmented self of terrorists”, with the options of “None of these”, or “Refused”. The questions were scored by applying a binary method with acknowledgements of a traumatic experience being given a score of one, and everything else given a score of zero.
Suicidal ideation was determined in the HOS on the basis of a positive response to the question: “In the last two weeks have you had thoughts that you would be better off dead or of hurting yourself in some way?” with 3.3% (n = 101) of the participants acknowledging this experience. In the IDACC project, however, suicidal ideation was determined by seeking a response to the following: “I don’t have any thoughts of killing myself”, “I have thoughts of killing myself but would not carry them out”, “I would like to kill myself if I had the chance”, and “I would kill myself if I had the chance. The suicide ideation questions were only asked when the CES-D score suggested psychopathology;
12.7% (n = 605) of the participants were approached on the subject. Of these, 17.9%
(n = 112) acknowledged suicidal thoughts.
6.3.3 Data Analysis
6.3.3.1 Health Omnibus Survey
Statistical analysis was conducted using SPSS Version 17 applying a threshold significance level of .05. Each of the nine traumatic events was examined for statistical significance in relation to suicidal ideation. Three non-statistically significant events (p >
0.05) were omitted from further investigation: direct combat experience in a war, involvement in a fire, flood or natural disaster, and tortured or a victim of terrorists.
The remaining six items were then subjected to principal axis factoring (PAF). PAF was chosen because it does not assume that all error is random, but rather it recognises random and systematic measurement error associated with a latent construct. The mathematical model in this approach analyses only shared variance and attempts to estimate and eliminate variance due to error. Consequently, PAF is particularly suited to exploratory analysis in which “a theoretical solution is uncontaminated by unique and error variability” (Tabachnick & Fidell, 2007, p. 635).
146 | Suicide and the intolerable state of a fragmented self
The Kaiser-Meyer-Olkin value was 0.70, exceeding Kaiser’s recommended value of 0.6, and Bartlett’s Test of Sphericity reached statistical significance χ 2 (15, n = 3015)
= 1697.48, p < 0.001, supporting the factorability of the correlation matrix. PAF revealed the presence of two factors with eigenvalues exceeding 1, explaining 33.95% and
18.84% of the variance respectively. This was supported by the scree plot. However, the results of a Parallel Analysis (PA) (Horn, 1965) suggested the possibility of three factors with 95th percentile eigenvalues exceeding the corresponding criterion values for a randomly generated data matrix of the same size. In PA, the number of factors is determined by comparing the size of eigenvalues obtained from the analysis to those obtained from a randomly generated data set of the same size. Only the PAF factors with eigenvalues exceeding the values obtained from the corresponding random data set are retained. Nevertheless, two factors were retained for further investigation as a three factor solution was ambiguous in the distribution of coefficients, and there is a tendency for PA to over-factor when it errs (Hayton, Allen, & Scarpello, 2004).
The two-factor structure explained 52.79% of the variance. Oblimin rotation with
Kaiser Normalisation revealed the presence of simple structure (Thurstone, 1947) with strong loadings on each of the two factors. The loadings for the Pattern and Structure matrices are presented as Table 6.1. In view of the clustering of the variables, factors 1 and 2 appear to represent a threat to self and violation of self respectively. Accordingly, two new variables (Threat and Violate) were computed to reflect these factors. K3.7
‘seriously physically assaulted’ was omitted from further commutation because of the similarity of the coefficients loading onto both factors.
147 | Suicide and the intolerable state of a fragmented self
Table 6.1 Pattern and Structure Matrix for the HOS PAF with Oblimin Rotation
Pattern Structure Communalities Traumatic Event Coefficients Coefficients Extraction 1 2 1 2
K3.2 Life-threatening accident .471 -.038 .456 .153 .209
K3.4 Witness someone badly injured/killed .642 -.081 .609 .179 .377
K3.5 Raped -.010 .572 .224 .574 .329
K3.6 Sexually molested -.010 .526 .206 .528 .278
K3.7 Seriously physically assaulted .372 .303 .497 .459 .326
K3.8 Threatened with weapon/held captive/kidnapped .422 .154 .484 .335 .254
Rotation converged in 5 iterations
The categorical nature of the dependent variable (suicidal ideation) prohibited a
multivariate analysis of the data. Accordingly, the variables threat and violation were
entered into a logistic regression.
6.3.3.2 IDACC Project
Statistical analysis was conducted using SPSS Version 17 applying a threshold
significance level of .05. Each of the nine traumatic events was examined for statistical
significance in relation to suicidal ideation. Two items were not statistically significant (p
> .05) and were omitted from further analysis: Tr7-1 (Seriously physically assaulted) and
Tr8 (Threatened with a weapon, held captive or kidnapped).
As with the HOS data, the trauma items were subjected to PAF. The Kaiser-
Meyer-Olkin value was 0.72, exceeding Kaiser’s recommended value of 0.6, and
Bartlett’s Test of Sphericity reached statistical significance χ 2 (36, n = 4772) = 1402.38,
p < 0.001, supporting the factorability of the correlation matrix. PAF revealed the
presence of two factors with eigenvalues exceeding 1, explaining 26.63% and 16.25% of
the variance respectively. The scree plot was ambiguous but the results of the PA also
148 | Suicide and the intolerable state of a fragmented self suggested two factors. Oblimin rotation with Kaiser Normalisation revealed the presence of simple structure with strong loadings on each of the two factors. The loadings for the
Pattern and Structure matrices are presented as Table 6.2. The trauma events loaded onto the factors in the same manner as the HOS data with no contradictions. Tr7
‘seriously physically attacked or assaulted’, and Tr9 ‘tortured or the victim of terrorists’ were omitted from further commutations because of the similarity in the coefficients loading onto both factors and coefficients < 0.3 respectively. Factors 1 and 2 were transformed to variables threat and violation respectively.
Table 6.2 Pattern and Structure Matrix for the IDACC PAF with Oblimin Rotation
Pattern Structure Communalities Traumatic Event Coefficients Coefficients Extraction 1 2 1 2
Tr1-1 Direct combat experience in war .401 -.149 .368 -.062 .157
Tr2-1 Life-threatening accident .525 -.018 .521 .096 .272
Tr3-1 Involved in fire, flood, natural disaster .437 .009 .439 .104 .193
Tr4-1 Witness someone badly injured/killed .623 -.012 .620 .123 .385 - .636 .078 .623 .392 Tr5-1 Raped .060
Tr6-1 Sexually molested -.032 .633 .105 .626 .393
Tr7-1 Seriously physically assaulted .444 .296 .508 .393 .342
Tr8-1 Threatened with weapon/held captive/ kidnap .513 .141 .544 .252 .314
Tr9-1 Tortured or victim of terrorists .136 .177 .174 .207 .060
Rotation converged in 6 iterations
Suicidal ideation was transformed into a categorical variable to enable a logistic regression to be performed in the same manner as the HOS data.
149 | Suicide and the intolerable state of a fragmented self
6.4 Results
6.4.1 Health Omnibus Survey
The logistic regression sought to determine whether a violation of self realised a higher likelihood of suicide ideation than a threat to self. Participants who indicated that they had experienced none of the listed traumatic events were set as the reference group. The model was statistically significant, χ 2 (2, n = 3010) = 93.56, p < 0.001, indicating that it was possible to distinguish between participants reporting suicidal ideation and those who did not. The model explained between 3.1% (Cox and Snell R square) and 12.0% (Nagelkerke R square) of the variance in suicidal ideation, and correctly classified 96.6% of cases. As illustrated in Table 6.3, both variables made a unique statistically significant contribution to the model. The strongest predictor of suicidal ideation was Violation of the self, recording an odds ratio of 41, indicating that these events were 41 times more likely to result in suicidal ideation than no traumatic experiences. For Threat to self category, the odds ratio of 12 indicates that the participants experiencing these events were 12 times more likely to report suicidal ideation than participants who reported having no traumatic experiences. When examined separately, the effect of biological sex was not statistically significant (p >.05).
Table 6.3 HOS logistic regression indicating the likelihood of experiencing suicidal ideation
Odds Ratio Category B S.E. Wald df p (95% C.I.)
No Trauma -1.28 .86 2.24 1
Threat .11 .38 8.27 1 = .004 1.12 (1.35 - 1.20)
Violate .35 .04 75.17 1 < .0001 1.41 (1.31 - 1.53)
Constant -3.96 .17 526.39 1 < .0001 .02
Variables entered on step 1: no trauma, threat, violate
150 | Suicide and the intolerable state of a fragmented self
6.4.2 IDACC Project
As with the HOS data, the logistic regression sought to determine whether a violation of self realised a higher likelihood of suicide ideation than a threat to self.
Participants who had not experienced the listed traumatic events were set as the reference group. The model was statistically significant, χ 2 (3, n = 4772) = 43.14, p <
0.001, indicating that it was possible to distinguish between participant 6.9% (Cox and
Snell R square) and 10.9% (Nagelkerke R square) of the variance in suicidal ideation, and correctly classified 81% of cases. As illustrated in Table 6.4, both variables made a unique statistically significant contribution to the model. In the same manner as the HOS results, the strongest predictor of suicidal ideation was Violation of the self. The violation category recorded an odds ratio of 133, indicating that people experiencing traumatic events that violated the self were 133 times more likely to report suicidal ideation than participants who reported no traumatic events. In comparison, the Threat to self category recorded and odds ratio of 1.26 suggesting that experiences of threat to self were likely to result in 26 times more reports of suicidal ideation. Biological sex was not a statistically significant factor (p > .05).
Table 6.4 IDACC logistic regression indicating the likelihood of experiencing suicidal ideation
Category B S.E. Wald df p Odds Ratio (95% C.I.)
No Trauma -.53 .26 4.10 1
Threat .23 .10 5.65 1 = .017 1.26 (1.04 - 1.52)
Violate .84 .17 25.70 1 < .0001 2.33 (1.68 – 3.22)
Constant -1.536 .30 26.28 1 < .0001 0.215
Variables entered on step 1: no trauma, threat, violate
151 | Suicide and the intolerable state of a fragmented self
6.5 Discussion
The current study sought to determine whether self-psychology’s theory of trauma is a plausible explanation for the differences in individual responses to traumatic events. The two factor result demonstrated that trauma is not a unitary construct.
Moreover, the results support the notion that the process of traumatisation is not simply a function of external events, but the result of the effect to the self, and the psychological sequelae that follow. Specifically, one’s sense of self appears to mediate the trauma response with suicidal ideation increasing at a greater rate when one’s sense of self is violated than when threatened.
Despite variations in the demographic characteristics of the participants in the two studies, the similar results of the factor analyses suggest that the internalising influence of a traumatic event extends beyond the current emphasis on the external characteristics of the event itself. Indeed, the two factor structure is difficult to explain in terms of the diagnostic criteria for trauma in the DSM-IV-TR. To recapitulate, Criterion A for stress related orders requires the exposure to an extreme traumatic event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
The person’s response must involve fear, helplessness or horror. According to Rosen
(2004), the establishment of PTSD was based on several assumptions, namely: (1) specific stressor criteria were linked to particular symptom criteria, (2) the characteristics of the events were the primary determinants of the response rather than individual vulnerability, and (3) traumatic experiences resulted in distinctive anatomical or physiological markers that differentiated PTSD from other psychopathologies. According to Blum (2003), this limited approach conceptualises psychological trauma as a stimulus flooding of the ego which is simply a reference to the immediate traumatic situation, and neglects the residual state of a “persisting pathogenic internal condition” (p. 416).
Although each of the events listed in the PTSD module of the CIDI are characteristic of the diagnostic criteria, individual variations in how traumatisation (as indicated by suicidal
152 | Suicide and the intolerable state of a fragmented self ideation) is reported questions the validity of those determinants. Moreover, there are many examples in the literature that suggest that the DSM-IV-TR criteria are determining externally defined characteristics of traumatisation rather than the subjective experiences of the victim. For example, Mikkelsen and Einarsen (2002), in their examination of victims of bullying noted that, although 76% of their sample reported symptoms indicative of PTSD, only 29% met the diagnostic criteria. Bowman (1999) also questioned the legitimacy of the DSM-IV-TR focus on “the event as the main causal factor to explain the disorder” (p. 21). Her examination of exposure to stressors concluded that the evidence undermines the trauma criteria; commenting that “individual differences are significantly more powerful than event characteristics in predicting PTSD” (p. 30). The results of the current study undermine understandings of the homogeneity of trauma, and support arguments questioning the construct validity of PTSD (e.g. Spitzer, First, & Wakefield,
2007; Tennant, 2004) and for dispensing with the stressor criterion in DSM-IV-TR (e.g.
Kraemer, Wittman, Jenewein, & Maier, 2009).
A two factor structure is consistent, however, with the trauma theory of self psychology and Janoff-Bulman’s (1989, 1992) cognitive theory of trauma. Janoff-
Bulman, following Epstein’s (1985) cognitive-experiential self-theory22, demonstrated that people’s assumptive worlds, or schemas, are shattered by traumatic experiences.
Moreover, he argued that these assumptions develop as integral structures of self, and are affectively and cognitively potent. These cognitive explanations, and accommodation of individual differences support Kohut’s argument that one’s self is a core determinant of whether a ‘toxic event’ (Bowman, 1999) becomes traumatic. The labelling of the factors in relation to the proximity of the experience to the self is also supported in the literature beyond the theory of self psychology, albeit implicitly. Several studies have shown that the interaction between trauma intensity and personality establish a vulnerability to, and severity of, traumatisation (e.g. Lauterbach & Vrana,
22 The cognitive-experiential self-theory recognises a structuralised self. “People do not simply have independent views about what they are like; rather, their views are organized into an adaptive, hierarchical conceptual system that organizes experience, directs behavior, and grows through its interaction with the data of experience” (Epstein, 1998, p. 214).
153 | Suicide and the intolerable state of a fragmented self
2001). However, trauma intensity is rarely defined and dependent on individual interpretation. Furthermore, measurement is invariably self-report and therefore subject to individual perceptions of the events which are themselves attenuated by the cumulative effect of exposure to stressors (Mikkelsen & Einarsen, 2002). For example,
Ariga et al. (2008) applied the traumatic event checklist from the Clinician-Administered
PTSD Scale (Blake et al., 1995) which assesses for PTSD against the DSM-IV-TR criteria along with five associated internalised features23. Notably, the features are characteristic of several of the constructs underlying the three prototypical patterns of the self (Baumeister, 1998) discussed in Chapter 2. Lauterbach and Vrana (2001) assessed trauma intensity by seeking a trauma exposure score against the questions: (1) the severity of the injuries, (2) whether they perceived that their life was in danger, (3) how traumatic the event was at the time, and (4) how traumatic the event is currently. The scale appears to be circular in its logic in that it parallels Criterion A and more likely measures the presence of traumatic symptomology rather than the intensity of the experience.
Given the ambiguity of the construct ‘intensity’, a plausible alternative
explanation, it is argued, is the proximal relationship between the experience and the
self. This can be demonstrated by examining the literature relating to the experiences
that load onto each of the factors presented in the results. All of the events associated
with ‘threat to self’ have been linked to a reduced intensity of traumatisation in
comparison to those that have been labelled ‘violation of self’ and the likelihood of
eliciting maladaptive attributions such as shame or guilt (Foa, Ehlers, Clark, Tolin, &
Orisillo, 1999). Several researchers from the cognitive sciences have argued that
appraisal-driven emotions and attributional strategies are “elicited and differentiated
according to an individual’s subjective evaluation of the personal significance” of the
experience (O'Donnell, Elliott, Jones Wolfgang, & Creamer, 2007, p. 174). Ehlers and
23 These features are guilt, derealisation, depersonalisation, dissociation and the reduction in awareness of the environment.
154 | Suicide and the intolerable state of a fragmented self
Clark (2000), for example, argue that trauma appraisal can be either internally or externally related. Internal appraisals concern whether positive or negative characteristics are attributed to one’s sense of self. For instance, negative cognitions such as viewing oneself as incapable and unacceptable contribute to the fear underpinning the experience. External appraisals, however, concern perceptions about whether the environment is dangerous and unpredictable. To illustrate, the results of the current study indicated that traumatic experiences that violate one’s sense of self such as rape or childhood sexual abuse (CSA) are more likely to elicit traumatisation in comparison to exposure to a fatal accident, or threat to self. Supporting this understanding is the study by Linden, Baumann, Rotter and Schippan (2007), which reported that traumatic experiences that elicit embitterment disorders (e.g. injustice, betrayal and rage), wherein individuals perceive themselves as ‘being hurt’, are accompanied by higher levels of trauma symptomology than events that do not give rise to these emotions. Experiences associated with embitterment compromise a child’s sense of agency by disrupting the development of cognitive components of the self
(Harter, 1999; Kohut, 1977). Indeed, the results of several studies have demonstrated that a child’s self-efficacy beliefs have an impact on their response to trauma.
Consequently, “sexually abused [children] will experience difficulty in attaining and maintaining and independent sense of self” (Diehl & Prout, 2002, p. 263).
CSA is a common24 form of early-life trauma and the individual differences insofar as traumatisation of the victim are striking. Intrafamilial CSA can be particularly traumatic as the relationship with the selfobject serves to structure the self. Positive early life selfobject transference experiences such as mirroring create an emotional harmony that, when repeated frequently, are internalised as secure attachment behaviour (Bowlby, 1969) from which a cohesive sense of self can evolve (Kohut, 1971,
1977). Research has revealed that CSA has a greater impact on adult functioning when
24 Reported prevalence rates of childhood sexual abuse range from 7% to 39% depending on definition and sampling, with female-to-male ratios in the order of 1.5:1 and 3:1 (Gilbert et al., 2009; Putnam, 2003).
155 | Suicide and the intolerable state of a fragmented self it involves selfobjects and objects. Indeed, several studies have demonstrated that incestuous experiences that involve intercourse within dysfunctional family dynamics result in greater traumatisation than CSA that is not penetrative or is extrafamilial (Dong,
Anda, Dube, Giles, & Felitti, 2003; Flemming, Mullen, Sibthorpe, & Bammer, 1999;
Goldney, Dal Grande, & Taylor, 2009). Moreover, the experience is exacerbated when there is no caring female selfobject available (Flemming, Mullen, & Bammer, 1997). In a controversial25 meta-analysis of CSA, Rind, Tromovitch and Bauserman (1998) noted that the family environment explained more variance in adjustment than the abuse itself.
Fassler, Amodeo, Griffin, Clay and Ellis (2005) reported that higher family expressiveness and cohesion were associated with better outcomes. They concluded that the occurrence of sexual abuse and the family environment was more important than the specific characteristics of the event. This is consistent with Goldney’s (1985) study which reported the relationship between negative parental representations and suicidal behaviour. Dong et al. (2003) refer to the neurosciences as a possible explanation of individual differences, suggesting that “early life experiences, whether negative or positive, contribute to the neurological development of children ... in ways that result in emotional, social, and cognitive impairments” (p. 635) and increasing risk for further vulnerability and psychopathology.
Alexander (1992) presented a formulation of familial dynamics within the framework of Bowlby’s (1969, 1988) attachment theory to CSA in an attempt to emphasise their influence as both a risk factor and mediator. She noted that disturbance of the self was a common category of symptoms associated with CSA. Bowlby (1973), in a manner similar to Kohut, explained that the self develops in response to the relational experiences with the primary caretaker. Thus, unmet or rejected needs result in a sense of self that is “unworthy, undeserving, and even bad” (Alexander, 1992, p. 191). Kobak and Hazan (1991) noted that the ‘inner working models’ (self) not only develop in
25 This study attracted criticism for errors in design and analysis (e.g. Dallam et al., 2001; Ondersma et al., 2001), which have been rebutted (Rind, Tromovitch, & Bauserman, 2001) .
156 | Suicide and the intolerable state of a fragmented self response to past relationships, but also function reciprocally within current relationships.
Stolorow and Atwood’s (1992) intersubjectivity theory of mutual influence in dyads is one of several approaches within self psychology that recognises the role of reciprocity.
The results of several studies suggest that paedophilic offenders target victims with an incohesive or vulnerable sense of self. For example, in two qualitative studies examining the manner in which offenders groom their victims, the offenders each revealed similar strategies that commenced with identifying vulnerable children. Several of the reported quotations suggest that the victims lacked the experience of positive selfobject transferences and were unable to self-soothe: seeking alternative transference strategies such as idealisation in compensation. For example, the offenders commented about the criteria of selection and their strategies for grooming:
a. From Conte, Wolf, and Smith (1989):
1. has the look of being vulnerable in some way
2. appeared more needy ... likes attention
3. let them know you are interested in them ... be someone who they could
trust
4. target children who appear to be not close to their parents ... look for
some kind of deficiency
b. And from Lang and Frenzel (1988):
1. saying ‘I love you’
2. the ‘you’re special’ approach
3. portray perfect father image
Similar strategies were reported by Gallagher, Fraser, Christmann and Hodgson (2006) in their report of international and internet child sexual abuse and exploitation. The authors also noted the individual differences in responses to paedophilic advances and sexual abuse. Gallagher (2009) emphasised that the process of grooming is a cautious strategy extended over time and intended to create an empathic relationship. Some of
157 | Suicide and the intolerable state of a fragmented self the effects of these experiences are an increased likelihood of being the victim of, and perpetrating, further sexual abuse, an inability to develop healthy intimate relationships and a greater risk of maladaptive behaviours such as substance abuse. Importantly, abusive childhood experiences are significant antecedents of suicidal behaviour
(Bebbington et al., 2009; Goldney et al., 2000; van Heeringen, 2001).
Consistent with studies examining prior interpersonal trauma, the participants from the IDACC sample appeared to experience greater distress in their response to their life-threatening cardiovascular condition when they had also experienced prior trauma (Nishith et al., 2000). Loss, or destabilisation, of the self appears to be a fundamental form of suffering for the chronically ill. Indeed, Charmaz’s (1983) qualitative study of chronically ill people (e.g. cardiovascular disease, cancer, multiple sclerosis) reported that these traumatic experiences resulted in the loss of many of the constructs underlying one’s sense of self as discussed in Chapter 4. For example, self-esteem, self-presentation, control and self-efficacy were all viewed by respondents as “former self-images crumbling away without the simultaneous development of equally valued new ones” (p.168). Similar experiences of an incohesive sense of self have been reported in several qualitative studies involving, for example, radical surgery (Berterö &
Chamberlain Wilmoth, 2007; Kelly, 1992), Alzheimer’s disease (Clare, 2003), and traumatic spinal cord injury (Yoshida, 1993). In terms of self-psychology, the elevated odds-ratios of experiencing suicidal ideation in the IDACC sample might be explained as the result of a destabilised self resulting from prior trauma which has, as a consequence, increased the person’s vulnerability for further instability or fragmentation. Or, as Wolf
(1995) explained, traumatic experiences “injure the self ... and cumulatively interfere with self functioning” (p.210). The differences between both groups in respect to the statistical significance of the listed traumatic events are understandable given the differences in mean age. The 15 year difference is substantial in terms of life experiences, particularly for the IDACC sample, with many more likely to have had traumatic early-life experiences in the period of austerity following WWII.
158 | Suicide and the intolerable state of a fragmented self
The results of the logistic regressions are consistent with the literature in that traumatic experiences are significantly related to suicidality. However, the differences in the likelihood of experiencing suicidal ideation between events which violate one’s sense of self, in comparison to a threat or no threat, suggest that the psychological responses to trauma “vary as a function of the victim’s characteristics and the nature of the [event] itself” (Kilpatrick et al., 1985, p. 120). That is, the self mediates one’s vulnerability and response to traumatic events. It might be argued that the similar participant response trajectories in both studies are an artefact of the measures employed, but given the results of the factor analyses this is unlikely. Noticeably, the higher odds ratios for experiencing suicidal ideation in the IDACC study, in comparison to the HOS, are consistent with the cumulative process of self-development discussed earlier. That is, prior trauma predisposes people to structural instability of the self, which is exacerbated by exposure to further traumatic stressors, thereby increasing one’s vulnerability to psychopathology and suicidal behaviour.
Wilson’s (2006b) model of the posttraumatic self (Figure 6.1), provides a useful model of trauma responses against which the results of the current study might be explained. Trauma has a “psychobiological progression that occurs simultaneously at all levels” (p.11) of core functioning (McEwen & Seeman, 1999; Schore, 2009; Wilson,
2006a) impacting on personality processes, identity configurations and systems of meaning.
159 | Suicide and the intolerable state of a fragmented self
Psychological Trauma
Impact on Self and organism
Personality Factors Identity Configurations Systems of Meaning
The posttraumatic self
Altered dimensions of self (e.g. continuity, connection, autonomy) Altered factors of personality (e.g. Five Factor Model, intrapsychic dynamics) Altered systems of affect regulation (e.g. shame, guilt, depression, rage) Altered ego-processes (e.g. flexibility, resilience, defence processes) Altered identity processes (e.g. sense of sameness and continuity) Altered trajectories of life-span development (e.g. patterns of epigenetic development) Altered systems of meaning and ideology (e.g. values, beliefs, attributional processes) Altered system of morality (e.g. moral reasoning and development) Formation of trauma complexes and PTSD (e.g. specific constellations of complexes)
Posttraumatic adaption and life-course development
Severe Pathology Optimal Health
Fragmented Cohesive
Adaptational continuum: posttraumatic personality types
Self-dissolution Posttraumatic self typologies Self-actualisation
© 2004 John P. Wilson
Figure 6.1 A model of the posttraumatic self adapted from Wilson (2006b, p. 11). Wilson’s adaptational continuum end-points of inert (pathological) and integrated (healthy) have been replaced with fragmented and cohesive respectively. Posttraumatic adaption and life-course development has a significant effect on the adaption continuum in determining whether the response is pathological or not.
The holistic effect of trauma on system functioning alters the integrated
constituents of self by changing schemas and adaptive behaviour patterns within
interpersonal relationships (Horowitz, 1991). This destabilising effect on the equilibrium
of the self has been demonstrated in several studies examining early-life traumatic experiences which have disrupted healthy developmental patterns (e.g. Nader, 2004).
Moreover, negative childhood experiences increase vulnerability to further stressors such
160 | Suicide and the intolerable state of a fragmented self as victimisation (Nishith et al., 2000). These findings support Kohut’s (1971) argument that the developing continuum of self configuration is particularly vulnerable to relational trauma. Indeed, it is within the sub-process of posttraumatic adaption and life-course development that experiences are either moderated or amplified (Wilson, 2006b). This self-actuating or resilience process is epigenetic and the result of selfobject transferences and other environmental experiences (Kohut, 1985b; Rutter, 2006; Wilson,
2006c). The cumulative process of self-development is demonstrated in the findings of
Orbach (1994, 1996) and Orbach, Kedem, Herman, and Apter (1995) who, inter alia, reported that prior trauma such as childhood sexual and physical abuse, predisposes people to structural instability of the self.
The structural destabilising effect of trauma threatens the integrity of self which can result in dissociative experiences of self and body. Maltsberger (1993, 2004) refers to the response to the experience of “impending psychic annihilation” (2004, p. 657) as suicidal collapse, and argues that when this occurs, the self “begins to disintegrate, and
[within] the grandiose magical scheming for mental survival ... body jettison becomes plausible” (2004, p. 653). Elaborating further, he commented that:
Some patients identify their bodies as the source of emotional anguish and
believe that by getting rid of the body, now experienced as an enemy, they will
escape the intolerable situation and somehow go on to life somewhere else –
suicide is imagined as an escape, and the suicidal act is not seen as self-
annihilatory, but as the killing of an enemy in self-defense” (p. 657) (emphasis
added).
Author Eckhart Tolle (2004), who also reports a dysfunctional and non-empathic childhood, disclosed a similar experience when referring to his own suicidal ideation:
The most loathsome thing of all, however, was my own existence. What was the
point in continuing to live with this burden of misery? Why carry on with this
161 | Suicide and the intolerable state of a fragmented self
continuous struggle? I could feel that a deep longing for annihilation, for
nonexistence, was now becoming much stronger than the instinctive desire to
continue to live. “I cannot live with myself any longer.” This was the thought that
kept repeating itself in my mind. Then I suddenly became aware of what a
peculiar thought it was. “Am I one or two? If I cannot live with myself, there must
be two of me: the ‘I’ and the ‘self’ that ‘I’ cannot live with. “Maybe,” I thought,
“only one of them is real” (p. 3).
Lifton (1971) commented that trauma experienced by an already incohesive or fragmented self intensifies the instability. The core of self is experienced as vulnerable
and numb and, as a consequence, is a likely depository for guilt and shame, which
further exacerbates the distress. Wilson (2006c) believes that in such extreme cases
annihilation is preferable to the inner torment of self fragmentation.
The strength of the present studies lies in the large number of participants.
However, several methodological limitations may have influenced the interpretation of
the data. The limitations regarding the HOS have been discussed earlier. The IDACC
data are problematic in that the sample was not representative of the general community
in terms of age or sex. Moreover, restricting the suicidal ideation questions to
participants with depressive symptomology would have influenced the results, given the
established relationship between psychopathology and suicidal behaviour.
The present studies demonstrate the critical role of self in the process of trauma
and supports the “distinction between trauma as an event (perceived extrospectively)
and trauma as a process (experienced introspectively)” (Lee & Martin, 1991, p. 289).
Although self-organisation is susceptible to a subjective experience in response to a
traumatic event, one’s sense of self appears to be a core determinate in the
interpretation of meaning associated with the event. For a cohesive self, the effect is
moderated and the subjective experience of trauma does not occur.
162 | Suicide and the intolerable state of a fragmented self
The non-significant effect of biological sex (as opposed to gender) is also consistent with self-psychology, in that the subjective experience of self is the product of transferences with selfobjects and objects and not simply the result of a “naturally occurring binary system” (Brothers, 1998, p. 233). This is addressed in the following chapter, which continues the examination of the relationship between self and suicidal behaviour by focusing specifically on the trauma that may be associated with sexual identity.
163 | Suicide and the intolerable state of a fragmented self
Chapter 7: Self, Sexuality and Suicidal Behaviour
Self, Sexuality and Suicidal Behaviour
Whereas [the public expression of sexuality] was seen in puritan and then the Victorian era as profligate and degenerate, indicative of a loss of self, today it is seen as compulsory physically, emotionally, and socially, indicative of an expression of self (Goren, 2003, p. 498).
7.1 Introduction
The current chapter continues the exploration of the relationship between self and suicidal behaviour by narrowing the focus of the examination to the role of sexual orientation. The discussion is not specifically directed at suicidality, but rather seeks to demonstrate that non-heterosexual populations are particularly vulnerable to fragmentation of self.
Before addressing the primary focus of the chapter, however, the definition of sexual orientation needs to be addressed. The necessity for this, it is argued, is because conflating biological sex with gender is problematic in terms of understanding the development and maintenance of the self. The term gender is frequently, and erroneously, presented in the literature as analogous to biological sex. Biological sex categorises people in terms of their sexual anatomy, whereas gender extends individual differences beyond the biological to encompass subjective issues such as social roles and sexual identity. Although our inner world is imbued with cultural conceptions, people create their own psychological gender by making some experiences or interpretations more salient than others, and these are presented as characteristic of one’s sense of self
(Chodorow, 1996). In this way, gender can be understood as an integral part of “the self
[which is] the principal and archetype of orientation and meaning” (Jung, 1961, p. 199).
Indeed, the process of self structuralisation best occurs in response to empathy and successful attempts to repair empathic failures with selfobjects (Atwood & Stolorow,
164 | Suicide and the intolerable state of a fragmented self
1984), and is not determined primarily by membership of a dichotomous categorisation arbitrarily assigned by sexual anatomy.
Evidence of the greater vulnerability for psychological distress in young sexual minority populations, in comparison to heterosexuals, is well documented in the literature
(Cochran, 2001; D'Augelli, Hershberger, & Pilkington, 2001; Meyer, 2003). So too experiences of self-injury (Martin et al., 2010; Whitlock, Eckenrode, & Silverman, 2006) and suicidal behaviour (Grossman & D'Augelli, 2007; King et al., 2008; Suicide
Prevention Resource Center, 2008; van Heeringen & Vincke, 2000). The stigma associated with non-heterosexuality is frequently argued to be the antecedent to what is referred to as ‘internalised homophobia’26 (e.g. McAndrew & Warne, 2010; Peterson &
Gerrity, 2006; Suicide Prevention Resource Centre, 2008); the effects of which are exacerbated when other marginalising factors are also present (e.g. colour, Moradi et al., 2010). Wright and Perry’s (2006) examination of sexual identity distress (a theoretical sub-dimension of internalised homophobia) concluded that this specific stressor is strongly related to general psychological distress. Moreover, the authors suggested that sexual identity distress may be the result of a “much more complex developmental process” (p. 106) than the stigma associated with membership of a sexual minority population.
Hatzenbuehler (2009) reports that two separate literatures have developed in an attempt to identify the factors underlying the increased psychological vulnerability of lesbian, gay and bisexual (LGB) populations. The first has focused on sexual minority stress associated with group-specific processes (Meyer, 2003), whereas the other has been directed toward the general psychological processes (Savin-Williams & Ream,
2003). Arguing for a theoretical model that integrates the two approaches,
Hatzenbuehler proposes a mediation framework (Figure 7.1) that reflects the three
26 Internalised homophobia’ refers to the negative and distressing thoughts and feelings experienced by some members of the lesbian and gay community about their sexuality, which are attributed to personal experiences of cultural heterosexism and victimisation (Williamson, 2000).
165 | Suicide and the intolerable state of a fragmented self distinct mental health burdens identified in the literature: (1) psychiatric epidemiology, (2) group-specific stressors, and (3) psychological processes.
NOTE: This figure is included on page 166 of the print copy of the thesis held in the University of Adelaide Library.
Figure 7.1 Psychological mediation framework adapted from Hatzenbuehler (2009, p. 712). Coping/emotion regulation, social/interpersonal experiences and cognitive functioning are all characteristic of contemporary understandings of the self (Baumeister, 1998).
Drawing on the literature, the argument is made that a mediation framework better explains why stigma-related stressors lead to psychopathology than moderation analyses. The model rests on Grant et al.’s (2003) delineation of the two processes wherein mediators are defined as responses activated (or caused) by a stressor, and moderators are the individual or social network characteristics prior to the stressor.
According to Hatzenbuehler, the three intermediary variables included in the model act independently as mediators to stressors. “Specifically, the framework suggests that stigma-related stress renders [members of] sexual minorities more vulnerable to general psychological processes that are known to predict psychopathology in heterosexuals”
(Hatzenbuehler, 2009, p. 712). Although the model is theoretically grounded in transactional definitions of stress, it seeks to separate the stress response from
166 | Suicide and the intolerable state of a fragmented self individual characteristics (self). For example, Hatzenbuehler offers the comment that
“[a]lthough the individual may possess some of the mediating characteristic prior to experiencing the stigma related stressor, within a meditational framework the mediator will be significantly altered subsequent to experiencing the stressor” (p.713). The model fails to acknowledge the complex nature of self and the possibility that the relationship between the event and the response is not unidirectional. This criticism is further justified by noting that the three proposed constructs mediating the relationship between the event and psychopathology are characteristic of several of the constructs underlying contemporary understandings of self addressed in Chapter 3.
Freud’s drive theory, and ego psychology generally, emphasise that mature sexuality is attained by subduing, sublimating or relinquishing “tenaciously held aims of childhood wishes” (Tolpin, 1997). Self psychology, however, views sexuality as an integral aspect of one’s sense of self, and how this is experienced in the transferences between selfobjects and objects directly effects the development of the construct
(Brothers, 1998; Kassoff, 1997). This means that all of the early-life experiences Freud referred to as infantile sexuality (e.g. anal, tactile, oral, and genital) are incorporated in self structures. Toplin (1997) notes that the:
main point about sexuality is that it reverberates in the very ways in which the self
developed over the whole course of childhood. The reverberation lasts for a
lifetime and is transiently reached into and re-experienced in connection with
one’s own sexual feelings and the sexual responsiveness of the other. Thus, with
sexual maturation come two interrelated forms of intense pleasure – pleasure
from sexuality, in and of itself, and pleasure from sexuality as a way of transiently
re-accessing the deepest roots of self-experience in primary connections with
responsive others [i.e. selfobjects] (p.184).
167 | Suicide and the intolerable state of a fragmented self
Given the benefits of positive sexual experiences as a healthy and “enhancing form of self renewal” (p. 185), frequent frustrations to a child’s transference attempts to satisfy narcissistic needs can have a deleterious effect on the development of one’s sexuality.
Indeed, thwarted early-life narcissistic needs can result in several maladaptive sexual behaviours indicative of deficits in self structure such as promiscuity (King et al., 2008), which Kohut (1996) viewed as a defensive measure to counteract the fear of fragmentation. For some, sexual experiences can be acutely traumatic with longings for the transference needs that were never realised, as well as a sensitivity to rejection and humiliation. This can also manifest in guilt when gendered self expressions are not responded to empathically.
Kohut’s (1971, 1985b) views on sexuality appear, at first, to focus on sexual orientation as a psychopathology by postulating that non-heterosexual behaviour can be understood as attempts to manage structural deficits of the self (see also Lee & Martin,
1991) . However, a closer examination of his writings reveals that Kohut considered
that sexual orientation could be problematic for some people; indicative of a crumbling
self and attempts to forestall fragmentation (Kohut, 1996). Stern (2003) explains: “if a
boy’s phase-appropriate desire to merge with his spiritually idealized father is
traumatically frustrated and his subsequent self-development is damaged as a result, he
might attempt to achieve the thwarted relation by merging sexually with a physically
perfect homosexual lover” (p.172). Goldberg (1972, 1995) continues this theme,
suggesting that some homosexual behaviours are structural compensations serving to
maintain or re-establish a cohesive sense of self. Central to Goldberg’s (1995) account
is the defensive role of disavowal27 in sexuality. Thus, for some people, sexuality and disavowal “become ‘emergency measures’ for managing distressing affects” (Ostrow &
Shelby, 2000, p. 130) and forestalling further fragmentation of the self. Nevertheless,
Kohut did not claim that homosexuality is, of itself, pathological. Indeed, in a seemingly passionate conclusion to a 1976 lecture, he questioned the role of heterosexuality as a
27 Disavowal is the process of ignoring meaning or reality, whereas denial pertains to the management of affects.
168 | Suicide and the intolerable state of a fragmented self defining feature of the human experience by commenting the “[t]he moron’s capacity to copulate – this may be heterosexual – does not outweigh Socrates’ homosexual propensities and the flowering of his mind and his contribution to Western culture” (cited in Strozier, 2001, p. 266).
Baumeister (2000) proposed that sexuality is not a cohesive essence, but is a fluid and variable response to socio-cultural and situational factors. For example, his literature review on the subject of sexuality concluded that, in comparison to males, women appear to have greater ‘erotic plasticity’ which is significantly related to the self
“structure-providing” (Tolpin, 1997, p. 175) benefits that accompany a close relationship with another. In terms of the developing self, the emerging emphasis within self- psychology appears to be on traumatic childhood transference patterns that undermine the self-sexuality relationship. Crawford’s (1996) contributions epitomise this approach.
Although Crawford accepts that people generally identify themselves as either male or female, she conceives sexuality as an “aspect of self-experience that crystallises in the self-selfobject matrix of intersubjective experience” (p.274). In a similar fashion,
Brothers (1998) commented that our “experience of self-as-gendered arises and is maintained within the context of relations between ourselves and those we need as recipients or providers of selfobject experience” (p.238). Thus, the development of one’s sexual identity is dependent upon positive transference experiences within a trustworthy milieu. Accompanying this trust in the selfobject is the expectation that the needed experiences will be provided regardless of the level of incongruence of our affect, cognitions and behaviour with cultural expectations. Selfobject demands for adherence to the naturally occurring, and therefore ‘normal’, binary system of sexual anatomy as a determinant of sexuality can be particularly traumatic for the developing self.
An empathic and supportive childhood environment provides for the expressions of selfobject fantasies to be free of constricting gender types. Brothers (1998) argues that positive transference experiences remove the anxieties that are commonly associated with defying expectations associated with biological sex. As a consequence,
169 | Suicide and the intolerable state of a fragmented self children feel comfortable about their sexuality and “the similarities and differences in the sexed bodies of others” (p. 238). Unfortunately, the development of self does not always occur in a sufficiently trustworthy environment. From birth, characteristics of self are attributed masculine or feminine according to cultural expectations. Furthermore, the provision of the necessary selfobject experiences is, in part, contingent on adherence to these expectations. Consequently, condemnation of gender-incongruent aspects of self intended to manage the development of a child’s sexual identity, may undermine the stability of self.
Accordingly, the current study seeks to confirm the self psychological perspective that gender, and therefore the gendered-self, in comparison to biological sex, is a more important factor in respect to suicidal behaviour.
7.2 Method
7.2.1 Survey Design and participants
The data were gathered for the Australian Epidemiological Study of Self Injury
(ANESSI) (Martin et al., 2010) conducted by the University of Queensland. The survey was conducted in the same manner as the Health Omnibus Study described in the previous chapter. However, for the current study the interviews were conducted in six languages: English, Greek, Italian, Chinese, Vietnamese, and Arabic. The initial sampling frame of 42,938 telephone numbers represented all Australian States and
Territories. Of these, 11722 participants were excluded because their telephone numbers were either disconnected or were commercial properties or facsimiles/modems.
From the 31,216 eligible telephone numbers, 12,006 (38.5%) Australians participated in the study with four later excluded because of missing or corrupted data. The participant response rates are detailed in Table 7.1.
170 | Suicide and the intolerable state of a fragmented self
Table 7.1 Participant response rates and reasons for not taking part
Reason for Non-participation Count % n
Initial eligible sample 31216 100
Refusals 14032 44.9
Parental refusal 671 3.5
Unable to contact after six attempts 2341 7.5
Language difficulties 726 2.3
Incapacitated and unable to participate (e.g. hearing impaired/ill) 912 2.9
Terminated interview 173 0.6
Respondent unavailable 351 1.1
Completed interviews 12010 38.5
Excluded because of data missing/corrupted 4 <.1
Final sample (n) 12010 100
7.3 Measures
Sexual orientation was reported against the categories: heterosexual (straight), homosexual (gay/lesbian), bisexual (bi). Suicide attempt was measured on the basis of the response to the question “Have you ever tried to kill yourself?” Suicidal ideation was determined by the responses to four questions (D4, D5, D6 & D7) contained in the severe depression sub-scale of the 28-item General Health Questionnaire (GHQ-28)
(Goldberg & Hillier, 1979) discussed in Chapter 6.
The final sample consisted of 12006 participants between 10 and 100 years of age (M = 42.19, SD = 19.76), with 50.5% females (n = 6063) and 49.5% males (n =
5943). Because of missing data or a participant refused to answer, sexual orientation, suicide attempt, and suicidal ideation was recorded against 11454, 11967, and 11940 participants respectively (Table 7.2 refers).
171 | Suicide and the intolerable state of a fragmented self
Table 7.2 Frequencies for sexual orientation, suicide attempt and suicidal ideation
Valid Cumulative Category Frequency % %
Sexual Orientation 11454
Heterosexual 10956 96.0 96.0
Gay 144 1.3 97.2
Bisexual 170 1.5 98.7
Suicide Attempt 11967
None 11389 94.9 94.9
Suicide Attempt 578 4.8 99.7
Suicidal Ideation 11940
None 10956 91.3 91.8
Suicidal Ideation 984 8.2 99.4
7.4 Data analysis
Univariate and bivariate analyses of the data were conducted using PASW
Version 17 applying a threshold significance level of .05.
7.5 Results
Suicide attempts were acknowledged by 4.8% of the respondents. The prevalence of suicide attempts for heterosexual, gay and bisexual participants was 4.7%
(n = 518), 15.97% (n= 23), and 21.8% (n = 37) respectively. Suicidal ideation was detected in 8.2% (n = 984) of the respondents. When examined separately the prevalence of suicidal ideation for heterosexual, gay and bisexual participants was 7.8%
(n = 855), 18.9% (n= 27), and 25.6% (n = 43) respectively. Age and biological sex were not statistically significant factors for suicide attempt or suicidal ideation.
172 | Suicide and the intolerable state of a fragmented self
A logistic regression was performed to determine the relationship between sexual orientation and suicide attempt. Suicide attempt was the dependent variable with heterosexuality set as the reference group. The model was statistically significant, χ 2 (2, n = 11967) = 85.62, p < 0.001, indicating that it was possible to distinguish between participants who did or did not report attempting suicide, however, it only explained between 0.7% (Cox and Snell R square) and 2.3% (Nagelkerke R square) of the variance, and correctly classified 95% of cases. The strongest predictor of suicide attempt was bisexuality, recording an odds ratio of 5.80, indicating that participants with this sexual orientation were 5.8 times more likely to report a suicide attempt than heterosexuals. Gay participants recorded an odds ratio of 3.95 (Table 7.3). Biological sex was not statistically significant.
Table 7.3 Results of the logistic regression indicating the likelihood of attempting suicide in terms of sexual orientation in comparison to heterosexuals
Odds Sexual Orientation B S.E. Wald df p (95% C.I.) Ratio
Gay 1.37 .24 35.21 1 <0.001 3.951 (2.51 – 6.22)
Bisexual 1.76 .19 84.88 1 <0.001 5.801 (3.99 – 8.43)
Constant -3.027 .05 4499.926 1 <0.001 .05
A further logistic regression was performed to examine the relationship between sexual orientation with suicidal ideation as the dependent variable. Heterosexuality was set as the reference group. The model was statistically significant, χ 2 (2, n = 11745) =
63.76, p < 0.001, indicating that it was possible to distinguish between participants who did or did not report experiencing suicidal ideation, but it only explained between 0.6%
(Cox and Snell R square) and 14% (Nagelkerke R square) of the variance, and correctly classified 92% of cases. As illustrated in Table 7.4, both gay and bisexual orientations made a unique statistically significant contribution to the model. Again, the strongest
173 | Suicide and the intolerable state of a fragmented self predictor of suicidal ideation was bisexuality, recording an odds ratio of 4.02, indicating that participants with this sexual orientation were four times more likely to report suicidal ideation than heterosexuals. Gay participants recorded an odds ratio of 2.76. Biological sex was not statistically significant.
Table 7.4 Results of the logistic regression indicating the likelihood of experiencing suicidal ideation in terms of sexual orientation in comparison to heterosexuals
Odds Sexual Orientation B S.E. Wald df p (95% C.I.) Ratio
Gay 1.02 .22 22.22 1 <0.001 2.76 (1.81 – 4.21)
Bisexual 1.39 .18 59.58 1 <0.001 4.02 (2.82 – 5.73)
Constant -2.461 .04 2869.96 1 <0.001 .09
7.6 Discussion
The present study sought to examine the relationship between sexual orientation
(the gendered self) and suicidal behaviour. The results clearly demonstrate that, regardless of age, sexual orientation rather than biological sex is a more appropriate construct in understanding individual differences in the relationship between subjective experiences and suicidality28. Although the significance of the difference is consistent with postmodernist thought (e.g. Foucault, 1987; Gergen, 1991), researchers have been slow to embrace sexual orientation as a demographic variable. Sell (2007), arguing for a definitive measure of sexual orientation to replace the current dichotomy of sexual anatomy, suggested that this might be because researchers are often confused about what it is they are studying when referring to sexual orientation, and the measures they employ do not always correspond with participant conceptualisations of the construct.
Nevertheless, the results suggest that sexual orientation might prove to be an effective
28 It might also be argued that the results reflect the level of internalised homophobia; however, the discussion that follows undermines the potency of this position.
174 | Suicide and the intolerable state of a fragmented self construct in understanding individual differences in many psychopathologies. Within the suicidality literature the relationship between sexual orientation (including transgendered populations29) is well established, but there is a paucity of evidence demonstrating the disparate influences of biological sex vis à vis sexual orientation.
The results extend the literature by demonstrating that the psychological vulnerability of LGB populations is not restricted to any particular age group, but persist throughout the life course. In comparison to heterosexuals, LGB populations are more likely to experience suicidal behaviour, with bisexuals more at risk, regardless of age.
These findings support Tolpin’s (1997) application of self psychology theory to sexuality discussed earlier. In particular, it appears that the development of sexual orientation resonates throughout life as it is “re-experienced in connection with one’s own sexual feelings and the sexual responsiveness of the other” (p. 184). Although the focus on stigma-related stressors has contributed significantly to understandings about the vulnerability of LGB populations, identifying and establishing selfobject and object relations may also be problematic. For example, non-heterosexuals may have difficulty in establishing these relationships because of the limited partnership options within alternative forms of sexual expression. Moreover, LGB relationships may, by necessity, be more defined by sexual orientation as an unambiguous statement to ensure one’s identity is fully understood by possible partners.
Notwithstanding the elevated risk for suicidal behaviour amongst the LGB populations, individual differences remain apparent. Savin-Williams and Ream (2003), in their examination of suicide attempts among sexual minority youth, concluded that their results “suggest that there exists a minority of sexual-minority youth who are at risk but that it would be inappropriate to characterize the entire population as such” (p. 509).
This is consistent with research that demonstrated that sexual minority youths are not a homogenous group and, like heterosexuals, demonstrate variations in individual
29 Transgender is not considered a sexual orientation but a gender identity. Nevertheless, this population is frequently included in research because it shares similar stressors because of their nonconformity with traditional sexual roles (Walls, Hancock, & Wisneski, 2007)
175 | Suicide and the intolerable state of a fragmented self differences in predictable ways (Fitzpatrick, Euton, Jones, & Schmidt, 2005; Savin-
Williams, 2001).
Although the literature has identified the vulnerability of sexual-minority populations in terms of particular sexual orientations, explanations for this appear to be limited to the effects surrounding stigma and marginalisation. Indeed, a common strategy employed in LGB research is to examine the populations separately and then present the results by amalgamating sexual orientation as one homogenous minority group (e.g. Clements-Nolle, Marx, & Katz, 2006; Hershberger & D'Augelli, 1995; Savin-
Williams & Ream, 2003). In this way, explanations for the differences in vulnerability to psychological distress between, for example, bisexuals and homosexuals are avoided.
Benjamin (2002) argues against the notion of homogenous gender development, and the associated assumption that the development of sexuality is a “simple trajectory toward heterosexual complementarity” (p. 198). Magee and Miller (2002) adopt a similar approach in their examination of the limitations of current models of gender identity, and recommend the expansion of transference theories to include early-life paternal transferences as a way to understand the complexity of the process of developing a sexual identity.
In light of the results of the present study demonstrating the significance of sexual identity over biological sex, what follows is an implementation of self psychology theory to explain this outcome in terms of trauma. The discussion follows closely Brother’s
(1995, 1998) self psychological perspective to understanding the development of a gendered self by focussing on dissociative experiences as a “fundamental aspect of
mental organization” (p. 234), together with the role of self-trust within the selfobject
relationship.
Traditional psychoanalytic perspectives on sexuality view the construct as a
concrete naturally occurring binary system of radically dichotomised masculine or
feminine characteristics which, according to Crawford (1996) “perpetuates a pathogenic
situation [leading to] ... the traumatic severing of self-experience” (Brothers, 1998, p.
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233). Flax (1990) comments that psychoanalysis and postmodern theories are both
“overtly and subtly gender bound and biased [despite the] ... centrality of gender relations to the organisation of the self” (p. 225) and that understandings of gender frequently obscure or exclude understandings beyond male heterosexuality.
Nevertheless, contemporary self psychology has been influenced by postmodernist thought and views sexuality in terms of what Flax refers to as ‘fluid subjectivities’, which acknowledge that sexual orientation can be a “core and coherent an experience as any structure of self and subjectivity [ but it can also] mutate, dissolve and prove irrelevant and insubstantial” (Harris, 1991, p. 197). Brothers (1998), inter alia, contends that the core of sexual orientation is best understood in terms of difference rather than essence, and that the self is gendered by absorbing and maintaining the contrast between the masculine and the feminine. As a fundamental component of self, and an organiser of subjectivity, our experience of developing and maintaining a sexual orientation also occurs within the context of selfobject experiences (Pangerl, 1996).
Importantly, gendering the self necessitates repairing empathic transference failures which activate the process of transmuting internalisation30 (Kohut, 1971, 1977) discussed in Chapter 2. Thus, “consolidating a stable gender identity requires the activation of pathological processes, insofar as any gender-incongruent thought, act, impulse, mood, or trait would have to be disowned, displaced, (mis)placed (as in projective identification), split off” (Goldner, 1991, pp. 258-259). It is the dissociative31 mechanisms associated with disowning gender-incongruent aspects of self-experience and the role of self-trust that Brothers (Brothers, 1995, 1998) offers as an explanation of the relationship between sexual orientation and psychopathology.
A fundamental tenet of self psychology is that one’s sense of self cannot develop in a vacuum and is always in need of selfobjects; these relationships form irreducible units of self-experience (Ulman & Brothers, 1988). Implicit within this theory is the notion
30 Transmuting internalisation refers to the formation of psychic structures which reinforce a cohesive sense of self. 31 Self psychology does not view dissociation as inherently pathological, but in some circumstances can be a defence against fragmentation (Bromberg, 1994).
177 | Suicide and the intolerable state of a fragmented self of self-trust: that is, if we are unable to trust others to serve as selfobjects, or ourselves to provide selfobject experiences for others, then “our emotional lives would be crippled”
(Brothers, 1992, p. 77). Self-trust refers to “the realm of trust involved in selfobject relations, and the dissociative aftermath of its betrayal” (Brothers, 1998, p. 234), and is defined as “the hope or wishful expectation of obtaining and providing selfobject experiences needed for [a sense of] cohesive selfhood” (Brothers, 1995, p. 33). It functions as a connection between unconscious selfobject fantasies which consist of
“affect-laden images of self and others” (p. 236) and subjective reality, or what Noy
(1980) refers to as a reality-orientated process. Consequently, experiences in subjective reality determine the extent to which one’s sense of self and others is considered reliable and trustworthy and may be included in selfobject fantasies. In a healthy milieu, these two functions operate simultaneously and as parallel processes of self development; sustaining the cohesion and “necessary illusion of being “one self’” (Noy, 1980, p. 193).
Crawford (1996) captures this understanding in her definition of gender as “conscious and unconscious fantasies of the sexed body derived from complex self-selfobject experiences” (p. 270). However, betrayals of self-trust that are experienced as traumatic destabilise the relationship between these two processes resulting in dissociative experiences. Brothers (1998) explains:
since only those deemed trustworthy are represented in selfobject fantasies, trust
in a betrayer is often intensified as a means of restoring shattered selfobject
fantasies. To maintain or confirm this intensified trust, the subjective reality of the
betrayed person must be dissociatively altered. Although this dissociative
alteration of reality is often needed to stem the tide of unbearable disintegration
anxiety, the person’s experience of self and others loses clarity and distinctness
and unsettling experiences of depersonalization, derealisation, and
disembodiment are common. Even more extreme forms of dissociation are
sometimes employed as aspects of self-experience antithetical to the
178 | Suicide and the intolerable state of a fragmented self
dissociatively altered reality are lost in what I have called ‘experiential black
holes’. ... Moreover, these black holes often result from unsymbolized, preverbal
experiences of trauma that occur very early in life and are never symbolically
represented. Since it is impossible to experience oneself as whole and cohesive
when important aspects of self-experience are dissociated, the trauma survivor
attempts to ‘fill in’ the black holes in a variety of ways (p. 237).
Brothers’ experiential black holes are also created by dissociated aspects associated with the development of a gendered self. If a person’s childhood was such that the selfobject could be trusted to provide the needed transference experiences no matter how incongruent our feelings or thoughts, the process of gendering the self would not be accompanied by anxieties associated with the role expectations of biological sex.
Moreover, the selfobject fantasy and subjective reality “would be synchronous, their experience of self-asgendered (sic) would probably be fluid without being chaotic, and cohesive without being rigid” (p. 239). However, sexual orientation rarely develops in an environment characterised by unconditional acceptance, and our sense of self is commonly gendered according to the expectations within the selfobject relationship.
Indeed, the satisfaction of transference needs is often dependent upon adherence to these expectations, which was clearly demonstrated in Ryan, Huebner, Diaz and
Sanchez’s (2009) comparative study of Latino and white non-Latino LGB young adults.
Cruel selfobject condemnations (e.g. mocking, physical punishment or withdrawing love) of what is viewed as gender-incongruent32 behaviour can be perceived as a betrayal of self-trust, resulting in a dissociative alteration of subjective reality. These experiences can inhibit the healthy development of a gendered self as incongruent sexual thoughts and feelings are kept from consciousness. Nevertheless, these thoughts and feelings may appear in selfobject fantasies and contribute to a destabilising of one’s sense of
32 Brothers (1998) emphasises that gender-incongruence is the subjective experience that one feels is inimical to the needed selfobject transferences.
179 | Suicide and the intolerable state of a fragmented self self. Both Aron (1995) and Crawford (1996) contend that regardless of biological sex, selfobject fantasies can represent self and others in any sexual orientation.
Similarly, one may experience a betrayal of self as a provider of selfobject
experiences for others. For example, a selfobject milieu that applies rejection or punitive
behaviour to ensure a ‘real boy’ to meet their expectations might be perceived as
evidence of selfobject disappointment. Brothers (1998) suggests that this
disappointment is viewed by the child as a betrayal of self as trustworthy. Furthermore,
the more negative the selfobject response to incongruent aspects of self expression, the
greater the likelihood that the child will experience self-trust betrayal.
Subsequent attempts to repair the shattered selfobject fantasies by restoring self-trust
and trust in others may result in disavowing and dissociating feminine aspects of self.
Frequently, the disavowal aspects of gender experience is concomitant with efforts
to confirm gender to which the betrayed person now fiercely clings ... sexuality
under these circumstances is likely to assume a driven, addictive quality” ... [and
as a result] his search for alter ego selfobject experience [is also] likely to be quite
driven, and his perceptions of himself-as-gendered – that which he regards as ‘me’
or ‘not me’ – are likely to be quite confused. Severe problems also arise when
caretakers (e.g. mother and father) disagree as to what constitutes gender
congruence (pp. 240-241).
This can occur when children develop around the provision of twinship33 experiences for their self-disordered selfobjects. The son of a mother who requires alter ego selfobject experiences because of her own disavowed masculine qualities “may feel compelled to present a macho hypermasculinity” (p.241). Similarly, if a father disavows feminine aspects of himself, the daughter may “embody an exaggerated and stereotypic femininity” (p.241). Selfobject experiences that have resulted in attempts to disavow both masculine and feminine aspects of self would be particularly traumatic. Brothers
33 Kohut’s proposed twinship transference refers to the need to relate to someone with similar skills and interests, a degree of likeness knowing that one is understood by someone similar to oneself.
180 | Suicide and the intolerable state of a fragmented self argues that attempts to regain or maintain a cohesive sense of self require connecting with disavowed aspects. For some, cohesion can only be attained by criticising these aspects as they are manifested in another, which only serves to maintain the experience of threat of fragmentation. Conversely, sexual orientation “may provide the means by which the betrayed person achieves a sense of blissful merger with the disavowed aspects of gendered selfhood” (p. 240). For those in lesbian and gay populations whose sexual orientation development has been traumatic, efforts to establish or maintain a sense of cohesion by connecting with disavowed aspects of self could lead to psychopathology. In comparison, similar attempts by bisexual individuals might prove more distressing if both masculine and feminine aspects of self had been disavowed.
This present study continued the exploration of the relationship between self and suicidal behaviour examining the relationship between sexual orientation and suicidal behaviour. The results support the literature in that there is a clear relationship between selfobject transferences and the reported suicidal psychopathology associated with sexual identity. Moreover, the theory of self psychology, as applied by Brothers (1998), provides a plausible explanation of individual differences and why the process of gendering the self can be a traumatic experience.
The strength of the present study lies in the large number of participants.
However, several methodological limitations may have influenced the interpretation of the data. The limitations regarding the method of data collection have been discussed earlier in regards to the Health Omnibus Survey and the South Australian Monitoring and
Surveillance System (Chapter 5). Although the response rate of 38.6% is consistent with international trends of declining telephone interview requests, it is difficult to determine the extent to which this biased the results. It may well be that the response rate was partly attributable to the ethics requirement to provide large amounts of information to potential respondents by post, as this may have increased their discomfort in participating in telephone interviews by needlessly alarming or overwhelming them.
181 | Suicide and the intolerable state of a fragmented self
7.7 Summary of Section B
The chapters within this section applied quantitative statistical analyses to a number of data sets in an effort to implicate the self in suicidality. This commenced in
Chapter 5 which identified a gap in the literature by demonstrating individual differences in vulnerability to suicidal behaviour. The results also revealed that Kohut’s understanding of the intolerable state of a fragmenting self is a common experience for suicidal ideators. Chapter 6 extended the examination by confirming the trauma theory of self psychology, which contends that one’s sense of self is a core determinate in the nature and intensity of an individual’s response. The present chapter concluded the examination by demonstrating individual differences in the relationship between sexual orientation and suicidality, and applying the theory of self psychology to explain how this might come about.
The final section commences with a mixed method study that seeks to measure the cohesiveness of self, and is followed by a validation study and a concluding
discussion.
182 | Suicide and the intolerable state of a fragmented self
SECTION C: MEASUREMENT OF SELF COHESION AND THE RELATIONSHIP WITH SUICIDAL BEHAVIOUR
Chapter 8: Measurement of the Self: Part 1
Measurement of the Self: Part 1
If I commit suicide, it will not be to destroy myself but to put myself back together again. Suicide will be for me only one means of violently reconquering myself, of brutally invading my being, of anticipating the unpredictable approaches of God. By suicide, I reintroduce my design in nature, I shall for the first time give things the shape of my will (Antonin Artaud, as cited in Hirschman, 1965, p. 56).
8.1 Introduction
Self psychology emphasises the importance of intimate transferences in the development and maintenance of the self, advocating that these emotional experiences are crucial for human psychological growth and survival (Kohut 1984). The selfobject’s role in this process lies at the core of the formation of healthy psychic structures which, in turn, reinforce a cohesive sense of self. Ideally, an empathic environment is provided in which the child’s need for recognition, acceptance and applause is satisfied through effective mirroring transference. Mirroring failures, in particular, can give rise to an inability to self soothe and narcissistic anger, the retention of early-life narcissistic grandiosity, and a fragmenting sense of self. In response to this, idealisation or twinship transferences may be sought in an effort to achieve the desired sense of self cohesion.
The defensive strategy of vertical splitting 34 may also be evident as one sequesters mental contents rather than eliminating them from consciousness.
The results of the studies presented in Section B supported the principal theoretical perspectives of self psychology. In particular, Chapters 7 and 8
34 Silverstein (2007) describes vertical splitting as a disavowal mechanism. That is, “an aspect of conscious awareness in which people know about and acknowledge particular actions, though they do not “know” that side of themselves experiencing such disavowed states ... an aspect of their experience is cut off from behavior. They do not know what propels their behavior, yet they understand that it is necessary and vital. Disavowal is not synonymous with the idea that affects may become isolated or walled off from thoughts [e.g. repression]. Further, reality is not distorted; thus, disavowed actions occur in reality. Rather, the meaning of that reality seems strangely unfamiliar” (p.249).
183 | Suicide and the intolerable state of a fragmented self demonstrated the mediating influence of self in the relationship between suicidal ideation and traumatic experiences. The results justify a further examination of suicidal behaviour to determine whether a fragmented sense of self might be a valid explanation for this behaviour.
The current study employed a sequential mixed-methods research design
(Creswell, 2009; Creswell & Plano Clark, 2007) to collect and analyse data relating to the phenomenological aspect of suicidal behaviour in terms of the self. Ivankova, Creswell and Stick (2006) defined the mixed-methods design as process of integrating both quantitative and qualitative data for the purpose of gaining a better understanding of the research question. In recent years there has been an increased interest in mixed- methods research designs in the health and social sciences (Elliott, Fischer, & Rennie,
1999), covering a diversity of subjects such as individual vulnerability and dissociative- like experiences in gamblers (McCormick, 2009), cultural differences in understandings and reactions to stress (Natasi et al., 2007), and bullying perspectives among rural youth
(Kulig, Hall, & Kalischuk, 2008). This approach has also been effectively employed in suicidality research (e.g. Larkin, Beautrais, Meredith, & Tabakakis, 2009).
The use of the mixed-methods design has been recommended by several researchers (Creswell, 2009; Creswell & Plano Clark, 2007; Onwuegbuzie & Johnson,
2006; Tashakkori & Teddlie, 2003) who argue that the combination of qualitative and quantitative data result in a greater understanding of the phenomenon under investigation than either approach alone. The integration of methodologies is particularly advocated when researching the sort of complex psychological phenomena presented in this dissertation (Creswell, 2009). Notwithstanding these endorsements, there is a controversy about the credibility of qualitative research and whether the results of both methods do indeed complement each other (Elliott et al., 1999). The core issue in the dispute is primarily one of epistemological philosophy. Quantitative research embraces a
184 | Suicide and the intolerable state of a fragmented self positivist philosophy of knowledge that seeks to establish objective understandings that are represented as regularities or laws (Polkinghorne, 1983). Thus, this approach views the participant as an object that can be universalised, resulting in research practices that generally maintain the subject-object dichotomy. Alternatively, qualitative research is claimed to challenge the validity of the traditional epistemological approach to knowledge, by deriving understandings from, inter alia, hermeneutic, pragmatic, and postmodernist traditions (Elliott et al., 1999). Accordingly, emphasis is placed on the individual nuances of the human experience in a manner that acknowledges the effects of history, language and culture. Thus, qualitative research is suited to understanding the participants’ perspectives that can be explained in terms of experienced meanings.
However, this relativist approach is “not solipsistic in that pains are taken to ground understandings of the matter empirically and to specify the researchers’ conceptual frameworks” (p. 217).
Although mixed-method designs are increasingly employed and accepted in research, the approach is not without its critics. Disapproval comes predominantly from qualitative “methodological fundamentalists” (Denzin, Lincoln, & Giardina, 2006, p. 774) in educational research. For example, Howe (2004) takes a strong, almost emotively moral, philosophical stand in arguing that mixed-methods are effectively a direct extrapolation of classical experimentalism which presupposes a methodological hierarchy with quantitative methods on top. Qualitative methods are regulated to “a largely auxiliary role in pursuit to the technocratic aim of accumulating of ‘what works’”.
According to Howe, mixed-method designs remove qualitative methods from their natural home in the critical and interpretative framework; ignoring the “ontological, epistemological, and axiomatic differences between positivist and postpositivist work”
(Denzin et al., 2006, p. 774). Conversely, the wider qualitative research community do acknowledge the benefit of mixing methods. Seale, Gobo, Gubrium and Silverman
(2004), for example, contest “the excesses of anti-methodological, ‘any-thing’ goes, romantic postmodernism” (Denzin et al., 2006, p. 775), advocating a pragmatic approach
185 | Suicide and the intolerable state of a fragmented self to research practice that involves a variety of resources, including, inter alia, theories, values and methods. Thus, the choice of research method is based on the most appropriate combinations in order to answer particular questions (Tashakkori & Teddlie,
2003).
The current study represents an attempt to explore the phenomenological aspect of suicidal behaviour in terms of the self, and to develop understandings grounded in the
experiences of participants who had attempted to end their lives. A mixed method
approach was essential in view of the subjective nature of self and because it has the
scope to produce further insight through the convergence of different data sources
(Creswell & Plano Clark, 2007). Indeed, addressing the subjective experience of self
required an approach that could accommodate the meanings that the participants
ascribed to their life experiences. In respect to the qualitative approach, thematic
analysis was central to the interpretation of individual narratives. Braun and Clarke
(2006) contend that thematic analysis provides an effective process for analysing and
reporting themes (patterns) within data. In comparison, grounded theory analysis, like
most qualitative methods, is an inductive process that seeks to generate a plausible
theory of the phenomenology embedded in the data, whereas thematic analysis can also
take a deductive approach. That is, a theoretically driven analysis is provided for in the
processes of engaging with participants and coding the data. In this case, both
approaches are taken: the data were initially reviewed for themes independent of theory,
and then Kohut’s theories of the self were imposed on the data. Thus, it was
hypothesised that:
1. The principal theoretical perspectives of self psychology relating to psychopathology would be greater evidence in people engaging in suicidal behaviour than controls. 2. Self cohesion could be measured, and 3. Suicidal behaviour would be associated with an unstable sense of self.
186 | Suicide and the intolerable state of a fragmented self
The sequential design utilised in the current study consisted of two data collection phases and sources: (1) semi-structured interviews and quantitative data gathering, and
(2) the administration of an on-line instrument representing the results of the converged data from (1). This approach is consistent with the general consensus that a qualitative study can be performed preparatory to quantitative research (Ivankova et al., 2006;
Neale, Allen, & Coombes, 2005). Triangulation was the applied method of seeking convergence of the data collected from both methods. Mays and Pope (2000) explained that triangulation is a common method of comparing the results of two or more methods of data collection (or sources) while examining the same phenomenon. Equal weighting was given to the results of both data collection methods during the subsequent analyses.
A social constructionist35 orientation was applied by the author in respect to the interpretation of the qualitative data36.
8.2 Phase 1: Suicide Attempters
8.2.1 Method
Ethics approval for the protocols employed within the study was granted by the
Royal Adelaide Hospital Human Research Ethics Committee.
8.2.1.1 Participants
The participants were all suicide attempters admitted to the Royal Adelaide
Hospital Emergency Department. Potential candidates were identified during the Mental
Health Team meetings, and only those patients who met the inclusion criteria were invited to participate. These were:
a. Any form of method of suicide attempt.
b. Adequate fluency in English.
35 Social constructionism (Burr, 2003; Gergen & Davis, 1985) is a sociological theory of knowledge that extends constructionism (Vygotsky, 1978) into social settings. The theory emphasises the importance of culture and context in what occurs in society, and the role that these understandings play in the construction of knowledge. Thus, groups construct knowledge for one another, collaboratively creating a culture of shared artefacts with shared meanings. 36 This follows Elliott et al.’s (1999) recommendation that the author’s applied theoretical orientations be specified when reporting qualitative results.
187 | Suicide and the intolerable state of a fragmented self
b. Less than 72 hours from the suicidal event, and
d. Aged between 18 and 60 years.
Participants detained under the Mental Health Act were also eligible to be included in the study subject to the approval of the mental health team Consultant
Psychiatrist. Detention in South Australia is frequently applied after admission to ensure the patient’s safety, and does not necessarily indicate that the person is unsuitable as a participant, or that their inclusion is inappropriate. This is also the case for people admitted under Section 23 of the Mental Health Act, which legitimises police apprehension and transport to the Emergency Department. Participants were excluded when psychotic or obtunded by their method of suicidal behaviour. Two male suicide attempters who attempted to hang themselves, and one female with Borderline
Personality Disorder declined the invitation to participate (Appendix A).
8.2.2 Measures
8.2.2.1 Mini Mental State Examination
The Mini Mental State Examination (MMSE) was included in the battery of instruments to confirm that the participant was not obtunded as a result of attempting to overdose (e.g. polypharmaceutical ingestion) or experiencing any form of cognitive impairment. The 11 question instrument was developed by Folstein, Folstein and
McHugh (1975) as a dementia screening instrument for clinicians, and is now used widely to evaluate a potential participant’s suitability for inclusion in clinical trials and studies. A maximum score of 30 can be realised on the MMSE and the respondent’s level of consciousness is determined on a continuum from Coma through Stupor, Drowsy to Alert. The instrument has been validated for the English language (Tinklenberg et al.,
1990) and several others (Chiu, Lee, Chung, & Kwong, 1994; Jones, 2006). The MMSE covers a broad range of cognitive domains such as language, short and long term memory, recall, orientation to time and place, and the ability to comprehend and respond
188 | Suicide and the intolerable state of a fragmented self to instructions (Molloy & Standish, 1997). It is used extensively in dementia research
(Anderson et al., 2007), and has been administered in studies examining, inter alia, the cognitive effects of ECT on severe mood disorder (Cohen et al., 2000), verbal memory in multiple sclerosis (Beatty, 2004), and cognitive decline following lacunar infarction
(Appelros & Andersson, 2006).
8.2.2.2 Visual Analogue Scale: Self Harm
To measure the participants” level of suicidal intent, a Visual Analogue Scale
(VAS) (Aitken, 1969; Zealley & Aitken, 1969) was included. The VAS has been applied in quantitative and qualitative studies (Cline, Herman, Shaw, & Morton, 1999), and is a valid method for measuring subjective feelings (Gift, 1991). Goldney (1979) validated this approach for suicidal behaviour as a way of providing “a simple means of assessing a suicidal subject’s intensity of wishing to live or die at the time of the attempt” (p.153), and is referred to hereafter as the Visual Analogue Scale – Self Harm (VASSH). The scale is a simple incremented 10cm line whereby a mark approaching 0 represents a strong wish to live and a mark approaching 10 represents a strong wish to die. The
VASSH has the benefit of simplicity in terms of comprehension and compilation, and does not require the participant to be particularly motivated.
8.2.2.3 Ruminative Response Scale
The Ruminative Response Scale (RRS) was included to determine the level of brooding (Chessick, 1985) and is one of four subscales from Nolen-Hoeksema and
Morrow’s (1991) Response Styles Questionnaire (RSQ). In the same manner as
O’Connor and Noyce’s (2008) examination of the extent to which brooding and reflection mediate the relationship between suicidal ideation and self-criticism, the original 22 item scale was reduced to 10 items. This follows Treynor, Gonzalez and Nolen-Hoeksema’s
(2003) analysis which identified two reliable five item factors within the RSS: brooding and reflection (α = .82 and .85 respectively). Brooding reflects the extent to which
189 | Suicide and the intolerable state of a fragmented self participants focus on their distress (e.g. “think ‘what am I doing to deserve this?’”).
Reflection refers to cognitively seeking a solution to the distress (e.g. “analyse your personality and try to understand why you are depressed”). Respondents are requested to indicate the frequency of each ruminating question on a four-point likert scale: (1) almost never, (2) sometimes, (3) often, and (4) almost always.
8.2.2.4 Modified Beck Self-Esteem Scales
Beck, Brown, Steer, Kuyken and Grisham (2001) developed the Beck Self-
Esteem Scales (BSE) to overcome the limitations of the single scale Beck Self-Concept
Test (Beck, Steer, Epstein, & Brown, 1990) which elicits self-evaluation in comparison to
others. The BSE has two scales: the Self Scale provides a means of rating a client’s
“absolute beliefs about themselves” (p.116) and the Other Scale relates to how clients
believe others evaluate them. Both measures consist of 18 pairs of adjectives reflecting
a positive and negative value (e.g. worthwhile–worthless) rated on a 10 point scale, and
are reported to have good psychometric properties with “high internal consistency,
adequate test-retest reliability and [appear] to measure unidimensional constructs of self-
esteem” (p. 122). The items applied by Beck and his colleagues were the result of an
analysis of verbatim clinical records seeking to identify the adjectives used by patients
when describing themselves. Following Beck et al. (2001), a semantic-differential format
was applied in respect to the items as “this requires respondents to weigh positive and
negative aspects of self against one another” (p.117). Consistent with self psychology,
the Other Scale was omitted, and an additional 18 theoretically determined (from self
psychology) subject pairs were added: peaceful-angry, proud-shamed, connected-
disconnected, self love-self hatred, kind-cruel, energetic-lethargic, complete-incomplete,
safe-threatened, vitalised-devitalised, full-empty, friendly-hostile, free-trapped, cautious-
impulsive, childhood emotional needs met-not met, close to parent/carer as a child-not
close, heard-not heard, voice-no voice, acknowledged-not acknowledged (Appendix B).
Hereafter referred to as the Adelaide Self Cohesion Scale (ASCS). The ASCS is not
190 | Suicide and the intolerable state of a fragmented self reverse scored following the observations of Beck et al. (2001) who noted that such presentations are problematic for psychologically distressed participants. The validity of the BSE in suicidality research has been demonstrated by Bhar, Ghahramanlou-
Holloway, Brown and Beck (2008) who reported that even in the context of depression and hopelessness, low self-esteem may further increase the risk for suicidal ideation.
8.3 Procedure
Potential participants were identified during the Emergency Department Mental
Health Team meeting. Having accepted the invitation to participate, read the information sheet and signed the consent form, the participant was administered the MMSE and completed two Analogue Scales, reflecting their attachment to life at the time of the suicide attempt and immediately prior to the commencement of the interview. Ten females and three males participated in the qualitative study (n = 13), with ages ranging between 19 to 43 years (M = 29.08, SD = 8.55). Table 8.1 details the demographics and unsolicited information disclosed during the interview: method, attempt number, and any pre-existing DSM-IV-TR diagnosis. The interviews were audio taped and varied in length between 35 and 80 minutes. Each followed a semi-structured format in which both open and closed questions were flexibly employed. The interviews commenced with the question “Many people have mixed thoughts and feelings when they are distressed. At the time you risked your life, what were your thoughts and feelings about living and dying?” The interviewer adopted a conversational stance to promote a two way dialogue, which permitted flexibility in accordance with the context of the discussion
(Griffin, 1990; Taylor & Ussher, 2001).
At an appropriate point during the interview the participant was asked to imagine that the researcher was an omnipotent genie and could provide three wishes (past, present or future); the participant was then asked to list and explain their wishes. At the conclusion of the interview, the participants completed the draft Adelaide Self Cohesion
Scale, the Ruminative Response Scale, and a final Analogue Scale. On occasions, the
191 | Suicide and the intolerable state of a fragmented self information provided in these instruments gave rise to further questions which were immediately addressed with the participants and included in the analysis.
Table 8.1 Participant demographics, method of attempt and mental health status
Pre-existing Method & Participant Sex Age Mental Health Attempt (#) Diagnosis
1 M 43 Overdose (1) None 2 F 26 Overdose (1) None
3 F 26 Cutting (1) Depression
4 M 19 Train (1) Depression
5 M 41 Electrocute (5) BPD 6 F 22 Cutting (4) BPD/MDE
7 F 39 Overdose (3) Undisclosed
8 F 34 Overdose (1) None
9 F 37 Overdose (3) BPD 10 F 27 Cutting (several) Undisclosed
11 F 21 Overdose (4) BPD
12 F 22 Overdose (several) BPD 13 F 21 Overdose (1) None
8.4 Phase 2: Healthy Controls and Ideators
Phase 2 continued the examination of the relationship between the construct of self and suicidal behaviour.
8.5 Method
Ethics approval for the protocols employed within the study was granted by the
University of Adelaide Human Research Ethics Committee.
192 | Suicide and the intolerable state of a fragmented self
8.5.1 Participants
First year undergraduate and postgraduate psychology students were invited to participate as a control group in an online survey using LimeSurvey (Version 1.70+)37.
The undergraduate students received course credit for their participation. The control group study consisted of 214 participants (221 responded but seven failed to complete the survey) ranging in age between 17 and 47 years (M = 21.07, SD = 5.32). Table 8.2 details the frequencies and percentages of the demographic and psychological well being responses. The large number of participants acknowledging suicidal ideation
(n = 30) prompted a post-survey email to all the undergraduate psychology students detailing the free counselling services available.
Table 8.2 Demographics and Psychological Well Being Responses
Measure Category Frequency %
Sex Male: 59 27.6
Female: 155 72.4
st Yes: 174 81.3 English 1 Language No: 40 18.7 Yes: 34 15.9 Mental Health Issue No: 180 84.1
Yes: 30 14.0 Suicidal ideation No: 184 86.0 Note: The thirty participants who acknowledged suicidal ideation were retained in the control group for the initial analysis. They were then re- identified as a separate group during the Rasch analysis to determine their score range location in comparison to the suicide attempters and non-ideating controls.
8.5.2 Measures
The survey included the draft Adelaide Self Cohesion Scale (ASCS), the brooding questions from the Ruminative Response Scale (RRS), the suicidal ideation question from the PRIME-MD depression inventory, a general mental health question, age, sex, and questioned whether English was the participant’s first language. The later question
37 LimeSurvey (formally PHPSurveyor) is an open source online survey software application that enables users without coding knowledge to develop, publish and collect responses to surveys
193 | Suicide and the intolerable state of a fragmented self was included to ensure that the results of the analysis were not confounded by English language difficulties in view of the large number of international students enrolled in
Psychology 1A and 1B. The survey concluded with details of free counselling services available.
8.6 Results
The results of phases 1 and 2 of the study are presented in the following two chapters to facilitate the data presentation and discussion. The thematic analysis of the interviews with suicide attempters is presented as Chapter 9. Chapter 10 reports the quantitative and qualitative data convergence and presents the statistical analysis leading to the development of the Adelaide Self Cohesion Scale.
194 | Suicide and the intolerable state of a fragmented self
Chapter 9: Measurement of the Self: Part 2
Measurement of the Self: Part 2
Suicide attempts have many meanings and, whatever their level of lethality, ought to be taken seriously. A person who attempts suicide because he believes that there is no use living may not necessarily mean that he wants to die but that he has exhausted the potential for being someone who matters (Shneidman, 1976, p.13).
9.1 Introduction
This chapter reports the thematic analysis of the transcripts taken from the interviews with 13 suicide attempters admitted to the Emergency Department of the
Royal Adelaide Hospital.
The interview transcriptions were analysed for evident themes independent of theory, and then again for confirmation of Kohut’s theoretical perspectives. The data were coded accordingly, and interpretation reliability (94.5%) was established by two colleagues familiar with qualitative methods providing independent analyses of both of two randomly selected interviews. Some of the variation in interpretation is attributed to the different levels of familiarity with the theory of self psychology. The majority of the participants were able to articulate their stories38 and exhibited candour as they did so.
Eight of the interviewees exhibited autobiographical memory deficits and were unable to recall specific early childhood experiences. Five struggled with sexual identity issues which, despite ‘coming out’, remained problematic for them. Many also acknowledged the inability of the selfobject to provide for their transference needs and attributed this to the selfobject’s own childhood experiences or their absence from the family home due to employment. Traumatic childhood experiences featured predominantly in the narratives of the participants, many of whom directly attributed their current circumstances to
38 The participants’ narratives are presented in bold to differentiate from the researcher whose questions or comments are occasionally included to elucidate. Pseudonyms have been applied and the participant number (#) and sex (M/F) follow the extract number.
195 | Suicide and the intolerable state of a fragmented self experiences of victimisation. Moreover, all of the participants appeared to have an inability to self-soothe in an adaptive manner, and exhibited an incapacity for self- compassion (Neff, 2003), albeit with individual variations. According to Neff, self- compassion entails three core components: ‘1) extending kindness and understanding to oneself; rather than harsh self-criticism and judgement; 2) seeing one’s experiences as part of the larger human experience rather than as separating and isolating; and 3)
holding one’s painful thoughts and feelings in balanced awareness rather than over-
identifying with them’ (p. 224).
9.2 Dominant Themes
The explicit desire to escape feelings of hopelessness, low self worth and a
sense of entrapment was the dominant theme for wishing to die. This was frequently
attributed to a lack of control over one’s life, and the frustration of not being accepted or
acknowledged:
Extract 1(#4M)
I just didn’t want to be here anymore ... it’s just too painful ... There was nothing that anyone could do to make any difference ... and that [no matter] how hard I’d actually tried to make a difference, it didn’t matter ... just total and utter despair.
Extract 2(#7F)
Um, my thoughts ... I guess at the time I pretty well thought [I was] worthless, um, like the thing ... that I wanted the most in my life I couldn’t have and couldn’t understand why. Um, couldn’t work out ... I just kept telling myself I tried everything, tried to do the right thing all the way through, tried everything I knew how to do to make things right and it just seemed that no matter what I did, I just kept getting pushed away ... [I] had to get away ...
196 | Suicide and the intolerable state of a fragmented self
Anger from another whose frustration at not being able to connect with the world was experienced as overwhelming:
Extract 3(#1M)
Umm ... not sure why ... ah feel it, like angry it’s how I feel, yeah it’s that ... wanted to kill the anger ... the anger.
The difference between self-harming behaviour and suicide attempt was clarified by two participants who had been diagnosed with Borderline Personality Disorder and one who exhibited sub-threshold traits of the disorder. All reported that picking or cutting their skin was intended to relieve negative emotions, whereas the suicide attempt was a genuine expression of the desire to die:
Extract 4(#9F)
I really wasn’t that concerned whether I woke up again or not. The waking up, as in whether I lived or died, wasn’t very important at that moment; it was getting away from this feeling ... I don’t understand exactly why I do it but I know it is a sort of self harm. Um, and it was a relief, even if it was a little microscopic skin thing then I would have to pick at it and make it go away ... I’d flatten it. And I’d pick those things till I bled. I’d get left with scars, but at the time it was mesmerising, it was kind like hypnotising and a way that I could escape and stopping my brain from thinking ... In the last few months I have almost by accident, discovered if I cut myself it doesn’t seem to hurt at the time when I am in this mindset, it doesn’t hurt and seeing this blood somehow makes me feel connected to being a person.
197 | Suicide and the intolerable state of a fragmented self
Extract 5(#10F)
Um, with the cutting it's more to feel something, um ... that it's even got to the point now where I get a bit out of control ... seeing the blood makes me feel that I'm alive. What about the attempts to kill yourself? Is there a difference? Yes, the cutting is to make me feel better, the suicide attempts I've had ... it's been that there haven’t been any other options ... I guess at the time I feel I would rather be dead than alive, because even though I'm alive I still don’t have a life.
Extract 6(#11F)
Um, I was about 11 and it was cutting. Mostly my arms and that gave me relief ... a lot of that was a control thing. Originally it helped me not eat which is what I wanted at the time, and then it became a cure all ... you know, if I got worried or distracted or upset. It was an outlet kind of thing. A way of distracting sort of thing, much more ... the cutting was very much ... I’ve forgotten the word. It wasn’t about dying, it was a misguided solution. So the intent then was not to kill yourself? No So when did that change? I self harmed continuously until 2005. In 2005 I actually used it as intent to kill myself...
The following extracts 7 and 8 exemplify the study’s overarching theme that the individual childhood selfobject mirroring transference needs of the participants were not adequately met. Both participants explicitly refer to failed selfobject transferences and the negative experiences associated with them.
198 | Suicide and the intolerable state of a fragmented self
Extract 7(#2F)
I think we are almost done. Is there anything else you would like to discuss or tell me about yourself that I should know about Rachel? Kids ... kids should be allowed to grow up and make mistakes so that they learn to grow into more autonomous adults. When you’re a little kid and you are trying to tell someone something they should listen, not tell you to go away because it’s too hard to ... they don’t agree. I remember them doing that so much it just made me feel very ignored, that my needs were never being met because nobody ... it was too hard, nobody wanted to. If action had been taken back then, when that started happening I would be a completely different person now. One who is ... yeah I am frightened to do some things by myself in case I make a mistake, in case it’s wrong.
Extract 8(#5M)
It only takes one derogative or referative [sic] um remark, from someone that they like. If they are idolising their parents, and the parents say you’re an idiot ... in a chastising way or even in a fun way. If they don’t find a way to change that and tell their kids that what they did was foolish and they’re not foolish and for the kid to understand that, that would be a big difference. It’d change things for you, it have changed things for me. Um, because then I would have known it wasn’t about everything, anything I’d done. And I don’t believe that [they] should have ever told me I was a mistake ... stupid.
Moreover, all the participants appear to have ‘exhausted the potential for being someone who matters’ (Shneidman, 1976, p.13) to someone else, or psychologically exhausted from their attempts to be so. Three major themes were evident independent of theory: a non-empathic childhood environment and a sense of betrayal, a high need for love and acknowledgement, and an inability to connect to establish an emotionally
199 | Suicide and the intolerable state of a fragmented self intimate relationship or social network. For self psychology, numerous examples of the major theoretical elements were obvious as participants struggled with their needs to deeply engage with others and be cherished for who they are. In Extract 9 a female participant is responding to the question about what it is she is seeking when she gives herself sexually to her ever changing male partners:
Extract 9(#12F)
... to give me love ... I want them to give me some damn respect!!! I want to be understood and loved like everybody [else].
9.3 Themes Independent of Theory
9.3.1 Non-empathic Childhood Environment
Although all of the participants reported an absence of empathy during their childhood, many expressed a love for their parents but nonetheless found their experiences distressing. Extracts 10, 11, and 12 poignantly illustrate this:
Extract 10(#5M)
Ah ... I loved them ... um ... I thought I got on quite well. Um, I was the youngest out of four kids um, and basically ah because I was more ... dyslexic I found it tough at school, back in my days at school dyslexia was ... not much known about ... so the teacher’s called me stupid, my dad called me stupid, my mum called me stupid ... everyone ... so I mean at the age of five years old I was told that I was a mistake ... stupid... Yeah ... yes that made me feel less worth. I was told later ... when I was five years old that I was an accident, I was a mistake and I wasn’t meant to be born ... Oh yes, I remember it clearly ... devastated, gutted, felt hollow inside. Um, they laughed about it ... they could see I was clearly upset. They just didn’t care; they just laughed it off and went back to watching TV.
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Extract 11(#2F)
I love her I do, she’s my mum. I love her and I know she has the best intentions, but her controlling ways ... I’ve never been able to become a person in my own right... I’ve done as I was told, especially by my parents. I might not have liked it, but in the end I ended up doing it, I feel in many ways manipulated into doing it. Like I could not say no, if I said no and they didn’t believe in what I was saying no to, they would find some way to punish me.
Extract 12(#13F)
The divorce ... was very scary to me because I felt that the person I knew as my mum, didn’t love me anymore ... she wasn’t feeding me, she wasn’t doing anything [for me].
Others also experienced little empathy in respect to significant life issues, as encapsulated in a woman’s recollections of her developing adolescent sexual identity:
Extract 13(#8F)
When I was a kid she’d caught me kissing [another] girl and she sent me to a psychiatrist, I can’t remember his name. For two years... How old were you? Eleven twelve. You know, and back then it was the wrong thing to do. You know I was wrong I was mentally unstable and I was this and that, this and that. I had it drummed into me that it was the wrong thing to do and you’ll go to hell and all that sort of stuff. Basically, I had the shit scared out of me ... that I can’t do that because that’s just not right, I’d go to hell. So that’s why it went that way and now it’s like back to the other way. Forcing you into psychotherapy, was that a difficult or turbulent period for you?
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I still don’t know where I am with it now ... I don’t know, I was so confused with everything at the moment that I don’t know what to think.
Additionally, some participants minimised what they perceived as their selfobject’s lack of empathy and responsibility to provide affection. This appeared to be a compensatory strategy to validate the belief that they were loved by the selfobject who was unable to provide the needed transference. Often, these expressions were contradictory:
Extract 14(#5M)
... my dad called me stupid ... He’d knock seven bells out of us, me ... me and John, my brother one up from me ... He [dad] had a very, very difficult upbringing ... um, if he got into a fight he had to win or else his dad would belt him. I thought he was a good dad then and still do now. If I were to say to you that if you would have had your dad do something more for you, what would it be? If he’d just pointed out something that he was proud of ... what I’d done.
Several participants reported that their private family life was very different from the public image, although the level of empathy did not vary regardless of the environment. During discussions about her mother, one participant explained:
Extract 15(#8F)
What would she [mother] say to you? I hate you. I wish you were never born. Why don’t you just run away and leave, we’d be better off without you, I wish you were never born. I wish you’d die. Endearing language Yeah... she basically told me she hated me and didn’t want me around ... If we were out in public and other people were around it was different, like she’d treat me the same as
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Linda [sister], we’d be just one happy family sort of thing. It was only behind closed doors that people didn’t see what really went on. I don’t know how to explain it, but when we were out in public it was all like we were one big happy family, like she had her two lovely kids and all that sort of stuff. But when we were behind closed doors it wasn’t like that at all. When we did go to family get-togethers we’d have to wear white frilly dresses and we weren’t allowed to move around, we had to sit right next to her and ... we were like little Barbie dolls. All the other kids would be running around playing and stuff but we weren’t allowed to.
Overall, the preceding extracts suggest that for the participants a non-empathic childhood environment obstructed the development of good-enough selfobject transferences. This appears to have resulted in a high need for love and acknowledgement:
9.3.2 Need for Love
Without exception, all the participants expressed a desire for greater love and acknowledgement, directing much of their behaviour towards realising this. Several accommodated much from others as they sought to achieve the desired result. Some participants expressed simple responses to the question of what was wanted from their parents:
Extract 16(#1M)
... to be loved, take me out ... be there
Another referring to her partner and children:
Extract 17(#8F)
... all I want is for someone ... one of my family to love me.
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Others explained their childhood experiences in the form of a capitulation that their need for a more intimate selfobject relationship may never be realised:
Extract 18(#7F)
It [love] was never shown to us. Growing up as kids my parents weren’t the type to say, you know, well done, really proud of you, love you ... the word love was never said in our house ... but, not that I think my parents never loved us, cos I’m sure they did but ... I guess they weren’t bought up that way so we weren’t bought that way either and they didn’t show emotions ... I’m thirty nine years old and I still try and make my father proud. You know, still try to do things to get his approval I guess.
One female participant recalled how in her adolescence she sought love and
affection from a young male adult to compensate for the inadequacy of the selfobject
transferences. She explains her vulnerability in the following abstract.
Extract 19(#9F)
I had in my brain that he was an adult, a grownup. And initially, he would listen to me, make eye contact with me, things my mother and father never did or took interest in, like little things at school. My opinions on something, how I felt... they wouldn’t make eye contact, they wouldn’t ... he was nice to me and... he’d give me a hug which I thought was a platonic hug. I felt starved to death for hugs. The platonic kind of hug, and he sort of pushed and pushed about the whole sexual thing and I said no, no, no for a long time, but I think I gave in because I was afraid I would lose this adult who was showing me this affection and attention ... supposed caring.
Vulnerability and a willingness to accommodate are also demonstrated by
another participant seeking to become someone who mattered to another. A strategy
of promiscuity is directed to that end:
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Extract 20(#12F)
She [mother] gave up on me when I was a baby ... Doesn't matter now, you want someone to love you ... [she] gave up on everything, just gave up. Gave up on love it just doesn’t exist just a crock of shit ... Men [also] don’t get me. They have no respect whatsoever, none, if you sleep with a guy on the first date that makes you a slut. But maybe it just makes you passionate, you can’t wait to sleep with them cos you think you really like them and they really like you. So what is it that you are looking for from them when you give yourself to them? Them to give me love How could that be demonstrated? You can feel it in the understanding, the happiness and the laughing. And in the staying together forever and in the words they say. In everything that they say ... in everything that they do shows you how someone feels...
The yearning to be loved and acknowledged appeared to be a strong influence on the participant’s world view and their behaviour. Yet, within this context most of the participants reported an inability to connect at the desired level of intimacy.
9.3.3 Inability to Intimately Connect
All the participants detailed a history of failed friendships, ruptured relationships and an inability to engage intimately with others. This was so for their selfobjects, siblings, partners and friends. Five of the participants recalled a childhood of family transience resulting in a lack of social networks and a narrow repertoire of engagement skills. The following abstract details what, for her, has become a pattern of rejection.
Extract 21(#2F)
... I tried to look at Brendan as a mistake, that I’d become too clingy and too needy. With Aaron I tried to do it very
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differently to play it cool, calm and collected. Yeah, not show too much interest straight off ... he responded very well to that, always calling me, always seeing me but the minute things started looking like they were going somewhere promising he suddenly said ‘no’... I just don’t think I come in a package that people could like. I’m too clingy too needy I’ve been told or too demanding or ... [I am] just not at the nice level that someone would love me...
Others simply reported their inability to connect:
Extract 22(#6F)
The sister ... turned 20 um. We’re very very different but yeah um, we don’t not get along ... I really didn’t make heaps of friends ... I sort of I didn’t really have [many friends] I tend to be a person with one or two very close friends. I’m not really a person, never have been, to have heaps of sort of acquaintances it doesn’t ... I’m much better with one on one contact than a group situation.
Extract 23(#11F)
I was in another [school] in year four, and I didn’t make friends there at all. Didn't fit in ... I always craved physical connection with people ... I'm not in any way a useful member of society or [able to be] a particularly good friend at the moment... I kind of craved physical closeness as an outward display of more inner closeness sort of thing.
Extract 24(#2F)
I was raised to believe that people who tried to kill themselves were selfish, people who thought only about themselves and didn’t give a damn about anyone else ... and I didn’t want to be like that and even when I tried, I didn’t think that there was anyone I could connect with ... that, you know, understood me. I can’t understand how it [the relationship with a boyfriend] all went so wrong, what was so
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terrible about me ... I’ve done a lot of things to please people, I’ve tried ...
Responding to the genie scenario and the provision of three wishes, eleven of the participants explicitly sought happiness as a first wish though some struggled with explanations as to what this meant for them. The remaining wishes were focussed on a more comfortable life (e.g. money, vocational change) in which the desired happiness could flourish. Participant 5 responded with only one wish, an emphatic ‘me not to be’.
Only two sought to specifically change the past:
Extract 25(#7F)
That ... I see the way that my brother and sister in law interact with my nieces and nephews, and always telling them that they love them, always giving them kisses, always just around them, spending time with them and playing with them. That would be my first wish that I’d had a childhood like that with my parents.
Extract 26(#9F)
I would like to have [had] more laughing, fun, acceptance – that it was ok to be imperfect. That mistakes were part of life and that it didn’t matter if we got ninety percent or ten percent ... it didn’t matter. If I got ninety percent or ten percent I was loved just for me. I honestly think I don’t know who I am. I would have liked to be as a child, as now, loved because I'm me, not because I wasn’t a boy, but it ... hey you're a cute kid, you’re funny, or you can put your ankle behind your head, isn’t that cool. All around, fun, laughter.
In summary, Kohut’s (1977) reference to Tragic Man appears to have some valence with participants directing their behaviour and cognitions to seeking fulfilment of the self. Moreover, their failures over-shadow their successes and their goals
207 | Suicide and the intolerable state of a fragmented self cannot be explained simply as seeking to satisfy pleasure drives. The result of the data analysis seeking confirmation of Kohut’s theoretical perspectives follows.
9.4 Themes Relating to Theoretical Perspectives
As noted earlier, the absence of empathic transferences in the development and maintenance of the self was apparent in all of the participants’ narratives.
Furthermore, all of the participants appear not to have experienced adequate mirroring transferences that self psychology considers essential to the positive development of a
sense of self cohesion.
9.4.1 Mirroring: The need for applause
Beyond extracts 7 and 8 which positioned the results of the study within the context of failed mirroring transference needs, other participants reported similar experiences.
Extract 27(#3F)
Anything that can help me understand the relationship between you and your parents. Betrayal, the lies ... broken promises ... ignore[d] me.
Extract 28(#6F)
my parents weren’t the type to say, you know, well done, really proud of you, love you ... the word love was never said in our house...
Extract 29(#9F)
I always felt I never ever met their expectations; I could never be good enough.
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For some, the experience of failed or inadequate mirroring transferences appears to have arrested the development of psychic structure formation from early life narcissistic grandiosity into a mature and cohesive sense of self.
9.4.2 Early Life Narcissistic Grandiosity
This primary developmental process was problematic for three of the participants and particularly evident during one interview. For this young man, early life narcissistic grandiosity appeared to be self soothing, albeit maladaptive. His behaviour could be understood as a strategy to accommodate a childhood in which he did not connect with his selfobjects, was frequently relocated, and subjected to physical and emotional abuse from his step mother.
Extract 30(#4M)
I do see myself as a leader ... elitist maybe. I see myself as I can achieve a lot more than most people can on this planet. I look at some people and I ... sitting on a bus looking around at all these people, you know. They’ve obviously got, you know, a very weak um ... grasp on life. It was then that I started to think that I was different, I couldn’t accept that people my own age ... their maturity levels... I had all these people saying ... praising me for the wonderful job I’d done [directing a school play]. I ah, even had the paper ... the school paper, you know [writing] ... blah blah blah year 11/12 year production outstanding success, you know, in bold letters...
9.4.3 Narcissistic Rage
Six participants experienced narcissistic rage in what appeared to be a response to the unbearable and intolerable frustration of failed attempts to realise positive transferences.
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Extract 31(#3F)
I always feel like hurting myself when I get angry ... I don’t just say I hate myself I’m going to hurt myself, it takes a while to lead up to [that] ... I get so sick of feeling like that ... very ... very angry with myself, I didn’t want to get to this position in my life ... the hatred’s there...
Extract 32(#5M)
I’m a peaceful person but there’s so much rage inside of me ... a lot of rage.
9.4.4 Idealisation: The need for security
Several participants sought idealisation transferences in response to their failed mirroring experiences. Most idealised a selfobject, partner or friend despite their inability to intimately connect with them. One found solace in the external object of God.
Extract 33(#6F)
I feel that God uses hard times like this to bring us closer to Him ... you get comfort um, there’s someone out there who knows you, who knows what’s going on. Who knows the past, the future, how you’re feeling right now you know and you can speak to them. You have a relationship with someone, or something, who is very very powerful and has control over everything, and so you are not really alone ... He made me so, He loves you and cares for you ... He still cares for you and looking after you, and there are greater things to come after ... this isn’t just what life is ah, it can be real dreadful now and horrible, um but the fact that it won’t be like that forever is a nice thought.
Similarly, others sought comfort in twinship transferences.
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9.4.5 Twinship/Alter Ego: The need to belong
Twinship transferences, or attempts to realise them, were evident in three of the participant’s stories. Speaking of his partner, the comments in the following extract summarise it eloquently:
Extract 34(#5M)
So she has a lot of troubled issues and ah she knows if she says something to me it’s alright ... you know things that I have spoke to you about. It’s alright to tell me things like that ... Two likeminded people hook up, and basically look after each other’s bruises.
Another participant, who unexpectedly became involved in a same sex relationship with a woman who had a similar history of failed heterosexual relationships, explains what it means for her:
Extract 35(#11F)
I mean a lot of it was the closeness, I mean yeah, it was the feeling of ... she was someone I could just be myself around a lot. I felt I could say anything and kind of knowing that she felt the same thing, and that we had an understanding of each other.
Envy was also an issue for some of these participants as they sought twinship transferences, suggesting a sense of fragmentation resulting from attempts to be sustained by another. For example, in extract 36 the envy is directed towards selfobjects
(or objects) who have found comfort through idealisation:
Extract 36(#4M)
... I envy my friends that, you know, can turn to something ... religion. I envy my friends that have something that I can’t accept.
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Superficial psychological intimacy was a notable characteristic of the participant’s experiences of twinship transferences. Though the engagements provided a minimal self soothing function, they did not appear to provide an entirely satisfactory alternative to the participant’s early life mirroring needs.
9.4.6 The Vertical Split
Only one participant reported an experience that might be interpreted as a vertical split:
Extract 37 (#6F)
Um, initially I think it’s because I didn’t want people to know the real me. I suppose I kinda feel often that there are two people; the upset one who can’t cope and the other one is the cheery face that everyone sees and thinks is good at this, and you know, good at sport and you know gets all good grades and ... but yeah but inside that’s not how I always feel, I suppose you don’t want people to see that part of you, I’d rather be the strong person.
9.4.7 Self Fragmentation
Several participants were unable to articulate their sensations beyond words
such as empty, incomplete and broken. However, two were able to describe a sense of
fragmentation and the anxiety associated with the experience of a crumbling self.
Extract 38 (#2F)
I feel like I am ...that I’m very vulnerable at the moment ... over the edge ... I just feel like I’m falling to pieces. I don’t connect with people ... that something’s different about me ... it’s just like the swan ... you see the beautiful swan sitting on the water looking very peaceful,
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but underneath its legs are kicking frantically. ... I’m being torn apart; I’m just ripping to shreds by myself...
Extract 39 (#9F)
... you slide and at this point you start to slide you sort of feeling of [being] out of control ... I don’t know who I am as a complete person or not. As a person I feel more a shattered person in a million pieces rather than complete and whole ... my sense of self is a mulched up mess.
9.5 Discussion
This study examined the phenomenological aspect of suicide attempts in terms of the self and self psychology. In particular, seeking support for Kohut’s (e.g. 1971, 1977) concept of an incohesive or fragmented sense of self. The qualitative data support the principal concepts of self psychology for this group of suicide attempters.
The results of the qualitative analysis identified the primary patterns within
Kohut’s (1977) tripolar model for the development and maintenance of self: mirroring, idealisation and twinship transferences. These suicide attempters appear to have developed in negative selfobject milieus in which there was little empathy and failed mirroring transferences. Consequently, this group of participants adopted compensatory strategies such as idealisation and/or twinship transferences to overcome the absence of acknowledgement and recognition. This is consistent with Kohut’s concept of an incohesive sense of self and attempts to forestall fragmentation, gain control
(Baumeister, 1998), or improve or escape the aversive side of self-awareness (Duval &
Wicklund, 1972). Between them, the participants interviewed exhibited narcissistic anger, early life narcissistic grandiosity, and their expressions of intolerable states of self appear ineradicably associated with negative childhood experiences. Moreover, their inability to self-soothe and their strategies employed to stabilise their sense of self have
213 | Suicide and the intolerable state of a fragmented self been maladaptive; frustrating their efforts to gain some control and exacerbating their distress.
The results suggest that suicidal behaviour is associated with self fragmentation.
Indeed, the participants made unambiguous references to an incohesive sense of self and all endorsed very negative aspects of self. The convergence of the data and the subsequent statistical analysis are presented in the following chapter.
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Chapter 10: Measurement of the Self: Part 3
Measurement of the Self: Part 3
No one suicides in a biographical vacuum; life histories are always relevant to the final act of suicide. Suicidal decisions develop over time and against certain social, psychological, and genetic (or biological) backdrops; they are never completely explained by acute, situational factors. (Maris, 1981, p. xvii)
10.1 Introduction
The current chapter presents the quantitative results from phases 1 and 2, together with the subsequent convergence of data relating to the ASCS and the statistical analysis.
The results of the Mini Mental State Examination (MMSE), Analogue Scale: Self
Harm (VASSH) and the Ruminating Response Scales (RSS) for the suicide attempters are presented as Table 10.1. The VASSH scores represent the following time points:
(1) suicide attempt, (2) pre-interview, and (3) post-interview; with means of 9, 4.62, and
3.57 respectively.
Table 10.1 Results for the Suicide attempters: (#), MMSE, RSS and VASSH scores.
Ruminating Response Scale VASSH # MMSE Brooding Reflection Total 1 2 3 1 27 15 12 27 10 6 4
2 26 14 10 24 10 6 6
3 30 17 14 17 10 6 5
4 30 13 10 23 9 3 1
5 28 16 13 29 10 8 8
6 30 14 13 27 7 3 2
7 30 12 14 26 9 1 1
8 29 13 13 26 9 3 2
9 29 17 14 31 8 5 2
10 30 14 10 21 9 5 6
11 28 15 13 28 9 5 4
12 30 12 18 30 8 1 0
13 27 15 13 28 9 8 5
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The responses from the suicide attempters and controls to the original 18 dimensions of the Beck Self-Esteem Scale (BSE) and the additional dimensions are presented as Tables 11.2 and 11.3 respectively. In the event a participant’s annotation on the scale was ambiguous, the score was rounded up; seven adjustments were made.
Table 10.2 Group response mean, standard error, and standard deviations for the original BSE dimensions
Original BSE Suicide Attempters Controls Dimensions M SE SD M SE SD
Successful-Unsuccessful 7.77 .41 1.48 4.26 .12 1.71
Attractive-Unattractive 7.00 .62 2.24 4.75 .12 1.75
Popular-Unpopular 6.61 .69 2.50 4.70 .11 1.67
Independent-Dependent 5.84 .81 2.91 3.90 .13 1.95
Honest-Dishonest 2.54 .49 1.76 3.08 .12 1.73
Desirable-Undesirable 7.38 .68 2.47 4.62 .12 1.75
Strong-Weak 7.00 .15 2.71 4.26 .13 1.87
Smart-Dumb 4.38 .82 2.96 3.67 .11 1.57
Powerful-Powerless 7.31 .64 2.32 4.88 .11 1.65
Loveable-Unlovable 8.38 .35 1.26 3.83 .13 1.84
Pleasant-Unpleasant 6.31 .62 2.25 3.48 .11 1.68
Efficient-Inefficient 5.77 .66 2.39 4.24 .14 2.01
Generous-Selfish 4.61 .64 2.29 3.43 .12 1.76
Responsible-Irresponsible 3.69 .70 2.53 3.19 .12 1.72
Worthwhile-Worthless 7.39 .74 2.66 3.56 .12 1.70
Interesting-Boring 4.85 .74 2.67 3.62 .12 1.68
Knowledgeable-Boring 3.00 .57 2.04 3.56 .11 1.58
Good-Bad 5.31 .82 2.95 3.93 .13 1.89
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Table 10.3 Group response mean, standard error, and standard deviation for the additional dimensions
Suicide Attempters Controls Additional Dimensions M SE SD M SE SD
Peaceful-Angry 8.15 .44 1.57 4.15 .12 1.78
Proud-Shameful 8.69 .38 1.38 4.23 .13 1.90
Connected-Disconnected 7.92 .58 2.10 4.48 .14 1.99
Self love-Self hate 9.00 .49 1.78 3.13 .10 1.48
Kind-Cruel 3.77 .66 2.39 4.29 .14 2.01
Energetic-Lethargic 6.31 .83 2.98 4.83 .15 2.14
Complete-Incomplete 8.62 .42 1.50 3.35 .12 1.75
Safe-Threatened 7.31 .66 2.39 4.26 .11 1.56
Vitalised-Devitalised 7.46 .62 2.22 4.27 .12 1.80
Full-Empty 8.23 .61 2.20 2.96 .11 1.57
Friendly-Hostile 5.46 1.07 3.86 3.96 .14 2.06
Free-Trapped 6.92 .78 2.81 4.46 .13 1.95
Cautious-Impulsive 6.00 .78 2.83 3.4 .54 2.25
Child Emotional Needs Met-Not Met 8.38 .59 2.14 3.19 .54 2.26
Close to parent/carer-Not Close 6.08 .8 2.87 3.29 .11 1.62
Heard-Not heard 8.31 .38 1.38 3.93 .12 1.79
Voice-No voice 8.38 .27 .96 3.82 .13 1.90
Acknowledged-Unacknowledged 8.69 .29 1.03 3.84 .13 1.92
The responses against all 36 dimensions for all the participants in both groups were then merged (n = 227) and a Rasch analysis (Winsteps Version 3.68.2) (Linacre,
2005) performed to determine the internal validity of the scale items in respect to the model.
217 | Suicide and the intolerable state of a fragmented self
10.2 Rasch Analysis
Rasch analysis is a unidimensional statistical method for testing an outcome scale against an algorithmic model developed by Rasch (1960). It is designed to be applied when a set of items are intended to be summed together to provide a total score.
Item response theory (IRT), including Rasch analysis, indicates what should be expected in responses to items if interval scale is to be achieved. “The model operationalizes the formal axioms that underpin measurement. These axioms, of additive conjoint measurement, are the rules for making measurements and will determine if ordinal or interval scales have been constructed” (Tennant & Conaghan, 2007, p. 1358).
The model assumes that the probability of a given participant affirming an item score is a logistic function of the relative distance between the item location and the participant location on a linear scale. Rasch analysis allows for item properties (e.g. level of difficulty) to be estimated even in circumstances where biased or unrepresentative samples are used. Within IRT, trait score and standard error estimates are not considered to be reliant on the population distribution. This is in contrast to classical test theory, which interprets test scores according to its location within a normal distribution. In accordance with IRT, Rasch analysis uses raw scores to estimate trait ability and places them on an equidistant logit (log odds unit) scale with item difficulty estimates. The response patterns achieved from a set of items in a question are summed together in a probabilistic form of Guttman (1950) scaling. Guttman scaling is a
“deterministic pattern that expects a strict hierarchical ordering of items (e.g. from low to high levels of activity limitation)” (Tennant & Conaghan, 2007, p. 1358). Because the item response options in the ASCS are polytomous, the Andrich (1978) Rating Scale
Model (RSM) was applied.
The mathematical equation for RSM is expressed as:
౮ ୣൣσౠసబሺିሺିஔሻሻ൧ ܲ௫ ൌ σ ቂσೣ ൫ఏିሺఒ ିఋ ሻ൯ቃ ೣసഎ ೕసഎ
218 | Suicide and the intolerable state of a fragmented self
whereσୀ ൬ቀߠ െ൫ߣȂߜ൯ቁ ൌ ܱ൰, ߣ is the item location parameter and ߜ is the
category intersection parameter. ߣis interpreted as the relative difficulty of a
particular item, and ߜ is the category threshold parameter assumed to be
constant across all items. Thus, each item in the RSM is described by a single
parameter ߣ on the latent trait scale (Cervellione, Lee, & Bonanno, 2008, p. 6).
The RSM is frequently applied to personality and attitude scales in which the
relative difficulty of steps within items (e.g. Likert type scale) are expected to remain
constant (Embretson & Reise, 2000) and the psychological intervals between each
categories are equal for all items (Fox & Jones, 1998). Items with a mean square fit
(MNSQ) between 0.7 and 1.3 were considered to have acceptable fit (Wright & Stone,
1979). For Rasch analysis, MNSQ is an index-of-fit of the item to the model, and is
determined by averaging the squared residual for each person-item combination and
averaging across all of the participants for each item (Cole, Rabin, Smith, & Kaufman,
2004). The MNSQ is calculated for both INFIT and OUTFIT. INFIT is a measure of the
differences between the observed and the expected response for those items that have
a difficulty level near to the participant’s ability level. OUTFIT includes the differences for
all of the items, irrespective of how far away the item difficulty is from the participant’s
ability (Tennant & Conaghan, 2007).
The first step of the analysis was to remove those participants who recorded
unexpected responses identified in the initial analysis. The analysis was then repeated
and items with insufficient fit (MNSQ < 0.7 and > 1.3) were removed from the scale. For
any response strings of redundant items, further item elimination was guided by the fit
statistics and the differential item functioning plot. For example, if two items recorded an
INFIT MNSQ of 1.09 and 1.10 with standard errors of 0.5, the item with the greater
difference between the controls and the suicide attempters (as indicated on the
differential item function (DIF) graph) was retained. The combined data for the brooding
219 | Suicide and the intolerable state of a fragmented self subscale of the Ruminative Response Scale (RRS) was similarly analysed separately in view of the different scoring ranges between the two scales (1 - 4 in the RRS against 1 -
10 in the ASCS).
10.2.1 Analysis of Self Dimensions
The first iteration identified 31 participants whose responses did not fit the model and these were subsequently removed, reducing the sample to 196. Seven iterations recalibrating the model followed, resulting in the sequential removal of 20 items (Table
10.4) with MNSQ fit values beyond the lower and upper thresholds of .07 and 1.3 logits respectively.
Table 10.4 Draft ASCS misfit items removed: Rasch statistics
Model Infit Outfit Item rt ߜSE Z Z
Child emotions met-not met .36 .06 2.26 8.6 2.06 7.8 .57
Cautious-Impulsive .35 .06 1.98 7.1 1.78 6.1 .55
Free-Trapped -.23 .05 1.69 5.6 1.73 5.9 .40
Kind-Cruel -.06 .05 1.62 5.0 1.45 3.8 .46
Independent-Dependent .03 .05 1.55 4.5 1.48 4.0 .51
Close to carer-Not close .09 .06 1.54 4.4 1.41 3.6 .61
Efficient-Inefficient -.11 .05 1.47 3.9 1.42 3.6 .71
Knowledgeable-Boring .31 .06 1.45 3.7 1.27 2.4 .45
Friendly-Hostile .04 .05 1.43 3.6 1.31 2.7 .61
Responsible-Irresponsible .54 .06 1.41 3.3 1.27 2.4 .57
Good-Bad .10 .06 1.41 3.5 1.26 2.3 .63
Generous-Selfish .33 .06 1.37 3.0 1.24 2.1 .50
Honest-Dishonest .60 .06 1.37 3.0 1.17 1.6 .50
Strong-Weak -.17 .05 1.36 3.1 1.32 2.9 .55
Smart-Dumb .29 .06 1.32 2.8 1.14 1.4 .57
Successful-Unsuccessful* .25 .06 .92 -.8 .81 -2.0 .79
Vitalised-Devitalised -.23 .05 .62 -4.2 .59 -4.2 .75
Peaceful-Angry -.20 .05 .61 -4.3 .62 -4.3 .79
Safe-Threatened -.21 .05 .60 -4.4 .56 -5.0 .72
Proud-Shamed -2.4 .05 .58 -4.8 .57 -5.0 .81
ߜ = item measure, SE = standard error, M = mean-square statistic, Z = standardised mean-square statistic, rt = point-biserial correlation between item and total model score. * Successful-Unsuccessful deleted because the infit statistics matched Worthwhile-Worthless 220 | Suicide and the intolerable state of a fragmented self
The remaining 16 items met the model fit criteria and were retained for the ASCS and are presented as Table 10.5. The results of the analysis on the retained self dimensions confirm that the assumption of unidimensionality is supported in the model.
The person-reliability and person-separation index were good at KR-20 39 = 0.95 and
4.12 respectively. Similarly, the item log-likelihood test (χ2 = 9998.94, df = 2917), probability (p<.001), and item-separation index of 6.3 suggest a good fit. The statistical summary and item fit statistics for the participants and the items are presented as Table
10.6
Table 10.5 Draft ASCS items retained
Model Infit Outfit Item rt ߜ SE M Z M Z Full - Empty .62 .06 1.16 1.5 1.01 .1 .78
Self Love - Self Hate .49 .06 1.14 1.3 .99 .0 .70
Pleasant - Unpleasant .37 .06 1.08 .8 .99 .0 .69
Complete - Incomplete .31 .06 1.21 1.9 1.15 1.4 .76
Interesting - Boring .31 .06 1.28 2.4 1.14 1.3 .64
Worthwhile - Worthless .26 .06 .90 -.9 .81 -2.0 .80
Have a Voice - No Voice .08 .06 1.02 .2 .98 -.1 .79
Acknowledged - Not Acknowledged .03 .06 .89 -1.0 .87 -1.3 .83
Lovable - Unlovable .01 .06 .77 -2.4 .75 -2.6 .83
Heard - Not heard .01 .06 .95 -.5 .91 -.9 .78
Connected - Disconnected -.32 .05 .96 -.3 .90 -.9 .77
Desirable - Undesirable -.37 .05 .86 -1.4 .86 -1.4 .74
Popular - Unpopular -.39 .05 .89 -1.0 .93 -.7 .69
Attractive - Unattractive -.39 .05 1.02 .2 1.03 .4 .68
Powerful - Powerless -.50 .05 1.10 .9 1.09 .9 .62
Energetic - Lethargic -.53 .05 1.22 2.0 1.30 2.7 .70
ߜ = item measure, SE = standard error, M = mean-square statistic, Z = standardised mean-square statistic, rt = point-biserial correlation between item and total model score
39 The KR-20 statistic is similar to Cronbach’s α.
221 | Suicide and the intolerable state of a fragmented self
Table 10.6 ASCS Self Dimensions: Rasch statistical summary
Infit Outfit Raw Model Count Measure Score Error MNSQ ZSTD MNSQ ZSTD
Summary of 196 measured persons:
M 52.8 16.0 -.48 .20 .98 -.3 .98 -.3
SD 23.2 .0 .88 .03 .71 1.8 .70 1.8
Max 134.0 16.0 2.24 .34 5.11 6.1 5.13 6.2
Min 11.0 16.0 -2.81 .16 .10 -4.4 .10 -4.5
Summary of 16 measured items:
M 647.0 196.0 .00 .06 1.03 .2 .98 -.2
SD 114.0 .0 .36 .00 .14 1.4 .13 1.3
Max 821.0 196.0 .62 .06 1.28 2.4 1.3 2.7
Min 465.0 196.0 -.53 .05 .77 -2.4 .75 -2.6
Figure 10.1 displays the person-item and item person maps. The person-item map on the left reveals a normally distributed sample with the item distribution suggesting some redundancy. However, further exploratory iterations did not improve the fit. In the item- persons map, there is a participant hierarchy that appears to support the theory of self psychology. In Rasch analysis terms, the suicide attempters endorsed more correct scores on the difficult questions meaning that this group scored higher on the negative self-evaluations than did the control group. Put another way, controls endorsed more positive experiences such as ‘being acknowledged’ (scoring low) than suicide attempters who endorsed negative experiences such as ‘not being acknowledged’ (scoring high).
Suicide ideators were generally located between the suicide attempters and controls.
222 | Suicide and the intolerable state of a fragmented self
PERSONS - MAP – ITEMS ITEM - MAP – PERSONS
Figure 10.1. The person-item and item-person maps for the ASCS self dimensions. The items ascend in order of difficulty, that is, the higher the item, the less likely it is endorsed by the controls. For the person-item map (left), the participant scores are displayed to the left of the axis and the item difficulty levels on the right. The item-person map (right) displays the item difficulty on the left of the axis and individual performance to the right. The locations of the suicide attempters are highlighted; three ideators are also included in the main group.
The non-uniform differential item functioning graph (Figure 10.2) clearly distinguishes the group-item responses in relation to each other. The results suggest the removal of ‘Worthwhile’, however, doing so did not improve the model fit and consequently the item was retained.
223 | Suicide and the intolerable state of a fragmented self
ITEM C I S
1.5
1
0.5
0
DIF Measure(diff.) -0.5
-1
Figure 10.2. The ASCS self dimensions non-uniform differential item function graph with ‘C’, ‘I’ and ‘S’ representing Controls, Suicidal Ideators and Suicide Attempters respectively. Group convergence on the item ‘Worthwhile’ is highlighted.
10.3 Rasch Analysis - Brooding Items
All five items of the brooding subscale fitted the model criteria at the first iteration, with
MNSQ fit values within the lower and upper thresholds of .07 and 1.3 logits respectively.
The statistical summary for the participants and the items is presented as Table 10.7 and indicates that the assumption of unidimensionality is supported in the model. Item reliability and separation for the model were .98 and 6.37 respectively. The person- reliability and person-separation index were acceptable at KR-20 = 0.77 and 1.91 respectively. Similarly, the item log-likelihood test (χ2 = 2030.46, df = 894), probability
(p<.001), and item-separation index of 6.5 suggest a good fit. The item fit are presented as Table 10.8.
224 | Suicide and the intolerable state of a fragmented self
Table 10.7 ASCS Brooding Items: Rasch Statistical Summary
Infit Outfit Raw Model Count Measure Score Error MNSQ ZSTD MNSQ ZSTD
Summary of 225 measured persons:
M 11.6 5.0 -.37 .73 .98 -.1 .98 -.1
SD 3.2 .0 1.60 .10 .71 1.1 .72 1.1
Max 19.0 5.0 3.59 1.13 3.93 3.0 3.80 2.9
Min 6.0 5.0 -3.87 .65 .13 -2.2 .13 -2.1
Summary of 5 measured items:
M 528.4 227 .00 .11 1.00 -.1 .98 -.2
SD 62.4 .0 .71 .00 .12 1.5 .11 1.2
Max 627.0 227 1.02 .11 1.09 1.0 1.09 .9
Min 441.0 227 -1.10 .10 .75 -3.0 .77 -2.6
Table 10.8 ASCS Brooding Items: Rasch item fit statistics
Model Infit Outfit r Item t ߜ SE M Z M Z
“What am I doing to deserve this?” 1.02 .11 1.09 1.0 1.09 .9 .57
“Why do I have problems other people don’t have?” .44 .11 1.04 .5 .99 -.1 .78
“Why do I always react this way?” -.11 .11 1.06 .7 1.06 .7 .70
“Why can’t I handle things better?” -.25 .11 1.04 .5 1.0 .0 .78
Think about a recent situation wishing it had gone better? -1.10 .10 .75 -3.0 .77 -2.6 .74
ߜ = item measure, SE = standard error, M = mean-square statistic, Z = standardised mean-square statistic, rt = point-biserial correlation between item and total model score
Figure 10.3 displays the person-item and item-person maps for the Brooding subscale. Both maps reveal a normally distributed sample. Unlike the ASCS results, a
225 | Suicide and the intolerable state of a fragmented self participant hierarchy is not demonstrated, with some ideators and controls scoring higher frequencies of brooding than the suicide attempters. However, as a group, the suicide attempters appear to have recorded greater brooding frequencies than the ideators or controls.
PERSONS - MAP – ITEM ITEMS - MAP - PERSONS
Each ‘#’ and ‘.’ represents three and one participant respectively Each ‘X’ represents each item Figure 10.3. The item-person map for the ASCS brooding items. The items ascend in order of difficulty, that is, the higher the item, the less likely it is endorsed by the controls. For the person-item map (left), the participant scores are displayed to the left of the axis and the item difficulty levels on the right. The item person (right) displays the item difficulty on the left of the axis and individual performance to the right. The suicide attempters are highlighted. 226 | Suicide and the intolerable state of a fragmented self The non-uniform differential item functioning graph (Figure 10.4) clearly distinguishes the group-item responses in relationship to each other ITEM C I S 3 2 1 0 -1 -2 DIF Measure(diff.) -3 -4 Figure 10.4. The brooding items non-uniform differential item function graph with ‘C’ , ‘I’ and ‘S’ representing Controls, Suicidal Ideators and Suicide Attempters respectively. 10.4 Configuration of the ASCS Although the Rasch analyses demonstrated good model fit, the proximity of items, in terms of logit measurement, are more finely discriminated than expected. This might be explained by the very nature of self which, in its complexity, would be unlikely to be captured adequately by a coarse-interval scale. The final ASCS (Appendix C) is a 23 item self-report instrument presented as three sections. The partitioned format reflects the results of the thematic analyses presented in Chapter 10, which confirmed that one’s sense of self is experientially located in both the past and present. Section 1 (Self Concept) seeks current beliefs regarding 13 adjective pairs. In light of the results of the thematic analysis, Section 2 (Transference Needs) addresses beliefs about five childhood experiences, and Section 3 (Ruminating Style) is 227 | Suicide and the intolerable state of a fragmented self the five-item brooding subscale. In the same manner as Beck et al. (2001), Sections 1 and 2 of the ASCS are presented in a semantic-differential format that requires respondents to weigh both positive and negative aspects of self against one another. Section 3 seeks a response between ‘Almost Never’ and ‘Almost Always’. Each section is presented in a non-labelled ten-point scale 40 (see Figure 10.5) and respondents are instructed to indicate the point that best represents their belief. The scale was not numbered to avoid response bias, and indication-points were introduced to overcome the previously noted problem associated with quantifying a simple analogue scale (rounding scores). The ASCS is not reverse scored because of the difficulty for psychologically distressed participants (Beck et al., 2001). Full o o o o o o o o o o Empty o Self - Love o o o o o o o o o Self - Hate o o o o o o o o o o Unpleasant Pleasant Figure 10.5. A sample of adjective pairs from Section 1 of the ASCS. Respondents are instructed to indicate (by crossing) the point that best represents their belief. The example indicates scores 8, 3, and 6 for the adjective pairs commencing full, self-love and pleasant respectively. 10.5 Discussion This comparative study examined the phenomenological aspect of suicidal behaviour in terms of the self and self psychology. The results of the qualitative and quantitative studies were complementary and demonstrated the utility of the mixed- methods design (Creswell, 2009; Creswell & Plano Clark, 2007; Elliott et al., 1999). The participants in the qualitative study shared their stories in a candid and illuminating manner. Moreover, their revelations of childhood rejection and trauma were acknowledged and had a significant influence on the final configuration of the ASCS (i.e. 40 The brooding subscale is extended from a five to ten point scale in the ASCS to provide continuity of presentation and reduce the likelihood of confusion for psychologically distressed participants (Beck et al., 2001). Whether this proves to be problematic will be determined in the next study which seeks validate the ASCS. 228 | Suicide and the intolerable state of a fragmented self Section 2). The results of the Visual Analogue Scale – Self Harm supported earlier studies by demonstrating that there is no iatrogenic risk associated with empathic engagement with people exhibiting suicidal behaviour (Gould et al., 2005; Larkin et al., 2009). Indeed, the experience of sharing their story in an accepting manner provided a level of personal acknowledgement to the participants, many whom hitherto had not believed that they had been heard (Kohut, 1977; Lee & Martin, 1991). The dominant reason attributed by the suicide attempters to their self-harming behaviour was to escape a psychologically intolerable state, characterised by negative feelings such as hopelessness, entrapment, and non-acceptance. The commonly recalled non-empathic childhood environment of trauma and rejection is consistent with the results of numerous studies examining the relationship between adverse early-life experiences and suicidal behaviour (e.g. Dube et al., 2001; Ferrada-Noli, Asberg, Ormstad, Lundin, & Sundbom, 1998). Most, if not all, of the recalled traumatic experiences were in some way related to a selfobject 41, and the exhaustive attempts by the participant to become ‘someone who matters’ (Shneidman, 1976, p.13). The acknowledgement by all the participants of some level of childhood trauma in the form of either family dysfunction (Seedat et al., 2005), or emotional, physical or sexual abuse (Anderson et al., 2002; Roy & Janal, 2006), demonstrates the significance of positive selfobject transferences. The negative endorsements on the draft ASCS by the suicide ideators in the control group suggest that this population had similar childhood experiences as the suicide attempters. Such negative childhood experiences are particularly problematic for the development of a mature and cohesive sense of self (Kohut, 1971, 1977, 1985b). Indeed, Klomek et al. (2007) reported that the quality of internalised mental representations of self and selfobject is directly linked to an individual’s psychological adjustment. Moreover, a number of commonalities among suicides have been reported in terms of attachment (selfobject relationship) and suicidal 41 Selfobject refers the primary significant other such as a parent or carer. People we incorporate as a psychological part of our own sense of self. 229 | Suicide and the intolerable state of a fragmented self behaviour. Ledgerwood (1999) lists several which were evident in the narratives of the suicide attempters; each, according to the theory of self psychology, can inhibit the development of a healthy sense of self and leave one vulnerable to fragmentation: a. A selfobject relationship characterised by an underlying threat of abandonment or the withdrawal of love. b. An underlying ambivalence toward the selfobject reflecting an inability to reconcile the simultaneous feelings of love and hate, resulting in feelings of guilt, and c. The family environment is characterised by a “profound symbiotic relationship” (p.72) which requires absolute fidelity to the family, and any normal developmental behaviour such as striving for autonomy or pursuing relationships is viewed as subversive. As a consequence, the child’s psychological developmental does not follow a healthy pattern, and the individual becomes trapped in the conflict between “detachment and enmeshment, leading to suicidal disintegration” (p.72). By contrast, the healthy controls appear to have had a more affirmative life experiences and have subsequently developed a cohesive sense of self and more adaptive coping strategies for responding to the challenges of life. The struggles with sexual identity and the victimisation and marginalisation associated with being gay also appeared to have undermined or inhibited the development of a cohesive sense of self. The narratives of the suicide attempts revealed that many negative, yet common, stressors experienced during the developmental years appear to intensify in the lives of people with a non-heterosexual orientation. Rejection and victimisation by the selfobject and/or objects to disclosures of a different sexual orientation have had significant and adverse effect on the lives some the participants whose sexuality was voiced as abnormal, or even evil, by significant others (D'Augelli et al., 2001; Hershberger & D'Augelli, 1995). Consequently, these 230 | Suicide and the intolerable state of a fragmented self experiences appear to have derailed productive transference patterns and consequently inhibited or damaged the development of a healthy sense of self. The effects of these adverse experiences have been retained and continue to be influential on the psychological wellbeing of the participants. For example, maladaptive coping behaviours such as substance abuse, (Roy, 2001), pathological gambling (Kausch, Rugle, & Rowland, 2006), or impulsivity (Roy, 2001) were reported. As expected, the overarching theme from the qualitative study was that the individual childhood selfobject mirroring transference needs of the participants were not met. In contrast, the control group endorsed more positive childhood experiences suggesting a stable sense of self. For the suicide attempters, a fragmented sense of self is can be understood when considering that the development of self is normally achieved by a childhood developmental path involving “stages characterised as truces in the tension” (Starzomski & Nussbaum, 2000, p. 475) between individual needs and the selfobject within an empathic milieu. A balance between these two demands results in a relatively cohesive and mature sense of self (Kegan, 1982; Kohut, 1977). This essential developmental environment was not available for the suicide attempters, resulting in a number of maladaptive compensatory strategies designed to redress their sense of instability. This follows Kohut’s (1985c) argument that personality development follows are largely environmentally prescribed trajectory, and that the critical self development experience of childhood cannot be recreated. All that is possible is to attempt to remedy “things that were left undone in that childhood or things that were not completely done” (p.249). Clearly, a powerful relationship exists between negative childhood experiences, the stability of self, and suicidality throughout the life span. The first hypothesis was that the principal theoretical perspectives of self psychology relating to psychopathology would be in greater evidence in people who engaged in suicidal behaviour than in controls. This was supported, with the thematic analysis identifying several of Kohut’s theoretical perspectives beyond the dominant theme of inadequate selfobject mirroring responses: 231 | Suicide and the intolerable state of a fragmented self a. Early life narcissistic grandiosity b. Narcissistic rage c. Idealisation d. Twinship/Alter Ego, and possibly e. The Vertical Split Each of these compensating strategies appeared to be directed toward establishing the individual as someone who is worthy of being acknowledged and loved. Reiser (1986), in his theoretical conceptualisation of the relationship between disturbances of the self and suicidal behaviour, commented that when people are: ... unable to find solace, serenity and peace in a stabilised selfobject relationship they compulsively yield themselves as selfobjects in relationship after relationship, until they are exhausted, dangerously enraged or broken hearted. When this exhaustion occurs simultaneously with a significant narcissistic defeat (for perfectionism in these children is ruthless and unsparing), then we witness a painful disintegration of the self, a subjective experience of depthless inner loneliness, pain, and suffering [e.g. psychache]. It is at such times when ... people seem driven to take their own lives (p. 241). Some of the narratives also appear to support Reiser’s argument that, ironically, although suicidal behaviour is an assault against the body, it may be a “defensive attempt to maintain self-cohesion ... to achieve psychological stabilization” (Abramowitz, 1995, p. 183). Doctors (1999) proffers the view that self-harm is often a ‘concretised’42 attempt to maintain or re-establish the organisation of their experiences in response to perceptions of disintegration; a loss of the sense of being human and of authoring their own experience. 42 Concretisation refers to the “encapsulation of [psychic] structures of experience by concrete, sensorimotor symbols” (Atwood & Stolorow, 1984, p. 85). 232 | Suicide and the intolerable state of a fragmented self The responses to the initial draft of the ASCS also support the notion of fragmentation with the suicide attempters endorsing more negative aspects of self than the suicidal ideators or controls. The ruminating style reported by suicide attempters and ideators in comparison to controls is consistent with Kohut’s (1978b, 1985b) observations that people with a fragmenting or incohesive sense of self are more inclined to brood, rather than reflect, about their lot in life. Moreover, the significance attributed to childhood experiences by suicide attempters is consistent with self psychology and psychoanalysis generally. The second hypothesis reasoned that self-cohesion could be measured is partially supported by the development of the ASCS which now requires validation. The final configuration of the instrument following a Rasch analysis of the theoretically extended Beck Self-Esteem Scale (BSE) met the criteria for good model fit. The deletion of half of the items on the BSE is not unexpected considering that self-esteem represents only one of 11 sub-categories located within the three prototypical patterns (Baumeister, 1998) of the experience of self discussed in Chapter 4. The results suggest that the construct of self can be considered to lie along a continuum of cohesion with a cohesive sense (healthy) at one end, and a fragmented or incohesive (pathological) state at the other. The individual within-group differences in the responses to each of the perceived dynamics of self in the ASCS also support, inter alia, Baumeister’s (1998) view that it is a complex construct. Abramowitz (1995) also argues that the dynamics of self are convoluted, suggesting that each “sector of a divided self carries authenticity; it is the lack of self-integration that is problematic” (p.177). This is contrary to Winnicott’s (1960) view of self, for example, that reduces the construct to a simple false/true dichotomy. Indeed, it may have been Kohut’s appreciation of, or apprehension about, the complex dynamics of the construct that discouraged him from offering an unambiguous definition (Lee & Martin, 1991; Silverstein, 2007). The results also support the final hypothesis which predicted that suicidal behaviour would be associated with self fragmentation. Not only did several suicide 233 | Suicide and the intolerable state of a fragmented self attempters make unambiguous references to an incohesive sense of self, the results of the Rasch analysis also revealed a participant group hierarchy related to their endorsement of aspects of self. That is, suicide attempters scored high on the ASCS by endorsing the more negative aspects of self than suicide ideators. Conversely, participants who did not experience any suicidality scored low because they endorsed more positive self experience questions/items. The results of the Rasch analysis suggest that, as one sense of self moves toward fragmentation, the likelihood of suicidality increases. Indeed, suicidal behaviour also appears to lie on a continuum as argued by O’Connor’s and Armitage (2003), and appears to follow a very similar developmental trajectory as self fragmentation (as measured by the ASCS). Although the use of mixed-methods design has a number of benefits, several methodological limitations may have influenced the interpretation of the data. The results of both the studies were dependent on the retrospective recall of the participants. This is particularly relevant to the qualitative analysis wherein the suicide attempters endeavoured to interpret and explain their experiences. For instance, it has been argued that self-reported motivations for engaging in any behaviour might be effected by recall bias (e.g. Ledgerwood & Petry, 2006). Recall of childhood traumatic experiences can also be biased by adulthood experiences (e.g. post and current relationships, psychopathology) and attempts to attribute meaning to current circumstances (Melchert & Parker, 1997; Simpson & Miller, 2002). Regardless of the accuracy of their autobiographical memories, the experiences for the participants appear to have had an overwhelming effect on their sense of self. Memory may not be viewed as the only problematic issue for the study, however, with a number of participants diagnosed with Borderline Personality Disorder (BPD). This population is characteristically manipulative and affectively unstable, which can be particularly problematic for researchers and clinical staff alike (Deans & Meocevic, 2006; 234 | Suicide and the intolerable state of a fragmented self Perseius, Öjehagen, Ekdahl, Asberg, & Samuelsson, 2003). Indeed, evidence of this was apparent during the interviews43 presented in the preceding chapter. Although people with BPD are frequently ascribed negative characteristics, these patients are at a high risk for suicidal behaviour (Brown, Newman, Charlesworth, Crits- Christoph, & Beck, 2004; Paris, 2002). In terms of self psychology, BPD is understood to be indicative of a devitalised self brought about by an inability to maintain defence mechanisms in response to stressors. Silverstein (2007) argues that BPD, together with paranoid and obsessive-compulsive personality disorders, are attempts to forestall fragmentation of the self, and are all characterised by ‘vulnerability to self-cohesion ruptures, potentiating fragmentation’ (p. 98). Thus, although the inclusion of participants diagnosed with BPD may, at first, appear problematic, the condition is simply another manifestation of a disordered self, and therefore should not be viewed as a confounding issue. Notwithstanding the results of the current study, further analyses are required to confirm the statistical differences in self between people who engage in suicidal behaviour and those who do not. Consequently, validation of the ASCS, and confirmation of the relationship between a fragmenting sense of self and suicidal behaviour are the subject of the final study presented in the following chapter. 43 Participant 10 (diagnosed with BPD) explained that the elevated post-interview Visual Analogue Scale: Self Harm score was intended to delay discharge. 235 | Suicide and the intolerable state of a fragmented self Chapter 11: Validation of the Adelaide Self Cohesion Scale Validation of the Adelaide Self Cohesion Scale However great a man's fear of life, suicide remains the courageous act, the clear-headed act of a mathematician. The suicide has judged by the laws of chance—so many odds against one that to live will be more miserable than to die. His sense of mathematics is greater than his sense of survival. But think how a sense of survival must clamour to be heard at the last moment, what excuses it must present of a totally unscientific nature (Greene, 1966, p. 103) 11.1 Introduction Gregory (2000) emphasises that “the merit of a psychological test is determined first by its reliability but then ultimately by its validity, [which is] ... a developmental process that begins with test construction and continues indefinitely” (pp. 95-96). The iterative nature of the process of review and refinement does not seek “to validate the test per se, but the scores derived from the test” (Benson, 1998, p. 10). The development of the Adelaide Self Cohesion Scale (ASCS) has followed what Cronbach (1989) referred to as a strong program of construct validation (see also Messick, 1995) . The scale development is also consistent with De Vellis’ (2003) eight step process of scale development, apart from the recommended expert review of items, which needs to be addressed in subsequent validity processes. For Cronbach, it is an empirically-driven process consisting of three components: substantive, structural and external. The substantive component refers to the process whereby “the theoretical domain of the construct is specified and then operationally defined in terms of the observed variables” (Benson, 1998, p. 11). This component was effectively concluded in the mixed method study presented in Chapters 8, 9 and 10. The structural component is the process of relating the items to the structure of the construct, which was the purpose of the Rasch analyses performed in Chapter 10. The final component of Cronbach’s process, and one of the aims of the present study, is the 236 | Suicide and the intolerable state of a fragmented self external stage, which seeks to demonstrate that the primary construct (in this instance self cohesion) covaries in the expected manner with suicidality. Although the results of the mixed methods study identified which theoretical variables warranted consideration as indicators of self cohesion, it was the subsequent Rasch analyses underlying the development of the ASCS that determined which of these variables fitted the model. Moreover, the results of the thematic analysis influenced how these might be meaningfully presented to participants. Nevertheless, the structure of the instrument and its effectiveness in estimating a respondent’s vulnerability to suicidal behaviour needs to be established. Messick (1995) emphasised the importance of validation being “an empirical evaluation of the meaning and consequences of measurement ...[that] combines scientific inquiry with rational argument to justify (or nullify) score interpretation and use” (p. 742). Accordingly, this study commences the final process of validation of the ASCS to determine whether the inferences made from it are appropriate, meaningful, and useful (American Education Research Association, American Psychological Association, & National Council on Measurement in Education, 1999; Cronbach, 1989). 11.2 Method Ethics approvals for the protocols employed within the study were granted by the human research ethics committees of the Royal Adelaide Hospital, South Australian Health Department, and the University of Adelaide. 11.2.1 Survey design and participants Data for this study were collected from the following sources: suicide attempters admitted to the Emergency Department of the Royal Adelaide Hospital, a random selection of respondents to the 2008 South Australian Health Omnibus Survey (described in Chapter 5) who had agreed to participate in future studies, and first year psychology students. The suicide attempters were administered the ASCS and the Mini 237 | Suicide and the intolerable state of a fragmented self Mental State Examination (MMSE)44 as in-patients, whereas the community controls from the 2008 HOS were interviewed by telephone45. The psychology students were invited to participate in an online survey (Appendix E) for course credits in the same manner as described in Chapter 8. 11.2.2 Measures Suicidal ideation within the controls and student samples was measured independently on the basis of responses to four questions contained in the severe depression sub-scale of the General Health Questionnaire (GHQ-28)(Goldberg & Hillier, 1979) described in Chapter 5. The total sample (n = 337) was aged between 17 and 88 years (M = 31.20, SD = 16.28). Males and females represented 33% and 67% of the total sample respectively (Table 11.1 refers). In terms of the group variables subject to analyses, the participant details are presented as Table 11.2. Table 11.1 Age and sex composition for the participant samples Sex Age Sample n M (% n) F (% n) M SD Community Controls (HOS) 112 52 (46) 60 (54) 50.98 14.94 Suicide Attempters 53 14 (26) 39 (74) 30.51 10.03 Psychology Students 222 64 (29) 158 (71) 20.96 5.13 Total Sample 387 130 (33) 287 (67) 31.20 16.28 No missing data 44 The MMSE was included to confirm that the participant was not experiencing any form of cognitive impairment as a result of their suicide attempt or medical care. 45As required by the SA Health HREC, data collection was performed by the same research company that undertook the 2009 HOS survey. 238 | Suicide and the intolerable state of a fragmented self Table 11.2 Age and sex composition for the suicidality groups Sex Age Suicidality Group n M (% n) F (% n) M SD Controls 250 82 (33) 168 (67) 32.76 17.99 Suicidal Ideators 84 30 (36) 54 (64) 27.00 13.12 Suicide Attempters 53 14 (26) 39 (74) 30.51 10.03 Total Sample 387 126 (33) 261 (67) 31.20 16.28 11.3 Data Analysis Descriptive and univariate analyses were performed using PASW Version 17 applying a threshold significance level of .05. Confirmatory Factor Analysis (CFA) was conducted with Mplus (Version 5, Muthén & Muthén, 2007). 11.4 Results 11.4.1 Confirmatory Factor Analysis A CFA of the RASCH-determined three factor structure of the ASCS (Table 11.3) resulted in a statistically significant chi-square goodness-of-fit index (χ² (63) = 353.267, p < .001), suggesting that the model provided poor fit to the data. However, Thompson (2004) argues that chi-square significance is “not very useful in evaluating fit of a single model” (p. 129) because these values are dependent on sample size, particularly when it exceeds 200 (see also Schreiber, Stage, King, Nora, & Barlow, 2006). Consequently, other fit indices were evaluated to justify the fit of the model. 239 | Suicide and the intolerable state of a fragmented self Table 11.3 Estimates for the ASCS Indicator Variable Estimate SE Indicator Variable Estimate SE Factor 1: Self Concept Factor 2: Transferences Needs Full–Empty 1.000 .000 Have a Voice–No Voice 1.000 .000 Self Love–Hate 1.074 .044 Acknowledged–Not Acknowledged 1.034 .039 Pleasant–Unpleasant .896 .053 Heard- Not Heard 1.063 .038 Complete–Incomplete 1.150 .062 Connected–Not Connected .832 .047 Interesting– Boring .861 .056 Treated Loyally- Betrayed .903 .051 Worthwhile– Worthless 1.048 .174 Lovable– Unlovable 1.143 .058 Desirable–Undesirable .921 .053 Factor 3: Ruminating Style Popular – Unpopular .813 .052 Deserve this? 1.000 .000 Attractive–Unattractive .853 .054 React this way? 1.132 .065 Powerful– Powerless .976 .056 Problems? 1.282 .070 Energetic .951 .064 Handle things better? 1.248 .071 In Control-Not in Control 1.166 .062 Wish gone better? 1.162 .068 *Two tailed p-value all <.001 The Absolute Fit Index (AFI) (McDonald, 1989; McDonald & Marsh, 1990) was calculated to examine the significant chi-square result. This index was chosen because it does not depend on comparisons with other models or the observed data (Tabachnick & Fidell, ሺχమିௗሻ 2007). The calculation is expressed as: AFI = expቔെǤͷ ቕ. The realised AFI value of ଵ .52 is below the recommended minimum of .9 (Hu & Bentler, 1999) which, like the significant chi-square result, suggests that the model would benefit from further refinement. Nevertheless, the Tucker and Lewis Index (TLI) (Tucker & Lewis, 1973) and the Comparative Fit Index (CFI) (Bentler, 1990) were acceptable at .920 and .929 respectively (Heubeck & Neill, 2000). The Standardised Square Root Mean Square 240 | Suicide and the intolerable state of a fragmented self Residual (SRMR) was also acceptable at .043, whereas the Root Mean Square Error of Approximation (RMSEA) coefficient of .109 was above the commonly accepted ceiling of .08 (Heubeck & Neill, 2000). It is notable that consensus has not yet been reached on the level of acceptability for the RMSEA value. Nevertheless, given the complexity of the model (Figure 11.1) and the sensitivity of RMSEA (and TLI) to model complexity (Potthast, 1993), and the acceptability of the SRMR value, the model was considered an acceptable fit (Schreiber et al., 2006). .789* Full .464* .833* Self Love .783* Pleasant .836* Complete .724* Interesting .310* Worthwhile .879* Self Lovable Concept .800* Desirable .744* Popular .752* .459 Attractive .799* Powerful .707* .847* Energetic .700* In Control .874* Voice .921* Acknowledg .738* .935* Transference Heard Needs .742* Connected .744* Loyalty .569* .750* Deserve .854* React Ruminating .883* Problems Style .865* Handle .835* Wishing Figure 11.1 CFA measurement of the ASCS, with all the coefficients significant* at p<.001 241 | Suicide and the intolerable state of a fragmented self Within the factor Self Concept, the indicator variables Full and Self Love appear to covary, but are retained separately because of the differences in meaning attributed to each; similarly, the variables Desirable and Attractive. Although the coefficient value of .310 for Worthwhile suggested that this latent variable be removed, the variable was retained because removing it did not improve the model. 11.4.2 Univariate Analyses To demonstrate construct validity, a one-way between-groups analysis of variances (ANOVA) was performed to explore the differences between suicidality group membership and self cohesion as measured by the ASCS. The scores were weighted by the three factor coefficients identified by the CFA and presented in Figure 11.1. There were no violations of assumptions, with an insignificant Levene statistic for the test of homogeneity of variances, and the scores on the ASCS were normally distributed. There was a significant difference between the ASCS scores for the three groups (attempters, ideators and controls): F(2, 384) = 193.22, p < .001, with a large effect size46, calculated using eta squared (η2), of .49. Age and biological sex were not statistically significant. Independent-samples t-tests revealed a statistically significant difference between the mean ASCS scores for each of the groups. The highest group mean difference was between the Attempters and controls: t (301) = 20.78, η2 = .59, p <.001 (two-tailed). The mean attempter score was 88.58 points higher than controls, whereas the ideator scores were 20.30 higher that controls: t (332) = 5.33, η2 = .08, p < .001 (two- tailed). The second highest group mean difference of 68.23 was between the Ideators and Attempters: t (135) = 11.64, η2 = .50, p <.001 (two-tailed). 46 The interpretations of effect sized follow Cohen’s (1988) proposed guidelines 242 | Suicide and the intolerable state of a fragmented self 11.5 Discussion The present preliminary study examined the psychometric properties of the ASCS by applying confirmatory factor and univariate analyses. Although the two Rasch analyses presented in the previous chapter identified those items which provided good model fit, the ASCS is an amalgamation of the results of both. Consequently, the structure, reliability, and validity of the instrument warranted examination. Overall, the results of the CFA supported the three factor model by indicating an adequate model fit, which is a positive result considering the complexity of the model and the construct of self. Nevertheless, a caveat is warranted: several indices recorded borderline values in terms of the criteria for acceptability of fit, indicating that further scale development is necessary. The significant differences in means between the groups demonstrated that the ASCS is highly sensitive to differences in self cohesion as reflected in suicidality. Interestingly, the results of the CFA, like those of the Rasch analyses, suggested the removal of the indicator variable Worthwhile. Although removing the item did not improve the model, its role in self concept requires further investigation. It is not unexpected that some of the indicator variables appear to covary given the complexity and subjective nature of the self, and illustrates the difficulty in capturing the essence of the construct. The demonstrated relationship between the latent variables is consistent with the theory of self psychology. In explanation, the adequate satisfaction of childhood transference needs has a profound impact on self concept, and attempts to establish or maintain a cohesive sense of self are frustrated by a brooding rumination style, which inhibits reflective problem solving. Although the results indicate that current self concept has a greater association with suicidality, autobiographical memories of early life transference experiences continue to influence one’s sense of self. The statistical insignificance of biological sex and age is also consistent with Kohut’s theories and the results of examination of the relationship between self, sexuality and suicidal behaviour 243 | Suicide and the intolerable state of a fragmented self presented in Chapter 7. Indeed, the development and maintenance of self is primarily dependent on selfobject transferences and is not simply the product of cultural mores or biological determinants. The results also demonstrate that the ASCS score is a valid indicator of the level of self cohesion, and can reliably discriminate between controls, suicidal ideators and suicide attempters, and thus provides further support to the relationship between a fragmented or incohesive sense of self, and suicidal behaviour. A number of limitations of the present study need to be acknowledged. The large number of university students may have influenced the results as this population is not representative of the general community. Unfortunately, this sample of convenience was necessary because the South Australian Department of Health’s Human Research Ethics Committee was not prepared to allow suicidal ideating participants from the 2008 Health Omnibus Survey (HOS) to be interviewed by telephone. The requirement to administer the ASCS to each in their home was beyond the available resources, as was the option of including the ASCS in a subsequent HOS. Finally, the effect of administering the scale online (students) or by telephone (controls) is unknown and requires further investigation. In summary, the ASCS appears to be a psychometrically sound measure of self cohesion with good preliminary reliability and validity. Nevertheless, further evaluation and refinement of the instrument is warranted to improve model fit. Given the heterogeneity of the sample, the three factor structure of the measure needs to be tested for invariance within a clinically homogenous group. 244 | Suicide and the intolerable state of a fragmented self Chapter 12: Concluding Discussion : Concluding Discussion An individual with negative early life experiences is likely to disregard self-preservation when coping with stress, however, and instead resort to coping that involves dissociation and perhaps self-destruction (Orbach, 2006, p. 195) 12.1 Chapter Overview This final chapter summarises and discusses the information presented in the preceding sections, and addresses the implications of the findings, methodological issues, and future research directions. Suicide remains a significant social challenge worldwide, with the World Health Organisation (2009) reporting that approximately one million people die by their own hand each year. In spite of the development of effective clinical interventions and the introduction of prevention strategies, the international suicide rate continues to increase. Moreover, the behaviour continues to resist an adequate explanation in spite of the exponential growth in the suicidality literature over the preceding 50 years. Adding to these concerns is the limited efficacy of therapeutic practices. Linehan (2006) noted that, despite the research and the “evident suffering of the individuals who ultimately kill themselves, attempt to do so, or wish to die, there is remarkably little research on whether therapeutic interventions ... are effective” (p. xiii) in reducing suicidal behaviour. Accordingly, the principal objective of this dissertation was to examine whether the application of Heinz Kohut’s theory of self psychology (e.g. Kohut, 1972, 1977, 1985b) could contribute further to understanding suicidality. Overall, the results indicate that one’s sense of self is a core determinant of individual vulnerability to suicidal behaviour, and that the theory of self psychology offers direction and understanding about how a cohesive sense of self can be developed and 245 | Suicide and the intolerable state of a fragmented self maintained. Significantly, the findings demonstrate that the theory of self psychology offers a plausible explanation of the individual differences in vulnerability to experiences of suicidality. This has a several important implications for clinical interventions and prevention strategies. 12.2 Theoretical Review 12.2.1 The Theory of Self Psychology Kohut’s theory of self psychology is a psychoanalytic approach to understanding the human experience. From Kohut’s perspective, the development and maintenance of a cohesive and healthy sense of self is the primary psychological objective of the human experience. This is achieved largely through positive early-life transference patterns with significant others (selfobjects): mirroring (the need for applause), idealisation (the need for security), and twinship/alter ego (the need to belong). Figure 12.1 illustrates the process of developing a cohesive sense of self. NOTE: This figure is included on page 246 of the print copy of the thesis held in the University of Adelaide Library. Figure 12.1 The process of empathic self object transferences (adapted from Kahn, 1985). 246 | Suicide and the intolerable state of a fragmented self Each transference pattern is analogous to a self regulatory psychological strategy available to realise a cohesive sense of self. Driven by the innate need for a reciprocal exchange between self and selfobject, the optimal frustration resulting from the inadvertent errors in transference experiences evokes the process of self adaption that, in turn, brings about the development of a mature and healthy sense of self. Consequently, the presence of age-inappropriate transferences is often indicative of unmet selfobject needs, and symptomatic of a fragmented or fragmenting sense of self. The theory of self psychology holds that the experience of self fragmentation is the most intolerable state of anxiety, from which people will do almost anything to escape (Baker & Baker, 1987; Kohut, 1984). 12.2.2 The Construct of Self Although there is no consensus on the definition of self, the argument has been made that the self is not simply a Western construct as some have suggested, but is a uniquely defining human characteristic. Nevertheless, it is acknowledged that one’s sense of self develops within a culturally determined environment, and is to some extent influenced by these experiences. However, self is a significantly subjective state – the “putative nucleus” (Berrios & Markova, 2003, p.9) of the human experience. Accordingly, Kircher and David’s (2003) definition of the self has been accepted as an adequate definition of the construct: the commonly shared [subjective] experience, that we know we are the same person across time, that we are the author of our own thoughts/actions, and that we are distinct from the environment. It is the immediate, pervasive, automatic feeling of being a whole person, different from others, constant over time [with a past, present and future], with a physical boundary, the centre of our experience (p.2). 247 | Suicide and the intolerable state of a fragmented self Furthermore, autobiographical memory appears to play a significant role by functioning to make sense of past memories in a manner that directs present and future behaviour, and provides a cohesive sense of self across one’s lifespan. Autobiographical memory is also essential for protoconversation; that is, the ability and need for a reciprocal exchange between self and selfobject. 12.3 Fight, Flight or Fragment One original contribution to theory resulting from the current project is the proposed extension to Cannon’s (1929) fight-flight response, which may further current understandings of psychological stress and suicidal behaviour. The adaptive process of evolution has resulted in the innate physiological survival response of responding to stressors by engaging (fight) or withdrawing (flight). The human executive system, however, appears to be unique in its capacity to generate psychological distress in the absence of a physical stressor and to project a sense of entrapment into the future (Williams, 1996). This is exacerbated by the active function of seeking to establish a sense of mastery (even if this is illusionary) by exerting control of self and the environment (Baumeister, 1998). Research has demonstrated that an inability to establish control can lead to several psychological issues such as mood disorders and impaired learning (e.g. Allan et al., 2007; Weems & Silverman, 2006). It might be argued that this intolerable space is analogous to learned helplessness (Seligman, 1975) in animals. However, studies of learned helplessness (maladaptive passivity) in animals frequently induce artificial external stressors that are only transiently encountered in the natural environment. For example, animals may be trapped by a predator, but this distressing experience is transient and resolved by death or escape. To subject an animal to artificially prolonged experiences of physiological distress and extrapolate this to human experiences is arguably anthropomorphic. Alloy and Seligman (1979) conceded that “[a]ll that is directly observed [in maladaptive passivity] is the fact that the organism fails to respond after successful 248 | Suicide and the intolerable state of a fragmented self responding [and is] ... is a theoretical inference” (p.231). Bekerian’s (1984) critique of the reformulated helplessness hypothesis (Abramson et al., 1978) concluded, inter alia, that the concept of helplessness requires further specification and that the theory is susceptible to notions of frames (i.e., perspectives for viewing acts, outcomes, or contingencies). All of these perspectives require the ability to project into the future, and all are uniquely characteristic of human executive functioning. Unfortunately, one cannot escape a psychological stressor in the same manner as avoiding a predator, and without the resources to either fight or flight, the proposed consequence is an intolerable state of a fragmented self which is, for some, a desperate space wherein self-induced annihilation is the best solution. 12.4 Primary Research Findings 12.4.1 Individual Differences The studies presented in Chapter 5 identified a theoretical gap in the literature by demonstrating that the relationship between psychological distress and suicidal behaviour is not a sufficient explanation for suicidality. Although the results of study 1 were consistent with other reports (e.g. Gili-Planas et al., 2001), in that psychological distress was associated with suicidal behaviour, the reverse does not appear to be the case. That is, not all highly distressed people experience thoughts of self harm. Despite those participants in the Very High category of psychological distress being 77 times more likely to report experiencing suicidal ideation compared to those in the Low category, only 52% reported having suicidal thoughts. Indeed, the demonstrated significance of individual differences provided the opportunity to examine Kohut’s perspective. Study 2 introduced Kohut’s idea of an intolerable and fragmenting sense of self, and revealed that it is a relatively common experience for those with thoughts of suicide. Some sense of personal fragmentation was detected in 43.2% of the participants. A subsequent analysis revealed that those participants who reported more 249 | Suicide and the intolerable state of a fragmented self frequent self fragmenting experiences were 72 times more likely to also experience suicidal ideation than those who had not experienced a sense of coming apart. 12.4.2 Self, Trauma and Suicidal Behaviour Studies 3 and 4 examined self psychology’s theory of trauma in the context of suicidality. To recapitulate, Kohut’s theory of trauma emphasises the function of the self and selfobjects within the traumatic experience. The results of the examination of two separate epidemiological data sets supported the distinction between trauma as an external event and trauma as a subjective experience. Trauma appears to be best understood in terms of its proximal relationship with self. For example, participants who had experienced traumatic events considered to violate one’s sense of self were 41 times more likely to have suicidal thoughts in comparison to those who had no traumatic experiences. When additional self stressors are present, such as a life-threatening cardiovascular disease, people with experiences of violations of self are 133 times more likely to report suicidal ideation than participants who did not report such experiences. Both studies also revealed that biological sex is not a statistically significant factor in terms of experiencing suicidal ideation in response to a stressor. This is a consistent finding in all of the studies, and supports the argument that one’s sense of self is not primarily determined by cultural mores, but is a deeply subjective experience that is common to both sexes. Moreover, one’s sense of self appears to be the primary influencing factor in the interpretation of the meaning associated with a traumatic event. Thus, the process appears to be that when the effect of a traumatic event is moderated by a cohesive sense of self the subjective experience of trauma does not occur. 12.4.3 Self, Sexuality and Suicidality Study 5 explored the role of sexuality and suicidal behaviour. The results are consistent with the contemporary view of self psychology that sexuality is a “core and coherent an experience as any structure of self” Harris, 1991, p. 197), and as a principal component of self is also an organiser of subjectivity. Furthermore, the findings 250 | Suicide and the intolerable state of a fragmented self complement the suicidality literature in that there is a clear relationship between selfobject transferences, sexual orientation (the gendered self) and suicidality. In terms of suicidal behaviour, both gay and bisexual orientations were more likely to have these experiences than heterosexuals. Bisexuality appears to be the strongest predictor, with participants in this group almost six times more likely to report a suicide attempt than heterosexuals. Similarly, bisexuals were four times more likely to ideate about suicide than heterosexuals. Sexual orientation, rather than biological sex, is significantly associated with suicidality. Importantly, the theory of self psychology offers a plausible explanation of individual differences in vulnerability to suicidality by explaining how the developmental process of sexual identity can be a traumatic experience. The results also suggest that gender might be a more useful research variable in suicidality (and psychological research generally) than biological sex. 12.4.4 Self Cohesion The mixed methods study clearly demonstrated the validity of the theory of self psychology and resulted in the preliminary development of the Adelaide Self Cohesion Scale (ASCS). All of Kohut’s principal ideas such as early life narcissistic grandiosity, narcissistic rage, and selfobject transferences were evident in the early-life experiences of those participants who experienced suicidal behaviour. These experiences were particularly obvious during the disclosures of the suicide attempters in the qualitative study. The results of studies 6 and 7 also support the understanding that the stability of self can be understood in terms of a continuum, commencing with a healthy cohesive state at one end, and a fragmented and maladaptive state at the other. The development of the ASCS followed Cronbach’s (1989) and De Vellis’ (2003) recommended approach to construct validation and illustrated that self cohesion can be measured. Of the original 36 proposed self concept items, the Rasch analyses identified 23 that fitted the model. For the ruminating subscale, all five brooding items fitted the model. However, unlike the hierarchical results of the self-concept subscale, the 251 | Suicide and the intolerable state of a fragmented self responses to each brooding item did not clearly discriminate between suicidal groups. Nevertheless, the total brooding scores were revealing, with suicide attempters recording greater brooding frequencies that ideators or controls. The preliminary validation attempt (study 8) supported the three factor model, although a number of indices did not meet, or were considered borderline against the accepted criteria for fit. The findings underscore the necessity to continue the process of validation in an effort to further refine the ASCS. Notwithstanding the requirement to further develop the measure, the results demonstrate that the scale is a useful measure for understanding psychological distress. It also illustrates that the development and maintenance of a cohesive and healthy sense of self (as measured by the scale) is an important psychological objective and is significantly associated with one’s vulnerability to suicidal behaviour. To that end, negative childhood transferences appear to frustrate or inhibit the development of a stable sense of self, whereas negative self concept and a brooding ruminating style undermine individual mastery and attempts to maintain or restore the stability of self. Notwithstanding the results of this thesis, it has yet to be determined whether the ASCS specifically measures self cohesion, or simply reflects Kohut’s general theoretical approach to the development and maintenance of a cohesive sense of self. 12.4.5 Comparisons with Existing Literature Contemporary theories of suicidality, when examined against the results of the studies presented in this thesis, do not impose a different interpretation on the data, although there are obvious differences in emphases. Rather, the comparative examination revealed that there appears to be an unstated rapprochement of theories currently underway as researchers and clinicians seek to overcome concerns about the inability of the literature to fully explain suicidal behaviour and the effectiveness of therapeutic interventions. Ellis’ (2006) effort to synthesise the seemingly disparate body of research (cognitive, behavioural, psychodynamic and social), and the development of 252 | Suicide and the intolerable state of a fragmented self the discipline of Neuro-psychoanalysis discussed in Chapter 3, are evidence of this. Within many of these perspectives, the influence of self and the presence of the intolerable state of self fragmentation are either implicitly or explicitly acknowledged. For example, Beck’s cognitive theory relating to suicidality and depression noted the common experience of conceptualising crises as “untenable or hopeless” (cited by Brown, Jeglic, Henriques, & Beck, 2006, p. 54). Similarly, Neimeyer and Winter’s (2006) discussion on suicidality in the broad context of Kelly’s (1955) personal construct theory noted the significance of personal differences, self, “and fragmenting systems of meaning that once provided a coherent self-narrative” (p.155). Orbach’s (1994, 2006) interest in what makes suicide possible, has resulted in a theory grounded in developmental and psychodynamic theory. Orbach, like Kohut, acknowledges the significance of intolerable early-life selfobject transferences47, and the potential for “estrangement between body and self” (Orbach, 2006, p. 195). The theory argues that there are various subjective facilitating factors (e.g. dissociative experiences) that increase a person’s vulnerability to suicide. Firestone’s (1997) recent psychodynamic separation theory also acknowledges the influence of negative early-life self object experiences (particularly parental hostility) on the role of self. Unlike Kohut, however, separation theory is primarily focused on negative thought processes (inner voice) than the structuralisation of self. Within the theory, self is conceptualised differently and presented as a dichotomous process of opposing self and antiself agencies. This concept of division of the mind holds that “people are divided between the self and the forces within them that oppose or attempt to destroy the self” (Firestone, 2006, p. 121). Thus, suicidal behaviour is considered indicative of “the extreme end of a continuum of destructive mental process, that results in the ultimate annihilation of self” (p.143). Notwithstanding the complementary nature of the results with many contemporary suicide theories, the findings do raise questions about some therapeutic interventions, 47 Orbach does not apply psychoanalytic language, but applies contemporary terms such as attachment, attunement and emotional communication 253 | Suicide and the intolerable state of a fragmented self which do not acknowledge the demonstrated relationship between early-life experiences and an individual’s vulnerability to psychopathology and suicidal behaviour. For example, the increasingly popular approach of Positive Psychology (Seligman, 1999; Seligman & Pawelski, 2003) which, “at first blush ... offers a seductive discourse, with much promise” (Fineman, 2006, p. 270). Positive Psychology claims to study those processes and circumstances “that contribute to the flourishing or optimal functioning of people” (Gable & Haidt, 2005, p. 103), and “offers an appealing vision of the recovered good self” Fineman, 2006, p.273). The school emerged in response to psychology’s alleged preoccupation with pathological behaviour. Rather than focus on the study of negative behaviour, Positive therapists seek to “ignite and nurture an individual’s potential for intrinsic, positive valuation, even though the goal may be external to the actor” (Fineman, 2006, p. 270). In doing so, the reciprocity of the relationship between positive and negative emotions is ignored. Instead, positive emotions such as happiness, love, and hope are fervently promoted to the near absolute exclusion of negative experiences, resulting in what Held (2004) considers to be an abandonment of the significance of individual differences. Positive psychologists appear to promote a moral agenda, which is unlikely to move perceptions of suicidal behaviour, for example, beyond the unhelpful past influences of religion or state. Explaining the rationale for the positive approach, Peterson and Seligman (2003, cited by Fineman, 2006) asserted that there is “a clear difference between people who are not suicidal and not self deprecating ... versus those who bound out of bed in the morning with smiles on their faces and twinkles in their eyes. The latter individuals can only be studied by measuring happiness” (p. 275). This broad and simplistic comment does little to advance understandings of psychological distress and appears to implicitly dismiss alternative research foci. It is also at odds with the adaptive benefits of some negative experiences in the development of one’s sense of self. Such benefits are not 254 | Suicide and the intolerable state of a fragmented self only acknowledged by psychoanalytic theorists, but within the broader contemporary psychological community. Tennen and Affleck (2003), for example, wrote that the “individual’s capacity to sustain an integrated and textured experience of himself or herself is an indicator of emotional maturity” (p. 167). Within the positive school, some have recognised the flaw of what critics refer to as the separation thesis (e.g. Held, 2004), and appreciate the necessity for both negative and positive experiences in personal development. Positive psychologists Larson, Hemenover, Norris, and Cacioppo (2003) demonstrated this with their comment that negative emotions “ may allow individuals to make sense of stressors, to gain mastery of future stressors, and to transcend traumatic experiences (p. 212). The studies presented herein suggest that the promoted positive virtues of love, hope and acceptance would be more effective if employed during early-life transference experiences to promote the development of a cohesive sense of self. Of further concern is the possibility that any perceived failures by clients to realise the promoted benefits of a positive attitude in isolation to negative experiences may be counterproductive and exacerbate an individual’s already distressed state. Overall, the findings are consistent with, and extend, several research directions and the associated literature on suicidality and psychological distress. In particular, the results support the theory of self psychology and demonstrate that Kohut’s paradigm has utility in terms of understanding individual differences in vulnerability to suicidal behaviour. In regard to the discipline of self psychology, Reiser’s (1984), Kay’s (1989), and Abramowitz’s (1995) contributions appear to be the only attempts to apply Kohut’s perspective to suicidality, although Doctors (1999) discussed how some self-cutting behaviour can represent “an attempt to counteract the experience of self loss and the consequent threat of personal annihilation suffered when the milieu is experienced as insufficiently affirming or assaulting” (p. 743). In characteristically psychoanalytic 255 | Suicide and the intolerable state of a fragmented self fashion, these authors draw on clinical examples to advance the theory of self psychology. Nevertheless, they all recognised the adverse effects associated with attempts to realise satisfactory selfobject transference experiences. Reiser (1984) made the observation that unmet transference needs “too often ... [result in] unbearable inner pain and the compulsion to seek peace through the ultimate act of self-destruction” (p. 241). Shneidman (1987), Williams (1999b), and Orbach and Mikulincer (2002), for example, are amongst many who have noted the intolerable mental pain associated with suicidality, and incorporated this understanding in their contributions to the subject. Nevertheless, examining the psychic structures that give rise to these experiences has been largely overlooked. On the other hand, the importance of lived experiences, particularly early life experiences, has been emphasised by several researchers. For example Jobes (2006) and Orbach (2006) support an existentialist and humanistic approach to understanding suicidal behaviour, with Orbach specifically noting the deleterious effects associated with negative childhood experiences. Importantly, this thesis provides further support to the importance of recognising the subjective authenticity of an individual’s lived experience in understanding the attraction of suicide as a means of annihilating intolerable distress. The statistical significance of the relationship between sexual identity (gender) and suicidality is consistent with the results of contemporary literature on the vulnerability of members of the Lesbian, Gay, and Bisexual communities (e.g. Meyer, 2003; Savin- Williams & Ream, 2003). However, the results undermine the traditional approach of researching and reporting suicidality in terms of biological sex. Notwithstanding the frequent practice of reporting simple prevalence rates by sex (e.g. Australian Bureau of Statistics, 2008; World Health Organisation, 2009), several studies have also found non significant results for this variable. For example, Fairweather-Schmidt’s (2007) 256 | Suicide and the intolerable state of a fragmented self examination of suicidality in an Australian community-based sample, reported the non- significance of sex after controlling for psychopathology and physical illness. 12.5 Implications 12.5.1 Clinical Implications The results support the assertion that the focus of any clinical intervention should be directed toward the specific mechanisms underlying the behaviour itself (e.g. O'Connor et al., 2007; Shafran, Cooper, & Fairburn, 2002, 2003), and enhancing the cohesiveness of self. Moreover, there appears a place in therapy for theory of self psychology beyond the psychoanalytic school whereby the development of a healthy and resilient self can be fostered. The findings, in particular those in regard to individual differences, explain why no single therapeutic approach is considered best practice in response to suicidal behaviour (O'Connor & Sheehy, 2000). This is an endorsement of the argument for therapists to develop a broad repertoire of evidence based intervention techniques that can be arranged to suit the client’s needs (e.g. Yalom, 2002). Similarly, the results validate structured clinical intervention processes such as the Collaborative Assessment and Management of Suicidality (Jobes & Drozd, 2004) discussed in Chapter 1. Moreover, this project has clearly demonstrated that therapists cannot ignore the environment in which the client’s sense of self developed or those experiences that have thwarted attempts to develop maintain or restore stability of the self. 12.5.2 Prevention Strategies The findings also suggest that prevention strategies, particularly psychoeducation, would benefit from including a focus on the development and maintenance of a cohesive sense of self. Anecdotally, people do not appear to be aware of the consequence of environmental influences on the development of the brain, and consequently one’s sense of self. Rather, the view within folk psychology seems to be that neurological development is analogous to an automated production line and that 257 | Suicide and the intolerable state of a fragmented self a child is resilient and thereby immune to exposure of negative experiences. Informing significant others, particularly parents and carers, of the long term significance of positive transference experiences for their children, and providing sufficient public resources to promote and encourage this would, most likely, be reflected in a reduced vulnerability to suicidal experiences. 12.5.3 Research Implications A number of issues beyond the obvious application of self psychology warrant further research. First, the subjective experiences of participants need to be acknowledged and controlled for to overcome possible confounding influences. Indeed, Beautrais (2000) criticised many population-based studies for not controlling for personal and social factors, which may have resulted in spurious findings. Second, gender rather than sex needs to be applied as a demographic variable to suicide. It is acknowledged that categorising gender is not a simple matter; however, some developmental researchers have applied sexual identity measures such as the Kinsey Scale (Kinsey, Pomeroy, & Martin, 1948; Kinsey, Pomeroy, Martin, & Gebhard, 1953) in an attempt to overcome this (e.g. Diamond, 2000). Nevertheless, the existing scales have been criticised as inadequate or inappropriate measures of identity (for a review see Coleman, 1987; Sell, 2007), and the issue appears to be largely unresolved. Thirdly, research needs to be directed toward identifying the critical periods necessary for the optimal development of healthy neurological substrates underlying individual differences in self construct. 12.5.4 Implications for Self Psychology Psychoanalytic theory has long been criticised for its seemingly simple and controversial explanations of the complexity of the human mind, its early preoccupation with sex, and its failure to move forward from its traditional culture of language and case studies toward evidence contributions to contemporary understandings within mainstream psychology (e.g. Cioffi, 1998; Torrey, 1993). These alienating characteristics 258 | Suicide and the intolerable state of a fragmented self of what Breger (2000) considered to be the beginning of a science have, to a large extent, undermined the potential utility of psychodynamic thought. It is acknowledged, however, that psychodynamic psychologists are increasingly applying experimental methods in an effort to integrate the theories of psychoanalysis with the science of psychology (Burton, Westen, & Kowalski, 2009). Although self psychology has developed divergent understanding from the traditional psychodynamic school, it nonetheless attracts the same criticisms. The results of this thesis have empirically demonstrated the utility of Kohut’s theories in terms of some suicidal behaviour (and psychological distress generally), and is an endorsement of the move towards an evidence base discipline. Arguably, the development of the ASCS as a measure of the principle focus of self psychology should facilitate this. 12.6 Methodological Considerations Although the use of mixed methodology has several benefits, this project has a number of limitations that warrant consideration when interpreting the findings. The results of all the studies were dependent upon the retrospective recall of participants, which is problematic when the participants attempt to interpret their own experiences, particularly recollections of abuse (Simpson & Miller, 2002). Ledgerwood and Petry (2006) also argue that recall bias may affect self-reported motivations for engaging in a particular behaviour. The inclusion of tertiary students in the development and preliminary validation if the ASCS could have confounded the results as this population is not representative of the community at large. Characteristically, suicidal behaviour (particularly attempted suicide) has a low base rate among the community. This has a significant impact on research as it influences the ability to detect effects as sample sizes are often inadequate. For the most part, however, the strength of this thesis is the large representative sample sizes in most of the studies. Several other strengths and limitations have been noted within the presentations of the studies and need not be reiterated. 259 | Suicide and the intolerable state of a fragmented self 12.7 Future Research The overall findings identified the need to include, within intervention and prevention strategies, an existential focus that addresses self cohesion, and the associated negative self experiences. To that end, the following specific objectives for future research are suggested: a. Further develop and explore the proposed fight, flight or fragment response to stressors in an effort to normalise the appeal of suicide as an escape from intolerable mental pain. b. Continue the validation process of the Adelaide Self Cohesion Scale as a useful measure of vulnerability to psychological distress, and subsequent suicidal behaviour. c. Develop a therapeutic approach to suicidal behaviour that directly addresses the client’s sense of self, or incorporate the theory of self psychology within existing non-psychoanalytic therapies. d. Examine whether psychoeducation directed toward the development and maintenance of one’s sense of self would benefit prevention strategies; and e. Develop a valid measure of sexual identity to replace the existing demographic variable of biological sex. Simultaneously, researchers might consider avoiding the term ‘gender’ when they are referring to sex. 12.8 Concluding Comment This thesis has investigated whether the theory of self psychology has utility in terms of advancing current understandings about suicidality. The results demonstrated that one’s sense of self is a (or the) core determinant of vulnerability to suicidal behaviour and psychological distress. 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Measurement of mood. Proceedings of the Royal Society of Medicine, 62, 993-996. Ziabreva, I., Poeggel, G., Schnabel, R., & Braun, K. (2003). Separation-induced receptor changes in the hippocampus and amygdala of octodon degus: Influence of maternal vocalizations. Journal of Neuroscience, 23, 5329-5336. Appendices Appendix A: Information sheet: Mixed methods study Appendix B: Draft Adelaide Self Cohesion Scale Appendix C: Adelaide Self Cohesion Scale Appendix D: Information sheet: Validation of Adelaide Self Cohesion Scale Appendix E: Screen shot of LimeSurvey – participant view 316 | Suicide and the intolerable state of a fragmented self APPENDIX A School of Psychology Faculty of Health Sciences University of Adelaide INVITATION TO PARTICIPATE IN A RESEARCH PROJECT INVESTIGATING THE RELATIONSHIP BETWEEN IDENTITY AND SELF-HARM This is a research project and you do not have to be involved. If you do not wish to participate, your medical care will not be affected in any way. Also, you may withdraw from the project at any time after you have commenced. My name is Peter Chamberlain and I am a postgraduate student within the School of Psychology and Discipline of Psychiatry at the University of Adelaide. I am currently undertaking a study of self-harming behaviours and am inviting people who have placed their lives at risk to take part in my study as volunteers. Considerable research has been directed toward the reasons why people attempt to harm themselves and much is now known about the relationship between this behaviour and issues such as psychological distress or trauma. However, there remain a number of people whose actions are not yet fully understood. The aim of this study is to examine what role perceptions of the self contribute to this behaviour. The self refers to how we see and understand ourselves as individuals and as part of groups such as families or friends. Or put another way, our private identity that is only completely known to ourselves. I am looking for common themes or patterns about perceptions of the self that might be helpful in explaining why people place their lives at risk. If you choose to participate, you will be asked to answer a short questionnaire to establish whether you are able to engage in an interview or not. In the event you are unable to continue, alternative arrangements can be made for another time. You will also be given a simple diagram on which to indicate the strength of your intention to harm yourself. We will then simply engage in a conversation about your life experiences such as your recollections as a child, relationships with others and how you believe these have contributed to your sense of self. The interview length is not fixed but will not exceed 60 minutes. The interview will be recorded; however, the information you provide will be treated confidentially and you will not be identified. The information will not be shown to anyone else other than my two supervisors. Again, you are free to withdraw from participation at any time, and if you chose to do so your medical care will not be affected in any way. If you wish to speak to someone not directly involved in this study about the ethical issues, your rights as a participant, or about the conduct of the study, you may contact the Chairman, Research Ethics Committee, Royal Adelaide Hospital on 8222 4139. Student Researcher: Peter Chamberlain 83033850 0448 208 895 Supervisors: Professor Robert Goldney Associate Professor Paul Delfabbro Department of Psychiatry School of Psychology University of Adelaide University of Adelaide 82224229 83035744 317 | Suicide and the intolerable state of a fragmented self Royal Adelaide Hospital CONSENT FORM PROTOCOL NAME: A thematic analysis of the perceptions and experiences of the self: qualitative interviews with suicide attempters. RESEARCHERS: Professor Robert Goldney, Associate Professor Paul Delfabbro, Mr Peter Chamberlain 1. The nature and purpose of the research project has been explained to me and I have received a copy of the invitation to participate. I understand it, and agree to take part. 2. I understand that I may not benefit from taking part in the trial. 3. I understand that, while information gained during the study may be published, I will not be identified and my personal results will remain confidential. 4. I understand that I can withdraw from the study at any stage and that this will not affect my medical care, now or in the future. 5. I have had the opportunity to discuss participating in this study with a family member or friend. Name of Subject: ………………………………………… Participant ID …………… Signed: …………………………………………………………… Dated: …………… I, Peter Chamberlain, certify that I have explained the study to the participant and consider that he/she understands what is involved. Signed: ……………………………………………………… Dated………… School of Psychology & Discipline of Psychiatry Faculty of Health Sciences University of Adelaide 318 | Suicide and the intolerable state of a fragmented self DRAFT ADELAIDE SELF COHESION SCALE APPENDIX B * Describe your beliefs about yourself on each of the lines below. Mark an ‘X’ at the point along the line which best indicates your evaluation of yourself at the time you self harmed Very Much ….…………….Slightly…………………..Very Much Successful Unsuccessful Attractive Unattractive Popular Unpopular Independent Dependent Honest Dishonest Desirable Undesirable Strong Weak Smart Dumb Powerful Powerless Lovable Unlovable Pleasant Unpleasant Beck Self-Esteem Scale Scale Self-Esteem Beck Efficient Inefficient Responsible Irresponsible Participant ….. ID Date Administered ….. /2008 Generous Selfish Modified Modified Worthwhile Worthless Interesting Boring Knowledgeable Ignorant Peaceful Angry Shame Proud School of Psychology & Discipline of Psychiatry University of Adelaide 319 | Suicide and the intolerable state of a fragmented self Very Much …….…………….Slightly………………….. Very Connected Disconnected Self Love Self Hatred Kind Cruel Energetic Lethargic Complete Incomplete Safe Threatened Vitalised Devitalised Full Empty Beck Self-Esteem Scale Scale Self-Esteem Beck Friendly Hostile Free Trapped Participant ….. ID /2008 ….. Administered Date Modified Modified Cautious Impulsive Needs not met Needs met as as a child a child Not close to Close to carer carer as a as a child child Good Bad Heard Not Heard Voice No Voice Not Acknowledged Acknowledged 320 | Suicide and the intolerable state of a fragmented self APPENDIX C Ψ Adelaide Self Cohesion Scale ID Sex Age Instructions: Please record your sex and age above. There are three sections to this scale printed on both sides of this sheet; please answer all the questions in each section by marking the point that best reflects your answer. For example: Loveable ooooooooooooo Unlovable Section 1: Self Concept Describe your current beliefs about yourself in respect to each of the descriptive lines below: Full o o o o o o o o o o Empty Self - Love o o o o o o o o o o Self - Hate Pleasant o o o o o o o o o o Unpleasant Complete o o o o o o o o o o Incomplete Interesting o o o o o o o o o o Boring Worthwhile o o o o o o o o o o Worthless Lovable o o o o o o o o o o Unlovable Desirable o o o o o o o o o o Undesirable Popular o o o o o o o o o o Unpopular Attractive o o o o o o o o o o Unattractive Powerful o o o o o o o o o o Powerless Energetic o o o o o o o o o o Tired In Control o o o o o o o o o o Not in Control Section 2: Transference Needs Describe your beliefs about your childhood experiences: Had a Voice o o o o o o o o o o No Voice Acknowledged o o o o o o o o o o Not Acknowledged Heard o o o o o o o o o o Not heard Connected o o o o o o o o o o Not Connected Treated loyally o o o o o o o o o o Betrayed PLEASE TURN OVER AND COMPLETE SECTION 3 321 | Suicide and the intolerable state of a fragmented self Section 3: Ruminating Style Please read each of the items below and indicate what you do when you feel sad, down or depressed. Please indicate what you generally do, not what you think you should do. a. Think “What am I doing to deserve this” Almost Never o o o o o o o o o o Almost Always b. Think, “Why do I always react this way?” Almost Never o o o o o o o o o o Almost Always c. Think, “Why do I have problems other people don’t have?” Almost Never o o o o o o o o o o Almost Always d. Think, “Why can't I handle things better?” Almost Never o o o o o o o o o o Almost Always e. Think about a recent situation wishing it had gone better? Almost Never o o o o o o o o o o Almost Always For Researcher: 1: 2: 3: Σ: Cat University of Adelaide School of Psychology & Discipline of Psychiatry 322 | Suicide and the intolerable state of a fragmented self APPENDIX D School of Psychology & Discipline of Psychiatry Faculty of Health Sciences University of Adelaide INVITATION TO PARTICIPATE IN A RESEARCH PROJECT INVESTIGATING THE RELATIONSHIP BETWEEN IDENTITY AND SELF-HARM This is a research project and you do not have to be involved. If you do not wish to participate, your medical care will not be affected in any way. Also, you may withdraw from the project at any time after you have commenced. My name is Peter Chamberlain and I am a postgraduate student within the School of Psychology and Discipline of Psychiatry at the University of Adelaide. I am currently undertaking a study of self-harming behaviours and I am inviting people to take part in my study as volunteers. Considerable research has been directed toward the reasons why people attempt to harm themselves and much is now known about the relationship between this behaviour and emotional distress. The aim of this study is to examine what role perceptions of the self contribute to this behaviour. The self refers to how we see and understand ourselves as individuals and as part of groups such as families or friends. Or put another way, our private identity that is only completely known to ourselves. I am looking to validate or confirm the results of an earlier study which resulted in the development of the Adelaide Self Cohesion Scale, which you will be asked to complete. If you choose to participate, you will be asked to answer a short questionnaire to establish whether you are able to engage in an interview or not. In the event you are unable to continue, alternative arrangements can be made for another time. You will then be given the Adelaide Self Cohesion Scale to complete about your sense of self. This should not take more than 15 minutes. If you are confused about any part of the questionnaire you may ask questions or offer comments. The information you provide will be treated confidentially and you will not be identified. The information will not be shown to anyone else other than my two supervisors. Again, you are free to withdraw from participation at any time, and if you chose to do so your medical care will not be affected in any way. If you wish to discuss your involvement with a family member or friend, you are free to do so and may delay signing the consent form and completing the questionnaire until you have had a chance to do this. If you wish to speak to someone not directly involved in this study about the ethical issues, your rights as a participant, or about the conduct of the study, you may contact the Chairman, Research Ethics Committee, Royal Adelaide Hospital on 8222 4139. Student Researcher: Peter Chamberlain 83033850 0448 208 895 Supervisors: Emeritus Professor Robert Goldney Associate Professor Paul Delfabbro Department of Psychiatry School of Psychology University of Adelaide University of Adelaide 82224229 83035744 323 | Suicide and the intolerable state of a fragmented self Royal Adelaide Hospital CONSENT FORM PROTOCOL NAME: Validation of the Adelaide Self Cohesion Scale: The relationship between suicidal behaviour and the construct of self. RESEARCHERS: Emeritus Professor Robert Goldney, Associate Professor Paul Delfabbro, Mr Peter Chamberlain 1. The nature and purpose of the research project has been explained to me and I have received a copy of the invitation to participate. I understand it, and agree to take part. 2. I understand that I may not benefit from taking part in the trial. 3. I understand that, while information gained during the study may be published, I will not be identified and my personal results will remain confidential. 4. I understand that I can withdraw from the study at any stage and that this will not affect my medical care, now or in the future. 5. I have been given the opportunity to discuss participating in this study with a family member or friend. Name of Subject: ……………………………………… Participant ID ……………… Signed: ……………………………………………………………… Dated: ……………… I, Peter Chamberlain, certify that I have explained the study to the participant and consider that he/she understands what is involved. Signed: ……………………………………………………… Dated…………..... School of Psychology & Discipline of Psychiatry Faculty of Health Sciences University of Adelaide 324 | Suicide and the intolerable state of a fragmented self APPENDIX E Screen Shot LimeSurvey – Participant View Online survey - validation of Adelaide Self Cohesion Scale Section 1 1: Describe your current beliefs about yourself on each of the lines below by clicking on the point along the line which best indicates your evaluation of yourself or how you feel. * 4: Please choose the appropriate response for each item: Popular 2 3 4 5 6 7 8 9 10 Unpopular * 3: Please choose the appropriate response for each item: 1 10 Attractive 2 3 4 5 6 7 8 9 Unattractive * 28: Please choose the appropriate response for each item: 1 Full 2 3 4 5 6 7 8 9 10 Empty * 10: Please choose the appropriate response for each item: 1 10 Powerful 2 3 4 5 6 7 8 9 Powerless * 24: Please choose the appropriate response for each item: 1 10 Energetic 2 3 4 5 6 7 8 9 Lethargic 325 | Suicide and the intolerable state of a fragmented self