From Psychological Strain to Disconnectedness
A Two-Factor Model Theory of Suicide
The Social Integration Theory of Suicide
About 120 years ago, Emile Durkheim in his book Suicide: A Study in Sociology elaborated his social integration theory of suicide (Durkheim, 1897/1951). Simply speaking, social integration is the degree to which a person feels connected to or accepted by a group or society. A person with a high level of integration feels accepted and loved by others and should have a low chance of suicide. A person with a low level of integration feels unwanted, excluded, or rejected by others and should have a high chance of suicide.
Durkheim used the concept of social integration to explain the higher suicide rate among those people who lack social connections. People who were single, divorced, or never married had fewer connections to others in society and were less likely to feel part of the larger community. Concerning religion, Protestants were more likely to die of suicide than Catholics or Jews, because the religious practices of the latter two religions emphasized the development of closer ties among their members than the former did. As to gender, since in most societies men have more freedom and are more independent than women, it can lead some men to feel that they have fewer significant relationships with other people and that it would be an admission of weakness to seek advice or comfort from others. This can lead to feelings of being cut off from a group or community. Therefore, men are at higher risk of suicide than women are worldwide. In sum, people who do not develop close ties or connectedness with others are more likely to die of suicide. Durkheim's association of social integration with suicide rate is still relevant today. People who attempt suicide are much more likely to say they feel lonely and isolated from others (feeling of thwarted belonging and perceived burdensomeness) and claim disconnections from society, confirming what Durkheim hypothesized over 100 years ago. The social integration theory of suicide has been widely tested and supported since its inception in 1897. Stack (2000) reviewed the findings of 84 sociological studies published over a 15-year period that dealt with tests of the modernization and/or social integration perspectives on suicide. He found the strongest support for social integration theory came from research on marital integration, wherein more than three quarters of the studies reported a significant relationship. Another notable study was conducted by Duberstein and colleagues (2004). Using a case–control psychological autopsy design, they compared 86 suicides and 86 living controls 50 years of age and older, and found that the association between family and social/community indicators of poor social integration and suicide is robust and largely independent of the presence of mental disorders. Besides the effect on suicide, social integration also has an impact on health. People who are married, live in a family, go to church, and connect to their community tend to be healthy both physically and mentally (Berkman, Glass, Brissette, & Seeman, 2000). However, although lack of social integration is closely related to suicide, it is by no means the cause of suicidal ideation. Low integration facilitates suicide when a person has suicide in mind.
The Interpersonal Theory of Suicide
The interpersonal theory of suicide (Joiner, 2005; Van Orden, Smith, Chen, & Conwell, 2015) suggests that suicide is likely to happen to an individual who has experienced thwarted belonging, perceived burdensomeness, and acquired capability, and claims that this social disconnectedness plus the means and environment is the cause of suicide. Since its inception in 2005, the theory has been supported by numerous evidence-based studies, which all found a strong correlation between social disconnectedness/capability and suicide/suicidal ideation/suicidal behavior. The correlation is true and unarguable; however, it is not the root or ultimate cause of suicide. Let us look at the analogy with cancer development. When a person is diagnosed with malignant tumorous disease, if the immune system is not strong enough, recovery with treatment is still possible. If the patient does not rest enough, does not observe his/her diet, or does not mentally take it easy, the illness could become worse. All these activities have nothing to do with the causes of cancer. Likewise, social disconnectedness and capability cannot be the root causes of suicidal mentality/thought. Many people in daily life feel constantly lonely, guiltily burdensome to others, and have easy access to suicide means, but most of them never think of suicide and have never tried suicide. For them, the immune system is weak, but they have not been infected with the disease. The disease is the cause. Stopping the disease or virus infection constitutes the primary level of prevention, while strengthening the immune system belongs to the secondary level of prevention. Strengthening the social connectedness or social integration and reducing the acquired capability or lethal means are only secondary to suicide prevention, which is less important and effective than finding the real causes of suicide. As facilitators of suicide, disconnectedness, operationalized by thwarted belonging and perceived burdensomeness, is actually Durkheim's lack of social integration. However, credit must be given to the interpersonal theory of suicide for including the measurement of these concepts, which Durkheim did not accomplish. The Interpersonal Needs Questionnaire (INQ) was devised by Van Orden, Witte, Gordon, Bender, and Joiner (2008) to measure the thwarted belonging and perceived burdensomeness proposed in the interpersonal theory of suicide. As these two elements are not sufficient to produce suicidal behavior in individuals, the Acquired Capability of Suicide Scale (ACSS) is added as one of the three measures for the INQ. Suicide capability can be acquired in various ways, including previous self-harm or injury, experiences (such as participating in a war), childhood experiences of abuse, and having a risk-taking approach to life (Joiner, 2005). To sociologists, Joiner's interpersonal theory of suicide is merely an operationalization of Durkheim's social integration theory of suicide and does not add any new information to the root or the ultimate cause of suicide. Joiner's thwarted belonging and perceived burdensomeness can be understood as social disconnectedness, and are at most two indicators of the latent variable called low social integration. Disconnectedness can facilitate suicidal behavior. When an individual is extremely frustrated and hopeless about life with thoughts that living is not worth the psychological pain, he or she is likely to end their life if social integration is low or absent. Social integration can be the immune system in suicide etiology. Thwarted belonging, perceived burdensomeness, and social disconnectedness are all indicators of a weak immune system against suicide. What caused the suicidal thought in the first place? What happened before the individual became extremely frustrated and hopeless about life with thoughts that living is not worth the psychological pain? The answers to these questions, if we can find them, should be the cause of suicide. Let us look at the analogical example of cancer development again. The cancerous virus or genes are definitely the cause of the disease. They exist in more people than can be identified. In other words, some of the infected people will develop malignant tumorous illness and some will not. The different immune mechanisms in the body distinguish those who are ill and those who are healthy. Those who are infected with cancerous cells and do not have a strong immune system will become sick. Those who do not originally have a strong immune system can build and strengthen it through exercise, diet, psychological adjustment, etc.
In sum, neither Durkheim's social integration theory nor Joiner's interpersonal theory explains the cause of suicide. Instead, the theories illustrate the facilitations of suicide or of the immune system against suicide. The theories might account for the conditions that are sufficient for suicide, but we still need to find the condition that is necessary for suicide. If increasing social integration is to strengthen the immune system (to decrease the sufficient conditions) against suicide, what is the necessary condition (cause) for suicide? Where did the suicidal virus or disease come from? In other words, what makes a person determined to die to begin with? To sociologists, the answers can only be found in the social structure, the environment, and the life of those individuals. The strain theory of suicide postulates that psychological strains usually precede a suicidal thought or determination.
The Three-Step Theory of Suicide
Klonsky and May (2014) suggested that an ideation-to-action link should guide suicide research in its theoretical development and prevention measures. They argued that the development of suicidal ideation and the progression from ideation to suicide attempts are two distinct processes. The three-step theory of suicide proposed that suicidal ideation is a function of the combination of pain (physical or psychological) and hopelessness. Then, social disconnectedness is a major risk factor for escalating suicidal ideation. Third, the theory views the progression from suicidal ideation to suicide attempts as being facilitated by acquired capability that includes dispositional and practical contributors to the capacity to attempt suicide (Klonsky & May, 2015). The three-step theory of suicide is a further development based on previous suicide theories of social integration by Durkheim (1897/1951) and interpersonal interaction by Joiner (2005). Social connectedness in the theory's second step is a protective factor against suicide, similar to social integration as proposed in Durkheim's theory, and the acquired capability, dispositional characteristics, and environment, etc. all facilitate the progress from suicidal ideation to suicide attempt. Klonsky and May's contribution in their new theory is the separation of Joiner's thwarted belonging/perceived burdensomeness and acquired capability into two different steps. The first step in the three-step theory of suicide is pain coupled with hopelessness as the motivation for suicidal ideation. Different sources of pain can lead an individual to a decreased desire to live. Pain can be physical or psychological or both (Baumeister, 1990; Ratcliffe, Enns, Belik, & Sareen, 2008). The theory argues that pain alone is not sufficient to produce suicidal ideation. If someone living in pain has hope that the situation can improve, the individual will likely focus on attaining a future with diminished pain rather than on the possibility of ending his or her life (Klonsky & May, 2015). For this reason, hopelessness is also required for the development of suicidal ideation. In other words, the combination of pain and hopelessness, or some inescapable pain, is what causes suicidal ideation to develop (May & Klonsky, 2013). However, the pain theory of suicide motivation is not new to us. Shneidman (1998) articulated a pain theory of suicide focused on individual factors, with psychache – psychological and emotional pain that reaches intolerable intensity – as the primary factor causing suicide motivation. Further, psychache is intolerable because there is no way out or it is an inescapable situation (Shneidman, 1985). Intolerable physical pain and inescapable psychological pain must be a major cause of suicide motivation, but neither Shneidman nor any other previous theorists have posited a parsimonious framework to account for the sources of the intolerable, unbearable, or inescapable nature of the pain. In sum, the three-step theory of suicide has separated the interpersonal theory of suicide into two parts. Social disconnectedness as measured by thwarted belonging and perceived burdensomeness is a major risk factor for escalated suicidal ideation, and acquired capability contributes to the actual action to suicide. For suicidal ideation, the three-step theory of suicide blames (explains it with) pain and hopelessness, in other words, inescapable and intolerable pain. But what caused the pain and hopelessness in an individual? Do we need to explore the mechanism by which the inescapable and intolerable pain developed in suicidal people? The strain theory of suicide may answer these questions.
The Strain Theory of Suicide: The Etiology of Suicide
Lack of social integration or lack of social connectedness plus acquired capability may escalate the progression from suicidal ideation to suicide attempt, but neither the social integration theory of Durkheim (1897/1951) nor the interpersonal theory of suicide of Joiner (2005) addressed the real cause of suicide, the cause of suicide motivation. One may argue that individuals who killed themselves did so because they were living in a condition without friends or family caring about them and with easy access to suicidal means such as firearms or lethal pesticides, but these are not the causes of the suicide. Likewise, we cannot say that the recent massacre in Paris was caused by the AK47s or even the terrorists. They were simply instrumental for a war of hate. Rather than being etiological, lack of social integration, low connectedness, and high capability are at most instrumental as facilitators of suicidal ideation, implying the sufficient condition in a causal link. Now the question is: "What is the necessary condition in the causal link of suicide?" Pain coupled with hopelessness seems to be the motivation for suicidal ideation, as the etiological cause of suicide, but the three-step theory of suicide by Klonsky and May (2015) did not elaborate on the comprehensive sources of psychological pain or the mechanism by which the pain becomes intolerable and the situation hopeless. The theoretical advances in this framework will help with a better understanding of the etiological cause of suicide so as to prepare for the awareness and education of society at the primary (upstream) level of suicide prevention. The strain theory of suicide posited that suicide is usually preceded by some psychological strains (Zhang, 2005; Zhang, Wieczorek, Conwell, & Tu, 2011). A strain is not simply a pressure or stress. People may frequently have the latter but not necessarily the former in daily life. A pressure or stress in daily life is a single-variable phenomenon, but strain is made up of at least two pressures or two variables. Similar to the formation of cognitive dissonance (Festinger, 1957) but more serious and detrimental than cognitive dissonance, a strain pulls or pushes an individual in different directions, so as to make the individual frustrated, upset, angry, or even painful. Examples include at least two differential cultural values, aspiration and reality, one's own status and that of others, and a crisis and coping ability. Like cognitive dissonance, strain is psychological frustration or even suffering for which one has to find a solution so as to reduce it or do away with it. But in truth, it is more serious, frustrating, threatening, and even painful than cognitive dissonance. The extreme solution for an unsolved strain is suicide. There are four sources of psychological strain that may cause suicidal ideation. Each of the four types of strain is derived from specific sources. A source of strain must consist of at least two conflicting social facts. If the two social facts are noncontradictory, there should be no strain.
Strain Source 1: Differential Values
When two conflicting social values or beliefs are competing in an individual's daily life, the person experiences value strain. The two conflicting social facts are the two competing personal beliefs internalized in the person's value system. A cult member may experience strain if the mainstream culture and the cult religion are both considered important in the cult member's daily life. Other examples include second-generation immigrants in the United States who have to abide by the ethnic cultural rules enforced in the family while simultaneously adapting to the American culture with peers and school. In rural China, young women appreciate gender egalitarianism advocated by the communist government, but at the same time they are trapped in a culture of sex discrimination traditionally cultivated by Confucianism. Another example that might be found in developing countries is the differential values of traditional collectivism and modern individualism. When the two conflicting values are taken as equally important in a person's daily life, the person experiences great strain. When one value is more important than the other, there is no strain (Zhang & Zhao, 2013).
Strain Source 2: Reality Versus Aspiration
If there is a discrepancy between an individual's aspiration or goals and the reality the person has to live with, the person experiences aspiration strain. The two conflicting social facts are one's ideal or goal and the reality that may prevent one from achieving it. An individual living in the United States expects to be wealthy or at least moderately successful as other Americans do, but in reality the means to achieve the goal is not equally available to the person because of his/her social status or for other reasons. Aspirations or goals can be aiming to get into a particular college, wanting to marry an ideal partner, and striving for a political cause, etc. If the reality is far from the aspiration, the person experiences strain. Another example may be found in rural China. A young woman aspiring to equal opportunity and equal treatment may have to live within the traditional and Confucian reality, exemplified by her family and village, which does not allow her to reach that goal. The larger the discrepancy between aspiration and reality, the greater the strain will be (Zhang, Kong, Gao, & Li, 2013).
Strain Source 3: Relative Deprivation
In the situation where an extremely poor individual realizes other people of the same or similar background are leading a much better life, the person experiences deprivation strain. The two conflicting social facts are one's own miserable life and the perceived wealth of comparative others. A person living in absolute poverty, where there is no comparison with others, does not necessarily feel bad, miserable, or deprived. On the other hand, if the same poor person understands that other people like him/her live a better life, he or she may feel deprived and upset about the situation. In an economically polarized society where the rich and poor live geographically close to each other, people are more likely to feel this discrepancy. In today's rural China, television, newspapers, magazines, and radio have brought home to rural youths how relatively affluent urban life is. Additionally, the young people who went to work in the cities (dagong) and returned to the village during holidays with luxury goods and exciting stories make the relative deprivation seem even more realistic. An increased perception of deprivation indicates a relatively greater strain for individuals (Zhang & Tao, 2013).
Strain Source 4: Deficient Coping
When facing a life crisis, some individuals are unable to cope with it and consequently experience coping strain. The two conflicting social facts are the life crisis and the appropriate coping capacity. Not everyone who experiences a crisis will experience strain. A crisis may be only a pressure or stress in daily life, and those individuals who are not able to cope with the crisis have strain. Crises such as loss of money, loss of status, loss of face, divorce, death of a loved one, etc. may lead to serious strain individuals who do not know how to cope with these negative life events. A high school boy who is constantly bullied and ridiculed by peers may experience great strain if he does not know how to handle the situation. Likewise, a Chinese rural young woman who is frequently wronged by her mother-in-law may feel strain if she is not psychologically ready to cope with the bad situation with support from other family members and the village. The less experienced in coping, the stronger the strain when a crisis occurs (Li & Zhang, 2012). The Psychological Strain Scales (PSS) have been developed for each of the four types of strains. The 60-item instrument (with 15 items for each strain) and the shortened 40-item instrument (with 10 items for each strain) have been validated with both US and Chinese samples (Zhang et al., 2014; Zhang & Lyu, 2014). The link from psychological strains to suicide has also been supported by a number of studies in the US and China (Li & Zhang, 2012; Sun, Li, Zhang, & Wu, 2015; Sun & Zhang, 2015; Yan, Zhang, & Zhao, 2012; Zhang & Lester, 2008; Zhang et al., 2011). Credit should be given to earlier sociologists and criminologists in the development of our strain theory of suicide. From Durkheim's anomie theory (Durkheim, 1893/1960), to Merton's strain theory of crime (Merton, 1938), and to Agnew's general strain theory of deviance (Agnew, 1992), these prior theories serve as foundations for the current strain theory of suicide. For example, the reality versus aspiration strain was mentioned earlier by Merton (1938) as a centerpiece of strain – narrowly defined in terms of failure to achieve financial success. Cohen (Cohen, 1965) then further developed this notion, and Agnew (2006a) broadened it to include a variety of gaps (not just for financial success) between reality and expectations as well as aspirations. Agnew also used a generalized simple concept – simply loss of a valued object such as a spouse or job or health (Agnew, 2006a, 2006b). Similarly in the strain theory of suicide, strain has to be perceived as unjust and harsh for it to trigger criminality (Agnew & Messner, 2015). The consequence of unjust and harsh perception is frustration, anger, and hopelessness, as conceptualized in the strain theory of suicide. The value conflict in the strain theory of suicide can also be traced to earlier ecological work on role conflict and suicide rates. An older study shows that female labor force participation was associated with greater female suicide rates and male suicide rates (Stack, 1978). Some follow-up studies replicated what was found earlier on role conflict in the US for a sample of other nations (Cutright & Fernquist, 2001; Pampel, 1998). These ecological studies associating role conflict and suicide rates at the national level reveal psychological value strains as risk factors of suicide. The strain theory of suicide is different and one step above previous strain theories, which all intend to explain how a crime develops but do not address suicide or suicidal thought as a deviant behavior. Although elements of aspiration strain and value strain can be found in previous studies on suicide, they were not conceptualized, generalized, or integrated into one single parsimonious theory as in the strain theory of suicide, which postulates that each suicide can be preceded by a psychological strain resulting from any or all of the following: value conflict, unreachable aspiration, relative deprivation, and coping deficiency. Another contribution of the strain theory of suicide is its individual-level measurements (Zhang et al., 2014; Zhang & Lyu, 2014), which provide far more detailed and better measures of the strains than do the vast majority of criminologists and suicidologists. Many of them work only with crude ecological data – for example, correlating the GINI index of income inequality with homicide rates or female labor force participation with suicide rates, as in some works on a large sample of whole nations.
The Two-Factor Model Theory of Suicide
Psychological strains cultivated in a social structure with negative life events can be the etiological reason for suicidal ideation and suicidal behavior, and social disconnectedness plus high capability may escalate the progression from ideation to behavior. Analogically, psychological strains can be a virus in the population that has affected a number of individuals, but only those with high social integration or connectedness and low capability (i.e., a strong immune system) may dodge suicide (i.e., a fatal disease). Further, psychological strains, which need to be understood as intolerable pain with hopelessness, can be the necessary condition that creates suicidal mentality, and lack of social integration or low connectedness and high capability may all be sufficient conditions for suicide. Figure 1 illustrates the parallel comparisons discussed here.
The two-factor model theory of suicide is a synthesis of the strain and integration theories. A similar model can be found in criminological studies. For example, relative deprivation (income inequality) will lead to crime only when integration (religion and family integration) is low. Strain creates pressures and incentives to engage in a crime, and social integration buffers the tendency toward deviant behavior (Messner & Rosenfeld, 1994–2013). Here we are elaborating a two-factor model of suicide theory, with the concepts of necessary and sufficient conditions. The strain theory of suicide lays out the necessary condition of a suicidal mind, while the interpersonal theory of suicide describes the sufficient condition for suicidal behavior. The two factors are interdependent in causing a suicide to happen. The strain theory of suicide details the sources of psychache of Shneidman (1998) and intolerable pain of Klonsky and May (2014), and the interpersonal theory of suicide operationalizes the concepts of social integration of Durkheim (1897/1951). Suicide can happen for various reasons, but we believe the social world and human behaviors operate with the same patterns as those found in the natural world. Social scientists are committed to finding the patterns in the social world and in human behavior. For human suicide, our aim is to identify a parsimonious theory so as to better understand this human behavior and design better measures for its prevention. The two-factor model theory of suicide, a parsimonious framework combining the strain theory of suicide and the interpersonal theory of suicide, might be the key in this quest. The strain theory of suicide accounts for the causes of suicidal ideation (Factor I), and the interpersonal theory of suicide lays out the major risk factors of suicidal behavior for those who already have suicide in mind. Since social disconnectedness and capability are seen as a factor after a suicidal thought in the model route, low connectedness and high capability can be moderators for the link from psychological strains to suicidal behaviors. An individual with intolerable pain, hopelessness, and psychological strains may seek killing him/herself to end the physical or psychological torture, and lack of social support and/or a prosuicidal environment will expedite the progression to suicide. On the other hand, a situation where the suicidal individuals experience friendly support and/or no facilitation will decrease the chance of their suicide attempt. As illustrated in Figure 2, in the link from psychological strains to suicide, disconnectedness and capability play the role of moderator. Mental disorders can be comorbid with suicide, both caused by psychological strains as a function of social structure. The role of mental disorders in suicide and the relationship between psychological strains and mental disorders are to be discussed in other work.
To test the two-factor model theory of suicide, large population data need to be obtained with sophisticated measurements of the critical variables for a comprehensive examination of the different roles played by psychological strains and disconnectedness/capability in suicidal behavior. Fortunately, we have established measures for both factors. The significance of establishing the two-factor model theory of suicide is twofold: The interpersonal theory of suicide offers the basis for the secondary level of prevention of suicide in selective and high-risk populations, while the strain theory of suicide provides the basis for the primary level of prevention in universal populations.
Dr. Zhang is Professor of Sociology at SUNY Buffalo State, USA, and Visiting Professor and Director of the Center for Suicide Prevention Research (CSPR) he established in 2011 at Shandong University in China. He has been studying suicide with NIMH grants and has published papers on both risk factors and theoretical conceptualization.
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