Discursive Constructions of the Suicidal Process

Dariusz Galasinski, Justyna Ziólkowska

• Publisher: Bloomsbury Academic
• Year: 2020
• ISBN:
  9781350107717
• Edition: 1
• Topic: Filología
• Subtopic: Sociolingüística

What is suicide? When does suicide start and when does it end? Who is involved? Examining narratives of suicide through a discourse analytic framework, Discursive Constructions of the Suicidal Process demonstrates how linguistic theories and methodologies can help answer these questions and cast light upon what suicide involves and means, both for those who commit an act and their loved ones. Engaging in close analysis of suicide letters written before the act and post-hoc narratives from after the event, this book is the first qualitative study to view suicide not as a single event outside time, but as a time-extended process. Exploring how suicide is experienced and narrated from two temporal perspectives, Dariusz Galasinski and Justyna Ziólkowska introduce discourse analysis to the field of suicidology. Arguing that studying suicide narratives and the reality they represent can add significantly to our understanding of the process, and in particular its experiences and meanings, Discursive Constructions of the Suicidal Process demonstrates the value of discourse analytic insights in informing, enriching and contextualising our knowledge of suicide.

1

Introduction

This book is about what a person does just before either taking their own life or attempting to. What happens a day, an hour, ten minutes before the suicidal act and death itself? We look at stories of the suicide process, accounts of what happens in the time leading to suicide. When does suicide start? When does it end? Who is involved? What does the act of suicide involve and mean?

We found to our continuing surprise that suicide and suicide attempts have so far been seen as events, moments outside time. They have never been studied as a process in which people do things which lead to their suicidal death and all those things which accompany them. Rather, in suicidology, the suicidal process is usually studied as the period between the first thoughts/wish of death and the suicidal act; others restrict the suicidal process to the last episode of thoughts/wish of suicide which preceded the particular suicide act. Suicidologists are interested in the chronology of events concomitant with subsequent elements of the process, as well as the relationship between the temporality of the process and psychological and socio-demographic variables.

We are interested in what happens in the time around the suicidal act. To date, no such insight has been offered. Suicide continues to be treated as a homogeneous event, outside time, without structure and ‘contents’. It is seen as a dot on the timeline without reflection on what the person about to kill themselves does at the most critical and tragic moment of their life.

Despite repeated and more and more frequent calls from suicidology for a significant increase in qualitative bottom-up research (e.g. Hjelmeland & Knizek, 2010), qualitative research into suicide and/or suicide attempts remains rare, while research into the context-situated suicidal process does not exist. In this book, we aim to offer a narrative perspective on suicide and its process. With its discursive, qualitative perspective, we offer insight into the experience of the suicidal process from the point of view of those who have engaged in suicidal actions. We also want to continue arguing for text-based discourse analysis as an important tool in understanding and deconstructing suicide.

Furthermore, despite the fact that much of the evidence related to suicide and its process is textual, discourse analysis has barely engaged with the issue and such evidence. Therefore, our book is also an attempt to offer a new perspective for discourse analysis. We would like to show not only how useful discourse analytic insights into issues related to suicide can be but also that these insights can be of use in suicide prevention activities.

Aims of the book

The main aim of the book is to offer a discourse analytic insight into stories of the process of suicide, written both in the farewell letters of those who have killed themselves and in the narratives of those who have survived their suicide attempt. We are interested in unpicking what is constructed to happen in the time before the act, how the people involved are constructed and, finally, how the act of taking one’s life is positioned in such narratives. In such a way, this book will focus on the basic model of the suicide process: the situation and activities immediately before a person takes their life.

And so, in this book we are interested in the narrated trajectory of the suicidal process. What are the constructions of its course, its beginning and its end? We are also interested in constructions of those involved in the suicide process. How does the person taking their life construct themselves at various stages of their journey? How do they position themselves in terms of control and agency? Finally, we are interested in how the act of suicide is constructed in the narratives of the process, and what the constructed role and function of communication about suicide is.

In sum, we shall be exploring discourses from people who were probably at the most dramatic juncture of their lives. We are interested in their accounts of that juncture as a time-extended process leading to an act aimed at killing them. We want to do this in a way which has not been done before: by analysing accounts of the suicide process focusing predominantly, though not exclusively, on the linguistic and discursive form through which the individuals construct themselves and the reality in which they position themselves.

But our book has another aim. To our knowledge, this is the first book in which an attempt is made to combine two sets of data: interviews with individuals with experience of a suicide attempt and suicide notes. Indeed, suicidology looking at suicide and suicidology interested in suicide notes seem to be almost entirely separate disciplines which barely come into contact with each other.

While research into suicide notes is quite large, it pales in comparison to the study of suicide itself (Scourfield et al., 2012 report 30,000 such articles since 1980). On the other hand, the voluminous Oxford Textbook of Suicidology and Suicide Prevention (Wasserman & Wasserman, 2009), containing 134 chapters and 872 pages, mentions suicide notes on one page. The later International Handbook of Suicide Prevention (O’Connor, Platt & Gordon, 2011), with only 36 chapters and 677 pages, contains no reference to suicide notes. The second edition of the handbook (O’Connor & Pirkis, 2016), with 823 pages, mentions suicide notes on only four pages and it is always just in passing. Suicide notes are not only not a priority in mainstream suicidology but also it seems they are hardly of interest.

By combining a corpus of interviews and a corpus of suicide notes, we want to show that the two corpora offer complementary insights and can and probably should be analysed next to each other. Since we suggest increased effort towards qualitative suicidology, the work on what seems to be separate areas of research should be combined in text-based suicidological research.

The book’s projects

This book arises out of our frustration with the dominant discourses of suicidology. Time and again, we see suicide constructed as a single, largely uncomplicated event which can be explained by a set of risk factors. We want to challenge this assumed simplicity of suicide. Suicide does not just happen; it consists of a set of activities which are constitutive of it.

And so, in contrast to the dominant suicidological views, we want to show the drama of suicide. We want to show that suicide has a start, takes time and effort, has an end, and the end does not necessarily have to come with death or loss of consciousness. We want to show that the suicide process extends beyond the attempt or applying of lethal action to oneself. And so, the first project of the book is to bring attention to the complexity of suicide.

This book, as we intimated before, is about the most dramatic event of anyone’s life. So, it is about people’s suffering. The stories that we heard in interviews and read in suicide notes were heart-wrenching. They were stories of rejection and self-rejection, failure, concealment, topped with unconditional love and yearning for reciprocity which in most cases never came. We were in touch with raw human misery. We hope that this book will do them justice. Also, as we delve into their suffering, we want to give it a voice. That is to say, we want to show their stories as they happened, not as we retell them. This is the second project of the book.

Now, even though our book is largely polemical, the third project is to offer a new perspective on suicide and suicide prevention. We see ourselves as critical friends of those endeavours and believe that qualitative perspectives in suicidology offer new and important contributions to efforts in preventing suicide. By understanding experiences of suicide, we begin to understand its social meanings and, through this, we begin to understand better how to design preventative interventions. And so, we are interested in setting up a dialogue between qualitative discourse analysis and the mainstream discourses of suicide, both in suicidology and in suicide prevention.

Suicide

‘Each suicide drama occurs in the mind of a unique individual’ (Shneidman, 1996: 5). Shneidman’s famous words about suicide reflect well the perspective on suicide we want to take in this book. In contrast to the dominant suicidological view, we want to focus on the individual experiences of people who decide to take the step of killing themselves. We want to understand suicide and its process as a socially situated act which, in contrast to what Shneidman proposes, does not only happen in a person’s mind but also happens in a particular social context through which suicide is made sense of by both the person who kills themselves and those who stay behind and must understand what happened.

Deaths by suicide are high. Every forty seconds someone in the world takes their life, making up not quite a million a year (WHO, 2019). Hudzik and Cannon (2014) report that more people die in suicidal acts than through wars or murder. According to Eurostat, in 2016 the suicide rate in the European Union was 10.33 suicides per 100,000 people. The lowest (3.89/100,000) was in Cyprus; the highest was in Lithuania (28.27/100,000). Moreover, researchers indicate that these figures are more than likely to be underestimated by at the very least 10 per cent, reaching, potentially, even 50 per cent (Silverman, 2006)! There are, of course, even more suicide attempts. Cautious estimates indicate that the number of suicide attempts is 10–15 times greater than the number of suicides; however, the American Foundation for Suicide Prevention (AFSP) estimates that 0.6 per cent of adults aged 18 or older have made at least one suicide attempt (AFSP, 2019).

Men commit suicide considerably more than women do and considerably so in high-income countries. This is the essence of the so-called gender paradox in suicide. Canetto and Sakinofsky (1998) observe that, while women have a higher incidence of suicide ideation and behaviour, more men kill themselves. The numbers are quite worrying. Men’s suicide rates had been increasing in the twentieth century (Cantor, 2000; see also Lemieux, Saman & Lutfiyya, 2014; cf. Atkinson, 1978; see also Shiner et al., 2009). Globally, in 2016 the male–female suicide ratio was 1.75:1; in Europe, it reached 3.47:1 and is the highest in the world, whereas in some European countries it is significantly higher. For example, in our native Poland the male–female suicide ratio goes beyond 7:1; in Lithuania, it is just under 7 (WHO, 2018). More men than women take their lives in almost all countries in the world; according to the United Nations’ World Health Organization (WHO) in 2016, there were only seven countries (from 183 listed) where women take their lives more frequently than men.

One could even say that being a man is the highest risk factor with regard to taking your life. Moreover, men’s suicide rate is rising. Indeed, suicide amongst men has been described as a silent epidemic. These rates differ according to age. In the United Kingdom, suicide is the biggest killer of men under fifty and it is a very sobering fact that as many as 42 per cent of men considered taking their own life, as the UK’s Office for National Statistics (ONS) reports (ONS, 2019a). To end with a particularly shocking US statistic, by age eighty-five the ratio of suicide between males and females was 53:1 (Szanto, Prigerson & Reynolds, 2001).

Over the centuries, attitudes towards suicide have changed significantly. In ancient Greece, suicide was accepted, especially if it was done for an important reason (e.g. bereavement, illness, honour; O’Connor & Sheehy, 2000). This tolerant attitude started to change with the rise of Christianity and the commandment not to kill, under which suicide fell. Suicide became an act against the ‘natural law’ (Hecht, 2013). In consequence, a person who killed themselves became a perpetrator of a crime (Marsh, 2013; Minois, 2001).

The beginning of the nineteenth century brought a new perspective on suicide. It was the first time that suicide was seen as either an illness or a symptom of an illness (Hacking, 1990; Marsh, 2010). Doctors received powers to secure, treat, control and assess suicide (Hacking, 1990). Nowadays, the common assumption is that suicide is a result of mental health problems (Battin, 1995; Marsh, 2010; Pridmore, 2011). A person who takes their life is represented as someone who suffers psychologically and kills themselves when in a bad psychological state. Common are publications in which authors state that you cannot commit suicide unless you are mentally ill (e.g. Harris & Barraclough, 1997; Jamison, 2004; Mościcki, 1997). A medicalized view of suicide is adopted beyond psychiatry; it is, for example, adopted by WHO.

Indeed, the medical view of suicide has recently been strengthened. In the DSM-5, the American Psychiatric Association (APA) indicated that it would look into suicidal behaviour with a view to determine whether it should be treated as a mental disorder, called Suicidal Behavior Disorder (APA, 2013). This is underscored by claims that suicide ideation can now be reduced pharmacologically (Yovell et al., 2015).

As might be expected, further medicalization of suicide is controversial. Some argue that treating suicidal behaviour as a separate disorder will allow the development of uniform terminology and improve the quality of research (Oquendo & Baca-Garcia, 2014). Moreover, such a move, it is argued, would enhance suicide prevention. Indeed, as WHO estimates, as many as 165,000 people annually could have been protected from suicide if they had received adequate psychiatric help (Bertolote et al., 2003).

The counterargument is that medicine cannot always effectively deal with suicidal behaviour even if medical practitioners know there is a risk. People kill themselves despite psychiatric help, including medication (Khan et al., 2003; see also Fergusson et al., 2005; Gunnell, Saperia & Ashby, 2005; Maris, 2015), while arguments that suicide must result from a mental disorder are countered with research that there are suicides where no mental illness was ever determined (e.g. Chen & Dilsaver, 1996; Conwell et al., 1996; Phillips et al., 2002).

Furthermore, suicide prevention is largely based on the biomedical model of suicide. Despite much effort, suicide rates tend to stay the same, while predicting suicide is still in the realm of fanciful aspiration (Pokorny, 1983, 1993; see also Large et al., 2011). Indeed, it is the social understanding of suicide which seems to offer more promising perspectives on suicide and its prevention. The British ONS reports that there are more suicides in deprived communities than in their non-deprived counterparts (ONS, 2019b). Such research builds on earlier studies which suggest that unemployment (which is up to four times higher in deprived communities) and other economic factors such as indebtedness significantly increase the risk of suicide (Mäki & Martikainen, 2012; Reeves et al., 2014). The medicalization of suicide will hardly help here.

The final point we would like to make here is that, for years now, there have been calls for standardized terminology and classification (Dear, 2001; De Leo et al., 2006; Maris, Berman & Silverman, 2000b; O’Carroll et al., 1996; Rosenberg et al., 1988; Rudd & Joiner, 1998). There is no doubt that uniform criteria of classification are of crucial importance to both researchers and clinicians. For example, for clinicians such a classification could lead to better risk assessment and management, as well as to better interventions.

Silverman (2013) proposes that the first modern classification of suicide and suicidal behaviour was created by Aaron Beck and colleagues (Beck, Resnik & Lettieri, 1974). They assumed three concepts for describing the spectrum of suicidality: suicide ideas, suicide attempts and completed suicide. Each of these categories was also assessed on five dimensions: certainty of the assessor (0–100 per cent), lethality (zero, low, medium or high), intent to die (zero, low, medium or high), circumstances without which suicide could not have happened (zero, low, medium or high) and the method. The most difficult of those dimensions was the intent to die.

This classification was used by O’Carrol and colleagues (1996) for creating a new system. The authors decided to base descriptions of suicidal behaviour on three characteristics: suicide intent, evidence for self-inflicted injury and consequences of the act (injury, no injury or death). This, in turn, was modified by Silverman and colleagues (2007a, 2007b) who suggested the introduction of indeterminacy into the system (undetermined suicide attempt, undetermined suicide-related death and self-inflicted death with undetermined intent).

Finally, the Centers for Disease Control and Prevention (CDC) (Crosby, Ortega & Melanson, 2011; Posner et al., 2007, 2014) expands their classification onto self-harm distinguished between suicidal and non-suicidal self-directed violence, adding indeterminate self-inflicted death as a third category.

Significantly, despite many terminologies and classification systems, so far none has been adopted universally. It is clear, however, that an ideal system should be atheoretical, acultural and consist of mutually exclusive concepts which comprise the full spectrum of suicidal behaviours and ideation (De Leo et al., 2006; Silverman, 2006). And even though doubts are expressed as to the possibility of arriving at such a classification (De Leo et al., 2006), the goal remains an important one.

Suicide and suicide attempt

De Leo and colleagues (2006) point to four elements which occur in all definitions of suicide analysed by them. Suicide is defined (1) as death in consequence of one’s behaviours; (2) through one’s agency (an act directed at oneself); (3) by the involvement of an intention to die; and (4) as the awareness of the consequences of the action performed (see also Farberow, 1980; Maris, Berman & Silverman, 2000a). A suicide attempt, on the other hand, is defined on the basis of the definition of suicide. In other words, a suicide attempt is an act of suicide where death did not occur (Crosby, Ortega & Melanson, 2011; Posner et al., 2007). The crucial aspect of a suicide attempt is the existence of the suicide intention, that is to say, the intention to take one’s own life, which, needless to say, raises difficult issues of how to determine such an intention after someone’s death.

Despite the fact that the term ‘suicide attempt’ is said to be used so widely and without rigour that it might mean little (O’Carroll et al., 1996), both clinical and research interest in it remains high. It is the suicide attempt that is the most important predictor of suicide (Brown et al., 2000; Fushimi, Sugawara & Saito, 2006; Harris & Barraclough, 1997; Joiner, 2005; Sokero et al., 2005). Just this fact alone suggests the significance of research into suicide attempts, as it is such experiences that give significant insight into suicide and its process.

We realize that some researchers question the status of homogeneous suicide attempts. Meeham and colleagues (1992) demonstrated that only one in ten suicide attempts resulted in hospitalization, only another two required medical attention and the lethality of the remaining 70 per cent is unknown. Other research shows that over half of people who attempt suicide do not seek medical help (Crosby, Cheltenham & Sacks, 1999). It is reasonable to ask therefore whether suicide attempts resulting in such drastically dif...