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Article

The Role of Self- Esteem in Suicides Among Young Men

Mette Lyberg Rasmussen1, Kari Dyregrov1,2, Hanne Haavind3, Antoon A. Leenaars1, and Gudrun Dieserud1

Abstract

This study explores self-esteem in suicide among young males with no earlier

history of suicide attempt(s) or treatment in mental health services. The data

come from an ongoing psychological autopsy study; 10 cases of young men aged

18 to 30, were selected to generate a phenomenologically based understanding of

the psychological mechanisms and processes involved in the suicidal process. The

analyses are based on in-depth interviews with 61 closely connected individuals,

as well as suicide notes. We used Interpretative Phenomenological Analysis. For

these young men, the transition to young adulthood, a period of major life chal-

lenges, seemed to be associated with personal defeats. According to their signifi-

cant others, the deceased seemed to have experienced intolerable discrepancies

between their actual performances and their ideal self standards. Four themes

emerged from the analysis: (a) striving to find a viable path to life as an adult man;

(b) experiencing a sense of failure according to own standards; (c) emotional self-

restriction in relationships; and (d) strong feelings of loneliness and rejection of

self. Improved understanding of suicides outside the mental illness paradigm may

have important implications for preventive strategies.

OMEGA—Journal of Death and

Dying

2018, Vol. 77(3) 217–239

! The Author(s) 2015

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DOI: 10.1177/0030222815601514

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1Norwegian Institute of Public Health, Division of Mental Health, Oslo, Norway 2Center for Crisis Psychology, Bergen, Norway 3Department of Psychology, University of Oslo, Norway

Corresponding Author:

Mette Lyberg Rasmussen, Norwegian Institute of Public Health, Division of Mental Health,

P.O. Box 4404, Nydalen, Norway.

Email: mera@fhi.no

Keywords

suicide, young men, self-esteem, shame, psychological autopsy, qualitative analysis,

suicide prevention

Our knowledge base for suicide prevention is largely based on studies of clinical populations, often indicating a causal relationship between suicide and mental disorder (e.g., Cavanagh, Carson, Sharpe, & Lawrie, 2003). However, several studies have not supported this causal link, and there is growing evidence that not all suicides are preceded by symptoms of serious mental disorder (Judd, Jackson, Komiti, Bell, & Fraser, 2012; O’Connor, Sheehy, & O’Connor, 1999; Owens, Booth, Briscoe, Lawrence, & Lloyd, 2003). From a preventive standpoint, due to high suicide rates among young men, there is a need to understand more of the complexity that places men in particular at risk (De Leo, 2002). Further, there is a need for greater understanding of suicide among individuals who do not present symptoms of serious mental illness prior to death (O’Connor & Sheehy, 2001; Shneidman, 1985). The transition from late adolescence to young adulthood is a period of major life challenges and developmental changes in the self (Erikson, 1968;Harter, 1999), a phenomenon often overlooked by suicide researchers (King, Apter, &Zohar, 2007; Leenaars, 2004). In particular, there is a need to understand more of the psychological characteristics and mechanisms, such as self-esteem, that regulate the dynamics of suicide in young individuals (Evans, Hawton, & Rodham, 2005; King et al., 2007). In the present study, self-esteem was explored in relation to suicide among young men from a nonclinical sample.

Self-Esteem and Suicide

Significant research on psychological processes leading to suicidal behavior has, in various ways, focused on deficits in self-esteem. In analyses of the self eva- luative component of the self-concept, negative self-evaluation in particular has been identified as a key factor in the suicidal process (Fergusson, Beautrais, & Horwood, 2003; Overholser, Adams, Lehnert, & Brinkman, 1995; Thompson, 2010). In several studies, suicide attempters have been found to have signifi- cantly lower self-esteem compared with both normal controls (Dieserud, Røysamb, Ekeberg, & Kraft, 2001; Grøholt, Ekeberg, Wichstrøm, & Haldorsen, 2005; Overholser et al., 1995) and psychiatric outpatients with no history of suicidal behavior (Dieserud et al., 2001). While these studies have effectively linked negative self-evaluation to suicide attempts, the nature of self-esteem in relation to suicide is still poorly understood (Harter, 2006).

A major problem of much of the research relating to self-esteem has been the conceptualization of self-esteem as a global measure of self-worth

218 OMEGA—Journal of Death and Dying 77(3)

(Crocker & Park, 2004; Mruk, 2006). Consequently, research has been focused on the examination of the level of self-esteem as the critical aspect in suicidal individuals. However, there is evidence suggesting that self-esteem should be conceptualized as a multidimensional developmental construct, including both competence and worth as primary components (Harter, 1999). Self-esteem, defined as, “the conviction that one is competent to live and worthy of living” (Branden, 1969, p. 110), is a complex construct (Mruk, 2006). A person’s self- esteem may be situation-specific as a person can have different perception of self- esteem in different relational contexts (Harter & Whitesell, 2003). In one of several studies, Harter and Whitesell (2003) found that while some adolescents reported stable self-worth across social contexts with parents, teachers, and classmates, others reported extreme variations. Other studies have shown that people whose self-esteem depends on approval from others can be particularly vulnerable toward acceptance and rejection and a need to live up to own/others’ expectations (Crocker & Park, 2004; Guay, Delisle, Fernet, Julien, & Sene_cal, 2008; Leary & Guadagno, 2011). Similarly, people whose self-esteem is based on their own competencies may be very vulnerable toward failure or lack of success in the domain in which they have invested their self-worth (Crocker & Park, 2004; Crocker & Wolfe, 2001; Deci & Ryan, 1995). Consequently, a major factor in self-esteem regulation is the perceived discrepancy between the ideal and actual self, such as might be illustrated when one falls short of expectations or standards in domains of importance (Deci & Ryan, 1995; Harter, 1999; Harter & Whitesell, 2003). Thus, a discrepancy between the ideal and actual self is sug- gested to be of central importance for the suicidal self (Baumeister, 1990; Vohs & Baumeister, 2010). Yet, such a discrepancy has been largely unexplored.

The Psychological Autopsy method (PA; Shneidman, 1993) has become a primary approach to studying suicide. Qualitative methods of analyses are con- sidered particularly suitable for studying the link between self-esteem and beha- vior (Mruk, 2006). Thus, there is a need for PA studies based on in-depth interviews with many informants, and qualitative methods of analyses if a better understanding of the interplay between internal and external factors influ- encing self-esteem in suicide is to be attained.

As a person’s self-esteem may vary by relationship context, it is important to explore both the mother’s and the father’s perception of how the relationship with their son has developed, and how they have handled the transition from being a dependent son to an independent young man. In similar ways, due to identification issues, the standards and ideals of significant male friends may be highly influential on the standards and ideals of the deceased. The issue of sexual identity and capacity for intimacy is of central existential value to young men (Erikson, 1968). This may be explored by information from intimate partners of the deceased. Through all significant relationships, self-esteem will be intrinsi- cally connected to standards of masculinity in the transition to adulthood (Connell, 2005).

Rasmussen et al. 219

The aim of the present study was to analyze the role of self-esteem in the suicidal process of young men with no prior psychiatric treatment and no pre- vious suicide attempts, in their transition from late adolescence to young adulthood.

Method

A Phenomenological Approach

The study is based on data from an ongoing PA study (Dieserud, 2006) where the main purpose is to generate a phenomenologically based understanding of the psychological mechanisms and processes involved in the suicidal process, by means of qualitative analyses. The study was based on in-depth interviews and suicide notes when available.

Sample

A sample of 10 young men who died by suicide was studied by analyzing in depth-interviews of four to eight key informants related to each suicide, as well as six suicide notes. A total of 61 individuals, who were closely connected to the deceased, were interviewed. All informants were over 18 years old.

The suicides of these 10 young men were selected from a total of 20 suicides from the PA study, among individuals with no prior psychiatric treatment and no previous suicide attempts. The selection was based on the first author’s first reading, rereading, and the construction of case narratives of all 20 suicides (120 interviews). A bottom-up approach starting with no fixed notions as to what would emerge from the narratives of the informants was used. As self-esteem issues became more and more salient in the construction of the case narratives of the young men due to a problematic doubleness in their self in the transition to adulthood, the choice of sample was governed by a wish for a deeper exploration of the role of self-esteem in these suicides. The doubleness was related to how these young men apparently had normal and successful developmental processes in the transition to adulthood, yet at the same time, struggled with difficulties related to normal developmental tasks. The 10 young deceased were all between 18 and 30 years of age, and represent all men under the age of 30 in the PA study. Both parents of the deceased were included as informants, with one exception where the father not available. Additionally, in most cases, the siblings of the deceased were also included as informants. Five of the deceased have had serious relationships to girlfriends, all these young woman were included as participants. All the deceased had between one and five close male friends who were also included as informants. Three of the deceased young men had lived together with their parents, five lived in rented apartments or houses, and two were homeowners. Three of the deceased were students

220 OMEGA—Journal of Death and Dying 77(3)

(high school/university), five were employed, and two were unemployed. One of the deceased was a father. The methods of suicide included hanging (8) and shooting (2). Almost all interviews took place between 6 and 18 months after the suicide; in one case, the interviews took place within 24 months of the suicide.

Procedure

Data were collected from all municipalities in the 7 of 19 counties in Norway with the highest number of suicides in 2003. All suicides took place during the time period 2005 to 2009. Chief municipal medical officers in the selected muni- cipalities were asked to (a) identify cases of suicide based on death certificates and forensic reports; (b) ensure the exclusion of those with previous suicide attempts and previous treatment in mental health services; and (c) contact the General Practitioner of the deceased, who provided the name and address of the deceased’s next of kin. The chief municipal medical officer sent a letter to the next of kin with thorough information about the project and purpose of the study. A consent form that the next of kin had to return to the project leader should they wish to participate was also included. In the letter, the infor- mants were asked to provide suicide notes, if available. To shorten the time needed for data collection, some informants were recruited by Center for Crisis Psychology in Bergen. As soon as the completed consent form was received, the informant was contacted by phone, by the interviewer, and a time and place for the interview was agreed on. After the interview, the infor- mant was asked to provide names and addresses of at least four other infor- mants who knew the deceased well. The procedure of sending a letter and consent form was then repeated, but now the letter was sent from the project leader (G. D.). Most of the interviews were conducted in the homes of the informants, some in the researchers’ offices, and some at hotels, depending on the preferences of the informants.

The interviews started with a narrative section, which opened with the researcher posing a question about the informants’ perception as to what led to the suicide: “What are your thoughts on the circumstances that led to the suicide of . . .?” This part of the interview was governed primarily by allowing the informant to speak without any interruptions or leading questions from the interviewer. After this section was completed, a problem-focused part of the interview was performed. In this part, the interviewer asked focused questions about topics not previously covered in the narrative section. The informants were also asked to clarify details from the narrative that needed to be fol- lowed-up or verified to ensure that the information provided was correctly perceived by the interviewer. A theme guide consisting of 16 categories based on Shneidman (1993) was used. The themes in this study cover details of the death, personal, and family history of the deceased, relationship issues,

Rasmussen et al. 221

personality, lifestyle, patterns of reaction to stress, alcohol or drug use, changes in the deceased before death, and strengths and successes.

Three researchers with extensive experience and knowledge in the field of suicidology and in-depth interviewing of bereaved individuals conducted the interviews (M. L. R., K. D., and G. D.). The interviews, lasting an average of 2.5 hr (range 1.5–3 hr), were audio-taped and transcribed verbatim. Each inter- view contained approximately 30 to 40 transcribed pages. To strengthen the interrater reliability of the transcriptions, a coding system for paralinguistic expressions including verbal pauses, laughter, and crying was used by two trained transcribers.

Ethical Considerations

All procedures were conducted in accordance with the Helsinki declaration. The study was approved by the Norwegian Regional Committee for Medical Research Ethics and the Data Inspectorate of Norway. The informants were contacted by letter in order to reduce pressure on informants concerning parti- cipation. In the recruitment letter, the purpose, method, and procedure of the study were described, and the informants were offered telephone contact with the researcher for more information. The participants were assured of anonym- ity, confidentiality, and freedom to withdraw from the study at any time. Thus, care of the participants during the entire research process was performed accord- ing to recommendations for research on vulnerable populations (Dyregrov, 2004). Informants were informed that data would be published in a nonidentifi- able way. At the end of the formal interview, a debriefing conversation was held to allow the participants ask questions, as well as for the researcher to ensure that the participants were not left in distress. Arrangements with mental health services were made for the participants who were in need for such.

Analysis of Data

Qualitative analysis was conducted following the flexible guidelines of Interpretative Phenomenological Analysis (IPA; Smith, Flowers, & Larkin, 2009). Since this study is concerned with the exploration of psychological pro- cesses and mechanisms involved in suicide, the procedure adopted involved treating the interviews and suicide notes around each suicide as one set of data. The analysis was carried out case by case, with an awareness of how each informant filled the existential space between the deceased and the infor- mant as a male friend, as a brother, as a son, and as a boyfriend. Additionally, since it was another person who was telling about—or trying to imagine–what was on the mind of the deceased, it was important that the informants were able to locate their notions about what could matter to the deceased during his life and in the period prior to the suicide, in actual experiences. Experiences could be

222 OMEGA—Journal of Death and Dying 77(3)

from their (longstanding) relationship and anchored in events that took place in time and social space. Thus, each of these young men was the subject of the analyses in relation to the existential issues (i.e., issues that matter for building and sustaining a sense of freedom and self-determination) at stake in their life prior to the suicide. In this sense, each informant was invited to contribute to an “insider” perspective as they saw it. During the interviews, “how do we know him” was an ongoing issue, open to interpretation and critical questions from the interviewer. In the analyses, when all interviews around the same case were pieced together, the researchers were concerned about construing the deceased as a subject and the suicide as influenced by the existential places that the deceased had inhabited. Thus, in line with the phenomenological and hermeneu- tical obligations of IPA, critical questions about the interpretations were con- tinually asked during the data analysis. By letting the deceased be the subject for our analysis, the researchers interpreted the informants’ interpretations of the deceased, through a triple hermeneutics (Smith et al., 2009).

The next stage of the analysis was to compare all the 10 cases with each other, looking for emerging themes and dynamics in the regulation of self-esteem in the transition to adulthood. For the first author, this involved returning to all the transcripts connected to each suicide and transforming the initial thoughts and questions to the data, based on notes from the first close readings, to codes for the emerging themes. The search was for themes that emerged across the cases. This involved both themes that emerged from comparing exis- tential issues from informants who shared the same position, like being with friends, being with mother, being with father, and so forth, and themes that emerged as similar for some cases across all of the interviews connected to the same suicide. Existential issues are telling the researcher about who one can—or cannot—be in the world, and existential places connect people in specific posi- tions. The regulation of self-esteem and the possible meanings of the suicidal act could therefore be seen as a set of tensions and movements between “actual and idealized existential places.” In keeping with the IPA idiographic commitment, it was important to allow new themes to emerge within each case when they were compared with other cases. In this way, the interpretation became an interactive process where the researcher moved back and forth between the various analy- tical stages, between the different informants around each suicide as well as between the suicides—always sticking to what the participants said. The con- cluding stage was to look for and connect all the superordinate themes across the suicides.

The validity and credibility of the analyses was based on triangulation on three levels. First, by using the PA-method, interviewing four to eight indivi- duals with close relationships to the deceased and analyzing suicide notes, it is assumed that it is possible to construct a valid picture of the deceased. Second, through a critical examination by the interpreters, who were the actual interviewers (M. L. R., K. D., and G. D.), attempts were made to

Rasmussen et al. 223

reduce interviewer bias. Third, the analysis was conducted by the first author (M. L. R.). To ensure that the analysis is not confined to one perspective, the developing analyses were continuously discussed within the other authors and within the research team (Yardley, 2008). Regarding reflexivity, the first, second, and fifth authors are female psychologists/sociologist with long experience in working with suicide prevention, suicide attempters, suicide bereaved, and qua- litative methodology. The third author is a female professor in clinical psychol- ogy with considerable experience within developmental psychology and a nestor within qualitative research. The fourth author is a male psychologist and a very experienced suicidologist, with a strong international reputation.

Results

Based on the qualitative analysis (IPA), four superordinate themes emerged: (a) striving to find a viable path to life as an adult man; (b) experiencing a sense of failure according to own standards; (c) emotional self-restriction in relation- ships; and (d) strong feelings of loneliness and rejection of self. Quotes are used to substantiate each of the superordinate themes, although in an anon- ymous way.

Striving to Find a Viable Path to Life as an Adult Man

All the deceased were described as coming from resourceful families in the sense that the men had grown up with both parents, or a mother, and a father figure. Parents, siblings, and friends would all describe the living conditions of the deceased as quite ordinary (very good) and before the suicide, the men func- tioned within the range of normality. The friends of these young men talked about deceased as individuals who were more or less in the same life situation as themselves, with respect to having good jobs, being financially stable, and as having many of the same interests in life. Although some of the deceased were described as excellent in their work, or as talented students, these men still seemed to move in the direction of overachievers or as persons who, in addition to being ambitious on their own behalf, also always helped others. Friends linked their own understanding of the suicide to the discrepancy between how the deceased constantly strived to live up to high self ideals, while at the same time struggling to function and adapt effectively in love and work. Some of the young men were described as being alone and too constrained to be able to overcome personal difficulties. In one way or another, all the deceased seemed to be striving to find their path in life through education or work.

The following refers to one of the deceased who was described by all his informants as a shy person and as being in limbo after high school. One infor- mant focused on how the deceased was striving to live up to an ideal standard of

224 OMEGA—Journal of Death and Dying 77(3)

achievement while, at the same time lacking the capacity to find a viable path in life,

And about that, yeah . . . that he couldn’t figure out what he should do with his life,

even though he did do something, he did apply for university in the end then

but . . . I don’t know if it was just like, for the sake of having a plan for show . . . it’s

difficult to figure things out you know, if you can’t find a path at all in life.

According to a friend, who was also shy, but who had managed to find a path in love and work, the deceased

was still in the same place . . . he was at home a lot, just by his computer . . . he didn’t

dare to open up . . . he had not made any progress toward girls either,

I think . . . there was like no attachment or anything.

In another case, a best friend described how the deceased identified with and tried to copy him, instead of making decisions for his life based on his own values and desires:

. . .we have spent much time together, both leisure time and time at work. We were

always together . . . and I sort of became a model for him. Whatever I did, he would

do all the time . . . he got restless if he did not manage these things . . .He really

wanted to be like me.

The deceased seemed to have coped by adapting the life styles, plans, and values of some “superior” others (friend, father, authorities, and boss). Many informants point to the importance of significant others for emotion-regulation and sense of self-worth, and described, like in the case above, how any discre- pancy from their standard created emotional stress:

He really looked up to his dad, was actually very afraid of his dad, I think. And yet

he sort of saw up to him, you know, that he could always ask for advice and

always, yeah . . . and he did that quite a lot, he called his dad about every-

thing . . . but at the same time he could get really angry if he felt that he did not

manage things just as well as his dad did, so he could get really angry.

In these two examples, the informants are referring to the lack of reciprocity in how the deceased compared himself to others. In another case, according to the ex-girlfriend, the deceased only seemed to find inner balance and be relaxed when he was very close to her (“as-one-with”). These young men seemed to have a strong need to seek emotional stability, safety, identity, and a sense of worth from another person. Thus, instead of drawing on their own capacities for finding their path in life, the young men in this study were constantly striving

Rasmussen et al. 225

to reach a perceived ideal standard for successful achievement. As a group, they were young men whose identities were tied up to a very high activity level, successful performance at work (or studies), good looking bodies/clothes/ girlfriend, and a perfect facade. These young men could not rely on their own judgments since they were in such great need for admiration, confirmation, nurturance, and guidance from those they regarded as their superior others. In one case, the ex-girlfriend described how she understood the striving of the deceased to cover up for an “unsecure” part of his self:

. . . he has always been very insecure, so he became very dependent on, very inspired

by his success and the confirmation he got from other people . . . and very concerned

about proving to the world that in a way he did well. So he was very, or he always

felt very . . . inferior through the years. He was very . . . it meant a lot to him to

succeed in a way, so be able to show people and be good enough.

Their intensity in life and their need for successful achievement were, by many friends and ex-girlfriends, understood as a compensation for a deeper sense of insecurity, worthlessness, inadequacy, deficiency, inner emptiness, and dread of being alone. Despite being described as successful professionals or students, many were at the same time understood as immature young men, and some were described as “not happy in life.” Thus, the deceased had difficulties related to both being alone and being with others. The sibling of one of the deceased said:

he thought it was incredibly difficult with girls. He didn’t quite know how to go

forward . . . how to create a stable relationship . . . that he didn’t function like this or

that, or that he couldn’t create good relationships.

Descriptions of difficulties related to finding a way to “connect with girls” or “develop a healthy love-relationship” were common for all these young men.

Experiencing a Sense of Failure According to Own Standards

In all cases, the suicidal act was understood as relating to a “self” that was aware of a failure to live up to a needed standard or expectations (own/other’s) and thereby self-blame for the loss of a necessary stability in life. These standards/ expectations were not necessarily related to a high or ideal standard, but the experience of this failure had been emotionally significant. Living up to a certain standard seemed necessary to preserve “the self as a whole” and therefore give the self a sense of worth.

For one of the men, although having had difficulties in being alone and seemingly in desperate need for an intimate relationship, he had not been able to establish a new relationship after a breakup with a woman several years

226 OMEGA—Journal of Death and Dying 77(3)

earlier. According to his informants, the deceased changed into to being “nothing,” an “outsider” or “felt like a failure” because he was not at the same place in life (with a girlfriend and a family) as his “superior” friend(s). His mother described:

But I think that, well in relation to the suicide . . . that it had been a difficult period

just now . . . and if he felt he couldn’t cope with the situation . . .working was his life.

In general, most of the deceased were not satisfied regarding their need for an intimate relationship, their need for matching their significant others’ standard of living or for successful achievement at work. Thus, the cultural expectations of the development of a more autonomous and independent self entering adulthood were not met. Described as very sensitive when making only minor mistakes, being criticized, or for perceived rejections, the deceased were thought to no longer see themselves as superior. Many informants considered this a critical factor related to the suicide. For some of the deceased, only a minor work transition seemed to have led to an unmanageable sense of social downfall.

In one case, the informants point to an observable change in the behavior of the deceased a couple of months before the suicide, which they connected to an upcoming separation in his love-relationship. He lost weight, got sleeping diffi- culties, became stressed, and started to complain that he felt his achievement at work wasn’t good enough any longer, although it was outstanding. Having identified with his “superior” friend, he followed his friend’s advice as if there was a powerful sense of obligation to do so,

I remember him saying that he was a man of principles, and he really was. He stuck

to his principles like a rock . . . even if he would want to act differently, he just could

not, due to his moral standard.

This may be understood as a desire to possess one’s self in a position of the same confidence and self-assurance as the person he identified with, and thus reflect the achievements and power of that person. However, facing conflicting ideals, this young man was understood as caught in between two incompatible “existential places.” Many of the deceased were described as being unable to put their conflicts or sorrows behind and move on, and they seemed to be stuck in a situation of self-blame.

The crucial impact of self-blame seems to have been central in all 10 suicides. According to one of the fathers, the deceased’s standard was to be “perfect in every way, afraid of making mistakes and fearing the consequences if he failed.” Even after attempting to rectify mistakes, it seemed he still ended up in a self- blaming situation. In his suicide note, he wrote that he could have done things differently. Thus, when a person who does not allow himself room for failure

Rasmussen et al. 227

fails, it is not the size of the discrepancy that is important but the significance of the discrepancy.

For several of the young men, a higher level of autonomy was expected from them when entering adulthood than they seemed to manage. Many informants stated that the deceased may have struggled with unmanageable feelings about themselves in the light of real or imagined evaluations by significant others. One informant described how he understood the situation when the deceased killed himself:

He probably regretted what he had done. Probably didn’t feel so very big, to put it

like that, and quite simply probably felt a bit like a failure . . . disappointed his

parents and disappointed himself, he had really messed it up.

As most of the suicides were understood as relating to a breakup of a love- relationship or the separation from the childhood home, the informants regarded dependence on other people as a main problem area for the deceased. Lacking a necessary inner base of self-worth, the deceased seemed to be depen- dent on significant others for confirmation and support. According to one ex- girlfriend, “So I’m not sure that he had regretted it in a way . . . the break up . . . only he sort of needed so badly to have someone there . . .”

Emotional Self-Restriction in Relationships

To understand why these young men chose suicide, when they seemed to have had other options, the informants turned to the emotional aspects of the deceased. For the deceased, failing to live up to standard/expectations created strong unbearable feelings of shame, disgrace, or anger. One of the deceased was described by the informants as very ashamed after having had an emotional break down some weeks before the suicide. One informant said: “. . .maybe he felt he would be looked upon as a weirdo and . . . then it’s better then it, yes, to keep the facade all the way until he could kind of escape from it all.” Exposing his self and all his flaws, for all to see, was understood as too much for him, as a private person, to bear. The awareness that his significant others, on whom he was dependent for his social life, had seen him the way he “really was” made it impossible for him to meet them again. Another of the young men wrote in his suicide note that he wanted to be forgotten like he had never existed. This could be interpreted like he was feeling too ashamed and worthless to even be worthy of remembrance.

One of the deceased, who was no longer able to hide behind his great super- iority, in a conversation with one of the informants only a few days before he killed himself, expressed “anger towards the whole world.” He said that he could not take another defeat, and that he hated himself. Not able to exist as the person he saw, he tried to change into someone else (new clothes and behavior).

228 OMEGA—Journal of Death and Dying 77(3)

In another case, one informant who spoke with the deceased a few days before he killed himself, observed, loneliness, shame, trapped anger, and self-condemnation,

And then he cried . . . all these bad feelings. I believe that he felt very much alone, it

was as though it was like his dark secret you know, that he had in a way become

very lonely in a way . . . so I figure that he maybe became, was starting to become

the person he hated most you know . . .And that he felt he no longer had control . . .

These young men were no longer able to control themselves: In essence, these young men had crossed a line. Once they had exposed what they may have perceived as their inferior self, this could never be undone. For one of the deceased, after being abandoned and violated in front of all his friends some days before he killed himself, anger was understood to be his main affect, in addition to shame. According to all his informants and his suicide note, this exposure was the last straw; underneath he was weighed down by too much trapped anger. In another case, the informants described the deceased’s aggres- sive outburst the night he killed himself like a “volcano,” where he had kept everything inside. When activated, it mobilized enormous powers that lasted for hours. According to the informants, this was typical for him with his temper, stubborn as he was, when he first decided on something, he could not stop. For another deceased, according to his suicide note, longstanding anxiety seemed to have been a main issue. Several of his informants pointed out that he lacked emotional capacity to handle even minor anxiety, meaning he was unable to handle even a small discrepancy between his ideal (perfect) and actual self, and therefore was seen as very restricted in his behavior.

Thus, common to all the deceased, from whoever’s perspective one examines it, was a lack of capacity to handle emotional distress or chaos, and a tendency to act upon oneself. Described by many of their parents as “private” young men, several siblings said “we never had deep conversations.” Their friends described them as someone who “did not show emotions,” “kept difficulties inside,” or “not the one we discussed emotional difficulties with.” According to their ex- girlfriends, although some were described as “very emotional” young men, when things were difficult “they withdrew,” or were “emotionally elusive.” Thus, common in all informants’ understanding was a lack of self-regulation. The deceased would try to keep a distance from the self through activities like work- ing, shopping, partying, sleeping, or being on the computer. One friend described how the deceased lacked emotional capacity to handle and act on his problems like this:

He has gone and carried it around, that mistake he made . . .He was in a chaotic

situation . . . could not take it any longer . . . did not know how to deal with the

situation . . . he was going in circles, it built up.

Rasmussen et al. 229

Strong Feelings of Loneliness and Rejection of Self

In the process of striving to find a path in life, many of the informants described a discrepancy between where the deceased’s “self” was located in real life and where it no longer could be, as well as the “existential place” where they needed to be. Unable to establish what they needed in their real lives, the suicidal act was understood as the last act from a failing self in desperate need to restore itself. One informant described how the deceased presented the discrepancy between where his self was located, where he could not stay any more, and the “existential place” where he needed to be:

And a week before he . . . took his life and, so he did call and say that he couldn’t

take it anymore like, “I can’t take it any longer,” . . . and he was so lonely and he

only wished he had a family. And . . . yeah, everything was so difficult, he was so

tired and like everything was just wrong you know . . . very hard to be by him-

self . . . and the only, the only thing he wanted was like to have a family you

know, and to be like safe and happy.

Similarly, in their suicide notes, many of the deceased described their self to be in a place of unbearable pain; they couldn’t take it any longer or they couldn’t live like this any more. Often, they blamed themselves for their misery. A few also blamed others. According to the informants, many deceased seemed to have idealized their longing instead of taking a problem-solving approach. Their longing for a better life could be understood as a result of lacking strategies to handle difficulties in their existing relationships, as well as a fear of being alone.

Further, in their suicide notes, many of the young men seem to have posi- tioned themselves as distributors of great love to everybody. Several presented “heaven” or “God” as the existential place they were longing for to “get peace” or “be free.” For some of the deceased, according to how it was understood by the informants, having been rejected from their “existential places” in real life only a short time before they killed themselves, heaven seems to have become their ideal solution. They were hoping for a continuation of existence. However, unable to handle the complex emotional situation in real life, from most of the informants’ points of view, the suicidal act was understood as a conscious and planned event, based on “choice of method,” “scene of the suicide,” and the fact that many of the deceased left suicide notes. Several informants related to dif- ferent suicides said that they had, “talked about death,” “death wasn’t unfami- liar to him,” “he had planned to die.”

There seemed to have been a double movement in the deceased. According to the suicide notes, the deceased “moved themselves” from a place in real life where their self was located, describing themselves as worthless and having had failed in life, to an alternative place—heaven/God—where they could be at ease with themselves. Heaven/God seemed to have become their escape as a

230 OMEGA—Journal of Death and Dying 77(3)

place with no demands, where their self-idealization could again be realized, and where their self was in a position of great power and worth. In his suicide note, one of the deceased placed his “self” next to God, from where he would lay and watch over his significant others and take care of them—as one who takes responsibilities for others and is caring for their safety. Yet, at the same time, the suicidal act was understood as a way of turning passive humiliation into active mastering in their real life, as a “revenge,” or as a way to “show others and to make them understand.” Thus, worthless on their own, unable to act differently to regulate emotions and thereby be able to comfort themselves, the suicidal act seems to have been a desperate operation by a failing self to restore itself.

Discussion

On the basis of these themes, a model is proposed as to how self-esteem may be involved in the process leading to suicide (see Figure 1). Taken together, these four themes constitute a dynamic model for how the young men were entrapped in what they may have experienced as an intolerable discrepancy between their actual performances as young men and their ideal standards.

Consistent with some theoretical models of suicidal behavior (Baumeister, 1990; Vohs & Baumeister, 2010), it was found that the suicidal crisis appeared to be related to an intense negative affect as a result of falling short of one’s own standards. The deceased seemed to blame themselves; they interpreted a per- ceived failure as a function of characteristics within the self. As shown by other studies, there seems to be the discrepancy between the ideal self and the actual performance that is crucial in suicide-related behavior (Chatard & Selimbegović, 2011; Cornette, Strauman, Abramson, & Busch, 2009; Orbach, Mikulincer, Cohen, & Stein, 1998). Contrary to Baumeister (1990) and Franck, Raedt, Dereu, and Van den Abbeele (2007), who suggested that it is the size of the discrepancy between ideal self and actual performance that is crucial for initiat- ing the suicidal process, these findings show that the size of the discrepancy is insignificant for someone whose standard (ideal self) does not allow room for any failure. When one’s self-esteem is threatened, it is the meaning of the failure that is crucial (Crocker & Park, 2004; Harter, 1999). In addition, it was found that the suicides in this study, despite being sudden and unexpected, were never- theless understood as the end result of a process developed over time, related to the capacity for ego development of the deceased (Erikson, 1968; Leenaars, 1991).

Using the psychosocial developmental theory of Erikson (1968), it could be argued that these young men had not resolved the process of ego formation in adolescence in a way that made them able to master the challenges of intimacy or to live by their own standards. Thus, these young men could not regulate their self-esteem or ambitions without approval from others. Instead, the deceased in

Rasmussen et al. 231

this study seemed to have arrived at adulthood without having consolidated their identity. The young men either may have undergone premature identity foreclosure, by assimilating into a significant other’s (father/friend/boss) identity structure, or may have been unable to engage in any form of identity formation, a state of identity diffusion (Kroger & Marcia, 2011). Consequently, one can assume that the young men proceeded into adulthood with unconstructed iden- tity elements based solely upon childhood identification. As a result, the young men had a strong commitment to their childhood internalized “ideal self” for self-esteem regulation (Kroger & Marcia, 2011). While “Ego identity refers to a sense of who one is, based on who one has been and who one can realistically imagine oneself to be in the future” (Marcia, 2002, p. 202), our findings suggest that the deceased entered adulthood with an idealized standard of their self that they were neither able to meet nor to defy. To protect a fragile self-esteem and to maintain a cohesion of the self (Erikson, 1968), many seemed to have found a viable path by becoming overachievers, driven by a high need for control and avoidance of failure. A similar pattern has been found in a recent study of suicide among the elderly (Kjølseth, Ekeberg, & Steihaug, 2009, 2010), in several studies of suicide related to perfectionism (Bell, Stanley, Mallon, & Manthorpe, 2010; Fortune, Stewart, Yadav, & Hawton, 2007; King et al., 2007) and in studies of suicide and narcissism (Ronningstam & Maltsberger, 1998; Ronningstam, Weinberg, & Maltsberger, 2008). In addition, their need to be in a love-relationship and to be a successful achiever may reflect the longing to merge with whom or what these young men hoped for, to complete them and fulfill their life aspirations and yearnings (Erikson, 1968; Morrison, 2009).

Discrepancy in self entering adulthood

Ideal self

Actual self

1. striving to find aviable path

2. sense of failure

3. emotional self-restriction

4. loneliness and rejection of self

Shame/ anger

Death

Discrepancy in self entering adulthood

Figure 1. A dynamic model of self-esteem regulation in the suicidal process.

232 OMEGA—Journal of Death and Dying 77(3)

The findings here suggest that the vulnerability in the self of the deceased seems to be related to a lack of a more developed, differentiated, and autono- mous self (Erikson, 1968; Leenaars, 1991). Deprived of inner resources to reduce emotional distress and maintain their self-worth, they were dependent on approval from significant others, successful achievements, good looking bodies, perfect facades, and so forth, to keep their self-esteem in balance (Crocker & Wolfe, 2001; Deci & Ryan, 1995; Maltsberger, 1986; Mruk, 2006). Our findings further suggest that losing exterior self-sustaining resources may precipitate a suicidal crisis among individuals who are dependent on them to keep their self-esteem in balance (Ronningstam et al., 2008). This may be in line with results from the qualitative PA study by Kjølseth et al. (2010), where self- esteem among the elderly was linked to activity and achievement, and the experi- ence of losing freedom of action had a strong negative effect on the self-esteem of the deceased, as if they “were losing themselves.” The researchers suggest that suicide can be seen as a way of attaining coherence in self. In the present study, the suicides could be understood as a way of releasing inner tension and restor- ing coherence in the self (Maltsberger, Ronningstam, Weinberg, Schechter, & Goldblatt, 2010). Thus, the suicide actually serves to increase one’s self-esteem (Maltsberger, 1997) and could be a final and desperate operation to restore one’s self and be free.

Contrary to most existing studies, indicating a causal relationship between suicide and mental illness, especially the occurrence of depression as an impor- tant risk factor for suicide (Cavanagh et al., 2003), few informants in this study mentioned depression or other mental illnesses in their narratives. This is in line with the views of suicidologists, who highlight that suicide cannot be explained by a diagnosis, as suicidal processes may or may not be linked to mental illness (Judd et al., 2012; O’Connor et al., 1999; Owens et al., 2003; Shneidman, 1985). In addition, although some of the informants point to impulsiveness as a char- acteristic of the deceased, the suicidal act was not understood primarily as an impulsive act (Wyder & De Leo, 2007). Instead, we found that the suicidal act was understood as a “triggered event” related to a previous significant event close in time (like a breakup with a girlfriend or a separation from family home), which again was understood in the light of the life history of the deceased (Rasmussen, Haavind, Dieserud, & Dyregrov, 2014). This is consistent with Mruk’s (2006) description of critical “self-esteem moments,” where certain situa- tions may challenge an individual’s current configuration of competence and worthiness in a way that reopens the individual’s history of unresolved biogra- phical self-esteem themes. This thereby puts self-esteem at stake. As expressed both in the informants’ interviews and in the suicide notes, the triggered event seemed to be related to how the deceased blamed themselves for not being able to live up to what they had to be in the eyes of their significant others (Baumeister, 1990; Crocker & Park, 2004; Harter & Whitesell, 2003). Dependence on others and being unable to adapt maturely to issues of

Rasmussen et al. 233

separation and independence, the young men seemed to have questioned their essential worth as human beings. This is consistent with some clinical descrip- tions of suicidal adolescents (Maltsberger, 1986), showing that the sequence leading to suicidal behavior seems to be set in motion by interpersonal conflict (Dieserud et al., 2001; Judd et al., 2012) or when external events demand a step that threatens to break the tie to a significant other (Wyder, Ward, & De Leo, 2009).

Toward the end of life, many of the deceased in the present study were appealing to their significant others for reassurance of worthiness and to be saved from an intolerable situation of loneliness and self-deceit. This aspiration toward autonomy and to merging with significant others is a conflicting yearning that will, according to Morrison (2009), result in inevitable shame for failures. These findings suggest, although trapped anger, guilt (self-blame) and anxiety seem to have been playing a part in this discrepancy, they all seem to have played a secondary role, while the primary emotional mortification was due to shame. Thus, it seems that the deceased may have felt that their personality simply did not add up to their ideals of masculinity (Connell, 2005; Payne, Swami, & Stanistreet, 2008). As shown by some other studies (Kalafat & Lester, 2000; Lansky, 1991; Ronningstam & Maltsberger, 1998), our findings suggest that it is the shame from having exposed the self as being unlovable or destructive or from being unable to have or tolerate close relationships, and in turn, being seen as unworthy, as a failure, defective, inadequate, out of control, and as a dis- appointment, that was the dominating affect in these young men’ suicides. It was the shame from being who one is, that was in the heart of these suicides (Leenaars, 1991; Lester, 1997; Shneidman, 1995).

Based on these findings of the pronounced shame in these suicidal individuals, it could be assumed that masculine gender-role stereotypes influence men in a way that can limit their ability to involve others, ask for help, and thereby use the health-care system, in times of personal difficulties (Connell, 2005; Payne et al., 2008). In line with Leenaars (2004), it is believed that young men in serious suicidal crises need to work with their self-concept, so that they can find their own standard for adult life and be able to handle their pain and regulate their emotions by themselves. In suicide preventive strategies targeted at young men, a stronger self-esteem perspective should be included than presently seems to be the case. The traditional expectations of men as “strong” and able to handle problems by themselves need to be challenged.

The findings from the present study need to be seen from a developmental perspective. More work is needed to identify the experiences that most power- fully impact on the development of self-esteem in relation to suicide.

One major challenge in suicide research is the matter of obtaining suitable data. Data based on interviews from third parties clearly has its limitations, especially if such data are used to assign diagnoses to deceased individuals (Hjelmeland, Dieserud, Dyregrov, Knizek, & Leenaars, 2012). Suicide notes

234 OMEGA—Journal of Death and Dying 77(3)

have proven to be a rewarding source of data as a starting point for compre- hending the suicidal act (Leenaars, 1991; Shneidman, 2004). Unlike most pre- vious PA studies (Cavanagh et al., 2003), this study used in-depth interviews with four to eight closely connected individuals to each suicide case, as well as examining the suicide notes. It was not possible to identify any other studies with a contextual perspective on suicides among individuals with no previous history of treatment in mental health or suicide attempt(s), utilizing such a large number of knowledgeable informants. In addition, this may be the first study that has investigated self-esteem regulation in nonclinical suicides, by using in-depth interviews with many closely connected informants, as well as suicide notes.

In general, studying “something on the inside” like self-esteem, based on third party interviews related to a small amount of cases has its limitations. However, suicide prevention based on epidemiological studies of generalities (the nomo- thetic approach) may miss some important specifics that we only can learn by studying individuals (the idiographic approach). By utilizing the IPA method of analysis, we were able to get closer to the complexities of psycholo- gical mechanisms and processes in suicides outside the mental illness paradigm, and thus generalize to theory. As theory plays a key role in understanding suicidal behavior, the results from the present study may add some important theoretical aspects of suicidology, which again may strengthen our preventive efforts.

Acknowledgments

This work forms part of the doctoral thesis of the first author to be submitted to the Department of Psychology, University of Oslo. The authors also want to thank the informants who participated in the study, as well as Melanie Straiton for her valuable

assistance in preparation of this manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, author- ship, and/or publication of this article: The project is supported by grants awarded by the Research Council of Norway.

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Author Biographies

Mette Lyberg Rasmussen, PhD, is a clinical psychologist and a suicide researcher at the Norwegian Institute of Public Health, Division of Mental Health.

Kari Dyregrov, professor Dr.philos, is a sociologist and a senior researcher at the Norwegian Institute of Public Health, Division of Mental Health, and Center for Crisis Psychology, Bergen.

Hanne Haavind, professor in Developmental Psychology, is a clinical psycholo- gist and a senior researcher at the Department of Psychology, University of Oslo, Norway.

Antoon A. Leenaars, PhD, is a clinical psychologist with private practice in Windsor, Canada, and a suicide researcher at the Norwegian Institute of Public Health, Division of Mental Health.

Gudrun Dieserud, PhD, is a clinical psychologist and a senior suicide researcher at the Norwegian Institute of Public Health, Division of Mental Health.

Rasmussen et al. 239

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CU_Horiz_RGB Unit 7 ‒ Scientific Knowledge, Contributions, and Methodology

CU_Horiz_RGB Unit 7 ‒ Scientific Knowledge, Contributions, and Methodology

Scientific Knowledge, Contributions, and Methodology Form

Complete this form based on your chosen and instructor-approved research study for the course project. Type your responses directly beneath the questions. Provide APA-style references and citations as needed.

Write the APA-formatted reference for your study.

Rasmussen, M. L., Dyregrov, K., Haavind, H., Leenaars, A. A., & Dieserud, G. (2018). The role of self-esteem in suicides among young men. OMEGA-Journal of Death and Dying, 77(3), 217-239. doi:10.1177/0030222815601514

Paste the persistent link for your study here.

http://web.a.ebscohost.com.library.capella.edu/ehost/pdfviewer/pdfviewer?vid=1&sid=5ebc9e43-086e-4f76-9333-015639604b30%40sdc-v-sessmgr03

Was the methodology used in the study qualitative or quantitative?

What was the approach used in the study?

· If your study was qualitative, the possible approaches include case study, phenomenology, ethnography, and grounded theory.

· If your study was quantitative, the three possible approaches are experimental, quasi-experimental, and non-experimental.

In order for research to have scientific merit in your field of study, it must contribute new, meaningful knowledge to your field. In a few sentences, summarize the new knowledge that was contributed by this research. Then, write one-to-two paragraphs explaining how this knowledge is meaningful to your field. Also, address the importance of the application of this knowledge by professionals in real-world settings.

In order for research to have scientific merit, it must advance the theories in your field of study. In one-to-two paragraphs, describe the theoretical foundations of the research and how the research advanced them. For example, the research may have tested, confirmed, extended, or modified a theory. Perhaps it generated a new theory.

Describe the sample and the sampling procedures; that is, the way in which the participants were selected. Avoid quoting the study, and use your own descriptions. Evaluate whether the sample and sampling procedures were appropriate for the methodology and approach.

Describe the data collection procedure. This would start after participants gave informed consent, and end when the participants have completed the study. Avoid quoting the study and use your own descriptions. If your methodology was qualitative, you might be describing interview procedures, for example. If your methodology was quantitative, make sure you describe any group assignment methods or any repeated measures, such as a pretest or post-test. Evaluate whether the data collection procedure was appropriate for the methodology and approach.

Describe the data analysis procedure. If your methodology was quantitative, you need only describe the procedure or the statistical tests. Avoid quoting the study and use your own descriptions. Evaluate whether the data analysis procedure was appropriate for the methodology and approach.

Describe the findings and the conclusions the researchers made. Evaluate whether the conclusions allowed the researchers to answer the research questions and address the research problem.

Provide an APA-formatted references list, compiling all of the resources you have used for the course project thus far.

1

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