The Role of Self- Esteem in Suicides Among Young Men

Mette Lyberg Rasmussen 1 , Kari Dyregrov

1,2 ,

Hanne Haavind 3 , Antoon A. Leenaars

1 , and

Gudrun Dieserud 1

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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1 Norwegian Institute of Public Health, Division of Mental Health, Oslo, Norway

2 Center for Crisis Psychology, Bergen, Norway

3 Department 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

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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 …

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