REVIEW OF RELATED LITERATURE AND STUDIES

This chapter focuses on the discussions regarding suicidal ideation. It also

discusses the review on suicide risk on adolescents. This chapter begins with the review
on the definition of suicide ideation and suicide to the discussion of psychache and locus
of hope as extension to hope theory.

Suicide Ideation and Suicide

According to Gutierrez, et al. (2000) and Maris (1992) cited by Schroth, C. A.
(2010), intuitively, suicide ideation is likely to precede suicide attempts and completion.
In fact, within the suicidology literature, it is widely accepted that suicide ideation is an
important risk factor related to future self-harmful behavior, including suicide attempts
and completion. However, when examining the literature, it is evident that there is a
complex relationship between suicide ideation and suicide attempt and/or suicide
completion. While suicide ideation has been shown to be related to the making of suicide
attempts, it is not related to the lethality of a suicide attempt or to the completion of the
suicide attempt.
Suicide ideation is considered as a risk factor for attempted and completed
suicide. Based on a longitudinal study conducted by Lewinsohn, et al. (1996), shows that
the more severe (high intent or planning) and pervasive (high frequency or duration) the
suicidal ideation, the more likely such ideation is to eventuate in an attempt.
However, Suicidal ideation, which refers to current plans and wishes to commit
suicide, logically precedes suicide but does not necessarily predict or lead to attempted or

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completed suicide in the medium to long term (Linden, et al., 2003; Scocco, et al., 2000
as cited by Smith, 2006).
Based on International Encyclopedia of the Social Sciences (1968), suicide is the
human act of self-inflicted, self-intentional cessation. According to Leenars (1999 p.
155; Leenars, 2010) suicide is a conscious act of self-induced annihilation, best
understood as a multidimensional malaise in a needful individual who defines an issue
for which the suicide is perceived as the best solution.
The term suicidality has been used to refer to a continuum of suicidal
manifestations ranging from thinking about suicide (i.e., suicidal ideation) through to
making a plan, attempting suicide, and ultimately completing suicide (Kessler, et al.,
2005; Kessler, et al., 1999; Nock, et al., 2008 as cited by Flamenbaum, 2009). Studies
indicate that these occurrences comprise a progression of suicidal behaviour, with each
expression conferring an increased risk for subsequent steps along the chain. For
example, Nock, et al. (2008) cited by Flamenbaum (2009) in a survey of almost 85,000
individuals across 17 countries, found that one-third of suicide ideators will make a
suicide plan, and over half of those with a plan will make an attempt at some point in
their lives, with the majority of these transitions taking place within one year of ideation
onset.
Another risk factor for suicide is motivation. According to Hawton and Catalan
(1987) and Kienhorst, De Wilde, Diekstra, & Wolters (1995) as cited by Bridge J.A. et al.
(2006), on their work, Adolescent Suicide and Suicidal Behavior, motivation is the
reason given by the patient and family for the suicidal intentions. For the one-third of

21

attempters with the highest suicidal intent, their motivation is to die or to permanently
escape a psychologically painful. Those attempters who wish to die, to escape a painful
situation (e.g., an abusive home). Often, motivations for engaging in suicidal behavior
reflect difficulties with social skills and interpersonal effectiveness.
Suicidal behavior is a major problem worldwide and, at the same time, has
received relatively little empirical attention according to Van Orden, et al. (2010).
Suicide is still poorly understood as a health issue. The media sometimes depict negative
images of the persons who commit suicide or their families. Reports are often found
under the police columns of the newspapers (for example, in the Philippines). There are
varying ways through which suicide is viewed - crime, sign of weakness, rational choice,
symptom of an illness, or the result of spirit possession. The stigmatization of suicide and
the fall-downs of it deeply affect families (WHO, 2005). In the Philippines, suicide is
emerging as a health challenge because of the rising number of Filipinos committing the
act (Sta. Maria, M., et al., 2015). However, suicide cases in the Philippines are likely to
be underreported. Registering a suicide is a complicated procedure involving several
different authorities, often including law enforcement. And in countries without reliable
registration of deaths, suicides simply die uncounted as reported by Lapea (2015).
Official suicide rates are lower in the Philippines than in many other countries in the
Western Pacific region (Redaniel, et al., 2011), because of the under-reporting of most of
the cases for not accepted by Catholic Church. As in other Catholic countries, a high
proportion of suicide deaths are likely to be misclassified as injury of undetermined intent
or accidents according to Redaniel, et al. (2011).

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Psychache and Suicide

Although both depression and hopelessness have received abundant support as
psychological predictors of suicidality, another variable is emerging as an important
predictor, as cited by Troister, T. (2009).
According to Shneidman (1993), Psychache is defined as an acute state of intense
psychological pain associated with feelings of shame, humiliation, hurt, anguish, despair,
loneliness, fear and dread. Thus, he also stated that it is a painful inner experience of
negative emotions as Shneidman (1999a) cited by Flamenbaum (2009). Further,
alternatively, psychache is the mental pain of being perturbed.
Psychache directly leads to suicide when the psychological pain exceeds an
individuals threshold of tolerance, and death is seen as the only solution to escape.
Shneidman (1993) outlined six progressions in the components of suicide: (1) occurrence
of life stresses and psychological insults; (2) influence of other vulnerabilities, such as
genetic and social factors; (3) perception of life stresses as negative and painful; (4)
perception of pain as unbearable and unacceptable; (5) thought that cessation of
consciousness is the solution for this pain; and (6) level of pain that exceeds ones
threshold for enduring psychache. The purpose common to suicide is to stop the painful
flow of consciousness (Shneidman, 1992 as cited by Flamenbaum, 2009). This
conceptualization of suicide is an escape from a painful internal state, views suicide as a
practical act, or problem-solving behavior as to Shneidman (1992) cited by Flamenbaum
(2009) and is consistent with observations by Beck (1963) cite by Flamenbaum (2009)

23

and other theories of suicide such as escape theory by Baumeister (1990) cited by
Flamenbaum (2009).
When it occurs, its reality is introspectively undeniable. Suicide occurs when the
psychache is deemed by that person to be unbearable. This means that suicide also has to
do with different individual thresholds for enduring psychological pain (Shneidman,
1985, 1992a, Leenaars, 1999, p. 239 as cited in Leenaars, 2010).
Hopelessness and depression are strong predictors of who will attempt, and die
by, suicide (Lester et al., 1979; Thompson, et al., 2005 as cited by Troister, & Holden,
2010), but neither one of these constructs alone or in combination is able to fully account
for and predict suicidality. As Edwin Shneidman (1993) proposed that psychological
pain, or psychache, is a necessary condition for suicide to occur, and that all other factors,
such as depression and hopelessness are secondary, and only relevant for suicide insofar
as their association with psychache. For an individual to die by suicide, Shneidman
(1984) cited by Troister & Holden (2010) asserts that the perception of the pain must be
unbearable for that person, and that the cessation of the pain, or psychache, by stopping
consciousness is seen as the only solution. He postulated that if the pain can be relieved,
the individual would be willing to continue to live.
Shneidman (1993) postulated that psychache is directly associated with
suicidality, and mediates the effects of other relevant psychological factors, such as
depression and hopelessness, in their association with suicide. It is a mistake according to
Shneidman, to equate depression with suicide. As cited by Flamenbaum (2009),
Shneidman asserted (1993):

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One can live long, unhappy life with depression not true of an acutely
suicidal state. Theoretically, no one has ever died of depression it is not
a legitimate cause of death on the death certificate but many people, too
many people have died of suicide.
Psychache itself, and the negative emotions that give rise to it, stem from
unfulfilled, frustrated, or thwarted psychological needs, as mentioned by Shneidman. He
declared that, there are many pointless deaths, but never a needless suicide; and so
identifying and addressing an individuals frustrated needs may help to reduce his or her
level of psychache and prevent suicide, as mentioned by Shneidman (Flamenbaum, 2009)
Upon using the Psychological Pain Assessment Scale (PPAS; Shneidman, 1999b
as cited by Troister, 2009), both current and worst-ever psychache were found to be
significantly higher in those patients deemed to be at risk of suicide by a psychiatrist
(Pompili, Lester, Leenars, Tatarelli, & Girardi, 2008 as cited by Troister, 2009). Other
researchers utilizing this scale found that worst ever psychache was associated with both
current depression and a history of suicide ideation (Lester, 2000 as cited by Troister,
2009). Due to the need for multi-item measures to examine current psychological pain,
past researchers recommended the use of other scales that can measure psychache.
To address the problems with Shneidmans scale, Holden, et al. (2001) created the
13-item Psychache Scale. The scale was evaluated on a group of university students, and
results showed that psychache and hopelessness were both unique contributors to suicide
ideation, but that psychache had the largest standardized regression coefficient. In a
sample of suicide attempters, Flynn and Holden (2007) cited by Troister, (2009) found

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that psychache, hopelessness, and internally and externally motivated reasons for
attempting suicide all provided unique statistical prediction to suicidality. Psychache was
also correlated with attempter status in an offender sample (Mills, Green, & Reddon,
2005 as cited in Troister, T., 2009). In a group of female university students, results
indicated that psychache was the only variable that contributed significant and unique
variation to the prediction of suicide ideation and self-injury (Troister, 2009).

Locus-of-Hope and Suicide

Most of the studies regarding suicidality have been shown to be associated with
hopelessness or pessimistic attitude about the future and identified it as an important risk
factor for suicidal behaviour according to Haatainen, et al. (2004) cited by Page, et al.
(2006). Page, et al. (2006) added that adolescents found hopelessness to be the strongest
cognitive variable linking suicidal ideation in both cultures (individualism and
collectivism) and in both boys and girls. According to Abramson, et al. (2000) cited by
Flamenbaum (2009), hopelessness is a pessimistic cognitive style encompassing an
expectation that highly desired outcomes will not occur or, conversely, that highly
aversive outcomes will occur, as well as a belief that there is nothing one can do to
change this outcome. He added, Hopelessness is postulated to be a cognitive vulnerability
and proximal sufficient cause of hopelessness depression, of which suicidality is a core
symptom. Furthermore, hopelessness, and in turn, suicidality, are likely to develop when
negative life events are viewed as important and attributed to stable and global causes.
Thus, hopelessness is also seen as a mediator in the relationship between negative life
events and suicidality as Flamenbaum (2009) concluded.

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On the contrary, collective countries promote interdependence, which these

people in this society value harmony in a group according to Cimatu (2008). Thus,
positive well-being in regards of connectedness takes part as a preventive barrier of
suicidal behavior.
According to Bernardo (2013), psychologists have made significant progress in
understanding the role of hope in human flourishing, in moderating the effects of threats
to wellbeing, and facilitating positive change in psychological treatment. A relatively
growing area of study in the field of positive psychology and well-being involves
Snyders Hope Theory as cited by Garcia & Sison (2012). Hope theory (Snyder, 2002)
posits that highly hopeful individuals are more successful in attaining their goals
primarily due to the cognitive interplay between pathway and agency thinking or the
ability to not only produce the necessary routes to a goal but also the motivation to
actively pursue the routes created. According to Garcia and Sicon (2012), Pathway
thinking refers to a persons perceived capability to constantly generate the necessary
routes that aids in goal attainment while agency thinking, on the other hand, refers to a
persons perceived capability to actively and constantly engage in the routes that have
been generated.
Bernardo (2010) extended Snyders Hope Theory. It premised that the models of
hope itself are highly internalized, meaning that individuals themselves are solely
responsible in being able to generate pathway and agency thinking. By considering
external agent that could contribute to and influence an individuals goal attainment
cognitions specifically the family, the peers and spiritual/supernatural beings, he
proposed dimension Locus-of-Hope as addition to Hope Theory which explains that the

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different sources of hope are associated with individualism and collectivism. Locus-ofhope refers to whether the components of trait hope involve internal or external agents
and internally or externally generated pathways. The internal locus-of-hope refers to the
individual as the agent of goal-attainment cognitions, whereas the external locus-of-hope
refers to significant others and external forces as agents of goal-attainment cognitions.
For the external locus-of-hope, with three sub-dimensions: family, peers, and
supernatural/spiritual beings or forces.
The three sub-dimensions proposed by Bernardo (2010) were derive from
Philippine studies of Briones (2009) and Tolentino (2009) that recognize the significance
of the members of ones family, of ones peers, and of God in attaining ones goals. The
reference to God reflects the Filipinos Catholic religious beliefs, but it is possible to
conceive of other spiritual beings (e.g., Allah, other deities) or even super natural forces
(e.g., fate, fengshui) as figuring in goal-directed cognitions, Bernardo (2010) added.
Research on hope theory documents how individual-focused agency and pathways are
associated with positive goal-directed cognitions and actions as stated by Snyder (1994)
cited by Bernardo (2010). Research on conjoint agency (Markus & Kitayama, 2003 as
cited in Bernardo, 2010), endogenous social agency (Miller, 2003 as cited by Bernardo,
2010), proxy, and collective/shared agency (Bandura, 2001; Bratman, 1999 as cited by
Bernardo, 2010) result of the theoretical and empirical bases reflected the goal-directed
cognitions as involving goals and actions of other people. As for the spiritual locus,
research shows links between dimensions of religiosity and/or spirituality and positive
goal-directed cognitions and actions (Bernardo, 2010).

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In the Philippines, as a collective country, individuals who see themselves as parts

of one or more collectives are primarily motivated by the norms and duties of those
groups, emphasizing connectedness with other members of the collectives according to
Cimatu (2008). Filipino people are known for their hopefulness that came from aspiring
people (i.e., family), resiliency, and faithfulness. However, suicide rate is continuously
increasing. According to Planco (2014), Filipinos have always been known to exhibit a
sunny disposition in life. Despite the tragedies and the daily chaos that have faced,
[Filipinos] can always muster the courage to bravely put up with a smile, tend to mask
persistent sadness, feelings of worthlessness or helplessness, feelings of guilt, crushing
low self-esteem, pessimism, and even secret panic attacks away from the scrutinizing
eyes of the public. Despite the need to see a mental health professional who may help to
get back to a healthy emotional and psychological state, Filipinos refuse to do so because
of the stigma from a society that tends to discriminate. Mostly, Filipinos are unaware that
when such conditions are left undiagnosed and untreated, it may lead to reckless behavior
or worse, suicide.
Regarding to an interdependent self by Markus and Kitayama (2005) as
mentioned by Myers (2010), one has a greater sense of belonging. If they were uprooted
and cut off from family, colleagues, and loyal friends, interdependent people would lose
the social connections that define who they are. They have not oneself but many selves:
self-with-parents, self-at-work, self-with-friends (Cross &others, 1992 as cited by Myers
2010). Thus, even preventive barriers of suicide as locus-of-hope or source of hope is
fragile to suicidality itself and reflected to the statement of Seligman that hope isn't

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simply a happy feeling it's a human survival mechanism, and we couldn't thrive without
it, as cited by Gidley, (2001).

Adolescents and Suicide

According to Wareerat Thanoi (2009) adolescent suicide risk behaviors is one of
the major mental health problems which causes death among youths between 15 and 24
years of age, and has been increasing in number over decades globally. Adolescence is a
period of life changes and most teenagers struggle with issues such as independence and
developing a sense of identity and a system of values and responsibilities. Redaniel, et al.
(2011) added that these struggles manifested in the high incidence of non-fatal self-harm
in this age group worldwide.
During the adolescence stage, adolescents self-concept and their perception of
Who am I? differs because of the cognitive changes that they experience, according to
Steinberg (2011) cited by Wong, Et al. (2013). Steinberg also stated that Piagets sociocognitive processes particularly abstract and hypothetical thinking and advancement also
affect how adolescents describe themselves. Some psychologists believe that adolescents
self-concepts are frequently disturbed. Unhappiness, disappointment and depression may
arise if there is a large discrepancy between adolescents actual and ideal self.
According to Ortiz (2004) cited by Wong, et al. (2013), normal development
during the adolescence stage includes self-searching in which adolescent try to be out of
his or her child-like self. It is also a period of capacity development and one of
heightened vulnerability and risk Meyers, et al. (2005) added as cited by Wong, et al.
(2013). This change is complicated by the conflict between an adolescents new sense of

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adult identity and remaining juvenile insecurities. Adolescents risky behaviors are also
related with this self-searching process (Ortiz, 2004 as cited in Wong, et al., 2013). As
stated by Balwin (2000; Mancini & Heubner, 2004; Wong, et al., 2013), risk behavior
hinders successful adolescent development. According to Meyers, et al. (2005),
adolescents are also faced with different challenges such as establishing an identity,
learning to function independently, growing intellectually and physically, choosing a
career, and developing love relationships. All of these tasks are difficult even in
supportive and stable surroundings. During periods of family instability and other forces
of cohesiveness, many adolescents think that they cannot cope up with life.
According to Larson, Wilson and Mortimer (2002) mentioned by George (2005) the
family is seen as the central source of support for adolescents worldwide. Further, they posit
that a positive parenting style acts as a protective factor, which enhances the adolescents
general wellbeing. In a study by Paulsen and Everall (2001) mentioned by George (2005),
they concluded that negative life events such as divorce in the family, the experience of death
or extreme school difficulties show a contribution towards suicidal thoughts. The authors
furthermore suggest that a build-up of daily stressors in the absence of an effective support
system can contribute towards suicidal behaviour. Pillay and Wassenaar (1997) mentioned

by George (2005) concluded that adolescents with a conflicting relationship with their
parents show a high incidence of self-destructive behaviours.

According to Gould, et al. (1996) cited by Bridge, et al. (2006), on their work,
Adolescent suicide and suicidal behavior, youth who are disconnected from major
support systems (school, work, and family) appear to be at very high risk for suicide,

31

particularly in the context of other risk factors that are likely to contribute to their
drifting status.
Thus, growing up in a supportive family allows for healthy development of
aspects such as self-esteem, motivation, religious and spiritual orientations, as well as
providing an emotionally safe and supportive environment for its members, concluded by
Thomlison (2002).

Synthesis
The related literature included to this study has significant relation to the given
variables in the sense that it gives the essential point of interpretation and information
regarding suicide as a serious public health problem worldwide. It occurs all over the
world and can take place at almost any age. Globally, suicide rates are highest in people
aged 70 years and over. In some countries, however, the highest rates are found among
the young (www.who.int, 2014 published).
In the Philippines, whilst the incidence of suicide is low compared to other
countries, it appears to have been increasing in recent years, particularly amongst males
according to Redaniel, et al. (2011). A large number of these cases reportedly Filipino
youth (Sta. Maria, M., et al, 2015) and Philippine Psychiatric Association has found that
[Philippines] have been on the rise for three decades, between the period of 1975 to 2005.
Notable is how the rates peak around the ages of 15 to 24 for both males and females
(Cruz, V., 2014). In means of sex, according to Redaniel, et al. (2011) cited by Wong, et
al. (2013), though more women than men attempt suicide in the Philippines, but as seen
in most other countries case fatality is higher in males, in part due to males preference

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for more violent/lethal methods of suicide. Further, the male-to-female ratio for suicide is
3.3:1 in the Philippines.
Philippines as collective country have natural preventive barriers against suicide
such as source of hope. Among these barriers, which psychiatrist Dr. Dinah PacquingNadera cited in her paper on suicide in the country, is "strong Catholic faith which
frowns upon suicide, discouraging families from reporting" as cited by Lapea, (2015).
Suicidal behaviour in the Philippines is reported to be low, there is likely to be underreporting because of its non-acceptance by the Catholic Church and the associated stigma
to the family, mentioned by Redaniel, et al. (2011). Example is the death of 15 years old
teen actress whose father had requested the police to refrain from pursing further
investigation as he is convinced that his daughter committed suicide, as per MauricioArriola, T. (2015).
While suicide rates are low in the Philippines, increases in incidence and
relatively high rates in adolescents and young adults, especially university students, thus
reasons for this excess in young people in the Philippines require further investigation
and improving data quality and better reporting of suicide deaths is likewise imperative to
inform and evaluate prevention strategies.