The emperor’s new clothes? A critical look at the interpersonal theory of suicide

Abstract

The Interpersonal Theory of Suicide currently seems to be the most popular theory in suicidology. It posits that suicide can be explained by the simultaneous presence of three risk factors only, namely acquired capability for suicide, thwarted belongingness, and perceived burdensomeness. Suicide is, however, widely accepted as a complex, multifactorial, and contextual phenomenon. It is, therefore, surprising that a theory comprised by three internal factors only is so uncritically embraced by suicide researchers. In this article, we scrutinize the theory’s background, core components, and purported empirical evidence and argue that its popularity is highly unwarranted.

In his book, Why People Die by Suicide, Joiner (2005) outlines the Interpersonal Theory of Suicide (IPTS)¹. Therein, he claims that suicide can be explained by three risk factors only, namely (acquired) capability for suicide², thwarted belongingness, and perceived burdensomeness. Five years after this book was published, Joiner’s research group delineated IPTS’s hypotheses more precisely and invited the scientific community to test the theory (Van Orden et al., 2010). The response to this invitation has been enormous. Every year, relatively large proportions of publications in the three main international suicide research journals refer to this theory (Table 1). Interestingly, the proportions are highest in Suicide and Life-Threatening Behavior; the journal where IPTS’s originator is Editor-in-Chief. Some authors explicitly state that they are testing the theory, whereas others, for instance, discuss their findings in light of it. Numerous studies of the theory are also published in other journals. Because of the enormous response, Joiner’s research group recently saw fit to conduct a systematic review and meta-analysis of all the studies conducted to date on the relationship between the theory’s constructs and suicidal behavior (Chu et al., 2017). Initially, 375 reports published in English were identified as potentially relevant to review (we will return to this meta-analysis later). No other suicide theories currently come close to such popularity.

Table 1. Proportions of publications referring to the IPTS in the main suicide research journals.

Journals	2013	2014	2015	2016	2017
Suicide and Life-Threatening Behavior	33%	45%	33%	32%	37%
Archives of Suicide Research	15%	25%	31%	20%	13%
Crisis^a	11%	13%	23%	18%	7%

^aEditorials excluded.

In general, suicide researchers seem to agree that suicide is a complex, multifactorial phenomenon. With qualitative research currently burgeoning, it is also increasingly recognized that suicide is a highly contextual phenomenon (Hjelmeland & Knizek, 2016; White, Marsh, Kral, & Morris, 2016). It is, therefore, surprising that a theory comprised by three internal/psychological factors only, is so extensively embraced rather than just ignored, rejected, or at least critiqued. With one exception, we have not identified any critical voices regarding the IPTS. The one critical text we found is the book The Interpersonal-Psychological Theory of Attempted and Completed Suicide – Conceptual and Empirical Issues by Paniagua, Black, Gallaway, and Coombs (2010). They refer to the IPTS as the “theory of everything” (p. 25) and describe the same astonishment as ours. After conducting a literature review they concluded:

…no single article was found that questioned the core assumptions of the theory (…) This suggested that something was wrong, in that either leading theoretical experts on suicide (…) were more interested in dealing with theories of suicide that are multifactorial (which is the opposite of Dr. Joiner’s theory) or that they did not want to spend time with a theory that is essentially reductionist in terms of claiming to be the final theoretical explanation of all suicide acts.” (Paniagua et al., 2010, p. xi)

Paniagua and colleagues then describe how their book is the very result of the difficulties they faced when they tried to publish an article outlining the major problems with the IPTS.

When a theory like the IPTS seems to become the dominant model to explain such a complex, multifactorial, and contextual phenomenon as suicide, there is every reason to scrutinize it critically. This should be a natural part of scientific development and is particularly important when the theory’s increased popularity may be contributing to drive suicide research in an unfruitful direction. The purpose of this article is thus to scrutinize and discuss the theory’s background, core components, and purported empirical evidence.

The theory’s background

The book Why People Die by Suicide (Joiner, 2005) starts with the author describing his father’s suicide. It actually seems like it was this suicide that triggered the development of the IPTS. On page 1, Joiner says:

Of course my dad’s death has deeply affected both my feelings about suicide and my understanding of it (…) My intellectual understanding of suicide evolved along a different track than my feelings. Informed by science and clinical work, I came to know more than most about suicide – on levels ranging from the molecular to the cultural. But here, too, my dad’s death never left me, for the simple fact that I could evaluate theories and studies on suicide not only by formal professional and scientific criteria, but also by whether they fit with what I know about my dad’s suicide. (Joiner, 2005, p. 1, italics added)

In this quote, Joiner explicitly states that he evaluates theories developed and studies conducted by other researchers partly on the basis of whether they fit with his father’s suicide (there are several similar examples throughout the book). Thus, already at the outset, he seems convinced that suicide is a phenomenon with a universal explanation independent of historical, social, ideological, political, economical, cultural, or gender-related contexts. That is, he completely disregards contexts within which suicidality is developed and maintained. Thus, within the framework of the IPTS, people are treated as artificial theoretical constructs.

This is further substantiated in the closing chapter of the book, where Joiner maintains:

My theory is not only about my dad, however. It is intended to be comprehensive but succinct: to have at least something to say about all deaths by suicide worldwide, across cultures, by employing three simple concepts (…) Past researchers and theorists have remarked on attraction to death among suicidal people – my theory specifies the conditions under which it happens, as well as why it happens. (Joiner, 2005, p. 226, italics added)

Here, Joiner basically states that the IPTS not only will explain all suicides everywhere but also the conditions under which they occur. This is only possible if people are stripped of their contextual biography. This is also tantamount to claiming that “all swans are white”. We will show that there are quite a few “black swans” out there and that the IPTS does not even come close to back up its significant claim. Hence, its dominating role in today’s suicidology is unwarranted.

The core components of the IPTS

The three core components of the IPTS are perceived burdensomeness, thwarted belongingness, and (acquired) capability for suicide. Perceived burdensomeness is feeling so ineffective that you perceive yourself a burden to others, and thus that others would be better off without you. Thwarted belongingness is a feeling of not belonging, of being alone (Joiner, 2005). Perceived burdensomeness and thwarted belongingness together comprise suicidal desire. The theory posits that both capability for suicide (outlined further below) and suicidal desire (that is, all three components) must be present for suicide (and near-lethal suicidal behavior) to occur (Joiner, 2005; Van Orden et al., 2010).

To demonstrate that the theory really explains all suicides everywhere, Joiner (2005) maintains: “[IPTS] is not only consistent with but illuminates the wide array of well-documented facts on suicide” (Joiner, 2005, p. 32). As suicide is a complex, multifactorial, and highly contextual phenomenon, we suggest to avoid using the concept “fact” with regard to it as if there are universal “truths” applicable to all suicides. However, one of Joiner’s “facts” that everyone can agree with, is that suicide is a relatively rare event. He offers an explanation why and takes this as evidence for his theory:

[Acquired] capability is (…) relatively rare and difficult to obtain. The other factors – perceived burdensomeness and failed belongingness – are relatively rare too. The confluence of these three factors, which according to my model is required for serious suicidal behaviour, is more rare still. The current framework explains – indeed predicts – that death by suicide will be a relatively rare event. (Joiner, 2005, p. 153)

Because all three components are theoretical constructs, this is hardly a valid argument. To claim that a combination of rare components predicts a rare event is nonsensical. That different factors are rare, does not necessarily mean they have anything to do with each other or with suicide, let alone that they predict it.

Flawed argumentation and cherry-picked evidence base

There are several (other) flaws in the argumentation for IPTS. Moreover, the initial empirical “evidence” claimed to support the theory was cherry-picked. Evidence not supporting the theory was available in abundance at the time of its development. Let’s first look at the relationship between perceived burdensomeness and thwarted belongingness.

Perceived burdensomeness and thwarted belongingness

Together, these two components comprise a suicidal desire. That is, both components (in addition to capability) must be present for suicide or near-lethal suicide attempt to occur (Joiner, 2005; Van Orden et al., 2010). However, perceived burdensomeness and thwarted belongingness might be present to a certain degree in many people from time to time, depending on their actual situation. The requirement with regard to suicide must then be that each must be present to a specific (high) degree over a specific time period and coinciding with the other over some unspecified time period and to a certain unspecified degree. This is rather unspecific, which basically makes it impossible to test the theory.

In an attempt to make it more specific, the Interpersonal Needs Questionnaire (INQ) was developed (Van Orden, Cukrowicz, Witte, & Joiner, 2012). The INQ originally consisted of 25 items, but following a string of factor analyses, the number of items was reduced to 15: nine related to thwarted belongingness (e.g., These days, other people care about me; These days, I feel like I belong; These days, I often feel like an outsider in social gatherings) and six related to perceived burdensomeness (e.g., These days, the people in my life would be happier without me; These days, I think I am a burden on society; These days, I think I make things worse for the people in my life; Van Orden et al., 2012). Each item is scored on a 7-point Likert Scale from “Not at all true for me” (score of 1) to “Very true for me” (score of 7), with six items reverse scored. This has hardly made the IPTS more testable. All the items start with “These days,” which is rather unspecific. Moreover, several qualitative psychological autopsy studies have clearly demonstrated that suicide must be understood in a life-course-perspective (Kjølseth, 2010; Rasmussen, 2013) and that risk/precipitating factors have little or no predictive value (Franklin et al., 2017).

There are also other problems. Perceived burdensomeness and/or thwarted belongingness certainly may be important contributors to several people’s suicidality. However, because perceived burdensomeness might require a feeling of being integrated with others, we find it difficult to see how these two components can be present simultaneously in the same person to such a high degree as must be required to constitute a suicidal desire. If you think no one cares about you, how can you perceive to be a burden (to them/whom)?

Another problem arises from Joiner’s explicit emphasis on perceptions with regard to these two components:

My model emphasizes perceived burdensomeness and perceived sense of low belongingness. It is painful for survivors to understand that their loved ones, lost to suicide, perceived these things about themselves; but it is helpful, I think, to understand that these were perceptions, not realities that should be blamed on survivors. (Joiner, 2005, p. 224, italics in the last sentence added)

This statement is problematic in several ways. First, if it is all about perceptions (of some feelings regarding burdensomeness and belongingness), the theory should perhaps be seen as an intra-personal rather than an inter-personal one. Hence, the “Intrapersonal Theory of Suicide” would be a more appropriate name. Such a name would also clearly indicate that this is indeed a theory that completely disregards context and sees suicidality as a strictly internal phenomenon. However, even an intra-personal theory based on feelings and perceptions have to take into account a specific individual’s context (and his/her interactions with the surroundings) to be able to claim any explanatory value.

Perhaps it is with the emphasis on perceptions we find the connection between the IPTS and mental disorder. It is indeed difficult to discuss the IPTS without also considering Joiner’s view on the relationship between suicide and mental disorder. He maintains “…there is no doubt whatsoever that mental illnesses play a role in suicidal behaviour” (Joiner, 2005, p. 152). At the time he wrote the book outlining the IPTS, he believed that mental illness was related to 95% of the suicides (Joiner, 2005). He now believes it is the case for 100% and sees “Suicide as a derangement of the self-sacrificial aspect of eusociality” (title of article by Joiner, Hom, Hagan, & Silva, 2016). In other words, from a speculative evolutionary standpoint, Joiner et al. (2016) claim that misperceptions are developed in some individuals and through suicide, they remove themselves and their misperceptions for the benefit of society. All the “blame”/responsibility for the suicide is thus located inside the suicidal individual and the context is just reduced to some evolutionary concepts. This, in turn, fuels our perception that this theory seems to be intra- rather than interpersonal, and that this intrapersonal (evolutionary) theory is both too reductionist and too speculative to be able to contribute meaningfully to the understanding of suicide, let alone to suicide prevention. Moreover, there is no valid evidence base for the perceived unambiguous relationship between mental disorder and suicide (Hjelmeland, Dieserud, Dyregrov, Knizek, & Leenaars, 2012; Hjelmeland & Knizek, 2017).

Furthermore, one cannot dismiss the fact that for some people who take their lives burdensomeness or thwarted belongingness are not about mere perceptions but hard realities. This should be self-evident, but since Joiner’s group keeps emphasizing that it is all about perceptions and a large part of the suicidological community seems to buy into it, we will illustrate our point with a number of examples. In one of his numerous sweeping generalizations, Joiner (2005) maintains that “the facile explanation that parents are responsible for their children’s death by suicide because of high demands is hardly worth considering. However, the explanation that people who perceive themselves as not measuring up and as being a burden are prone to suicidal behavior is more serious and is supported by numerous research studies” (p. 111, italics in original). Yet, Rasmussen, Haavind, and Dieserud (2018) found exactly that for some young men, their inability to live up to the high demands/standards that their fathers (or father figures) had explicitly expressed over years, played a significant role in their suicides. The success demanding fathers had never allowed their sons to show any weakness. As a result, the young men’s suicides were aggressively directed at their fathers, at the same time as they were staged to position themselves as heroic. Thus, the suicides of these young men appeared as signature acts of compensatory masculinity (Rasmussen et al., 2018).

We can also use some of the common risk factors as examples to illustrate further that issues of burdensomeness and belongingness related to suicidality most definitely can be grounded in hard realities and not just mere (mis)perceptions. Social isolation, family conflict, sexual minority status, unemployment, and serious physical illness are all common risk factors for suicide. If you, in a strictly religious community, are ostracized from your family and congregation (where you have all your friends) because you are gay, and your parents explicitly say that it would have been better if you were dead than gay (Nordbø, 2009), lack of belongingness is not a mere perception; you are actually treated as if you do not belong. If you have put so much of your time, energy, and even identity into your job that your wife has left you, your children hate you for not prioritizing being with them, and you have lost all contact with your friends, and then lose your job, feeling you do not belong cannot be dismissed as a misperception. You may very well be a burden to your wife if you have become seriously ill and dependent upon her to take care of you; a wife that right before you received your diagnosis was about to leave you because she had met someone else, but now feels obliged to stay and take care of you.

As extensively outlined in a psychopolitical autopsy study by Mills (2018), also some structural/political factors contribute to people not only perceiving themselves to be a burden; they are explicitly treated as such by a hostile welfare system. Following the financial crisis in the UK, increased numbers of suicide were found, especially among people who had experienced welfare reform. According to Mills (2018), such austerity suicides must be understood as: “embedded within an affective economy of the anxiety caused by punitive welfare retrenchment, the stigmatization of being a recipient of benefits, and the internalization of market logic that assigns value through ‘productivity’ and conceptualizes welfare entitlement as economic ‘burden’”. Her study includes examples where people, while being under assessment for eligibility of receiving financial support, explicitly were asked: “Can you tell me why you haven’t killed yourself yet?” Under such circumstances, burdensomeness is not a mere (mis)perception: “People are killing themselves because they feel exactly the way the Government is telling them they should feel – a burden” (Mills, 2018).

All these examples illustrate that burdensomeness and thwarted belongingness can be far from mere perceptions, and one of the most serious problems with the IPTS is that it so completely disregards the context making some people suicidal. By stating that: “but it is helpful, I think, to understand that these were perceptions, not realities that should be blamed on survivors,” Joiner completely acquits the surroundings’ potential contributions to an individual’s suicidality. We will deal further with acquired capability below, but here it is relevant to look at one of the ways people can acquire the capability to suicide, according to Joiner (2005). This is another common risk factor, namely by having been exposed to (childhood) sexual abuse. However, where there is sexual abuse, there has to be at least one abuser, and often this abuser is a close family member.

Of course, we have to tread carefully here and not go around blaming all suicides on family members. Some people who take their lives have grown up in loving, well-functional families; their problems originate elsewhere. But, we simply cannot and should not absolve the entire context completely (or elevate it to a speculative evolutionary level). Numerous studies have demonstrated clearly how crucial for the development and maintenance of suicidality are, in different ways for different individuals, the social, cultural, and political or structural contexts where people live their lives (e.g., Hjelmeland & Knizek, 2016; Staples & Widger, 2012; White et al., 2016). Whether this is an abusive or dysfunctional family, a hostile welfare system, or other social, cultural, and/or political structures, they are completely disregarded by the IPTS. Instead, and based on a speculative (evolutionary) perspective, all the “responsibility” for the suicidality is placed inside a mentally disordered individual’s mind.

(Acquired) capability to suicide

There are also problems with Joiner’s (2005) argumentation regarding how people acquire the capability to suicide. He asks: “How does one get used to and become competent and courageous regarding suicide?” and answers: “In a word, practice” (p. 50). The most important way you can acquire the capability to take your own life is by attempting suicide (Joiner, 2005). Attempted suicide is indeed one of the most important risk factors for suicide; about 40% of those who take their lives have a history of self-harm or suicide attempt(s) (Hawton & van Heeringen, 2009). This means, however, that around 60% of those who take their lives have no history of self-harm or suicide attempts.

Consequently, Joiner describes other ways in which you can acquire the necessary capability to take your life: “…the trajectory toward serious suicidality is characterized by increased ability to endure pain and provocation” (p. 78). Thus, also other painful experiences contribute to build up the capability for suicide. Some of the examples he mentions are getting injured in accidents, being exposed to childhood sexual or physical abuse, participating in violent sports, or getting tattoos. Through such painful experiences, your ability to endure pain and provocation is supposed to increase, as is then your capability to take your life (Joiner, 2005). Even the speculative concept “mental rehearsal” (Joiner, 2005, p. 81) is used to explain suicides without previous attempts.

There are several problems with this argumentation and its relation to suicide rates. Let’s first look at gender. Joiner (2005) explains “the fact” that more men than women kill themselves by “the fact” that men acquire more capability to enact lethal self-injury. As described above, Joiner (2005) states that the most important way you can acquire capability to take your life is by attempting suicide. However, in general, with the exception of some countries and regions, more women than men attempt suicide (WHO, 2014). Thus, we should then expect the IPTS to postulate a higher suicide rate for women than for men, rather than the opposite.

Joiner’s (2005) explanation for this discrepancy is that women’s suicide attempts are less violent than men’s and that men acquire their capability by more exposure to guns, to physical fights, and to violent sports like boxing and football. This makes men gradually more able to tolerate pain, which he sees as a necessary factor for acquiring capability to suicide. Van Orden et al. (2010) explicitly say that women are less able to develop acquired capability for suicide “because they have lower pain and fear tolerance than men” (p. 592). There are several problems with this argument.

First, we would think that giving birth might be more painful than getting knocked about on a football field. Second, pain tolerance/threshold has been found to be connected to psychological factors, such as gendered acceptability of pain expression and expectations. Indeed, much research has shown that men have a higher pain threshold than women. This may, in turn, have created an expectation that men will have a higher pain tolerance than women. Such gendered expectations have actually been shown to predict reported pain tolerance (Nayak, Shiflett, Eshun, & Levine, 2000), and manipulation of gender-specific tolerance expectations alter gender differences in pain tolerance, pain threshold, and pain ratings (Robinson, Gagnon, Riley, & Price, 2003). Third, recent research shows that men might not necessarily have a higher pain threshold than women. The commonly found gender difference can actually be ascribed to women’s higher tendency to be influenced by fear of the consequences of pain, rather than a lower tolerance for pain per se (Vambheim & Øien, 2017). In addition to all this, there will be great individual variation. The picture is, therefore, a lot more nuanced than recognized by Van Orden et al. (2010) and therefore weakens their arguments for higher pain tolerance among men explaining why men would have more acquired capability to suicide.

Moreover, Joiner’s (2005) argumentation does not add up with his simultaneous emphasis of attempted suicide being the most important way to acquire capability for suicide. Even if an overdose might be perceived as a less violent method, it may still be considered “training” towards acquired capability, at least with regard to suicide by overdose. Besides, most suicide methods, including violent ones, may not be physically painful at all, at least not in all cases. If death is instant, as usually is the case if you shoot yourself in the head or jump from a tall building and land on concrete, little or no physical pain is felt. To fall asleep and never wake up after taking an overdose of sleeping pills, is not likely to be physically painful.

As mentioned above, sexual abuse is another of Joiner’s (2005) examples of how people can acquire capability to suicide. However, childhood sexual abuse is more prevalent among females than males (Barth, Bermetz, Heim, Trelle, & Tonia, 2013). Thus, the IPTS should then, again, postulate a higher suicide rate for women compared to men, rather than the opposite. Thus, the way Joiner and his coauthors are arguing to support the IPTS is indeed strained; they are really struggling to make all things fit with the theory. They seem particularly adamant to describe women as virtually incapable of taking their lives. Such argumentation reminds us of Durkheim (1897/1951) who thought that women were not intellectually complex or brave enough to be able to take their own lives.

Then there is age. According to the IPTS, it takes time to acquire capability to enact lethal self-harm. In other words, “if the acquired capability to enact lethal self-injury increases with age, so then should suicide” (Joiner, 2005, p. 162). This is indeed the case in many countries, which then is taken as support of the theory. But, there is at least one “black swan” with regard to this, even from “the West”: in Norway, the suicide rate does not increase with age (Norwegian Death Registry, 2018). The age difference in suicide rates fluctuates somewhat from year to year, but in general, there are hardly any differences between age-groups for men, whereas for women, the suicide rate is highest among the middle-aged (45–64 year-olds; Norwegian Death Registry, 2018). There are several other examples of how Joiner (2005), at the same time as he basically claims that the theory can explain all suicides everywhere, seems to have cherry-picked a few studies that may be interpreted to support the theory.

Additional problems with the IPTS

Paniagua and colleagues (2010) mention several examples of problems related to some of Joiner’s “facts,” in addition to the ones regarding gender and age. In fact, Paniagua et al. (2010) outline five additional major problems connected to the IPTS, of which we will mention only one. Many of the studies purporting to test the IPTS, and that is included in Joiner, Buchman-Schmitt, Chu, and Hom’s (2017) list of studies said to support it, are violating fundamental assumptions of the very theory they claim to be testing. Thus, they are not really testing the theory at all. The violations Paniagua et al. mention are (1) even if this theory is explicitly said to separate suicidal ideation from suicide and serious suicide attempts, many of the studies said to test it, are actually on suicidal ideation, and (2) even if the theory explicitly says that all three components must be present simultaneously, many “tests” only include one or two of them and therefore can at best be considered partial tests. As we will outline further below, the IPTS is, in fact, virtually impossible to test. It would, however, be relatively easy to show that suicide indeed may occur without all three components present.

We will outline an example from our own research, inspired by the following statement by Joiner (2005): “Psychological autopsy studies would also be useful tests of the theory (…) A psychological autopsy that shows little evidence of one or more of these variables in those who have died by suicide would represent a grave challenge to the present theory” (Joiner, 2005, p. 229). Our research group conducted such a study in northern Uganda (Kizza, Knizek, Kinyanda, & Hjelmeland, 2012a, 2012b). Unfortunately, there is no space to present the context of this study in depth (for this, we refer to Kizza, 2012). Suffice to say that this study was conducted among the Acholi (predominant ethnic group in the area) in Internally Displaced Peoples’ camps (IDP-camps) in northern Uganda. There, suicide was found to be connected to the changes in gender roles and responsibilities enforced by two decades of civil conflict. Because of this conflict, two million people were forced to live in IDP-camps under horrific conditions for about ten years (Kizza, 2012).

In this context, consequences of hegemonic masculinity seemed to have played an important role in suicides for both men and women. For men, because they were unable to live up to the traditional masculinity ideal and took their life to escape the resulting shame and humiliation, and, for women, because they were unwilling to continue in the traditional submissive role after having gained some empowerment when forced to take over the role as breadwinners (Hjelmeland & Knizek, 2016; Kizza et al., 2012a, 2012b). The women had to put up with husbands spending their hard-earned money on gambling, alcohol, and not only womanizing but marrying more wives, explicitly against the first wife’s will. Because of cultural traditions, they had no right to complain or fight this. If they did, they were beaten and abused. They could also not divorce and go back to their parents because that would mean the dowry having to be paid back, which their parents could not afford due to extreme poverty. Their husbands also brought home HIV/AIDS because of extramarital affairs. Thus, the women had no control over their own or their children’s health since the husband by the authority of cultural tradition could demand unprotected sex whenever he wanted. The women thus found themselves trapped in an unbearable situation and their only way out, literally, was suicide (Kizza, 2012; Kizza et al., 2012b). Thus, these women’s suicides can be interpreted as a desperate protest against the worst excesses of masculine domination, or as the only available means to escape from the unbearable situation (Hjelmeland, 2018).

Can the IPTS explain suicide for women in this context? With all the violence and atrocities they had been exposed to, they could probably fulfill a potential criterion of acquired capability. Maybe we could even say that they perceived not belonging (although reducing this to a mere perception might not have been acceptable to the women in question). However, to say that they took their lives because they perceived being a burden, we think would be an insult to these women. The same would be the case if we attempted to explain their suicides by mental disorder. This would in so many ways disregard the horrific conditions under which they were living. The findings of our study do indeed, to use Joiner’s own words: “represent a grave challenge to the present theory” (Joiner, 2005, p. 229).

Our findings from northern Uganda, where the majority are Christian, are in keeping with what Canetto (2015) found in her comprehensive review of suicidal behavior among Muslim women across a number of countries in Asia, Africa, Europe, and the Middle-East. Canetto found a unique script of Muslim women’s suicidality as a desperate rebellion against, or escape from, the suffocating restrictions and abuse women have to endure within their families and societies. This has now been found across a multitude of cultural contexts (Staples & Widger, 2012). For some women, suicide may indeed be the only way out of family and social oppression and abuse, and to reduce their suicides to some psychological misperceptions, particularly about being a burden, linked to mental disorder, is misguided.

The recent review and meta-analysis of the IPTS

All the problems outlined above taken into consideration, we are quite astonished by all the (uncritical) empirical attention this theory has received. So much attention, in fact, that Joiner’s research group recently saw fit to conduct the aforementioned review and meta-analysis of over a decade of research across a number of different groups and countries (Chu et al., 2017). As mentioned above, 375 reports published in English were initially identified as potentially relevant to review. To be included in the meta-analysis, however, certain inclusion criteria regarding effect sizes and use of validated measures (e.g., the INQ), had to be fulfilled (for further details, see Chu et al., 2017). In the end, 114 reports (comprising 122 samples) were included in the meta-analysis. Samples included in the studies of the theory are diverse and comprise psychiatric inpatients and outpatients, prison inmates, undergraduate students, sexual minorities, military personnel, physicians, fire-fighters, and older adults (Joiner et al., 2017). The authors do not provide a list of all the countries in which research on the theory has been conducted, but the INQ has been translated into Chinese, Korean, French, German, Portuguese, and Slovene (Chu et al., 2017).

In the abstract, Chu et al. (2017) claim that “This meta-analysis generally found support for the interpersonal theory of suicide.” At the same time, however, they admit that effect sizes were only weak to moderate, and thus that it has only a modest potential clinical significance. Moreover, and as evidenced in Chu et al.’s own report, Paniagua et al.’s criticism from 2010 that most studies are not really testing the theory at all, still holds. Bearing in mind that the IPTS is a theory about suicide (and near-lethal suicide attempts), and the fact that the theory requires all three components to be present for a suicide to occur, Chu et al.’s substantiation of their claim that the results of the meta-analysis generally supported the theory is misleading: “the interaction between thwarted belongingness and perceived burdensomeness was significantly associated with suicidal ideation; and the interaction between thwarted belongingness, perceived burdensomeness, and capability for suicide was significantly related to a greater number of prior suicide attempts” (italics added). They really struggle to make the research fit with the theory and their conclusion about research supporting the IPTS is clearly strained. Interestingly, in a systematic review of studies of the IPTS published only a year before the one by Chu and colleagues, the authors found that “the IPTS may not be as clearly defined nor supported as initially thought” (Ma, Batterham, Calear, & Han, 2016, p. 40).

Based on the fact that the IPTS “was designed to explain the occurrence of lethal or near-lethal suicidal behaviors” (Chu et al., 2017), and in light of the fact that “the extant literature has overwhelmingly neglected to test this hypothesis” (Chu et al., 2017), it is actually difficult to see the rationale for conducting this very meta-analysis at all. Chu et al. (2017) then go on to state that “moving forward, it will be critical to adjust our approach to directly test the interpersonal theory hypotheses originally posited by Joiner (2005) and Van Orden and colleagues (2010).” Thus, on the one hand, they claim that their meta-analysis supports the IPTS; but, on the other hand, they admit that the theory has not yet been tested at all.

Chu et al. (2017) propose a number of directions for future research aiming to test the theory. We posit, however, that the IPTS is virtually impossible to test. The main method by which to test the theory with regard to suicide would be by means of psychological autopsy studies (as also emphasized by Joiner, 2005). That is, to interview people bereaved by suicide. Since many of the items in the INQ are about what the deceased person might have felt or thought, it would be impossible for study participants to respond to the items reliably. We have previously demonstrated that this is the case with regard to many of the questions asked to assign psychiatric diagnoses to deceased persons in psychological autopsies (Hjelmeland et al., 2012). The items regarding perceived burdensomeness and thwarted belongingness in the INQ are subject to the same criticism. Thus, participants’ responses would be mere speculations with regard to questions about a deceased person’s feelings or thoughts; speculations that in addition could be seriously affected by the strong emotions connected to losing someone to suicide (that even might be exacerbated by the very nature of some of the items in the INQ).

In the case of near-lethal suicide attempts, the actual persons being assessed could fill in the questionnaire themselves. Even then, however, there would be great problems with regard to reliability (and validity). All items start with “These days,….” First, this is rather unspecific, and second, the responses would be seriously affected by how their surroundings have reacted to the suicide attempt. A person feeling all alone before the attempt but who then experiences family and friends rallying around him/her after the attempt would perhaps have scored the items differently before compared to after the attempt. It would, however, be impossible for researchers to know whether this is the case or not, if so for whom, or with regard to which items. In other words, as with suicide, it is virtually impossible to test the theory following near-lethal suicide attempt.

This leaves us with the prediction of future suicide risk, which was in fact what the IPTS originally was designed for (Joiner, 2005; Van Orden et al., 2010). This is another reason to ask why this meta-analysis of studies mainly not testing the theory was conducted. The results actually show that the theory’s components are not better predictors of suicide risk than traditional risk factors (Chu et al., 2017). Chu et al. (2017) recommend longitudinal studies, but with the low base rate of suicide, samples would have to be enormous to have sufficient statistical power. And, the larger the sample, the more heterogeneous it becomes, both in terms of individual and contextual factors; and, the more remote from the individuals meant to benefit from the research are the results (Hjelmeland & Knizek, 2016). Franklin et al. (2017) have demonstrated that “there is no evidence that any known risk factor – broad or specific – approach what many might define as clinical significance”. Is there any reason to think that this would be different with regard to the very unspecific theoretical constructs perceived burdensomeness and thwarted belongingness? Let alone capability to suicide, which Chu et al. (2017) admit is associated with “substantial measurement issues”?

Chu et al. (2017) claim that we just need more stringent tests of the theory’s assumptions. We assume that more stringent means continued complete disregard of the all-important context. However, Chu et al. (2017) do on some level recognize the importance of context when they acknowledge that some results of their meta-analysis indicate that the nature of capability is complex and context-dependent as it for some, in keeping with the IPTS, increases the suicide risk, whereas for others, contrary to the IPTS, is protective. “If so,” they say, “this would conceptually complicate matters” (Chu et al., 2017). What they rather should accept, however, is that matters regarding suicide are complex and impossible to explain by completely disregarding the context in which suicidality develops and is maintained, and therefore that all attempts at trying to explain or predict suicide by means of such a reductionist and completely decontextualized theory are futile. Thus, not only is the IPTS virtually impossible to test (as evidenced in Chu et al.’s own meta-analysis), it is also not worth pursuing further because of its dubious foundation as well as reductionist and speculative character.

In fact, Joiner’s research group seems to be affected by what Douglas said more than 50 years ago about theory development in suicidology in his book Social Meanings of Suicide:

One of the most general problems, to be found (…) is the use of the argumentative and casuistic-deductive methods in attempting to show one theory is better than the others because it explains or even predicts the data better. Theories of suicide have been pressed into the service of more general ideas and theories which the individual theorists assumed to be true before they came to the data on suicide. They then deduced what must be true of suicide in general if the general idea they where trying to prove was, as they assumed, true. But they have often gone one step further: they have tried to give the impression that they went from the data to the theory, that they had used an inductive method. This positivistic rhetoric has often given a scientific aura to these works when the actual methods used were anything but scientific. (Douglas, 1967, p. 153)

The initial cherry-picking of research to support the assumptions by its originator, and the now recent attempt to give the impression that the theory indeed is supported by research, when it is clear that most of the research allegedly supporting it is not testing the theory at all, seems to fit with Douglas’ old criticism.

Concluding remarks

We can understand that simple response to complex problems might be appealing, and some degree of IPTS’s components might definitely be involved in some suicides. However, the IPTS is sold as a “theory of everything” (Paniagua et al., 2010), allegedly explaining all suicides everywhere (Joiner, 2005), when, in fact, it is so reductionist and decontextual that we question whether it is capable of explaining a single suicide anywhere. The main problem is, however, not the IPTS per se. In a relatively theory poor field such as suicidology, all attempts at theory development should be welcomed and vividly discussed. However, it is quite astonishing that such a simplistic and intra-personal theory so uncritically is embraced by a scientific audience, three decades after Boldt (1988) maintained: “The suicidologist who limits his or her study to the individual’s psyche has a hand on only one part of the ‘suicidal elephant’” (p. 101) and that:

Scholars who seek a universal understanding of suicide (…) fail to appreciate the degree to which their logic and ideas are influenced by the unique cultural ground from which they grew (…) Despite their best efforts to achieve universal, culture-free theories, their perceptions are inevitably and profoundly shaped by ethnocentric, contempocentric, and egocentric values, experiences, concepts, prejudices, and so on. (p. 102)

Chu et al.’s (2017) claim that the IPTS “has contributed to substantial advances in the scientific and clinical understanding of suicide and related conditions” is highly unwarranted. If anything, all the focus on this speculative and reductionist theory has contributed to derail suicide research, with potentially unfortunate consequences for treatment and prevention. For instance, Van Orden et al. (2012) recommend that the INQ be used in risk assessment and that perceived burdensomeness and thwarted belongingness are important targets for intervention. However, some patients may justly find the explicit emphasis on these being mere perceptions and not realities offensive since it means they and their problems are not taken seriously. This will, in turn, most likely have negative consequences for the all-important therapeutic alliance and thus for the outcome of the therapy. Standardization, which the IPTS necessarily entails, challenges clinicians’ connection with their patients (Hagen, Hjelmeland, & Knizek, 2017). This can be detrimental as the resulting “one-size-fits-all” approach may be de-humanizing in that it serves to distance and marginalize patients (Rogers & Soyka, 2004), which, in turn, may contribute to increase rather than decrease the suicide risk. By disregarding individual and contextual differences, standardized risk assessment and treatment approaches have proven to take time and attention away from what the patient needs (Large & Ryan, 2014). Therapists should rather adopt a listening perspective (Østlie, 2018) and also be open to the possibility that suicidality might be about other issues than perceived burdensomeness and thwarted belongingness; issues that very well might be in the patients’ contexts and not just in their minds (Hjelmeland & Knizek, 2016).

Another serious problem, in addition to its reductionistic outset, is that the IPTS is grounded in linear causal thinking, where perceived burdensomeness and thwarted belongingness are claimed to be “proximal causes of suicidal desire” (Van Orden et al., 2012, p. 197). The concept of cause with regard to suicide is, however, problematic. Although he did not discuss suicide specifically, Bruner’s words from his book Acts of meaning (Bruner, 1990) are highly relevant here, when he maintains that we must:

venture beyond the conventional aims of positivist science with its ideals of reductionism, causal explanation and prediction (…) To insist upon explanation in terms of “causes” simply bars us from trying to understand how human beings interpret their worlds and how we interpret their acts of interpretation (…) Are not plausible interpretations preferable to causal explanations, particularly when the achievement of a causal explanation forces us to artificialize what we are studying to a point almost beyond recognition as representative of human life? (p. xiii)

We cannot limit our study of something as complex and contextual as suicide “to ways of thinking that grew out of yesterday’s physics” (Bruner, 1990, p. xiii). Suicide must be understood in a life-course perspective; not in terms of simplistic “proximal causes” but through the life-history with developmental and relational issues taken into consideration in the analysis. For this, we need qualitative research (Hjelmeland & Knizek, 2016).

Recently, Joiner and his team outlined a sociobiological extension of the IPTS (Joiner et al., 2016, 2017). Socio-biology stems from evolutionary theory and is a controversial field where far-reaching conclusions are drawn on extremely meager and speculative grounds. The theory thus is currently being developed further in an even more speculative direction compared to the outset. We hope that this development will contribute to make more obvious the speculative basis of this theory, and its inability to contribute meaningfully to suicide prevention. However, with the current biologification of the field (Hjelmeland, 2013), we are afraid its popularity will continue to grow. With this article, we hope to at least initiate a much-needed debate about the IPTS. We suggest that the limited resources would be better spent on research with potential to provide more contextual understandings of suicide.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

Notes

1 In the literature, the theory is sometimes referred to as the Interpersonal Theory of Suicide and other times as the Interpersonal-Psychological Theory of Suicide. Here, we will use the former (abbreviated: IPTS).

2 Originally, this component was referred to “acquired capability for suicide”. In a recent paper, Joiner’s research group has, however, argued that the broader term “capability for suicide” should now be used, since this will encompass both the acquired element as well as potential genetic contributions (Chu et al., 2017).