Clinical Neuropsychiatry (2012) 9, 6, 221-224
PERCEIVED BURDENSOMENESS AND THWARTED BELONGING: AN INVESTIGATION OF
THE INTERPERSONAL THEORY OF SUICIDE
David Lester & John F. Gunn III
Abstract
Objective: Joiner’s interpersonal theory of suicide proposes that two risk factors are present in those who die
by suicide – perceived burdensomeness and thwarted belonging. A previous study examined the presence of these
risk factors in a large sample of Australian suicide notes (Gunn & Lester 2012), and the present study investigated
the presence of both perceived burdensomeness and thwarted belonging in several samples of suicide notes. Eleven
samples of suicide notes, totaling 664 notes, were read and rated by both authors for the presence of thwarted belonging
and perceived burdensomeness, eight of which have not been rated for the presence of these two variables before.
Method: The criteria used were the same as used by Gunn and Lester (2012). The results indicated that thwarted
belonging was present in the content of the notes more often than perceived burdensomeness (medians 42.5% versus
15.5%) and that both were rarely present in the same note (9.5%). There were no consistent differences by age and sex
in the presence of these themes.
Results: The results indicated that perceived burdensomeness is rarely evident in suicide notes, whereas thwarted
belonging is more common in suicide notes.
Conclusions: However, the majority of suicide notes did not contain evidence of these themes and, therefore, failed
to confirm Joiner’s theory.
Key words: thwarted belongingness, perceived burdensomeness, suicide notes, Interpersonal Theory of Suicide
Declaration of interest: none
David Lester, The Richard Stockton College of New Jersey
John F. Gunn III, Turnersville, New Jersey
Corresponding author
David Lester
Psychology Program
The Richard Stockton College of New Jersey
Galloway, NJ 08205
[email protected]
Joiner (2005) proposed that those who die by
suicide are characterized by three risk factors: (i)
perceived burdensomeness, (ii) thwarted belonging,
and (iii) an acquired capability for self-harm. Perceived
burdensomeness is the thought that one is a burden on
others in some way. This perception could stem from
the fact that one is indeed a burden, but it may also be
an irrational thought that is present only in the potential
suicide’s mind. The significant others may not perceive
the suicidal individual as a burden. This burden may
be financial or emotional or simply being in a position
that others have to take care of the individual. Thwarted
belonging refers to being socially isolated when one in
fact would like the company of others, or it may result
from the loss of a significant other through desertion
and divorce or through loss resulting from the death of
significant others, and it includes loneliness.
Joiner argued, however, that these precipitating
factors were not, in themselves, sufficient to lead an
individual to choose suicide. The individual must also
have acquired the ability to overcome a natural aversion
to hurting oneself during the suicidal act. This acquired
capability may have arisen from previous attempts
to commit suicide, by childhood experiences of pain
(possibly from sexual and physical abuse), or from later
life experiences (such as being involved in combat in
wartime).
Most of the research to test this theory has been
carried out on clinical groups of psychiatric patients
and attempted suicides and on non-clinical groups such
as college students, using brief inventories to measure
these three factors. Most of this research has confirmed
the associations of these three risk factors with measures
of suicidality (Van Orden et al. 2010). For example, Van
Orden et al. (2006) found that self-reported perceived
burdensomeness was associated with current suicidal
ideation and a history of attempted suicide in a sample
of psychiatric patients.
However, the best tests of the theory would
come from studies of completed suicides, and so far,
Submitted September 2012, Accepted December 2012
221
© 2012 Giovanni Fioriti Editore s.r.l.
David Lester & John F. Gunn III
Joiner has employed studies of the content of suicide
notes from completed suicides. In a study of suicide
notes from completed and attempted suicides in an
American city, Joiner et al. (2002) found that perceived
burdensomeness was more common in the notes from
completed suicides than in those from attempted
suicides. Pettit et al. (2002) found that the lethality of
the method of suicide used by a small sample of Chinese
suicides in their teens and twenties was negatively
associated with perceived burdensomeness.
The present study examined several samples of
suicide notes, that the senior author has collected,
for the presence of content reflecting perceived
burdensomeness and thwarted belonging. Since the
research involved the same two judges for each sample
of suicide notes, it was decided to use these same two
judges to examine the two sets of notes studied in
the earlier research by Joiner and his colleagues. The
present paper also includes the results of a previous
study by the two authors on a sample of Australian
suicide notes for comparison (Gunn et al. 2012).
Method
Samples of Suicide Notes
The present study focused on collections of suicide
notes previously collected but never examined for
content relevant to Joiner’s interpersonal theory of
suicide. Ten of the samples were previously used to
explore other variables (such as the presence of anger)
but have not been rated for the presence of thwarted
belonging and perceived burdensomeness.
(1) Fourteen suicide notes written by alcoholics in
the United States (Murphy 1992). Nine were from men
and five from women, mean age 44.8 (SD = 6.8).
(2) Sixty-three notes from Seiden and Tauber (1970)
from the San Francisco area in California. Twenty-one
were written by suicides, 21 were simulated notes
written by non-suicidal individuals, and 21 were “hoax”
notes, left on the Golden Gate Bridge but which police
later determined were written by individuals who had
planned to fake their own suicide and move on to a new
life elsewhere in the United States.
(3) Sixty-six notes from Shneidman and Farberow
(1957) from men in California, 33 of which were
genuine suicide notes and 33 of which were simulated
suicide notes written by non-suicidal individuals. All
were men, and the ages were not stated.
(4) Fifty-three genuine suicide notes written by men
and women in California (Leenaars 1988). Thirty-four
were men, and 19 women. Their ages were not stated.
(5) Fifty-two genuine suicide notes written by
individuals who died by suicide in Erie County (New
York) (Lester and Reeve 1982). Thirty-five were from
men and 17 from women, mean age 42.2 (SD = 17.3).
(6) Twenty-eight genuine suicide notes from
Canadian individuals who had died by suicide (Leenaars
1992). Sixteen were from men, six from women, and
six of unknown sex.
(7) Forty genuine suicide notes written by Germans
who had died by suicide (Heim and Lester 1991).
Twenty were men and 20 women; mean age 35.3 (SD
= 17.2).
(8) Thirty genuine suicides notes written by
Russians who died by suicide (obtained from Dmitri
Schustov, personal communication, circa 1990).
222
In addition, two sets of notes had been used in
previous studies by Joiner et al. (2002) and Pettit et al.
(2002), but had been rated by different judges than in
the present study.
(9) Forty genuine suicide notes were from a town
in the southwestern region of the United States, 20 of
which were written by completed suicides and 20 of
which were written by attempted suicides (Brevard
et al. 1990). Nineteen were men and 21 women; their
mean age was 36.6 (SD = 15.4).
(10) Seventeen notes were written by young
individuals in the teens and twenties in China who had
died by suicide (He et al. 2001). Eight were men and 9
women; their mean age was 22.4 (SD = 3.4).
(11) Finally, a set of 261 genuine suicide notes from
Australia the results from which have already been
published (Gunn et al. 2012).
Ratings
Each note was independently rated by two judges
for the presence of perceived burdensomeness and
thwarted belonging. The content was rated as clearly
present, possibly present, and absent. For the purposes
of the present study, clearly present and possibly
present were combined. The two judges met to resolve
disagreements. The median level of agreement initially
was 86.5% for perceived burdensomeness and 83% for
thwarted belonging.
Joiner has not provided a coding manual for
perceived burdensomeness or thwarted belonging. The
present raters used the following criteria.
Perceived Burdensomeness
1. Subjects perceive themselves to be a burden on
those who care for them or those that they care
about
2. Subjects feel that things would be better off if they
were not around especially in an interpersonal
sense, making comments like, “This is for the
best,” “You’ll be better off without me”
3. Subjects feel that they are an emotional burden
(e.g., make everyone around them miserable, cause
others pain) or a financial burden (e.g., draining
family savings and cost of medical care)
4. Subjects feel that their death will bring about some
good for those that they care about
Thwarted Belonging
1. Subjects feel disconnected from others
2. Subjects perceive that they are isolated from the
group and do not fit in: (i) may express feelings
of being alone or being lonely, (ii) may express
a sense of disconnect, or (iii) may associate their
suicide with a recent loss of someone important
Joiner’s Interpersonal Theory of Suicide proposed
that a third variable was critical for suicide to occur,
an acquired capability for suicide. This refers to past
experiences of the suicidal individual (such as sexual
abuse in childhood and combat experience in war).
None of the suicide notes referred to past experiences
such as these, and so this variable was not a focus of
the present study.
Results
The results of the analyses are shown in table 1. It can
Clinical Neuropsychiatry (2012) 9, 6
An investigation of the interpersonal theory of suicide
be seen that the presence of perceived burdensomeness
was noted in 9% to 33% of the samples of genuine
suicide notes (median 15.5%) and thwarted belonging
in 14% to 65% (median 42.5%). Thus, thwarted
belonging was more common in the genuine suicide
notes than was perceived burdensomeness. Both
themes were present at the same time in 0% to 21% of
the genuine suicide notes (median 9.5%).
Two of the samples included genuine and simulated
notes. In the notes from Shneidman and Farberow
(1957), the genuine and simulated notes did not differ
significantly in perceived burdensomeness (21% versus
27%, respectively, X2 = 0.57, df = 1), but the genuine
suicide notes significantly more often had the theme of
thwarted belonging (45% versus 12%: X2 = 8.94, df = 1,
p = .003). Seiden and Tauber (1970) also had samples of
genuine and simulated suicide notes. In their notes, the
Table 1. The presence of perceived burdensomeness and thwarted belonging in suicide notes
SourceN
Perceived
Thwarted
Both
Sample
burdensome
belonging
present
USA: Murphy (1992)14
21%57%21%
Alcoholic
USA: Seiden & Tauber (1970)
21
33%
14%
10% Genuine CS
21
5%24% 0%
Simulated
21
29%48%10%
Hoax
USA: Shneidman & Farberow(1957) 33
21%
45%
9% Genuine
33
27%12% 3%
Simulated
USA: Brevard et al. (1990)
40
18%
35%
0% 20CS/20AS
20
30%40% 0%
Genuine CS
20
5%30% 0%
Genuine AS
USA: Leenaars (1988)
53
9%
47%
2% Genuine CS
USA: Lester & Reeve (1992)
52
17%
37%
12% Genuine CS
Australia: Gunn et al. (2012)
261 10.%
31%
4% Genuine CS
Canada: Leenaars (1992)
28
14%
46%
11% Genuine CS
China: He et al. (2001)
17
6%
65%
6% Genuine CS
Germany: Heim & Lester (1991)
40
13%
65%
10% Genuine CS
Russia: Schustov30
13%27% 7%
28CS/2AS
Table 2. Correlations with sex and age
N Correlations
PerceivedThwarted
burdensomebelonging
AgeSexAgeSex
Alcoholics
14
-0.11-0.04-0.19 0.23
Russian notes30
-0.31
-0.22
0.01
-0.53*
Canada
22
-
0.02
-
0.15
Los Angeles 53
-
0.11
-
0.08
Buffalo
52 -0.28
-0.12
-0.14
0.19
Germany
40
0.15-0.08-0.17-0.11
Chinese
17
0.12
0.27
-0.22
-0.54*
Australia
261
0.05-0.13*-0.17**-0.04
* two-tailed p < .01
** two-tailed p < .01
Clinical Neuropsychiatry (2012) 9, 6
223
David Lester & John F. Gunn III
genuine suicide notes had perceived burdensomeness
significantly more often than the simulated notes (33%
versus 5%, (X2 = 5.56, df = 1, p < .02) but did not differ
in thwarted belonging (14% versus 24%, X2 = 0.62, df
= 1). The hoax notes resembled the genuine notes in
perceived burdensomeness and the simulated notes in
thwarted belonging.
A comparison of the suicides notes from completed
and attempted suicides indicated that the completed
suicide notes had significantly more burdensomeness
(30% versus 5%, X2 = 4.33, df = 1, p < .05) but did not
differ in thwarted belonging (40% versus 30%, X2 =
0.44, df = 1).
Of the eight samples, only one significant association
was found by sex for perceived burdensomeness (for
the 261 Australian suicide notes, the phi correlation
coefficient was –0.13, p < .05) and two for thwarted
belonging (for the 30 Russian suicide notes, the phi
correlation was –0.53, p < .05, and for the 17 Chinese
suicide notes the phi correlation was –0.54, p < .05).
Over the eight samples, there was no consistency in
whether the association was positive or negative (see
table 2).
Only six samples had data for age. None of
the correlations were significant for perceived
burdensomeness and only one for thwarted belonging
(for the 261 Australian suicide notes, the point biserial
correlation was –0.13, p < .05) (see table 2).
Discussion
The present study of 11 sets of suicide notes indicated
that thwarted belonging was rated as present in notes
more often than perceived burdensomeness (medians
42.5% versus 15.5%, respectively), but that both were
rarely present in the same note (median 9.5%). It is
clear, therefore, that this study of the content in eleven
samples of suicide notes failed to show that Joiner’s
Interpersonal Theory of Suicide applies to more than
a minority of suicides. Previous research has been
carried out mainly on individuals with suicidal ideation
or who have made a suicide attempt (see Van Orden et
al. 2010), and so the applicability of Joiner’s theory to
completed suicides has not been demonstrated.
There were no consistent differences in the presence
of these themes in two sets of simulated versus genuine
suicide notes. Furthermore, over all the samples, there
were no consistent differences in the presence of these
themes by age and sex. However, one sample was large
(n= 261) and, in this sample, men less often wrote about
perceived burdensomeness than did women, and older
suicides less often wrote about thwarted belonging.
This suggests the importance in future research of
obtaining larger samples of suicide notes than is
typically obtained for most research on suicide notes.
Collecting large samples is difficult, but may provide
more reliable findings.
224
However, regardless of the limitations associated
with the use of suicide notes, this study failed to
support the assertion of the Interpersonal Theory of
Suicide based on the content of 11 different samples
of suicide notes. Suicide notes have been used in the
past to test the Interpersonal Theory of Suicide (Joiner
et al. 2002, Pettit et al. 2002) but both studies used
small samples. This study, utilizing a large and diverse
sample of suicide notes, did not find that perceived
burdensomeness was a common theme in suicide notes.
Future research will be needed to determine if this is
a byproduct of the use of suicide notes or if it is an
indication that the Interpersonal Theory of Suicide is
helpful in understanding only a few cases of completed
suicide.
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