The Influence of Traditional Culture and the Interpersonal Psychological Theory on Suicide Research in Korea.

Korea has the highest suicide rate amongst the OECD countries. Yet, its research on suicidal behaviors has been primitive. While the Interpersonal Psychological Theory of Suicide has gained global attention, there has only been a few researches, which examined its applicability in Korea. In this article, we review the previous studies on suicide and examine the association between the Interpersonal Psychological Theory of Suicide and traditional Korean culture, with an emphasis on Collectivism and Confucianism. We propose that pathways to suicide might vary depending on cultural influences. Clinical implications and suggestions for future research will be discussed.

INTRODUCTION

Suicide is a leading cause of death, which affects millions worldwide.123 However, research on the detrimental phenomenon has been restricted for various reasons, including that there has been no comprehensive theory that encompass results from previous studies and suggest directions for future research.45 Recently, Joiner's Interpersonal Theory of Suicide (IPTS) has been gaining increased empirical support, suggesting it as a possible solution to the previously mentioned limitation of suicide research.56789

According to the IPTS, death by suicide occurs only when an individual develops the desire to commit suicide and the ability to put it into action.57 The desire to commit suicide is composed of two affect laden cognitions: thwarted belongingness and perceived burdensomeness.57 Thwarted belongingness is a state in which an individual's ‘need to belong’ is hindered; it is comprised of the feeling of loneliness and the lack of sufficient reciprocal relationships. Perceived burdensomeness, on the other hand, is a cognitive state in which individuals believe themselves to be a liability towards significant others; it is consisted of the cognition that one is a burden and the negative affect of self-hatred. While the experience of a single component is thought to predict passive suicide ideation (i.e., ‘It would be better if I were dead’), the concurrent experience of both components, tagged with the thought that they are stable and unchanging (i.e., hopelessness), is believed to predict active suicide ideation (i.e., ‘I want to kill myself’) (Figure 1).579

Figure 1

The Interpersonal Psychological Theory of Suicide (IPTS). The shaded items indicate the core constructs of the IPTS.

However, the progression from an active suicide ideation to a death by suicide depends on the presence of a third component: acquired capability.579 Self-preservation is such a robust natural instinct that only a few can willingly withdraw it. In order to overcome this basic human nature, individuals must acquire the capability to commit suicide. The IPTS posits that constant exposure to provocative or painful events (i.e., physical abuse, sexual abuse, combat exposure, previous suicide attempt etc.) habituates individuals towards pain.5 Through this continuous process, individuals develop an elevated tolerance towards pain and a decreased fear of death, which ultimately enable them to utilize more lethal measures when attempting suicide (Figure 1).10

IPTS has provided apt explanations to unresolved discrepancy between the prevalence of suicide ideation and suicide attempt; ideation is possible when two constructs (i.e., thwarted belongingness and perceived burdensomeness) are present, whereas, all three constructs have to be present in order to attempt suicide (Figure 1). The theory has also provided profound insight and accelerated research in suicidal behaviors.9 Its constructs have demonstrated stronger predictive power than some of the most warranted variables that have previously been associated with suicide, such as depression, hopelessness and social support.111213 Various studies have confirmed its significance across multiple ages, clinical samples, combat veterans and even specific populations such as prison inmates.14151617181920212223 Yet, motives for suicide often vary by culture, and for a theory to be truly comprehensive it should not only be applicable to all ages and clinical symptoms, but also to different ethnicities and cultural influences.24 Minimal effort has been made to examine the usefulness of the IPTS in various cultures8 and only a handful of studies have tested it in Korea (Table 1). We believe that the IPTS successfully portrays much of the cultural and social influences that prevails in Korea and that the theory will enhance our understanding of suicide in the nation. In this article, we will review some of the previous literature that has applied the IPTS in Korea and discuss its clinical implications and directions for future research.

Table 1

Peer-reviewed Korean researches on the IPTS (N=11)

Dissertations have been excluded. Papers have been searched through DBpia on Sep. 1st, 2016. IPTS: Interpersonal Psychological Theory of Suicide, PB: Perceived Burdensomeness, TB: Thwarted Belongingness, AC: Acquired Capability

CULTURE AND SUICIDE

Collectivism and suicidal behavior

Culture influences one's cognition, emotion, and motivation.252627 Among the various frameworks that have been developed in order to systematically understand disparate cultural influences, Hofstede's concept of ‘individualism’ and ‘collectivism’ has laid a firm foundation for cross-cultural researches.2628 Collectivistic societies operate upon the core principle of a sense of connectedness and unity. The self is construed in relations to others and evaluated upon the ability to fit in into one's intergroup. Emotions that promote harmonious relationships are emphasized and experienced more frequently. Motives for action are those that enhance one's feeling of relatedness and promote integration into the group (i.e., repression of the self, control over one's desires).24252627

Korea is one of the most collectivistic societies, which greatly emphasizes family relations.2528293031 Although strong bonds with family members and familial support usually act as protective factors against suicide,32 disturbed family relationships, conversely, can have devastating effects.333435 In a nationwide study that examined risk factors of suicide attempts in 2754 adolescents, Bae et al.36 identified the level of intimacy with family as the most powerful predictor of suicide attempt in the potentially depressed group. Hong37 examined the associations between family dysfunction, interpersonal needs, and suicide ideation, and reported that experiences of parental abuse, both verbal and physical, was mediated by thwarted belongingness, and perceived burdensomeness to increase thoughts of suicide in Korean adolescents. While such results are not confined to Korea, Clarke et al.38 identified that suicidal Asians are more likely to report low senses of belongingness than suicidal Caucasians. Hence, it is arguable that impacts of disturbed family relationships can be more hazardous in Korea ironically because it places so much value on the intergroup.39 Furthermore, in a study about sexual preferences and suicide ideation, Kim and Yang40 discovered greater effects of thwarted belongingness, and perceived burdensomeness on suicide ideation in Korean homosexuals than heterosexuals. This result suggests that gay and lesbians worry more about being accepted by significant others. Not only do they worry about fitting in, but Korea's low tolerance towards homosexuals might cause them perceive themselves as a liability towards their family and the society.

Confucianism and suicidal behavior

Another aspect that requires attention in order to understand cultural influences that may affect suicidal behavior in Korea, is Confucianism. Collectivism in Korea has Confucian origins and as a result, stresses parental and filial duties.25 In order to preserve unity within the family (i.e., Collectivism), parents are obliged to provide for their children and children are demanded to meet their parents' expectations (i.e., Confucianism). Negative consequences occur when either the parents or the children are unable to fulfill their role. Ha et al.41 found significant effects of thwarted belongingness and perceived burdensomeness in older adults, who were over 65-years-old, and suggested that the inability to provide financial support for their family might play a crucial role. Similarly, Chu and Lee42 identified that older adults were more vulnerable than adolescents toward perceived burdensomeness, and explained that the results are highly attributable to their weakening health and also their fragile financial circumstances.

The burden to comply with a certain role is not parent specific. Often times children experience a corresponding stress, as they are expected to endorse the beliefs and values of their parents, and to live up to their expectations.25 A common phenomenon that children suffer from is ‘education fever,’ which is characterized by the parents' excessive aspiration for their children's education. Contrary to the common belief, major motivations for education fever are not vicarious pleasure or personal satisfaction, but to support children's success.43 In other words, it is a means to provide, hence to fulfill the role as a parent and maintain family bondage. Regardless of the intent, boundless interest of the parents is a cause of academic stress, which has been constantly associated with suicidal behaviors.4445 According to a national survey in Korea, adolescents rated academic stress as the number one reason for desiring suicide.46 In addition, Seok47 found a significant interaction between perceived burdensomeness and academic stress to predict suicide ideation in female adolescents.

Along the developmental course, experiences of academic stress often have aggravating effects on another common risk factor for suicide: unemployment. While various studies have confirmed the association between unemployment stress and suicide desire,484950 Yoo and Son51 asserted that Koreans might experience a greater degree of stress from unemployment because immense amounts have been invested into their education. As collectivistic societies show a bias towards negative self-appraisal,25 adults who are unable to find a job might falsely attribute the cause of their unemployment to personal inabilities rather than harsh economic circumstances and perceive themselves to be a burden upon their parents, who have made full dedications.

Modernization, generation gaps, and suicidal behavior

So far we have mentioned how Korea's cultural characteristics overlap with the constructs for suicidal behavior identified by the IPTS. Yet, it might be a bit rash to contend that Korea is solely collectivistic. Rapid industrialization and modernization in Korea over the past few decades have promoted individualism, bringing changes in family structure and values. The dominant family structure has changed from extended to nuclear, and the fertility rate has decreased from 4.21 to 1.23 children per woman.52 This transition could have increased experiences of thwarted belongingness, which can be protected by large family size, as household size is negatively correlated with suicide rate.5354 Also, generation gaps have increased due to younger generations moving toward individualism.555657 This gap would lead to differences in familialistic values-values that reflect family unity and support-between generations. According to Baumann et al.,58 gaps in familialism between mothers and daughters is associated with decreased mutuality and increased externalizing behavior, which in turn predict suicide attempts. Generation gap could also lead to tension between parent and their children,59 which is associated with high risk for suicidal behaviors.6061

CONCLUSION

In this article, we have reviewed the previous literature on suicide to examine the relationship between the constructs of the IPTS and collectivism in Korea. When positive, collectivistic values can protect individuals from suicide by promoting a sense of oneness.62 However, when unable to abide by its standards, it can also act as a catalyst to suicidal behaviors. While Joiner has posited that the coexistence of thwarted belongingness and perceived burdensomeness predict suicidal desire, collectivism in Korea suggests that pathways to suicide might be culturally dependent. For example, in a collectivistic society, inability to fit into an intergroup might cause feelings of loneliness (i.e., thwarted belongingness), which then can be interpreted as a personal liability (i.e., perceived burdensomeness). Such possibilities demand further investigation.

Despite the usefulness of the IPTS to understand suicide, efforts to apply the theory in a Korean population have been scant. For example, the interpersonal needs questionnaire, which measures thwarted belongingness and perceived burdensomeness, has been validated only in older adults, limiting its generalizability.63 Other studies have used self-translated versions that lack psychometric validation. In addition, most of the studies have focused solely on suicidal desire, neglecting ‘acquired capability,’ or have not been peer-reviewed. Based on the similarities between Korea's culture and the IPTS, we firmly believe that the theory demands more attention. and that its thorough application holds the potential to enhance the understanding of suicidal behavior in Korea.