The Suicidal Process and Self-Esteem

Abstract

It has not been made clear whether self-esteem is associated with the severity of suicidal behavior.
To test the association between responses to a self-esteem inventory and levels of suicidal behavior as conceptualized in the notion of the suicide process.
Questions on the severity of suicidal behavior over the lifespan (death wishes, ideation, plans, and attempts), as well as a self-esteem inventory, were administered to 227 university undergraduates.
A negative relationship was found between the level of suicidality and self-esteem. As hypothesized, there were fewer cases in each succeeding level of seriousness of suicidal behavior. However, nearly all cases from any particular level were contained in the cohort of individuals who had displayed suicidal behavior at a less serious level.
This suggests a possible progression through each of the stages of suicidal behavior, with very few cases showing a level of suicidal behavior that was not associated with a previous, less serious, form. It was hypothesized that early entry into the suicidal process may be indicated by low self-esteem, thus, allowing for a more timely preventive intervention.

Full text

A.H. Thompson:Self-Esteem and SuicideCrisis2010;Vol. 31(6):311–316© 2010HogrefePublishing
Research Trends
The Suicidal Process and Self-Esteem
Angus H. Thompson
Institute of Health Economics, Edmonton, Alberta, Canada
Abstract. Background: It has not been made clear whether self-esteem is associated with the severity of suicidal behavior. Aims: To test
the association between responses to a self-esteem inventory and levels of suicidal behavior as conceptualized in the notion of the suicide
process. Methods: Questions on the severity of suicidal behavior over the lifespan (death wishes, ideation, plans, and attempts), as well
as a self-esteem inventory, were administered to 227 university undergraduates. Results: A negative relationship was found between the
level of suicidality and self-esteem. As hypothesized, there were fewer cases in each succeeding level of seriousness of suicidal behavior.
However, nearly all cases from any particular level were contained in the cohort of individuals who had displayed suicidal behavior at a
less serious level. Conclusions: This suggests a possible progression through each of the stages of suicidal behavior, with very few cases
showing a level of suicidal behavior that was not associated with a previous, less serious, form. It was hypothesized that early entry into
the suicidal process may be indicated by low self-esteem, thus, allowing for a more timely preventive intervention.
Keywords: suicide, ideation, attempts, self-esteem, suicide process
Self-esteem has been one of the most widely studied con-
cepts in the mental health field and has been linked to a
wide variety of mental health conditions and behaviors.
Many studies have demonstrated strong connections be-
tween self-esteem and both suicidal ideation and suicide
attempts (Bhar, Ghahramanlou-Holloway, Brown, & Beck,
2008; Marciano & Kazdin, 1994; Overholser, Adams, Leh-
nert, & Brinkman, 1995; Roberts, Roberts, & Chen 1998;
Wild, Flisher, & Lombard, 2004). Other investigations into
this relationship have focused on more specific aspects of
suicidal behavior such as death wishes, suicidal ideation
and making a suicide plan, as well as on suicide attempts.
These particular behaviors are commonly viewed as com-
prising an orderly progression. That is, suicidal ideation is
generally thought to precede a suicide attempt (Beck, Ko-
vacs, & Weissman, 1979) and movement from a death wish
through to a suicide attempt has been discussed under the
concept of “the suicide process” (Portzky, Audenaert, &
van Heeringen, 2005; Runeson, Beskow, & Waern, 1996;
van Heeringen, Hawton, & Williams, 2000) or interpreted
as a hierarchy of intent (Mo?cicki, 1989). However, few
studies have systematically examined the relationship be-
tween these levels of suicidal behavior and any measure of
mental health. Recently, however, it has been observed that
those with early-onset depression progressed to more seri-
ous levels of suicidality than those with later onset (Thomp-
son, 2008).
Self-esteem is generally regarded as a stable personality
characteristic that reflects a sense of personal worth (Ro-
senberg, 1965). The concept is not to be confused with self-
efficacy or self-confidence, which are related to a belief in
one’s ability to perform. Although self-esteem correlates
with depression and may, thus, be causally linked, these
conditions also need to be distinguished since the former
is a self-rating and the latter a description of mood. Indeed,
Thompson, Barnsley, and Battle (2004) have suggested that
low self-esteem may generally precede depression, indicat-
ing that the link may be functional but not necessarily con-
temporaneous.
Not surprisingly, then, self-esteem is frequently noted as
a correlate, and often as a predictor, of one or another of
the components of the suicidal process (e.g., Hidaka et al.
2008; Martin, Richardson, Bergen, Roeger, & Allison,
2005; McAuliffe, et al. 2005; McGee & Williams, 2000;
McGee, Williams, & Nada-Raja, 2001; Park, Schepp, Jang,
& Koo, 2006; Reinherz, Tanner, Berger, Beardslee, & Fitz-
maurice, 2006). In spite of this, and even with the interest
in both self-esteem and the suicidal process, there have
been no studies that have arranged these suicidal behaviors
in order of seriousness and examined changes in self-es-
teem across the resulting dimension.
This study, then, was designed to examine the relation-
ship between self-esteem and suicidality, with the expecta-
tion that progressive decreases in self-esteem would be as-
sociated with increases in the seriousness of suicidal be-
havior.
It should be noted that there are still some definitional
issues pertaining to the suicidal process. Researchers in this
area (e.g., Portzky et al., 2005; Runeson et al., 1996; van
Heeringen et al., 2000) have described the progression
through the levels of the suicide process in terms of “sever-
ity,” “seriousness,” “lethality,” or “intent.” However, not
all individuals exhibiting suicidal behavior may actually
wish to die, including even some who have made a suicide
attempt (Kreitman, Phillip, Greer, & Bagley, 1969). There-
fore, terms like “lethality” or “intent,” could be misleading.
DOI: 10.1027/0227-5910/a000045
© 2010 Hogrefe Publishing Crisis 2010; Vol. 31(6):311–316

Van Heeringen (2001) has provided more on this defini-
tional issue. At present, it appears prudent to view the con-
cept of the suicide process as a working hypothesis that will
allow us to work toward further refinements. Until consen-
sus is reached on the most useful way to describe move-
ment through the suicide process, the commonly used
terms should be viewed with a certain allowance for impre-
cision.
In this study, the terms “seriousness” and “suicidality”
have been adopted to address variations in the level of sui-
cidal behavior to avoid debatable claims about severity
and/or lethality.
Method
Subjects
Participants were students in two nonintroductory under-
graduate psychology classes at a Canadian university . Par-
ticipation was voluntary, but it appeared that all, or nearly
all, of the students present completed the questionnaire.
There were a total of 227 participants; 80 (35%) were male.
Ages ranged from 17.8 to 46.3 years. The age distribution
showed a positive skew, with a mode of 19 years, median
of 21.4 years, and a mean of 23.4 years (SD = 5.70).
An information statement was placed at the beginning
of the questionnaire to explain that participation was vol-
untary and that a decision to participate or to not participate
would have no bearing on marks or any other aspect per-
taining to studies at the university. Students were asked to
supply their university identification number to allow link-
age with their course marks (not used in the present study).
It was made clear that all information would be kept con-
fidential and that the identification numbers would be de-
leted as soon as the linkage was made. This study was ap-
proved by the Ethics Committee of the Department of Psy-
chology at the University of Alberta.
Measures
The items used to assess the level of suicidality were adapt-
ed from the Diagnostic Interview Schedule (Robins, Hel-
zer, Croughan, Williams, & Spitzer, 1981), and are similar
in nature to items introduced in an epidemiologic study by
Paykel, Myers, Lindenthal, and Tanner (1974). The pur-
pose was to create a scale representing meaningful incre-
ments in suicidal intent. The four resultant questions, re-
spectively representing a death wish (without suicidal con-
tent), suicidal ideation (thoughts of taking one’s one life),
making a plan, and making an attempt, are as follows:
1. Has there ever been a period when you felt like you
wanted to die?
2. Have you felt so low you thought of committing suicide?
3. Have you ever made definite plans to commit suicide
(even though you did not actually make an attempt)?
4. Have you ever attempted suicide?
Self-esteem was measured with the Culture-Free Self-Es-
teem Inventory (CFSEI; Battle, 1981). An important con-
sideration in the selection of this instrument was the fact
that it was developed on a Canadian sample (Battle, 1981),
thus providing norms that were well suited to the partici-
pants in the present study. The adult form (AD) of this pa-
per and pencil test produces a total self-esteem score with
three component subscales; Social, Personal, and General
self-esteem, comprising, respectively, 8, 8, and 16 items.
Test-retest reliabilities are high (0.81). However, internal
consistency reliabilities were not as strong, showing Cron-
bach’s αvalues of 0.78, 0.72, and 0.57 for general, person-
al, and social self-esteem, respectively (Brooke, 1995);
with social self-esteem falling below the generally accept-
ed standard of 0.70. Concurrent validity was supported by
positive correlations (.71 to .80) between the child/adoles-
cent form of the CFSEI and Coopersmith’s (1967) Self-Es-
teem Inventory (Battle, 1981). No concurrent validity data
were shown for the CFSEI adult form. A number of studies
have shown positive associations between the CFSEI and
a variety of measures of depression, with correlations rang-
ing from 0.34 to 0.75 (Brooke, 1995).
In view of the fact that all of the subjects were students,
academic self-esteem was also of interest. Therefore, a 10-
item Academic Self-Esteem scale (not included in the adult
Form, AD) was adapted from the child/adolescent scale of
the same test (Form A), and added to the questionnaire used
in the present study. A similar approach to the inclusion of
the child/adolescent academic scale in the adult form was
successfully undertaken by Mendoza (1995). Since the
norms for the child/adolescent CFSEI academic subscale
are nonetheless not suitable for use in a study of adults, the
results for the academic subscale were calculated as if the
sample displayed the same mean and standard deviation as
the normative population. Given that this assumption may
be incorrect, main effect contrasts of subscale means could
be biased. However, comparison of subscale means is of
little interest here, and the analyses will, thus, focus on dif-
ferences in the level of suicidal behavior.
A total self-esteem score was calculated by summing the
scores of the four component scales. Raw scores were con-
verted to T-scores (mean = 50, SD = 10) for analysis and
presentation of results.
Results
The results of an assessment of the internal consistency of
the four subscales of the CFSEI showed that three of the
scales produced Cronbach’s αcoefficients that surpassed
the 0.70 standard; Personal (0.77), General (0.81), and Ac-
ademic (0.73). The fourth, Social (0.60), was marginal,
312 A. H. Thompson: Self-Esteem and Suicide
Crisis 2010; Vol. 31(6):311–316 © 2010 Hogrefe Publishing

matching its relatively low performance on the normative
sample.
Of first importance, 52% of the students had, at some
time in their lives, engaged in some form of suicidal idea-
tion or behavior. As Table 1 indicates, nearly all of these
had, at some time, wished to be dead, fewer expressed
suicidal ideation, and the number making plans to take
their own lives was considerably lower than that. Al-
though a relatively small number had made a suicide at-
tempt, it still stands at a disturbing rate of 1 in 20 persons.
This rate lies within the range reported in reviews by
Angst, Degonda and Ernst in 1992, Weissman et al. in
1999, and Welch in 2001, but is higher that reported by
Bertolote et al. in 2005.
Also shown in Table 1 is the classification of the most
serious level of suicidal behavior attained by the respon-
dents. A one-way analysis of variance (ANOVA) showed
that total self-esteem varied significantly with changes in
the level of suicidal behavior, F(4, 191) = 7.61, p< .001.
Figure 1 clearly shows that as the level of suicidal behavior
increased, mean total self-esteem scores decreased. Post-
hoc polynomial analysis showed that the linear trend was
statistically significant, F(1, 191) = 20.28, p< .001, but the
departure from linearity was not, F(3, 191) = 0.60. The ab-
sence of a statistically significant nonlinear presence indi-
cates that there is no reason to question the conclusion that
the data can best be described as a linear gradient of de-
creasing self-esteem on increasing suicidality.
Since unequal cell sizes may affect the ANOVA as-
sumption of equal group variance, Levene’s test for ho-
mogeneity of variance was applied to the raw data. The
result was a statistically significant departure from equal-
ity, Levene’s Statistic (4/222) = 5.80, p< .001. However,
ANOVA is very robust when it comes to the assumption
of homogeneity. The variances of the five severity groups
ranged from a high of 93.5 down to 30.7, a ratio of 3.0,
which is within the acceptable range (below 4×) suggest-
ed by Moore (1995).
The trend analysis of the relationship between severity
of suicidal behavior and total self-esteem produced sim-
ilar results for each of the component subscales of the
CFSEI. This was tested posthoc by conducting a one-way
ANOVA on each of the four self-esteem subscales (a fac-
torial analysis was not used since the within-subject com-
parisons across self-esteem levels were not of interest).
The significance levels were adjusted upward to compen-
sate for the multiple comparisons involved when evalu-
ating the subscales in this way.
Table 1. Respondents distributed according to the level of
severity of suicidal behavior
None Death
wish
Ideation Plan Attempt
Total* 108 (48%) 115 (51%) 80 (35%) 26 (12%) 12 (5%)
Most
serious#
38 (17%) 52 (23%) 16 (7%) 12 (5%)
Note. *Many respondents reported more than one type of parasuicidal
behavior, thus the row total exceeds 100%. #Categories are mutually
exclusive. Assignment was determined by each person’s most serious
level of suicidal behavior.
Figure 1. Total self-esteem and suicid-
al behavior among university stu-
dents.
A. H. Thompson: Self-Esteem and Suicide 313
© 2010 Hogrefe Publishing Crisis 2010; Vol. 31(6):311–316

A significant linear trend was observed for all four sub-
scales with none showing a statistically significant departure
from linearity (for General, Social, Academic, and Personal
self-esteem, respectively, the FLinear values were 14.51, p<
.001; 6.48, p<.05;8.67,p< .05; and 10.53, p<.01).No
further analysis of the subscales was conducted since they
mirror the downward trend found for total self-esteem.
Of further interest is the probability that a particular level
of suicidal behavior was “preceded” by a less serious level.
The results of this analysis are shown in Table 2. Clearly,
nearly all of those who exhibited a particular level of suicidal
behavior had experienced what are hypothesized to be ante-
cedent suicidal behaviors. That is, 91% of attempts were pre-
ceded by plans; plans, in turn, were associated with ideation
in all cases; and ideation was associated with a death wish in
96% of cases.
Although these findings appear at first glance to be some-
what banal (i.e., it is difficult to imagine how someone could
make a suicide plan without thinking about it beforehand),
the results noted in the previous paragraphs make it clear that
each level of suicidality has a different meaning – at least in
terms of self-esteem. Furthermore, this kind of analysis begs
the question of whether the results suggest something differ-
ent when the levels are viewed in reverse order (their sup-
posed chronological sequence). It turns out thatthey do – the
associations were considerably lower in magnitude when
viewed in this way, but remained at meaningful levels. That
is, of those with a death wish, 67% exhibited suicidal idea-
tion; only 33% of ideators produced a plan, and just 38% of
those who made a plan also made an attempt. These data are
in line with the view that the five levels (an absence of sui-
cidal behavior being the first) represent a progression of in-
creasing seriousness, with the number of participants drop-
ping at each level. This inverse relationship between serious-
ness of behavior and the lifetime prevalence of suicidality is
in accord with the findings from a number of community
surveys (De Leo, Cerin, Spathonis, & Burgis, 2005; Kessler,
Borges, & Walters, 1999; Mo?cicki et al., 1988; Paykel et al.,
1974; Rancans, Lapins, Salander Renberg, & Jacobsson,
2003).
Discussion
The results of this study demonstrate that self-esteem is
associated with the seriousness of suicidal behavior and
that the association is linear. The fact that self-esteem goes
down as the severity of suicidal behavior goes up does not,
however, prove causation. That is, we cannot say that sui-
cidal behavior is a consequence of lowered self-esteem.
Nor can we rule out the opposing hypothesis that current
self-esteem scores have been affected by previous suicidal
behavior. Our understanding of the sequence of events
would be enhanced by the inclusion of age data for both
variables in future studies of this nature. The primary im-
portance of this finding lies in the association. This extends
the previous findings on the self-esteem/suicidal behavior
relationship by indicating the existence of a gradient that
involves seriousness. That is, one way or the other, there is
a clear relationship indicating that increases in the serious-
ness of suicidal behavior are associated with decreases in
self-esteem.
It should be noted that this finding was based on a stu-
dent sample and generalization to other groups has not yet
been demonstrated. Furthermore, there are two caveats that
need to be applied to the notion of self-esteem and to the
nature of the proposed suicidal process. First, self-esteem
is being used here to serve as an important indicator of
well-being, not to denote a behavior that can be modified
to produce a therapeutic outcome – this latter notion being
hotly disputed by many (Burr & Christensen, 1992; Selig-
man, 1991; Smelser, 1989). Second, a number of investi-
gators have indicated that it would be a mistake to consider
the suicidal process to be invariant. For example, Wyder
and De Leo (2007) have suggested that the process would
be better characterized as fluctuating, rather than smooth;
Bertolote et al. (2005) have noted that it varies according
to culture; and Fortune, Stewart, Yadav, and Hawton (2007)
have identified three types of suicidal processes – not one.
Nevertheless, the fact that each level of suicidal behav-
ior was almost always associated with the adjoining, less
serious, level of suicidal behavior supports the hypothesis
that end-point suicidality follows a suicidal process of in-
creasing intensity that begins with occasional thoughts of
death (Angst et al., 1992) and stops at some point along a
single continuum whose last possible position is completed
suicide. The reason, then, that prediction forward along this
scale is less than perfect appears to be because some indi-
viduals move to a certain level of severity and go no further
– not because the construct of the suicidal process is faulty
or because of measurement error. We are, nonetheless, left
with the difficulty of predicting a low probability event
(e.g., a suicide attempt) from an early behavior (e.g., a wish
to die) that is exhibited at some point by a large proportion
of the population. Thus, early suicidal behavior appears to
have very high sensitivity for completed suicide (it captures
most cases of more serious suicidal behavior), but very low
specificity (it also captures many false positives) – a tradi-
tional problem in research on risk factors (Leon, Friedman,
Sweeney, Brown, & Mann, 1990).
This paper shows a linear relationship between two im-
portant variables that lie along a developmental pathway.
This indicates that detection of early entry into the suicidal
Table 2. The proportion of individuals acknowledging a
particular level of suicidal behavior who also dis-
played relatively “lower” levels of severity
Lower level relative to index level
Index level % with a plan % with ideation % with a death wish
Attempt 91% 100% 100%
Plan 100% 100%
Ideation 96%
314 A. H. Thompson: Self-Esteem and Suicide
Crisis 2010; Vol. 31(6):311–316 © 2010 Hogrefe Publishing

process can allow the provision of preventive interventions
that can, in many cases, be applied well before the advent
of more serious suicidal actions. The importance of the re-
lationship with self-esteem lies in the fact that early suicidal
behavior (i.e., a death wish, a suicidal thought) is not easily
detected unless expressed in a public way. Low self-es-
teem, on the other hand, is usually manifest in observable
behaviors, and its formal (questionnaire) assessment is not
deemed to be as intrusive as questions about suicidal
thoughts or actions. Thus, among children, evidence of low
self-esteem should raise enough concern about future sui-
cidal behavior and other personal difficulties that further
investigation, at the least, should be deemed necessary.
Acknowledgment
Yan Jin provided valuable assistance in data collection and
the early literature search.
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About the author
Dr. Angus Thompson has served as Vice-President of the Cana-
dian Association for Suicide Prevention and has previously man-
aged Alberta’s Provincial Suicidology program. He has served as
a clinical psychologist, policy analyst, and senior manager. Re-
search involvement includes suicide, mental health, problem
gambling, and health services with a recent focus on work pro-
ductivity.
Angus H. Thompson
Institute of Health Economics
1200 – 10405 Jasper Avenue
Edmonton, Alberta T5 J 3N4
Canada
Tel. +1 780 448-4881
Fax +1 780 448-0018
E-mail gthompson@ihe.ca
316 A. H. Thompson: Self-Esteem and Suicide
Crisis 2010; Vol. 31(6):311–316 © 2010 Hogrefe Publishing