Meaning in Life and Demoralization Constructs in Light of the Interpersonal Theory of Suicide: A Trans-Theoretical Hypothesis for a Cross-Sectional Study

Abstract

Following V. Frankl’s (in the 1950s) and J. Frank’s (in the 1970s) historical definitions of the constructs Meaning in Life (MiL) and demoralization, there have been a multitude of studies which have described them from different theoretical perspectives. These constructs are closely linked, with the lack of MiL as one of the subconstructs underlying the definition of demoralization. Numerous studies have shown that MiL and demoralization affect suicidality, as protective and risk factors, respectively. The Interpersonal Theory of Suicide (IPTS) is a more recent framework conceptualized by T. Joiner (in the 2000s) to provide an additional possible reading key in the effort to better understand suicidality. By analogy to a previous study by E. Kleiman & J. Beaver (2013), examining MiL and demoralization in suicidality through a perspective of the IPTS framework can be of considerable interest. This study showed, in a cohort of undergraduate students, that MiL mediated the relationship between two variables associated with IPTS (perceived burdensomeness and thwarted belongingness) and suicidal ideation (SI). Taking into consideration future studies that these latter authors advocated, our aim is to verify this finding using a cross-sectional study. Differences in our approach would include a) studying a clinical population (suicidal patients attending an emergency department), b) analyzing relationships not only with SI but also with suicidal attempts (SA), and c) in consideration of the interconnection between MiL and demoralization, exploring also the possible role of demoralization as a mediator. The clinical implication lies in identifying multi-faceted targets that may be useful to mitigate suicidality risk in individuals, both in prevention and therapy intervention.

In recognition of the importance of meaning to the well-being of humans, V. Frankl provided a historical definition of the construct Meaning in Life (MiL), which arose from three inherent assumptions: a) perception and the search for beauty, b), creativity, and c) the effort to choose one’s attitude, also under despondent circumstances.¹ The past 20 years have seen a surge in defining MiL from different theoretical perspectives.^2–6 Among them, C. Park proposed an integrated model of meaning-making in the context of a particular environmental encounter.² This author not only distinguished between global and situational meaning but also suggested that meaning and meaning-making efforts should be considered in the evaluation of the process aimed at adjusting one’s experiences of events that are discrepant with one’s larger beliefs, plans, and desires.² M. Steger proposed a model of MiL in which two sub-constructs are distinguished: the presence of MiL and the search for MiL, each having different clinical implications.³ He also proposed that a consensus in various MiL’s conceptualizations could be reached on three dimensions, respectively the cognitive, motivational, and evaluative: a) coherence, or a sense of comprehensibility and self-concordant ability of making sense centered on the perception that stimuli are predictable and conform to recognizable personal patterns. It is especially activated in situations where meaning is disrupted and the individual experiences distress and the related necessity to construct or reconstruct a framework to understand and transcend chaos; b) purpose, or a feeling of core goals, aims, and direction in life; and 3) significance, or a focus on how important and inherently valuable one’s life as a whole feels beyond trivial or momentary elements.⁴ When all three components are taken together, a definition for MiL emerges from “the web of connections, interpretations, aspirations, and evaluations” that “1) make our experiences comprehensible, 2) direct our efforts toward a desired future, and 3) provide a sense that our lives matter and are worthwhile”.^3,4,6

First introduced in the psychiatric literature by J. Frank, demoralization was defined as a specific cluster of symptoms arising from a

persistent failure to cope with internally or externally induced stresses that the person and those close to him expect him to handle. Its characteristic features, not all of which need to be present in any one person, are feelings of impotence, isolation, and despair.⁷

Similar to MiL, multiple refinements of this initial definition and supplementary theoretical contributions have followed over time.^8–10 A widely used model of demoralization is the one proposed by D. Kissane D. and D. Clarke, in which the construct of demoralization is supported by the presence of five sub-constructs: 1) loss of meaning, 2) hopelessness, 3) helplessness, 4) sense of failure, and 5) dysphoria.^11,12 The two concepts of MiL and demoralization are closely linked, with the lack of MiL as one of the sub-constructs underlying the construct of demoralization.^11,12

Both MiL and demoralization play a role in affecting suicidality, respectively as protective and risk factors. This concept has recently been summarized in a systematic review¹³ and supported by some previous analyses by our group in a cohort of patients attending an emergency department for suicidal ideation (SI) and suicidal attempt (SA)^14–16

The Interpersonal Theory of Suicide (IPTS), conceptualized by T. Joiner, posits that the desire to die by suicide is fostered by the amalgamation of two constructs, the perceived burdensomeness (PB), ie, the belief that one is a burden to others, and the thwarted belongingness (TB), ie, the belief that one does not belong to a group. The third construct, the acquired capability for suicide (AC), is conceived as an essential prerequisite for executing the desire to die and moving on to the suicidal behavior (SB), including SA and completed suicides.^17,18 Also this theory, similarly to a multitude of previous studies, was confirmed by some of our above-mentioned analyses.^19–23

The role of MiL in the framework of IPTS was examined for the first time in an elegant work by E. Kleiman & J. Beaver.²⁴ Given that both PB^25,26 and social exclusion (which can be related to TB)²⁷ can predict decreased MiL, and since PB and TB can predict SI,^17,18 the authors hypothesized that MiL can mediate the relationship between SI and these IPTS constructs. This was demonstrated in non-clinical population (a cohort of undergraduate students).²⁴

Taking into consideration the perspectives for future studies that E. Kleiman & J. Beaver advocated,²⁴ we aim to verify their hypothesis of MiL as a mediator in the relationship between PB/TB of IPTS and SI by a cross-sectional study. Differences in our approach would include: a) using a clinical population (a well-characterized population of suicidal patients attending an emergency department that was investigated in our previous studies^{14–16,19–23}), b) analyzing the relationship not only with SI but also with SA, and c) extending the exploration to a possible mediator role also for demoralization, considering the interconnectedness between MiL and demoralization (Figure 1).

Figure 1.

Study hypothesis scheme.

Abbreviations: AC, acquired capability for suicide; MiL, Meaning in Life; PB, perceived burdensomeness; SA, suicide attempt; SB, suicidal behavior; SI, suicidal ideation; TB, thwarted belongingness.

Exploration of the etiopathogenetic role in suicidality of these non-neurobiological factors is intended to be only complementary to recognized neurobiological factors, which span and intersect on multiple levels, including genetic, epigenetic, biochemical, neurotransmettitorial, hormonal, anatomic, and neuro-(conventional or functional) radiological.^27–30 Finally, the clinical purpose of creating and verifying hypotheses related to the etiopathogenesis of suicidality lies in identifying multi-faceted targets that may be useful to mitigate suicidality risk in individuals, both in prevention and in therapeutic interventions.^31–35

Funding Statement

This work did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Disclosure

The authors report no conflicts of interest in this work.