Entrapment and escape: Exploring the relationship between suicide and emigration in a post-communist country

Abstract

Background:

Suicide rate in Hungary was nearly the highest in the world in the decades preceding the transition of the social system. Shortly after the transition in 1989, a radical decrease in fatal suicides occurred, parallel with a marked increase in emigration.

Methods:

We analyzed the data published by the Hungarian Central Statistical Office to detect if there was an association between the remarkable drop in suicide rates and the changes in emigration rates from 1995 to 2019.

Results:

The results of a brief statistical analysis on the correlation between suicide rate and emigration confirmed a strong negative relationship (r = −.855, p = .00). For more precise results, we applied linear regression analysis, which showed that the emigration rate predicted 73.2% of suicide rate variances with a high predictive value (β = −.983).

Conclusion:

The study provides a possible explanation through a phenomenological analysis on major life transformations. Relating the arrested flight/cry of pain theory, the theory of rites of passage and double-bind communication resulted a comprehensive and coherent, but not exhaustive explanation on the relationship between suicide and emigration.

Introduction

According to a WHO estimate (World Health Organization [WHO], 2019) 800,000 people die by suicide every year, making it the 18th leading cause of death globally. Despite this fact, dying by suicide is rarely at the center of public attention. On the one hand, it is often treated as a taboo, as suicide questions the prevailing values and visions of a society. On the other hand, suicide is usually not perceived as a social problem but is associated with mental disorders, to be prevented mainly by medication. Leenaars in his systemic study on suicide has claimed that ‘Suicide is a multi-dimensional malaise. Metaphorically speaking, it is an intrapsychic drama on an interpersonal stage’ (Leenaars, 1996, p. 221).

The marked decline in suicide rate began right after the change of the social system in Hungary that coincided with the introduction of selective serotonin reuptake inhibitors (SSRIs), a new group of antidepressants. Most professionals were convinced that the new medication explained for the sudden drop. In this case, however, the drop should strongly correlate with the use of the medication, irrespectively of any social and cultural factors. This is not so: in the countries where there has been a significant change in the social system (e.g. in Central and Eastern European countries, Russia, and, most recently, in China) a marked decrease has been experienced, whereas in the United States, with its widespread use of SSRIs, a slight increase has occurred.

As Figure 1 shows, Hungary’s case is quite prominent. In this study, we attempt to outline a new, though partial explanation for the experienced change, admitting that the complexity of suicide requires a highly complex approach. Here we focus on some sociocultural factors and connect these to the theory of arrested flight and cry of pain (Rasmussen et al., 2010; Williams & Pollock, 2001).

Figure 1.

Suicide rate in 1990 versus 2017.

Source. Ritchie et al. (2015).

Strong traditions in social and cultural psychiatry in Hungary in the 1980s and 90s opened the road toward a new area, discursive suicidology, integrating several areas of sociology, cultural anthropology, and communication into suicidology (Buda, 2001; Fekete, 2004; Kézdi, 2000; Oravecz, 2004). Kézdi,¹ who shared the Durkheimian view that suicide was a social fact, associated the sudden drop in the 1990s with the ‘world passport’, a travel document that people had longed for but were not allowed to possess in the previous system. Citizens had to pass a rigorous ‘reliability check’ before visiting a country outside the Soviet sphere of influence. The new ‘world passport’ introduced in 1988, 1 year before the change of the social system, was the close equivalent of the documents used in Western Europe. Emigration soon became a possibility. Hungary’s accession to the European Union in 2004 further facilitated the process and granted new freedoms for the citizens.

Research questions

This study discusses possible relationships between the rise in emigration and the remarkable drop in suicide rates. Statistically speaking, is there a negative correlation between the number of fatal suicides and emigration? Zonda et al. (2013) interpreting internal migration as a sign of poor social integration, hypothesized that integration was a core factor to reduce suicide. This Durkheimian approach, however, did not seem to work well in their model, as they found a weak negative association with a predictive value of β = −.220 between migration rates and suicide rates when comparing the different regions in Hungary. Further, migration was identified as a protective factor in rural areas and a risk factor in the capital. Is there a more consistent explanation for this puzzling fact?

Emigration, immigration, and suicide: A demographic approach

In their review article, Ratkowska and De Leo (2013) have concluded that the phenomena related to suicide, such as suicide ideation, suicide attempts, and suicide rates are closely related to migration. Migration may be driven by economic factors or by vital threats in the home environment (as with asylum seekers and refugees). Emigration is defined as moving from one’s own culture to a different context and settling down in the new environment.

Migration is a major life transformation involving three different phases:

• - pre-migration (making the decision, and preparations)

• - act of emigration (physical transfer)

• - post-migration (integration in the host country) (Ratkowska & De Leo, 2013).

Suicide rate among immigrants is often higher than that of the host population because of several risk factors, such as the stressful experience of migration, the loss of previous social status, roles, and social network, and, in some cases, accompanying financial problems and discrimination. Acculturation stress is less if migration is voluntary, the immigrants have a relatively high social status and available social supports and can build a positive future vision in the new environment. A review on statistical figures usually confirms that immigrants’ suicide rates are like those in the country of origin. Interestingly, although the suicide rate among Hungarian immigrants is one of the highest in Europe, a finding in Slovenia has revealed convergence tendencies, a suicide rate similar to that in the host country (Ratkowska & De Leo, 2013). Garssen et al. (2006) also demonstrated a decrease in suicide statistics among Hungarian women in the Netherlands. Spallek et al. (2015) in their review article concluded that ‘the suicide risk of immigrant populations depends to a considerable degree on cultural factors, and on the suicide risk in the countries of origin’ (p. 8), also mentioning some Eastern European exceptions to this general rule. The ‘healthy/resilient immigrant’ notion, and the rise in socioeconomic status provide an explanation for such findings (Duldualo et al., 2009, cit. Hollander et al., 2020; Ratkowska & De Leo, 2013). To sum it up, immigrants are a non-homogenous group, their motivations are varied, and there are huge differences in the host countries’ attitudes toward them.

Reliability and validity of the statistical data on suicide

There are considerable differences in the reliability of suicide statistics: underreporting usually ranges between 10% and 30%, depending on the classification and registration protocols in the given country. These estimates are the results of the re-evaluation of undetermined deaths, open verdicts, and unintentional poisoning and drowning cases. Under-reporting is often due to misinterpretations, as determining the cause of death may involve a subjective evaluation (Tøllefsen et al., 2012). Insurance policies, lack of autopsy as a medical routine in doubtful cases, or the surviving family’s interest to escape the stigma of suicide may also influence the statistics (Bakst et al., 2016). In certain countries/certain eras, political, and religious considerations may block the verification and publication of the data (WHO, 2016).

Hungary has long introduced rigorous criteria for determining suicide deaths, therefore the data have high reliability and validity: ‘underestimation is crudely estimated (. . .) 10% for countries such as Finland, Hungary and Austria’ (Bakst et al., 2016, p. 120). In Hungary, both suicide and undetermined death is on the decrease for both males and females (Kõlves et al., 2013).

Changes in the protocol of determining the cause of death may also occur, but this does not apply to suicide statistics in Hungary. However, there was a change in emigration records: since 2013, there is no notification obligation for those temporarily leaving the country to live abroad (i.e. not with a final and explicit decision on emigration). Consequently, the actual number of persons leaving the country could be higher between 2013 and 2019.

A phenomenological approach to suicide and migration: Rites of passages

“Partire è un po’ morire.” (“Leaving is a bit like dying”)

The stages of emigration correspond to phases of rites of passage first described by Van Gennep (1960). These phases are defined as separation, liminality (an in-between, insecure state) and reincorporation as an arrival in the new social context. The structure of rites of passage mimics the universal birth experience: woeful but inescapable separation from a previously nurturing, but a gradually narrowing developmental context (possibly, the first human experience on entrapment), followed by the helplessness of ‘unconditional waiting’ (Berguno, 2001) to be accompanied by vital risks, struggles, and pain. Finally, the infant as an ‘alien’ is arrived in an environment that is incommensurable with the previous one. As Szakolczai (2009, p. 147) argues, ‘the sequential order of a rite of passage is the sequence of lived experience’. By experience, he means an event that involves our entire existence and is much beyond a mere impression. A rite of passage transforms one’s status, roles, and identity, therefore, the theory has its deep relevance in psychological crises states. Tacey (2005) in his cultural anthropological analysis on suicide among young adults claims that suicide is the result of a rite of passage gone wrong. In our modern era, previous rites that used to guide and structure major life transformations, also ensuring community support and validation, are often missing. Now we understand life transformations in terms of crises states or traumas. At the same time, the main spiritual message of ritual death and subsequent rebirth has been lost (Tacey, 2005).

Traditionally, the loss of previous identity equals to ritual death that is not necessarily understood as metaphorical and is indeed not ‘only metaphorical’ (Szakolczai, 2009, p. 147). Our metaphors are rooted in and are inseparable from our physical existence as a source domain (Lakoff & Johnson, 1981). Concrete, physical risks are inherently involved in several major life transitions, and are also present in initiation rites, a prototype for rites of passage. People usually adequately orient themselves in a physical and a cultural context; but in times of crisis, they may misinterpret the death of the previous identity as the physical destruction of the self. ‘The psyche presents this urge as metaphorical, but it is not going to be experienced metaphorically by the person in great distress’ (Tacey, 2005, p. 123). Explanations for deficiencies in one’s symbolic capacity include the possibility of mental disorders, as well as cultural factors that highlight the physical, material, or technical over the mental and spiritual issues – especially in a society with communist traditions. For example, Chinese citizens usually communicate about their depression in terms of boredom, pain, fatigue, and dizziness (Ratkowska & De Leo, 2013).

Experiencing chaos and disorder is a prerequisite for major life transformations (Bussolari & Goodell, 2009; Johnson et al., 2000; Erdős, 2018). This is a liminal feature that is functional in initiation and healing rites and facilitates substantial identity deconstruction and reconstruction (see Table 1).

Table 1.

Functional and phenomenological characteristics of crisis states and rites of passages.

Crisis/presuicidal syndrome	Rite of passage (liminal phase)
Vital risks and threats	Vital risks and threats
Pains and sufferings	Pains and sufferings
Possibility of identity reconstruction	Possibility of identity reconstruction
Final common pathway	Totality of humankind, homogenization
Conflict and ambivalence in relationships; situational constriction	Temporary loss of social network and commitments, loss of social status
Ambivalence	Ambivalence, in-built paradoxes
Dependence, helplessness	Surrender, obedience
Isolation	Community support and guidance. Controlling and witnessing the transformation.
Entrapment, no escape	Expected passivity, no escape
The communication of crisis is the crisis of communication	Silence or ritual texts
Cognitive constriction	A not knowing attitude, simple-mindedness
Dynamic constriction	Accepting pain, sufferings, and the related emotions
Loss of control	Giving up control
Hopelessness	Sustained hopes
Struggling with existential questions	Spiritual responses to existential questions provided by the community

Source. Own compilation based on Turner (1969), Shneidman (1990), Stagg (2014), Tacey (2005), and Ringel (1974).

Entrapment, double bind, and communist systems

Whether or not an individual is able to respond to the challenges of life transformations may depend on their personal resilience, and on the resources their sociocultural environment provides for identity reconstruction. For example, a research identified a positive correlation between suicide and conservative governance, and the authors related this finding to an increase in individuality (Page et al., 2002), leading to lower community support. Based on the above theories, another important aspect of such governance is that it yields fewer opportunities to experiment with alternative lifestyles in times of life transformations.

Communist dictatorships are especially rigid, conservative systems, equipped with a specific ruling technique, the establishment and consolidation of ‘permanent transition’ (Szakolczai, 1996). In a subsequent article Szakolczai (2009) referred to Bateson’s (1972) idea on schismogenesis: ‘societies can be stuck for a long time in a state where the previous unity was broken, and yet the schismatic components are forced to stay together, producing an unpleasant, violent, harrowing, truly miserable existence’ (Szakolczai, 2009, p. 155).

In his analysis on suicide in Hungary and Belarus, Smith (2002) focused on double bind situations when seeking for an explanation for the exceptionally high rates in these countries. Between 1975 and 1992, the rate of fatal suicides was around 40/100,000 inhabitants in Hungary, with a peak in 1983 when 4,911 persons died by suicide (Hungarian Central Statistical Office, 2020). Communist dictatorships bring about double bind situations with inescapable and incompatible requirements from unquestionable authorities. These messages lead to a highly confused and passive state on part of the recipients (Bateson, 1972), manifested in learned helplessness behavior and experiences on entrapment. In such systems, governance is based on the inconsistency of rules and the resulting self-censorship on part of the citizens. Communication is highly paradoxical and paralyzing, such as the frequent external requirement to ‘exercise self-criticism’ or common involvement in a ‘permanent revolution’ as salient examples of double bind discourse (Erdős & Kelemen, 2011). Previous sociocultural traditions are changed ‘for once and all’, depriving the people of shared meanings and symbols. For example, holidays and celebrations as anchoring points of identity and cyclic cultural renewal were changed into meaningless or even aggressive messages in Hungary. Between 1945 and 1989, the Soviet authority had to be celebrated, commemorating the Great October Socialist Revolution, or Hungary’s lasting occupation as the ‘Liberation Day’ on 4th April, while most of the previous national and religious holidays were prohibited. Further, the society suffered from the destructive consequences of silenced stories, not being able to communicate about their past traumas, including the defeat of the 1956 Revolution and War of Independence that personally affected and traumatized most families in the country. Hungary’s ‘soft dictatorship’, beginning in the 1970s, heavily relied on techniques of manipulation instead of open aggression, with the predominance of vague (empty or floating) signifiers and paradoxical discursive resources that were largely unfit for identity reconstruction (Erdős & Kelemen, 2011).

Entrapment and suicide

Lester (1994) evaluated the relevance of theories on suicide by conducting a specific form of psychological autopsy of 30 suicides of well-known persons. He compared 150 statements based on 15 leading theories to persons’ biographical contents. Beck’s theory has proven the most relevant, with central concepts as cognitive distortions substantiating hopelessness, negative future expectations, helplessness, self-criticism, self-blame, and the wish to escape. Other theorists (as Leenaars, 1996; Maris, 1981, cit. Lester, 1994) have highlighted confusion and chaos in communication, a history of losses and failures, aggression turned toward the self, and failed or abortive transitions. These classical theories and the phenomenological approach are still relevant in the medical discourse about suicide (Voros et al., 2021), and the above characteristics are clearly related to pre-transition Hungarian conditions.

The cry of pain (CoP) model of suicide is a further elaboration on the earlier notions, building on the diathesis-stress theory and the idea of arrested flight (Rasmussen et al., 2010). In their CoP model, Williams and Pollock (2001) conceive of suicidal behavior as a response to a situation that has three critical components: defeat, perception of no escape and no rescue (the latter understood as lack of social supports), and lack of positive future visions. Persons captured in such situations experience helplessness and hopelessness, as demonstrated by the results of positive future thinking tasks (Rasmussen et al., 2010). In their investigation on a clinical sample of 113 patients of self-harm behavior, the authors have differentiated between internal and external entrapment. Internal entrapment is brought about by own thoughts and feelings (‘I feel powerless to change myself’/Rasmussen et al., 2010, p. 19/). External entrapment refers to limitations imposed by external situations and people. Naturally, these external experiences gradually become the subjects of internalization, as demonstrated in the classical learned helplessness experiment (Seligman, 1975). Both entrapment types were identified as significant predictors of suicidal ideation, and total entrapment had a mediating role between defeat and suicidal ideation. Similarly, positive future thinking acted as a mediator between entrapment and suicidal ideation; and it was negatively associated with suicidal ideation. Clarke et al. (2016) in their analysis on entrapment among self-harm patients found that ‘The majority of participants (55/58; 94.8%) reported that prior to their self-harm episode, they felt they wanted to escape and get away from things’ (p. 5). Blocked anger was present in about two third of the entire sample.

Method

We were curious to see if there was an association between the remarkable drop in suicide rates and the changes in emigration rates from 1995 to 2019 in Hungary, interpreting emigration as a constructive rite of passage and an escape from entrapment (see Table 2, Figure 2).

Table 2.

Emigration and suicide numbers by year in Hungary.

Year	Emigration	Fatal suicides
1995	772	3,369
1996	809	3,438
1997	894	3,214
1998	716	3,247
1999	2,042	3,328
2000	3,280	3,269
2001	6,002	2,979
2002	4,194	2,843
2003	3,122	2,801
2004	2,121	2,742
2005	2,024	2,621
2006	1,910	2,461
2007	2,671	2,450
2008	5,350	2,477
2009	4,883	2,461
2010	7,318	2,492
2011	12,413	2,422
2012	12,964	2,350
2013	21,580	2,093
2014	31,385	1,927
2015	32,852	1,870
2016	29,425	1,763
2017	26,957	1,634
2018	23,808	1,656
2019	21,900	1,550

Source. Hungarian Central Statistical Office (2013, 2020).

Figure 2.

Suicide and emigration rate by year in Hungary.

Results

Pearson Correlation, used to test the relationship, has confirmed that there is a strong correlation between the variables (see Table 3).

Table 3.

Correlations between suicide rates and emigration from 1995 to 2019.

	Suicide rate
	r	p
Emigration rate	−.855	.00**
Year of emigration	−.983	.00**

Note. **p < .01.

For more precise correlations, we have also examined the associations between suicide rates and emigration employing linear regression analysis.

A significant regression equation was found between the drop in suicide rates and emigration rate (F (1, 23) = 62.699; p = .000; p < .05), with an R² of .732, that is, the emigration rate predicted 73.2% of suicide rate variances (see Table 4), with a high predictive value (β = −.855).

Table 4.

Linear connection between suicide rates and emigration from 1995 to 2019.

	Suicide rate
	R	R²	B	SE of B	β	t	p
Emigration rate	.855	.732	−.045	.006	−.855	−7.918	.00**
Year of emigration	.983	.966	−78.458	3.089	−.983	−25.400	.00**

Note. **p < .01.

Likewise, a significant regression equation was found between the drop in suicide rates and the year of emigration (F (1, 23) = 645.159; p = .000; p < .05), with an R² of .966, showing that the year of emigration predicted 96.6% of suicide rate variances (see Table 4), with a high predictive value as well (β = −.983).

Discussion

Hungary, a post-communist country has experienced an exceptional decrease in suicide rates and a simultaneous increase in emigration rates. Following a Durkheimian logic, both migration (emigration) and suicide are a sign of poor social integration. In a previous study on suicide risk factors by Zonda et al. (2013), the role of internal migration was not central and rather contradictory. Our results on have confirmed that there is a strong, statistically significant negative relationship between suicide and emigration rates in Hungary. We are aware that overlaps between the social groups dying by suicide before the transition and emigrating after is a theoretical possibility: a rise in one may be balanced by a reduction in the other. There is available evidence that the suicide rate of Hungarian immigrants in several host countries is characterized by convergence tendencies: suicide and emigration appear as alternative pathways.

We propose a new interpretation based on an interdisciplinary approach that does not contradict the explanatory principle of poor social integration but complements it with classical and recent approaches to suicide. The results of our phenomenological analysis imply that suicide and migration have an important common denominator; namely, that both are related to and motivated by major transformations (crisis experiences) in one’s life. Life transformations might lead to marginalization if the person is entrapped in the liminal phase of the transition (Turner, 1974). This would happen when adequate sociocultural and personal resources for identity reconstruction are missing, and reintegration to society is contradictory to one’s values. Integration into an authoritarian society is not a constructive option. Often, it is a compromise that ensures one’s mere survival.

When other strategies, including submission, have failed, arrested flight as an endpoint of defense occurs (Dixon, 1998). As our phenomenological analysis demonstrates, a communist dictatorship is a social context that permanently recreates entrapment/no escape situations and renders it difficult for the individual to think in terms of possible alternatives and build a positive future vision. Hungary’s soft dictatorship was a specific formation with its highly manipulative double bind discourse based on paradoxes and obscure meanings. This way, not only one’s identifications with positive role models but counter-identifications with the cultural idols of the dictatorship were impeded. Due to self-censorship and self-accusation practices, the individual becomes isolated, and experiences meaninglessness and hopelessness in times of personal crises as periods of enhanced self-reflections and vulnerability.

The results of our statistical analysis are in accordance with our theoretical model comprising the arrested flight theory, the theory of rite of passage and the conclusions of previous studies on post-communist sociocultural legacy. These results suggest that there are strong social and cultural factors in the background of suicide, and its main predictor, self-harm. The 2013 change in the Hungarian emigration records is a limitation of the study; however, higher numbers would only strengthen the negative relationship between suicide and emigration. Alternative explanations may also emerge that fall outside the scope of this study.

Conclusions

We have examined some theoretical and statistical links between emigration and fatal suicide in Hungary, a European country with the most salient drop in suicide rates between 1995 and 2019. This study interprets both events as responses to the necessity of major life transformations and argues that, in some cases, suicide is a response to the sociocultural context of dictatorships with its learned helplessness patterns and frequent entrapment experiences. These, together with hopelessness, blocked anger, and the forced habit of ‘self-criticism’ (self-accusation) could contribute to the exceptional rise in suicide statistics in the 1970s and 1980s in Hungary. Such an environment is characterized by the lack of resources for experimenting with alternative identities and identity reconstruction. The idea of having alternatives to choose from is perceived as a major threat for an authoritarian system. The change of the social system in 1989 in Hungary opened the possibility of emigration, a physical and mental-level escape allowing personal choices, positive future visions, and a prospective rise in social status and resources.

The exact nature of the negative relationship between emigration and suicide could be further explored by introducing new research projects in the following areas:

• - systematic cross-country comparisons between the suicide rates and emigration, with a special focus on the countries with a communist past and recent system changes (Central and Eastern European and some Asian countries),

• - a qualitative research on the decision-making processes of immigrants coming from these countries,

• - a longitudinal study on the suicide statistics of immigrants within the host countries.

This study has connected theories and data from different areas of social sciences to outline an explanation on the recent changes in suicide in a post-communist country, Hungary. Suicide is a phenomenon that has not a single cause, but is the result of complex psychological, social, cultural, and biological factors. Relating the arrested flight/cry of pain theory, the theory of rites of passage, and postulations on double bind communication has resulted a comprehensive and coherent, but not exhaustive explanation on the relationship between suicide and emigration. Further research, integrating new, unexplored perspectives, could enrich our current knowledge on the problem of suicide.