In a previous post, I made the argument that sociology needs to go beyond just incorporating culture into a sociology of suicide. It needs a cultural theory altogether. But, what would that look like? What would be its framework? One obvious issue, that it would need to deal with is meaning, meaning making, and who is “responsible” for meaning making. Sociology has largely ignored the problem of meaning in studying suicide, choosing instead to pursue the population-level study of the distribution of suicide, while suicidology, until rather recently, cared very little about meaning, culture, or, anything socially constructed, for that matter. Meaning, however, matters. For instance, consider the political and social implications behind the move from the term committed suicide (Smith 1983) to “completed” or “died” by suicide. Semantics, to be sure, but with real implications for intention, motive, causal attribution, and stigma.
Not surprisingly, the problematization of meaning was at the heart of the earliest and most interesting critiques of the Durkheimian macro-structural approach (Douglas 1968; Atkinson 1978). The idea was that Durkheim’s approach depended on the veracity of official statistics about suicide. Otherwise, how could we trust the significance of comparisons between and within countries’ suicide rates or causal explanations about why rates in one place or among one group (e.g., religious categories) changed over time? The issue, which is a very legitimate issue, is that those doing the documentation of suicide – primarily, but not limited to medical examiners and coroners – are not always dealing with clearcut cases of suicide. They have to do inductive and deductive work around so-called “suspicious” deaths (Timmermans 2006). Adding to this less-than-objective determinative process is the fact that medical examiners serve multiple masters, including the medical sphere that licensed them, the legal sphere which may call them in to testify as expert witnesses, and the domestic sphere which, in many cases, has plenty of incentive to have a suspicious death declared anything but a suicide (e.g., insurnace claims, stigma and shame). Taken together, there are reasons to cast doubt on – or at least reasons to scrutinize – how official statistics are constructed and whether they measure what they purport to measure. [Incidentally, the question of whether or not statistics do what they aim to do remains an open question, but it is worth noting that Pescosolido and Mendelson (1986) convincingly showed that the social causes identified by Durkheim stood up against these claims of explicit and implicit bias.]
Setting this aside what would a sociology not committed to the study of the social distribution of suicide look like? In future essays, I will try to tackle the diversity of possibilities a cultural turn in the sociology of suicide might take shape as, but for now there is the question of who makes the beliefs about suicide that American, and perhaps most Western, nations adopt? There is no point in stretching this argument to the point of determinism as a cultural sociology of suicide would care about the diversity of meanings in play as well. But, taking up the thread in the earliest critiques, it remains a central task to ask who makes the meanings that the public, media, and even scientific communities take for granted? For Douglas, Atkinson, and others, it was/is medical examiners/coronorers and their consanguines. But, what about the psychiatric/psychological “industrial-complex?” That is to say, what about the people who are in the business of defining/disagnosing/treating suicide (Abrutyn and Mueller 2021)? Their centrality, which from a sociology of professions and occupations is surprisingly overlooked, are a key faction in the construction and perpetuation of meaning. So much so that an entire counter-movement in the interstitial space between psychology, social work, and anthroplogy has sprung up against them in the guide of critical suicidology (White et al. 2015). Hence, the professionalization process in the 1970s and 80s should be of paramount concern for a sociology of suicide that builds off of culture and its principle mechanism: meaning.
The Briefest History of the Diagnosticians
As an important caveat, one of the fundamental strengths of historical and organizational sociologies is that they focus on the collective and not the individual. It is important, then, to place the following discussion in its proper context: Psychologists and psychiatrists, then and now, were not nefariously plotting to scam people or to cause harm – in fact, in my experience the vast majority are committed to the opposite. Many things that happen, when refracted through historical lenses, show that changes – intentional or not – occur when groups of individuals, sometimes as a single group in a movement or other times aggregated, respond to social pressures beyond their control. They feel their material and ideal interests are threatened, real or not, and respond in ways that aim to protect what it their’s. In particular, when a class of people, like therapists or clinicians, feel their livelihood is being squeezed, like any occupational group, they will respond in ways meant to prevent losing their jobs/careers, their privilege and status, and/or their power.
In the 1970s, several intersecting historical forces created the conditions for professionalization (Horwitz 2002). The government and various community-level organizations began pushing a different mental health agenda, shifting from the stigmatizing institutional model to the disease/medical model. The world was changing, as asylums/institutions were expensive and had come under intense scrutiny by social scientists (Goffman 1961; Scheff 1966) and pop cultural figures (Kesey 1963 – One Flew Over the Cuckoos Nest) regarding their inhumane treatment of patients. A massive economic restructuring drove insurance companies to begin to change their policies toward mental health and psychiatry, creating a need for diagnostic checklists that could suffice for bureaucratic processing. Gone were the days a therapist could simply say a paient needs “X”, rather they needed to check boxes for processing the insurance claim. Amidst changes in insurance and government regulation, pharmeceutical companies saw opportunity. Ince the 1950s, they had pushed similar versions of SSRIs as today but to no avail (Herzberg 2009). Psychoanalysis had no need for drug treatment so long as therapy for anxiety/neuroses cotoinued to be covered by insurance or middle-upper class clients. Finally, the explosive growth of public, higher education in the early 1960s did what it did to many established social sciences: brought a ton of new approaches driven by cadres of newly minted graduates who had grown to challenge hegemonic holds across disciplines as they prusued their own careers. Psychoanalysis’ days were numbered as various forms of cognitive science proliferated and pushed new ideas about the etiology, diagnosis, and treatment of mental disorders.
Like the shift to mental illness-as-disease, the claim to professionalize psychiatry was built around the medical model doctors had used less than a century prior: their knowledge and practices would depend on the scientific method and evidence-based research (Conrad and Slodden 2013). A committee was tasked with reviewing the research on mental illness, discerning what hard proof there was for myriad disorders. Following a medical model, the goal was to only include in the DSM-III discreet diseases, as determined by their having discreet etiologies, diagnoses, and prognoses (Horwitz 2002). But, as with any community of scientific knowledge producers, this was not a task achieved in a vacuum safe from politics and competing interests (Merton 1979).
Psychoanalysts, in particular, felt the acute threat to their livelihood this project promised. Neuroses and most psychoanalytic disorders were not founded in anything approaching the rigor suggested by the experimental or clinical trials found in medicine (Horwtiz and Wakefield 2007). It was built up from individual patient histories, generalized with or without generalizble evidence. The fear was not unfounded: if the DSM-III became the official “bible” of psychology, clients would eventually prefer those who adhered to it, while the APA could, theoretically, become like the AMA with the power to certify/decertify practitioners. So, they fought back, as did many other clinicians fearing their skill sets would be less valuable in the DSM era. Ultimately, the final product, published in 1980, looked nothing the vision that the committee was tasked with realizing.
For instance, far too many disorders included in the DSM were not discrete in their etiology, diagnoses, or prognoses. Decades of research, independent of and sponsered by drgu companties coupled not find an organic source of, say, depression, so they downplayed this crieria. Of course, this sleight of hand was a major indictment of their claims to parallel medical doctor status. In part, because the same treatments became common for a diverse array of disorders, with little understandng of why they worked in some cases and why many patients could never find a single treatment that worked (Karp 2016). Nonetheless, the writing and publishing of expert knowledge is powerful (Goody 1986). And so many drug treatments for medical disorders had become normalized, that between the DSM and the presumed efficacy of drugs (which was a much cheaper alternative for insurance companies than long-term therapy) gave the mascent professiona legitimacy. The claim that serotonin levels were directly related to mental disorders (and therefore supposedly treatable with SSRIs) became widely accepted through the field, mass media, pop culture, and common sense, despite the empirical evidence to the contrary (Moncrieff et al. 2022), but which became so diffuse through psychology, mass media, and eventually common sense claims-making.
With the backing of “science,” the book became the source of routinizing training, knowledge claims, practical repertoires, and meaning-making. Psychologists were like doctors, just for the mind. It made no difference that several disorders were totally political and social. For example, the inclusion of homosexuality as a disorder was only a disorder in so far as a community declared it as such. (Removing it, incidentally, required a concerted and sustained political movement by lay activists and radical psychologists alike (Bayer 1987)). Indeed, by the time Prozac Nation was published and made into a popular movie, the psychological industrial-complex (psychological science, insurance companies, community organizations preferring the disease model over the stigmatizing institutionalization model, and drug companies) was a taken-for-granted force to be reckoned with (Pearlin et al. 2007). Even with the recent meta-study debunking the organic etiological claims of depression (Moncrieff et al. 2022), the damage has been done. “They” are the trusted source for anything labeled mental health-related. Hence their dominance in suicidology since its inception, and in their hegemonic hold over the causal explanations we accept as either real – psycheache (Shneidman 1995), loneliness/hopelessness (Joiner 2005; Klonsky and May 2015), and escape from psychic pain (Baumeister 1990) – or suppose are real – e.g., mental illness causes suicide (Mueller et al. 2021).
When Douglas (1968) and Atkinson (1978) wrote their treatises, they had no clue that the DSM-III would emerge or that pop culture, lay society, and the scientific community would come to revere the psychological/medical approach to mental health. This approach naturally spread into the science of suicide. And, like doctors in the 1950s and 1960s (Starr 1982), the notion that suicide is caused by intrapersonal forces, be they mental illness, psycheache, or any number of cognitive appraisals like hopelessness and loneliness, was solidified as the result of psychology’s ascent to dominance (Cavanaugh et al. 2003). This is not to say that Durkheim’s work or sociology had managed to diffuse their own empirically grounded claims that suicide was caused by social forces. Indeed, to the contrary, Durkheim’s work has not made much a of dent because it has virtually nothing to do with why people die by suicide and everything to do with demonstrating that social factors constrain or facilitate suicidality among certain groups or classes of people. Important, indeed, but peripheral to the business of explaining suicide as a social behavior. Of course, it is questionable how well the professionalized version of psychiatry has done, given rates have grown over the last two decades despite billions of dollars spent on psychological research.
Most obviously related to the proclivities of a profession rooted in a diagnostic manual – and its pitfalls – are the efforts to catalogue individual risk factors. Over 150 risk factors have been identified as correlated with suicide, rendering these factors useless in explaining or predicting suicide.
Predictably, the psychological industrial-complex tends not to offer social explanations like those typically reflected in artwork (Stack and Bowman 2012) nor consults the insights sociology might lend (Mueller et al. 2021). On the one hand, the vast majority of movies made in the 1900s involving suicide featured social causes most prominently: relationship strains, unrequited love, status disruptions, and so forth. While this may feel anecdotal, stories resonate because they make sense to the viewer, not because of their implausibility. On the other hand, the very notion of what a mental disorder is (Scheff 1966) and, more importantly, what it means – e.g., is it good or bad, a sign of stigma or one of creativity – remains socially constructed (Horwitz 2002; Pearlin et al. 2007). One need only consider the disappearance of once popular diagnoses, like hysteria (Micale 2019), homosexuality (Bayer 1987), or anxiety (Horwitz 2010) – which, incidentally, were largely replaced by the ubiquitous depression diagnosis – to understand how unorganic most mental disorders likely are (besides, perhaps, schizophrenia and bipolar disorders). But, their expert status has cemented, in the minds of the public, media, and scientific community, the idea that suicide, like mental health, is caused by intrapersonal forces and not interpersonal.
Unfortuntely, the question of meaning-making and meaning-makers is beyond the scope of short blog post, but I think it serves the larger goal: a cultural sociology of suicide must begin by examining and revealing how psychologists have built up the meanings of suicide in the U.S. and throughout the West, how and why alternative explanations and meanings have emerged and persisted or failed to, and how their science is translated into public-facing knowledge. What might this look like?
For one thing, I am unaware of studies that actually interview and/or observe, ethnographically, psychologists and psychiatrists. What do we know? How do they process clients? How do they think about suicide, mental health, and the use of diagnostics? Anticipating other posts, it would also be prudent to think creatively about how to study just how impactful psychological beliefs about suicide are for those who have completed, attempted, and are thinking about suicide? Do they frame and understand their feelings, attitudes, and actions within a psychological model? How are these beliefs distribtued across time and space, and what sorts of factors cause them to expand or contract? And, how do rival beliefs succeed or fail to succeed against the dominant hold psychological beliefs presumably have over the majority of Americans?
Admittedly, these questions are not focused on suicide, per se, or victims, survivors, or prevention science. Instead, they are focused on cultural production and dissemination. To me, that is one good starting point for introducing a cultural theory to suicidology, because it reveals the process by which suicidology became suicidology, its beliefs are constructed and distributed, and cultural ideas circulate, reach a peak, and contract. From there, we can begin asking about the mechanisms by which these beliefs become available, accessible, and applicable to people.