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Claiming the lives of over 48,000 Americans per year, suicide is the 10th leading cause of death in the United States (CDC, 2018).  This number alone may present as shocking to many; however, this number only depicts the amount of deaths due to suicide.  It does not take into account the estimated 1.4 million suicide attempts that occur nearly every year, in addition to the 48,000 deaths. Clearly, there is a vast difference between the number of suicide attempts and deaths by suicide.  Understanding the mechanism that differentiates an attempt from a death is pertinent to conceptualization and treatment of those struggling with suicidality. Research suggests that one key distinguishing variable is found when analyzing the lethality of the means used to attempt suicide. While only accounting for 5% of suicide attempts, suicide by firearm accounts for approximately 50% of deaths by suicide (CDC, 2016). Consequently, suicide plans and means play a large role in turning an attempt into death.  A common myth about suicide is that restriction of means does not matter because the suicidal person will find a way to die by suicide. This myth neglects the fact that all suicide attempts, not including a firearm, only lead to death in approximately 4% of attempts (Conner et al., 2019). Furthermore, only 7% of survivors go on to die by suicide within nine years of their previous attempt (Owens et al., 2002). This suggests that the “incurable suicidal ideation”, meaning if the myth were to be true, represents the minority of individuals.  Moreover, a reduction in lethal suicide attempts could significantly reduce deaths by suicide.

In itself, literature understanding the more lethal means is insufficient. Researchers and clinicians need to understand both what types of individuals are attracted to more lethal means and why they are attracted. In terms of gender differences, statistics show that females are three times more likely to attempt suicide; however, males are four times more likely to die by suicide (CDC, 2019). Occam’s razor suggests that the simplest explanation is often the best explanation. In relation to deaths by suicide, the reason males account for such a disproportionate number of deaths is because they are more likely to use lethal means during their suicide attempts (Choo et al., 2017). Researchers hypothesize due to gender norms, women may “prefer” a more “feminine” method that equates to lower effectiveness (i.e., abuse of hypnotics, exsanguinations) while men “prefer” more “masculine” methods that are considered more violent (i.e., fire arms, jumping from a height, hanging; Tsirigotis et al., 2011). The better suicidal behavior is understood, the more likely it can be prevented.

Psychological Theories and Suicide

Various psychological theories have attempted to conceptualize suicidal ideation, plans, means, and intent. Common theories used when treating suicidality include, but are not limited to, social learning theory, interpersonal theory, and exposure/habituation. These theories attempt to understand the catalyst of suicidality, which may later lead to the driving force in engaging in such related behaviors. These theories will later be applied to how videogame usage interacts with suicide.

Social Learning Theory

Social learning theory is an approach that conceptualizes the behavioral learning process that individuals undergo (Bandura, 1977). It suggests that there is an innate tendency within individuals to learn through direct experience/observation of other’s behaviors. Further, the theory poses that learning is also derived from experience and observation of the consequences that accompany the observed behaviors (Bandura, 1977). This ideology can be seen across various suicide assessments such as asking about family history of suicide (i.e., SAFE-T with C-SSRS). It is well established in research that a familial history of suicide significantly increases one’s risk of suicide (Qin et al., 2002). Observing from family members who have attempted or died by suicide may lend in the manifestation of suicidality in a person. The Werther effect, the idea that publicized suicide is correlated with an increase in suicides (Phillips, 1974), has also been considered within this realm of thinking. The Werther effect is also referred to as suicide contagion and suicide suggestion (Schaffer, 2018). Within suicide contagion, Gould (1990) notes that suicide can be “contagious,” passing from one person to another through behavioral cognition and social learning theory. Copycat suicides fall into this category as well, which can be defined as a suicide that emulates another suicide learned from local knowledge or accounts of the suicide. Understanding that suicidal behavior can be learned or observed is important, especially as shows like, 13 Reasons Why, a story that romanticized a teenager’s experience of suicide, continues to be aired. After the show was released on Netflix, there was a significant increase in Google searches of “How to kill yourself” (Ayers, 2017). Throughout the course of this paper, the association between social learning theory and playing video games will be explored as it relates to suicidal behaviors.

Interpersonal Theory of Suicide

One of the most accepted theories of suicidal behavior is the interpersonal theory of suicide (Joiner, 2007). This theory proposes that individuals are at an increased risk factor for suicidal behaviors when they meet a combination of three key risk factors—perceived burdensomeness, thwarted belongingness, and an acquired capability for suicide (Joiner, 2007). Perceived burdensomeness is the belief of being a burden on society. More simply put, the idea that one’s death is more meaningful than one’s life. Thwarted belongingness is the concept rooted in the human fundamental need to feel accepted by others. Therefore, a lack of social connectedness and increases of social isolation are linked with higher rates of death by suicide (Trout, 1980). Acquired capability for suicide builds upon basic biological programming. The fear of death is an instinctive and rather powerful driving force in any being. Consequently, an individual’s relationship with this fear is only altered through increased experiences with painful or provocative life events/experiences (PPEs) in which they become desensitized to their fear.

A meta-analysis of 122 studies that examined the interpersonal theory of suicide found an interaction between perceived burdensomeness and thwarted belongingness is linked with suicidal ideation (Chu et al., 2017). However, this interaction alone was not linked to a higher number of suicide attempts. The researchers found that it was interaction of all three risk factors that was significantly associated with an increased number of suicide attempts (Chu et al., 2017). Suicidal ideation alone is not a behavior. These findings suggest that acquired capability for suicide is the catalyst that leads to suicidal behaviors.

Habituation/Exposure

Joiner (2007) described acquired capability for suicide as a combination of both an increased sense of fearlessness and toleration of pain.  It is suggested that the development of these two factors is derived from the process of “habituation.”  Joiner describes habituation as “a decrement in response due to repeated stimulation” (2010, p. 6).  Joiner’s process of habituation draws similar conclusions with the general aggression model (Anderson & Bushman, 2002).  The general aggression model argues that cognition, affect, and arousal mediates the effects of situational and personological/dispositional variables on aggression. Within their framework, they posit that repeated violent media exposure leads to desensitization towards violence (Anderson & Bushman, 2002).  Through desensitization, cognitive, affective, and physiological processes that typically act as inhibitors towards aggressive responses are altered.  With this framework, they argue this repeated stimulation of violent media can lead to increased aggression in attitudes, outlooks, beliefs, and behaviors (Anderson & Bushman, 2002).  It is important to note that aggression is on a spectrum. As such, it is challenging to provide precise and distinct constructs regarding aggression. In psychological research, aggression is typically defined as behavior with the intent to harm others (VandenBos, 2007), and violence is defined as the extreme form of aggression or the intent to use physical force (Krug et al., 2002). Psychological philosophers, such as Freud and Nietzsche, suggested that anger turned inward is a catalyst of depressive and suicidal symptomatology (Gilbert, 2010).

Another way to view repeated stimulation is through social learning theory whereas the decrement in responses is attributed to the observed consequences of the behavior.  Repeated stimulation can manifest in a variety of ways, including but not limited to, self-harm behaviors, history of abuse, history of trauma, intake restriction in eating disorders, etc. The restriction of intake in eating disorders is an illustrative parallel as eating is another basic biological function. To constantly restrict intake is to constantly feel the physical pain associated with intense hunger. Over longer periods of times, individuals may develop a tolerance to this pain. Increased tolerance equates to decrement in observed consequences. Similarly, the repeated exposure to forms of violence, death, and suicide in video games may lead to altered cognitions related to the observed consequences of death or suicide.

There are adaptive reasons one may engage in videogame playing. Players may use gaming as a way to distract themselves from daily life issues as a form of distress tolerance, or one may enjoy the social relationships that have been created in a virtual world (Ryan et al., 2006). Ultimately, video games can serve as a coping mechanism, form of socialization, create personal achievement, and engage in types of competition (Laconi et al., 2017). On the other hand, problematic video game use has been associated with a low self-esteem, low self-efficacy, anger, and clinical symptoms of anxiety and depressive disorders (Wang et al., 2018). Other concerns of video game use could be lack of real-life friends and increased loneliness (Kowert et al., 2014a; Lemmen et al., 2011). Tauet and colleagues (2017) posits that playing videogames may be appealing to those with poor psychological functioning as it allows them to immerse themselves in another environment, therefore, those who are drawn to video games may have an inherent predisposition to mental health concerns, such as suicide.

Video Games and Psychological Theories

Recent research suggests that exposure and playing of violent video games may be another form of repeated stimulation.  In one such study, researchers randomly assigned 81 male participants to engage in either a first-person racing game or a first-person shooter game. Following the video game exposure, participants were asked to complete both a cold pressor task, such as placing a hand or forearm in water, and a game based on risk taking behavior. After accounting for group differences, the researchers found participants demonstrating higher pain tolerance and increased risk-taking behaviors after playing the violent, first shooter, video game (Teismann et al., 2014). This suggests that even a single incident of exposure to playing violent video games can lead to riskier behavior. Consequently, an acquired capability of suicidal behavior occurs through increased risk taking and pain tolerance. This combination nearly mirrors Joiner (2010) belief on risk factors associated with suicide. Bandura’s social learning theory would suggest that playing violent video games allows for the participants to be exposed to the violent behaviors in the games, becoming more socialized to actions that lead to death. Additionally, the observed consequences are important to consider. For example, most violent games let you “respawn” or start over following the death of your character. Religious beliefs and reincarnation aside, this message alone is one that downplays the consequences of death which can ultimately impact the value placed on and behaviors associated with living.

One issue that is often raised with regard to the previously mentioned study is that the population may not accurately represent the population of people that play violent video games. Dilemmas such as this question the generalizability and application of these studies. This has encouraged researchers to study individuals who already play video games on a more frequent basis. In one such study, Förtsch et al. (2021) studied the relationship between habitual engagement in violent video games and acquired capability for suicide. Similar to the previously discussed study, participants engaged in a cold pressor test to measure pain tolerance and self report measures to measure fearlessness about death. Their results indicated that frequent violent video game players demonstrated both higher pain tolerance as well as fearlessness about death when compared to non-gamers (Förtsch et al., 2021). Therefore, there is continuity in results and outcomes between the general public and frequent videogame players.  In sum, it is possible that violent video games increase pain tolerance and decrease fear of death, which is associated with suicidal behavior. It is also important to acknowledge reverse causality of these results. It is also a possibility that individuals that are already experiencing fearlessness of death or increased pain tolerance might be more frequently drawn to engage in violent video games.

While suicidal behaviors or attempts were not accounted for in the previous study, it is important to acknowledge that research suggests that individuals are able to develop acquired capability for suicide prior to any perceived burdensomeness or thwarted belonging (Van Orden et al., 2010). Meaning, an individual can have live experiences that develop increased fearlessness and tolerance of pain. Spending time in the military is just one example of an experience that can lead to reduction in fear and tolerance of pain. Data suggests that veterans are anywhere from 41%-61% more likely to die by suicide than the general population (Department of Veteran Affairs, 2020). One possible explanation is that veterans may tend to have higher levels of fearlessness and tolerance of pain. If veterans experience increased levels of thwarted belonging and perceived burdensomeness, then they may be more likely to attempt suicide as a result of the already developed capability for suicide. Therefore, it is possible that other experiences that may develop reduction in fear and increased pain tolerance, such as habitual engagement in violent video games, may transition into more lethal attempts of death by suicide if suicidal ideation (as defined by thwarted belonging and perceived burdensomeness) is later developed. Future research should engage in assessing this hypothesis. Additionally, clinicians working with frequent violent video game users should utilize more vigilance and assessment when suspecting burdensomeness or a lack of belonging, especially given the potentially isolating nature of solo video game playing and other demographic predispositions.

Another study designed to test the relationship between the interpersonal-theory of suicide and violent video game exposure found less conclusive results. Researchers conducted a study comprised of 781 undergraduate students that play video games on a more frequent basis. Their findings indicated that individuals with higher levels of violent video game exposure reported increased fearlessness of death; however, no increase in pain tolerance was reported (Gauthier et al., 2014). This inconsistency with the previous study suggests that there is at least a partial association between acquired capability for suicide and violent video game exposure. Yet, the question of to what extent still remains. Once again as a note of caution, it is important to remember that correlation does not imply causation. It is also possible that these findings may suggest participants that generally are less afraid of death choose to play more violent video games. While fearlessness of death can be related to risk-taking behavior, such as self-harm or other actions that may lead to death, this study shows that the research is mixed on whether or not videogames are associated to suicide.

As previously mentioned, repeated stimulation can occur in a variety of ways. However, the aforementioned studies only analyzed one form of repeated stimulation. In attempts to clarify the association between acquired capability for suicide and violent video games, researchers isolated the desired variable by accounting for previous “painful and provocative events” (PPEs; Mitchell et al., 2015). In their study, they analyzed 228 college students that play video games on a weekly basis. They found that participants that played action/violent video games scored higher on an instrument designed to measure acquired capability for suicide after accounting for PPEs (Mitchell et al., 2015). This finding suggests that real world implications exist. It suggests that individuals experiencing suicidal ideation may be at an increased risk for suicidal behaviors if they are engaging in frequent violent video game exposure. It is also important to note that this association was not observed between exposure to video games of other content/categories.

Video Games and Depression

In one study, Pezzeca (2009) compared levels of depression and loneliness between individuals that engaged in role-playing games either via a video game or pencil-and-paper format. The results indicate that individuals that engaged in video game role-playing games scored higher on measures of depression. Further, his findings suggest that individuals that engage more excessively in role-playing games (video game or paper) score higher on both measures of depression and isolation (Pezzeca, 2009). It is important to note that these findings are associations rather than causality. According to social learning theory, one potential understanding of these results is that individuals learn different behaviors and their consequences through excessive role-playing video games. These people may develop a preference for the newly learned information which can lead to feelings of isolation from the world in which they learned the less approved behaviors/consequences. A second hypothesis takes a reverse causality approach. Perhaps individuals with baseline higher levels of depression and isolation have a preference for engaging in role-playing video games in attempts to find a sense of belonging in a new group that they value. In this case, individuals as social learners are not content with the consequences they have learned. This results in seeking a new environment where they can develop a new learning of behaviors/consequences. Regardless, it is important for clinicians to recognize that a combination of excessive violent video game and role-playing video games may require increased evaluation, attention, and care.

Clinical Implications

Several risks associated with video game exposure have been explored; however, there are potential benefits that may exist. Using Joiner’s (2010) definition of thwarted belongingness, research has suggested that individuals may actually be able to develop a sense of identity as an integral part of a group of value. Researchers found that communication with anonymous strangers via the internet leads to decreased levels of depression and loneliness. Encouraging use of virtual social support could be a possible treatment recommendation while treating folks who play videogames. This may also disrupt feelings of thwarted belongingness as it leads to increased feelings of self-esteem and social support (Shaw & Gant, 2004). Similarly, Carras et al. (2017) found that depressive symptomology can be attenuated in adolescent gamers if they are engaging in more social gaming experiences and perceive friendship through these experiences.

These findings suggest that online video game play that includes communication with other players may be a protective factor for at risk individuals. Further research should be conducted to explore the protective factors that social learning and group identification can create even within higher risk groups such as those engaging in excessive violent and roleplaying video games. Additionally, future research should aim to analyze the potential moderation effects of these protective factors as it relates to areas such as depressive symptomology.

In sum, videogame use can be an adaptive and maladaptive for its players. Social learning theory and Interpersonal theory of suicide all lend in aiding the conceptualization of suicidal behavior and videogame use but as depicted in this text, the impact so specific to the person given their history and risk and protective factors. Videogame use can increase, diversify, and broaden an individual’s social support while encouraging creativity and critical thinking, it can also expose and habituate them to violence, ultimately increasing the capacity for suicide.  Therefore, it is imperative to explore, rather than stigmatize, client’s videogame use and understand the advantages or disadvantages to their playing.

 

Cite This Article

Deitte, J., & Ross-Nash, Z. (2021, August). Exploring suicide and violent videogames. [Web article]. Retrieved from http://www.societyforpsychotherapy.org/exploring-suicide-and-violent-videogames

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