Understanding Suicidal Behaviors

If you don’t understand the suicidal process then you won’t know what to ask or what to do

Overlap of Spheres of Influence for Suicidal Behavior

IndividualPeers/Family

CommunitySociety

Final Common Pathway

Despair Despair & &

ShameShame

Adversity

Impulsivity

Irrationality

Helplessness

Isolation

Capability

IndividualPeer/FamilySociety

Community

“Addressing risk factors across the various levels of the ecological model may

contribute to decreases in more than one type of violence.”

Violence – A global public health problem, World Health Organization, 2002, p. 15.

Stress-Diathesis Hypothesis

Suicide is an Outcome that RequiresSeveral Things to go Wrong All at OnceSuicide is an Outcome that RequiresSeveral Things to go Wrong All at Once

BiologicalFactors

FamilialRisk

SerotonergicFunction

NeurochemicalRegulators

Demographics

Pathophysiology

ImmediateTriggers

Access To Weapons

SevereDefeat

MajorLoss

WorseningPrognosis

ProximalFactors

Hopelessness

Intoxication

ImpulsivenessAggressiveness

NegativeExpectancy

Severe Chronic Pain

PredisposingFactors

Major PsychiatricSyndromes

SubstanceUse/Abuse

PersonalityProfile

AbuseSyndromes

Severe Medical/Neurological Illness

Public HumiliationShame

Why Are Individuals Suicidal?• Suicidal behavior represents a way of coping with

state of high, negative, emotional arousal (Wagner, 1997)

• Suicide is a solution to an intolerable psychological state of pain (Shneidman, 1996)

• A stressful event (e.g., perceived rejection, major failure, sudden unexpected losses) is the proximal trigger in an individual with a predisposition to suicidal behaviors (self-destructive; impulsive; aggressive; self-harming) (Mann et al., 1998)

• Suicide is a cry for help – an interpersonal communication (people don’t really want to die; just want to get help with living) (Farberow & Shneidman, 1961)

SUICIDE – A MODEL*

DISORDER

MoodSubstance AbuseAggressionAnxietyNeurochemistry

In troubleLossHumiliation

Anxiety – DreadHopelessnessAnger

STRESSEVENT

MOODCHANGE

TaboosSupportVentilationMental StatePresence ofothers

SURVIVAL

INHIBITION TaboosMethod availableRecent exampleExcitation/impulsivitySolitude

SUICIDE

FACILITATION

*David Shaffer, M.D., Columbia U.

Suicide Risk varies over time…

and throughout the life of the individual

Why Now?Changes in:• Medication• Psychiatric

Symptoms• Physical

Symptoms• Social Support• Professional

Support

• Impulsivity Controls

• Violence Potential

• Sense of Hope

• Sense of a Future

• Sense of Stability

• Sense of Security

Reasons for Suicide

• Escape from pain - emotional, physical

• Revenge, punishment, manipulation – against an aggressor

• Rebirth• Control and power – an act of mastery to replace feeling

helpless, hopeless, useless, worthless

• Reunion – with a loved one

• Self-punishment – for feelings of guilt or sinfulness

• Taking action - to be less burdensome to others

Are There Common Risk Factors Across Diagnoses?

• Depression - may be present across diagnoses. Severity? Depends on type.

• Anxiety/agitation/ panic - may be present across across diagnoses

• Alcohol and Substance Abuse - may be present across diagnoses

• Hopelessness - may be present across diagnoses

SHNEIDMAN’S CONCEPT OF PSYCHOLOGICAL

PAIN

Shneidman’s Ten Commonalities of Suicide (1985)

1. The common stimulus is unendurable psychological pain (i.e., psychache).

2. The common stressor in suicide is frustrated psychological needs.3. The common purpose of suicide is to seek a solution.4. The common goal of suicide is cessation of consciousness.5. The common emotion in suicide is hopelessness-helplessness.6. The common internal attitude toward suicide is ambivalence.7. The common cognitive state in suicide is constriction.8. The common interpersonal act in suicide is communication of intention.9. The common action in suicide is egression (i.e., escape).10. The common consistency in suicide is with life-long coping patterns.

Basic Elements of the Suicidal Scenario

• A sense of unbearable psychological pain, which is directly related to thwarted psychological needs

• Traumatizing self-denigration - a self-image that will not tolerate intense psychological pain

• A marked constriction of the mind and an unrealistic narrowing of life’s actions

Basic Elements of the Suicidal Scenario II

• A sense of isolation - a feeling of desertion and the loss of support of significant others

• An overwhelmingly desperate feeling of hopelessness - a sense that nothing effective can be done

• A conscious decision that egression - leaving, exiting, or stopping life - is the only (or at least the best possible) solution to the problem of unbearable pain

Shneidman (1992)

Psychological Needs

• Shneidman: “For practical purposes, most suicides tend to fall into one of five clusters of psychological needs. They reflect different kinds of psychological pain.” (1996, p. 25)

• They are: thwarted love ruptured relationships assaulted self-image fractured control excessive anger related to frustrated needs for dominance

Some Thwarted Psychological Needs

• Lack of control related to the needs for achievement, order and understanding

• Problems with self-image related to frustrated needs for affiliation (love; acceptance; belonging)

• Problems with key relationships related to grief and loss in life

• Excessive anger, rage, and hostility

Shneidman’s Cubic Model of Suicide

(Shneidman, 1987)

Pain(Psychache)

Press (stress)

low

high

intolerable

Low pain

CompletedSUICIDE

Perturbation1 3 4 52

1

3

4

5

2

21

34

5

Eliminating Psychological Pain

• Suicidal thinking and behavior “makes sense” to the pt. when viewed in the context of his/her history, vulnerabilities, and circumstances

• Accept that a pt. may be suicidal and validate the depth of the pt.’s strong feelings and desire to be free of pain

• Understand the functional or useful purpose of suicidality to the pt.

• Understand that most suicidal individuals suffer from a state of mental pain or anguish and a loss of self-respect

• Maintain a non-judgmental and supportive stance

Eliminating Psychological Pain II• Voice authentic concern and a true desire to help

the pt. - Be willing to work/stay with the pt., be optimistic and instill

hopefulness, assure that the pt. receives “state of the art” treatment, and express a conviction that he/she is a valuable human being and “worth it”

- Do whatever it takes, however long it takes, regardless of time of day to conduct a thorough assessment

• View each pt. as an individual with his/her unique set of issues and circumstances and someone the clinician seeks to understand thoroughly within the pt.’s own context - rather than as a stereotypic “suicidal patent”

Eliminating Psychological Pain III• Communicate to pts. that helping them to resolve their problem(s) is

most important and possible through therapy

- their pain is real - suicidal thinking and behavior has been helpful in coping with the pain - but alternative means of coping are more effective

• It is critical to communicate: - that ending the pt.’s emotional pain is the most important goal and possible

through therapy - that preserving the pt.’s life is essential and the therapist will not do

anything to hurt the pt. or help to end his/her life - support and encouragement that therapy will help

Eliminating Psychological Pain IV• Create an atmosphere in which the pt. feels safe in

sharing information about his/her suicidal thoughts, intent, plans, and behaviors

- encourage honest reporting of suicidality

- don’t hesitate in using the “s” word

- communicate that you are not frightened by the potential for suicidal behaviors in your pt.

Eliminating Psychological Pain V• Share what you know about the suicidal state of mind

- such explanations can provide some immediate relief and lessen the burden of this situation for the pt.

- share information concerning emotions frequently experienced by suicidal individuals. Knowing that others have felt similar feelings and recovered often alleviates anxiety and provides pts. With some sense of control and a more positive outlook for the future

• Honestly express to the pt. why it is important that the person continue to live

- a basic empathic and compassionate attitude (not pity) toward the person that is genuine

Eliminating Psychological Pain VI• Be empathic to the suicidal wish

- assume the pt.’s perspective and “seeing” how this person has reached as dead end without trying to interfere, stop, or correct suicidal wishes

- being empathic doesn’t connote agreement with the suicidal intention, rather it is a way of connecting with the person’s experience and being a listener and companion at a time of crisis

- being empathic creates an atmosphere of trust and results in lessening of the person’s sense of loneliness

Eliminating Psychological Pain VII• The thoughtfulness and thoroughness of the questioning

about suicide may convey to the pt. that a fellow human cares…and may represent to the pt. the first realization of hope

• A strong, positive relationship with a suicidal individual is absolutely essential. At times, if all else fails, the strength of the relationship may keep a person alive during a crisis

- the therapist’s attitude must be caring, not neutral - the therapeutic alliance is built upon the therapist’s desire to

collaborate with the pt. to develop the pt.’s growth and development and to function more successfully

- counter-transference reactions (e.g. hate; malice) must be expected and kept in check

What to Ask About

• Psychological pain: hurt, anguish, misery• Stress: being pressured or overwhelmed• Agitation: emotional urgency, need to take action• Hopelessness: things will never get better no matter

what• Self-hate: disliking oneself; no self-esteem or self-

respect• Plans: degree of specificity of method, time, and place• Actions: taken towards implementing a plan• Intent: what one hopes to achieve by suicide or what

suicide means to the pt.

Shneidman on Suicide (2001)

I believe that suicide is essentially a drama of the mind, where the suicidal

drama is almost always driven by psychological pain, the pain of the

negative emotions - what I call psychache. Psychache is at the dark heart of suicide: no psychache, no

suicide.

Remember……….

Suicide is NOT the problem

Suicide is only the solution to a perceived insoluble problem that is no longer tolerable

Serious Attempt or Death by Suicide

Those Who Desire Suicide

Those Who Are Capable of Suicide

PerceivedBurdensomeness

ThwartedBelongingness

Sketch of the Theory

The Acquired Capability to Enact Lethal Self-Injury

• Accrues with repeated and escalating experiences involving pain and provocation, such as– Past suicidal behavior, but not only that…– Repeated injuries (e.g., childhood physical abuse).– Repeated witnessing of pain, violence, or injury (cf.

physicians).– Any repeated exposure to pain and provocation.

The Acquired Capability to Enact Lethal Self-Injury: Habituation

• Habituation: Response decrement due to repeated stimulation.

The Acquired Capability to Enact Lethal Self-Injury

• With repeated exposure, one habituates – the “taboo” and prohibited quality of suicidal behavior diminishes, and so may the fear and pain associated with self-harm.

• Relatedly, opponent-processes may be involved.

The Acquired Capability to Enact Lethal Self-Injury

• Opponent process theory (Solomon, 1980) predicts that, with repetition, the effects of a provocative stimulus diminish, and the opposite effect, or opponent process, becomes amplified and strengthened. The opponent process for suicidal people may be that they become more competent and fearless, and may even experience increasing reinforcement, with repeated practice at suicidal behavior.

Serious Attempt or Death by Suicide

Those Who Desire Suicide

Those Who Are Capable of Suicide

PerceivedBurdensomeness

ThwartedBelongingness

Sketch of the Theory

Constituents of the Desire for Death

• Perceived Burdensomeness

• Thwarted Belongingness

Perceived Burdensomeness

• Feeling ineffective to the degree that others are burdened is among the strongest sources of all for the desire for suicide.

Constituents of the Desire for Death

• Perceived Burdensomeness

• Thwarted Belongingness

Thwarted Belongingness• The need to belong to valued groups

or relationships is a powerful, fundamental, and extremely pervasive human motivation. When this need is thwarted, numerous negative effects on health, adjustment, and well-being have been documented.

Thwarted Belongingness• The view taken here is that this need is so powerful

that, when satisfied, it can prevent suicide even when perceived burdensomeness and the acquired ability to enact lethal self-injury are in place. By the same token, when the need is thwarted, risk for suicide is increased. My argument is that the thwarting of this fundamental need is powerful enough to contribute to the desire for death. This perspective is similar to the classic work of Durkheim (1897), who proposed that suicide results, in part, from failure of social integration.

Prevention/Treatment Implications

• The model’s logic is that prevention of “acquired ability” OR of “burdensomeness” OR of “thwarted belongingness” will prevent serious suicidality.

• Belongingness may be the most malleable and most powerful.

• Example PSA: “Keep your old friends and make new ones – it’s powerful medicine.”

• CBT for burdensomeness and low belongingness