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
Individual
Peers/Family
Community
Society
Final Common Pathway
Adversity
Impulsivity
Irrationality
Helplessness
Despair
&
Shame
Isolation
Capability
“Addressing risk factors across the various
levels of the ecological model may
contribute to decreases in more than one
type of violence.”
Community
Society
Individual
Peer/Family
Violence – A global public health problem, World Health Organization, 2002, p. 15.
Stress-Diathesis Hypothesis
Suicide is an Outcome that Requires
Several Things to go Wrong All at Once
Biological
Factors
Familial
Risk
Predisposing
Factors
Major Psychiatric
Syndromes
Proximal
Factors
Immediate
Triggers
Hopelessness
Public Humiliation
Shame
Intoxication
Access To
Weapons
Serotonergic
Function
Substance
Use/Abuse
Neurochemical
Regulators
Personality
Profile
Impulsiveness
Aggressiveness
Severe
Defeat
Demographics
Abuse
Syndromes
Negative
Expectancy
Major
Loss
Pathophysiology
Severe Medical/
Neurological Illness
Severe
Chronic Pain
Worsening
Prognosis
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
STRESS
EVENT
MOOD
CHANGE
INHIBITION
SURVIVAL
Taboos
Support
Ventilation
Mental State
Presence of
others
*David Shaffer, M.D., Columbia U.
Mood
Substance Abuse
Aggression
Anxiety
Neurochemistry
In trouble
Loss
Humiliation
Anxiety – Dread
Hopelessness
Anger
FACILITATION
SUICIDE
Taboos
Method available
Recent example
Excitation/impulsivity
Solitude
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.
2.
3.
4.
5.
6.
7.
8.
9.
10.
The common stimulus is unendurable psychological pain (i.e.,
psychache).
The common stressor in suicide is frustrated psychological needs.
The common purpose of suicide is to seek a solution.
The common goal of suicide is cessation of consciousness.
The common emotion in suicide is hopelessness-helplessness.
The common internal attitude toward suicide is ambivalence.
The common cognitive state in suicide is constriction.
The common interpersonal act in suicide is communication of intention.
The common action in suicide is egression (i.e., escape).
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
Press (stress)
high
1
2
4
5
3
5
4
Completed
SUICIDE
3
intolerable
Low pain
Pain
(Psychache)
2
1
low
Perturbation
1
(Shneidman, 1987)
2
3
4
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 selfrespect
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
Sketch of the Theory
Those Who
Desire Suicide
Perceived
Burdensomeness
Those Who Are
Capable of Suicide
Thwarted
Belongingness
Serious Attempt or Death by Suicide
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.
Sketch of the Theory
Those Who
Desire Suicide
Perceived
Burdensomeness
Those Who Are
Capable of Suicide
Thwarted
Belongingness
Serious Attempt or Death by Suicide
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