Understanding Suicidal Behaviors If you don’t understand the

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Understanding Suicidal Behaviors If you don’t understand the Powered By Docstoc
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


      Final Common Pathway

     Adversity              Helplessness

Impulsivity         &         Isolation

  Irrationality             Capability
“Addressing risk factors across the various
    levels of the ecological model may
 contribute to decreases in more than one
              type of violence.”

                       Community                                             Individual
    Society                                         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        Predisposing             Proximal         Immediate
 Factors             Factors               Factors           Triggers
   Familial            Major Psychiatric    Hopelessness    Public Humiliation
    Risk                 Syndromes                               Shame

 Serotonergic         Substance                                Access To
   Function           Use/Abuse                                 Weapons

Neurochemical         Personality           Impulsiveness        Severe
 Regulators             Profile            Aggressiveness        Defeat

                        Abuse                 Negative            Major
 Demographics         Syndromes              Expectancy           Loss

                    Severe Medical/           Severe            Worsening
Pathophysiology                             Chronic Pain
                   Neurological Illness                         Prognosis
Why Are Individuals Suicidal?
• Suicidal behavior represents a way of coping with
  state of high, negative, emotional arousal (Wagner,
• 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)
                            DISORDER             Substance Abuse

                               STRESS            In trouble
                               EVENT             Humiliation

                                                 Anxiety – Dread
                               MOOD              Hopelessness
                              CHANGE             Anger

                             Taboos                              Taboos
INHIBITION                 Support        FACILITATION         Method available
                           Ventilation                         Recent example
                           Mental State                        Excitation/impulsivity
                           Presence of                         Solitude
  SURVIVAL                                  SUICIDE
*David Shaffer, M.D., Columbia U.
   Suicide Risk
varies over time…
throughout the life
 of the individual
          Why Now?
Changes in:
• Medication       •   Impulsivity Controls
• Psychiatric      •   Violence Potential
                   •   Sense of Hope
• Physical
  Symptoms         •   Sense of a Future
• Social Support   •   Sense of Stability
• Professional     •   Sense of Security
           Reasons for Suicide
• Escape from pain - emotional, physical
• Revenge, punishment, manipulation – against an
• 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

• Alcohol and Substance Abuse - may be present across

• Hopelessness - may be present across diagnoses
      Shneidman’s Ten Commonalities of Suicide (1985)
1.    The common stimulus is unendurable psychological pain (i.e.,
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
• 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
• 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
• 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)
                                  1                             high
                          3                                     5
                   4                                                   Completed
              5                                                 4
               Low pain

(Psychache)                                                     1

                          1       2    3    4   5

  (Shneidman, 1987)
   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

• 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
•   Self-hate: disliking oneself; no self-esteem or self-
•   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 is NOT the problem

Suicide is only the solution
 to a perceived insoluble
 problem that is no longer
Sketch of the Theory
 Those Who
Desire Suicide

                         Those Who Are
                       Capable of Suicide


         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.
  – Any repeated exposure to pain and provocation.
The Acquired Capability to Enact
   Lethal Self-Injury: Habituation
• Habituation
  : Response
  due to
    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
     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

                         Those Who Are
                       Capable of Suicide


         Serious Attempt or Death by Suicide
Constituents of the Desire for

• 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

• Perceived

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

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