1. Understanding Suicidal Behaviors If you don’t understand the suicidal process then you won’t know what to ask or what to do

2. Overlap of Spheres of Influence for Suicidal Behavior
Individual
Peers/Family
Community
Society

3. Final Common Pathway Despair & Shame Adversity Helplessness
Impulsivity
Isolation
Irrationality
Capability

4. “Addressing risk factors across the various levels of the ecological model may contribute to decreases in more than one type of violence.”
Individual
Peer/Family
Society
Community
Violence – A global public health problem, World Health Organization, 2002, p. 15.

5. Stress-Diathesis Hypothesis

6. Suicide is an Outcome that Requires
Several Things to go Wrong All at Once
Biological
Factors
Predisposing
Factors
Proximal
Factors
Immediate
Triggers
Familial
Risk
Major Psychiatric
Syndromes
Hopelessness
Public Humiliation
Shame
Serotonergic
Function
Substance
Use/Abuse
Access To
Weapons
Intoxication
Neurochemical
Regulators
Personality
Profile
Impulsiveness
Aggressiveness
Severe
Defeat
Every suicide is different; every suicide has its own story.
2. This slide describes one convenient way of organizing the chapters of every story. For example, Fred, an 80 year old white male; his father committed suicide (i.e., biological factors). At the present time, Fred has major depression (i.e., predisposing factor); Fred starts drinking (i.e., proximal factor). Fred’s wife is caught having an affair with Fred’s best friend; Fred has access to a firearm (i.e., immediate triggers)—one story.
3. Jane is the high school senior with bipolar disorder who has told everyone she is going to Princeton. When she doesn’t get accepted, Jane feels publicly humiliated; she impulsively jumps from a parking structure—another story.
4. There are countless such stories.
5. The goal of suicide assessment is to “read” all the chapter’s and intervene before the last, and final, chapter is written.
Abuse
Syndromes
Negative
Expectancy
Major
Loss
Demographics
Severe Medical/
Neurological Illness
Severe
Chronic Pain
Worsening
Prognosis
Pathophysiology

7. 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)

9. SUICIDE – A MODEL* DISORDER STRESS EVENT MOOD CHANGE INHIBITION
Mood Substance Abuse Aggression Anxiety Neurochemistry
DISORDER
STRESS EVENT
In trouble Loss Humiliation
MOOD CHANGE
Anxiety – Dread Hopelessness Anger
SURVIVAL
INHIBITION
Taboos
Support
Ventilation
Mental State
Presence of
others
Taboos
Method available
Recent example
Excitation/impulsivity
Solitude
FACILITATION
SUICIDE
*David Shaffer, M.D., Columbia U.

10. Suicide Risk varies over time… and throughout the life of the individual

11. 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

12. 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

13. 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

14. CONCEPT OF PSYCHOLOGICAL PAIN
SHNEIDMAN’S
CONCEPT OF PSYCHOLOGICAL
PAIN

15. Shneidman’s Ten Commonalities of Suicide (1985)
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.

16. 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

17. 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)

18. 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

19. 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

20. Shneidman’s Cubic Model of Suicide
Press (stress) 1
high 2 5 3 4
Completed
SUICIDE 5 4 3 2
Pain
(Psychache)
Low pain
intolerable 1
low
Perturbation 1 3 4 5 2
(Shneidman, 1987)

21. 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

22. 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”

23. 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

24. 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.

25. 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

26. 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

27. 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

28. 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.

29. 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.

30. Remember……….
Suicide is NOT the problem
Suicide is only the solution to a perceived insoluble problem that is no longer tolerable

32. Serious Attempt or Death by Suicide
Sketch of the Theory
Those Who
Desire Suicide
Perceived
Burdensomeness
Those Who Are Capable of Suicide
Thwarted
Belongingness
Serious Attempt or Death by Suicide

33. 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.

34. The Acquired Capability to Enact Lethal Self-Injury: Habituation
Habituation: Response decrement due to repeated stimulation.

35. 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.

36. 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.

37. Serious Attempt or Death by Suicide
Sketch of the Theory
Those Who
Desire Suicide
Perceived
Burdensomeness
Those Who Are Capable of Suicide
Thwarted
Belongingness
Serious Attempt or Death by Suicide

38. Constituents of the Desire for Death
Perceived Burdensomeness
Thwarted Belongingness

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

40. Constituents of the Desire for Death
Perceived Burdensomeness
Thwarted Belongingness

41. 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.

42. 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.

43. 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