Janet S. McCord, PhD, FT Chair, Edwin S. Shneidman Program in Thanatology Marian University of Fond du Lac, WI September, 2011 Shneidman in a Nutshell: Psychache and Suicide

Learning Objectives At the end of this presentation, the participant will be able to discuss: – The CONTEXT: Summarize Shneidman’s progression of thought over time. – The CONTENT: Define psychache – The APPLICATION: Discuss ways of using psychache in intervention and prevention strategies.

The Context: Shneidman’s Progression of Thought Over Time

Ancestry and Birth (1918)

Young Adulthood 1934 – 1940: UCLA (undergraduate and Master’s in psychology) 1949 – 1942: worked as civil servant 1942 – 1946: Captain in Army Air Force 1946 – 1948: Doctoral program in Clinical Psychology at USC – Schizophrenia and the MAPS Test 1948: Full time for Veterans Administration 1950: Meets Henry Murray 1961: Harvard University – U.S. Public Health Services special research fellow

Shneidman and Suicide 1949: Discovers suicide notes in LA County Coroner’s vault 1955: 3-year research grant from NIMH 1958: Los Angeles Suicide Prevention Center created – Shneidman, Norman Farberow, Robert Litman – : 7-year project grant from NIMH

National Suicide Prevention 1966 – 1969: NIMH and National Suicide Prevention Program – Number of SPC’s nationally increased from 3 to 200 in two years 1968 – 1971: Co-edited the Bulletin of Suicidology 1968: Founded the American Association of Suicidology 1970: UCLA Medical School Department of Psychiatry – Shifted focus to thanatology and terminally ill – Studied a special “kind” of suicidal person

The Content: Define psychache

Henry Murray’s Explorations in Personality 1938 Function of personality: – Reduce inner tension – Self-expression – Reduction of conflicts (by scheduling and social conformity) Reduction of inner tension – Satisfaction of inner demands or “needs”

Definition of Suicide (1977) Shneidman’s Intentionally Non-traditional Approach Not lean on “suicidological giants” – Freud, Durkheim Eschew demographics Ignore all psychiatric categories Assume that 100% of suicidal persons are perturbed Approach from non-suicidal theoretical directions

1)Situational 1.Common stimulus: unbearable psychological pain 2.Common stressor: frustrated needs 2)Conative (purpose, goal) 3.Common purpose: to seek a solution 4.Common goal: cessation of consciousness 3)Affective 5.Common emotion: hopelessness-helplessness 6.Common internal attitude: ambivalence 4)Cognitive 7.Common cognitive state: constriction (tunneling) 5)Relational 8.Common interpersonal act: communication of intention 9.Common action: escape 6)Serial 10.Common consistency: lifelong coping patterns

Perturbation Not to be confused with psychache State of being emotionally upset, disturbed, disquiet – Jobes: agitation Both cognitive constriction and penchant for self-harm Impulse to do something to alter current situation Psychological energy driving the suicidal action

Shneidman’s Cubic Model of Suicide (1987) Completed Suicide High to Low Perturbation/ Agitation Low to High Psychache (Pain) Low to High Press (Stress)

Murray Need Form Abasement Achievement Affiliation Aggression Autonomy Counteraction Defendance Deference Dominance Exhibition Harmavoidance Inviolacy Nurturance Order Play Rejection Sentience Shame-avoidance Succorance Understanding

Murray Need Form (Shneidman, 1996) Rank order Sum of 100

Two Kinds of Needs Modal Needs – Weighted needs that characterize the personality Vital Needs – Needs an individual focuses on under stress, suffering, heightened inner tension, and in mental pain Vital Needs Modal Needs

Five “Clusters” of Needs Thwarted love, acceptance, belonging – succorance, affiliation Fractured control, predictability, arrangement – achievement, autonomy, order, understanding Assaulted self-image and avoidance of shame – affiliation, defendance, shame-avoidance Ruptured key relationships and grief – affiliation, nurturance Excessive anger, rage, hostility – dominance, aggression, counteraction

In a Nutshell Suicide stems from psychological pain Psychological pain comes from frustrated psychological needs peculiar to each person Threshold for pain is unique to each person – Can be related to early childhood assaults and losses – “I tend to believe that, at rock bottom, the pains that drive suicide relate primarily not to the precipitous absence of... happiness in adulthood, but to the haunting losses of childhood’s special joys.” (Shneidman, 1996, 164)

Psychache as Cause of Suicide “The implications of this psychological view are quite extensive. For one thing, it means that our best route to understanding suicide is not through the study of the structure of the brain, nor the study of social statistics, nor the study of mental diseases, but directly through the study of human emotions described in plain English, in the words of the suicidal person.” (Shneidman, 1996, 6)

Shneidman’s Two Questions Where do you hurt? How can I help?

How willing am I to be inconvenienced by another person’s answers to the two most important questions? (with gratitude to Harold Ivan Smith)

The Application: Discuss ways of using psychache in intervention and prevention

Aeschi Working Group Konrad Michel, M.D. Antoon A. Leenaars, Ph.D. David A. Jobes, Ph.D. John T. Maltsberger, M.D. Israel Orbach, Ph.D. Ladislav Valach, Ph.D. Richard A. Young, Ph.D. Michael Bostwick, M.D. February 2000: first Aeschi Working Group meeting

Historical “Medical Model” Approach 1.Suicide attempt and/or expression of suicidality with plan a)Patient hospitalized (frequently) b)Therapist and patient (normally) sit across from one another. c)Therapist interviews patient to assess risk of further suicidal actions through looking for clinical risk factors/psychiatric disorder(s): depression, lack of sleep, poor appetitie, anhedonia, and suicidality. Interview may last 30 minutes Aeschi Working Group

21 st Century Approach Psychotropic medication and outpatient treatment – Cheap – Medication compliance not good – When hospitalization is allowed, it is usually inadequate – Poor outcomes can lead to death and lawsuits (even against outpatient mental health providers) – Many clinicians refuse to treat suicidal patients

Collaborative Assessment and Management of Suicidality (CAMS) David Jobes, PhD, Catholic University of America A philosophy and clinical approach – Suicide viewed as a coping mechanism Alternative means of coping can be learned – Clinical assessment and treatment planning – Management of suicidal risk with suicidal outpatients – Strong therapeutic alliance is required for success

Three Phases 1.Initial “Index” Assessment/treatment planning 2.Clinical tracking 3.Clinical outcomes Core multipurpose tool: SSF – Serves as a clinical roadmap throughout clinical process all the way to outcomes Engages patient in assessment and treatment planning

CENTRAL: Strong therapeutic relationship with the suicidal person Suicidal person is engaged in the assessment of their own suicidal risk Suicidal person is engaged in co-authoring the treatment plan Suicidal person takes responsibility for their own safety and stability Goal: – Reduce or eliminate hospitalization – Reduce use of suicide as a coping mechanism – Improve problem-solving skills – Enhance reasons for living

“When coping and problem solving improves, the option of suicide can be made systematically obsolete through thoughtful and systematic clinical care that is central to the CAMS approach.” (Jobes, Managing Suicidal Risk: A Collaborative Approach, 2006, 6-7)

David Jobes’ “Truisms” Most suicidal people do not want an end to their biological existence; – rather, they want an end to their psychological pain and suffering. Most suicidal people tell others (including mental health professionals) that they are thinking about suicide as a compelling option for coping with their pain. Most suicidal people have psychological problems, social problems, and poor methods for coping with pain – – all things that mental health professionals are usually well trained to tackle. (Jobes, Managing Suicidal Risk: A Collaborative Approach, 2006, 7)

“... I am passionately interested in providing a reasonable response to ending psychological pain without costing a patient his or her life. I have heard what my suicidal patients have said about their pain and suffering and I am dedicated to responding effectively to that pain and suffering. I am especially resolved to use my training and skills to fundamentally address psychological and social problems, creating whole new and better ways of coping with seemingly unbearable pain.... Helping our patients find a way to choose life is the point of all our efforts in this most crucial of all clinical endeavors.” (Jobes, Managing Suicidal Risk: A Collaborative Approach, 2006, 7)

Suicide Status Form (SSF © Jobes, 2000 ) Core multi-purpose tool used within Jobes’ Collaborative Assessment and Management of Suicidality approach Used for: – Core assessment – Treatment planning – Tracking – Outcome mapping

CAMS Research Suicidal Air Force personnel (n = 55) at two Air Force Life Skills Clinics in Colorado (Jobes et. al., 2005) One-third of those who sought mental health care had suicidal ideation Trained clinicians in CAMS Retrospective study comparing group (n=25) treated with CAMS with group (n=30) who received “treatment as usual” Suicidal patients in CAMS group – CAMS group needed fewer sessions (10 to 12 against more than 20 in non-CAMS group) – TAU group had 25 ER visits compared with 5 in CAMS in 6 months following index MHC

CAMS in Other Settings Hotlines and Crisis Centers Outpatient clinics Community mental health centers – Requires more time, patience and perseverance when used with the psychotic and delusional Private practice Forensic settings (use currently limited) Emergency departments – Research on whether or not CAMS use will improve attendance at NDAs Inpatient settings – Mayo Clinic – Switzerland

Psychache in Other Settings Psycho-education – Group settings – Individual counseling Clinical grief counseling – Use of SSF may be appropriate if survivor is exhibiting suicidality Community education – Stigma associated with Incomplete understanding of the dynamics of suicidality Fear Centuries of religious/ social/ legal discrimination

References Shneidman, Edwin S. – The Suicidal Mind. Oxford University Press, 1998 – Suicide as Psychache: A Clinical Approach to Suicidal Behavior. Rowman & Littlefield Inc., 1995 – A Life in Death. Self published – Definition of Suicide. Jason Aronson, Jobes, David A. – Managing Suicidal Risk: A Collaborative Approach. The Guilford Press, 2006