Applying Psychological Theories of Suicide to Suicide Prevention Siobhan O’Neill MPsychSc, PhD, CPsychol Professor of Mental Health Sciences University of Ulster

Plan of Presentation Theories of suicide. Characteristics of deaths by suicide in NI. Suicidal behaviour in NI (ideation, plans and attempts). Mapping theories to prevention.

Durkheim’s Theory (1897/1951) Degrees of imbalance of social integration and moral regulation. Egoistic. Result of a weakening of the bonds that normally integrate individuals into the collectivity: in other words a breakdown of social integration. Altruistic. Occurs in societies with high integration, where individual needs are seen as less important than the society's needs as a whole. Anomic: Considered the product of moral deregulation and a lack of definition of legitimate aspirations through a restraining social ethic (e.g. religion). Fatalistic: person prefers to die than to carry on living within their society.

Schneidman’s Theory of Suicide Suicide = solution to psychological pain (Psychache). Goal orientated behaviour with annihilation of consciousness or pain as its outcome. Unmet psychological need describes the stressor leading to the suicidal decision. Emotion of overwhelming hopelessness. Reduced cognitive state serves to desensitize the individual and heighten ambivalence. Alternatives to suicide are constricted by current perceptual state.

Schneidman’s ‘Psychache’ (1996) Unmet need, relative to perceived norms heightens risk of suicide, determined by learned responses during early experience. Thwarted love: a frustrated need for comfort and alliance; Fractured control: loss or perceived lack of autonomy; Assaulted self-image: individual need for affiliation and avoidance of shame; Ruptured key relationships: responses to interpersonal difficulties and grief experienced by loss of a nurturing presence; Excessive anger, rage and hostility = a thwarted need for dominance.

Joiner’s interpersonal-psychological theory of suicidal behaviour (2005) Thwarted belongingness, Perceived burdensomeness, Acquired capability for suicide.  

Thwarted belongingness Feeling disconnected from others, reporting a sense of isolation . Alternatively, while others might care, nobody can relate . Dysfunctional automatic thoughts: characteristic of mental illness and skew the individuals' perceptions.  Estrangement from others who have not experienced the same overwhelming emotions, regardless of prior connection.  

Perceived burdensomeness Distorted automatic thoughts, unable to contribute to society.  They are not making any worthwhile contributions to the world around them.  Perceived liability: others' lives would be improved if they were to disappear.  Therapeutic interventions: Cognitive behavioral approaches such as behaviour activation and cognitive restructuring can increase positive experiences while diminishing the tendency to view the environment through distorted lenses.  Goal setting and attainment may increase self-sufficiency. 

Acquired capability for suicide In order to enact lethal self-harm, an individual must habituate to physical pain and the fear of death.  Person must become accustomed to pain and fear. Habituation, occurs through repeated exposure.  Physical pain becomes less pronounced over time when our body becomes accustomed to the experience.  Those who frequently self-harm experience pain analgesia - the absence of pain - during self-injury episodes.  Repeated attempts contribute to acquired capability.  Experiences that involve witnessing pain and violence, even in the absence of physical pain, can contribute to the acquired capability.

Integrated Motivational-Volitional Model (O’Connor, 2011)

Integrated Motivational-Volitional Model (O’Connor, 2011)

Integrated Motivational-Volitional Model (O’Connor, 2011)

Integrated Motivational-Volitional Model (O’Connor, 2011)

Integrated Motivational-Volitional Model (O’Connor, 2011)

NI Suicide study Characteristics of the deceased 2005-2011 (N=1667) Funded by Public Health Agency R & D Division. Ethical approval, confidentiality agreement Researcher based in coroner’s office. Suicides and undetermined deaths (algorithm  probable suicides). Coronial data: witness statements, post mortem, medical files. Coded by the researchers. Anonymised data, binary codes on >40 categories of variables. Iron key encryption. X-Y coordinates for locations. O’Neill, Corry, Murphy, Bunting (2014) Journal of Affective Disorders

Main Points 77% male. Rates high from 20-60 years. The highest proportion were single (39.1% women & 48.3% men). Almost a third lived alone at time of death (31.4%). 22.8% lived in the parental home (including younger individuals and those who returned to the family home in adulthood). More than a fifth lived with a spouse (21%). 35% were employed at time of death, compared to 50.3% who were classified as unemployed or “other”.

Prior Adverse Events (61%) Not known 39% Employment issues 5.1% Financial concerns 5.3% Health fears 5.7% Death/ grief 10.7% Relationship probs 34%

Emotions Loneliness Isolation Entrapment “UNBEARABLE PAIN” Shame Guilt Failure Burdensomeness “UNBEARABLE PAIN”

Method of Suicide Hanging (60.5%) Drowning (7.9%) Overdose (18.7) Gassing (2.6%) Firearms (3.4%) Other (6.9%)

WORLD MENTAL HEALTH The NI Study of Health and Stress Standardised interviews in > 40 countries with >100,000 participants worldwide. Coordinated by Harvard and the World Health Organisation. Computerised interview methods developed at the Survey Research Centre University of Michigan (training certification). Trained lay interviewers from RES & MORI. Clustered random sample. 68% response rate, 4340 participants. Funded by: NI Public Health Agency, Research & Development Division

Suicidal Behaviour in Northern Ireland NI Study of Health and Stress (World Mental Health Survey Initiative; 68% rr, n=4340). Ideation: Seriously considered suicide. Females: 10.6%, Males: 7% Made a plan for suicide. Females: 2.5%, Males: 2.4% Suicide attempt. Females: 4.3%, Males: 2.3% O'Neill S, Ferry F, Murphy S, Corry C, et al. (2014) Patterns of Suicidal Ideation and Behavior in Northern Ireland and Associations with Conflict Related Trauma. PLoS ONE 9(3): e91532. doi:10.1371/journal.pone.0091532 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0091532

Trauma and Suicidal Behaviour in NI Ideation Mental disorder 8.6 Non-conflict trauma 1.8 Conflict related trauma 2.3 Plan Mental disorder 15.8 Non-conflict trauma N/S Conflict related trauma 2.2 Attempt Mental disorder 15.2 Non-conflict trauma 2.6 Conflict related trauma N/S

WHY? OR Conflict experience is protective. Conflict associated with increased likelihood of death on first attempt.  Look at theories of suicide: Joiner/ Klonsky/ O’Connor

Why do people die by suicide? Suicide is a goal directed behaviour to address unbearable pain. Pain + Hopelessness  thoughts of suicide (ideation). Connectedness prevents enaction. If pain > connectedness  plan. Whether this leads to death is dependent upon capability or access to means. If total capability > fear of attempting attempt.

The Northern Ireland Context Conflict increases connectedness. Post conflict: reduced connectedness (especially those who have been most affected). Exposure to pain  habituation (less fear/ more expertise). Access to means. Cognitive access to means: Information.

Suicide prevention: The next steps Creating a culture of social integration and connectedness. Looking at emotional responses to life events. Evidence based treatments for mental disorders. Seeking help is a sign of strength. Considering acquired capability and access to means (including cognitive access to means). Improving the validity of the data on suicide.

Thank You @profsiobhanon sm.oneill@ulster.ac.uk Dr Colette Corry Professor Brendan Bunting Dr Sharon Brady Dr Finola Ferry Dr Edel Ennis Dr Sam Murphy Danielle McFeeters Tony Benson Coroner Mr Lecky and his staff @profsiobhanon sm.oneill@ulster.ac.uk