Overlap of Spheres of Influence for Suicidal Behavior

1. Understanding Suicidal BehaviorsIf 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 Adversity Helplessness Despair & Shame Impulsivity Isolation Irrationality Capability

4. Community Individual Peer/Family Society “Addressing risk factors across the various levels of the ecological model may contribute to decreases in more than one type of violence.” 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 Immediate Triggers Proximal Factors Predisposing Factors Biological Factors Familial Risk Major Psychiatric Syndromes Public Humiliation Shame Hopelessness Substance Use/Abuse Access To Weapons Serotonergic Function Intoxication Impulsiveness Aggressiveness Severe Defeat Personality Profile Neurochemical Regulators Abuse Syndromes Negative Expectancy Major Loss Demographics Severe Chronic Pain Severe Medical/ Neurological Illness 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* STRESSEVENT MOODCHANGE INHIBITION SUICIDE SURVIVAL MoodSubstance AbuseAggressionAnxietyNeurochemistry DISORDER In troubleLossHumiliation Anxiety – DreadHopelessnessAnger Taboos Support Ventilation Mental State Presence of others Taboos Method available Recent example Excitation/impulsivity Solitude FACILITATION *David Shaffer, M.D., Columbia U.

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

11. 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 Why Now?

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. SHNEIDMAN’S CONCEPT OF PSYCHOLOGICAL PAIN

15. Shneidman’s Ten Commonalities of Suicide (1985) • The common stimulus is unendurablepsychological pain (i.e., psychache). • The common stressor in suicide is frustratedpsychological 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. Completed SUICIDE 1 2 3 4 5 Shneidman’s Cubic Model of Suicide Press (stress) high 1 2 5 3 4 5 4 3 2 Pain (Psychache) Low pain intolerable 1 low Perturbation (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. Sketch of the Theory Those Who Desire Suicide Perceived Burdensomeness Those Who Are Capable of Suicide Serious Attempt or Death by Suicide Thwarted Belongingness

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

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