Understanding Suicidal Behaviors If you don

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Understanding Suicidal BehaviorsIf you dont
understand the suicidal process then you wont
know what to ask or what to do
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Overlap of Spheres of Influence for Suicidal
Behavior
Individual
Peers/Family
Community
Society
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Final Common Pathway
Adversity
Helplessness
Despair Shame
Impulsivity
Isolation
Irrationality
Capability
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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.
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Stress-Diathesis Hypothesis
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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
Hopelessness
Public Humiliation Shame
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
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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 dont really want to die
  just want to get help with living) (Farberow
  Shneidman, 1961)

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SUICIDE A MODEL
MoodSubstance AbuseAggressionAnxietyNeurochemi
stry
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.
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Suicide Risk varies over time and throughout
the life of the individual
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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

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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

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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

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• SHNEIDMANS
• CONCEPT OF PSYCHOLOGICAL
• PAIN

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Shneidmans 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.

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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 lifes actions

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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)

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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

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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

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Shneidmans Cubic Model of Suicide
Press (stress)
high
1
2
5
3
4
4
5
3
2
Pain (Psychache)
Low pain
intolerable
1
low
Perturbation
(Shneidman, 1987)
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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

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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

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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

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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
• - dont hesitate in using the s word
• - communicate that you are not frightened by
  the potential for suicidal behaviors in your pt.

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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

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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 doesnt connote agreement
  with the suicidal intention, rather it is a way
  of connecting with the persons 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 persons
  sense of loneliness

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Eliminating Psychological Pain VII

• The thoughtfulness and thoroughness of the
  questioning about suicide may convey to the pt.
  that a fellow human caresand 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 therapists attitude must be caring,
  not neutral
• - the therapeutic alliance is built upon the
  therapists 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

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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.

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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.

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Remember.

• Suicide is NOT the problem
• Suicide is only the solution to a perceived
  insoluble problem that is no longer tolerable

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Sketch of the Theory
Those Who Desire Suicide
Perceived Burdensomeness
Those Who Are Capable of Suicide
Thwarted Belongingness

• Serious Attempt or Death by Suicide

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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.

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The Acquired Capability to Enact Lethal
Self-Injury Habituation

• Habituation Response decrement due to repeated
  stimulation.

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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.

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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.

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Sketch of the Theory
Those Who Desire Suicide
Perceived Burdensomeness
Those Who Are Capable of Suicide
Thwarted Belongingness

• Serious Attempt or Death by Suicide

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Constituents of the Desire for Death

• Perceived Burdensomeness
• Thwarted Belongingness

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Perceived Burdensomeness

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

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Constituents of the Desire for Death

• Perceived Burdensomeness
• Thwarted Belongingness

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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.

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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.

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Prevention/Treatment Implications

• The models 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 its powerful medicine.
• CBT for burdensomeness and low belongingness