This is part Two of the commentary on “The Interpersonal-Psychological Theory of Suicidal Behavior.” The following sections will elaborate on the three main components. One caveat: this theory is more geared to people with mood disorders, but not the more common personality disorders like Borderline Personality disorder.
The first question was “What is the desire for suicide, and what are its constituent parts?” Joiner states that two deeply held beliefs or perceptions must be held at the same time, and for a long period of time. The first is an unwavering state of “perceived burdensomeness” which is defined by the view or perception that one’s life/existence burdens family members, friends and/or society, in general. Joiner states that this produces the idea that death would be preferable and of more value to family, friends, and society at large. This perception ~ it is important to note ~ represents a potentially fatal misperception.
Past research, although not direct empirical tests of the Theory of Interpersonal-Psychological, have found that “perceived burdensomeness” especially toward family is correlated with suicidal ideation among community participants and high-suicide-risk groups (DeCatanzaro 1995). Past research has also documented an association between “perceived burdensomeness” and suicidal ideation.
Direct tests of the theory have been supportive, as well. In two separate studies of suicide notes, the raters detected more expressions of being a burden in people who had died by suicide compared to those who had tried but had survived. It also occurred in people who had died by suicide using a violent means versus those who used less violent methods. People who committed suicide using a gun for example, showed a higher degree of burdensomeness than those who chose a less violent method.
In a study of psychotherapy outpatients showed a measure of “perceived burdensomeness” was a healthy predictor of suicide attempt status, and of current suicidal ideation even while controlling for powerful covariates such as hopelessness (Van Orden, Lynam, Hollar, & Joiner 2006.)
The second condition that must be present, and have been present for a period of time is the concept of “low belongingness or social alienation” ~ which is defined as a sense of being alienated from others, or not an integral part of a family, circle of friends, or other valued group. As with research on “perceived burdensomeness,” there is a great deal of evidence that this factor is implicated in suicidal behavior. Although, very little of this evidence derives from direct empirical tests of the Theory of Interpersonal-Psychological of Suicidal Behavior, a strong case can be made that that of all the risk factors for suicide, ranging from the molecular to cultural levels, the strongest and most predictive support has emerged for indices related to social alienation (Boardman, Grimboldeston, Handley, Jones & Willmott, 1999.)
The connection between belonging (or its absence) and suicidality has been established for a number populations including adolescents, college students, the elderly, and psychiatric inpatients. What I find interesting is that suicide rates go down during times of celebration (people are coming together to celebrate a common event); Joiner, Hollar & Van Orden, 2006. Suicide rates also go down during times of collective crisis such as the 9/11 bombings, and for about a week after the assassination of President Kennedy (people pull together to commiserate.)
Direct tests of The Interpersonal-Psychological Theory of Suicidal Behavior
Conner, Britton, Sworts & Joiner evaluated 131 methadone patients who displayed a high level of “low belongingness,” and found that it predicted a lifetime history of suicide attempts that were not accidental overdoses. The association was specific to actual attempts and not suicidal ideation. This association crossed demographics, correlates of suicidal behavior and other interpersonal variables.
The third component is the “acquired ability to enact lethal self-injury.” Feelings of “perceived burdensomeness” and “low sense of belonging” may instill a desire for suicide, but they are not sufficient on their own to produce an attempt. The third element of the ability to inflict lethal self-harm has to be in place. At this point, the theory assumes a fight with one’s innate self-preservation instincts. However, according to the theory, a person having fought this battle repeatedly and in different settings instills the ability to override the self preservation instinct ~ should such an individual want to do so. Experiences often include previous self-injury, but can also include repeated accidents numerous physical fights; and occupations like physician and front-line soldier in which repeated exposure either direct or vicariously to pain and self-injury produces the acquired ability to commit the act of suicide.
The basis of this proposition is primarily an “opponent-process” theory which suggests that repeated exposure to affective stimuli results in the stimuli being unable to exact the same response, and instead the opposite reaction is strengthened (Solomon, 1980). Based on this, it is hypothesized that the capability to commit suicide comes from repeated exposure to painful or fearsome experiences. This results in habituation and a lessening of the fear or pain response. Thus, the capability to end one’s own life is largely due to this habituation.
The basic implication of this habituation is that past suicidal behavior will cause individuals to become “immune” to the pain and fear of self-injury making future attempts more likely. A history of suicide attempts has been found to be a strong predictor of future attempts, suicidal behavior, and completed attempts (Joiner et. al., 2005). The highest levels of “acquired capability” were reported by people with multiple past attempts as the theory would predict.
Acquiring the capability to commit suicide is not limited to past behavior ~ it can be acquired by habituation to other fear or pain-inducing behaviors (e.g., non-suicidal behavior like cutting, self-starvation, physical abuse, etc.). For example, the behavior of cutting oneself has been shown to anticipate a higher likelihood for suicide attempts and those who have a longer history of self-injury, use of varied methods tend to report an absence of pain during self-injury ~ all indicative of habituation and tolerance (Nock, Joiner, Gordon, Richardson, & Prinstein, 2006). Aside from direct exposure, the theory also puts forth the idea that vicarious exposure to pain and injury may produce the capacity for suicide. Physicians fit in this group with high suicide rates despite many protective factors (hawton, Clements, Sakarowitch, Simkin, & decks, 2001).
The Interactive Nature of the Theory
The interactive nature of the theory suggests a three-way relationship between the main concepts. Particularly, the ideas of “perceived burdensomeness” must be present with “low sense of belonging” to produce the will to die. However, that will or desire will not be acted upon unless in the presence of the “acquired capacity” for lethal self-harm.
To date, four studies have looked at the interactive nature of the model. All have shown significant statistical interaction among the three major concepts even while controlling for covariates such as depression, gender and age.
The Interpersonal-Psychological Theory is promising with growing empirical data to support it. It suggests that clinicians be aware of their patients’ levels of belongingness, sense of burdensomeness, and acquired capability (especially previous attempts; my own therapist spent 10 minutes today assuring herself that I wasn’t writing an elaborate suicide note. Far from it, mostly these days I am irritable) as this awareness may aid in suicide risk assessment and therefore, being able to target therapies.
Full link to article here: http://www.apa.org/science/about/psa/2009/06/sci-brief.aspx