I am a firm believer that having a strong foundation in theory allows for the creation of rich and compassionate conceptualizations. This is especially true for making sense of suicide.
In this post I will provide a brief review of two of the three frameworks I use the most. First, I’ll discuss Thomas Joiner’s Interpersonal Theory of Suicide. Second, I’ll introduce David Jobes’ Collaborative Assessment and Management of Suicide (CAMS). In a future post I’ll go over Marsha Linehan’s Dialectical Behavior Therapy (DBT). I’ll also talk about commonalities across all three models.
Interpersonal Theory of Suicide
The Interpersonal Theory of Suicide posits that suicide risk is greatest when you are have perceived burdensomeness, thwarted belongingness, hopelessness, and have acquired capability for suicide.
Burdensomeness, Belonging, and Hopelessness
Perceived burdensomeness is the genuine belief that others will be better off without you. Those others can be your immediate family, friend group, military unit, religious community, society at large, and even the natural world. It is the belief that your continued existence is a drain on resources and that you are a burden. Thwarted belongingness is the sense of not fitting in, of being different and out of balance with your ecological system. When we perceive ourselves as not fitting in, we do not have needed connections. As a result we can struggle to feel seen and understood. Hopelessness is the belief that no matter what you do or what might occur, your circumstances will not get better. This expectation is particularly true for belonging and burdensomeness. How you feel and how things are right now, are how it is always going to be.
Acquired Capability
Suicide goes against evolutionary and biological instincts to survive. We typically feel fear when there is a risk of injury, pain, or death. When we sense death is near, we instinctively start to panic. Acquired capability is the loss of this fear due to circumstances demanding the ability to tolerate and even dissociate from 1) the fear of pain, 2) actual pain, and 3) the fear of death and dying. This can occur through our work, for example, EMTs, firefights, police, and the military, must be able to turn off their fear to do their jobs. Repeated self-harm and/or multiple suicide attempts can also yield the same result due to desensitization to the inherent aversiveness of these behaviors.
In Summary
As such, when we feel we are a burden, don’t belong, are hopeless, and have a high psychological and physical tolerance for the fear of death/dying, suicide makes sense. It is seen as a viable option for coping with unceasing suffering. This framework makes it easier to understand why someone might be struggling with suicide. It also provides areas to target in treatment – reducing suicidal planning and self-harm as coping, removing access to lethal means, increasing hope, building connections, and exploring worth in new ways.
Collaborative Assessment and Management of Suicide (CAMS)
CAMS is a therapeutic frame work for assessing and managing suicidal ideations. I’ll go into a lot more detail about how CAMS works in a future blog on interventions. For now, I’ll be reviewing the theory behind it. The initial session of CAMS uses the Suicide Status Form (SSF) to provide an in-depth, collaborative, and compassionate assessment of suicide. The SSF assesses 5 core constructs: psychological pain, stress, agitation, hopelessness, and self-hate. This portion of the SSF derives from the work of Shneidman, Beck, and Bauemister.
Schneidman, Beck, and Baumeister
In 1978 Shneidman proposed the Cubic Model wherein suicide is most likely to occur when there is concurrent and maximal (measured on a scale of 1-5, with 5 as the highest) psychological pain, press (modified to stress on the SSF), and perturbation (agitation, referring to the need to act, on the SSF). Beck’s Cognitive Theory, combines hopelessness with the Cognitive Triads. It is believed that one’s negative thoughts about the self, others, and the world will never change or improve. Baumeister proposed the Escape Theory explaining suicide as the only viable option for “escaping [the] intolerable experience of [the] self” that is fueled by persistent self-hate.
Quantifying Risk
The next sections of the SSF measures overall risk quantitatively and qualitatively. It asks for reasons for living and dying, self-versus other motivation for dying, and the one thing that would make the client no longer suicidal. The section on reasons for living versus dying is inspired by Linehan’s Reasons for Living Inventory. To combat the pull for suicide, one must connect with the other non-suicidal related factors of one’s life.
This section also calls upon Shneidman’s psychological autopsy work. In this research, Shneidman identified ten commonalities of those who died by suicide. Two notable commonalities include “the common cognitive state in suicide is constriction” and “the common internal attitude toward suicide is ambivalence.” The former refers to the tunnel vision that can occur when suicide is perceived as the only option. Neuroimaging research has demonstrated that when in a suicidal crisis (or other highly emotive state), the frontal lobe, which allows for problem-solving, holding of different perspectives, considering consequences etc., is essentially off line. This reinforces the importance of buying time to get out of the crisis to see suicide isn’t the only answer, to build skills, and be able to engage in effective problem-solving.
The role of ambivalence in understanding suicide is essential. As clinicians, it is our “in” for motivating change. More on this when we get to interventions.
To learn more about these theories check out:
Dr. Joiner’s Book: Why People Die by Suicide
Dr. Jobes’ Website: Camscare
For Clinicians: If you are new to this material, I hope it helps you make sense of suicide in a new more comprehensive way. If you were already familiar with it, I hope this was a good refresher.
For Those Seeking Healing: As I said in my last suicide post, I hope this material helps you feel seen and understood and gives you hope that heling is possible. You may also benefit from the resources mentioned above. Again, these posts, and those resources, do not equate to emergency interventions or therapy. Please call 9-8-8 or go to your local emergency room if you are in crisis.
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