Suicidal behavior is a major problem worldwide and, at the same time, has received relatively little empirical attention. This relative lack of empirical attention may be due in part to a relative absence of theory development regarding suicidal behavior. The current article presents the interpersonal theory of suicidal behavior. We propose that the most dangerous form of suicidal desire is caused by the simultaneous presence of two interpersonal constructs—thwarted belongingness and perceived burdensomeness (and hopelessness about these states)—and further that the capability to engage in suicidal behavior is separate from the desire to engage in suicidal behavior. According to the theory, the capability for suicidal behavior emerges, via habituation and opponent processes, in response to repeated exposure to physically painful and/or fear-inducing experiences. In the current article, the theory’s hypotheses are more precisely delineated than in previous presentations (Joiner, 2005), with the aim of inviting scientific inquiry and potential falsification of the theory’s hypotheses.

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The Interpersonal Theory of Suicide

Recently, the psychological construct mindfulness has received a great deal of attention. The majority of research has focused on clinical studies to evaluate the efficacy of mindfulness-based interventions. This line of research has led to promising data suggesting mindfulness-based interventions are effective for treatment of both psychological and physical symptoms. However, an equally important direction for future research is to investigate questions concerning mechanisms of action underlying mindfulness-based interventions. This theoretical paper proposes a model of mindfulness, in an effort to elucidate potential mechanisms to explain how mindfulness affects positive change. Potential implications and future directions for the empirical study of mechanisms involved in mindfulness are addressed.

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Mechanisms of mindfulness.

Suicidal behavior is a leading cause of injury and death worldwide. Information about the epidemiology of such behavior is important for policy-making and prevention. The authors reviewed government data on suicide and suicidal behavior and conducted a systematic review of studies on the epidemiology of suicide published from 1997 to 2007. The authors' aims were to examine the prevalence of, trends in, and risk and protective factors for suicidal behavior in the United States and cross-nationally. The data revealed significant cross-national variability in the prevalence of suicidal behavior but consistency in age of onset, transition probabilities, and key risk factors. Suicide is more prevalent among men, whereas nonfatal suicidal behaviors are more prevalent among women and persons who are young, are unmarried, or have a psychiatric disorder. Despite an increase in the treatment of suicidal persons over the past decade, incidence rates of suicidal behavior have remained largely unchanged. Most epidemiologic research on suicidal behavior has focused on patterns and correlates of prevalence. The next generation of studies must examine synergistic effects among modifiable risk and protective factors. New studies must incorporate recent advances in survey methods and clinical assessment. Results should be used in ongoing efforts to decrease the significant loss of life caused by suicidal behavior.

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Suicide and Suicidal Behavior

Effects of Mindfulness on Psychological Health: A Review of Empirical Studies

https://www2.psych.ubc.ca/~klonsky/publications/functions_2007.pdf

The functions of deliberate self-injury: a review of the evidence.

Context Dialectical behavior therapy (DBT) is a treatment for suicidal behavior and borderline personality disorder with well-documented efficacy. Objective To evaluate the hypothesis that unique aspects of DBT are more efficacious compared with treatment offered by non–behavioral psychotherapy experts. Design One-year randomized controlled trial, plus 1 year of posttreatment follow-up. Setting University outpatient clinic and community practice. Participants One hundred one clinically referred women with recent suicidal and self-injurious behaviors meeting DSM-IV criteria, matched to condition on age, suicide attempt history, negative prognostic indication, and number of lifetime intentional self-injuries and psychiatric hospitalizations. Intervention One year of DBT or 1 year of community treatment by experts (developed to maximize internal validity by controlling for therapist sex, availability, expertise, allegiance, training and experience, consultation availability, and institutional prestige). Main Outcome Measures Trimester assessments of suicidal behaviors, emergency services use, and general psychological functioning. Measures were selected based on previous outcome studies of DBT. Outcome variables were evaluated by blinded assessors. Results Dialectical behavior therapy was associated with better outcomes in the intent-to-treat analysis than community treatment by experts in most target areas during the 2-year treatment and follow-up period. Subjects receiving DBT were half as likely to make a suicide attempt (hazard ratio, 2.66; P  = .005), required less hospitalization for suicide ideation (F 1,92 =7.3; P  = .004), and had lower medical risk (F 1,50 =3.2; P  = .04) across all suicide attempts and self-injurious acts combined. Subjects receiving DBT were less likely to drop out of treatment (hazard ratio, 3.2; P 1,92 =6.0; P  = .007) and psychiatric emergency department visits (F 1,92 =2.9; P  = .04). Conclusions Our findings replicate those of previous studies of DBT and suggest that the effectiveness of DBT cannot reasonably be attributed to general factors associated with expert psychotherapy. Dialectical behavior therapy appears to be uniquely effective in reducing suicide attempts.

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Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder

The purpose of this study was to examine patterns of self-reported suicidality and distress during research assessments in a sample of 63 women meeting criteria for borderline personality disorder and current and chronic suicidality. The risk management protocol we used during the two-year study period (University of Washington Risk Assessment Protocol; UWRAP) is described. Results indicated that changes in suicidality following assessments were small and relatively infrequent, and were just as likely to reflect decreases in suicidality as increases (17.5% versus 16.4% of sessions, respectively). Further, longitudinal analyses indicated that changes in suicidality became increasingly rare over the course of the 2-year study. Ratings of distress were more changeable than suicidality, underscoring the need for separate measurement of these constructs when assessing risk. With the aid of the UWRAP, our assessors judged 15 participants as high-risk status in 28 assessment sessions (3.7% of all sessions). In comparison to the rest of the sample, these individuals were of significantly greater clinical severity as measured by the HRSD 17-item, GAF scores, number and severity of previous suicide attempts, and number of previous psychiatric hospitalizations. Low-intensity risk intervention strategies (e.g., validating participant's feelings) were typically sufficient to reduce risk in these participants. Overall, our findings indicate that research with highly suicidal individuals can be done safely with the use of well-trained assessors and an appropriate crisis management protocol.

Risky assessments: participant suicidality and distress associated with research assessments in a treatment study of suicidal behavior

Skills Practice in Dialectical Behavior Therapy for Suicidal Women Meeting Criteria for Borderline Personality Disorder

The leaders in treatment of suicidal complex consumers offer insight into the best strategies to promote engagement in life-saving care. The authors, however, go beyond this traditional application of Dialectical Behavior Therapy (DBT) and discuss how strategies may be applied across a wide range of populations. Particularly, readers will gain an advanced understanding of how apply very specific engagement techniques in the context of treatment-interfering behaviors. These encompass patient-centered, therapist-centered, and context-centered strategies.

Noam Lindenboim

Papers

Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder

Risky assessments: participant suicidality and distress associated with research assessments in a treatment study of suicidal behavior

Skills Practice in Dialectical Behavior Therapy for Suicidal Women Meeting Criteria for Borderline Personality Disorder

DBT and Treatment Engagement in the Context of Highly Suicidal Complex Clients