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.

/pdf/the-interpersonal-theory-of-suicide-38t99pb95m.pdf

The Interpersonal Theory of Suicide

Measurement and control of response bias.

This article proposes that binge eating is motivated by a desire to escape from self-awareness. Binge eaters suffer from high standards and expectations, especially an acute sensitivity to the difficult (perceived) demands of others. When they fall short of these standards, they develop an aversive pattern of high self-awareness, characterized by unflattering views of self and concern over how they are perceived by others. These aversive self-perceptions are accompanied by emotional distress, which often includes anxiety and depression. To escape from this unpleasant state, binge eaters attempt the cognitive response of narrowing attention to the immediate stimulus environment and avoiding broadly meaningful thought. This narrowing of attention disengages normal inhibitions against eating and fosters an uncritical acceptance of irrational beliefs and thoughts. The escape model is capable of integrating much of the available evidence about binge eating.

http://psych415.class.uic.edu/Readings/Heatherton,%20Binge%20&%20escape,%20PsyBull,%201991.pdf

Binge eating as escape from self-awareness.

A randomized clinical trial was conducted to evaluate the effectiveness of a cognitive-behavioral therapy, ie, dialectical behavior therapy, for the treatment of chronically parasuicidal women who met criteria for borderline personality disorder. The treatment lasted 1 year, with assessment every 4 months. The control condition was "treatment as usual" in the community. At most assessment points and during the entire year, the subjects who received dialectical behavior therapy had fewer incidences of parasuicide and less medically severe parasuicides, were more likely to stay in individual therapy, and had fewer inpatient psychiatric days. There were no between-group differences on measures of depression, hopelessness, suicide ideation, or reasons for living although scores on all four measures decreased throughout the year.

https://jamanetwork.com/journals/jamapsychiatry/articlepdf/495579/archpsyc_48_12_003.pdf

Cognitive-Behavioral Treatment of Chronically Parasuicidal Borderline Patients

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.

/pdf/two-year-randomized-controlled-trial-and-follow-up-of-4yuoi4l4pe.pdf

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

University of Washington Catholic University of AmericaStevan Lars Nielsen and John A. ChilesUniversity of WashingtonThe studies presented here describe the development of an instrument to measurea range of beliefs potentially important as reasons for not committing suicide.Sixty-five individuals generated 72 distinct reasons; these were reduced to 48 byfactor analyses performed on two additional samples, and the items were arrangedinto the Reasons for Living Inventory (RFL), which requires a rating of howimportant each reason would be for living if suicide was contemplated. In ad-dition, factor analyses indicated six primary reasons for living: Survival and Cop-ing Beliefs, Responsibility to Family, Child-Related Concerns, Fear of Suicide,Fear of Social Disapproval, and Moral Objections. The RFL was then given totwo additional samples, 197 Seattle shoppers and 175 psychiatric inpatients. Bothsamples were divided into several suicidal (ideators and parasuicides) and non-suicidal groups. Separate multivariate analyses of variance indicated that the RFLdifferentiated suicidal from nonsuicidal individuals in both samples. In the shop-ping-center sample, the Fear of Suicide scale further differentiated between pre-vious ideators and previous parasuicides. In the clinical sample, the Child-RelatedConcerns scales differentiated between current suicide ideators and current para-suicides. In both samples, the Survival and Coping, the Responsibility to Family,and the Child-Related Concerns scales were most useful in differentiating thegroups. Results were maintained when the effect of recent stress was held constant.The frequency of suicidal behavior sug- point in their lifetime; between 53% and 67%gests that it is a phenomenon that cannot be report seriously considering it.ignored. Over 25,000 individuals a year kill The majority of research in the field ofthemselves in the United States (U.S. Vital suicidology, to date, has been directed atStatistics, 1973, 1975), and it is estimated identifying characteristics of suicidal personsthat two to eight times this number, or from to enhance prediction of suicidal behavior50,000 to 200,000 persons a year parasuicide (Beck, Resnick, & Lettieri, 1974; Kreitman,(i.e., intentionally self-injure, behavior usu- 1977;Neuringer, 1974). With few exceptionsally labeled in the U.S. as attempted suicide; (e.g., Goodstein, 1982) almost all of this workBerman, 1975). Linehan and colleagues (Li- has focused on identifying maladaptive at-nehan & Laffaw, in press; Linehan & Nielsen, tributes of suicidal persons. Little attention1981; Linehan, Note 1) found that from 10% has been given the question of whether sui-to 16% of an adult, general population in cidal persons lack important adaptive char-Seattle report attempting suicide at some acteristics present among nonsuicidal indi-viduals, and, if so, what these characteristicsThis research was supported by National Institute might be.Grant MH34486. Focusing on adaptive, life-maintaining

Reasons for Staying Alive When You Are Thinking of Killing Yourself: The Reasons for Living Inventory

Reasons for staying alive when you are thinking of killing yourself

Many branches of medicine rely heavily on lab tests to monitor client treatment response and use this information to modify their treatment. By contrast, those who offer psychological interventions seldom rely on formal assessments (lab tests) to monitor their clients' response to treatment. Data are presented that demonstrate that clinicians rarely accurately predict who will not benefit from psychotherapy. This finding is contrasted with the use of a questionnaire (lab test data) and decision rules on the basis of a client's expected progress. Results have indicated that formal methods of monitoring were able to identify 100% of the patients whose condition had deteriorated at termination, and 85% by the time they had attended three treatment sessions. Practitioners are encouraged to consider formal methods of identifying the deteriorating client.

A lab test and algorithms for identifying clients at risk for treatment failure.

Empirically supported psychotherapies, treatment guidelines, best practices, and treatment manuals are methods proposed to enhance treatment outcomes in routine practice. Patient-focused research systems provide a compatible and contrasting methodology. Such systems monitor and feed back information about a patient's progress during psychotherapy for the purpose of enhancing outcomes. A meta-analytic review of three large-scale studies is summarized and suggests that formally monitoring patient progress has a significant impact on clients who show a poor initial response to treatment. Implementation of this feedback system reduced deterioration by 4% to 8% and increased positive outcomes. Our interpretation of these results suggests that it may be time for clinicians routinely and formally to monitor patient treatment response.

Is It Time for Clinicians to Routinely Track Patient Outcome? A Meta‐Analysis

Patient-focused research attempts to provide information that answers the question: Is this treatment benefiting this patient? Although several systems have been developed to monitor and provide feedback about a patient's response to psychotherapy, few if any have been tested empirically. The current study divided 609 patients into four groups (two experimental and two control) to determine if feedback regarding patient progress, when provided to a therapist, affected patient outcome and number of sessions attended. Results showed that feedback increased the duration of treatment and improved outcome relative to patients in the control condition who were predicted to be treatment failures. Twice as many patients in the feedback group achieved clinically significant or reliable change and one-third as many were classified as deteriorated by the time treatment ended. For those patients who were predicted to have a positive response to treatment, feedback to therapists resulted in a reduction in the number of treatment sessions without reducing positive outcomes.

Stevan Lars Nielsen

Papers

Reasons for Staying Alive When You Are Thinking of Killing Yourself: The Reasons for Living Inventory

Reasons for staying alive when you are thinking of killing yourself

A lab test and algorithms for identifying clients at risk for treatment failure.

Is It Time for Clinicians to Routinely Track Patient Outcome? A Meta‐Analysis

The Effects of Providing Therapists With Feedback on Patient Progress During Psychotherapy: Are Outcomes Enhanced?