Am I in danger of suicide? — Joiner’s Theory

There are very important things this article discusses which I can absolutely relate to right now: The feeling of thwarted belongingness, perceived burdensomeness and the desire to just end it all (see Dead Man Walking posted on this blog). What a very educational and interesting read.

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Joiner’s interpersonal-psychological theory of suicidal behavior

M.Anestis Photoby Michael D. Anestis, M.S.

There are few, if any, more troubling phenomena in the world than suicide.  Recent data suggests that suicide is the 11th leading cause of death overall in the United States, 8th for males and 16th for females (American Association of Suicidology, 2005).  Each year, approximately 30,000 individuals die by suicide in the United States alone, which computes to an approximate total of 80 per day and one every 18 minutes.  For every completion, there are approximately 25 attempts, meaning there are approximately 750,000 suicide attempts annually in the United States (American Association of Suicidology, 2005).  This heart-breaking phenomenon reflects a significant amount of suffering among those who complete suicide and leaves in its wake an unfathomable number of mourners.

Given the magnitude of the situation, the need for a theory capable of providing a framework within which to understand suicide and to develop systematic interventions would be impossible to overstate. In 2005, Thomas Joiner of Florida State University put forth such a theory, the interpersonal-psychological theory of suicidal behavior.  The theory states that, in order to die by suicide, an individual must develop high levels of three specific variables: a sense of thwarted belongingness, a perception of functioning as a burden on others, and the acquired capability for suicide.  The first two variables, thwarted belongingness and perceived burdensomeness, comprise the desire for suicide.

Evidence indicates that, when individuals die by suicide, they often feel disconnected from others.  This feeling can reflect a sense on the part of the individuals that nobody truly cares about them or, alternatively, it can reflect a sense that, while others might care, nobody can relate to them and understand their situation.  Both sensations leave individuals feeling intolerably isolated.  In reality, individuals who die by suicide rarely, if ever, truly lack others who care about them, but the dysfunctional automatic thoughts that are characteristic of mental illness skew the individuals’ perceptions of the world around them.  The second description – the sense on the part of some individuals that, while others care, they can not relate to their experience – is a potential partial explanation for suicidality in returning veterans who re-enter civilian life after the experience of war.  In such cases, individuals can feel estranged from others who did not experience the same overwhelming events, regardless of how close they had been prior to its occurrence.

Perceived burdensomeness, like thwarted belongingness, is generally driven by distorted automatic thoughts.  Individuals experiencing elevations in this variable have the sense that they are not making any worthwhile contributions to the world around them.  They not only feel as though they are not assets, but in fact believe that they are liabilities and that others’ lives would be improved if they were to disappear.  Again, such beliefs are rarely, if ever, true, but they are nonetheless a common cognitive tendency on the part of individuals after experiencing particular types of events.  Losing a job, missing a promotion, transitioning into retirement, and failing a course are several examples of types of experiences that could prompt a sense of burdensomeness.

Both components of the desire for suicide are suitable targets for therapeutic interventions.  Cognitive behavioral approaches such asbehavioral activation and cognitive restructuring can help such individuals increase the amount of positive experiences they have while diminishing the tendency to view their environment through distorted lenses.  Setting specific, graded goals with clearly defined paths towards accomplishing them can serve to increase an individual’s sense of self-sufficiency.  An empathic and scientifically-minded therapist can help to make individuals feel as though somebody is listening and there are reasons to seek a better outcome.

A somewhat more difficult point for intervention and a less familiar concept to the world at large is Joiner’s (2005) concept of the acquired capability for suicide.  The interpersonal-psychological theory of suicidal behavior argues that, in order to enact lethal self-harm, an individual must habituate to physical pain and the fear of death.  Self-preservation is our natural instinct and this instinct is extremely strong.  In order to overcome this, an individual must become accustomed to pain and fear and be able to tolerate them in significantly higher than average doses.  This process of habituation occurs through repeated exposure to painful and provocative events.

Just as a loud, unexpected noise is frightening when first heard, but becomes less noticeable when it occurs repeatedly, physical pain becomes less pronounced over time when our body becomes accustomed to the experience.  A large collection of empirical studies have provided compelling evidence supporting this point.  For example, Nock and Prinstein (2005) found that individuals who frequently self-injure experience pain analgesia – the absence of pain – during self-injury episodes.  Additionally, a lack of pain during self-injury episodes has been shown to predict an individual’s number of lifetime suicide attempts (Nock, Gordon, Joiner, Lloyd-Richardson, & Prinstein, 2006).  Orbach, Mikulincer, King, Cohen, and Stein (1997) developed a particularly compelling study that expanded further upon this idea.  They found that individuals admitted to an emergency room immediately following a suicide attempt exhibited higher pain threshold (when they first feel pain) and tolerance (when pain becomes too much to bear) than did individuals admitted to that same emergency room following accidental injuries.  Here, not only did the experience of pain appear to impact the manner in which pain was perceived, but the effect was stronger when individuals had intentionally self-inflicted pain.  In another study, Orbach and colleagues (1996) found that individuals with multiple past suicide attempts could tolerate more pain than could individuals with zero or one past suicide attempt.

These findings are all consistent with Joiner’s (2005) idea that individuals must acquire the capability for suicide before a completed attempt is likely to occur.  This explains, in part, why there are so many attempts for every completion – most individuals who attempt have the desire, but not the capability for, suicide.  Repeated attempts, however, contribute to an individual’s acquired capability.  Additionally, experiences that involve witnessing pain and violence, even in the absence of physical pain, are believed to be capable of contributing to the acquired capability, which might explain why physicians in emergency room settings and soldiers who witness injuries but are not hurt themselves are vulnerable to suicidal behavior.

Recently, in addition to the findings mentioned above, a series of studies have been undertaken that have directly measured the acquired capability for suicide using a self-report measure entitled the Acquired Capability for Suicide Scale (Bender, Gordon, & Joiner, 2007).  Van Orden, Witte, Gordon, Bender, and Joiner (2008) found that the number of previously experienced painful and provocative events predicted individuals’ levels of the acquired capability.  Additionally, individuals with higher scores on the measure of the acquired capability demonstrated higher levels of physiological pain tolerance and had a greater number of prior suicide attempts.

So why are theories such as Joiner’s (2005) interpersonal-psychological theory of suicidal behavior so important?  By understanding the underlying mechanisms that leave individual’s vulnerable to suicide, researchers and clinicians can design optimally effective treatment interventions that aim to quickly diminish the symptoms that contribute to risk.  Additionally, understanding the variables that increase risk allows for systematic risk assessments that take the guess work out of determining whether an individual is in imminent danger.  Also, by clarifying the true nature of suicide risk, we can hopefully diminish the pervasive reach of misinformation on this topic.  Suicide, as it turns out, does not need to be a mysterious and poorly understood phenomenon.  It is capable of being understood through research just like any other health concern and the efforts put forth by the researchers mentioned above and countless others contributing to this cause will serve to bring clarity and hope to a behavior that has troubled mankind since its inception.