Motivation and emotion/Book/2013/Suicidality and motivation

Overview
"The secret of health for both mind and body is not to mourn for the past, not to worry about the future, nor to anticipate troubles, but to live in the present moment wisely and earnestly. (Buddha)"

Suicide including the act of and also suicidal ideation is a large part of today’s research and also an increasingly important issue. Whilst there is numerous assistance in helping those in need, only a small percentage of people seek help or understand why they may be feeling this way. In this chapter the underlying motives involved in suicidality will be explored including psychological theories and motivational factors such as interpersonal theory of suicide, as well as what can be done if feelings of suicidality occurs. By the end of this chapter you should have an understanding of; And,
 * Psychological theories involved in suicidality
 * Main methods of assessment
 * Motivational factors
 * How to overcome suicidality

What is suicidality
Constantly evolving, suicidality can be described as any self-initiated behaviour relating to suicide (Silverman, Berman, Sandddal, O’Carroll & Joiner, 2007). These behaviours can include but are not strictly limited to ideations or suicidal thoughts, communications and behaviours (Silverman et.al, 2007). It is important to note that these behaviours may vary in regards to occurrence (i.e. frequency) of intent and also the frequency of which self-inflicted physical injury occurs (Van Orden et.al, 2010). In addition to this, self-inflicted harm does not always reflect the intention to die (Silverman et.al. 2007). To truly explore the notion of suicidality, you must look at other definitions within this concept. Suicide attempts can be characterised as the self-initiated act of potentially fatal behaviour with the intention to die however these result in non-fatal outcomes (Shneidman, 1985). Alternatively suicide is defined as suicide attempts that result in fatal outcomes (Shneidman, 1985). Building upon this, suicidality refers to not only lethal and non lethal suicide attempts (Van Orden et.al, 2007). Van Orden et.al (2007) refers to non-lethal suicide as attempts of suicide with non-fatal outcomes and lethal suicide as fatal outcomes.

Signs and symptoms linked to suicidality
There are different types of behaviour or signs that is consistent with suicidal related behaviour before the attempt of suicide. The following table explores some of them. It should be noted however, that these symptoms vary and are situational (Kitchener, Jorm & Kelly, 2011).

Table 1: Signs and symptoms of suicidality

Case Study Example

Alice is a 24 year old woman who has been suffering from major depressive disorder and general anxiety disorder. Alice not wanting to burden anyone with how she feels has become closed off from her friends, rarely leaving her room. Her housemates complain that they never see her and that they never see her eat. When they do, Alice is often drinking and they see faint red marks on her wrist. To cope with feelings of hopeless Alice has started to self-harm. Furthermore when speaking to Alice, she finds it difficult to concentrate and has trouble sleeping, often relying on an hour of sleep to get by. In addition to this Alice has begun thinking that she is a burden to everyone and feels as though she has no control over her life.

As in the case study, several behaviours indicating suicidal ideation and behaviour can be identified, from the information presented earlier, can you list the behaviours that Alice is experiencing that may indicate sucidality?

Durkheim theory of suicide
Durkheim (1897) explored how social integrations correlations with suicidality, proposing that a lack of social integration will lead to the increase risk of suicide due to a lack of social connection that goes beyond the needs for themselves(Pope, 1975). In studying suicide, Durkheim (1987) created three archetypes of suicide(Pope, 1975);
 * 1) Altruistic Suicide – Refers to the type of suicidal person who identifies with a social groups’ ideals, beliefs and interests (Pope, 1975). This type of suicide is willing to sacrifice their own needs to serve the needs of the groups (Pope, 1975). In regard to suicide, this archetype will become unhappy and therefore commit suicide due to group expectations not being filled (Jones, 1986). An example of this can be seen with martyrs.
 * 2) Egoistic Suicide – Jones (1986) refers to the egoistic suicide as a person who does not form strong social relationships. Often self-centred and detached, these people are likely to attempt suicide due to lack of commitment to social groups thus actions will not affect anyone but the individual (Jones, 1986).
 * 3) Anomic Suicide – Defined as being in the state of normlessness, an individual is lost (Durkheim, 1897). Referring to a state of limbo and cognitive disorientation, a person experiences lost sense of belonging (Jones, 1986). Occurring during extreme changes in social groups, a person develops a state of unknown which results in the increase risk of suicide (Jones, 1986).
 * As with all theories it should be noted that limitations can be found. Whilst it developed and explored the social aspect of suicide, Durkheim (1897) theory of suicide lacks coverage of individual factors indicating a large gap in knowledge (Jones, 1986).

The inner voice theory
Explored by Firestone (1986), the theory of the inner voice is used to understand why suicide may occur. Described as the notion of intrusive, negative thoughts about an individual own self, and sometimes that of others experience (Firestone 1986). Usually a hostile attitude towards themselves, the inner voice, according to Firestone (1986) triggers a self-destructive process when left unchallenged, suicide is the concluding thought. {| cellpadding="10" cellspacing="5" style="float: right; width: 40%; background-color: Silver; margin-left: auto; margin-right: auto"
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Imagine everyday a series of negative thoughts constantly berating you, entering your mind. Making a mistake causes thoughts such as “You are a failure! Can you do anything right?” Before an important speech or presentation, “Everyone is going to laugh at you. You are going to stuff up.” These negative thoughts are constantly being introduced into the mind of a person contemplating suicide

Relating the inner voice back to suicide, Firestone (1986) theorises that long exposure of the inner voice when left unchallenged creates a self-destructive process with the ultimate goal of suicide.

Interpersonal theory of suicide
Interpersonal Theory of Suicide briefly states that suicidal desires is caused by the simultaneous presence of two interpersonal constructs, that being thwarted belongingness and perceived burdensomeness (Van Orden, Witte, Cukrowicz, Braithwaite, Selby & Joiner, 2008). Also this theory explores a persons’ capability to transition from suicidal ideation to the act of suicide (Van Orden et.al, 2008). Proposed by Joiner (2005), interpersonal theory of suicide looks to explore and give meaning as to why suicidality and in turn suicide occurs. This modern theory contains three aspects explaining the causation of suicidal behaviour (Van Orden et.al, 2010). Within the theoretical framework the first two variables, thwarted belongingness and perceived burdensomeness, are attributed to the desire for suicide whilst the third aspect, acquired capability, explores the transition from desire into action (Joiner, 2005). Through the exploration of each aspect, meaning and understanding can be formed into understanding the motives behind suicidality (Van Orden et.al, 2010).

Thwarted belongingness
As described in the theoretical framework model of interpersonal theory of suicide, thwarted belongingness refers to the experience whereby a person becomes alienated from others and feels like they do not simply belong (Joiner, Hollar & Van Orden, 2006). This can include any social construct such as friendship groups and family. Joiner (2005) suggests that social isolation or belonging has a strong correlation with suicidality and therefore when this occurs an individual is more likely to develop suicidal ideations. This notion is further supported by Joiner, Hollar and Van Orden (2006) who found that in times of celebrations, tragedy, hardships or any other event that triggers individuals to come together, the rate of death through suicide has decreased thus it is safe to infer that with proper social networks and a strong sense of belonging, the likelihood of suicidality would be reduced as the inherent social need is maintained. It should also be noted that degrees of thwarted belongingness is not stable, varying overtime (Van Orden, et.al, 2010).
 * Expanding on previous research, thwarted belongingness is described as a multidimensional construct (Baumeister & Leary, 1995). This essentially means that belonging is comprised of two aspects; frequently pleasant and positive interactions and interactions needed to be long term and stable (Van Orden et.al, 2010). Without these two aspects belonging cannot occur and feelings of loneliness and social alienation will begin to rise (Van Orden et.al, 2010). These aspects can be characterised with feeling or stating, “I feel alone, I feel disconnected and, I feel as though there is no one I can turn to.”

Perceived burdensomeness
Similar to the previous aspect, perceived burdensomeness involves intrusive thoughts that are often distorted from reality (Van Orden et al., 2010). According to Van Orden et.al (2010) perceived burdensomeness revolves around family and friendship systems, driven by the distorted thought that themselves or the problems they face are or will be a burden to their social constructs such as family. Furthermore intrusive thoughts manifest leading to the individual not only thinking that they are not ‘good enough’ but also believe that those around them would be happier and ‘at ease’ if they were not around and just disappeared (Joiner, Perttit, Walker, Voelz, Cruz, Rudd, et al., 2002). This notion is highlighted in DeCatanzaro (1995) study exploring the correlation of burden and suicidal ideation. DeCatanzaro found that feelings of burdensomeness in family situations resulting in a higher rate of suicidal ideation and suicide. This study also suggested that family conflict and negative events associated with family and friends lead to a higher perceived burdensomeness (DeCatanzaro, 1995). This study expands on Woznica and Shapiro (1990) own research whom found similar results.
 * Through this perceived burdensomeness can therefore be defined as an aspect of interpersonal theory of suicide, focusing on the notion that developing from negative events from social constructs, perceived burdensomeness is created resulting in intrusive and distorted view (Van Orden et al., 2010). This view involves the idea that they are not good enough for their friends and family but also the belief that they burden their family and friends so much to the point that they will be happier without their presence in their lives (Van Orden et al., 2010).

Acquired capability of suicide
The third aspect surrounding interpersonal theory of suicide involves the notion that a third element besides perceived burdensomeness and thwarted belongingness must be present in order for a suicide attempt to take place (Van Orden et al., 2010). According to Joiner et al., (2002) thwarted belongingness and perceived burdensomeness whilst creates a desire for suicide, combined they are simply not enough to result in a suicide attempt. It is suggested that an acquired capability of suicide must form (Joiner et al., 2002). Van Orden et al. (2010) suggests four things must be present in order to achieve the acquired capability of suicide.
 * 1) Lowered fear of death – A study conducted by Lineham, Goodstein, Nielsen and Chiles (1983), found that fear of death is one of the most frequent reasons cited as to why a person chooses not to enact in the act of suicide. Thus it can be inferred that when there is a lowered fear of death, suicide is more likely to occur
 * 2) Elevated physical pain tolerance – A women ingested toilet bowl cleaner, a product containing hydrochloric acid, and later died after four hours (Holm-Denoma, White, Gordon, Herzog, Frank, Fichter, et al., 2008). Research suggest that a high pain tolerance was needed to commit this act of suicide. From this it can be concluded that to be capable of suicide, a high tolerance of pain must be present. This notion is further supported by Joiner (2005).
 * 3) Habituation and opponent processes – a response is elicited by a stimulus called the primary response (Solomon & Corbit, 1978). This response will be counteracted by a secondary or opponent response that is usually opposite of the former (Solomon & Corbit, 1978). In addition to this the opponent response will gain in strength if stimulus is repeated (Solomon & Corbit, 1978). This notion in regards to suicide suggests that frequent thoughts of suicide and attempts whilst fearful at first will gradually become the opposite such as relief (Van Orden et al., 2010).
 * 4) Painful and provocative experiences – This suggests that painful and provocative events that individuals experience result in a higher risk of committing suicide (Van Orden et al., 2010). Experiences include, combat exposure, previous suicidal attempts, abuse and family displacement (Van Orden et al., 2010).

Prevalence
General Statistics (National Survey of Mental Health and Wellbeing, 2007) Age and Gender (National Survey of Mental Health and Wellbeing, 2007)
 * 13.3% of Australians aged 16-85 years have experienced suicidal ideation,
 * 2.1 million Australians having thought about taking their own life
 * 3.3% have attempted suicide.
 * 2.4% of the total population has reported experiencing suicidality, this essentially works out to over 380,000 people
 * 2.3% or 370,000 has experienced suicidal ideation
 * 0.6% of the Australian population or 91,000 have made plans to commit suicide
 * 0.4% or 65,000 Australians have attempted suicide.

Table 2: The rate of suicidal deaths by percentage and gender

From Table 2 it can be inferred that young adults and middle aged adults are more likely to experience phases of suicidality compared to the rest of the populations such as the elderly. Furthermore from the data, males seem to be more at risk to attempt suicide. However, it should be noted that women are much more likely to experience onsets of suicidality. Men, 1.9% compared to Women, 2.8% (National Survey of Mental Health and Wellbeing, 2007).
 * It should be noted that these statistics are incomplete due to survey being self-report, many individuals may not to admit to sucidality (National Survey of Mental Health and Wellbeing, 2007).

Methods for measuring motivation for suicidality
There are many methods for assessing the motivations behind suicidality, such as, Beck Hopelessness Scale (BHS), Scale for Suicide Ideation (SSI), Modified Scale for Suicidal Ideation(MSSI) and Beck Scale for Suicide Ideation (BSI) (Beck & Steer, 1991). Both MSSI and BSI in particular are effective means in determining not only the motivations related to suicidality but also indicating desire to commit suicide (Beck, Steer, 1991).

Beck Scale for Suicide Ideation
The BSI is a tool used by health professionals in determining suicidal ideation, such as an individual’s desire for suicide (Beck, Steer, 1991). Highly reliable and highly applicable, this scale is a 19 item measure of assessment that explores the motives such as hopelessness (Beck, Steer, 1991).

Modified Scale for Suicidal Ideation
Built upon the SSI, the MSSI is an 18 item scale which like the BSI explores an individual’s state, risk of suicide, level of suicide ideation and motivations behind desire (Miller, Norman, Bishop & Dow, 1986). Generally accepted, this scale focuses more towards young adults (Miller et al., 1986).

Motivational Factors
According to Van Orden et al. (2010) as well as the theories previously mention there are numerous motivational factors which contribute to the increased risk of suicidality. It is interesting to note that one factor does not simply cause a person to contemplate and act upon suicide but rather a combination of various factors (Van Orden et al., 2010).

Age
As previously seen through prevalence, age plays a critical factor in the motivation of suicidality (National Survey of Mental Health and Wellbeing, 2007) (Refer to Table 2). Between the ages of 20-29, suicide rates are at their highest, after which interestingly the rate of suicide in both males and females decline (National Survey of Mental Health and Wellbeing, 2007).

Mental State
As concluded by research the mental state of a person can greatly attribute to the increased likelihood of suicidality (Van Orden et al., 2010). Depression is one main example of this notion (Van Orden et al., 2010). Suicide is often considered an outcome of untreated depression therefore it is safe to infer that long term suffering will increase risk of suicidality due to shared similar states of mind. (Fairweather-Schmidt, Anstey & Mackinnon (2009). A study conducted by Fairweather-Schmidt, Anstey and Mackinnon (2009) explored the correlation between depression and suicide. The study found that there is an underlying factorial relationship between the two (Fairweather-Schmidt, Anstey & Mackinnon, 2009).

Social Isolation
Argued by Dervic, Brent and Oquendo (2008), social isolation is one of the lead factors in the motivation of suicidality. Withdrawal from socialisation is one of the factors addressed in the interpersonal theory of suicide which states that social isolation contributes to the desire to contemplate suicide (Van Orden et al., 2010). It should also be noted that studies have shown strong social structures result in decreased suicidality therefore, it can be inferred that a clear link exists between social isolation and suicidal behaviour (Van Orden et al., 2010).

Environment
Environmental factors are an integral part in increasing the risk of suicidality (Van Orden et al., 2010). Environmental factors such as family problems and in particular recent unemployment are thought to achieve this notion through the creation of stress (Van Orden et al., 2010). According to Van Orden et al. (2010) stress is thought to increase the desire for attempting suicide. Previous research has shown that a common factor in suicide is unemployment however, Lester and Yang (2003) found that significant association has yet been found thus suggesting stress induced from unemployment facilitates the desire of suicide.

Overcoming suicidality
The previous video introduces what overcoming suicidality involves. The first and most important step in overcoming suicidality and fighting off negative thoughts of contemplating suicide, is to become more open, to begin talking to someone you trust and then followed by a trusted health professional. Kitchener, Jorm and Kelly (2011) suggest that talking about your problems takes away feelings of hopelessness.

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If you know someone who is feeling this way, let them know that you are there for them. Sit down with them, let them know you care and can see what they are going through then listen. Let that person open up and tell you how they are feeling. Offer support and guide them to seek help.

Treatment
There are numerous treatments available to decrease the desire for suicide and thus the onset of suicidality. Cognitive behavioural therapy (CBT) is thought to be an effective means in the treatment of suicidality (Rudd, 2012).

Cognitive behavioural therapy
Cognitive behavioural therapy is a type of psychotherapy that is characterised by its distinguishable features (Rudd, 2012). Describable as a short term, structured therapy, CBT focuses on either emotional, behavioural and/or psychiatric issues (Rudd, 2012). CBT identifies problem thoughts and behaviours and through a cognitive approach looks to change it (Rudd, 2012). In regards to suicidality, Rudd (2012) suggests CBT is an effective form of treatment as it targets the reasoning and cause of the behaviour.

Conclusion
The theory of interpersonal suicide is the primary theory surrounding the motivation of suicidality. Exploring the notion that three aspects are needed for lethal suicide to take place, suggesting that, thwarted belongingness, perceived burdensomeness and acquired capability to suicide are integral in the motivation to suicide. Other motivational factors are involved such as age, environmental factors, mental state and especially that of social isolation. Suicidality is a major mental health problem affecting a lot of the population and it's integral that an understanding must be formed.



Test your knowledge
{Suicidality is...? - Thoughts of suicide - Attempts and act of suicide - Self-initiated behaviour + All of the above
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{Which of these is NOT a sign and symptom of suicidality? + Excessive buying of material items - Social isolation - Giving away of possessions - Mood swings
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{True or False: Thwarted belongingness, acquired capability to suicide and perceived burdensomeness are all aspects of the interpersonal theory of suicide. + TRUE - FALSE
 * type=""}

{True or False: Women are more likely to attempt lethal suicide than that of men - TRUE + FALSE
 * type=""}