The Clinical Angle - Silva & Van Orden
The Interpersonal Theory of Suicide
Caroline Silva, Ph.D., University of Rochester Medical Center
Kimberly Van Orden, Ph.D., University of Rochester Medical Center
Suicide affects millions of individuals around the world. In the United States alone, suicide is the 10th leading cause of death, with nearly 43,000 people dying by suicide each year (Kochanek, Murphy, Xu, & Tejada-Vera, 2016). Assessing and treating suicidal behavior can be daunting tasks for clinicians. For this clinical angle segment, we will detail a contemporary theory of suicidal behavior that provides a framework for identifying pernicious risk factors and its treatment implications.
The interpersonal theory of suicide (Joiner, 2005; Van Orden et al., 2010) proposes that people die by suicide because they have both the desire and capability to do so. The theory posits that suicidal desire arises as a result of the joint presence of two psychological states - thwarted belongingness and perceived burdensomeness. Thwarted belongingness is posited to be characterized by loneliness and lack of reciprocal care. Perceived burdensomeness is posited to be characterized by self-hatred and feeling like a liability to others. Either of these states is considered a proximal and sufficient cause of passive suicidal ideation. When these two states are experienced simultaneously and perceived as unchanging, however, they are proposed to be proximal and sufficient causes of active suicidal desire.
Importantly, the theory states that suicidal desire is necessary, but not sufficient for death by suicide. The theory specifies that individuals must also have the capability to engage in suicidal behavior, known as the acquired capability for suicide. Acquired capability is conceptualized as both cognitive (lowered fear of death) and physical (elevated physical pain tolerance) in nature. The acquired capability for suicide is thought to develop with repeated exposure to painful and provocative stimuli. According to the theory, suicidal desire escalates to suicidal intent when fearlessness about death is also present. The theory specifies, however, that intent will only lead to serious suicidal behavior (i.e., lethal or near-lethal suicide attempts) in the presence of elevated physical pain tolerance. Thus, the theory indicates that the joint presence of three constructs – thwarted belongingness, perceived burdensomeness, and acquired capability – is necessary for death by suicide.
Consistent with the theory, suicidal ideation has been associated with perceived burdensomeness (e.g., Joiner et al., 2002; Van Orden, Lynam, Hollar, & Joiner, 2006), thwarted belongingness (e.g., Conner, Britton, Sworts, & Joiner, 2007), and their interaction (Joiner et al., 2009; Van Orden, Witte, Gordon, Bender, & Joiner, 2008) even when controlling for other robust predictors of suicidality like depression (Joiner et al., 2009; Van Orden et al., 2008). Perceived burdensomeness and thwarted belongingness also predicted suicidal ideation (i.e., 1 month later) among an undergraduate sample (Van Orden, Cukrowicz, Witte, & Joiner, 2012). The joint presence of thwarted belongingness, perceived burdensomeness, and acquired capability has been associated with suicidal behavior as well (e.g., Joiner et al., 2009).
The theory holds important implications for clinical work with suicidal patients (Chu et al., 2015; Joiner, Van Orden, Witte, & Rudd, 2009; Stellrecht et al., 2006). The theory constructs can be assessed when determining suicide risk and identifying treatment targets. Information about prior suicide attempts, nonsuicidal self-injury, and other painful and provocative experiences can inform clinicians about the presence of elevated acquired capability for suicide. Although acquired capability is considered relatively static (i.e., not a directly modifiable treatment target), its presence can inform the use of safety planning or means restriction, particularly for times of crisis. These actions can include firearm safety and other ways of restricting access to lethal means, which can be conceptualized as blocking acquired capability. Patient reports of a lack of meaningful social connections, feeling like a liability to others, and hopelessness about these things improving, should also raise clinician concern -- particularly if a patient also endorses elevated tolerance to pain or fearlessness about injury and death. Clinicians can inquire further about resolved plans about suicide and/or preparations for suicide in this case to determine if an individual is at imminent risk.
Because thwarted belongingness and perceived burdensomeness both involve maladaptive cognitions or behaviors related to one’s importance and integration with others, these conditions are thought to be dynamic and modifiable (i.e., potential treatment targets). Thus, perceptions of burdensomeness and thwarted belongingness may be responsive to cognitive behavioral techniques, such as cognitive restructuring and behavioral activation. For example, challenging perceived burdensomeness can involve generating evidence that the patient’s death is not worth more than their life. Encouraging patients to engage in social activities may also provide evidence to challenge these thoughts by increasing contribution to others (e.g., volunteering) or connection with others.
In sum, the interpersonal theory of suicide identifies three risk factors for suicide: thwarted belongingness, perceived burdensomeness, and acquired capability. Suicide risk assessments and interventions can be tailored to address these risk factors and prevent death by suicide.
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Conner, K. R., Britton, P. C., Sworts, L. M., & Joiner, T. E. (2007). Suicide attempts among individuals with opiate dependence: The critical role of belonging. Addictive Behaviors, 32(7), 1395-1404.
Joiner, T. E. (2005). Why people die by suicide. Cambridge, MA: Harvard University.
Joiner, T. E., Pettit, J. W., Walker, R. L., Voelz, Z. R., Cruz, J., Rudd, M. D., & Lester, D. (2002). Perceived burdensomeness and suicidality: Two studies on the suicide notes of those attempting and those completing suicide. Journal of Social and Clinical Psychology, 21(5), 531-545.
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Joiner, T. E., Van Orden, K. A., Witte, T. K., Selby, E. A., Ribeiro, J. D., Lewis, R., & Rudd, M. D. (2009). Main predictions of the interpersonal–psychological theory of suicidal behavior: Empirical tests in two samples of young adults. Journal of Abnormal Psychology, 118(3), 634-646.
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