MODELS OF SUICIDE
Suicidal behaviour had been traditionally understood within the biomedicalillness model. However, this model is limited as the focus is on the identification of underlying pathology despite the fact that pathology alone is not a sufficient explanation for suicidal behaviour (Sheehy & O’Connor 2002).
Shneidman’s cubic model (1972,1987,1993)
Shneidman was an early pioneer of the psychological understanding and treatment of suicidality. In 1968, he founded the American Association of Suicidology and the principal US journal for suicide studies, Suicide and Life Threatening Behavior. Until Shneidman, suicide was seen as the consequence of mental illness or derangement. In Shneidman’s “cubic model” of suicidal behaviour, “psychache” is the primary dimension when individuals are considering suicide. (The two other dimensions are stress and perturbation.) Psychache is defined as general psychological pain reaching intolerable intensity. It encompasses shame, guilt, humiliation, loneliness, fear, angst and dread. For Shneidman, suicide is best understood as the complete stopping of one’s consciousness and unendurable pain. It is seen by the suffering person as the solution to life’s painful and pressing problems. A suicide-focused intervention then attempts to help the suicidal person find other ways to reduce or manage their pain (Figure 1.1).
Figure 1.1 Shneidman's cubic model of suicide (1987).
CBT posits that most suicide attempts function as an escape or an avoidance of intense psychological emotional pain. This involves a process known as negative reinforcement via the reduction of aversive, internal emotional states (Linehan 1993; Joiner 2005). Positive reinforcement of suicidal behaviour, for example from being rescued and concern from others, can apply but in a minority of cases. Beck (1996) introduced the concept of the suicide mode which Rudd (2000) elaborated on. CBT addresses four elements to the suicide mode:
- 1. Cognition (suicidal belief system), e.g. perceived burdensomeness;
- 2. Emotion (depression, guilt, anxiety, shame);
- 3. Physiology (e.g. insomnia, chronic physical pain);
- 4. Behaviour (maladaptive coping strategies including substance use, social withdrawal and self-harm).
Cry of pain or entrapment model
Mark Williams is Professor of Clinical Psychology at the University of Oxford, Director of the Oxford Mindfulness Centre and works with the Oxford Centre of Suicide Research investigating psychological mechanisms in suicidal behaviour in recurrent depression. Williams (W illiams 1997; W illiams 6c Pollock 2000,2001) broadened Baumeister’s (1990) theory of Suicide as Escape from Self. The cry of pain (CoP) model conceptualises suicidal behaviour as the response (or cry) to a situation that has three components: defeat, no escape and no rescue. It is founded on an evolutionary approach to understanding suicidal behaviour in depression.
The CoP model has introduced a number of important concepts. “Arrested flight” (Gilbert 8c Allan 1998) is a phenomenon which describes a situation where an animal, such as a bird, is defeated but flight is blocked and cannot escape. It has been suggested that suicidal ideation arises from the feeling of entrapment, but it is when the individual fails to find alternative ways to solve their problems that this can be exacerbated into suicidal behaviour (Williams et al 2005). The CoP model has a strong empirical basis demonstrating the importance of defeat and entrapment affecting mood and behaviour. It has incorporated psychobiological and evolutionary factors and has established the importance for the perceptions of defeat and entrapment in mediating stress and depression. Recognising that not all depressed patients are suicidal, it implicates the role of entrapment and hopelessness in exacerbating feelings of defeat and depression in the development of suicidality. In some studies, hopelessness has been a better predictor of suicide than depression itself (Wetzel 1976; Beck et al 1989). The model has led to the development of treatment interventions. For example, based on the observation that hopelessness is related to an inability to generate possible positive future events (MacLeod et al 1993), Williams and Pollock (2001) suggest that the therapy could encourage clients to practise generating positive events with a focus on the near future, which may engender a sense of possible change.
However, this model has been widely criticised for lack of clarity. Johnson et al 2008 argue the concepts are unclear in their theoretical basis because:
- • They are not clear in their usage, definition and measurement.
- • The concepts are unclear in that being derived from animal behaviour they do not map clearly on to human cognition. This is not to say they are not useful, but they are not coterminous.
- • Most tellingly, the one study that tested the CoP model did not find that the concepts were significant and independent predictors of suicide behaviour.
- • The translation of concepts from the model into treatment strategies has not been particularly forthcoming or productive
Joiner’s interpersonal-psychological theory
Figure 1.2 The interpersonal psychological theory of suicidal behaviour (Adapted from Joiner (2005)).
According to Joiner’s model (Joiner, 2005), the simultaneous presence of thwarted belongingness and perceived burdensomeness produces the desire for suicide. Whilst the desire for suicide is necessary, it alone will not result in suicide. Rather, Joiner asserts that one must also have acquired the capability to overcome one’s natural fear of death. The desire to end one’s life from hopelessness, perceived burdensomeness, or low belongingness plus the ability to do so leads to suicidal intent. The model predicts that suicidality is reduced by these protective factors which act as buffers:
- • connectedness;
- • perceived social support;
- • engagement with children; family and services.
Joiner’s is widely recognised as probably the most comprehensive model for understanding and predicting suicide in an individual, but it has limited utility in terms of treatment.
The fluid vulnerability theory (FVT)
Rudd (2006) proposes the fluid vulnerability theory (FVT) in which suicide risk is conceptualised as an interaction of baseline risk (e.g. genetic predisposition and trauma history) with acute risk (e.g. recent loss of a job or end of a relationship). Upon resolution of an acute suicidal episode, individuals return to their baseline level. This can remain high in chronically suicidal individuals and clinicians need to be alert to that. The baseline risk for patients with a history of multiple suicide attempts is higher and endures for a longer period of time than those with a minimal history or no history of previous suicide attempts.
The integrated motivational-volitional model (IMV)
O’Connor and Kirtley (2018) propose that defeat and entrapment drive the emergence of suicidal ideation and that a group of factors, entitled volitional moderators (VTVls), govern the transition from suicidal ideation to suicidal behaviour. According to the integrated motivational-volitional model, VMs include:
- • access to the means of suicide;
- • exposure to suicidal behaviour;
- • capability for suicide (fearlessness about death and increased physical pain tolerance);
- • planning;
- • impulsivity;
- • mental imagery;
- • past suicidal behaviour.