Understanding Suicide
In Helping Active Military, Veterans & Their Families
Build Resilience in Facing Risk and Adversity
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Prologue
To get a more complete understanding of whom Daniel Somers was have a look at the CNN write up and family pictures of Daniel with his wife Angel and his parents Howard and Jean at:
The goal of this segment of our coverage on working with the military and their families is intended to look more closely as what feeds the desire for suicide and how we can assist the military both active and veterans and their families to work on building their resilience so as to prevent future suicides like Daniel's in the future.
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Introduction
Resilience is a “buzz word” which military members who have been deployed to Iraq and Afghanistan have come to hate and despise. In Yellow Ribbon Events used to promote healthy reintegration of the military, feedback given is that “I have heard all this trash about resilience so much that I need enough of my own resilience not to get angry, outraged and turned off every time someone brings up that term to me.” In working with active duty military, veterans and their families it is imperative that Mental Health Practitioners not over use “buss word” terminology so as to turn off and/or alienate the very people they are trying to serve. It is for this reason the following information is aimed at providing alternatives by which Mental Health Clinicians can encourage, promote, and enhance “Resilience Building” within the services they provide the active duty, veterans and/or their families to better assist their reintegration, coping with the emotional, physical, and behavioral issues resulting for their active service in the Iraq (OIF) and Afghanistan (OEF) conflicts.
The alarming rates of suicide within the military and veteran community is pushing all helpers to explore how effectively they are doing in helping the re-integration efforts. There is a need to take at look at the theory on suicide first posted by Thomas J Joiner Jr in 2005 called Interpersonal Psychological Theory of Suicide to see what contributes to "suicidal" ideation and attempts so that we can develop a program of resilence building which addresses the suicidal risk factors and enables the people being served to have greater hope in life to accept life on life's terms and not give up and turn away from living.
The Rand Corporation in 2011 identified this definition “Resilience is the capacity to adapt successfully in the presence of risk and adversity” (Jensen and Fraser, 2005), which they utilized in their study: Promoting Psychological Resilience in the U.S. Military. The Rand group identified four distinct contributors to factors which build resilience in the military which were: the individuals, their families, their military units and their communities. Individual factors were: positive coping; positive affect; positive thinking; realism; behavioral control; physical fitness and altruism. Family factors were: emotional ties; communication; support; closeness; nurturing and adaptability. Military unit factors were: positive command climate; teamwork and cohesion. Community factors were: belongingness; cohesion; connectedness and collective efficacy.
Joiner's Interpersonal Theory of Suicide identifies three factors which contribute to suicidal ideation and actions: (1) Belongingness is defined as a powerful and fundamentally pervasive motivation.(2) Burdensomeness- involves the perception that one is so ineffective that loved ones are threatened and inconvenienced. This perception involves the mental calculation, ‘My death is worth more than my life to those I care about.” (3) The acquired capability to enact suicide: which is established through previous experience (or practice) with suicidal elements, such as history of facing violence, pain, injury, or past attempts that serve to numb one to the stigma, fear, and potential pain of attempting suicide.
Let's look at Daniel Somer's to see why his letter is so relevent to this discussion. Daniel was in the Iraq War and completed 2 deployments. In 2004-2005, he was assigned to a Tactical Human-Intelligence Team (THT) in Baghdad, Iraq, where he ran more than 400 combat missions as a machine gunner in the turret of a Humvee, interviewed countless Iraqis ranging from concerned citizens to community leaders and government officials, and interrogated dozens of insurgents and terrorist suspects. In 2006-2007, Daniel worked with Joint Special Operations Command (JSOC) through his unit in Mosul where he ran the Northern Iraq Intelligence Center. His official role was as a senior analyst for the Levant (Lebanon, Syria, Jordan, Israel, and part of Turkey). In 2007 he was diagnosed with PTSD, TBI, and Gulf War Syndrome, fibromyalgia and a host of other medical problems He sought treatment through therapy, medication, music and film production
Daniel’s letter shows us the three components of Joiner’s Interpersonal Theory of Suicide and teaches us a lesson about the need for us to change how we work to help our Military, Vets and their families to grow in resilience.
Perceived Burdensomess: "I am a burden."
“The fact is, for as long as I can remember my motivation for getting up every day has been so that you would not have to bury me. As things have continued to get worse, it has become clear that this alone is not a sufficient reason to carry on. The fact is, I am not getting better, I am not going to get better, and I will most certainly deteriorate further as time goes on. From a logical standpoint, it is better to simply end things quickly and let any repercussions from that play out in the short term than to drag things out into the long term.”
“You will perhaps be sad for a time, but over time you will forget and begin to carry on. Far better that than to inflict my growing misery upon you for years and decades to come, dragging you down with me. It is because I love you that I can not do this to you. You will come to see that it is a far better thing as one day after another passes during which you do not have to worry about me or even give me a second thought. You will find that your world is better without me in it.”
Thwarted Belongingness: "I am alone"
“I really have been trying to hang on, for more than a decade now. Each day has been a testament to the extent to which I cared, suffering unspeakable horror as quietly as possible so that you could feel as though I was still here for you. In truth, I was nothing more than a prop, filling space so that my absence would not be noted. In truth, I have already been absent for a long, long time.”
Capability for Suicide: "I am not afraid to die"
“My body has become nothing but a cage, a source of pain and constant problems. The illness I have has caused me pain that not even the strongest medicines could dull, and there is no cure. All day, every day a screaming agony in every nerve ending in my body. It is nothing short of torture. My mind is a wasteland, filled with visions of incredible horror, unceasing depression, and crippling anxiety, even with all of the medications the doctors dare give. Simple things that everyone else takes for granted are nearly impossible for me. I can not laugh or cry. I can barely leave the house. I derive no pleasure from any activity. Everything simply comes down to passing time until I can sleep again. Now, to sleep forever seems to be the most merciful thing.”
“This is what brought me to my actual final mission. Not suicide, but a mercy killing. I know how to kill, and I know how to do it so that there is no pain whatsoever. It was quick, and I did not suffer. And above all, now I am free. I feel no more pain. I have no more nightmares or flashbacks or hallucinations. I am no longer constantly depressed or afraid or worried.
I am free.
I ask that you be happy for me for that. It is perhaps the best break I could have hoped for. Please accept this and be glad for me."
Daniel Somers
There is no question that Daniel Somers' was at the intersection of the three critical suicidal factors and even though he was getting help for himself and even though he loved his wife and his family, he was ready to die to and he did.
This site will cover the research into Joiner's Theory and present a chronological picture of how his theory evolved since 2005. It will also offer an alternative to explain why many folks are willing to die even if they have not had combat experience.
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By 2010, in the developed world, suicide became the leading cause of death for people age 15-49 according to the Institute of Health Metrics and Evaluation, Global Burden of Disease, 2010.
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In 2010 worldwide deaths from suicide outnumbered deaths from war (17,670), natural disasters (196,018), and murder (456,268). The Institute of Health Metrics and Evaluation, Global Burden of disease, 2010
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Thomas Joiner's Interpersonal Theory of Suicide above is based on his belief that people commit suicide:
- Because they want to.
- Because they can.
He explained that “People will die by suicide when they have both the desire to die and the ability to die.” When Joiner broke down “the desire” and “the ability,” he found what he believes is the one true pathway to suicide. It’s a “clearly delineated danger zone,” a set of three overlapping conditions that combine to create a dark alley of the soul.
The conditions are tightly defined, and they overlap rarely enough to explain the relatively rare act of suicide. But what’s alarming is that each condition itself isn’t extreme or unusual, and the combined suicidal state of mind is not unfathomably psychotic
On the contrary, suicide’s Venn diagram is composed of circles we all routinely step in, or near, never realizing we are in the deadly center until it’s too late. Joiner’s conditions of suicide are the conditions of everyday life. This becomes more extreme for those active military and veterans who have been deployed to the wars in Afghanistan and Iraq or are on homebase here in the states being prepared to be deployed eventually.
It is for this reason that we must explore better ways to build resilience in our active and veteran military members and their families.
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Surprisingly in preparing for this presentation I realized that my entire career has been focused on building resilience and helping folks build a sense of “Belonging” while letting go of a sense of “Being a Burden” while simultaneously developing a rational perspective on life so as to let go of the “Capacity to commit Suicide”
When I retired from private practice in 1999 my wife reminded me that I was successful in never having a successful suicide on my watch!
What did I do then that you as mental health professionals can do today to help our military, veterans and their families build their resilience by
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increasing their sense of belonging
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Increasing their feeling needed, wanted & cherished
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wanting to live life to the fullest
What we did in my practice is now what we are encouraging mental health professionals to use when working with active military, veterans and their families. We encourage you to use the SEA's System of Recovery and Tools for Coping Series available on this website.
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SEA's Model of Recovery
The Self-Esteem Seekers Anonymous model of recovery is on www.coping.us
The model is a set of tools which make recovery a workable process for anyone committed to making changes in life so as to grow in self-esteem, build resilience and let go of the three major factors of Joiner’s Interpersonal Theory of Suicide.
The SEA's Model works most effectively in a SEA’s group as describe at http://coping.us/seasmanual/introductiontoseas.html, which is a 12 Step model weekly program where each week the participants explore the TOOLS for COPING in the SEA’S System of Recovery.
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What We Can Do to Build Resilience in Others
In its 2004 report on Resilience, the APA reported that the best way to build resilience is to do the following:
- Make connections
- Avoid seeing crises as insurmountable problems
- Accept that change is a part of living
- Move toward your goals
- Take decisive actions
- Look for opportunities for self-discovery
- Nurture a positive view of yourself
- Keep things in perspective
- Maintain a hopeful outlook
- Take care of yourself
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Chronological of the Evolution of the Interpersonal-Psychology Theory of Suicide as it relates to the increase rate of suicide among the military
Thomas Joiner Jr in 2005 explored the physiological and psychological components of suicide which led to Joiner’s Interpersonal Psychological Theory of Suicide. In his article he and his co-authors concluded that the Neurobiological and Psychological factors converged in the highest risk factors for suicide were (1) dysregulated impulse control and (2) propensity to intense psychological pain (e.g., social isolation, hopelessness).
Joiner, T. E., Brown, J.S. & Wingate, L.R. (2005). The Psychology and Neurobiology of Suicidal Behavior. Annual Review of Psychology; 2005; 56, 287-314. DOI: 10.1146/annurev.psych.56.09110320 Click here to view article
In 2006 the Interpersonal Psychological Theory of attempted and completed suicide a was described as having three components which are necessary, but not sufficient, for an individual to die by suicide: (1) the acquired capability to enact lethal self-injury, (2) a sense that one is a burden on others, and (3) the sense that one does not belong to a valued social group.
Nadia E. Stellrecht, N.E., Gordon, K.H., Van Orden, K., Witte, T.K., Wingate, L.R., Cukrowicz, K.C., Butler, M., Schmidt, N.B. , Fitzpatrick. K. & Joiner T.E. (2006).Clinical Applications of the Interpersonal-Psychological Theory of Attempted and Completed Suicide. Journal of Clinical Psychology 62(2), 211–222. DOI: 10.1002/jclp.20224 Click here to view article
In 2008 another group of researchers testing Joiner’s Theory that lethally suicidal individuals perceive that they are an unbearable burden on their family, friends, and/or society (burdensomeness); their efforts at establishing and maintaining social connections have repeatedly been thwarted or have failed (failed belongingness); and through multiple experiences they have acquired the ability to engage in suicidal behavior. When all three elements are present, suicidal behavior with lethal intent is likely and imminent. This study concluded that acquiring the ability to engage in suicidal behavior may be related to having witnessed, experienced, or engaged in more violence than others, because violence exposure would be one way to habituate—either directly or vicariously—to pain and provocation. It is known that a large percentage OEF/OIF veterans report a history of combat. Habituation to pain and subsequent acquired ability secondary to combat exposure, coupled with a post deployment sense of failed/thwarted belongingness and/or burdensomeness would, according to Joiner’s theory, place veterans at increased risk for suicidal behavior.
Brenner, L.A., Gutierrez, P.M., Cornette, M.M., Betthauser, L.M., Bahraini, N. & Staves, P.J. (2008). A Qualitative Study of Potential Suicide Risk Factors in Returning Combat Veterans. Journal of Mental Health Counseling, 30(3), 211–225. Click here to view article
Joiner and another group of researchers in 2008 found that the interpersonal–psychological theory of suicidal behavior proposes that an individual will not die by suicide unless he or she has both the desire to die by suicide and the ability to do so. The results of all three studies presented in their article were consistent with this view.
Van Orden, K.A., Witte, T.K., Gordon, K.H., Bender, T.J. & Joiner, T.E. (2008). Suicidal Desire and the Capability for Suicide: Tests of the Interpersonal–Psychological Theory of Suicidal Behavior Among Adults. Journal of Consulting and Clinical Psychology, 76(1), 72-83. DOI: 10.1037/0022-006X.76.1.72 Click here to view article
In 2008, Joiner and colleagues pointed out that second leading cause of death among active duty military personnel is suicide which is a significant public health problem. They took each component of Joiner’s theory and studied it to see if Air Force Suicides met the three criteria (1) The acquired capability to enact suicide: which is established through previous experience (or practice) with suicidal elements, such as history of facing violence, pain, injury, or past attempts that serve to numb one to the stigma, fear, and potential pain of attempting suicide. (2) Burdensomeness- involves the perception that one is so ineffective that loved ones are threatened and inconvenienced. This perception involves the mental calculation, ‘My death is worth more than mylife to those I care about.” (3) Belongingness is defined as a powerful and fundamentally pervasive motivation. Those who die by suicide often seem to experience isolation and withdrawal prior to death. This was found to differentiate those in the Air Force who committed suicide from 1996-2006 from a controlled non-suicidal group of Air Force Personnel.
Nademin, E., Jobes, D.A., Pflanz, S. E., Jacoby, A.M., Ghahramanlou-Holloway, M., Campise, R., Joiner, T., Wagner, B.M. & Johnson, L. (2008). An Investigation of Interpersonal-Psychological Variables in Air Force Suicides: A Controlled- Comparison Study. Archives of Suicide Research, 12, 309–326. DOI: 10.1080/13811110802324847 Click here to view article
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In a 2009 study, Joiner and colleagues tested if the three variables of the Interpersonal-Psychology of Suicide—acquired capacity for suicidal behavior, perceived burdensomeness, and low belongingness— interact to predict suicidal behavior and their results supported this prediction.
Joiner, T.E., Van Orden, K.M., Witte, T.K., Selby, E.A. & Rudd, M.D., 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. DOI: 10.1037/a0016500 Click here to view article
In a 2009 commentary talking about suicide prevention programming, Joiner pointed out that learned fearlessness is a fairly stable quality and not very malleable, so is probably not a promising prevention target. In contrast, perceived burdensomeness and failed belonging are more fluid, dynamic, and changeable, and thus represent potential leverage points for suicide prevention programs.
Joiner, T.E. (2009). Commentary: Suicide Prevention in Schools as Viewed Through the Interpersonal-Psychological Theory of Suicidal Behavior. School Psychology Review, 38(2), 244–248. Click here to view article
Riberio & Joiner also in 2009 pointed out that the interpersonal-psychological theory holds that an individual will engage in serious suicidal behavior if he or she has both the desire to die and the capability to act on that desire. They stated that this is a powerful belief in that it underscores the critical difference between suicidal ideation and suicidal behavior—a distinction that many other theories of suicide fail to account for. They went on to point out that this theory not only addresses the question of who wants to die by suicide but speaks to the question of who can die by suicide as well.
Riberio, J.D. & Joiner, T.E. (2009). The Interpersonal-Psychological Theory of Suicidal Behavior: Current Status and Future Directions. Journal of Clinical Psychology, 68(12), 1291-1299. DOI: 10.1002/jclp.20621 Click here to view article
In 2009, Joiner and colleagues used two case studies of Active Duty personnel from the Iraq war to demonstrate the three variables of the Interpersonal-psychological theory and pointed out that veterans of combat in particular need quality interventions which increase their sense of belongingness and reduce their sense of burdensomeness.
Anestis, M.D., Bryan, C.J., Cornette, M.M. & Joiner, T.E. (2009). Understanding Suicidal Behavior in the Military: An Evaluation of Joiner’s Interpersonal-Psychological Theory of Suicidal Behavior in Two Case Studies of Active Duty Post-Deployers. Journal of Mental Health Counseling, 31(1), 60-75. Click here to view article
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In 2010 a research project utilized Joiner’s theoretical framework to compare suicide attempters with ideators and a control group. They found that self-reported fearlessness and pain insensitivity can differentiate suicide attempters and suicide ideators. Their results suggested that one’s self-perception (i.e., cognitions regarding fear and pain tolerance) are more functionally related to suicide attempts than psychophysiological reactivity to suicide-related stimuli.
Smith, P.N., Cukrowicz, K.C., Poindexter, E.K., Hobson, V. & Cohen, L.M. (2010). The Acquired Capability for Suicide: A Comparison of Suicide Attempters, Suicide Ideators, and Non-suicidal controls. Depression and Anxiety, 27, 871–877. Click here to view article
In 2010 researchers looked at which of the three Joiner’s theory variables were most present for veterans of combat experience. They tested to see if the theory’s proposal that “acquired capability” may be particularly influenced by military experience, because combat exposure may cause habituation to fear of painful experiences such as suicide. They used clinical and nonclinical samples of military personnel deployed to Iraq, and their results indicated that a greater range of combat experiences predicts acquired capability above and beyond depression and post-traumatic stress disorder symptoms, previous suicidality, and other common risk factors for suicide.
Bryan, C.J., Cukrowicz, K.C., West, C.L. & Morrow, C.E.(2010).Combat Experience and the Acquired Capability for Suicide. Journal of Clinical Psychology, 66(10), 1044-1058. DOI: 10.1002/jclp.20703 Click here to view article
Van Orden and other colleagues of Thomas Joiner in 2010 detailed how Joiner’s Interpersonal-Psychological Theory of Suicide points out that 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. They also pointed out that 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. They concluded that prevention efforts targeting thwarted belongingness and perceived burdensomeness may be effective. For example, public health campaigns promoting the importance of maintaining social connections and social contributions could impact suicide rates. They strongly support the use of the interpersonal theory to improve clinical care for suicidal patients and as a basis for suicide prevention.
Van Orden, K.A., Witte, T.K., Cukrowicz, K.C. & Joiner, T.E. (2010). The Interpersonal Theory of Suicide. Psychological Review, 117(2), 575-600. DOI: 10.1037/a0018697 Click here to view article
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In 2011, Joiner and colleagues research focused in on events causing “displacement from parents”—such as parental death, abandonment of the adolescent, or divorce—as being a risk factor for adolescent suicide and related to Joiner’s Interpersonal Psychological Theory of Suicide concept of failed belonging. They found in two distinct studies a close relationships of displacement from parents as contributing to failed belonging thus setting up a risk for adolescent suicide.
Timmons, K.A., Selby, E.A., Lewinsohn, P.M. & Joiner, T.J. (2011). Parental Displacement and Adolescent Suicidality:Exploring the Role of Failed Belonging. Journal of Clinical Child & Adolescent Psychology, 40(6), 807–817. DOI: 10.1080/15374416.2011.614584 Click here to view article
In 2012, Joiner and colleagues provided an overview of the literature on nonsuicidal self-injury, its relation to suicidal behavior, and how the interpersonal theory of suicide conceptualizes this relationship.
Joiner, T.E., Ribeiro, J.D. & Silva, C. (2012). Nonsuicidal Self-Injury, Suicidal Behavior, and Their Co-occurrence as Viewed Through the Lens of the Interpersonal Theory of Suicide. Current Directions in Psychological Science, 21, 342-347. Click here to view article
Joiner and colleagues in 2012 researched the properties of the Interpersonal Needs Questionnaire (INQ) which was based on Thomas Joiner’s interpersonal theory of suicide and was developed to measure thwarted belongingness and perceived burdensomeness which according to the theory are both proximal causes of desire for suicide.
Van Orden, K.A., Cukrowicz, K.C., Witte, T.K. & Joiner, T.E. (2012). Thwarted Belongingness and Perceived Burdensomeness: Construct Validity and Psychometric Properties of the Interpersonal Needs Questionnaire. Psychological Assessment, 24(1), 197–215. DOI: 10.1037/a0025358 Click here to view article
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A 2013 study found that the link between combat exposure and suicide risk might not be as direct or robust as it is often believed to be, given that the largest number of military suicides were by individuals who had never been deployed. However this finding then supports the theory of adverse childhood or young adolescent life experiences prior to entering the military were equal contributors to suicidal risk among the military.
Bryan, C.J., Hernandez, A.M. Allison, S. & Clemans, T. (2013). Combat Exposure and Suicide Risk in Two Samples of Military Personnel. Journal of Clinical Psychology, 69(1), 64-77. DOI: 10.1002/jclp.21932 Click here to view article
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Consider ACE Criteria when Screening for Suicide or for Poor Resilience
The Center for Disease Control has done studies on the impact of Adverse Childhood Experiences on the health of individuals. The ACE study has found that these adverse experiences are major risk factors leading to mental illness and poor quality of life. These adverse childhood experiences must be considered when you are screening for suicide or when you find an individual is lacking in resilience in bouncing back from the adversities of life.
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ACE (Adverse Childhood Experiences)
Abuse
1. Emotional Abuse
2. Physical Abuse
3. Sexual Abuse
Neglect
4. Emotional Neglect
5. Physical Neglect
Household Dysfunction
6. Mother was treated violently
7. Household substance abuse
8. Household mental illness
9. Parental separation or divorce
10. Incarcerated household member
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To learn more about Trauma Focused Therapy Cognitive Behavioral Therapy which is mentioned in the ACE materials go to: http://tfcbt.musc.edu/. On this site you are able to take an online course in TFCBT as well.
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