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Article Excerpt
According to the interpersonal-psychological theory of attempted and completed suicide (Joiner, 2005) suicide-related behavior is contingent upon three factors: acquired ability, burdensomeness, and failed belongingness. Qualitative research methodology was employed to explore these concepts among a group of returning Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) combat veterans. A sample of 16 individuals participated in interviews. Themes emerged regarding combat as a context for exposure to pain, subsequent coping strategies, and perceptions of burdensomeness, failed belongingness, and increased pain tolerance. Suicidal behavior was also articulated as a means of coping with risk factors outlined by Joiner. These results highlight the potential utility of this theory for OEF/OIF veterans. Interventions aimed at decreasing emotional dysregulation, and lessening perceptions of burdensomeness and failed belongingness may reduce risk for suicidal behavior.
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While the ability to identify factors that make an individual more or less likely to engage in suicidal behavior has significant clinical utility (Beck, Steer, Kovacs, & Garrison, 1985; Jobes & Mann, 1999), such knowledge does not allow us to predict who will die by suicide. Recent work by Joiner (2005) represents years of theory building, refinement, and empirical validation aimed at increasing understanding about how and why people become suicidal. The foundation of Joiner's (2005) theory, the interpersonal-psychological theory of attempted and completed suicide, is 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.
Components of the theory have been tested in adults (Joiner, Pettit, Walker, Voelz, Cruz, & Rudd, 2002; Joiner & Rudd, 2000), college students, and adolescents (Joiner, Rudd, Rouleau, & Wagner, 2000). However, research has only begun to explore whether the theory applies to veterans (Cornette, Deboard, Clark, Holloway, Brenner, Gutierrez, et al., 2007; Cornette, deRoon-Cassini, Joiner, & Proescher, 2006). The importance of identifying means of assessing risk in this population is highlighted by a recent study of U.S. male military veterans aged 18 and older (Kaplan, Huguet, McFarland, & Newsom, 2007). Such individuals were twice as likely to die by suicide when compared with nonveteran males. Those who were white, had [greater than or equal to] 12 years of education, or activity limitations were at greater risk (Kaplan, Huguet, McFarland, & Newsom, 2007). Previous research has demonstrated that combat-related experiences also place veterans at risk (Bullman & Kang, 1996). Demographically, those aged 20-29 represent the majority of returning Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) veterans who seek care within the Veterans Administration (VA) system (VHA Office of Public Health, 2006); in the U.S. general population, young people aged 15-24 make the largest number of suicide attempts each year (Centers for Disease Control and Prevention [CDC], 2006). Suicide is also on the rise among soldiers, with 2006 having the highest number of confirmed cases since 1990 (Lorge, 2008). To facilitate treatment and prevent future OEF/OIF suicides, increased understanding of risk factors for veteran suicidal behavior is needed.
Acquiring the ability to engage in suicidal behavior may be related to "hav[ing] 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" (Joiner, 2005, p. 70). Hoge, Auchterlonie, and Milliken (2006) found that 65.1% of OIF soldiers and 46% of OEF soldiers reported 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.
Perceived burdensomeness and failed belongingness contribute to the desire to die, and habituation to pain impacts an individual's ability for engaging in suicidal behavior (Joiner, 2005). Figure 1 outlines the spheres of suicide risk, with those individuals at highest risk being represented by the area where the spheres overlap. Although all three components are believed to be relevant to understanding veteran suicide, habituation to pain is the most complex concept to apply, so it will be given the most attention in this paper.
[FIGURE 1 OMITTED]
Qualitative research can be particularly useful in clarifying less-understood phenomena (Strauss & Corbin, 1990). As the concepts introduced in the theory are not well-understood in this population, we employed this methodology. In particular, our goal was to elucidate the complex details regarding OEF/OIF veterans' perceptions about potential suicide risk factors, habituation to pain, burdensomeness, and belongingness. This study was also intended as the first in a series leading to the development of new measures to assess the constructs in veterans. Work of this type often begins with a qualitative study from which initial items can be generated (Haynes, Richard, & Kubany, 1995).
To elicit OEF/OIF-specific information about concepts hypothesized to increase risk for suicidal behavior, questions were posed about habitation to pain, perceived burdensomeness, and failed belongingness. We paid particular attention to whether combat was a context for exposure to pain and thus resulted in habituation to pain. Other questions dealt with burdensomeness and belongingness in the context of past military experiences and reintegration into civilian life. The final question in each section of the interview asked about "the most extreme" way the respondent might cope with the issue raised. Although no specific questions regarding suicide were asked and the word suicide was intentionally not included in interview questions, we were interested in whether themes related to suicide would emerge spontaneously in response to all three constructs.
METHODS
Participants
With the approval of the...
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