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Article Excerpt
Suicide in the military is a growing concern. We reviewed empirical studies and used two case studies to illustrate the potential explanatory role of Joiner's (2005) interpersonal-psychological theory of suicidal behavior: The theory posits that three variables--perceived burdensomeness, thwarted belongingness, and acquired capability for suicide--determine the risk of an individual engaging in a lethal suicide attempt. In our case studies, we illustrate how these variables might be affected in an active duty population post-deployment. Although methodological limitations preclude conclusive determinations, the case studies provide a framework within which to understand the phenomenon of suicide in the military. Future work that examines these findings empirically will be invaluable to both researchers and mental health counselors.
INTRODUCTION
Suicide is a massive public health problem (National Institute for Mental Health [NIMH], 2008), but there are relatively few comprehensive and rigorous theories for better understanding and diminishing the phenomenon. Although suicide occurs in a wide variety of populations, suicide in the military has sparked an understandable and particularly strong surge of recent interest (Lorge, 2008). The need for an empirically supported, well-tested theory of suicidal behavior that might be applied to this population is readily apparent.
Joiner (2005) proposed an interpersonal-psychological theory of suicidal behavior that indicates three variables must be present for an individual to die by suicide. The first of these, a sense of thwarted belongingness, involves a sense on the part of the individual that he or she lacks meaningful connections to others and that previously solid relationships have become strained or lost. The second, perceived burdensomeness, involves a sense on the part of the individual that he or she is a burden to the world, someone who not only fails to make meaningful contributions but is also a liability. Taken together, the theory says, these two perceptions produce the desire for suicide.
The third variable, acquired capability for suicide, involves the degree to which an individual is able to enact a lethal suicide attempt. Joiner (2005) posited that, because a lethal or near-lethal suicide attempt is fearsome and often pain-inducing, habituation to the fear and pain is a prerequisite for serious suicidal behavior. The theory suggests that repeated exposure to painful and provocative events habituates individuals to stimuli that previously would have been highly aversive, with respect to both fear and physiological responses. Thus behaviors like self-injury (painful) and experiences like witnessing or engaging in violence (provocative) may increase an individual's acquired capability for suicide.
In this paper we seek to examine how this theory might apply to two active-duty post-deployers. A clearer understanding of which individuals in this population are at risk for suicide attempts and death may allow for improved prevention and treatment efforts. An understanding of the mechanisms behind suicidal behavior may also allow for more efficient and empirically based risk assessments, potentially stimulating more accurate and earlier responses. Brenner et al. (2008), in examining Joiner's (2005) theory in a military population, identified consistent themes of perceived burdensomeness, thwarted belongingness, and an acquired capability for suicide that may have been influenced by combat experiences. We build upon this work by examining events in the lives of two individuals that may have represented or influenced the three components of Joiner's theory and perhaps affected their suicide risk.
Joiner's (2005) theory implies that not all individuals who desire suicide are capable of completing the act, and similarly not all who are capable desire to engage in suicidal behavior. The acquired capability for suicide is thus a necessary but not sufficient risk factor for suicide completion. How individuals acquire this risk factor may vary, but the path universally involves repeated exposure to or experiencing of painful and provocative events. Consistent with Solomon's opponent-process theory (1980), Joiner proposed that such repeated exposures habituate an individual to fear and physical pain and therefore dampen his or her initial aversive response (a-process) and amplify potential reinforcement (b-process).
Consistent with the idea of habituation from repeated exposure to painful and provocative events, Nock and Prinstein (2005) reported that some individuals who repeatedly self-injure report little or no pain during self-injury. Pain analgesia in response to repeated self-inflicted injuries is consistent with the idea that over time individuals develop the ability to engage in more serious suicide attempts that would otherwise involve too much discomfort. Along these lines, Orbach, Mikulincer, King, Cohen, and Stein (1997) demonstrated that adolescents with multiple suicide attempts exhibit higher thermal pain thresholds and greater pain tolerance in general than do individuals with one or no suicide attempts. Here again, repeated self-inflicted injuries predicted a greater ability to withstand physical pain, corroborating the construct of the acquired capability for suicide.
Orbach, Stein, Palgi, Asherov, Har-Even, and Elizur (1996) compared individuals who reported to an emergency room after a suicide attempt with others who reported to an emergency room due to accidental injuries. Participants were approached after their condition was stabilized by medical personnel. The experiment was described as an examination of physical pain and personality characteristics, and participants were told that the procedure would involve mild electric shocks. Those who had attempted suicide showed higher pain tolerance than their nonsuicidal counterparts. Here, it appears that intentionally self-inflicted injuries have more potential for increasing pain tolerance than do painful but unintentional injuries. Given that suicide attempts theoretically require practice and a diminished pain response, these findings are consistent with Joiner's (2005) theory: individuals who intentionally injured themselves appeared able to withstand more physical discomfort.
Nock, Joiner, Gordon, Lloyd-Richardson, and Prinstein (2006) studied an inpatient sample of individuals who reported a history of repeated nonsuicidal self-injury (NSSI) in the previous 12 months to explore the relationship of repeated self-injury to suicidal behavior. Participants were adolescents (23 males, 66 females), 87.6% of whom met criteria for an Axis I personality disorder and 67.3% of whom met criteria for an Axis II disorder. The authors reported that the number of self-injury episodes, the severity of the self-injury, and the self-reported lack of physical pain during self-injury episodes predicted suicide attempts.
Even within a sample comprised entirely of individuals who have experienced some degree of pain and provocation, the severity of the pain appears to predict suicidal behavior. For instance, Joiner et al. (2007) reported that childhood physical abuse and...
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