(suicidal ideation) arises through two key constructs: perceived burdensomeness and failed belongingness . Perceived burdensomeness is the individual’s belief that not only is he or she flawed in some capacity but that his or her existence burdens friends and family. While the suicidal individual believes this calculation to be correct, it is a potentially fatal misconception. Perceived burdensomeness occurs when a person believes his death is worth more than his life to others (Teismann, Forkmann, Rath, Glaesmer, & Margraf, 2016). Failed belongingness is the sense that the individual is alienated from his or her significant others. When this feeling is combined with perceived burdensomeness, Joiner’s theory suggests that all ties to life are cut off and the desire for death becomes seen as an option. Thwarted belongingness results when the basic human need of connection to others (Hom, Chu, Schneider, Lim, Hirsch, Gutierrez, & Joiner, 2017), is not met. When an individual experiences the desire to die, as a function of impaired belonging and perceived burdensomeness, that does not necessarily mean that individual engages in suicidal behavior. For suicidal behavior, the individual must exhibit acquired capability. According to the IPTS, the acquired capability for suicide is believed to be one of three proximal, jointly necessary, and jointly sufficient causes that must be present before a person will die by suicide; the other two factors are perceived burdensomeness and low (or thwarted) belongingness . Acquired capability for suicide is a construct made up of both pain tolerance and fearlessness about death. Specifically, according to the IPTS, humans have been evolutionarily designed to fear Three Step Theory (3st; Klonsky & May, 2015) Although Joiner’s Interpersonal Theory has made substantial improvements in our understanding of suicidal behavior, the truth is that suicidal behavior is a complex phenomenon and is influenced by a larger number of interacting variables than even the brightest human mind can integrate. This has led to more modern research approaches utilizing complexity science and machine learning in attempts to understand the interplay between more variables than are humanly comprehensible (Ribeiro et al., 2019). As these efforts continue, however, one major theoretical breakthrough in the field has been to narrow down the issue of suicide into one essential component: the transition from suicidal ideation into suicidal action. This issue is best exemplified by a recent “ideation-to-action” model proposed by Klonsky and May (2015), referred to as the Three-Step Theory ( 3ST). The issue of ideation-to-action in suicidal behavior starts with the understanding that there are a substantial number of individuals who experience suicidal ideation, and yet only a small fraction of those individuals ever goes on to attempt suicide, and even fewer die by suicide. Ideation-to-action models attempt to understand this transition and what factors spur an individual to move from suicide contemplation into suicidal planning, preparation, and behavior. The first step in the 3ST (Step 1) posits that the individual first experiences a combination of psychological pain and hopelessness that leads to the development of suicidal ideation. This may be a function of various variables, including but not Psychological Questionnaires and Interviews The Columbia-Suicide Severity Rating Scale (C-SSRS; Posner et al., 2011) is a questionnaire used for suicide assessment that can also be conducted in an interview format. It is available in 114 country-specific languages. Mental health training is not required to administer the C-SSRS. Three versions of the C-SSRS are available for use in clinical practice. The Lifetime/ Recent version is used to gather lifetime history of suicidality as well as any recent suicidal ideation and/or behavior. The Since Last Visit version assesses suicidality since the patient’s last
dying, and thus, in order to overcome this fear and make a lethal suicide attempt, a person must become accustomed to the fear and pain involved in dying. The theory further posits that the capability for suicide is developed over time with repeated exposure to pain (e.g., childhood abuse, injuries) and provocative events (e.g., being in combat, shooting a gun, bungee jumping). The acquired capability for suicide is believed to be elevated primarily through behaviors and physical experiences and has been found to be in part genetically determined (Rimkevicience, Hawgood, O’Gorman, & De Leo, 2017). Notably, Chu and colleagues (2017) found evidence for the distinctiveness of the acquired capability for suicide from suicidal ideation. In other words, one may have acquired the capability for suicide, but have no suicidal desire. Conversely, one may have suicidal desire, but lack the capability to die by suicide. However, having elevated acquired capability in conjunction with perceived burdensomeness and low belongingness is believed to put an individual at risk for death by suicide. Thus, according to Joiner’s model, suicide attempts and deaths will only arise when an individual experiences all three essential risk factors simultaneously: thwarted belongingness, perceived burdensomeness, and acquired capability for suicidal behavior. Overall, the Interpersonal Theory of Suicide has done much to advance the understanding of suicide and has garnered an impressive level of empirical support. However, the nature of science is to strive for the most accurate and predictive level of understanding possible, and additional advances building on the interpersonal theory continue to be made. exclusive to those factors outlined in the interpersonal theory of suicide. In this step pain can be derived from a variety of sources, but the feeling of hopelessness is necessary because it creates the perception that this pain will not fade. Step 2 in the 3ST then posits that suicidal ideation escalates as psychological pain intensifies and overwhelms feelings of interpersonal connection. In this case, interpersonal connectedness is viewed as one of the final safeguards against the desire for death, and if those bonds are overcome, risk for suicide becomes more severe. Finally, Step 3 in the 3ST suggests that suicidal ideation can only be acted upon when an individual develops an acquired capability for suicidal behavior (from the interpersonal theory or suicide). It is only at this stage that suicidal behavior can occur. The 3ST has made substantial contributions to the theoretical basis of suicide and helps build an understanding of the process that patients may experience in the development of suicidal ideation (initial desire to die) and eventually into enacting suicidal behavior. Ongoing research continues to provide support for the 3ST model as well (Klonsky, Saffer, & Bryan, 2018). Overall, major progress continues to be made in enhancing our understanding of the causes of suicidal behavior; the better we can understand these causes, the better we can improve our suicide risk assessment and intervention efforts. The next section details suicide risk assessment, including ways in which these assessments have been enhanced by integrating the above- outlined theories of suicidal behavior.
SUICIDE RISK ASSESSMENT TOOLS
visit. The Screener version of the C-SSRS is a truncated form of the full version. Various professionals can administer this scale, including physicians, nurses, psychologists, social workers, peer counselors, coordinators, research assistants, high school students, teachers, and clergy. The C-SSRS supports suicide risk assessment through a series of simple, plain-language questions. The answers help users identify whether someone is at risk for suicide, assess the severity and immediacy of that risk, and gauge the level of support the person needs. Users of the C-SSRS tool ask people:
EliteLearning.com/Social-Work
Book Code: SWUS1524
Page 100
Powered by FlippingBook