WASHINGTON, - Why? What makes people attempt suicide? It's a vital question, as the answer could help mental health professionals and even friends and family better recognize when they need to step in to help to save a life.
Theories about suicide motives abound, but as one presenter noted June 20 at the annual suicide prevention conference sponsored jointly by the Defense and Veterans Affairs departments, not much data exists on the question.
Craig J. Bryan, a doctor of psychology, is associate director of the National Center for Veterans Studies at the University of Utah and an assistant professor for the university's psychology department. At the conference, he presented the results of a study aimed at identifying the motives of 72 active-duty service members who attempted suicide.
"They had collectively attempted suicide 136 times over their lives," he said, adding that 21 percent never attempted suicide and two participants had made five attempts each.
Study participants - 66 men and six women - ranged in age from 19 to 44 and had served between one and 19 years in the military. Each person referred to the study had been discharged from an inpatient hospital stay for suicide risk.
Bryan noted the study also served as a course of treatment. Phase 1 focused on crisis management and distress tolerance. Phase 2 aimed at problem solving and restructuring of the participants' suicide belief systems, and Phase 3 was dedicated to relapse prevention.
Each participant built a crisis response plan and underwent sleep therapy as part of the study, he said, and patients completed an average of 12 sessions - as many as 17 for some - before "graduating" from the study.
Phase 1 must target emotion regulation, Bryan emphasized. Patients have to learn to deal effectively with painful emotions or they can't progress further in therapy, he said.
Most theories about suicide motivation assume suicidal attempts primarily stem from emotional distress, Bryan said. He described two models of approach and treatment for suicidal behaviors: the "syndromal model," which assumes an underlying psychiatric disorder in suicidal patients, and the "functional model," which seeks to explain why people attempt suicide so patients can learn how to cope with challenges.
Bryan told the conference audience that the "functional model of self-harm" widely referenced in suicide prevention work notes four major groups of possible suicide motives:
- Emotional relief, or the desire to stop bad feelings;
- Feeling generation, or the desire to feel something even if it's bad;
- Avoidance and escape, or the desire to avoid punishment from others or avoid doing something undesirable; and
- Interpersonal influence, or the desire to get attention or "let others know how I feel."
Identifying the "why" is one of the essential ingredients to reduce suicide attempt rates, he said, because once patients understand their motivations, they can develop strategies and coping skills to deal with those challenges.
Bryan said one aim of the study, which used the functional model, was to teach patients "how to suffer in a way that doesn't require you to die."
The study asked participants to identify their own motives for a suicide attempt from a list of 33 potential reasons, which were divided among the functional model's four groups. Each patient chose one to 29 reasons, Bryan said, with 10.43 factors as the mean result.
All participants selected emotional relief, specifically "to stop bad feelings," as a factor, he said, though 95 percent also noted other reasons.
Bryan described the frequency of other factors noted in the study. Participants identified avoidance or escape - with the top single reason being "to get away or escape from other people" - as a factor 82.4 percent of the time. Interpersonal influence was noted by 80.1 percent of participants, with the most-cited response being "to communicate or let others know how desperate you were." And 72.8 percent endorsed feeling generation as a factor, with "to feel something, even if it was pain" as the most common response.
After patients confronted the reasons they had attempted or considered suicide, Bryan said, "It was like a light bulb went on." While all of the participants originally said they attempted suicide because they wanted to die, 95 percent acknowledged after selecting factors they realized they had not wanted to die, but wanted to end emotional pain.
"What this means from a clinical standpoint is we have to start integrating these behavioral [and] functional understandings of suicide attempts into our treatment," he said. "This is a primary mechanism or ingredient of ... behavioral therapy, which is the treatment that we're currently testing for active-duty Soldiers."
As part of the study, participants received a "smart book" during their first 30 minutes of therapy, Bryan said. Patients wrote in the books throughout their course of therapy, adding lessons learned during each session about what was working for them.
At the end of Phase 3, the smart book comes out again and participants review the lessons and skills, Bryan said. If patients get "stuck" in thinking about how a previous suicide attempt could have been handled differently or how to face a current challenge, the smart books remind them of approaches they learned in therapy. "It is a core intervention," he said.