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A Behavioral Assessment Of The Reinforcement Contingencies Associated With The Occurrence Of Suicidal Behaviors

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A Behavioral Assessment Of The Reinforcement Contingencies Associated With The Occurrence Of Suicidal Behaviors

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TAPPER, Bruce John, 1947-
A BEHAVIORAL ASSESSMENT OF THE REINFORCEMENT
CONTINGENCIES ASSOCIATED WITH THE OCCURRENCE
OF SUICIDAL BEHAVIORS.
University of Southern California, Ph.D., 1975
Psychology, clinical
Xerox University Microfilms f Ann Arbor, Michigan 48106
THIS DISSERTATION HAS BEEN MICROFILMED EXACTLY AS RECEIVED.
A BEHAVIORAL ASSESSMENT OP THE REINFORCEMENT
CONTINGENCIES ASSOCIATED WITH THE
OCCURRENCE OP SUICIDAL BEHAVIORS
by
Bruce John Tapper
A Dissertation Presented to the
FACULTY OP THE GRADUATE SCHOOL
UNIVERSITY OP SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OP PHILOSOPHY
(Psychology)
January, 1975
UNIVERSITY OF SOUTHERN CALIFORNIA
T H E G R A D U A T E S C H O O L
U N IV E R S IT Y P A R K
L O S A N G E L E S . C A L IF O R N IA 9 0 0 0 7
This dissertation, w ritten by
BRUCE JOHN TAPPER
under the direction of hXB.... Dissertation C o m
mittee, and approved by a ll its members, has
been presented to and accepted by T h e Graduate
School, in p artia l fulfillm en t of requirements of
the degree of
D O C T O R O F P H I L O S O P H Y
Dean
D a te A V . kkj:.. . L . i f f . .
DISSERTATION, C O M M ITTEE
ACKNOWLEDGEMENTS
In addition to the invaluable assistance
offered to me by my committee, the following agencies
and individuals have contributed greatly appreciated
assistance:
The United States Veterans Administration
provided both a subsidy to the author and the scientific
resources and encouragement to work on this type of
research, and these are gratefully acknowledged. Dr.
Norman L. Parberow, Dr. Allen E. Edwards, Douglas
MacKinnon, and John Williams of the Veterans
Administration were especially helpful in their
criticism and technical aid.
Special thanks are extended to Maxine Bernard
of the Veterans Administration and Steven Southern
of the University of Southern California for their
aid in selecting and interviewing subjects for this
project.
Computing assistance was obtained from the
Health Sciences Computing Facility, UCLA, supported
by NIH Special Research Resources Grant RR-3.
Finally, Dr. Curtis D. Booraem and Dr. Gary
E. Bodner of the California Youth Authority, Norwalk,
are acknowledged for their critical evaluations, their
availability, and above all, their patience.
ABSTRACT
Suicidal behavior was examined as a set of instrumentally
learned responses whose occurrence is determined by the same principles
governing the performance of any operantly conditioned behavior. The
present study addressed two central questions: (l) What are the types
of events occurring in the lives of suicidal persons which might
serve as reinforcers for their suicidal behaviors and distinguish
them from non-suicidal persons? (2) Are changes in the frequencies
of any of these events related to changes in the frequency and
severity of suicidal behaviors over specified time spans?
Two groups of psychiatric outpatients were matched on the
basis of sex, age and non-psychotic diagnosis of depression or
anxious depression. Ss in the suicidal group reported at least one
suicide attempt in their histories and that suicidal preoccupation
was a current problem, while the control group reported no suicidal
behavior in the last 10 years. All Ss participated in a structured
interview which assessed frequencies of two types of events which
might serve as positive or negative reinforcers related to the
occurrence of suicidal behaviors. These were (l) events occurring
in the social environment external to the S^ and (2) covert events
and attitudes occurring within the £. In addition, Ss in the
suicidal group participated in two follow-up interviews to assess
changes in these events and any related changes in their frequency
of suicidal behaviors.
iii
A between-groups comparison was conducted employing a step
wise discriminant function analysis. Items which were highly accurate
in predicting correct group membership were primarily negatively
reinforcing events. These were the number of losses perceived
himself to have suffered, the number and severity of rejections £ had
experienced, the cognitive rehearsal of death under conditions of
imagined stress, and attitudes concerning fear of death and perception
of control over the time of one's death. Contrary to the predicted
results, no differences were found on the measures of number of
suicidal models in Ss' histories, state of physical health, number of
coping mechanisms Ss typically employed in order to alleviate stress,
their concept of afterlife, or number and type o^ positive reinforcers
received for non-suicidal behaviors. In addition, suicidal £s
demonstrated higher levels of both situational and chronic anxiety,
possibly as a co-effect of the greater perceived amount of negative
stimuli in their environments.
The within-group comparison of the suicidal Ss over time
demonstrated highly significant correlations between changes in
suicidal behavior and changes in both negative social stimuli
(rejections, experiences of powerlessness) and positive social inter
actions. There were also significant correlations between changes in
suicidal behavior and both changes in state of health and changes in
self-reinforcement following previous suicidal responses.
The results are interpreted as supporting the model which
implies that suicidal behavior is an avoidance response to noxious
stimuli in this depressed population. It is not clear whether the
number and severity of negative events experienced by suicidal Ss is
objectively greater than that of control Ss or is simply perceived as
greater, but there is evidence that suicidal Ss are involved in a
greater number of negative social interactions. The frequency of
suicidal behavior also appears to be highly related to changes in
these social stimuli over time. Thus, the most productive targets
for modification by the therapist seeking to modify suicidal acting
out appear to be (l) correcting deficits in interpersonal assertive
skills, (2) desensitization to losses, and (3) modification of covert
rehearsals of death-related behaviors.
v
TABLE OP CONTENTS
Acknowledgements ........................................... ii
Abstract..................................................... ill
Table of Contents ............ vi
I,lot of Tables............................................... vii
CHAPTER I - HISTORICAL REVIEW ............................ 1
Suicide Prediction Literature ................ 1
Statement of the Problem .................... 36
Hypotheses ................................... 37
CHAPTER II - METHOD ....................................... 47
Subjects ..................................... 47
Materials..................................... 48
Experimenters ................................. 31
Procedure..................................... 31
Data Analysis................................. 33
CHAPTER III - RESULTS ..................................... 55
Between-Groups Comparison .................... 55
STAI ......................................... 55
Pleasant Events Schedule ...................... 56
Discriminant Analyses........ . .............. 56
Overall Correlation Matrix .................. 76
Manipulation Checks .......................... 80
Within Group Comparison of the Suicidal Group. . 80
CHAPTER IV - DISCUSSION..................................... 86
CHAPTER V - CONCLUSIONS....................................... 107
BIBLIOGRAPHY ............................................... 112
APPENDIX A - INITIAL INTERVIEW FORM...........................121
APPENDIX B - TWO-WEEK FOLLOWUP............................... 138
vi
LIST OP TABLES
Table Page
1. Stepwise Discriminant Analysis with 9 Variables, with
Means for Each Group.............................. 58
2. Stepwise Discriminant Analysis with 26 Variables,
with Means for Each Group .................... 60
3. Stepwise Discriminant Analysis with 8 Variables . . . 63
4. Stepwise Discriminant Analysis with 25 Variables . . . 65
5. Stepwise Discriminant Analysis with 24 Variables . . . 68
6. Stepwise Discriminant Analysis with 19 "Stimulus"
Variables........................................ 71
7. Stepwise Discriminant Analysis with 5 "Response"
Variables........................................ 73
8. Stepwise Discriminant Analysis with 8 "Positive
Stimulus" Variables ................................... 74
9. Stepwise Discriminant Analysis with 11 "Negative
Stimulus" Variables ................................... 75
10. Correlation Matrix of 11 Moderate to Highly Predictive
Variables from Stepwise Discriminant Analysis .... 77
11. Correlations of 10 Data Points with the Variables
of Which They Were Components .................. 79
12. Correlations of Changes in Intensity of Suicidal
Pehavior Over Time with Changes in Repeated
Measures Variables .................................. 82
13. Correlations of Changes in Intensity of Suicidal
Behavior Over Time with Changes in Social
Interactions and Positive Social Reinforcement .... 83
14. Correlations of Changes in Intensity of Suicidal
Behavior Over Time v/ith Changes in Individual Items. . 84
vii
CHAPTER I
HISTORICAL REVIEW
Suicide Prediction Literature
Research in the field of suicide prediction has been a
notoriously difficult task historically because of methodological
problems which seem to exist at every level. In order to provide a
clearer framework from which research in this area can be evaluated,
a discussion of these problems will precede the research review.
The confusion begins with the lack of a universally accepted
definition of suicide. There is general agreement among researchers
that a suicide death has taken place only if the victim knows that
his actions will result in his death. This leads to the difficult
problem of trying to identify the victim's thoughts and motivational
state immediately prior to his death in order to certify whether or
not the death was a suicide. Stengel and Farberow (1968) surveyed
the methods for classification of deaths as suicides among several
nations and found wide variability between and even within countries.
Laws declaring suicide a crime and the routine use of autopsies by
public health officials have been shown to have very marked effects
on the number of officially recorded suicides.
Another problem has been the difficulty of accurately pre
dicting an event which has a very low base rate of occurrence. Suicide
death is a serious public health problem in the U.S., being the
eleventh leading cause of death. The annual number of suicides
1
(22,000 or 11 per 100,000 population) is greater than the number of
homicides (18,000), and is continuing to rise (Farberow, et al, 1970).
However, the frequency of this event in the general population remains
only .001% per year. It is conceivable that all suicides could fall
into the accepted statistical error range, and it is very difficult
to develop any predictive device that would be more accurate than
simply assuming nonoccurrence of the event. A researcher attempting to
predict the occurrence of the relatively rare event of suicide in the
general population would be on the safest statistical grounds by
assuming nonoccurrence, but would be on the shakiest ethical grounds
by ignoring potential deaths.
Neuringer (1974) notes that as research in the area increases,
the number of proposed typologies has increased to a confusing degree.
He lists intentional suicide, chronic suicidal behavior, automatization
suicide, manipulation suicide, indirect suicide,
probability suicide, self-destructive behavior, suicidal threats,
suicidal thinking, and even what he somewhat tongue-in-cheek calls
"test suicide". This is where (p. 9) "a man is considered to be
suicidal if he gives suicidal and/or depressive responses on psycho
logical tests, especially projective personality tests."
Brown and Sheran (1972) state that nearly all suicide research
consists of attempts to isolate signs which are more characteristic of
persons who commit suicide than persons who do not. They note that
the problem of inclusion-exclusion must be considered when researchers
seek predictive signs. If "sign A" is true of 5% of committers and 1%
of nonoommitters, it is more characteristic of committers but is not
useful because it has failed to identify 957° of the committers. If
"sign B" is true of 95$ of committers but is also true of 90$ of non-
committers, it may be more characteristic of committers but has
mistakenly overincluded much of the non-commit population (e.g., almost
all suicide victims are "unhappy," but most unhappy people do not
commit suicide). The exclusion of noncommitters is extremely important
in the prediction of this low base rate behavior. A useful sign would
be "sign C," if it were true of 95$ of committers and only 5$ of non-
committers. It would correctly include almost all committers end
exclude almost all noncommitters.
Data collection has several problem issues related to it.
Neuringer (1962) has labeled two general categories of data collection,
these being l) the method of residuals, and 2) the method of substitute
subjects. The method of residuals involves the examination of personal
artifacts of a deceased victim and interviewing the survivors to
determine environmental stresses and the victim's psychological state
immediately prior to his death. The method of substitute subjects
makes use of interview or written data from suicide threateners and
attempters who represent what Neuringer calls "pale carbon copies" of
suicide committers.
In an extensive review of suicide prediction literature,
Lester (1973) has pointed out a recurrent pattern. Y/hen a study found
differences between attempters and completers, it would usually con
clude that data from attempters could not be used to make inferences
about completers. Y/hen a study found no difference, it usually
defended the method of substitute subjects. Farberow and Shneidman
(1955) found no differences between attempters and completers on
demographic, sociologic, or early family life variables, but found
significant differences on psychiatric diagnoses, method of attempt,
and suicidal history. Lester proposes that these data support the use
of substitute subjects. He argues that since a continuum exists for
the lethality of the method of suicide attempts, then there may exist
continuums on most or all variables which have been found to be
related to the occurrence of suicidal behaviors. He believes that all
the variables are continuous, and that there exists a continuum from a
nonlethal gesture to a completed suicide. Neuringer (1974) cautions
that there is no proof at present that suicidal behavior is a monotonic
continuum, and that the utilization of alcoholism, accident proneness,
and other moderately self-injurious acts as "suicide equivalents" in
research should be approached carefully.
When suicide attempters are studied in prediction research,
Neuringer lists four additional problems of control. The first is the
feedback effects of the attempt itself. After a first suicide attempt,
people may receive social reinforcement, experience catharsis, suffer
central nervous system damage, or be disfigured. In these cases,
personality measures given before and after the attempt would probably
differ. The second problem is the effect of hospitalization. A
suicidal patient typically receives closer observation than other
patients, and his treatment may be markedly different from other
patients even on the same ward. The third problem is that of defining
an adequate control population. Some psychiatric patients may be
unwilling to talk about their suicidal history and be incorrectly
4
included in a non-suicidal control group. The last problem is the
impossibility of complete validation of prediction, since one cannot
establish a no-treatment control group in which Ss are allowed to kill
themselves. Researchers are obligated to provide some type of treat
ment for every subject they consider to be an acute suicidal risk.
The aforementioned issues are general problems affecting all
types of research in the field of suicide. Now that these more
general issues have been considered, the research on suicide which has
been conducted under more specific theoretical models can be
discussed.
Zubin (1974) has divided the numerous models of suicide re
search into two definitive categories, the ecological models and the
clinical models. The ecological models are concerned with predicting
and explaining suicide rates, while the clinical models focus on
individual differences. The ecological models generally examine the
relationships between various demographic variables and the suicide
rates within specific populations. These sociological models do not
attempt to make predictions for individual cases, but are concerned
only with explanation of suicide rates. However, this does not mean
that demographic data are of no predictive value to clinicians because
they overinclude so many noncommitters, as Diggory (1974) has claimed.
These data are of use to the clinical researcher for two reasons. One
is the identification of specific characteristics of populations with
the highest risk of suicide, which clinicians must consider when
defining any control group. Several of these characteristics (dis
cussed below) have consistently shown high correlations with suicide
5
rates, and should be matched between experimental and control popula
tions to eliminate confounding. The other is that these data may help
to point out the most common sources of stress which may provide
motivation toward suicide in that population. Using this information,
clinicians may then be able to isolate and systematically examine the
effects of these stresses on individuals. For these reasons, a brief
discussion of the results of research investigating the demographic
variables under the ecological models will follow.
Sex; A consistent finding is that more males than females
commit suicide. Shneidman and Farberow (l96l) found a ratio of
approximately 70 male to 30 female completed suicides in Los Angeles.
Brown and Sheran (1972) found a somewhat closer ratio for Los Angeles
ten years later, 55 to 45 respectively, and this may reflect a recent
change in what has historically been a relatively invariant ratio.
McCulloch, Philip and Carstairs (1967) found a similar close ratio in
England, leading to speculation that the increasingly independent roles
of women are leading to an equalization of the male-female suicide
rate. With respect to suicide attempts, Brown and Sheran report that
women make nearly four times as many unsuccessful attempts as men, and
that men more often commit suicide on their first attempt.
Age; Dublin (1963) found that although the suicide rate for
white males increases with age, the rate for women and nonwhites is
only moderately related to age. He concludes that age is an important
predictor of suicide risk only among white males. Hendin (1969) found
a bimodal distribution of ages among urban Blacks in the United States
with peaks in the suicide rate in the 20-30 year age range and the
6
over 55.
Race: Dublin (1963) found the rate of suicide among Blacks to
be lower than that of whites. The only group significantly higher
than whites in the United States was American Indians (Resnik, 1970).
Marital Status: Tuckman and Youngman (1968) and Cohen _et al.
(1966) both found a much higher incidence of suicide among people who
had been married and then were either separated, divorced or widowed
than among those who were presently married or single.
Employment: Breed (1963) found that unemployment and partial
employment were highly related to suicide among males. Powell (1958)
found an increase in the suicide rate among men at the time of
retirement.
Place of residence: Shneidman and Farberow (l96l) found the
suicide rates in apartment living areas of Los Angeles to be higher
than that of single family residences. Half of San Francisco's
reported suicides were by residents of the downtown area where the
population is more transient, Cohen et al. (1966) found.
Living arrangements: Shneidman and Farberow (l97l) in Los
Angeles and Sainsbury (1955) in London both found that 20 to 30^ of
suicide committers were living alone at the time of their deaths,
while only 5 to 10^ of the general population lived alone.
Other demographic groups which have been shown to be high risk
are delinquents (Cohen, et al., I960)j people whose early years were
characterized by the prolonged absence of one parent ("broken homes")
(Dorpat, Jackson and Ripley, 1965)} drug addicts (Cohen, at*, 1966);
alcoholics (Rushing, 1968, Pokorny, 1964) and homosexuals (Farberow,
7
Heilig and Litman, 1968).
Other less notable studies have correlated suicide deaths with
the time of day, time of year, weather conditions, sunspot activity,
and phases of the moon. This research appears to be of dubious pre
dictive value for the clinical researcher.
Litman (1974) has computed the suicide rates and amount of
suicide risk for selected populations. The rates are computed per
100.000 population.
1 = non risk. E.g.: Children under 12 years of age, the event is
exceptionally rare.
10 = minimal. E.g.: Students, young men, older women.
100 = low. E.g.: Psychiatric patients, addicts, alcoholics.
1.000 = moderate. E.g.: Attempters hospitalized for overdoses or
wounds, manic-depressives.
10.000 = high. E.g.: Serious attempters in a psychiatric hospital,
depressed older male alcoholics who call Suicide
Prevention Center.
As noted previously, the data from ecological research will
provide only information concerning suicide rates and will not
attempt to predict the outcome of individual cases. The latter is the
aim of the clinical models. The value of the demographic data for the
clinical researcher is that they will identify the specific high risk
populations where suicidal individuals are most likely to be found for
research and treatment, and will identify the population variables the
clinician must control for when matching Ss in any research design.
Clinical research in the area of suicide typically has sought
sought to identify some unique sign or signs in people's histories
that will separate those with a very high risk of suicide death from
persons with a lower risk. This research can be divided into three
subgroups: the use of standardized psychological tests to predict
suicide, the construction of predictive scales based on personal
history information, and the testing of models of behavior extended
from other areas of psychology.
Research involving standardized psychological tests has been
minimally productive for several reasons. The problem of low base
rate of the behavior reappears: these tests are constructed from
statistical bases which routinely contain an error factor. They are
not designed to perfectly predict anything, but rather to place a
subject within some range on a particular norm. Conceivably, all
suicides could fall into the accepted statistical error range as
pointed out earlier.
Many studies in this area show inconsistency in their choice
of relevant variables used for matching control groups, or use no
control group at all. DeVries (1968) examined 75 studies involving
the use of psychological tests. No control groups at all were used in
23 studies and were discarded from his analysis. Of the studies using
control groups, he made no attempt to determine the adequacy of the
groups' compositions. Forty-seven of the remaining studies reported
some significant differences between the suicide attempt and control
groups. The MMPI and the Rorschach appeared to DeVries to yield the
most consistent results.
DeVries discussed two approaches using the Rorschach, a
configurational pattern approach (Hertz, 1949) and a checklist of
specific signs made in Ss' responses to particular cards (Martin, I960).
DeVries concluded that the checklist would prove of high predictive
value in future use, but subsequent replications (Drake and Rusnak,
1966; Neuringer, McEvoy and Schlesinger, 1965) found that the time
elapsed between the administration of the test and the occurrence of a
suicide attempt was of critical importance, and he has suggested that
suicidal tendencies are time-bound phenomena and that this type of
testing will only identify an acutely suicidal population. In
Piotrowski's (1968) review of projective tests of suicidal behavior,
he has proposed that the time element may be the most critical variable
in determining suicide potential, and that no psychological test that
has been developed to date can predict the timing of the occurrence
of a behavior.
Cutter and Farberow (1970) have utilized a variation known as
the consensus Rorschach, where the and his significant others are
asked to reach agreement as to what they see on the cards. The content
of the response is not as important as the interaction process by
which the decision is reached. The investigators found this tool of
value in assessing the stresses associated with the S/s verbal inter
actions with his family and friends.
With regard to the MMPI, DeVries (1968) found no significant
differences between controls, suicide throateners, attempters, or
completers on a profile analysis, but that a set of specific items
selected from the inventory could successfully identify the suicide
threat group from the others. It could not, however, identify the
10
commit group (Farberow and DeVries, 1967). DeVries (1967) also
constructed a 55-item inventory similar to the set of MMPI selected
items and had the same result: the suicide threat group stood out from
all others, but the commit group could not be differentiated from
attempts or controls. While DeVries concluded optimistically that
these types of tests will be of increasing value, Brown and Sheran
(1972) have noted that it may be as accurate and much more convenient
simply to ask a person whether or not he is suicidal.
Other widely used psychological tests which have been utilized
in attempting to identify suicidal people are the Thematic Apperception
Test (McEvoy, 1963 , 1974); the Bender-Gestalt (Nawas and Worth, 1968);
the Sentence Completion Test (Efron, I960); the Bosenzweig Picture
Frustration Test, the Hildreth Feeling and Attitude Scale, and the
Maslow Social Personality Inventory (Eisenthal, 1974), all without
success. Lester (1970) concluded that to date there has been no
standardized psychological test that has produced any data which can
predict suicide risk with any greater accuracy than a clinical Judg
ment made by an interviewer. He adds that the results of projective
tests depend primarily on the skill of the administrator rather them
on any intrinsic merit of the tests.
Farberow, et al. (1970) hypothesized that the lack of success
using traditional psychological tests may be due to the application of
tese tests at only one time, in order to measure the existence of a
"trait." They argue that most clinicians observe suicidal states as
being transitory. A patient may feel very suicidal one day and the
feeling is completely absent in a month. The authors state (p. 17),
11
In all probability it is the changing, rather than the
unchanging characteristics of the individual that will prove
predictive. By testing at intervals cohorts of high risk
individuals it should be possible to correlate successive
test results with at least self-reports of the fluctuations
in severity of suicidal ideation. Not only may longitudinal
studies help to distinguish the serious from the non-serious,
but also they may uncover more reliable or more discriminating
danger signals.
Brown and Sheran (1972) observe that the tests used up to now
measure signs that are of long-term duration ("traits") and are gen
erally insensitive to short-term effects. They cite Cutter's (1968)
study concerning the accuracy of prediction by Rorschach being time-
bounded, and a study by Neuringer and Lettieri (1970) which showed
suicidal people to be more dichotomous in their evaluative thinking.
The actively suicidal Ss in this study tended to rate objects on a
semantic differential more in the extreme ranges than did a psychiatric
control population and a group who had been suicidal but were no longer
in crisis. Brown and Sheran conclude from these data that the most
accurate prediction will be one which combines both long-term trait
data with short-term efforts.
The construction of clinical scales has met with a great deal
more success than has the use of psychological tests. Clinical scales
generally consist of demographic variables combined in a linear or a
weighted scoring format with information concerning the S_'s suicidal
behavior, such as the number of prior suicide attempts. Scales offer
several advantages in improvement of suicide prediction. A schedule
of this type is usually derived within a specific population (e.g.
hospitalized patients) and need not include extraneous variables which
lead to errors of overinclusion in more heterogeneous populations.
12
Long term risks may be assessed from personal history items, while
short-duration signs may be included to assess immediate risk. The
data are amenable to analysis in search of higher order interactions,
such as combining repeated measures of short-term signs with long
term variables to assess whether or not the suicidal £'s behavior fits
a pattern.
The inclusion of information concerning previous suicidal
behavior appears to be the key in reducing the errors of overinclusion
produced by the demographic data alone. Several aspects of suicidal
behavior have been shown to discriminate potential deaths from high
risk populations, and are included on several scales.
Previous suicidal communication is one important factor. Dorpat
and Boswell (1963) found that 82/? of a sample of suicide committers had
previously communicated suicidal ideas or had specifically stated their
intent to commit suicide. Farberow and Simon (1969) and Rudestam
(1969) found similar results. The occurrence of a previous suicide
attempt also appears to be important. In a review of 15 follow-up
studies based on prior suicide attempts, Dorpat and Ripley (1967)
estimated that between 20 and 65°/o of suicide committers had made prior
attempts. They also estimated that 10 to 2($ of all those who attempt
suicide go on to commit suicide at a later date.
The relationship of seriousness of previous suicide attempts to
probability of future suicide death is not as clear (Motto, 1965).
Tuckman and Youngman (1968) did find evidence that the more serious
the prior attempt, the higher the probability of future suicide death
was. The equivocal results in earlier studies may have been due to the
13
vagueness of measures used to judge the lethality of an attempt.
Cutter (1970) has separated the suicide attempt into three component
parts, each of which he measures on a 6-point scale to arrive at a
lethality index of high interrater reliability. These components are
the amount of planning, the choice of method of self-injury, and the
provisions made by the victim to facilitate or prevent rescue. In his
validation of this lethality index on the case histories of V.A.
hospital patients who committed suicide, Cutter found that the lethal
ity of attempts appeared to increase with practice, and was greatest
immediately prior to the fatal attempt, supporting the results of
Tuckman and Youngman (1968).
The existence of a suicide plan has been shown to be an impor
tant predictor by Dorpat and Ripley (i960). They concluded that well
over 5C$ of their sample of committed suicides had used procedures
which required some amount of planning, or they actually went to
isolated places. Heilig, Farberow and Litman (1968) developed a
numerical rating system for the lethality of a suicide plan, which has
been used to assess the immediate risk of telephone callers to the Los
Angeles Suicide Prevention Center. They break the suicide plan down
into components of l) lethality of the proposed method, 2) availability
of the means, and 3) the specificity of time of day and presence of
others nearby able to give help.
Since clinical scales are such a recent innovation, most
exhibit errors of overinclusion. This is to be expected with new
instruments and these errors should decrease as scales are validated
on increasingly homogeneous populations. The clinical scales
14
currently In use with hospitalized populations generally select items
from case histories without a direct interview. Scales combining
demographic items with summaries of psychiatric examinations have been
employed by Miskimins and Wilson (1969) and Bolin, et al. (1968). The
most accurate scales which identify committers (but still overinclude
many noncommitters) have included interview material with demographic
and case history information. Fawcett, Leff and Bunney (1969) found
that the most predictive variables for a hospitalized population were
the stated intent to die, information regarding £'s unwillingness to
take any action which might jeopardize relationships they were depen
dent upon, and behavior changes prior to an attempt.
Two widely used scales for non-hospitalized patients are the
Tuckman and Youngman (1968) Scale and the Suicide Prevention Center
Lethality Index (l97l). The former is based almost entirely on demo
graphic data and tends to overinclude by up to 94% in the commit range.
On the other hand, the SPC Lethality Index combines demographic data
with the suicide plan, the presence of environmental and interpersonal
stresses, and resources available to the person. At first it was
used to assess both long and short-term risk, but Litman, Farberow,
Wold and Brown (1974) report that accuracy is improved when measure
ments of acute and chronic risk are separated.
In summary, the use of clinical scales to predict suicide risk
in specified populations still suffers from errors of overinclusion,
but their combination of ecological with clinical data shows a great
deal of potential for refinement of prediction.
The clinical research on psychological tests and scale
15
construction which has been reviewed here is representative of efforts
to construct theories of prediction based on data which has already
been collected. That is to say, the proposing of a model follows the
discovery of some relationship. An alternative mode of suicide re
search has been to extend a model of behavior from some other branch
of psychology and to test whether or not this model can account for
the occurrence of suicidal behaviors. The extension of other psycho
logical models to incorporate suicidal behavior has been a fairly
recent development. Lester (1973) explains that this is the result of
the consideration of suicidal behavior as being the exception rather
than the rule in psychology. He observes that suicide is central to
many theories of society in the field of sociology, while in psycho
logy it is rarely incorporated into any full systems. It has usually
appeared as the footnote in someone's model of behavior causation,
the unwanted and infrequently occurring dependent measure.
Since suicidal behavior has been largely defined by psycholo
gists as deviant and exceptional, it has frequently been investigated
in the same manner as other abnormal or so-called "pathological"
behaviors, under the medical disease model.
Under the general heading of clinical models, Zubin (1974) has
identified five subcategories of predictive models. These are the
genetic, the internal environment, the developmental, the neuro-
physio logical, and the learning theory models.
The genetic and the internal environment models are both direct
extensions of the disease model, seeking to identify the biologic
defects of the suicidal organism. The genetic model (Kallman and
16
Anastasio, 1946) hypothesized that suicidal tendencies might be
inherited, but data from an identical twin study of 200 pairs of twins
showed only one instance of a pair of twins who committed suicide.
The authors concluded that suicidal behavior is not genetically based.
The internal environment model proposes that certain chemical
changes taking place in the body may be the precipitating factor in
the occurrence of suicidal behaviors. Bunney and Fawcett (1965) found
that suicide attempters and committers generally had a higher level of
urinary 17-hydroxycorticosteroids at the time of their suicide
attempts. However, a replication by Levy and Hansen (1969) did not
show results which firmly supported Bunney and Fawcett, since two of
their Ss who committed suicide showed no change whatever in their
corticosteroid levels. Platman, Plutchik and Weinstein (l97l) per
formed several repeated measures of blood plasma cortisol levels on
one manic-depressive S^. They found a continuing increase in the
plasma cortisol level over a six-week period prior to a suicide
attempt, and a rapid return to a normal level immediately following a
wrist-slashing episode. The authors emphasize that no cause-effect
relationship can be inferred from this study, and that only one was
used. Since so little data exist to either support or refute the
internal environment model, no conclusions can be drawn concerning it
at this time.
Developmental models of suicide include those derived from
psychoanalytic theories of Freud, and the more recent perceptual-
maturational theories. The Freudian model which explains suloide
aggression turned inward is disputed by several researchers. According
17
to this formulation, acting out against others and acting out against
oneself (suicide) would be located on opposite poles. Offenkrantz,
et al. (1957) found that their suicidal Ss were characterized by
temper tantrums, delinquency, and poor work performance records. They
were aggressive toward themselves and other people. Tuckman, Kleiner
and Lavell (1959) analyzed the content of 165 notes left by people who
had committed suicide, and found that only lc /o of the note-writers
mentioned aggression directed toward themselves. West (1965) found as
many suicide attempts among murderers in England and Wales as among
people who committed suicide and were not involved in homicidal behav
ior in those countries. In addition, he found that 1/3 of the homi
cides in England and Wales were murder-suicides, where the murderer
killed himself immediately after the homicide. It is unlikely that
aggression can be turned outward and then flip-flop inward at the
same moment. West added that his Ss displayed behavior more indicative
of despair than aggression prior to their deaths. One would thus be
forced to accept the model of depression as aggression turned inward,
and evidence is accumulating from learning theorists that depression
is more of an extinction phenomenon than a redirection of aggression.
The evidence supporting a behavioral model of depression will be
discussed later.
Another developmental model of suicide is based on the work of
Rotter (1966) regarding a person’s locus of control. Rotter proposes
that during every person's earlier years, he develops a learned set
of expectancies with relation to where the majority of his reinforcers
are located. Each person develops a set over time that his reinforcers
18
are either internally controlled (high i), or that his behavior is
for the most part externally controlled (high E) by powers outside
of himself.
Researchers using the Rotter (1966) I-E Scale expected to find
most depressives and suicidals to be high I, blaming themselves for
failures. However, Williams and Nickels (1969) found that Ss who
scored high on the DeVries (1966) scale of suicide potential had high
E scores. Lamont (1972) also found unexpectedly high E scores using
depressed Ss and did an item analysis of their responses. He dis
covered the high E scores to be an artifact of the mood level content
of the items. The wording of the K items is more depressing in tone,
and the depressively worded items were more frequently chosen by de
pressed S_s. Nondepressed £s chose the more optimistically worded
items, regardless of their I or E orientation.
Zubin (1974) has proposed that whether a person is a high I or
a high E is not important in predicting whether or not he will become
suicidal. He states that if external circumstances force a person who
has strongly established an I or E set to reverse the set to its
opposite locus, he may be unable to cope with the sudden shift and
become suicidal. For example, a highly independent person who fails
and must be cared for by others or a highly dependent person who is
suddenly forced out on his own may both experience suicidal crises.
Under this model the problem the person experiences is a perceptual
one with regard to a radical alteration of his learned set of expec
tancies. Zubin adds that research on locus of control deals only with
this perception and is not an objective measurement of where the
19
reinforcers are really coming from.
The model of suicidal behavior which stems from analogue re
search comparing depressed and suicidal individuals to animals placed
in highly stressful situations with no escape (Seligman and Maier, 196^
is labeled by Zubin as the neurophysiologic model. Why this model is
specified as "neurophysiologic" rather than simply "extinction" is not
made clear by Zubin. The phenomena characteristic of this model are
not necessarily exclusively those of classical conditioning, which the
term "neurophysiologic" implies, but may be characteristic of operant
conditioning also. This question of choice of labels will not be dis-
dussed further here. The responses observed in an experimental situ
ation which led to the formulation of this model where than an animal
which was repeatedly shocked and could not escape the situation even
tually ceased to perform any overt motor behaviors and would not per
form an escape response even when no longer restrained. This resultant
lack of adaptive responding was labeled by Seligman as "conditioned
helplessness." Wolpe's (l97l) analysis of this phenomenon is (p.363-4)
"...that during the period of inescapable shocks...the dog 'uses up'
its repertoire of adaptive responses to shock...each response in turn
fails - is unreinforced - and in failing tends toward extinction.
Eventually, when the whole repertoire has been extinguished, motor
responding ceases. Very little motor response should be expected sub
sequently to the administration of shock in any environment."
Wolpe states three similarities of conditioned helplessness to
clinical depression. These are l) diminished response initiation,
where no one can seem to motivate a patient to perform even simple
20
behaviors; 2) a diminished repertoire of responses; and 3) cognitive
difficulty, where even if the proper responses are demonstrated, there
is no behavior change unless the patient is led physically through the
performance sequence several times.
Despite similarities, one can criticize the neurophysiological
model on two grounds. The first is that the electric shock of infra-
human organisms may not be analogous to the types of interpersonal
stresses that may contribute to depressive and suicidal behaviors in
humans. There are no experimental data on humans at present to validate
the extension of this model to include humans as well as lower organ
isms. The second criticism is that Wolpe assumes that all adaptive re
sponses are extinguished. This does not account for a person experienc
ing a great deal of success in one personally meaningful facet of his
life, such as business, and still experiencing depression or committing
suicide. More research with humans is necessary on this model to vali
date its extension from lower mammals.
The final model to be considered is the learning theory model.
During the last few years, evidence has begun to accumulate that
learning theory models may make a major contribution to the prediction
and prevention of suicidal behavior. Ullmann and Krasner (1969),
Cutter (l97l) and Frederick and Hesnik (l97l) have hypothesized that
suicide is not a unique deviant act peculiar to one category of de
fective personality, but that the full range of suicidal behavior is
a response class subject to the same laws of reinforcement and learning
as any more adaptive operant behavior. Cutter has proposed that the
outcome of life or death in any specific suicidal episode is the re
sult of several chance factors operating in that particular
21
environment, such as the choice of method or actions of other people to
save the victim. Both Cutter and Frederick and Resnik believe that the
act of self-injury is learned vicariously. That is, a set of possible
responses for injuring oneself may be learned via modeling the self-
injurious behavior of significant others or of characters in the pop
ular media. The actual occurrence of a self-injurious response would
be a function of some combination of as yet unspecified influences
operating in the person's environment and his repertoire of methods for
coping with them.
Although learning theories have been in use as models for re
search on human behavior for decades, their extension into the field
of suicide research has begun only very recently, for two reasons. One
has been the inability of learning theorists to explain suicide within
a system based on goal-directedness. The other reason has been the
examination of suicide as a mediational variable, a condition of an
organism, rather them simply as a dependent variable, a set of observ
able behaviors.
Lester (1973) discusses the problem of accounting for self-
destructive behaviors within the framework of learning theories, which
generally rely on either a homeostatic or a pleasure principle model of
motivation. Theories based on dynamic homeostasis propose that all
behavior is the result of the organism seeking to achieve physiological
or psychological equilibrium. Theories based on the pleasure principle
explain all behavior as the organism's efforts to achieve pleasure.
Neuringer (1962) felt that these theories could not adequately
explain the occurrence of suicidal behaviors. His reasoning was that
22
avoidance mechanisms are dynamic (e.g. fainting, sleep, catatonia,
where the organism remains physically intact) and that suicide is an
entropic form of homeostasis, the complete cessation of all bodily
activity, which is found only in death. Lester (1973) argued that
Neuringer arbitrarily defined an "adjustment" made by a person to
achieve homeostasis as something which would help the person go on
living. Using this definition, a person becoming psychotic as a de
fense against suicide would be an adjustment, while a person’s com-
miting suicide as a defense against beoming psychotic would not.
Lester states that if a state of dynamic homeostasis is defined as the
continuation of bodily processes, then Neuringer is correct that
suicidal behavior cannot be explained in this theoretical framework.
However, Lester proposes instead that a form of the pleasure principle
be utilized which is not based on bodily continuation. He contends
that if "happiness" is defined as the goal, an individual might sub
jectively rate death or cessation ahead of other alternatives of the
possible outcomes of a crisis. For certain people under great stress,
death might appear to the person to be a better adjustment to achieve
a relative state of pleasure than anything the person perceives that
life has to offer. Thus, self-destructive behavior could be included
in a learning theory framework.
The problem of treating suicide as a mediational construct
rather than a dependent variable is discussed by Neuringer (1974) in
his review of psychological studies of suicide risk. He states (p.225)
It appears the procedures that focus on the use of overt
behavior (the lethality schedules and survey researches) are
more effective than those techniques that depend on
23
hypothesized intervening mediational constructs. Techniques
utilizing behavior (without reference to mediational, moti
vational, or personality states) in a direct comparison between
suicidal and non-suicidal individuals seem to yield more con
clusive results than do procedures that derive their starting
points from hypothesized mediational concepts.
He continues (p. 227):
What is being suggested here is that suicidal risk evalu
ation should be based only on observed and compared behaviors
rather than actively derived from mediational concepts. There
are dangers connected with perceiving suicide as anything else
than an empirical behavioral event.
The unity conceptualization of suicide (that it is a
discrete entity rather than the outcome of a heterogeneous act
of influences] has led us to believe that it plays the role of
mediator between events (stimuli)and as a determinor of be
havioral outcomes (responses)...It may be more productive to
think of suicide not as the arbiter of behavior, but of it as
the behavior itself: a behavior that may be invoked by any of
a large class of stimuli and mediators. I am proposing that
suicidal behavior ought to be thought of as a general response
tendency hierarchy, and which can be evoked by a wide variety
of conditions...The concept of suicide as a mediational unity
has forced us to think of suicide as a disorder rather than a
symptom. The symptom needs treatment...
Only a few theorists to date have adopted the orientation that
suicide may be examined as simply one alternative, albeit a very
dramatic one, in a person's response hierarchy for dealing with a
variety of situations.
Ullmann and Krasner (1969) view suicidal behaviors as learned
responses for coping with severe stresses. The problem then becomes
one of predicting under what conditions the suicidal responses are
most likely to occur for that individual. Ullmann and Krasner proposed
this formulation only as a model for future research, since they had
no experimental data for its validation.
Cutter (l97l) adopted a similar viewpoint, proposing that
24
suicidal behavior is a learned response to what he termed "perceived
deprivation According to this formulation, a person who perceives
himself to be in an unsatisfactory state engages in increasingly
extreme alternative behaviors in order to change his perception of his
present uncomfortable circumstances. Once a suicidal behavior is
performed or is even seriously considered as a coping strategy, the
behavior gains a disproportionate strength in the person's hierarchy,
leading to what clinicians often label "suicidal preoccupation Cutter
hypothesizes that this phenomenon is due to lack of information about
what the experience of death is like. Information about every ex
periential state of living is available, but since no one has ever died
and lived to tell about it, the possible aversive consequences of death
remain a mystery. Cutter proposes that as the stresses in a person's
life increase, the alternatives the person perceives that life has to
offer decrease and the attractiveness of death is increased. Pre
occupation with death may assume almost obsessional characteristics
under these conditions, due to lack of solid information as to the
negative consequences of dying.
Cutter (1970) attempted to predict suicide potential on the
basis of a construct he called the "wish to die ." He viewed this
construct as being separate from the act of self-injury and from the
life or death outcome of the act. Cutter hypothesized the wish to
die to be a component of the group of behaviors which are part of the
process of a suicide attempt, necessary but not sufficient to actually
trigger the act. He operationalized the wish to die as a combination
of the S/s actual suicide plan and his preoccupation with death,
25
measured by means of a questionnaire. Validation of this instrument
was carried out only on a psychiatric inpatient population, with no
control group. The test was designed to be time sensitive, to detect
changes in short-term signs of risk. However, repeated administration
of the instrument led to a gradual perseveration of responses, pro
bably due to familiarity of those particular stimuli. In spite of
this weakness, Cutter's method of combining measurement of repeated
short-term signs with longer term case history signs of risk showed a
great deal of promise. No further validation of his instrument has
been performed to date.
Jacobs (l97l) attempted an experimental validation of Litnan's
(1965) hypothesis that suicidal behavior is the final outcome of a
progressive failure of adaption, rather than a sudden and unpredictable
event. Jacobs' central hypothesis was that in his subject population
of adolescents, suicide attempts resulted from the Ss' feelings that
they had been subject to a "progressive isolation from meaningful
social relationships," He felt that suicide attempters and completers
were subject to the same process, and that this process, by which a
decision was reached to make a suicide attempt, followed a logical
sequence.
Jacobs saw this process as consisting of (1) a life long-history
of interpersonal problems, (2) an escalation of these problems at the
onset of adolescence beyond the level usually associated with this
commonly problem-filled period, (3) progressive failure of adaptive
coping techniques, (4) a chain reaction dissolution of meaningful
social relationships immediately preceding the suicide attempt, and
26
(5) an internal process by which the justifies the alternative of
suicide to himself.
Jacobs' data revealed several important findings. One was that
the suicidal group experienced more serious, disruptive, unwanted and
unanticipated events than controls. The suicidal group had a greater
incidence of being suspended from or quitting school, serious illness,
hospitalization, broken romances, incarceration in Juvenile Hall, and
unplanned pregnancies. More of this group were judged by their parents
as behavior problems, and experienced greater disciplinary actions by
parents. The typical sequence of behaviors preceding a suicide
attempt was rebellion, followed by psychological withdrawal (depressed
affect) and then physical withdrawal (running away). Jacobs found that
only 2 or his 35 Ss did not follow this exact sequence of behaviors
before they made a suicide attempt. Jacobs also found that many Ss
did engage in a self-convincing procedure before making an attempt.
The most common sequence was one of defining problems as being exter
nally caused, the _S feeling that he did all he could but failed, and
thus that death was necessary. The above data give strong support to
the view that suicidal behaviors are learned and are performed as
coping responses in the face of perceived stress.
Frederick and Resnik (l97l) have proposed a Hullian learning
theory model to explain the learning and maintenance of suicidal be
havior. They emphasize that their model is based on only a small
amount of their clinical data, and therefore they hypothesize it
simply as a basis from which future research may be derived.
The authors feel very strongly that not only is the overt act
27
of self-injury learned, but that each component that precedes the overt
act (fantasy, planning, threats, etc.) is subject to the influences of
learning. They state that suicide is not a pnenomenon with a unitary
cause, but like other clinical syndromes such as alcoholism, may have a
wide variety of causes resulting in the same response. They believe
that a number of complex variables may affect the occurrence of suicidal
behaviors, such a personality, environment, and strength of past re
sponses made in similar situations. What the responses have in common
is that they are the end products of operant learning procedures.
This model has several strengths. One is that it demonstrates
how suicidal behaviors can be maintained by positive reinforcers in the
absence of any depressive symptoms. Revenge on a significant other or
simply the attention given to a person following a self-injury may be
strong positive reinforcers. The Hullian stimulus-response learning
model they employ explains the performance of all behavior, including
suicide, as a "direct multiplicative function of drive or motivation
multiplied by those past learned associations or habits connected with
such behavior." (p. 44). Self-injury may become the preferred re
sponse in certain situations due to the reinforcement contingencies
operating there, or may be extinguished it if is repeated several times
and no longer elicits the same amount of attention from significant
others. The authors demonstrate through use of a mathematical model
how the extinction of a larger class of adaptive responses will leave
the with a smaller set of strongly reinforced responses (including
suicide) with a higher statistical probability of occurrence as well
as greater habit strength. They show how under certain hypothetical
28
circumstances, the motivation and habit strength of a potential sui
cidal response can become stronger than other adaptive responses and be
elicited by a single positive (or negative) reinforcement. They add
that associative learning principles may possibly be involved, where
performance of a self-destructive response in a specific situation may
become associated with that situation. The £[ would have a greater
probability of making a future suicide attempt in that type of situa
tion although other situations might cause the £ greater stress but
not precipitate a suicide attempt.
The only criticism of this model is that it appears to over
classify most suicidal behavior as being a drive reduction phenomenon
based on the primary drive of anxiety. Y/hile it can be demonstrated
that suicidal behavior may be reinforcing to a person because it leads
to a temporary reduction in anxiety, their utilization of anxiety
simply as a drive state may be erroneous. Neuringer (1974) prefers to
view anxiety as an analogue to suicide rather than a cause. He defines
both anxiety and suicide as general response tendencies to any of a
large class of noxious stimuli. Aside from its reliance on anxiety as
a primary drive state in the learning of suicidal behaviors, this
model of Frederick and Resnik is an excellent framework from which
hypotheses can be tested.
Neuringer (1970) proposes a learning theory model of suicidal
behavior based upon avoidance responding. Neuringer does not approach
the question of positive reinforcement for suicidal responses, which
Frederick and Resnik did include in their model. Neuringer states
29
(p. 228):
Suicidal behaviors are learned behaviors which have their
basis in unlearned responses. The basic inborn parent response
for suicidal behavior is the’avoidance reflex.,,The avoidance
reflex gives rise to a host of more complex responses (e.g.
denial, avoidance, retreat, and flight). These complex re
sponses may be further elaborated into even more complicated
response patterns (hysterical blindness, excessive sleeping,
schizophrenic withdrawal, etc). Suicidal behavior is only one
member of the family of avoidance reflex elaborations. A
large number of the other avoidance reflex-based responses
seem to be concurrently evoked along with the suicidal
behaviors.
In proposing that suicidal behaviors are avoidance responses to
stress, Neuringer has at the same time made a useful suggestion and
clouded it by introducing a separate issue. His discussion of the
"avoidance reflex" appears to be based on the assumption that a
classically conditioned autonomic nervous system effect mediates the
acquisition of instrumentally learned avoidance responses (Rescorla
and Solomon, 1967). There is evidence that the mediator for acqui
sition is not classically conditioned emotional arousal, but rather is
the process of covert rehearsal of alternative behaviors. While Wolpe
(1958) believed that deep physiological relaxation was necessary in
removal of avoidance responses (desensitization of phobias), Wolpin
and Raines (1966) successfully reduced avoidance responses by pre
senting only imagery of the feared stimuli without relaxation.
Wilson's (1967) explanation of this effect was that the Ss cognitively
rehearsed behaviors for coping with the feared object and that this
extinguished their avoidance responses. Lacey (1967) proposed that
autonomic arousal responses are co-effects of avoidance responses and
that they are not causally related.
Thus, Neuringer's (1974) hypothesis explaining suicide as an
30
avoidance response may be clouded unnecessarily by his introduction of
the issue of classical conditioning. These recent findings concerning
the operant nature of avoidance responses indicate that a mediator
other than or in addition to physiological arousal is present. The
covert rehearsal of death-related alternatives may be a self-reinforcer
which maintains suicidal behavior. Manno (1972) found that in over
weight Ss, positive imagery concerning the benefits of not eating and
negative imagery concerning the aversive consequences of eating were
both effective in modifying overt eating behavior. Suicidal people
might similarly raise or lower the probability of engaging in overt
self-injury by covertly rehearsing the positive or negative conse
quences of the act.
Zubin (1974) supports the Frederick and Resnik model that sui
cidal people have learned self-destructive behavior the same way they
have learned other more adaptive coping mechanisms, either through
successful reduction of stress or positive manipulation of the environ
ment. He does not present any new data in his review, but discusses
what he sees as the most productive direction future research should
take. He states, (p. 13):
One of the contributions of learning theory to the diag
nosis of any disorder is the determination of the contingencies
in which deviant beliavior occurs and what maintains such be
havior. Such behavioral analyses constitute the basis for
behavior therapy. Target symptoms are found on which the
efforts of the therapist can be focused. Similar analyses of
contingencies that elicit suicidal behavior (including ideation)
and those that maintain it can become a new direction for
suicidal research.
(p. 23)
For the learning theory model, we need careful observa
tional studies of the selected group to determine what
31
situations tend to reinforce suicidal ideation and what
maintains such behavior.
To date, there has been no systematic baseline observation and
classification of any general categories of reinforcers which elicit
suicidal behavior in specified populations. However, one field of
clinical study where this has been accomplished is in the area of
depression. The value of this research for the present discussion is
that depression is an observable symptom occurring in a high proportion
of people exhibiting suicidal behavior. Although not all patients
prone to depression Eire suicidal and not all suicidal people appear to
be depressed, a much higher proportion of people identified as suicidal
concurrently exhibit depressive symptoms than any other psychiatric
symptoms.
A number of models of depression based on leEirning theory have
been proposed (Wolpe, 1971, Seligman, 1971, LibermEin smd Raskin, 197l).
However, the only research which has systematically classified the
specific behaviors of depressed patients and the reinforcing events
associated with these behaviors of depressed patients has been
carried out by Lewinsohn (1973) and his colleagues. They have de
rived a behavioral model of depression based on the observations of
Perster (1965) and Lazarus (1968) that many depressed people appeared
to have suffered interpersonal losses which caused sudden reductions
in the reinforcement schedule maintaining their interpersonal be
havior. Lewinsohn, Shaffer and Libet (1969) formulated a model which
explains the symptoms of depression as being secondary to a low rate
of response contingent positive reinforcement.
They propose that when a person ceases to receive reinforcement
32
for a large number of social behaviors, the person stops performing
these behaviors. The depressed person is considered to be on a pro
longed extinction schedule, the results of which sire a low rate of
motor behavior, social isolation, somatic symptoms such as fatigue,
and verbalizations of unworthiness and guilt. The cognitive mani
festations such as feelings of guilt and low self-esteem may vary
widely among individuals, and the authors propose that these differ
ences sure due to a self-labeling process. Schachter and Singer (1962)
found that a state of physiological arousal could be labeled as
either euphoric or unpleasant by £s, and Lewinsohn e£ al. (1969)
believe that each depressed £ can label his uncomfortable state of
non-reinforcement individually as sickness, guilt or inadequacy. The
cognitive changes are maintained by the continued lack of response
contingent positive reinforcement.
Several studies yielded empirical results consistent with this
behavioral theory. I.acPhillamey and Lewinsohn (l97l) developed sin
instrument called the Pleasant Bvents Schedule, listing 320 activities
which a large subject pool judged to be positively reinforcing. The
PBS measures both how often the S_ engages in each activity and how
pleasant the £[ finds each activity. In addition to measuring the S/s
activity level and amount of available reinforcement (activities £ 3
finds pleasant), the frequency of each item multiplied by its pleasant
ness gives an index of net positive reinforcement. Lewinsohn smd
Libet (1972) found a significant association between mood and the
number of "pleasant" activities engaged in. When pleasant activities
and changes in depressive moods were measured on a daily basis, Ss'
33
mood changes were highly correlated with the number of activities
engaged in the same day. The higher the frequency of pleasant
activities, the less depressed was their mood. Many of the activities
which were most highly correlated with positive mood changes were
social interactions. MacPhillamey and Lewinsohn (1972) found that
depressed Ss had a lower activity level than nondepressed £s, rated
fewer items as pleasant, had a lower net obtained pleasure score than
either a psychiatric control or normal group, and thus appeared to be
receiving less positive reinforcement. Both control groups were
roughly equal on these measures, suggesting that the observed effect
is unique to depressed S_s.
libet and Lewinsohn (1973) also attempted to operationalize
the concept of social skill with regard to depressed people. They
define social skill as the ability to emit behaviors which are posi
tively reinforced by others, and they hypothesize that depressed people
lack the skill to elicit positive and avoid negative reinforcement
from other people. Using a complex coding systan recording the verbal
interactions of participants in several therapy groups, the authors
found depressed Ss emitted interpersonal behaviors at only about half
the rate of nondepressed Ss. The interpersonal efficiency (the ratio
of verbalizations given to received, the amount of reciprocity in
interpersonal interactions) of depressed Ss was lower than that of
nondepressed Ss, The interpersonal range, or number of other people
an S_ chooses to interact with, was much more restricted in depressed
£s. This leaves the S^ with a greater likelihood of having hi3 verbal
behavior extinguished, should the few people he limits his
interactions to ever fail to respond. The depressed Ss expressed fewer
positive statements in interactions, thus failing to reinforce the
attention of others. Finally, the action latency of a depressed S/s
response to other people's verbalizations was typically longer, and
thus they tended to both "lose the floor" in speaking, and fail to
respond quickly enough to be reinforcing to the previous speaker.
It is probable that many of the contingencies Lewinsohn and his
colleagues have observed shaping the behavior of depressives are also
operating in the shaping of suicidal behavior.
The preceding review indicates that the processes of extinction
of interpersonal behavior, instrumental avoidance responding to
stressful situations, and positive reinforcements received for self-
destructive responses may all be interacting in the formation and
maintenance of suicidal behavior.
35
Statement of the Problem:
Baaed on the preceding discussion, it would appear that the next
logical step for research to take under the learning theory model is
a careful observational study of suicidal and non-suicidal Ss to de
termine the differing reinforcement contingencies which discriminate
between these groups. If it can be demonstrated that specific rein
forcing events (both positive and negative) have a higher frequency
of occurrence in the suicidal group than in the non-suicidal group,
these events would become the targets for therapeutic intervention.
In addition, the events occurring in the suicidal group which are most
highly correlated with repeated occurrences of suicidal behaviors could
be identified as the most productive targets for modification.
The present study will address the following problems:
1. When a suicidal population and a non-suicidal popula
tion are matched according to diagnosis (Ss in both groups
diagnosed as depressed and not psychotic) and relevant demo
graphic variables, are there differences in specific reinforce
ment contingencies operating in the 3s' respective environments
which can discriminate between the groups?
2. In a population which has repeatedly exhibited suicidal
behavior, do changes in reinforcement contingencies over a
specified time span correlate with changes in frequency and
severity of suicidal behavior occurring during that same time
period?
Groups:
1. Suicidal: Outpatients with diagnoses of depression and no
36
evidence of psychosis who have made suicide attempts and report that
suicidal preoccupation continues to be a problem for them.
2. Control: Outpatients with diagnoses of depression and no
evidence of psychosis, and no report of any overt suicidal behavior
(threats or attempts) during the last ten years.
Hypotheses:
1. The frequency of engaging in positively reinforcing activi
ties and the net amount of positive reinforcement obtained for non-
suicidal behaviors will be lower in the suicidal group than in the
control group.
2. While both groups will exhibit the extinction (non-reinforee-
ment) of social behavior characteristic of depressives, the suicidal
group will perceive more negatively reinforcing noxious stimuli to be
present in their personal environments and perceive themselves to be
suffering a greater number and subjectively more serious losses than
the control group.
3. A co-effect of the greater number of negative reinforcers
present in the environments of and more losses suffered by the suici
dal Ss will be a higher chronic (trait) anxiety level and situational
(state) anxiety level than the control Ss.
4. If "adaptive coping mechanisms" are defined as non-suicidal
responses performed in stressful situations in order to relieve the
stress, the suicidal group will report performing a smaller repertoire
of adaptive coping mechanisms than the control group in stressful
situations.
5. The suicidal group will have a significantly larger number
37
of models in their past who have committed suicide than the control
group.
6. Attitudes toward death will differ significantly between the
groups, (a) The suicidal group will report less fear of death, view
death as a subjectively more pleasant state, perceive greater control
over the time of their death and perceive less difficulty in causing
their own death than the control group, (b) Cognitive rehearsal of
death-related alternatives will be more frequent in the suicidal
group, with these £5s reporting a preference for death over life in a
greater number of imagined stressful situations than the control
group.
7. Within the suicidal group, the frequency of suicidal
ideation and overt suicidal behavior over specified time periods will
be positively correlated with increases in negative stimuli in each
£*s environment and negatively correlated with increases in positive
social and material reinforcers.
8. Within the suicidal group, changes in the frequency of
suicidal ideation and overt suicidal behavior over time will be
positively correlated with changes in both positive externally ad
ministered reinforcement received for previous suicidal responses and
positive self-reinforcement which follows the occurrence of suicidal
behaviors.
38
BETWEEN - GROUPS COMPARISON:
A. Independent Variables
The number of potential independent variables in this study is
quite large, since there is an extensive range of possible reinforce
ment contingencies associated with the occurrence of suicidal be
haviors. No study conducted to date has systematically categorized
all of the possible positive and negative reinforcement contingencies
which may influence the occurrence of suicidal behaviors. The
independent variables selected for examination here are drawn from
several sources. Initially, the diverse results of previous research
which correlated various behavioral patterns and events with the
occurrence of suicidal acts were cast into a learning theoretical
framework. The remaining independent variables are factors which are
as yet unexamined in their relationship to suicidal behavior. They
are derived directly from learning predictions concerning the perform
ance of any operant response. The basis for selection of each in
dependent variable is discussed below.
1. Losses: The experience of a recent loss may be an important
factor contributing to the occurrence of suicidal behavior. Murphy
and Robins (1967) found that most alcoholics who committed suicide
had suffered some kind of loss in the six weeks prior to their deaths.
Parberow and McEvoy (1966) categorized four types of losses suffered
39
among depressed males who committed suicide. These were (l) object
loss, such as a spouse who was emotionally depended upon, (2) invol
utional, such as retirement and loss of income because of old age,
(3) egoistic, where the had always been alone and had resisted
treatment, and (4) medical, such as a debilitating disease. Breed
(1967) proposed three categories of losses among males who committed
suicide irrespective of age or diagnosis. These were (1) position
(downward economic mobility), (2) personal, through lack of a close
relationship, uncomfortable relationship, rejection, or death, and
(3) mutuality, through inability to derive satisfaction from business
or social interactions.
Thus, some measurement of the frequency, severity, and reversi
bility of major losses a person has suffered may be predictive of the
occurrence of suicidal behaviors. Within a learning framework losses
should act as negative reinforcers shaping suicidal behavior.
2. Models: The presence of a significant other who committed
suicide has been proposed by Frederick and Resnik (l97l) as one of the
most important sources of initial learning of suicidal responses. They
hypothesize that most people who attempt suicide know someone who or
know of someone who has either committed or attempted suicide.
3. State of Health: Physical illness may be an important
contributing factor to suicidal behavior. Motto and Green (1958)
found that 4C$ of committed suicides and 60$ of attempted suicides had
been under medical care within six months of the last suicide attempt.
The authors added that most of the complaints were characteristic of
stress reactions, such as insomnia, headaches, and gastric problems.
40
In a learning theory framework, ill health would act as a negative
reinforcer contributing to the occurrence of suicidal responses.
4. Perception of afterlife: A person1s perception of what
death is may have some effect on his willingness to die. Shneidman
(1968) proposes four classifications of death-related behaviors, any of
which a person could adopt as his own concept of death. These are:
(a) cessation, the stopping of any futher conscious experience;
(b) termination, the stopping of all physiological processes, which
may occur along with cessation, or without cessation, as in Christian
life-after-death; (c) interruption, the temporary suspension of
consciousness, as in sleep or coma; and (d) continuation, with a pain
less transition to another pleasant life as in reincarnation. In a
learning theory framework, a person's perception of a pleasant life
after death or a continuation of consciousness would be a positive
reinforcer for suicide, and the perception of death as an interruption
or cessation of stress would be a negative reinforcer shaping suicidal
behaviors. As discussed previously (Manno, 1972), the covert rehearsal
of the consequences of a behavior influences the probability of its
occurrence.
5. Perception of the possible consequences of suicidal behavior:
The possible negative consequences of suicidal behaviors may be co
vertly rehearsed and reduce the probability of suicidal behaviors.
For example, previous painful self-injuries or fears of deserting
significant others by dying may be potential consequences which inhibit
suicidal responses.
6. Cognitive rehearsal of death under stress: If death is
41
perceived as a positively reinforcing state or as a relief from
stress as proposed above, the range of stressful situations which
could cause a person to cognitively rehearse his own death would be
much larger for people who are suicidal. Presentation of a set of
imagined stressful situations should generate more cognitive choices
of death in a suicidal group than in a control group.
7. Coping mechanisms: The size of a person's repertoire of
non-suicidal responses for coping with stressful situations may be
highly related to the probability of occurrence of suicidal responses.
Caplan (1964) has proposed a homeostatic model of a person's reactions
to stress. He hypothesized that a person's emotional equilibrium is
maintained by a set of learned coping techniques employed to solve
day-to-day problems and keep stress at as low a level as possible.
When several coping techniques fail or a problem has unusually great
personal impact, the emotional reaction to the situation may pre
cipitate a crisis, which includes the possibility of suicide. Within
the learning framework employed here, the number of coping mechanisms
a person employs under stress would have a direct relationship on the
likelihood of that person's engaging in suicidal behaviors.
8. Acquisition of positive reinforcement by non-suicidal
responses: Prior research has demonstrated that suicidal responses
may be performed to extract positive reinforcers from the environment
as well as to relieve stress. Hankoff (l96l) found that suicide
attempts among Marines on duty occurred in clusters when there was
maximal secondary gain, such as hospitalization and relief from duty.
When these rewards were withdrawn, the number of suicide attempts
42
attempts declined markedly. The most common secondary gain appears to
be the direct manipulation of other people. Sifneos (1966) found that
66/0 of Ss who attempted suicide were trying to manipulate or control
another person, usually a partner in a dyad. It appears that suicidal
people either do not perform or simply have failed to learn the inter
personal behaviors necessary to acquire social reinforcement. Barter
et al. (1968) found that adolescent multiple suicide attempters had
significantly less active social lives than Ss who made only one
attempt. Fawcett (1966) observed that the majority of suicidal Ss
seemed totally unable to communicate to significant others exactly
what they wanted from their relationships. They also appeared unable
to bargain or fight effectively with their spouse or partner. Libet
and Lewinsohn (1974) noted that the social skills (performance of
behaviors which are positively reinforced by others) of depressed Ss
are much lower than those of nondepressed Ss. The learning theory
framework used here would predict that the frequency and success of
non-suicidal responses in acquiring positive reinforcers are negative
ly related to the probability of occurrence of suicidal behaviors.
8. Aversive stimuli which extinguish adaptive, non-suicidal
responses: As stated previously, personal losses may act as negative
reinforcers shaping suicidal responses as avoidance behavior. Other
negative social stimuli may serve both as sources of stress (as losses
do), or may act as punishers to suppress more adaptive responses.
Hattem (1964) studied several married couples in which one partner
was suicidal, and found that several Ss attributed their suicidal
feelings to the spouse's rejection. Self-ratings by the spouses showed
43
them to be competitive and generally emotionally unsupportive of the
suicidal partner. Harris (1964) followed up these same Ss and found
that people who remained partners in these exploitive dyads remained
suicidal longer theui those who left the relationship. Ganzler (1967)
found that a leirge number of suicidal Ss described themselves as being
constantly on the verge of social isolation (usually through threats of
a partner to leave) and feeling powerless in crisis situations. Peck
(1965) described the spouses of suicidal Ss as frequently being double-
binders in communication. The spouses commonly denied any pathology on
their own part, and either ridiculed or discounted the suicidal
partner's complaints. V/ithin the learning model, these types of social
punishers suppress adaptive interpersonal behaviors and raise the
probability of suicide.
B. Dependent Variables:
The major dependent variable in the between-groupu comparison
is membership in the suicidal or control groups as predicted by the
independent variables. Two related dependent variables are being
measured separately between groups because they are co-effects secondary
to the effects of the independent variables. These are the chronic
and situational anxiety levels of each _S, and a combination of the
activity level and net positive reinforcement received by each £3.
44
WITHIN - GROUP ANALYSIS:
A. Independent Variables
For the within-group analysis of the suicidal group, the
independent variables will consist of several repeated measures.
Several are variables included and already discussed in the between-
groups analysis. These are (l) changes in state of health, (2)changes
in the frequency of performance of non-suicidal interpersonal be
haviors, (3) changes in the frequency of social punishers, and
(4) occurrence of new losses. Two additional independent variables
added exclusively for the within-group analysis are (5) positive
reinforcement for suicidal behaviors through successful manipulation
of others, and (6) self-reinforcing behavior following overt
suicidal behavior.
The issue of manipulation of others through suicidal behavior
was discussed in part in the previous section. The frequency of
suicide attempts among chronic attempters appears to be strongly in
fluenced by the positive attention of others as well as the negative
stimulation of unsatisfactory relationships. Kass, Silvers, and
Abroms (19Y2) found that among female hysterics, there was a regular
pattern of attempts to manipulate men first by sexual game-playing,
then histrionic behavior, and finally suicidal gestures or attempts.
Frederick and Resnik (1971) found that the attention of the psychia
trist was a powerful positive reinforcer for suicidal gestures among
their Ss. They add that the timing of a suicidal response may often
45
be based on the person's expectancy of maximal positive gain for that
response. The importance of covert rehearsal as a self-reinforcer for
suicidal behavior has already been discussed. In addition to fantasies
of suicide under stress acting as self-reinforcers for future suicidal
behavior, learning theory would predict that any self-reinforcement
following an overt suicidal act would serve to reinforce that response.
The person's internal judgment of the success of his overt suicidal
behaviors would be an important positive or negative reinforcer for
future overt suicidal acts, as well as feelings of pleasure or stress
reduction following suicidal activities.
B. Dependent Variables:
The dependent variables for the within-group comparison are the
frequency and severity of suicidal behaviors performed during the
tine span over which the independent variables are measured.
46
CHAPTER II
METHOD
Subjects:
£s in the suicidal population consisted of outpatients in
treatment at the Los Angeles Suicide Prevention Center and at the
Mental Hygiene Clinic at the Brentwood Veterans Administration Hospital
in Los Angeles. Twenty-five Ss were selected, 14 male and 11 female,
ranging in age from 17 to 48 years old, with a median age of 30. Ss
were selected according to the following criteria: (a) diagnosis of
depression or a combination of anxiety and depressive neuroses, with no
evidence of psychosis or history of narcotics addiction; (b) no in
patient psychiatric hospitalization in the last 90 days prior to their
interview; (c) no medical hospitalization of over 5 days duration in
the last 30 days; and (d) a history of suicidal behavior defined by at
least one recorded attempt and the self-report that suicidal preoccupa
tion was a current problem at the time of the interview. Participation
was on a voluntary basis with no payment to the Ss with the exception
of transportation fees. Ss in the control population consisted of 25
outpatients from the V.A. Mental Hygiene Clinic and the Benjamin Rush
Clinic in Los Angeles. Fifteen male and ten female £s ranging in age
from 18 to 63 years old with a median age of 33 were selected, matched
with the suicidal group according to the diagnostic criteria stated
above. The control group also had no inpatient psychiatric hospitali
zation in the last 90 days or medical hospitalization of over 5 days
47
duration in the last 30 days. The control Ss, however, reported no
overt suicidal behavior during the last 10 years.
Materials:
(l) Wold Mood Log (Wold, 197l) as a measure of depression. The
Wold is a 10-item self-rating scale. (2) Spielberger Self-Evaluation
Questionnaire (Spielberger, e_t al. 1968) as a self-rated measure of
both situational and chronic anxiety levels. (3) Subjective Units of
Discomfort Scale or SUDS level (Wolpe and Lazarus, 1966), as a
measure of immediate discomfort. (4) Pleasant Events Schedule (Mac-
Phillamey and Lewinsohn, 1971) as a measure of net positive reinforce
ment obtained from the environment and the S/s activity level. This
320-item self-rating scale combines the number of reinforcing activi
ties engaged in by the S^ and how subjectively reinforcing finds
these activities. (5) A structured interview form developed by the
writer to record the Ss* suicidal histories and assess the reinforce
ment contingencies under investigation in the present study. The
interview questions were designed to provide quantifiable measures of
each of the independent variables in the between-groups analysis.
These variables were (l) losses, (2) models, (3) state of health,
(4) perception of afterlife, (5) perception of the possible consequen
ces of suicidal behavior, (6) cognitive rehearsals of death under
stress, (7) coping mechanisms, (8) acquisition of positive reinforce
ment by non-suicidal responses, and (9) aversive social stimuli. The
questions were constructed in a format which permitted the responses
to be rank-ordered for most efficient data analysis. Measurement of
the three variables of coping mechanisms, models, and cognitive
rehearsal of death under stress was carried out using one question for
each. Prom two to seven questions each were utilized to measure the
remaining six variables because of their breadth of definition. This
made it possible to select the best one or combination of questions to
measure each variable. In addition, this permitted the identification
of components of a variable which might prove to be independent from
other components and justify their definitions as separate variables.
The variable of state of health was measured using two questions, one
on present health and one on effects of previous illnesses. Percep
tion of afterlife was measured by two questions, one pertaining direct
ly to S^s view of himself after death and one concerning his percep
tion of the amount of control he exerted over the time of his own
death. Perception of the possible consequences of suicidal behavior
was measured using three questions. These involved S/s fear of death,
his perception of how difficult it would be to cause his own death,
and the concerns he had about attempting suicide that might make him
change his mind. Aversive social stimuli were measured using four
questions. These measured experiences of rejection, experiences of
powerlessness, experiences of embarrassment, and number and outcome of
arguments. The variable concerning losses contained five components.
These were number and type of losses, subjective rating of the serious
ness of the losses, the permanence of the losses, the effects the
losses had on 5's abilities to perform in other areas of his everyday
life, and the loss of enjoyment in other areas of S/s life. The
acquisition of positive reinforcers contained seven components:
ability to make friends, the frequency of new acquaintances, the
49
frequency of interpersonal interactions, the enjoyability of inter
actions, acquisition of major gains or recovery of loss, experiences
of pride and respect, and experiences of acceptance from other people.
A total of 26 questions were included in the inventory and are
reproduced in appendix (a ).
Since many of the questions tapped either depressing or anxiety-
provoking information from the Ss, the order of presentation of the
questions was balanced to place the majority of directly death-related
topics near the beginning. The remainder of the questions with
positive and negative affectual connotations were alternated as much
as possible, with the conclusion of the interview being worded posi
tively. This was done so that the interview itself would not be
regarded by the as an additional source of stress and contribute
any further reinforcement toward suicidal acting out. Information
regarding the S/s suicidal histories for the within-group comparison
was included in this interview form. The independent variables
measured here were (l) positive reinforcement for suicidal behavior
through manipulation of others, and (2) self-reinforcing behavior
following overt suicidal behavior. The dependent variables measured
here were (1) number and lethality of suicide attempts, (2) number and
severity of suicidal verbalizations, and (3) frequency of suicidal
fantasies. The entire text of this interview form appears in
appendix (a).
In addition to this interview form, a shorter version was
constructed for repeated measurements over time. This form measured
changes in the independent variables of (1) positive reinforcement
50
through manipulation of others by suicidal behaviors, (2) self-
reinforcing behavior following overt suicidal behavior, (3) state of
health, (4) performance of non-suicidal interpersonal behaviors,
(5) frequency of social punishers, and (6) new losses. This shorter
form also measured the dependent variables of (1) number and lethality
of suicide attempts, (2) number and severity of suicidal verbaliza
tions, and (3) frequency of suicidal fantasies. The text of this
second interview form appears in appendix (b).
Experimenters:
The interviews were conducted by the writer and by one graduate
and one undergraduate psychology student. The writer trained each of
the students in the administration of all testing materials. The
exact wording of each question appeared on the interview form, and was
repeated verbatim by the _E.
Procedure:
The control Ss were interviewed individually at the outpatient
clinic they attended. They were informed by their therapists that
volunteers were needed to participate in a research project investi
gating the connections between depression and suicide. Ss who
volunteered were scheduled for interviews by the writer so that each
1 3 interviewed approximately one-third of the Ss. The first 5 inter
views were conducted with all I3s in attendance for an interrater
reliability check. Only one E spoke during these interviews after
introducing the other people in the room. The interview took approx
imately one hour. The Pleasant Events Schedule was given to each
to be completed at home and was returned either by mail or in person
51
by £ to the clinic where _E picked it up at a later time.
The suicidal Ss were also interviewed individually at their
respective clinics in the same manner as controls. Their participation
was solicited in the same voluntary manner as the control Ss. The
only difference in procedure was that suicidal £s were asked to return
for two followup interviews at two-week intervals following their
initial interview. This followup interview took approximately 20
minutes. Whenever possible, a different J2 conducted each followup
to control for the possible effect of £[ trying to please a particular
_E by showing improvement on certain questions.
The order of presentation of test materials was identical for
each S^. In both groups, the SUDS level was measured first, followed
by the Wold Mood Log and the Spielberger Self-Evaluation Questionnaire.
The structured interview followed these tests. In the control group,
however, the section on suicidal history was not administered since by
definition the control group had no suicidal behavior to report. A
second SUDS level was administered at the end of the interview to
assess the anxiety provoking value of the interview itself. If the
interview was found to be upsetting to the S^, E would discuss this with
the S^ until S_'s feelings were resolved on this topic. At the conclu
sion of the session, the _E handed the £ the Pleasant Events Schedule
to be completed at home.
The followup interviews for the suicidal Ss consisted of
administration of the SUDS level, Wold Mood Log, the short form inter
view, and a second SUDS level as in previous interviews. The final
interview was followed by a debriefing of Ss concerning expected
52
results of the study if they so requested.
Data Analysis:
The between-groups comparison was analyzed by a stepwise
discriminant function analysis (Dixon, 1973). The BMD-07M program at
the UCLA Health Sciences Computing Center was employed for this pur
pose. This method (D.F.A.) was chosen because as Lettieri (1974,
pp. 46-47) states, it is a "means of selecting from a large number of
items those which have the most predictive value and of combining
these with the aim of making the combination a more powerful pre
dictor than any of the individual items alone." This method will also
eliminate redundant variables, and it is open-ended (additional
variables may be added at a later time). The independent variables
are the scores obtained from measurements of the 9 categories of
reinforcement contingencies, and the dependent variable is membership
in either the suicidal or control group as predicted by the D.F.A.
program. An overall correlation matrix using the BMD-02D program was
performed as an additional check for redundant variables.
The analyses of the proposed co-effects of the independent
variables between groups (anxiety scores, activity level, net positive
reinforcement obtained) was performed by _t-tests for independent means.
The within-group comparison of the suicidal Ss consisted of a
Pearson jc correlation between each of the independent variables (the
measurements of changes in each of these reinforcement contingencies
over time) and changes in the intensity of suicidal behavior. The
intensity scores are a combination of the frequency of suicidal
behaviors multiplied by their severity. Severity is computed here by
53
assigning a weight to each type of suicidal behavior according to
the Criteria for Rating Suicidal Intention (V.A. Central Research
Unit, 1971).
54
CHAPTER III
RESULTS
As discussed in the previous section, five types of analyses
were performed. Those were (l) between-groups comparisons of the
State-Trait Anxiety Inventory and of the Pleasant Events Schedule
using _t-tests for independent means, (2) between-groups comparisons of
the 26 data points on the structured interview form using stepwise
discriminant function analyses, ( 3) an overall correlation matrix of
the interview form items to check for redundant items, (4) between-
groups manipulation checks of the Subjective Units of Discomfort and
of depression scores on the Wold Mood Log using _t-tests for independent
means, anil (5) a within-group comparison of the suicidal Ss correlating
changes in their intensity of suicidal behavior with changes in
repeated measures questions in followup interviews, using Pearson
product-moment correlations (Pearson _r). The stepwise discriminant
function analyses were pei'formed using the program BMD-07K of the
Biomedical Computer Programs (Dixon, 1973) at the UCLA Health Sciences
Computing Center. The overall correlation matrix employed the BMD-02D
program in the same facility.
I. Between-Groups Comparisons:
A. State-Trait Anxiety Inventory (STAl): Significant differ
ences in the predicted direction of higher anxiety scores for the
suicidal group were found for both the state (situational) anxiety
and the trait (chronic) anxiety measures of the STAI. Mean state
55
anxiety scores were 55.1 for suicidals, 46.1 for controls (t= -1.90,
^.05 one—tailed). Mean trait anxiety scores showed even greater
discrepancy, 60.8 for suicidals, 49.1 for controls (_t= -3.00,^.001
one-tailed).
B. Pleasant Events Schedule (PES): No significant differences
were found between groups in net positive reinforcement scores or
activity level on the PES. It had been predicted that the suicidal
group would have significantly lower scores, but both net positive
reinforcement scores between groups and activity levels between groups
were quite similar. Mean positive reinforcement scores for suicidals
= 721, mean for controls = 798, _ t = -0.36. Mean activity level scores
= 356 for suicidals, = 351 for controls, _t= -0.07. In view of these
results, it was decided to test whether the types of reinforcing
activities engaged in by each group measured by the PES differed.
Activities which could only be performed alone and activities which
involved interpersonal interactions were analyzed separately to attempt
to answer this question. No significant differences were found
between groups when performance of solitary activities and performance
of interpersonal activities were separated. The mean for solitary
activities in the suicidal group = 222, controls = 235, _t = -0.21.
The mean for interpersonal activities for suicidals = 343, for
controls = 334, _t = .05.
C. Discriminant Analyses: The original conceptualization of
this portion of the data analysis was that 26 data points from the
structured interview form would be employed to measure 9 proposed
variables. It was decided to conduct discriminant analyses using both
56
a 9-variable format and a format using all 26 data points as separate
variables in order to identify whether or not one data point might be
a better measure of a variable than a combination of scores.
In both of these analyses, one data point correctly identified
46 out of 50 cases in their respective groups (24 suicidals, 22
controls, 92% accuracy). The potency of this one variable, cognitive
rehearsal of death under conditions of imagined stress, was so great
that in the 9-variable analysis, maximum correct identification was
47 of 50 cases, an increase of 1 case (2%) with the addition of the
remaining 8 variables. (See Table l).
57
TABLE I
Stepwise Discriminant Analysis with 9 Variables, with Means for Each Group.
[fame of Variable Rank
Total Number of
Cases Correctly
Identified
Number of
Suicide Cases
Correct
dumber of
Control Cases
Correct
Per
Cent
Accuracy
Mean for
Suicidal
Group
Mean for
Control
Group
Cognitive rehearsal
of death under
imagined stress 1 46 24 22 92# 7.44 2.48
Concept of afterlife
and control over
time of death 2 45
22
23 90# 6.76 5.44
Social punishers 3
46
23 23 92# 33.04 10.44
Concerns over
possible consequen
ces of suicide 4 47 24
23 94# 17.32
19.43
Index of losses
suffered 5 47 24 23 94# 15.28 6.76
Number of coping
mechanisms
employed 6 47 23 24 9.4#
19.80 19.68
Presence of
suicidal models 7 47 23 24 94# 1.44 0.96
State of health 8 46 22 24 92# 6.60 5.56
Positive reinforcers
for nonsuicidal
behaviors
9 46 22 | 24 92# 43.88 52.80
V/hen all 26 data points were treated as separate variables,
a combination of 15 of these variables yielded perfect prediction
(50 out of 50 cases correctly identified). Cognitive rehearsal
correctly identified 92/£ of the cases, and the additional 14 variables
accounted for the remaining 8° J o of the cases (See Table 2).
59
TABLE 2
Stepwise Discriminant Analysis with 26 Variables, with Means for Each Group
Name of Variable Rank
Total Number of
Cases Correctly
Identified
Number of
Suicide Cases
Correct
Number of
Control Cases
Correct
Per
Cent
Accuracy
Mean for
Suicidal
Group
Mean for
Control
Group
Cognitive rehearsal
of death under
imagined stress 1 46 24 22 92/i 7.44 2.48
Number of
losses
stiff ered 2 43 21 22 86/o 3.24 0.84
Concerns
over killing
oneself 3 45 22
23 98% 10.88 12.04
Control over the
time of one's
death 4 45 22
23 9 8% 3.00 2.80
Frequency of
making new
acquaintances
5 45
22
23 905b 5.36 6.12
Number of
coping
mechanisms 6 45 22
23 90% 19.80 19.68
Experiences of
major
gains 7 47 24 23 945b 4.40 6.40
dumber and
severity of
rejections 8 48 23 25 96% 9.16 1.20
Difficulty of
causing one's
own death
9 49 23 25 98% 3.44 4.52
TABLE 2 (Continued)
Name of Variable Rank
Total Number of
Cases Correctly
Identified
Number of
Suicide Cases
Correct
Number of
Control Cases
Correct
Per
Cent
Accuracy
Mean for
Suicidal
Group
Mean for
Control
Group
Number and
severity of
embarrassments 10 49 24 25 98# 1.72 0.24
Peelings about
business and social
interactions 11 49 24 25 98# 8.48 9.72
Frequency of
interpersonal
interactions 12 49 24 25 98# 7.12 7.92
Frequency and sever
ity of experiences
of powerlessness 13 49 24 25 98% 14.60 4.40
Frequency and
outcome of
arguments 14 49 24 25 98# 14.04 5.32
Experiences of
pride and respect
from others
15 50 25 25 loo# 2.72 4.76
Permanence or
reversibility of
losses suffered 16 50 25 25 100# 3.88 2.32
Generalization of
losses to lack of
enjoyment of other
activities 17 50 25 25 100# 1.40 0.52
Frequency of feelings
of acceptance and
liking from others 18 50 25 25
100# 8.60 10.28
TABLE 2 (Continued)
Name of Variable Rank
Total Number of
Cases Correctly
Identified
Number of
Suicide Cases
Correct
Number of
Control Cases
Correct
Per
Cent
Accuracy
Mean for
Suicidal
Group
Mean for
Control
Group
Pear of death 19 50 25 25 100$ 2.84 1.80
Presence of
suicidal models 20 50 25 25 1005b 1.44 0.96
Description of
present state
of health 21 50 25 25 100$ 2.IS 2.44
Effects of losses on
ability to perform
other behaviors 22 50 25 25 100$ 2.84 1.36
Concept of one's
afterlife 23 50 25 25 100$ 3.92 3.64
Ongoing physical
illnesses 24 50
25 25 100$ 3.84 3.12
Ability to make
new friends
25 50
25 25 100$ 7.20 7.60
Subjective ratings
of seriousness of
loss suffered 26 50 25 25 100$ 3.84 1.76
The results presented in Table 2 do not demonstrate differences
in predictive ability among the remaining 25 items after the 92$
accurate prediction of the first variable, so two subsequent analyses
were performed minus the cognitive rehearsal variable in order to test
the relative predictive strengths of the remaining data points.
The analysis using 8 variables (minus cognitive rehearsal) shows
that a combination of 4 variables (index of losses, social punishers,
concept of afterlife, and fear of death) correctly identified 46 of
50 cases {92%). The additional 4 variables of state of health,
number of coping mechanisms, presence of suicidal models, and positive
reinforcers for non-suicidal behaviors did not improve the prediction
of group membership (see Table 3).
TABLE 3
Stepwise Discriminant Analysis with 8 Variables
Name of Variable Rank
Total Number of
Cases Correctly
Identified
Number of
Suicide Cases
Correct
Number of
Controls
Correct
Per
Cent
Accuracy
Index
of losses 1 38 20 18 76%
Social
punishers 2 41 20 21 82$
Concept of after
life and control
over time of own
death
?
44 21 23 88$
Concerns over
consequences
of suicide 4 46 22 24 92$
State
of health
5 45
21 24 90$
Coping
mechanisms 6 45 21 24 90$
Suicidal
models 7 45 21 24 90$
Positive rein
forcers for non-
suicidal
behaviors 8
45
21 24 .90$ , „
63
The analysis using 25 items as separate variables resulted in
the identification of another highly predictive variable which account
ed for most of the variance. This variable was the number of losses
the £ reported having suffered. This data point was more accurate in
correct prediction of group membership when used alone (42 of 50 cases,
84%) than when combined with 4 other data points into an index of loss
in the previous analysis (58 of 50, 76%). A combination of 9 data
points correctly identified 49 of 50 cases (9&%t see Table 4).
Addition of any of the remaining 16 data points did not increase pre
dictive accuracy.
64
TABLE 4
Stepwise Discriminant Analysis with 25 Variables
Name of Variable Rank
Total Number of
Cases Correctly
Identified
Number of
Suicide Cases
Correct
Number of
Control Cases
Correct
Per
Cent
Accuracy
Number of losses 1 42
17 25
V*.
00
Fear of death 2 44 19 25 88$
Difficulty of
causing own death 3 44 19 25 88$
Control over
time of death 4 47 22
25 94$
Rejections 5 46 21
25 92$
Generali zation
of losses 6 48
23 25 96$
Coping mechanisms 7 48
23 25 96$
Permanence of losses 8 47 22 25 94$
Arguments
9 49 24 25 98$
Frequency of
new acquaintances 10 47 23 24 94$
Major gains 11 48 24 24 96$
Suicidal models 12 48 24 24 96$
Embarrassments 13 48 24 24 96$ . _
TABLE 4 (Continued)
Name of Variable Rank
Total Number of
Cases Correctly
Identified
Number of
Suicide Cases
Correct
Number of
Control Cases
Correct
Per
Cent
Accuracy
Concerns over
killing self 14 47 23 24 94$
Ability to
make friends 15 49 24 25 98%
Peelings of business
and social interactions 16 49 24 25 98$
Experiences of
pride and respect 17 49 24 25 98$
Experiences of
acceptance and liking 18 49 24 25 98$
Present state
of health
19 49 24 25 98$
Effects of losses
on other abilities 20 49 24 25 98$
Experiences of
powerlessness 21
49 24 25 98$
Physical illnesses 22
49 24 25 98$
Subjective
ratings of losses 23 49 24 25 98$
Concept of
afterlife 24 49 24 25 98$
Frequency of
social interactions 25 49 24 25 98$
The discovery of this second highly predictive variable of
number of losses led to the performance of another discriminant
analysis excluding this variable. This was done to test whether other
variables would show increases in their predictive accuracy when the
variable accounting for the largest portion of the variance was re
moved. The subsequent analysis included 24 data points examined as
separate variables, and results showed that a combination of 3 varia
bles could correctly predict 48 of 50 cases (96$, see Table 5).
Inclusion of 10 additional variables improved prediction by one case
(49 of 50, 98$).
67
TABLE 5
Stepwise Discriminant Analysis with 24 Variables
Name of Variable Rank
Total Number of
Cases Correctly
Identified
Number of
Suicide Cases
Correct
Number of
Control Cases
Correct
Per
Cent
Accuracy
Pear of death 1 39 17 22 78$
Rejections 2
43
21 22 86$
Difficulty of
causing own death 3 48
23 25 96$
Generalization
of losses 4 44 20 24 88$
Control over
time of one's death
5 47 22
25 94$
Ability
to make friends 6 46 21
25 92$
Embarrassments 7 47 22
25 94$
Frequency of
new acquaintances 8 47 22
25 94$
Peelings of business
and social interactions 9 48 22
25 96$
Coping mechanisms 10 48 22
25 96$
Major gains 11 48 22 25 96$
Concerns over
killing self 12 48 22 25 96$
Experiences
of pride and respect 13 48 22
25 96$
TABLE 5 (Continued)
Name of Variable Rank
Total Number of
Cases Correctly
Identified
Number of
Suicide Cases
Correct
Number of
Control Cases
Correct
Per
Cent
Accuracy
Experiences of
acceptance and liking 14 48 22
25 96%
Experiences
of powerlessness 15
48 22
25 96%
Permanence of losses 16 48 22
25 96%
Effects of losses
on other abilities 17 48 22
25 96%
Subjective
rating of losses 18 48 22
25 96%
Pre sent
state of health 19 48 22 25 96%
Physical illnesses 20 48 22 25 96%
Arguments 21 48 22
25 96%
Concepts of afterlife 22 48 22 25 96%
Prequency of interactions
23 48 22 25 96%
Suicidal models 24 48 22
25 96%
In order to investigate whether or not certain new combinations
of the remaining 24 data points could equal the predictive accuracy of
the 2 extremely potent variables of cognitive rehearsal of death and
number of losses, additional analyses were performed. These 24 data
points were first grouped into "stimulus" variables and "response"
variables. The "stimulus" variables consisted of 19 items which
measured events external to and could be interpreted as possible
"causal" events (rejections, embarrassments, major gains, interpersonal
interactions, etc. - see Table 6).
70
TABLE 6
Stepwise Discriminant Analysis with IQ "Stimulus" Variables
Name of Variable Rank
Total Number of
Cases Correctly
Identified
Number of
Suicide Cases
Correct
Number of
Control Cases
Correct
Per
Cent
Accuracy
Subjective rating
of losses 1 35 21 14 10%
Rejections 2 41
19
22 82%
Frequency of
new acquaintances 3 42 18 24 84%
Ability to
make friends 4 43 19 24 86%
Experiences
of powerlessness 5 43 19 24 66%
Experiences
of pride and respect 6
43 19 24 86%
Experiences of
acceptance and liking 7 44 20 24 88%
Embarrassments 8 44 20 24 88%
Suicidal models
q
44 20 24 88%
Feelings of business
and social interactions 10
45 21 24 90%
Frequency
of interactions 11 45 21 24 90%
Major gains 12
45
21 24 90%
TABLE 6 (Continued)
flame of Variable Rank
Total Number of
Cases Correctly
Identified
Number of
Suicide Cases
Correct
Number of
Control Cases
Correct
Per
Cent
Accuracy
Present
state of health 13 46 21 24 92%
Physical illnesses 14 46 21 24 92%
Effects of
losses on abilities 15 46 21 24 92%
Permanence
of losses 16 46 21 24 92%
Coping mechanisms 17 46 21 24 92%
1enerali zat i on
of losses 18 46 21 24 92%
Arguments 19 46 21 24 92%
The "response" variables were 5 questions which measured
attitudes within the £[ (fear of death, etc. - see Table 7).
TABLE 7
Stepwise Discriminant Analysis with 5 "Response" Variables
Name of Variable Rank
Total Number
of Cases
Correctly
Identified
Number of
Suicide
Cases
Correct
Number of
Control
Cases
Correct
Per
Cent
Accuracy
Pear
of death 1 39 17 22 l&fo
Difficulty of
causing own death 2 42
19 20 l&/o
Control over time
of one's death
?
42 20 22 8 4 %
Concerns over
killing self 4
42 20 22 8 4 %
Concept
of afterlife 5
42 20 22 84%
As shown in the tables above, a combination of 4 stimulus
variables correctly identified 43 of 50 cases (86%). A combination of
13 variables increased the number of correct predictions by 3, to 46
of 50 (92%). The additional 6 variables did not increase predictive
accuracy. A combination of 3 response variables correctly identified
42 of 50 cases (84$).
The final analyses separated the "stimulus" variables into
"positive" events and "negative" events. This was performed in order
to attempt to identify what types of reinforcing external events
might be more powerful in discriminating suicidals from controls. A
discriminant analysis of the 8 "positive" variables yielded a
maximally accurate prediction of 35 of 50 cases (7C%) using 3 varia
bles. The additional 5 variables subsequently reduced predictive
73
ability (see Table 8).
TABLE 8
Stepwise Discriminant Analysis with 8 "Positive Stimulus" Variables
Name of Variable Rank]
Total Number
of Cases
Correctly
Identified
Number of
Suicide
Cases
Correct
Number of
Control
Cases
Correct
Per
Cent
Accuracy
Experiences of
pride and respect 1 31 15 16 62$
Peelings of business
and social interactions 2 29 17 12 58$
Peelings of accept
ance and liking 5 35 16 IS
70$
Ability to
make friends 4 32 17 15 64$
Frequency of new
acquaintances 5 34 19 15
68$
Major
gains 6 34 19 15
68$
Frequency
of interactions 7 35
20 15 70$
Coping mechanisms 8 32 19 13 64$
A discriminant analysis of the 11 "negative" stimulus variables
resulted in more accurate prediction of group membership. A combina
tion of 3 variables correctly identified 43 of 50 cases (86$). The
addition of the remaining 8 variables slightly reduced predictive
accuracy (see Table 9).
74
TABLE 9
Stepwise Discriminant Analysis with 11 "Negative Stimulus" Variables
Name of Variable Rank
Total Number
of Cases
Correctly
Identified
Number of
Suicide
Cases
Correct
Number of
Control
Cases
Correct
Per
Cent
Accuracy
Subjective
rating of losses 1 35 21 14 7C$
Rejections 2 41 19
22 8252
Experiences of
powerlessness 3 43 20
23
86/2
Suicidal models 4 42
19 23 84%
Present
state of health 5 41 19
22 82?2
Generali zation
of losses 6 41 19
22 8252
Physical illnesses 7 41 19
22 82%
Effects of losses
on other abilities 8 40 18 22 8052
Arguments 9 41 19
22 8252
Embarra s sment s 10 41 19
22 8252
Permanence
of losses 11 41 19
22 8252
A summary of the between-groups stepwise discriminant analysis
is as follows: Cognitive rehearsal of death correctly identifies 92%
of cases alone, and one component of the proposed index of loss var
iable, the number of losses suffered, is 84/2 accurate alone and de
creases in predictive accuracy when combined with other measures of
this index. Other items which were highly predictive of group member
ship but less accurate than the previous two are fear of death, the
difficulty of causing one's own death, number and severity of
75
rejections, subjective ratings of seriousness of losses, and
experiences of powerlessness. Additional data points which contribute
a small amount of predictive accuracy in some analyses are general
ization of losses to other areas of S/s life which lose their enjoy-
ability, perceived control over the time of one's own death, exper
iences of pride and respect, and frequency of new acquaintances. The
variables of number of coping mechanisms, state of health, and presence
of suicidal models were of low predictive accuracy in all of the
analyses.
D. Overall Correlation Matrix of Interview Form Items:
The entire correlation matrix of all 26 data points will not be
reproduced here. The 11 data points in the previous summary which did
show moderate to high predictive accuracy appear in Table 10.
76
Frequency of
new acquaintances
Pride and respect
Difficulty
of causing own death
Control over time of death
Fear of death
o
o
§
H*
c+
H-
< 4
< T >
► i
0 >
£r
( D
P
4
C O
p
Powerlessness
< D
CD
O
c+
H«
O
P
C O
Generalization of losses
CO
c
O'
L j.
CD
o
c+
H*
< 5
O
4
P
c+
H*
g
O
H)
M
O
C O
C O
o
C O
Number of losses
I &
00
3L
- F *
V J 1
S>
o
V J 1
ON
< ? >
ON
Ol o
ON
•
CD
l.C
Number of losses
J
o
J
i-1
ro
J
ro
•
V J 1
•
ro
- P *
• •
- P *
•
- p*
•
vn
ON
l.C
Subjective rating of losses
. 1
o ( V )
. »
M
o
•
M
ro
•
O
• •
OJ
V J N
•
V > J
1.0
Generalization of losses
. 1
o
J
ro
V j4
J
ro
on
•
- F *
•
C T \
•
V J l
v j i
•
CD
M
1.0
Rejections
. 1
O
C T i
J
M
J
ro
on
•
V > 0
o
•
M
- f *
•
ui
V J 1
1.0
Powerlessness
I
•
- P *
J
- t k
-s
. »
ui
•
V J 1
on
•
O
tt
1.0
Cognitive rehearsal
•
M
«
ro
O
•
ro
N J 1
•
o
on
M
•
Q
Fear of death
•
ro
- r *
J
VJl
J
ro
H
M
•
o
Control
over time of death
•
h-»
•
H
•
o
Difficulty
of causing own death
•
V > J
CD
M
•
o Pride and respect
H
•
O
Frequency of
new acquaintances
Correlation Matrix o f 1 1 Moderate t o Highly Predictive Variables
The highest correlations appear among items which were
originally proposed as components of a composite variable. Number of
losses correlates .78 with subjective rating of losses, and .63 with
generalization of loss. Subjective rating is correlated .56 with
generalization of loss. Rejections are correlated .81 with experiences
of powerlessness.
Cognitive rehearsal of death, the most accurate predictor
between groups, correlates most highly with other highly significant
predictors between groups: .68 with number of losses, .57 with
subjective ratings of losses, .5? with rejections, .55 with powerless
ness, and .56 with control over time of death. The cognitive rehear
sal variable correlates negatively with difficulty in causing one's
own death (-.45) and experiences of pride and respect (-.47).
Two data points which had originally been measured as the
combined concerns over the consequences of suicide variable, fear of
death and difficulty of causing one's own death, correlated -.21 with
each other. Two other items which had originally been combined as
components of the positive reinforcement variable, these being
experiences of pride and respect and frequency of new acquaintances,
correlated .38. A correlation of .70 was found between rejections
and number of losses. This relationship was investigated more closely,
and the number of losses suffered which involved the loss of another
person was correlated with the number of rejections. The correlation
coefficient found here was much lower, -.15.
Ten of the 11 items discussed above were also correlated with
the composite variables of which these data points were originally
78
conceptualized as components. The cognitive rehearsal variable was
excluded from this analysis because it was measured using only one
data point. The correlations of these items with the variables they
were intended to measure are presented in Table 11.
TABLE 11
Correlations of 10 Data Points with the Variables of Y/hich They
Were Components
Name
of Composite Variable Name of Data Point
Correlation
(r) Coefficient
Index of loss Number of losses .80
Subjective
rating of loss .93
Generalization
of loss .72
Social punishers Rejections .83
Powerlessness .89
Concerns Over conse
quences of suicide
Difficulty of
causing own death .59
Pear of death .29
Perception
of afterlife
Control over
time of death .61
Positive reinforcement
for nonsuicidal behavior
Experiences of
pride and respect .77
Frequency of
new acquaintances .66
All items on the questionnaire were correlated with the sex,
age, employment vs. non-employment and residence of the Ss, and no
significant correlations were found on these dimensions.
79
E. Manipulation Checks:
1. Subjective Units of Discomfort (SUDS Level):
The SUDS Levels administered before and after each interview indicated
no significant pre-post differences within either the suicidal or the
control groups (jt = 0.71 for suicidals, _t = 0.59 for controls). It
was expected that the interview would lead to an increase in SUDS
scores in most Ss in the suicidal group, but the reverse trend was
found. Twelve Ss in the suicidal group showed a slight decrease in
SUDS after the first interview, 3 showed increases and 10 remained the
same. The control group showed 10 decreases, 2 increases, and 13
scores remained the same. Similar results were found in the followup
interview in the suicidal group, with a slight trend toward decreased
SUDS, but no significant differences.
2. 7/old Mood Log:
Depression scores on the '//old Mood Log showed no significant differ
ences between the suicidal and the control groups (t = -0.78),
indicating that the Ss' levels of depression on the day of the
interview were comparable between groups.
3. Interrater Reliability:
Interrater reliability was .88 among 3 raters for the 12 Ss interviewed
with all 3 JEs present.
II. V/ithin-Group Comparison of the Suicidal Group:
The within-group analysis consisted of comparisons of changes
in the intensity of suicidal behavior over time with changes in each
of the 6 repeated measures variables over two 2-week intervals. The
80
changes in suicidal behavior over time were also compared with changes
in the individual data points within each variable to test which
component might be the best measure of that variable. Pearson
product-moment coefficients (Pearson j?) were computed for the change
scores of suicidal behavior and the change scores of the repeated
measures variables.
Data from 19 Ss who oompleted all interviews were included
in this analysis. With this reduced N, an £ significantly greater
than 0 (>.0l) requires a product-moment coefficient >»41 at the
.05 level of confidence.
The six variables originally proposed for the repeated
measures analysis were self-reinforcement following suicidal behaviors,
state of health, positive reinforcement for non-suicidal behaviors,
negative social reinforcement (social punishers), new losses, and
positive reinforcement obtained from others for suicidal behaviors.
The latter 2 variables were subsequently dropped from the analysis,
the first because of the extremely low frequency of reports of new
losses (only 3 in 19 Ss). The second was eliminated because of a low
reported frequency of effects of suicidal behavior on others over time
compounded by a clerical error which failed to include this question
on several followup interview forms, and sharply reducing the usable
.3 for this variable.
The results of the correlations of the change scores over the
2 two-week time periods is summarized in Table 12.
81
TABLE 12
Correlations of Changes in Intensity of Suicidal Behavior Over Time
with Changes in Repeated Measures Variables
Variable
Correlation (r)
with changes in
suicidal behav
ior over first
two-week period
Variance
(x*)
Correlation (r)
with changes in
suicidal behav
ior over second
two-week period
Variance
(x5)
Self-
reinforcement
.23 .05 .54 .29
Health -.18
.03 .73 .53
Positive
reinforcement -.15 .02 -.48
.23
Social
punishment .69 .47 .32 .10
Table 12 indicates that changes in all 4 composite variables
are significantly correlated with changes in suicidal behavior in at
least one of the 2-week time periods measured. Separation of the
positive reinforcement for non-suicidal behavior variable into 2
components, social interaction and social reinforcement (see Table 13)
indicates that changes in the social interaction component have a
highly significant negative correlation with changes in suicidal
behavior, and that this relationship is consistent over time. The
social reinforcement component is not highly correlated when it is
examined separately from social interaction.
82
TABLE 13
Correlations of Changes in Intensity of Suicidal Behavior Over Time
with Changes in Social Interactions and Positive Social Reinforcement
Variable
Correlation (r)
with changes in
suicidal behav
ior over first
two-week period
Variance
(x2)
Correlation (r)
with changes in
suicidal behav
ior over second
two-week period
Variance
(x2) . . .
Positive
Reinforcement
(combined)
-.15 .02 -.48
.23
Social Interactions -.61 .37 -.65
.42
Positive
Sx;ial
Reinforcement .09 .01 -.35 .12
Use of one component item alone or a combination of fewer
component data points does not raise the correlation coefficients of
the composite self-reinforcement or the 2 composite positive reinforce
ment variables. However, rejection used alone in the social punish
ment group raises the correlation coefficient to a highly significant
level for both time periods. Each component of the social punishment
group is highly significant during at least one time period (see
Table 14). State of health does not appear in this table because it
was measured using only one data point.
83
TABLE 14
Correlations of Changes in Intensity of Suicidal Behavior Over Time
with Changes in Individual Items
Item
Correlation (r)
with changes in
suicidal behav
ior over first
two-week period
Variance
. (n2)
Correlation (r)
with changes in
suicidal behav
ior over second
two-week period
Variance
(X?)
Positive feelings
after suicidal
thoughts .06
O
o
•
.38 .14
Positive feelings
after suicidal
communications .10 .01
.31 .09
Positive feelings
after suicidal ges
tures or attempt .18
.03 .75 .56
Combined
self-reinforcement
K\
CM
•
.05 .54 .29
New
acquaintances -.05 .002
i
•
VJl
.42
Frequency of
interactions -.40 .16 -.67 .44
Feelings of
business and social
interaction -.19 .03 -.49 .24
Combined social
interaction -.61 .57 -.65
.42
Via.ior gains .25 .06 -.46 .21
Experiences
of pride and
respect
.13..
.02 -.06 .003
Experiences of
acceptance and
liking .19 .03 -.27 .07
Combined positive
social
reinforcement
.03
.01 -.35 .12
84
TABLE 14 (Continued)
Item
Correlation (r)
with changes in
suicidal behav
ior over first
two-week period
Variance
(i2)
Correlation (r)
with changes in
suicidal behav
ior over second
two-week period
Variance
(i2)
Embarrassments .12 .01 .53 .28
Arguments .65 .42 .10 .01
Experiences
of powerlessness .56
.31 .53 .28
Rejections .69 .47 .79 .62
Combined
social punishment .69 .47 .32 .10
85
CHAPTER IV
DISCUSSION
The hypotheses presented in Chapter 1 will be discussed in
the same order in the following section.
Hypothesis 1 posited that suicidal Ss would engage in fewer
positively reinforcing activities and would demonstrate a lower net
amount of positive reinforcement received for non-suicidal behaviors
than control Ss.
The data did not support this hypothesis. In fact, the activ
ity level scores (356 for suicidals, 351 for controls) on the Pleasant
Events Schedule were remarkably similar, and both were well into the
"depressed" range of scores found by MacPhillamey and Lewinsohn (1972),
below the mean of 503 for their depressed S_s. The similar means found
here for net obtained positive reinforcement (721 for suicidals,
798 for controls), solitary activities (222 for suicidals, 234 for
controls) and interpersonal activities (343 for suicidals, 334 for
controls) all tend to support the null hypothesis.
The results of the discriminant analyses showed the positive
reinforcers for non-suicidal responses to be the least accurate pre
dictor between groups as a set of items. As a composite variable, it
ranked lowest of all 9 variables in correctly identifying suicidals
and controls. When this composite variable's 8 component items were
examined separately as "positive stimulus" variables, the maximally
86
accurate prediction was 35 of 50 cases (70$) using 3 items. These
items were experiences of pride and respect, the feelings of business
and social interactions, and experiences of acceptance by others.
Only 2 items, the frequency of new acquaintances and experiences of
pride and respect, showed any consistent predictive accuracy when the
8 positive reinforcement items were included in other analyses which
encompassed the remaining variables connoting more negative stimuli.
In the 24-item analysis which excluded the more potent questions of
cognitive rehearsal of death and number of losses, the first positive
reinforcement item appeared after 94$ prediction had been achieved
using 5 items from the categories of attitudes toward death and social
punishers. In the 19-item analysis of all "stimulus" variables,
frequency of new acquaintances appeared somewhat stronger, ranking
third behind subjective rating of losses and rejections, adding 2$
to the predictive ability of the first 2 items (84$ to 86$).
The conclusion that may be drawn from these data are that the
suicidal group does not have a significantly lower rate of positive
reinforcement for adaptive behavior than the control group, contrary
to the original prediction. The Pleasant Events Schedule showed no
differences between groups, and the discriminant analyses demonstrated
that while a few items enhanced the ability to correctly identify
suicidals from controls, their predictive strength was minimal, adding
little to the strength of items based on negative experiences. As
noted previously, the low PES scores for both groups were in the range
typical of depressed Ss. Since it was determined by use of the Wold
Mood Log that both groups were experiencing similar levels of
depression, and it was found that similar low rates of positive
reinforcement were experienced by both groups, these data support
Lewinsohn's (1973) model of depression as an extinction phenomenon.
The low predictive accuracy of positive reinforcement in discriminating
depressed suicidals from depressed controls indicate that the exten
sion of this extinction model to suicidal behavior may not be
warranted. Rather, it seems to indicate that a greater frequency of
occurrence of negative events in Ss' lives may be more critical in
separating suicidal from non-suicidal depressed Ss than a simple
lack of positive reinforcement.
Hypothesis 2 predicted that Ss in both groups would exhibit
the non-reinforcement of social behaviors which is characteristic of
depressives, but that suicidal S_s would perceive a greater frequency
and severity of negatively reinforcing events to be present in their
environments, such as personal losses and interpersonal difficulties.
This prediction was strongly supported by the data. When the
variable of cognitive rehearsal of death was removed from the analyses,
items related to loss and social punishment were of extremely high
predictive accuracy. The number of losses item alone was 84$ accurate
in discriminating suicidals from controls, with means of 3.24 losses
for suicidals and 0.84 for controls. Other component items of the
index of loss variable were also highly predictive, the next most
accurate being subjective rating of the seriousness of the loss (70$
accurate when considered alone) and generalization of the feelings of
loss so that many previously reinforcing activities were no longer
enjoyable. The number of losses (84$) was found to be more accurate
than the combined index of loss (76$), and this may be due to the
experience of at least one loss being the prerequisite to responding to
other components of the question (e.g., how bad did the loss feel, how
permanent does the loss appear?). As noted in Table 10, number and
subjective rating of losses are correlated .78, and appear to be
redundant. Generalization of loss, while slightly weaker in predictive
accuracy (ranking behind fear of death and rejections), is more
independent of number of losses, the correlation between these items
being .63. These 3 indices of loss appear consistently highly pre
dictive in several analyses (see Tables 4, 5, 6, 9), and it can be
concluded that the suicidal Ss in this sample can accurately be
identified from controls on the basis of their self-reports of greater
numbers of losses, higher subjective rating of seriousness of losses,
and to some extent, the generalization of loss to other areas of their
lives which become less enjoyable.
The types of losses suffered by Ss were treated separately
from the discriminant analyses, since no objective measure of what
type of loss is worse than another can be made (the subjective var
iation between Ss would be too great), and the data are thus not
amenable to rank order. The types of losses were grouped here accord-
int to Breed's (1967) model of (l) position loss (job, money, skills),
(2) personal loss (death, rejection, someone moving away), and (3)
mutuality loss (loss of respect, of freedom, loss of power or effect
iveness in dealing with others); a fourth category of physical loss
(health, beauty or sexuality) similar to Farberow and McEvoy's (1966)
category of "medical loss" was included.
No statistical comparisons of the frequencies of different
types of losses suffered between groups were performed due to the
low frequency of occurrence of losses in the control group. An in
spection of the different proportions of losses reported by each
group in each category revealed the following trends. Both groups
reported roughly similar frequencies of losses in the personal and
health categories. However, the suicidal group also reported fairly
high frequencies of losses in the position and mutuality categories,
while the control group reported close to zero losses in these
categories. This may indicate that losses of a more material nature
that reflect on a person's abilities more so than his relationships or
health are more conducive toward suicidal behavior. Alternatively,
this could simply mean that a material loss added to a personal loss
is much more stressful than a personal loss alone, since the two
frequently occurred together within the suicidal Ss. It should be
emphasized that these data are purely speculative due to the smaller
number of losses reported by the control group.
The composite variable of social punishment ranks closely
behind losses in predictive accuracy, and a combination of the two is
more accurate than either one alone. Of the 4 components of social
punishment (embarrassments, arguments, rejections, and experiences of
powerlessness), only the latter 2 are consistently highly predictive
(see Tables 4, 5, 6, 9), and powerlessness appears to be redundant,
correlated .81 with rejections (see Table 10). Although rejections
and number of losses (the strongest component item of each of their
respective composite variables) are correlated .70 with each other,
90
they do not appear to be redundant. As noted in the previous section,
when the number of losses involving other people is correlated with the
number of rejections, the relationship is only .15. This indicates
that the items are independent of each other, and that the high
correlation of the overall items are independent of each other, and
that the high correlation of the overall items is probably due to
their both being independently highly accurate predictors of group
membership.
Closer inspection of the items discarded as redundant by the
discriminant analyses yields other data of interest. With regard to
perceived reversibility of losses, a significant difference is evi
denced between suicidal and control S_s. On a scale of 6, a cutoff
score of <^3.0 indicated the 3^ perceived there was a fair to good
chance of recovering the loss, and >3.0 indicated a poor to no chance
of recovering the loss. Keans were ?.88 for suicidals, 2.32 for
controls. However, this finding was obscured by this item's .88
correlation with subjective rating of loss which led to its being
assigned a low rank by the discriminant analysis program.
Another finding of note was the differences in the types of
situations where 3s (23 suicidals, 21 controls) reported experiencing
feelings of being powerless and unable to get their way in some situa
tions. On each of the social punishment items, responses were measured
in 5 different types of situations. Those were with the spouse or
lover, with the family, with friends, on the job or at school, with
co-workers or fellow students, and with agents of some bureaucracy.
In the suicidal group, Ss experienced powerlessness in a greater
91
number of situations than control Ss. Both groups experienced
frequent problems with spouses or lovers, on the job, or with
bureaucracies. However, the suicidal group reported powerlessness
with the family in 16 of 25 cases, and with friends in 13 out of 25.
The control group reported powerlessness with the family in only 4
of 25 cases, and with friends 3 out of 25. The data for the rejection
question were inspected for evidence of a similar trend, and in addi
tion to the previously reported finding of a significantly higher
number of rejections in the suicidal group, it was found that most of
these rejections were reported as being from friends (17 of 25),
followed by family (l3 of 25), by agents of a bureaucracy (9 of 25),
by spouse or lover (8 of 25), and co-workers (3 of 25). The control
group reported a total of 11 cases of rejection, with 1 by friends,
3 by family, 3 by spouse or lover, 2 by agents of bureaucracies and
2 by co-workers. What these data may indicate is that most depressed
people experience powerlessness, and to some lesser extent, rejection.
What appears to be critical in identifying the suicidal from the non-
suicidal depressive is the variety of situations he may be ex
periencing social punishment in. The controls in this study appeared
to have "safe" areas of their lives, that is, while they might ex
perience difficulty in dealing with a single relationship or with a
bureaucracy, they seem to be generally able to interact with family
and friends without severe setbacks. In addition, 6C$ of suicidals
lived alone, while only 38$ of controls lived alone. Several inter
pretations may be ventured, among them that suicidals have less ability
or desire to live cooperatively with others, that they have lost
92
relationships and do not find new ones as easily as controls, or a
combination of these factors.
These data concerning losses and social punishers support the
hypothesis that Ss in the suicidal group perceive more noxious social
stimuli in their environment (in the form of rejections and experiences
of powerlessness), and perceive themselves to be suffering more and
greater losses than the controls. It may be argued that indeed they
perceive these events to be more frequent, but that the number of
objectively measured negative situations may be equal, and that the
suicidal Ss suffer from a perceptual problem of defining these events
in a more negative fashion. The present 3tudy did not attempt to
objectively observe the Ss to measure the frequency of these events,
but relied only on self-report. However, the questions on loss and
social punishment were worded in such a way as to extract the most
objective information possible from the Ss, requesting the Ss to very
briefly describe each situation they reported under each of the loss
and social punishment questions, so that generalized response of
"everyone rejects me" or "I lost everything" would be discouraged. In
addition, the suicidal group reported a greater number of material
losses, such as jobs and money, which are the types of situations
least distorted by subjective interpretation.
It was found that approximately 60^ of each group was unem
ployed at the time of the first interview, but that the unemployed
suicidal Ss had typically lost their jobs more recently. Eighty-
eight percent of control Ss had been out of work for over 1 year,
while 46% of suicidal Ss had lost their jobs within the last 6 months.
93
Since the definition of "loss" on this interview stipulated that it was
an event which the felt was still affecting him, the recency of
leaving employment among suicidal Ss would indicate a greater likeli
hood of these events being labeled as "losses." People who had not
worked for periods of several months or years would be more likely to
have accepted unemployment as a routine and normal state of affairs,
while people who had just been laid off or quit work would be more
likely to feel they had suffered a substantial material loss and
disruption of routine.
The wording of the questions and the reports of material loss
lend some support to the view that the suicidal S^s really are ex
periencing objectively more negative stimuli in their environments,
but the possibility of problems in perceptual definition of the
situations remains a very strong one. One additional point which
should be mentioned is that if indeed the suicidals are involved in
more socially punishing situations, no evidence is reported here as
to how instrumental the S_ was in causing the loss or rejection to take
place. Evidence exists (Harris, 1964, Ganzler, 1967), that suicidal
people are characterized by involving themselves in interpersonal
situations where there is a high likelihood of being rejected or
otherwise losing in interpersonal exchanges. Libet and Lewinsohn
(l97l) reported similar data, that depressed Ss lacked the social skill
to elicit positive and avoid negative reinforcement from other people.
The current study made no attempt to answer questions of skill deficits
or choice of people to interact with as possible causative agents.
When the results discussed under this hypothesis are
94
integrated with those of the first hypothesis concerning possible
reinforcement, it suggests even more strongly that depression is
primarily an extinction phenomenon, and that the addition of negative
reinforcement through rejection or loss may lead to the occurrence of
suicidal behaviors. Because the current study is correlational in
nature, no conclusions regarding cause and effect relationships can
be inferred in the discussion of this or any of the hypotheses which
follow. However, the data do lend support to Neuringer's (1970) model
of suicidal behavior being in many cases an avoidance response to a
general class of noxious stimuli.
Hypothesis 3 predicted that suicidal Ss would exhibit higher
situational (state) and chronic (trait) anxiety levels than control
Ss, as a possible co-effect of a greater number of negative reinforcers
present in the environments of suicidal Ss.
These predictions were both supported by the data. Suicidal
Ss had significantly higher levels of both state and trait anxiety as
measured by the STAI. It appears likely that either the more frequent
occurrence of negatively reinforcing events in the lives of suicidal
S_s as compared with controls, or the suicidal Ss' more frequent
interpretations of the events of their lives as being negative, gen
erates higher levels of anxiety in these people. This result may be
interpreted as support for the Frederick and Resnik (l97l) model of
suicidal behavior as being a drive reduction phenomenon based on
anxiety, but as Neuringer (1974) has proposed, anxiety and suicide
may be independent general response tendencies to the same class of
noxious stimuli. They may occur at the same point in time, but either
95
one does not necessarily cause the other. The data from the present
study cannot be used to resolve this question of anxiety as a cause
or simply a co-effect.
Hypothesis 4 posited that the number of adaptive coping
responses (non-suicidal behaviors performed in order to relieve stress)
in the repertoires of suicidal £s would be lower than that of control
Ss. This hypothesis was not supported by the data. Of the 17
behaviors listed as possible coping responses, there were no signifi
cant differences between groups as to number of behaviors in Ss'
repertoires or in preference for specific types of behaviors. The
highest frequency behaviors in both groups were listening to music or
watching TV, reading or writing, fantasizing about pleasant situations,
becoming physically active, and smoking. The only coping behavior
which appeared to differ between groups was a higher frequency of
sleeping in the suicidal group. However, in a comparison of 17 be
haviors, it would be predicted that at least one significant difference
would appear by chance alone, and no conclusions should be inferred on
the basis of this one difference.
A possible explanation for this finding of no difference
between groups in size of repertoire of coping mechanisms may be that
the critical variable is not number of mechanisms employed, but rather
is the S/s satisfaction with the effectiveness of particular mechanisms.
Only the number and frequency of employment of coping mechanisms was
assessed here, and not the effectiveness of these behaviors in reducing
stress. It is possible that the sizes of the repertoires of coping
responses were similar across groups, but that the mechanisms the
96
control group used were more successful in terminating or reducing
experiences of stress. Future research on this topic would require
assessing the Ss' perceptions of the effectiveness of their personal
repertoires of coping responses.
An alternative explanation might be that since both groups are
diagnosed as depressed, the sizes of Ss' repertoires of coping mechan
isms in each group may be smaller than those of nondepressed Ss. Since
the suicidal group is experiencing or perceiving a greater frequency
of stress-inducing stimuli (as discussed under Hypothesis 2), it is
then possible that the suicidal £s exhaust their repertoires of coping
responses frequently and subsequently begin to emit suicidal behaviors
as avoidance responses to the stress, while the stresses the control
Ss experience are never quite enough to exhaust their coping responses.
Neither of these possible explanations can be tested using the
present data, and are subjects for future research.
Hypothesis 5 predicted that a larger number of models who
committed suicide would be reported in the histories of suicidal S_s
than control Ss. This hypothesis was not supported by the data.
Almost 2/3 of the Ss in each group knew someone personally who had
committed suicide, and this proportion is higher than that of the
general population. However, given that all the Ss are depressed and
are outpatients in therapy, it does not seem unusual that their
frequency of contact with others who committed suicide is higher than
that of a more heterogeneous population. What the data indicate is
that the majority of Ss in both groups have had the opportunity to
learn the behavior via modeling, but only one group has chosen to
97
perform the behavior. The data can still be interpreted as support
for the position of Frederick and Resnik (l97l), that the behavior may
be learned in one trial through modeling, and that from that time on,
the issue iB one of performance of the previously learned responses.
The opportunities for learning about suicide in this culture are
numerous (personal contact, conversation, news media), and given the
dramatic nature of the behavior, people are unlikely to forget that
suicide exists as an alternative response in stressful situations,
once they have perceived its existence. The most important question
seems to be under what conditions is the behavior likely to be per
formed, rather than the source of the learning.
Hypothesis 6 (a) predicted that the suicidal group would
report less fear of death, view death as a subjectively more pleasant
state, perceive greater control over the time of their deaths, and
perceive less difficulty in causing their own death than the control
group.
This hypothesis was supported in part by the data. The most
accurate predictor of group membership among the 5 "attitude toward
death" items was fear of death. Most suicidals described themselves as
either accepting of death or viewed death as a relief, while most
controls described themselves as afraid of death or chose the response
that it would just happen some day and there was no use worrying about
it, which may be considered a form of death-denial. A second highly
predictive item was the difficulty of causing one's own death. Most
controls responded that causing their own death would be either very
hard under any circumstances, or fairly hard except under conditions
98
of extreme stress. Most suicidals responded either that it would be
fairly easy if they had a good reason, or very easy under any circum
stances. Control over the time of one's death was also of some pre
dictive value, although not as strong as the previously discussed
items. Most Ss in both groups responded that a person takes some part
in determining the time of his own death, but the suicidal group
generally chose the response of "a great deal of control" while the
control group more frequently responded "some control," when the choi
ces were "no control by anyone," "control by God or Pate," "some
control by the person" or "complete control." The differences are not
of as high a magnitude as the previously discussed items, but there is
a trend here toward placing control over the time of death more in the
hands of the individual.
The remaining 2 items assessing the concerns the Ss would have
over the possible consequences of suicidal behavior, and their concept
of afterlife did not show any differences between groups. The majority
of Sjs in both groups responded that they viewed death as nothingness.
Contrary to the predicted result, suicidal Ss did not show any sig
nificant trend toward viewing death as a pleasant state, such as a
restful place, a Heaven, or a happier reincarnation. It appears that
for this suicidal population, the important motivator of behavior is
not so much the attractiveness of death as the wish to avoid negative
stimulation in life. With respect to the number and strength of
concerns Ss had about the possible consequences of suicidal behaviors,
there was no significant difference between groups. It was expected
that the control group would show a greater number of concerns, but
99
this was not found. The controls generally expressed a fear of death
as a major concern more frequently than suicidals (as they had on a
previous question), but no other trends were found. Both groups
responded that the financial or anotional desertion of other people
was their greatest concern, and that the possibility of not going to
a pleasant afterlife was their least concern. The only portion of
this question which appeared to discriminate the groups at all was the
fear of death, and this was measured independently by another more
accurately predictive item.
The conclusion which may be drawn here is that the attitudes
toward death of suicidal Ss do differ significantly from control Ss
on certain dimensions, these being fear of death, and the perception
of difficulty of causing one's own death and control over the time
of one's death. The question of exactly how much motivation the
maintenance of these attitudes contributes toward the performance of
suicidal behaviors cannot be answered with the current data. As
Cautela (l970) and Manno (1972) observed, the covert rehearsal of the
positive or negative consequences of a behavior raised the probability
of its occurrence. However, the questions asked here did not measure
the frequency of the covert rehearsals of the Ss' attitudes toward
death. Pew differences were found here on measures of concerns over
negative consequences of suicidal behavior, or covert rehearsal of a
pleasant afterlife. However, the absence of a fear of death among the
suicidal Ss combined with their attitude that causing their own deaths
would not be extremely difficult could be interpreted as a lack of
covert inhibitors of suicidal behaviors. Under conditions of stress
100
when the probability of suicide as an avoidance response is raisedy
the suicidal group appears to have a lower frequency of covert self-
reinforcing responses which are life-oriented and which might have an
inhibitory effect on suicidal responses. Thus, in this way the Ss'
attitudes toward death may be factors which affect the probability of
occurrence of suicidal behaviors.
Hypothesis 6 (b) was also concerned with Ss' attitudes toward
death and predicted that the suicidal Ss would report a preference for
death over life in a greater number of possible stressful situations
than control S_s.
This prediction was supported very strongly by the data. The
measurement of this variable alone resulted in 92% accurate prediction
of group membership. A list of 18 stressful situations was presented
to each 5_, and the suicidals chose a mean of 7.44 situations and the
controls a mean of 2.48. This finding indicates that there are a
greater number of events in the lives of the suicidal S_s that have the
potential to trigger death-related fantasies. This has two major
implications. One is that due simply to the greater number of situa
tions selected, the probability of death rehearsals is raised even if
both groups encounter the same situations. The other implication is
that previously discussed questions demonstrated that the suicidals do
experience more negative events (or at least perceive more negative
events) than controls, so the probability of encountering a situation
which will result in a death-related fantasy is raised still further.
The suicidal Ss' responses of choosing more numerous situations of
preference of death over life may be interpreted as meaning the
101
suicidals are "more sensitive," or that their perception of events is
more negative. Alternatively, it could mean that they had already
experienced many of these situations and were not willing to face
them again, while controls had not as frequently experienced them.
The only conclusion that can be drawn is that the suicidal group is
more likely to encounter situations which will trigger fantasies
concerning death over life, and that these may become self-reinforcers
which raise the probability of suicidal behaviors.
Hypothesis 7 concerned changes in repeated measures over 2
two-week time periods within the suicidal group only. The predictions
were that positive correlations would be found between changes in
negative stimuli and changes in suicidal ideation and overt behavior
over time, and that negative correlations would be found between
changes in positively reinforcing stimuli and suicidal behavior.
This hypothesis was supported by the data. As shown in Table
14, high positive correlations were found between changes in intensity
of suicidal behavior (frequency combined with seriousness) and changes
in negative stimuli. The highest correlations were with rejections
(.69 and .79 over 2 two-week spans), followed by powerlessness,
arguments and embarrassments. Both embarrassments and arguments showed
high correlations in only 1 time period, and this appeared to be due
to their lower frequency of occurrence. As in the between-groups
analysis, rejection appeared to be the most sensitive measure of
social punishment.
Changes in state of health were significantly correlated with
changes in suicidal behavior in only 1 of the 2 time periods, the
102
first being -.18 and the second .73. The reason for the large
discrepancy is not clear. One possibility is that if there is any
cause-effect relationship between health and suicide, there may be a
time lag Involved in its effect, as opposed to the possibly more
immediate effects of social punishment. The explanation is at best
uncertain, but this variable appears to merit future investigation.
The index of losses, the other form of negative stimulation investi
gated, was not included in this analysis because of an extremely low
frequency of occurrence during the 4-week time span measured for
each S^.
As shown in Table 13, all of the positive reinforcement for
non-suicidal behavior items analyzed together did not show significant
correlations. However, the separation of social interaction items
from other positive reinforcement items resulted in a significant
negative correlation with changes in suicidal behavior, as predicted.
That is, as social interactions were increasing, suicidal behavior
was decreasing, and vice-versa. Very few increases (or decreases) in
material reinforcers were noted during the time period under observa
tion, and did not appear strongly related to changes in suicidal
behavior in this analysis. Data discussed under Hypothesis 2 indicate
that material losses may possibly be a very important determinant of
suicidal behavior, but these losses are generally lower in frequency
than interpersonal reinforcers or punishers.
It should be noted that 2 of the variables which showed no
differences between groups did show significant correlations with
suicidal behavior within the suicidal group over time. These were
103
state of health and the social interaction component of positive
reinforcement. Apparently, although the magnitude of both variables
cannot be distinguished clearly between groups, Ss may still be
reacting to changes in individual levels of these variables within
themselves. In addition, the variable of loss which was so highly
predictive between groups has a low frequency of occurrence and does
not appear useful for predicting time-sensitive relationships precisely.
The most significant within-group relationships appear within the
measures that are most time-sensitive, these being positive social
interactions and negative social stimulation (such as rejections).
Two closing statements of caution should be made here. One is
to re-emphasize that the Pearson _r correlations do not show cause and
effect, and that all that has been demonstrated here is co-occurrence
within 2-week time periods. It does point out, however, the types of
events that may have causal significance over time and which should be
investigated more closely. The other caution is that the correlations
were performed on decreases as well as increases in suicidal behavior,
with over half the changes in suicidal behavior being decreases. This
may be interpreted either as a weakness or as a strength. The weak
ness is a smaller number of data points from which to imply that
events are causal of increases in suicidal behavior. The strength is
that the correlations were significant for both aspects of suicidal
behavior, increases and decreases. The obvious solution to the
weakness is to increase the subject population in future research to
include more Ss who exhibit increases in suicidal behavior.
Hypothesis 8 also concerned changes within the suicidal group
104
over time. The prediction here was that positive correlations would
be found between changes in suicidal behavior and changes in both
self-reinforcement and reinforcement by other people following previous
suicidal responses.
This hypothesis was supported in part by the data. As stated
earlier, a low reported frequency of change scores in externally
administered reinforcement through suicidal manipulation of others,
combined with a clerical error, prevented the computation of a
correlation between the "manipulation of others" variable and changes
in suicidal behavior. The question concerning the reinforcing value
of manipulation of other people through suicidal acting out cannot be
answered in the present study and must be addressed by future research.
Significant correlations between changes in self-reinforcement
following previous suicidal behaviors and changes in the frequency of
subsequent suicidal behaviors were found for one time period, but were
not consistent across both time periods. None of the 3 components of
this variable (positive feelings following suicidal thoughts, following
suicidal communications, and following suicidal gestures or attempts)
was correlated significantly with changes in suicidal behavior during
the first 2-week period, but the first 2 approached significance
(.38 and .31, respectively) and the third component was highly sig
nificant (.75) during the second time period. This component of
positive feelings following a suicidal gesture or attempt was the most
highly correlated in either time period, but unfortunately was a
lower frequency response than the other 2 components. Since the
majority of overt suicidal behaviors occurred during the second time
105
period, this may indicate that self-reinforcement following a
suicide attempt is more closely associated with increases in suicidal
behavior than are self-reinforcements following suicidal fantasies
or communications. However, it may be of value to consider data from
the latter 2 components due to a lower frequency of occurrence and
thus availability of the former. The data concerning this hypothesis
are not conclusive, but do show the trend that changes in self-rein
forcement are positively associated with changes in suicidal behavior,
and that this trend may be most likely to occur following a suicide
attempt.
106
CHAPTER V
CONCLUSIONS AND IMPLICATIONS FOR FUTURE RESEARCH
This study was performed in order to attempt to add experimen
tal validation to a behavioral model of suicide. The major questions
under investigation here were (l) could any specific reinforcing
contingencies be identified which could separate suicidal from non-
suicidal Sb in an otherwise homogeneous population?, and (2) could any
specific reinforcing contingencies be identified within a suicidal
population which correlated highly with the occurrence of suicidal
behaviors over specified time periods? Eight hypotheses based on
these questions were tested, and 5 were supported fully or in part by
the data, while 3 were not supported.
Several types of events which could act as reinforcing contin
gencies for the occurrence of suicidal behavior were identified. The
events which most accurately discriminated suicidal from non-suicidal
depressed Ss were primarily negatively reinforcing, such as the
suffering of losses and experiences of rejection. Both groups experi
enced similar low rates of positive reinforcement for non-suicidal
behaviors, contrary to the predicted finding, the key to correct
identification of Ss appearing to be a preponderance of negative rather
than a lack of positive reinforcement in this population. The anxiety
level of the suicidal group was found to be significantly higher,
possibly due to a greater real or perceived amount of negative stimuli
present in the environments of these Ss.
107
Internal events such as the covert rehearsal of death-related
alternatives under conditions of imagined stress, and the attitudes
of less fear of death, less perceived difficulty in causing one's own
death, and greater perceived control over the time of one's death
were also highly accurate in separating suicidal from control Ss. No
differences were found with regard to the frequency or amount of
coping mechanisms employed under stress, or the presence of suicidal
models in the Ss' histories.
In all, 11 of 26 items were found to be of medium to high
predictive accuracy between groups. It should be noted that these
items correctly identified both suicidals and controls in this pop
ulation, with few errors of overinclusion of control Ss and under-
inclusion of suicidal S_s.
Within the suicidal group, several types of events were found
to be significantly correlated v/ith changes in suicidal behavior over
time. The highest correlations were a positive relationship between
changes in social punishers (especially rejection) and changes in
suicidal behavior, and a negative relationship between changes in the
frequency of social interaction and changes in suicidal behavior.
Significant positive correlations were also found for changes in the
variables of physical health and self-reinforcement with changes in
suicidal behavior, but were less consistent over time. Changes in
the amounts of losses suffered and amount of suicidal manipulation of
others were not computed because of low change scores. As stated
previously, these data do not provide proof of any cause-effect
relationship, but do indicate what types of changing events may have
108
some causal link with the occurrence of suicidal behaviors.
The data appear to most strongly support the model of
Neuringer (1970) of suicide as an avoidance response to noxious
stimuli in the environment of this particular population. The data
collected here did not include information on positive reinforcement
of suicidal behaviors, except on a self-reinforcement level, so the
model of Frederick and Resnik is neither supported or refuted.
These data may be of use both for diagnostic and treatment
purposes. With regard to diagnosis, the 11 items which appeared to
discriminate the most accurately between groups may in the future be
combined into a questionnaire for the purposes of assessing suicide
risk. Some cautions should be noted, however. First is that these
items do not assess lethality (the probability of making a suicide
attempt), they merely distinguish the chronically suicidal Ss from
those who are not suicidal. Second is that the validation of these
items requires replication using new subject populations. Since S_s
in the present study were aware that the project was an investigation
of suicidal behavior, the validation would ideally consist of Ss
being asked these questions without their knowing the purpose was
diagnostic evaluation of suicidal behavior, and the _E being unaware
of the Ss' suicidal histories until those questions were completed.
These measures should also be compared with instruments assessing
differing levels of lethality rather than a suicidal vs. non-suicidal
dichotomy, since suicidal behavior is a set of responses which vary
in frequency and strength rather than a trait which someone "has" or
"doesn't have." The reason that a suicidal vs. non-suicidal
dichotomy appeared in the present study was that S_s were selected
from opposite ends of a suicidal vs. non-suicidal continuum in order
to be able to clearly identify any possible differences, with refine
ment of degrees of lethality to take place in the future. If the
above cautions are not considered, the result would be a questionnaire
which can only separate depressed outpatient suicide attempters who
talk about their suicidal behavior from depressed outpatients who do
not engage in suicidal behavior.
The data may also be useful for treatment purposes. It was
demonstrated that suicidals are characterized by experiences of cer
tain types of events, both internal and external, which are generally
negatively reinforcing. As stated previously, it is possible that the
suicidals are merely perceiving more negative stimuli in their
environments, but it is likely that in many cases these events are
really occurring and contributing toward suicidal acting out. It is
also likely that the suicidal 3s more frequently involve themselves in
situations where these negative events are more likely to occur, but
this type of data was not sought in the present study. Information
concerning the variables which discriminate between the groups
(external events, internal attitudes and covert rehearsals) and those
that are related to changes in suicidal behavior over time can be used
to develop a baseline from which modification of the suicidal behaviors
can be undertaken. Useful techniques might be desensitization to
losses, the teaching of assertive techniques oriented toward loss
recovery, toward avoidance of social punishment, and towards increasing
frequencies of positive social interactions; thought-stopping of
death-related fantasies; and interventions to reduce positive self-
reinforcing responses which follow suicidal behaviors. Use of the data
from the present study for the above discussed diagnostic and treat
ment purposes requires followup studies on other depressed populations
for validation, and later on non-depressed populations to test the
limits of the utility of this information.
Ill
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120
APPENDIX A
INITIAL INTERVIEW FORM
Cover Sheet:
Name:
Address:___________________________________
Phone:_____________________________________
Sex:
!)
Male
Female
Marital Status:
Living Situation:
1
2
3;
Age: 1) 15 - 19
2) 20 - 24
3) 25 - 29
Single 4) 30-34
Married
5) 35 - 39
Separated 6) 40 - 45
Divorced
7) 45 - 49
Widowed 8) 50 - 54
9) 55 - 59
10 60 - 64
Alone
11)
Over 65
With Parents
With Spouse, Girlfriend, Boyfriend
4) With Friends, Roommates
How Long?
______ l) Less than 2 months
________ 2)2-6 months
________ 3) 6 months - 1 year
________ 4) Over 1 year
Now Employed? ________ Yes ________ No Type of_Job_____
________ l) Part Time 2) Full Time
If not employed, how long since last job?
________ l) Less than 2 months
________ 2)2-6 months
________ 3) 6 months - 1 year
________ 4) Over 1 year
121
1.
3.
(a) How long ago was the first time in your life you felt
suicidal?
________ years ________ months
(b) How long ago was the first attempt?
________ years months
(c) How many attempts have you made? __
weeks
(1) One
(2) Two
3) Three to five
l4J Six or more
2. Can you describe your most recent attempt?_
How long did you plan for the attempt?____
What method did you use?___________________
How much chance was there that you would be found?_
(Refer to V.A. Criteria for Rating Suicidal Intention, enter
lethality rating in the space below.)
Rating__________
Can you describe what types of suicidal behavior you have engaged
in during the most recent time in your life that you felt suicidal?
By "suicidal behavior" we mean anything from mentioning to someone
you are thinking about death to actually trying to kill yourself.
Can you say how many times you did each thing?
(Repeat for the last two weeks)
1 = one time 1 = more than a year ago
2 = two or three times 2 = six months to a year ago
3=4-7 times 3 = one to six months ago
4 = more than 7 times 4 = one week to one month ago
5 = in the last week
(Code type and frequency of behavior below)
How long ago?
(l) Mild communication
in passing
(3) Strong overt
communication
(5) Physical gesture
(7) Moderate intent
attempt
(9) Highly lethal
attempt
Total for last
two weeks only
Scoring:
Multiply
across, add
right column
and total at
bottom.
Total Overall
122
4a. How often did you experience suicidal thoughts during the last
time in your life that you felt suicidal?
Once a week or less
A few times per week
Almost daily
Several times a day
(Repeat for the last two weeks only)
Once a week or less
A few times per week
Almost daily
Several times a day
4b. How long ago was the last time you experienced suicidal thoughts?
(Check one)
_________ (l) One week to one month ago
2) Pour days to one week ago
________ 3) Two or three days ago
_________ (4) In the last 24 hours
4c. How long did the most recent period v\here you experienced suicidal
thoughts last? (Check one)
One month or more
One week to one month
Three days to one week
Only a day or two
(1)
(2)
(3)
(4)
(1)
(2)
3
(4)
(i)
2
(3)
(4)
123
SELF-REINFORCEMENT FOR PREVIOUS SUICIDAL BEHAVIOR:
1. How have you felt after having your most recent suicidal thoughts
or fantasies? Were these feelings strong, moderate or slight?
(Prompt, using responses below). Scoring: multiply across, add
total at bottom.
1 = slightly
2 = moderately
3 = strongly
_______x (o) Weak, out of control,
ineffective
_______x (o) Scared, anxious, agitated
_______x (l) Confused
_______x (2) Comforted, pleasant
_______x (3) More resolved, stronger
________ Total
2. How did you feel after making your most recent suicide communica-
tions?(Prompt» giving some of the responses below). Were these
feelings strong, moderate or slight? Scoring: multiply across,
add total at bottom.
1 = slightly
2 = moderately
3 = strongly
_______x (0) Ashamed, sorry, foolish
_______x (0) Angry, frustrated by the
reaction of others
_______x (0) More depressed
_______x (0) Neutral, not much feeling
_______x (l) Relieved, pleased that it
brought help
_______x (2) More powerful, more in control
of people around me
________ Total
3. What were your feelings after your most recent suicide attempt?
(Prompt, giving some of responses below.) Were these feelings
strong, moderate or slight? (Note: Can check more than one
response.) Scoring: multiply across, add total at bottom.
1 = slightly
2 = moderately
j = strongly _______^ pearfuit afraid, not willing
to try again
_______x (OJ Ashamed, foolish
________x (l) Relieved, less tense
_______x (2) Cleansed, exhilarated
_______x (2) Sorry that the attempt failed
Total
124
SUICIDAL MANIPULATION OP OTHERS:
Which people in your life do you think your suicidal behavior has had
an effect on? What do you think the effect on other people was of
your most serious or your most frequent suicidal behavior? Was it
positive or negative? How strong do you think this effect was for
each of these people?
(Explain strong, moderate, slight or no effect. Explain positive or
negative as listed below. Prompt each of the significant others if
necessary. Record on chart below.)
0 = no effect
1 = slight effect
2 = moderate effect
3 = strong effect
Positive effect = mobilized help from them, led to better communication
between S_ and others, helped others to see 3_'s problems more clearly,
led to some resolution of conflicts.
Negative effect = drove others away, made then label 3_ as sick or crazy
or beyond help, scared others so they felt they could not communicate
with 0_, caused others to dislike U_.
Scoring: add each column.
Negative effect Positive effect
Spouse_____________________________ ________
Father ________ ________
Mother ________ ________
Sister(s) ________ ________
Brother(s) ________ ________
Other relatives..which?___________________________________
Girl/boy friend ________ ________
Close friends
(Can list more) ____________________ ________
Therapist ________ ________
Employer _______ ________
Co-workers ________ ________
Others (teachers,
counselors, etc) ______ ________
Total Total
125
COPING InECHANISKS:
When you begin to feel depressed, or begin to have bad feelings about
yourself or situations, or become nervous, what are some of the things
you do to avoid these feelings? How often? Scoring: add total of
column at bottom.
1 = rarely
2 = sometimes
3 = often
________ l) actively dealing v/ith the feelings when they
start, until they are worked out
________ 2) getting help from friends to help deal with
the feelings
________ 3) being physically active and forgetting about it
________ 4) interacting with people to take your mind off
the situation and forgetting it
________ 5) calling your therapist or a counseling service
________ 6) reading or writing
7) listening to music, watching TV
______ 8; fantasizing about pleasant things
________ 9) taking tranquilizers
________10) praying
________ll) meditating
12) smoking
________13) eating
________14) drinking alcohol
________15) just letting it go on
________16) sleeping
________17) crying
18) other
Total
126
STATE OP HEALTH:
(a) How would you describe your present physical health? (Check one)
________(l) excellent
________(2) good
________(3) fair
________(4) poor
________(5) extremely poor
(b) Have you had any illnesses or other physical problems that you are
concerned about?
________(l) yes (0) no
If yes, what were they?__________________________________
(c) How serious did you consider the problem? Scoring: add total of
(c) and (d)
________(l) mildly serious
________(2) moderately serious
________(3) extremely serious
(d) How often did the problem occur?
________(l) for a brief period, and is now cleared up
________(2) for an extended period, but is now cleared up
________(3) it recurred a few times
________(4) it recurred frequently
Total
SUICIDAL MODELS:
Scoring: add (a) and (b) at bottom
(a) Have you ever known anyone personally who committed suicide?
________ (l) yes ________ (0) no What was the person's relation
to you?___________________________________________________________
(b) Have you ever known anyone personally who committed suicide who
you thought was correct in doing so, or seemed to have ample
justification for it? ______(l)yes (o)no
If yes, give the person's relation to you and state briefly why
you thought that they might be better off dead._________________
Total
127
;
CONCEPTION OP AFTERLIFE:
1. Y/hat do you believe will become of you after your death? (Check
one)
1) no one can understand what happens after death
2) there will be a long, unpleasant afterlife,
like Purgatory or Hell
(3) there will be absolute nothingness, death is
the end of all forms of mental or physical
existence, there is no such thing as after
life
4) death is like a long, peaceful sleep
5) there will be some form of return to the
world, such as reincarnation
________ (6) there will be a long, very pleasant afterlife,
like Heaven
________ (0) other form of afterlife_____________________
2. How much control do you believe a person has over the time of
his own death? (Check one)
it is purely by chance, there is no control by
anyone or any power
only God, fate or some power of the universe
has control over it
a person has some control over it
a person has a great deal of control over it
a person has complete control over it, each
person really determines the time of his/her
own death, consciously or unconsciously
( 1)
( 2)
(3)
4
(5)
128
CONCERNS OVER POSSIBLE CONSEQUENCES OP SUICIDAL BEHAVIOR:
1. You know that every person, including yourself, is going to die
someday. How do you feel about the fact that you will some day
die? (Prompt response using the choices below.)
________ (l) afraid of death
________ (2) it will just happen some time and there is
no use worrying about it
________ (3) can probably accept death v/hen it appears
imminent
________ (4) death will be a welcome relief from this
world
2. How hard would it be for you to cause your own death?
________ (l) very hard to carry out under any circumstances
________ (2) fairly hard except under conditions of great
stress
_________ (3) relatively easy if I were completely decided
and felt I had a good reason
________ (4) relatively easy if under severe emotional
upset
________ (3) very easy to do under most circumstances
3. If you were planning to kill yourself, what are some of the things
that might stop you, or at least make you think seriously about
not killing yourself? (Prompt responses below.) (Can check
several.) Scoring: add total at bottom.
1 = not very important
2 = of some concern
3 = of great concern
________ the fear of what death is
________ the fear of the pain of dying
________ that past self-injuries v/ere painful
________ that I could not go to heaven or any good
afterlife
________ that I would be deserting certain people, either
emotionally or financially
________ that society would try to punish my family
financially or socially
________ that I might not die right away and/or be disabled
________ other considerations: please describe___________
129
SOCIAL PUNISHERS:
1. Have you been involved in any arguments with people in the last
Two weeks? _______ _______ (®) no With whom? How often?
How did you feel after the argument?
(Code how often in column to left of situation, code how it felt in
column to right of situation.) Scoring: multiply across, add
total on right at bottom.
How often
1) once
2) 2 or 3 times
3) 4-7 times; a number
of times
4) over 8 times;
numerous times
How did it feel?
17
2)
3
4
elated, it ended very
happily
satisfied
neutral, a stand-off
dissatisfied, uneasy
5) upset, angry, very unhappy
with spouse or lover ________
with family ________
with friends ______
on job or at school ________
with agents of some _______
bureaucracy
Other: __________
Total
2. Have you experienced occasions where you have felt ineffective,
powerless, or unassertive in getting your own way in dealing with
other people or with a system in the last two weeks?
________ yes ______ (°) no
How often did you experience this? In what situations? How
unpleasant did it feel?
(Code how often in column to left of situation, code how unpleasant
in column to right of situation.) Scoring: multiply across, add
on right at bottom.
How often How unpleasant
once 1) slightly
2 or 3 times; a 2 moderately
few times
3)
extremely
4-7 times; a number
of times
over 8 times; numerous
times
130
SOCIAL PUNISHERS (Continued):
with spouse or lover ________
with family ________
with friends _______
on job or at school ________
with some other system ________
or bureaucracy
other:__________________________
_______ Total
Have you experienced any rejection by other people in the last two
weeks? ________ yes ________ (o) no By whom? How often? How
unpleasant did these occasions feel?
(Code how often in column to left of situation, code how it felt in
column to right of situation.)
total on right at bottom.
Scoring: Multiply across, add
How often
1) once
2) 2 or 3 times; a few
times
3) 4-7 times; a number
of times
4) over 0 times; numerou;
times
How unpleasant did it feel?
l) slightly
?) moderately
3) extremely
by spousr or lover ________
by family ________
by friends ________
by co-worker3 or ________
fellow students
by agents of some ________
bureaucracy
other people_________________
Total
Have you had any embarrassing experiences in the last two weeks?
________ yes (0) no How often? How unpleasant were
these experiences?
Scoring: Multiply across, add total on right at bottom.
How often How pleasant
________ l) once 1) slightly
________ 2) 2 or 3 times 2) moderately
________ 3) 4-7 times; 3) strongly
a number of
times ________ Total
________ 4) over 8 times;
numerous times
131
POSITIVE REINFORCERS FOR NON-SUICIOAL BEHAVIORS:
1. Do you feel you can meet people and make friends easily?
_________ (l) yes ________ (o) no
2. (a) How often do you make new acquaintances? (Code below)
Scoring: Add (a) and (b) at bottom
very rarely
only on occasion
once a week or less
a few times a v/eek
almost every day
(b) Is this often enough to satisfy you? (Code below)
1) no, it is not satisfactory at all to me
2) no, but I don't feel any discomfort about it
3) yes, but I would not mind meeting new people
more often
_________ (4) yes, I feel satisfied
________ Total
3. (a) Who do you most frequently interact with? (Code below)
Scoring: add (a) and (b) at bottom
almost no one
only a small circle of acquaintances, I have
no friends who are close to me
very few friends or family
only with friends or family I know well
mostly friends and family, less frequently
with others
many people - friends, co-workers, acquaintan
ces, family
(b) Are these contacts frequent enough to satisfy you? (code
below)
1) I have no desire to interact with people
2) no, I do not interact with enou^i people and
would definitely like to know more people
3) no, I feel very cut off from people I like
4) no, there are certain people I definitely do
not see enough
(5) yes, but some people I would like to see more
of and we don't have the time to get together
(6) yes, they are satisfactory
Total
(1)
(2)
(3)
(4)
(5)
132
POSITIVE REINFORCERS FOR NON-SUICIDAL BEHAVIORS(Continued):
(a) Of the people you see the most in business-type relationships,
how have the interactions in the last month generally felt
to you? Scoring: add (a) and (b) at bottom.
1) very negative in most cases
2) not very enjoyable in most cases
3J neutral, not much feeling either way
4) mixed, a lot of good and bad
5) mostly enjoyable, but with definite
problems with certain people. Who?__________
________ (6) mostly enjoyable, with a few annoyances
________ (7) very enjoyable
(b) Of the people you see the most socially, how have the inter
actions In the last month generally felt to you?
1) very negative in most cases
2) not very enjoyable in most cases
3) neutral, not much feeling either way
4; mixed, a lot of good and bad
(3) mostly enjoyable, but with definite problems
with certain people. Who?___________________
6) mostly enjoyable, with a few annoyances
7) very enjoyable
Total
Do you feel that you have made any major gains lately, or recovered
any major losses you may have suffered?______ (l) yes
________ (0) no
Can you name the best things that have happened to you lately?
(Prompt if n e c e s s a r y ) _____________________________________
Have you experienced feelings of being accepted and well-liked in
the last month? ________ yes no By whom? How often?
How pleasant did these occasions feel?
(Code how often in column to left of situation, code how it felt
in column to right of situation). Scoring: Multiply across, add
total on right at bottom.
How often How pleasant did it feel?
1) once T) slightly
2) 2 or 3 times, a 2) moderately
few times 3) strongly
3) 4-7 times; a number
of times
4) over 8 times; numerous times
Total
POSITIVE RSINFORCHRS FOR NON-SUICIDAL BEHAVIORS(Continued)
________ by spouse or lover _________
________ by family _________
________ by friends _________
________ by co-workers or __________
fellow students
________ by agents of some _ _ _ _ _ _
bureaucracy
________ Other people_________
_________ Total
7. Nave you had any experiences in the last month where you felt
proud and respected by others? yes (o) no
Scoring: multiply across, add total on right at bottom.
How often How pleasant
________ l) once 1) slightly
________ 2) 2 or 3 times _______ 2) moderatel
________ 3) a few times; _______ 3) extremely
4-7 times
________ 4) on numerous
j
occasions,
0 or more times
Ijtal
Briefly describe the experiences:_
134
70GNITIVH REHEARSAL OP DEATH UNDER CONDITIONS OF IMAGINED STRESS:
Scoring: add total number of responses checked at bottom.
Try to imagine yourself involved in some of the stressful situations
listed below. Which of these conditions do you think would be so
stressful to you that you might prefer to be dead? You may check as
many as you like.
________ l) if stricken with a painful, incurable disease that would
soon be fatal
________ ?) if you felt no longer productive by either society's or
your own standards
________ 3) if you felt you were a burden to your family and/or friends
________ 4) if you felt rejected by your lover or spouse
________ 5) if you felt you were rejected by your friends
________ 6) if you felt that you simply had no friends
________ 7J if you thought there was something incurably wrong with
your mind, such as brain damage
________ 8) if you felt you were severely physically handicapped
________ 9) if you thought you were becoming psychotic (crazy, insane)
________lo) if it would help to save another person's life, rescuing
someone in great danger
________ll) if life seemed to lack meaning for you
________12^ if you became bored
________13) if you felt terribly embarrassed, ashamed, disgraced,
guilty
________lk) if you felt you had badly hurt someone
15) if the most important person in the world to you died
________16) if you lost your moot important material possessions
17) if you felt ineffective, insignificant, unable to have much
impact on people or situations
18) if you felt you had no freedom, were incarcerated, were
severely restricted in doing things for yourself
19) other: Please describe_____________________________________
Total
135
INDEX OP LOSSES:
Do you feel you have suffered any major losses in your life you
feel are still affecting you? ________yes ________no. If yes,
what kind of loss was it?
________ l) job
(position) 2) money
_____________________ 3) skills or competence
________ 4) someone close who recently died-
who was the person?
(personal) 5) someone close rejected you-
who was the person?
___________________________ 6) someone close had to leave you,
through no fault of yours-moved away,
went into service, to jail, etc.
(mutuality) 7) loss of power or effectiveness to
make any impact on other people or
on the world in general
______ 8) loss of freedom of some kind
____________________________ _ 9) loss of the respect of other people
(physical) ~~10) health or physical capabilities
__________________________ ll) loss of some quality important to
self-image, such as beauty, sex
uality, youth. Please describe.
________12) any other type of loss feels
strongly about. Please describe
br i ef ly_____________________________
If you rated your worst possible loss on a scale of numbers and it
got a maximum score of 9, where would you place your most recent
major loss in comparison to it, if "1" meant it didn't bother you
at all and "9" meant it was the absolute worst thing that could
happen? (Prompt and code).
1 2 3 4 5 6 78 9
did not bother a lot, but troubled terribly,
me at all soon passed could not be worse
How permanent do you feel this loss is? (Prompt and code below.)
________ l) it should be relatively easy to recover the loss
________ 2) it will be a bit difficult, but I am confident that I
can recover it
________ 3) it will be very difficult, but there is a good chance
that with hard work and luck I can recover it
________ 4) it will be extremely hard to recover the loss, the
chances of recovery in all case are slim even with a
lot of work and luck
INDEX OP LOSSES (Continued):
5) there is practically no chance of recovering this
particular loss
6) the circumstances are irreversible, there is absolutely
no chance of recovering what I lost
4. If this loss has affected your abilities to perform in other areas
of your life do you feel that: (Check one)
l) the effect is only temporary and will be easy to remedy
2) the effect is quite bad now, but if the loss is re
covered, these problems will in turn be solved
3) the effect is quite bad now, but I should be able to
adjust to the loss and the other problems will
eventually be solved
4) the effect is very strong on other areas of my life,
and I don't think I can cope with those problems unless
the loss is recovered
5) the effect has been so bad that even if I recover the
loss, I feel that it has had a long-term or permanent
effect on other areas
5. Since this major loss, have you found that any activities or
events which you used to find pleasurable are no longer enjoyable?
Scoring: number of activities.
________ yes ________ no
If yes, what are these activities?________________________________
Total:____
Can you briefly describe how they were related to the loss?
137
APPENDIX B
TWO-WEEK FOLLOWUP
Suicidal Behavior:
1. How often did you experience suicidal thoughts during the last two
weeks?
0) not at all
1) once a week or less
2) a few times per week
3) almost daily
4) several times a day
2. How long did the most recent period where you experienced suicidal
thoughts last during the last two weeks?
1) only a day or two
2) three days to one week
3. San you describe what types of suicidal behavior you have engaged
in during the last two weeks? By "suicidal behavior" vie mean
anything from mentioning to someone that you are thinking about
dying to actually trying to kill yourself. Can you say how many
times you did each thing?
1 = one time
2 = two or three times
3=4-7 times
4 = more than 7 times
(Code type and frequency)
l) Mild communication in passing
3) Strong overt communication
5) Physical gesture
________ 7) Moderate intent attempt
_________ (9) Highly lethal attempt
________ Total
4. If an attempt was made in the last two weeks, can you describe it?
How long did you plan for the attempt?
What method did you use?
How much chance was there that you would be found ?
(Refer to V.A. Criteria for Rating Suicidal Intention, enter
lethality rating in space below).
Rating: _________
138
SELF-REINFORCEMENTS:
What were your feelings after this most recent suicide attempt?
(Prompt, giving some of responses below.) Were these feelings
strong, moderate or slight? (Note: can check more than one
response).
1 = slightly
2 = moderately
3 = strongly
________x(o) fearful, afraid, not willing to try again
________x(o) ashamed, foolish
________x(l) relieved, less tense
________x(l) in better control of the situation
________x(2) cleansed, exhilarated
________x(2) sorry that the attempt failed
________ Total
How have you felt after hvaing suicidal thoughts or fantasies during
the last two weeks? Were these feelings strong, moderate or slight?
(Prompt, using responses below.)
1 = slightly
2 = moderately
3 = strongly
________x(o) weak, out of control, ineffective
________x(o) scared, anxious, agitated
________x(l) confused
________x(2) comforted, pleasant
________x(3) more resolved, stronger
________ Total
How did you feel after making suicidal communications during the
last two weeks? (Prompt, giving some of the responses below). V/ere
these feelings strong, moderate or slight?
1 = slightly
2 = moderately
3 = strongly
________x( o) ashamed, sorry, foolish
________x(o) angry, frustrated by the reaction of others
________x(o) more depressed
________x(o) neutral
x(l) relieved, pleased that it brought help
x(2) more powerful, more in control of people around me
Tota- 1 .
SUICIDAL MANIPULATION OP OTHERS:
Which people in your life do you think your suicidal behavior has had
an effect on during the last two weeks? V/hat do you think the effect
on other people was of your most serious or your most frequent
suicidal behavior? Was it positive or negative? How strong do you
think this effect was for each of these people?
Explain strong, moderate, slight or no effect. Explain positive or
negative as listed below. Prompt each of the significant others if
necessary. Record on chart below.
0 = no effect
1 = slight effect
2 = moderate effect
3 = strong effect
Positive effect = mobilized help from them, led to better communica
tion between and others, helped others to see £['s problems more
clearly, led to some resolution of conflicts.
Negative effect = drove others away, made them label S as sick or
crazy or beyond help, scared others so they felt they could not
communicate with S_, caused others to dislike S^.
Negative effect Positive effect
Spouse ________ ________
Father ________ ________
Mother ________ ________
Sister(s) ________ ________
Rrother(s) ________ ________
Other relatives...
which?_______________ ________ ________
Girl/boy friend ________ ________
Close friends
(can list more)__________________ ________
Therapist ________ ________
Employer________________ ________ ________
Co-workers ________ ________
Othcns (teachers,
counselors, etc)_________________ ________
________ Total Total
140
STATS OP HEALTH:
(a) Have you had any illnesses or other physical problems that you
are concerned about in the last two weeks?
________ yes ________ no
If yes, what were they?
(b) How serious did you consider the problem?
1) mildly serious
2) moderately serious
3) extremely serious
(c) How often did the problem occur?
________ (l) for a brief period, and is now cleared up
(2) for an extended period, but is now cleared up
________ (3) it recurred a few times
________ (4) it recurred frequently
Scoring: Add (b) and (c)
Total
SOCIAL PUNISHERS
1. Have you Icen involved in any arguments with people in the last
two weeks? yes no Y/ith whom? How often?
How did you feel after the argument?
Scoring: Multiply across, add total at bottom.
(Code how often in column to left of situation, code how it felt in
column to right of situation).
How often How did it feel?
1) once l) elated, it ended very happily
2 2 or 3 times, a few times 2) satisfied
3) 4-7 times; a number of times 3) neutral, a stand-off
4) over 8 times; numerous times 4) dissatisfied, uneasy
5) upset, angry, very unhappy
________ with spouse or lover ________
________ with family ________
________ with friends ________
________ on job or at school ________
_______ with agents of some ________
bureaucracy
________ other*______________ ________
_______ Total
141
SOCIAL PUNISHERS (Continued):
Have you experienced occasions where you have felt ineffective,
powerless, or unassertive in getting your own way in dealing with
other people or with a system in the last two weeks?
________ yes ________ no
How often did you experience this? In what situations? How
unpleasant did you feel?
(Code how often in column to left of situation, code how unpleasant
in column to right of situation). Scoring: Multiply across, add
total at bottom.
How often
1) once
2) 2 or 3 times; a few times
3) 4-7 times; a number of times
4) over 8 times; numerous times
________ with spouse or lover
________ with family
________ with friends
________ on job or at school
________ with some other systemj______
a bureaucracy
________ other:__________________________
________ Total
Have you experienced any rejection by other people in the last
two weeks? ________ yes ________ no T3y whom? How often?
How unpleasant did these occasions feel?
(Code how often in column to left of situation, code how it felt in
column to right of situation). Scoring: multiply across, add
total at bottom
How often
1) once
2) 2 or 3 times; a few times
3; 4-7 times; a number of times
4) over 8 times; numerous times
________ by spouse or lover
________ by family
________ by friends
________ by co-worker or
fellow students
by agents of some
bureaucracy
________ other people
How unpleasant
1) slightly
2) moderately
3) extremely
How unpleasant
1) slightly
2) moderately
3) extremely
Total
SOCIAL PUNISHERS (Continued):
4. Have you had any embarrassing experiences in the last two weeks?
yes no
How often? How unpleasant were these experiences? Scoring:
multiply across add total at bottom.
How often How pleasant
_________ (l) once (1) slightly
_________ (2) 2 or 3 times (2) moderately
_________ (3) intermittently, (3) extremely
4-7 times
_________ (4) on numerous occasions,
8 or more times Total
POSITIVE RHINFORCERS FOR NON-SUICIML BEHAVIOR:
1. (a) How often have you made new acquaintances? (Code below).
Scoring: add (a) and (b).
1) very rarely
2) only on occasion
K'j) once a v/eek or less
4) a few times a week
5) almost every day
(b) Is this often enough to satisfy you? (Code below).
1) no, it is not satisfactory at all to me
2) no, but I don't feel any discomfort about it
3) yes, but I would not mind meeting new people more
often
(4) yes, I feel satisfied
________ Total
fc) Y/ho have you most frequently interacted with in the last week?
(Code below). Scoring: add (a) and (b).
(l) many people— friends, co-workers, acquaintances,
family
2) mostly friends and family, less frequently with others
3) only with friends or family I know well
4) very few friends or family
5) only a small circle of acquaintances, I have no
friends who are close to me
(6) almost no one
143
POSITIVE REIRTOHCKRS FOR NON-SUICIDAL BEHAVIOR (Continued):
(b) Are these contacts frequent enough to satisfy you?
(Code below).
1) yes, they are satisfactory
2) yes, but some people I would like to see more of and
we don't have the time to get together
(3) no, there are certain people I definitely do not
see enough
4) no, I feel very cut off from people I like
5) no, I do not interact with enough people and would
definitely like to know more people
________ (6) I have no desire to interact with people
________ Total
3. Of the people you see the most in business-type relationships, how
have the interactions in the last two weeks generally felt to you?
Scoring: add (a) and (b)
(a)
1) very negative in most cases
2) not very enjoyable in most cases
3) neutral, not much feeling either way
4) mixed, a lot of good and bad
5) mostly enjoyable, but v/ith definite problems with
certain people. Who?___________________________
6) mostly enjoyable, with a few annoyances
7) very enjoyable
Of the people you see the most socially, how have the interactions
in the last two weeks generally felt to you?
(b)
1) very negative in most cases
2) not very enjoyable in most cases
3) neutral, not much feeling either way
4) mixed, a lot of good and bad
5) mostly enjoyable, but with definitely problems with
certain people. Who?______________________________
6) mostly enjoyable, with a few annoyances
7) very enjoyable
Of the people you see the most socially, how have the interactions
in the last two weeks generally felt to you?
4. Do you feel that you have made any major gains in the last two
weeks, or recovered any major losses you may have suffered?
_______ yes _ _ _ _ _ no
Can you name the best things that have happened to you lately?
(Prompt if necessary).___________________________________________
144
POSITIVE REINFORCERS FOR NON-SUICIDAL BEHAVIOR (Continued):
Have you experienced feelings of being accepted and well-liked in
the last two weeks? ________ yes ________ no By whom?
How often? How pleasant did these occasions feel?
(Code how often in column to left of situation, code how it felt in
column to right of situation). Scoring: multiply across, add
total at bottom.
How often
1) once
2) 2 or 3 times, a few times
3) 4-7 times} a number of times
4) over 8 times; numerous times
How pleasant did it feel?
1) slightly
2) moderately
3) strongly
by spouse or lover ________
by family ________
by friends ________
by co-workers or______ ________
fellow students
by agents of some ________
bureaucracy
other people:__________________
Total
Have you had any experiences in the last week where you felt
proud and respected by others? ________ yes ________ no
How often? How pleasant were these experiences?
Scoring: multiply across, add total at bottom
How often How pleasant?
________ (l) once (l) slightly
________ (2) 2 or 3 times (2) moderately
________ (3) a few times, (3) extremely
4-7 times
(4) on numerous occasions,
8 or more times Total
Briefly describe the experiences_
INDEX OP LOSSES:
1. Do you feel you have suffered any major losses in the last two
weeks? yes ________ no If yes, what kind of loss was
it?
l) job
2) money
3) skills or competence
4) someone close who recently died— who was the person?
5) someone close rejected you— -who was the person?
6) someone close had to leave you, through no fault of
yours— moved av/ay, went into service, to jail, etc
7) loss of power or effectiveness to make any impact on
other people or on the world in general
________ 0) loss of freedom of some kind
9) loss of the respect of other people
________10) health or physical capabilities
________ll) loss of some quality important to self-image, such as
beauty, sexuality, youth. Please describe:___________
12) any other type of loss _D feels strongly about. Please
describe briefly:______________________________________
2. If you rated this worst possible loss on a scale of numbers and it
got a maximum score of 9, whore would you place your most recent
major loss in comparison to it, if "1" meant it didn't bother you
at all and "9" meant it was the absolute worst thing that could
liappen? (Prompt and code).
1 2 3 4 5 6 7 p 9
3. How permanent do you feel this loss is? (prompt and code below).
________ (l) it should be relatively easy to recover the loss
________ (2) it will be a bit difficult, but I am confident that
I can recover it
________ (3) it will be very difficult, but there is a good chance
that with hard work and luck I can recover it
________ (4) it will be extremely hard to recover the loss, the
chances of recovery in any case are slim even with a
lot of work and luck
________ (5) there is practically no chance of recovering this
particular loss
________ (6) the circumstances are irreversible, there is absolute
ly no chance of recovering what I lost
146
SELF-REINFORCEMENTS (Continued):
If this loss has affected your abilities to perform in other areas
of your life, do you feel that:
(l) the effect is only temporary and will be easy to
remedy
(2) the effect is quite bad now, but if the loss is
recovered, these problems will in turn be solved
(3) the effect is quite bad now, but I should be able to
adjust to the loss and the other problems will
eventually be solved
(4) the effect is very strong on other areas of my life,
and I don't think I can cope with those problems
unless the loss is recovered
(5) the effect has been so bad that even if I recover
the loss I feel that it has had a long-term or
permanent effect on other areas
Since this major loss, have you found that any activities or
events which you used to find pleasurable tire no longer enjoyable?
________ yes _________ no
If yes, what are these activities?_________________________________
Can you briefly describe how they were related to the loss?

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Asset Metadata

Creator Tapper, Bruce John (author)

Core Title A Behavioral Assessment Of The Reinforcement Contingencies Associated With The Occurrence Of Suicidal Behaviors

Degree Doctor of Philosophy

Degree Program Psychology

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag OAI-PMH Harvest,Psychology, clinical

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Wolpin, Milton (committee chair), [illegible] (committee member), Frankel, Andrew Steven (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c20-549118

Unique identifier UC11225898

Identifier 7519040.pdf (filename),usctheses-c20-549118 (legacy record id)

Legacy Identifier 7519040.pdf

Dmrecord 549118

Document Type Dissertation

Rights Tapper, Bruce John

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA