by Michael D. Anestis, M.S.
In an earlier article, I described Joiner's interpersonal-psychological theory of suicidal behavior (Joiner, 2005). The theory posits that, in order to engage in a lethal suicide attempt, an individual must have both the desire and the capability to do so. Those with only the desire or the capability are unlikely to utilize lethal means in a suicide attempt. This, in part, explains why attempts are so much more frequent that completed suicide attempts, as not every individual who desires suicide is capable of utilizing means likely to result in completion.
The desire for suicide is comprised of two variables: thwarted belongingness and perceived burdensomeness. Thwarted belongingness involves a sense on the part of an individual that he does not have meaningful connections with others, either because others do not care about him or others simply are not able to relate to his experiences (e.g., a veteran returning to civilian life post-deployment). Perceived burdensomeness is a sense on the part of the individual that she does not make meaningful contributions to her world and, instead, serves as a liability to others.
The acquired capability for suicide, the aspect of Joiner's theory that is most distinct from prior theories, involves habituation to physiological pain and the fear of death. This capability is developed through repeated exposure to painful and provocative events, whether that involves being injured (e.g., non-suicidal self-injury, prior suicide attempts, battle wounds) or witnessing pain and gruesome injuries in others. In a sense, individuals learn to overcome an innate biological drive towards self-preservation that typically prevents individuals from engaging in lethal self-injury. In our prior article on this theory, we discussed these variables in greater detail, including extensive descriptions of data supporting the various components of the theory.
In the latest issue of Archives of Suicide Research, Michelle Cornette and colleagues (2009) contributed an article that applies Joiner's (2005) theory to physicians and medical trainees. Because it is a review article, this particular manuscript does not involve direct measurement of the three components of Joiner's (2005) theory, but it does summarize prior research consistent with the theory and provides a solid foundation for future research in this area.
The authors provided compelling rationale for their manuscript: evidence indicates that physicians exhibit a higher suicide rate than does the general population (Schernhammer & Colditz, 2004). In fact, studies indicate that physicians may be nearly three times as likely to die by suicide than is the general population (Stack, 2004), a striking statistic given that, generally speaking, physicians are not the demographic that comes to mind when individuals think about the idea of suicide. The obvious question raised by these numbers is why physicians would be at such a heightened risk for suicide. Joiner's (2005) theory, the authors argue, provides a logical answer consistent with prior empirical evidence.
The majority of the article focuses on the various ways that physicians and medical trainees might be vulnerable to elevations in the three components of the theory: thwarted belongingness, perceived burdensomeness, and the acquired capability for suicide. The vulnerability to thwarted belongingness, they argued, is quite clear. Medical training is a grueling, all encompassing experience that leaves little time for social interactions. Prior studies have shown that medical students who are married or who co-habitate report better overall mental health (Brahmness, Fixdal, & Vaglum, 1991). Additionally, the authors point out, medical students frequently endorse that spending time with friends is a pivotal coping mechanism that allows them to manage the rigors of their training (Chew-Graham, Rogers, & Yassin, 2003). The problem with this, however, is that the training demands of medical school often do not allow for such interactions. Additionally, medical students report feeling that seeking mental health services provided by the medical school would be stigmatizing (Chew-Graham, Rogers, & Yassin, 2003) and could potentially serve as an obstacle to future advancement (see Craig Bryan's article on PTSD in the military for a similar example of difficulties seeking mental health services). This situation leaves medical students in an unfortunate position, as they do not have time to seek support from peers and family and do not feel comfortable seeking support from the services provided by their school.
With respect to perceived burdensomeness, the authors provided a more extensive list of potential vulnerabilities, including perceived or actual academic failure, academic burnout, financial burdens, and an exaggerated sense of responsibility for the lives of patients. Henning, Ey, and Shaw (1998) reported that a significant proportion of medical students report feeling like impostors - as though they do not deserve to be in medical school and are not the intellectual equals of their classmates - and engaging in self-directed perfectionism. Yates and James (2006) reported that 10-15% of medical students qualify as struggling academically. Additional studies have demonstrated that academic struggles contribute to increased stressed and diminished mental health and that approximately 45% of medical students meet criteria for academic burnout (Dyrba, Thomsa, Huntington, et al., 2006). This data presents a picture of medical students as frequently overwhelmed, highly driven to succeed, and no longer passionately engaged with the material at hand. In addition to academic based distress, a significant proportion of medical students incur high levels of debt, which creates additional stress and can contribute to an individual's sense that he or she is a burden to others (Joiner, 2005; see Bob Leahy's article on dealing with financial worry for tips on managing finance related anxiety). As such, there are a variety of avenues through which medical students could theoretically develop a sense that they are failing to make meaningful contributions and causing problems for other individuals in their lives. Importantly, the perceptions involved in perceived burdensomeness and thwarted belongingness are almost always distorted and inaccurate, but their lack of validity do not diminish their influence on the individuals that experience them.
All of these findings are compelling; however, many of them can also be applied to other high stress fields and training situations (e.g., lawyers, investment bankers). The question then becomes, what is unique about this particular profession that would contribute to its heightened suicide rate. The answer to this appears to rest in the vulnerability to the acquired capability for suicide. Essentially, the authors argue that the nature of training and the day-to-day experiences for physicians involves a significant exposure to pain and death. This repeated exposure, they argue, dampens physicians' emotional responses to pain and suffering and, in a sense, inoculates them to stimuli that, for most individuals, are highly aversive. Empirical data seem to support this idea. Sundin, Gaines, and Knapp (1979) found that dental students reported a greater fear of death than did medical students. One theoretical explanation for this is that medical students experience significant exposure to death in their training and have consequently habituated to the concept whereas dental students receive no such training and consequently maintain a more normative response to the idea of death. Charlton and colleagues (1994) found support for this by measuring medical students' attitudes towards death prior to and after their first experience dissecting cadavers. The authors found that the students' emotional reactivity decreased in the months following this first experience, indicating the they were no longer uncomfortable with experiences involving death and dissection. The point here is not that medical students are blunted emotionally, but rather that they simply develop a tolerance for particular stimuli that are generally highly aversive and which serve as a deterrent in suicidal and self-injurious behaviors.
Ultimately, Cornette and colleagues (2009) present a rich and compelling case that Joiner's interpersonal-psychological theory of suicidal behavior (2005) is a valuable framework within which to consider suicide risk in this population. The training and day-to-day experiences of physicians by definition must involve exposure to pain and provocation, so this paper highlights the importance of understanding vulnerabilities to the desire for suicide and providing adequate, non-stigmatized interventions geared towards increasing social belongingness and decreasing physician and medical trainees' beliefs that they are burdensome to others. The acquired capability for suicide in and of itself is not necessarily a bad thing. When accompanied by the desire for suicide, quite obviously, the acquired capability is highly dangerous; however, routine, systematic assessments for the desire for suicide can mitigate this risk by identifying individuals who are struggling and helping them to develop sufficient coping mechanisms. Much of the evidence put forth in this review paper discussed medical students rather than actual physicians, so future work that extends these findings to physicians would be invaluable.
At this point, Joiner's (2005) theory is widely accepted and well supported by data, but I am curious what you think about the theory in general and its application to this particular population. Might there be alternative explanations for the heightened suicide rate in this population? Are there considerations left out of the theory?
If you would like to read more about the interpersonal-psychological theory of suicidal behavior or you are interested in learning how to systematically assess and treat suicide risk, we recommend the following products, all of which are available through our online store:
Why People Die by Suicide
The Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients
Treating Suicidal Behavior: An Effective, Time-Limited Approach (Treatment Manuals For Practitioners)
Simple Treatments for Complex Problems: A Flexible Cognitive Behavior Analysis System Approach To Psychotherapy
If you are experiencing thoughts of suicide, please call 1-800-273-TALK for free, 24 hour help. Additionally, calling 911 is a viable option.
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University
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