Psychotherapy Brown Bag

The NFL and suicide

by Michael D. Anestis, Ph.D.

The other day, a friend of mine shared a link to an ESPN story written by former NFL linebacker George Koonce in which he courageously shared his story of struggling to adjust to post-NFL life.  This is a topic that I've thought about from time to time in the past and which was already on my mind in the wake of Junior Seau's recent death by suicide and I wanted to take the opportunity today to write a bit about it and to hear your thoughts on the issue.

Before getting into the specifics of this particular situation, let me quickly refresh your memory on the Interpersonal-Psychological Theory of Suicidal Behavior (IPTS; Joiner, 2005).  I've written about this a ton on PBB, as I was trained by Dr.Joiner and the theory is a core feature of my own research (click here for our initial article on this), but it's worth setting the stage for this by quickly outlining the key components.  The theory points out that there is an important difference between the desire to die by suicide and the ability to die by suicide - that the vast majority of those who want to die by suicide can't and the vast majority of those who could do not want to do so. 

The desire is said to be comprised of two variables: thwarted belongingness and perceived burdensomeness.  Thwarted belongingness is a sense on the part of an individual that he or she lacks meaningful connections to others - either that others do not care about them or that although others care they do not fully understand them, thereby leaving a sense of distance.  Perceived burdensomeness is a sense on the part of an individual that he or she makes no meaningful contributions to the world - that their death would be worth more than their continued life.  When both of these variables are present, and particularly when an individual feels hopeless about these two issues, the desire for suicide becomes much more likely (see Van Orden et al., 2010 for a summary of the data supporting the IPTS).

The ability for suicide is a bit more of an unusual idea.  At its core, the idea behind this variable is that we are not inherently capable of killing ourselves.  The will to live is woven into our genes and the drive to survive makes inflicting lethal self-harm remarkably difficult.  This, in large part, explains why there are somewhere between 8.5 and 25 non-fatal suicide attempts for every death by suicide and an enormous number of individuals who desire death by suicide but never attempt.  Taking it a step further, Joiner's point here is that suicidal behavior is both terrifying and physically painful/uncomfortable and that, in order to engage in serious or lethal suicidal behavior, an individual must develop the ability to tolerate great amounts of physical pain and to overcome the fear of death/bodily harm.  What research has shown is that this habituation process occurs through repeated exposure to painful and/or provocative events (PPEs).  PPEs can be a lot of things.  They could be repeated episodes of non-suicidal self-injury, witnessing death/physical injuries in others, or even experiencing flashbacks of injuries you've had in the past (e.g., Anestis et al., in press; Joiner et al., 2009).  Keep these points in mind as you read this and consider how they might be relevant to NFL players transitioning into post-NFL life.

One of the main issues discussed by Koonce is one that I have been talking about with colleagues quite a bit and a point I've seen discussed in various media outlets as well: adjusting to life after the NFL is an extreme struggle for some players.  When I think about that transition, I tend to see a parallel with the situation experienced by soldiers reintegrating into civilian life post-deployment.  Now don't get me wrong here - this is not another misguided comparison of football to war.  Not at all.  The overlap I see isn't one in which they are all "soldiers."  Rather, much like military personnel deployed in OIF/OEF, NFL players spend a portion of their life sharing an experience that differs greatly from that of most Americans.  It is an insulated culture in which they have a clear membership and purpose and are celebrated for that reason.  As Koonce says in his article, football becomes their identity and, in that sense, they share a bond with other players that would be difficult for any of us not involved in that experience to fully grasp.  They train relentlessly to perform their duties and then, one day, they're done.  Suddenly, for a lot of them purpose and group membership are a lot less clear.  Certainly many of them have families that love them dearly, but those family members likely did not share the NFL experience and, in that sense, the former players may still feel somewhat distant.  Think back to my description of thwarted belongingness and perceived burdensomeness...see any relevance here? 

Now, that particular aspect of the NFL experience isn't altogether different from a lot of professions.   A lot of people are a bit adrift when they transition out of an experience around which they've built much of their identity.  In fact, men over the age of 65 have the highest rate of death by suicide of anyone - signalling that retirement may, in fact, serve as a risk factor for some.  The thing is, NFL players retire MUCH younger than most of us do.  In a lot of ways, this sounds (and in many cases, is) wonderful, but that no doubt depends upon the individual.  In  some ways, it might simply push a risk factor typically applied to older adults (or to young soldiers suddenly thrust back into the life of a civilian) to a younger age bracket.

Another issue that sets former NFL players apart from others (and strengthens the parallel to military service), however, is in the likely impact of their chosen career on the acquired capability for suicide.  Playing football involves years of physically demanding and painful experiences.  Players put their bodies at risk every time they step on the field, every time they make a catch across the middle, lower their shoulders to make a hit, or step in front of a blitzing linebacker to protect the quarterback.  The very nature of their job requires them to absorb immense amounts of physical punishment and to develop the ability to not only tolerate the pain, but overcome the fear of experiencing physical harm.  Here again, a parallel to military service is strong.  We've published data showing that US Air Force personnel who recently completed basic training reported higher levels of the acquired capability than did civilian clinical and non-clinical samples.  Certain jobs require you to experience pain differently and to recalibrate your response to risk.  That adjustment is pivotal for the survival of those in those jobs while they are involved in the job itself and, in and of itself, the adjustment is not problematic.  The question, however, is what happens if those folks develop suicidal desire. It may be easier for former NFL players to act on suicidal desire, particularly with respect to lethal means, than it is for individuals whose lives have not involved so much pain and provocation.

My point here is not to say that military service or professional football are bad.  Quite the opposite, actually.  My point, rather, is to say that, given the inherent risks associated with playing football, steps need to be taken in order help former players enhance their sense of purpose and belongingness after their playing days are over.  This could involve a multitude of options, but involving former players in the league somehow (through NFL charities, some sort of former NFL players golf tour, etc...) could serve to ease that transition a bit and keep vulnerable individuals from getting stuck in a cycle that ultimately results in the desire for death.

I would give almost anything to actually collect data on NFL players and alums to measure these ideas, but that is likely impossible, so it is important to keep in mind here that my thoughts on these issues are just thoughts and not empirically-based opinions.  Thinking about things in this way, however, seems more useful to me (and certainly more solution-oriented) than simply looking at former players and shaking your head at them because you think having lived a life of celebrity and wealth should make it easy to overcome life transitions that are inherently difficult.

I would be interested in hearing your thoughts on this.  Certainly I have not mentioned CTE here at all and that's a relevant issue to consider (and not one that is in any way inconsistent with these ideas).  What else do you think plays a role here?  What should be done?

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Dr. Mike Anestis is an incoming assistant professor in the Department of Psychology at the University of Southern Mississippi

Sources cited in this post:

Anestis, M.D., Tull, M.T., Bagge, C.L., & Gratz, K.L. (in press).  The moderating role of distress toelrance in the relationship between posttraumatic stress disorder symptom clusters and suicidal behavior among trauma-exposed substance users in residential treatment.  Archives of Suicide Research.

Joiner, T.E. (2005).  Why people die by suicide.  Cambridge, MA: Harvard University Press.

Joiner, T.E., Van Orden, K.A., Witte, T.K., Selby, E.A. Ribeiro, J., Lewis, R., & Rudd, M.D. (2009).  Main predictions of the interpersonal-psychological theory of suicidal behavior: Empirical tests in two samples of young adults.  Journal of Abnormal Psychology, 118, 634-646.

Van Orden, K.A., Witte, T.K., Cukrowicz, K.C., Braithwaite, S.R., Selby, E.A., & Joiner, T.E. (2010).  The interpersonal theory of suicide.  Psychological Review, 117, 575-600.

More DSM-V Talk

by Michael D. Anestis, Ph.D.

DSM-V is certainly in the news these days.  Recently, the folks responsible for developing the forthcoming new edition of the diagnostic manual announced that they were backing off their plans for two potential new diagnoses, a decision that was met with widespread applause.  Now, Allen Frances has reported that, at the annual APA convention, data regarding the reliability of the proposed diagnostic structure for DSM-V from the field trials are now available and the results are....horrifying.

A little history here.  In the first two editions of the DSM, diagnoses were generally described in vague terms that emphasized symptoms that were difficult to assess and measure with any consistency.  In this sense, the writers of the early manuals did not place much of a premium on reliability, which in this particular sense refers to the degree to which two clinicians who assess the same patient will agree on the presence or absence of a particular diagnosis.  When DSM-III came around, psychodynamic jargon and other unclear phrasing was removed and a heavy emphasis was placed on behavioral indicators and other symptoms that could more reliably measured.   In doing this, they vastly increased the reliability of the diagnoses in the manual, although some feared that, as a result, they decreased the validitiy (in this case, validity refers to the degree to which the diagnosis as described actually represent the diagnosis as it occurs in reality).  To some extent, increasing reliability can require a decrease in validity (e.g., I might removed a confusing criterion that truly is a part of the disorder in order to increase the likelihood that people will agree whether or not somebody has that disorder).  This is a particularly important issue to consider with the present controversy.

Back to the present.  Dr.Frances reported that the kappa values - a measure of agreement between clinicians as to whether or not an individual meets criteria for a diagnosis - were just awful for a large number of disorders.  For instance:

• Depression - kappa = .32
• Generalized anxiety disorder - kappa = .2
• PTSD - kappa = .67
• Autism spectrum disorder - kappa = .69
• Antisocial personality disorder - kappa = .22
• Obsessive-compulsive disorder - kappa = .31

To give some context to those numbers, kappas of .4 have historically been considered "poor," and, indeed, the results of the DSM-III field trials left the authors of that decision confident that kappas below .6 would be a cause for concern (Spitzer, Williams, & Endicott, 2012).  Frances put forth a number of potential explanations for the problematic data for DSM-V diagnostic categories.  Amongst his arguments were:

• Nobody on the DSM-V committees was capable of developing clearly worded and succint diagnostic criteria and, as such, the wording was a recipe for disaster (and the results forseeable)
• The complexity of the procedures involved in the DSM-V field trials was over the top, again setting folks up to fail
• A second stage of the field trials in which poor data would be addressed through revision and further data collection was canceled due to timing and financial issues (as well as the need to meet publication deadlines).

From what I've read, there is near universal concern about these results within the field.  Some authors have noted that traditional standards for kappa evaluation are unrealistically high and that the new diagnoses might need to sacrifie some reliability for validity (e.g., Kraemer, Kupfer, Clarke, Narrow, & Regier, 2012).  Looking at these numbers, however, you have to wonder whether too much of one is being sacrified for unknown levels of the other.

Issues like this concern me for a number of reasons.  First, the obvious.  It doesn't look good for our field when, in an effort to enhance the scientific and clinical value of our diagnostic system, we create a system that yields chaotic levels of disagreement amonst clinicians regarding whether or not a particular disorder is present.  Nobody expects perfection on that front, but we need to not be lowering the bar at this point.  Second, I feel as though this might increase the strength of calls to abandon diagnostic systems entirely.  Although I obviously sympathize with the sentiments behind not "labeling" folks who are struggling, a properly developed and implemented diagnostic system doesn't do that.  What it does is create a single language that all researchers and clinicians can speak with respect to the presentations of individuals struggling with mental illness.  Doing this allows for systematic research on particular treatments, trajectories of particular symptom clusters, and other important issues, thereby enabling accountability with respect to what clinicians should and should not do for their clients.  Although a poor diagnostic system will pathologize normal processes, a lack of diagnostic system will result in chaos (e.g., without a diagnosis, which treatment will be used and how will we assess success and to whom will the results of such treatments be compared?).  In a sense, I see this almost as an argument to strive for a good government rather than choosing anarchy when the government proves imperfect.  We need a system within which to work - the fact that so many individuals out there practice sham treatments even WITH data pointing towards better options should speak clearly to our inability to function effectively without guidelines.  Don't get me wrong here, - I'm not suggesting that this outcome is anywhere close to happening.  I just think that missteps like this result in increased energy being spent on issues unlikely to move us forward, so in the end, we all lose.

DSM-V is not a simple issue and a lot of brilliant and well-intentioned people vehemently disagree on these issues. How this all plays out will have an enormous impact not only on those of us working within the field, but everyone in the world who struggles with mental illness.

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Dr. Mike Anestis is an incoming assistant professor in the Department of Psychology at the University of Southern Mississippi

Articles cited in this post:

Kraemer, H.C., Kupfer, D.J., Clake, D.E., Narrow, W.E., & Regier, D.A. (2012).  Response to Spitzer et al letter.  American Journal of Psychiatry, 169, 537-538.

Spitzer, R.L., Williams, J.B.W., & Endicott, J. (2012).  Standards for DSM-5 reliability.  American Journal of Psychiatry, 169, 537.

DSM-V Changes

by Michael D. Anestis, Ph.D.

The remarkably controversial development of DSM-V took another major turn with the revelation that two proposed changes are now being dropped (click here to read a summary).  Both Attenuated Psychosis Syndrome and Mixed Anxiety Depressive Disorder have been removed from consideration as new diagnoses.  I don't have time to reflect much on these changes this morning, but wanted to share the link and invite your thoughts on this shift and others you'd like to see in the forthcoming diagnostic manual.

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Dr. Mike Anestis is an incoming assistant professor in the Department of Psychology at the University of Southern Mississippi

Two interesting suicide-related findings

by Michael D. Anestis, Ph.D.

Earlier today, when I learned about the death by suicide of former NFL linebacker Junior Seau, I decided it would be worthwhile to write a quick post on interesting new findings related to suicidal behavior.  None of the findings below are directly related to this story, but in the spirit of raising awareness, I thought there might be some value in quickly summarizing a couple of cool effects that I came across in the current issue of Suicide and Life-Threatening Behavior.  We've discussed similar findings in the past, but replication is remarkably important in science and, as such, I chose to bring these studies up on PBB.

Interesting finding #1:

I've discussed this issue at length in the past (link, link), but its importance cannot be overstated.  There is an understandable and widely held belief that talking to people about suicide might increase their risk for thinking about or even engaging in suicidal behavior.  A growing number of studies have not only debunked this myth, but have acutally shown that the opposite is true: that asking about suicide appears to decrease levels of suicidal ideation, particularly in high risk samples. 

In a study in the current issue of SLTB, Chrarles Mathias and colleagues (2012) recruited 170 adolescents (age 12-17; 50% male; 57% Hispanic) who had experienced psychiatric inpatient care.  Participants were assessed for suicidal ideation at baseline and then again every six months for up to two years.  Suicidal ideation was assessed using a self-report questionnaire.  Of the 170 participants, 159 completed the second assessment, 126 completed the third, 77 completed the fourth, and 54 completed all five.  Three of the lost participants were missing due to attrition (e.g., did no return for an appointment).  The remainder were missing due to the fact that their initial assessment occurred late enough in the project that the project had ended before they could have completed all time points.  In other words, the missing data should not be seen as a sign that individuals were becoming increasingly severe and dropping out of the study due to that increased severity. 

What did they find?  First off, a greater number of assessments was associated with lower suicidal ideation in the final assessment, even after accounting for initial levels of suicidal ideation.  In other words, not only did asking about suicidal ideation once no cause an increase in thoughts of suicide, but asking repeatedly was actually associated with continuingly decreasing levels of ideation.  In total, 51% of the participants reported a decrease in ideation during the study, 29% reported no change, and 21% experienced an increase from their first to final assessment.  Furthermore, amongst those who reported decreases in ideation, substantially more reported large decreases than moderate or small decreases.  On the flip side of that coin, amonst those who reported increases, more reported small increases than moderate or large increases (the difference between small and large was not statistically significant, however).

Using more comprehensive model testing procedures, the authors found that individuals who reported low levels of ideation at the onset of the study tended not to experience meaningful increases in ideation in response to repeated assessments.  Indviduals with moderate levels of ideation typically reported a decline in ideation between the first and second assessments, but no significant change beyond that point.  Perhaps most importantly, individuals who initially reported high levels of ideation typically reported sharp declines in ideation during the first year, followed by a less steep decline in year 2.

There were several other interesting findings in this study, but the take home message is clear and entirely consistent with prior work on this topic: assessing for suicide risk is not only safe, but beneficial, particularly with high risk individuals.  In other words, there is substantial potential value and no discernable risk with the institution of wide spread suicide risk assessment protocols.

Interesting finding #2:

In our past discussions of the interpersonal-psychological theory of suicidal behavior (IPTS), we have discussed the importance of thwarted belongingness as a driving force behind suicidal desire.  Put simply, when individuals feel as though they lack meaningful connections to others, the likelihood that they will desire death by suicide increases substantially.  In many cases, efforts to decrease thwarted belongingness focus on close individuals bonds and understandably so.  That being said, such relationships are not the only path towards increasing an individuals sense of belonging.  A couple of years ago, I discussed work examining the relationship between professional sporting events and suicidal behavior (link) and a study in the current issue of SLTB replicated the effects noted in that earlier PBB article.

Specifically, Gaelle Encrenaz and colleagues (2012) examined the association between the 1998 World Cup and monthly deaths by suicide in France.  Controlling for the effects of variables like seasonality (e.g., deaths by suicide peak in the spring), the authors found that, between June 11th and July 11th of 1998, there was a decrease of 95 deaths by suicide - a 10.3% decrease from the norm.  Furthermore, they found a decrease of 19.9% on days following games (victories, in this case) by the French team.

Do these findings mean that the occurance and associated outcomes of sporting events are amongst the most important variables to consider in suicide resarch?  Of course not.  What they indicate, however, is that events that cause us to feel connected to a group make us feel very differently about ourselves and, perhaps most importantly, about our death.

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Dr. Mike Anestis is an incoming assistant professor in the Department of Psychology at the University of Southern Mississippi.

Articles cited in this post:

Encrenaz, G., Contrand, B., Leffondre, K., Queinec, R., Aouba, A., Jougla, E., Miras, A., & Lagarde, E. (2012). Impact of the 1998 Football World Cup on suicide rates in France: Results from the National Death Registry.  Suicide and Life-Threatening Behavior, 42, 129-135.

Mathias, C.W., Furr, R.M., Sheftall, A.H., Hill-Kapturczak, N., Crum, P., & Dougherty, D.M. (2012).  What's the harm in asking about suicidal ideation? Suicide and Life-Threatening Behavior, 42, 1-11.