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1 Florida State University Libraries Honors Theses The Division of Undergraduate Studies 2014 Non-Suicidal Self-Injury and Risk for Suicidality: A Test of the Interpersonal Theory of Suicide Tawny Shelton Follow this and additional works at the FSU Digital Library. For more information, please contact lib-ir@fsu.edu

2 THE FLORIDA STATE UNIVERSITY COLLEGE OF ARTS AND SCIENCES NON-SUICIDAL SELF-INJURY AND RISK FOR SUICIDALITY: A TEST OF THE INTERPERSONAL THEORY OF SUICIDE By Tawny Summer Shelton A Thesis submitted to the Department of Psychology in partial fulfillment of the requirements for graduation with the Honors in the Major Degree Awarded: Spring, 2014

3 The members of the Defense Committee approve the thesis of Tawny Summer Shelton s defended on April 23, Dr. Thomas Joiner Thesis Director Dr. Ashby Plant Committee Member Dr. Steve Ramsier Committee Member

4 Abstract Non-suicidal self-injury (NSSI) is defined as the infliction of bodily harm in the absence of lethal intent and includes behaviors such has cutting, hitting, or scratching oneself (Nock, 2010). NSSI is prevalent among college populations, with one study reporting that 17% of students have engaged in self-injurious behavior at least once in their lifetime (Whitlock, Eckenrode, & Silverman, 2006). Importantly, research suggests that individuals who engage in NSSI are at an increased risk for suicidal thoughts and behaviors (i.e., suicidality; Van Orden, Witte, Cukrowicz, Braithwaite, Selby, & Joiner, 2010), but further research is required to understand why individuals who self-injure are at an increased risk for suicide. The purpose of the current study was to examine the relationship between self-injury and suicidality through the lens of the interpersonal theory of suicide (Joiner, 2005). Patients from a community mental health clinic completing a variety of self-report questionnaires assessing history of self-injury, depression, suicidality, and constructs related to the interpersonal theory (i.e., perceived burdensomeness, thwarted belongingness, and acquired capability for suicide). Results indicate that among individuals with a history of self-injurious behaviors, perceived burdensomeness, but not thwarted belongingness was associated with higher levels of suicidality above and beyond the acquired capability for suicide. Overall, results provide some insight into why some (but not all) individuals with NSSI are at risk for suicide.

5 Non-Suicidal Self-Injury and Risk for Suicidality: A Test of the Interpersonal Theory of Suicide Non-suicidal self-injury (NSSI) is defined as self-inflicted injury without the intent to die, and includes behaviors such as cutting, burning, or hitting oneself (Nock, 2010). These behaviors are prevalent among young adults, with one study finding 12-17% of undergraduates engage in self-harming behaviors (Whitlock, Eells, Cummings, & Purrington, 2009). Research suggests that individuals who engage in NSSI are at an increased risk for suicide (Nock, Joiner Jr., Gordon, Lloyd-Richardson, & Prinstein, 2006). However, only 28-55% of people who engage in NSSI experience suicidality; most do not actually make a lethal suicide attempt (or engage in suicidal behavior; Muehlenkamp & Kerr, 2010). Similarly, one study found that in a sample of individuals who engage in self-injury, only 4% reported a suicide attempt (Brausch & Gutierrez, 2010). Little research has specifically examined differences between individuals who engage in NSSI and concurrent suicidality versus those who are not suicidal. One prominent theory of suicide that may shed light on the co-occurrence of NSSI and suicidality is the interpersonal theory of suicide (Joiner, 2005; Van Orden et al., 2010). This theory provides one explanation as to why individuals with NSSI are at increased risk for suicidality; however, no study to our knowledge has specifically tested this theory in the context of NSSI. This theory hypothesizes that in order to die by suicide one must have the desire to die and be physically capable of engaging in self-harm. According to this theory, this physical capability (termed acquired capability for suicide) is acquired through exposure to various painful and provocative events. However, even though an individual may have the ability to engage in lethal self-injury (e.g., individuals who engage in NSSI), it does not necessarily mean that they want to die. Arguably, all individuals who self-injure have high levels of acquired

6 capability, yet the vast majority of individuals who self-injure do not die by or even attempt suicide. This study examined whether other constructs of the interpersonal theory of suicide, namely low levels of belongingness and high levels of perceived burdensomeness, are associated with suicidality among those who engage in NSSI even while controlling for acquired capability. Interpersonal Theory of Suicide As previously mentioned, the interpersonal theory of suicide posits that individuals who die by suicide have both the desire and the capability to die (Joiner, 2005; Van Orden et al., 2010). Below is a review of the constructs of this theory and how it may inform research on associations between NSSI and suicidality. Acquired Capability for Suicide. Death by suicide is physically painful and some individuals may overcome this fear of death and pain when they no longer find dangerous experiences threatening. More specifically, the capability to die is acquired through exposure to painful and provocative events that decrease fear of death and increase pain tolerance. Given that death is inherently fearsome, acquiring the capability for suicide requires an individual to habituate to pain and life threatening experiences. Once one overcomes this fear, s/he may be able to enact lethal self-harm. If an individual does not have the capability to tolerate pain, then according to the theory, s/he would not be able die by suicide, despite having a strong desire to do so. Indeed, the interpersonal theory suggests that painful and provocative experiences increase acquired capability by partially increasing pain tolerance (Franklin, Hessel, & Prinstein, 2011). For example, one study demonstrated that diminished pain perception was found only among individuals who endorsed in NSSI (Franklin, Aaron, Arthur, Shorkey, & Prinstein, 2012). Self-injury is a painful act, and repeated self-injurious behaviors may increase pain tolerance and

7 diminish fear of pain. Over time, individuals may increase this acquired capability for suicide by gradually inflicting self-harm, and as such, fear of death and pain may be reduced. Given its potential role in increasing pain tolerance and fearlessness about death, NSSI may increase risk for suicide through increasing this acquired capability for suicide. Indeed, previous studies have found that exposure to painful and provocative experiences and developing a tolerance to pain is associated with suicidality (Bender, Gordon, Konrad, & Joiner Jr., 2011). However, according to the interpersonal theory, despite having acquired an elevated risk for suicide, possessing the desire for death is what would distinguish individuals who engage in selfinjury and exhibit suicidality from those who do not. Desire for Suicide. The interpersonal theory of suicide posits that two main constructs contribute to the desire to die: thwarted belongingness (e.g., loneliness, alienation) and perceived burdensomeness (e.g., feeling like one is a burden on others; Van Orden, Witte, Cukrowicz, Braithwaite, Selby, & Joiner, 2010). Although research suggests that NSSI may contribute to future suicidal behavior through increasing acquired capability for suicide (Van Orden K. A., Witte, Gordon, Bender, & Joiner Jr., 2008), it may also be associated with feelings of burdensomeness and belongingness in a subset of individuals who engage in NSSI. The two constructs of suicidal desire may not be present in those who engage in NSSI without any suicidal ideation. Thwarted belongingness. One explanation for differences in suicidality among individuals who engage in NSSI is that individuals with suicidality have fewer connections to family and are less likely to fear suicide (Klonsky & Muehlenkamp, 2007). Humans have psychological needs that must be met and without meeting these needs, an impaired lifestyle may foster; a sense of feeling connected with others is natural and necessary (Baumeister & Leary,

8 1995). When this need is no longer met and an individual has a sense that one does not belong, it is referred to as thwarted belongingness. Humans have a tendency to want to belong, and being connected to a social group, whether it is family or friends, has a strong impact on an individual s life (Baumeister & Leary, 1995). When feelings of belongingness are not met, a sense of disconnection with others may influence an individual s sense of effectiveness (i.e., feeling ineffective in their lives and the lives of others) and a desire to die by suicide may develop. Perceived Burdensomeness. When individuals develop the perception that they are a burden on others (i.e., family members and close friends), they feel as though they have no control over their lives and have the distorted belief that they are an unwanted liability. Perceived burdensomeness may also manifest as feelings of self-hate or a negative self-image and lead to feelings of being insufficient. When individuals perceive themselves as ineffectual, this exhibits negative associations within themselves. Not only does this ineffectiveness affect an individual at an intrapersonal level but also this overabundance of self-inefficiency is perceived to affect others. This perception of negatively affecting the people around oneself is viewed as being permanent, which further reinforces their view of being a burden on others. No matter how inaccurate and distorted this perception may be, an individual s behavior is influenced by their feelings of burdensomeness. Individuals may harbor feelings that the lives of their friends and loved ones will benefit from their death; their death becomes more of a value to them than their own life. If a sense of connection to others gives individuals a will to live, then when these feelings are not present or are distorted, an individual may develop the desire for suicide (Joiner, 2005). The role of perceived burdensomeness specifically influences suicidal behavior, and individuals who perceive themselves as a burden on others manifest escalated feelings of suicidal

9 desire. Examining individuals who endorse self-injury and their associations with the determinants of suicidal desire may provide insight into the co-occurrence of NSSI and suicidality. This study attempted to address a gap in the literature by testing the interpersonal theory of suicide among a sample of individuals with a history of self-injurious behaviors. From the perspective of the interpersonal theory of suicide, examining the constructs of thwarted belongingness and perceived burdensomeness may help explain why only some individuals who engage in NSSI, and not all despite high levels of acquired capability are at a greater risk for suicidality. It was hypothesized that among a clinical sample of individuals who have engaged in self-injury, higher levels of thwarted belongingness and perceived burdensomeness will be associated with higher levels of suicidality, above and beyond associations with acquired capability for suicide. Methods Participants The sample of participants consisted of 403 outpatients seeking services at an outpatient community mental health psychology training clinic. Ages ranged from 18 to 65 with the average age being: (SD=10.82). Participants were predominately female: (N=104, 75.9%). Approximately 74.4% of the sample identified as non-hispanic Caucasian, 11.0% as Hispanic, 12.6% as African American, 1.5% as Asian/Pacific Islander, and 0.5% as American Indian/Alaskan Native. The marital status of participants indicated that 76.4% had never been married, 12.2% were married, 9.4% were divorced, 1.2% were separated, and 0.7% were widowed. Additionally, one hundred and six participants (26.3%) reported receiving psychological/psychiatric services previously. These patients present with a variety of clinical

10 disorders and are only referred elsewhere if they are in need of immediate inpatient hospitalization. The training clinic provides a service to the community with a sliding scale fee depending on income. Procedures All participants completed a series of self-report measures and demographic information prior to their first intake session and beginning treatment at the clinic. All participants signed consent forms acknowledging that their responses will be used for the purposes of research in accordance with standards set by the FSU Institutional Review Board. Measures The Interpersonal Needs Questionnaire (INQ; Van Orden, Witte, Gordon, Bender, & Joiner Jr., 2008). The INQ is a 15-item self-report questionnaire that was developed to specifically measure core constructs of the interpersonal theory of suicide (i.e., current levels of burdensomeness and belongingness; Van Orden, Cukrowicz, Witte, & Joiner Jr., 2012). There are nine items that measure an individual s level of belongingness, or feeling of connectedness to others (e.g., These days other people care about me ). Six items measure an individual s perceived burdensomeness, which is the extent of how much an individual feels like they are a burden on others (e.g.., These days I feel like a burden on people in my life ). Participants indicate how these statements apply to them by scoring them on a 7-point Likert scale ranging from not at all true for me to very true for me. This measure has been shown to be reliable in clinical and undergraduate samples: Cronbach s alpha=.85 and.89 for belongingness and burdensomeness (Van Orden, Witte, Gordon, Bender, & Joiner Jr., 2008), as well as in the current study (Cronbach s alpha=.89 for both burdensomeness and belongingness). Acquired Capability for Suicide Scale (ACSS; Bender et al., 2011). The ACSS used is a 6-item measure designed to assess an individual s fearlessness about death (e.g., I am not at

11 all afraid to die ), and in turn, whether an individual feels that s/he would be capable of engaging in suicidal behavior (e.g., I am not disturbed by death being the end of life as I know it ), if the desire occurs. Participants are asked to indicate, using a 5-point Likert scale, to whether or not each item is true for them. This shortened version of the ACSS has demonstrated adequate reliability, with an alpha coefficient of.90, within a clinical setting (Bender, Gordon, Konrad, & Joiner Jr., 2011). Reliability for the current study was Cronbach s alpha=.64. Impulsive Behavior Scale (IBS; Rossotto, Yager, & Rorty, 1998). The IBS is a 25- item self-report questionnaire that assesses how many times an individual engages in certain selfdestructive and impulsive behaviors (i.e., self-mutilation, promiscuous sex). Participants indicate how many times they have engaged in each of these behaviors by rating them on a 5-point Likert scale, ranging from never to regularly. In a clinical sample, the IBS has previously demonstrated good reliability with an alpha coefficient of.89 (Anestis, Smith, Fink, & Joiner, 2009). This scale was used to determine whether individuals have ever engaged in NSSI. Specifically, a history of self-injurious behaviors was assessed by a single-item question on the IBS that asked individuals if they had a history of self-mutilation. Responses were dichotomized as yes/no for presence or absence of self-injurious behaviors. Beck Scale for Suicidal Ideation (BSS; Beck & Steer, 1991). The BSS is a 21-item scale that is used to assess for suicidal ideation and intent within the past week. This scale is scored on a 3-point Likert scale with scores ranging from 0-2, the summation of each of these scores creates a total score; the higher responses indicate higher levels of suicide risk (Beck A. T., Steer, Sanderson, & Skeie, 1991). This measure of suicidality has shown good reliability and validity across samples (Beck, Brown, & Steer, 1997), as well as in the current study (Cronbach s alpha=.86).

12 Depressive Symptom Inventory-Suicidality Subscale (DSI-SS; Metalsky & Joiner, 1997). The DSI-SS assesses for current levels of suicidal ideation and consists of four self-report items focusing on frequency and intensity of suicidal thoughts and impulses. Responses are scored on a 4-point Likert scale ranging from 0 to 3 and the total scores can range from 0 to 12. High scores represent an increased level of suicidal ideation. Reliability in the current study was good with an alpha of.91. Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996). The BDI-II is a 21-item scale that will assess the presence and severity of depressive symptoms within the past week of the individual (Beck, Steer, & Brown, 1996). The severity is assessed on a 4-point Likert-scale, with responses ranging from: 0 to 3. High scores indicate more severe depressive symptoms. In this study the BDI was used to assess depressive symptoms which were included as a covariate in analyses. Reliability in the current study was good (alpha=.94). Results Overall, one hundred thirty six participants endorsed a history of self-injurious behaviors and 248 reported no history. Individuals who engaged in self-injurious behaviors were compared to individuals without any history of self-injury on demographic and psychological variables using independent samples t-tests (Table 1). As expected, individuals with a history of self-injury endorsed higher levels on all theory variables including acquired capability, burdensomeness, and belongingness as well as depression and suicidal ideation. Furthermore, after controlling for age, gender, and depressive symptoms, individuals with a history of self-injury still had greater feelings of thwarted belongingness (F=13.25, df=383, p<.001) and perceived burdensomeness (F=7.73, df=383, p<.01) compared to individuals without a history of self-injury. However, the groups no longer differed on acquired capability scores (F=1.01, df=383, p=.38).

13 PB, TB, and suicidality in individuals with a history of self-injury. Within the group of individuals who endorsed self-injurious behaviors, multiple regression analyses were conducted to determine whether thwarted belongingness and perceived burdensomeness were associated with risk for suicidality as assessed by the DSI-SS and BSS (i.e., dependent variables) while controlling for gender, age, depression, and acquired capability. Results indicate that perceived burdensomeness was significantly associated with suicidality above and beyond the covariates (perceived burdensomeness: β = 0.51, p <.0001, semi partial R 2 = 0.14); however, thwarted belongingness (thwarted belongingness: β = -0.13, p =.18, semi partial R 2 = 0.008) was not significantly associated with suicidality as measured by the DSI-SS (DSI-SS: r = 0.56, p <.0001). When perceived burdensomeness (perceived burdensomeness: β = 0.52, p <.0001, semi partial R 2 = 0.14) and thwarted belongingness (thwarted belongingness: β = -0.11, p = 0.24, semi partial R 2 = 0.006) were measured by the BSS (BSS: r = 0.62, p <.0001), results were the same as when measuring by the DSI-SS. Interaction between PB and TB. Given that the interpersonal theory of suicide actually posits that the simultaneous presence of both perceived burdensomeness and thwarted belongingness increase risk of suicidality, we also conducted regression analyses examining whether the interaction between burdensomeness and thwarted belongingness were associated with suicidality above and beyond acquired capability. Perceived burdensomeness and thwarted belongingness were centered and entered into a regression with BSS total score (suicidal ideation) entered as the dependent variable. The interaction between perceived burdensomeness and thwarted belongingness was not significantly associated with increased suicidal ideation (β = 0.05, p = 0.66, semi partial R 2 = ). However burdensomeness was still significant

14 (perceived burdensomeness centered: β = 0.49, p <.0001, semi partial R 2 = 0.07; thwarted belongingness centered: β = -0.12, p = 0.22, semi partial R 2 = 0.008). This model was repeated using DSI-SS (rather than BSS) as the dependent variable. Results were similar; there was no significant interaction between perceived burdensomeness and thwarted belongingness (β = 0.04, p = 0.76, semi partial R 2 = ), and perceived burdensomeness remained the only significant variable in predicting suicidal ideation (perceived burdensomeness: β = 0.48, p <.001, semi partial R 2 = 0.06; thwarted belongingness: β = -0.14, p = 0.76, semi partial R 2 = 0.01) while controlling for age, gender, and depression. Discussion The purpose of the current study was to examine different constructs of the interpersonal theory of suicide in a clinical sample of patients, many of whom exhibited self-injurious behaviors. It tested the hypothesis that within a sample of individuals who have engaged in selfinjury, higher levels of thwarted belongingness and perceived burdensomeness would be associated with higher levels of suicidality, above and beyond the acquired capability for suicide. Although individuals with a history of self-injurious behaviors endorsed increased depression, suicidality, perceived burdensomeness, thwarted belongingness, and acquired capability compared to individuals without a history of self-injury, our other hypotheses were only partially supported. Specifically, perceived burdensomeness was significantly associated with suicidality while controlling for acquired capability, depression, gender and age; however, thwarted belongingness was not. As expected, the current study found that individuals with a history of self-injury had higher levels of perceived burdensomeness and that within individuals with a history of selfinjury, perceived burdensomeness was significantly associated with suicidality. This finding is

15 consistent with the interpersonal theory of suicide such that higher levels of burdensomeness are posited to contribute to increased suicidal ideation (Van Orden, Lynam, Hollar, & Joiner Jr., 2006). Indeed, it is possible that individuals who engage in self-injurious behaviors have higher levels of perceived burdensomeness because self-injury may result in seeking medical attention, whether it is from a physical wound or just needing psychological services. If these medical services cause their family financial hardship, these individuals may feel responsible for the inconveniences their family may encounter. Thus, individuals who self-injure may perceive their medical treatments as negatively affecting their family, which may increase feelings of perceived burdensomeness. Furthermore, the finding that perceived burdensomeness is significantly associated with levels of suicidality even while controlling for levels of acquired capability provides insight into why some, but not all, individuals who engage in self-injury have increased suicidality, despite, theoretically, all having high levels of acquired capability. Overall, these results suggest that focusing on improving interpersonal relationships and reducing perceptions of burdensomeness in individuals who engage in self-injurious behavior may help decrease risk for suicidality. Although findings related to burdensomeness were consistent with the interpersonal theory of suicide, thwarted belongingness was not found to be significantly associated with suicidality in individuals with self-injury above and beyond acquired capability. According to the theory, thwarted belongingness is essential for the development of the desire to die by suicide (Joiner, 2005). One potential reason for the lack of an association between thwarted belongingness and increased risk of suicidality among individuals with self-injury in the current sample is the homogeneity of the sample. Individuals within our clinical sample had relatively low scores on thwarted belongingness, so there may not have been sufficient variability to detect

16 significant associations; perceived burdensomeness was more prominent among individuals who engage in self-injury in the current sample. Results indicate that despite high levels of acquired capability, individuals with higher levels of perceived burdensomeness but not thwarted belongingness are at an increased risk for suicidality. Importantly, the interpersonal theory of suicide posits that the combination of both high levels of thwarted belongingness and perceived burdensomeness puts someone most at risk for developing severe suicidal ideation. However, there was not a significant interaction between these two variables in our sample. This finding is consistent with some previous studies that have also found a significant association between perceived burdensomeness but not thwarted belongingness (Van Orden K. A., Witte, Gordon, Bender, & Joiner Jr., 2008). These results suggest that among individuals who engage in self-injury, having increased levels of perceived burdensomeness may be sufficient to increase risk for suicidality even without the presence of high thwarted belongingness. Overall, the current study has a number of strengths to acknowledge. First, this study examined the relationship between the constructs of the interpersonal theory of suicide and suicidality among individuals who engage in self-injurious behaviors. Second, the study was conducted within a clinical sample of outpatients from a mental health clinic who had experienced many symptoms, allowing a relatively large sample of individuals who engaged in self-injurious behavior. Third, measures with good psychometric properties were used in the analyses along with a variety of statistical analyses to draw conclusions. Fourth, this study advances research on the interpersonal theory of suicide by examining the relationship between increased suicidality among individuals with a history of self-injurious behaviors.

17 Despite these strengths, several limitations should be noted. For one, individuals were asked if they had a history of self-mutilation and did not ask participants to indicate whether or not they had the intention of dying at the time of self-injury. Inclusion of this single-item measure was a limitation because we were not directly able to determine whether individuals were engaging in self-injury with or without the intention to die; without individuals indicating their intent, it was unknown whether individuals were engaging in NSSI or attempting suicide. Involving measures that indicate whether an individual was currently experiencing any suicidal ideation at the time of self-injury and how often and prevalent an individual engaged in selfinjury would provide more details regarding participants experience of self-injury. However, the question clearly indicates that each participant who was examined in the regression analyses reported a history of self-mutilation. As stated in the hypothesis, participants that were going to be examined were individuals who endorsed in NSSI; because of insufficient information of whether participants engaged in NSSI at the time of the incident, individuals were assessed as previously engaging in self-injurious behavior rather than engaging in NSSI. Future research is essential to determine whether thwarted belongingness leads to increased risk for suicidality among individuals who engage in self-injury. A longitudinal study among individuals who engage in self-injury would help determine if thwarted belongingness is related to increased risk of suicidality. In conclusion, the results from the current study provide evidence to suggest that perceived burdensomeness is associated with higher levels of suicidal ideation, while controlling for acquired capability among individuals with a history of self-injurious behaviors. Results indicate that high levels of perceived burdensomeness may provide explanation as to why only some individuals who engage in self-mutilating behavior are at greater risk for suicidality.

18 Insight into indicators of suicide risk in individuals who engage in self-injury will aid in future research and ultimately help clinicians with intervention strategies.

19 Table 1. Comparison of Individuals with a History of Self-Injury and those without on Demographic and Psychological Variables. Individuals with history of self-injury Individuals without history of self-injury Mean St. Dev. Mean St. Dev. t p Age Gender < DSI-SS total < score BSS total score < Acquired Capability Perceived < Burdensomeness Thwarted < Belongingness Note. Coding for gender: females =1 and males =2.

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