MEDIATING FACTORS BETWEEN MALADAPTIVE PERFECTIONISM AND SUICIDE: THE ROLE OF THE INTERPERSONAL-PSYCHOLOGICAL THEORY OF SUICIDAL BEHAVIOR

Transcription

1 MEDIATING FACTORS BETWEEN MALADAPTIVE PERFECTIONISM AND SUICIDE: THE ROLE OF THE INTERPERSONAL-PSYCHOLOGICAL THEORY OF SUICIDAL BEHAVIOR By MEREDITH LEIGH SLISH Bachelor of Arts in Psychology Oklahoma State University Stillwater, Oklahoma 2006 Submitted to the Faculty of the Graduate College of the Oklahoma State University in partial fulfillment of the requirements for the Degree of MASTER OF SCIENCE December, 2009

2 MEDIATING FACTORS BETWEEN MALADAPTIVE PERFECTIONISM AND SUICIDE: THE ROLE OF THE INTERPERSONAL-PSYCHOLOGICAL THEORY OF SUICIDAL BEHAVIOR Thesis Approved: Dr. LaRicka R. Wingate Thesis Adviser Dr. Thad R. Leffingwell Dr. Larry L. Mullins Dr. A. Gordon Emslie Dean of the Graduate College ii

3 ACKNOWLEDGMENTS I would like to thank my mentor, Dr. LaRicka R. Wingate, for her unwavering support throughout this project. Her encouragement, knowledge, and patience made this project possible. I would also like to thank my committee members, Dr. Thad R. Leffingwell and Dr. Larry L. Mullins, for their support, time, and advice throughout this project. I would also like to thank my parents, Jack and Darlene Keeling, as well as my sister, Lauren Keeling, for their unconditional love and support. They are the people who have shaped me into the woman I am today, and for that I am truly grateful. Finally, I would like to thank my loving husband, John Slish. He has been present for each new chapter in my life and has always been my greatest supporter. His love, patience, kindness, and encouragement have made all the difference and have made all of this possible. iii

4 TABLE OF CONTENTS Chapter Page I. INTRODUCTION...1 II. REVIEW OF THE LITERATURE...7 Perfectionism...7 Theory of Interest and the Almost Perfect Scale...12 Two Constructs of Perfectionism: Adaptive and Maladaptive...13 Maladaptive Perfectionism and Distress...14 Perfectionism and Depression...15 Perfectionism and Suicide...16 The Interpersonal Psychological Theory of Suicidal Behavior...19 The Interpersonal Psychological Theory of Suicidal Behavior and Perfectionism28 The Present Study...36 III. METHODS...38 Participants...38 Measures...38 Demographics Questionnaire...38 The Almost Perfect Scale Revised...38 Interpersonal Needs Questionnaire...40 Center for Epidemiological Studies Depression Scale...41 Depressive Symptom Index Suicidality Subscale...42 Acquired Capability for Suicide Scale...43 Procedure...43 iv

5 Chapter Page IV. RESULTS...45 V. DISCUSSION...52 Limitations...56 Future Research and Clinical Implications...59 REFERENCES...63 APPENDICES...77 APPENDIX A Demographic Information...78 Demographic Information...79 APPENDIX B Measures...83 Almost Perfect Scale Revised...84 Interpersonal Needs Questionnaire...86 Center for Epidemiological Studies Depression Scale...88 Depressive Symptom Index Suicidality Subscale...90 Acquired Capability for Suicide Scale...91 APPENDIX C IRB Approval Page...93 IRB Approval...94 APPENDIX D Tables...95 v

6 LIST OF TABLES Table Page 1. Demographics of the Three Groups of Perfectionists Correlation Matrix for Mediational Analyses Regression Analyses for Maladaptive Perfectionism and Suicidal Ideation: Burdensomeness as a Mediator Regression Analyses for Maladaptive Perfectionism and Suicidal Ideation: Acquired Capability as a Mediator Regression Analyses for Maladaptive Perfectionism and Suicidal Ideation: Belongingness as a Mediator Means, Standard Deviations, and ANOVAs by Group Analysis of Variance: Pairwise Comparisons for CES-D Analysis of Variance: Pairwise Comparisons for DSI-SS vi

7 CHAPTER I INTRODUCTION Perfectionism is a multidimensional construct which may contain both positive aspects and negative aspects (Blatt, 1995; Frost, Marten, Lahart, & Rosenblate, 1990; Hamachek, 1978; Hewitt & Flett, 1991a, 1991b; Slaney, Ashby, & Trippi, 1995). Much of the current work on perfectionism has drawn upon the early writings of Hamachek (1978) who proposed that perfectionism was comprised of both normal and neurotic perfectionists. Hamachek (1978) defined normal perfectionism as an individual s ability to obtain pleasure from meticulous effort, striving to excel, and being able to be less precise in their work when applicable. On the other hand, Hamachek (1978) postulated that neurotic perfectionists place intense effort on avoidance of failure, are never satisfied in what would normally be a job well done, and have deep seated feelings of inferiority though they continuously seek approval by others. These early hypotheses regarding the characteristics and behaviors of perfectionists laid the groundwork for many of the current lines of research. Negative or maladaptive perfectionism has been found to greatly impact the perfectionistic individual s functioning (Blatt, 1995). Maladaptive perfectionism generally follows Hamachek s definition of the neurotic perfectionist but also 1

8 incorporates discrepancies between actual performance expectations and ideal performance expectations as a defining feature. Maladaptive perfectionism has been shown to affect mental health, interpersonal functioning, and academics (Accordino, Accordino, & Slaney, 2000; Baumeister, 1990; Blatt, 1995; Blatt & Zuroff, 1992; Burns, 1980; Delise, 1986, 1990; Dunkley et al., 2000; Grzegorek et al., 2004; Hamachek, 1978; Hewitt & Flett, 1990, 1991; Slade & Owens, 1998; Slaney et al., 2001). Avoidant coping and low perceived social support (Dunkley et al., 2000), higher self-criticism (Blatt & Zuroff, 1992), symptoms of depression (Dunkley et al., 2000; Hewitt & Flett, 1990, 1991, 1993; Hewitt, Flett, & Ediger, 1996), suicidal ideation (Baumeister, 1990; Delise, 1986, 1990), and stress (Dean & Range, 1996; Hewitt, Flett, & Weber, 1994; Rice, Leever, Christopher, & Porter, 2006) are just a few of the factors that have been correlated with the occurrence of maladaptive perfectionism. Multiple studies have examined self-reported symptoms of depression and maladaptive perfectionism (Hewitt & Flett, 1990,1991a; Slaney et al., 2001). With those studies as a basis, subsequent studies have examined perfectionism in suicidal ideators and attempters (Adkins & Parker, 1996; Delise, 1986, 1990; Hewitt, Norton, Flett, Callander, & Cowan, 1998). Studies illustrating the link between specific constructs of perfectionism and suicide have found support for protective factors (Rice, Leever, Christopher, & Porter, 2006) and risk factors among individuals (Dean & Range, 1996). Researchers have argued that the adaptive or healthy aspects of perfectionism serve as motivational or protective factors for the individual. Conversely, the maladaptive or unhealthy aspects of perfectionism serve as risk factors to the individual. A recent conceptualization of suicidal behavior may account for why some maladaptive 2

9 perfectionists ideate about, attempt, or have the capability to complete suicide. Joiner s (2005) Interpersonal-Psychological Theory of Suicidal Behavior may provide insight into the reasons for the desire to commit suicide and the ability to act on the suicidal ideations in perfectionistic individuals. Joiner s (2005) theory is comprised of three main components which are necessary for an individual to complete what would otherwise be an attempt at suicide. Those three components are perceptions of thwarted belongingness, perceived burdensomeness, and acquired capability to enact lethal self-harm. Both the components of thwarted belongingness and perceived burdensomeness have similarities to several of the factors that accompany the maladaptive aspects of perfectionism. Increased self criticism and lowered self-esteem over performance in perfectionistic individuals have been shown to lead to feelings of inferiority and inadequacy to obtain goals and complete tasks (Ashby & Kottman, 1996; Hamachek, 1978; Slaney, Rice, & Ashby, 2002). Obstacles such as attempting to achieve the unachievable and doubts regarding actions and abilities, may lead perfectionists to feel as though they cannot contribute anything meaningful to society. Perfectionists with increased levels of maladaptive features may feel like a burden to family members and society. These feelings reflect Joiner s construct of perceived burdensomeness. The literature also maintains that perceived or actual absence of social support is a risk factor for suicide. Maladaptive perfectionists who perceive the absence of social support or who experience actual isolation are at an increased risk for suicide (Dunkley et al., 2000; Durkheim, 1897, 1951; Rice et al., 2006; Shneidman, 1981). The perfectionism literature that highlights the link between social 3

10 isolation and the perceived absence of social support provides a theoretical link to Joiner s construct of thwarted belongingness. The literature on perfectionism does not currently contain references to constructs or correlates that mirror acquired capability to enact lethal self-harm. Joiner (2005) defines acquired capability as the practice of self-harm over time. Individuals who engage in self-harming behaviors have, over time, practiced physical self-harm and have thereby increased their capacity or endurance for pain. Through this repeated exposure to pain, they are able to increase the intensity of the inflicted pain. As they expose themselves to higher intensity pain they also become more capable to handle or deal with the emotional, mental, and physical pain that accompanies self injury. A high need for achievement is a defining feature of perfectionism. In their attempt to achieve their goals and succeed, perfectionists may put themselves in situations which may increase the possibility of being hurt. For example, increased drive to be better at activities like sports may expose individuals to situations which may be potentially physically harmful (increased susceptibility to injury). The risk for harm may also be present in a chosen career. A career in a field which exposes an individual to danger or blood (e.g. surgeons, firefighters, or police officers) may desensitize the individual to the fear and anxiety surrounding hurting oneself. This habituation to self pain or the pain of others may then generalize to a lack of fear regarding death. Therefore, in a high achieving perfectionistic sample, the susceptibility to harm and desensitization may increase as their drive to attain their goals increases. The potential link between acquired capability and perfectionism is novel due to the absence of 4

11 literature examining the relationship of perfectionism with constructs similar to Joiner s conceptualization of acquired capability. The goal of the current study was to obtain a more in-depth understanding of the mechanisms at work in the maladaptive perfectionist that may lead them to ideate, attempt, and commit suicide. Joiner s theory may have significant clinical implications in the identification, intervention, and treatment of those identified as maladaptive perfectionists at an increased risk for suicide. In the current study, the primary hypothesis integrated Joiner s (2005) Interpersonal-Psychological Theory of Suicidal Behavior with Slaney and colleagues (2001) definition of the maladaptive perfectionist. Slaney and colleagues (2001) defined maladaptive perfectionists as having a perceived discrepancy between the standards they set for themselves and their actual performance. The three components of Joiner s theory (e.g. perceived burdensomeness, thwarted belongingness, and acquired capability) were examined individually as mediational variables between maladaptive perfectionists and self-reported suicidal ideation. It was hypothesized that 1) perceived burdensomeness would mediate the relationship between maladaptive perfectionism and suicidal ideation, 2) thwarted belongingness would mediate the relationship between maladaptive perfectionism and suicidal ideation and 3) acquired capability to enact lethal self-harm would mediate the relationship between maladaptive perfectionism and suicidal ideation. The current study also sought to replicate past findings regarding the self-reported levels of depressive symptoms and suicidal ideation present among three categories of perfectionists. The three categories of perfectionists in the current sample were defined as adaptive perfectionists, maladaptive perfectionists, and non-perfectionists. These 5

12 categories come from the work of Slaney and colleagues (2001). It was hypothesized that self-reported symptoms of depression and suicidal ideations would be the highest in the maladaptive perfectionist group, followed by the non-perfectionists, and lastly followed by adaptive perfectionists. 6

13 CHAPTER II REVIEW OF THE LITERATURE Perfectionism Perfectionism has been conceptualized as containing many different aspects and is generally considered a multidimensional and multicategorical construct (Blatt, 1995; Frost, Heimberg, Holt, Mattia, & Neubauer, 1993; Frost, Marten, Lahart, & Rosenblate, 1990; Hewitt & Flett, 1991; Slaney, Ashby, & Trippi, 1995). The literature is rife with theories of perfectionism and objective measures of each unique construct. Some of the conceptualizations of perfectionism focus specifically on the negative facets. Others concede that there may be positive/negative, healthy/unhealthy, or adaptive/maladaptive facets to perfectionism. Many of the early theories of perfectionism are illustrated by the works of Hamachek (1978), Beck (1983), Blatt (1974), Burns (1980), Pacht (1984), and Pirot (1986), but it was Hamachek s (1978) theory that pioneered the research into perfectionism as we know it today. Hamachek (1978) proposed that there were two categories of perfectionists. Individuals were either normal perfectionists or neurotic perfectionists. The normal perfectionists were characterized as having high standards for themselves. Even though normal perfectionists standards were high, they were also 7

14 proposed to be flexible. This allowed them to be less precise when the opportunity permitted and were thought to have no feelings of distress over their less precise performance. Normal perfectionists were also identified as being tedious and meticulous, obtaining a sense of pleasure and fulfillment through their efforts. On the other hand neurotic perfectionists were thought to have high and inflexible standards for themselves. Hamachek thought that as a result of their inflexibility the individuals would always feel as though they were not meeting the high standards that they placed on themselves. This feeling of failure or inadequacy then led the neurotic perfectionist to experience distress. Many of the later theories of perfectionism drew off of Hamachek s work to better explain their own unique theories and assist in the construction of objective measures by which to quantify their theories. One of the first scales developed to measure the construct of perfectionism was Burns s (1980) Perfectionism Scale. Burns s hypothesized that high personal standards and self-defeating attitudes defined perfectionism. He proposed these items were often observed in people who suffered from symptoms of anxiety and depression (Blatt, 1995; Burns, 1980; Slaney, Rice, Mobley, Trippi, & Ashby, 2001). Essentially, Burns conceptualized perfectionism as being characterized by self-defeating attitudes. The work of Burns in the area of perfectionism inspired other researchers to examine the potential facets of perfectionism and also inspired others to construct objective measures to accurately measure their theories of perfectionism. In 1990, Frost, Marten, Lahart, and Rosenblate developed the Frost Multidimensional Perfectionism Scale (FMPS). Frost and colleagues felt that the construct of perfectionism could be defined in terms of positive and negative aspects of individuals intrapersonal and 8

15 interpersonal behaviors. The authors felt that the positive and negative behaviors exhibited by perfectionists were characterized by excessive concerns over mistakes, high personal standards, emphasis on parental criticism, an emphasis on parental expectations, doubts about one s actions, and high levels of organization (Blatt, 1995; Frost el at., 1990; Rice, Ashby, & Slaney, 2007). Frost and colleagues felt that the perfectionist s need for order, organization and adherence to high personal standards, were essentially adaptive and positive behaviors. These adaptive features helped to establish good work habits, motivation for high achievement, and motivation to obtain individual goals. The authors felt that the maladaptive or negative aspects of perfectionism were characterized by the perception of high parental standards and expectations, excessive concern over making mistakes, and doubt regarding one s actions. Though there were positive facets to their theory of perfectionism, they conceptualized perfectionism overall as a negative trait and emphasized the negative features and psychological concerns of perfectionism (Slaney, Rice, Mobley, Trippi, & Ashby, 2001). Hewitt and Flett (1991b) also proposed a model of perfectionism. Hewitt and Flett (1991b) felt as though there were essentially three components to perfectionism. Their construct of perfectionism contained the components of self-oriented perfectionism, other-oriented perfectionism, and socially prescribed perfectionism. Self-oriented perfectionism was defined as inwardly focused in the perfectionistic individual; unrealistic and unattainably high goals and standards were set by the individual. The self-oriented perfectionist would then hold themselves to these goals and standards with intense self-criticism. They were conceptualized as accepting nothing less than perfection; no flaws, no failures. Hewitt and Flett concluded that self-oriented 9

16 perfectionism was most closely tied to achievement stressors because of its internalizing features (Hewitt & Flett, 1993). Other-oriented perfectionism was proposed as the perfectionistic individual s inclination to hold others to the same standards as they hold themselves. Hewitt and Flett felt that they would judge, scrutinize, and criticize others for their inability to meet the unrealistic and unattainable goals. Lastly, Hewitt and Flett proposed socially prescribed perfectionism as the perfectionist s tendency to feel as though others are imposing unrealistic and demanding expectations, standards, and goals on them. To the perfectionistic individual, feel as though they must meet these unattainable goals and standards in order to gain approval and acceptance by those who imposed the standards on them. The individual may perceive this situation as uncontrollable. The perception of uncontrollability has been shown to lead to the manifestation of anger, anxiety, helplessness, hopelessness, depression, and suicidal ideations (Blatt, 1995). Hewitt and Flett s (1991b) theory of perfectionism (self-oriented, other-oriented, and socially prescribed) emphasized the negative aspects of perfectionism. They conceptualized perfectionism, overall, as problematic with no adaptive or healthy aspect to the construct (Slaney et al., 2001). Slade and Owens (1998) modeled their theory of perfectionism off of Hamachek s early work. To Slade and Owens, perfectionism was composed of positive perfectionism and negative perfectionism. They felt that positive perfectionism was inherently healthy and was characterized by high personal standards, high organizational levels, self-oriented perfectionism, and achievement (Flett & Hewitt, 2006; Slade & Owens, 1998). Slade and Owens identified negative perfectionism as unhealthy. Slade and Owens proposed negative perfectionism to be associated with high levels of 10

17 maladaptive self evaluation, disappointment, neuroticism, and socially prescribed perfectionism. Whereas Slade and Owens encouraged positive perfectionism, they proposed that negative perfectionism ought to be avoided or corrected rather than encouraged. Accordino, Accordino, and Slaney (2000) proposed a maladaptive and adaptive theory of perfectionism. They hypothesized that adaptive perfectionists were flexible in their standards, flexible in their goals, high in self-esteem, and high in social adjustment. Accordino, Accordino, and Slaney also felt that adaptive perfectionists were still able to gain satisfaction from their performance even if they were not perfect (Accordino, Accordino, & Slaney, 2000; Hamachek, 1978; Rice, Leever, Christopher & Porter, 2006). Because of these characteristics, Accordino and colleagues felt that adaptive perfectionists had higher levels of motivation and achievement. In contrast, Accordino and colleagues felt that maladaptive perfectionists would experience high levels of anxiety and fear at both perceived and real failure. They also proposed that maladaptive perfectionists would be overly self-critical. This would eventually lead to doubt about abilities and the inability to be happy or experience pleasure from any effort put forth (Accordino, Accordino, & Slaney, 2000; Hamachek, 1978). Dunkley and colleagues (2000) theorized that perfectionism consisted of two dimensions; personal standards perfectionism and evaluative concerns perfectionism. Personal standards perfectionism was identified as adaptive and evaluative concerns perfectionism was identified as maladaptive. Personal standards perfectionism was defined by engagement in harsh self-evaluations which increased stress in the individual. Despite an increase in stress, these individuals engaged in active problem solving and 11

18 active coping strategies (Dunkley et al., 2000; Flett, Russo, & Hewitt, 1994). Evaluative concerns perfectionism was defined as the perception of other s negative evaluations of the individual and the exertion of their unrealistic standards on the individual. This was thought to lead to overly critical self-evaluations which inhibited ability to perform and the ability to be satisfied with the performance. Theory of Interest and the Almost Perfect Scale While Frost et al. (1990) and Hewitt and Flett (1991b) emphasized the negative characteristics of perfectionism in their theories, others thought that there were inherent adaptive or positive aspects to perfectionism. By conceptualizing not only the unhealthy or maladaptive aspects of perfectionism but also emphasizing the healthy and adaptive aspects of perfectionism, Slaney and Johnson (1992) developed the Almost Perfect Scale of perfectionism as a means to encompass and objectively measure both of those aspects. Slaney and Johnson felt that the adherence to order and high standards captured the essence of the positive or adaptive aspects of perfectionism (Slaney et al., 2001). The authors also felt that high levels of anxiety, tendency towards procrastination, and interpersonal difficulties characterized the maladaptive perfectionist. Over time, it appeared as though Slaney and Johnson s (1992) conceptualization of the maladaptive perfectionist was not accurate. Through the work of qualitative studies (Slaney & Ashby, 1996; Slaney, Chadha, Mobley, & Kennedy, 2000), it seemed that it was actually the difference between perceived or expected performance and actual performance that caused perfectionists distress. Through the work of Slaney and Ashby (1996) and Slaney et al. (2000), it was determined that the discrepancy between actual and ideal self was what was actually maladaptive in the perfectionistic individual. 12

19 Two Constructs of Perfectionism: Adaptive and Maladaptive Several factor analyses were conducted on the Almost Perfect Scale (APS; Slaney & Johnson, 1992), the Frost Multidimensional Perfectionism Scale (FMPS; Frost, Marten, Lahart, & Rosenblate, 1990), and the Hewitt and Flett Multidimensional Perfectionism Scale (HFMPS; Hewitt & Flett, 1991b) to determine what each of the measures were essentially measuring (Frost, Heimberg, Holt, Mattia, & Neubauer, 1993; Rice, Ashby, & Slaney, 1998; Slaney, Ashby, & Trippi,1995). In general, the studies found that two factors emerged when all of the measures were analyzed. These two higher order factors were called positive striving and maladaptive evaluation concerns (Frost et al., 1993; Slaney, Ashby, & Trippi, 1995) or otherwise known as adaptive and maladaptive perfectionism (Rice, Ashby, and Slaney, 1998). These findings gave support to Hamachek s (1978) original conceptualization of the normal and neurotic perfectionist. Due to the research indicating essentially two types of perfectionism (e.g. adaptive and maladaptive), the original Almost Perfect Scale for the measurement of perfectionism was revised. The original authors of the scale, Slaney and Johnson (1992), along with Rice, Mobley, Trippi, and Ashby, revised the original scale to make the Almost Perfect Scale-Revised (APS-R; Slaney et al., 1996). The revisions of the scale sought to specifically address the two types of perfectionism that had been revealed in the factor analyses previously mentioned. Rice and colleagues kept the High Standards subscale along with the Order subscale from the original measure and added them to the revised version of the measure in order to capture the positive aspects of perfectionism. Next, Rice and colleagues added a new subscale to the measure which, they hoped, 13

20 would serve to capture the negative or maladaptive aspects of perfectionism. They called it the Discrepancy subscale. Again, they constructed the scale so that the High Standards and Order subscales would capture the adaptive perfectionistic qualities of the individual and the Discrepancy subscale would capture the maladaptive perfectionistic qualities of the individual. The new Discrepancy subscale appeared to adequately measure the negative aspect of perfectionism and made sense with the lay definitions and descriptions of the construct of perfectionism (Slaney et al., 2001). The maladaptive aspects of perfectionism included hypersensitivity to perceived failure, catastrophic ideations in response to mistakes, perceived feelings of inferiority, feelings low self-esteem, and the tendency to discount any successes they may encounter (Ashby & Kottman, 1996; Slaney, Rice, & Ashby, 2002). Maladaptive Perfectionism and Distress Maladaptive perfectionism has been identified as causing distress to the individual. As such, maladaptive perfectionism has been linked to a variety of disorders such as obsessive-compulsive disorder and panic disorder (Flett, Hewitt, & Dyck, 1989; Hewitt & Flett, 1991b; Straub, 1987), substance abuse (Hewitt, Norton, Flett, Callander, & Cowan, 1998), migraines (Brewerton & George, 1993), chronic aches and pains (Forman, Tosi, & Rudy, 1987), personality disorders (Hewitt, Flett, & Turnbull- Donovan, 1992), Type A personality (Flett, Hewitt, Blankstein, Kirk, & Dynin, 1994), and eating disorders (Axtell & Newlon, 1993; Blatt, 1995; Flett & Hewitt, 2002; Hewitt & Flett, 1991b; Pacht, 1984). Along with the array of psychological disorders and other distressing conditions that may accompany perfectionism, states or traits such as procrastination, shame and guilt, feelings of failure, lower achievement and motivation, 14

21 and low self-esteem have also been linked to maladaptive perfectionism (Accordino, Accordino, & Slaney, 2000; Hamachek, 1978; Hewitt & Flett, 1991a; Pacht, 1984; Sorotzkin, 1985). Perfectionism and Depression Perfectionism has been studied in relation to many different psychological disorders, but it is depression that has been most closely correlated to the construct. Because depression may lead to suicidal ideation in some individuals it is important to first understand the link between depression and perfectionism. Depression is a risk factor for the development of suicidal ideations. However, those individuals who exhibit symptoms of depression do not necessarily develop suicidal ideations. Conversely, those who have suicidal ideations do not necessarily exhibit symptoms of depression (i.e. Borderline Personality Disorder). One study that examined the relationship between depression and maladaptive perfectionism was conducted by Hewitt and Flett (1991a). Hewitt and Flett (1991a) found that socially prescribed perfectionism (the maladaptive perception in which others hold the perfectionist to high standards) was elevated in depressed patients. Other research has shown that non-perfectionists, on average, tend to show fewer symptoms of depression and higher levels of self-esteem in comparison to maladaptive perfectionists (Grzegorek et al., 2004). Blatt and Zuroff (1992) felt that high levels of self-criticism and high levels of maladaptive perfectionism may leave individuals vulnerable to perceived experiences of failure. They went on to suggest that the perception of failure and the individual s reactions to failure, may lead to increased levels of depression (Blatt & Zuroff, 1992). 15

22 Rice and Ashby (2007) found that the amount of self-reported discrepancy by the perfectionistic individual (as measured by the APS-R) and symptoms of depression were significantly correlated. The higher the levels of self-reported discrepancy on the APS-R, the more symptoms of depression the person endorsed. Rice and Ashby (2007) found that maladaptive perfectionists had significantly higher depression scores than adaptive perfectionists. They also found that non-perfectionists fell between maladaptive and adaptive perfectionists on levels of depression (Rice & Ashby, 2007). Slaney, Rice, Mobley, Trippi, and Ashby (2001) found that higher scores on the Discrepancy subscale of the APS-R were related to lower self-esteem and negative psychological adjustment. The work focusing on perfectionism and depression helped researchers to better understand in link of perfectionism to affect. One of the possible criteria or symptoms for a diagnosis of Major Depressive Disorder is suicidal ideation. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (2000) specifies the criterion as recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide (p. 356). Because of the link between depression and suicide, the research surrounding perfectionism has also examined the effects of perfectionism on suicidal ideations, attempts, and completions. Perfectionism and Suicide Suicide claimed the lives of 32,637 Americans in 2005 and was subsequently the eleventh leading cause of death in the United States (American Association of Suicidology, 2008). Whereas depression is a hallmark feature of and often times leads to suicidal ideation, attempts, and completions, suicide is often the pinnacle of distress for 16

23 an individual, perfectionist or not. Because of the alarming statistics surrounding suicide in the U.S., many researchers have identified it as an area warranting further study. Research has shown that perfectionism can be linked to suicidal ideation and suicide attempts. Hewitt, Norton, Flett, Callander, and Cowan (1998) proposed that selforiented perfectionism and socially prescribed perfectionism (both maladaptive types of perfectionism) may lead to the manifestation of suicidal ideations because of the individual s perceptions of failure. Hewitt and colleagues likened their theory of perfectionism and suicide to Baumeister s (1990) theory of Escape from Self, in which unrealistic standards set the stage for blame and failure, eventually leading to suicide attempts. It is the perception of failure and blame which leads the perfectionistic individual to feel as though they contribute nothing to society and are worthless to others. These maladaptive perceptions lead to an increase in depressive symptoms and suicidal ideations. In their 1998 study of suicidal alcoholics, Hewitt and colleagues found that socially prescribed perfectionism, depression, and hopelessness were higher in those who attempted suicide. They also found that other-oriented perfectionism, socially prescribed perfectionism, hopelessness, and depression predicted suicide attempts (Hewitt et al., 1998). In their 1992 study, Hewitt, Flett, and Turnbull-Donovan found that socially prescribed perfectionism correlated with suicidal intent and threat after controlling for depression and hopelessness. In their initial clinical sample, Hewitt and colleagues did not find support for a relationship between self-oriented perfectionism and suicidal threat. Boergers, Spirito, and Donaldson (1998) found that among inpatient adolescent suicide 17

24 attempters, socially prescribed perfectionism predicted suicidal ideation and was endorsed as a particular reason for the adolescents attempted suicide. Dean and Range (1996) proposed that perfectionism, though not a construct in the original escape theory proposed by Baumeister (1990), may relate to negative life stress. They also hypothesized that socially prescribed perfectionism and self-oriented perfectionism (both maladaptive forms of perfectionism) may lead to suicidal ideation. They felt that the perfectionistic person would set unrealistically high standards and goals for themselves which embodies self-oriented and socially prescribed perfectionism. According to Dean and Range (1996) if the person had stable, internal, global attributions, these characteristics would lead to the manifestation of anxiety and depression (discrepancies). The person was hypothesized to then become self-aware and would focus specifically on their inadequacies, incompetence, unattractiveness, and guilt. These feelings were thought to perpetuate internal states of distress such as depression and anxiety. Eventually the person was hypothesized to spiral into a state of hopelessness. Dean and Range (1996) stated that, the individual experiences a reduction in inhibitions, so that certain inner restraints to suicide such as reasons for living are removed. Consequently, he or she commits suicide (p. 417). In their study, Dean and Range (1996) replicated the findings of Hewitt et al. (1992), and found that socially prescribed perfectionism was significantly correlated with suicidal behaviors. Though socially prescribed perfectionism was correlated with suicidal behaviors, in a regression equation it failed to account for the variance above and beyond other variables. They also found that self-oriented and other-oriented perfectionism were not significantly correlated with suicidal behaviors. 18

25 Rice and colleagues (2003) proposed that maladaptive perfectionists strive to fulfill their high standards and to do so they must persistently put forth effort. Though the maladaptive perfectionist puts forth the effort in order to fulfill their high standards, their efforts are simultaneously perceived as being inadequate and unable to meet their selfimposed standards. Because of their perceived inadequacy, Rice and colleagues (2003) thought that dysfunctional cognitive processes could result in the perfectionist s increased risk for hopelessness, depression, and suicide. Hewitt, Flett, and Weber (1994) found that socially prescribed perfectionism and self-oriented perfectionism levels were elevated in moderately and highly suicidal ideating individuals as compared to low ideating individuals. Similar results were found in both a college and clinical sample after controlling for hopelessness and depression (Hewitt, Flett, & Weber, 1994). They also found that self-oriented perfectionism moderated the link between suicidal ideation and life stressors (Hewitt, Flett, & Weber, 1994). In all, perfectionism has been linked to suicide and affective dysregulation in many studies. Though many people have examined factors such as social isolation, social integration, hopelessness, depression, and stress, other theories may better account for the feelings of social isolation and failure that are present in perfectionistic individuals experiencing suicidal ideations. The Interpersonal-Psychological Theory of Suicidal Behavior is one theory that may provide further insight into the characteristics observed in maladaptive perfectionists. The Interpersonal Psychological Theory of Suicidal Behavior 19

26 A recent theory of suicide may provide further insight into the correlation between perfectionism and suicidal ideation. In 2005, Joiner developed the Interpersonal-Psychological Theory of Suicidal Behavior as a means to better understand suicidal ideators, attempters, and completers. Joiner s theory is composed of three distinct pieces. According to the theory, the three aspects of perceived burdensomeness, feelings of thwarted belongingness, and acquired capability to enact self-harm on oneself must be present in order to complete a suicide that would otherwise be an attempt. It is an interpersonal-psychological theory in that a person cannot die by suicide unless they have both the desire, to die which is brought about by the perception of a dearth of resources from others, and the ability to die by suicide (Van Orden et al., 2008). The theory is interpersonal because the individual must feel that a connection to others has been thwarted (thwarted belongingness) and that they no longer contribute anything meaningful to others (perceived burdensomeness). Joiner (2005) described humans as being social creatures due to our deep rooted desire to have meaningful connections to other humans. Humans fulfill such connections by means of family, social groups, teams, religious affiliations and so on. Joiner proposed that those people who feel as though they do not belong to or do not have meaningful connections to a group or other individuals, are at an increased risk for suicide. This theory is supported by other areas of research that are suggestive of social isolation as a risk factor, whereas social support networks or social connections serve as buffers or protective factors to suicide (Baumeister & Leary, 1995; Joiner, Hollar, & Van Orden, 2006). People who are socially isolated do not feel as though they belong and may have distorted views of how their death would be perceived (i.e., no one would miss 20

27 them). Joiner s theory incorporates the construct of thwarted belongingness as an interpersonal risk factor for suicide. Joiner s theory built off of Baumeister and Leary (1995) and Durkheim s (1897) theories of interpersonal belongingness. Baumeister and Leary argued that the need to belong is incredibly powerful, and when thwarted, can lead to adjustment, well-being, and health problems (Joiner, Hollar, & Van Orden, 2006). Perceived feelings of being uncared for and a dearth of positive social interactions comprises thwarted belongingness, which if left unsatisfied and to its own means, increases the risk for suicide exponentially. Joiner et al. (2006) compared Baumeister and Leary s theory to Durkheim s (1897) theory which states that a failure at social integration results in suicide. According to Durkheim, there are three basic types of suicide; altruistic, egoistic, and anomic (Shneidman, 1981). Durkheim felt that if there was too little social integration (belongingness or social connection) that egoistic suicide would amount and thus the individual and society would lack a common bond which united them together in a meaningful way (Joiner et al., 2006). Durkheim (1897) felt that when the transcendent nature of human society breaks down, then people begin to acquire feelings of hopelessness or purposelessness and suicide rates subsequently increase. Baumeister and Leary (1995) theorized that the need to belong is met when there is a sense of being cared about and when the individual obtains frequent positive interactions with people who, they perceive, care about them. They also posited that a stable relationship will satisfy the need to belong better than unstable and changing relationships with others. Therefore stable relationships lead to feelings of belongingness whereas unstable relationships, no matter how many are acquired, will not satisfy the 21

28 need for belongingness. Baumeister and Leary also proposed that the individual s sense of belongingness will only be partially satisfied if the person does not have face to face interactions but does have the sense of a caring relationship (Baumeister & Leary, 1995; Joiner et al., 2006). Individuals not only need the sense or perception of belonging, they also need face-to-face interactions with the individuals whom they perceive as caring about them. Drawing off of the aforementioned theories, Joiner integrated all of the factors into his 2005 theory of suicide. Joiner felt that the sense of thwarted belongingness was a vital risk factor to suicide but if the need for belongingness was met, it could potentially buffer against suicide. If the individual has relationships that are unstable, distant and without proximity, rare or sporadic, and distasteful, they may not feel as though they belong, thus increasing their risk for suicide. Joiner s theory also emphasized that feelings of burdensomeness, or a sense of thwarted effectiveness, can be a risk factor for suicide. Perceived burdensomeness is often the result of the faulty belief that the individual contributes nothing to society. They may feel as though they receive more than they contribute, and because they are not contributing to society or others in general, they feel as though others must support them. Thus, they feel as though they have burdened others. Because of the perception of having contributed nothing to others or society, these individuals may feel as though they are incompetent, unsuccessful, or hopeless. Their perception of their incompetence or unsuccessfulness, may lead to the perception of weakness within themselves. This weakness may then lead to their distorted view of their behavior, or lack thereof, having a negative impact on the lives of others. They may feel that their persistent negative mood 22

29 or the subjective quantity of problems may be too intense for a loved one to handle (Stellrecht et al., 2006, p. 215). Eventually they may feel that others would be better off if they were no longer living. Therefore the feeling of being a burden on others, according to Joiner (2005), increases the risk for suicide. Baumeister s (1990) Escape from Self model of suicide, was spawned out of his general theory of escape (Baumeister & Sher, 1988). In it Baumeister made the suggestion that individuals influenced by cognitive factors, negative life events, and emotional states, may attempt to escape from their negative affect and the self-awareness, which is aversive to them (Baumeister, 1990; Pettit & Joiner, 2006). The initial chain of events may stem from the experience of negative life events. Out of the negative life event arises a discrepancy, and it is the discrepancy between the individual s standards for themselves (the desired outcome) and the actual outcome that can lead to an internal attribution surrounding the negative life event. According to Baumeister, they then see failure to obtain their desired outcome as their own incompetence rather than attributing the perceived failure to external causes. The process of making internal attributions about one s own failures, incompetence, or inadequacies may make the individual more selfaware which perpetuates their negative affect. The individual then may wish to escape from their negative views of themselves, disregarding the costs or future effects (which Baumeister referred to as cognitive deconstruction or mental narrowing). The individual then turns to their ultimate perception of escape; suicide (Baumeister, 1990; Pettit & Joiner, 2006). Overall, the escape theory of suicide and the process of cognitive deconstruction was thought to lead to disinhibition, irrationality, and the minimizing of affect resulting in a lack of emotionality in the individual. 23

30 Because Joiner drew from Baumeister s work when creating his own theory, his construct of burdensomeness is reflective of Baumeister s original theory. Joiner felt as though it was the state of perceived failure that could potentially lead to feelings of ineffectiveness, incompetence, and overall burdensomeness. It was these feelings that would subsequently give the individual the desire to take their life. Joiner did explain in his theory that it is not actual burdensomeness that the individual endures, but rather the perception of being a burden on others. It is the perception and cognitive distortion that creates the desire for suicide. Like Baumeister (1990) speculated as well, cognitive factors such as internal attributions for one s failures can lead to the misperception of being a burden on others or on society. Two studies conducted by Joiner and colleagues (2002) analyzed suicide notes written by suicide attempters and suicide completers. They found that the notes of completers contained more perceptions of burdensomeness than the notes of the attempters. They also found that the level of perceived burdensomeness also predicted the lethality of the measure used to attempt or commit suicide. Joiner proposed that methods such as a gunshot wound to the head were considered more lethal than taking a lethal amount of a substance and overdosing (Joiner et al., 2002; Stellrecht et al., 2006). The quality of family relationships has also been shown to impact suicidal ideation (DeCantanzaro, 1995; Van Orden et al., 2006). Brown et al., (1999) found that the subjective feelings of being a burden on relatives were significantly predictive of suicide risk. DeCantanzaro (1995) found that perceived burdensomeness in family relations was correlated with increased suicide risk. Van Orden and colleagues (2006) hypothesized that perceived burdensomeness would relate to past suicide attempts and current ideation 24

31 even after controlling for depressive symptoms, hopelessness, and personality disorders. They found that perceived burdensomeness was a predictor of suicidality above and beyond hopelessness, which is considered one of the most robust predictors of suicidality. Lastly, Joiner (2005) proposed that those who commit suicide have acquired a capability to enact lethal self-harm upon themselves. Whereas, perceived burdensomeness and thwarted belongingness create the desire to commit suicide, acquired capability is the ability to commit suicide. The literature supports the link between past suicide attempts and future suicidal behavior (Brown et al., 2000; Joiner, 2005; Maser et al., 2002). The intensity of future suicidal ideations, suicide attempts, and potential for completed suicide are all predicted by previous suicide attempts. It is proposed that such individuals have, over time, practiced physical self-harm and have thereby increased their capacity or endurance for pain. Through this repeated exposure to pain, they are able to increase the intensity of the inflicted pain. As they expose themselves to higher intensity pain they also become more capable to handle or deal with the emotional, mental, and physical pain which accompanies self-injury. Past research has also supported the claim that suicidal individuals show a greater tolerance for pain than their non-suicidal cohort (Orbach, Mikulincer, King, Cohen, & Stein, 1997). It has also been proposed that certain types of individuals may place themselves in situations which may expose them to forms of pain or injuries other than self-harm or self-injurious behaviors. Therefore the ability to enact suicide, or acquired capability, may occur through other avenues such as high risk situations. Risk-taking behavior includes intravenous drug users, exposure to physical violence, and non-suicidal selfinjurious behavior (Darke & Ross, 2002; Kidd & Kral, 2002; Van Orden et al., 2008; 25

32 Whitlock & Broadhurst, 1969). People who put themselves in positions of potential harm for non-suicidal self-injury include professional athletes (who push their bodies to the limits), prostitutes, and people who engage in aggressive violent behavior (Van Orden et al., 2008). Thus, in line with a behavioral perspective, through the continual exposure to pain via self-harm and the anxiety that accompanies the self-harm, the individual habituates to the feelings and the somatic experience is extinguished in the body. Eventually the individual ultimately overcomes the fear of death. Van Orden and colleagues (2008) conducted a series of three studies that tested Joiner s Interpersonal-Psychological Theory of Suicidal Behavior in and adult population. Study 1 proposed and sought to answer the question who wants to die by suicide? (Van Orden et al., 2008, p. 73). In order to answer this question, Van Orden and colleagues looked at the constructs of perceived burdensomeness and thwarted belongingness in a sample of 309 undergraduate students at Florida State University. They hypothesized that burdensomeness and belongingness, when analyzed together in a regression analysis, would account for the majority of the variance in suicidal desire above and beyond the contribution of either construct alone (p. 73). It was hypothesized that burdensomeness and belongingness were the source of the most serious form of suicidal desire according to the theory (p. 73). In their analyses, Van Orden and colleagues found that when taken together, burdensomeness and belongingness did account for more of the variance in suicidal ideation above and beyond age, gender, depression, or either burdensomeness or belongingness alone. In study 2, Van Orden and colleagues sought to answer who can die by suicide? (p. 75) by testing the construct of acquired capability. They proposed that non-attempters 26

33 would have the lowest levels of acquired capability, single attempters would have medium levels of acquired capability, and multiple attempters would have the highest levels of acquired capability. They also went on to hypothesize that those people who exposed themselves to provocative or painful situations and experiences, would also have elevated levels of acquired capability. In both hypotheses, other risk factors such as depressive symptoms, suicidal ideation (burdensomeness and belongingness), gender and age were controlled for. Their sample consisted of 228 outpatient clients from the Florida State University Psychology Clinic. The analyses revealed that their first hypothesis was supported; multiple attempters had the highest levels of acquired capability, followed by single attempters, and lastly non-attempters. Their second hypothesis was also supported; Van Orden and colleagues found that exposure to provocative or painful experiences did predict acquired capability even after controlling for other variables that have been associated with increased suicide risk in the past literature. Interestingly, Van Orden and colleagues found that gender was a significant predictor of acquired capability level; men displaying more acquired capability than women. This is an interesting finding because it supports the statistics published by the American Association of Suicidology (2008) which states that more men commit suicide though women are more likely to attempt. Because of their high levels of acquired capability, men are better able to carry out their plans for suicide than are women. Van Orden and colleagues did not find a relationship between self described depressive symptoms and acquired capability, which they asserted was not surprising due to the fact that most people who meet criteria for depression do not in fact commit suicide. The depressed patients may have suicidal ideation or desire as indicated by levels of 27