criminology

Article

A Theory-Based Approach to Understanding Suicide Risk in Shelter-Seeking Women

Caitlin Wolford-Clevenger1 and Phillip N. Smith1

Abstract Women seeking shelter from intimate partner violence are at an increased risk for suicide ideation and attempts compared to women in the general population. Control-based violence, which is common among shelter-seeking women, may play a pivotal role in the development of suicide ideation and attempts. Current risk assessment and management practices for shelter-seeking women are limited by the lack of an empirically grounded understanding of increased risk in this population. We argue that in order to more effectively promote risk assessment and management, an empirically supported theory that is sensitive to the experiences of shelter-seeking women is needed. Such a theory-driven approach has the benefits of identifying and prioritizing targetable areas for intervention. Here, we review the evidence for the link between coercive control and suicide ideation and attempts from the perspective of Baumeister’s escape theory of suicide. This theory has the potential to explain the role of coer- cive control in the development of suicide ideation and eventual attempts in shelter-seeking women. Implications for suicide risk assessment and prevention in domestic violence shelters are discussed.

Keywords coercive control, intimate partner violence, suicide risk, shelter seeking, and escape theory

Intimate partner violence (IPV) is a serious public health concern,

affecting one in three women in their lifetime in the United States

(Black et al., 2011). Research has implicated IPV for several neg-

ative mental health outcomes (Campbell, 2002), including

suicide-related thoughts and behaviors (Bergman & Brismar,

1991; Golding, 1999; Langhinrichsen-Rohling, Snarr, Smith

Slep, Heyman, & Foran, 2011; Simon, Anderson, Thompson,

Crosby, & Sacks, 2002). In particular, abused women who seek

safety at a domestic violence shelter may be at greatest risk, with

one third of shelter-seeking women reporting suicide ideation or

suicide attempts (Golding, 1999; Kirkwood, 1993). However, sui-

cide risk in shelter-seeking women may go unrecognized and

untreated as no documented, uniform procedure for suicide risk

assessment and intervention exists in shelters across the United

States. Moreover, a majority of shelters do not provide psycholo-

gical treatment, likely due to limited resources (Roberts & Lewis,

2000). Therefore, shelter-seeking women may endure long waits

for treatment, experience increased psychological distress, sui-

cide ideation, and resultant risk for death by suicide. We argue

that an empirically based theory that identifies critical compo-

nents underlying the process by which shelter-seeking women

come to be at risk for suicide is essential for guiding suicide risk

assessment and management practices in shelter settings.

The Trajectory to Death by Suicide

Suicide risk is not static and several predisposing biopsycho-

social factors converge to result in death by suicide.

Understanding the overtime variations in risk along the trajec-

tory to suicide is essential for effective suicide risk assess-

ment and management (Joiner, 2002; Silverman, Berman,

Sanddal, O’Carroll, & Joiner, 2007a). Furthermore, it is

essential to adopt clear and consistent definitions of suicide-

related thoughts and behaviors to improve the validity and

reliability of research findings and translation of findings to

clinical practice (Silverman et al., 2007a).

In many clinical settings, the earliest indicator of potential

suicide risk is evidence of suicide ideation, defined as thoughts

of suicide that can vary in frequency, duration, intensity, and

content (Silverman, Berman, Sanddal, O’Carroll, & Joiner,

2007b). However, the term suicide ideation is often used to

describe a myriad of cognitions, introducing problems with

specificity and accurate risk designation. For example, it is

important to distinguish suicide ideation from death ideation,

which involves thoughts of death, being dead, or typically not

existing (Smith et al., 2012). Although some who experience

death ideation will go on to develop suicide ideation, this expe-

rience is common (up to 48.6%) for women who have

1 Department of Psychology, University of South Alabama, Mobile, AL, USA

Corresponding Author:

Phillip N. Smith, Psychology Department, University of South Alabama, 75 S.

University Blvd. (UCOM 1000), Mobile, AL 36688, USA.

Email: [email protected]

TRAUMA, VIOLENCE, & ABUSE 2015, Vol. 16(2) 169-178 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1524838013517562 tva.sagepub.com

experienced significant trauma histories and ongoing interperso-

nal distress (Smith et al., 2012). However, particular variations

of suicide ideation are indicative of greater risk than others. Pas- sive suicide ideation involves thoughts of or wishes for suicide but does not involve thoughts of a plan or method. Active suicide ideation, on the other hand, involves thoughts of suicide, poten- tial methods for suicide, and, when most severe, plans and pre-

parations for suicide (Joiner, Rudd, & Rajab, 1997; Silverman

et al., 2007b). Although passive suicide ideation should warrant

attention, active ideation that includes resolved plans and pre-

parations denotes greater acute suicide risk (Joiner, 2002; Joiner

et al., 1997; Joiner, Walker, Rudd, & Jobes, 1999).

In addition to the varying active and specific nature of sui-

cide ideation discussed, suicide ideation varies in intentionality

toward behavior. Given that patients’ predictions of attempts

are more accurate than some providers (Peterson, Skeem, &

Manchak, 2011), examining and understanding the nature of

the expressed or implied intent is critical (Silverman et al.,

2007b). Such intent may be subtle, remain unexpressed, or,

conversely, involve specific indications, or suicide threats, that

an individual will engage in suicide-related behaviors. These

behaviors can include self-inflicted body tissue damage with-

out intending to die (i.e., nonsuicidal self-injury [NSSI]), which

often serves specific functions, such as relieving emotional dis-

tress (Klonsky, 2007). In the presence of any nonzero level of

intent to die, such self-inflicted injury is considered a suicide

attempt or—if death results—suicide (Silverman et al.,

2007b). One of the greatest difficulties in shelter settings may

be discerning NSSI from suicide attempts, as both are prevalent

given the incidence of complex trauma, borderline personality

disorder (BPD), and posttraumatic stress disorder (PTSD) in

this population (Weaver & Clum, 1996). Complex trauma

symptomology is specifically related to early, chronic interper-

sonal trauma, and includes emotional dysregulation, dissocia-

tion, NSSI, and suicide attempts (van der Kolk, Roth,

Pelcovitz, Sunday, & Spinazzola, 2005). Such a prevalence

of complex trauma, BPD, and PTSD would make it difficult

to distinguish whether self-injury is driven by intent to die

rather than other functions (e.g., emotion regulation; Klonsky,

2007). Therefore, assessing the intent underlying suicide

threats and related behaviors will allow providers to accurately

determine level of suicide risk and intervene appropriately.

Finally, providers involved in assessing and managing

suicide risk must consider that the trajectory to suicide is not

a linear progression from passive to active suicide ideation,

from ideation to suicide attempt and, ultimately, to death

by suicide. In fact, the trajectory begins arguably prena-

tally—with biological diatheses such as variations in serotonin

and testosterone exposure and development (Arango et al.,

2001; Arango, Underwood, Gubbi, & Mann, 1995; Witte &

Smith, 2008). Environmental stressors, such as interpersonal

discord, bring about suicide ideation that—when expressed—

indicates potential risk (Yen et al., 2005). Suicide-related

thoughts often serve a function other than to prepare for suicide,

most notably the intent to escape the state of psychological pain

or psychache (Shneidman, 1993). Some argue that even the

intent to die is simply an extreme expression of the wish to

escape psychache (Silverman et al., 2007a). However, as suicide

ideation fails to serve its intended function of escape, suicide-

related thoughts and the related psychache may yield to beha-

vior. Thus, understanding the intended function underlying

expressed suicide-related thoughts and behaviors is critical. At

the beginning of the trajectory, suicide ideation may be intended

as a temporary escape from a stressor, whereas near the end of

the trajectory such thoughts may cease to provide an escape, ren-

dering death by suicide to be perceived as a more sustainable

solution (Joiner, 2002; Joiner & Rudd, 2000).

IPV

Like suicide-related thoughts and behaviors, IPV is heteroge-

neous; ranging in frequency, severity, and chronicity of vio-

lence (Langhinrichsen-Rohling, 2010). In order to better

understand and prevent IPV, researchers have attempted to

construct typologies based on presumed important aspects of

IPV. For example, Holtzworth-Munroe and Stuart (1994) clas-

sified perpetrators based on their documented differences in

physiological reactivity (Gottman, Jacobson, Rushe, & Shortt,

1995), psychopathology, and frequency, severity, and general-

ity of physical abuse (Gondolf, 1988; Hamberger & Hastings,

1986; Holtzworth-Munroe & Rehman, 2000). Such classifica-

tions were developed to specify treatment planning for each

subtype, for example, by focusing less resources on perpetra-

tors high in psychopathy (Gondolf, 1988). Unfortunately,

typologies based on perpetrators’ characteristics or forms of

abuse (i.e., physical, sexual, and psychological) have proven

limited as forms often co-occur (O’Leary, Malone, & Tyree,

1994), and characteristics fail to differentiate groups as pre-

dicted (Huss & Langhinrichsen-Rohling, 2006; Waltz, Bab-

cock, Jacobson, & Gottman, 2000). Most importantly,

however, such typologies have not been effectively employed

in clinical settings, demonstrating limited practical utility

(Langhinrichsen-Rohling, Huss, & Ramsey, 2000; Lohr,

Bonge, Witte, Hamberger, & Langhinrichsen-Rohling, 2005).

Missing from these typologies has been the consideration of

motivations for violence or the function the violence is pre-

sumed to serve. Discerning the functions of violence will iden-

tify targetable areas for violence prevention as well as refine

treatment of mental health sequelae (e.g., suicide) associated

with the violence. Johnson (1995) proposed a typology based

on the function (i.e., coercion vs. conflict) and the direction

of the violence (i.e., unidirectional vs. bidirectional). He pos-

ited two bidirectional violent relationships: one in which one

partner is physically violent in response to the other’s control-

ling violence (violent resistance) and one in which both part-

ners fight to exert control over the other (mutual violent

control; Johnson, 2006; Johnson & Ferraro, 2000). Two unidir-

ectional violent relationships were proposed: one in which the

agent’s physical violence occurs in response to escalating con-

flicts (situational couple violence) and one in which one partner

perpetrates a pattern of violence to gain control over the other

(intimate terrorism).

170 TRAUMA, VIOLENCE, & ABUSE 16(2)

Johnson’s typology is particularly useful compared to previ-

ous models in considering the application of theory to the assess-

ment and prevention of suicide in shelter-seeking women. First,

his framework is able to explain the gender symmetry debate

present in IPV research. Findings suggest that the majority of

IPV assessed in agency samples (e.g., shelters) is intimate terror-

ism perpetrated by males; whereas IPV assessed in community

samples is predominately situational violence perpetrated

equally by males and females (Frye, Manganello, Campbell,

Walton-Moss, & Wilt, 2006; Graham-Kevan & Archer, 2003;

Johnson, 2006; Johnson & Leone, 2005; Langhinrichsen-

Rohling, 2006; Laroche, 2005; Leone, 2011; Leone, Johnson,

& Cohan, 2007; Rosen, Stith, Few, Daly, & Tritt, 2005; Tanha,

Beck, Figueredo, & Raghavan, 2010). Second, evidence sug-

gests Johnson’s typology improves upon past classifications by

ascribing the heterogeneity of IPV to both partners’ use and

function of violence. He accomplishes this by placing less

emphasis on severity of violence and more on both partners’ use

of violence to either resolve conflict or exert control. Finally,

distinguishing IPV by these functions will improve our under-

standing and prevention of suicide risk in shelter-seeking women

by targeting coercive control as a risk factor (Leone, 2011).

Control-Based Violence, Suicide Ideation, and Attempts

Control-based violence increases risk for suicide ideation,

threats, and attempts independent of physical violence severity,

substance use, and depressive symptoms, but not PTSD symp-

toms (Leone, 2011; Pico-Alfonso et al., 2006). This finding sug-

gests that PTSD symptoms may play a specific role in the

relationship between coercive control and suicide risk. Indirect

support for the relationship between coercive control and suicide

ideation and attempts has emerged from samples assumed to be

predominantly intimate terrorism targets (e.g., shelters and

emergency departments; Johnson, 1995). Golding’s (1999)

meta-analysis reported higher rates of suicide ideation and

attempts in women seeking help from IPV in shelter (34%) and emergency department samples (20%) compared to women in general population samples (6.6%). Additionally, women identi- fied to be at risk for intimate partner homicide through the Dan-

ger Assessment (Campbell, Webster, & Glass, 2009) are likely

targets of coercive control, as measures of intimate partner homi-

cide risk typically tap controlling behaviors (e.g., threats, isola-

tion, and surveillance). As would be expected, women at risk for

intimate partner homicide are significantly likely to have a his-

tory of threatened or attempted suicide (Cavanaugh, Messing,

Del-Colle, O’Sullivan, & Campbell, 2011; Sato-DiLorenzo &

Sharps, 2007). Finally, psychological abuse, consisting of con-

trolling behaviors, is predictive of both suicide ideation and

attempts in women presenting to emergency departments for a

suicide attempt (Kaslow et al., 1998) or other medical problems

(Houry, Kemball, Rhodes, & Kaslow, 2006).

Based on these findings, we argue that coercive control is

most functionally relevant for the development of suicide risk

in IPV targets. Further, given that coercive control is prevalent

in shelter-seeking women, models that explicate these relation-

ships will be of importance for assessing and managing risk in

these settings. Although theoretical models of suicide are avail-

able, no discussions of the implications and applications of

such theories to this population have been offered. Such a

framework is necessary to contextualize risk and identify targe-

table areas for prevention and treatment of suicide risk in

women seeking shelter from control-based violence.

Suicide as Escape From the Self

Baumeister’s (1990) escape theory of suicide is a promising

framework for understanding suicide risk in shelter-seeking

women. Escape theory contextualizes how specific life events,

such as seeking shelter and the interpersonal discord that typi-

cally accompanies it, promote suicide risk by describing specific

psychological processes. In contrast to theories of suicide that

center on risk factors for suicide rather than specific contextual

events, such as hopelessness (Beck, Brown, Berchick, Stewart,

& Steer, 1990), social integration (Durkheim, 1897), psychache

(Shneidman, 1993), and the interpersonal theory (Joiner, 2005;

Van Orden et al., 2010), escape theory will guide identification

of targetable points for suicide risk assessment and intervention

in shelter settings. Broadly, escape theory posits that self-blame

for difficult life events increases painful self-awareness and

motivations to escape such awareness. Motivations to escape

aversive self-awareness generate a state of restricted cognitive

flexibility termed cognitive deconstruction, which ultimately

facilitates suicide ideation and attempts to die by suicide (Bau-

meister, 1990). Coercive control plays a pivotal role in the devel-

opment and maintenance of suicide risk in shelter-seeking

women in the context of escape theory.

Women seeking shelter from a violent relationship face an

acute major life event that is very difficult or discrepant with

expectations (see Figure 1). Indeed, negative life events such

as interpersonal discord (Yen et al., 2005) and rejection (Bau-

meister, 1990; Twenge, Catanese, & Baumeister, 2003) are sig-

nificant predictors of acute episodes of suicidal desire, suicide

attempts, and deaths by suicide (Conner et al., 2012; Hill, Pet-

tit, Green, Morgan, & Schatte, 2012; Smith et al., 2012). As

such, the acute interpersonal discord and act of seeking safety

from a violent relationship create a selected vulnerability for

suicide risk for these women. Seeking shelter also comes with

practical and social difficulties that increase distress such as

finding employment, housing, and engaging in legal processes.

Women exposed to greater coercive control are more likely to

experience these difficulties due to coercive tactics such as eco-

nomic control and stalking behaviors (Dutton & Goodman,

2005). Critical to the development of suicide ideation, women

exposed to greater coercive control are likely to blame them-

selves for the abuse and conflict, the need to seek shelter, and

related difficulties due to the psychological warfare of blame

and guilt perpetrated against them (Kirkwood, 1993; Peterson

& Seligman, 1983; Reviere et al., 2007). Targets of coercive

control are also more likely to make such internal attributions

due to unsuccessful past help-seeking attempts and feeling

Wolford-Clevenger and Smith 171

incapable or at fault for failing to cease the violence (Leone

et al., 2007). According to escape theory, this self-blame brings

about painful self-awareness, psychache, and motivations to elim-

inate or escape such pain (Baumeister, 1990). Of course, not all

shelter-seeking women are suicidal. Women seeking shelter from

non-controlling violence may attribute any related distress to exter-

nal sources (e.g., the perpetrator) and experience less painful self-

awareness. Such external attributions would be predicted to pro-

mote increased self-efficacy and greater relief about reaching

safety from the abuse (Peterson & Seligman, 1983). This interpre-

tation is in line with reports of greater hopefulness and less distress

during shelter seeking, despite the aforementioned stressors that

accompany shelter seeking (Clements, Sabourin, & Spiby, 2004;

Clements & Sawhney, 2000).

Thus, coercive control is the key variable underlying the pro-

cess by which shelter-seeking women become vulnerable for

painful self-awareness and resultant escape motivations. Women

exposed to greater coercive control attempt to escape such

awareness by cognitive deconstruction (Baumeister, 1990). Cog-

nitive deconstruction is a temporary state in which higher level

thinking and associated emotions are eliminated by a constricted

focus to immediate goals, physical acts, and sensory input (Bau-

meister, 1990). Such a state is akin to emotional numbing and

dissociative responses to victimization common of complex

trauma victims and individuals experiencing BPD and PTSD

symptomology (Frieze, Hymer, & Greenberg, 1987). As such,

individuals with a histories of complex trauma, BPD, and/or

PTSD may be at greater risk for suicide ideation and attempts

(Foote, Smolin, Neft, & Lipschitz, 2008; Guerra, Calhoun,

Mid-Atlantic Mental Illness Research, & Education and Clinical

Center Workgroup, 2011; Wedig et al., 2012) due in part

because they are especially predisposed to this deconstructed

state during heightened painful awareness and distress.

The narrowed focus to the present inherent to cognitive

deconstruction breeds disinhibition, irrational thought, and

problem-solving difficulties (Dixon, Heppner, & Rudd,

1994; Howat & Davidson, 2002), including deficits that

characterize suicide attempters such as Black and White,

rigid thinking (Neuringer, 1961, 1964), and impulsivity

(Patsiokas, Clum, & Luscomb, 1979). Such a cognitive–

emotional state is effective, at least initially, in coping with

the aversive self-awareness generated by internal attribu-

tions. This state, however, is only temporarily effective and

cannot be sustained, causing women to alternate between

states of painful self-awareness and the emotionless state

of cognitive deconstruction. As women begin to recognize

the temporary nature of cognitive deconstruction, hopeless-

ness about permanent escape increases. Problem-solving

deficits, irrational thought, and disinhibition make more

severe and risky thoughts and behaviors—such as suicide

ideation—more acceptable to reduce aversive self-

awareness. Women who exhibit complex trauma histories,

BPD, and PTSD symptoms may resort to NSSI as a means

for emotional relief that likely worked during previous

stressors (Brown, Comtois, & Linehan, 2002; van der Kolk

et al., 2005), which—while unintended—can be lethal

(Klonsky, 2007). As wishes for death and NSSI decrease

in effectiveness in relieving the psychache, women must

progress and attempt suicide to achieve similar escape (Bau-

meister, 1990; Joiner, 2002). The lethality of the attempt is

partially contingent on women’s ability to engage in lethal

self-injury, which is typically expressed through availability

and familiarity with lethal means (Smith & Cukrowicz,

2010). Thus, the degree to which escape is not achieved

interacts with the ability to lethally self-injure, resulting in

death by suicide (Baumeister, 1990).

Figure 1. Suicide ideation and attempts in shelter-seeking women within the framework of escape theory.

172 TRAUMA, VIOLENCE, & ABUSE 16(2)

Clinical Implications

Given the high rates of suicide ideation and attempts in shelter-

seeking women (Golding, 1999), a standard practice for identify-

ing and managing suicide risk in shelter settings is sorely needed.

Most shelters do not have adequate financial and staff resources to

provide extensive psychological treatments; making traditional

therapies for suicide and related behaviors, such as dialectical

behavior therapy, unsuitable. Therefore, we restrict our discus-

sion to recommendations for assessing and targeting immediate

suicide risk factors that are manageable within shelter settings

without prolonged therapy. We provide basic information with

references to detailed procedures from evidence-based recom-

mendations for outpatient practice (Bryan & Rudd, 2006; Joiner

et al., 1999). For individuals who have received formal training,

we emphasize areas of risk novel to the escape model presented.

This model will be especially useful for guiding identification of

risk and specific points for intervention in these settings.

Assessment

According to escape theory, events preceding and associated with

shelter-seeking are triggers for the process leading to suicide idea-

tion. Therefore, we recommend that suicide risk assessment

should be conducted at each intake. When assessing suicide risk,

practitioners should assess both chronic and acute suicide risk.

Chronic risk is described as a ‘‘baseline’’ level of risk for suicide

and is generally informed by an individual’s suicide attempt his-

tory, with two or more attempts indicating at least moderate

chronic risk (see Bryan & Rudd, 2006; Joiner et al., 1999, for a

detailed review). Individuals with elevated chronic risk have a

lower threshold for experiencing an acute crisis—even in the

absence of an external event—and tend to have more enduring

crises compared to nonattempters and single attempters (Joiner

& Rudd, 2000). Interpreted through the lens of escape theory,

multiple suicide attempters are prone to experiencing enduring

aversive self-awareness and also have frequently experienced the

futility of cognitive deconstruction in relieving psychache. There-

fore, shelter-seeking women with multiple suicide attempts are

vulnerable for experiencing their situation as an enduring crisis

that is not effectively managed by cognitive deconstruction,

which would result in suicide ideation. Practitioners should con-

tinually monitor and assess women with histories of multiple sui-

cide attempts, given that they will more readily enter distress

states and shift from cognitive deconstruction to suicide ideation.

Practitioners could identify chronic risk by examining items

on homicide risk assessments typically given at intake (e.g., dan-

ger assessment) that inquire about women’s histories of threaten-

ing or attempting suicide. Positive endorsements on these items

should direct further assessment of chronic risk by evaluating the

women’s suicide attempt histories. We recommend using a com-

prehensive interview that assesses the presence of the intent to

die in self-injuring events (e.g., The Columbia-Suicide Severity

Rating Scale; Posner et al., 2011). Given the incidence of BPD,

PTSD, and complex trauma in shelter settings, symptoms of

affect dysregulation, impulse control, and dissociation should

be noted as indicators of chronic risk given these symptoms pre-

dispose individuals for entering cognitive deconstruction and

progressing to attempt suicide in the face of internal or external

stressors (Brown et al., 2002; Joiner & Rudd, 2000).

Although chronic suicide risk is relatively static, acute risk

varies according to the precipitating stressor (e.g., interpersonal

loss), present symptomology (e.g., hopelessness), impulsivity,

and lack of protective factors (e.g., social support; Bryan &

Rudd, 2006). Standard risk assessments indicate collecting

information about the frequency, intensity, and duration of sui-

cide ideation, the presence of intent (i.e., implicit and explicit),

plans and methods considered, and preparation for suicide

(e.g., collecting pills). Additionally, methods and plans consid-

ered should be assessed until the individual denies other meth-

ods, as many suicidal individuals do not initially disclose the

most lethal method considered (Bryan & Rudd, 2006).

Given escape theory’s orientation to specific contextual events

and subsequent psychological processes, providers should use

escape theory as a guide for identifying acute risk by observing

women’s responses to the stressor of entering shelter. Responses

that would serve as critical indicators of acute risk include psy-

chache, as indicated by depressed affect, self-blame, hopeless-

ness, and evidence of the deconstructed state such as blunted or

flat affect, problem-solving deficits, disinhibition, and dissocia-

tion (Baumeister, 1990). According to escape theory, PTSD

symptoms of emotional numbing or experiential avoidance are

concerning indicators that suicide risk has increased as the

individual is attempting to manage a state of painful self-

awareness. However, as discussed, cognitive deconstruction only

provides temporary relief. Upon unsuccessful resolution of the

state of painful self-awareness, agitation and perturbation, which

are indicators of acute suicide risk, are likely to result (Busch,

Fawcett, & Jacobs, 2003; Shneidman, 1993). Careful attention

should be paid to individuals with histories of additional interper-

sonal traumas (e.g., childhood sexual abuse and adult sexual

assault), as complex symptomology predisposes them to dissocia-

tive responses to distress (van der Kolk et al., 2005).

After a thorough assessment of factors involved in chronic

and acute risk, practitioners should be well equipped to desig-

nate suicide risk and initiate safety planning and risk manage-

ment. According to escape theory and recommendations for

designating suicide risk in outpatient settings, women seeking

shelter are presenting with a noteworthy risk factor: the inter-

personal loss and violence preceding shelter. Thus, women

with chronic risk (i.e., multiple suicide attempts) are at moder-

ate risk, given their vulnerability to acute crises (Joiner et al.,

1999). Women with chronic risk reporting passive suicide idea-

tion are at severe risk, while those reporting active ideation

(e.g., identified time and method) are at extreme risk.

Nonattempters or single attempters with low acute risk and

no additional risk factors can be deemed at low or mild risk,

because they do not exhibit chronic risk but are experiencing

interpersonal stressors that are documented to increase suicide

risk (Yen et al., 2005). Endorsement of passive suicide ideation

in addition to a risk factor consistent with the theory (e.g.,

hopelessness and self-blame), nonattempters or single

Wolford-Clevenger and Smith 173

attempters should be placed at moderate suicide risk. Evidence

of active suicide ideation (e.g., plans and preparation), how-

ever, should warrant at minimum moderate risk designation.

If nonattempters or single attempters endorse active ideation

paired with an additional risk factor, severe to extreme risk

should be designated (Joiner et al., 1999). In sum, practitioners

designating suicide risk should consider the chronic and acute

risk factors consistent with escape theory including the stres-

sors of seeking safety at a shelter.

Management

Following designation of acute suicide risk, practitioners’ most

immediate decision is whether to manage the women’s suicide

risk through outpatient or inpatient referral. For women identi-

fied to be at severe to extreme acute risk for suicide, referrals

for psychiatric inpatient treatment are addressed through emer-

gency medicine. It is important to adopt a collaborative

approach when discussing seeking emergency services. Doing

so will reduce the need to break confidentiality and will reduce

the possibility of women perceiving the situation as coercive

(Rudd, Madrusiak, & Jobes, 2006).

Unfortunately, women who are not at high acute risk often

endure long waits for outpatient treatment and most shelters are

not equipped to provide in-house treatment (Roberts & Lewis,

2000). Domestic violence shelters are also limited in that the

length of stay is quite short and does not lend itself to prolonged

treatments, such as cognitive therapy. Also important, there is lit-

tle support for the notion that suicide risk abates upon treatment of

the primary psychiatric condition (Linehan, 2008). This under-

lines the usefulness of this model in shelter settings for guiding

practitioners’ management of suicide risk beyond targeting spe-

cific psychiatric symptoms, information that may not be readily

available or amendable compared to contextual risk factors in

shelters (i.e., stress resulting from recent assault). However, cli-

ents presenting with BPD and complex PTSD symptoms should

be referred to clinics specializing in intensive treatments for BPD

and complex trauma such as dialectical behavior therapy and

phase-oriented therapy; though such clinics are often sparse (van

der Kolk, 2002). Phase-oriented therapy in particular may be use-

ful for reducing suicide risk, as it aims to teach the individual to

label emotional responses to distressing stimuli to reduce avoid-

ance and emotional numbing responses to internal and external

cues of distress (van der Kolk, 2002). In short, phase-oriented

therapy would directly treat the propensity for cognitive decon-

struction during an aversive state, thus reducing risk for suicide

ideation and eventual attempts.

While awaiting outpatient treatment, practitioners should

manage clients with mild to moderate risk by first collaborating

with the women by discussing a ‘‘commitment to treatment’’

agreement, developing a safety plan, and increasing contact with

social supports (Joiner et al., 1999; Rudd et al., 2006). According

to escape theory, practitioners should aim to prevent feelings of

unmet expectations by promoting hope during the intake process

and throughout the shelter. For example, during intake, staff

should emphasize successes of shelter services in aiding women

achieve independence and freedom from their abusers. Display-

ing encouraging information throughout the shelter about surviv-

ing abuse and regaining control through available resources will

increase women’s perceptions of control, hopefulness, relief, and

reduce vulnerability to self-blame (Nurius et al., 2003). For

women who experience self-blame for failed expectations,

encouraging self-forgiveness about any perceived failures may

prevent or reduce painful self-awareness and resultant cognitive

deconstruction. Additionally, shelters may provide brief mind-

fulness intervention groups for teaching distress toleration

through body scan, meditation, and practicing self-compassion.

While IPV victims have reported difficulties with mindfulness-

based techniques given the heightened focus on painful emo-

tions, with practice they report experiencing reduced distress

(Bermudez et al., 2013). Practitioners should note that individu-

als with PTSD, complex trauma, or BPD have greater difficulties

tolerating distress and will struggle most with reducing aversive

self-awareness using mindfulness-based techniques (Sass,

Berenbaum, & Abrams, 2013).

Shelters could reduce the likelihood of cognitive deconstruc-

tion by decreasing avoidance coping and increasing active coping

skills through group-formatted problem-solving therapy (Mal-

ouff, Thorsteinsson, & Schutte, 2007; Nezu, 2004). However,

women’s use of avoidance coping strategies largely depends on

contextual influences such as cumulative trauma, violence sever-

ity, relationship length, and prior unsuccessful active coping (e.g.,

calling police and talking to a friend) (Waldrop & Resnick, 2004).

Therefore, increasing active coping strategies will only be useful

when paired with increasing resources that will aid them in the

context of a violent, isolating relationship such as the develop-

ment of social support, career skills, and accessing social services

(Moos, 1995; Sullivan, Basta, Tan, & Davidson, 1992). Given

that women with complex trauma, PTSD, or BPD have a propen-

sity toward states of avoidance and dissociation, referrals to out-

patient treatment to resolve these symptoms must be made (Amir,

Kaplan, Efroni, & Kotler, 1999). Furthermore, given that the

alternation between the deconstructed state and painful self-

awareness breeds greater hopelessness and a greater propensity

for suicide ideation, special attention may be given to women who

have been in shelter for a longer duration, especially if the alter-

nating symptoms of both negative affect and emotional numbness

are observed. Inquiring about and restricting means when possi-

ble such as potentially lethal medication and previous partners’

firearms is necessary to prevent women’s access to lethal means

for suicide. Finally, continual monitoring and awareness of

increases in acute risk is critical to ensure women’s safety (Joiner

et al., 1999).

Limitations and Future Directions

The extant literature supporting the notion that coercive con-

trol increases risk for suicide in targets of IPV suffers many

limitations (see Tables 1 and 2 for a summary of critical find-

ings and implications). First, studies either dichotomize coer-

cive control or use measures that are not designed to measure

coercive control (i.e., the danger assessment). Studies should

174 TRAUMA, VIOLENCE, & ABUSE 16(2)

measure coercive control dimensionally using a validated

measure that is designed to assess coercive control (Dutton

& Goodman, 2005) instead of comparing groups of high and

low coercive control victimization, which reduces power,

effect size, individual differences, and increases risk for Type

I error (MacCallum, Zhang, Preacher, & Rucker, 2002). Sec-

ond, no study to date investigating the relationship between

coercive control and suicide risk assesses the intent to die in

measuring a suicide attempt—an element that is critical for

valid measurement of suicide attempts. Relatedly, many stud-

ies combine suicide ideation, threats, and attempts into a sin-

gle outcome variable, making it impossible to establish the

level of risk coercive control confers for distinct suicidal out-

comes. Finally, longitudinal examination of the development

of suicide risk in targets of IPV is needed to establish a tem-

poral relationship between control-based violence experi-

enced in relationships and increased suicide risk.

In addition to these methodological limitations, the existing

literature is incomplete due to a lack of theoretical guidance.

As such, this literature would benefit from studies developing

or testing theories of suicide in explaining suicide risk in

shelter-seeking women. For example, future studies should

examine the relationships among self-blame, negative affect,

and characteristics of the deconstructed state in shelter-seeking

women who experience varying levels of control-based vio-

lence. Additionally, the literature is severely lacking in

examining whether women who are prone to suicide-related

thoughts and behaviors in addition to coercive control are

women who exhibit BPD traits. Research must examine this pos-

sible relationship, yet should not exclude the potential usefulness

of a theory in identifying functionally relevant areas for interven-

tion in women with BPD symptoms. Most importantly, though,

is that research must aim to identify what factors drive shelter-

seeking women to make an actual attempt versus engage in sui-

cide ideation. This limited area of research would benefit from

theoretical guidance. Perhaps examining the extent to which

women’s current situations are discrepant to their relationship

expectancies could delineate how some targets come to think

about suicide while others do not. Furthermore, examining past

help-seeking behaviors and related hopelessness may elucidate

why some women attempt suicide while others think about it.

Future research should explore these areas and identify areas for

reducing suicide risk in targets of IPV.

Conclusions

We have discussed how escape theory can be used to explain

the role coercive control victimization plays in the develop-

ment of suicide risk in shelter-seeking women. This model

shows promising utility for use in shelter settings, where stan-

dard suicide risk assessment and management are lacking.

Additional research is required to test the usefulness of this

model for understanding, assessing, and managing suicide risk

in shelter-seeking women.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, author-

ship, and/or publication of this article.

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10.1037/0022-006x.73.1.99

Author Biographies

Caitlin Wolford-Clevenger is pursuing her MS in Psychology at the

University of South Alabama where she received her BA in psychol-

ogy. Her research interests focus on understanding the development of

suicide ideation, suicide attempts, and nonsuicidal self-injury in survi-

vors of interpersonal violence.

Phillip N. Smith received his PhD in clinical psychology from Texas

Tech University and completed a 2-year postdoctoral fellowship at the

Center for the Study and Prevention of Suicide in the Department of

Psychiatry at the University of Rochester Medical Center. His

research interests center on the understanding, assessment, and treat-

ment of suicidal patients.

178 TRAUMA, VIOLENCE, & ABUSE 16(2)