Daisy Arabella ONLY

WITHIN THE CONFINES OF CHARACTER: A Review of Suicidal Behavior and

Personality Style

Katie C. Lewis, PhD Albany Medical College

Kevin B. Meehan, PhD, Nicole M. Cain, PhD, and

Philip S. Wong, PhD Long Island University, Brooklyn

Suicide is estimated to be 1 of the top 5 leading causes of death for individuals between the ages of 5 and 44. Although the majority of empirical research on suicide has focused on specific risk factors, this has not led to improvement in the prediction of suicide in specific individuals. Contemporary theories such as the Interpersonal-Psychological or Escape theory of suicide have provided promising models of self-destructive behavior, improving on risk factor research by focusing on the connections between precipitating stressors and individual personality-based processes. However, these theories remain limited because of their assumption that all suicidal individuals experience similar vulnerabilities to the same sources of psychological trauma (e.g., interpersonal isolation or experiences of failure and shame). This review argues for an alternative per- sonality-based conceptualization of suicide that contextualizes risk factors within broader models of personality, including considerations of personality- based cognitive and affective processes such as primary motivating psycholog- ical needs, attentional biases, and capacities for impulse control. The integration of contemporary personality theory with new and developing methodological approaches to suicide research will aim toward a more sensitive and compre- hensive understanding of suicidal behavior in specific individuals, and greater accuracy in prediction of risk at the clinical assessment level.

Keywords: suicide, personality, interpersonal-psychological theory, escape theory, cognitive-affective processing

This article was published Online First March 23, 2015. Katie C. Lewis, PhD, Department of Psychiatry, Albany Medical College; Kevin B. Meehan,

PhD, Nicole M. Cain, PhD, and Philip S. Wong, PhD, Department of Psychology, Long Island University, Brooklyn.

Correspondence concerning this article should be addressed to Katie C. Lewis, PhD, Depart- ment of Psychiatry, Albany Medical College, 25 Hackett Blvd., MC 164, Albany NY 12208. E-mail: [email protected]

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Psychoanalytic Psychology © 2015 American Psychological Association 2016, Vol. 33, No. 1, 179 –202 0736-9735/16/$12.00 http://dx.doi.org/10.1037/a0038956

179

In modern Western society, suicide is considered to be a major public health issue (Goldsmith et al., 2002), and behavioral scientists have worked tirelessly to develop treatment programs with the explicit goal of preventing suicide (Berman, 2007; Linehan, 1986). Between the years of 2009 –2011, suicide was estimated to be one of the top five leading causes of death for individuals between the ages of 5 and 44 (and the 10th leading cause of death for all ages during the same period; Murphy, Xu, & Kochanek, 2012). A recent report from the Centers for Disease Control and Prevention (CDC) showed that suicide rates in adults aged 35– 64 had increased by nearly 30% between the years 1999 and 2010 (Sullivan, Annest, Luo, Simon, & Dahlberg, 2013). It is a tragic fact that much less is known about the underlying causes and potential prevention strategies for suicide than what is known in regards to many other leading causes of death, such as heart disease and many forms of cancer. One reason for this may be the qualitative difference between suicide, which is primarily (and many would argue entirely) a psychological event, and other leading causes of death because of accidents or medical conditions. Identifying the motivation for taking one’s own life is in many ways a more subtle and philosophically complex task than, as an example, identifying genetic loadings for a specific physical disease, which can lead to preventative (and in many cases life-saving) treatments.

The first official Task Force on suicide, assembled in 1965 through the Center for Studies on Suicide Prevention (CSSP), identified the development of a comprehensive model for suicidal behavior as a top priority for the then-nascent field of suicidology (Berman, 2007). Despite the large body of theoretical and empirical literature that has accumulated since this goal was initially proposed, researchers have made relatively little progress in understanding the underlying mechanisms and causes of suicidal behavior, especially when compared to the progress that has been made in the field of clinical psychology on the etiology, course, and treatment of other major clinical phenomena (e.g., depression, schizophrenia, or substance abuse).

The current review identifies connections between myriad facets of personality func- tioning and proneness to suicidal behavior and points to evidence for a personality-based model of suicidal behavior, specifically utilizing the two-polarities model of personality proposed by Blatt (2004). Articles and chapters were included from a broad range of clinical perspectives on both suicide and personality functioning and include work from both theoretical and empirical paradigms.1 However, this review is necessarily selective; articles were included based on their relevance to the topic of suicide and personality functioning and the quality of empirical work or theoretical model proposed.

1 Two main approaches were used during our review of the literature. First, we performed a series of PsycINFO and PEP-Web electronic database searches using key terms relating to suicide and self-harming behaviors, and normal and pathological personality functioning. Examples of search terms relating to suicide included “suicide,” “self-destructive behaviors,” and “self-harm.” These terms were used in combination with search terms relating to personality functioning, such as “dependency,” “self-criticism,” “impulsivity,” “psychopathology,” and “resilience.” Terms re- lating to specific theories of interest (such as “escape theory,” “interpersonal theory,” “resource- depletion,” “CAPS model,” etc.) and authors (Blatt, Joiner, Shneidman, Baumeister, etc.) were also included in our search of the literature. Secondly, the authors identified relevant review articles (e.g., Gvion & Apter, 2011; Linehan, 1986; Mischel, 2004; Pompili, 2010) and book chapters (e.g., Baechler, 2001; Blatt, 2004; Joiner, 2005; Shneidman, 1996) for review, and also used the references of these works to identify additional relevant resources.

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180 LEWIS, MEEHAN, CAIN, AND WONG

Prevalence

Although completed suicides account for �38,000 deaths per year in the United States (Murphy et al., 2012), it has been estimated that the number of suicide attempts (non- completed) ranges anywhere between 4 and 200 times higher (Goldsmith et al., 2002). Although some researchers have proposed that individuals who complete suicide represent a distinct group within the broader category of suicidal individuals (Handelman & Lester, 2007; Linehan, 1986), others have downplayed this distinction, instead focusing on identifying general markers for suicidality regardless of the “success” of the attempt (Brent, 2010; Webster & Jackson, 1997). Research studies that have found significant differences between suicide attempters and completers have detected relatively minute distinctions between the two groups, with little clinical utility in the identification of those who are “truly” at risk. For example, Handelman and Lester (2007) found that suicide completers used an average of four more “positive emotion” words in their suicide notes compared to those who had unsuccessfully attempted suicide (7 words total on average, vs. 3 words). The authors did not integrate this result into a broader conceptual theory, leaving the significance of this subtle but nonetheless surprising finding unclear. Other researchers have found no differences in other seemingly important variables, such as hopelessness or depression, between attempters and completers (Lester, Beck, & Mitchell, 1979). In general, the search for differences between those who complete suicide versus those who make unsuccessful attempts has, thus far, led to limited and inconsistent results, with many indications that there is little to be gained from distinguishing between the two groups on a psychological level.

Risk Factor Research

The majority of empirical research on suicide has focused on the identification of potential risk factors for suicide, which has implicated a wide and disparate range of sociodemo- graphic and psychological variables related to suicide, including impulsivity (Stanford et al., 2009), hostility (Joiner, 2005; Kaslow et al., 2006; Kaslow et al., 1998), hopeless- ness and troubles in interpersonal relationships (Hall, Platt, & Hall, 1999), disruptions in serotonergic functioning (Baldessarini & Tondo, 2007), epidemiological studies of spe- cific blood types (Lester, 2004), being an adult or young adult (Murphy et al., 2012), and having at least one psychiatric diagnosis (Ortigo, Westen, & Bradley, 2009).

By far, the factor receiving the widest empirical support for the prediction of suicide attempts is a prior history of suicide attempts (Goldsmith et al., 2002; Joiner et al., 2005; McLean, Maxwell, Platt, Harris, & Jepson, 2008; Miranda et al., 2008; Monnin et al., 2012). Studies across multiple diverse samples have demonstrated that once an initial suicide attempt is made, the risk for making a subsequent attempt is increased substan- tially (Hawton, Comabella, Haw, & Saunders, 2013; Large, Sharma, Cannon, Ryan, & Nielssen, 2011). This relationship has been shown to retain statistical significance even when a wide array of other well-established risk factors for suicide, such as hopelessness and depression, are controlled for (Joiner et al., 2005). However, as with many other risk factors for suicide, some studies have failed to replicate this finding (Hall et al., 1999), and there remains a concern that prior suicide attempt history is not particularly useful in preventing initial attempts.

Several sociodemographic factors have been found to be associated with increased risk for suicidal behavior, including sex (men are known to complete suicide at a higher rate

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181SUICIDAL BEHAVIOR AND PERSONALITY STYLE

than women, while women tend to make more frequent nonlethal attempts), lower education levels, and unemployment (Goldsmith et al., 2002; McLean et al., 2008). Medical conditions such as insomnia have been found to relate to increased risk in several studies (Hall et al., 1999; Hawton & van Heeringen, 2009), and medical illness in general has been associated with completed suicide independently of any documented mental health condition (Logan, Hall, & Karch, 2011).

Psychiatric disturbance has been identified as another important risk factor for suicidal behavior; it is estimated that up to 90% of individuals who attempt or complete suicide suffer from psychiatric conditions, although only 10% of individuals with mental health issues ever attempt suicide (Goldsmith et al., 2002; McLean et al., 2008). Epidemiological studies have shown that comorbidity of psychiatric disturbance significantly increases an individuals’ risk for attempting suicide (Nock & Kessler, 2006; Pawlak et al., 2013), and specific psychiatric disorders such as major depression, bipolar disorder, and borderline and antisocial personality disorder in and of themselves have been linked to increased risk for suicidal behavior (Berk, Jeglic, Brown, Henriques, & Beck, 2007; Hawton et al., 2013; Pawlak et al., 2013; Turnbull, Cox, Oleski, & Katz, 2013). Other psychological variables such as anger/hostility, perfectionism, and hopelessness have also received support as risk indicators for suicide (Hawton et al., 2013; Nock & Kessler, 2006; Stanford et al., 2009; see also Goldsmith et al., 2002 and McLean et al., 2008 for comprehensive reviews). Past experiences of trauma have received widespread empirical support as a risk factor for future suicidal behavior (Nock & Kessler, 2006), with one large-scale study finding that subjects who had experienced childhood rape or molestation were three to 11 times more likely to make a suicide attempt than those without this history (Molnar, Berkman, & Buka, 2001).

Replication of significant results has been inconsistent across risk factors, how- ever. Findings from the World Health Organization World Mental Health Surveys, for example, found that having a history of sexual or interpersonal violence was associ- ated with an increased risk for suicidal ideation, but not for actual attempts (Stein et al., 2010). Similarly, Joiner et al. (2005) analyzed the relationship between prior attempt history and future suicide attempts, controlling for a large number of estab- lished risk factors such as gender, socioeconomic and marital status, levels of depression and hopelessness, family history of suicide, and personality-based vari- ables such as borderline symptoms and problem-solving capacities. While the asso- ciation of prior attempt history to subsequent attempts remained significant after controlling for these covariates, the opposite was not the case (i.e., each covariate was reduced to nonsignificance after prior attempt history was controlled for; Joiner et al., 2005). A meta-analysis conducted by Large et al. (2011) failed to find any association between a number of risk factors and later suicide attempts in clinical samples of patients recently discharged from inpatient treatment, and in fact found that only 3% of patients meeting criteria for being at “high risk” for suicide later went on to complete suicide (in contrast to �60% of the patients identified as “low risk” who later committed suicide). These studies suggest that the relative utility of risk factors for the prediction of suicidal behavior is uncertain at best, with limited evidence to support the idea that a single variable or set of variables will be useful in the prediction of suicide for all or even most at-risk individuals.

The issue of the specific definition of what constitutes a suicide “attempt” has plagued researchers for decades, and may in fact be one factor affecting the incon- sistency in research results over time (Nock & Kessler, 2006). Confusion over the boundary between terms such as “suicide attempt,” “gesture,” “deliberate self-harm,”

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and “parasuicide” has led to inconsistency in how suicidal behavior is defined and measured across studies. Estimating the prevalence of suicidal behavior nationally and internationally has been fraught with complications and inaccuracies, because of factors such as inconsistency in reporting practices and difficulties in assessing suicidal intent postmortem (Claassen et al., 2010). More recently, researchers have questioned the accuracy of individuals’ self-report regarding their own attempt history. Findings from the National Comorbidity Survey (Nock & Kessler, 2006), for example, found the prevalence of suicide attempts to be 4.6% in a random sample of 5,877 individuals; within this group, however, nearly half of the individuals acknowl- edged that they had not explicitly intended to die during their attempt, but rather hoped to communicate their pain and distress to others (accounting for 1.9% of the whole sample, as opposed to 2.7% who acknowledged at least some intention to die during their attempt).

Most recently, approaches to the assessment of suicide risk have included the development of innovative methodologies for identifying implicit behavioral markers for suicidal behavior, effectively circumventing the problematic issues associated with reliance on self-report measures. Methodologies such as the Implicit Association Test (IAT) that assess the associative patterns between implicit personality-based cognitive and affective processes may be potentially useful in identifying the situation-behavior response patterns that are characteristic of individuals with different personality types (Mischel, 2004). Through the use of methods such as the IAT and modified Stroop tasks, researchers have recently found that suicidal individuals demonstrate a marked attentional bias toward suicide-related stimuli, and a stronger association between suicide and their own self-concept, compared to nonsuicidal individuals (Cha, Najmi, Park, Finn, & Nock, 2010; Nock et al., 2010). These methods have been shown to have greater predictive accuracy for later suicidal behaviors than that of trained clinicians, or of subjects’ own assessment of their future risk for suicide (Nock et al., 2010). These results provide early evidence that suicidality may, for some individuals, become an integrated part of personality structure, guiding cognitive processing, affect, and behavioral reactivity to environmental and interpersonal stimuli.

While gaining knowledge of risk factors for suicide within at-risk populations is important, the study of risk factors alone has not led to a synthesized model of suicidality, or a greater ability for clinicians to predict suicide in specific individuals (Fowler, 2012). Many risk factors are overly general (e.g., male sex or psychiatric disturbance), while others have been shown to bear an inconsistent relationship to suicide. Although the identification of risk factors associated with suicidality is an important endeavor, the incorporation of these factors into a clinically meaningful model has yet to be accom- plished.

Limitations of Suicide Theory and Risk Factor Research

A problematic assumption by suicide researchers and theorists alike is that suicidal individuals are a relatively homogenous group, in terms of specific risk factors and motivations for suicide (Farberow & Shneidman, 1955; Pompili, 2010). The study of risk factors for suicide has historically been conducted under the assumption that identified factors can be generalized to most, if not all, suicidal people. The inconsistency of results across studies adds weight to the argument that the impact of risk factors on suicidality

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likely varies depending on other factors, such as personality structure or other psycho- logical variables.

In response to dilemmas such as these, numerous researchers have suggested that conceptualizing suicidal individuals as a homogenous group is essentially counterproduc- tive for research purposes, as many important risk factors that could help predict suicide in certain subgroups may be lost by grouping all attempters together (Giegling et al., 2009; Pompili, 2011). Because of this, suicide researchers have increasingly utilized more focused approaches in their efforts to understand the underlying mechanisms of suicidal behavior, such as identifying the characteristics of participants who choose specific methods for their attempts (Racette & Sauvageau, 2007), life events preceding completed suicide attempts (Heikkinen, Henriksson, Isometsa, & Marttunen, 1997), and suicidal behaviors in patients with specific psychiatric diagnoses (Blasco-Fontecilla et al., 2009; McGirr, Paris, Lesage, Renaud, & Turecki, 2009). Additionally, the results of several empirical studies aimed at identifying the role of specific personality-based variables in the emergence of suicidality have highlighted the potential importance of general person- ality style in suicidal behavior (Chatard & Selimbegovic, 2011; Giegling et al., 2009; Joiner et al., 2009).

The Role of Personality in Suicide

One way suicide has been conceptualized is, in essence, as a solution to a problem; regardless of whether the problem is the frustration of interpersonal (Joiner, 2005) or achievement-related needs (Baumeister, 1990), intolerable psychic anguish (Shneidman, 1996), or loss of identity coherence (Maltsberger, 2004). Baechler (2001) has even gone so far as to state that “. . . it is not the act, which is only the solution, but the problem that is pathological” (p. 70, italics added). Almost all theorists in the field of suicidology agree that suicide serves the specific function of bringing to an end a situation that has become unbearable for the individual. Various theorists propose that a gradual constricting of the cognitive field because of overwhelming negative affect leaves the victim feeling con- vinced that ending their lives is the only way to resolve the problem (Baumeister, 1990; Shneidman, 1996). From this perspective, what is of greatest interest in the study of the development of suicidality is “the problem,” or the source of the person’s anguish or distress, which carries such a high degree of subjective importance that the individual is willing to engage in total self-destruction to “resolve” the issue.

The problem in this sense likely emerges from a devastating disruption of circum- stances within the suicidal individual’s life that are of high personal salience based on the individual’s lived experiences, rather than reflecting upsetting situations that are more general or impersonal in nature (Pompili, 2010). For example, Shneidman (1996) dis- cusses the case of “Ariel,” a young suicidal woman, who has struggled throughout her life with loneliness and perpetually thwarted efforts to elicit love and care. Ariel describes the “final straw” preceding her first suicide attempt as an incident in which her former boyfriend failed to appreciate the deep personal meaning and importance of a holiday gift she had given him, preferring instead a more expensive gift from his current girlfriend. Although she identifies this specific event as triggering her suicide attempt, she acknowl- edges that a series of similar interpersonal experiences led up to this crucial moment.

Personality theorists have argued that certain aspects of experience become most subjectively important to an individual when they are intimately connected to personality- based processes such as values, goals, past memories and experiences, affects, and sense

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of self and identity (Mischel, 2004). An individual’s personality structure is a powerful filter through which external events and circumstances are attentionally selected, encoded, and interpreted, rendering similar situations as differentially meaningful to different people. Therefore, it is necessary to understand the personal psychological meaning of the triggering circumstances for suicidal behavior within individuals by examining the im- portance of the event in the context of broader personality structure.

Personality-Centered Models of Suicidal Behavior

The idea that suicide arises in response to problems of high personal relevance resonates with models of suicidal crises that emphasize the role of thwarted psychological needs in the development of suicidality. Shneidman (1996) argued that the desire for death arises in circumstances where important subjective psychological needs are frustrated, resulting in a state of intolerable negative affectivity called “psychache.” Shneidman’s approach to the study of suicide was heavily influenced by the work of Murray (2008), whose theory of personality is rooted in the idea that an individual’s personality structure is partly organized around specific psychological needs, such as the need for achievement, order, autonomy, affiliation, or nurturance. Rather than striving to refine these needs into a concise and specific theory of suicide for purposes of generalization, Shneidman (1996) argued for the importance of each individual’s unique personality organization in the development of suicidal behavior, emphasizing that personality patterns and experiences across the life span play a vital role in a person’s eventual suicide. Shneidman’s theoretical perspective is closely connected to the conceptualization of suicide as a response to a specific problem; a problem that is particular to the individual’s unique overall personality pattern, and which serves as a primary organizing force.

Shneidman’s writings have influenced generations of suicide researchers; however, direct empirical evaluations of his theory have been practically nonexistent, with modern suicidologists observing that his theory represents a “goldmine” of hypotheses amenable to empirical study (Berman, 2007, p. 221). Although a wide range of contemporary theoretical models exist, many remain primarily concerned with the investigation of specific constructs or risk factors (e.g., Beck, Kovacs, & Weissman, 1979; Gvion & Apter, 2011), rather than considering the interaction of personality processes as a whole with potential sources of emotional and environmental risk. Nonetheless, a small number of contemporary models rooted in Shneidman’s personality-based approach exist that have yielded empirical support for the connection between personality organization and risk for suicidal behavior.

The Interpersonal-Psychological Theory of Suicide

Joiner’s (2005) interpersonal-psychological theory of suicide is one example of a com- prehensive, personality-based model of suicidal behavior. The interpersonal- psychological theory focuses instead on two particular interpersonal concerns, character- ized by different constellations of psychological needs related to interpersonal relationships: thwarted belongingness, or the experience of being alienated from one’s social group, and perceived burdensomeness, or the sense that one’s existence is a burden to others or society.

These concepts have received much empirical support as correlates of suicidality in certain individuals. For example, in a large ethnically diverse sample of young

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185SUICIDAL BEHAVIOR AND PERSONALITY STYLE

adults, Joiner et al. (2009) found that participants who reported a lower sense of mattering to others (interpreted as greater perceived burdensomeness) and a low sense of family support (interpreted as thwarted belongingness) reported greater levels of suicidal ideation compared with those with a greater sense of mattering and greater family support, after controlling for levels of depression. Although these results demonstrate the importance of interpersonal variables on suicidal ideation, the con- ceptual validity of the specific measures used to operationalize belongingness and burdensomeness remains open to question. The study was also limited in its exclusive focus on suicidal ideation, rather than history of suicide attempts. This latter limitation was corrected in a follow-up study using a clinical adult sample that reported either a recent suicide attempt or recent severe suicidal ideation. In this study, the authors (Joiner et al., 2009) found that thwarted belongingness and perceived burdensomeness predicted current suicide attempt status (attempt vs. ideation) in those with a history of multiple past attempts, but not in participants who reported only a single past attempt. These results indicate that while interpersonal concerns may be related to suicidal behavior, this relationship exists primarily in a subset of patients who are vulnerable to making multiple nonlethal suicide attempts.

The Escape Theory of Suicide

Other personality-based theories of suicide have examined a set of different psycho- logical needs in the emergence of suicidal behavior. Shneidman (1996, p. 157) identified “escape” as one of the primary goals of suicide; this idea has been elaborated upon in Baumeister’s “escape theory” of suicide (1990). The escape theory of suicide asserts that suicide occurs when a person experiences failure in regards to a personally meaningful goal, and consequently interprets this failure as evidence that they are in some way defective as a human being, leading to a desire to escape this painful self-awareness through suicide. Escape theory emphasizes the characteristic co-occurrence of high expectations of the self and an internal attribution of failure as a primary mechanism through which the motivation for suicide arises, implying that the frustration of psychological needs related to achievement, dominance, and shame- avoidance may relate to later suicidal behavior.

A recent empirical evaluation of the escape theory of suicide provided support for the idea that failure to achieve subjectively important goals, and an internal attribution of this failure, increases the accessibility of suicide-related thoughts. Using a non- clinical university sample, Chatard and Selimbegovic (2011) found that subjects who were primed with “failure” scenarios demonstrated increased accessibility of suicide- related thoughts compared to subjects who were primed with a neutral or “death” prompt. However, this effect was present only in subjects who reported a high baseline level of self-consciousness and a tendency to rely on “escapist” coping strategies (e.g., daydreaming or drinking alcohol). The authors interpreted these findings as evidence that “suicide-related thoughts arise as a result of a motivation to escape from negative self-awareness, when individuals realize that they fail to attain an important standard” (Chatard & Selimbegovic, 2011, p. 600). The authors’ use of priming strategies to identify implicit associations between specific environmental triggers and accessibility of suicide-related thoughts builds upon the work of Nock et al. (2010) to show that specific psychologically meaningful features of an individual’s experience can leave them at increased risk for suicidal crises, depending on the

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relative salience of the occurring situation or event to one’s broader personality structure.

These findings, in addition to the work of Joiner et al. (2009), support Shneidman’s (1996) proposal that enduring personality characteristics are important in the development of suicidality. While the work of Chatard and Selimbegovic (2011) suggests that the escape theory of suicide may be particularly applicable to individuals who are disposi- tionally vulnerable to experiences of shame and self-criticism in the face of failure, the interpersonal-psychological theory of suicide (Joiner, 2005) may be relevant to a separate group of suicidal individuals who are sensitive to interpersonal disruptions, loss, or abandonment. Although each theory provides persuasive arguments for how an individual with specific personality-based vulnerabilities may find him- or herself within a suicidal crisis, the types of individuals they describe are clearly different, both in the nature of their vulnerabilities and their motivations for ending their own lives. Each theory describes a separate group of individuals, likely with distinct personality organizations that are essential to consider in efforts to gain greater understanding of the path that leads the person toward suicide.

Limitations of Interpersonal and Escape Theory

While the results of multiple studies provide empirical support for both the escape and interpersonal-psychological theories of suicide, they have important limitations, including a focus on only suicidal ideation rather than actual attempts (Chatard & Selimbegovic, 2011; Joiner et al., 2009), the inclusion of only acute sources of distress rather than broader characterological sensitivities (Joiner et al., 2009), and a difficulty in operation- alizing complex psychological constructs, such as thwarted interpersonal needs, with clarity and consistency across diverse samples (Joiner et al., 2009; Van Orden, Witte, Gordon, Bender, & Joiner, 2008). In addition, both the interpersonal-psychological theory (Joiner, 2005) and escape theory of suicide (Baumeister, 1990) remain explicitly focused on the assumption that suicidal individuals are a relatively homogenous group. Both theories assume that all suicidal individuals are impacted by similar negative events or stimuli (e.g., interpersonal distress or abandonment, vs. self-blame or negative self- awareness), and that individuals commit suicide to achieve a common goal (e.g., either to end unbearable feelings of loneliness, or to escape from intolerable negative self- awareness). However, the empirical evidence suggests that there are subgroups of suicidal individuals who arrive at the decision to end their own life based on differing sources of motivation; first, an interpersonally oriented group, sensitive to concerns such as aban- donment or alienation from others, and a second group that is more reactive to internal concerns, prone to self-criticism or self-hatred in the face of perceived failure. These theories show that individuals within these two personality groups demonstrate emotional sensitivity and attentional bias toward specific yet differential features of their experiences and environments as a definitional part of their basic personality structure; this bias in turn leaves them vulnerable to stress and suicidal crises in reaction to different kinds of situations and circumstances (e.g., interpersonal rejection vs. humiliation or shame).

Interpersonal Relatedness and Self-Definition

One theory of personality that remains consistent with the potential subgroups described by the interpersonal and escape theories of suicide is Sidney Blatt’s distinction between

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individuals who are primarily concerned with issues of interpersonal relatedness (“ana- clitic”) and those primarily concerned with issues of autonomy and self-definition (“in- trojective;” see Blatt, 2004 for review). Blatt’s theory (Blatt, 2004; Blatt, Shahar, & Zuroff, 2001), falling under the general umbrella of two-polarities models of personality (Luyten & Blatt, 2013), is based on the assumption that personality development occurs in the context of an ongoing developmental dialectic between the need to form meaningful attachments to others (relatedness) and the need to develop a separate sense of identity and independence (autonomy). Ideally, the process of balancing these needs throughout childhood and adulthood leads to a sense of positive connectedness with others, as well as a sense of personal effectiveness and individuation. This balance leads to the capacity to form mutually satisfying interpersonal relationships and to achieve a differentiated and solid sense of self (Campos, Besser, & Blatt, 2011). Under less ideal circumstances in which these two developmental processes are disrupted, individuals may become overly preoccupied with one set of concerns, leading to an impaired ability to develop a balanced and integrated sense of self and other.

Interpersonally oriented individuals are characterized by preoccupations with issues of closeness, affiliation, and interpersonal connectedness; these individuals are especially sensitive to situations of separation and loss, and tend to respond to such situations with feelings of helplessness and emptiness. They maintain a strong desire for nurturance and closeness with others and often exhibit dependency behaviors. In terms of Murray’s (2008) psychological needs, interpersonally oriented individuals can be conceptualized as being organized around the need for affiliation, nurturance, and succorance. The charac- teristic psychological needs and concerns of the interpersonally oriented personality type resonate with the suicidal individuals characterized by the interpersonal-psychological theory of suicide (Joiner, 2005), which emphasizes the importance of relational disrup- tions in the emergence of suicidal behavior.

In contrast, the escape theory of suicide (Baumeister, 1990), which emphasizes the importance of experiences of shame and personal failure, is consistent with the primacy of self-criticism in Blatt’s “introjective” personality type. According to Blatt (2004), introjective individuals are primarily concerned with self-definition and are characterized by preoccupation with issues of identity, autonomy, and achievement. They can be highly self-critical, and tend to experience feelings of guilt and self-blame in instances of perceived failure. They are often isolated from others and do not necessarily seek fulfillment through the establishment of close interpersonal relationships (Blatt, 2004). Forms of psychopathology that relate to a pathological focus on self-definition may include paranoid processes, narcissism, obsessive tendencies, or manifestations of depres- sion characterized by feelings of guilt or shame (Campos et al., 2011). This personality organization can be conceptualized as centering on Murray’s (2008) psychological needs of achievement, autonomy, order, and shame-avoidance.

Suicidal Behavior in Individuals Organized Around Interpersonal Relatedness Versus Self-Definition

These two general dimensions of personality map well onto the escape and interper- sonal-psychological theories of suicide (Baumeister, 1990; Joiner, 2005), and one research study using Blatt’s model has shown that introjective and anaclitic individ- uals show distinct motivations for suicidal behavior that are indeed characteristic of their broader personality functioning. Fazaa and Page (2003) found that self-critical, introjective patients were more likely to have made a suicide attempt in response to

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a personal or professional failure, that their intention in attempting suicide was to escape, and that their suicide attempts on the whole were rated as more lethal than their anaclitic counterparts. Interpersonally oriented, anaclitic suicide attempters were more likely to have made their attempt in response to an interpersonal stressor, and indicated that their intention in attempting suicide was to communicate their feelings of distress to others. Although the findings of Fazaa and Page (2003) are important in connecting suicidal behaviors with personality configuration, the study was limited in its use of a nonclinical sample and its exclusive focus on suicidal participants, with no analysis of a control group of nonattempters for comparison. Understanding the specific mechanisms that contribute to vulnerability for suicide in these two person- ality groups may provide information that can be used to identify and develop treatment interventions for patients at risk for suicide.

Psychoanalytic researchers and theorists have described specific subtypes of suicidal individuals who carry similar characteristics to those with interpersonally oriented personality styles versus those organized more around self-definition. For example, Maltsberger and Buie (1980) have articulate two clusters of motivational fantasies underlying suicidal behavior, which broadly correspond to issues of inter- personal relatedness and identity/self-definition. The first cluster, framing suicide as a means of punishment or revenge, focuses on the pain associated with deprivation of attachment through suicide; this loss of interpersonal connectedness through self- inflicted death functions both as a means of exacting revenge on others, and also a method of punishing oneself for perceived “badness” or unworthiness of love. This theory posits that for some individuals, the act of suicide functions as a powerful tool for channeling aggression toward both the self and others, robbing each party of “their dearest possession” (Menninger, 1933, as cited in Maltsberger & Buie, 1980)— interpersonal closeness and intimacy. The second cluster, which focuses on purpose of suicide for riddance of an enemy, highlights instead the role of suicide in eradicating feelings of self-hate arising. Such feelings, arising from internal conflict between part-objects that are experienced as weak and helpless and those that are persecutory and contemptuous, leave the suicidal individual in such anguish that a total obliter- ation of consciousness through suicide is seen as the only solution. Rather than focusing on relational or attachment-related conflict and desire to engage the inter- personal world through self-destructive acts, this second cluster of motivational fantasies focuses instead on the desire for escape and the elimination of identity- related feelings of pain and torment.

Ronningstam (2007) has similarly described two subgroups of suicidal individuals: one who characteristically seeks out opportunities to demonstrate their skills and accomplishments to others, and react intensely and negatively to criticism and to instances of perceived loss or failure, and another group who may attempt suicide out of a desire to exert “control, retaliation, and revenge” on others; similar to a subset of patients with BPD whom Kernberg (2004) described as attempting suicide as a way “to exercise sadistic control over others” (p. 57). Ronningstam’s (2007) assertion that the former group is motivated to attempt suicide in response to criticism, shame, and failure, while the latter is motivated by interpersonal concerns, is consistent with the empirical findings of Fazaa and Page (2003) for motivations for suicide in introjective and anaclitic individuals.

Despite the apparent connection between personality organization and suicidal behav- ior, it remains unclear why certain individuals with similar personality structures attempt suicide, whereas others do not. Although extensive theoretical and empirical evidence

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demonstrating the role of personality in the development of the motivation for suicide has been shown, the specific mechanisms that turn suicidal thoughts into action remain unknown.

Staying Cool in Hot Situations: Capacity for Self-Regulation and Suicide

Personality theorists have long been interested in exploring differences in adaptive functioning within individuals who have similar personality styles. Within the CAPS model of personality (Mischel, 2004; Mischel & Shoda, 1995), the capacity for effective self-regulation in the context of “hot,” emotionally activating situations has been identified as an important element of adaptive functioning. Empirical evidence has shown for example that individuals who are able to utilize cognitive “cooling” strategies (e.g., distraction techniques or focusing on long-term goals) in affectively charged situations fair better in most domains of functioning than those who do not use such techniques; even when these individuals share similar overall personality styles (Ayduk et al., 2008; see Mischel & Ayduk, 2002 for a review).

Similar cooling capacities such as effortful control have shown particular strength as predictors of adaptive functioning and decreased levels of psychopathology in individuals with high levels of rejection sensitivity (Meehan, De Panfilis, Cain, & Clarkin, 2014). Poor effortful control has also been associated with greater levels of distress and greater prevalence of intrusive interpersonal problems in a nonclinical young adult sample (Cain, De Panfilis, Meehan, & Clarkin, 2013). Further, poor effortful control was related to increased self-reported impulsivity and aggressive behavior, indicating that impairments in self-regulation are related to maladaptive behavioral outcomes (Meehan, De Panfilis, Cain, & Clarkin, 2013). This suggests that a poor ability to tolerate negative affect through the use of effective cognitive control strategies may contribute to competition among cognitive resources in moments of heightened distress, leading to proneness to external- izing behaviors.

Resource-Depletion Models of Self-Control and the Allure of Suicide

Several studies have shown that effective self-regulation depends on cognitive resources that may become depleted as conflictual environmental and psychological demands increase in frequency and intensity. The strength model of self-control (Baumeister, Vohs, & Tice, 2007), for example, is founded on a depleted-resource hypothesis, emphasizing that an individual’s ability to remain in control of their behavior is vulnerable to deterioration following repeated exertion. According to this model, when an individual encounters ongoing competing demands or conflicts in their daily environment, their ability to resist engaging in the more immediately rewarding and/or stress-reducing option will be challenged, and efforts to self-regulate in the service of longer-term goals or appropriate social behavior will become increasingly difficult.

Several studies have supported the validity of this model (Baumeister et al., 2007). A recent study that utilized event-sampling methods in a sample of community adults found that individuals experienced greater difficulties in resisting a desire that conflicted with a long-term goal when they had frequently and/or recently resisted the same desire or other temptations in prior situations that same day (Hofmann, Vohs, & Baumeister, 2012). Another study using the same sample found that the relative strength of a desire was related to how successful an individual was in resisting it (Hofmann, Baumeister, Forster, & Vohs, 2012). One study found that the act of decision-making in and of itself

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contributed to impairments in behavioral self-control during later experimental situations (Vohs et al., 2008). Taken together, these studies show that increases in conflictual environmental and psychological demands deplete resources needed to resist appealing activities or behaviors that offer reward or an immediate reduction in feelings of stress, even if such behaviors are detrimental to longer-term goals.

The theoretical connections between resource-depletion models of self-control and proneness to engagement in suicidal behavior have been noted (Vohs & Baumeister, 2000), although to our knowledge there has, thus far, been no empirical study evaluating this relationship directly. Vohs and Baumeister (2000) argued that, consistent with resource-depletion models and the escape theory of suicide, important cognitive resources may be exhausted as individuals in crises repeatedly try to manage negative affect and ongoing experiences of aversive self-awareness. Failure to achieve sufficient relief from these experiences contributes to further negative affect and aversive self-awareness, and to reduced faith in self-regulatory capacities, leading to an ongoing cycle of worsening depletion and increasing vulnerability to impulse inhibition. Although individuals may eventually bolster their cognitive resilience through positive experiences of self-efficacy (that Vohs and Baumeister (2000) argue should be the focus of psychotherapy with suicidal individuals), others who are unable to gain such positive experiences remain at heightened risk for eventually acting on suicidal impulses.

A review of qualitative studies featuring samples of suicide attempt survivors revealed common beliefs among subjects that suicide is perceived to be a solution to psychic pain during times of acute distress. Further, many subjects reported an intense struggle with the “desire to give in to suicide” before their attempts (Lakeman & Fitzgerald, 2008, p. 121, italics added), suggesting that individuals experience the pull toward suicide as a powerful force against which they must actively resist. From the perspective of resource-depletion theory, this pull constitutes yet another conflictual desire that individuals must fight against, further exhausting cognitive resources that have already been taxed by the situations causing their initial despair.

By and large, researchers acknowledge that human beings demonstrate an extraordi- nary capacity to engage in self-regulation during the common competing demands of everyday life. Despite this, proponents of the strength model of self-control suggest that although incidences of resource depletion tend to be relatively transient, “there are levels of depletion beyond which people may be unable to control themselves effectively, regardless of what is at stake” (Baumeister et al., 2007, p. 353, italics added). At a certain point, the exhaustion of managing psychic pain and conflict may leave a person without sufficient resources to resist the pull of suicide as a final solution. Although the act of suicide itself undoubtedly conflicts with all other long-term goals by the very nature of its absolute finality, evidence from the strength model of self-control suggests that individ- uals may be most likely to attempt suicide after an extended and dramatic depletion of their available cognitive resources, after persistent but ultimately unsuccessful efforts to attenuate painful intrapsychic experiences.

Interaction of Environment and Personality in Eliciting Suicidal Crises

The specific nature of situational stressors and their degree of personal salience in relation to an individual’s personality organization have been shown to impact the degree to which self-regulatory strategies result in adaptive emotional reactions and outcome. In a study of individuals with high rejection sensitivity, for example, subjects who demonstrated effective self-regulatory strategies in instances of perceived rejection reported better

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quality of interpersonal relationships in general than those who did not (Ayduk et al., 2000). Although all rejection-sensitive subjects reported increased distress in situations of interpersonal rejection, those who were able to utilize cognitive distancing techniques were able to better manage their reactions of stress than those who remained focused on their negative affective experiences in the moment. In contrast, individuals who were not rejection sensitive reported similar levels of positive interpersonal functioning regardless of their capacity to self-regulate in situations of perceived rejection. This finding indicates that self-regulatory strategies are most important in situations that are both stress-inducing and of high personal salience in connection with broader personality structure. Overall, these studies confirm that the capacity to balance competition among cognitive resources and remain reflective in situations that are personally upsetting is of vital importance in managing impulsive and potentially dangerous behavioral responses. Self-regulation through the maintenance of cognitive control may, therefore, be important to consider in connection to differences in proneness to suicidal behavior in individuals with similar overall personality styles.

Impulsivity and Suicide: The Need for a More Differentiated Model

Researchers have argued that self-regulation in the context of emotionally activating situations is strongly related to impulse control (Ayduk et al., 2000). Although much of the research aimed at identifying risk factors for suicide has led to inconsistent or contradictory results, the impact of impulsivity in suicidal and self-destructive behaviors has been demonstrated numerous times and is believed by most suicidologists to play an important role in suicidal behavior. Within psychoanalytic literature on suicidal behavior, Lindner (2006) has emphasized the powerful nature of the suicidal individual’s experience of “great helplessness and massive pressure to act,” highlighting the negative impact of early relational disruptions and experiences of abandonment in weakening the ability to engage in effective affect regulation and impulse control. Herzog (2004) similarly iden- tifies early negative experiences with parental figures as playing an essential role in interfering with the development of adaptive self-regulation skills, pointing to the neces- sity of both the “attuned mother” and “modulating father” in helping children learn to manage their emotions and behavior. In many personality-based theories of suicide, impulsivity has been described as an indirect contributor to the ability to act on suicidal impulses, rather than as a direct motivating or causal force. Baumeister (1990), describing the role of impulsivity in the escape theory of suicide, stated that a gradual reduction of impulse inhibition occurs in conjunction with a heightened sense of despair in reaction to intolerable negative self-awareness; this lack of impulse control increases the likelihood that an individual will act on their suicidal thoughts, although the thoughts and desire for suicide itself originate in personality-based factors beyond global levels of impulsivity.

Joiner’s (2005) interpersonal-psychological theory of suicide offers a different model of impulsivity and suicide, proposing that impulsivity is a stable personality feature within individuals who are characteristically emotionally reactive in response to disruptions in their environment, leading to a general lifelong pattern of engaging in impulsive behaviors across multiple varied situations. In terms of situation-behavior response patterns, the interpersonal-psychological theory of suicide would suggest that individuals who fre- quently display impulsive behavior as a part of their situation-response repertoire develop an “acquired capability” for suicide over time through their repeated engagement in impulsive, dangerous activities. Both the interpersonal-psychological and escape theory of

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suicide propose that impulsivity helps “pave the way” for the ability to act on suicidal impulses, while remaining unrelated to the actual situational motivation for suicide.

The CAPS model of personality (Mischel, 2004; Mischel & Shoda, 1995) argues that an individual’s demonstration of a particular personality trait is only meaningful if it is considered within the context of their characteristic situation-behavior response patterns, rather than being considered simply at overall aggregate levels across unrelated situations. Although impulsivity has been identified as an important risk factor for suicide, the inconsistency in results across studies may be partially explained by the problematic de-contextualization of impulsivity as a trait from its situation-specific expression in suicidal individuals. For example, although some studies have shown that trait levels of impulsivity (usually measured by self-report, or relevant clinician-rated symptoms) are related to suicidal behavior (Kaslow et al., 2004; Nock & Kessler, 2006; Webster & Jackson, 1997), others have failed to find a connection between trait levels of impulsivity and the degree of “impulsiveness” of suicide attempts. Witte et al. (2008), for example, found that individuals with higher self-reported impulsivity levels actually engaged in greater planning for their suicide attempt than those who were less impulsive. This result indicates that “impulsive behaviors” assessed within certain situations or contexts, such as engagement in reckless driving or frequent drug use, may not generalize or necessarily be relevant in other situations, including moments of suicidal crisis.

While the majority of research on suicide and impulsivity has examined impulsivity through the aggregation of trait levels in individuals across situations (e.g., self-report measures asking about behaviors in daily life; Stanford et al., 2009), other researchers have approached the issue from a more context-specific perspective; for example, inves- tigating whether impulsivity predicts suicidal behavior in individuals who are only impulsive in certain situations or circumstances. Several studies have demonstrated that a specific type of impulsivity, in which impulsive behaviors arise only in the context of overwhelming negative affect, is related to suicidal behavior and attempts (Bornavalova, Tull, Gratz, Levy, & Lejuez, 2011; Klonsky & May, 2010). This type of impulsivity, referred to as “negative urgency” (Whiteside & Lynam, 2001), refers to an impulsive reaction tendency that occurs only in situations that are particularly emotionally upsetting, in contrast to other conceptualizations of impulsivity than may describe a more general- ized tendency to act in an impulsive manner. Although this study did not take into account personality structure or the elements of specific situations that may trigger a person to become upset, the findings do support other research demonstrating the importance of loss of self-regulatory functions (indicated by loss of impulse control) in “hot,” emotionally activating situations (Cain et al., 2013; Meehan et al., 2013; Mischel & Ayduk, 2002), and confirm that such a response pattern can facilitate engagement in suicidal behavior. Additionally, evidence exists to suggest that loss of affective and behavioral control may relate differentially to suicide based on gender; whereas men, for example, are known to more commonly engage in sensation-seeking (Cross, Copping, & Campbell, 2011) and externalizing behaviors (Brody & Hall, 2008), women are more likely to engage in rumination or other internalizing coping strategies (Brody & Hall, 2008). More research is needed to clarify which individuals under what circumstances may be left with reduced capacity to resist acting on self-destructive impulses.

Aggressive-Impulsivity (or Impulsive Aggression)

A separate and complicating factor in the connection between impulsivity and suicide is the role of aggression in self-destructive behavior. Early theories of suicide often high-

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lighted the importance of aggressive impulses as a primary force driving suicidal behavior (Freud, 1957; Menninger, 1956). Psychodynamic theorists such as Sigmund Freud (1957) and Karl Menninger (1956) noted the importance of aggression turned inward against the self (or “murder in the 180th degree;” Shneidman, 1996) in the development of suicidal motivation and behavior. Freud (1957, p. 251) stated that “. . . no neurotic harbors thoughts of suicide which he has not turned back upon himself from murderous impulses against others,” emphasizing a belief that the act of suicide originates as a response to a profound and intolerable aggression initially directed externally. Menninger (1956) sim- ilarly stressed the important role of aggression in the desire for self-inflicted death, identifying the three basic psychological components of suicide as the wish to kill, the wish to be killed, and the wish to die. More contemporary theories highlight conflicts surrounding the desire to both inflict and receive punishment. Goldblatt (2010) for example, in discussing the suicidal behavior of masochistically organized individuals, points to the chronically suicidal individual’s ambivalence over the final act of taking their own life: “to kill the sufferer would deprive such a patient of his most cherished victim” (p. 95). In models of self-destruction focusing on aggression and power, suicide is recognized as a means of experiencing both control and empowerment over unbearable situations while also reenforcing feelings of rage and helplessness; the suicidal individual “feels strengthened by the fantasy of active control while at the same time experiencing the powerlessness of the torture victim” (Goldblatt, 2010, p. 97).

A large and growing body of research has demonstrated complex connections between aggression, impulsivity, and suicidal behavior (see Gvion & Apter, 2011 for a review). Efforts to clarify the relationship between these variables over the past several decades, however, has been complicated by several methodological issues, perhaps most impor- tantly by an ongoing inconsistency in the operationalization and measurement of each construct within research studies (e.g., state vs. trait definitions, self-report vs. behavioral measures). Although some researchers maintain a belief that impulsivity and aggression stem from a common genetic foundation (“impulsive-aggressiveness;” Brent, 2010), others hypothesize that they are genetically related yet distinct personality traits (Houston & Stanford, 2005); still others argue that they are entirely separate constructs despite their shared relationship to self-destructive behaviors (Gvion & Apter, 2011). A recent study using self-report methods identified important relationships between aggressive and impulsive behaviors and poor capacity for effortful control in a nonclinical young adult sample (Meehan et al., 2013), indicating that poor self-regulatory capacities can lead to increases in both impulsive and aggressive behaviors in the context of heightened distress. In a comprehensive review of empirical investigations of the relationship between ag- gression, impulsivity, and suicide, Gvion and Apter (2011) highlight the lack of clarity in findings over the past several decades, describing the current state of the literature as “confusing and contradictory and not easy to organize in a coherent manner” (p. 104). They conclude their review by suggesting that the constructs of impulsivity and aggres- sion are most likely to be useful in differentiating individuals who make near-lethal suicide attempts from those who make more frequent, nonmedically serious suicide attempts.

The question again is raised about the relative value of considering trait levels of variables such as aggression or impulsivity in aggregate, rather than within the specific situational contexts in which they are elicited and expressed. Shoda, Mischel, and Wright (1994; see also Mischel & Shoda, 1995) have shown that individuals indeed demonstrate varying levels of verbal aggression depending on the interpersonal context of the situation; levels that nonetheless form relatively stable patterns in their expression depending on the

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specific features of the situation (e.g., Child A is verbally aggressive toward peers but not adults, whereas Child B shows the opposite pattern). Although aggregating verbal ag- gression levels across both peer and adult situations may give the impression that Child A and Child B are similar, a more fine-grained analysis of the specific situation-behavior response patterns of each child reveals more detailed and nuanced information that is tremendously more useful in the prediction of future behavior. The practice of de- contextualizing specific traits such as aggression and impulsivity—traits that are broadly acknowledged to be associated with suicidality—may be another primary contributor to the current inconsistency in the literature.

While multiple findings support the idea of a connection between suicidal behavior, aggression, and impulsivity, a comprehensive theory that accounts for the manner in which trait impulsivity and the capacity to manage aggressive impulses relates to an increased risk for suicidal behavior in some individuals, but not others, has yet to be elucidated (Gvion & Apter, 2011). In fact, the inconsistency of findings connecting these character traits to suicidality may indicate that each construct plays a different role in facilitating engagement in suicidal behaviors depending on other factors, such as general personality style, capacity for effective self-regulation and effortful control, the cumula- tive effects of repeated distress, conflict or trauma and corresponding taxation on an individual’s capacity for self-control, and the context-specific situation-behavioral re- sponse patterns that are elicited in suicidal individuals by different features of their experiences and environments. The study of specific personality traits such as impulsivity and aggression as potential risk factors for suicide in general would undoubtedly benefit from the precision and clarity of a situation-response behavior analysis approach that contextualizes the trait within situations and circumstances that are personally relevant to the suicidal individual and their emerging motivations for engaging in suicidal behavior.

Discussion

Although research on suicidal behavior has led to many valuable findings over the past several decades, the field has been limited by an implicit assumption that suicidal individuals are primarily a homogenous group. This problematic assumption has led to contradictory findings on potential risk factors for suicide, and studies have been unable to provide adequate insight toward the effective prediction of suicidal behaviors in specific individuals. Suicide research more recently has attempted to incorporate a consideration of personality and internal dynamic processes (Fazaa & Page, 2003; Kaslow et al., 1998); however, these studies have often carried substantial limitations including problems in methodology, limitations in sample characteristics, a focus on suicidal ideation rather than actual suicidal behavior, and failure to include control groups of nonsuicidal individuals.

The theoretical models and empirical research reviewed in this article suggest that an individual’s personality organization— here broadly defined as their general motivating psychological orientation toward specific needs and concerns, and their characteristic situation-response patterns—relates in a powerful way to the motivational forces under- lying suicidal behavior. Baechler’s (2001) emphasis on the importance of the problem in emergent suicidal behavior suggests the possibility that the same subjective needs and concerns that drive the person to seek fulfillment in life may also, under less fortunate circumstances, influence the same individual to decide to end their own life. Shneidman (1996) has provided elegant and persuasive examples of this idea in his published case

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studies, and indeed, other personality-based research into suicidal behavior has supported this general hypothesis (e.g., Fazaa & Page, 2003).

The two-polarities models of personality proposed by Blatt (2004) has impressive evidence supporting their clinical utility and conceptual validity, and further research into suicidal behavior may benefit from the inclusion of this theory in future models as a way to investigate potential subgroups of suicidal individuals. Similarly, Mischel’s (2004; Mischel & Shoda, 1995) CAPS model of personality provides a useful paradigm for investigating the specific situations in which suicidal behavior may be elicited in indi- viduals with similar personality styles, including a consideration of their global self- regulatory capacities and impulse control in moments of distress.

There are likely few who would argue that personality style alone operates as a risk factor for suicide; as with most psychological phenomena, complex relationships exist between personality and other psychological variables that serve to move an individual from chronic to acute risk (Pompili, 2011). What is clear from the current state of the literature is that the study of any factor or set of factors in isolation does not increase the ability to predict suicidal behavior in specific individuals. Although evidence exists to confirm that individuals with different personality styles arrive at the decision to end their lives via differentiated and complex pathways (Fazaa & Page, 2003), research is needed that furthers our understanding of why individuals with similar personality styles may demonstrate differential proneness to suicidal crises. The two-polarities model of inter- personal-relatedness and self-definition carries substantial promise as a theoretical frame- work for the assessment and exploration of personality groups who are vulnerable to suicidal crises in important and differentiated ways, whereas the CAPS model of person- ality (Mischel, 2004; Mischel & Shoda, 1995) provides an empirical framework for studying the specific, contextualized patterns of personality-relevant situations, behavioral signatures, and self-regulatory capacities that further differentiate between those at risk for suicide and those who are not within similar personality groups.

It is likely that individuals who are primarily interpersonally oriented would be most vulnerable to strong negative affect in situations that involve interpersonal intimacy, more specifically at times when there is a risk or threat of abandonment, loss of love or acceptance, or severance of prior connectedness. In contrast, those who are primarily concerned with issues of self-definition would be most emotionally vulnerable in situa- tions where the opportunity to demonstrate skill, mastery, superiority, or control results in failure, humiliation, feelings of inferiority, or shame. Within each personality group, those who will be most vulnerable to acting on suicidal impulses are individuals who have demonstrated recent but persistent failures to successfully use effective self-regulation strategies, and who are therefore without sufficient cognitive resources to call upon cooling strategies to disengage from the negative feelings associated with the most recent precipitating stressor. In particular, individuals who have incorporated the possibility of suicide as a response option into their implicit cognitive and affective processing network over time will be at particular risk for acting in self-destructive ways (Cha et al., 2010; Chatard & Selimbegovic, 2011; Nock et al., 2010).

These descriptions represent hypotheses that are amenable to empirical investigation, particularly through mixed method design strategies that are sensitive not only to the fluctuation of risk factors over time and across situations within individuals with different personality types, but to the detection of social– cognitive reasoning patterns and assign- ment of personal psychological meaning to the specific events leading up to a suicide attempt (see, e.g., Eaton, South, & Krueger, 2009; Rogers & Apel, 2010). Furthermore, increasing awareness of the interaction between personality organization, emotional and

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environmental stressors, and proneness to suicidal behavior may assist clinicians in developing a more accurate and sensitive clinical approach to working with suicidal individuals. Shneidman (1996) recommended a two-stage model for treatment of suicidal individuals, the first stage including a detailed assessment of the individual’s core organizing psychological needs, and the second involving a long-term reexamination and restructuring of the specific “life-threatening” needs related to the current suicidal crisis (p. 140). Within this generalized therapeutic model, clinicians are granted the flexibility to tailor interventions to each patient based on their specific personality structure and presenting concerns, whereas at the same time establishing a sequential method for arriving at a comprehensive understanding of the biographical context of the individuals’ current crisis, and allowing for an assessment of other sources of potential risk in the future. While Shneidman’s (1996) clinical writings and other published case studies (e.g., Lindner’s (2006) analysis of personality organization and transference/countertransfer- ence issues in working with suicidal male patients) provide initial templates and concep- tual approaches to working with suicidal individuals, empirical research is needed that distinguishes the relative efficacy of specific intervention techniques and approaches for working with suicidal individuals with differing personality styles.

Future research should additionally investigate the importance of various established risk factors in the context of broader personality organization, using the two polarities model of personality organization as a lens through which to identify salient situation- response patterns relevant to emergent suicidal behavior. Attaining a clearer and more differentiated understanding of the interaction between identified risk variables, enduring personality characteristics and organization, and how personality configuration and self- regulatory capacities and resources interact with environmental factors to produce the emergence of suicidal behavior remains a goal of highest importance. Acquiring the ability to implement a more sensitive approach in the clinical assessment of suicidality may substantially improve the capacity of treatment providers to identify and effectively treat those who are at risk for ending their own lives.

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202 LEWIS, MEEHAN, CAIN, AND WONG