The interpersonal-psychological theory of suicidal behavior: Current empirical status (2023)

Thomas Joiner grew up in Georgia, went to college at Princeton, and received his PhD in Clinical Psychology from the University of Texas at Austin. He is Distinguished Research Professor and The Bright-Burton Professor in the Department of Psychology at Florida State University. Dr. Joiner’s work is on the psychology, neurobiology, and treatment of suicidal behavior and related conditions. Author of over 385 peer-reviewed publications, Dr. Joiner was recently awarded the Guggenheim Fellowship, the Shneidman Award for excellence in suicide research from the American Association of Suicidology, and the Award for Distinguished Scientific Early Career Contributions from the American Psychological Association, as well as research grants from the National Institute of Mental Health and various foundations. Dr. Joiner is editor of the American Psychological Association’s Clinician’s Research Digest, editor of the Journal of Social & Clinical Psychology, and Editor-in-Chief of the journal Suicide & Life-Threatening Behavior, and he has authored or edited fifteen books, including Why People Die By Suicide, published in 2005 by Harvard University Press. He runs a part-time clinical and consulting practice specializing in suicidal behavior, including legal consultation on suits involving death by suicide. He lives in Tallahassee, Florida, with his wife and two sons.

The interpersonal-psychological theory of suicidal behavior (Joiner, 2005) proposes that an individual will not die by suicide unless s/he has both the desire to die by suicide and the ability to do so. What is the desire for suicide, and what are its constituent parts? What is the ability to die by suicide and in whom and how does it develop?

In answer to the first question of who desires suicide, the theory asserts that when people hold two specific psychological states in their minds simultaneously, and when they do so for long enough, they develop the desire for death. The two psychological states are perceived burdensomeness and a sense of low belongingness or social alienation. In answer to the second question regarding capability for suicide, self-preservation is a powerful enough instinct that few can overcome it by force of will. The few who can have developed a fearlessness of pain, injury, and death, which, according to the theory, they acquire through a process of repeatedly experiencing painful and otherwise provocative events. These experiences often include previous self-injury, but can also include other experiences, such as repeated accidental injuries; numerous physical fights; and occupations like physician and front-line soldier in which exposure to pain and injury, either directly or vicariously, is common.

What is the current empirical base bearing on this conceptualization? Some of it is indirect, though a growing body of direct empirical findings is accruing. In the following sections, evidence and concepts regarding each of the theory’s three main components are reviewed.

Perceived Burdensomeness

Perceived burdensomeness is the view that one’s existence burdens family, friends, and/or society. This view produces the idea that “my death will be worth more than my life to family, friends, society, etc.” – a view, it is important to emphasize, that represents a potentially fatal misperception. Past research, though not designed to test the interpersonal-psychological theory, nonetheless has documented an association between higher levels of perceived burdensomeness and suicidal ideation. DeCatanzaro (1995), for instance, found that perceived burdensomeness toward family was correlated with suicidal ideation among community participants and high-suicide-risk groups. Direct tests of the theory have been supportive as well. In two studies of suicide notes, Joiner et al. (2002) showed that raters detected more expressions of burdensomeness in: 1) the notes of people who had died by suicide compared to the notes of those who intended to die but survived; and 2) the notes of those who died by violent means compared to the notes of those who died by less violent means. In a study of psychotherapy outpatients, Van Orden, Lynam, Hollar, and Joiner (2006) showed that a measure of perceived burdensomeness was a robust predictor of suicide attempt status and of current suicidal ideation, even controlling for powerful suicide-related covariates like hopelessness.

Low Belonging/Social Alienation

A low sense of belongingness is the experience that one is alienated from others, not an integral part of a family, circle of friends, or other valued group. As with the research base on perceived burdensomeness, there is abundant evidence that this factor is implicated in suicidal behavior. However, relatively little of this evidence derives from direct tests of the interpersonal-psychological theory. Indeed, a persuasive case can be made that, of all the risk factors for suicidal behavior, ranging from the molecular to the cultural levels, the strongest and most uniform support has emerged for indices related to social isolation (e.g., Boardman, Grimbaldeston, Handley, Jones, & Willmott, 1999). The connection between belonging (or its absence) and suicidality has been established for a number of diverse populations, including young adolescents, college students, elderly individuals, and psychiatric inpatients. Furthermore, suicide rates go down during times of celebration (when people pull together to celebrate; Joiner, Hollar, & Van Orden, 2006) and during times of hardship or tragedy (when people pull together to commiserate). For instance, there was a low rate of death by suicide in the U.S. on September 11, 2001, as there was the week after President Kennedy’s assassination (Biller, 1977).

With regard to studies framed as direct tests of this aspect of the interpersonal-psychological theory, Conner, Britton, Sworts, and Joiner (2007) evaluated 131 methadone maintenance patients, and demonstrated that low feelings of belongingness predicted lifetime history of suicide attempts. As expected, in a fairly stringent test of specificity, this association was specific to suicidal behavior; belongingness was unrelated to unintentional overdoses. This specific association held even after a rigorous accounting for demographic characteristics, correlates of suicidal behavior, and other interpersonal variables.

In another study, Van Orden, Witt, Bender, and Joiner (2008) showed that, as predicted, college students’ suicidal ideation peaked in the summer semester (there is a late spring-early summer peak in suicidality, contrary to what most assume), and furthermore, found that low belonging in the summer (when the campus is less active) accounted, in part, for the association between semester and suicidality.

Acquired Ability to Enact Lethal Self-Injury

While feelings of burdensomeness and low belongingness may instill a desire for suicide, they are not sufficient to ensure that desire will lead to a suicide attempt. Indeed, in order for this to occur, the theory suggests a third element must be present: the acquired ability for lethal self-injury. This aspect of the theory suggests that suicide entails a fight with self-preservation motives. According to the theory, having fought this battle repeatedly and in different domains instills the capacity to stare down the self-preservation instinct—should an individual develop the desire to.

The basis for this proposition rests primarily on the principles of opponent-process theory, which suggests that with repeated exposure to an affective stimulus, the reaction to that stimulus shifts over time such that the stimulus loses its ability to elicit the original response and, instead, the opposite response is strengthened (Solomon, 1980). In light of this, it is hypothesized that the capability for suicide is acquired largely through repeated exposure to painful or fearsome experiences. This results in habituation and, in turn, a higher tolerance for pain and a sense of fearlessness in the face of death. Acquired capability is viewed as a continuous construct, accumulating over time with repeated exposure to salient experiences and influenced by the nature of those experiences such that more painful and provocative experiences will confer greater capacity for suicide.

A clear implication of this is that past suicidal behavior will habituate individuals to the pain and fear of self-injury, making future suicidality, on average, more likely. Indeed, a history of suicide attempts has been found to be a strong predictor of future suicidal behavior including death by suicide (Joiner et al., 2005; Brown, Beck, Steer, & Grisham, 2000). Moreover, Joiner and colleagues (2005) have found that individuals with past suicide attempts experienced more serious forms of future suicidality, as compared to others who did not have a history of suicidality and, crucially, this association was not accounted for by other variables (e.g., mood disorder status, personality disorder status, family history variables). Relatedly, it has also been found that individuals with a history of suicide attempts evidence higher pain tolerance in general (Orbach, Mikulincer, King, Cohen, & Stein 1997). Also, in a direct test of acquired capability for suicide, Van Orden, Witte, Gordon, Bender, and Joiner (2008) used a scale designed to tap the construct, and showed that number of past suicide attempts significantly predicted levels of acquired capability in a sample of clinical outpatients. The highest levels of acquired capability were reported by individuals with multiple past attempts, as the theory would predict.

Yet, acquiring the capacity for suicide is not limited to prior suicidal behavior—it can also be acquired through repeated experience with other painful and fear-inducing behaviors (e.g., non-suicidal self-injury, self-starvation, physical abuse, etc.). For instance, in the case of non-suicidal self-injury, prior research has suggested that the likelihood of suicide attempts is greater in individuals who have a longer history of self-injury, use a greater number of methods, and report absence of physical pain during self-injury–all characteristics suggestive of habituation and tolerance (Nock, Joiner, Gordon, Richardson, & Prinstein, 2006).

Lastly, aside from direct exposure, the theory also posits that even exposure to others’ pain and injury may produce the capacity for suicide. Physicians fit this hypothesis, evidencing high suicide rates despite many protective factors (Hawton, Clements, Sakarovitch, Simkin, & Deeks, 2001).

The Interactive Nature of the Theory

Thus far each component of the theory has been described in isolation, providing evidence for the independent effects of perceived burdensomeness, failed belongingness, and acquired capability on levels of suicidality. We have not yet explored the interactive nature of the theory, which posits a three-way interaction between these components. Particularly, the theory suggests that the joint occurrence of perceived burdensomeness and failed belongingness is sufficient to produce the desire to die, and that this desire translates into lethal or near-lethal behavior only in the presence of the acquired capacity for lethality.

To date, four studies bear on the interactive aspects of the model, two described in Van Orden et al. (2008), and two described in Joiner et al. (in press). In a study of undergraduates, Van Orden et al. (2008) showed that the statistical interaction between (high) burdensomeness and (low) belonging predicted current suicidal ideation; this occurred beyond important covariates, like depressive symptoms. A second study on psychotherapy outpatients also provided evidence for a statistical interaction between scores on an acquired capability measure and an index of perceived burdensomeness, such that acquired capability in the presence of high levels of perceived burdensomeness predicted clinician ratings of suicide risk—again, above and beyond the contribution of other risk factors (i.e., depression scores, gender, and age). In the first of the Joiner et al. studies, in a large, diverse, and representative community sample of young people, burdensomeness and low belonging interacted to predict suicidal ideation. In the second study, acquired capacity, perceived burdensomeness, and low belonging interacted as hypothesized to predict suicide attempt status in a clinical sample of young adults.

The interpersonal-psychological theory is promising, with a growing empirical base to support it. The theory suggests that clinicians be cognizant of their patients’ levels of belongingness, burdensomeness, and acquired capability (especially previous suicide attempts), as this knowledge may aid clinicians in the task of suicide risk assessment and of targeting therapeutics.

References

Biller, O.A. (1977). Suicide related to the assassination of President John F. Kennedy. Suicide and Life Threatening Behavior, 7, 40-44.

Brown, G., Beck, A. T., Steer, R., & Grisham, J. (2000). Risk factors for suicide in psychiatric outpatients: A 20-year prospective study. Journal of Consulting and Clinical Psychology, 68, 371–377.

Boardman, A. P., Grimbaldeston, A. H., Handley, C., Jones, P. W., & Willmott, S. (1999). The North Staffordshire suicide study: a case-control study of suicide in one health district. Psychological Medicine, 29, 27-33.

Conner, K., Britton, P., Sworts, L., & Joiner, T. (2007). Suicide attempts among individuals with opiate dependence: The critical role of felt belonging. Addictive Behaviors, 32, 1395-1404.

DeCatanzaro, D. (1995). Reproductive status, family interactions, and suicidal ideation: Surveys of the general public and high-risk groups. Ethology & Sociobiology, 16, 385-394.

Hawton, K., Clements, A., Sakarovitch, C., Simkin, S., & Deeks, J.J. (2001). Suicide in doctors: A study of risk according to gender, seniority, and specialty in medical practitioners in England and Wales, 1979-1995. Journal of Epidemiology and Community Health, 55, 296-300.

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

Joiner, T.E., Conwell, Y., Fitzpatrick, K.K., Witte, T.K., Schmidt, N.B., Berlim, M.T., et al. (2005). Four studies on how past and current suicidality relate even when “everything but the kitchen sink” is covaried. Journal of Abnormal Psychology, 114, 291-303.

Joiner, Jr., T. E., Hollar, D., & Van Orden, K. A. (2006). On Buckeyes, Gators, Super Bowl Sunday, and the Miracle on Ice: “Pulling Together” is associated with lower suicide rates. Journal of Social and Clinical Psychology, 25, 180-196.

Joiner, T., Pettit, J. W., Walker, R. L., Voelz, Z. R., Cruz, J., Rudd, M. D., et al. (2002). Perceived burdensomeness and suicidality: Two studies on the suicide notes of those attempting and those completing suicide. Journal of Social & Clinical Psychology, 21, 531-545.

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

Nock, M., Joiner, T., Gordon, K., Lloyd-Richardson, E., & Prinstein, M. (2006). Non-suicidal self-injury: Diagnostic correlates and relation to suicide attempts. Psychiatry Research, 144, 65-72.

Orbach, I., Mikulincer, M., King, R., Cohen, D., & Stein, D. (1997). Thresholds and tolerance of physical pain in suicidal and nonsuicidal adolescents. Journal of Consulting and Clinical Psychology, 65, 646-652.

Rudd, M.D., Joiner, T.E., & Rajab, M.H. (1996). Relationships among suicide ideators, attemptors, and multiple attemptors in a young-adult sample. Journal of Abnormal Psychology, 105, 541-550.

Solomon, R. L. (1980). The opponent-process theory of acquired motivation: The costs of pleasure and benefits of pain. American Psychologist, 35, 691–712.

Van Orden, K. A., Lynam, M. E., Hollar, D., & Joiner, T. E., Jr. (2006). Perceived Burdensomeness as an Indicator of Suicidal Symptoms. Cognitive Therapy and Research, 30, 457-467.

Van Orden, K.A., Witte, T.K., Gordon, K.H., Bender, T.W., & Joiner, T.E. (2008). Suicidal desire and the capability for suicide: Tests of the interpersonal-psychological theory of suicidal behavior among adults. Journal of Consulting and Clinical Psychology, 76, 72-83.

Van Orden, K., Witte, T., James, L., Castro, Y., Gordon, K., Braithwaite, S., et al. (2008). Suicidal ideation in college students varies across semesters: The mediating role of belongingness. Suicide & Life-Threatening Behavior, 38, 427-435.