Looked at through Joiner's IPPT (2005) both suicide completions and attempts involve a belief of being a burden or feeling worthless, a belief of non-belonging or disconnected from those one cares about, an intense desire to die, and an acquired capability for lethal self harm achieved through mental practice of a plan, abuse, experiencing violence, or other factors. The only difference is that in an attempt the outcome, for some reason, was not death. Similarly in O'Connor's Integrated Motivation-Volitional Theory (2011) both attempters and completers presumably experienced a pre-motivational phase, where fixed risk factors and life events may set the stage, and a motivational phase, where ideation is fueled by feelings of entrapment, defeat, or loss, and a volitional stage where a specific plan and means are present and may result in an attempt that may be fatal or not.
Perhaps the difference lies in the forms of suicidality rather than the outcomes? Is it the “chronic suiciders” (Paris 2007), individuals with borderline personality disorder who repeatedly use threats and attempts to manipulate, cope or solve problems without intent to die, who differ from the “acute suiciders” who definitely have intent to die when they make an attempt and who use distinctly lethal means?.
In continuing to think about this question it occurs to me that perhaps I am wrestling with what might be called a "myth of sucide prevention research." What the proponents of the completers/attempters different groups premise may be doing is contrasting the victims of lethal/fatal suicide attempts ("completers") with those who are parasuicidal rather than acutely suicidal and whose attempts and other "suicidal behavior" is not driven by any intent to die.
Well all of this presupposes that the variables actually represent what has been going on in the minds of those who succeeded in killing themselves. Something to which we have no access and the choice to analyze their actions a certain way is entirely dependent on the proposed theories of experts like Joiner. His arguments like of other suicidologists is from an a priori framework. That is his philosophic or metaphysical (perhaps unacknowledged or unaware) paradigmatic commitments shaped perhaps by the researcher's personal experiences, frame the analysis and conveniently the researcher finds the "data" to support the framework from which he shapes his model and explanation.
It is not my experience that people who attempt suicide (and survive) and people who complete suicide are distinct populations. I respect Joiner's work and find it elegantly descriptive and explanatory, yet not predictive in the individual case; indeed the majority of people with the same constellation of factors are not actively suicidal let alone complete suicide.
I have worked a lot clinically with risk assessment documents and interviews (20 years in mental health) and we continue to focus on clarifying past attempts, and both the degree of lethality and impulsivity, since both in practice and in the literature the single greatest predictor of suicide completion is past attempts. So they are slippery categories, Tony, as you note: 'The only difference is that in an attempt the outcome, for some reason, was not death.'
Borderline personality disorder does indeed typically correlate with greater numbers of attempt presentations and a different feeling to the presentations (or perhaps more accurately a different feeling in the clinician...).
Something further on language:
For what it is worth, I feel the idea of 'intent' to die is often misunderstood by laypeople and families, and I try not to use it in my work with people. Over 3 years working exclusively with suicidal persons it was not my experience that the intention immediately prior to an overdose, gassing or attempted hanging persisted immediately after when in hospital, let alone 6-8 weeks later.
There was typically both remorse - at troubling services, at upsetting family - and relief at survival. There was real commitment, in the short term, to change to more adaptive coping and problem solving and receive help, despite pride, when unemployment and/or more entrenched poverty were associated with the attempt.
The term 'deliberate' self-harm is more negative and imprecise still, since cutting behaviours are not typically about a desire to be cut so much as a mixture of other things including: a relief of psychological pain through manifesting it physically, a way to communicate distress to others (without words) to give them an opportunity to initiate assistance, and seeking consistency (making oneself ugly or flawed because one feels that way inside).
Melissa: I agree that Joiner's theory has limitations in confirming that a specific individual is acutely suicidal and in imminent danger of acting on a plan. I think that he would also. Nonetheless at the aggregate level it definitely adds to our understanding of "why people die by suicide." It also lives up to one of his aims in that it can help those who have lost someone to suicide understand what may have happened. As an aside I have found that in the county where I work the overwhelming majority of civil petitions requesting involuntary psychiatric evaluations cite what sounds like burdensomeness and disconnectiveness in describing behaviors of people felt to be at risk of suicide. Some also allude to acquired capability (e.g., "He knows all about weapons because he was in the army.") It would be interesting to integrate the "Integrated the Motivational–Volitional (IMV) Model of Suicidal Behavior" (O’Connor, 2011) with the Joiner model. The "motivational" and "volitional" stages seem to fill in some missing elements of the IPPT.
I hate to put cold-water on what are genuinely sincere efforts to help regarding an existentially tragic occurrence, but I would suggest that finding the causal model for self-murder will be done when we find the causal model for Catholicism or Atheism or being a Republican. It is as Thomas Szasz has carefully argued not a scientific issue and is motivated by many things and is really an answer to something rather than a problem (for the person not necessarily those around him).
Joiner although sincere has the tragedy of his father's suicide pressing him for a scientific explanation. It appears that that tragedy shaped his professional interests and his belief system that as for other mental health issues (i.e. what is mental illness) has no necessary scientific answers no matter how edifying such answer would be if true. Researchers committed to an academic career research what they can and within the frameworks they have been taught. The unknown as it is at this moment unknowable by definition is better left alone since no academic is rewarded for failure. in fact we are admonished not to have too many of them if we intend to have an academic career. The human existential tragedy and individual experiences in swimming in it are infinitely complex and science only goes so far.
"For more than 20 years (see Maris 1992), it seems to be accepted that suicide completers and attempters are two distinct populations."
I don't see this being true at all. In my experience it is a matter of self esteem coupled with a background of abusive treatment and the relative level of self esteem the individual has, or the reasons that the person has to live relative to the pain he/she is experiencing. I see it as being complex and also on a continuum. For example, within a family person A is the scapegoat, maybe because their self esteem was low because their talents were not appreciated. Perhaps one parent felt empathy for the child and one felt disdain setting up a perfect storm for destruction of self esteem. This person has the least reason to want to live and may attempt suicide several times before either success is achieved, or reasons for living outweigh the pressing need to die. Person B is held in high esteem because their talents are highly valued as well as allowed to flourish. This person may feel guilty for the poor treatment of the sibling who is scapegoated. This person may feel the pain that would drive he/she to be plagued with the desire to escape that feeling through suicide, but only goes as far as thoughts because he/she has too much to lose by completing the idea. Person C is held in high esteem for their talents but does not complete the expectations promised by their natural ability. This person may not have empathy for the scapegoat because they feel no guilt, perhaps they are the main recipient of the abuse in the family. Although this persons pain is as great as the scapegoats because of the intense abuse, the valued talents of person C keep he/she from achieving death as an endpoint to the suicidal drive. As you can see this particular case is very complex, yet all three persons in this scenario are subject to various levels of commitment to suicidal thoughts and attempts. Perhaps the parents feel these compulsions as well and are a model for the offspring. This example is not necessarily complete but meant to illustrate the complexity and family dynamics that can propagate suicidal tendencies in individuals over a continuum, not two distinct populations, but balanced on self esteem and the circumstances for living versus dying based on what the person has to live for at any given moment and the concomitant need to escape the intense pain of living...
Found an article by Beautrais reporting on research on this question which concludes: "Suicides and medically serious suicide attempts are two overlapping populations that
share common psychiatric diagnostic and history features, but are distinguished by gender and patterning of psychiatric disorder." See A. Beautrais, "Suicides and serious suicide attempts: two populations or one ?" Psychological Medicine, 2001, 31, 837–845.
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