Since 1949, Edwin Shneidman has done extensive research in the field of suicidology. He began his research by looking at suicide notes in the coroner’s office in Los Angeles (Shneidman, 1996). During his intensive research, he came up with the term, “psychache” to refer to the mental pain, which, when intense, makes life so horrible and horrendous, that the sufferer can only think about suicide as the only option out of his/her misery.
Psychache can be defined as “hurt, anguish, soreness, aching, psychological pain in the psyche, the mind (Shneidman, 1996).” Risk factors associated with suicide are only relevant as far as they can relate to psychache (Shneidman, 1993, 2005). Dr. Shneidman believes that the true cause of anyone’s thoughts of killing themselves derive from this “psychache.”
During my research for this paper, I concluded that literature concerning the cause for individuals to resort to suicide is sadly lacking. Most of the assessment scales for determining suicide risk focus on basically, two concepts as proposed by Rosenberg (1999), action based and affective based interventions.
Action-based interventions can include items such as a “no suicide” contract, increase sessions or phone check-ins, and, if appropriate, hospitalization.
Affective based interventions focus on feeling and thoughts that are behind the suicidal ideation.
Attempts have been made by several researchers for implementing a framework for something close to a “standard” for treatment care that is not determined by litigation (Brown, Jones, Betts, & Wu, 2003; Joiner & Rudd, 2000; Joiner, Walker, Rudd, & Jobes, 1999; Kral & Sakinofsky, 1994; Rosenberg, 1999; Rudd, 1998; Rudd, Joiner, Jobes, & King, 1999; Sommers-Flanagan, Rothman, & Schenkler, 2000; Walker, Joiner, & Rudd, 2001). Discussion of litigation is not the objective of this paper, so if the reader is interested, Brown et al (2003) would be the work to which one is referred.
The frameworks provided by these researchers have provided many useful scales in determining risk and lethality of suicide, but do not include the assessment of psychological pain. In Range and Knott’s (1997) analysis of twenty assessment instruments, not one of the twenty examined includes an assessment of psychological pain. One reason for this is the subjectivity on the individual’s emotions, thoughts, mental state, and experience (Kral & Sakinofsky, 1994). According to Kral and Sakinofsky (1994), suicidologists are in general agreement that “predicting suicide for a given individual is that, like many human states, the suicidal state has a temporal, fluctuating dimension”. They propose that the evaluation of psychache experience, the psychological state of the suicidal person, is the key to accurate risk assessment.
Psychache is subjective. A person is not going to feel the exactly the same way for any length of time. However, if the level of perturbation (mental anguish) increases in intensity for too long, the individual is going to feel a need to escape from the anguish and despair by any means necessary, including by not existing any more. If suicide is seen as the only option, the only form of escape, lethality of a suicide attempt is high risk. Kral and Sakinofsky (1994) have stated that treatment of perturbation will reduce lethality and treatment of lethality ideation will reduce perturbation as these two states can feed off one another (Kral & Sakinofsky, 1994).
A scale to the assessment of suicide risk would be to have a scale of the person’s needs and current psychological pain. Dr. Shneidman believes, as do I, that when psychache is intense, perturbation is intolerable, and one or more psychological needs are thwarted or blocked, suicide is seen as the only option of relieving the psychache (Shneidman, 1999). He has based these needs on described by Henry Murray’s (1938) Explorations in Personality. Shneidman has developed 20 psychological needs. These needs are weighted and the total sum is 100 (see table 1 for an example).
Table 1
Murray Need Form
_______________________________________________________________________
Subject: ____________________Sex: _______Age: ______Rater:________Date:_______
_______________________________________________________________________
_____ ABATEMENT The need to submit passively; to belittle oneself.
_____ ACHIEVEMENT To accomplish something difficult; to overcome.
_____ AFFILIATION To adhere to a friend or group; to affiliate.
_____ AGGRESSION To overcome opposition forcefully; fight, attack.
_____ AUTONOMY To be independent and free; to shake off restraint.
_____ COUNTERACTION To make up for loss by retrieving; get even
_____ DEFENDANCE To vindicate the self against criticism or blame
_____ DEFERENCE To admire and support, praise emulate a superior
_____ DOMINANCE To control, influence, and direct others; dominate
_____ EXHIBITION To excite, fascinate, amuse, entertain others
_____ HARMAVOIDANCE To avoid pain, injury, illness, and death.
_____ INVIOLACY To protect the self and one’s psychological space.
_____ NURTURANCE To feed, help console, protect, nurture another.
_____ ORDER To achieve organization and order among things and ideas
_____ PLAY To act for fun; to seek pleasure for its own sake.
_____ REJECTION To exclude, banish, jilt, or expel another person.
_____ SENTIENCE To seek sensuous, creature-comfort experience.
_____ SHAME-AVOIDANCE To avoid humiliation and embarrassment
_____ SUCCORANCE To have one’s needs gratified; to be loved
_____ UNDERSTANDING To know answers; to know the hows and whys.
100
(Shneidman, 1999; used with permission)
References:
Brown, G. S., Jones, E. R., Betts, E., & Wu, J. (2003). Improving suicide risk assessment in a managed care environment. Crisis, 24(2), 49-55.
Joiner, T. E., & Rudd, M. D. (2000). Intensity and duration of suicidal crises vary as a function of previous suicide attempts and negative life events. Journal of Counseling and Clinical Psychology, 68(5), 909-916.
Joiner, T. E., Walker, R. L., Rudd, M. D., & Jobes, D. A. (1999). Scientizing and routinizing the assessment of suicidality in outpatient practice. Professional Psychology: Research and Practice, 30(5), 447-453.
Kral, M. J., & Sakinofsky, I. (1994). Clinical model for suicide risk assessment. Death Studies, 18, 311-326.
Murray, H. A. (1938). Explorations in personality. New York: Oxford University Press.
Range, L. M., & Knott, E. C. (1997). Twenty suicide assessment instruments: Evaluation and recommendations. Death Studies, 21(1), 25-58.
Rosenberg, J. I. (1999). Suicide prevention: An integrated training model using affective and action-based interventions. Professional Psychology: Research and Practice, 30(1), 83-87.
Rudd, M. D. (1998). An integrative conceptual and organizational framework for treating suicidal behavior. Psychotherapy, 35(3), 346-360.
Rudd, M. D., Joiner, T. E., Jobes, D. A., & King, C. A. (1999). The outpatient treatment of suicidality: An integration of science and recognition of its limitations. Professional Psychology: Research and Practice, 30(5), 437-446.
Shneidman, E. (1996). The suicidal mind: Oxford University Press.
Shneidman, E. S. (1993). Commentary: Suicide as psychache. Journal of Nervous and Mental Disease, 181, 147-149.
Shneidman, E. S. (1996). Suicide as psychache.New York and London: New York University Press.
Shneidman, E. S. (1999). The psychological pain assessment scale. Suicide and Life-Threatening Behavior, 29(4), 287-294.
Shneidman, E. S. (2005). How I read. Suicide and Life-Threatening Behavior, 35(2), 117-120.
Sommers-Flanagan, J., Rothman, M., & Schenkler, R. (2000). Training psychologists to become competent suicide assessment interviewers: Commentary on Rosenberg’s(1999) suicide prevention. Professional Psychology: Research and Practice, 31(1), 99-100.
Walker, R. L., Joiner, T. E., & Rudd, M. D. (2001). The course of post-crisis suicidal symptoms: How and for whom is suicide “cathartic”? Suicide and Life-Threatening Behavior, 31(2), 144-152.
Copyright 2013, Collerone, G
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