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The Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients
Reviewed by Cheryl A. Chessick, M.D.
Am J Psychiatry 2010;167:109-110. doi:10.1176/appi.ajp.2009.09050679
View Author and Article Information

The author reports no financial relationships with commercial interests.

Book review accepted for publication August 2009 (doi: 10.1176/appi.ajp.2009.09050679).

Accepted August , 2009.

Copyright © American Psychiatric Association

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As stated in its introduction, the purpose of this book is "to demystify clinical work with suicidal patients by grounding this work within a model of suicidal behaviors, the Interpersonal Theory of Suicide" (p. 3). The reason why people kill themselves, according to Dr. Joiner's theory, is "because they can and because they want to—because they develop both the desire and the capability to do so" (p. 4). Luckily, lethal self-injury is associated with so much fear and pain that few people are capable of it. Thus, only those with both the capability and the desire are at risk, according to the theory. Perceived burdensomeness and failed belongingness compose the construct of suicidal desire and are thought to be more fluid and dynamic than acquired capability. Suicidal desire is proposed to be more malleable and responsive to short-term intervention than capability.

Dr. Joiner lays out the "Clinical Terrain Covered in This Guidebook" (p. 4) in six chapters. Chapter 1 focuses on the DSM diagnoses that are more commonly associated with suicidal behavior than others, that is, the "major five" (p. 21), including major depressive disorder, bipolar disorder, schizophrenia, anorexia nervosa, and borderline personality disorder. Ninety percent of individuals who die by suicide have an axis I mental disorder (p. 22); thus, knowledge of each disorder and the literature concerning suicidal ideation/behavior associated with each are important. Although not an exhaustive discussion of each disorder, certainly a respectable amount of data is presented.

Chapter 2 offers the author's recommendations on what information should be gathered in the process of suicide risk assessments, as well as how to optimally obtain and analyze the information. Neither being an alarmist nor ignoring symptoms is recommended. Warning signs have been published over time; these are imprecise and may result in a high number of false positives. Although not particularly problematic for the general public, the clinician is in a different situation, needing to provide a more accurate assessment. "Suicide risk assessment frameworks, therefore, are formalized procedures for clinicians, i.e., indications of what signs or symptoms to assess and what questions to ask, how to combine information on current and past symptoms to determine current risk and indications of what actions to take given risk designations. The primary goal of these frameworks is to establish the degree of current risk of suicide, including the presence or absence of clear and imminent risk" (p. 56).

The theory proposes that clinicians should assess two main domains: desire for suicide and capability for suicide. Specific questions as well as scales for both desire and capability are presented, along with a summary of each dimension. Capability is divided into acquired capability over the long term as well as current indicators, such as high intent for suicide or fearlessness about suicide. Lastly, a "Risk Assessment Decision Tree" (p. 68) is presented, along with directions for an interview to complete the tree. Examples are provided as benchmarks to rank suicide risk as low, moderate, or high, with either severe or extreme qualification.

Other risk assessment frameworks, such as the Collaborative Assessment and Management of Suicidality, the Chronological Assessment of Suicide Events (CASE) (p. 64), as well as the University of Washington Risk Assessment Protocol (p. 66), are presented and compared to the Interpersonal Theory of Suicide Risk Assessment. Common themes in risk assessments include the role of rapport between clinician and client, the need to assess planning and preparation as potential signs of imminent risk, and the decision tree. "Risk frameworks are most useful when they not only provide guidelines on what domains to assess but guide clinicians in determining levels of risk and choosing appropriate interventions" (p. 80).

Chapters 3, 4, and 5 address treatment. Chapter 3 describes crisis intervention strategies and techniques through the lens of the theory. A crisis is defined as a situation in which "an individual is experiencing intense thoughts about suicide, combined with dysphoria and the subjective experience that he or she cannot cope effectively with these emotions, and will act on his or her suicidal thoughts" (p. 84). A main goal is to moderate the pain of the current crisis so that it is within a tolerable range. Each level of risk, from low to high risk as described in chapter 2, is addressed with specific tools, such as providing emergency numbers like the National Suicide Prevention Lifeline for low risk or creating a "crisis card" (p. 95). An example of an intervention in the moderate risk group may be completing a "symptom-matching hierarchy" (p. 99), such as engaging in pleasant activities to address hopelessness. I was impressed by the matching of the level of intervention with the level of risk.

Chapter 4 focuses on treatments that work for suicidal behavior and surveys various treatment approaches. Descriptions of evidenced-based therapies are presented and include cognitive therapies, dialectical behavioral therapy, problem-solving therapy, multisystemic therapy, and partial hospitalization with psychoanalytic focus, as well as interpersonal and mindfulness-based cognitive therapy, which have preliminary data. Dr. Joiner presents his own open trial data addressing all aspects of his model of suicide. As he describes it, his approach seems easy to teach, learn, and implement. The three main principles are assessing interpersonal problems, supporting motivation for treatment, and increasing self-control.

Chapter 5 focuses on the therapeutic relationship. "The goal in using a stance that emphasizes a blend of collaboration and self-determination is to create a therapeutic environment that facilitates motivation for therapy and also directly targets sources of suicidal desire" (p. 146). A discussion of how much availability clinicians should offer between sessions based on patient needs and personal limitations is presented.

Chapter 6 offers a broader perspective on the interpersonal theory by addressing suicide prevention and public health campaigns. Sixty-eight percent of people who die by suicide were not seen in a mental health setting during the 12 months preceding their death (p. 167). Thus, a more multifaceted approach is needed. Possibilities of universal prevention strategies like getting rid of weapons or erecting barriers at high-risk locations are options that have limitations, as Dr. Joiner points out. The importance of interpersonal relationships is emphasized. Facilitating hope in the process of assessment and treatment is paramount. Dr. Joiner makes a compelling case that his treatment model can engender hope in suicidal patients.

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