Contribuciones de Shneidman Al Pensamiento Suicida

8/13/2019 Contribuciones de Shneidman Al Pensamiento Suicida

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2SHNEIDM AN 'S CON TRIBUTION STO THE UND ERSTAND ING OFSUICIDALT H I N K I N GDAVID A.JOBESAN DKATHRYNN .NELSON

In 1949, Ed win S. Shneidm an, running a half-ho ur errand for his bossat the Veteran's Administration (VA) hospital , found himself in thevaul tsof th e coroner's office in LosAngeles. At the relatively tender professionalageof 31, you ng Shn eidman's simple errand became a life-chang ing eventfor him and for the larger pu rsuitofsuicidologyand suicide prev ention as wehave come toknow ittoday.-AsDr.Shneidman (1991) recalled,

The fulcrum momentof mysuicidologicallifewas not when Icame acrossseveralhu ndr ed suicide notes in a coroner's vau lt while on an errand forthe d irector of the V A hospital, but rather a few minu tes later, in theinstant when I had a glimmeringthat their vast potential couldbe im-measurably increased if I did not read them, but compared them, in acontrolled blind exp erim ent, with sim ulated suicide notesthatm ight beelicited from matched nonsuicidal persons, (p .2 4 7 )Shn eidman later ventured back to the vaul tin the coroner's office andreceived perm ission to use 72 1 suicide notes for research purposes.Withhis

friend andcolleague No rma n Farberow,who hadthaty ear receivedhis PhD

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from theUniversityofCaliforniaat LosAngeles, alineofseminal researchin the studyof suicide notes was launched; inthat moment, contemporarysuicidologywasborn.

Shneidman andFarberow's initial suicidenote research collaborationwould ultimately spawn much ofwhat now definesand shapes suicidologyand suicide prevention today. Drs. Shneidman, Farberow, and Robert Litman(along withkey staff colleagues Tabachnick, Heilig, Klugman, Wold, andPeck) founded and created the fabled Los Angeles Suicide Prevention Cen-ter (LASPC), a veritable suicidology Garden of Eden.Thisgroup of innova-tors simultaneously initiatednewlinesofempirical suicide-related research,generated whole linesof newtheory,andcreatedawealthofclinical wisdompertainingtoworking with suicidal individuals.

In retrospect, it isdifficult to appreciate th e full impact and scope ofShneidman'svariousandconsiderable contributions. Indeed, much of thelanguage that wecommonly use in suicidologythe word suicidology, fo rexamplewaseither directly coined by Shneidman or indirectly shaped byhisthinking, intellectual influence, and scholarly contributions. Shneidmaniswell known, even infamous,for his many neologisms.. Beyond the coretermofsuicidology,Shneidman isalso credited with developing many addi-tional wordsandtermsin the field,includingpsychologicalautopsy,postvention,subintentioneddeath,perturbation, and psychache,among others. To completethe fullpictureofcontributionsand tocontextualizehisrolein the field, it isimportant tofurthernotethatShneidman was the founding president of theAmerican Association of Suicidology in 1968 aswellas the founding editorinchiefofthat organization's premier scientific journalSuicideandL ife-Threat-eningB ehavior.

When one considers Shneidman's historic contributions to the con-temporarypsychological understandingofsuicideand the larger suicide pre-vention movement, it is obviousthatan examination of his contributions totheareaofsuicidologyisessentialto thecurrent text.Tothatend, Shneidmanhassaidagreat deal abouttheroleofcognitionand hasmany ideas regardingsuicidal thinking.

Throughout his career in suicidology, Shneidman's theoretical workhas consistently and directly addressed cognitive aspects of suicide. Further-more, his research has unfailingly examined, either directly or indirectly,cognitive processes and the inherentnature of suicidal thinking. Moreover,muchof hisclinically oriented writing addresses cognitive aspectsof thesui-cidal mind with insights about how one best approaches, assesses, and treatsapatientwhoentertains thoughtsofending life.

We must observe, however,thatShneidman would never call himself acognitivist,either in termsof theoretical approach or in termsof clinicalpractice. Unquestionably,heardently represents himselfas apassionate men-talist;he holds the fervent viewthatsuicide exists as aphenomenonof themind.Inthis regard, Shneidman iscaptivatedbyintrospectionandphenom-

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enology and stresses the psychology ofsuicideas it exists inmentation. Tothis end, Shneidman (2001) said, .

M y view [o fsuicide]isdefinitely men talistic. Ibelievethatsuicideis amatterof themind.The mindthat mysterious microtemporal substance-free secretion, has a mind of its own; the m ain business of the m ind istomind its ownbusiness.When itcomestosuicidewhich is mymainbusinessIam a 21st-century mentalist. (p. 201)Certainly, cognition is implicated in Shneidman's psychology ofsui-cide,bu t it is not acore featureinShneidm an's thin king. As weshall makeplain in the course of this chapter, cognition inShneidman's view is but acrucialpiece of the whole m ental pie of suicide and is deeply im plicated in

suicidal states. Yet without equivocation, inShneidman'swo rldview of sui-cide, the sun, stars, and moon all rise and set on one central constructpsychache. As Shneidm an (200 1) put it ,

I believethat suicide is essentially a drama in the mind, where the sui-cidal drama isalmost always driven by psychological pain, the painofnegative emotionsw hatIcallpsychache.Psychache is at the darkheartofsuicide;nopsychache, no suicide,(p.200 )The reason for strongly em phasizing Shneidm an's perspective as a pas-sionate mentalist is not to min imizehis work related to cognition .andsuicidebecause it is considerableb ut to represent,frame,and contextualizeaccuratelythis p arti cu lar aspect of his wo rk w ithi n the total ity of his psycho-logical approach to understanding suicide. In other words, even thoughShneidman is not aself-defined cog nitivist assuch,henevertheless has hadagreat appreciationfor the keyrolethatcognition playsin the total psychol-ogyofsuicide.In this chapter, w e thus endeavor to present a balanced, thoughtful,

and contextualized pictureofShneidman'sco ntributions to our understand-ingo fsuicidal think ing, with aparticu lar emphasisoh hiscontributions thatare most specificto cognition. A t timesw e may take certain liberties wheninterpreting some ofthis work,as weendeavor toattend to the focus of thecurrent text (i.e., cognition and suicide). Forexam ple, this chapter beganwith th e story of a young Shneidman wan dering through th e vault of thecoroner's office considering the^potential importance of researching suicidenotes.A snoted,this fateful spark of a research idea ignited an en tire fieldofstudy and spurred a larger movement in societythat we should earnestly,purposefully, and methodically endeavor to prevent th e tragedyofsuicide.Beyond this aspect, however,the importanceof theShneidmanandFarberowstudies of suicide notes cannot be overstated. For what are suicidenotesifnot the final psychological considerations, musings,feelings, requests, com-munications, thoughtscognitionsofthe suicidal person?As awritten tes-tament to an individual 's tragic suicidal end, the-studyof suicide notes his-

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torically marked asignificant beginning for the study ofsuicideas alargerfield and,as weshallsee,italso fund am entally shaped Shn eidman's thinkingand v iews on the topic of suicide. To that end, we explore some of Shneidman'skey theoretical, empirical, and clinical contributions to historic as well ascontem porary suicidology.

SHN EIDM AN'S THEORETICAL WORK RELATEDTO COGNITION AND SUICIDE

Shneidman's theoretical contributions to our understandingofcogni-tion and suicide are both direct and indirect. In terms of direct contribu-tions, we are referring to those aspects of his workthatspeakspecifically toand directly address the nature of suicidal cognitions. Our discussion of theso-called indirect co ntribu tions inclu des those aspectsofShneidman's theo-retical work that have shifted and shaped new and different waysofpsycho-logicallyu nde rstand ing how suicide actua lly occurs. To this end, we emp ha-size here a few of these theoretical contributions including (a) the logicofsuicide, (b) the 10 commonalities of suicide, (c) cognitive constriction andsuicide, (d) the cubic modelofsuicide,and (e) aphorismsofsuicide.

The Logic of SuicideShneidm an was among the first to trul y explore the thinkin g process ofth e suicidal individu al, wh at he called th e logic of suicide (Shneidman,1959). This was to be an area of theoretical workthat Shneidman wouldpursue throughout his career insuicidology. W riting abo ut th e logic ofsui-

cide, Shneidman (1985) asserted the following:Figuratively speaking and from th e point ofview of logic, th e suicidalindividualhangs him selffrom hismajor premise and m akes an erroneousdeductive leap into oblivion . . . reason is asmuch a part of suicideasemotion is.Jus tas emotions mayfeel necessary at the m om ent of theirexpression, so illogical conclusions may seem sensible wh en they oc-cupyand sway the mind. (p . 136)This particular quote marks the beginning of Shneidman's discussionofcognitiveaspectsof suicide in his im portant 1985text,D efinitionofSuicide(Shneidman, 1985). What follows is a far-reaching discussion of the phe-nomenological nature ofsuicidal think ing and how an indiv idual 's styleof

reasoning, cognitive man euvers, and beliefs fundam entally shape virtuallyevery suicidal act. As Shneidman noted,There is no single suicidal logic; however,there are features of logicalstyles and ways of mentating that facilitate (even predispose) suicidalbehav ior. I call these k inds of reasoning catalogical because they are de-

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structive; they are-destructive notonlyin. thesense that they abrogatethe rulesforlogicalan dsemanticclarity,butthey also destroythelogi-cianwho thinks them.(p. 137) . In asynopsis sucha sthis, it iscriticaltoquote Shneidman's ownwords

at length to highlight his unique and idiosyncratic way of considering thetopicofsuicide.It isplainto usthatno onetalksorwrites about suicide quitethe wayShneidman does. Sometimes overly complexandelliptical,hiswrit-in ginvariably challenges thereadertothinkandrethink what they thoughtthey knew.Inchallenginghisreaderstothink, Shneidman also compels themto consider their preexisting assumptions and open their minds to the poten-tialworthof hisideas. Frankly,hiswritingisoccasionally elusive andsome-t imesoverly complicated; we find thatsome of his work requires multiplereadingsto reallygrasptheessential points. However, Shneidman's theoriz-ing and writing is often cleverand imaginative. Forbetteror for worse, al-though many suicidologist scholars have said similaror related things asShneidman, virtuallyno one in the field hassynthesizedandelaboratedonthe theory and perspective on suicide with quite the depth and scope asShneidman. Thus, in discussing the logic ofsuicideto his readers, Shneidmancustomarilyand characteristically endeavors toopennewdoorsoftheoriz-ing, inspire new lines of empirical research, and challenge clinicians to con-sider,reconsider,andperhaps change howthey clinically engagea personw hoentertains thoughts ofsuicide.The 10 Commonalities of Suicide

In the previouslymentioned text,T heD efinition ofSuicide, Shneidman(1985) distilled andcrystallizedhisthinkingaround the notion that'com-pleted suicides tendtoshare muchincommon. Specifically, Shneidman out-lined whathecallsthe 10commonalitiesofsuicide.Thesecommon charac-teristicsinclude the following: .:

1. The common stimulusinsuicideisunendurable psychologi-calpain.2 . The common stressor in suicide is frustrated psychological

needs.3. The common purpose of suicide is to seek a solution.4. Thecommon goalofsuicideis thecessationofconsciousness.5.'The common emotion insuicideis hopelessness-helplessness.6. The common internal attitude toward suicide is ambivalence.7.The commoncognitivestateinsuicideisconstriction.8. The common interpersonal act in suicide is communicationofintention,9. The common action insuicideisegression.10. The common consistency in suicide iswith lifelong coping

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The fieldofsuicidologyfor man y years has struggled to define the charac-teristics (e.g., risk factors)that are consistent across suicides while simulta-neouslyworking toward understanding in divid ualdifferences in the pursuitofcreating typologies, subtypes, or m akin g sense of atypical suicides. In the midstofthisstruggle, Shneidman's10 commonalitiesprovide a relatively concisewaytothinkabouta coherent coreofinterrelated constructs that define, orga-nize,and synthesizethe essential psychologyofvirtuallyevery suicid al act.Among the 10comm onalities, thesev enth specifically speaksto cogni-tionas itpertainsto thecompletion ofsuicide. Com men ting onthis particu-la rcom m onality, Shneidm an (1985) said,

I am not one whobelievesthatsuicideisbest un derstoodas apsychosis,a neurosis,or a character disorder. Ibelievethat it is much more accu-ratelyseenas amoreo rless transie nt psycholog ical constriction of affectand intellect.Synonyms fo rco nstriction are a tunneling orfocusingornarrowing of the range ofoptions usually availableto that indiv idua l 'sconsciousness when th e mind is not panicked into dichotomous think-ing:either some specific (almost magical)totalsolution orcessation;a llornothing ... therangeo fchoices hasnarrowedtotwonot very muchofa range. The usual life-sustaining images of loved ones are not disre-garded;worse, they are not even w ithin the range of wh at is in the m ind,(pp. 138-139)

CognitiveConstrictionShneidman's theoreticalworkandelaborationsoncognitive constric-tion are among his most enduring contributions. When Shneidman talksabou t the logic of suicide , the critica l role of cog nitive c onstriction is read ilyapparen t. In m any of his works, Sh neidm an endeavored to identify,describe,andportraythenature andprocessesofconstricted suicida l thinking a tun-neling and narrowing of perspective, a dangerous reduction of the person'srange ofproblem -solving options (e.g., Shneidm an, 1993). In his descrip-tion of psychological my opia, Shneidm an depicted an insidious processwh ereby constricted dichotomous think ing leads the suicid al person into adespe rate psychological space. Closelyconnectedto thedan gerous psycho-logical state of cognitiveconstriction is Shneidman's notion of perturba-tion.ForShneidman(1993), th econceptofpertu rbatio n m ost directlyandprincipal ly refers to a state of being em otionally upset, disturbe d, and dis-quieted often a state most notable for its proc livity foraction. In relationto suicide, perturbation also implicates cognitive constriction wherein heargues that acute suicidal states are dr iven by this intense penchant forself-harm or ill-advisedaction. In this state of emotional upset, cognitiveconstriction often contributes to a rapid reduction and deconstruction ofthe patient 's perceptual and cognitive range ofproblem solving, resultingin black-and-white dichotomous thinking (e.g. , endless suffering vs. im-mediate and eternal relief).

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S h n e i d m a n ' s C u b i c Modelo fSuicidePress ( s t ress )

Pain( p s y c h a c h e ) g

C o m p l e t e dS u i c i d e

lo wPer tu rba t ion

(Shne idm an ,1987)Figure2 1 Shneidman's cubicmodelofpain-press-perturbation. From APsychological ApproachtoSuicide, by E. S.Shneidman, 1987,in G . R.Vandenbosand B. K.Bryant (Eds.),Cataclysms, Crises and Catastrophes:PsychologyinAction. Washington,DC:American Psychological Association.Copyright1987by the American Psychological Association.

The CubicModel of SuicideShneidman's (1987) cubic model ofsuicide conceptualizes suicidalbe-haviorsasoccurringfrom aconfluenceofthree psychological forcesthatex-is tonthreeaxes.Asshown inFigure2.1,the firstaxisinthis cubic modelisunbearable psychological pain (thepreviously mentioned core notionofpsychache)thatcan beratedfrom lo w(.1)to high(5).The second axisisthatof unrelenting psychological pressures (refer to Murray's 1938notion of presses )orstressorsthatcan berated fromlow tohigh (1-5).The thirdaxis is the previously mentioned perturbation construct, also rated from lo w

tohigh (1-5).Within this cubic model, Shneidman assertedthatevery sui-cidal person completes the act ofsuicidebybeingat themaximum levelsofpain, press,andperturbationthe 5-5-5 corner cubelet.of the model. Heallowedthatnotevery personwho is inthis cubelet will necessarily commitsuicideb utinsistedthatevery personw hocommits suicideispsychologicallyinthis cubeletat the timeof theact.

One of theessential virtuesof thecubic modelisthatitcreatesathree-dimensional methodofconceptualizing suicidal behavioral events.Thismodelmakesclearthatsuicidal behaviorsarefundamentally situation specific;thereisalwaysasynergyofevents, circumstances, psychological suffering, and up-setthatcome togetherat acriticalpointintimetocreatealethalbehavioralmoment. Withinarelatively simple three-dimensional model, Shneidmandescribed whathebelieves createsthedecisive suicidalact.In sodoing,hemoved usbeyond exhaustive one-dimension listsofsuicide risk factorsthat

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actually predict very l i tt le. Conceptually sophisticated, comprehensive, re-sea rchab le , and c l i n i ca l ly useful , the cu b ic m ode l i s em blem at i c o fShneidman'swork.AphorismsofSuicide

Shneidman (1984) has offered arange ofaphorisms pertaining tosui-cidethatarenotewor thya ndprovidefurther theoretical insighton hisgen-eralviews about suicide.1A lthoug h we do not recount all 2 0 of his originalaphorisms,a few arepart icular ly notable as weround out our considerationof his theoretical contributions. For example, consider th e following fouraphorismsofsuicide:

1. There are two basic, albeit contradictory, truths about sui-cide: (a ) suicide should never be completed when one is de-pressed (o r perturbedor constricted); and (b) almost everysuicideis com pleted for reasons that m ake sense to the person

. who doesit. ' . . .2 . The p rim ary thoug ht disorder in suicide isthatof a pathologi-cal narrowin g of the mind'sfocus, called constriction, whichtakes the form ofseeing only tw ochoices: either som ething

painfully unsatisfactory or cessatipn.3. There is noth ing intrinsically wrong (or abe rrant) in think-in gab out suicide; i t is abno rma l only when one thinks thatsuicide is the onlysolution.4.. The chief shortcoming ofsuicideisthatit unnecessarily an-swers areme diable challenge witha permanent negativeso-lution.Incontrast, livin gis along-termset ofresolutions w ithoftentimes onlyfleetingresults.

SHNEIDMAN' S RESEARCH CONTRIBUTIONSRELATED TOCOGN ITIONAN DSUICIDEAlthough Shneidm an is perhaps best known for his theorizing and hiscontributions toclinical w ork withsuicidalpatients, he hasbeen an activeempirical researcher throughout his career. Indeed, his research contribu-tions are considerable, and his research and theories h ave sparked add itionalem pirical wo rk am ong m any other suicidologists as we ll. Altho ugh not all ofShneidman's research bears directly on the study ofsuicideand cognition,

we have opted to present a broad ov erview of his research to con textu alizeth e cognitive aspects of his work. As noted further on, Shneidman's firstempirical researchw as in psychological assessment, but for ourpurposes webegin our discussion wh ere we began this cha pter, e xam ining his initial em-piricalw ork w ith No rm an Farberow in the study of suicide notes.36 JOBESANDN EL SON


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Suicide NoteResearchAs p reviously noted, Shneidm an's formal work in suicidology began in1949 wh enhediscovered.a troveo fsuicide notes in the LosAngeles Co unty

Coroner's Office. What he latercalled ascientist's dream, Shneidmanquickly realizedthat suicide notes held a wealth of extraordinarily usefulinform ation abo ut the inherent na ture of suicide in the preciousfinal m o-mentsthatpreceded self-inflicted suicidal d eath.Intheirfirstcontrolled studiesofsuicide notes, S hneid m anandFarberow(1957a, 1957b) developed m ethodologies th at u ncovered critical early psy-chological know ledge abo ut suicide. In their studiescomp aring genuine ver-sus simu lated suicide notes along w ith studies using other methodologies,these early pioneers in suicidology foun dthathate directed toward othersandself-blame werebothevident in the notes they studied.Theirinvestiga-tions of suicide notes show edthat suicidal persons were deep ly amb ivalent.M oreover , within th econtext of this ambivalence, suicide could beunder-stood as the turning of outw ard mu rdero us impulses against the self. Wishesand needs that had previo usly been directed against a traumatic event ortoward someone who had rejected th e suicide completer w ere inverted anddirected at the self. Thus, suicidewasund erstood as aform ofveiledorovertaggressionagainstthe self murderin the180thdegree (Shn eidm an, 1985).Shneidman and Farberow (1960) went on to further analyze 948sui-cide notes ob tained in a3-ye ar periodin the Lo sAngeles area. They deducedthatthe reasons indicated for suicidevarywith the type of area in wh ich theperson lived. In Area Ty pe I (m ost advantaged su bu rbs), the su icide notesdepicted people who were tired of life; in Area Type III (most advantagedapa rtme nt a reas), the notes frequently noted illness as a reason for suicide;Area II was unrem arkab le. Shneidm an and Farberow concluded that thosefrom m ode rately adv antag ed areas expressedthemost emotion intheirnotesand might have benefited most from psychotherapy.Those from the leastadvantaged areas seldom gave reasons fo r their suicidebut usually gave in -structions fo rdispositionof their corpse or their estate. (A little-known an-ecdote:In the early 1990s, Shneidman returnedto the LosAngeles Cou ntyCoroner's Office to determine whether th e contents ofsuicide notes hadchanged. Heconcluded that they essentially hadnot; Sh neidm an, 1996b.)Shneidman also researched the actualwrit ingo fsuicide notesand howthey may or may not predict a completed suicide. In 1973, Shneidman de-scribed suicide notes as dull and poignantly pedestrian (p. 390 ). H e sug-gestedthatapersonwhocould w riteameaningful suicidenotewouldnot b ein the p osition of com pleting suicide. In a similar vein, Sh neidman (19 72 )presented samplesfrom 100self-ob ituaries elicited from college students in1969. He concluded that the young have difficulty in objectifyingthem-selves orseeing themselves asdead,asevidenced bytheir difficulty in com-pleting t h e task.

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Descriptive-RiskFactor StudiesIn 1966, Farberow, Shneidman, and Neuringer established that sui-cide-significant variables werefound in the life history and hospital records

of2 18male m ental hospital patientswho had completed suicideincomp ari-sonto 220 controlpatients.Theydetermined thatthe following areas coulddiscriminate betwe en the two groups: population characteristics, diagnoses,early childhood, marital histories, educational achievements, military his-tory, and prehospi ta l and hospita l diff icul t ies . In 1955, Farberow andShneidmanreviewedanamnesticandpsychiatric dataforattempted,threat-ened, and completed suicide cases. They concluded that the dangerousp a-tient, suicidally speaking , is the one w ith a h istory of previou s suicidal at-tempts or threats, and that th e most dangerous period iswhen th e patientappears tohaverecovered, anotionthat foreshadowed solid empirical evi-dencethatw ould appear decades later (e.g., Joiner, R udd , Ro uleau,& Wagner,2000).E isenthal, Farberow, and Shneidm an (1966) conducted afollow-upstudyof912patientsin a VAN europsychiatric Hospital who hadbeenplaced onsuicide observation statusfrom 1954 to 1958. Complete data were obtainedfor 90% of the patients. Forty percent of these patients manifested furthersuicidalbehavior, 6% com pleted suicide, 17% made nonlethal attempts, and17% reported suicidal ideation. Suicide history, demographic information,andpsychiatric hospitalizationdid not discriminateany ofthese group s.Theresearchers concludedthatth e abilitytopredictasuicidewas am odest8% to13%, whereas the best predictors for an attempt ranged from 23% to 29%.They concluded that in this particular population, suicide is more likely tooccurthanin thepsychiatric hospitalorgeneral population (Eisenthale tal.,1966).Terman Longitudinal Data

Shneidman used a data set archived by the MurrayCenteroriginallycollectedbyTerman(1922 )and hisco llaborators (Terman,Sears,Cronbach,& Sears, 1922) tostudysuicidein the intellectuallygifted. Usinga method-ologythatincluded teacher no minations and intelligence testing, 1,470 chil-dren in California with an IQ of 135 or greater were selected fo r fur therstudy. From 1927 to 1928, 58 siblings of the participants were added as acomparison control group.Of the 1,528 participants in the study,856wereboysand 672w ere girls;the average date ofbirthfor the samplewas1910. In1922,parentsfilledout an extensive questionnaire describing the child's birth,previous health, education, social experiences, interests, and conduct. Thechildren's teachers filled out acomparable questionnaire. The children tooka battery ofintelligence, achievement,and personality tests and answeredquestionn aires abou t their interestsand their knowledgeon arangeo fissues.38 JOBESANDN ELS ON


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Comparable data were subsequently collected at 4-year intervals. In 1972,1977,and 1982,the follow-updatacollectionswere increasingly oriented to.problemsof aging^ issues oflifesatisfactions, retirement, living arrangements, health, and vitality.The data collected in 1986 included questions aboutchanges in well-being, time use, importance of religion, perspectives on lifeaccomplishments, and changes in familyrelationships,concerns,and goals.Shneidman(1971) analyzed 30 casesfrom this data set for which longitudi-nal personality data were availablefrom 1921 to 1960. All individuals stud-ied were male Caucasians with high IQs. Five had died by suicide (all bygunshot), 10 (matched) individuals had died natural deaths from cancer orheartdisease, and 15 were still living. A blind clinical analysis was conductedprimarilyintermsof two ofShneidman's guiding conceptsperturbation andlethalityby means of a Meyerian lifechart and a psychological autopsy,respectively. Results indicated that fourof the fiveindividuals deemed to bemost suicidal had, infact, completed suicide,achanceprobabilityof 1 but of1,131. Shneidman concluded that some, prodromal clues to thesesuicideswereinstability, trauma,andcertain personality traits.The roleof the sig-nificantother and the burning out ofaffectseemed prominent. Hefurtherconcluded thatasuicidein a50-year-old person couldbeseenas adiscern-ible part of a lifestyle, as well as a predictable outcome, by the time thatperson is 30 years of agea precursor to Maris's (1981) notionof the suicidalcareer. .; .Psychological Testing '

Shneidmanbecame deeply involved in personality testing research inthe early stagesof hisprofessional career.He wasparticularly interested inproject ivepersonality assessmentandeven inventedhis owntest called theMake-A-Picture Story (MAPS). The MAPS test (Shneidman, 1949, 1952)wasdeveloped to assist the practitioner in arriving at differential diagnosesandleadto adeeper understandingofindividual psychodynamics.The basictestmaterial of the MAPS consists of 21 background pictures printed achro-matically on thin cardboard and 67 figures and wasused with adolescentsandadults. Shneidman himself used this extensively (e.g.; Shneidman, 1948a,1948b); others (e.g., Heuvelman &Graybill, 1990; Nueringer&Orr, 1968)appliedthe MAPS testtovarious studiesofpsychopathology.

Shneidman's first study using MAPS analyzed.the formal responseso f50normaland 50psychotic individualsto the MAPS test.Theseresponseswerecompared on the basis of approximately 800 signs, such asfigurenum-ber, repetition, placement, selection, interaction signs, activity, meaning,chronology, background, and time. Of the approximately 800 signs, 64 dif-ferentiatedthenormal andpsychotic groupsat the 10%levelofconfidence.On thebasisofthese significant signs, Shneidman (1948a) concluded thatschizophrenia can be extremely variable and that there is evidence of ex-



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treme interest in the.self, social isolation, and an absence of being boundedby th e dictates ofreality.H is research showedthat individuals with schizo-

phrenia overused symbols, inhibited and repressed aggression,had anxietyand fearfulness, and (among male patients) lacked identification with themalerole and had a tendency to debase or degrade women.In 1986, Shneidman gavetheMAPS Test to 14undergraduateswhowerestudied intensively at theHarvard Psychological Clinic byHenry M urrayandhiscolleagues durin gtheyearsfrom 1959to 1962.Aprotocolof aHarvard seniorwas presented to illustrate the use of the MAPS in drawing inferences aboutpersonalitycharacteristics suchasaggression, soc iability,and achievement.In terms of other personality assessment research, Shneidman andFarberow (1958) began to lookat data from patients' responses to the The-matic Apperception Test (TAT) and how this assessment tool related tosuicidality.Theydraftedthe firstreportof the resultsof TAT dataobtainedfrom-patientsw ho either attem pted or completed suicide and compared themwith similar data obtained from nonsuicidal patients. They concluded thatexclusiveuse of the TA T could not successfully discrimina te suicidal versusnonsuicidal patients.As wehave discussed prev iously , Shn eidman's theoretical workonpsy-chological p ain an d suicide is one of his central and lasting co ntribu tions(Shneidman, 1996b).To this end, Shneidman.developed the PsychologicalPain Survey in an attempt to measure or quantify psychache (Shneidman,1993).To create this assessment approach, he used the Method ofPairedCom parisons, in which an inciden t, such as one from aNazi concentrationcamp, iscited as ananchorpoint ofextreme psychological pain and thesui-cidal person is asked to rate his or her own psychache compared with theincident (Shneidman, 1993, 1999).The suicid al person ratesthe psycho-logical pa in of aperson in variou s stimulus picturesofsuffering individualson aL ikert scale from 1 to 9. The individualthen rateshis or her ow npainon' the same scale using comparison ratin g as a psychological reference poin t.Outgrowthsof Shneidman's TheoryandResearch

Dozens ofempirical studies have d rawn directlyfrom Shneidman's ear-lier theoretical and empirical work.Forexample, a considerable amount ofempiricalwo rk has been done on suicide notes, as well as Shneidm an's no-tions ofpsychache, the 10comm onalities ofsuicide,and the cubic modelofsuicide, to name but a few ofShn eidman's ideasthat have spawned linesofempiricalinquiry.Su icide notes continue to be a rich source of data on the psychology ofsuicide. For example, Leenaars has conducted a series of studies over theyearsusinga nd e xtending v arious methodologies developedby 'Shneidmanand Farberow (Leenaars, 1988a, 1989). Som e m ore recent studies hav e con-tinued toexpand on ideas originally developedinShneidman's early workin40 . JOBESAND NELSON


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this area (e.g., Baueret al., 1997; Black, 1993; Diamond, More, Hawkins,&Soucar, 1995;O'Connor&L eenaars, 200 3).An excellent exam ple of recent em pirical wo rk inspired by Shn eidman'stheorizing inpsychological pa in comesfrom D r.IsraelOrbachandcolleagues( O r b a c h , M i k u l i n c e r , G i l b o a -S e h e c h t m a n , & S i ro ta , 2003; Orbach,Mikulincer, Sirota, & Gilboa-Schechtman, 200 3).These researchers haveconducted a series of studies using factor analysis to stu dy intensively thenature of psychological pain and how such pain differentiates suicidal pa-tients from other clinical samples. Additional interest and empirical workusing the psychache construct can be seen in other recent work; For ex-amp le, Berlim et al.(200 3) have examinedthe roleo fpsychache in asampleofsuicidaloutp atients with mood disordersinBrazil,andZim merm an (1995)studiedpsychache to .determine whether itcovaries w ith social welfare andsuicide rates. Variousstudiesofcom mo nalities across suicides have appeared through-out the l i terature. For example, although certain patterns of constructs inyoung adults ' suicidesmay differ psychologicallyfrom older adult patterns,significant commonal i t ies ofsuicidecu t acrossthe adul t life span (Bauer etal.,1997; Leenaars, 1988a). However,Werth (1996) hasdirectly challengedShneidman's list of 10com mo nalities and assertedthat it isinherently bi-asedagainst allowingfor the possibilityofrational suicide.

Jobesand colleagues (Jobes,Jacoby , Cimb olic, & H ustead, 1997) usedavarietyofideasfrom Shneidman's workin their development of the Sui-cide Status Form (SSF) and a subsequent use of the SSF in a clinical ap-proach called the Collaborative Assessment and M anagem ent of Su icidality(CAMS) ; refer to Jobes (2000) and Jobes and Drozd (2004). Indeed, Jobesaridcolleagues (2 004 )further studied qu alitative phenomenological descrip-tions of suicida lity as per w ritten responses to' incom plete sentencepromptsaboutasuicidal patien t's p sychach e, press,andpe rturbation.Theseresearch-ers have shown that open-ended patient-written descriptors ofthese con-structscan be reliably coded into m ean ingfulcontentcategories. M oreover,one recent clinical studyofvariousp sychological constructs has clearly shownthatpsychological painwasranked by asampleofsu icidal outpatients as thenumber one problem related to theirsuicidality (Jobes, 2 003).Shneidman isproba bly best knownfor his theorizingand clinical wis-dom on suicidal patients. A closer exa m ination of his extensive empiricalwork,ho we ver, revealsbothgroun dbreak ing methodologies and m any find-ingsthatpreceded more recent findingsin the contemp orary research l itera-ture. Perhaps even more valuable, his research and theories have sparkedadditionalfollow-up investigationsin.supportof his.work and have alsoledotherresea rchers to ch allenge some of his ideas aswell.N ot to acknowledgethe em pirical researcher in Shn eidm an is to miss a critical component ofwhat madehisscholarly contribu tionssoinf luential .



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SHNEIDMAN' SPRACTICE CO NTRIBUTIONSRELATED TOCOGN ITIONAN D SUICIDEA practicing clinician throughou t his professionallife, Shneidman has

written extensively about clinicalpracticewith suicidalpatientsandrecountednumerouscase exam ples througho ut his wri t ing.In examininghiswork,weagain find that Shneidman does not specifically and directly emph asize a cog nitive therapy appro ach w ith suicidal patien ts.Whenh isworkisexam-ined throug h a cognitive lens, howe ver, a great deal of his writin g on clinicalsuicidologyeith er dire ctly or in direc tly addresses and underscores cognitiveaspectsofsuicidality.Forexam ple, more than 2decades ago,he (1985) w rote,

The main point of wo rking w ith a lethally oriented person in the giveand take of talk, the advice, the in terpre tation s, the listening is to in-crease that individual 'spsycho logical senseofpossible choices . . .withthis inm indand keep ingin mind alsoth e four psychological compo-nents of the suicidalstateofmin d (heightened inimica li ty, elevated per-turbation , conspicuous constriction ofintellectualfocus, and the ideaofcessation as the solut ion)then a relatively simpleformula fo r treat-ment can bestated. . . .S imply put , the way to savea highly suicidalperson is to decrease the con striction , tha t is, to wid en the range of pos-siblethoughtsa ndfantasies (from th edichotomous two eitheronespe-cific outcomeordeathtoat least three ormorepo ssibilitiesfor an ad-mittedly less-than-perfect solut ion), most im portan t ly witho ut whichthe attempt tobroaden constriction willnot workto decrease theindividual'sper turbat ion , (pp .141-142)In this quote, we see Shneidman's clear emphasis on workingon thecognitive aspects of suicide; indeed, it seems to be q uite a central aspect tohis clinical approach. Across his writingon clinical practice with suicidalindividuals,Shneidmanhasadvocatedathoughtful, strategic,andincrementalapproach to pe rsuading, convincing, inviting, entreating , and cajoling th e

patient to reconsider suicide.The goalis tohelpthe patient tochart apos-siblenew course of action for dealing w ith the psychological pa in from thenecessity of death to the pos sibilities inheren t in a reconsidered life. In oureffort to elaborate on S hneidman's clinical contributions, we march ou r waythrough work related to the clinical applications of the 10com mon alities,the cubic model, psychotherapy maneuv ers, as well as Shneidm an's notionofpain-oriented psychotherapy , which he calls anodyne therapy.

ClinicalResponses to the 10 CommonalitiesIn relation to our earlier theoretical discussion of Shneidman's 10commonalities of suicide, Shneidm an (1985) noted the distinct clinical

implicationsof this theoretical work.As he observed, the 10 commonal i -

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EXHIBIT 2.1Shneidman's10CommonalitiesofSuicideCommonality Clinicalresponse

1. Stimulus (unbearable pain): Reducethepain.2. Stressor (frustratedpsychologicalneeds): llthefrustratedneeds.3. Purpose(toseekasolution): . Provideaviableanswer.4: Goal(cessationofconsciousness): Indicatealternatives.5. Emotion (hopeless-helpless): Givetransfusionsofhope.6. Internal attitude (ambivalence): Playfortime.7. Cognitive state (constriction): Increasethe options.8. Interpersonalact N(communication ofintent): Listento thecry,involveothers.9. Action (egression): Blocktheexit.10.Consistency (with lifelong Invokepreviouspositivepatterns): patternsofsuccessfulcoping.

ties (see Exhibit 2.1) have obviousand practical clinical implicationsforsaving a life.Shneidman (1980) observedthatsuicidal patients areinvariably keenon doing something.Knowing this simplefact iscritical to shaping clinicaltreatment with suicidal patients. In Shneidman's view, the clinical suici-dologist should not be at allhesitant to go about doing anumber ofsuchsomethings toavertasuicide. Clinically responding to the 10commonali-ties listed earlier isvery much inthatspirit.The CubicModeland Clinical Intervention

The clinical application of thecubic modelofsuicideis auniqueway ofclinically understanding anacuteand lethal psychological state (the5-5-5.cubelet ) . In this regard,the clinical implications of this simple model areself-evident.Namely, whentheclinician does virtually anythingtohelp movea suicidal patient figuratively out of the comercubeletof the model, thenthatpatient isshifted in asignificantly less dangerous psychological space.Clinically targetinganddecreasing psychological pain (e.g., with talk therapy),orchestrating areduction of feltpresses (e.g.,achange in job or amedicalleavefrom college),andameliorating perturbation (e.g., with medication oracalming influence) can be asignificantan dpotentially life-saving clinicalresponse (Shneidman, 1980;seealsoacase examplebyJobes&Drozd, 2004).PsychotherapeuticManeuvers

In manyof hiswritings, Shneidman hassaidthatthesuicidal patientdemands (and should in turn receive) a different kind ofclinical relation-ship. Indeed,asShneidman (1985) himself said,



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W orking witha highlysuicidal person demands adifferent kind of in-volvement.Theremay be an important conceptual difference betweenordinary psychotherapy withindividualswheredyingo r livingis not theissueandpsych otherapy w ith acu tely suicidal personsasthere isbetweenordinarypsychotherapyan d ordinary talk. (p . 141)W e wan t to underscore Shneidm an's emphasis (within reason) of psy-

chotherapeutically going the extra m ile for the suicidal patient. H e has vig-orouslyarguedfor astrategicand incremental kind ofcl inical m aneuvering.Indeed,in hisbook TheSuicidalMind, Shneidman (1996a) dedicatedan en-tire chap ter todiscussing2 4psychotherapeutic m aneuvers that th e cliniciancan use to match clinical treatm ent to a suicidal patient 's idiosy ncraticfrus-trated psychological needs. Examples of these maneuvers include establish,explain,arrange fo r,monitor,andexploretonamebut ahandful. In this fash-ion, Shneidman made it clear thatthe suicidalpatient gets fundamentallystuck in his or her psychologicalsuffering, wherein cognitive constrictionandperturba tion come together tobecome th e figurative lethal psychologi-calnoose closing aroundthe neckof thepatient.To appro priately respond,the clinician m ust respond decisive ly. In 1985, Sh neidm an said,

the way tosaveaperson's life is to dosom ething. Those somethingsincludeputt ingthatinformation (tha t the person is in trouble w ith him -self) into th e stream of communicat ion, let t ing others know about it ,breakingw hat could be a fatal secret, talking to the person, talkingtoothers,profferinghelp, ge tting loved ones interested and responsive, cre-ating action around the person, showing response indicating concern,and, ifpossible,offering love. (pp.142-143)Again,at theriskoftakingcertaininterpretivelibertiesto keep withinthe focus of th i s text , an othe r way of un de rs ta nd ing th i s aspect ofShneidman's clinical approach is to think of it as a version of cognitiverestructuring and problem solving.With his overt emphasison clinically

addressingcogn itive constriction-dichotbm ous think ingandact ive behav-ioral interventions, Shneidman can at t im es sound a bit like acognitive-behaviora l enthus ias t . However , g iven that Shne idman is a protege ofpersonologist Henry Murray , there is no inconsistency here; this pa rt icularcognitive aspectofShneidman ' s th inking issimply apar tof am uch largerpsychological consideration of the w hole (su icid al) person. The po int isthatShneidmanwas among the first to argue for a fundam ental ly differentkind of clinical approach when one encounters a suic ida l pa t ient . In thisregard, he changed th e thinking of his contemporaries and thereby influ-enced manyotherc linician-scholars w hofol lowed .Pain-Oriented Psychotherapy

It is fi tt ing to end our chapter with a discussion of Sh neidma n's (2 001 )relatively recent bottom -l ine thinking about psychotherapy w ith suicidal44 JOBESA N DNELSON


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individuals. Specifically,we are referring to hisconcept ofanodyne therapy.Thisapproachto psychotherapy once again emphasizesShneidman'skeeninterest in psychological needs an d his prima ry preoccupation w ith psycho-logical pain (i.e., psych ache)as itpertainstosuicidality. Shneidman (2 001) 'summarized the essenceof hisapproach asfollows:Ibelievethatthe ruleforsavingalife inbalance'can, amazingly enough,

be rather simplyput: Reduce the inner pain.Whenthat isdone, thenth e inner-felt necessity to suicide becomes redefined, th e me ntal, pres-sure islowered,and the person'can choose tolive. ... Ibelieve that,,inlargepart, psychotherapy consistsinhelping th e patient reconceptualize

the can'ts, the won'ts, the absolutes, and the rion-negotiables of the.patient's presentfirmlyheld positions; to widen the stub bornlyfixedblind-erso fpresent perceptions; tothink the unthinkable, (p. 201)Thetherapeutic cognitiverestructuring and astrategicclinicaleffort to

shift and change the thoughts and perceptions of the suicidalpatient areobvious. . . . .AsdescribedbyShneidman (2 001),anodyne refers to an agent (a be-nign individual acting as helper) that relieves pain (p. 2 02 ). M oreover,Shneidman assertedthat the goal of anodyne therapy is not necessarily thecureof m ental disease; rather, the emphasis of this approach is on the sooth-ing of the suicidal person's psychological pain. A lthough anodyne therapyrecognizes the fundamental importance offrustrated psychological needsasparto f the etiologyofsuicidality,the treatment ispositively oriented inthat itseeksto liberate th e individualfrom narrow, truncating, unhealthy, life-endangeringviewsofthe -se l f (p.2 02 ) .Given Shneidman's insistence that allsu icides stem from intolerablyfeltpsychache arid the related pa in source of un m et psychological needs, theclinician's role issimply to serve-asan anodynea personwhohelps relievefelt pain.When clinicians position themselves in such a waythat they ad-dressandrespond to the essential psychological needsthatareidiosyncrati-callydistressing to their patierits,then heightened perturbation willlessen,th e heed fo rescape maydecrease,andpatients m aythus be in aposition tochoose to live. Thisnotion essentially captures more than 50 yearsofShn eidman's clinical w isdom on h ow one best works clinically w ith a sui-cidal person. . ' ' '

, CONCLUSION ' : .

Throughout this chapter, wehave endeavored to revealth econsider-able contributions of acom pletely orig inal -thin ker , scholar, scientist, andclinician. Although we areobviously great admirersof Dr.Shneidman's w ork,.wehave nevertheless sought to present his contributions in theory, research,andpractice in abalanced and objectivemanner.W e have quoted his own . ' S H N EI D M AN ' S CON T RIBUT ION S '. 45


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wordsatlengththroughoutthischapter toprovideawindowintothe way hethinksand togivethereadera clearer sense of howShneidmanputsthingswith his own sense of panache and his idiosyncratic style of writing.Shneidmanloves ideas, words,and findingdistinctive waysofsayingimpor-tantthings.As the founder ofmodern-daysuicidology,Shneidman'slegacyisrichand hasspurreda vibrant field thatworkstoadvanceon many frontsincludingthoseconsideredhere(i.e.,theory,empiricalscience, andclinicalpractice). Asnoted throughoutthischapter,eventhoughShneidmandoesnot considerhimselfacognitivistper se, this currentvolumeon cognitionand suicidewouldbenotablyincompletewithoutdulyconsideringhiscogni-tion'related contributions.Indeed, muchof hisworkdirectly bears on thetopic athand,and additionalaspectsof hisworkhavefurther relevanceandmeaningwhenreexaminedthrougha cognitive lens.

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Contribuciones de Shneidman Al Pensamiento Suicida