Journal of Affective Disorders 144 (2013) 148–152

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Journal of Affective Disorders

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Research report

Reasons for suicide attempts in a clinical sample of active duty soldiers

Craig J. Bryan a,n, M. David Rudd a, Evelyn Wertenberger b

a National Center for Veterans Studies, The University of Utah, Salt Lake City, UT 84112, USAb Fort Carson, Colorado (CO 80913), USA

a r t i c l e i n f o

Article history:

Received 24 April 2012

Received in revised form

18 June 2012

Accepted 20 June 2012Available online 1 August 2012

Keywords:

Suicide

Military

Functional model

Motivation

27/$ - see front matter & 2012 Elsevier B.V. A

x.doi.org/10.1016/j.jad.2012.06.030

esponding author.

ail addresses: craig.bryan@utah.edu,

yan@psych.utah.edu (C.J. Bryan).

a b s t r a c t

Background: Self-reported reasons for suicide attempts were examined in a sample of active duty

soldiers who had attempted suicide using a functional approach that classifies suicidal behaviors into

four primary functions of reinforcement: automatic negative (AN-R; to reduce aversive internal

experiences), automatic positive (AP-R; to generate desired internal experiences), social negative

(SN-R; to avoid aversive contextual demands), and social positive (SP-R; to generate desired environ-

mental contexts). Based on previous theory and research, the authors hypothesized that soldiers would

attempt suicide primarily to reduce aversive internal experiences (i.e., AN-R).

Methods: 72 soldiers (66 male, 6 female; 65.3% Caucasian, 9.7% African-American, 2.8% Asian, 2.8%

Pacific Islander, 4.2% Native American, and 9.7% ‘‘other’’; age M¼27.34, SD¼6.50) were interviewed

using the Suicide Attempt Self Injury Interview to assess suicidal intent, method, lethality, and reasons

for attempting suicide.

Results: Soldiers endorsed attempting suicide for both automatic and social reasons, with multiple

functions being endorsed in 95% of attempts. AN-R was endorsed in 100% of suicide attempts, and was

primary to other functions. Suicidal intent was weakly correlated with AN-R, AP-R, and SN-R functions

(rso .22), and medical lethality was very weakly correlated with only the SP-R function (r¼ .18).

Limitations: Small sample size and retrospective self-report methodology.

Conclusions: Soldiers attempt suicide primarily to alleviate emotional distress. Reasons for attempting

suicide do not correlate strongly with suicidal intent or medical lethality.

& 2012 Elsevier B.V. All rights reserved.

1. Introduction

Since 2004, the number of suicides by members of the U.S.Armed Forces has more than doubled, which has presented aparticularly vexing and frustrating problem for military leaders,mental health professionals, and suicide experts. Suicide attempts,which are defined as self-enacted, potentially injurious behaviorswith nonfatal outcomes for which there is evidence, whetherexplicit or implicit, of intent to die (Silverman et al., 2007), alsoappear to be increasing in frequency among military personnel,although estimates of this behavioral pattern are less reliable(Ramchand et al., 2011). Suicidal behavior is a problem that is notsolely confined to the military, however. Over 30,000 deaths bysuicide occur each year in the U.S., consistently placing suicideamong the top ten causes of death (Centers for Disease Control,2011). Nonfatal suicide attempts are much more common thansuicide deaths, with an estimated prevalence rate of 2.7% within theU.S. general population (Nock and Kessler, 2006). Suicide attemptsare the clearest and most robust predictors of future suicide deaths

ll rights reserved.

(Beautrais, 2004; Joiner et al., 2005; Ostamo and Lonnqvist, 2001)and are the closest behavioral pattern to completed suicide;improved understanding of suicide attempts can therefore providecritical information for understanding suicide deaths.

Traditional approaches for understanding suicidal behaviorhave primarily adopted a psychiatric syndromal model, whichfocuses on the classification and treatment of behaviors basedupon their topographical features, typically signs and symptoms ofassociated psychiatric disorders. In the syndromal approach, suici-dal behavior is generally conceptualized as a symptom manifesta-tion of the underlying psychiatric disorder (Jobes, 2006). Incontrast, a functional approach classifies and treats behaviorsaccording to the functional processes or underlying mechanismsthat activate and maintain the behaviors over time, which aretypically understood to be antecedent and consequent contextualinfluences (Hayes et al., 1996) that impact suicidal behaviorsregardless of the associated psychiatric condition. Although theuse of functional approaches has contributed to significantadvances in understanding and treating psychological and beha-vioral disorders, it has not been widely or systematically applied tounderstanding suicidal behaviors within the military. In order tosufficiently address the problem of military suicide, it is necessaryto first understand why service members attempt suicide.

C.J. Bryan et al. / Journal of Affective Disorders 144 (2013) 148–152 149

Nock and Prinstein (2004) have proposed four primary func-tions of nonsuicidal self-injury that differ along two dimensions:reinforcement that is positive (i.e., followed by a pleasant stimu-lus) versus negative (i.e., followed by the removal of an unplea-sant stimulus), and contingencies which are automatic (i.e.,internally-focused) versus social (i.e., externally-focused). Thesefour functions have also been identified among women withborderline personality disorder (Brown et al., 2002). In the currentstudy, we seek to extend this functional model to suicideattempts among active duty military personnel.

Automatic reinforcement contingencies include reasons forattempting suicide that are designed to modify or regulate one’sown internal psychological state. Automatic negative reinforcement

refers to attempting suicide for the purpose of reducing oralleviating unpleasant emotional or psychological states (e.g., ‘‘tostop bad feelings’’ or ‘‘to escape from my thoughts’’). Most leadingtheories of suicidal behavior are based in large part on this specificfunction, conceptualizing suicidal behaviors in large part or in fullas an attempt to reduce or escape intense psychological pain(Joiner, 2005; Linehan, 1993; Rudd, 2000; Schneidman, 1993).Supporting this claim are findings that the most common reasonsgiven for suicide attempts include dying and escaping/obtainingrelief from emotional distress (Boergers et al., 1998; Brown et al.,2002; Varadaraj et al., 1986). Automatic positive reinforcement

refers to attempting suicide for the purpose of obtaining desiredpsychological states (e.g., ‘‘to feel something, even if it was pain’’or ‘‘to punish yourself’’). In automatic positive reinforcement, theindividual seeks to create an emotional or psychological state, incontrast to automatic negative reinforcement, in which the indi-vidual seeks to remove an emotional or psychological state.

In contrast to automatic reinforcement contingencies, social con-tingencies include reasons for attempting suicide that are designed tomodify or regulate one’s external environment. Social negative rein-

forcement therefore refers to suicide attempts for the purposes ofavoiding interpersonal tasks or demands (e.g., ‘‘to get out of doingsomething’’ or ‘‘to get away or escape from other people’’). Within themilitary, this function is a source of particular concern to militaryleaders and medical professionals given that some service membersuse suicidal behaviors (or the appearance of suicidal behaviors) forthe explicit purpose of avoiding undesirable tasks such as reporting toduty, deploying, and continued service in the military. Unfortunately,despite general consensus that this is a very real issue and clinicalsituation for most military leaders and health care providers, thereare currently no estimates of how prevalent this particular function isamong service members who attempt suicide. Social positive reinfor-

cement refers to suicide attempts for the purpose of obtaining orcreating a desired environmental or interpersonal condition (e.g., ‘‘toget help’’ or ‘‘to communicate or let others know how desperate youwere’’). This fourth function, typically referred to by clinicians as‘‘manipulation’’ or ‘‘attention-seeking,’’ has similarly received littleempirical attention (Nock and Prinstein, 2004).

The primary aim of the current study was to examine thereasons for attempting suicide among a clinical sample of activeduty soldiers. Consistent with prior reports, we considered thefollowing hypotheses: (1) automatic negative reinforcementwould be the most frequently endorsed reasons for attemptingsuicide, and (2) relative to other functions, automatic negativereinforcement would be the primary reason for suicide attempts.

2. Method

2.1. Participants

Participants included 93 active duty soldiers referred for astandardized evaluation as part of a randomized clinical trial

testing a brief psychotherapy to reduce suicide attempts. Soldierswere evaluated within 48 h of discharge from one of several localinpatient psychiatric facilities due to either a suicide attempt oracute suicide risk. Of these 93 soldiers, 72 (77.4%) reported atleast one suicide attempt during their lives. Because the purposeof the current study was to identify reasons for attemptingsuicide, only these 72 suicide attempters were included. The 72suicide attempters were predominantly male (66 male, 6 female)and aged 19 to 44 years (M¼27.34, SD¼6.50). Participants hadbeen in the military an average of 5.45 years (SD¼4.01, range:1 to 19 years), and self-reported the following racial status:Caucasian (65.3%), African-American (9.7%), Asian (2.8%), PacificIslander (2.8%), Native American (4.2%), and ‘‘other’’ (9.7%).Separate from race, 22.2% reported Hispanic or Latino ethnicity.The majority of participants were married (53.5%), followed bysingle (18.3%), separated (14.1%), dating/engaged (7.0%), divorced(5.6%), and widowed (1.4%). There were no demographic differ-ences between those who had attempted suicide versus thosewho had never attempted suicide.

2.2. Procedure

Data were obtained from comprehensive evaluations adminis-tered to all soldiers participating in a clinical trial testing anoutpatient treatment to reduce suicidal behaviors. Participantswere referred upon discharge from inpatient hospitalization dueto acute suicide risk, and completed self-report measures andstructured interviews at intake and at 3- and 6-month follow-ups.The study was approved by the Institutional Review Boards of theMadigan Army Medical Center and the University of Utah.

2.3. Measure

The suicide attempt self-injury interview (SASII; Linehan et al.,2006a) is a structured clinical interview designed to assess thefactors involved in nonfatal suicide attempts and intentional self-injury, which can be used to differentiate suicide attempts fromnonsuicidal self-injury and/or other forms of deliberate self-harm.The SASII assesses factors including method, lethality, impulsivity,subjective versus objective intent, reasons for the attempt, andconsequences of the attempt. On the basis of all informationobtained, the evaluator classified the behavior as a suicideattempt (whether ambivalent or not) versus nonsuicidal self-injury, based primarily on the assessed level of subjective and/orobjective intent. A suicide attempt (regardless of level of ambiva-lence) was defined as a self-enacted, potentially injurious beha-vior with nonfatal outcome for which there is evidence, whetherexplicit or implicit, of intent to die (cf. Silverman et al., 2007). TheSASII has high interrater reliability (.871–.978, Mdn¼ .956) acrossthe assessor-related items. Very high consistency has been foundbetween retrospective (4þ months) report of suicide attempts bypatients as compared to weekly reports (ICC¼ .91), suggestingthat retrospective report is comparable to regular, ongoingreports of suicide attempts. Comparison of reports on the SASIIrelative to medical record verification has additionally supportedthe instrument’s validity in assessing medical lethality and out-come. In the current study, the SASII was used to assess up tothree distinct suicide attempts made during the assessmentperiod: the first attempt, the ‘‘worst point’’ suicide attempt (i.e.,the episode during which the patient most strongly desireddeath), and the most recent suicide attempt. In the current study,interrater agreement was assessed via review of assessment notesby a second rater. Raters agreed on the classification of suicideattempts in all cases in the current study.

Suicidal intent was assessed by asking participants to self-ratethe intensity of their desire for suicide during each attempt on a

Table 1Frequency of endorsed reasons for attempting suicide among 72 soldiers (n¼136

attempts).

Item n %

Automatic negative reinforcement (a¼ .82)

1 To stop bad feelingsa 136 100.0

30 To stop feeling sad 78 57.4

17a To get away or escape from your thoughts and memories 76 55.9

17b To get away or escape from your feelings 76 55.9

28 To obtain relief from a terrible state of mind 62 45.6

25 To relieve feelings of aloneness, emptiness or isolation 61 44.9

21 To stop feeling angry or frustrated or enraged 59 43.4

23 To relieve anxiety or terror 59 43.4

26 To stop feeling self-hatred, shame 57 41.9

17d To get away or escape from yourself 56 41.2

18 To stop feeling numb or dead 37 27.2

Automatic positive reinforcement (a¼ .44)

6 To feel something, even if it was pain 92 67.6

7 To punish yourself 29 21.3

12 To give you something, anything to do 21 15.4

C.J. Bryan et al. / Journal of Affective Disorders 144 (2013) 148–152150

scale ranging from 0 (‘‘not at all’’) to 6 (‘‘I was extremely serious,intended to die, and was not ambivalent at all’’). Medical lethalitywas rated by the evaluator using standardized criteria on a scaleranging from 1 (‘‘very low’’; e.g., less than or equal to 5 pills,scratching, head banging, etc.) to 6 (‘‘severe’’; e.g., pulling triggerof loaded gun aimed at a vital area, jumping from a high place,hanging). To assess the functions of each suicide attempt, parti-cipants were presented with a list of 33 potential reasons forattempting suicide then asked if each reason applied during thesuicide attempt being assessed using a dichotomous (yes/no)format. Brown et al. (2002) have previously organized thesereasons into four rationally-derived clusters that have showngood interrater agreement and which correspond to the fourfunctional categories described by Nock and Prinstein (2004):emotion relief (automatic negative reinforcement), feeling gen-eration (automatic positive reinforcement), avoidance/escape(social negative reinforcement), and interpersonal influence(social positive reinforcement).

11 To prove to yourself that things really were badb 12 8.8

Social negative reinforcement (a¼ .48)

17c To get away or escape from other people 56 41.2

8 To get a vacation from having to try so hard 53 39.0

17 To get away or escape 51 37.5

20 To prevent being hurt in a worse way 29 21.3

24 To distract yourself from other problems 16 11.8

9 To get out of doing somethingb 14 10.3

Social positive reinforcement (a¼ .73)

2 To communicate or let others know how desperate you

were

94 69.1

27 To express anger or frustration 34 25.0

3 To get help 31 22.8

15 To make others better off 23 16.9

22 To demonstrate to others how wrong they are/were 22 16.2

29 To make others understand how desperate you are 20 14.7

4 To gain admission into a hospital or treatment program 19 14.0

14 To get back at or hurt someone 17 12.5

10 To shock or impress othersb 10 7.4

13 To get other people to act differently or changeb 5 3.7

a Item not included in reliability estimation due to 100% endorsement,

resulting in zero variance.b Items not included in reliability estimation due to very low endorsement

rates, which resulted in unstable estimations.

Table 2Means, standard deviations, and intercorrelations of reasons for attempting

suicide among functional domains.

Function # reasons

endorsed M (SD)

% reasons

endorsed M (SD)

A-NR A-PR S-NR S-PR

A-NR 5.57 (.26) .51 (.27) a,b,c –

A-PR 1.13 (.08) .28 (.24) a,d .33nn –

S-NR 1.71 (.10) .29 (.20) b,e .61nn .44nn –

S-PR 2.02 (.16) .20 (.19) c,d,e .38nn .40nn .47nn –

nn po . 001; means denoted by a shared superscript significantly differ from

each other at po .001; A-NR¼automatic negative reinforcement; A-PR¼auto-

matic positive reinforcement; S-NR¼social negative reinforcement; S-PR¼social

positive reinforcement.

3. Results

The mean number of attempts in the current study was 2.01(SD¼ .96, Mdn¼2), with a range from zero (21.7%) to five (1.1%),for a total of 136 suicide attempts by the 72 participants. Themethods of suicide attempt were, in descending order of fre-quency: drugs/medication overdose (36.0%); scratching/cutting(20.6%); firearm (18.4%); hanging (8.8%); transportation-related(4.4%); jumping (2.9%); alcohol consumption (2.9%); asphyxiation(2.2%); drowning (1.5%); and poisoning/caustic substance, step-ping into traffic, and ‘‘other’’ (.7%).

3.1. Reasons for attempting suicide

On average, participants reported a mean of 10.43 reasons forattempting per attempt (SD¼5.48, range: 1 to 29). Participantsreported a mean of 5.57 (SD¼3.00) automatic negative reinforce-ment, 1.13 (SD¼ .95) automatic positive reinforcement, 1.71(SD¼1.21) social negative reinforcement, and 2.02 (SD¼1.88)social positive reinforcement reasons per suicide attempt. Thefrequencies of each reason reported by participants for attempt-ing suicide are listed in Table 1, organized according to the fourfunctions. Internal consistency estimates for each of the fourfunctions were, in descending order,.82 (automatic negativereinforcement),.73 (social positive reinforcement),.48 (socialnegative reinforcement), and.44 (automatic positive reinforce-ment). The single most commonly reported reason for attemptingsuicide, endorsed in 100% of all suicide attempts, was ‘‘to stop badfeelings’’. Four items were each endorsed by fewer than 10participants (‘‘to prove to yourself that things really were bad’’,‘‘to get out of doing something’’, ‘‘to shock or impress others’’, and‘‘to get other people to act differently or change’’). The mostcommonly reported function for suicide attempts was automaticnegative reinforcement, which was endorsed in 100% of suicideattempts, followed by social negative reinforcement (82.4%),social positive reinforcement (80.1%), and automatic positivereinforcement (72.8%).

The relative frequency of each of the four functions was nextevaluated by summing the total number of reasons endorsedwithin each functional category, then dividing by the totalnumber to obtain the mean item response for each function(see Table 2). A repeated measures analysis of variance indicateda significant overall difference among the functions’ meanscores, F (3, 133)¼62.977, po .001, partial h2

¼ .587. Post-hocpaired t-tests indicated that a significantly greater proportion ofreasons from the automatic negative reinforcement function was

reported relative to all other functions (pso .001, ds41.50), and asignificantly smaller proportion of reasons from the social posi-tive reinforcement function was reported relative to all otherfunctions (pso .001, ds4 .60) with the exception of automaticpositive reinforcement (p¼ .903, d¼ .16). Results remainedunchanged when controlling for the effects of gender, F (1,134)¼ .114, p¼ .736, partial h2

¼ .001).We next sought to determine the nature of co-occurring

functions within a given suicide attempt. The number of reasonsendorsed within each of the four functions were moderatelycorrelated with each other (rs4 .33), suggesting that as the

C.J. Bryan et al. / Journal of Affective Disorders 144 (2013) 148–152 151

reasons for attempting suicide increased in one domain, theytended to increase in other domains as well (see Table 2). Of the136 assessed suicide attempts, only 7 (5.1%) were associated withreasons from only one functional domain (i.e., the automaticnegative reinforcement), 16 (11.8%) were associated with reasonsfrom two domains, 35 (25.7%) were associated with reasons fromthree domains, and 78 (57.4%) were associated with reasons fromall four domains. Co-occurrence of multiple domains in general,and with automatic negative reinforcement in particular (whichoccurred in 100% of assessed suicide attempts), was thereforeextremely common.

3.2. Associations with suicidal intent and lethality

Both self-reported suicidal intent (M¼4.92, SD¼1.46) andevaluator-rated medical lethality (M¼4.21, SD¼1.74) were high.Correlations among suicidal intent, medical lethality, and eachfunction were next calculated. Suicidal intent demonstrated smallbut significant positive correlations with automatic negative(r¼ .20, p¼ .018), automatic positive (r¼ .21, p¼ .016), and socialnegative (r¼ .19, p¼ .025) reinforcement, but not social positivereinforcement (r¼ .06, p¼ .528). Medical lethality demonstrated asmall positive correlation with social positive reinforcement (r¼ .18,p¼ .034), but not with any other function (rso .13, ps4 .137).

4. Discussion

Results of the current study suggest that active duty soldiersattempt suicide for many reasons, but the primary reasonsinvolve the reduction of uncomfortable or aversive internalpsychological states. Similarly, soldiers’ reasons for attemptingsuicide are only very weakly associated with suicidal intent ormedical lethality. These findings support the primary claim ofmany leading theories of suicide, which is that the primaryfunction of suicidal behaviors is to reduce or escape from intensepsychological suffering.

The current study further suggests that soldiers attemptsuicide for reasons that are consistent with learning theory andprevious research with other populations (Brown et al., 2002;Nock and Prinstein, 2004), and extends the functional model ofself-injurious behaviors to suicide attempts among active dutysoldiers. Automatic negative reinforcement reasons for suicideattempts were endorsed most frequently and to a greater degreethan reasons from other functional domains, indicating that theprimary purpose for attempting suicide among active dutysoldiers is to reduce or avoid psychological or emotional discom-fort and pain. Our results further indicate that when soldiersattempt suicide for purposes that are socially-oriented (e.g., toexpress anger or frustration, or to get out of doing something),automatic negative reinforcement also tends to operate as a co-occurring and/or more salient function. This has critical implica-tions for the assessment and treatment of suicidal soldiers, sincesocially-oriented reasons for suicidal behaviors are often viewednegatively (e.g., ‘‘attention-seeking’’ or ‘‘manipulative’’) by clin-icians, which can adversely affect clinical judgment. These datafurther suggest that clinicians would be mistaken in assumingthat the first reason reported (or suspected) for attemptingsuicide is the only reason operating for a soldier, as it appearsthat soldiers generally have multiple reasons for attemptingsuicide that span across multiple functions. Structuring treatmenton the framework of the functional model can also lead to moreeffective interventions with soldiers who have attempted suicide.For instance, explicit skills training in alternative behaviors thatserve an emotion regulation function (e.g., mindfulness, relaxa-tion, cognitive restructuring) could replace the use of suicidal

behaviors for this same purpose. Indeed, the very treatments thatare most effective for reducing suicide attempt rates, such asdialectical behavior therapy (Linehan et al., 2006b) and cognitivetherapy (Brown et al., 2005), are based on this principle.

The present study is limited by its relatively small sample sizeand restriction to active duty soldiers who had attempted suicide.Although our sample is sufficiently sized to answer the primaryquestions of interest, our results should nonetheless be replicatedwith larger military populations, ideally with personnel frommultiple Branches of service. Second, our study focuses only onthose soldiers who had already attempted suicide. It is possiblethat a soldier’s reasons for attempting suicide differ before theattempt is made relative to after the attempt. Alternatively, asoldier’s reasons might change in intensity or salience over time.Related to these issues, the exclusive reliance on self-report toretrospectively assess reasons for attempting suicide is a limita-tion due to possible memory degradation or bias, and thepossibility of motivationally-driven distortions or inaccuraciesin reporting. Future studies that incorporate longitudinal designsutilizing multiple sources of information could potentially over-come these limitations. Despite these limitations, this study shedsimportant light on the motives and reasons that drive suicidalbehavior among soldiers, and provide some important clues forthe effective assessment and management of this population.

Conflict of interestNone of the authors have any conflicts of interest.

Role of funding sourceThis study was supported by a Department of Defense grant to M. David Rudd

(#W81XWH-09-1-0569). The views expressed in this article are those of the

authors and do not necessarily represent the position or policy of the U.S.

Government, the Department of Defense, or the Department of the Army.

AcknowledgmentThe authors would like to express their appreciation to Sean Williams, Kim

Arne, and Sharon Stone for their work on the current study.

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