Burden, Belonging, and Response to Pain in Veterans

Suicide is a significant problem among Veterans of the U.S. Military. Katz (2007) reported
that there were 144 suicides among Veterans who served in Operation Enduring Freedom (OEF)
and/or Operation Iraqi Freedom (OIF) from 2002-2005. There is no nationwide surveillance
system that tracks Veteran suicides. However, the National Violent Death Reporting System
(NVDRS) created in 2003 by the Centers for Disease Control and Prevention (CDC) with the
purpose of gathering thorough information about suicides and other violent deaths allows
researchers to reasonably extrapolate national suicide rates for Veterans. A CDC report
(2006) based on NVDRS data estimated that approximately 6,500 veterans from all wars die by
suicide each year, accounting for approximately 20% of suicides per year nationwide. While
much is known about risk factors for suicide (e.g., Beck, Steer, Kovacs, & Garrison, 1985;
Jobes & Mann, 1999) such information has little clinical utility for predicting whether or
not an individual is likely to die by suicide in the near-term. One of the few attempts to
address this issue is the interpersonal-psychological theory of suicide (Joiner, 2005). The
interpersonal psychological theory proposes that people die by suicide for three reasons:
(1) they perceive themselves as a burden to others; (2) they experience a profound feeling
of disconnectedness from others, what Joiner (2005) calls ''thwarted belongingness'' (p.
118); and (3) they have become habituated to the fear and physical pain inherent in a
suicidal act by repeatedly enduring painful and provocative situations, whether through such
experiences as repeated suicide attempts, other physically painful experiences, or frequent
exposure to danger. Importantly, all three factors must be present for a suicide to occur,
according to the interpersonal-psychological theory; together, these three characteristics
are ''proximal, causal, interactive risk factors'' (Van Orden, Witte, Gordon et al., 2008a,
p. 72). Components of the theory have been tested in adults (Joiner, Pettit, Walker, Voelz,
Cruz, & Rudd, 2002; Joiner & Rudd, 2000), college students, and adolescents (Joiner, Rudd,
Rouleau, & Wagner, 2000). However, research has only begun to explore whether the theory
applies to Veterans (Cornette, Deboard, Clark, Holloway, Brenner, Gutierrez, et al., 2007;
Cornette, deRoon-Cassini, Joiner, & Proescher, 2006). Brenner et al. (2008) conducted a
qualitative study of OEF/OIF Veterans which found relevance of the theory to their
experiences. In particular, themes emerged around combat as a context for exposure to
painful stimuli, perceptions of burdensomeness, and failed belongingness. This theory shows
promise for designing prevention and clinical intervention strategies for Veterans, but more
data are needed on which to base such work. To facilitate testing the
interpersonal-psychological theory of suicide, Joiner and colleagues have developed several
instruments (Bender, Gordon, & Joiner, 2007; Bryan, Morrow, Anestis, & Joiner, 2010; Van
Orden,Witte, Gordon et al., 2008a). The Interpersonal Needs Questionnaire (INQ) taps into
the constructs of thwarted belongingness and perceived burdensomeness. The Acquired
Capability for Suicide Scale (ACSS; Van Orden et al., 2008) measures fearlessness about
suicide. The current study will focus on the 12-item version of the INQ (INQ-12; Van Orden,
Witte, Gordon, Bender, & Joiner, 2008a) recently validated by Freedenthal, Lamis, Osman,
Kahlo, and Gutierrez (2011). This measure contains seven items that assess perceived
burdensomeness and five items that assess belongingness. An example of a burdensomeness item
in the INQ-12 is, ''These days, I think I have failed the people in my life''. An example of
a belongingness item is, ''These days, other people care about me''. The ACSS is a 20-item
measure rated on a scale of 1 (not at all like me) to 5 (very much like me). Sample items
include, "I am not at all afraid to die" and "I can tolerate a lot more pain than most
people". Van Orden et al. report acceptable convergent and discriminant validity. The
authors also reported a strong negative correlation with the fear of suicide subscale on the
Reasons for Living Inventory (RFL; Linehan, Nielsen, & Chiles, 1983) and a positive
correlation with the courage to kill oneself item on the Beck Scale for Suicide Ideation
(BSS; Beck & Steer, 1991). Bender, Gordon, Bresin, and Joiner (2011) reported acceptable
internal consistency as well. However, formal psychometric studies of the ACSS have yet to
be conducted. Joiner (2005) describes burdensomeness, failed belongingness and acquired
capability as separate constructs, with the INQ-12 and ACSS designed to assess each
independently. However, for purposes of explaining whether a given individual is likely to
die by suicide, Joiner et al. (2009) explain that the first two constructs together create
the desire for death and that the third is necessary for a person to engage in potentially
lethal self-harm behavior. Therefore, a complex interaction between the three is proposed.
Support for this interaction was found by Joiner et al. in two independent samples, one
community sample of young adults and a second drawing on archival data from active duty
military personnel being treated for a recent significant suicide-related event (e.g.,
serious ideation or attempt). A major limitation of this study was that measures of the
constructs differed, making it somewhat difficult to determine what was being assessed in
the two samples. Additionally, in their psychometric examination of the INQ-12 Freedenthal
and colleagues (2011) found evidence of an overarching factor uniting the two subscales of
burdensomeness and failed belongingness. Assessing for suicide risk is a key element of the
clinical management of high-risk individuals (Gutierrez et al., 2009), but is only the first
step. To adequately select appropriate interventions clinicians must know what is driving an
individual's suicidality (Jobes, 2006) and also what factors are keeping the person from
acting on their thoughts and urges. This information better helps the clinician and client
to develop strategies aimed at creating (or rediscovering) what makes life worth living;
focusing on plans, goals, and hope for the future (Jobes, Comtois, Brenner, & Gutierrez,
2011). Historically, the RFL (Linehan et al., 1983) has been one of the primary measures of
protective factors against suicide, and indeed has shown great utility. A potentially
related area of study is the role of one's values. The consciously chosen way in which an
individual lives her life, the driving force behind her actions, and the desired outcomes of
her behaviors define what an individual values (Luoma, Hayes, & Walser, 2007). Helping
clients live lives consistent with their values provides purpose and meaning, gives
direction to their choices, and allows them to set reasonable, flexible goals likely to
motivate meaningful action (Luoma et al.). Accomplishing these things should greatly
facilitate reducing an individual's risk of suicide, since it answers the fundamental
existential question "why is life worth living?" Ciarrochi and Bailey (2008) created the
Survey of Life Principles to assess values, and provide preliminary support for its use in
their manual.

Inclusion Criteria:

- Military veteran

- 18 or older

- Ability to respond to questions regarding the informed consent

Exclusion Criteria:

- Active-duty military

- Non-English speaking

- Inability to respond to questions regarding the informed consent procedure