THE ROLE OF SELF-ESTEEM AND SELF-CRITICISM IN SUICIDAL THOUGHTS AND BEHAVIOURS A thesis submitted to the University of Manchester for the degree of Doctor of Clinical Psychology in the faculty of Biology, Medicine and Health 2017 Catherine F. O’Neill School of Health Sciences Division of Psychology and Mental Health LIST OF CONTENTS List of Appendices…………………………………………………………………………………………………………..3 List of Tables…………………………………………………………………………………………………………………..3 List of Figures………………………………………………………………………………………………………………….3 Word Count…………………………………………………………………………………………………………………...4 Thesis Abstract……………………………………………………………………………………………………………….5 Declaration…………………………………………………………………………………………………………………….7 Copyright Statement………………………………………………………………………………………………………8 Acknowledgements………………………………………………………………………………………………………..9 Paper 1: Systematic Review Abstract………………………………………………………………………………………………………………………………………………………11 Introduction………………………………………………………………………………………………………………………………………………..13 Method……………………………………………………………………………………………………………………………………………………….20 Results………………………………………………………………………………………………………………………………………………………...23 Discussion……………………………………………………………………………………………………………………………………………………42 Conclusion……………………………………………………………………………………………………………………………………………………52 References…………………………………………………………………………………………………………………………………………………..52 Paper 2: Experimental Paper Abstract……………………………………………………………………………………………………………………………………………………….63 Introduction…………………………………………………………………………………………………………………………………………………64 Method………………………………………………………………………………………………………………………………………………………..74 Results………………………………………………………………………………………………………………………………………………………….80 Discussion…………………………………………………………………………………………………………………………………………………….88 Conclusion……………………………………………………………………………………………………………………………………………………94 References……………………………………………………………………………………………………………………………………………………95 Paper 3: Critical Reflection Introduction………………………………………………………………………………………………………………………………………………….100 Definitions……………………………………………………………………………………………………………………………………………………101 Paper one reflections……………………………………………………………………………………………………………………………………106 Paper two reflections……………………………………………………………………………………………………………………………………114 Overall conclusions……………………………………………………………………………………………………………………………………….124 References…………………………………………………………………………………………………………………………………………………….125 2 LIST OF APPENDICES Appendix A: Author submission guidelines – Clinical Psychology Review 131 Appendix B: Author submission checklist – Journal of Abnormal Psychology 143 Appendix C: BECS Study Protocol 146 Appendix D: Protocol for Managing Disclosure of Risk 160 Appendix E: Participant Information Sheet 171 Appendix F: Ethical Approval, University of Manchester 174 Appendix G: Ethical Approval, NHS 176 Appendix H: Ethical Approval Manchester Mental Health and Social Care Trust 183 Appendix I: Data Extraction Sheet for Systematic Review 185 LIST OF TABLES Systematic Review Table 1: Included Studies and extracted data 26 Table 2: Results of Newcastle-Ottowa scale adapted for cross-sectional studies 31 Experimental Paper Table 1: Participants by self-reported diagnosis/ mental health condition 81 Table 2: Descriptive statistics 82 Table 3: Bivariate correlations of all variables 82 Table 4: Partial correlations controlling for depression and hopelessness 82 Table 5: Multiple regression predicting suicide probability (inadequate self) 84 Table 6: Multiple regression predicting suicide probability (self-attacking) 86 Reflective Paper Table 1: Factor analysis of self-esteem scales 112 LIST OF FIGURES Figure 1 IMV model of Suicide (O’Connor, 2011) 68 Figure 2 PRISMA diagram 25 Figure 3 Mediation analysis – entrapment as mediator- inadequacy 86 Figure 4 Mediation analysis – entrapment as mediator – self-attacking 88 3 WORD COUNT Section Word count Thesis abstract 368 Systematic review 9,944 Empirical paper 6,715 Critical reflection 6,272 Total 23,299 4 THESIS ABSTRACT This thesis forms part of the examination for the degree of Doctor of Clinical Psychology in the Faculty of Biology, Medicine and Health at the University of Manchester. This thesis has been written by Catherine Frances O’Neill and submitted in December 2017 for examination January 2018. The thesis focuses on the relationship between self-esteem, self-criticism, self- reassurance and suicidality. Paper one describes a systematic literature review and meta- analyses of the available research on self-esteem and suicidality. The review aimed to examine the relationship between self-esteem and suicidality, and whether there were any key moderators or mediators of this relationship. The findings indicate that there is an overall moderate negative relationship between global self-esteem and suicidality with an r=-0.42. Where studies examined levels of contingent self-esteem (i.e. self-esteem based upon external factors such as academic achievement and appearance) there was a stronger relationship with suicidal ideation and behaviours. Implicit self-esteem was measured by one study, which showed no relationship to suicide, however the combination of high implicit and low explicit self-esteem was significantly related. The review illustrated the need for further investigation of the relative contingency of self-esteem to suicidality, along with differences in implicit and explicit self-esteem and suicidality. Further longitudinal and experimental studies are also warranted to explore causality. Paper two describes an investigation into the role of self-criticism, specifically feelings of inadequacy and self-attacking, self-reassurance and suicide risk. A total of 101 participants from mental health inpatient and community mental health settings completed questionnaires for this study. Results indicated that self-attacking was significantly 5 associated with suicide risk, when hopelessness and depression were controlled for in the analysis. Entrapment, hopelessness and self-attacking were significant predictors of suicide risk, above depression, which was non-significant. Inadequacy was not a significant predictor of suicide risk. Self-reassurance, whilst negatively related to both self-attacking and inadequacy, did not moderate the relationship between self-attacking, inadequacy and suicide risk. The theoretical, clinical and research implications, along with limitations are discussed within this paper. Paper three provides a critical reflection of papers one and two, including an exploration of the challenges of defining and measuring self-esteem, self-criticism and suicide. Personal reflections and recommendations for good practice in future suicide research are included in this paper. 6 DECLARATION No portion of the work referred to in the thesis has been submitted in support of an application for another degree or qualification of this or any other university or other institute of learning 7 COPYRIGHT STATEMENT i. The author of this thesis (including any appendices and/or schedules to this thesis) owns certain copyright or related rights in it (the “Copyright”) and s/he has given The University of Manchester certain rights to use such Copyright, including for administrative purposes. ii. Copies of this thesis, either in full or in extracts and whether in hard or electronic copy, may be made only in accordance with the Copyright, Designs and Patents Act 1988 (as amended) and regulations issued under it or, where appropriate, in accordance with licensing agreements which the University has from time to time. This page must form part of any such copies made. iii. The ownership of certain Copyright, patents, designs, trademarks and other intellectual property (the “Intellectual Property”) and any reproductions of copyright works in the thesis, for example graphs and tables (“Reproductions”), which may be described in this thesis, may not be owned by the author and may be owned by third parties. Such Intellectual Property and Reproductions cannot and must not be made available for use without the prior written permission of the owner(s) of the relevant Intellectual Property and/or Reproductions. iv. Further information on the conditions under which disclosure, publication and commercialisation of this thesis, the Copyright and any Intellectual Property and/or Reproductions described in it may take place is available in the University IP Policy (see http://documents.manchester.ac.uk/DocuInfo.aspx?DocID=24420), in any relevant Thesis restriction declarations deposited in the University Library, The University Library’s regulations (see http://www.library.manchester.ac.uk/about/regulations/) and in The University’s policy on Presentation of Theses 8 ACKNOWLEDGEMENTS I would like to thank my Supervisors, Professor Gillian Haddock and Dr Daniel Pratt for their support and guidance in developing this thesis. I would also like to acknowledge the unwavering support of my Husband, Stephen Jackson - thank you Steve, for all your time, patience and understanding. Also to my daughter Maia, for being such a wonderful counterpoint to this process, spending time with you has been the best part of these last 2 years. Finally, thank you to the ClinPsyD Mum’s and my BECS trainee colleagues, you are all amazing, inspiring, strong women -your support has been invaluable. 9 PAPER ONE: SYSTEMATIC REVIEW The role of self-esteem in suicidal thoughts and behaviour: A systematic review The following paper has been prepared for submission to the Journal of Clinical Psychology Review. The guidelines for authors can be found in Appendix A. Abstract 196 Main Text (excluding 9,748 references) 10 ABSTRACT Self-to-self relating has been highlighted