ABC’S OF SUICIDOLOGY: THE ROLE OF AFFECT IN SUICIDAL BEHAVIORS AND COGNITIONS A Dissertation Presented to The Graduate Faculty of The University of Akron In Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy Cynthia Ann Yamokoski August 2006 ABC’S OF SUICIDOLOGY: THE ROLE OF AFFECT IN SUICIDAL BEHAVIORS AND COGNITIONS Cynthia Ann Yamokoski Dissertation Approved: Accepted: _____________________________ ______________________________ Advisor Department Chair Karen R. Scheel Sajit Zachariah _____________________________ ______________________________ Committee Member Dean of the College Sharon Kruse Patricia A. Nelson _____________________________ ______________________________ Committee Member Dean of the Graduate School James Rogers George R. Newkome _____________________________ _______________________________ Committee Member Date Robert Schwartz _____________________________ Committee Member Linda Subich ii ABSTRACT The study of affect and cognition has been important in understanding suicide; however, the research and literature historically have placed more emphasis upon cognitive factors. Clearly, cognitive processes play a significant role in suicidal thoughts and behaviors, but it is also important to increase the focus on affect. There is support for the role of affect and the fact that cognition and affect combine with one another to impact suicidal behaviors. These findings may be advanced through the application of a theoretical model of affect in order to gain insight into the manner in which cognition and affect specifically relate to one another to impact suicidal thoughts and behaviors. Other goals of the current study were to examine the relationship between affect and cognition in suicidal individuals, to determine if different patterns of affect exist for different subtypes of suicidal individuals (i.e., no suicidality, suicidal ideation only, suicidal behaviors), and to assess the unique role of affect in relation to cognition. Participants in this study (n = 104) completed a series of questionnaires to measure suicidal thoughts and behaviors, hopelessness and affect. Results supported the hypothesis that positive affect and negative affect were related to suicidal thoughts and behaviors, and it was found that negative affect plays a more important role. Statistical analyses did not support the hypothesis that there were different patterns of affect for the various forms of suicidal behaviors, but visual analysis of graphs offered preliminary iii support for some unique patterns. An additional result of this study was that affect accounted for a significant amount of the variance in suicidal ideation, but not suicidal behaviors, above the cognitive variable of hopelessness. This means that it is important to study both cognitive and affect variables in order to gain more understanding about suicidal ideation. Some implications of this study are that therapists may gain more information about suicidal thoughts and behaviors if they assess both positive and negative affect, and it is possible that incorporating affect may enhance treatment outcomes. Follow up research is required to test these implications. In conclusion, affect is important to study in relationship to suicide, and it may provide additional information not gleaned from the more customary focus upon cognition in the suicide literature. iv ACKNOWLEDGEMENTS There are many people who I would like to personally thank for helping me arrive to where I am at today. Mom: I definitely get my work ethic from you and I believe that it is the one characteristic that has helped me achieve the most in life. Thanks for always being in my corner and for teaching me to get back up when I am down and to go back in for more. Your constant love and support have provided me with the strength and confidence to accomplish any feat. Dad: Thanks for always being the voice of reason and for being the most selfless person I know. You have modeled to me how to truly listen to and to respect others. Also, thanks for passing down the “Yamo ants-in-the-pants” gene that has provided me with boundless energy! I know that you both refuse credit for my successes, but you have made me who I am today. Erik: Thank you for teaching me to be a strong person and to persevere. I know that the lessons you have taught me were not always easy, but you have given me strength and hope. I believe in you just as you have always believed in me. Jen: To my best friend and sister in crime. Thank you for making me smile and laugh constantly. Your friendship has been a steady source of support and love over these years. “Fate made us sisters, but time has made us best friends.” I love you all so much and I could never thank you enough. Thank you to my husband Rich for giving me the greatest gifts in life: love, patience, encouragement, many warm meals at 11:00 p.m., neck rubs after I have sat at the computer for hours, and of course, our little Tyson. My life is truly complete. You v have made many sacrifices over the past seven years and I appreciate it more than I could ever let you know. And Tyson… little man, you will never know the joy that you bring to my life. Thank you for bringing total balance to my life and for reminding me of what is most important. Your smile lights up my world on the darkest day and I love you more than you will ever know. Karen, you deserve a huge thank you. You have been an outstanding mentor and role model to me in every stage of my training. Thank you for your support, guidance, and advice. It has been a wonderful experience working with you over the past five years! And finally, thank you to my committee members, and all of my instructors, clients, students and classmates over the years. vi TABLE OF CONTENTS Page LIST OF TABLES ………………….…………………………………………………… x LIST OF FIGURES …………………………………………………………………….. xi CHAPTER I. INTRODUCTION AND OVERVIEW OF THE PROBLEM ……………………….. 1 The Problem: Prevalence, Theory and Research …………...…………………… 2 Prevalence ……………..…………………………………………….…… 2 Role of cognitions in suicide …………...…..……………………………. 3 Emergence of affect emphasis ……………..………...…………………... 5 Affect in suicide literature .………………....…………………………... 10 Importance of theory in suicidology …..……...………………………… 15 Circumplex theory of affect …..…………………...……………………. 16 Current study …………………………………………………………………… 20 II. REVIEW OF THE LITERATURE ………………………………………………… 21 Types of suicidal behaviors ……………………………………………………. 22 Emphasis on cognition within the suicide literature …………………………… 24 Major theories of suicidality ……………………………………………. 25 Major variables in suicide theory and research …………………………. 29 Current treatment approaches …………………………………………... 38 The role of affect in the suicide literature ……………………………………... 41 vii “Affect” literature that is not studying affect ………………...………… 42 Non-theoretical affect studies: Empirically-derived risk-factors …….… 43 Support for the importance of studying affect in suicidal individuals .......45 Circumplex model of affect …………………………………………………… 54 Current study ………………………………………………………………….. 64 III. METHODOLOGY ………………………………………………………………... 67 Participants ……………………………………………………………………. 67 Procedure ……………………………………………………………………… 72 Measures ………………………………………………………………………. 72 Research questions and data analysis procedures ……………………………... 85 IV. RESULTS …………………………………………………………………………. 88 Data screening ………………………………………………………………….. 88 Preliminary and descriptive analyses …………………………………………... 93 Primary analyses ……………………………………………………………….. 98 Exploratory graphic analysis ……………………………………………….…. 106 V. DISCUSSION .…...……………………………………………………………….. 111 Review of research hypotheses and results ……………………………………. 111 Implications ……………………………………………………………………. 121 Limitations …………………………………………………………………….. 124 Future research ………………………………………………………………… 129 Summary ………………………………………………………………………. 132 REFERENCES ……………………………………………………………………….. 134 APPENDICES ………………………………………………………………………... 151 viii APPENDIX A. COVER LETTER …………….………….…………………... 152 APPENDIX B. RESEARCH QUESTIONNAIRE ………….………..……….. 154 APPENDIX C. INSTITUTIONAL REVIEW BOARD APPROVAL………… 165 ix LIST OF TABLES Table Page 3.1 Sample demographics ………………………….……………………………... 69 4.1 Pearson correlation coefficients ………….…………………………………… 92 4.2 Means of standard deviations of variables ………………….………………… 94 4.3 Prevalence of suicidal thoughts and behaviors in sample …….………………. 97 4.4 Canonical correlation analysis results ……………………….………………. 101 4.5 Hierarchical regression analyses on suicidal ideation ……….………………. 104 4.6 Hierarchical regression analyses on suicidal behaviors ……………………... 105 x LIST OF FIGURES Figure Page 1.1 Circumplex model of affect………..…………………………………………. 18 4.1 Histograms and distributions of variables ……………..……………………… 89 4.2 Canonical correlation analysis …………………………………….………… 102 4.3 Scatterplots of PA and NA for suicide risk groups …………………………. 107 xi CHAPTER I INTRODUCTION AND OVERVIEW OF THE PROBLEM Affect and cognition both have been important in the study of suicide throughout history. Theories and research on suicide, however, have focused more upon the cognitive processes involved in ending one’s own life. This cognitive information has been beneficial in enhancing our understanding of suicide, but it is also important to increase the focus on affect and to do so through a theoretically-grounded approach. Words and cognitive processes alone may not paint a complete picture of the suicidal individual’s emotional pain, nor adequately convey the individual’s internal conflict. Instead, the interplay