Self-Destructive Processes and Suicide

Israel Orbach, PhD

Department of Psychology, Bar-Ilan University, Ramat Gan, Israel.

Abstract: This paper focuses on theoretical, empirical and clinical accounts of self-destructive processes in the generalpopulation, with a particular focus on suicidal individuals. The theoretical perspective includes views on self-destruc-tion as (A) a motivated wish or need, (B) an outcome of emotional distress, (C) an outcome of distorted cognitions,and (D) as a general personality feature. The different principles of destructive operations that are inherent in each ofthe theoretical propositions are delineated. Examination of the empirical data reveals that various self-destructive pro-cesses described in theory are involved in suicidal behavior. The case studies demonstrate how the various self-de-structive processes lead to suicidal behavior. These studies also show that in each individual case, there is more thanone self-destructive process at work. It is suggested that suicidal behavior does not only evolve from external pressureand negative life events; rather, self-destructive tendencies may produce unbearable mental pain that culminates insuicidal behavior.

Much of the research on suicidal behavior empha-sizes the role of stress factors, risk factors, and per-sonal vulnerabilities. In a recent review article,Gould et al. (1) summarize the data obtained fromresearch on adolescent suicide during the past 10years. This paper focuses on suicide rates; epidemio-logical factors (age, gender, ethnicity); personalcharacteristics (psychopathology, prior suicide at-tempts, hopelessness, problem-solving difficulties,aggressive-impulsive behavior, sexual orientationand biological factors); family characteristics (his-tory of suicidal behavior, parental divorce, parent-child relationships); life stressors (negative lifeevents, physical abuse, sexual abuse); and socio-en-vironmental and contextual factors (socioeconomicstatus, school and work problems). The authors con-clude that, to date, adolescent suicide can be under-stood as an effect of youth psychiatric disorders, afamily history of suicide and psychopathology,stressful life events and access to firearms.

Taking a different perspective, Orbach (2) sug-gests that suicide cannot be understood outside ofthe long-standing self-destructive processes thatgenerated it. Self-destructive processes are activeand provocative, behavioral, and ideational opera-tions aimed against one’s own interests. They consistof a cluster of beliefs, cognitions, emotions and ten-dencies that reflect patterns of self-abuse that erode

one’s sense of well-being, self-love, interpersonalrelationships and harmony with reality. Suicidal peo-ple, it is argued, tend to take an active role in creatingtheir internal and external stressors, as well as in thecreation of negative life events (3, 4). Eventually, theeroding effects of the self-destructive processes turninto mental pain that leads to suicide (5).

Recently, Joiner (6) articulated the role of self-propagating and erosive processes involved in de-pression chronicity. No such comprehensive attemptwas made regarding suicide. The present paper is yetanother attempt to consider the relationship be-tween self-destructive processes and suicidal behav-ior from theoretical, empirical and clinicalperspectives. Hopefully, the integration of thesethree perspectives will lead to a better understandingof suicidal behavior.

Theoretical Perspectives

A. Self-destruction as a motivated wish or need

The death instinct. Freud’s conceptualization of thedeath instinct behaviors reflecting self-destructivetendencies, guilt feelings, suicide, melancholia, mas-ochism and sadism are furnished with a motiva-tional force of their own, as well as with a specificmechanism of action, that is the repetition compul-sion. The death instinct drives man to the ultimate

Isr J Psychiatry Relat Sci Vol 44 No. 4 (2007) 266–279

Address for Correspondence: Israel Orbach, PhD, Department of Psychology, Bar-Ilan University, Ramat Gan 52900,Israel. E-mail: orbachi@mail.biu.ac.il

state of quiescence — death through the urge inher-ent in organic life to restore an earlier state of things(see 7)

According to Freud (8), self-destructive pro-cesses culminate in depression and suicide. Theseprocesses are rooted in pathological mourning. Thepathological mourning has its origin in an ambiva-lent love-hate relationship with a lost close person.The anger toward the lost person is turned inwardand takes on the form of sadistic self-punishment. Itis a murder in 180 degrees. In Freud’s terminology,the superego punishes the ego unconsciously withguilt and creates an impulse to die. Thus, the redirec-tion of aggression originally aimed at the lost, loved-hated person relieves guilt over aggressive thoughtsand opens the way for reunion with the loved person.Hence, Freud (8) views suicide as a result of loss, am-bivalent feelings, guilt, self-hate and inwardly turnedaggression in order to reunite with the lost person.

Menninger (9) further elaborates on Freud’s in-stinctual self-destructive behavior. He identifiedthree major dynamics of suicidal behavior: the wishto kill (ego — aggression turned inward); the wish tobe killed (superego — self-aggression stemmingfrom guilt); and the wish to die. Although the wish tokill is expressed in acts against oneself, the aggres-sion is intended for an ambivalently valued person.The greatest torture for a mother is to see her childbeing killed (by him/her). Hence, the person whokills him/herself exhibits an overwhelming degree ofaggression against the loved and hated person by de-stroying things that are dear to that person. The wishto be killed is, of course, a submission to death stem-ming from intense superego guilt for forbidden sex-ual and aggressive unconscious wishes. The wish todie does not represent a conscious (ego) wish to killor a superego self-punishment. Rather it representsthe vicissitudes and individual differences in thestrength of the unconscious death instinct (id). Thewish to die represents a desire to return to the peaceof the womb. The wish to die comes into playthrough non-fatal self-destructive acts and in self-exposure to dangerous, yet pleasurable activities,such as mountain climbing, car racing and so on.This third wish is a form of toying with death, be-cause of the innate intensity of the death instinct.

The internal saboteur. Fairbairn (10) provides an ob-

ject relations version of self-destructive behavior, al-though he did not relate directly to suicidal behavior.He believes that all forms of externally and internallydirected aggression stem from actual experiences ofabuse and neglect. Fairbairn identifies an inner orga-nization of early very negative experiences. Theseexperiences are crystallized into an “internal sabo-teur.” The internal saboteur is an inner attitude ofself-hate and hatred for others that takes on the formof a bossy, sneering, belittling inner voice. Theseinner attitudes control one’s self attitudes and rela-tionships with others and steer behavior towardpunition of self and others, vindictiveness, rejectionand provocation. According to Fairbairn, early nega-tive experiences are far more powerful in determin-ing personality than are early positive experiences.An individual with a self perceived history of abusetends to recreate these experiences of abuse in orderto recapture the early emotional or physical abuse.The motivation for repetition of aspects of an earlierabusive relationship according to Fairbairn is theneed to hold on to bad relationships (and bad ob-jects) rather than be left with no relationships at all(see also 11).

Self-theories provide a different version of moti-vated self-destruction that pertains to suicide andself-harming behavior. Stolorow (12) claims that selfinflicting pain may be a way of self enhancement.Paradoxically, masochism and self-destructive be-haviors may boost self-esteem and self-value, en-hance a sense of continuity of the self in time, andprovide a sense of self-cohesion and boundaries be-tween self and non-self. The experience of physicalpain on the surface of the body can help a disinte-grating self establish a sense of bodily boundaries(self-differentiation) and inner cohesion, as well as asense of liveliness (though painful experiences).

To a person with a history of receiving care char-acterized by pain, trauma and sadomasochism, re-peating of such features in one’s own self-careprovides a sense of self-consistency. Self-perpetuatedself-abuse also allows for a sense of control and om-nipotence over a once uncontrollable situation. Insum, certain forms of self-destructive behavior mayresult in a satisfying experience in terms of achievingself-enhancement, self-boundaries, inner cohesionand control. The most painful experience for a per-son in distress is the experience of disintegration.

ISRAEL ORBACH 267

Thus suicide may be chosen as a last resort of main-taining self-cohesion when moments of high distressgenerate feelings of self-disintegration. In a similarline of thinking, Sacksteder (13) suggests that self-destructive behavior is a form of negative identity. Anegative identity, he claims, is better than no identity.

Common to the theoretical conceptualizationsthat view self-destruction as being motivated by awish or by a need for self-enhancement is the ideathat cessation is not only an escape from unbearablepain, but it is also intended to achieve a goal or fulfilla need. This goal or need may be joining a loved one(in fantasy), enhancing self-worth or gaining love.Shneidman (14) states it very clearly that the very actof suicide is perceived by the suicidal person as beinginstrumental in fulfilling a specific need.

B. Self-destruction as an outcome of emotionaldistress and failure to protect the selfBaumeister (15, 16) views the protection of a positiveself-image, self-esteem and self-interest as crucial inthe pursuit of well-being. People indeed tend to en-hance behaviors, experiences and circumstances thatincrease their self-image, esteem and interest, and doeverything in their power to avoid harming andthwarting themselves. Nevertheless, under certaincircumstances, people will act against their own self-interest. Baumeister’s paradoxical assumption is that,in essence, the core motive in self-destructive behav-ior is to protect oneself from psychological distress.However, due to failure in coping, appraisal, evalua-tion of the situation and other faulty strategies, oneends up unintentionally in a self-destructive mode ofbehavior.

Baumeister (16) points at three culprits responsi-ble for thwarting self-protective and self-enhancingbehavior into self-destructive behavior: threatenedegotism, failed self-regulation and emotional dis-tress.

Egotism serves the self by accruing reinforce-ments of positive self-perception and self-love. Ego-tism is naturally threatened by encounters withsituations capable of lowering one’s self-esteem. Thepursuit of self-interest requires a rational analysisthat takes into consideration long-term outcomes ofone’s actions. An event or situation that may be po-tentially threatening to the ego is experienced as animmediate crisis that removes long-range implica-

tions from immediate consideration. The egotisti-cally threatened person tries to escape such a dis-tressing experience as soon as possible. The sufferingperson is likely to choose the response that offers themost immediate escape from the negative affect andthreat. In the extreme case of suicide, for example,the suicidal person does not seek to punish him/her-self, but seeks to escape the immediate negative im-plications to the self due to a certain failure.

Self-regulation is the way in which individualsturn negative affects and outcomes into positive onesfor the sake of the self. Successful self-regulation re-quires accurate appraisal of what is in the self ’s bestinterest, as well as skill in pursuing and executingsuch benefits. Failure in appraisal or pursuit result infailed self-regulation. An example of faulty self-regu-lation is the chronic use of alcohol to dilute emo-tional distress and negative experiences. Whilealcohol intoxication provides immediate relief, itdoes so at the expense of self-control, inhibition,self-monitoring and impulse control. As this exam-ple indicates, self-detriment may actually result fromuncalculated attempts to restore self-interest, i.e.,shortsighted consideration of future implications.Distraught people choose the risky course only be-cause they ignore its downside.

Another version of self-destruction as a failure toprotect the self is offered by Swann (17), who sug-gests that people actively seek out information that isconsistent with their self-perception, even whensuch feedback is negative. This is especially true forindividuals with low self-esteem and depression.Negative information is preferred over positive feed-back and is perceived as more reliable since it is con-sistent with one’s own self-perception. Suchindividuals tend to seek out rejections and feel closerto partners who express negative opinions towardthem. While negative feedback provides a sense ofconsistency, at the same time negative feedback in-creases negative self- image as well as negative emo-tions including depression. Thus, a vicious circle isformed in which negative feedback and rejectingpartners further enhance the negative self-image andincrease one’s negative mood and depression, andthese strengthen the tendency to seek out new nega-tive feedback and so on. Recently, Weinberg (18) hasempirically documented negative feedback seekingin suicidal inpatients.

268 SELF-DESTRUCTIVE PROCESSES

According to these views on self-destructive pro-cesses, self-inflicted damage is usually rooted in ex-ternal pressures that constitute a threat to the self orelicits intense emotional distress. This situation givesrise to faulty coping strategies that cannot eliminatethe stress or threats and eventually end up in an inef-fective form of escape that culminates with evenmore distress and pressures.

C. Self-destruction as an outcome of distortedcognitions

Multiple theoreticians and researchers have identi-fied self-destructive processes that are based onfaulty self-perceptions and world perceptions (e.g.,19–21). Documentation of the thoughts andcognitions of self-destructive individuals often indi-cate distorted contents (e.g., faulty beliefs andschemas), modes of thinking (e.g., negativity, rigid-ity, irrationality), emotional tone of cognitions (pes-simism, threats, catastrophization), and thoughtprocesses (e.g., negative attributions, faulty general-izations, illogical conclusions, faulty reasoning,memory distortions and selectivity, and difficultiesin producing alternatives).

The following is a more detailed account of thedistorted thoughts and cognitions linked with self-destructive behavior.

Distorted beliefs . Beck (22) observed thatmaladaptive behavior and negative affect are oftengoverned by distorted and maladaptive cognitions.Beck terms these maladaptive cognitions the cogni-tive triad consisting of negative views of the self, oth-ers and the future (e.g., I am inadequate, undesirable,worthless; the world makes too many demands onme; life represents constant defeat; life will always in-volve the suffering it has for me now). Recently,Rudd (23) applied Beck’s cognitive construct of de-pression to the belief system of suicidal people: Mylife is hopeless (hopelessness); I don’t deserve to live(unlovability); I can’t solve this (helplessness); and Ican’t stand the pain (poor tolerance).

Moreover, Beck (22) discovered that the de-pressed person’s thoughts are governed by an auto-matic thought system of internal rather thaninterpersonal communication, and that this internalsystem is characterized by negative self-evaluation,attributions of the negative to the self, negative ex-

pectancies, negative inferences and recall. Thesecharacteristics of the internal thought mechanismare manifested in low self-esteem, self-blame, andself-criticism, negative predictions, negative inter-pretation of experiences, and unpleasant recollec-tions. Much of the positive self-relevant informationis filtered out, while negative self-relevant informa-tion is readily admitted. Beck also notes a variety oferrors in the patient’s depressive thinking. He labeledthese as selective abstractions, overgeneralizations,and the exaggerations of the negative aspects of theirexperiences. According to Beck (22), these thoughtpatterns are automatic and extremely negative in na-ture. Another aspect of the distorted beliefs is a fixed(and usually negative) meaning that is attributed tospecific events (e.g., If my husband does not smile atme, it means that he does not care for me). The de-pressed patient construes his/her experiences andfuture expectations on the basis of these beliefs. Suchbeliefs are founded early in life and become embed-ded in a structured schema.

Rigidity in solving problems. Difficulties in problemsolving or difficulties in producing alternative solu-tions to a problematic situation is yet another aspectof self-destructive behavior. Individuals experienc-ing difficulties in divergent thinking are unable todevelop efficient solutions while under stress (24-27). These difficulties are related to cognitive ex-tremities, rigidity, passivity and appraising a prob-lem situation as being a threat rather than achallenge (24). In the process of trying to solve aproblem, some individuals focus on and identifywith more negative aspects of a problematic situa-tion than the positive and challenging aspects (28).Further, the problem solving of suicidal people ischaracterized by reliance on others, avoidance, disre-gard of the future and drastic solutions (29). Due toaccumulative failures experienced by suicidal young-sters throughout life, they have been found to per-ceive problem situations as being totally unsolvable(30).

Faulty logic and dichotomies. Shneidman (14, 31)points out two additional cognitively destructivetraps that exist especially in the mind of the suicidalperson: catalogical syllogism and dichotomousthinking.

Catalogical syllogism starts off in the suicidal

ISRAEL ORBACH 269

person with a false major premise and from there on,the flowing conclusion may seem to be valid even byrigid Aristotelian standards. For example, a suicidalperson may think that: “If anyone kills him/herself,then he/she will get attention: I will kill myself.Therefore, I will get attention.” According toShneidman, this reasoning exemplifies a psycho-se-mantic fallacy that may occur whenever an individ-ual thinks about his/her own death. He/she imagineshim/herself as a spectator-survivor in a world afterdeath. The fallacy lies in the fact that the “I” that thesuicidal person is talking about will no longer existto receive the imagined experiences.

The other cognitive trap that Shneidman identi-fies in suicidal individuals is constricted or dichoto-mous thinking. The suicidal person’s mind views theworld, the self and the present situation in terms ofeither/or, good or bad, love or hate. The language ofdichotomous thinking is based on absolutes like “al-ways,” “never,” “forever,” and “only.” Thinking in po-larities leaves no room for a spectrum of possibilitiesthat can grant hope or gradual change.

In general, self-destructive behaviors that arerooted in distorted cognitions are destructive in andof themselves. These distortions are habitual and au-tomatic, uncontrolled, and create emotional distressby their mere operation. Extreme destructive acts areperceived as a response to these distorted, stress-in-ducing cognitions.

D. Self-destructive behavior as a generalfeature of the personality

Some individuals are not only characterized by cer-tain self-destructive features, but also by a dominantpersonality feature that leads to self-destruction.Such individuals can be described as suffering from aself-destructive personality. Dominant self-destruc-tive personality features include perfectionism, aself-defeating personality and impulsivity.

Blatt: Destructive personality configurations. Blatt(32) posits that personality develops as a conse-quence of a complex interaction between two funda-mental developmental lines: (a) the development ofthe capacity to establish mature and satisfying inter-personal relationships and (b) the development of arealistic, positive and integrated self-definition andidentity. In normal development, these two person-

ality dimensions evolve in an interactive and recipro-cal way to create a balance between relatedness andself-definition. However, a relative emphasis on ei-ther interpersonal relatedness or self-definition mayresult in two broad configurations ofpsychopathology. An overemphasized interpersonalrelatedness may lead to an anaclitic (or dependent)depression, whereas overemphasized individualityand self-definition may result in self-critical (orintrojective) depression. Anaclitic depression in-volves a deep longing to be loved and cared for. Thedependent person fears loneliness, abandonmentand rejection. He/she is strongly motivated to estab-lish intimate relationships, and will placate others inorder to maintain security and gratification. Theoverly individualized person is characterized by self-criticism, feelings of inferiority and guilt. Such an in-dividual suffers from a chronic fear of disapproval,criticism and rejection. He or she strives for exces-sive achievement and perfection, and is often highlycompetitive. Through over-compensation, the self-critical person strives to achieve and maintain ap-proval and acceptance. Both personality configura-tions in their extreme forms are implicated in self-destructive behavior.

Shahar and Priel (33) conglomerate empirical ev-idence from several authors that suggest that de-pendency and self-criticism influence the socialcontext. These studies revealed, among other find-ings, that self-criticism predicted elevated levels ofinterpersonal problems, hostility toward romanticpartners, elevated levels of stressful events and lowerperceptions of social support. Self-criticism was alsofound to suppress the impact of positive life events.

Blatt (34) linked self-critical depression to de-structive perfectionism. Actually, Blatt suggests thatthere is a great overlap between perfectionism andthe self-critical configuration in terms of harsh self-scrutiny and self-evaluation, chronic fear of disap-proval and chronic fear of rejection. There is also anoverlap in terms of competitiveness with one’s selfand demands made of one’s self. Perfectionists aredriven by an intense need to avoid failure. Nothingseems quite good enough and they are unable to de-rive satisfaction from what they do. They are en-gaged in an endless cycle of self-defeating over-strivings in which each task becomes yet anotherthreatening challenge due to their deep feelings of

270 SELF-DESTRUCTIVE PROCESSES

inferiority. They are constantly engaged in a viciouscycle of trying to accomplish unrealistic demandsand thereby defeating themselves.

Joiner (6) has pointed out several self-propagat-ing processes in chronically depressed individualsthat seem to be related to the dependent personalityconfiguration and that might be involved in suicidalbehavior of such individuals. One such process thatcan be defined as a process of self-generation ofstress is the excessive reassurance-seeking, that is thetendency to repeatedly seek assurance from others asto worth and lovability. Such a repetitive pattern canevoke frustration, irritation and even depression inothers and thus elicit a response of rejection.

Impulsivity. Impulsivity can be defined as an endur-ing tendency to react hastily rather than deliberately.This tendency is based on immediate gratification asopposed to future-oriented problem solving (35, 36).Impulsivity is usually manifested in negative, mostlydysphoric and irritated emotional states.

Feelings of exacerbated tension and emotionaldiscomfort lead the impulsive individual into astruggle between the impulse for immediate reliefand the need for self-preservation. The impulsive in-dividual lacks the ability for affect regulation, forself-soothing and self-comfort, resulting in affect in-stability that is an abrupt rise in overwhelming affectand intense affective reactivity to environmentalevents. Because of the high arousability of negativeaffect and tension, the impulsive individual tends torespond impulsively in order to relieve the tensionwithout giving him/herself time to consider the ad-verse consequences of his/her behavior.

The most outstanding manifestation of an impul-sive personality is the difficulty to control impulses,especially self-aggression, as well as aggression di-rected toward others. Impulsivity was found to be re-lated to a wide range of maladaptive self-destructivebehaviors, such as kleptomania, pyromania, inter-mittent explosiveness, substance abuse, antisocialbehavior, bulimia, conduct disorder and self-mutila-tion (35).

Nihilistic attitude toward life. Self-destructive pro-cesses and behaviors can also be viewed from theperspective of long-term development of attitudestoward life. In the course of such developments, onemay adopt a basic negative attitude toward life and

living, and engage in an all-encompassing career ofself-destruction. Maris (37) contends that “From theexistential perspective under the best conditions, lifeis short, painful, fickle, often lonely and anxiety-gen-erating” (pp. xviii-xix). Self-destruction is a result ofa nihilistic attitude characterized by an inability or arefusal to accept the conditions of one’s life. Becauseof this intolerance and accumulated stress and fail-ures from early life, individuals may adopt self-de-structive coping methods in order to escape life’sdifficulties. Individuals with a nihilistic existentialstand toward life will engage in various self-destruc-tive behaviors that Maris termed as a suicidal career.Such individuals may move from non-fatal self-de-structive behavior, such as alcoholism, isolation, op-position, violence, drug abuse, risk-taking, until thecareer is culminated in a fatal action of completedsuicide. Actually what Maris describes as a nihilisticattitude toward life itself is in many ways similar towhat is often related to as a self-defeating personalitycharacterized by a combination of self-destructivetendencies, such as masochism, self-criticism, sub-missiveness, self-punitiveness, self-abnegation, neg-ativism, rejection of help and provocativeness (e.g.,3, 38, 39).

This category of destructive behavior that stemsfrom personality traits can be characterized as a de-structive mode of action. Here the patterns of actionare not necessarily due to wishes, types of cognitionor self-regulatory strategies. The actions themselvesand the way people operate and conduct their livesare destructive.

Some Empirical and ObservationalEvidence of Self-Destructive Behavior inSuicidal Individuals

In this section, empirical and observational data ofself-destructive behavior in suicidal individuals willbe presented.

Aggression turned inward and impulsivityMaiuro et al. (40) demonstrated that suicidal malepsychiatric patients tend to display moreintrapunitive and covert hostility than nonsuicidalpatients. Rustein and Goldberg (41) provided empir-ical evidence to this phenomenon showing that ag-gressive stimulation increases depression and the

ISRAEL ORBACH 271

turning of aggression inward in hospitalized suicidalpatients. At the same time, there is evidence that ex-ternal-directed aggression and inner-directed ag-gression can coalesce in violent suicide (42).

Impulsivity is one of the most critical risk factorsof suicidal behavior at all ages. Conner et al. (43), forexample, found that impulsivity was strongly associ-ated with suicidality even after accounting for alco-hol dependency and aggression. Oquendo et al. (44)found that impulsivity was one of the important pre-dictors of suicidal behavior with major depression,in a two-year follow-up study. Forteza et al. (45) re-ported that impulsivity was a critical risk factor forboth males and females. Impulsivity is also related tolow levels of serotonin transport (5-HTT) which, inturn, is associated with violent suicidal behavior andaggression (46).

Apter et al. (47) compared suicidal and non-sui-cidal psychiatric patients on a battery of tests. Eachof the two groups was also divided into violent andnon-violent participants. It was found that only twoof the violent participants had not been admitted fora suicide attempt. Suicide risk was found to be posi-tively related to levels of impulsivity and anger;hence, violent and impulsive persons may direct ag-gression externally as well as inwardly.

Rigidity and dichotomous thinkingThese aspects of self-destructive behavior havemostly been observed in clinical settings (14), butthere are also some empirical studies that have pro-vided evidence for the existence of these features insuicidal individuals. Suicidal individuals have beenfound to be rigid in their personality structure, cog-nition, self-definition and behavior (20, 48, 49). Sim-ilarly, Eliason (50) compared psychiatric suicideattempters and non-attempters. The attempters werefound to have much more rigid personalities andrigid cognitions than the former. Gil (51) also foundthat rigidity and impulsivity were two of the five fac-tors that explained suicidal ideation among psychiat-ric patients.

Provocative behavior and negation of helpMaltsberger and Buie (52) observed that suicidal pa-tients prefer to reconstruct early sadomasochistic re-lationships and elicit hateful responses on the part ofothers through their provocative behavior. Kullgen

(38) analyzed treatment files of borderline patientswho committed suicide and found that more thanhalf of the suicides’ negative reactions, rejection andcontempt on the part of the physicians toward pa-tients were documented. Kernberg (53), Novick (54)and Asch (55) observed similar provocative behaviorin their suicidal patients. Deane et al. (56) found thatsuicidal individuals avoid or reject help from family,friends and professionals. The association betweensuicidality and the rejection of help was not relatedto the level of hopelessness; thus, negation of helpseems to be a personality characteristic rather than alack of belief in future change. Similar findings werereported by Deane et al. (57) and Carlton and Deane(58).

Self-generated stress and self-defeatingbehaviorIsometsa et al. (59) studied stressful life events in sui-cide completers, and determined that most of theseevents were self-generated. Heikkinen et al. (60)studied autopsies of 56 borderline and 56 non-bor-derline patients who completed suicide. In 53 of thecases, the families of the suicide completers reportedthe presence of stressful life events prior to suicide.Forty of these experiences were judged to be as self-generated stress.

Lester and Hoffman (61) studied self-defeatingbehavior in suicide attempters and ideators. Theyfound a significant association between self-defeat-ing tendencies and suicidal behavior even after con-trolling for depression, gender and age.

Self-hate, guilt and self-devaluationShneidman (31) documented extreme expressions ofself-hate and hatred towards others in the autopsiesof suicide completers. Joiner et al. (62) investigatedthe relationship between self-hate, suicide attemptsand suicidal ideation in two separate studies. In thefirst study, they examined military personnel whoexhibited suicidal behavior. It was found that self-hate and suicidality were more correlated amongpeople with a diagnosis of schizophrenia thanamong patients with a diagnosis of major depres-sion. In the second study, they examined schizo-phrenic and depressed inpatients, and again found astrong association between self-hate and suicidal be-havior. Brevard et al. (63) analyzed the suicide notes

272 SELF-DESTRUCTIVE PROCESSES

of completers and attempters. The notes of the com-pleters evidenced significantly more self-blame ref-erences than those of the attempters.

In Tatman et al.’s (42) study, self-devaluation wasfound to distinguish between suicidal and non-sui-cidal adolescents. Kaplan and Pokorny (64, 65) stud-ied the predictive power of self-devaluation in a verylarge adolescent sample. They found that self-deval-uation predicted suicidal behavior even after twoyears.

PerfectionismThe two types of depression, anaclitic and self criti-cal, that have been suggested by Blatt (32), have alsobeen implemented in suicidal behavior. Self-criticaldepression is mediated according to Blatt by patho-logical perfectionism. In a number of studies, it wasfound that different aspects of perfectionism wereassociated with suicidal ideation and suicide at-tempts in both adolescents and adults (66, 67). Apteret al. (68) have reported in a postmortem analysis ofa sample of completed suicides that perfectionistictendencies were very frequent among the suicidecompleters.

In a recent study, Brunstein-Klomek (69) foundthe dependent personality who may suffer fromanaclitic depression tends to exhibit suicidal behav-ior and suicidal tendencies.

Self-Destructive Behavior in the ClinicalSetting

The following are descriptions of several self-de-structive behaviors and how they are related to thesuicidal process. These descriptions are based ontherapeutic interactions with suicidal people and theemphasis is on the clinical descriptive perspectiverather than the theoretical-empirical perspective.

Self-destruction motivated by guilt feelingsGuilt feelings are some of the most potent feelingsthat lead to direct and primary self-destruction. Oneof the major dynamics of suicide is an individual’sbelief that he or she has hurt or caused damage to an-other person. This is exemplified in the followingclinical case.

Dina, a very suicidal widow, could not obtain hervery desired doctoral degree because she could not

complete the concluding section of her dissertation.As it turned out this situation was related to her rela-tionship with her late husband. At first, she hintedthat her husband was a war casualty, but later she dis-closed that he had committed suicide and that shehad actually danced with joy on his grave because atlast she was free from a marriage in which she suf-fered a great deal. Only after her husband’s suicidecould she fulfill her long-standing dream to pursuean academic career. Dina reported that she had re-peated hallucinatory nightmares in which her hus-band would appear, knocking on the doors and wallsand would enter her bedroom, saying: “You belongto me; come with me, forget your dissertation.”Dina’s guilt about her murderous anger toward herhusband and her belief that she might have precipi-tated his suicide were at the heart of her being stuckin the last chapter of her dissertation as well as in hersubsequent suicide attempts.

The need for self-punishment was so strong inDina that it outlived the therapeutic workingthrough the source of the self-destructive chain.After Dina completed her dissertation she still feltthe need to punish herself. As she approached thestage to receive her diploma, she fainted — a sym-bolic death and suicide.

Self-entrapment as a way of lifeOne form of self-entrapment is provoking others tomistreating behavior or to continually fail oneself onpurpose. This is most evident in people who have along-standing ambivalence about life, conflicted bythe equally strong wish to live and the wish to die.Thus, provocation and its consequent eliciting of theill wills of others serve to tilt the scale and to solvethe ambivalences about life and death. At the pointwhere the almost deliberate deterioration of life be-comes unbearable, the person reaches a final resolu-tion of the conflict. One adolescent girl, who hadrepeatedly attempted suicide, exhibited this ten-dency in a sudden outburst against her therapist:“You don’t understand that I need everybody toknow how bad I am. I do not deserve to live. Every-one must agree that I need to die.” Following her owndisjointed logic, this young woman pushed herselfand her life to actual extreme episodes of misbehav-ior and failure in order to justify her suicide. Anothersuicidal adolescent would regularly leave her panties

ISRAEL ORBACH 273

stained with menstrual blood in the middle of theguest room floor, a predictable provocation whichcaused her mother to scream at her: “So, do it al-ready; jump and get it over and done with.”

Another common form of self-entrapment is de-liberate self-imposed failures that propel the suffer-ing individual from bad to worse. This tragic processwas described in detail in the suicide note of a soldierwho put an end to his life after failing an army train-ing course that was of critical importance to him. Hebegan his note by describing the series of failures thathe had experienced during his lifetime. As a child hehad failed in learning to ride a bicycle as fast as hehad wanted, later in school he failed in living up tohis parents’ expectations to excel in school. Aftercompleting a long list of disappointments and fail-ures he goes on to describe the more recent series ofself-inflicted entanglements. He hid his most recentfailure in the army from his parents and friends, andeven tried to keep it from his commanding officers.He told each person a different story and heaped onelie on top of another, even though he knew that hisdeception would ultimately be discovered. More-over, each time he had tried to solve an entangle-ment, he only added to the web of deceptions until,at the end of his life, he became tied up in an insolu-ble tangle of lies. It was as if he had personally di-rected the drama he believed to be his destined fate: atale of woven failures.

Cognitive self-entrapmentCognitive self-entrapment can take on differentforms. In one form of this entrapment, the thoughtsand feelings involved in a conflict are continuallycounterbalanced in such a way as to render the con-flict insoluble. A young man whose fear of conscrip-tion to the army led to suicidal thoughts said to me:“I can’t join the army, but I also don’t want to avoidbeing drafted.” Every attempt on his part to tip thebalance in either direction was immediately met witha persuasive counter-argument that restored the le-thal state of no way out and intensified the suicidalideation.

Another aspect of cognitive entrapment experi-enced by suicidal people is a regressed and chrono-logically reversed form of thinking in which theeffect took precedent to the cause. Similar to moralrealism in young children, some suicidal individuals

come to judge their own intentions according toother people’s actions toward them. Dina the suicidalwoman described above would repeatedly and retro-actively interpret others offending her as a naturalextension of her guilt or worthlessness. When herparents or her husband would beat her, she wouldfeel that she must have deserved it. Whenever shewas attacked, she felt that she was actually the ag-gressor, not the victim. It is no wonder, therefore,that instead of feeling anger at the beatings and hu-miliation, she felt intense shame; instead of takingaction to cope with her anger, she endeavored tocope with her shame.

Self-hatredShneidman (31) talks of inimicality in the suicidalperson, that is, his or her inner enemy. Self-directedenmity is not merely negative self-perception, self-esteem or dissatisfaction with oneself. This innerenemy undertakes an active and violent offenseagainst the self. It entails an attack on one’s mentalexistence and the essence of one’s individuality. Aparticularly striking example of this self-abuse wasseen in an extremely suicidal young woman.Tragically, she eventually committed suicide. Whilein therapy, she would wear an expression of disgustwhenever she talked about herself, saying thingssuch as: “I’m disgusting, I stink, and I’m dirty, filthyand lazy. There is nothing good about me. I onlyhate, damage and destroy everything I own. I’m onebig lump of everything that is bad.” Every word sheuttered was tainted with self-disgust; she simplycould not stand herself. She was a young mother, ed-ucated, intelligent, creative, interesting and beauti-ful, yet she was completely incapable of seeinganything positive in herself, things that others couldeasily see in her. Any attempt to tell her about thepositive impression she made was in such stark con-trast to her self-experience that it was met with ragethat bordered on loss of control. Not only did she notbelieve the words of praise, she simply was unable tohear them. In fact, positive words seem to strike herlike the blows of a hammer.

“I want all or nothing”Many suicidal people have suffered from deprivationof basic needs of love, care and recognition. If suchdeprivations are not compensated for quite early in

274 SELF-DESTRUCTIVE PROCESSES

life, they tend to settle in as a stable experience ac-companied by extreme feelings of neediness, frustra-tion and anger. Such individuals constantly seek outothers for love and care in a way that can never besatisfied. In the minds of those individuals, the deepsense of frustration and deprivation can be compen-sated for only by a complete, total and uncompro-mising providence. Receiving only some, only partof what one needs is not only not enough, but is re-jected completely, as if saying: “If I can’t get it all, Ineed nothing.” Thus, the sense of frustration, depri-vation and anger is constantly growing.

This was evidenced in one suicidal patient, a 35-year-old woman. As one of six children, she felt thatshe was ignored and uncared for. This feelingseemed to be grounded to some degree in real lifeevents. When she was 10 years old, her parentsadopted an orphan, a girl the same age as the patient.The patient was asked to take an active role in the ab-sorption of the orphan into their family. She wasasked, for example, to share her books, clothes, foodand other favorite things with the adopted orphan.At the same time she felt that her parents ignored herown needs. In response, the patient developed aneating disorder. This patient felt that while themother continued to care for and feed the adoptedgirl, she totally ignored her own daughter’s eatingdisorder.

The patient grew up to be a demanding, frus-trated and angry person who always complainedabout what she is not getting from others and, at thesame time, angrily rejecting what she was getting. Ifshe could not get it all, she refused to receive a littleor part of it. This tendency was repeatedly demon-strated in the therapeutic work. For example, attimes of distress, she would request additional ses-sions to take place on a specific day and hour. If thetherapist could not adhere to her request, she wouldangrily reject any other alternative time, thus re-en-acting her relationship with her mother and re-expe-riencing a sense of deprivation, anger and rejection,and then would make a suicide attempt.

Creating losses and making oneself dispensableThis self-destructive process pertains to the constantand continual sense of loss and expectations for fu-ture losses. In such a pattern, the life narrative is per-ceived as a sequence of endless losses. External losses

are paralleled by inner losses which necessitate ad-justments and compromises. While suicidal personsare neither capable of making nor enduring thesechanges, they may actually assume an active role increating losses. This pattern is evident in the life nar-rative of a middle-aged suicidal man. He was theyoungest child in a family with nine children. At ayoung age, he lost an older brother in a war. Twoyears later, two of his sisters died from illness oneafter the other. He felt that he “lost” his father, whobecame engaged in a lifelong bereavement andmourning process. He believed that he had never re-ceived enough love from his mother who favored theother brothers and their children until she died, atwhich time he lost her love forever. At this point, heemigrated from his native country, which he experi-enced as an additional loss. When his son stoppedobserving a religious lifestyle, he experienced thischange in his son as another desertion. At that point,the man severed his ties with his son (as he had donewith some of his brothers and friends before) and be-came depressed and suicidal.

A process that is similar to creating the loss ofothers is creating a sense of being dispensable. “Ev-erybody will be better off without me” or “I was su-perfluous from the moment I was born” are typicalstatements heard by many suicidal individuals. Theyfeel and believe that there has always been a lack of fitbetween themselves and their environment. They re-call constantly being treated as an external distur-bance, as if they were in someone’s way. Oneadolescent girl wrote in a suicide note to her parentsfound after her death: “You always told me that I amin your way and constantly spoiling things for you. Inever felt that I am important at all and I feel that Isimply do not exist. Good-bye.”

In a 19-page-long letter, she spelled out how on somany occasions she felt dispensable and unnoticed.However, in every case she described, it was obviousthat she made herself unnoticed and dispensable. Onone occasion, when a boy her age approached herand showed a keen interest in her, she literallysteered him to her girlfriend. She then complainedhow this instance was reflective of so many otherswhereby people treated her as if she did not exist.

Perfectionism and impulsivityDora, a 28-year-old married physician who had just

ISRAEL ORBACH 275

completed her medical studies, came to therapy in astate of panic. She was flooded with anxiety regard-ing her ability to be a physician and feared disap-proval by her patients and supervisors. She was justabout to begin residency in a prestigious hospital,but was paralyzed by her anxieties. Her future, as sheenvisioned it, was bleak and she anticipated total fail-ure and disappointment to herself, her parents,friends, peers and supervisors. She considered kill-ing herself as an escape from this intolerable situa-tion. She had already made several attempts in thepast.

Dora was an excellent student, always at the topof her class, but before any examination, evaluationor feedback, she responded with extreme anxiety,restlessness and somatic complaints. She would be-come depressed for days whenever another studentreceived a higher grade than she did. She had to bethe best; there was no other way for her.

In therapy, she was advised to postpone her resi-dency for awhile in order to be able to work throughsome of her anxieties. She gladly accepted the advice.When she told her parents about this decision, theyresponded with some disapproval. She cut short hervisit to her parents, drove to the nearby woods, andoverdosed on medication. She was found uncon-scious with the help of the police and was hospital-ized for a few days. Because of the suicide attempt,Dora was summoned to a special committee of theHealth Ministry to evaluate her ability to assume theduties of residency. In the subsequent therapy ses-sion, she threatened to kill herself if the committeewould prevent her from completing her training as aphysician. She did not accept any of the alternativesthat were considered to cope with this new problem.When she arrived home, she made another suicideattempt and again was hospitalized at the same facil-ity in which she was treated after her first attempt.

After a few quiet months during which she madeseveral threats to kill herself, but with no actual at-tempts, she reported feeling much better and wasready to resume residency. (This was approved bythe special committee of the Health Ministry.)Again, Dora felt flooded by anxieties and fear, butwas able to compose herself and began a trainingworkshop before starting the residency program.She did very well in the workshop and felt encour-aged. After several days at work when she was about

to leave to go home, a senior physician commentedto her that in this hospital, the physicians are verydedicated to their work and do not leave work thatearly. She called her therapist again in panic andtears. She was sure that the next day she would befired, that her supervisors were not satisfied with herperformance, and that she wanted to quit. After along talk, she quieted down. Next morning, she over-dosed again. She called her husband before slippinginto unconsciousness and told him that she did notwant to die. It took her five days to wake up, but shewoke up with severe neurological disturbances andwith an almost total loss of memory.

Discussion

In this paper, I have tried to delineate self-destruc-tive processes theoretical and empirical perspectivesand as seen in clinical settings and their contributionto suicidal behavior and suicide. Suicide is not just aresponse to external stressful events. Much of the an-guish and unbearable pain is produced by the sui-cidal person him/herself in the way he/she construeshim/herself, the world, and in the way he or she re-acts to distress.

The various theories view self-destructive behav-ior from different perspectives. The dynamic theo-ries emphasize the wish-fulfillment that is embodiedin self-destruction and suicide. Baumeister’s cogni-tive approach views self-destructions as a reflectionof inappropriate strategies to external stress that onlyincrease the emotional distress in the long run.Other cognitive theories suggest that distortedcognitions are responsible for the production ofinner stress. Theories that view self-destruction asan outcome of certain personality characteristicsemphasize the destructive mode of action of suicidalindividuals.

Empirical work on various self-destructive pro-cesses provides evidence that all or most of the self-destructive processes suggested by the theories areindeed at work in suicidal individuals.

The clinical data regarding the specific cases pre-sented in this paper show that different self-destruc-tive processes can coexist in the suicidal person. Theself-destructive processes do not necessarily work inisolation because they come from emotional, cogni-tive and action modes of operation, combining to

276 SELF-DESTRUCTIVE PROCESSES

produce at times total self-destruction, yet each sui-cidal individual may present a unique set of self-de-structive processes.

The case studies presented here also show that, inone way or another, self-destructive processes havean early beginning and continue throughout life, andat times of stress are initiated by the person. In mostcases, one can also find aspects of self-hate, provoca-tion of stress, and the need for perfection and com-pleteness. All these configurations of experience andaction are self-destructive.

I believe that each of the self-destructive pro-cesses creates, in a different way, the experience ofunbearable mental pain and need to escape from thatpain (see 5). Mental pain is a subjective experienceand can take on different forms, such as deep frustra-tion of one’s most important needs, sense of intensedevaluation, narcissistic heart, irreversibility of thepain, hopelessness, helplessness, unbearable rageand sense of loss. As it was shown, self-destructiveprocesses can be involved in the production of suchexperiences. When the pain culminates into a statethat can no longer be tolerated, it is usually experi-enced as a total disintegration and as an inner catas-trophe with the potential of bringing about total self-annihilation.

This notion of the existence of self-destructiveprocesses in suicidal behavior does not negate theepidemiological approach taken by Gould et al. (1).Rather, it is complementary to the epidemiologicalapproach. The two perspectives should be taken intoaccount in the prevention and treatment of suicidalbehavior

References

1. Gould MS, Velting DM, Shaffer D. Youth suicide riskand preventative intervention: A review of the past 10years. Am J Child Adolesc Psychiatry 2003;42:386–406.

2. Orbach I. Therapeutic empathy with the suicidal wish:Principles of therapy with suicidal individuals. Am JPsychother 2001;55:166–184.

3. Orbach I. A taxonomy of factors related to suicidal be-havior. Clin Psychol: Science Practice 1997;4:208–224.

4. Davila J, Hammer C, Burge D, Paley B, Daley SE. Poorinterpersonal problem solving as a mechanism of stressgeneration in depression among adolescent women. JAbnorm Psychol 1995;104:592–600

5. Shneidman ES. The suicidal mind. New York: OxfordUniversity, 1996.

6. Joiner T. Depression’s vicious scream: Self-propagatingand erosive processes in depression chronicity. ClinPsychol: Science Practice 2000;7:203–218.

7. Rychlack JF. Introduction to personality and psycho-therapy: A theory construction approach. Boston:Houghton Mifflin, 1973.

8. Freud S. Mourning and melancholia. In: Strachey J, ed-itor and translator. The standard edition of the com-plete psychological works of Sigmund Freud (Vol. 14)London: Hogarth, 1947: pp. 237–254.

9. Menninger K. Man against himself. New York: Har-court, Brace, 1938.

10. Fairbairn WRD. Psychoanalytic studies of the person-ality. London: Routledge, 1952.

11. Seinfeld J. The parental and maternal functions of thepsychotherapist. Northvale, N.J.: Jason Aronson, 1991.

12. Stolorow RD. The narcissistic function of masochism(and sadism). Int J Psychoanal 1975;56:441–448.

13. Sacksteder JL. Thoughts on the positive value of nega-tive identity. In: Montgomery JD, Grief AC, editors.Masochism: The treatment of self-inflicted suffering.Madison, Conn.: International Universities, 1989: pp.105–121.

14. Shneidman ES. Definition of suicide. New York: Wiley,1985.

15. Baumeister RF. Suicide as escape from self. Psychol Rev1990;97:90–113.

16. Baumeister RF. Esteem threat, self-regulatory break-down, and emotional distress as factors in self-defeat-ing behavior. Rev Gen Psychol 1997;1:145–174.

17. Swann WB, Jr., Wenzlaff RM, Tafarodi RW. Depressionand the search for negative evaluations: More evidenceof the role of self-verification strivings. J AbnormPsychol 1992;101:203–306.

18. Weinberg I. Self-defeating behavior and suicide. Un-published doctoral dissertation, Department of Psy-chology, Bar-Ilan University, Ramat Gan, Israel, 2005.

19. Beck AT. Cognitive therapy: A 30-year retrospective.Am Psychologist 1991;46:368–375.

20. Ellis A. Reason and emotion in psychotherapy. NewYork: Lyle Stewart, 1962.

21. Heimpel SA, Wood JV, Marshall MA, Brown JD. Dopeople with low self-esteem really want to feel better?Self-esteem differences in motivation to repair negativemoods. J Pers Soc Psychol 2000;82:128–147.

22. Beck AT. Cognitive therapy and the emotional disor-der. New York: International Universities, 1976.

23. Rudd DM. The suicidal mode: Cognitive behavioralmodel of suicidality. Suicide Life-Threatening Behav2000;30:18–33.

24. Lazarus RS, Folkman S. Stress, appraisal and coping.New York: Springer, 1984.

ISRAEL ORBACH 277

25. Levenson M, Neuringer C. Problem-solving behaviorin suicidal adolescents. J Consult Clin Psychol 1971;37:433–436.

26. Orbach I, Rosenheim E, Hary E. Some aspects of cog-nitive functioning in suicidal children. J Am AcadChild Adolesc Psychiatry 1987;26:181–185.

27. Schotte DE, Clum G. Problem-solving skills in suicidalpsychiatric patients. J Consult Clin Psychol 1987;55:49–54.

28. Wilson KG, Stelzer J, Bergman JN, Kral MJ, InayatollahM, Elliott CA. Problem solving and coping in adoles-cent attempters. Suicide Life-Threatening Behav 1995;25:241–252.

29. Orbach I, Bar-Joseph H, Dror N. Styles of problemsolving in suicidal individuals. Suicide Life-Threaten-ing Behav 1990;20:57–64.

30. Orbach I, Mikulincer M, Blumenson R, Mester R, SteinD. The subjective experience of problem irresolvabilityin suicidal adolescents: Dynamics and measurement.Suicide Life-Threatening Behav 1999;29:150–164.

31. Shneidman ES. Voices of death. New York: Harper &Row, 1980.

32. Blatt S. Interpersonal relatedness and self-definition:Two personality configurations and their implicationsfor psychopathology and psychotherapy. In: Singer J,editor. Repression and dissociation. Chicago: Univer-sity of Chicago, 1990: pp. 299–335.

33. Shahar G, Priel B. Active vulnerability, adolescent dis-tress, and the mediating/suppressing role of life events.Person Individ Diff 2003;35:199–218.

34. Blatt S. The destructiveness of perfectionism. Am Psy-chologist 1995;50:1003–1020.

35. Barratt ES. Impulsiveness and aggression. In: MonahanJ, Stedman H, editors. Violence and mental disorder:Developments in risk assessment. Chicago: Universityof Chicago, 1994.

36. Herpertz S, Sass H, Favazza, AB. Impulsivity in self-mutilative behavior: Psychometric and biological find-ings. J Psychiat Res 1997;31:451–465.

37. Maris RW. Pathways to suicide: A survey of self-de-structive behaviors. Baltimore: Johns Hopkins Univer-sity, 1981.

38. Kullgren G. Factors associated with completed suicidein borderline personality disorder. J Nerv Ment Dis1988;176:40–44.

39. Simons R. Self-defeating and sadistic personality disor-ders: Needed addition to the diagnostic nomenclature.J Pers Dis 1987;1:161–167.

40. Maiuro RD, O’Sullivan MC, Vitaliano PP. Anger, hos-tility and depression in assaultive vs. suicide-attempt-ing males. J Clin Psychol 1989;45:531–541.

41. Rustein EH, Goldberg L. The effects of aggressive stim-ulation on suicidal patients: An experimental study ofthe psychoanalytic theory of suicide. In: Rubinstein I,editor. Psychoanalysis and contemporary sciences(Vol. 2). New York: Macmillan, 1973: pp. 157–174.

42. Tatman SM, Greene AL, Karr LC. Use of the suicideprobability scale (SPS) with adolescents. Suicide Life-Threatening Behav 1993;23:188–203.

43. Conner KR, Meldrum S, Wieczorek WF, DubersteinPR, Welte JW. The association of irritability andimpulsivity with suicidal ideation among 15- to 20-year-old males. Suicide Life-Threatening Behav 2004;34:363–373.

44. Oquendo MA, Galfalvy H, Russo S, Ellis SP,Grunebaum MF, Burke A, Mann JJ. Prospective studyof clinical predictors of suicidal acts after a major de-pressive episode in patients with major depressive dis-order or bipolar disorder. Am J Psychiatry 2004;161:1433–1441.

45. Forteza CG, Lira LR, Gutierrez MAC, EcheagarrayFAW. Psychosocial correlates of depression, suicidalideation, and suicide attempt among Mexican adoles-cents. Psicothema 2003;15:524–532.

46. Lindstrom MB, Ryding E, Bosson P, Ahnlide JA, RosenI, Traskman-Bendz L. Impulsivity related to brain sero-tonin transporter binding capacity in suicide attempt-ers. Eur Neuropsychopharmacol 2004;14:295–300.

47. Apter A, Plutchik R, Van Praag HM. Anxiety,impulsivity and depressed mood in relation to suicidaland violent behavior. Acta Psychiatr Scand 1993;87:1–5.

48. Clark CD, Fawcett J. Risk factor for suicide in schizo-phrenia and other psychotic and non-psychotic disor-ders. J Nerv Ment Dis 1992;179:259–266.

49. Duberstein PR. Openness to experience and completedsuicide across the second half of life. Int Psychogeriat1995;7:183–198.

50. Eliason RV. The roles of cognitive rigidity andimpulsivity in adolescent suicide attempts. Disserta-tion Abstracts International: B 2001;62:1075.

51. Gil S. Predicting suicidal ideation among psychiatricpatients: The tridimensional personality theory per-spective. Omega 2003;46:215–224.

52. Maltsberger JT, Buie DH, Jr. Countertransference hatein the treatment of suicidal patients. Arch GenPsychiatry 1973;30:633–635.

53. Kernberg O. Clinical dimensions of masochism. J AmPsychoanal Assoc 1987;36:1005–1029.

54. Novick J. Attempted suicide in adolescence: The sui-cide sequence. In: Maltsberger JT, Goldblatt MJ, edi-tors. Essential papers on suicide. New York: New YorkUniversity, 1984.

55. Asch SS. Suicide and the hidden executioner. In:Maltsberger, Goldblatt MJ, editors. Essential papers onsuicide. New York: New York University, 1984.

278 SELF-DESTRUCTIVE PROCESSES

56. Deane FP, Wilson CJ, Ciarrochi J. Suicidal ideation andhelp-negation: Not just hopelessness in prior help. JClin Psychol 2001;57:901–914.

57. Deane FP, Skogstad P, Williams M. Impact of attitudes,ethnicity, and quality of prior therapy on New Zealandmale prisoners’ intentions to seek professional psycho-logical help. Int J Advancement Counseling 1999;21:55–67.

58. Carlton PA, Deane FP. Impact of attitudes and suicidalideation on adolescents’ intention to seek professionalpsychological help. J Abnorm Soc Psychol 2000;66:151–156.

59. Isometsa E, Heikkinen M, Henriksson M, Aro H,Lonnqvist J. Recent life events and completed suicide inbipolar affective disorder: A comparison with majordepressive suicides. J Affect Dis 1995;33:99–106.

60. Heikkinen ME, Henriksson MM, Isometsa ET,Marttunen MJ, Aro HM, Lonnqvist JK. Recent lifeevents and suicide in personality disorders. J NervMent Dis 1997;185: 373–380.

61. Lester D, Hoffman S. Self-defeating behavior, depres-sion, and suicidal preoccupation. Psychol Rep 1992;70:1106

62. Joiner TE, Jr., Gencoz F, Gencoz T, Metalsky GI, RuddMD. The relation of self-hatred and suicidality in peo-

ple with schizophrenia-spectrum symptoms. J Psycho-path Behav Assessment 2001;23:107–115.

63. Brevard A, Lester D, Young BA. A comparison of sui-cide notes written by suicide completers and suicide at-tempts. Crisis 1990;11:7–11.

64. Kaplan HB, Pokorny A. Self-derogation and suicide. I.Self-derogation as a suicidal response. Soc Sci Med1976;10:113–118.

65. Kaplan HB, Pokorny A. Self-attitudes and suicidal be-havior. Suicide Life-Threatening Behav 1976;6:23–25.

66. Hewitt PL, Flett GL, Weber C. Dimensions of perfec-tionism and suicidal ideation. Cog Therapy Res 1994;18:439–460.

67. Hewitt PL, Norton GR, Flett GL, Callander L, Cowan T.Dimensions of perfectionism, helplessness, and at-tempted suicide. Suicide Life-Threatening Behav 1998;28: 395–406.

68. Apter A, Bleich A, King RA, Korn S, Fluch S, Kotler M,Cohen DJ. Death without warning? A clinical postmor-tem study of suicide in 45 Israeli adolescent males.Arch Gen Psychiatry 1993;50:138–142.

69. Brunstein-Klomek A. Self and object representation ofsuicidal adolescents. Unpublished manuscript, Depart-ment of Psychology, Bar-Ilan University, Ramat Gan,Israel, 2005.

ISRAEL ORBACH 279