Profile: Thomas Joiner and the Study of Suicide
Thomas Joiner is an academic psychologist and leading expert on suicide. He is the author of Myths about Suicide and Why People Die by Suicide, which outlines his influential model, The Interpersonal Theory of Suicide. He is a Professor of Psychology and Director of the Laboratory for the Study and Prevention of Suicide-Related Conditions and Behaviors, both at Florida State University. As part of our Profile series, he sat down with Psychology Tools to talk about understanding human nature, his journey within the study of suicidal behavior, and how American Football has helped shape his theory of suicide.
An intellectual and personal path to the study of suicidal behavior
You began your clinical training focusing on depression. What led you to shift your focus to the study of suicide?
My interest in suicidal behavior has been abiding, although at first depression was the focus. There are two things that I think caused the shift to happen. One is an intellectual issue that I think is a fundamental question about understanding human nature, which is ‘What about human nature can go so wrong, that suicide happens?’ I think suicidal behavior is a key part of this, it’s an upsetting and disturbing one, but a key part nonetheless, and it’s almost like opening a window onto understanding human nature itself. Intellectually, I think that’s interesting and worth pursuing. That developed in me in the 80s, in college and in graduate school. Then in 1990, this struck home very personally, with the loss of my dad who died by suicide that year. That made an intellectual issue, which was already a profound and fascinating one, suddenly become personal and urgent to me. It’s those two things, mostly, that lead to the focus.
Can you talk a little more about suicidal behavior being a key to understanding human nature and how you approach this?
There’s an academic tradition within academic psychology focused on psychopathology as a way to understand human nature, as opposed to being focused on understanding mental health conditions in and of themselves, which is also very important. This tradition is to go one step beyond that very general step and use psychopathology as a lens to study human nature itself. I think it’s an important lens. One way to approach this would be to explore how people achieve thriving, flourishing, connection and fulfillment. That’s a defensible way to try to understand human nature, but it may well be that an even better way to understand it is through malfunctions. Looking at catastrophic, disastrous malfunctions, and piecing together what the implications are for human nature from that. I think both efforts are worthy and laudable. Understanding mental health conditions in and of themselves is key – they are a profound form of suffering, and commonly misunderstood and undertreated, so studying them is very worthwhile and valuable, and I do that in my own professional life. But I’m also attracted intellectually to go a step further and try to understand more about human nature itself.
As you develop your work further, do you feel you are gaining a deeper understanding of human nature, or does it keep opening up new questions for you?
I would say there’s a lot of both. I do feel like I’ve gained a pretty deep understanding of the roots of these kinds of tragedies, one that is much deeper than I had at the outset of my intellectual journey, and one that has gained influence. But temperamentally, I am not one to rest on my laurels, and so I don’t think my ideas are all that great. I think they’re good in a relative sense, but in an absolute sense, they’re not that great. We have a lot to learn, and therefore questions are always on my mind about doing better, understanding more. Figuring out the dark matter type areas in our field, which I think are just as big as they are in astrophysics, for example.
The Interpersonal Theory of Suicide
For those not familiar with it, could you give a summary of your Interpersonal Theory of Suicide?
In a nutshell, the theory is that it’s useful to distinguish between ideas about death by suicide and desire for suicide. Ideation and suicidal thoughts are fairly common, and they are a form of suffering in and of themselves, and of clinical concern. The theory has ideas about where suicidal ideation comes from, but a key insight of the model is that ideation is one thing, and action, or behavior, is a wholly different question. That’s an important insight – a lot of the people who have ideation about suicide never come close to an attempt, much less a lethal attempt, and that cries out for explanation.
Before my conceptual work, I don’t think there really was a very good explanation of that, or even much attention to that distinction, which is an obvious and important one; desire versus the capability to die by suicide. These are separable processes, with separate trajectories that lead up to them.
For the desire piece, the theory is twofold. It’s the combination of feeling like you don’t belong, and that your life or your existence burdens others; be it to society, to family, to loved ones, or to your own self, you are a burden. In addition, also concluding that this is permanent situation; that this is how things are going to be, going forward. That’s the driver according to our model of desire, but capability is a different matter. That is driven by things like fearlessness of death, fearlessness of pain, pain tolerance, knowledge and familiarity with things that may be used in a lethal suicide attempt. When those three processes come together in the same individual, that’s when the model predicts a lethal outcome.
According to your model, what is the thinking regarding why a person could begin that transition from ideation towards capability?
Not all of it, but a considerable part of it is genetic, and related to temperament. It’s hard to estimate, but the best study on this would estimate it at about 40% of the variable being genetic. That is a little higher than what I would have thought at the outset, 20-25 years ago, but fear-based elements, fear and pain processing are very genetic. So looking at it through that view, it’s not too surprising that it’s pretty heavily genetic. The rest of it, we think, has to do with learning experiences regarding being faced with pain. Experiences of injury, maybe violence or abuse. Occupational factors can come into play if the work is very physical, for example if it’s very rugged. Quite an array of factors can drive the non-genetic piece, but essentially, we think it’s a combination of genetic factors and learned experiences of having faced fear and physical pain.
When you were developing the theory, did the different processes emerge at the same time or was it clear to you even at the start, that there was a new component that hadn’t been discussed before?
It’s a little hard to trace that. I don’t think the elements of the theory relating to belonging and burdensomeness, were that shocking conceptually – they had already been broached, but I’ve always had a strong sense of physicality, and probably more than many other professors. I grew up playing American football, and that’s just a rare combination for a professor in American academia. To this day, I look back very fondly on that. It’s a hard sport, it’ll teach you lessons about facing pain and injury and fear, so I’ve always just had an awareness of the physical limits of bodies, and an awareness of the brutality of the sport. I think these things have been influences on why my mind was drawn, not so much to the abstract and the intellectualized versions of these, but to having a real and practical understanding of the physicality of suicidal behavior. I think that’s probably influenced part of my intellectual development and how the capability component of the theory became clear to me.
What do you think this experience taught you about physicality?
The physical elements of the sport, the pain and the impact to your body definitely became more familiar and less shocking. But not only that, they became more enticing and exciting. You can develop a kind of appetite for it. It’s not natural, and I’m not saying that it’s necessarily a good thing. I’m saying it’s something that I grew up with and that had a big influence on me. It can be a very, very dangerous thing actually, and I recognize that, but there’s a deep, deep place in my heart for those experiences despite their danger. There’s definitely a habituation, but once you get past that there’s even a type of appetite or hunger that kicks in. And I think that can be relevant in trajectories towards suicidal behavior too.
Looking at the theory from a clinical perspective, why is it important for clinicians to know about it and how is it helpful for them clinically?
I started off in graduate school in the 80s, much more pulled towards clinical work than towards scientific work. I’ve always been very clinically focused and aware that the work needs to be translatable. I’m also aware that in this particular domain, there was a chaos to it. At one point, a colleague and I tried to count the number of risk factors of suicidal behavior that have been documented in suicide literature, and we got into the hundreds. That’s interesting, perhaps to professors, but it’s a chaotic mess for clinicians. I think that’s one virtue of the theory, that it imposes order on that chaos.
All the risk factors can be relevant, but they’re relevant because they feed into these final three common pathways. Clinically, if you focus on those final common pathways, it’s manageable, but even more importantly, it’s probably the most important leverage point. If it’s a final common pathway for hundreds of risk factors, it’s a very sensible leverage point to target clinically.
How can clinicians translate the theory to enable effective work with suicidal clients who aren’t being open with their thoughts and feelings?
The theory is meant to apply across the board, but you’re pointing to a regular and often vexing clinical problem which is that not everybody is going to be open. However, especially with regard to the capability part of the model, but not only with regard to it, it can be judged behaviorally. Observationally and with questioning of family members and others, I think certainly the capability element, but also the belonging part, can be judged.
Even in somebody who’s wholly uncooperative, behaviorally you can see indicators of capability, fearlessness and those kinds of traits. And you can judge withdrawal, so people starting to socially withdraw and be alienated. There’s an air about them, a feeling, that one can get behaviorally. The burdensome piece is more of a problem and does require trust and rapport between a client and a clinician.
Has the theory been refined since it was published?
There are things that are in the works right now that I think are going to do that. We’ve been very aware all along of the imperfections of the theory. What that means is that all the approaches and explanations are partial, and what that in turn means is that there’s a lot more to explain.
The current efforts, about which I’m really excited and enthusiastic, are trying to push that boundary out. One way to do that is to look at automatic processing, implicit processing that occurs below the level of awareness. None of that is in the original statement of the theory, but we have a revision in process. The work is finished and it’s now in the review process for publishing in Psychological Review. Things are looking very favorable, but the process is a long one.
This implicit cognition update (the revised version) doesn’t really change the overall concepts, but it does deepen them and adds in an additional level. There’s no question that implicit processing is an influence on human behavior. There’s robust literature going back decades, on implicit influence in areas like relationship formation, attitude formation – politically for instance, or with regard to any topic in the news. People have very explicit ideas about these things, but there’s also implicit impact, and that’s got a lot of currency now. With regard to social justice movements, and areas like discrimination and racism, the understanding is that there’s an implicit aspect to them, but these kinds of attitudes have not been much explored in the theories of suicidal behavior, and our new work incorporates this.
It’s certainly partly my work, but it’s driven by two social psychologists that I’ve become friends with and research collaborators with, named Michael Olsen, at the University of Tennessee, and Jim McNulty, who’s a colleague of mine at Florida State. They’ve worked all along on implicit attitudes and implicit cognition. They’ve been they’ve mostly applied it to relationships; how do people form romantic relationships, how do they form and sustain themselves, and how do they break up? They have a long history in that area, and now we’ve joined forces and applied it to suicidal behavior.
Arbitration and scientific fluency
Sadly, a majority of clinical psychologists never publish. What motivates you to carry out and publish research – what is different about you, what drives you? And why do you value research as well as clinical practice?
When I went to college, I got immediately drawn to fields like philosophy, because I found the ideas exciting. But I’m a very pragmatic person and back then it seemed to me anyway, that they had very interesting and exciting ideas but they never answered the question. It was just an endless debate, because there was no way to resolve it. At the same time, I started to become aware of academic psychology, pretty much looking at the same questions, but with a way to answer them, and that really appealed to my practical side. That gave me respect all along for research and for sciences. It’s not good enough to just pose extremely interesting questions and possibilities and ideas, we need a way to arbitrate them. One of the crowning achievements of humans is science, because it’s a way – an imperfect way – but the best way by far to arbitrate important questions. That drew me to research, but it wasn’t totally natural for me, it took a while. A key turning point was a really wonderful statistics professor, who was able to teach statistics as a sort of language, and it was a wonderful experience. It made something that was really alien to me, statistics, become another language I spoke and when that happened, you know, the rest of it was not that hard to me. I think once you’ve mastered that language, that’s a real key to scientific fluency and achievement, in my opinion.
What’s your balance of clinical work and research? What’s valuable about that balance?
In addition to research, we run a psychotherapy training clinic, through our Department of Psychology at Florida State. All the PhD students in clinical psychology cycle through that clinic for their second and third years, for their clinical training. I direct that clinic and that keeps me connected clinically. It’s probably the most important and rewarding part, at least in my judgement, of being a professor. I was a professor to medical school for a few years, during the 90s. During those years, I was really productive, but I did not have graduate students. Then the awareness started to dawn on me there was a main gap in my professional life, and that motivated the move to from a Department of Psychiatry to Department of Psychology. Having graduate students, especially of the caliber we have, has been a real delight. It’s not easy, but it’s very gratifying.
I’ve always maintained clinical practice. In the early 2000s it was mainly a psychotherapy practice. Nowadays, it’s there’s a little bit of that, but it’s mainly a consulting practice consulting to lawyers and into business and behavioral health companies. In America, lawyers often have to delve into tragedy, or suicides that are being litigated. Often with reason, because there are a lot of times when hospitals, doctors, psychologists, psychiatrists, counsellors, social workers, etc., do a really suboptimal job, and that does lead to suicides. That can be the subject of a lawsuit, and some lawyers bring people like me to act as consultants, so these days, that’s the main focus of my clinical consulting practice.
A sense of efficacy and hope for the future
How do you take care of yourself, when working with such grave forms of suffering and its effects?
I think because I have a strong of a sense of efficacy, it hasn’t been a problem for me. That’s my view of things in a lot of professions. It’s not just people focused on suicidal behavior, but people focused on schizophrenia, and bipolar disorder, and all sorts of deep forms of suffering. I think all of them are subject to or at risk of burnout and demoralization, unless they feel like they’re making a difference. I feel like I am. I’ve never felt a sense of helplessness or burn out. I’m very aware of how tragic and even desperately grave these tragedies are, but because I feel like I’m making a difference, it doesn’t feel as oppressive or heavy.
Looking back at your student self, what do you wish you knew then, that you know now?
I would start with appreciating the virtues of my training. The main one that comes to mind is my major professor. His name is Gerald Metalsky. I was his first student, and I think that’s relevant, because he really invested in me and I cherish that, but that was in the academic, scholarly research domain. Clinically, I’m afraid back then anyway, the training was very poor, and I didn’t learn or know much. That is reflected in my own life, and I didn’t see my own dad’s suicide coming. Now I know in retrospect there were clear indications, but I didn’t know it at the time, that’s how suboptimal clinical training back then was on understanding suicide. I didn’t really pick up on that until internship and then beyond. So, looking back I would just want to be better clinically, and be aware of its importance whilst training.
What do you find most pleasing about the way students are being taught now, compared to what you learned during training?
I’ve used the awareness of the importance clinical excellence to make sure that the students we’re training are extremely effective in all domains clinically, scientifically, etc. Back then, I never saw any of my supervisors in action. I just think that’s wrong and so I’ve made it a point to be really involved. For example, doing role plays, or making myself vulnerable as a therapist in front of students because that’s the reality of it. Even very seasoned people can struggle depending on the situation, and students need to see that in the people they look up to.
I think we’ve come a long way on that. I think the training now, in departments like ours where there’s a focus on it, is exemplary, although there’s ways to improve that. But these students are incredible, and we ask an enormous amount of them; to hopefully be leaders in research and science and scholarship, and at the same time to become very good clinicians; it’s like asking people to do two really hard, full time jobs. These students are up to it, and it’s an inspiration.
I think we have a long way to go with things like prediction, and therapeutics to make them optimized. We need to continue to be mindful and thoughtful about issues of social justice, and it is not clear that that’s attended to sufficiently even in departments that are aware and trying to do their best. If there are things that are lacking, it’s probably in those ways, but compared to back in the 80s, I just think we’ve come a long way!
What is exciting and hopeful for you in this field now?
I’m very hopeful because of the people that are following in our footsteps now. That is by far my main professional contribution and achievement – being involved in teaching and developing the next generation of psychologists. They’re just starting out and they are exciting. A solid handful are now full professors, and then there’s a whole cadre of associate professors, and assistant professors behind them. Not to mention my current students. I would also point out how different it is from the 80’s, where there wasn’t the caliber of laboratories there are now. Now, there are many around the world now. So that’s very exciting in terms of what knowledge and thinking will emerge from these opportunities.
How do you think psychologists, or your current students, might be treating suicidal behavior differently in twenty years’ time?
It’s so hard to say but that’s what makes it interesting. There are already psychologists challenging the current ideas, which I encourage. That can only make things better, so I’m not afraid of challenge, or even honorable defeat, so to speak. I think a lot of scholars and professors and scientists are concerned by it, but to me that is a misunderstanding of the enterprise. There’s a student who’s an assistant professor at Florida State, her name is Jess Ribeiro. She and I, and her students just got a paper accepted in the Journal of Abnormal Psychology. The paper is not favorable to my theory, but my student led it, her students did it, and I’m a co-author on the paper. I think that’s how science should be. The data will speak. Not just in that one study, but as part of the montage of studies that in 20 years, might be judged as a mosaic that overturns a theory or revolutionizes one. I’m comfortable with that. If the students we are teaching now can do that, that’s just going to be to the greater good, and will lead to great advances in understanding and clinical practice.