Exploring the role of self-compassion in self-harm and suicidal ideation

Background: To date suicide research has mostly focussed on the presence of risk factors for suicide, and as a result, we have a good understanding of how these factors interact and contribute to risk. However, despite major advances in understanding the psychology of suicide and self-harm there are many gaps in our knowledge. In particular, the evidence for factors that may protect against suicide risk is limited. Self‐compassion has been implicated in the aetiology and course of mental health with evidence suggesting an association between greater self‐compassion and lower emotional distress. Adopting a compassionate stance to the self may help individuals tolerate difficult emotions, and as self-compassion can be developed through meditation type exercises, it may present a potentially modifiable protective factor for psychological distress and perhaps protect against suicide risk. However, research into self-compassion, suicide and self-harm is a relatively new field and our understanding of how self-compassion relates to risk-factors and self-harm as a whole is limited. This thesis presents five studies designed to address the following research questions: 1. What is the nature of self-compassion?; 2. What is the relationship between self-compassion and suicidal ideation or self-harm?; 3. Is a brief self-compassion exercise acceptable to individuals with a history of self-harm? Methods: A range of self-report and experimental measures were utilised to address the above research questions. To investigate the first research question, the factor structure of the Self-Compassion Scale (SCS; Neff, 2003 a,b) was assessed in study 2. Exploratory and confirmatory factor analytical techniques were used (Time 1, n=526; Time 2, n= 332). Construct divergence of the SCS and a measure of self-criticism was assessed in studies 3 and 5. To address the second research question, a systematic review of the literature (study 1) was conducted to establish the extent of the extant knowledge on this relationship. In studies 3 and 5 self-compassion was investigated within the context of risk factors selected from the Integrated Motivational-Volitional model of suicidal behaviour (IMV; O’Connor & Kirtley, 2018; O’Connor, 2011). Study 3: a longitudinal (Time 1, n=514; Time 2, n= 269) online self-report survey was conducted to explore self-compassion’s role within the motivational phase of the IMV model. The SCS was included along with the core constructs (defeat and entrapment) of the motivational phase of the IMV model and suicidal ideation history. Studies 4 and 5 were laboratory studies which used experimental and qualitative components to develop and pilot a self-compassion exercise (SCM). Study 4 (n= 8) assessed the acceptability of the SCM to individuals with a history of self-harm (Question 3). Specifically study 4 contained a qualitative component to elicit feedback on the SCM and explore participant’s experiences of compassion. Study 5 (n= 61) was a randomised controlled comparison of the SCM versus relaxation exercise on autobiographical memory; an established risk factor for suicidality from the IMV model (Question 2). Results: Addressing the first research question, the factor analysis confirmed a bifactorial model of the SCS indicating that both total score or and subscale scores are valid. Additionally, the SCS demonstrated significant divergence from self-criticism indicating that these measures assess different constructs. In respect of research question 2, consistent with the systematic review, all the studies herein found that higher self-compassion was associated with no history of suicidal ideation or self-harm and lower levels of psychological distress. In studies 3 and 5, components of the SCS were found to mediate the different pathways between selected risk factors and suicidal ideation and self-harm. Individual mediation models indicated that defeat and entrapment were mediated by SCS total score and isolation; the entrapment-suicidal ideation relationship was mediated by isolation, self-kindness and self-judgement. In study 5 the relationship between overgeneral autobiographical memory and suicidal ideation was mediated by all the negative SCS subscales, mindfulness and the SCS total score. Also in study 5, non-significant opposing trends were evident for the SCM and relaxation exercises. Specifically, following the exercises, a main effect was observed in recall latency to negative cues; latency decreased following the SCM whereas latency increased following the relaxation exercise (both non-significant). Non-significant increases in specific memories were observed following the SCM while no change was observed following the relaxation exercise. This may suggest that SCM and relaxation exercises operate differentially within autobiographical memory. There was clear evidence that a brief self-compassion exercise acceptable in individuals with a history of self-harm with only some minor changes in administration highlighted. Following the SCM increases in self-compassion were reported by participants. Conclusions: The range of methods used in these studies allowed an in-depth evaluation of self-compassion’s role in suicidal ideation and self-harm. In line with previous research, the findings suggest that high levels of self-compassion are associated with lower suicidal ideation and self-harm. The results also indicate that components of self-compassion may play a role throughout the motivational phase of the IMV model. Findings from the laboratory studies indicated that individuals with a history of self-harm found the brief self-compassion exercise acceptable. Our findings demonstrate that a brief self-compassion meditation is acceptable and produces changes in levels of compassion. Signals in the data from study 5 suggest that brief self-compassion exercises may be useful to investigate the relationship between self-compassion and autobiographical memory. Overall, these findings suggest that self-compassion may be an important clinical target as, given the interconnected nature of its components, targeting self-compassion may have diffuse effects on various risk factors for suicidal ideation and self-harm. Further research should investigate feasibility and outcome signals of compassion-focussed interventions for suicidal behaviour. Ultimately further research is needed to better understand the role of self-compassion in suicidal ideation and self-harm

An investigation of the factor structure of the Self-Compassion Scale

The Self-Compassion Scale (SCS) is the most widely used measure of self-compassion. The scale is constructed of six factors measuring positive and negative components of compassion. Support for this factor structure has been subject to debate and alternative factor structures have been proposed. We tested the proposed factor structures against existing models of the SCS including one derived from an exploratory factor analysis of our data. Respondents (n = 526) completed the original version of the SCS online at two time points, at baseline (time 1) and 2.5 months later (n = 332, time 2). Exploratory factor analysis (EFA) was carried out on time 1 data and confirmatory factor analyses (CFA) were conducted on time 2 data and retested using time 1 data. The EFA yielded a five-factor model. CFA was used to compare the following models: Neff’s original six-factor correlated and higher-order models; a single-factor, two-factor, five-factor model (as suggested by the EFA) and a bi-factorial model. The bi-factorial model was the best fit to the data followed by the six-factor correlated model. Omega indices were calculated and yielded support for the bi-factorial model of SCS. In conclusion, this study supports the use of the six-factor scoring method of the SCS and the use of an overarching self-compassion score

Suicide risk in personality disorders: a systematic review

Purpose of review: This systematic review aimed to distil recent literature investigating psychosocial factors which may account for the association between personality disorder (PD) and suicide attempt or suicide death. Recent findings: Suicide risk is particularly elevated in people with PD compared to those with no, or many other, mental health diagnoses. Despite this, suicide prevention strategies for PD populations have not progressed markedly in recent years. It is critical, therefore, to identify additional factors associated with suicide in PD populations. Summary: Of the 34 studies included in this review, most identified a relationship between personality disorder and suicide attempt and/or death. Historical interpersonal factors (e.g., childhood trauma), drug and alcohol use, and ideation-to-enaction factors were commonly associated with suicide-related outcomes. Interventions that provide interpersonal support may reduce suicide attempts. Limitations of the review include the heterogeneity of studies and small sample sizes

Adverse Childhood Experiences and Hospital-Treated Self-Harm

Adverse childhood experiences (ACEs) have been implicated in a range of negative health outcomes in adulthood, including increased suicide mortality. In this study, we explored the relationship between ACEs and hospital-treated self-harm. Specifically, we investigated whether those who had a history of repeat self-harm reported more ACEs than those who had self-harmed for the first time. Patients (n = 189) admitted to two hospitals in Glasgow (UK) following first-time (n = 41) or repeated (n = 148) self-harm completed psychosocial measures. Univariate analyses revealed that those presenting with repeat self-harm reported higher depressive symptoms, anxiety symptoms, intent to die, and ACEs, and lower dependent attachment style. However, only ACEs, along with female gender and depressive symptoms, significantly differentiated between the repeat self-harm group and the first-time self-harm group in the multivariate model. Controlling for all other psychosocial variables, participants who reported 4+ ACEs were significantly more likely to be in the repeat self-harm group as compared to those who experienced 0–3 ACEs. This finding highlights the pernicious effect of exposure to multiple ACEs. Further research is urgently required to better understand the mechanisms that explain this relationship. Clinicians should be aware of the extent of the association between ACEs and repeat self-harm

Designing a Massive Open Online Course (MOOC): Understanding Suicide and Suicide Prevention Strategies in a Global Context. Findings from the March and Sep 2019 runs

Introduction: Suicide prevention is a global public health challenge. Increasing evidence-based knowledge and understanding of suicide needs to be central to suicide prevention efforts worldwide. We aimed to design a 3 week Massive Open Online Course (MOOC) to allow students to gain a broader understanding of suicide as a global issue. Methods: A multidisciplinary team of psychiatrists, psychologists, suicide researchers, people with lived experience and digital learning technologists developed the educational content. To ensure a safe learning environment, the World Health Organisation (WHO) guidelines on safe reporting of suicides was adhered to. Self–care activities were embedded throughout each week of the MOOC and wellbeing resources were signposted at the end of each step. Once the draft MOOC was completed, extensive consultation occurred. External feedback was obtained from a range of key stakeholders and a number of organisations were approached for endorsement or accreditation. Five teaching assistants were employed to aid course moderation. Results/Discussion: The MOOC launched in March and September 2019 with five organisational endorsements and one accreditation. Over 3,000 students engaged in the MOOC with 4,410 discussion comments. Student discussions were monitored by staff. The MOOC appeared to have a global reach with 51% of learners residing in the UK, 5% in Australia, 4% in the United States, 3% in Mexico, 2% in Canada, India and China and 1% in Russia and Saudi Arabia. Completion data from 276 learners reported that 93.5% (n=258) felt the course met or exceeded expectations and 95.7% (n=264) reported new learning. Conclusion: There appears to be a global demand for education on suicide prevention. Early outcome data suggested that new knowledge can be delivered through a MOOC. Learner safety needs to be carefully considered when developing and delivering online learning. Thorough and careful moderation is essential to ensure that learners engage safely with the content

Testing mood-activated psychological markers for suicidal ideation

To what extent are death- and life-oriented psychological processes among suicidal individuals activated by mood? According to Teasdale’s (1988) Differential Activation Hypothesis, we would expect that negative mood-activated psychological processes are maladaptive among suicide ideators (vs. non-ideators) and predictive of subsequent suicidal ideation. This, however, has never been prospectively studied. To address this knowledge gap, we conducted a prospective study assessing psychological risk factors via the Death/Life Implicit Association Test (IAT) and the Suicide Stroop task before and after a temporary negative mood induction. Suicidal ideation was assessed one and six months later. Results based on Death/Life IAT performance largely supported hypotheses, such that suicide ideators demonstrated significantly weaker implicit identification with life after (vs. before) the negative mood induction. Non-ideators demonstrated no significant change, maintaining strong identification with life irrespective of mood. Of note, this baseline interaction may have been accounted for by depressive symptoms. Identification with death (vs. life) predicted greater likelihood of suicidal ideation one month later, controlling for depressive symptoms and baseline suicidal ideation. Only negative mood-activated identification with death predicted suicidal ideation six months later. Suicide Stroop scores did not change as a function of mood or predict subsequent suicidal ideation. Death/Life IAT findings support the Differential Activation Hypothesis and suggest that suicide ideators’ identification with life is more variable and easily weakened by negative mood relative to non-ideators. We encourage future work to consider the potential role of transient mood and the importance of measuring psychological processes that pertain to both death and life

Suicide attempts and non-suicidal self-harm: national prevalence study of young adults

Background There are few prevalence studies of suicide attempts and non-suicidal self-harm (NSSH). Aims We aimed to estimate the prevalence of thoughts of NSSH, suicidal thoughts, NSSH and suicide attempts among 18- to 34-year-olds in Scotland. Method We interviewed a representative sample of young adults from across Scotland. Results We interviewed 3508 young people; 11.3 and 16.2% reported a lifetime history of suicide attempts and NSSH, respectively. The first episode of NSSH tended to precede the first suicide attempt by about 2 years. Age at onset of NSSH and suicide attempt was younger in females. Earlier age at onset was associated with more frequent NSSH/suicide attempts. Women are significantly more likely to report NSSH and suicide attempts compared with men. Conclusions One in nine young people has attempted suicide and one in six has engaged in NSSH. Clinicians should be vigilant, as suicide attempts and NSSH are relatively common

Predicting suicidal ideation in a nationally representative sample of young adults: a 12-month prospective study

Background Evidence-based theoretical models outlining the pathways to the development of suicidal ideation may inform treatment. The current research draws from the Interpersonal Theory of Suicide (IPT) and the Integrated Motivational-Volitional (IMV) Model of suicidal behaviour, and aims to test the interaction between perceived burdensomeness and thwarted belongingness as proposed by the IPT model, and the defeat–entrapment pathway as proposed by the IMV model, in the prediction of suicidal ideation at 12-month follow-up. Methods The Scottish Wellbeing Study is a nationally representative prospective study of young people aged 18–34 years (n = 3508) from across Scotland, who completed a baseline interview and a 12-month follow-up (n = 2420). The core factors from both the IPT (perceived burdensomeness and thwarted belongingness) and the IMV model (defeat, internal and external entrapment) were measured alongside demographics, depressive symptoms and suicidal ideation at baseline. At 12-month follow-up suicidal ideation was assessed again. Results In multiple regression analysis perceived burdensomeness and internal entrapment, with baseline suicidal ideation, predicted 12-month suicidal ideation. No support for the interaction between perceived burdensomeness and thwarted belongingness in predicting 12-month suicidal ideation was found. However, there was evidence that internal, but not external, entrapment mediated the relationship between defeat and 12-month suicidal ideation, but no support was found for the moderation of burdensomeness and belongingness on the entrapment to suicidal ideation pathway. Conclusions The current findings highlight the importance of targeting perceived burdensomeness and internal entrapment to reduce the likelihood that suicidal ideation emerges in at risk individuals.Output Status: Forthcoming/Available Onlin

Predicting future suicidal behaviour in young adults, with different machine learning techniques: a population-based longitudinal study

Background: The predictive accuracy of suicidal behaviour has not improved over the last decades. We aimed to explore the potential of machine learning to predict future suicidal behaviour using population-based longitudinal data. Method: Baseline risk data assessed within the Scottish wellbeing study, in which 3508 young adults (18-34 years) completed a battery of psychological measures, were used to predict both suicide ideation and suicide attempts at one-year follow-up. The performance of the following algorithms was compared: regular logistic regression, K-nearest neighbors, classification tree, random forests, gradient boosting and support vector machine. Results: At one year follow up, 2428 respondents (71%) finished the second assessment. 336 respondents (14%) reported suicide ideation between baseline and follow up, and 50 (2%) reported a suicide attempt. All performance metrics were highly similar across methods. The random forest algorithm was the best algorithm to predict suicide ideation (AUC 0.83, PPV 0.52, BA 0.74) and the gradient boosting to predict suicide attempt (AUC 0.80, PPV 0.10, BA 0.69). Limitations: The number of respondents with suicidal behaviour at follow up was small. We only had data on psychological risk factors, limiting the potential of the more complex machine learning algorithms to outperform regular logistical regression. Conclusions: When applied to population-based longitudinal data containing multiple psychological measurements, machine learning techniques did not significantly improve the predictive accuracy of suicidal behavior. Adding more detailed data on for example employment, education or previous health care uptake, might result in better performance of machine learning over regular logistical regression