coping styles and suicide risk

Acta Psychiatr Scand 1996: 93: 489-493 Printed in U K - all rights reserved

Copyright 0 Munksgaard I996 ACTA PSYCHIATRICA

SCANDINAVICA ISSN 0001-690X

Coping styles and suicide risk

Horesh N, Rolnick T, Iancu I, Dannon P, Lepkifker E, Apter A, Kotler M. Coping styles and suicide risk, Acta Psychiatr Scand 1996: 93: 489-493. 0 Munksgaard 1996.

A total of 30 psychiatric in-patients admitted because of suicidal behaviour were compared with 30 non-suicidal psychiatric in-patients and 32 healthy controls on measures of suicide risk and coping styles. The three groups were similar with regard to demographic variables, but the suicidal group scored higher on the suicide risk scale. Suicidal patients were significantly less likely to use the coping styles of minimization and mapping. They were unable to de-emphasize the importance of a perceived problem or source of stress. They also lacked the ability to obtain new information required to resolve stressful life events. Four coping styles correlated negatively with the suicide risk (minimization, replacement, mapping and reversal), while another three (suppression, blame and substitution) correlated positively. These findings may have important implications for therapists and primary prevention workers, and might pave the way towards recognition of the role played by coping styles in predicting suicide and its use for cognitive intervention in these high-risk patients.

N. Horesh’, T. Rolnick2, 1. lancu2, P. Dannon2, E. Lepkifkd, A. ApteP, M. Kotlel2 ‘Shalvata Psychiatric Hospital, Hod Hasharon, ‘Psychiatric Division, Sheba Medical Center, Tel Hashomer and 3Children and Adolescent Psychiatry Department, Geha Psychiatric Hospital, Petah Tikva. all affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

Key words: suicide risk; coping style; suicide prevention

Moshe Kotler. Psychiatiy Division, Sheba Medical Center, Tel Hashomer, Israel

Accepted For publication December 2. 1995

Introduction

Coping mechanisms serve as an internal source of emotional strength and mediate a person’s reaction to any perceived stress, whether internal or exter- nal. According to Cohen and Lazarus (l), coping is defined as the ‘cognitive and behavioural efforts used to master, tolerate, and reduce demands that tax or exceed a person’s resources’. Several studies have demonstrated a crucial role of coping styles in buffering the impacts of different stressors on the development of overt psychiatric morbidity (2). It appears that it is not the stressor alone that leads to serious outcome, but the way in which the person perceives and responds to it. Thus, Lineham et al. (3) reported that individuals who attempt suicide have more difficulties in coping with interpersonal problems than do non-suicidal psychiatric patients or members of the general population. Suicidal patients are less able to consider alternatives (4,5) or to think flexibly (6-9), and may persist in ineffective problem solving even after more effec- tive strategies have been presented (10).

Several studies have examined the impact of different coping styles on suicide risk. Kotler et al. (11) compared a group of suicidal in-patients with a non-suicidal group, and reported that the suicidal

patients were less likely to use the coping style of minimization to deal with life problems. Botsis et al. (12) compared similar groups and reported that the suicidal patients used almost all coping styles less frequently than the non-suicidal patients. Among suicidal patients, the risk of suicide was negatively correlated with the coping styles of minimization, replacement and blame. Suicide risk was shown to be predicted by coping style.

In another study, Joseph0 & Plutchik (13) inves- tigated the relationship between interpersonal problems, coping styles and suicide risk among 71 adult psychiatric in-patients. They showed that interpersonal problems and the coping style of suppression (tendency to avoid a threatening situ, ation) were found to be significantly and positive13 correlated with suicide risk. Several other coping styles were found to be significantly associated with suicide risk (13).

In the present study, we aimed to investigate further the relationship between the different coping styles and suicide risk. This is the first study to examine these variables in Israeli patients, and we have modified and extended the study’s method- ology by adding a third group of healthy controls,

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in accordance with Orbach’s postulation (8), which stipulates that in order to find suicide predictors, one must assess the variable in three groups: suicidal patients, non-suicidal patients and healthy controls.

Material and methods

Subjects

A total of 60 in-patients from the Sheba Medical Center and 32 healthy controls (technological and paramedical staff of another medical centre) were interviewed. The interviews took place within 30 days after admission of the patient. All patients who were willing to participate in the study signed informed consent forms. Exclusion criteria included age under 18 years or above 64 years, cognitive impairment, organic syndromes and lan- guage difficulties. No attempt was made to select any particular diagnostic category of patients, since clinical experience indicates that patients belonging to diverse diagnostic groups are at risk for suicide.

Patients were selected for the study group if the reason for admission was a suicide attempt or severe and overt suicidal ideation with a definite plan to act. For each such patient, a non-suicidal patient and a healthy control were matched according to sex, age and diagnoses. In total, our sample included 30 suicidal in-patients, 30 non-suicidal in- patients and 32 healthy controls.

Assessment

Each patient was interviewed by a psychiatrist regarding the reasons for admission and the events leading to their suicidal behaviour or ideation. Patients were then placed in one of four broad diagnostic categories: (a) psychotic spectrum disorders (e.g. schizophrenia, brief reactive disorder, etc.); (b) affective spectrum disorders (e.g. major depression, bipolar disorder, dys- thymia, etc.); (c) anxiety spectrum disorders (e.g. generalized anxiety disorder, panic disorder, post- traumatic stress disorder); and (d) personality disorder spectrum. We used this system of catego- rization in order to make the best approximate comparison of the diagnostic distribution in the in-patient group, and to facilitate and simplify the problem of matching.

Measures

A battery of self-report questionnaires was given to the subjects, and a member of our team attended the sessions in order to answer questions and make clarifications. The psychometric instruments used

in this study measured either suicide risk or coping styles.

Suicide risk

This variable was measured with the Suicide Risk Scale (SRS) (14), which consists of 26 items, to each of which the patient gives a response of either ‘true’ or ‘false’. They include items on past history of suicide attempts, present strength of suicidal impulses, feelings of depression and hopelessness and other items that have been reported to be associated with suicide attempts. The internal reliability of the scale has been found to be 0.84, indicat- ing a high degree of intercorrelations among the items. The SRS also discriminates between patient and non-patient groups, and is of satisfactory sensi- tivity and specificity (14-17).

Coping styles

These were assessed with the Albert Einstein Col- lege of Medicine (AECOM) Coping Styles Scale (17). This is a 95-item scale with a 4-possibility spectrum ranging from ‘never’ to ‘very often’. The scale measures eight basic coping styles that are used for reducing stress and coping with life problems. These coping styles are suppression (avoiding the problem), help-seeking (asking for help), replacement (dealing with problems by finding alternative solutions), blame (blaming others for the problems), substitution (engaging in tension- reduction activities such as sports), mapping (col- lecting information about the problem), reversal (acting the opposite of the way one feels) and minimization (minimizing the importance of the problem). The internal validity of the questionnaire was found to have an alpha value of between 0.58 and 0.79, with a mean alpha value of 0.70. The questionnaire had both predictive validity (18) and discriminative validity (19).

Statistical analysis

We compared the AECOM coping styles scores in the three groups using ANOVA and Scheffe aposterior analysis, in order to detect the source of the significant difference. The correlation between the suicide risk (as assessed by the SRS) and different coping styles score was examined.

Results

The demographic characteristics of the three study groups were found to be similar (Table 1). The patient’s diagnoses were similar in the in-patient groups. Seven patients were diagnosed with psy-

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Table 1. Demographic characteristics of the sample group ~

Significance Variable Suicidal group Non-suicidal group Control subjects

Mean age ?SD (years) 31.6214.05 29.1+1007 34.3k8.26 NS

Marital status (YO) Age range (years) 18-65 18-59 18-53

Single 57 63 31 Married 23 20 56 NS Divorced 17 14 13 Widowed 3 3 0

Percentage of male subjects 43 54 47 NS

Europe/America 29 29 19 Asia/Africa 7 7 0 NS Israel 64 64 81

Sex distribution

Ethnicity (%)

NS, not significant

chotic disorders, 7 patients with affective disorders, 6 patients with anxiety disorders and 10 patients with personality disorders in each group.

In order to assess the reliability of SRS and AECOM, we performed an analysis of Cronbach’s coefficient alpha. The SRS had an alpha value of 0.82. The AECOM had the following alpha values: minimization, 0.61; suppression, 0.80; help-seeking, 0.71; replacement, 0.43; blame, 0.78; substitution, 0.52; mapping, 0.71; reversal, 0.57.

As expected, the SRS scores of the different study groups were significantly different (P<0.001, F= 38.22, df = 2.881, providing additional validation of the scale. An aposterior analysis (Sheffe’s analysis) showed that the suicidal patient group (mean SRS score=39.48+6.06) was significantly different from the other two groups. Values for the non- suicidal in-patients (mean SRS score=33.4+4.45) also differed significantly from those for the controls (29.18+3.03).

In addition, we assessed the relationship between suicide risk and the various coping styles scores among the suicidal patients, the non-suicidal patients and the controls. Table 2 shows the scores on the various subscales in each group. An

Table 2 Coping styles scores in the three study groups

ANOVA analysis revealed that the suicidal group scored significantly lower for coping styles of mapping and minimization. Both psychiatric patient groups differed in their use of the coping styles of suppression, replacement and blame. Thus the psychiatric patients (suicidal and non-suicidal) made more use of the coping styles of suppression and blame, and less use of replacement. No statistically significant differences were found in the use of help-seeking, substitution and reversal.

Table 3 shows the Pearson correlations between the coping styles and the suicide risk in the entire sample. The coping styles of replacement, reversal, minimization and mapping were negatively correlated with suicide risk, whereas the coping styles of blame, suppression and substitution were positively correlated with suicide risk. The coping style of help-seeking showed no significant correlation with suicide risk.

Discussion

The major findings of our study may be summa- rized as follows. (a) The variables that discrimi- nated between the suicidal group and the other two

Coping style Suicidal group (I) Non-suicidal group (11) Control subjects (111) Significance Sheffe‘s analysisa

Minimization Suppression Help-seeking Replacement Blame Substitution Mapping Reversal

27.525.2 31.227.7 30.025.9 30 026.2 25.326.9 24.2k4.3 24.425 0 24.524.8

31 5 2 5 1 31 4 2 6 5 30 5 2 6 2 32 5 2 4 4 2 5 1 2 5 4 23 4 2 5 3 26 9 2 4 8 25 3 2 4 8

29.024.0 24.825.2 28.824.6 33.853.7 19.824 2 22.7 24.3 27.422.7 25.723.5

** * *x

NS

**I

NS

NS

1 4 1 I. 1 1 > 1 1 1

14 111

* fY0.05, ** P<O.01. *** P<O.OOl, NS. not significant. a Source of statistically significant differences between the three groups

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Table 3. Correlation between coping styles and suicide risk

Coping style na Correlation P-value

Minimization 78 -0.27 10.01 Suppression 70 0.40 10.001 Help-seeking 83 0 17 NS Replacement 78 -0.46 10.001 Blame 72 0.44 10.001 Substitution 83 0.26 10.01 Mapping 81 -0.50 1 0 001 Reversal 81 -0 23 <0.05

NS, not significant. a n, number of respondents to each subscale out of the total number of respondents (92) in the sample.

groups were the risk of suicide and a low score for the coping style of mapping. (b) The suicidal group had significantly lower scores for the coping style of minimization than the psychiatric controls, but did not differ significantly from the healthy controls. (c) The coping styles of blame, suppression and substitution were positively correlated with the risk of suicide, whereas the coping styles of mapping, replacement, minimization and reversal were negatively correlated with the risk of suicide.

The coping style that differentiated between the suicidal patients and the other two groups was mapping. This coping style is also negatively correlated with suicide risk. Suicidal patients lack the ability to obtain information and fail to look for alternative solutions. This is in agreement with the hypothesis proposed by Shneidman (20), that the suicidal person is unable to differentiate between important and unimportant sources of pressure, and has difficulty in finding alternatives to problems of everyday life.

Suicidal patients tend to use the coping style of minimization significantly less than do psychiatric controls. This coping style refers to a personal tendency to de-emphasize the burden and importance of a perceived stressful event. The fact that suicidal patients have low scores for this specific coping style suggests that they are unable to buffer and neutralize the impact of stressors, and that they tend to ‘make mountains out of mole hills’. This may contribute to their exaggerated reaction to stressful situations, which results in a suicide attempt as a last resort. This finding is in agreement with the result of a previous study by our research group (11).

Interestingly, the healthy controls scored some- what higher on the minimization variable, but not significantly so. This finding may be explained by the fact that a reasonable level of minimization may serve as a healthy and relatively adaptive coping mechanism. It is the relative lack of the

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ability to minimize (typical of suicidal patients), or a kind of overuse (typical of psychiatric patients), that renders patients prone to suicide.

Three coping styles (blame, suppression and substitution) were positively correlated with the risk of suicide. It appears that blaming others for one’s problems, avoiding the problem or engaging in indirect tension-reducing approaches, serve to augment suicidal behaviour. The common denom- inator of all of these three coping styles is basic avoidance or bypassing of the real problem, and in the long term these approaches are maladaptive. It is not surprising that the prolonged ‘overuse’ of such coping strategies may lead to the accumula- tion of unsolved problems. This in turn increases the sense of emotional impasse and may eventually lead to suicidal behaviour.

The coping styles of mapping, replacement, minimization and reversal were negatively correlated with the suicide risk. Minimizing the severity of the problem, learning about the situation, looking for alternative ways to solve it and trying to make the best of the situation decrease the suicide risk, thus functioning as attenuators. Help-seeking activities were not more frequent in suicidal patients. These individuals do not seek help more than non-suicidal patients, thus complicating the detection of suicidal behaviour. This finding supports the assertions of Sherer (21) and Kralik & Danforth (22), that students with problems often do not seek treat- ment, and would tend to advocate the need for an outreach policy in the community.

Apter et al. (23) reported that the defence mechanisms of repression and denial were positively and negatively correlated, respectively, with suicide risk. The parallels of these mechanisms on the cognitive level are the coping styles of suppression and minimization. Our findings support the above observation.

Our results have possible implications for the study of suicide and for attempts to influence the risk of suicidality, both in psychiatric patients and in the general population (23, 24). Enrichment of the repertoire of adaptive coping strategies of such individuals, with emphasis on their use of minimization, as well as mapping, might rechannel their typical pattern of self-destructive behaviour to more mature patterns of response in subsequent stressful situations. Further studies applying such intervention strategies may prove to be of value in the field of suicide prevention.

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