Mental Pain and Its Relationship to Suicidality and Life Meaning

Suicide and Life-Threatening Behavior 33(3) Fall 2003  2003 The American Association of Suicidology

231

Mental Pain and Its Relationship to Suicidality and Life Meaning ISRAEL ORBACH, PHD, MARIO MIKULINCER, PHD, EVA GILBOA-SCHECHTMAN, PHD, AND PINHAS SIROTA, MD

Shneidman (1996) proposed that intense mental pain is related to suicide. Relatedly, Frankl (1963) argued that the loss of life’s meaning is related to intense mental pain. The first goal of this research was to test Shneidman’s proposition by comparing the mental pain of suicidal and nonsuicidal individuals. Meaning in life and optimism are the polar opposites of suicidality and hopelessness, and the examination of these variables in relation to mental pain was undertaken to provide a test of Frankl’s proposition. In two studies, a relationship between a newly developed measure of mental pain—the Orbach & Mikulincer Mental Pain Scale, 2002 (OMMP; see also Orbach, Mikulincer, Sirota & Gilboa-Schechtman, 2002)— and suicidal behavior and life meaning were examined. Results confirmed both propositions. Implications for the study of mental pain and suicide are discussed.

Mental pain is an old and frequently used concept in clinical psychology and in psychiatry and is believed to be at the heart of psychopathology (Frankl, 1963; Jobes, 2000). One of the first and most extensive contributions to the clarification of this concept was provided by Shneidman (1985), who coined the term “psychache” for this experience. Shneidman states that mental pain is energized by frustrated or thwarted essential needs. He proposes that negative emotions such as guilt, shame, humiliation, disgrace, grief, hopelessness, and rage turn into a generalized experience of unbearable mental pain—a state of ISRAEL ORBACH, MARIO MIKULINCER, and EVA GILBOA-SCHECHTMAN are with the Department of Psychology at Bar-Ilan University, Ramat-Gan, Israel. PINHAS SIROTA is with the Abarbanel Mental Health Center in Bat-Yam, Israel, and Sackler Faculty of Medicine, Tel-Aviv University. Address correspondence to Israel Orbach, Department of Psychology, Bar-Ilan University, Ramat-Gan, 52900, Israel; E-mail: orbachi@mail .biu.ac.il

emotional perturbation (Shneidman, 1980, 1993, 1996). When pain reaches a high intensity and when there is no foreseeable change in the future, the suicidal person seeks to escape pain by committing suicide. Shneidman (1999) also provided a preliminary operationalization of mental pain by measuring the degree of need frustration and perturbation; however, as of yet, this assessment procedure has not been validated empirically. Bolger (1999) produced a self-narrative approach to mental pain by analyzing the scripts of the emotional pain in people who suffered traumatic experiences. Her analysis yielded a definition of mental pain as “brokenness of the self ” consisting of a sense of woundedness, disconnection (from a loved one), loss of self, loss of control, and a sense of alarm. Although Bolger described and defined the experience of mental pain, she did not provide an operationalized assessment of this concept. Highlighting the centrality of the concept for the study of psychopathology, Orbach, Mikulincer, Sirota, and Gilboa-Schecht-

232

MENTAL PAIN, SUICIDALITY AND LIFE MEANING

man (2003) have conceptualized mental pain as a wide range of subjective experiences characterized as an awareness of negative changes in the self and in its functions accompanied by negative feelings. They have created the Orbach and Mikulincer Mental Pain (OMMP) Scale assessing the dimensions and the intensity of this experience, which consists of nine factors: lack of control, irreversibility of pain, emotional flooding, narcissist wounds, estrangement, emotional flooding, confusion, need for social support, and emptiness. These experiential entities share some similarities with some aspects of definitions of mental pain discussed by Shneidman and Bolger. For example, aspects related to a sense of loss of self, perturbation, woundedness, and lack of meaning resonate with the factors of lack of control, emotional turmoil, narcissist wounds, and emptiness in this scale. But there are some aspects in the present scale that are not reflected in previous definitions and these include irreversibility of pain, emotional freezing, estrangement, confusion, and need for others. All in all, the OMMP Scale provides a rich web of experiential qualities that define mental pain. In a series of studies designed to assess the discriminative and convergent validity of the OMMP Scale, it was found to be related to depression, anxiety, and emotional coping strategies. This suggests that the OMMP possesses convergent validity with other related constructs. The pain factors that repeatedly emerge in association with the studied variables include irreversibility, lack of control, emptiness, emotional flooding, emotional freezing, and estrangement. However, these associations are quite moderate, suggesting that the mental pain scale assesses a subjective experience that is significantly differentiated from other measures of distress, and that the concept of mental pain is significantly differentiated from the concepts of anxiety and of depression. One of the most significant associations yet to be examined using the construct of mental pain is suicidality. Shneidman (1993, 1996) argued that intolerable psychological

pain, when deemed unbearable by the individual, will lead to suicide. In other words, understanding suicide is understanding the individual differences in thresholds for enduring mental pain (Shneidman, 1993). According to Shneidman, individuals with a history of suicidal behavior would report higher levels of mental pain than clinically distressed individuals who have not attempted suicide. The first goal of the present work was to test this proposition by comparing mental pain of suicidal and nonsuicidal participants; however, it is suggested that the relationship between mental pain and suicidal behavior should be studied in a wider context of psychological variables that have been evidenced to strongly contribute to suicidal behavior, including depression (e.g., Maris, 1981), anxiety (e.g., Fawcett, 1988), and hopelessness (e.g., Beck, Steer, Beck, & Newman, 1993). In Study 1 we have investigated these relationships in three groups: suicidal inpatients, nonsuicidal inpatients, and nonclinical controls. An additional purpose of Study 1 was to explore the relationship between mental pain and emotional expressivity (Gross & Oliver, 1998). Emotional expressivity refers to individual differences in the extent to which people outwardly display their emotions (Kring, Smith, & Neale, 1994). We hold that it is critical to examine the degree of overlap between mental pain and expressiveness. A strong association between the two measures might suggest that mental pain is merely a compound of the degree to which people are willing to disclose or display their feelings and not a natural outgrowth of the pain they experience. A weak association between the two measures may indicate that the two measures are relatively independent, thus conceptually enhancing the concept of mental pain. A further goal of the present paper was to examine the relationships between mental pain on the one hand, and negative life events, optimism, and meaning in life on the other. Meaning in life and optimism are the polar opposites of suicidality and hopeless-

ORBACH ET AL. ness, and the examination of these variables is likely to provide a further test of the proposition that mental pain is related to the loss of life’s value. Testing this proposition was the main goal of Study 2. One important source of coping is the personal resource of being able to remain optimistic (Scheier & Carver, 1985). Carver and Scheier argue that in times of adversity people react with a range of negative emotions. The balance among such feelings appears to be related to the individual’s degree of optimism and pessimism, that is, the degree to which one expects positive outcomes in the face of difficulties. It is believed that an optimistic attitude energizes the person to employ active strategies and to seek positive results rather than giving in, thereby regulating possible negative feelings (Carver & Scheier, 2000). Many studies show that optimists experience less distress than pessimists when dealing with life’s adversities and that optimism is considered to be a moderator of distress (e.g., Aspinwall & Taylor, 1992; Carver & Gaines, 1987; Long, 1993; Shifren & Hooker, 1995; Zeidner & Hammer, 1992). It is hypothesized that optimism can be considered a moderator of mental pain just as it is a moderator of general stress. Therefore, we expect to find that optimism will be inversely related to mental pain. Meaning in life is also related to mental pain. Frankl (1963) has posited that mental pain is actually a reflection of emptiness and meaninglessness. The individual’s ability to structure life on the basis of a comprehensive view that dictates his or her duties, values, goals, beliefs, and actions can be considered as a personality resource that also has a regulatory function (Orbach, Iluz, & Rosenheim, 1987). Empirical studies show lack of meaning and lack of commitment to be related to depression (e.g., Iluz, 1990), to fear of death (e.g., Orbach et al., 1987), to drug abuse (e.g., Newcomb & Harlow, 1986), and to difficulties in bereavement (e.g., Florian, 1989). Assessing the ability to overcome loss, Davis, Nolen-Hoeksema, and Larson (1998) have suggested that finding ways to assign meaning to the loss experience enhances cop-

233 ing. We assume, therefore, that a high level of meaning as defined by commitment to goals will also be inversely related to mental pain. This hypothesis will be examined in Study 2.

STUDY 1

Method Participants. Suicidal inpatients consisting of 32 adults, ages 25–60 (M = 32.43, SD = 5.43) (14 males, 18 females), were chosen from the adult ward of the Abarbanel Mental Health Center. All attempted suicide just prior to their hospitalization. Suicide attempts included drugs (n = 15), cutting (n = 7), hanging (n = 5), jumping (n = 3), and shooting (n = 2). They were characterized by the following diagnosis: major depression (n = 15); bipolar depression (n = 12); Psychotic depression (n = 5). Diagnosis was based on the Schedule of Affective Disorders and Schizophrenia (SADS; Spitzer, Endicotte, & Robins, 1975), a regular procedure at the Abarbanel Mental Health Center. The nonsuicidal inpatients, also from the Abarbanel Hospital, consisted of 29 adults, ages 25–60 (M = 34.28, SD = 6.71) (11 males, 18 females). According to medical reports, staff reports, and patients’ self-reports, none had made a suicide attempt. They were characterized by the following diagnosis: major depression (n = 11); bipolar depression (n = 12); psychotic depression (n = 6). There was no significant difference in length of hospitalization between the two inpatient groups. Control participants were approached in neighborhood community centers. They consisted of 30 adults, ages 25–60 (M = 31.62, SD = 5.84) (14 males, 16 females). Exclusion criteria were active psychotic state and below sixth grade reading ability. Instruments and Procedure. All inpatients and control participants were first approached by the experimenter (a graduate student) to request participation in the study. Approximately one third of the patients were

234


tested a few days after admission; the rest were recruited from patients who were already hospitalized for varying periods. Time of hospitalization was recorded in all cases. The study was presented as research on suffering and mental pain. The Helsinki Committee’s informed consent was read to the participants and an appointment was arranged for testing. Sessions were held individually in a secluded room. All participants received the scales in random order. The research assistants had no information as to who made a suicide attempt or the type of the attempt. Attempters were identified by the hospital staff only after the completion of data collection. The experience of mental pain was assessed by the OMMP Scale (see Orbach et al., 2003). This self-rating 5-point Likert scale with 44 items consists of nine factors: (1) irreversibility, (2) loss of control, (3) narcissist wounds, (4) emotional flooding, (5) freezing, (6) self-estrangement, (7) confusion, (8) social distancing, and (9) emptiness (4 items). Higher values on each scale reflect higher mental pain. In the current sample, Cronbach alpha coefficients for the nine OMMP factors ranged between .82 and .94. Suicidal tendencies were assessed by the Multi-Attitude Suicidal Tendencies Scale (MAST; Orbach et al., 1991). This selfrating, 5-point scale with 30 items provides four independent scores of suicidal tendencies: (1) attraction to life (AL), (2) repulsion by life (RL), (3) attraction to death (AD), and (4) repulsion by death (RD). High attraction to life and repulsion by death reflect low suicidal tendencies, while high repulsion by life and attraction to death reflect high suicidal tendencies. Internal consistency of the scales range from .76 to .83, and the internal consistency of the entire scale is .92. Hopelessness was assessed by Beck’s Hopelessness Scale (Beck, Weissman, Lester, & Trexler, 1974). This is the best known and most widely used scale for evaluation of hopelessness. Each of the 20 statements is rated on a 4-point scale: the higher the score, the greater the hopelessness. Anxiety and depression tendencies were

assessed by the Cognitions Checklist (CCL; Beck, Brown, Steer, & Eidelson, 1987; Steer, Beck, Clark, & Beck, 1994). This scale measures the frequency of automatic thoughts that are relevant to anxiety (12 items) and to depression (14 items) separately and that typify depressed and anxious patients. It was used as an indication for the degree of anxiety and depression. The authors reported a high degree of reliability and discriminant and concurrent validity. Two general scores were computed by averaging the items in each subscale. Higher scores reflect higher levels of automatic thoughts, typical of people who are high in anxiety and depression, respectively. Emotional expressiveness was assessed by the Emotional Expressiveness Scale (Gross & Oliver, 1998). This instrument is a 71item, 7-point rating scale (ranging from 1 = strongly agree to 7 = strongly disagree) that consists of five factors, which include: expressive confidence (e.g., “At small parties I am the center of attention”); positive expressiveness (e.g., “when I am happy, my feelings show”); negative expressiveness (e.g., “When I am angry, people around me usually know”); inputs intensity (e.g., “I experience my emotions very strongly”); and masking (e.g., “I am not always the person I appear to be”). The inner consistency ranges from α = .72 to α = .88. Results and Discussion Mental Pain Experience and Suicidality. Table 1 presents the means, standard deviations, and values of F-tests between the three experimental groups on the nine OMMP factors. A multivariate analysis of variance (MANOVA) yielded a significant difference between study groups in the set of the nine OMMP factors, F(18, 160) = 2.44, p < .01. Univariate analyses of variance (ANOVAs) indicated that this difference was significant in most of the OMMP factors, with the exceptions of narcissist wounds and social distancing (see Fs in Table 1). Scheff post hoc tests (α = .05) revealed that suicidal patients scored higher in the OMMP factors than

ORBACH ET AL.

235

TABLE 1

Means, Standard Deviations, and F Ratios of OMMP Factors According to Study Groups OMMP factors Irreversibility M SD Loss of control M SD Narcissist wounds M SD Emotional flooding M SD Freezing M SD Self-estrangement M SD Confusion M SD Social distancing M SD Emptiness M SD

Suicidal

Psychiatric

Control

F(2, 88)

3.66a 1.21

2.68b 1.10

2.42b 0.67

12.67**

3.13a 1.17

2.33b 1.02

1.89b 0.62

13.21**

3.62a 1.40

3.38a 1.56

3.52a 0.96

0.24

3.28a 1.41

2.27b 1.35

2.31b 0.76

6.84**

2.74a 1.47

1.87b 1.42

1.68b 0.69

6.37**

2.62a 1.26

2.10b 1.33

1.76b 0.63

4.60*

3.57a 1.25

2.60b 1.58

2.77b 0.79

5.39**

2.83a 1.13

2.69a 1.01

3.05a 0.76

1.07

2.58a 1.47

1.60b 1.11

1.37b 0.68

9.82**

Note. *p < .05; **p < .01. Means with different letters were significantly different at alpha = .05

both psychiatric patients and control participants (see means and standard deviations in Table 1). No significant difference was found between psychiatric patients and control participants. A discriminant analysis indicated that the significant difference between the suicidal group and the two other study groups was mainly explained by the unique contributions of the OMMP factors of irreversibility (standard discriminant coefficient of .37), loss of control (.37), and emptiness (.38). Table 2 presents Pearson correlations between the nine OMMP factors and measures of suicidality (the four MAST factors), measures of distress (hopelessness, depression, and anxiety), and measures of emotional ex-

pressiveness (expressive confidence, positive expressiveness, negative expressiveness, inputs intensity, and masking). The table reveals that, with the exception of the narcissist wounds and social distancing factors, OMMP factors were inversely associated with the attraction to life score and positively associated with the attraction to death and repulsion by life scores. No significant association was found between the OMMP factors and the repulsion by death score. A canonical correlation yielded a single significant canonical function, F(36, 294) = 2.94, p < .01. This function was defined by the contributions of attraction to life and repulsion by life scores (standardized canonical coefficients of −.72 and .41),

236


TABLE 2

Pearson Correlations Between OMMP Factors and Other Assessed Variables Mental Pain Experience Factors Variables MAST factors Attraction to Life Attraction to Death Repulsion by Life Repulsion by Death Affective Measures Hopelessness Depression Anxiety Emotional Expressiveness Expressive Confidence Positive Expressivity Negative Expressivity Inputs Intensity Masking

1

2

−.56** −.58** .56** .41** .49** .51** .04 −.11 .56** .59** .62**

3 −.11 .17 .19 −.10

.55** .58** .49**

.27** .28** .34**

−.35** −.27** −.15 −.23* .43** .29** .18 .03 .09 .19

−.15 −.19 .29** .42** −.13

4

5

6

7

−.35** −.27** −.26* −.22* .26* .25* .24* .23* .51** .31** .38** .22* −.14 −.10 −.11 −.11 .42** .64** .59**

.28** .35** .34**

.40** .36** .34**

−.38** −.28** −.30* −.11 −.08 −.19 .35** .27** .23* .37** .11 .10 .07 .28** −.10

.32** .41** .51**

8

9

−.04 .02 .13 −.07

−.43** .29* .39** −.04

.08 .17 .15

.42** .41** .45**

−.40* −.06 −.41** −.01 −.02 .41** .35** .26* .15 .17 −.12 −.12 −.11 .03 .12

Note. *p < .05; **p < .01 1 = Irreversibility; 2 = Loss of control; 3 = Narcissist wounds; 4 = Emotional flooding; 5 = Freezing; 6 = Self-estrangement; 7 = Confusion; 8 = Social distancing; 9 = Emptiness.

on the one hand, and the OMMP factors of irreversibility (.54), loss of control (.35), and emptiness (.37), on the other. Importantly, these three OMMP factors were found to have a unique contribution to the differentiation between suicidal and nonsuicidal groups. The Intervening Role of Hopelessness, Depression, and Anxiety. We have also examined the associations between mental pain experience and scores of hopelessness, depression, and anxiety as well as the extent to which these scores could explain the association between the OMMP factors and suicidality. As can be seen in Table 2, Pearson correlations yielded significant associations between hopelessness, depression, and anxiety, on the one hand, and most of the OMMP factors (with the exception of the social distancing factor), on the other. Importantly, similar significant associations were also found when Pearson correlations were computed separately in each study group. A canonical correlation yielded a significant canonical function, F(27, 302) = 2.67, p < .01. This function was defined by the contribu-

tions of the depression and anxiety scores (standardized canonical coefficients of .54 and .45) and the OMMP factors of irreversibility (.58), loss of control (.43), emotional flooding (.38), and freezing (.36). The addition of hopelessness, depression, and anxiety scores to the OMMP factors within the discriminant analysis of the three study groups weakened the unique contributions of the OMMP factors of irreversibility and loss of control (standard discriminant coefficients of .17 and .01), but did not affect the unique contribution of the emptiness factor (.36). That is, the OMMP factor of emptiness still made a unique contribution to the differentiation of suicidal and nonsuicidal groups beyond the contribution of hopelessness, depression, and anxiety. Parallel findings were observed when hopelessness, depression, and anxiety scores were added to the nine OMMP factors in the canonical correlation with the four MAST factors. Again, the unique contributions of most of the OMMP factors were low (standardized canonical coefficients ranging from .01 to .12),

ORBACH ET AL. with the only exception of the emptiness factor (.38). Again, the OMMP factor of emptiness still made a unique contribution to MAST suicidal tendencies beyond the contribution of hopelessness, depression, and anxiety. The Intervening Role of Emotional Expressiveness. Finally, we examined the associations between mental pain experience and the five emotional expressiveness factors as well as the extent to which these factors could explain the association between the OMMP factors and suicidality. Pearson correlations between the nine OMMP factors and the five expressiveness factors (expressive confidence, positive expressiveness, negative expressiveness, inputs intensity, and masking) revealed the following significant associations (see Table 2): (a) expressive confidence was inversely associated with most of the OMMP factors, with the exception of the narcissist wounds and social distancing factors; (b) positive expressiveness was inversely associated only with the OMMP factors of loss of control and emptiness; (c) negative expressiveness was positively associated with most of the OMMP factors, with the exception of the emptiness factor; (d) inputs intensity was positively associated with the OMMP factors of narcissist wounds and emotional flooding; and (e) masking was positively associated only with the OMMP factor of freezing. Importantly, these significant associations were also found when Pearson correlations were computed separately in each study group. A canonical correlation yielded two significant canonical functions, F(45, 283) = 4.01, p < .01; F(36, 215) = 2.73, p < .01. The first function was defined by the contributions of the expressiveness confidence and negative expressiveness scores (standardized canonical coefficients of −.43 and .39) and the OMMP factors of irreversibility (.48) and confusion (.40). The second function was defined by the contributions of input intensity (.54) and the OMMP factor of narcissist wounds (.48) and emotional flooding (.35). The addition of the five emotional expressiveness scores to the nine OMMP factors within the discriminant analysis of the

237 three study groups did not affect the original unique contributions of the OMMP factors. In this analysis, the OMMP factors of irreversibility, loss of control, and emptiness still made a unique contribution to the differentiation of suicidal and nonsuicidal groups beyond the contribution of emotional expressiveness (standardized discriminant coefficients of .37, .35, and .36, respectively). Parallel findings were observed when the five emotional expressiveness scores were added to the nine OMMP factors in the canonical correlation with the four MAST factors. Again, the OMMP factors of irreversibility, loss of control, and emptiness still made unique contributions to the variance of the MAST factors beyond the contribution of emotional expressiveness (standardized canonical coefficients of .43, .36, and .36, respectively).

STUDY 2

Method Participants. The sample consisted of 98 Israeli students from Bar-Ilan University (75 women and 23 men, ranging in age from 19 to 39, Mdn = 22), who volunteered to participate in the study without any monetary reward. Instruments and Procedure. The study was conducted on an individual basis and participants were asked to complete a set of questionnaires tapping mental pain, optimism, and meaning of life. The order of the questionnaires was randomized across participants. Mental pain was assessed by the OMMP (see Study 1). In the present study the participants were not considered to be in a present crisis. Therefore, they were asked to respond not to mental pain at the present time, but at its worst. Cronbach alpha coefficients for the OMMP factors ranged between .77 and .92. On this basis, we computed nine factor scores by averaging items that belonged to a factor (see Table 1). Optimism was assessed by the Life Ori-

238


entation Test (LOT-R; Scheier, Carver, & Bridges, 1994). The scale consists of 10 items that are scored on a 5-point scale from 1 (strongly disagree) to 5 (strongly agree). The scale consists of six optimism items (e.g., “In uncertain times, I usually expect the best”) and four fillers (e.g., “It’s easy for me to relax”). Scheier et al. (1994) report satisfactory psychometric data. Cronbach alpha coefficient for optimism was also adequate (.77), allowing us to complete a total optimism score by averaging the optimism items. Commitment to values (meaning) was measured by means of the Batista and Almond Life Regard Scale. It consists of 28 items with a 5-point rating for each item. The following are some examples for the items used: “I am completely clear about the goals of my life,” and “There are some goals in my life to which I devote myself completely.” Batista and Almond (1973) report a satisfactory test-retest reliability of r = .94. This scale was highly correlated with several similar scales that measure meaning of life. Results Table 3 presents Pearson correlations between the OMMP factors and measures of optimism and life regard. As can be seen from the table, Pearson correlations indicated that optimism and life regard were sig-

TABLE 3

Pearson Correlations Between OMMP Factors and Scores of Optimism and Life Regard OMMP factors Irreversibility Loss of Control Narcissist Wounds Emotional Flooding Freezing Self-estrangement Confusion Social Distancing Emptiness

Optimism

Life Regard

−.35** −.26* −.15 −.31** −.35** −.28** −.23* −.01 −.33**

−.28** −.29** −.01 −.21* −.32** −.29** −.27* −.12 −.29**

Note. *p < .05; **p < .01

nificantly and inversely associated with most of the OMMP factors, with the exceptions of narcissist wounds and social distancing. The higher a person’s optimism and life regard, the lower his or her scores on the OMMP factors. Although these associations were significant, the OMMP factors were associated to a relatively low to moderate degree with both optimism (rs between −.23 to −.35, Mdn = −.28) and life regard (rs between −.21 to −.32, Mdn = .29). This finding implies that the OMMP factors had a unique variance beyond their associations with optimism and life regard. A canonical correlation between the nine OMMP factors and the optimism and life regard scores yielded a single significant multivariate function, F(18, 174) = 2.03, p < .05. This function was defined by the contributions of optimism and life regard scores (standardized canonical coefficient of −.54 and −.56) and the OMMP factors of irreversibility (.40), freezing (.45), self-estrangement (.39), and emptiness (.37). Thus, optimism as a coping strategy and meaning as a representation of life perspective and lifestyle have a mitigating effect on mental pain coming from life’s adversities.

GENERAL DISCUSSION

The findings of the present studies confirm the hypothesis regarding the positive relationship between mental pain and suicidality on the one hand (Study 1), and a negative relationship between mental pain and life regard and optimism on the other (Study 2). Consistent with our first hypothesis, in seven of its nine factors, OMMP differentiated between suicidal inpatients and both nonsuicidal inpatients and normal controls. Consistent with our second hypothesis, the negative associations of seven out of nine scales of the OMMP and optimism and life regard support Frankl’s (1963) definition of mental pain as lack of meaning. In Study 1, the pain factors of irreversibility, loss of control, and emptiness discriminated between suicidal and nonsuicidal participants, but only emptiness remained a

ORBACH ET AL. significant factor when hopelessness, depression, and anxiety were partialed out. Similar but not identical findings were found regarding the association between mental pain and the other variables, including suicidal tendencies. This suggests that the OMMP factors can discriminate between suicidal and nonsuicidal participants along with other important variables related to suicide (hopelessness, depression, anxiety, and suicidal tendencies), though the unique contribution of OMMP to this discrimination becomes limited to the factor of emptiness only, when including the other variables in the discrimination analysis. Indeed, it seems likely that the experience of emptiness, of loss of meaning, and of lack of future-directedness is a driving force behind the attempts of some individuals to attempt to put an end to their suffering. Moreover, the negative correlations between optimism and life-meaning provide further support for this direction. The findings of this study indicate that the associations between some of the OMMP factors and suicidal tendencies, hopelessness, depression, anxiety, and emotional expressivity are significant, but range between low to moderate correlations. Taken together with our previous findings regarding the relation between mental pain and measures of depression and anxiety, these data suggest that, although mental pain is related to the associated measures of emotional distress and emotional expressivity, it does not overlap with these concepts. Moreover, mental pain seems to allow a window into the suffering of suicidal patients over and above that provided by the distress measures (anxiety, depression, and hopelessness). Put differently, the construct of mental pain appears to provide a broader insight into the experience of suicidal individuals than the standard distress measures. A critical test for the mental pain scale was its ability to differentiate between suicidal and nonsuicidal participants. While these groups of individuals differed significantly from each other on most OMMP factors, only emptiness was found to have a “purely” unique contribution for suicide attempts over and

239 above hopelessness. Although this finding favors Frankl’s (1963) definition of mental pain as lack of meaning, it raises questions about the discriminative power of the rest of the pain factors. But this finding may also be due to some methodological shortcoming of Study 1. For example, in that study we failed to include a measure of suicidal intention. It is possible that the inclusion of such a measure in the analysis would have revealed that suicidal individuals with serious suicidal intentions are differentiated from the others over and above hopelessness and depression along other pain factors as well. Such an explanation is consistent with Shneidman’s (1985) contention that people who make non-serious suicide attempts suffer from bearable mental pain, while serious suicide attempters suffer from intense unbearable pain. Another possible explanation is that the results of the present data represent a variation of a particular sample and additional examinations may reveal a stronger, unique contribution of mental pain to suicidal behavior. Indeed, a preliminary statistical analysis of an ongoing study with groups of participants similar to those of the present study showed a unique contribution of five of the OMMP factors over and above hopelessness and depression (Orbach & Mikulincer, 2002). Inconsistent with our expectations, no subscale of mental pain differentiated between nonsuicidal inpatients and controls in Study 1. We entertain several possible explanations for this finding. First, it is possible that when normal participants were asked regarding their experience of mental pain, they may have interpreted the question as referring to the intensity of their mental pain at its worst rather than at the present just as they were asked to do. In contrast, when nonsuicidal inpatients were requested to describe their mental pain, they referred to their current experiences. That is, the comparison between the two groups may entail a comparison between a maximal intensity experience (for the control group) and an everyday level (for the nonsuicidal patient group). A clearer separation between worst levels and current levels of mental pain may help clarify this issue. Second, it

240


is possible that the lack of difference in the experience of mental pain among the nonsuicidal inpatients and normal groups reflects an effective operation of defenses of the nonsuicidal inpatient. Apter, Plutchik, Sevy, and Kron (1989), for example, found that suicidal patients employ less effective defenses than nonsuicidal psychiatric inpatients. The more effective defenses of the nonsuicidal inpatient in addition to the protective characteristics of the pathology itself (see Cameron, 1963) could have been responsible for the observed similarity in the subjective experience of pain (though not in pathology) between the nonsuicidal inpatients and normal controls in this study. The inclusion of a defense mechanism test in future investigations of pathology may help clarify this issue.

The construct of mental pain can make an important contribution to the study of the subjective state of mind related to suicidality. In line with Shneidman’s (1993, 1996) theory, our findings can be taken as a preliminary confirmation that this construct can be viewed as the essence of the suicidal mind. Further research should attempt to delineate the unique aspects of the mental pain experience that may characterize a particular individual and different suicidal dynamics. An important dimension of Shneidman’s theory that remains to be investigated is the level of a person’s tolerance to mental pain experiences. We are currently constructing an additional scale tapping this construct with the hope that it will further enhance our understanding of the suicidal mind.

REFERENCES APTER, A., PLUTCHIK, R., SEVY, S., & KRON, M. (1989). Defense mechanisms in risk of suicide and risk of violence. American Journal of Psychiatry, 146, 1027–1031. ASPINWALL, L. G., & TAYLOR, S. E. (1992). Modeling cognitive adaptation: A longitudinal investigation of the impact of individual differences and coping on college adjustment and performance. Journal of Personality and Social Psychology, 61, 755–765. BATISTA, J., & ALMOND, R. (1973). The development of meaning in life. Psychiatry, 36, 409– 427. BECK, A. T., BROWN, G., STEER, R. A., & EIDELSON, J. I. (1987). Differentiating anxiety and depression: A test of cognitive content specificity hypothesis. Journal of Abnormal Psychology, 96, 179–183. BECK, A. T., STEER, R. A., BECK, J. S., & NEWMAN, C. F. (1993). Hopelessness, depression, suicidal ideation, and clinical diagnosis of depression. Suicide and Life-Threatening Behavior, 23, 139– 145. BECK, A. T., WEISSMAN, A., LESTER, D., & TREXLER, L. (1974). The measurement of pessimism: The hopelessness scale. Journal of Consulting and Clinical Psychology, 42, 861–865. BOLGER, E. A. (1999). Grounded theory analysis of emotional pain. Psychotherapy Research, 9, 342–362. CAMERON, N. (1963). Personality development and psychopathology: A dynamic approach. Boston: Houghton Mifflin.

CARVER, C. S., & GAINES, J. G. (1987). Optimism, pessimism, and postpartum depression. Cognitive Therapy and Research, 11, 449–462. CARVER, C. S., & SCHEIER, M. F. (2000). Autonomy and self regulation. Psychological Inquiry, 11, 284–291. DAVIS, C. J., NOLEN-HOEKSEMA, S., & LARSON, J. (1998). Making sense of loss and benefiting from the experience: Two construals of meaning. Journal of Personality and Social Psychology, 75, 561–574. FAWCETT, J. (1988). Predictors of early suicide: Identification and appropriate intervention. Journal of Clinical Psychology, 49(Suppl.). FLORIAN, V. (1989). Meaning and purpose in life of bereaved parents whose son fell during active military service. Omega, 20, 91–102. FRANKL, V. E. (1963). Man’s search for meaning: An introduction to logotherapy. New York: Washington Square Press. GROSS, J. J., & OLIVER, P. J. (1998). Mapping the domains of expressivity: Multimethod evidence for a hierarchical model. Journal of Personality and Social Psychology, 74, 170–191. ILUZ, A. (1990). Meaning in life, content, and structure and its relationship to well-being. Unpublished doctoral dissertation, Department of Psychology, Bar-Ilan University, Ramat-Gan, Israel. JOBES, D. A. (2000). Collaborating to prevent suicide: A clinical research approach. Suicide and Life-Threatening Behavior, 30, 8–17. KRING, A. M., SMITH, D. A., & NEALE,

ORBACH ET AL. J. M. (1994). Individual differences in dispositional expressiveness: Development and validation of the emotional expressiveness scale. Journal of Personality and Social Psychology, 66, 934–949. LONG, B. C. (1993). Coping strategies of male managers: A prospective analysis of predictors of psychosomatic symptoms and job satisfaction. Journal of Vocational Behavior, 42, 184–199. MARIS, R. W. (1981). Pathways to suicide: A survey of self-destructive behavior. Baltimore: Johns Hopkins University Press. NEWCOMB, M. D., & HARLOW, L. L. (1986). Life events and substance use among adolescents: Mediating effects of perceived loss of control and meaninglessness in life. Journal of Personality and Social Psychology, 51, 564–577. ORBACH, I., ILUZ, A., & ROSENHEIM, E. (1987). Value systems and commitment to goals as a function of age, integration of personality, and fear of death. International Journal of Behavioral Development, 10, 225–239. ORBACH, I., MILSTEIN, I., HAR-EVEN, D., APTER, A., TIANO, S., & ELIZUR, A. (1991). A Multi-Attitude Suicide Tendency Scale for adolescents. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 3, 389–404. ORBACH, I., & MIKULINCER, M. (2002). Mental pain and pathology. Unpublished study, Department of Psychology, Bar-Ilan University, Israel. ORBACH, I., MIKULINCER, M., SIROTA, P., & GILBOA-SCHECHTMAN, E. (2003). Mental pain: A multidimensional operationalization and definition. Suicide and Life-Threatening Behavior, 33, 219–230. SCHEIER, M. F., & CARVER, C. S. (1985). Optimism, coping, and health: Assessment and

241 implications of generalized outcome expectancies. Health Psychology, 4, 219–247. SCHEIER, M. F., CARVER, C. S., & BRIDGES, M. W. (1994). Optimism from neuroticism (and trait anxiety, self-mastery, and selfesteem): A reevaluation of the Life Orientation Test. Journal of Personality and Social Psychology, 67, 1063–1078. SHIFREN, K., & HOOKER, K. (1995). Stability and change in optimism: A study among spouse caregivers. Experimental Aging Research, 21, 59–76. SHNEIDMAN, E. S. (1980). Voices of death. New York: Basic Books. SHNEIDMAN, E. S. (1985). Definition of suicide. New York: Wiley. SHNEIDMAN, E. S. (1993). Suicide as psychache. Journal of Nervous and Mental Disease, 181, 147–149. SHNEIDMAN, E. S. (1996). The suicidal mind. New York: Oxford University Press. SHNEIDMAN, E. (1999). The psychological pain assessment scale. Suicide and Life-Threatening Behavior, 29, 287–294. SPITZER, R. L., ENDICOTTE, J., & ROBINS, E. (1975). Clinical criteria and DSM-III. American Journal of Psychiatry, 132, 1187–1192. STEER, R. A., BECK, A. T., CLARK, D. A., & BECK, J. S. (1994). Psychometric properties of the cognition checklist with psychiatric outpatients and university students. Psychological Assessment, 6, 67–70. ZEIDNER, M., & HAMMER, A. L. (1992). Coping with missile attack: Resources, strategies, and outcomes. Journal of Personality, 60, 709–746. Manuscript Received: December 26, 2001 Revision Accepted: November 22, 2002