Suicide and Life-Threatening Behavior 45 (3) June 2015 © 2014 The American Association of Suicidology DOI: 10.1111/sltb.12126
271
Sources of Psychological Pain and Suicidal Thoughts Among Homeless Adults CAROL COOHEY, PHD, SCOTT D. EASTON, PHD, JOOYOUNG KONG, MSW, PHD, JULIE K. W. BOCKENSTEDT, PHD
AND
Homeless adults experience problems in multiple areas of their lives. It was hypothesized that adults who were troubled by problems in more areas of their lives would be more likely to report suicidal thoughts. The sample included 457 homeless men and women who resided in three emergency shelters. The number of sources of psychological pain, past suicide attempts, and being a man predicted current suicidal thoughts, but being diagnosed with a depressive disorder did not. Shelter workers should ask adults whether they have attempted suicide in the past and how troubled they are by each area of their lives. Each year, an estimated 1.5 million people enter homeless shelter services, although many more people experience homelessness (U.S. Department of Housing & Urban Development, 2012). Homeless adults often experience problems in multiple areas of their lives, and they experience these problems at higher rates than adults who are not homeless. Homeless adults, for example, are more likely than nonhomeless adults to be unemployed, be arrested, and be incarcerated (Health Care for the Homeless, Inc., 2011; Kushel, Hahn, Evans, Bangsberg, & Moss, 2005). They are also more likely than the general population to suffer from chronic health conditions, including asthma, diabetes, hypertension, AIDS/HIV, and CAROL COOHEY, School of Social Work, University of Iowa, Iowa City, IA, USA; SCOTT D. EASTON and JOOYOUNG KONG , Graduate School of Social Work, Boston College, Chestnut Hill, MA, USA; JULIE K. W. BOCKENSTEDT, Humility of Mary Shelter, Inc., Humility of Mary Housing, Inc., Davenport, IA, USA. We would like to thank Sandra Walters, LISW, for interviewing the participants and her ongoing support of adults in shelter. Address correspondence to Carol Coohey, School of Social Work, University of Iowa, Iowa City, IA 52242, USA; E-mail: carol-coohey@ uiowa.edu
tuberculosis (Nataro, Khan, Kim, Nasaruddin, & Desai, 2012; Zlotnick & Zerger, 2008). Approximately 20% to 25% of homeless adults have a serious mental illness, such as a depressive, bipolar, schizophrenic, or personality disorder, which is substantially higher than the percentage in the general population (4%; National Coalition for the Homeless, 2006; Kahn & Fawcett, 2008). Furthermore, alcohol and drug use is common among the homeless population. In one study based on a nationally representative sample, Dietz (2010) found that the percentage of homeless adults who reported having a lifetime alcohol problem and a lifetime drug problem were, respectively, 63% and 60%. Homeless adults also experience more relationship problems, such as higher levels of social isolation, than nonhomeless adults (Burkey, Kim, & Breakey, 2011; Hwang et al., 2009). Finally, several studies have found that a relatively large proportion of homeless adults report a history of victimization; depending on the study, 20% to 60% of homeless adults reported sexual or physical abuse in childhood or adulthood (Benda, 2005; Fitzpatrick, Irwin, LaGory, & Ritchey, 2007; Torchalla, Strehlau, Li, Schuetz, & Krausz, 2012).
272
SOURCES
Because many homeless people experience problems in multiple areas of their lives, it is not surprising that they are more likely to report suicidal thoughts and attempts than people who are not homeless. According to Fitzpatrick et al. (2007), about 3% of adults in the general population report suicidal thoughts annually; adults who are homeless report thoughts of suicide at a rate that is at least four to five times higher. People who are residing in shelters may be at even higher risk of suicide thoughts and attempts. For example, in a recent study by Coohey, Bockenstedt, and Gilster (2013), over 40% of adults in shelter had thought about killing themselves, and 27% of adults had tried to kill themselves during their lifetime. Many, perhaps most, shelters do not have on-site counselors or therapists who can assess suicide risk (Gardner, 2010). Therefore, it is important to understand which factors put homeless adults residing in shelters at higher risk of suicide. This information could be used by shelter workers to determine whether to refer them for a more thorough psychological assessment. The concept of psychological pain, and its role in suicidality, has received increasing attention over the last decade and may be an important concept to include when assessing homeless adults’ risk for suicide. Shneidman (1993) defined psychological pain, or psychache, as the “hurt, anguish, soreness, aching, psychological pain in the psyche, the mind” (p. 145). Several studies have tested the relationship between intense emotional and psychological pain in diverse populations and found that it was related to greater risk of suicidal thoughts and attempts (Lester, 2000; Mills, Green, & Reddon, 2005; Olie, Guillaume, Jaussent, Courtet, & Jollant, 2010; Orbach, Mikulincer, Sirota, & Gilboa-Schechtman, 2003). A recent study by Patterson and Holden (2012) showed that psychological pain was related to suicidal thoughts and attempts among adults who were homeless. Understanding whether and how much psychological pain a homeless person is in,
OF
PSYCHOLOGICAL PAIN
AND
SUICIDAL THOUGHTS
therefore, may be a critical area of assessment. Researchers have developed several approaches to assess psychological pain (Holden, Mehta, Chnningham, & Mcleod, 2001; Li et al., 2013; Olie et al., 2010; Orbach et al., 2003; Shneidman, 1999). These approaches focus on the intensity or the frequency of painful feelings, and not on the source or sources of their psychological pain. Instead of examining whether a person is experiencing psychological pain overall, we wanted to describe the sources of their troubles and whether the number of sources of psychological pain was related to suicidal ideation. These sources included being very troubled by employment, legal, medical, psychological, substance use, and social relationship problems and being very troubled by past emotional abuse, physical abuse, and sexual abuse. We believe that adults may separate out and evaluate these different areas of their lives; when their thoughts move from one area to the next and they continuously feel psychological pain, the likelihood that they will think about escaping their pain may increase. Disaggregating sources of psychological pain may also provide critical information to practitioners when intervening with homeless adults who are suicidal. Understanding the different sources of their troubles may be especially useful for intake workers at shelters who could then refer homeless adults to services that address the source of their psychological pain. While understanding the number of sources of psychological pain may be useful in assessing risk of suicidality, other factors such as depression, past suicide attempts, and gender are potentially important predictors and, thus, need to be accounted for when predicting suicidal thoughts. Many, but not all, studies show that depression is related to suicidal thoughts among homeless adults (Benda, 2003, 2005; Eynan et al., 2002; Fitzpatrick et al., 2007; Torchalla et al., 2012). While there appears to be evidence that depression is related to suicidal thoughts among homeless adults, these
COOHEY
ET AL.
studies did not account for psychological pain. Drawing on Shneidman’s (1993) theory, Patterson and Holden (2012) proposed that when psychological pain was accounted for, factors such as depression would not be related to suicidality. They found psychological pain predicted suicidal thoughts and attempts but depression did not. Many studies have shown that past suicide attempts are related to current suicidal thoughts. In their review of the literature, Van Orden et al. (2010) found that the most reliable and potent predictor of suicidal thoughts and attempts was a prior history of suicide attempts. However, among the studies on homeless adults that we reviewed, none of the studies controlled for past suicide attempts (Benda, 2003, 2005; Desai, Liu-Mares, Dausey, & Rosenheck, 2003; Dietz, 2010; Eynan et al., 2002; Fitzpatrick et al., 2007; Patterson & Holden, 2012; Torchalla et al., 2012). Thus, it is important to account for past suicide attempts when predicting current suicidal thoughts among homeless adults. Finally, many, but not all, studies show that women in the general population are more likely to report suicidal thoughts than men (Schrijvers, Bollen, & Sabbe, 2012). This finding is somewhat consistent with research on adults who are homeless. Benda (2005), Dietz (2010), Eynan et al. (2002), and Torchalla et al. (2012) found homeless women were more likely than homeless men to report thoughts of suicide in the past year. However, Fitzpatrick et al. (2007) found that homeless men were more likely than homeless women to report thinking about killing themselves. Therefore, we account for gender in our model predicting suicidal thoughts.
METHODS
Participants We used secondary data to test our hypotheses. The convenience sample
273 included homeless men and women who resided at three federally funded emergency shelters between April 2006 and July 2008. The shelters were centrally located in a metropolitan area in the Midwest with a population of about 380,000 residents. After excluding adults with missing data on the dependent variable, suicidal thoughts (eight participants), the sample included 457 homeless adults. Sample Characteristics. Demographic characteristics for our sample are included in Table 1. The sample included a larger proportion of women (61.7%) than men (38.3%). The average age of participants was 38.7 years old, and the majority of participants were between the ages of 18 and 50 (83.4%). Almost 75% of participants had obtained at least a high school diploma. Most of the participants were divorced or separated (45.1%) or never married (44.6%), and 74.7% of the participants were parents. Although a large proportion of adults were parents, less than 15% of the sample had a minor child with them in shelter. In the last 30 days, about 62% of the participants had received public assistance, and 37% of participants had received employment income. Almost all of the participants were either White non-Hispanic (66.1%) or African American (28.9%; other or more than one race/ethnicity: 5.0%). Procedures An experienced mental health counselor administered the instruments during the intake process at the shelters. The counselor had a master’s degree and was licensed by the state to diagnose and treat mental health disorders. The intake process included administration of the Addiction Severity Index (ASI; McLellan, Luborsky, O’Brien, & Woody, 1980), other standardized measures, and administrative forms developed by the shelter staff. The interview took about 90 to 120 minutes to complete. The authors’ institutional review boards approved this study.
274
SOURCES
OF
PSYCHOLOGICAL PAIN
AND
SUICIDAL THOUGHTS
TABLE 1
Relationship Between Demographic Characteristics and Serious Suicidal Thoughts Serious Suicidal Thoughts
Age (M) Age (%)
271
Sources of Psychological Pain and Suicidal Thoughts Among Homeless Adults CAROL COOHEY, PHD, SCOTT D. EASTON, PHD, JOOYOUNG KONG, MSW, PHD, JULIE K. W. BOCKENSTEDT, PHD
AND
Homeless adults experience problems in multiple areas of their lives. It was hypothesized that adults who were troubled by problems in more areas of their lives would be more likely to report suicidal thoughts. The sample included 457 homeless men and women who resided in three emergency shelters. The number of sources of psychological pain, past suicide attempts, and being a man predicted current suicidal thoughts, but being diagnosed with a depressive disorder did not. Shelter workers should ask adults whether they have attempted suicide in the past and how troubled they are by each area of their lives. Each year, an estimated 1.5 million people enter homeless shelter services, although many more people experience homelessness (U.S. Department of Housing & Urban Development, 2012). Homeless adults often experience problems in multiple areas of their lives, and they experience these problems at higher rates than adults who are not homeless. Homeless adults, for example, are more likely than nonhomeless adults to be unemployed, be arrested, and be incarcerated (Health Care for the Homeless, Inc., 2011; Kushel, Hahn, Evans, Bangsberg, & Moss, 2005). They are also more likely than the general population to suffer from chronic health conditions, including asthma, diabetes, hypertension, AIDS/HIV, and CAROL COOHEY, School of Social Work, University of Iowa, Iowa City, IA, USA; SCOTT D. EASTON and JOOYOUNG KONG , Graduate School of Social Work, Boston College, Chestnut Hill, MA, USA; JULIE K. W. BOCKENSTEDT, Humility of Mary Shelter, Inc., Humility of Mary Housing, Inc., Davenport, IA, USA. We would like to thank Sandra Walters, LISW, for interviewing the participants and her ongoing support of adults in shelter. Address correspondence to Carol Coohey, School of Social Work, University of Iowa, Iowa City, IA 52242, USA; E-mail: carol-coohey@ uiowa.edu
tuberculosis (Nataro, Khan, Kim, Nasaruddin, & Desai, 2012; Zlotnick & Zerger, 2008). Approximately 20% to 25% of homeless adults have a serious mental illness, such as a depressive, bipolar, schizophrenic, or personality disorder, which is substantially higher than the percentage in the general population (4%; National Coalition for the Homeless, 2006; Kahn & Fawcett, 2008). Furthermore, alcohol and drug use is common among the homeless population. In one study based on a nationally representative sample, Dietz (2010) found that the percentage of homeless adults who reported having a lifetime alcohol problem and a lifetime drug problem were, respectively, 63% and 60%. Homeless adults also experience more relationship problems, such as higher levels of social isolation, than nonhomeless adults (Burkey, Kim, & Breakey, 2011; Hwang et al., 2009). Finally, several studies have found that a relatively large proportion of homeless adults report a history of victimization; depending on the study, 20% to 60% of homeless adults reported sexual or physical abuse in childhood or adulthood (Benda, 2005; Fitzpatrick, Irwin, LaGory, & Ritchey, 2007; Torchalla, Strehlau, Li, Schuetz, & Krausz, 2012).
272
SOURCES
Because many homeless people experience problems in multiple areas of their lives, it is not surprising that they are more likely to report suicidal thoughts and attempts than people who are not homeless. According to Fitzpatrick et al. (2007), about 3% of adults in the general population report suicidal thoughts annually; adults who are homeless report thoughts of suicide at a rate that is at least four to five times higher. People who are residing in shelters may be at even higher risk of suicide thoughts and attempts. For example, in a recent study by Coohey, Bockenstedt, and Gilster (2013), over 40% of adults in shelter had thought about killing themselves, and 27% of adults had tried to kill themselves during their lifetime. Many, perhaps most, shelters do not have on-site counselors or therapists who can assess suicide risk (Gardner, 2010). Therefore, it is important to understand which factors put homeless adults residing in shelters at higher risk of suicide. This information could be used by shelter workers to determine whether to refer them for a more thorough psychological assessment. The concept of psychological pain, and its role in suicidality, has received increasing attention over the last decade and may be an important concept to include when assessing homeless adults’ risk for suicide. Shneidman (1993) defined psychological pain, or psychache, as the “hurt, anguish, soreness, aching, psychological pain in the psyche, the mind” (p. 145). Several studies have tested the relationship between intense emotional and psychological pain in diverse populations and found that it was related to greater risk of suicidal thoughts and attempts (Lester, 2000; Mills, Green, & Reddon, 2005; Olie, Guillaume, Jaussent, Courtet, & Jollant, 2010; Orbach, Mikulincer, Sirota, & Gilboa-Schechtman, 2003). A recent study by Patterson and Holden (2012) showed that psychological pain was related to suicidal thoughts and attempts among adults who were homeless. Understanding whether and how much psychological pain a homeless person is in,
OF
PSYCHOLOGICAL PAIN
AND
SUICIDAL THOUGHTS
therefore, may be a critical area of assessment. Researchers have developed several approaches to assess psychological pain (Holden, Mehta, Chnningham, & Mcleod, 2001; Li et al., 2013; Olie et al., 2010; Orbach et al., 2003; Shneidman, 1999). These approaches focus on the intensity or the frequency of painful feelings, and not on the source or sources of their psychological pain. Instead of examining whether a person is experiencing psychological pain overall, we wanted to describe the sources of their troubles and whether the number of sources of psychological pain was related to suicidal ideation. These sources included being very troubled by employment, legal, medical, psychological, substance use, and social relationship problems and being very troubled by past emotional abuse, physical abuse, and sexual abuse. We believe that adults may separate out and evaluate these different areas of their lives; when their thoughts move from one area to the next and they continuously feel psychological pain, the likelihood that they will think about escaping their pain may increase. Disaggregating sources of psychological pain may also provide critical information to practitioners when intervening with homeless adults who are suicidal. Understanding the different sources of their troubles may be especially useful for intake workers at shelters who could then refer homeless adults to services that address the source of their psychological pain. While understanding the number of sources of psychological pain may be useful in assessing risk of suicidality, other factors such as depression, past suicide attempts, and gender are potentially important predictors and, thus, need to be accounted for when predicting suicidal thoughts. Many, but not all, studies show that depression is related to suicidal thoughts among homeless adults (Benda, 2003, 2005; Eynan et al., 2002; Fitzpatrick et al., 2007; Torchalla et al., 2012). While there appears to be evidence that depression is related to suicidal thoughts among homeless adults, these
COOHEY
ET AL.
studies did not account for psychological pain. Drawing on Shneidman’s (1993) theory, Patterson and Holden (2012) proposed that when psychological pain was accounted for, factors such as depression would not be related to suicidality. They found psychological pain predicted suicidal thoughts and attempts but depression did not. Many studies have shown that past suicide attempts are related to current suicidal thoughts. In their review of the literature, Van Orden et al. (2010) found that the most reliable and potent predictor of suicidal thoughts and attempts was a prior history of suicide attempts. However, among the studies on homeless adults that we reviewed, none of the studies controlled for past suicide attempts (Benda, 2003, 2005; Desai, Liu-Mares, Dausey, & Rosenheck, 2003; Dietz, 2010; Eynan et al., 2002; Fitzpatrick et al., 2007; Patterson & Holden, 2012; Torchalla et al., 2012). Thus, it is important to account for past suicide attempts when predicting current suicidal thoughts among homeless adults. Finally, many, but not all, studies show that women in the general population are more likely to report suicidal thoughts than men (Schrijvers, Bollen, & Sabbe, 2012). This finding is somewhat consistent with research on adults who are homeless. Benda (2005), Dietz (2010), Eynan et al. (2002), and Torchalla et al. (2012) found homeless women were more likely than homeless men to report thoughts of suicide in the past year. However, Fitzpatrick et al. (2007) found that homeless men were more likely than homeless women to report thinking about killing themselves. Therefore, we account for gender in our model predicting suicidal thoughts.
METHODS
Participants We used secondary data to test our hypotheses. The convenience sample
273 included homeless men and women who resided at three federally funded emergency shelters between April 2006 and July 2008. The shelters were centrally located in a metropolitan area in the Midwest with a population of about 380,000 residents. After excluding adults with missing data on the dependent variable, suicidal thoughts (eight participants), the sample included 457 homeless adults. Sample Characteristics. Demographic characteristics for our sample are included in Table 1. The sample included a larger proportion of women (61.7%) than men (38.3%). The average age of participants was 38.7 years old, and the majority of participants were between the ages of 18 and 50 (83.4%). Almost 75% of participants had obtained at least a high school diploma. Most of the participants were divorced or separated (45.1%) or never married (44.6%), and 74.7% of the participants were parents. Although a large proportion of adults were parents, less than 15% of the sample had a minor child with them in shelter. In the last 30 days, about 62% of the participants had received public assistance, and 37% of participants had received employment income. Almost all of the participants were either White non-Hispanic (66.1%) or African American (28.9%; other or more than one race/ethnicity: 5.0%). Procedures An experienced mental health counselor administered the instruments during the intake process at the shelters. The counselor had a master’s degree and was licensed by the state to diagnose and treat mental health disorders. The intake process included administration of the Addiction Severity Index (ASI; McLellan, Luborsky, O’Brien, & Woody, 1980), other standardized measures, and administrative forms developed by the shelter staff. The interview took about 90 to 120 minutes to complete. The authors’ institutional review boards approved this study.
274
SOURCES
OF
PSYCHOLOGICAL PAIN
AND
SUICIDAL THOUGHTS
TABLE 1
Relationship Between Demographic Characteristics and Serious Suicidal Thoughts Serious Suicidal Thoughts
Age (M) Age (%)
