Section VII Home

Behavioral Emergencies Update


Section on Clinical Emergenices and Crises
American Psychological Assn.
Section 7 Contact Info

In this issue...

The President's Column: Treatments for suicidal individuals: An exciting update

The Role of Core Competencies in Suicide Risk Assessment and Management

"Clinical Emergencies and Crises" at the 2006 APA Convention

Section Members in Press

Victimization, Violence, and Suicide: To What Extent Are They Inter-Related?

Borderline Personality Features Predict Self-Injurious Behavior in Adolescents

Photos from APA-New Orleans

Section VII Board Members


Victimization, Violence, and Suicide:
To What Extent Are They Inter-Related?

by Phillip M. Kleespies, Ph.D. - VA Boston Healthcare System

The behavioral emergencies have been said to include instances of suicidal behavior, violent behavior, and interpersonal victimization (Kleespies, 1998). They are linked in that the potential outcome of each involves intentionally in.icted serious harm or death to an individual. The possibility that such highrisk behaviors may have a more complex inter-relatedness has not been a major focus of inquiry until relatively recently. Rather, suicide research, violence research, and research on interpersonal victimization have been regarded as relatively independent areas of study (Lutzker and Wyatt, 2006).

Some investigators, however, have presented evidence suggestive of possible pathways between victimization in childhood and suicidality, the perpetration of violence, and re-victimization in adulthood. Thus, Dean Kilpatrick, in his Section VII Presidential Address (Kilpatrick, 2005), discussed data from a National Survey of Adolescents (Kilpatrick, et al, 2003) involving more than four thousand interviewees ranging in age from 12-17. He noted that having been a victim increased the risk of suicide attemptsafter controlling for risk of depression, PTSD, and drug use disorders. He also noted that, after controlling for other mental health problems, victimization increased the risk for the perpetration of violence. Finally, in a 7-8 year follow up study, he reported that young women who were victimized as adolescents and developed PTSD were at high risk for re-victimization. In addition, Ehrensaft, et al, (2003) examined data gathered prospectively on a community sample of 543 children over a period of 20 yearsto test the relationship between childhood maltreatment, power assertive punishment in childhood, and exposure to violence between parents on subsequent risk for adult partner violence. Amongst otherthings, they found that physical injury by a caretaker directly increased the probability of using similar violent tactics of con.ict resolution in future intimate relationships. They also found that exposure to violence between parents posed the greatest independent risk for being a victim of any act of partner violence. Although the development of a conduct disorder in adolescence mediated the effect of child abuse, exposure to violence between parents and power assertive punishment were nonetheless additional and potent predictors of the perpetration of violence on partners.

The findings of Kilpatrick, et al, (2003) and of Ehrensaft, et al, (2003) are supported by the extensive literature reviews of Kolko (2002) on child physical abuse and of Berliner and Elliott (2002) on the sexual abuse of children. Kolko has summarized many studies demonstrating that a history of physical abuse in childhood puts individuals at greater risk of future aggression, poor anger modulation, impulsivity, and violent behavior; while Berliner and Elliott have noted numerous studies showing that a history of sexual abuse in childhood can lead to greater risk of depression, anxiety, lower self-esteem, and suicidal behavior. Thus, interpersonal victimization (particularly in childhood and adolescence), in addition to, at times, being a behavioral emergency itself, also appears to be a contributing factor in the development of other, future, behavioral emergencies.

For many years, Plutchik and his colleagues (e.g., Plutchik, Botsis, and van Praag, 1995) have theorizedthat suicide and violence re.ect an underlying aggressive impulse that is modified by variables that they have referred to as ampli.ers and attenuators. To support their theory, they have cited evidence of the overlap of suicidal and violent behavior in hospitalized psychotic adolescents and in incarcerated juvenile delinquents as well as in adult psychiatric inpatients. In this same vein, Mann, Waternaux, Haas, and Malone (1999) conducted a study in which they interviewed 347 consecutive admissions to apsychiatric hospital and found that rates of lifetime aggression and impulsivity were signi.cantly greater in suicide attempters than in those who had never attempted suicide. They concluded that, in estimating the risk of future suicidal acts, clinicians should factor in lifetime impulsivity and/or aggression. Similarly, Apter, et al, (1995) assessed 163 consecutive admissions to an adolescent psychiatricinpatient unit for depression, suicidal behaviors, and violent behaviors. They found that both depression and violent behavior correlated signi.cantly with suicidal behavior scores, but there was no signi.cant correlation between violent behaviors and depressive symptoms. The authors hypothesized that there may be two types of suicidal behavior during adolescence: (1) a planned desire to die secondary to depression, and (2) behavior related to problems with aggression and impulse control.

Clearly, not all childhood victims of abuse become suicidal or violent adolescents or adults. Likewise, not every individual who has dif.culty with impulsivity and aggression is also on a path to suicidality in the future. It appears that there may be many paths to suicide or to violence. The evidence cited above, however, suggests that victimization and abuse in childhood could play a key role, for some, in the later development of suicidal and/or violent tendencies. Likewise, it appears that dif.culty in regulating impulsivity and aggression could be a factor, for some, in the development of a proclivity for suicidal behavior as well as violent behavior. As Lutzker and Wyatt (2006) have noted, there is logic to the suggestion that a greater understanding of these potential linkages could be achieved via crosscutting work; i.e., through greater collaboration among those involved in what have typically been segregated areas of study – interpersonal victimization, violence, and suicide.



Apter, A., Gothelf, D., Orbach, I., Weizman, R., Ratzoni, G., Har-Even, D., and Tyano, S. (1995). Correlation of suicidal and violent behavior in different diagnostic categories in hospitalized adolescent patients. Journal of the Academy of Child and Adolescent Psychiatry, 34, 912-918.

Berliner, L., and Elliott, D. (2002). Sexual abuse of children. In J. Myers, L. Berliner, J. Briere, C. Hendrix, C. Jenny, & T. Reid (Eds.): The APSAC handbook on child maltreatment (2nd ed., pp. 55-78). Thousand Oaks, CA: Sage Publications.

Ehrensaft, M., Cohen, P., Brown, J., Smailes, E., Chen, H., and Johnson, J. (2003). Intergenerational transmission of partner violence: A 20-year prospective study. Journal of Consulting and Clinical Psychology, 71, 741-753.

Kilpatrick, D. (2005). The role of trauma in behavioral emergencies: Implications for policy and practice. Presidential address for Section VII of Division 12. Presented at 113th Annual Convention of the American Psy-
chological Association. Washington, DC, August 19, 2005.

Kilpatrick, D., Ruggiero, K., Acierno, R., Saunders, B., Resnick, H., and Best, C. (2003). Violence and risk of PTSD, major depression, substance abuse/dependence, and comorbidity: Results from the National Survey of Adolescents. Journal of Consulting and Clinical Psychology, 71, 692-700.

Kleespies, P. (1998). Emergencies in mental health practice: Evaluation and management. NY: Guilford Press.

Kolko, D. (2002). Child physical abuse. In J. Myers, L. Berliner, J. Briere, C. Hendrix, C. Jenny, & T. Reid (Eds.): The APSAC handbook on child maltreatment (2nd ed., pp. 21-54). Thousand Oaks, CA: Sage Publications.

Lutzker, J., and Wyatt, J. (2006). Introduction. In J. Lutzker (Ed.): Preventing violence: Research and evidence-based intervention strategies (pp. 3-15). Washington, DC: APA Books.

Mann, J., Waternaux, C., Haas, G., and Malone, K. (1999). Toward a clinical model of suicidal behavior in psychiatric patients. American Journal of Psychiatry, 156, 181-188.

Plutchik, R., Botsis, A., and van Praag, H. (1995). Psychopathology, self-esteem, sexual and ego functions as correlates of suicide and violence risk. Archives of Suicide Research, 1, 27-38.