The ebb and flow of the wish to live and the wish to die among suicidal military personnel

- The balance of the wish to live and wish to die predicts suicidal behavior.
- Suicide attempts are driven by the wish to live more so than the wish to die.
- Brief cognitive behavioral therapy (BCBT) differentially affects the wish to live.
- In BCBT, the wish to live destabilizes or resets the wish to die over time.
- Affecting the wish to live may be a mechanism of action of effective therapies.

BackgroundThe relative balance between the wish to live and the wish to die (i.e., suicidal ambivalence) is a robust predictor of suicidal behavior and may be a mechanism underlying the effectiveness of treatments that reduce suicidal behaviors. To date, however, few studies have explored possible mechanisms of action in these treatments.MethodActive duty Soldiers (N=152) with a recent suicide attempt and/or active suicide ideation were randomized to receive brief cognitive behavioral therapy (BCBT) or treatment as usual (TAU). The Suicide Attempt Self-Injury Inventory (Linehan et al., 2006a) was used to assess the incidence of suicide attempts during the 2-year follow-up. The wish to live and the wish to die were assessed with items 1 and 2, respectively, of the Beck Scale for Suicide Ideation (Beck and Steer, 1991).ResultsAcross both treatments, the wish to live was significantly weaker among patients who attempted suicide but the wish to die was stronger only among patients who attempted suicide in TAU. Among nonattempters, the wish to die stabilized the wish to live, but among attempters the wish to live and the wish to die were not associated with each other. In BCBT the wish to live destabilized the wish to die among nonattempters.LimitationsSelf-report methodology, predominantly male sample.ConclusionsThe emergence of suicidal behavior is driven primarily by the absence of the wish to live. BCBT is associated with a unique coupling of an ambivalent wish to live and wish to die, which may suggest an underlying mechanism of action.