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Published in final edited form as: Behav Res Ther. 2023 Aug 25;169:104388. doi: 10.1016/j.brat.2023.104388

Self-burdensomeness, other-burdensomeness, and suicidal ideation

Tobias Teismann a,*, Julia Brailovskaia a, Morgan Robison b, Thomas E Joiner b
PMCID: PMC11800759  NIHMSID: NIHMS2041578  PMID: 37643552

Abstract

Perceiving oneself as a burden to others (other-burdensomeness), as well as perceiving one’s selfhood as a burden (self-burdensomeness), have been proposed as risk factors for suicidal ideation. Yet, it is unclear whether the altruistic motive of being a burden to others or the self-oriented motive of being a burden on oneself is more relevant to suicidal ideation. Given this background, two rival mediation models were tested. Data from N = 228 outpatients (64% female; age: M(SD) = 38.69 (12.27), range:17–65) undergoing psychotherapy were collected at two measurement time points over a three-month period (first measurement = T1, second measurement = T2). The significant positive association between other-burdensomeness (T1) and suicidal ideation (T2) was partially mediated by self-burdensomeness (T1). Furthermore, the significant positive association between self-burdensomeness (T1) and suicidal ideation (T2) was partially mediated by other-burdensomeness (T1). Results suggest that suicidal ideation can develop from both an altruistic, self-sacrificial perception of being a burden to others, as well as from a more self-oriented perception of being a burden to oneself. There is no indication that either self-burdensomeness or other-burdensomeness is a stronger indicator in the development of suicidal ideation.

Keywords: Suicidal ideation, Interpersonal theory of suicide, Perceived burdensomeness, Acute suicidal affective disturbance

1. Introduction

Suicidal ideation, contemplation or preoccupation regarding ending one’s life, is a known predictor of death by suicide (Franklin et al., 2017) and one of the most common reasons for psychiatric hospitalizations (e. g., Bowers, 2005). In light of this background, Jobes and Joiner (2019) pointed to the vital importance of attending to suicidal ideation in research and treatment as a preventative measure against suicidal behaviors, and also of promoting higher quality of life. Therefore, it is particularly important to continue refining our understanding of the pathways leading to the development of suicidal ideation. According to the Interpersonal Psychological Theory of Suicide (Joiner, 2005; Van Orden et al., 2010), two proximal and causal risk factors must be present in order for someone to develop the desire for suicide: perceived burdensomeness and thwarted belongingness (each viewed by the individual as intractable). Perceived burdensomeness refers to the view that one’s existence is a burden on family members and friends (“Others would be better off if I were gone”). Thwarted belongingness refers to the experience that one is alienated from others, not an integral part of a family, circle of friends, or another valued group (“I am alone”).

Empirical research indicates that perceived burdensomeness is strongly associated with suicidal ideation, whereas findings on thwarted belongingness trend similarly but are somewhat less consistent (Chu et al., 2017; Ma et al., 2016). The association between perceived burdensomeness and suicidal ideation has been observed in different samples (e.g., students, soldiers, outpatients), using different assessment strategies and under statistical control of various concurrent risk factors (e.g., age, depression). Additionally, perceived burdensomeness has been found to be both a moderator and mediator between suicide-related behaviors and other risk and protective factors (Hill & Pettit, 2014). Finally, perceived burdensomeness was shown to precede elevations of suicidal ideation in prospective studies (e.g., Teismann et al., 2016, 2017). Taken together, the perception of being a burden on others (other-burdensomeness) is a strong risk factor for suicidal ideation.

It is therefore consequential that the perception of being a burden to others has been included as one feature of an acute suicidal syndrome, the Acute Suicidal Affective Disturbance (ASAD) syndrome (Rogers et al., 2017, 2019; Stanley et al., 2016; Tucker et al., 2016). ASAD is proposed to be a time-limited arousal state defined by the following criteria: “(a) A geometric increase in suicidal intent over the course of hours or days (as opposed to weeks or months); (b) One (or both) of the following: marked social alienation (e.g., severe social withdrawal, disgust with others, perception that one is a liability on others), and/or marked self-alienation (e.g., views that one’s selfhood is a burden, self-disgust); (c) Perceptions that the foregoing are hopelessly intractable; and (d) Two or more manifestations of overarousal (e.g., insomnia, nightmares, agitation, irritability)” (Stanley et al., 2016, p. 98). The importance of being a burden to others is displayed in criterion B. However, criterion B does not only highlight the importance of perceiving oneself as a burden to others, but also the importance of perceiving one’s selfhood as a burden (self-burdensomeness). Self-burdensomeness includes affectively laden cognitions of low self-worth (“I am a burden to myself”), self-disgust and self-hatred (“I hate myself”). In fact, suicide has been understood as an escape from aversive self-awareness (Baumeister, 1990) and various studies have pointed to self-disgust and self-hate (e.g., Brake et al., 2017; Turnell et al., 2019) as indicators of suicide risk. According to this view, the proximal cause of suicidal ideation and suicide itself is the ultimate desire to escape from the burden of intolerably aversive self-awareness.

To the best of our knowledge, no study to date has investigated the association between self-burdensomeness and other-burdensomeness. Rogers et al. (2019, p. 1002) surmised that “hatred of the self may contribute to feelings of perceived burdensomeness and suicidality.” As such, one might expect other-burdensomeness to mediate the association between self-burdensomeness and suicidal ideation. A total mediation effect would underline the importance of altruistic, self-sacrificial motives for the development of suicidal ideation (cf., Joiner et al., 2016): On this view, suicidal ideation should only emerge if being a burden on oneself leads to the perception of being a burden to others. However, it is also possible that the impression of being a burden on others causes a state of heightened self-burdensomeness leading to suicidal ideation. In this case a total mediation effect would underline the importance of self-oriented motives for the development of suicidal ideation: Being a burden to others makes self-awareness aversive, thereby causing suicidal ideation.

Given this background, the purpose of the present prospective study was to investigate the association between self-burdensomeness, other-burdensomeness, and suicidal ideation in a sample of adult outpatients. More specifically, we tested two rivaling hypotheses: (1). Other-burdensomeness mediates the association between self-burdensomeness and suicidal ideation vs. (2.) Self-burdensomeness mediates the association between other-burdensomeness and suicidal ideation.

2. Methods

2.1. Participants

The study sample comprises N = 228 outpatients (64% female; age: M(SD) = 38.69 (12.27), range: 17–65; 100% Caucasian) undergoing cognitive-behavioral therapy at an outpatient university clinic in the Ruhr-area in Germany between April 2010 and April 2011. Assessments were conducted prior to treatment (T1) and again about three months (mean [M] = 3.24, standard deviation [SD] = 0.97) after the pretreatment assessment (T2). The most common main diagnoses according to the International Classification of Diseases (ICD-10) were affective disorders (F3: 54.8%) and neurotic, stress-related and somatoform disorders (F4: 36.4%). In total, 45.6% (n = 104) reported current suicidal ideation (DSISS≥1) and 12.7% (n = 28) reported at least one lifetime suicide attempt.

All patients were informed that the clinic regularly conducts research and provided informed consent prior to participation. In order to assure a standard of quality, all clients seeking help at the clinic are required to fill out questionnaires prior to their intake. No compensation is given to clients for doing so. This study was reviewed and approved by the local Ethics Committee.

2.2. Measures

2.2.1. Interpersonal needs questionnaire – perceived burdensomeness subscale

(INQ-PB; Van Orden et al., 2012; German Version: Hallensleben et al., 2016). Other-burdensomeness was assessed using the six items of the INQ-PB (e.g., “These days I feel like a burden on the people in my life”). All items are to be answered on a 7-point Likert scale ranging from “1” (not at all true for me) to “7” (very true for me). The German version of the INQ shows good psychometric properties (Hallensleben et al., 2016). Accordingly, internal consistency was very good in the current study: α = 0.93.

2.2.2. Self-burdensomeness scale

(SBS; German version: Gebauer et al., 2009). Self-burdensomeness was assessed with a modified version of the INQ-PB. As such in the six items of the INQ-PB the term “people in my life” became replaced by “I/myself”. For example, the item “These days I think I make things worse for the people in my life” was changed to “These days I have been making my own life situation worse.” Internal consistency was comparable to the internal consistency of the INQ-PB, α = 0.92.

2.2.3. Depressive symptom inventory – suicidality subscale

(DSI-SS; Joiner et al., 2002; German version: von Glischinski et al., 2016). The DSI-SS is a 4-item scale designed to measure the frequency and intensity of suicidal ideation symptoms over the past two weeks. Scores on each item range from 0 (e.g., “I do not have thoughts of killing myself”) to 3 (e.g., “I always have thoughts of killing myself”), with higher values indicating more severe suicidal ideation. The German version of the scale has been shown to possess strong psychometric properties (von Glischinski et al., 2016). The internal consistency (Cronbach’s α) for the DSISS in the current sample was α = 0.90. In addition, lifetime suicide attempts were assessed by one item asking whether they had ever tried to kill themselves and if that was the case, how often they had attempted to do so.

2.3. Statistical analyses

Statistical analyses were conducted using SPSS 24 and the macro Process version 2.16.1 (www.processmacro.org/index.html; Hayes, 2013). After descriptive analyses, the relationship between the investigated variables was assessed by zero-order bivariate correlation analyses as well as partial correlation analyses (controlling for suicidal ideation at T1). Next, two mediation models (Process: model 4) were calculated. The first model included other-burdensomeness (T1) as a predictor, self-burdensomeness (T1) as a mediator and suicidal ideation (T2) as the outcome, controlling for age and gender as covariates. The basic relationship between other-burdensomeness (T1) and suicidal ideation (T2) was denoted by c (total effect). The path of other-burdensomeness (T1) to self-burdensomeness (T1) was denoted by a; b denoted the path of self-burdensomeness (T1) to suicidal ideation (T2). The indirect effect (ab) was represented by the combined effect of path a and path b. Path c’ denoted the direct effect of other-burdensomeness (T1) to suicidal ideation (T2) after the inclusion of self-burdensomeness (T1) into the model. The bootstrapping procedure (10,000 samples) that provides accelerated confidence intervals (95% CI) assessed the mediation effect. PM (the ratio of the indirect effect to the total effect) served as a mediation effect measure. In the second model, self-burdensomeness (T1) was included as a predictor and other-burdensomeness (T1) as a mediator. Suicidal ideation (T2) served again as the outcome; age and gender were controlled for.

3. Results

Other-burdensomeness (T1; M(SD) = 15.36 (9.46), range: 6–42) was significantly positively correlated with self-burdensomeness (T1; M(SD) = 18.44 (10.14), range: 6–42), r = 0.730, p < .001, and suicidal ideation (T2; M(SD) = 1.20 (1.84), range: 0–8), r = 0.408, p < .001. Self-burdensomeness (T1) and suicidal ideation (T2) were also significantly positively correlated, r = 0.420, p < .001. When controlling for suicidal ideation at T1, other-burdensomeness (T1) was still significantly correlated with suicidal ideation (T2), pr = .149, p < .05, whereas self-burdensomeness was not, pr = .116, n.s.

Both mediation models revealed partial mediation effects. Fig. 1a shows that in the first model the basic relationship between other-burdensomeness (T1) and suicidal ideation (T2) was significant (total effect, c: p < .001). After the inclusion of self-burdensomeness (T1) in the model, this relationship remained significant (direct effect, c’: p = .014). The link between other-burdensomeness (T1) and self-burdensomeness (T1) (a: p < .001), and the association between self-burdensomeness (T1) and suicidal ideation (T2) (b: p = .002) were both significant. The indirect effect (ab) was significant, b = 0.038, SE = 0.014, 95%CI[0.012, 0.068]; PM: b = 0.478, SE = 0.208, 95%CI[0.145, 0.963].

Fig. 1.

Fig. 1.

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Mediation model including other-burdensomeness, self-burdensomeness and suicide ideation.

Note. c = total effect, c’ = direct effect; b = standardized regression coefficient, SE = standard error, CI = confidence intervall

As presented in Fig. 1b, in the second model, the basic relationship between self-burdensomeness (T1) and suicidal ideation (T2) was significant (c: p < .001), and it remains significant after the inclusion of other-burdensomeness (T1) (c’: p = .002). The relationship between self-burdensomeness (T1) and other-burdensomeness (T1) (a: p < .001), and the association between other-burdensomeness (T1) and suicidal ideation (T2) (b: p = .014) were both significant. The indirect effect (ab) was significant, b = 0.029, SE = 0.013, 95%CI[0.002, 0.055]; PM: b = 0.366, SE = 0.186, 95%CI[0.022, 0.757].

4. Discussion

The aim of the present study was to examine the association between self-burdensomeness, other-burdensomeness, and suicidal ideation. There were two main findings: (1.) The association between self-burdensomeness and suicidal ideation is partially mediated by other-burdensomeness; (2.) The association between other-burdensomeness and suicidal ideation is partially mediated by self-burdensomeness. As such, this work suggests that suicidal ideation might result from an altruistic, self-sacrificial perception of being a burden to others, as well as from a more self-oriented perception of being a burden to oneself: Being a burden to others might contribute to an aversive awareness of self, leading to suicidal ideation and being a burden to oneself might contribute to the perception of being a burden to others, leading to suicidal ideation. Taken together, there is no indication that either self-burdensomeness or other-burdensomeness is more relevant to an understanding of suicidal ideation. Both factors matter and both factors seem to be closely intertwined. In this sense, both factors can exert their influence on suicidal ideation via the other. Although results are less clear cut than was expected, the general result pattern supports the way criterion B of the ASAD syndrome is formulated: “One (or both) of the following: marked social alienation (e.g., severe social withdrawal, disgust with others, perception that one is a liability on others), and/or marked self-alienation (e.g., views that one’s selfhood is a burden, self-disgust)” (Stanley et al., 2016, p. 98; italics added). Nevertheless, in view of the core assumptions of the Interpersonal-Psychological Theory of Suicide (Joiner, 2005; Van Orden et al., 2010), one would have expected that other-burdensomeness mediates the association between other risk factors – including self-burdensomeness – on suicidal ideation (cf., Rogers et al., 2019).

Still, in line with previous research showing an association between perceived burdensomeness and suicidal ideation (Chu et al., 2017; Ma et al., 2016), the current study demonstrated that other-burdensomeness is significantly associated with suicidal ideation in a prospective study design. The same is true for self-burdensomeness. Yet, the association between pretreatment self-burdensomeness and a prospective assessment of suicidal ideation was no longer significant when controlling for pretreatment suicidal ideation. However, it should be cautioned against overestimating this result, as both other-burdensomeness and self-burdensomeness showed comparably small associations with suicidal ideation assessed three months after the initial assessment – when controlling for pretreatment suicidal ideation. In general, one may speculate that perceptions of other-burdensomeness and self-burdensomeness are just different expressions of an activated suicidal mode (Rudd, 2006). In line with this assumption, Roeder and Cole (2019) recently proposed to conceptualize different suicide-specific cognitions “as reinforcing one another in ways that exacerbate or maintain a larger system of negative beliefs, and then to treat this negative belief system (not specific parts of it) as a higher-order construct that serves as a more optimal predictor of suicidal ideation” (p. 11). Essentially the entirety of the existing literature testing the Interpersonal Theory focuses on other-burdensomeness and does not include assessments of self-burdensomeness. This is quite understandable given the emphases of the initial statements of the theory (Joiner, 2005; Van Orden et al., 2010). Nevertheless, this suggests that effects for burdensomeness in the existing literature, though robust, may be underestimated due to the exclusion of self-burdensomeness.

Clinically, the present results underscore the need to ask for perceptions of being a burden to others as well as perceptions of being a burden to oneself in risk assessments with suicidal patients (Chu et al., 2015; Joiner et al., 2009). In some patients, other-burdensomeness will be a stronger “suicide driver” (cf., Jobes, 2016) and in others, self-burdensomeness. This must be taken into account in case conceptualization and treatment planning. Cognitive restructuring methods (i. e. evidence gathering, discussion of cognitive distortions), empty chair dialogues and/or the involvement of relatives/friends can be used to challenge the idea that one is a burden to others or that others would be better off if one no longer existed (Teismann & Friedrich, 2022). In addition, affected individuals can be referred to a psycho-educational online site (https://betteroffwithyou.org.au) that specifically addresses the idea that one is a burden to others. Finally, different studies showed that perceived burdensomeness is malleable through a variety of targeted (web-based) interventions (Allan et al., 2018; Buitron et al., 2022; Hill & Pettit, 2019; Lieberman et al., 2023; Short et al., 2019). Techniques to foster self-compassion, purpose and meaning making (Gordon, 2021), two-chair dialogues focusing on the “inner critic” as well as strategies for dealing with negative emotionality seem suitable to reduce the impression of being a burden on oneself (cf. Linehan, 1996). Given that self-burdensomeness can potentially arise in very different ways, accurate case conceptualization is needed before therapeutic techniques can be selected.

Several limitations have to be considered when interpreting the results of the present study. First, since the sample was 100% Caucasian, it is unclear how the findings would generalize to a more diverse ethnic population. In principle, it cannot be assumed that findings obtained in studies in Western industrialized countries can be generalized to culturally different groups of people (cf. Brailovskaia et al., 2021); especially with regard to the differentiation between self- and other burdensomeness, an analysis in more collectivistic societies would be very interesting (Oyserman et al., 2002). From a developmental perspective, the question arises from which age a differentiation between self- and other burdensomeness is made. Furthermore, future studies should be conducted using an inpatient sample with more intense suicidal ideation and behavior. Second, the study was not set up as a formal test either of the ASAD syndrome (Rogers et al., 2019) or of the Interpersonal-Psychological Theory of Suicide (Joiner, 2005). Therefore, further constructs of central relevance to the syndrome and/or the theory have not been assessed in the current study. Against this background, the present study does not allow generalizing conclusions regarding the validity of the syndrome or the theory. Third, with regard to the high fluctuation of suicidal ideation, more measurement time points should be used in future studies. Ecological Momentary Assessments (EMA) would be suitable for this purpose. In this context, it should be emphasized that changes in self- and other-burdensomeness were not assessed in the present study. There are studies on the therapeutic amelioration of other-burdensomeness (e.g. Teismann et al., 2016, 2017), yet studies on the therapeutic changeability of self-burdensomness are still lacking. Fifth there are various limitations associated with the use of mediation analysis (e.g. unmeasured confounding, measurement error; Lee et al., 2021); therefore a replication using alternative statistical approaches and/or additional analysis might be warranted.

However, despite the limitations, this study provides novel understanding regarding the relevance of self-burdensomeness, i.e., a state of aversive self-awareness, as well as other-burdensomeness, i.e., the perception that one’s existence is a burden on family members and friends, in understanding suicidal ideation. Future research should build upon this work through experimental manipulation of both self- and other-burdensomeness to specify the directionality and magnitude of how burdensomeness is formed and perpetuated.

Acknowledgements

The authors would like to thank Jochen Gebauer for invaluable input.

Role of the funding source

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Footnotes

CRediT authorship contribution statement

Tobias Teismann: Writing – original draft, revised version, coordinated the study, performed participant recruitment, data collection, data processing and statistical, Formal analysis. Julia Brailovskaia: statistical, Formal analysis. Morgan Robison: Writing – original draft, revised version. Thomas E. Joiner: Writing – original draft, revised version, study design and interpretation of the data. All authors read and approved the final version of the manuscript.

Declaration of competing interest

None.

Data availability

Data will be made available on request.

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Data Availability Statement

Data will be made available on request.

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