Hopelessness and Positive and Negative Future Thinking in Parasuicide

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British Journal of Clinical Psychology (2005), 44, 495504

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Hopelessness and positive and negative future

thinking in parasuicide
Andrew K. MacLeod*, Philip Tata, Peter Tyrer, Ulrike Schmidt,
Kate Davidson and Simon Thompson**
Royal Holloway, University of London, UK
Objectives. Hopelessness about the future is a key element in suicidal behaviour.
The aim of the present study was to examine possible components of hopelessness, in
particular, to contrast positive and negative future thinking and to examine separately
number, expectancy, and value of anticipated positive and negative future experiences.
Design.
A correlational design.
Method.
Repeat parasuicide patients (N 441) were administered the Beck
Hopelessness Scale, the Hospital Anxiety and Depression Scale and the future thinking
task, a measure of future positive and negative thinking that assesses number, perceived
likelihood, and perceived value of anticipated future positive and negative events.
Results. Consistent with predictions, hopelessness correlated more strongly with
lack of positive thoughts about the future than it did with presence of negative thoughts.
Both positive and negative future thinking showed a relationship to hopelessness over
and above their relationships to depression (positive future thinking) and anxiety
(negative future thinking). Number and likelihood of positive events and likelihood and
value of negative events showed both simple and partial relationships to hopelessness.
Number of negative events related to hopelessness but only after the other future
thinking variables had been controlled for and value of positive events no longer related
to hopelessness after controlling for the other variables
Conclusions. Hopelessness about the future in suicidal individuals is a multi-faceted
construct but lack of positive future thinking is more important than presence of
negative future thinking.
A major goal of current government health policies is to reduce suicide rates. Reduction of
death rates from suicide and undetermined injury by at least a fifth represents one of four
major health targets in the UK for the year 2010 (Department of Health, 1999). The U.S.
* Correspondence should be addressed to Dr Andrew MacLeod, Department of Psychology, Royal Holloway, University of
London, Egham Hill, Egham, Surrey TW20 0EX, UK (e-mail: a.macleod@rhul.ac.uk).
** On behalf of the POPMACT Group: for further details please see p. 504.
DOI:10.1348/014466505X35704

496
Andrew K. MacLeod et al.
governments health targets also aim at a reduction in suicide over the same period, from a
base rate of 10.8/100,000 to 6.8/100,000 per annum (US Department of Health and
Human Services, 2000). Suicide reduction represents the ultimate goal but because of
suicides relative rarity and the difficulty of targeting at-risk individuals, attention has
focused on parasuicide, which refers to any deliberate but non-fatal act of self-harm,
whatever the medical seriousness or lethality (Kreitman, 1977). Those with an episode of
parasuicide, usually an overdose, are at greatly increased risk of suicide as well as being at
high risk of repetition of parasuicide (Maris, Berman, Maltsberger, & Yufit, 1992).
Understanding some of the key psychological processes involved in parasuicide is
therefore likely to be of great value in informing interventions and helping to target risk
assessments.
There is strong evidence that hopelessness is the key psychological variable in
suicidal behaviour. Studies report that hopelessness mediates the relationship
between depression and suicidal intent (Salter & Platt, 1990), predicts repetition of
parasuicide 6 months later (Petrie, Chamberlain, & Clarke, 1988), and predicts
completed suicides up to 10 years later (Beck, Brown, & Steer, 1989; Fawcett et al.,
1990). Understanding more about what hopelessness is therefore becomes of
considerable clinical as well as theoretical interest. The Beck Hopelessness Scale
(BHS; Beck, Weissman, Lester, & Trexler, 1974) assesses global outlook for the future
but attempts to break it down into constituent parts through principal components
analysis have produced very inconsistent factor structures, and it may be best thought
of as unidimensional (Aish & Wasserman, 2001).
MacLeod and colleagues (MacLeod, Pankhania, Lee, & Mitchell, 1997; MacLeod,
Rose, & Williams, 1993; MacLeod et al., 1998) developed a task-based measure that
breaks future-directed thinking in parasuicide into component parts. In the future
thinking task developed by these authors, individuals are asked to think of future
positive events (things they are looking forward to) and negative events (things they are
not looking forward to), for a range of future time periods. Results have consistently
shown that parasuicide patients are less able than controls to provide events they are
looking forward to but do not differ from controls in the number of events they are not
looking forward to (Conaghan & Davidson, 2002; MacLeod et al., 1997; MacLeod et al.,
1993). This effect is consistent across the different future time periods. It therefore
appears that the future thinking of parasuicidal individuals is characterized mainly by a
lack of positive anticipation in the absence of any increase in negative anticipation.
MacLeod et al. (1998) modified the future thinking task to include two other aspects
of future thinking the perceived likelihood of an outcome and its value or importance.
These constructs are seen as key elements of decision making and action, most clearly
expressed in expectancy-value models (e.g. Eccles & Wigfield, 2002). A composite
measure that included expectancy and value as well as number of anticipated events
also showed that parasuicide patients were characterized by lack of positive future
thinking in the absence of any increased negative future thinking (MacLeod et al., 1998).
However, the individual components were not looked at separately it may be that
certain elements of negative future thinking are related to suicidal hopelessness.
If lack of positive future thinking is involved in hopelessness there should also be a
direct correlation between the two variables. Sidley, Calam, Wells, Hughes, and Whitaker
(1999) found that within a sample of self-harming individuals, hopelessness as measured
by the BHS correlated significantly negatively with number of positive items on the future
thinking task but did not correlate with number of negative items. However, the sample
was small (N 36) and future thinking was measured only by the number of positive and

Hopelessness and future thinking
497
negative future events that participants could think of. What would appear to be needed
is a large-scale study that looks at the relationship of hopelessness to positive and negative
future thinking, including the combined and separate relationships to hopelessness of
anticipated number, perceived likelihood, and perceived value of future events.
Understanding the different elements of hopelessness allows new opportunities for both
theoretical analysis and clinical applications. The first aim of the present study was to look
at the relationship of hopelessness to positive and negative future thinking within a large
sample of parasuicide patients, using a measure that includes perceived likelihood and
value as well as number of events anticipated. In addition, the incremental relationship of
future thinking to hopelessness over and above any relationship to depression and
anxiety was also examined, as depression and anxiety have been shown to relate to
positive and negative thinking, respectively, (MacLeod & Byrne, 1996). As part of the
assessment for a treatment trial (Tyrer et al., 2003b), a large sample of patients with a
recent and at least one other episode of parasuicide completed measures of hopelessness,
future thinking, depression, and anxiety. It was predicted that hopelessness would be
more strongly correlated with overall positive future thinking than with overall negative
future thinking and that these relationships would be over and above any relationships of
depression and anxiety with future thinking. The second aim of the study was to assess
the degree to which individual components (number, likelihood, and value) contributed
to any observed relationships between hopelessness and overall positive future thinking
and overall negative future thinking.
Method
Participants
Patients presenting with an episode of parasuicide at one of nine accident and
emergency departments across five centres (West London, South London, Nottingham,
Glasgow, and Edinburgh) were assessed for inclusion in the study. Patients were seen as
close as possible to the index episode, and almost always within 7 days. Inclusion
criteria were (1) age between 16 and 65, and (2) having at least one other episode of
parasuicide, in addition to the index episode. Exclusion criteria were (1) insufficient
knowledge of English language to complete assessment, (2) ICD-10 (World Health
Organization, 1992) diagnosis within the organic, alcohol, or drug dependence,
schizophrenia, or bipolar affective disorder groups, and (3) temporary residence in the
area therefore making them likely to be unavailable for follow-up. Potential participants
who were homeless were included if they were likely to be available for follow-up.
A total of 480 patients were recruited into the study over a 2-year period. In addition,
493 were eligible but not included, mainly due to being unable to be assessed before
discharge. Participants and eligible non-participants were very similar in sociodemographic characteristics (see Tyrer et al., 2003a). Of the 480 patients, 441 provided
complete data for the measures reported here, and therefore the data reported in this
paper are based on these participants.
Measures and procedure
As part of the wider study, participants completed a range of measures (Tyrer et al.,
2003a) including those described below. The future thinking task was always completed
at the beginning of the assessment session in order to prevent priming from other
self-report or interview-based measures.

498
Beck Hopelessness Scale (Beck et al., 1974)

This is a 20-item, truefalse measure of generalized negative expectancies about ones
own future. Eleven items are negatively phrased (e.g. My future seems dark to me) and
nine items are positively phrased (e.g. I can look forward to more good times than bad
times). The scale has good reliability and validity, for example, internal reliability is
typically in excess of .90 (Beck & Steer, 1988)
Hospital Anxiety and Depression Scale (HADS, Zigmond & Snaith, 1983)
This is a 14-item scale that assesses anxiety (HADS-A, 7 items) and depression (HADS-D,
7 items). The scale has been shown in a large scale, recent study (51,000 participants) to
have the predicted two-factor structure and to have good internal consistency
(Mykletun, Stordahl, & Dahl, 2001).
Future Thinking Task (MacLeod et al., 1998)

In this task participants are required to think of potential future experiences occurring
over three different time periods the next week, including today; the next year; and
the next 510 years. The time periods were presented verbally, one at a time, and in the
order given above. There were two conditions, one where participants were asked to
think of future positive experiences and the other where they were asked to think of
future negative experiences. For each of the three time periods in each of the two
conditions, participants were given a time limit of 1 minute to generate as many
responses as they could. Participants were told that they would be required to think
about things occurring to them over three different time periods in the future. It was
explained that these could be trivial or important things and that they could be things
that they knew were going to happen or things that they thought might reasonably
happen. Participants were instructed to say aloud a brief description of as many things as
possible for each time period and were told to keep trying until the time limit was up.
For the positive condition, they were asked to think of positive things in the future
things that they were looking forward to, things that they would enjoy. For the negative
condition, they were asked to think of negative things in the future things that they
were worried about or not looking forward to. The order of presentation of positive and
negative conditions was counterbalanced across participants, with each participant
receiving both conditions. The items generated by participants were written down by
the researcher. After giving their responses, participants were verbally re-presented with
those responses and asked to rate each one on how likely they thought it was to happen
(likelihood) and if it did happen how they would feel at the time (value), each on a
7-point scale. The likelihood rating scale was anchored by 1 not at all likely and
7 extremely likely. To capture the negativity/positivity of the value rating, this scale
ran from 2 3 very negative to 3 very positive.
Following MacLeod et al. (1998), composite measures of positive and negative future
thinking were calculated from number of items mean likelihood ratings for those
items mean value ratings for those items. Thus, someone who thought of five things
he or she was looking forward to over the next week, gave an average likelihood rating
of 5.5 (out of 7) for those items and an average pleasure rating of 2.5 (out of 3) for those
items would get a score of 68.75 for that condition. In order to have a more easily
interpretable directionality of scoring, mean value scores for the negative condition
were reflected to positive scores. This change did not affect any statistics; it simply

499
meant that a high score on the negative value, and therefore also a total negative score,
could be more easily interpreted as a high negative score. Mean value scores for positive
ratings were left unchanged. In addition to the composite scores, the exploratory
analyses also looked at scores of total number of positive and negative items, mean
likelihood ratings for positive and negative items, and mean value ratings for positive and
negative items. In all cases, scores were collapsed across the three time periods as
previous research has not found any effects relating to time period.
Results
Table 1 shows the socio-demographic characteristics and parasuicide history of the
participants.
Table 1. Sociodemographic characteristics and suicidal behaviour history of the sample (N 441)
Variable
Age (years)
Gender
Male
Female
Marital status
Single
Married or cohabiting
Divorced or separated
Widowed
Ethnicity
White
Other
Parasuicide history
More than one previous attempt?
Yes
No
Age at first attempt (years)
Years between index and previous episode
Mean (SD) or Number (%)

31.2 (11.2)
145 (33%)
296 (67%)
245 (56%)
104 (24%)
84 (19%)
8 (2%)
415 (94%)
26 (6%)
318 (72%)
114 (26%)
23.0 (9.9)
2.8 (5.2)
The means and standard deviations of all the main variables were: BHS (M 12:5,
SD 5:3), HADS-D (M 11:2, SD 4:6), HADS-A (M 14:1, SD 4:0) total positive
future thinking (M 101:9, SD 80:8), total negative future thinking (M 67:9,
SD 57:3), number of positive items (M 7:5, SD 5:3), number of negative items
(M 6:4, SD 4:5), mean likelihood ratings of positive items (M 5:1, SD 1:3),
mean likelihood ratings of negative items (M 5:0, SD 1:3), mean value of positive
items (M 2:6, SD 0:5), and mean value of negative items (M 2:1, SD 0:8). Some
variables distributions were skewed and were transformed following the guidelines of
Tabachnik and Fidell (1996), which resulted in normal distributions except for value
scores in both positive and negative conditions. The untransformed scores for these two
variables were used in analyses, which is acceptable given the large sample size and
fairly restricted scale range.
Both total positive future thinking scores (r 2:35, p , :001) and total
negative future thinking scores (r :17, p , :001) correlated significantly with BHS

500
in the expected directions.1 Positive and negative future thinking correlated

significantly with each other (r :34, p , :001), which probably reflects the general
verbal fluency element to the task. The significance of difference between the PositiveBHS and Negative-BHS correlations was calculated using a formula for comparing
dependent correlations (Edwards, 1965). The correlations did differ significantly
(t439 10:7, p , :001). However, such a difference could simply be an artefact of
the directionality of the scoring; the real test is whether the magnitude of the
correlations differed independently of their signs. The scoring for the negative
condition was reversed, thus leaving a comparison of r 2:35 versus r 2:17. This
difference was still significant (t439 2:6, p , :01). Therefore, the hypothesis that
positive future thinking would correlate more strongly than negative future thinking
with hopelessness was supported.
Multiple regressions were carried out to examine the relationship of hopelessness
to future thinking over and above any relationship of depression and anxiety to future
thinking. Anxiety and depression were entered first and hopelessness next, with
positive future thinking and, separately, negative future thinking as dependent
variables. The results are shown in Table 2. For both positive future thinking and
negative future thinking, hopelessness showed an incremental relationship to future
thinking, over and above the relationship of anxiety and depression to future thinking.
For positive future thinking, in the final model with each of the other variables being
controlled for both depression (standardized regression coefficient, B 23:0,
p , :01) and hopelessness (B 25:3, p , :001) showed significant relationships
whereas anxiety (B 0:06, ns) did not. For negative future thinking, anxiety
(B 0:14, p , :01) and hopelessness (B 0:11, p , :05) showed relationships but
depression (B 0:04, ns) did not.
Table 2. Multiple regressions predicting positive future thinking and negative future thinking by anxiety,
depression and hopelessness/BHS
Model
Variables
Positive future thinking

1
HADS-A and HADS-D
2
BHS
Negative future thinking
1
HADS-A and HADS-D
2
BHS
Adj R2
R2 change
Significance
.09
.14
.09
.05
F2; 448 21:9, p , :001

F1; 447 28:1, p , :001
.05
.06
.05
.01
F2; 446 12:4, p , :001

F1; 445 4:3, p , :05
Note. HADS-A anxiety, HADS-D depression, BHS Beck hopelessness scale.
The individual components of the future thinking task were looked at separately in
order to assess the relative contributions to hopelessness of number, likelihood, and
value. Separate multiple regressions were carried out predicting BHS scores from the
three positive variables and BHS scores from the three negative variables. The three
positive variables predicted BHS scores (F3; 414 23:5, p , :001, adjusted R 2 :14)
1
The correlations of BHS with individual time periods were similar to each other (positive week, r 2:25, positive year,
r 2.28, positive 510 years, r 2.22, all p, :001; negative week, r.16, negative year, r.25 and negative 510 years,
r.16, all p, :01).

501
as did the three negative variables (F3; 422 14:0, p , :001, adjusted R 2 :08).
Table 3 shows the standardized partial regression coefficients of each predictor variable
and their significance, from the regressions of BHS on the three positive variables and
BHS on the three negative variables. The standardized univariate regression coefficients
are shown for comparison. All three positive variables contributed independently to
BHS scores. In the case of the negative variables, BHS was predicted by likelihood and by
value but not by number, after controlling for the other variables. Finally, putting the six
variables into one large regression showed that the six variables predicted hopelessness
(F6; 402 23:1, p , .001, adjusted R 2 :25). Results were similar to the previous,
individual regressions except that positive value was reduced to non-significance
( p :16) and negative number became a significant predictor ( p , :001).
Table 3. Standardized regression coefficients and partial regression coefficients from respective
univariate and multiple regressions of BHS on number, likelihood, and value scores for positive and for
negative conditions separately
Positive variables predicting BHS
Negative variables predicting BHS
Variables
Univariate regression
coefficient
Partial regression
coefficient
Univariate regression
coefficient
Partial regression
coefficient
Number
Likelihood
Value
2 .28***
2 .31***
2 .13**
2 .19***
2 .28***
2 .11*
.05
.28***
.09
.06
.28***
.10*
Note. ***p , :001, **p , :01, *p , :05; BHS Beck hopelessness scale.
Discussion
As predicted, hopelessness correlated more strongly with positive future thinking than
it did with negative future thinking. In both cases, the relationship was independent of
anxiety and depression. Consistent with previous findings (e.g. MacLeod & Byrne,
1996), depression related to positive future thinking and anxiety to negative future
thinking. Number and likelihood of positive events and likelihood and value of negative
events were clearly related to hopelessness. The relationship of positive value and
negative number to hopelessness were less clear, and depended on their overlap or nonoverlap with other variables. After controlling for all the other future thinking variables,
negative number became significantly related to hopelessness and positive value ceased
to be significantly related to hopelessness.
The emphasis on positive future thinking in suicidal behaviour is consistent with
previous findings using the future thinking task (e.g. MacLeod et al., 1998), but extends
this research to show that within a large sample of parasuicide patients a broad
measure of positive future thinking that includes components of perceived likelihood
and value, as well as number, is directly related to hopelessness. The fact that positive
and negative cognitions show different effects is consistent with a growing body of
research that views positive and negative aspects of experience as reflecting the activity
of separate systems rather than being unipolar opposites (e.g. Ito & Cacciopo, 1998).
The findings are in fact also broadly consistent with the way that hopelessness has been
talked about. For example, Beck and Steer (1988) state that hopeless individuals

502
believe: (1) that nothing will turn out right for them, (2) that they will never succeed at
what they attempt to do, (3) that their important goals can never be obtained, and
(4) that their worst problems will never be solved (Beck & Steer, 1988, p. 1). The first
three of these clearly reflect thoughts about the non-occurrence of positive future
outcomes.
Negative future thinking was related to hopelessness, though the effect was clearer
for perceived likelihood and cost of the outcomes. Number of negative outcomes
anticipated did not relate to hopelessness except when included as a predictor with the
positive variables. This is a difficult finding to explain and is probably the result of the
high correlation (r :58) between number of positive and number of negative events.
The findings do suggest a different mechanism for how anticipated positive outcomes
relate to well-being compared with negative outcomes. Taylor (1991) has reviewed a
wide range of evidence showing that negative events elicit stronger and more rapid
reactions (cognitive, behavioural, and emotional) than do positive events. Anticipated
negative events may also show this effect. Following this line of reasoning, number may
be less important for negative events because an impact threshold is reached more
quickly with one or a few events, whereas for positive events, whose impact is less,
there may be a cumulative effect. The fact that the value of negative events was clearly
related to hopelessness whereas the value of positive events was not reinforces the idea
of quality of negative events and quantity of positive events being important.
The findings also highlight why previous research using only number of outcomes
anticipated emphasized the importance of positive future thinking over negative future
thinking. Hopelessness is clearly a multifaceted construct. Consistent with the findings
here, Warren, Zgourides, and Jones (1989) found that perceived likelihood of negative
outcomes was a particularly strong predictor of avoidance behaviour in anxious
patients. Low perceived likelihood of positive outcomes was also a strong predictor of
hopelessness, suggesting the importance of research that elucidates the processes
underlying perceived likelihood.
There are a number of limitations to the study. Although highly significant, the total
variance in hopelessness explained by future thinking (25%) is limited. With a large
sample size and with the error variance associated with these types of measures this is
perhaps not surprising, but it does suggest that other factors need to be taken into
account in understanding hopelessness. The representativeness of the sample was also
compromised by only approximately half of those who were eligible taking part in the
study. This is not unusual in parasuicide research and those who took part did not differ
in basic characteristics from those who did, but it does inject a note of caution about
generalizing the findings to parasuicide in general.
The findings have a number of theoretical and clinical implications. They suggest
that hopelessness can be broken down into component parts that are consistent with
existing normative models of judgment and decision making. There may be further
advantage in applying these models and constructs to understanding suicidal
hopelessness. For example, Eccles and Wigfield (2002) discuss four different types of
value attainment value, intrinsic value, utility value, and cost related to outcomes.
Such a typology may help to explain further the value element of suicidal future
thinking. Kahneman and Tversky (1982) have described processes underlying perceived
likelihood judgments, which may usefully be applied to understanding hopelessness.
Clinically, breaking hopelessness down in constituent parts also gives clearer
possibilities for intervention, for example, using cognitive techniques to change
perceived likelihood of future positive and negative outcomes or helping individuals to

503
engage in goals and activities that give them a greater quantity of future positive events
to anticipate. Understanding the psychological basis of hopelessness certainly has the
potential to contribute towards the ambitious targets that have been set for the
reduction of suicidal behaviour.
Acknowledgements
This work was supported by a grant from the Medical Research Council of Great Britain.
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S. Cooper, K. Davidson, C. Ferguson, L. Kim, C. Freeman, S. Frost, J. Godley, J. Greenshields,
J. Henderson, N. Holden, V. Jones, P. Keech, M. Knapp, C. Logan, C. Manley, A. MacLeod,
R. Murphy, L. Patience, L. Ramsey, S. de Munoz, U. Schmidt, J. Scott, H. Sievewright,
K., Sivukumar, P. Tata, S. Thompson, S. Thornton, P. Tyrer, O. Okoumunne, and S. Wessely.
Received 24 July 2003; revised version received 24 June 2004

Hopelessness and Positive and Negative Future Thinking in Parasuicide

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Hopelessness and Positive and Negative Future Thinking in Parasuicide

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British Journal of Clinical Psychology (2005), 44, 495504