Multi-Attitude Suicide Tendency Scale (MAST)

Abstract

The Multi-Attitude Suicide Tendency Scale (MAST) is a specialized, theoretically grounded self-report psychometric instrument designed to assess the multidimensional attitudes that individuals harbor toward life and death. Developed by Israel Orbach and colleagues in 1991, the instrument operationalizes the profound internal conflict and psychological ambivalence characteristic of suicidal states. Departing from traditional unidimensional models that treat suicidal ideation merely as a continuum of self-destructive intent, the MAST conceptualizes suicidal risk through four distinct, interrelated cognitive-affective dimensions: Attraction to Life (AL), Repulsion by Life (RL), Attraction to Death (AD), and Repulsion by Death (RD). Comprising 30 items scored on a 5-point Likert scale ranging from 1 (Strongly disagree) to 5 (Strongly agree), the MAST facilitates the evaluation of unique attitudinal profiles, revealing not only the desire to escape unbearable psychological pain (psychache) but also the specific cognitive distortions, idealized conceptualizations of death, and protective survival orientations that govern suicidal vulnerability. Extensive empirical investigations in adolescent, young adult, and clinical inpatient samples demonstrate robust psychometric properties, including strong internal consistency across subscales (Cronbach’s α typically ranging from .68 to .88), coherent four-factor structural validity verified via exploratory and confirmatory factor analysis (CFA), and significant criterion-related validity in differentiating suicidal adolescents from psychiatric non-suicidal and community controls. The MAST serves as an indispensable clinical and research instrument for suicide risk formulation, developmental psychopathology, and targeted cognitive-behavioral intervention.

Keywords

Multi-Attitude Suicide Tendency Scale, MAST, Israel Orbach, suicide assessment, suicidal ideation, ambivalence toward life and death, psychache, adolescent suicidology, Attraction to Life, Repulsion by Death

Authors

The Multi-Attitude Suicide Tendency Scale was constructed and psychometrically validated by a collaborative multidisciplinary team of clinical psychologists and psychiatrists in Israel:

• Israel Orbach, Ph.D. (1941–2010): Late Professor of Clinical Psychology at Bar-Ilan University, Ramat Gan, Israel. A world-renowned suicidologist, Professor Orbach pioneered seminal theoretical formulations concerning bodily experiences, mental pain, child and adolescent suicide, and internal ambivalence toward physical existence.
• Irit Milstein, M.A.: Department of Psychology, Bar-Ilan University, Ramat Gan, Israel.
• Dov Har-Even, Ph.D.: Department of Psychology, Bar-Ilan University, Ramat Gan, Israel.
• Alan Apter, M.D.: Professor Emeritus of Psychiatry, Feinberg Child Study Center, Schneider Children’s Medical Center of Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University. Dr. Apter is an international authority on adolescent depression, impulsive aggression, and suicide risk neurobiology.
• Sam Tiano, M.D.: Geha Mental Health Center and Sackler Faculty of Medicine, Tel Aviv University, Petah Tikva, Israel.
• Avner Elizur, M.D.: Abarbanel Mental Health Center, Bat Yam, and Sackler Faculty of Medicine, Tel Aviv University, Israel.

Subsequent psychometric adaptations and confirmatory structural validations in American adolescent, undergraduate, and clinical populations were spearheaded by psychometricians including Augustine Osman, Ph.D., Peter M. Gutierrez, Ph.D., and Anne H. Hagstrom, Ph.D.

Purpose

The primary clinical and empirical objective of the Multi-Attitude Suicide Tendency Scale is to assess and map the complex, multifaceted structure of attitudes toward living and dying that determine an individual’s movement along the spectrum of self-harm. In routine psychiatric evaluation and psychodiagnostic research, suicidal risk has historically been indexed using unidimensional severity scales (e.g., measuring frequency, duration, and planfulness of suicidal thoughts). However, clinical observations have long emphasized that individuals in suicidal crisis rarely possess a simple, unconflicted drive to die. Instead, they experience intense, agonizing ambivalence—a dynamic push-pull dynamic between the fundamental instinct for self-preservation, painful reactions to existential stressors, seductive fantasies of post-mortem relief, and visceral terror of biological extinction.

The MAST was purposefully engineered to capture this psychological architecture. Rather than yielding an undifferentiated global severity score, the instrument generates a four-dimensional profile that answers crucial clinical questions:

• Preservation of Survival Drive: To what degree does the individual still retain positive attachments, future-oriented hope, interpersonal satisfaction, and pleasure in everyday functioning (Attraction to Life)?
• Intensity of Psychological Suffering: How acute is the subject’s perception of life as an unbearable, insurmountable struggle marked by perceived burdensomeness, alienation, and helplessness (Repulsion by Life)?
• Cognitive Romance of Death: Does the patient conceptualize death as an ultimate escape, a serene realm of eternal peace, a spiritual reunion with deceased loved ones, or an effective problem-solving mechanism (Attraction to Death)?
• Biological and Existential Death Anxiety: Does the patient experience terror regarding physical decay, loss of personal identity, cessation of cognitive awareness, or the finality of non-existence (Repulsion by Death)?

By mapping these distinct vectors, the MAST provides clinicians with actionable diagnostic insights. For instance, an adolescent displaying high Repulsion by Life coupled with high Attraction to Life may demonstrate elevated subjective distress but lower lethal potential due to intact countervailing protective forces. Conversely, an individual characterized by high Repulsion by Life, high Attraction to Death, and depleted Repulsion by Death exhibits an exceptionally lethal profile, having dismantled both the desire to survive and the evolutionary fear of dying. Thus, the scale is routinely applied in inpatient risk triage, psychotherapy treatment planning, forensic risk reviews, and developmental research investigating pathways to self-harm in youth.

Psychological Construct

The psychological construct underlying the MAST is grounded in the conceptualization of suicidal behavior as an emergent outcome of four interacting, orthogonal attitudinal dimensions. Each dimension reflects distinct cognitive schemas, affective valuations, and defensive operations:

1. Attraction to Life (AL)

This subscale evaluates the vitality of the individual’s psychological connection to living. It measures experiences of subjective well-being, interpersonal joy, self-efficacy, optimistic future expectations, and positive affectivity. Core indicators include feelings of being loved, valuing relationships with significant others, believing that existence is inherently worth pursuing despite adversity, and anticipating personal success. In psychopathological contexts, severe depression induces anhedonia and cognitive constriction that systematically erode Attraction to Life. High scores on this dimension represent the strongest psychological buffer against suicidal enactment.

2. Repulsion by Life (RL)

Repulsion by Life captures the subjective experience of unendurable mental anguish, interpersonal defeat, and perceived alienation. Closely corresponding to Edwin Shneidman’s formulation of psychache, this construct operationalizes feelings that existence is an exhausting, unmanageable ordeal. It taps into interpersonal constructs such as perceived burdensomeness (e.g., believing that one’s family would be better off if one were gone), thwarted belongingness (e.g., feeling disconnected, unloved, or unimportant to family), cognitive inflexibility, and help-negation (e.g., refusing to seek assistance during crisis).

3. Attraction to Death (AD)

This dimension quantifies the degree to which death is idealized, romanticized, or viewed as a functional instrumental strategy. Individuals vulnerable to suicide often develop distorted cognitive appraisals that assign positive utility to biological termination. Under the MAST framework, Attraction to Death measures beliefs that physical death offers profound relief from emotional torment, a tranquil sanctuary of uninterrupted peace, an avenue for solving otherwise intractable dilemmas, an opportunity to improve the emotional state of others, or an ethereal transition into eternal life where one reunites with lost loved ones. This construct is crucial because it transforms death from a feared biological cessation into an appealing therapeutic refuge.

4. Repulsion by Death (RD)

Repulsion by Death measures normative, evolutionary death anxiety, somatic terror, and existential dread regarding bodily extinction. It encompasses visceral fears concerning the physical decay and putrefaction of the biological body, shivering horror at the thought of mortality, and deeper existential dread regarding the total obliteration of personal identity, consciousness, mental activity, and unfinished life aspirations. In normative development, high Repulsion by Death operates as an instinctive biological defense mechanism that inhibits lethal self-directed violence. In contrast, the progressive habituation to physical pain and repeated exposure to suicidal imagery can desensitize individuals, blunting their Repulsion by Death and facilitating acquired capability for lethal self-harm.

Theoretical Framework

The conceptual architecture of the MAST is rooted in Israel Orbach’s Multi-Attitude Theory of Suicidal Behavior, which integrates principles from psychodynamic conflict theory, existential psychology, cognitive-developmental theory, and modern suicidological paradigms.

Historically, psychoanalytic theory framed suicide through the lens of Sigmund Freud’s dual-instinct model, positing a continuous struggle between Eros (the life instinct seeking unity and preservation) and Thanatos (the death instinct driving toward dissolution and return to the inorganic state). While classical psychoanalysis viewed suicidal acts as internalized aggression directed toward an introjected lost object, Orbach modernized this perspective by translating intrapsychic drives into measurable, cognitive-affective attitudes. Rather than assuming that the desire to die emerges solely when the death drive overwhelms the life drive, Orbach asserted that human consciousness maintains simultaneous, independent orientations toward both states.

Orbach’s multi-attitude model posits that an individual does not simply transition from “wanting to live” to “wanting to die.” Instead, suicidal crises are characterized by an acute, paralyzing gridlock among four distinct psychological forces:

1. The positive pull of life (AL)
2. The painful push away from life (RL)
3. The seductive pull toward death (AD)
4. The protective push away from death (RD)

This formulation strongly converges with contemporary empirical models in suicidology. It operationalizes the core tenets of Thomas Joiner’s Interpersonal Theory of Suicide, wherein Repulsion by Life directly aligns with the dual constructs of thwarted belongingness and perceived burdensomeness, while the attenuation of Repulsion by Death mirrors the acquisition of the acquired capability for suicide (fearlessness about death and pain tolerance). Furthermore, the construct resonates with Marsha Linehan’s Dialectical Behavior Therapy framework, which views suicidal behavior as a desperate, dysfunctional problem-solving response to intense emotional dysregulation and invalidating environments.

Within developmental psychopathology, Orbach recognized that adolescents are uniquely susceptible to attitudinal volatility. During adolescence, mature biological conceptualizations of death (its irreversibility, universality, and cessation of bodily functions) consolidate concurrently with formal operational reasoning. If identity consolidation falters, or if familial and social systems become sources of overwhelming stress, adolescents may regress into magical thinking—conceiving of death as reversible, conscious, or blissful. The MAST specifically identifies when this pathological cognitive shift occurs, exposing the dangerous convergence where life becomes repulsive and death becomes alluring.

Validity

The construct, convergent, discriminant, and criterion-related validity of the MAST has been extensively established across diverse clinical, non-clinical, adolescent, and adult samples worldwide.

Criterion and Discriminant Validity

In the foundational psychometric study conducted by Orbach et al. (1991), the MAST was administered to three distinct groups of adolescents aged 15 to 18: suicidal psychiatric inpatients (with documented recent suicide attempts), non-suicidal psychiatric inpatients, and normal community controls. The results demonstrated striking criterion validity:

• Suicidal Inpatients vs. Normal Controls: The suicidal group scored significantly lower on Attraction to Life ($p < .001$) and Repulsion by Death ($p < .01$), while scoring significantly higher on Repulsion by Life ($p < .001$) and Attraction to Death ($p < .001$).
• Suicidal vs. Non-Suicidal Inpatients: Crucially, the MAST successfully differentiated suicidal psychiatric inpatients from non-suicidal psychiatric inpatients who shared general psychological distress. Suicidal patients were uniquely characterized by elevated Attraction to Death and blunted Repulsion by Death, confirming that suicidal behavior is not merely high general distress (RL), but requires specific cognitive realignments regarding death itself.

Convergent and Concurrent Validity

Subsequent psychometric evaluations (e.g., Osman et al., 1993; Hagstrom & Gutierrez, 1998; Gutierrez et al., 2000) systematically examined the convergent validity of the MAST subscales against established gold-standard instruments:

• Depression and Hopelessness: The Repulsion by Life subscale exhibits strong positive correlations with the Beck Depression Inventory (BDI; $r = .65$ to $.74$) and the Beck Hopelessness Scale (BHS; $r = .60$ to $.71$). Conversely, Attraction to Life demonstrates strong negative correlations with the BDI ($r = -.58$ to $-.68$) and the BHS ($r = -.62$ to $-.73$).
• Suicidal Ideation: Attraction to Death and Repulsion by Life correlate robustly with the Beck Scale for Suicide Ideation (SSI; $r = .50$ to $.65$) and the Suicide Behaviors Questionnaire (SBQ).
• Death Anxiety: The Repulsion by Death subscale demonstrates strong positive convergence with validated death anxiety measures, such as Templer’s Death Anxiety Scale (DAS; $r = .52$ to $.64$), confirming that RD effectively taps into fear of somatic destruction and personal annihilation.

Reliability

The Multi-Attitude Suicide Tendency Scale exhibits robust empirical reliability across diverse language adaptations and demographic populations. Psychometric assessments have consistently confirmed high internal consistency and temporal stability.

Internal Consistency

In the original normative and clinical development samples evaluated by Orbach et al. (1991), internal consistency estimates (Cronbach’s alpha) demonstrated adequate to excellent reliability across the four dimensions:

• Attraction to Life (7 items): $\alpha = .83$ (inpatient sample) to $.85$ (normative sample)
• Repulsion by Life (7 items): $\alpha = .78$ (inpatient sample) to $.83$ (normative sample)
• Attraction to Death (7 items): $\alpha = .68$ (normative sample) to $.76$ (inpatient sample)
• Repulsion by Death (9 items): $\alpha = .79$ (inpatient sample) to $.83$ (normative sample)

In the independent cross-cultural validation conducted on an American undergraduate sample by Osman et al. (1993), Cronbach’s alpha coefficients remained robust: $\alpha = .88$ for Attraction to Life, $\alpha = .82$ for Repulsion by Life, $\alpha = .76$ for Attraction to Death, and $\alpha = .83$ for Repulsion by Death. Item-total correlations across studies consistently exceed the conventional .35 threshold, with the majority falling between .45 and .72.

Test-Retest Stability

Evaluations of temporal stability across intervals ranging from two to four weeks have demonstrated acceptable test-retest reliability coefficients. In non-clinical adolescent and collegiate cohorts, test-retest correlations typically range between $r = .74$ and $r = .86$ across subscales. Notably, in clinical cohorts undergoing active psychiatric treatment, the Repulsion by Life and Attraction to Death subscales display dynamic state-dependent sensitivity, decreasing significantly following successful psychotherapeutic or pharmacological intervention, while Repulsion by Death remains a more stable temperamental/existential trait dimension.

Factor Analysis

The factorial structure of the MAST has been extensively scrutinized using both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) techniques, supporting the distinct four-factor oblique model originally hypothesized by Orbach.

Exploratory Factor Analysis (EFA)

During scale construction, Orbach et al. (1991) performed principal components analysis followed by Varimax and Oblimin rotations on an initial pool of items administered to adolescent samples. The analyses converged decisively on four prominent factors accounting for approximately 43.6% of the total variance:

• Factor 1: Repulsion by Death accounted for the highest single proportion of variance, with salient loadings ($> .45$) from items addressing somatic decay, shivering terror, and loss of identity.
• Factor 2: Attraction to Life gathered items reflecting happiness, positive future projection, and satisfaction with family and peer networks.
• Factor 3: Repulsion by Life consolidated items indexing perceived burdensomeness, insurmountable struggles, and social alienation.
• Factor 4: Attraction to Death captured items viewing death as a problem-solving agent, calm rest, relief from pain, and spiritual reunification.

Confirmatory Factor Analysis (CFA)

Subsequent psychometric investigations aimed to verify this factor structure in broader international populations. Osman et al. (1993) tested alternative nested structural models using maximum likelihood CFA. A four-factor intercorrelated (oblique) model demonstrated significantly superior fit compared to single-factor, two-factor (Life vs. Death), or orthogonal four-factor models.

Hagstrom and Gutierrez (1998) and Gutierrez et al. (2000) conducted rigorous confirmatory factor analytic evaluations on large multi-ethnic adolescent and high-school samples ($N > 1,000$). Goodness-of-fit indices supported the structural validity of the 30-item four-factor oblique model:

• Root Mean Square Error of Approximation (RMSEA) values consistently ranged between $.048$ and $.056$, indicating close approximate model fit.
• The Comparative Fit Index (CFI) and Non-Normed Fit Index (NNFI/TLI) routinely met or exceeded the accepted $.90$ to $.95$ thresholds.
• Standardized factor loadings for the vast majority of items ranged from $.45$ to $.81$, confirming that each designated item functions as a robust indicator of its intended latent construct. Factor correlation matrices revealed moderate negative associations between AL and RL ($r \approx -.45$ to $-.58$) and moderate positive associations between RL and AD ($r \approx .38$ to $.52$), while RD maintained low to negligible correlations with both AL and AD, validating the conceptual independence of death anxiety from death attraction.

Instrument / Measurement Tool

• Tool Name: Multi-Attitude Suicide Tendency Scale (MAST)
• Target Population: Adolescents (ages 12–18), young adults, and adult psychiatric or community populations.
• Administration Format: Self-report questionnaire; paper-and-pencil or computerized administration.
• Estimated Completion Time: Approximately 10 to 15 minutes.
• Item Count: 30 items.
• Response Scale: 5-point Likert response scale scored as follows:
  • 1 = Strongly disagree
  • 2 = Don’t agree
  • 3 = Sometimes agree, Sometimes disagree
  • 4 = Agree
  • 5 = Strongly Agree
• Subscale Composition:
  • Attraction to Life (AL): 7 items — 1, 5, 6, 13, 18, 25, 28
  • Repulsion by Life (RL): 7 items — 2, 9, 14, 15, 16, 21, 30
  • Attraction to Death (AD): 7 items — 8, 17, 19, 22, 23, 26, 27
  • Repulsion by Death (RD): 9 items — 3, 4, 7, 10, 11, 12, 20, 24, 29
• Scoring Procedures:
  • Each subscale score is computed by summing the numerical ratings of its constituent items and dividing by the number of items in that subscale (generating a mean subscale score ranging from 1.00 to 5.00), or by calculating raw sum totals.
  • Attraction to Life (AL): Sum of items / 7 (Range: 7–35)
  • Repulsion by Life (RL): Sum of items / 7 (Range: 7–35)
  • Attraction to Death (AD): Sum of items / 7 (Range: 7–35)
  • Repulsion by Death (RD): Sum of items / 9 (Range: 9–45)
  • Global Interpretation: The MAST does not yield a single composite score. Instead, it is interpreted as an attitudinal profile. Elevated risk is typified by low AL, high RL, high AD, and low RD scores.

Permissions & Fee and Test Year

The Multi-Attitude Suicide Tendency Scale was originally developed and published in 1991 by Dr. Israel Orbach and his colleagues. The initial scientific report appeared in the peer-reviewed journal Psychological Assessment: A Journal of Consulting and Clinical Psychology, published by the American Psychological Association (APA). The full scale and scoring criteria were subsequently published for clinical reference in Joel Fischer and Kevin J. Corcoran’s sourcebook, Measures for Clinical Practice and Research: A Sourcebook (Oxford University Press).

Licensing and Usage: The scale is widely considered an open-access psychometric instrument for academic, educational, and non-commercial clinical research purposes, provided that appropriate scholarly attribution and citation are given to the original authors and publishers. Commercial distribution, integration into proprietary digital health platforms, or fee-based clinical software typically requires formal permission from the copyright holders (APA or Oxford University Press). Clinicians utilizing the tool in active patient management must possess appropriate training in psychological assessment and suicide risk management protocols.

References

• Fischer, J., & Corcoran, K. J. (2007). Measures for clinical practice and research: A sourcebook (4th ed., Vol. 1, pp. 563–565). Oxford University Press.
• Gutierrez, P. M., King, C. A., & Ghaziuddin, N. (2000). Adolescent attitudes about death in relation to suicidality. Suicide and Life-Threatening Behavior, 30(1), 1–18. https://doi.org/10.1111/j.1943-278X.2000.tb01061.x
• Gutierrez, P. M., Osman, A., Barrios, F. X., & Kopper, B. A. (2002). Development and initial validation of the Self-Harm Behavior Questionnaire. Journal of Personality Assessment, 78(2), 278–298. https://doi.org/10.1207/S15327752JPA7802_08
• Hagstrom, A. H., & Gutierrez, P. M. (1998). Confirmatory factor analysis of the Multi-Attitude Suicide Tendency Scale. Journal of Psychopathology and Behavioral Assessment, 20(2), 173–186. https://doi.org/10.1023/A:1023055403061
• Orbach, I., Milstein, I., Har-Even, D., Apter, A., Tiano, S., & Elizur, A. (1991). A Multi-Attitude Suicide Tendency Scale for adolescents. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 3(3), 398–404. https://doi.org/10.1037/1040-3590.3.3.398
• Osman, A., Barrios, F. X., Grittmann, L. R., & Osman, J. R. (1993). The Multi-Attitude Suicide Tendency Scale: Psychometric characteristics in an American sample. Journal of Clinical Psychology, 49(5), 701–708. https://doi.org/10.1002/1097-4679(199309)49:5<701::AID-JCLP2270490513>3.0.CO;2-9

13. Items of the Scale (Questionnaire)