Chapter 1

The Suicidal Problem and The Problem of Suicide



Overview

This first chapter introduces the reader to the big picture of suicide in the United States and the approach used in this manual. In western civilization, attitudes towards suicide have moved between tolerance and denial. It is currently caught between earlier taboos and the call for death with dignity in the face of medical postponement of death. Behavioral sciences have reported an extensive accumulation of newer objective knowledge that is scattered in learned journals yet remains largely unused by mental health professionals. In the field of suicidology there is also a noticeable lack of consensus regarding measures of risk and appropriate intervention. This manual attempts to provide in one place the most useful and relevant information available so as to facilitate greater access and subsequent usage.

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Introduction

The suicidal problem deals with the wish to die, the acts of self injury, the vital outcome, suicide rates, risks of death, lethality of preferred methods, efforts to prevent and other practical issues. The problem of suicide addresses the explanations and the motivations. It is the search for necessary and sufficient causes. This book reviews the current status of existing explanations, and provides a quick reference to major areas of suicidal behavior.

Between the two covers, the readers will find everything the non specialist might need to know in a hurry when providing care for a person at risk for future self injuries. Indeed, there is people will ever want to know about the subject of suicide. The scope of this book is to allow the reader to move from the bare essentials in practical decision making to sufficient coverage for the experts who wish to see the current status of selected areas.

The clinical universality of the suicidal problem exposes everyone, to victims. Their behavior includes ideation, threats, verbalizations, or self defeating behavior in between attempts or commits. The range of readers can include any one who is concerned, but is meant to give technical support to care givers or gate keepers. These are the staff of emergency rooms, hot lines, police, probation, clergy, health care people and many others. It is also intended for primary mental health care personnel who provide crisis interventions, and longer range follow up care.

Immediately following the appearance of a person at risk, comes the issues of assessment and optimal care. Sadly, current assessments do not yield sufficient prediction for those who will die respect to specific steps for suicide prevention. For those people who indicate they want to kill themselves, the usual care more here than most is 72 hour `holds' or supervision and psychotropic medications. When patients change their minds or verbalizations, they are typically released on their own recognizance with pious or cynical recommendations for after care. Victims at emergency rooms are offered even less. Callers to centers are usually not on the verge of killing themselves and are appropriately served with crisis counselling and referrals for identified needs.

This current state is partly a response to the unpredictability of suicidal outcome, and partly to long standing minimal standards of care in serving suicidal people. There is a pessimism present in the management of the high risk victims that allows otherwise conscientious and competent mental health professionals to shrug their collective shoulders and say "there's nothing we can do" or to argue that even mental patients have the "right to kill themselves". The latter tends to get blurred with the problem of death with dignity for people with serious illness. These issues will be discussed later in this first chapter and in the section on cancer patients in chapter seven.

Such lower standards of care can be changed by making suicide prevention knowledge more accessible to everyone. The suicide prevention triangle manual and the forthcoming computer program with the same name are my personal efforts to facilitate this goal. There is a great deal more known about the suicide problem than gets into text books, classrooms, internships and residencies. Making the knowledge more available is a significant step towards improving clinical practice.

The table of contents will guide the reader to the chapters and sections most relevant to their interests or needs. I have attempted to present the content in a "top down" perspective going from the general to the more specific and from the past to the present and future.

The author takes the position that potential victims initiate suicidal events in order to change specific contents of their awareness. Their lives are regarded as unacceptable because the meanings the meanings they hold converge on self defined criteria for when death is preferable. As personal distress increases past some threshold for action, these people equate a wish to return to an earlier, more satisfying state, is equated to a wish for death. Physical termination is expected to change awareness without necessarily ceasing such awareness of self and existence. These points will be elaborated and documented more fully in chapter four.

The balance of this chapter will review the history of suicide prevention in western civilization, death with dignity, self injury rituals in other societies, suicidal rituals in the west, a "flow" chart of stages for the suicidal career, and a description of what can be called the suicidal life cycle.

Chapter two reviews the current unpredictability of suicide and the issues which cause the chance outcomes of assessments by existing methods. The discussion will be organized into epistemology, psychology, and biology. A partial response to the difficulties has been the emergence of distinctions between efforts to assess risk for death, from lethality of self injury plans from suicidal intention.

A converging development is the role of depression in explaining, causing or facilitating the problem of suicide. Recent efforts have isolated the loss of hope, or pessimism as the critical agent for suicidal intention.

Another aspect of suicide prevention, is the phenomenon of deliberate self harm with and without the wish to die. Whether this be incidental to sexual orgasms of people otherwise normal, or to inmates of prisons and mental hospitals during the course of some form of psychiatric disorder, the problem of preventing unecessary self injuries continue. Chapter three includes a review of past and current theories of the problem of suicide and its explanation. Chapters four presents the suicide prevention triangle model. Chapter five describes methods of assessing suicidal behavior. In chapter six the various possible interventions will be discussed. These range from good practices in any health organization to letter follow up for individuals refusing psychotherapy or group services. In between are cognitive behavior modification for various stages of depression and suggestions for conducting a psychological autopsy that fosters staff development. Chapter seven reviews known high risk groups and discusses current status of knowledge. Some potential communalities are considered that make such diverse people more at risk for suicide. Chapter eight is a systematic effort to identify developments over the last ten years that can be regarded as novel and contributing significant innovations towards the goal of better prevention.

Chapter nine presents an epilogue of possible improvements in suicide prevention. Chapter ten lists all the known audio visual material for training, plus books written before and after 1938, and known bibliographies. It also includes appendices of useful information about suicide which may be difficult to locate without significant effort.

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Suicide prevention before the 20th century

The author surveyed works of art dealing with suicidal themes in western civilization for the last 2500 years (Cutter, 1983). One of the major findings was the evolution of contemporary thinking with respect to contemporary suicidal behavior, using visual art as data for the conclusions. Thus illustrations of self injury themes moved from the heroic, to the stigmatized, to the irrational, the depressed, the ambivalent, and to actions that suggest a call for help. Along the way corresponding deterrents were the concepts of sin, crime, insanity, depression, psychotherapy and hotlines. During the stigmatized era abuse of the corpse, confiscation of property, stigmatization of memory and punishment of the soul were additional methods used to deter self injury. Residuals of these primarily western orientations are still influential in current taboos.

These changing notions of suicide, parallel cultural changes from the dominance of the church in the middle ages, to the emergence of the renaissance. This overlapped the rise of the middle class along with the evolution of the common law. In the late 18th century the industrial revolution began and Pinel first intro duced humane management of the insane in what became known as moral treatment in the early 19th century. Later the irrational and depressive aspects of suicide were identified in psychiatry. In more recent times, the depressing aspects of industries and wars were reflected in works of art and the portrayal of the victims of suicide with symptoms of clinical depression. Between the two great wars the phenomenon of ambivalence, mixed feelings about living or dying began to surface in works of art and were later identified in suicidal victims. In the last half century the enigmatic content of visual art can be said to mirror the parallel behavior of victims whose distress prompts equally enigmatic calls for help, and the efforts of the contemporary suicide prevention movement. Table-1 provides a chronology of suicide prevention in western civilization.

Table 1

Chronology of Suicide Prevention in Western Civilization

Date Event Concept
1000-500 B.C. Biblical suicides compiled from oral tradition; written in modern version. Suicide is a consequence of immoral behaviour.
400 B.C. Hippocrated attributes suicide to melancholic humour. Depression is a cause of suicide.
100 A.D. Plutarch describes an ordinance to prevent maidens from hanging themselves. Deterrent value of publicity.
240 Ptolomy II Philadelphias prohibits writings of Hegesias. Repression of seductive writings.
346 Coptic funeral rites denied to suicides in Egypt. Punishment of the soul.
354-430 Writings of St.Augustine. Suicide is the greatest sin.
563 Council of Brega denies Christian burial to suicides. Punishment of the soul and of survivors.
590 Antisidorum council rejects offering on behalf of suicides. No possibility of grace for suicides.
593 Council of Toledo. Excommunication of suicide victim.
967 King Edgar of England applies to civil law. Suicide becomes a crime.
1300s Felo de se; common law allows confiscation of property and desecration of the corpse of a suicide victim. Public and secular punishment of the victim and the family; stigmatization of the victim.
1632-1677 Spinoza attributes suicide to duress, physical or psychological. Unnatural motive.
1600s Reformation makes exceptions for "distractions" due to madness, idiocy, immaturity, and pain. Impaired freedom to choose.
1628 Burton publishes Anatomy of Melancholia. Clinical attitude is introduced.
1644 Donne's Biothanatos published. The victim is defended.
1777 Hume publishes On Suicide. Sympathy for victims.
1763 Merrian publishes Memoir surle Suicide Suicide is described as result of illness by an early "psychiatrist".
1760s Confiscation and desecration fall into disuse. Suicide is a product of mental disorder; law reflects changing practice.
1790 Moore publishes Full Inquiry into Subject of Suicide. Rebuts right-to-commit-suicide arguments; stresses individual differences; suggests public education before seduction by suicide.
1827 Esquirol publishes Sur la Monomanic. Suicide is a psychiatric problem.
1850 Confiscation and desecration laws repealed. Public reluctance to stigmatize overtly; increasing shifts toward insanity explanation.
1840-1897 Winslow publishes Anatomy of Suicide, 1840.
Morselli publishes Suicide: An Essay on Comparative Moral Statistics, 1879.
Masaryk publishes Suicide as Social Mass Phenomenon, 1881.
Durkheim publishes Suicide, 1897.
Orderly qualities of suicide discovered.
1905 Antisuicide bureau of the Salvation Army established. Philosophy of "soup, soap, and salvation" anticipates befriending.
1906 National Save-a-Life League started by Henry Warren, minister. Anticipates "cry for help" crisis intervention; first American suicide prevention service.
1920 Freud publishes Beyond the Pleasure Principle. Revived influence of "wish to die" in clinical behaviour is related to aggression; death instinct coequal to sex.
1927 Rost publishes Bibliography des Selbstmord. First guide to world literature; utilizes graphics.
1933 Dublin and Bunzel publish To Be or Not to Be Epidemiology of suicide in the U.S. notes large numbers; history of suicide prevention, public health approach.
1935-36 Zilboorg publishes research articles. Unconscious hostility, inability to love, role of broken home.
1938 Menninger publishes Man Against Himself. Wish to kill, to be killed and to die; elements of hostility in "chronic" suicide.
1938 Fedden publishes Social History of Suicide. Social historical survey; literate evaluation of suicide knowledge.
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Early Justifications for Suicide

In the two thousand year period from archaic Greek through the late Roman empire, suicidal deaths were common, accepted, but often legal consequences were imposed on the survivors. This could lead to forfeiture of property and wealth. The heirs and survivors were understandably concerned about such consequences and were motivated to come forward with various explanations, defenses, or justifications which would exonerate the victim's motives, and avoid consequences. I am indebted to Anton J. L. Van Hooff, Senior Lecturer in Ancient History at Nijmegen University, The Netherlands for research, and findings published in his book "From Autothanasia to Suicide".

Dr. Van Hooff offers twelve possible reasons for wishing to die which can justify an action to achieve a suicidal death. He bases these ideas on a review of personal documents which he himself has translated from the original classic Greek, Latin or Hebrew languages. Readers wishing to know more about his methods, and data are referred to his text which is sufficiently impressive.

The reasons he offers reflect the idiom of the eras, but can often be freely translate to contemporary motives. Thus item number 2 on this list sounds like unbearable pain. I will attempt a synonymous phrase wherever possible.

  1. Shame (pudor latin, aidoos shame)
  2. Psychological pain, mourning, distress-anxiety
  3. Unbearable physical disorders-pain
  4. Frenzy-manic behavior
  5. Ostentatious self sacrifice, e.g. Socrates
  6. Tired of life, as in aged or ennui
  7. Guilt objective or subjective (found in dysthymia)
  8. By external necessity-execution
  9. Devotion to a cause-heroism
  10. Loyalty to a leader or spouse
  11. Despairing of deliverance-loss of hope
  12. To bring a curse upon somebody-hostility

These justifications have a face validity which is often quite appealing to the inexperienced who contemplate the choice of death over life. The health professional who attempts to guide people in this situation needs to remember several suicide prevention principles.

Self injury occurs in all known civilizations. Less well known is its occurrence in Chinese, Japanese, Indian, Persian, Judaic, and Pre-Columbian cultures as reflect in their respective arts. Table-2 (below) lists the known self injury rituals in the various cultures mentioned. These were not suicidal as we understand this word today. They were intended as sacrificial, expiatory, or in the service of a socially approved goal, with death being merely an incidental and not necessarily regrettable by product.

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Natural death versus violent death in America

Suicidal death is one of three violent modes of death in peace time.The other two are homicide and accident. All three account for less than 3% of annual deaths in Americans each year. The balance is due to natural causes. Yet public information media devote a reverse degree of emphasis on the violent modes. Such excess emphasis feeds the pornography of death (Gorer, 1965) in American culture and individual attitudes. By analogy with sexual repression, American awareness of natural death is repressed or forgotten and thus avoided, but gets displaced instead to violent forms of death preoccupations. Consequently, orienta tions to suicide are distorted by this substitution process. Historical taboos are recalled from the cultural past and influence the present extremes of emotions that anxiety can stir. Table-2 lists historically known self injury rituals which carry the positive emotional aspects in American culture.

Table 2

Self injury rituals and practices

Anorexia the state where a person loses their appetite sufficiently to suffer great and often life threatening weight losses. Generally, this state is associated with hysterical personality disorders in the past, but is now increasingly rationalized by feminine fashions and professional dancers. See bulimia for contrast.

Bulimia a compulsive over eating thought to be a form of mental illness in which anxiety is controlled by excessive intake of anything edible. The preoccupation with certain categories of food such as sweets gives it a psychodynamic meaning.

Crucifixion when preferred by early Christians to the forced choice of giving up their beliefs and faith in Christ. Roman era.

Drawing blood as in sacrificial gestures and ritual self injury in sun god worship of central American indians. Examples are penetration of cheeks, tongue, penis, etc. Pre-columbian.

Dueling in the leisure class, a European ritual common until the late 19th or early 20th century. Western.

Falling on ones sword when face with defeat or failure; Roman and Greek.

Gambling associated with dueling in the past, but with alcohol intake and self injury in the present the American ethos.

Gladiatorial fighting with beasts or other other men for exhibition during Roman times and early Christian era.

Hara Kiri a ritual Japanese form of suicide to expiate public shame, synonymous with sepuku which is restricted to the Samurai class of warriors. Different than suicide by a Japanese person.

Heart Sacrifice Pre-columbian ritual in Central America in which the still beating heart is cut out of the volunteer by priests to appease the sun god. Later this was extended to prisoners taken in battle or arranged contests called "flower wars".

Hippolytus gesture of grief first observed in Grecian history and art, but carried over to early Christian and later cultures.

Also associated with self injuries as expressions of grief in Mediterranean groups. Consists of clenched fist raised to forehead in a vigorous striking motion.

Ixtab Mayan goddess of self hanging. Only method deemed appropriate, and with a place reserved in the afterlife for suicides.

Je Satsu secular suicide in Japan includes all methods of self injury.

Jumping into Cenotes a Pre-columbian ritual in which volunteers and later "others" were recruited to jump or be thrown into a limestone pit full of water while bound hand and foot. At the end of the day, they were pulled out of the water, if still alive, and were required to report their communications with the gods or the dead.

Krissing self stabbing ritual using the Balinese dagger known as the Kriss.

Normal risk taking the preoccupation with sports requiring great caution because of the high risk of injury or death. Usually involves highly technical equipment such as in scuba diving, spelunking, skiing sport flying car racing,etc. Can extend to other activities such as reckless driving, "playing chicken", etc

Oroboros the snake that eats its own tail, symbol of the whole and hole itself, used in alchemy and associated with witchcraft or magic.

Running Amok custom among the Maoris of impulsively provoking others to kill by assaulting all who are encountered in the course of one last wild charge through a public place.

Russian Roulette, a largely American image and practice in which a person fires a pistol at the temple of his own head with only one bullet in a six cylinder revolver, which is located randomly by prior spinning. Popularized in the media and originally described in Russian novels by writers like Pushkin and Lermontov based on an idea first mentioned by Lord Byron.

Natural death on the other hand is not only under emphasized in the media, it has all but disappeared in medical practice. Death is always due to a pathological cause, and medical technology has extended the dying process without doing much for cure. As a result, the present generation finds that natural death and the dying process has changed. Where our grandparents could expect to die at home, suddenly from old age, we look forward to dying slowly, in a strange place such as the intensive care unit, from incurable illness. These changes have resulted in two significant forces complicating the problem of suicide.

The first is the pornography of death, and the second is the absence of an appropriate dying process. These encourage the euthanasia movement to argue for the right to die with dignity through acts of suicide or homicide. In the context of terminally ill patients, and suicide of the elderly, it is necessary for health professionals to distinguish efforts to achieve appropriate death from the clinically motivated behavior of some irrational people.

One way to differentiate is to provide death counselling and observe the patient's response. People bring to the dying process their previous style of coping with school, work, family, property, and other health care. In the absence of history of psychopathology, one would expect terminal patients to respond positively to appropriately delivered information about alternatives. Unexpected reactions suggest emotional histories that impede good judgment.

The section on cancer in chapter seven contains an extended discussion on the options available to the health professional who is seeking to provide optimal care for the "terminally" ill. The thrust there is to support individual choice and positive orientations to life and death. This can be done by reducing the anxiety of the unfamiliar, in short positive death education which tries to undo the prevailing pornography of death. This can be followed by giving the victim tasks to accomplish in order to achieve death with dignity. These tasks are: taking care of last things, saying good by to significant others, expressing sentiments to these people, and giving words of wisdom to them. The latter is in analogy with the biblical blessing as modeled by Jacob on his death bed. This positive orientation puts the victim at more peace with the dying process and assigns significant activities to the victim who is given an otherwise passive role.

Medically, the objective choices are to continue life support technology and wait for a miracle, or to stop these and let nature take its course. These are extremely difficult choices to make, especially if the victim is comatose. This state can be prevented by the execution of a durable power of attorney for health care along with the instruction to cease medical efforts when deemed hopeless. In the absence of such documentation, the significant other has the burden of cutting the Gordian knot.

For the victim with mental processes intact, the best advice I can suggest is to avoid the hospital for that last illness. Like most of us, the wisdom to achieve this is probably lacking. The next best thing is to resist medical interventions that reduce awareness, whether these be extended morphine medications for pain or life supports that shrink the patients environment to the inside of some device. However, any of these is more preferable than asking another to engage in homicide or facilitating victim suicide. Assisted death is a more positive concept, if assistance is limited to keeping the patient comfortable. Administration of toxic substances approaches homicide too closely. Whatever the resolution chosen, in any given person it expresses the unique relation of the victim to the surviving others and has a validity beyond the principles any one can proclaim.

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Suicide Outcome and Flow Chart for High Risk People

Figure 1a Figure 1b

This figure lays out possible longitudinal relations between known suicidal phenomena. The starting point is the suicide rates for age, sex, and race such that everyone belongs to a cohort or group with a known rate per 100,000 live people. Thus while suicide is shocking in teenagers, it is impossible in newborns, infants and children before school age. Later it becomes possi ble but still very rare. However significant experiences do occur after birth that are relevant if not causal to adult suicidal behavior.

People do not suddenly decide to kill themselves. The behavior that results in self injury actions is over determined with respect to factors such as preferred method, the sources of distress and the death wish itself. The wish to die itself is secondary to an implicit criterion for when death is preferable. As this standard is approached by perception of reality, that is itself often selective, the wish to die increases until a threshold for action is passed. At this time the victim becomes ready to choose a self injury method. This in turn is influenced by previous experiences, and the meanings and values held by the victim with respect to this method. The people and circumstances in the environment facilitate or impede self injury behavior by doing what is usual in their relation s to the victim.

The licensed health professional is usually aware of these factors, but lacks a model to organize and evaluate these data. The suicide outcome and life cycle chart attempts to put all aspects of a high risk person into perspective, by looking beyond clinical episodes to the total life span of the victim. The discussion here is organized by stages of the process.

Predisposing Factors

There are circumstances in the history of any person which increase vulnerability and predispose for high risk of suicidal deaths.

Birth Simply being born predisposes every American to the base rate of approximately 20 men or 7 women per year. These are derived from the national rates of suicidal death in 1979(1981). While women suicides overall are much lower, the current trend is for younger women to kill themselves more often than in the past. Those under 35 have shown a dramatically higher suicide rate in recent years (Seiden, 1969; 1981).

Early significant losses Childhood bereavement, the loss of one or more parents while still a child predisposes for adult mental illness, criminality, cancer, and suicide. The way childhood bereavement is managed is important, but the correlation with adult hazards seems to be clear (Dorpat, et al 1965; Greer,1966; Bunch & Barraclough, 1971).

Other health factors and new losses The occurrence of adult illnesses and other catastrophes, affect the stresses and aggravate vulnerabilities. However, the most dramatic influence is the occurrence of new significant losses. Where identified, the health professional should not hesitate to use this information in planning suicide prevention strategy. The earlier experiences create vulnerability, while the later events exert more stress if replicating the earlier.

Role of significant other The variety of ways family members can relate to each other is known to aggravate mental health or support positive living. Spousal relations can take the form of cooperative-supportive patterns or competitive-consuming interactions (Shneidman, 1971) Perceived object loss, whether by death, separation or rejection, has long been recognized as the modal psycho dynamic explaining the occurrence of affect disorders, namely depression; especially where observable trauma, failure, or catastrophe are not identifiable (Shneidman, 1971).

Previous suicide attempts Prior self injury behavior is the single most reliable predictor of future suicidal attempts. History of one prior attempt yields a suicide rate of 1500 per 100,000 live attempters, per year. A history of two or more self injury incidents in the past, yields a rate of 15,000 commits per 100,000 live multiple attempters per year. These statistics do not consider the lethality of any attempts; merely their occurrence (Litman & Farberow, 1974;Stengel, 1972)

Additional factors, mainly epidemiological add to the degree of risk for death per year of identified groups of people. The licensed health professional should identify those factors that increase the probability of future self injury behavior, whether epidemiological or more clinical, and utilize these in assessing or planning for prevention (Litman et al, 1974)

Stress and Vulnerability Factors

Whether the stress or vulnerability model is employed, some factors represent a combination of both in the life cycle of the high risk person.

Age and Sex In the US, suicide rates increase with age. The older a person is, the greater the risk of death from suicide. The amount of risk in the general population is quite low. About 2 or 3 % per year of all deaths occur in a suicidal mode. The recent increase in suicide for those under 35 (NCHS 1985) and especially males 20-29 begins to approximate the rates of men in their sixties. Currently, women under 25 are at far greater risk than previously and rivaling women in the 45 age class. All women are at far lesser risk than all men at every age level. These statements apply to the US only. Seiden (1986) has noted that such higher rates are associated with increased percentages of young people in the general population. The age phenomenon is different in other cultures and in the US at different times.

Marital status Living alone or with some one is significant in evaluating risk of death for a suicidal mode. Males living alone have double the rate of suicide than men living with someone at ages above 60. The divorced or separated show a significantly higher suicide rate than the general population at all ages (Dominion, 1976).

Medical and surgical illnesses with associated treatments Patients in hospitals for other than psychiatric problems show a higher rate of suicidal deaths than the general population with comparable ages. Whether the increased stress or vulnerability model is employed, the older patient, 60 plus, is at greater risk and requires more professional attention for this danger (Farberow, 1982).

These factors need to be reviewed in order for the health professional to be aware of who the high risk clients are and when their greatest vulnerability occurs. There is no such thing as zero risk. It is also ineffectual to give massive responses to moderate risks. In between, increased awareness of risk can be matched with increasing degrees of observation, support and explicit attention.

Suicide Sequence

Wish to die As perceptions of experiences approach some personal standard for when psychological cessation is preferable, the individual begins to wish for death with increasing intensity. Operationally, this wish is for surcease or escape rather than physical termination; current language blurs these ideas (Cutter, 1983).

Choice of self injury method As the wish to die increases some people begin to consider the various methods of inflicting self injury. Eventually one method is preferred and effectively chosen. Implementation of this method occurs during the planning stage.

Suicide planning Suicide planning occurs when a high risk person begins to solve the existential problems of choosing a preferred method of self injury, obtaining access to it, preventing rescue and preparing for the time and place of death (Weisman & Worden, 1974).

Methods available Having defined a preferred method and planned its implementation. The next stage is the behavioral steps leading to access of the means (weapons,pills). The final step is the start of the self injury.

Lethality The degree of self injury and the time needed for it to occur, measures the degree of lethality. The criteria for judging this occurs elsewhere in the workbook. The degree of lethality defines a margin of error for intervention. Fast acting methods require equally fast and intense interventions. Slower acting methods permit more opportunities for support, problem solving, and psychotherapy.

Random events and ambivalence There is no method guaranteed to yield instant death. Death outcomes contain error factors that no one can completely eliminate nor predict. These include random events where chance factors influence the others to interrupt or rescue the victim. Conversely, these same chance factors can yield death even with minimal lethality. There is of course the ultimate error variance coming from the victim who change their minds, before during or after a self injury incident, and effectively rescue themselves.

Self injury behavior The observable self injury incident is always the resultant of the preceding sequence of choices, however blurred or fast these may come.

Vital outcome Following a self injury incident, the victim may or may not survive. Death is an all or none phenomenon. Those who die are classified as suicide. Those who survive tend to be managed like all others, after a temporary crisis. This simple dichotomy distorts the process. Survivors carry an increased risk. Family or significant others never fully forget; their subsequent behavior is inherently rewarding by the over reactions to the high risk victim. The reinforcements partake of the same psychological forces that sexual orgasm, or substance abuse does in reinforcing associated behavior to occur again and again.

Where death occurs, the survivors experience some increased vulnerability to their own self injury behavior. Where the victim survives, the cycle starts over again with the same or increasing probabilities of recurrence at some time in the future.

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High risk life cycle

The high risk life cycle in Table-3 is more focused on the ideas that go into a suicidal career implied in the clinical flow chart. The items in this table refer to phenomena described in the suicidology literature or clinical wisdom associated with providing prevention.

Table 3

High Risk Life Cycle

Early Stage
  • Bereavement before ages 13-15 & other significant losses
  • Parental or surrogate suicide at any age
  • Unusual or premature death of parent after age 16
  • Identified behaviour or emotional problems before age 16
  • Maladjustment at school, work, or military
  • Marital problems
  • older male, living alone
  • under 35
  • History of treatment for mental disorders
Middle Stage
  • No meaning to life
  • Alcohol, drug dependence
  • Pain, sleep, bowel, weight, skin, other chronic problems
  • Medical compliance in long term illnesses e.g. diabetes
  • Onset of life threatening illness; heart, cancer, stroke
  • Dependent-dissatisfied behaviour
  • New losses
  • Two or more serious accidents including overdose
  • Institutionalization; hospital, prison
  • Self injury behaviour; low lethality, saves self
End Stage
  • Personal resources exhausted
  • Significant losses in last two years
  • Loss of hope
  • Criteria for death approached
  • Significant others more consuming or competitive
  • Aimlessness, drifting in and out of community agencies
  • Depression, acute or recent
  • Substance addiction
  • Disbled and/or unemployed
  • One or more self injuries with increasing lethality
  • Preferred method identifiable
  • Has plan with method available
The presence of these characteristics helps to place the client in some perspective with respect to urgency of intervention. If the majority of these identifiable conditions are in the end stage, the health professional has less margin of time for planning intervention strategies, and must mobilize these with more extremes of effort.

The thrust of this table is to give the reader a sense of what is early or later in the career of a suicidal victim. The items that are identified as early are associated with childhood experiences and the role modeling of their parents, or surrogates. Early problem behavior at home, in school, and later at work or in the military or in marital adjustment are general signposts of later problems in general. These are findings associated with alcoholism, crime, mental illness and anti social behavior. Not all of these experiences result in suicide and not every suicide has these in their background. However, the correlations are high enough to support these as "signs" to be considered.

Somewhat unrelated to the above are early signs for other groups. These are the older males living alone, younger males 20-35, and any one with history of treatment for mental illness. Again the correlations support a heightened concern for risk of future self injury behavior. This is not the same as dealing with a client who is threatening to kill him or her self. The value of the factors in this table is to plan for a person who is not thinking of suicide during reader's contacts, but is at greater risk for doing so in the future.

This logic becomes more relevant when the client exhibits symptoms in the middle phases. Primarily because the behaviors go beyond high risk history, and into more recent, adult actions that are more positively associated with suicidal behaviors. Again the client may not be conscious of an intent to die while in the readers presence, but during interview will acknowledge past or future thoughts including the choice of a method and some planning. The latter is a significant criteria for placing the client at greater risk.

The end stage items overlap serious social and mental disorders and are problematic for people whose life is not so visibly disrupted. For this latter group items 22-25 would be more relevant. Depression or substance addiction are more complicated to identify an a client. There are degrees of depression with the lesser degrees permitting more behavior of any kind and thus allowing self injuries. This begins to overlap with substance dependence, when a withdrawal state is started. Many prescriptions of the anti anxiety kind, tend to create a depression as substance falls below threshold for effect for that person. Substance dependence is far more common in suicide than is generally recognized. Next to age, its presence in the history of the client is the most reliable correlate of suicide. Many victims are cross addicted between alcohol and prescriptions. Only a careful history will identify those who are dependent or abusing.

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Summary

This first chapter provides an orientation to the manual and provides some introductory information about the nature of suicide in the US. First is its history in western civilization, and the evolution of attitudes towards this subject which moved from pre christian tolerance to christian denial. In the renaisance it emerged as heroic. With the rise of the middle class and common law of England, suicide became stigmatized. After the industrial revolution the irrational aspects of suicide were recognized. At the end of the 19th century, the depressive elements of suicide were rediscovered. Between the world wars, the mixed motivations for life and death were identified starting with Freud and his death wish and continuing with the recognition of ambivalence in most suicidal victims. The most recent change has been the perspective where the enigmatic behavior of potential victims can be construed as a call for help, which justifies organized effort to block self injury behavior. This last point of view is contradicted by a somewhat tangential call for death with dignity in the context of serious illness which can be regarded as heroic suicide. The latter is often associated with vigorous medical care to postpone death regardless of consequences. The advocates of heroic suicide do not pay sufficient attention to the wishes of the potential victim during end stages and the constructive alternative of passive medical care. Both perspectives encounter the historical taboos about suicide as a mortal sin. More knowledge, awareness and its spread through all media is proposed as steps towards humane change, that neither shortens nor extends life by arbitrary actions. The American Association of Suicidology has issued a postion paper on this issue which explores the implications in greater depth while arguing against active efforts to assist in termination.


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Copyright© FRED CUTTER, Phd.