In the last 40 years, suicide prevention and research has flourished. Yet the prediction of suicidal death remains problematic. The inability of health professionals to anticipate future self injury behavior is often used to support therapeutic pessimism with respect to long term interventions for high risk people. This chapter attempts to list the obstacles and suggest a usable position for the worker providing care, conducting research, or faced with a client in between attempts whose future behavior requires assessment and prevention planning.
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Suicide ideation, threats, verbalizations, or self defeating behavior in between attempts are the signs of a high risk person. When encountered, these behaviors demand a worker's response. Any action assumes some kind of judgment about the degree of risk carried by the potential victim. This represents assessment.
The usual effort is to ask the client "Do you have suicidal thoughts?" This simple minded question is valuable, but too frontal and consequently elicits many manipulative or denial kinds of answers along with a lesser number of genuine ones. Even a "yes" answer requires follow up inquiries about the nature of these thoughts. A better alternative would be to ask a sequence of questions in the context of history taking where distressing items are reported. These questions would start with: "Do all these (bad events) make you wish you were dead?" The follow up question would be "Have you thought of a way to kill yourself?" This opens up the topic of previous attempts, and rescues, plus current suicide planning and the opportunity to develop a prevention plan.
The preceding is an example of a simple, useful and necessary assessment which can occur in the context of a clinical history. The information permits an assessment of intention, lethality of planning and the resistances to prevention efforts. From such data the ensuing evaluation carries an implicit prediction. Future suicide behavior is very likely in the near future, or not likely enough to warrant any precautions. Most of these assess ments, however crudely made, turn out to be correct in the sense that the majority of clients do not attempt nor die from self injury. However some do attempt and some die. Suicidal events are always unexpected to the victim, the family, and the care givers. Simultaneously, there is also an inevitability aspect which surfaces in the postvention period when the suicidal career is identified and the pattern becomes more visible. This element feeds therapeutic fatalism for other clients, i.e. the pervasive feeling that suicide intention is not really recognizable and long term self injury behaviour is unpreventable. The reason for this orientation probably comes from human experiences withsuicide before the clinical encounters with suicidal clients.Therapeutic reluctance, if not pessimism, is observable in longterm support to high risk people, in between calls for help. High risk people do not receive the same priority of attention that volunteers in suicide prevention centers provide for acute calls. Support during the two year interval following an initial crisis remains the burden of the mental health professional in a leadership role.
Here, there seems to exist therapeutic doubts justified by the absence of predictability. Such treatment reluctance about long term suicide prevention is neither scientific, appropriate nor professional. The source of it is shaped by training defaults and concern for short term goals of prevention only. Pessimism about the preventability of suicide comes from the training process of mental health professionals where interns and advanced trainees observe and experience unexpected suicidal events, followed by unresolved grief and guilt from first encounters with self injurious clients. In turn, their is an implication of inadequate role modeling in preceptors for coping with client casualties. In addition to this training default there is also the larger American ethos of immediate rewards for short term efforts and essential neglect for the longer range outcomes.
Many practical administrators consider the cost/benefit ratio of suicide assessment as not justifying high priority for professional attention, since predictability is so limited. The occurrence of a suicide attempt or commit, is sufficiently distressing to care givers and administrators to warrant extreme effort. Some jails will use solitary confinement for days and weeks during short term incarceration in order to block self injury behavior, whether or not this turns out to be clinically relevant. Some overloaded mental health services will accept the risk of self injury events rather than assess and offer special services. These extremes of prevention response are usually justified by the lack of predictability. However, the reluctance to assess systematically, using available knowledge is quite often due to therapeutic discouragement about outcomes.
There are cost effective options that permit sufficient evaluation to plan prevention programs and interventions. More systematic assessment methods are reviewed in Chapter five and interventions in chapter six. Here, the technical obstacles to useful prediction will be reviewed first, and alternatives suggested for coping with these, and especially in the context of clinical care.
The discussion will be organized from three points of view: the philosophy of knowledge about suicide prediction, the psychology of predicting self injury, and a review of recent progress in the biochemistry of the wish to die.
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If the criterion for prediction is suicidal death, one makes the assumption that death itself is predictable. This premise is not fully tenable at the present state of medical knowledge for diseases such as heart, stroke, cancer, kidney, emphesyma, etc. where the progressive nature of the illness is known to result in death, but the moment of death is difficult to identify, let alone predict. For suicidal death, the difficulties are even more formidable, because the existing high risk criteria correlate at statistical levels that account for less than 65% (correlation coefficients of less than .80) of predicted outcomes, survival or death; i.e. large amounts of error variance.
Prediction of suicidal death at the individual level may never be possible, especially within a clinically manageable time constraint. Here it is important to note that existing clinical prediction of a future event is really the anticipation of the next attempt, regardless of vital outcome. This subtle distinction opens the door to a prediction criterion, attempt behavior, that may be more achievable than an all or none death or life outcomes. The objections and options will be listed later.
The current practical alternative is the use of actuarial type specification of membership in a high risk population which is more possible through a process called risk estimation (Motto, 1985). The original work identified risk levels in the subsequent two years. More recently, Motto (1989) has identified nine signs of high risk in the subsequent 60 days. Neither Motto nor others suggest that these scales should be employed alone, but should be used as supplements to professional judgment in managing individual cases.
Similarly, the recognition that there are actuarial base rates for occurrence even without visible clinical signs, is a different kind of risk estimation. Using well known risk estimators such as age, sex, race, marital status, prior attempts, treatment for mental illness, loss of hope, etc, it is possible to estimate the number of expected commits, and attempts in any jurisdiction or treatment unit. The resulting numbers can be used as an expectation against which to compare actual frequencies of occurrence, that can provide feedback for program effectiveness. This in turn allows for documentation of treatment quality in other contexts such as defending against malpractice allegations. The method of computing a base rate is described in chapter five. Another application is to create special treatment efforts, such as groups for people with previous attempts in their histories. Here the knowledge of a specific kind of high risk can identify people for special treatment/prevention efforts such as by suicide prevention classes as described in chapter six.
The medical model for death prediction as used in current practice assumes a relatively known disease process with well marked stages of decline. The suicidal syndrome (Gernsbacher, 1986) is neither that well marked nor does much consensus exist for current assessments and prognoses. The life cycle and career models described in chapter one illustrate an example of this logic, and can be used if supported with appropriate therapeutic optimism.
Life and death results are peculiarly vulnerable to chance factors in the all or non criterion of survival. Highly lethal victims of self injuries can be rescued by heroic and unlikely efforts, while minimally lethal victims can die accidentally (Davis, 1969). These random outcomes introduce a large amount of error variance in the criterion of survival which reduces the subsequent significance levels for any predictive score. Such lowered validities create the problem of false positives and the high cost of caring for potential victims who do not harm themselves. There is also the more unfortunate consequences of false negatives, victims who go on to an unpredicted suicidal death. The usual "research criterion" is to assume everyone is, or everyone is not suicidal. These assumptions ignore skills and knowledge that is available to make educated guesses about selected clients. At the very least continued service contacts in the two years following an initial presentation for care, especially for an attempt, is the single most useful prevention effort available to any care giver or center. The availability of care givers attention helps deter, and provides updates in current status of the potential victim, which does indeed reduce self injury behavior, therefore "spoiling" the prediction of suicidal death from the research point of view. This practice is laudable. It should continue, but it does reduce the quality of prediction efforts at the statistical level (See number 3 below).
The effectiveness of suicide prediction is usually judged on the basis of clients who have received maximum professional intervention. To do less would be unethical. In effect the treatment team has done everything possible to prevent self injury and to foil the prediction of death. The obstacle here is to predict commits and non-commits. The false positives or false negatives which always occur, reduce the obtained coefficients of correlation or other statistical index. The more effective the intervening treatment the greater the number of false positive predictions. The ones receiving less attention, become more vulnerable to suicidal outcomes, not so much because of unpredictability, but because the dichotomy of commit non-commit is a false separation, i.e. all clients need care. The solution is to build in suicide prevention monitoring for all patients, by making any treatment effort contain some element of evaluation.
When suicidal deaths are used as a criterion, an avoidable methodological problem is created in the effort to demonstrate effective prediction. In most clinical settings, the frequency of occurrence of any suicidal death is quite small in any one or two year time period. In turn, this limits research to the larger centers with resources to follow high risk people for longer intervals of time. The results lose their applicability to clients coming to smaller and local centers. The small samples will impede subsequent efforts to replicate findings. This has occurred with psychological tests and is recurring with biological markers. Whimsical peculiarities of the sample studied tend to confound variations of sex, race, age, education, income and relations because these reference variables cannot be matched due to small numbers.
Typically, these research subjects come from psychiatric or inmate populations. They are not normal, typical nor reflective of the first attempters or completers, in any population. In deed, published studies usually fail to achieve the equivalent prediction results even in the subjects drawn from the same sources because the comparability factors have changed in the new samples.
The alternative criteria is to use the self injury incident itself, whether or not death occurs. Additionally, a time estimate for when this event will occur differentiates the immediate prospect of self injury from occurrences over longer intervals. The prediction objective becomes the time to the next self destructive action. This shift avoids the error variance created by life and death outcomes, and adds systematic rigor by defining expected periods of high risk. This alternative increases the number available for study. Additional advantages are less randomness to the occurrence, the victim is more available for study and the attempt incident itself is the event or variable most associated with suicidal death.
Here it is sufficient to emphasize that attempt behavior requires classification by degree of lethality, intention to die, and past frequency of occurrence. Are these first time lethal efforts or one of many low lethal events, often called para suicide. Always, there continues to exist the need to identify age, sex, race, and socioeconomic factors which can account for variations in rates or frequencies and protect against sampling artifacts.
Another barrier to prediction comes from the search for causality in which indications are equated with causes, e.g. hopelessness is an indicator not a cause of suicidal intentions. Biological markers of suicide may identify people at greater risk, but will not explain causation, any more than extended unemployment or war time conditions explain increased suicide rates. These are really correlations, i.e. co-related. While the association of an indicator and an outcome is useful, additional effort is needed before causality can be assigned and prediction supported.
The blurring of indicators and causes, exaggerates the impact of prediction failures because the former always carry large error variances or false classifications, while the latter is perceived as giving near certainty. The practical value of this distinction is to take the signs as indications for caretaker concern, with the initiation of attention for the source of distress. Along the way it is prophylactic to include an element of longer term suicide prevention, knowing full well that client continuation will not be hailed as a prediction or treatment success, and that self injury events will be construed as prediction or diagnostic failures. In both eventualities, the care takers' narcissism, or self confidence in clinical competence, may be threatened unecessarily.
Optimal care lowers the suicide rate of a treatment population, and while it can save lives, the inevitable suicide attempts and deaths of individuals is not a prediction failure but rather an insufficiency of treatment efforts.
The meaning of death to the potential victim of suicide is another source of clinical unpredictability. Death is usually assumed to mean the same thing to everyone, at least those in the same ethnic group or members of a shared belief system, i.e. religious, educational, occupational subgroups. However, there is good reason to believe that each unique individual develops notions about life and its meanings which translate to special significance for death. So that the wish to die is motivated by different forces and yields unique results from the victim's viewpoint, even though ending in death to each one. The situation is illustrated by Patrick Henry's cry "give me liberty or give me death".
The inability to experience death itself, allows fantasies and intellectualizations about death to persist. It is well known that young persons especially, do not appreciate the finality of death. Most expect to continue in some form after death occurs. It is equally well known that among older people there is a tendency to view suicidal death as an appropriate solution to an intolerable situation with terminal illness, isolation, grief, or loss of significance to existence. In between these age groups are people with life styles that are associated with higher risk for suicidal behavior such as alcoholism, homosexuality, epilepsy, incarceration, etc. The intermediate group has great resistance to changing their life styles whether it comes from addiction or preference, despite the expected risks.
The age dimension illustrates one limited example of how meanings of suicidal death vary with stage of existence. Death orientations is a more profound array of ideas. People believing in reincarnation or some form of life after death are more tempted to consider suicide as an option. Similarly for those victims who have a sense they will feel better after suicide. Immortality of the soul in the context of a religious faith is an exception provided the faith of the individual has not been secularized. Other factors such as values also color the meanings of any death and play a role in allowing victims to choose self injury behavior when criteria for preferring death are fulfilled. In this context, educating the young for the meaning of death, which is really equivalent to meanings of life, may be the best single primary suicide prevention strategy available in this era.
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The major suggestion here is to shift the criterion for prediction to suicide attempts. In doing so, there are at least three methodological issues which will provoke controversies.
The differences reported in the suicidology literature between attempt and commit populations is the major objection to using attempts as criterion. Weiss (1959) explicitly proposed this difference while Davis (1969) contrasts it with the polar opposite; namely that there is a continuum from attempt to commit. He concludes that the data is still incomplete. Stengel (1971) & Kreitman (1981) among others have reported characteristics of attempt and commit victims which support the position that these are basically different populations given the data observed. There are at least four weaknesses of this `conventional wisdom'.
The first is sampling errors. Reported data do not necessarily include the entire populations of committing and especially of attempting victims. Ferrence & Johnson (1974) in a rigorous review made a systematic effort to identify all victims of self injury regardless of apparent lethality. They found an attempt rate of 730/100,000, which is more than double the usual rates. More recently, Smith & Crawford (1986) have reported that 90% of all youthful attempts are not reported.
Given the existence of selective reporting, the prevailing bias would view male survivors using low lethality methods as in less need of help and therefore less worthy of reporting, i.e. not a "serious" attempt. Conversely women who die from self injuries are more likely to be "protected" from the stigma of a suicidal death, by well intentioned gatekeepers. Both possibilities would skew reported data in the attempt and commit samples away from each other.
The second objection is the confounding of different subgroups of attempters into one population, with the presumption that all are alike. Increasing age alone is a major change factor that is correlated with reduced attempts in both sexes (Davis, 1967). Worden & Sterling-Smith (1973) compared multiple suicide attempters with randomly selected single attemptors and found that the former made initial attempts earlier, at lower lethality levels, had more intense prior psychiatric treatment, and received more extensive subsequent treatment. The authors also differentiated another subgroup of multiple attemptors whose initial self injury occurred when they were older, exhibited more lethality and longer intervals between attempts. They were also at greater risk for commit.
Eyman and Smith (1986) have found that some of the apparent differences between attempt and commit data is due to a blurring of subgroups within the attempt samples for those with four or less incidents versus those with five or more. In their study, all subjects were selected on the basis of at least one serious (highly lethal) attempt. They report that the four or less subgroup exhibited increasing lethality in their methods with more of them ending in commit than the five or more sample. Pierce (1984) comes to a similar conclusion using a more inclusive self harm criterion.
Crumley (1982) in his review of the literature on adolescent victims concludes that survivors of serious attempts should be viewed as more lethal, with greater degree of internal pain, decreased reality testing and long-standing pathology, most often a depressed syndrome. Kahan & Pattison (1984) have reviewed the variety of possibilities in classifying attemptors. This led to their formulation of a self harm syndrome as one among several attempt sub samples. Treating all attemptors as one homogeneous population confounds subgroup differences and obscures potential interventions or predictions by a diffuse notion of an "average attempter". Similarly, male youth suicides have doubled, crested, and seem to be dropping over the last 25 years. Attempt rate estimates have also varied dramatically during this same period period, both by sex and age.
A third weakness is changing group trends which vary over time. Bille-Brahe & Nielsen (1986) in their Denmark survey found increasing numbers of males attempt suicide. National Vital Statistics in the USA for female suicide rates have been declining since 1971, while males continued to rise during this period.
A fourth problem is the changes over the career of the suicidal victim. Some para suicide go on to commit and some of their characteristics have been described. There seems to be an evolution from less to more lethal methods or at least more thorough planning (Eyman & Smith, 1986). Barnes (1986) in a semistructured....... interview of self harm victims notes that in a six month follow up there were more suicide completes in the repeaters group. McKenna (1975) found that more chronic and acute callers commit one month after initial contact at centers in Canada.
A side issue worthy of notice the phenomenon of manipulative motives which is actually more problematic than it appears to be because of at least two ambiguities; 1) the attempter is realistically planning to achieve a goal after the suicidal event, following which the victim expects to survive. 2) the attempter expects to continue in the next life after a suicidal death. The first is manipulative, the second assumes continuation after physical death. The failure to differentiate these two motives reduces all attemptors to an oversimplified manipulative intentions. The optimal management of victims with such different outlooks is necessarily a unique clinical process.
Clum Patsiokas & Luscomb 1979) note the reinforcement of para suicide in their review and model for treatment. Rosenbaum & Richman (1971) report more than half of their sample perceived significant others who wished them dead. The authors imply suicidal behavior as at least a partial response. Lonnqvist & Suokas-Muje (1986) identified staff feelings towards attempt victims, and noted unfavorable attitudes by primary care personnel, especially in emergency rooms. Such negative attention can reinforce self injury behavior while also imposing more stigmatization of the victim.
A review of reported psycho dynamics in the literature for 57 case studies provides an instructive array of motivations for self harm behavior which presume some degree of prior, and ongoing reinforcements (Kahan & Pattison, 1984). Reimer & Arantewicz (1986) report the suicide facilitating attitudes by a "fairly large amount physicians". They state this as a confirmation of a finding first noted by Ringel in 1965. Repeat attempts permit a rehearsal process that can improve efficiency of methods selected in some para suicide victims. Here the well known association between prior attempts and increased subsequent commits provide some documentation for the existence of a suicidal career.
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The apparent differences reported between attempt and commit data can be explained as artifacts from incomplete samples, blurring of lethality levels, confounding of subgroups especially over time, as well as within the life cycle of the victim, and the aggravating effects of social response by gate keepers or significant others. Rather than being members of a different but less lethal subgroup, attempters can be regarded as earlier in their suicidal career. Over time their lethality can increase to a point when some join the ranks of the commits. The fact that most do not is fortunate, and does not of itself contradict the career model. It is clinically more useful to regard the reported characteristics of attemptors as evolving. This shift in perspective makes it possible to think of all attempt behavior as part of the life history of self injurious victims, some of whom may continue the process until it ends in completed suicide.
The various degrees of lethality observable in the self injury methods by victims are separate from the next self injurious event. The prediction of the next suicidal incident can be separated from its lethality. The two judgments tend to overlap in one estimate of suicidal death outcome. Weisman & Worden (1972) have used global estimates of lethality in their well known risk-rescue ratings which contribute to total score for prediction of death outcomes. Smith (1981,1982) has used the concept of lethality in reviewing the Rorschach, Wechsler Bellvue, Word Association, and MMPI tests with four subgroups; commit, serious, low, and no self injuries. He was able to achieve some replication of Rorschach signs. This is similar to an earlier study on Rorschach replicability using continuous scores of lethality as a criterion of intention to die (Cutter, Jorgensen, & Farberow; 1968). Elsewhere (Cutter, Jorgensen, Farberow, & Ganzler, 1968; Cutter 1983) describe the rating schedule. It reviews the amount of planning, the choice of preferred method and the effort to prevent rescue. These independent factors together yield an estimate of total lethality of any self injury plan for the next incident, that is able to discriminate attempts from commits at statistically significant levels.
Smith, Conroy & Ehler (1984, and Smith (1984) have recently reported on a ten point lethality scale that also looks more precisely at degrees of self injurious behavior in assessing suicidal studies as well as clinical cases. Pallis, Barraclough, Levely, Jenkins & Sainesbury (1982) and Pallis, Gibbons, & Pierce (1984) have developed an internationality scale which utilizes items that equate the wish to die with degrees of lethality. A potential obstacle to prediction can occur when the method can remain lethal even though the intent diminishes and vice versa. The lethality rating is an additional assessment, of the degree of self destructiveness apparent in a preferred method. Those clients identified as having low lethality, but high risk of repetition can be approached appropriately by recognizing the greater margin for rescue. The preceding permits the utilization of a fuller range of interventions with less need for 'suicide precaution' type of controls. The attempt victims with low lethality could be managed as other behavior disorders, rather than as acutely self injurious. Conversely, those who plan to use more lethal self injury procedures require long term prevention efforts that recognize the increased degrees of risk for death in the six to 24 months following rescue (Motto, 1985). The all or none type suicidal precautions now employed often block availability of preferred treatment methods (Glaser, 1981) and suffer from a high cost-benefit ratio with respect to the number of false positives, i.e. those high risk people who do not commit.
Each of these assessment methods provide the opportunity to evaluate degree of self injury planning and identify margin for longer range interventions. As such they add more clinical options, and narrow the prediction problem to the next self injury incident.
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The methods and variables appropriate to short range prediction (1-60 days) versus longer periods (2 - 24 months) are qualitatively different for each.
The behaviors that are prognostic of the next attempt are not as well developed conceptually and statistically as are the demographic type predictors of commits (Motto, 1985). The main reason is that predicting suicidal death has been deemed more urgent. Attempts have received less priority. However, the wish to die or impulse to injure oneself is also more difficult to assess because the motivations relevant to acute management are more transitory. Ambivalence itself documents the changing motives between the wish for life and the wish for death. Shneidman has tried (1985) to describe domains of behavior relevant to better understanding and prevention. Each of his common characteristics contain potential predictor variables for the next self injury incident as well as other values noted by Pfeiffer (1986).
1. The behavior most apparent is the wish to die (Cutter, 1971). Shneidman's common motives suggest that this 'simple goal' is the tip of the iceberg that includes efforts to seek cessation of awareness, achieve a solution, avoid psychological pain, surrender to hopelessness and more. All of these provide partial explanations worthy of professional attention. Patients indicating an intention to end their lives regardless of stated motives require the most immediate interventions. Yet those who deny this intention are also in danger of impulsive or secretive self injuries. In addition there are those who engage in self injuries without an intention to die, but even here death can occur as an unexpected outcome. Between the ambiguity of presentation and the need for immediate action, precise assessment gets less priority in the all or none decision to impose suicide precautions. Current efforts to assess this intention (Kovacs, & Weissman, 1979);Pallis et al, 1982 et al; Cutter, 1987; Silverstein, 1980) is not incorporated into systematic assessment.
The recommended approach is to ask the client directly. However, the connotations carry a perjorative impact with defensive replies distorting the answers. There are relatively more reassuring ways to inquire, that may be taught, but are not usually modeled nor practiced. In addition there are some psychological instruments that can approach this issue more efficiently if time permits their administration. Chief among these are the scales listed in the Suicide Prevention Triangle (Cutter, 1987). Another approach is the measurement of satisfaction reported for high risk people (Breed & Huffine, 1979; Andrew & Withey, 1976). Satisfaction is reported to be negatively related to self injury behavior by Silverstein (1980) and is construed as an inverse measure of the wish to die by Cutter (1983).
2. The lethality of self injury planning has been discussed earlier, but is noted here as a potential variable that is independent of the wish to die, and which yields immediate practical values. Assessing lethality creates a window of opportunity to try optimal clinical management until the acute wish to die is replaced by the relatively more benign, but high risk phase, where the wish to live dominates. While a current wish to die requires an equally current and quick intervention, lower lethalities permit less extreme efforts. e.g. group supervision rather than one to one. In current practice, degrees of supervision (Cutter, 1983) are not systematically applied for corresponding degrees of lethality.
The lethality assessment raises the question of a preferred method for a future attempt. There is some clinical basis for expecting the choice of non random methods and the continuation of a past preference into future self injury behaviors (Lester, Beck & Trexler,1975). Assessments of these preferred methods is helpful especially in combination with other risk factors (Eyman & Smith, 1986). With the exception of schizophreniacs and victims who are earlier in the career of a suicidal victim, there tends to be a rehearsal phenomenon that narrows the range of acceptable methods for the victim (Cutter, 1983).
Such current lethality levels provide a limiting range to future lethalities, and thus permit some small help in gauging the margin for delaying suicide precautions. In many cases the knowledge of a preferred method, such as with a gun, can be used to block access to that specific method. At the same time, less effort need be spent to block access to others such as hanging or jumping. Knowledge of preferred methods allows improvements in protecting potential victims. Regretfully, such knowledge does not contribute to predicting the next incident, with the exception when clients are unable to give a preferred method, one can infer less likelihood of self injury action, but even this needs to be monitored frequently.
The self injurious client who has little intention to die, has not yielded to efforts for better prediction or primary prevention according to Clum et al (1979) who concludes these patients are better managed by stress reduction and cognitive restructuring. Yet the decision to offer this alternative presumes a low lethality which needs to be reassessed for effective current management.
3. The degree of cooperation in making a prevention plan, is especially appropriate for those denying a current wish to die. The behavioral willingness to plan a prevention strategy reflects the current absence of the wish to die; any reluctance reflects a residual ambivalence. Willingness to cooperate with life saving efforts such as giving up the means of self injury, contracts not to engage in self injuries, identification of possible rescuers, acceptance of support groups, suicide prevention classes (Cutter, 1977), etc, documents the dominance of the wish to live. The specific willingness to block access to a preferred self injury method is optimal (Cutter, 1983). Resistance is ominous. These behavioral data provide milestones that measure the client's ability to continue life and cooperate with a treatment plan, or its opposite the readiness to act on a self injury method. Such clinical information has prognostic value for the days following an acute episode, a time of greater risk for new self injury incidents in those treated at emergency rooms or discharged from psychiatric hospitals. The prevention plans need to be reviewed at least weekly, and often daily, in order to be used reliably.
4. The readiness to cease parallels the wish to die, but is a more passive willingness to accept death and is usually associated with aging, a time when suicide and death rates increase. The readiness is a more ongoing force, usually overlooked because of its frequency in many people, its extended presence before action occurs (Cutter, 1974,1978) and apparent "naturalness" in older persons. Its presence predisposes for the occasions when the wish to die becomes more active as in self injuries. The readiness to die can be judged five aspects of daily living. The inability to give one or more examples in each of the following areas implies an increased readiness. At least one example of each affirms a residual wish to live.
5. An observer's willingness to suspect suicidal motives is a key factor in starting an assessment. Even professionally trained care givers in mental health settings are often reluctant or unable to adopt such a premise. The danger here is the consequences of false positives or reinforcement of para suicide behavior. Wrobleski & McIntosh (1986) in their list of short term interpersonal clues to youth suicide list 15 items derived from survivors of 158 commits. While interesting for frequency of occurrence an observer would need to have a prior perception of a wish to die. The clues support the conclusion, but are not effective unless a prior suspicion exists.
An alternative and traditional resource to identify patients at greater risk is the use of clinical inference in psychological testing. Here too the professional must suspect suicidal intentions before initiation of the process which can be successful. The past failures (Lester, 1970) stem mainly from efforts to predict death outcomes, rather than to identify people at greater risk of self injuries. Smith (1982) illustrates this in his report of 85% effective identification of forty patients whose outcome was classified into commits, serious attempts, mild attempts, and no histories; essentially degree of lethality. He accomplished this by a return to classical projective testing logic using data from the Wechsler Bellevue, word association, TAT, and the Rorschach. He formulated psycho dynamic motivations as a basis for expected outcome classification.
Another alternative for dealing with the reluctance to initiate a suicide
assessment are two items from Motto's (1985) risk estimation scale. These
represent possible signals of when to evaluate:
Such items can help the gatekeeper recognize when to call for the review of "clues". Subjective variables are inherently transient, and unreliable, but with adequate training and some appropriate methodology as suggested earlier this is where one set of predictors can be found. All of these are areas that offer some potential to identify signs of suicidal intent, or future behavior.
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The 1986 summer issue of Suicide and Life Threatening Behavior was devoted to the biology of suicide. Ronald Maris, the journal editor wrote a preface listing 17 findings that reflect cooccurrences of biological changes and self destructive outcomes which were documented in that special issue. Motto (1986) in the first chapter on clinical considerations notes that none of the ten candidates for markers of suicidal risk have a clear application in clinical work at present and must be considered as areas of continuing research. "If confirming data is accumulated, the most that would be accomplished is a welcome addition to the list of risk factors associated with suicidal death." Self injury prediction would continue to be unpredictable in a given subject.
The biology of suicide holds much promise, but like psychological testing 30 years ago, its validation methodology suffers from the use of small samples, ambiguous criteria for suicidal intent or outcome which confound heterogeneous motives, and the failure to control for sex, age, race, diagnoses, and social class of the subjects studied. Even with these more rigorous procedures, the question will still remain are biological factors simply markers or do they play a causal role.
Biological rhythms in human behavior were identified by Wilhelm Fliess in 1886 and later in his book "The rhythms of life" in 1906. Fliess' close association with Sigmund Freud helped to popularize his ideas. Fliess postulated a physical rhythm of strength and endurance over a 23 day cycle which he called the masculine. In contrast, the feminine cycle of sensitivity, love and other feelings had a 28 day period. A third cycle is attributed to H. Swoboda in 1909 which has 33 days and reflects creativity, and cognitive acumen. In application Fliess' logic parallel's menstrual cycles where certain days are more vulnerable to accidents, or failures. A great deal of subsequent research has been conducted in chronobiology of clearly cyclical events such as sleep, mating, depression. A review and Copyright introduction to the novice is contained in the "Clocks that time us" by Moore-Ede, Sulzman & Fuller (1982).
Thompson (1984) in reviewing the literature on endogenous circadian rhythms and psychiatry, concludes that there is an association with anorexia nervosa, anxiety, chronic schizophrenia, depression and personality disorders with affective disorders generating the most research.
Finger (1984) in his review of the literature discusses the extent to which the results of psychological investigations can be distorted by the influence of circadian rhythmicity. These vary with time of day, interact with temperament, and social conditions. Loss of normal time relations among various daily rhythms leads to impairments and may be involved in such outcome phenomena as jet lag, shift work, or certain psychiatric disorders.
D'Andrea, Black & Stayrook (1984) used critical and semi critical day categories of the three biorhythms to classify 993 veterans who committed suicide. They obtained discrepancies between expectations due to chance and their actual observations which supported the association of biorhythms with suicidal outcomes.
The Fliess-Swoboda model for three biorhythms has found its way into the public domain of computer programs written in the basic language. Its convenience allows investigators to enter with a birthday, and one or more subsequent dates, to achieve an array of indications for where each rhythm falls for specified calendar days. In turn this allows a judgment of critical, semi critical or non critical days for the three identified biorhthyms and their respective cycles. In the computer programs these are called cognitive (33day), sensitivity (28 day), and physical (23 day).
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The effective prediction of suicidal death remains problematic. One of the major obstacles is the use of premises that take life or death as an appropriate criterion. The alternative proposed is to use the next self injury event, regardless of lethality of method, and to estimate the time interval to its occurrence. In adopting this strategy workers will need to consider three major issues in making this shift. The first is the reported differences between attemptors and commitors which can be resolved by the model of suicidal careers and focuses on the changes through time of a given victim. Doing so permits the periods of greatest danger to be defined for most professional attention. This model implies that there are frequent and longer periods of lesser risk, associated with a corresponding reduction of professional scrutiny. The ability to recognize the difference between the higher and lesser risk periods in the same person is the burden of more research and clinical wisdom.
The second issue is the separation of lethality of self injury ratings from the assessment of risk. The criteria for each is different and the management options increase with specified lethality levels.
The third change needed is to consider more subjective, overlooked, new and transitory motives than in the past. A list of eight domains that offer promise are briefly described. These are: the wish to die, degrees of cooperation with prevention planning, ambivalence towards living, suggestibility by the examples of others, influence of gatekeepers or significant others, and integration of biological factors including biorhythm data. The large array of data to be considered in effective efforts to predict the next self injury, points to the need for computer processing in order to review all information. Computer interviews also have potential for patient generated answers to systematic assessments. Such direct patient statements provide the best potential source of new short term predictors.
The recent emergence of biological factors or markers for suicidal outcomes is an exciting new dimension. It suffers from the same methodological errors that beset psychological testing for signs of suicide 30 years ago. Both kinds of approaches need to pay more attention to adequate sampling (size and reference variables like age, sex, race, socioeconomic status and diagnosis). Both need to make efforts to differentiate between markers that correlate and those that may predict suicidal outcomes. Biological and psychological factors together may be able to explain the problem of suicide.
The last 40 years of effort to predict suicidal outcomes, while heuristic have been disappointing. New alternatives are suggested since these can encourage scientific optimism, professional hope and gatekeeper enthusiasm. All of these have inspirational value to potential victims. The writer encourages optimism in all workers since when aroused, it is never inhibited by insufficient knowledge nor contrary beliefs, but is always available as a source of energy for constructive suicide prevention.
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