Suicidal intent is superficially simple to describe. However its scientific study extends to risk for death estimation on the one hand and underlying motivations or causes on the other. Both are exceedingly difficult topics to pursue in terms of methodologies. This section will review the scientific literature since 1979 for estimation of risk for death and singular motives for self injury.
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Kreitman (1982) after reviewing the literature of prediction and prevention concludes that there are no proven scientific bases for specific prediction. The major obstacles are reviewed to a more actuarial type of risk estimation for suicidal death over a two year period.
The Previous efforts to predict suicidal death often blurred items that measured intention to die, motivation for self injury, lethality of methods, and risk estimation for death in the various scales developed before 1978. The list of scales given earlier in this manual reflects the overlapping. Hatton & Valente (1977) factors associated with higher risk of suicide commit. They array degrees of each with increased risk of commit. In summary, these factors are anxiety, depression, isolation/withdrawal, daily functioning, resources, coping strategies, availability of significant others, satisfaction with previous psychiatric help,stability of life style,abuse of alcohol/drugs, previous attempt, disorientation/disorganization, hostility,degree of planning.
Risk estimation scales can serve to identify high risk people for long range prophylactic or educational interventions, even though their clinical value is more limited.
The Suicide Potential Scale by Cull & Gill (1983) has the advantage of using almost all non suicidal content items that a client can answer directly. The scores are used to assign the person to one of four levels of risk for lethal self injuries but not necessarily death outcomes. Its validity and reliability are acceptable for prophylactic measures with clients at greatest risk. The validation sample did not include commits. The scores yield a profile of three other scales: hopelessness, negative self evaluation, and hostility.
Pierce (1977,1981,1984), Pallis, Barraclough, Levely, Jenkins, & Sainsbury (1982) and Pallis, Gibbons, & Pierce 1986 have developed an intentionality scale that appears to be effective. However, they tend to use lethality items as measures of intention also. The scale is described in the tests section.
Patterson (1983) reports on a new risk estimation scale that has the advantage of easy use called the SAD PERSON scale. It is described in the section on tests, page 20.
Bruni (1985) identified birth events as factors in subsequent adolescent suicide. These are lack of prenatal care, chronic disease in the mother, and respiratory distress at birth. 52 commits were matched with two control groups for sex, race, and hospital of birth. Committed suicides showed 60% versus 11.5% & 19% for the control groups of the possible risk factors.
Moses (1985) notes that males are at greater risk for suicide if they are over 45 with chronic illness and a traditional, inflexible belief system that prevents sharing of feelings, asking for help, or viewing self as in other than a provider roles.
Tomlinson-Keasy (1986) attempted to identify 8 completed suicides from 15 women who died from other causes, and 17 women who were still alive. All 40 were matched for age at death and were subjects of the Terman study of Genius. Seven variables that were effective as possible predictors of suicides in females were found. These are physical health, early loss of father, stress in the family of origin, problems with alcohol, and three indices of mental health. The latter refers to signatures of suicide identified by Shneidman (1971) in an earlier study, self reports of temperament, cumulative mental health ratings developed by Terman & Oden (1959). Shneidman's signatures are suicide attempts, anxiety, alcohol abuse, drug abuse, homosexuality, conspicuous instability, and depression. The temperament ratings are happiness, moodiness, impulsivity, self confidence, emotionality and sense of inferiority. These were each rated on an ll point scale and combined for a total temperament score. Mental health ratings based on combining adjustment scores with a method of managing these problems by summing scores from each.
Motto (1986) has reported a 15 item scale and scoring system that allows the user to assign a risk level to any given subject. This risk is expressed as membership in a sample with a known degree of probability for death over the next two years. The scale is easy to administer, takes little additional time, and consists of items that are usually known. Relatively new items are the review of weight change (gain or loss of more than 10%) amount of sleep per night (6 hours or more), subject's dissatisfaction with previous care, and the interviewer's negative subjective reaction to the client.
Roy (1982) in a matched controlled study of 90 psychiatric patient suicides found significantly more chronic schizophreniacs or recurrent affective disorders and histories of previous attempts. The commits were younger, more likely to be single, unemployed, living alone, and depressed. Of the 75 outpatient suicides 58% had seen a psychiatrist within the preceding week, 81% had been admitted in their last contact, and most significant for prediction, 44% committed with one month of discharge.
Lesch & Walter (1985) confirm studies indicating that suicide commit in post alcohol treatment programs is low. In a four year follow-up of 356 patients 13 committed which equals 3.6% for the total follow up period or 0.9% per year. Almost all follow-ups of previous attempts by non alcoholics yield more than 1% per year commits. Hopelessness emerges as the significant variable in estimation of risk and motivation for suicide. A series of studies elucidating the relation between depression, hopelessness, and suicidal intent have appeared. (Farberow 1972)
Kazdin (1983) studied the relation of the three in latency (pre- puberty) children. He reports that measures are highly inter correlated and concludes hopelessness alone is an effective measure.
Petrie & Chamberlain (1983) using 54 younger mainly overdose attempters found hopelessness to be the key variable in the prediction of suicidal intent using Zung (1965) items as criteria. Social desirability was not a factor in this clinical sample which contrasts with Lineham and Nielsen (1981) finding with shoppers in the Seattle area.
Dyer & Kreitman (1984) confirmed their own earlier studies on the correlation of hopelessness, depression & intention in 120 hospital referred para suicide patients, but conclude that depression and intent are dependent on hopelessness.
Drake & Cotton (1986) studied 102 chronic schizophreniacs of whom 15 had committed suicide. A control group of 15 who had not was used for comparison. Retrospective ratings for depression (DSM III criteria) and hopelessness indicated that suicidal status was more effectively accounted for by hopelessness.
Sklar (1986) compared 50 hospitalized suicide attempters with 315 suicide and non suicide high school students. The hospitalized had a higher depression, hopelessness and stress scores, and lower family cohesion and adaptability scores.
These studies confirm the power of the pessimism scale introduced by Beck, Weissman, Lester, & Trexler (1974) and seem to isolate the critical factor from the more generalized depression diagnoses. Beck (1985) has found that items dealing with pessimism, sense of failure, self dislike, and suicide ideation to be the most powerful in identifying depressed patients at greatest risk for suicidal death in long term follow-up.
Motives for suicide tend to get equated with causality in the folk wisdom models such as "disappointments in love explain suicidal lovers". The public information media tend to use the causality model in reporting suicide phenomena and interpreting research. The deficiency of this thinking is the tendency to equate correlations with cause effect and to ignore contributing factors such as the stress of need deprivations or the predisposing factors of psychological vulnerabilities that together enhance the impulse to act in a self injurious way. Popular use of causality models tends to yield over simplified explanations. On the other hand, the more sophisticated interpretations are harder to apply to practical prevention efforts.
In scientific writing their is also the tendency to over simplify by a narrowed focus of attention as in the Durckheimian and Freudian ideas of sociology and psychoanalysis respectively. The current suicidology literature is replete with studies that identify increased rates with unemployment,religious observance, divorce, status integration, etc" reflecting the sociology of suicide. The opposite also exists in the form of studies of significant loss, strict child rearing, parental conflicts, endogenous depression, conflicts, loss of hope, etc. reflecting the psychology of unique individual motivations.
Making sense of suicide continues to be difficult for the survivors, the public, and the suicidologists. This section is slanted towards explanations that rely on premises of necessary and sufficient causation to distinguish between those that do and most that do not, injure themselves given apparently equivalent motives.
The suicide prevention triangle model itself (Cutter, 1983) is an effort to address the issue of clinical motives that permit professional rescuers a selective intervention in the most direct way possible. The model borrows from fire prevention logic. The wish to die is the spark, the acts of self injury are analogous to oxygen and distress represents the fuel that together produce the fire which consumes in acts of suicide. Lacking any element prevents self injury behavior. When all three are present a necessary and sufficient condition exists for suicidal behavior (Cutter, 1983).
Stephens (1983) contrasts sociological and psychological methods in the vocabulary of motives for completed suicide as manifested in suicide notes. The comparison is between "interpersonal activity which is oriented towards making sense to the self and to others..." versus "internal pushes towards actions that views motives as well springs to behavior". From sociological perspective she argues successfully that both victims and non victims develop motive vocabularies that provide acceptable explanations. She documents her position by comparing studies of suicide notes in the suicidology literature with her own survey of 106 faculty members of a four year college on what kind of situation "justified" suicide. She identified nine motives in the suicide note literature and compared these to her own data. Stephens concludes that there is evidence for a shared language of "suicide talk", which effectively serves to justify the self injury action to the victim and their survivors. The victims see themselves as heroic or at least rational in their motives.
A confirmation of this ideas is from an overlooked source of motivational explanations for suicidal behavior in the form of images from works of visual art (Cutter, 1983). Almost 1000 artists in western art history are known to have depicted the theme of suicide in one or more works of art. The artist uses motives that reflect the belief systems of his or her contemporaries in that era and place. The most frequent image is that of heroic suicide where the self injurious act is shown in a rational, public, and positive context either shared by the viewers or supported by the patron. Frequent examples are Cleopatra, Lucretia, Ajax or Marcus Curtius. In more recent times the artists have also shown stigmatized, irrational, depressed, ambivalent, and cry for help images which reflect changing orientations in contemporary attitudes of the time. All of these artistic representations are apparent in current clinical victims who tend to explain their own self injury actions in more rational terms such as suggested by the heroic images.
The scientific literature is certainly less dramatic and complete in providing its wisdom on the subject of motives for suicide. Jean Bachelor (1980) has proposed the model that suicide denotes "all behavior that seeks and finds solutions to existential problems by making an attempt on the life of the subject." While attractive as a treatment/intervention model, psychologically it fails to discriminate problem solving behavior that results in continued life from those that injure themselves. It does not provide the necessary and sufficient reason for the action. Bachelor also seems to assume that people know what they are choosing when they select death as the option. He ignores the perspective of the victim who may assume that their will be a continuation of the self after a point of termination. In this, both Bachelor and the victims share the view that suicide is simply another problem solving action. They can do this because their is implied agreement about the mental state of death that Shneidman calls cessation. The victims tend to expect some form of continuation of the self after termination. Parenthetically, the problem solving motives seem to assume a life after death, which may be relevant for younger suicides who are less able to believe in a world without themselves continuing to exist. The explanation dissolves into the inability of individuals to experience death and the necessarily incomplete and unique notions most individuals entertain about the meanings of death for themselves.
Bachelor (1980) provides a profound and useful clarification of concepts. He views suicidal action as problem solving behavior that is oriented to accomplishing some objective, in his phrase " in order to ..." He also contrasts this with a larger purpose, a "because". Bachelor starts with a typology of suicidal actions. These are hostility, escape, oblative (sacrificial), & Ludic (game in the sense of chance or trial by ordeal). He explicitly denies that the typology equals cause or motives. The meanings of the types are instead strategic simulations that allow a logical, if not rational, solution for the victim to achieve a unique end.
The "in order to" objectives are future oriented, while the because" ones are retrospective rationales. Bachelor illustrates with the example of a person opening an umbrella "in order" to prevent getting wet "because" the person dislikes wearing wet clothes. The because focuses on the kind of victims and the situations which are prone to suicide. Bachelor who is a social philosopher presents clear formulations that provide heuristic concepts to the suicidologist.
Lester & Hummel (1980) rated the apparent motives of 52 victims (18-74), derived from their suicide notes in terms of Menninger's three motives. The whole group exhibited wishes to die, and desire to kill. However only the older subjects were less likely to exhibit a desire to be killed.
Parker (1981) attempted to classify the meanings of suicide to young para suicide patients by using a repertory grid method of ll paired opposite behaviors. He concluded that overdose may have a respite meaning for low intentioned victims and suicidal death for the high intentioned. He used the Beck suicide intent scale (1974) as criteria. This study seems to confirm the inability of victims to accept cessation.
Martin (1984) confirms the old wisdom that religious practice reduces the likelihood of suicidal deaths in the US based on 1972-1978 rates and church attendance.
Adams (1981) reports two studies. The first compares college students with intact families to those where one or both parents died before the students were 16 and a second group of students where parents were divorced or separated. A subsequent review of suicidal behavior for all subjects provided the basis for comparison. He found more suicidal ideation and attempts in students whose parents have died or were separated than those with intact families. The second study sought out victims of attempted suicides (N=98) and compared them to controls (N=102). Parental loss was found to be greater in the attempted suicide group. Both studies looked at details of family stability which differentiated suicidal and non suicidal subjects. Severe childhood discipline and parental conflict were related to adult psychiatric inpatient acts of self destructive behaviors in clinically depressed patients (DSM III criteria) by Yesavage (1985). This is an interesting finding but the authors did not report on non psychotic adults with similar child rearing.
Van Hoesel (1983) attempted to identify an empirical typology of suicide derived from 10 existing classification systems on 404 suicide case histories. He found 5 clusters that account for 86% of the cases. These are: aggression, alienation, escape, depression/low self esteem, and confusion.
Motivations for suicidal death remain unique and inexplicable varying with age, sex, degree of intention to die, lethality of methods, and estimated risk for death. The efforts to develop a generalized motive for suicide as illustrated by Menninger's three wishes remains disappointing. Even so more knowledge is accumulating including the awareness that classical explanations do not hold up under empirical scrutiny. The clinical value of existing sophistication allows for the separate evaluations of risk, motive, intent,and lethality. Suicidologists have begun to identify more singular motives for suicide such as the readiness for death, the wish to die, , hopelessness, need for respite, etc. These are useful because separate evaluations of each provides greater opportunity to exercise professional judgment in evaluation of unique profiles and permits more effective management.
Thus for example, knowing that a client threatening to kill him or her self also has a preferred method that can be considered low in lethality permits recommending optimal treatment procedures. In this situation the need for "suicidal precautions" can be subordinated to the higher priority of treatment. This position can be accepted even though a risk estimation for suicidal death over the next two years may be relatively high.
The last ten years have not yielded a consensus among suicidologists about the necessary and sufficient reason to explain suicidal motivations. The concepts and methodologies have become more sophisticated and there is reason to be optimistic. Yet there seems to be a cacophony of models, meanings, and methods, no one of which commands enough confidence to yield universal adoption among suicidologists, while the gatekeepers continue to provide minimal effort for high risk populations.
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The concept of lethality has evolved from earlier efforts to measure suicidal intention and probability of suicide by looking at methods of self injury. The logic was quite simple. Suicidal deaths were more likely to occur when victims used highly damaging, fast acting, and irreversible methods such as hanging, jumping from high places, shooting, etc. and to do so where rescue was blocked. Items reflecting choice of methods, degrees of planning or prevention of rescue were included in earlier scales to predict or estimate risk for death. Most of these scales are listed on page 20. Page 23 identifies overlaps and utilization of lethality items.
With increasing recognition of lethality as a separate dimension (Weisman & Worden, 1972; Cutter, 1987), the more recent articles have used various ad hoc criteria. This in turn facilitated more systematic measures and the publication of objective scales. This section will list those available, and review research with and without lethality scales. The recognition of lethality by different disciplines has received more attention in the last ten years and will also be reviewed here.
The Los Angeles Suicide Prevention Center developed a suicide potential rating scale known as the SPRS (Litman & Farberow 1961) which included items that were associated with risk of death and degree of self injury in method or plan. The whole assessment was intended to yield a measure of lethality in the combined sense of intention to kill oneself and high damage to the victim's body. Many subsequent studies utilized the SPRS as a measure of lethality and will be cited later.
Weisman & Worden (1972) recognized the ambiguities of lethality
in their development of the well known risk-rescue scale.
"...found it useful to distinguish three forms of lethality;
They chose to utilize implementation. Their subsequent scale contains items of self injury, and rescue which permit an estimate of risk for death. Worden (1976) later used the risk- rescue rating on 40 subjects to establish three levels of lethality of self injury and related these to a wide variety of psycho social measures by means of a factor analysis. He reports thirteen factors, the most important of which are a history of psychosis, poor social relations,, intent to die, and life threatening behavior. A serendipitous result was the apparent support for the risk rescue scale as a measure of intent. Although the data may not be generalizable, Worden argues for use of lethality measures as a continuum to study other factors associated with suicide.
In the late 1960's, I also equated the wish to die with operations that would yield death. This led to a lethality of self injury scale reported as the intention to die (Cutter, Jorgenson, Farberow, 1968). See page 24. Later this and other data led to my distinction of suicide behavior as a wish to die, an act of self injury or vital outcomes (1971).
Wenz(1977) reports a scale to measure suicide potential in the general population using the city of Flint MI. He defines this as increasing lethality of three subjective states: suicidal ideation, suicidal threats, actual and suicide attempts. He collects data from census tracts with high and low suicidal activity. Thus his scale seems to be a community lethality measure.
Gorenc, Kleff & Welz (1981) tried to separate intent to die from seriousness of self injury. They used an eight interval scale to measure intent and seriousness, by physicians and patients. The criteria they give in their article is conceptually simple, but lacking in examples and thus ambiguous. Their study is interesting in providing inter correlation coefficients for lethality and intent, by professional and client. The high correlations among all possibilities suggest that the two scales are statistically alike although "conceptually different". Both scales seem to rely upon lethality items. The correlation coefficient in the patient sample is much higher for intent and seriousness than the same for professionals.
Smith, Conroy, & Ehler (1984) have reported a lethality rating scale which has 9 well defined anchor points with examples, and uses the relative lethality of an extensive table of drugs. These tables contain more medications than a similar survey reported by Sterling-Smith (1974). The careful and explicit criteria make this a more reliable scale and will encourage greater standardization among suicidologists. Dale Smith (1984) using 30 subjects from four mental health and crisis centers found good validity and reliability with his scales.
Pallis Gibbons & Pierce (1984) report a method to estimate suicide risk among attempted suicides which essentially relies on items reflecting lethality, victim post hoc reports of intent and planning, and professional estimates of risk.
Schmidtke & Schaller (1983) used a lethality questionnaire as an ad hoc scale to study intent and social desirability of patient self reports following an attempt,. These data wee elicited over 3 different intervals with 21 males and 31 females. He reports increased concealment of the attempt and greater acceptance of the "failed attempt".
Traditionally, suicide attempts were regarded as serious or gestural based on the apparent severity of injuries or near injury sustained by the victim. These were predicated on the assumption that intention to die was reflected by the degree of self damage apparent in the attempt behavior. Shneidman and Farberow (1961) popularized the use of threat, attempt, commit classifications as more objective, non-perjorative approaches to the measure of intention to die. Later, this led to the concept of lethality as the intention to kill oneself (Shneidman 1969). Subsequent research has relied upon the wisdom of various authors in formulating criteria for degrees of lethality which tend to use one or more of the categories of lethality formulated by Weisman & Worden (1972). The recent literature continues and exemplifies this approach.
Wetzel (1977) factor analyzed Beck's Intent scale, using 48 attempters and 56 threateners. He identified four factors: seriousness of intent, lethality of the act, precautions against interference, and failure to initiate rescue after the attempt. His measures of lethality were clinical judgments based on the circumstances of the suicidal behavior. He notes that character disorders report more seriousness read as lethality, at times of attempt and in later recall.
Neuringer (1979) used the semantic differential to study life and death concepts of 3 groups of females with differing "lethality" levels using the SPRS from Los Angeles. High levels rated life negatively and death positively.
Farmer and Rhode (1980) surveyed method of suicide in Europe. They conclude that availability plus social acceptability of highly lethal methods explain why some countries report higher mortality with specific methods such as domestic gas, fire arms, hanging.
Goldney & Pilowsky (1980) note that about 1/3 of female attempters, showed endogenous depression. This cut across three levels of lethality previously established by clinical judgment. They used the Levine-Pilowsky (1969) scale for depression as a basis for the diagnosis.
Goldney (1981) classifed 110 female survivors (ages 18-30) of drug overdose into three levels of medical lethality. High victims had recent psychiatric contact had taken more than 20 caps of medications (mostly anti depressants), exhibited high intent to die, hopelessness, and came from higher socioeconomic status. They differed in showing less history of violence, less death anxiety, little alcohol use, tended to have schizophrenic personality traits, and (were not in a relation).
Roy-Byrne (1983) used 45 subjects who met research criteria for major affective disorders (32 bipolar, 13 unipolar), reports that 5HIAA did not discriminate between those who attempted suicide from those who did not. There was also a lack of difference for family history of suicide also. This is an example where lethality of method, or suicide intent were not used as control variables. The increased sophistication of biochemical assessments were impeded by a less sophisticated psychological criterion. See the sections on Alcoholism and Biology for current reviews of findings and methodology. Biochemical studies seem to be starting with the criteria that the more behavioral research of the fifties and sixties tried.
Dwyer & Jones (1983) used four categories of analgesics in classifying self poisoning deaths by females in 18-44 age range. These are propoxyphene, aspirin, paracetamol, and others with 62.9 % being propoxyphene. While not really a scale the classification is extremely practical in assessing and managing specific cases for degrees of lethality.
Clarkin et al (1984) compared psychiatric diagnosis and severity of self injury behavior between adolescents and young adults hospitalized following an attempt. The depression disorders were the same in both age groups. The degree of lethality and frequency of attempts were approximately equal. They found that age is not associated with lethality. They concluded it is possible to diagnose adolescents using the same criteria as adults if they manifest the same symptoms.
Peterson (1985) studied 30 gunshot survivors at an urban center, all of whom would have been fatal except for medical rescue. Half had used alcohol/drugs immediately before and more than half had experienced interpersonal conflict just before the incident.
In a somewhat tangential note, an illustration of the failure to be precise about intent and lethality comes from the clinical problem of managing malingerers, and suicide attempts in the same settings, and separating these from subcultures that approve of self injuries. Walsh (1985) has differentiated between self mutilators and para suicide victims who require different understanding and therapy. Using a sample of 50 adolescent mutilators, Walsh argues that the motives and contexts are different and should be addressed by different treatment models.
Haycock (1983) reports data that argues against the efficacy of serious and non-serious dichotomies used to distinguish degrees of lethality. He used lethality ratings on 62 male prisoners following self injury behavior.
Reynolds & Eaton (1985) studied 749 consecutive cases over a three year period with attempted suicide. In 94 there were three prior attempts while 364 were in their first attempt. Using rating scales multiple attempters showed higher lethality and more depression but lower impulsivity scores.
Pierce (1984) using his 1981) intention scale on repeated attempts notes that those who attempted once in five years were significantly higher for second episode while multiple attempts scored lower for second episode. Patients under 35 were most at risk for repeats with increased intent within two years. These results reflect the degree of lethality in the sense of self damaging behavior, and the patient's intention to die.
Kowalski & Crawford (1986) using victims of suicide attempts, classified them into mild versus serious attempts by means of Smith,Conroy, & Ehler (1984) lethality of attempt scale. For 106 adolescents ages 13-19, lethality levels did not indicate intent. Age, family patterns, role models were more significant. On the other hand, Eyman & Smith (1986) using 101 adult with one attempt found that lethality of attempt and suicide intention scales were highly correlated. The apparent discrepancy is probably attributable to the intention scale developed by Smith et al which tends to use lethality items. They report that intent differs with lethality levels, but are effective discriminators.
The increasing availability of these lethality scales allows suicidologists to control for levels of self damaging behavior in their studies of other relevant factors in self injury acts such as depression, loss of hope, risk for death. etc. The research in the last ten years documents that victims can differ in their degree of self damaging behavior even though they all may have a wish to die or exhibit varying levels of intent as measured by other scales.
Allowing for the ambiguity between lethality and intent, there were a number of articles in the last ten years that reviewed the ability of a discipline to recognize the clinical condition of lethality.
Holmes & Howard (1980) using the Los Angeles SPRS as criteria of knowledge surveyed eight different mental health disciplines of 30 each. The results showed degrees of knowledge in the following order: psychiatrists, physicians, psychologists, social workers, ministers, college students. The degree of knowledge seemed to be associated with the amount of specific training for suicide prevention.
Josefowitz, et al, (1983) reports a similar study with chiropractors who seemed to do as well as ministers and college students using the same criterion. Bascue (1982) studied the ability to recognize lethality factors by psychiatric nursing assistants. Carmacic (1981) studied the acceptability of suicide attempters and their perceived intentions to die as rated by registered nurses. Barbee (1978) examined conflicting views and uses of precautions with suicidal patients. Knowledge of lethality by nurses, and role of staff in treatment were also examined.
Inman et al (1984) studied the relationship between lethality factors and the capacity to respond appropriately to suicidal people by use of a survey with 89 nursing students. The resulting lack of association between the two documents independence with both having potentially important suicide prevention competencies.
Domino & Swain (1986) surveyed eight mental health professionals (N=280) with respect to knowledge about lethality and attitudes to suicide. Clergy scored lowest. Those who recognized greater number of suicidal signs and symptoms viewed suicide as a reaction to external factors rather than manipulation or inner drives.
It is encouraging to see the reduction of the tendency to label survivors with pejorative phrases such as "non-serious", manipulative, engaging in gestures, attention getting, etc. Fortunately, these have given way to more professional rubrics such as severe and mild or para suicide. Kahan & Pattison (1984) have addressed this issue more appropriately in their proposal for a distinctive diagnosis of deliberate self harm syndrome.
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People at greater risk for a suicidal death than the general population in the United States can be considered high risk. This implies that their usual, pre clinical status is much like that of any public health disease. Some people are considered high risk for heart disease others for cancer or stroke. Epidemiological factors are used to identify the degree of risk in all of these medical outcomes. The same is possible for probabilities of death by self injury.
This chart uses the rate of suicidal death each year to establish probabilities for each epidemiological factor indicated. These are age, sex, prior mental illness, prior suicide attempts, living alone, alcoholism and recency of hospital discharge. Such information can be used by the health professional as background guide lines when making clinical or management decisions such as readiness for discharge, or frequency of clinic visits. For example follow up visits after hospitalization should be tapered over a six month interval from daily to weekly to monthly to bimonthly. The first year requires regular contact whether by weekly group therapy or monthly letters.
The approximate column is a nmemonic device to help the reader remember the increasing risk levels with changing factors. All ratios are one death to the given number of live people per year.All data is male except where female is indicated.
| CRITERIA | US APPROXIMATE | US EXACT |
|---|---|---|
| General Pop.Male,white | 1:5,000 | 1:4831 |
| General Pop,Female,white | 1:15,000 | 1:16393 |
| Both sexes, white | 1:10,000 | 1:8064 |
| Prior mental illness | 1:500 | 1:370 |
| One Prior Attempt | 1:50 | 1:67 |
| Two Prior Attempts | 1:5 | 1:7 |
| Over 65,living alone | 1:200 | 1:195 |
| Above plus one attempt | 1:20 | 1:19 |
| Two prior attempts with alcoholism. | --- | 1:12 |
| Ratio of death outcomes to live callers at LA SP Center (1974) measured from initial call. | ||
| During first month | 1:27.3 | (3600/100,000) |
| During first six months | 1:50.0 | (2000/100,000) |
| During first year | 1:71.4 | (1400/100,000) |
| During first two years | 1:95.2 | (1050/100,000) |
| During first six years | 1:181.8 | ( 550/100,000) |
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It is possible to estimate a base rate of expected occurrence of suicidal deaths per year for any given health center or professional practice, by using known rates associated with epidemiological variables. The enclosed work sheets allow the computation of an expected number per year. The age sex specific rates published in the Statistical Abstracts of the US for 1982-83 (page 77) provides the numbers used on the enclosed work sheet. Page two provides for the extrapolation of this computation to estimating the expected number of suicide attempts within the same facility.
In using the enclosed work sheet, it should be noted that each line yields an incremental fraction of the population meeting that criteria. To minimize decimals, the computation is based on rates per 1,000,000 an increase by a factor of ten. This is corrected on line nine by dividing by 1,000,000 to obtain an absolute number of deaths per health setting per year. The estimate of attempts to commit varies from 25 (Fox, 1977) to 3 Stengel, 1964). Shneidman & Farberow (1961) estimated 8.6 in California. Farberow (1972) in his survey of attempt follow-up studies lists the number of suicidal deaths, attempts, and periods of observation. If the percentage given for each is reduced to annual estimates and than expressed as decimal equivalents, a ratio can be defined between both. This permits deriving the number of attempts from the number of commits. For the eleven studies listed, the estimates vary from 1.75 to 12.0 attempts per year for international sources. American locales did not list data on attempts. The user can substitute the best guess available for the specific locale. When in doubt 10 is both useful and optimal. Ten is indicated on the work sheet.
The recent concern for youth suicide and attempts has yielded data that there are at least 40 attempts for every youthful commit. There are estimates as high as 200. In centers that treat clients under 25 the base rate computation should use the approximations seem most appropriate.
Given the existence of high risk people within the population served by any health professional or setting, a number of deaths from self injury is to be expected. The prediction of this number is constructive because it provides a criterion for evaluating quality of health care. The occurrence of more or less than this base rate documents better or less than optimal care. Rather than permitting arrogance or defensiveness these data facilitate objective recognition of good quality health care or needs for improvement. This book contains model work sheets for estimating the number of expected deaths and self injury incidents per year. However, experience demonstrates that the actual information is difficult and laborious to obtain. Where this is the case approximations should be used.
Work sheet for year:______
(any unit of time can be used but should be converted to annual rates)
Name:_____________________________________Date__________
On each line below, find the number of patients treated for
each factor.
Multiply this by the first number on that same line.
1. Length of Mental Illness:
| 0-12 months | 3710 x _________=____________ |
| 13-24 months | 7420 x _________=____________ |
| 25-36 months | 11130 x _________=____________ |
| 36+ months | 11480 x _________=____________ |
| Sums | =____________ |
|---|
2. Age sex specific (1994 data)
| Age | Males | Females |
|---|---|---|
| 15-24 | 214x__________=_________ | 46x________ =_________ |
| 25-44 | 252x__________=_________ | 82x________ =_________ |
| 45-64 | 243x__________=_________ | 94x________ =_________ |
| 65+ | 382x__________=_________ | 60x________ =_________ |
| Sums | ________________ | ________________ |
| Sum of male and female increments | ________________ | |
| 3. | Males over 65, living alone | 3670x________ =_________ |
| Same; one prior attempt | 3670x________ =_________ | |
| 4. | Divorced, separated, both sexes | 2400x________ =_________ |
| 5. | One prior attempt | 15000x________ =_________ |
| Two prior attempts | 150,000x________ =_________ | |
| Sum of both | =_________ | |
| 7. | Recent discharge(less than 6 mo#) | 2000x________ =_________ |
| 8 | Sum of increments, line 1-7 above | ___________________ |
| 9 | Line #8 divided by 1,000,000 No of expected deaths in the next year |
=_________ |
| 10. | Total number of expected deaths (line 9): | =_________ |
| 11. | Multiply by 10 (ratio of attempts to commits): | =_________ |
| Additional attempts due to the factors listed below: | ||
|---|---|---|
| 12. | Multiply sum of female increment by 10 | 10x________ =_________ |
| 13. | Multiply sum of females under 35 by 10 | 10x________ =_________ |
| 14. | Multiply one prior attempt increment by 10 | 10x________ =_________ |
| 15. | Multiply two prior attempt increment by 10 | 10x________ =_________ |
| 16. | Sum of increments in lines 12-15 | ____________________ |
| 17. | Line 16 divided by 1,000,000 | ____________________ |
| 18. | Total no of attempts (line 11 + line 17) | ____________________ |
*See introductory remarks for best estimate of local attempt ratio
and especially for victims under 25.
Remarks:
Name of Person completing form : _________________________
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Despite the existence of many assessment devices and a long history of effort, the prediction of suicidal deaths is hardly beyond chance levels (Farberow & Mackinnon, 1975). The epistemology of prediction itself is really debatable, since even with a highly reliable and valid measure of death outcome, health professionals would intervene and "spoil" the predicted result (Murphey, 1974; Maris,1968,1969). Elsewhere (Cutter,1977;1987) I have suggested that it is more reliable to attempt prediction of future self injury incidents rather than death. See the section on prediction for a more extended discussion.
Regardless of purpose, professionals conducting prevention, treatment, or research are faced with a confusing array of instruments. Some order can be given by identifying common usages and grouping them by apparent function rather than titles.
| Risk for suicidal death | Suicidal Intention |
|---|---|
| Cull & Gill, (1982) SPS Cutter, (1968) pg 36 Exner, (1978) pg 36 Farberow & Makinnon (1974) Letteri, (1974) predict |
Beck Kovacs & Weissman (1979) Cutter (1983) pg 38 Satisfact. Cutter 1983) pg 40 Signif loss |
| Motto, (1985) estimation Patterson, (1983) SAD PERSON Tuckman & Youngman (1968) RISK |
Pallis et al |
| Lethality of self injuries | Depression |
| Cutter 1968, 1983 pg 24 Pierce 1977, 1981, 1984 Smith Conroy & Ehlers (1982) SPRS (1961) Weisman & Worden (1972) |
aside from MMPI, CPI, etc Hamilton (1960) Levine & Pilowsky (197-) Zung (1965) |
| Future/Hope | Miscellaneous |
| Beck et al (1974)pessimism | Calhoun et al 1981 parental reaction to youth suicide |
| Ganzler (1968) pg 32 self in future Yuffit 1982 (time) |
Cutter (1983) pg 30 draw a suicide Reynolds (1987) ideation |
COMMENTS
This 20 item true false scale measures ideation reflecting hopelessness that is sensitive to clinical changes in degrees of depression. The scores were factor analyzed into three scales: affective, loss of motivation, and future expectations. Construct validity studies were consistent as was reliability in different samples. Norm group based on 294 hospitalized suicide attempters.
This 19 item, objective choice test yields one total score ranging from 0-38 which appears to measure active suicidal desire, specific plans for suicide, and passive suicidal desire according to a factor analysis of the items.
This scale measures reactions to family & survivors of youth suicides. Range, McDonald,& Anderson (1987) confirm its reliability and validity for assessing reactions to youth suicide and recommend its use in future research.
Western Psychological Services, This scale assesses the probability that a client belongs to a high risk population, using empirically derived items without specific suicidal content.
This 11 item objective style scale uses data from health records to arrive at a total score based on weights. Norms are given for degrees of risk for suicidal deaths. Live subjects can be considered as showing probability of future self injury behavior.
This 17 item rating scale are judged on three or five point criteria for depressed mood, suicide, work, retardation, agitation, GI symptoms, hypochondriasis, insight, loss of weight, genital, insomnia, anxiety, and subdivisions of the latter two. The author suggests its use be limited to clients already diagnosed as suffering fom affective disorders in order to quantify the results of an interview. The scale depends on the skill of the interviewer.
Four objective scales for sex and age groups, with long and short forms based upon telephone evaluation of a caller who acknowledges suicidal intention. These are not intended for those who deny suicidal intent. Clinically, the caller can be construed as likely to have more self injury incidents.
This 15 item scale completed by an observer identifies the membership of a subject in populations with various degrees of risk for death over the subsequent two years.
The SAD PERSON scale is a risk estimation instrument that has the advantage of easy use. It is based on a review of ten items summarized by the acronym. These are: sex, age, depression, previous attempt, ethanol abuse, rational thinking loss, social supports lacking, organized plan, no spouse. These earn one point each if present and a total of five or more justifies hospitalization. Medical students were taught this method and demonstrated successful application to a low risk and a high risk patient previously rated by three experienced clinicians. A control group of students rated both patients at higher risk levels than the experienced clinicians.
The items of this scale reflect 1) circumstances related to the attempt and generally oriented to prevention of rescue 2) self report of lethality of methods, intent to die, premeditation,reaction to survival 3) professional assessment based on the predictability of outcome and need for medical help to prevent death.
The author published a preliminary manual for suicidal ideation in adolescents, which he regards as a precursor for suicidal intent and self injury. He explicitly denies that it can predict, but believes it can be construed as a cry for help.
This scale used items based on 17 epidemiological factors associated with higher rates of suicidal death in 3800 suicide attempters. Scoring consists of assigning one point for each factor exhibited by one patient. A total score is tabulated that places the subject in high, medium or low suicide rate population. The live subject with such a rating can be regarded also as likely to have degrees of self injury behavior.
This scale uses operational measures of planning, lethality, and prevention of rescue in past attempts to arrive at weighted scores reflecting degrees of risk for future self injury events and the associated lethality.
The client can take this test orally or by reading. It is untimed and requires about 15 minutes. It is appropriate for ages 16 and older. The rationale is based on the impaired development of future perspective in potential victims with conscious or intrusive pre conscious thoughts of suicide. The test yields the following scores: present, past, future, and total. The scale also permits scores for omission, faking, and bizarre.
This 20 item test is scored on a 1-4 scale and is given directly to the patient to quantify the symptoms of depression.
The scales described earlier tap common behaviors even though worded differently. The author tabulated the overlapping items by defining the categories listed next. The intent was to provide some minimal operational statements. Further definitions exist in the terms section of this workbook.
DISTRESS describes the behavior that implies insufficient stress management, agitation, or manifest anxiety.
ACT describes self injury behavior including degree of lethality apparent.
PLAN items refer to efforts for arranging a self injury event, and the amount of time or effort expended to achieve this.
RESCUE items describe the efforts to prevent others from interrupting a self injury action.
RISK LEVEL items give the epidemiological probability of death in the next year from a self injury.
RESOURCES, SOCIAL items indicate the lack of available resources, which tend to increase stress precipitating self injury behavior.
VULNERABILITY, PSYCHOLOGICAL describes items of pre existing attitudes that predispose the victim to more self injury behavior.
| Lettieri Scales | Old Male | Young Male | Old Female | Young Female | Sum |
|---|---|---|---|---|---|
| Distress | 4 | 3 | 1 | 3 | 11 |
| Wish | 0 | 1 | 1 | 0 | 2 |
| Act | 0 | 0 | 1 | 1 | 2 |
| Plan | 0 | 0 | 0 | 0 | 0 |
| Rescue | 0 | 0 | 0 | 0 | 0 |
| Risk level | 1 | 2 | 4 | 1 | 8 |
| Resource/Soc | 5 | 2 | 1 | 1 | 9 |
| Vulnerability | 3 | 1 | 2 | 2 | 8 |
| Other Scales | Farberow & Mackinnon |
Beck et al | Weisman & Worden |
Tuckman & Youngman |
Sum |
| Distress | 6 | 0 | 0 | 0 | 6 |
| Wish | 0 | 0 | 0 | 1 | 1 |
| Act | 0 | 0 | 5 | 1 | 6 |
| Plan | 0 | 3 | 0 | 0 | 3 |
| Rescue | 0 | 3 | 5 | 2 | 10 |
| Risk level | 2 | 0 | 0 | 7 | 9 |
| Resource/Soc | 1 | 2 | 0 | 5 | 8 |
| Vulnerability | 2 | 0 | 0 | 1 | 3 |
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Name__________________________________________________Date________
Informant_________________________________Relation___________________
Date of incident__________________________Time_______________________
Place of incident(bathroom, etc)_____________________________________
Other persons present________________________________________________
Self injury method used______________________________________________
What became of instrument used_______________________________________
Parts of body injured________________________________________________
Substances ingested (give name,quantity, size of pills; estimate
if unknown)__________________________________________________________
Describe prior preparations made for this self injury________________
_____________________________________________________________________
Were prior verbalizations made about self injury?____________________
_____________________________________________________________________
Did the victim take steps to prevent rescue? What?___________________
ICDA No (E950-959)___________ Suicide note: Yes_______ No_______
(attach copy of note if available)
Was person hospitalized as a consequence of this incident?
If yes give details of treatment, length of stay, name of hospital, dates,
etc.
_____________________________________________________________________
If available attach copy of law enforcement report
Give dates of prior self injury incidents, and methods used
_____________________________________________________________________
_____________________________________________________________________
Signature:
_____________________________________________________________________
Print name and title of professional below.
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| Name of prescription Common (generic) | Estimated minimum number of units for a lethal ingestion to a 150lb person in typical dosage. |
|---|---|
| Aspirin, (Acetylsalicylate) | 90/5 grains |
| Amytal (Amobarbital) | 30/50mg |
| Arcane (Trihexiphenideyl) | 47/50 mg |
| Asendin (Amoxapine) | 66/50 mg |
| Atarax (Hydroxyzine HCL) | 164/10 mg |
| Ativan (Lorazepam) | 1648/2 mg |
| Aventyl (Nortryptyline HCL) | 84/25 mg |
| Benadryl (Diphenhydramine) | 26/50 mg |
| Butisol (Butabarbital) | 30/30 mg |
| Carbrital (Pentobarbital+) | 10/100 mg |
| Chloral Hydrate (Noctec,Felsules) | 7.5/250 mg |
| Codein | 8/60 mg |
| Compazine (Prochlorperazine) | 66/15 mg |
| Compoz (Diphenhydramine) | 53/25 mg |
| Contac (Chlorpheniramine,Phenlpropa nolamine) | 35/cap |
| Cope (Aspirin, Methapyrilene) | 64/tab |
| Coricidin (Chlorpheniramine, aspriring) | 84/tab |
| Coricidin D (above plus Phyenlpropanolamin) | 78/tab |
| Coumadin | 47/2 mg |
| Dalmane (Flurazepam HCL) | 110/30 mg |
| Darvocet-N (Propoxyphene Napsylate) | 46/50 mg |
| Darvon (Propoxyphene) | 36/65 mg |
| Demerol (Meperidine) | 19/50 mg |
| Desipramine HCL (Norpramin, Pertorfrane) | 15/150 mg |
| Dextroamphetimine, Dexidrine | 20/5 mg |
| Dilantin (Diphenylhydantoin) | 66/100 mg |
| Doriden (Glutethimide) | 12/500 mg |
| Dramamine (Dimenhydrinate) | 33/50 mg |
| Dristan Tablets | 78/tab |
| Dristan Capsules | 19/cap |
| Elavil (Amitriptyline) | 120/25 mg |
| Excedrin | 22/tab |
| Fiorinal | 28/tab |
| Equanil, Miltown Meprospan (Meprobamate) | 17/400 mg |
| Haldol (Haloperidol) | 49/20 mg |
| Librium (Chlordiasepoxide) | 330/10 mg |
| Lithium Carbonate | 15/300 mg |
| Lomotil | 75/tab |
| Loxitane (Loxapine) | 66/50 mg |
| Luminal (Phenobarital) | 45/30 mg |
| Mellaril (Thioridazine) | 39/25 mg |
| Methadone(Dolophin HCL) | 19/5 mg |
| Nardil (Phenelzine So4) | 110/15 mg |
| Navane (Thiothixene HCL) | 49/ 20 mg |
| Nembutal (Pentobarbital) | 10/100 mg |
| Nodoz (Caffeine) | 120/tab |
| Noludar (Methyprylon) | 17/300 mg |
| Nytol, (Methapyrilene+) | 107/25 mg |
| Paraldehyde | 1-3/oz |
| Parnate (Tranycypromine SO4) | 164/10 mg |
| Percodan (Oxycodon) | 94/4.5 mg |
| Phenobarbital | 47/30 mg |
| Placydil (Ehtchlorvynol) | 13/500 mg |
| Quaalude (Methaqualone) | 44/150 mg |
| Quiet World | 58/tab |
| Ritalin (Methylphenidate HCL) | 9/20 mg |
| Seconal (Secobarbital) | 19/100 mg |
| Serax (Oxazepam) | 110/30 mg |
| Sleepeze (Pyrilamine maleate) | 105/25 mg |
| Sominex (Pyrilamine maleate) | 105/25 mg |
| Sominex-2 (Diphenhydramine HCL) | 53/25 mg |
| Stelazine (Trifluoperazine) | 198/5 mg |
| Sinequan (Doxepin HCL) | 23/100 mg |
| Sudafed (Pseudophedrine) | 31/30 mg |
| Talwin (Pentazocine) | 6/50 mg |
| Thorazine (Chlorpromazine) | 19/50 mg |
| Tofranil (Imipramine) | 46/50 mg |
| Tuinal (Amo/secobarbital) | 15/100 mg |
| Tylenol (Acetamineophen) Regular Extra |
40/325mg 26/500mg |
| Valium (Diazepam) | 658/5 mg |
| Valmid (Ethinamate) | 13/500 mg |
| Veronal Bs (Barbital) | 100/30 mg |
| Xanax | 7500/1 mg |
List of toxic household products often ingested and minimal dose reported as fatal.
| Doxal bleach | 1/6 oz |
| Drawing ink | 15 oz |
| Furniture polish (kerosine) | 1 oz |
| Iodine | 3 1/2 oz |
| Lighter fluid (petroleum distillates) | 1 oz |
| Nail polish (toulene) | 1/6 oz |
| Nail polish remover (acetone) | 1 oz |
| Oleander leaves | 2800 mg |
| Paint thinner | several ounces |
| Rat poison (warfarin) | 10-100 mg daily (Repeated dosage required) |
| Shaving lotion (alcohol, methyl) | 20 oz |
| Silicone shoe waterproofer | 1 oz |
| Ten o Six lotion | 30 oz |
Adapted by the author from..
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The ubiquitous human figure drawing test can be adapted to assess lethality of self injury experiences or planning by the simple expedient of asking a subject to draw a suicide. The usual resistances to cooperating will be encountered, and the psychologist familiar with administering this task should utilize the usual efforts to gain cooperation. In addition, suggestions can be made to the effect that most people are familiar with the topic from the information media and can choose any example they have encountered before.
The completed drawing is reviewed as a projective test, with the premise that the subject has demonstrated a preference for the plan drawn. The data thus elicited can be evaluated for lethality much like any self injury behavior. However, these do not provide information about if or when the subject might act.
A schema for evaluating the quality of the drawings is attached. These were developed as research tools by Cutter (1976), White (1980), and Silverman (1980). The test is useful as a non verbal approach to primary processes involved in the wish to die, or the act of self injury. It does not give direct information about the "if" or "when" of suicide, but rather the "how" and "what". In the context of suicide prevention classes the test elicits group feelings or processes that can lead to resolution of distress and better management of self injury behavior.
| Rating: | Description |
|---|---|
| 0 | Blank sheet, or unable to draw an act of self injury; even though human figure is drawn in some recognizable way. Include words only even when they suggest self injury e.g. crucifixion, lynching, smoking, drinking over eating, etc |
| 1 | Minimal injury; drawings are vague, hard to see. Flippant or silly picture. Unrealistic methods, or death symbol even th# done with explicit detail. |
| 2 | Minimal injury; drawings are vague with injury suggested more by words written on page or attitude inferred. Change of mind also detected, before during or after drawing. |
| 3 | Fast rescue/slow injury method drawn. Swallows object, drowning with rescue indicated, "accidents on purpose" , etc |
| 4 | Cuts wrists, bangs head on hard object, hurting self; but drawing not convincing or conveys a diminished lethality |
| 5 | Slow injury; deep cuts, small amount of pills |
| 6 | Deeper cuts if shown, more pills than above, with additional severity cues suggested in drawing or observations. |
| 7 | Unpredictable outcome by method drawn. Pills/alcohol indicated, stabbing to torso, hypodermic to arm, jumping from high wall (ten feet), drowning. |
| 8 | Turns on heating gas, jumping in front of or out of a moving vehicle; jump from bridge or ledge, auto accident (not clearly suicidal). |
| 9 | Certain/slow: Single car accident, on purpose, stabbing at vital area (heart), car exhaust method by hose or in closed garage. |
| 10 | Overdose of identified substance; heroin, amphetamines, barbiturates, poisons. subject's estimates of amounts needed are above the minimal dose. |
| 11 | Hanging, gunshot to torso, jump in front of heav vehicle such as train or truck. |
| 12 | Gunshot to head; jump from sky scraper or other tall place; injection of substances with lethality clearly indicated |
| Reduce above scores by the following criteria; | |
| (-2) | figure not in the act although method drawn |
| (-1) | lethality of method is not convincing; figure seems alive, |
| (-1/2) | more than one method drawn or indicated |
| (+1) | severity cues, and death details present |
A total score is useful in research studies. It is not intended as a predictor of suicidal death outcome. Silverman (1980) noted it was uncorrelated with risk rescue ratings. Nor did it correlate with the wish to die. The face validity suggests lethality of planning, and degree of self injury likely. Its greater value is to facilitate a suicide prevention plan that attends to all primary process motives identified.
Notes :
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This assessment procedure is derived from an unpublished dissertation by Sidney Ganzler (1968). It utilizes a semantic differential like approach to evaluating three concepts in terms of adjective pairs reflecting social affiliation or isolation. The three concepts are my past, my life now, and my future. The subject checks a preference on each line between the adjective pairs. The examiner assigns a score of one to seven. The ratings for all adjective pairs are summed to yield a total score ranging from 7 to 49. The lower score reflects the affiliation needs, and the higher reflects social isolation.
Ganzler's research documented significant differences in group averages between, people in crisis, those using self injury as a coping means, and those psychiatric samples with neither. Norms are not available since his samples came from a limited social strata. The clinician can use the face validity for qualitative evaluations or to compare the individual against previous scores. Ideally local norms can be developed with a sample of 30 or more clients.
The rating sheets are attached.
| The adjective pairs are: | ||
|---|---|---|
| full | - | empty |
| loved | - | unloved |
| isolated | - | intimate |
| alone | - | together |
| close | - | apart |
| helped | - | abandoned |
| lonely | - | accompanied |
| shared | - | unshared |
| accepted | - | rejected |
| uncomforted | - | comforted |
| solitary | - | united |
Ganzler asked his subjects to rate the concepts along a seven point continuum similar in presentation to the semantic differential. The instructions shown are added by this author.
Place an "X" in the space that best describes your feeling
| ----- | ----- | ----- | ----- | ----- | ----- | ----- | ----- | ||
| FULL | : | : | : | : | : | : | : | : | EMPTY |
| LOVED | : | : | : | : | : | : | : | : | UNLOVED |
| ISOLATED | : | : | : | : | : | : | : | : | INTIMATE |
| ALONE | : | : | : | : | : | : | : | : | TOGETHER |
| CLOSE | : | : | : | : | : | : | : | : | APART |
| HELPED | : | : | : | : | : | : | : | : | ABANDONED |
| LONELY | : | : | : | : | : | : | : | : | ACCOMPANIED |
| SHARED | : | : | : | : | : | : | : | : | UNSHARED |
| ACCEPTED | : | : | : | : | : | : | : | : | REJECTED |
| UNCOMFORTED | : | : | : | : | : | : | : | : | COMFORTED |
| SOLITARY | : | : | : | : | : | : | : | : | UNITED |
| ----- | ----- | ----- | ----- | ----- | ----- | ----- | ----- |
Place an "X" in the space that best describes your feeling
| ----- | ----- | ----- | ----- | ----- | ----- | ----- | ----- | ||
| FULL | : | : | : | : | : | : | : | : | EMPTY |
| LOVED | : | : | : | : | : | : | : | : | UNLOVED |
| ISOLATED | : | : | : | : | : | : | : | : | INTIMATE |
| ALONE | : | : | : | : | : | : | : | : | TOGETHER |
| CLOSE | : | : | : | : | : | : | : | : | APART |
| HELPED | : | : | : | : | : | : | : | : | ABANDONED |
| LONELY | : | : | : | : | : | : | : | : | ACCOMPANIED |
| SHARED | : | : | : | : | : | : | : | : | UNSHARED |
| ACCEPTED | : | : | : | : | : | : | : | : | REJECTED |
| UNCOMFORTED | : | : | : | : | : | : | : | : | COMFORTED |
| SOLITARY | : | : | : | : | : | : | : | : | UNITED |
| ----- | ----- | ----- | ----- | ----- | ----- | ----- | ----- |
Place an "X" in the space that best describes your feeling
| ----- | ----- | ----- | ----- | ----- | ----- | ----- | ----- | ||
| FULL | : | : | : | : | : | : | : | : | EMPTY |
| LOVED | : | : | : | : | : | : | : | : | UNLOVED |
| ISOLATED | : | : | : | : | : | : | : | : | INTIMATE |
| ALONE | : | : | : | : | : | : | : | : | TOGETHER |
| CLOSE | : | : | : | : | : | : | : | : | APART |
| HELPED | : | : | : | : | : | : | : | : | ABANDONED |
| LONELY | : | : | : | : | : | : | : | : | ACCOMPANIED |
| SHARED | : | : | : | : | : | : | : | : | UNSHARED |
| ACCEPTED | : | : | : | : | : | : | : | : | REJECTED |
| UNCOMFORTED | : | : | : | : | : | : | : | : | COMFORTED |
| SOLITARY | : | : | : | : | : | : | : | : | UNITED |
| ----- | ----- | ----- | ----- | ----- | ----- | ----- | ----- |
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The Rorschach identification of suicide has been hampered by the blurring of the wish to die with suicidal death outcomes. The original signs of suicide identified by Piotrowski, Hertz & others have been validated against criterion groups who died or survived self injury behavior. The dichotomous group of randomly rescued people led to confounding of different motivations and a resulting failure to replicate. However in at least one attempt where the criterion was degrees of intention, measured by lethality of method, planning and prevention of rescue (Cutter, et al 1968) more of the classic signs were replicated than in a comparison approach with dichotomies. Malariga (1973) has also replicated these signs. Exner (1978) has refined these same signs and along with adding more psycho metric precision, also utilized the criterion of intention as measured by "the greatest probability of producing death, and permit the least amount time for rescue."
The older signs described in the Rorschach literature, will be listed here and replications reported by Cutter et al 1968) will be indicated. The more recent list and largely additional signs reported by Exner (1978) will be listed separately since the scoring is contingent upon his system. These two lists permit the reader to be aware of the accumulated wisdom in the use of the Rorschach procedures, and to choose the list which is more appropriate to their own Rorschach.
The presence of these signs in some critical degree identify subjects who are at greater risk for more lethal self injuries over the next two years. The clinical acuteness or immediacy can be judged from qualitative processes in the protocol itself, by noting experienced distress, and fragility of resources to cope with these feelings. If these signs are related to other evaluations self injury behavior or lethality ratings better assessment as well as intervention can be offered.
Both lists require an appreciation for the degrees of the wish to die and lethality of planning as criteria, rather than the more traditional all or none, suicide non-suicide decisions.
Traditional Signs as reported by Martin, (1951), confirmed by Daston & Sackheim (1960), and extended by Sapolsky (1963) and Lindner (1950). Asterisks indicate successful replication by Cutter, Jorgensen, Farberow (1968). Percentages in brackets show level of confidence achieved in tests of significance.
EXNER SIGNS (1978)
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This simple scale has high user acceptance and emphasized the positive. The client assigns a rating of one to ten for each item. The ten scores are summed. There is an additional optional item that is simply added to the total when endorsed. The total score measures the projected degree of satisfaction that a subject expresses at the time and place of the test. Implicitly, such an endorsement reflects the subject's wish to live, and inversely the absence of satisfaction or the wish to die. Silverman (1980) has demonstrated a high correlation with lethality ratings of previous suicide attempts in his sample of 30 California felons using the risk rescue ratings (Weisman & Worden, 1974). Average ratings on his sample were 47.3 and standard deviation of 14.5 if converted from a six item to an 11 item version reported here.
Employees at a health fair who volunteered to take this scale achieved an average score of 75.3 with a standard deviation of 11.5 for l1 men and 10 women. Nineteen male dialysis patients at the Sepulveda VA achieved an average of 75.5 with a standard deviation of 15.7
The lower satisfaction scores in the prison population is consistent with their known history of social pathology and previous attempts. In addition Silverman, also reports that the satisfaction scores correlated best with risk rescue and the Beck hopelessness scale.
These group scores are not intended to provide norms but merely to share previous experiences. The user can apply this scale for serial testing of a high risk person over an interval of observation where changes provide clues to alterations in the wish to live or die.
SATISFACTION SCALE
Name : ____________________________________ Date : __________
Estimate the amount of satisfaction you have today for each of these aspects of your life, by circling a number from one to ten
| Source of satisfaction | Least | Most | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Appearance | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| Eating | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| Energy | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| Home | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| Love | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| Others | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| Money | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| Projects | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| Recreation | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| Self Sufficiency | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| Additional Source (specify please) |
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
Total Satisfaction (Sum of all circled numbers) _____
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Significant losses in childhood are known to predispose to adult pathology (Bunch & Baraclough,1971; Dorpat, Jackson, Ripley,1965: Greer,1966). Parental bereavement before adolescence has been reported in such diverse pathologies as the various cancers, mental illness, crime or suicide. While still controversial this aspect of potential explanations for self injury behavior is worthy of continuing evaluation in every high risk subject.
Significant losses include other events besides death or separation. Losses can occur by person, body part, skill, social role, or from sentimental possessions. The significant loss survey elicits data in these areas both past and recent. The checklist was modified by Tinker (1977, Silverman (1980)and Rubenstein (1981).
The scale provided in this book is intended to survey all losses perceived as important to the subject both in the past and in more recent years. The model implied here is that early losses are predisposing with more recent ones playing a precipitating role in the sense of adding stress to a vulnerable person. By assigning ages to the losses listed, the subject projects when, as well as what, was important in his or her background.
The items listed can be summed to provide a total count of recalled or experienced losses. These sums lack a measure of affective impact, nor are the norms available, applicable to all patients. However, the health professional can use the responses as a measure of extent, and when seasoned with professional judgment provides a clinical sense of impact and vulnerability. In this context, it can be noted that Silverman (1980) reported a significant correlation, between past losses and suicidal intent as measured by the risk rescue ratings.
These data help introduce more clinical predictions and can be understood by clients. Well handled, these loss identifications can lead to skillful interventions such that their negative impact can be resolved.
NOTES
SIGNIFICANT LOSS CHECKLIST
| Name_________________________________________ | Date________ | ||
| AGE __________ | BIRTH DATE________ | ||
| This checklist is designed to discover the important losses that people have experienced in their lives. You are being asked to identify the ones that pertain to you. Write in your age at the time the specific loss occurred to you. Leave the line blank if if it does not apply to you. | |||
| Loss of person | First name | Relation to you | Your age then |
|---|---|---|---|
| 1. Death | A______________ | _______________ | _____________ |
| B______________ | _______________ | _____________ | |
| 2. Separation | A______________ | _______________ | _____________ |
| B______________ | _______________ | _____________ | |
| Body Part | Describe Cause | Your age then | |
| 3. Vitality | ________________________________ | _____________ | |
| 4. Limb | ________________________________ | _____________ | |
| 5. Sense Organ | ________________________________ | _____________ | |
| 6. Other | ________________________________ | _____________ | |
| Activities | |||
| 7. Ability to work | ________________________________ | _____________ | |
| 8. Love from family | ________________________________ | _____________ | |
| 9. Self Respect | ________________________________ | _____________ | |
| 10. Other | ________________________________ | _____________ | |
| Possessions | |||
| 11. Business/Job | ________________________________ | _____________ | |
| 12. Home, property | ________________________________ | _____________ | |
| 13. Pet | ________________________________ | _____________ | |
| 14. Other | ________________________________ | _____________ | |
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Everybody thinks about their own death at one time or another.Many people develop an idea of when they would rather cease to be. The following questions are intended to make clear those ideas.
Name_____________________________________________Date_____________
2. Under what circumstances would you prefer to be dead?
___________________________________________________________________
3. Have you ever thought about a way of achieving death with dignity
if the above circumstances came true?
Yes_____No_____Please describe:_____________________________________
___________________________________________________________________
4. Would you say good bye or tell anyone if you knew you were going
to die shortly?
Yes_____No_____Please describe:_____________________________________
___________________________________________________________________
5. Have you made arrangements for your property, disposition of your
body and memorial services in the event of your death?
Yes_____No_____Please describe:_____________________________________
___________________________________________________________________
6. If you answered no above, is there a reason? Please describe.
___________________________________________________________________
___________________________________________________________________
7. Anything else you want to say about your readiness to die?
___________________________________________________________________
___________________________________________________________________
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Three aspects of self injury behavior influence the lethality of the
vital outcome. These three are independent of each other and additive in
yielding assessment of degrees of self damage likely to occur (Cutter,1970).
These three factors are
Each can be rated on a scale of 0 to 6 by criteria provided here. All three ratings can be summed to yield total scores ranging from zero to eighteen. Average ratings for suicide attempts among veterans was 10.0. Average ratings among veterans who killed themselves was 13.3 with significant overlap in the two populations. The two samples were both neuropsychiatric and achieved comparable ratings for prior attempts. The N for attemptsample was 30; for the commit 60.
Thus the ratings are useful in establishing the probability of serious damage in the next self injury incident, while not able to predict likelihood of death. This is consistent with the current state of knowledge in not permitting statistical prediction of death outcomes from self injuries (Mackinnon & Farberow, 1975).
The attached criteria can be rated formally as indicated above or used as guides to sharpen clinical judgment in making quick evaluations of the lethality of any given attempt; whether actual or verbalized. The formal rating assigned represents a bottom in that succeeding attempts or repeated planning tends to increase the overall lethality. The clinical should expect future self injury behavior to be more lethal than in the past.
NOTES
| 0. | No Planning. No preparation apparent. Can include acknowledgment that thoughts about suicide were had. |
| 1. | Intent inferred by actions, but otherwise ambiguous. No planning apparent. The observed self injury actions occur as part of impulsive, psychotic, substance influence. Accidental features are prominent. Include lack of judgment in the absence of the above. |
| 2. | Implicit intent apparent by prior verbalizations. Planning is superficial; has some knowledge of method and place as demonstrated by the actual effort or plan. Opportunistic features prominent, uses methods available, immediately. |
| 3. | Explicit intent apparent. Some preparation in evidence as in efforts to accumulate medication, obtain a gun, but no setting of time or place. |
| 4. | Advanced preparation with respect to availability of method choice of place or time; not both or no information noted. Shorter interval between first thought and start of self injury action (less than one week). |
| 5. | More advanced preparation with respect to availability of method, place, and time. Can include "alcohol for courage". Longer interval between first thought and start of self injury action (more than one week) Include paranoid delusional states. |
| 6. | More evidence than in #5 of planning; is aware of movement of potential rescuers; preparation of notes, wills, insurance; elaborate efforts to obtain or construct a method. Give a lower rating if elements of impulsivity present. |
NOTES
| 0. | Self injury simulating. No damage possible. Can include more lethal method planned, if subject changes mind before acting on it. |
| 1. | Inadequate or ineffectual as taken. Examples: swallowed buttons, overdose of castor oil, cutting wrists with nail file. |
| 2. | Low order of effectiveness such as superficial cutting of wrists, depth unspecified, pushed hand through glass window, or banged head on wall. |
| 3. | Moderate effectiveness. Deeper cut on wrists, requiring stitches; jumped into deep water, can swim; ingested unknown amounts of non prescription drugs available in bathroom cabinet. None or small amounts of prescription drugs. Do not include street drugs. |
| 4. | Ambiguous outcomes, potentially lethal. Ingested unknown amounts of prescription pills. Takes part of own prescription but leaves some. Presence of alcohol in any detectable amount, include cross addicting prescriptions used as anti anxiety agents by patients. Turned on household gas; jumped in front of or out of a moving vehicle. Jumped in water cannot swim. Cut tendons deeply. No information and street drugs scored here. |
| 5. | Higher effectiveness. Cutting or stabbing at vital organs, explicit description available. Took Chloroform. Ingested known household poisons. Carbon monoxide poisoning from car exhaust. Takes all of own prescription. |
| 6. | Higher order of effectiveness. Irreversible method, no time for rescue; gunshot, hanging, jumping from high places, or in front of a train or other heavy vehicle; Injected toxic substance in blood vessels. |
NOTES
| 0. | Subject rescues self before, during, or after a self injury incident. |
| 1. | Subject makes the attempt in the presence of one or more others, ignores lethality of method preferred. Exclude suicide pact. |
| 2. | Somebody notified before, or sought out immediately after the incident, especially a medical resource. |
| 3. | Somebody expected momentarily. Subject is, or should be aware of this potential rescuer. |
| 4. | Subject makes no effort to facilitate or prevent rescue. No information scored here. Leaves rescue to chance. |
| 5. | Method carried out or attempted in a place where possibility of intervention is minimal. Fast acting methods that preclude intervention would be rated here. If subject is rescued it would be due to chance. |
| 6. | Subject takes active and elaborate measures to avoid intervention. Registers in hotel under assumed name, leaves "do not disturb" sign on door. |
NOTES
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Assessment of suicide remains a complex and obstacle laden domain because of previous failures to specify operational criteria of suicidal intention, differentiate these from motivations for self injury behavior, and delineation of outcome criteria for prediction efforts.
Progress is occurring in these contexts with the recognition that intention to die is quite different from the lethality of the methods chosen to achieve death. Further progress has occurred in the shift to risk estimation of populations rather than prediction of suicidal death in a clinical case. Many new tests have appeared in the last forty years that contribute relatively more information about some aspect of suicidal behavior. Some of these are reviewed in this chapter, with efforts to identify common aspects such as the wish to die, the acts of self injury and measures of distress associated with depression, perturbation, loss of hope and suicidal threats.
A new, and as yet not fully applied, concept is the use of a base rate to estimate the expected number of commits and self injury victims. The value of this information is in permitting comparison of expected with observed incidences of victim behavior. These differences permit measurement of the efficacy of care, in general and of a specified treatment program for an identified sample at risk. The basic minimum evaluation should include questions about as the presence of a wish to die, suicidal plan, availability of method and prior attempts.
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