Chapter 6




In recent times, the suicidology literature has provided descriptions of additional methods and better understanding of motivational issues that facilitate more optimal interventions. These methods also represent developments corresponding with the changing policies on hospitalization increasing reliance on anti-depressant medications. These behavioral and cognitive approaches represent additional attention to distressed patients focused on specific aspects which contribute to perturbation and suicidal behavior over the 2 to 4 month period following an attempt or treatment. This chapter describes the ones reported in the current literature that seen to yield better prevention options when introduced, but are not universally practiced and remain relatively esoteric or new to health care professionals.

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Good Practices For Suicide Prevention In Any Health Setting

Effective suicide prevention requires a systems approach, since one human cannot effectively control another from engaging in any willful act such as crime, drug abuse, sexual behavior, or self injury. However, some humans can introduce change, create obstacles or inspire hope. The health professional brings special resources to the task of suicide prevention in addition to their more human talents. First among these is the power and respect that their specialized knowledge, however limited, inspires in all health care clients. Such knowledge can be enhanced by thinking long range and in terms of the life cycle of high risk people coming for care. Effectively, the health professional needs to plan a suicide prevention role for everyone who participates in the care of the client. Suicide prevention is everyone's responsibility no matter what the paid assignment may be. The following list of good practices represent an array of activities that all personnel can be asked to take, without overloading or working out of classification.

All professionals need instructions in how to report the facts of a suicidal event. The present clinical entries in health records are incomplete, inadequately described, and lacking in operational descriptions of the facts constituting the event. This occurs partly because there is a literal breakdown of communication between those with the information and the health person who receives the news. Since most deaths or self injuries occur away from the health setting, the resulting telephone or newspaper accounts get garbled or lost in transition. However, even when the information is available health personnel fail to ask relevant questions or record significant details: who, what, where, when, how. The police investigative report is a good model of what a clinical entry should contain. This book has a Self Injury Incident Form that provides guidelines for the kind of information needed in describing any suicidal event.

Such information once elicited should be evaluated in order to assess lethality of methods and the degree of preference expressed in its selection. For those who survived the incident such assessment permits better planning for the prevention of the next self injury event. The rating schedules provided in this book allows the health professional to assess the kind and degree of supervision following any one self injury incident, and permits longer range planning. Changes through several attempts can be assessed to identify increasing lethality or overdetermination for any one method. The data can be utilized in developing a suicide prevention plan, with or without the client's cooperation. All of the facts can be used in identifying the degree of high risk for future self injury behavior.

A fourth and more practical value of these data come in making management decisions for a manipulative or borderline client. Not all people who exhibit a wish to die need to be hospitalized nor supervised. The degree of lethality can differentiate those whose preferred methods of self injury provide more margin for survival than others. While all people exhibiting acute wishes to die are worthy of professional attention, the kind and degree of care is best decided by judgments based on the lethality of self injury method most likely to be used. The assessment of this lethality is facilitated by the criteria presented in this book.

Routine interviews with significant others, whether a self injury or death has occurred, is desirable for better health care (Rudestam, 1975). This represents a kind of psychological first aid for people who have been exposed to a trauma. Survivors have much distress, whether it be guilt, shame, anger, or anxiety that is often assuaged by the professional opportunity to review the feelings with a neutral observer. A second value is to obtain some of the clinical facts considered important for an adequate assessment of the self injury event. Where the client has survived, these interviews provide data and rapport for clinical planning to deter future self injury events. There is the long range prophylactic value that significant others, especially children, are at some greater risk for developing their own future self injury behavior following a traumatic event in their family (Paffenberger & Asnes, 1961; Greer, 1966;Bunch & Baraclough, 1971; Dorpat, 1973; Lester & Beck, 1976). There is a tendency for survivors as well as health care professionals to reinforce the self injury behavior of clients by the attention and over reactions to death wishes, threats, and gestures. These can be minimized by appropriately oriented health professionals.

Psychological autopsies (Weisman & Kastenbaum,1972; Weisman, 1974) should be organized following every suicidal event. Instituting these has the value of desensitizing all health professionals so that they can employ their best judgment free from duress, guilt, or anxiety. These meetings themselves are constructive in developing more information and explanations than are usually found. They also provide clinical forums for teaching health teams to work more closely together in planning for long range care as well as suicide prevention. The cost of these meetings is far less than apparent at first thought. Suicide is just as distressing to staff as it is to survivors, and much professional time is spent in trying to manage personal grief, which is much more appropriately handled in team settings. A checklist for conducting a psychological autopsy is given in this book.

The adoption of the preceding good practices will yield more information than is clinically usable in preventing future self injuries of the specific client. However, to accomplish this goal a suicide prevention plan must be formulated for each potential victim. This should be done with the participation of the client whenever possible, but regardless it must be accomplished at the earliest opportunity. A form is provided in this book to facilitate this goal. The basic strategy is to identify the preferred method whether it be the most recent or the one given as likely to be chosen in the future. Next the steps that might deter or block access to it should be specified. In identifying these, it is important to permit primary process logic as perceived or expressed by the client. These have the value of patient involvement and credibility. The plan adopted should meet some professional judgment of improved prevention while retaining as much of the client's feelings as possible. Such a plan can be adapted to a quasi contract where the client agrees not to act until calling the professional. However, the clinician should be cautioned to think in terms of limited time spans; hours and days rather than weeks. Suicide prevention plans should be reviewed frequently, but especially at clinical choice points such as discharge planning or treatment changes.

Exit interviewing should be explicit planning opportunities for each person as some phase of health care is completed. whether inpatient discharge, or outpatient follow-up. It is well documented that the first 3-6 months post hospital is the period of greatest risk for clients with prior self injury histories (Resnik & Lettieri, 1974). People with one or more previous incidents of self injury are considered high risk for the rest of their life. The exit interview can identify the factors associated with degree of risk and the lethality to be expected in the future based on past incidents (Farberow, 1981). In addition, such a review can formulate or update a suicide prevention plan. This would be the time to insure that coping with stress is adequate, and for building in specific suicide prevention resources such as letter follow up. Especial emphasis should be placed upon designating helpful people and insuring their availability.

Letter follow up has been demonstrated to be effective in reducing suicide rates of high risk people (Motto, 1978). Simply sending a friendly letter offering help and assurance, whether or not accepted, is by itself correlated with reduced death outcomes from self injury. A sample array of quarterly letters for 24 months is included in this book.

Suicide prevention classes for high risk people in between suicide attempts has been observed to be effective as strategy (Cutter, 1977). The content and selection criteria for conducting these group interventions are also described in this book. It should be noted that this procedure is intended for clients in between acute episodes of psychosis, depression, or the wish to die.

Self help groups represent an additional resource for high risk people in between acute episodes. It can be modeled after AA, Recovery Inc. or Patient Clubs. Where established, these represent an additional resource not otherwise available. Like any support group, there is a need for continuity of direction and leadership. These are most often provided by health professionals (Cutter, 1960; Heilig, Farberow, Litman, & Shneidman, 1968). Survivors Anonymous and Survivors of Suicide (SOS) are recent examples that express this good practice.

A suicide prevention committee is a resource group of professionals in any health setting organized in a multi disciplinary model to solve problems, and advise the staff of optimal procedures. Such a committee when functioning well provides a neutral group that leads psychological autopsies and gives guidelines to the whole health team. In smaller clinics or solo practice, the size and composition of the committee would necessarily be different. Local associations of peers could fill this need in the absence of a formal committee structure.

Annual awards for outstanding acts of suicide prevention to individuals or health teams should be made by the suicide prevention committee or appropriate alternate. Such awards can take the form of cash or recognition certificates, plaques, and publicity in the local media. While these awards can be given at any time, there is some advantage to correlating them with national suicide prevention week or annual mental health observances. The net effect is to reinforce positive action while destigmatizing the negative aspects of suicide prevention.

Research or evaluation is always salutary in that the circumstances that are required to conduct any health study also permit more objective management of self injury data. While financial support and release time, may not always be available, individuals need encouragement to pursue research goals as a labor of love. The value here is that all self injury behavior is a negative, while all efforts to study it is a positive. The process of testing a hypothesis by data is a good suicide prevention practice in its own right since it tends to enhance the environment in which care is provided.

Scheduled health professional training in better suicide prevention is also a good practice. This represents continuing education and helps facilitate the professional growth needed to enhance the team capability. Aside from knowledge itself, the process of seeking, finding, and sharing the various audio visual material available promotes better communication and systems capability. A list of sound tapes, video cassettes, 16mm documentary movies is provided in this book. A list of books on suicide published before 1938 and after is also included. All of them have some merit as judged by the increments of knowledge they offer the whole field.

Every health facility and professional should compute a base rate of expected self injuries and suicidal deaths for the next year. These are computed from the epidemiological factors and the associated suicide rates for each. These are: age, sex, prior attempts, marital status, symptoms of depression, living alone and recency of discharge from health facility. Such a base rate provides a standard against which to judge the effectiveness of health care. Most facilities actually experience a far lower number of deaths than base rates would suggest. A work sheet for base rate computation is included in this book.

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Guidelines For The Client Suicide Prevention Plan

Clinical information that is elicited in the area of previous self injury behavior can be assessed to establish future risk of recurrence and degree of lethality to be expected. Such data can be communicated to other health care professionals and the clients themselves motivated to follow these. The health professional need only complete the form provided in this book, with the client's participation, and make copies available to everyone concerned through the health records.

During remission, or after the acute episode of wishing to die, the client can cooperate in helping the health professional develop a suicide prevention plan. The items in this form merely elicit the relevant information. Starting with the last self injury incident, or planning, the client and the professional list those items that can impede a future plan to achieve a preferred of self injury. Both the plan and the impediments, will include primary process logic, and meanings that are not objectively logical, but are powerful precisely because these tap into unconscious motivations, overdetermined by earlier, probably childhood experiences.

Accumulate any and all steps that deter a preferred self injury plan. The health professional can suggest additional steps, but must make sure, that the client is comfortable with these. Final implementation depends on the client's ability to act during a crisis. The planning process should also help clarify, and rehearse the prevention steps that will deter the preferred self injury. Resource people should be listed in priority to be contacted; first, second, third, etc. If client is ambivalent, attempt to resolve reluctance, or list with qualifications.

Contracts with clients can be made by having them sign at the bottom. However, as a clinical procedure, such arrangements assume a close rapport of some minimal intensity. Under the best of circumstances, such contracts are short term, measured in hours or days. These should be renewed at least weekly in face to face contacts, or daily by telephone. Letter follow ups are a long range intervention that assume the client is not in crisis at last contact. The mailing address permits its implementation at a later date and alters the client to expect these. See the model follow up letters in this book.

The plan can be inserted into the health record so as to alert other colleagues to support it. The client should be given a copy at the time this form is completed. Modifications can be made to improve the plan whenever the client is seen. Additional copies may be provided in case the client loses the original.

Suicide Prevention Plan for _____________________________________

Date completed:____________ Most recent attempt date:____________

Describe apparent planning:

Method used:


Satisfaction score:
(wish to live)

Loss list completed (Y/N)
(compare early & recent)

Prevention steps:
(developed in cooperation with client)

Resource people:
Rank order ---------------------------- Relation ---------------------------- Tel No.

Suicide prevention classes (y/n)______ Letter follow ups (y/n)_____
(dates to attend)

Signature of client__________________ Signature of preparer_______________
Name: Name:
Tel. No: Tel. No:

History of previous self injury incidents for ___________________


Date ____________time___________address_______________________________

Location(bedroom, alley, etc) ____________________________________________

Planning _____________________________________________________________

Method used _________________________________________________________


Alcohol/substance used ________________________________________________

Precipitating losses (if any) ______________________________________________


Date ____________time___________address_______________________________

Location(bedroom, alley, etc) ____________________________________________

Planning _____________________________________________________________

Method used _________________________________________________________


Alcohol/substance used ________________________________________________

Precipitating losses (if any) ______________________________________________

For third and fourth incidents add additional sheets as necessary.

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Degrees Of Observation For Degrees Of Preventive Supervision

Clinical management of patients considered acute can be provided on the basis of the degree of apparent intention to die rather than on an all-or-none basis in which one-to-one supervision is the only recourse. The following steps represent increasing degrees of staff supervision for increasing degrees of risk to the patient. The criteria for making these evaluations and assessments are provided elsewhere in this book. Here suggestions will be provided for behavioral management.

RISK LEVEL 1. Close observation, more than is usually practiced for routine care
a) restrict to unit
b) wear pajamas or special clothing
c) frequent contacts with personnel, more than once per hour
d) assigned bed near staff office
e) strict implementation of existing security procedures, especially with respect to contraband, potential instruments, etc.
f) evaluation for changes in wish to die motives
g) frequent assessment of preferred method and appropriate interventions
RISK LEVEL 2. Closer observation than in #1 above
a) visual observation by staff at all times
b) locking unit, if not already a locked facility
c) daily evaluations for changes in wish to die motives
d) notify primary therapist of changes noted
e) monitor preferred method, as needed.
RISK LEVEL 3. Closest observation.
a) One to one observation
b) search possessions, room and body for all possible self injury instruments
c) more than daily evaluations for changes in wish to die motives
d) assessment of preferred method once per day, and appropriate changes in observation strategy to prevent the indicated self injury behavior.

Levels 1, 2 & 3 are accumulative and represent increasing degrees of observation and intervention to match the increasing degrees of intent and kinds of methods preferred. Where the patient is actively, or continuously attempting to hurt self more extreme steps should be taken such as seclusion and restraints with hourly observation and support procedures provided by existing standards of care. As the degree of intention to de diminishes, and the acute suicidal stages begin to resolve, the levels can be reduced but with explicit evaluations, decisions, and documentations. Long term interventions should be started before the patient is returned to ordinary treatment regime.

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Letter Follow Up After Discharge From Active Treatment

These model letters are to be sent at least quarterly to clients identified as high risk for a future self injury incident. These can be sent regardless of response to past interventions, and have been demonstrated to be of some value in reducing subsequent suicide rates (Motto et al. 1978).

The sender should be known personally to the client. Ideally it should be the main therapist or the case manager. Often this is not possible especially when clients have made a negative transference to this person. Clearly it helps to have some one signing the letter who is known and for whom the feelings are at least neutral if not totally positive. The letters can be prepared by clerks or work study students, and signed by the preferred person; if possible some handwritten notes are always more personal. These can be incorporated into the model letters contained in this book.

Word processing letters can be used, if there is no attempt to deceive, and seasoned with sensitivity to the individual receiving the letter. Some respond to humor, some to frankness, and others to personally written notes.

In the last analysis it is better to send a letter than to do nothing during the follow up period. An optional note for word processing letters to be included in the first letter if deemed appropriate is illustrated text.

These letters are prepared by our staff and produced by our word processing equipment. Each one is reviewed and signed by the person responsibilities for you continuing care, who may add some more personal remarks as the occasion arises.

Dear Mr Smith,
We hope everything continues to go well for you since we talked three months ago. We know you prefer to manage your own affairs and respect your decision to do so. This note and the ones that will follow, are intended to encourage you in this choice, and your decision to go on with your life. We also want to assure you of our continuing availability should you need our assistance.


the staff.

Dear Mr. Smith,
Just another note to wish you well and assure you of our continuing availability should you want our assistance. We assume you are doing fine these last six months.


the staff.

Dear Mr. Smith,
Its been nine months since we talked to you last. We wish you well in your efforts to manage your affairs and are still available if anything comes up where you want our assistance.


the staff.

Dear Mr. Smith,
We are pleased to remind you that it has been 12 months since we saw you last. We assume you have been able to manage your affairs without help from us. We will continue these notes to let you know we are cheering for you, and that we are still available should anything change.


the staff.

Dear Mr. Smith,
It has been 18 months since our last meeting. We are pleased to think you are getting along fine by your own efforts. Let us hear from you if you can drop us a card. Otherwise we are still cheering for your continued success.


the staff.

Dear Mr. Smith,
Congratulations! Its been two years since we had our last meeting, and you are clearly managing on your own. This is the last note scheduled, but we would be glad to continue them if you would let us know of your interest.


the staff.

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Organizations, Support Groups and Scientific Journals


OUROBUROS, snake that eats its own tailOuroburous, the snake that eats its own tail


American Association of Suicidology, Central Office, Washinton, DC The AAS conducts annual meetings, prints a directory of mental health professionals who specialize in suicidology and are members. The same directory lists Suicide Prevention Centers in the US & Canada. The AAS supports public information, sponsors a journal (SUICIDE AND LIFE THREATENING BEHAVIOR) and a newsletter (LINK).

Annual conference on Gay & Lesbian Suicide, San Francisco Suicide Prevention Center, 3940 Geary Blvd, San Francisco CA 94118.

Befrienders International, Samaritans Worldwide, Mrs Vanda Scott, PO Box 50029, Dalls TX 75250-information for volunteers worldwide.
E-mail :

Canadian Association Of Suicide Prevention.
E-mail :

International Association for Suicide Prevention, Sponsors biannual meetings, Crisis, & efforts to deter suicide.

Samaritan Centers in ths US are listed in the directory published by the AAS. A call to any one listed below will lead to current centers and telephone numbers in other cities.

Chicago 312 947-8844
Boston 617 536-2460
Providence 401 272-4044
Washington DC 202 546-1544
Samaritans for E-mail :

The Center for Thantological Research & Education Inc, 391 Atlantic Ave, Brooklyn NY 11217 distributes books, tapes, and publications dealing with death, dying and suicide.

Crisis Line International, PO Box 2354, Joliet IL 60434 )815) 744-5592-consulting service to develop a telephone hotline system for meeting various community, social service, school, business and industrial needs.

Project Life Saver, Suicide Prevention Center, Inc, PO Box 1393, Dayton OH 45401-1393-A manual for child and adolescent suicide prevention education in two school systems. Other manuals and publications are available free of charge if a stamped self addressed 10 x 12 inch envelope is sent with a request.

Suicide Information & Education Center (SIEC), 201, 1615-10th Avenue SW, Galgary Alberta T3C OJ7 (405) 245-3900 - provides a computer accessible database, a resource center and information clearing house.


(205) 473-3525
Robert L Godwin, Jr

LA CA 90006
(213) 386-5111
Janet Belland

20165 DEVON
(303) 596-2575
LaRita Archibald

(302) 655-8847 OR 652-0326
REV. Paul Bauer & Rev Marlene Walters

(312) 236-5172
Charles T Rubey

(312) 426-8611

(317) 353-4743

PO BOX 80738
(504) 924-1595

SEASONS:Suicide Bereavement
(301) 788-9377
Douglas Tipperman

(612) 929-6448

(616) 455-0372

(518) 482-0799

2421 13th st nw
canton oh 44708
(419) 452-6000
Susan Gross

(216) 362-0000
Don C Wolfe

(513) 223-9096
Wanda Y Johnson

(513) 683-1227 OR 523-8646
Sally Housmyer & Cynthia Kelley

(401) 272-4243
Carolyn B. Drew

PO BOX 16961
(817) 924-9201
Patty Grub & Larry Grubb

PO BOX 40068
(901) 276-1111
Mary Pucket

201-723 14TH ST NW
(402) 283-7591
Judith Blythe

residents of Seattle/King Countries, State of Washington, 1530
East Lake East, # 301, Seattle WA 98102
(206) 447-3210


Afterwards, a quarterly newsletter about suicide and suicide grief. Editor Adina Wrobleski. 5124 Grove St Minneapolis MN 55436.

Crisis, Semi Annual, Editor Raymond Battegay Published by C J Hogrefe Inc. 12 Bruce Park Ave, Toronto ONT M4P 2S3, Canada.

Omega, Quarterly, Editor Robert Kastenbaum, Published by Saywood Publishing Co. Suicide & Life Threatening Behavior, Quarterly, Editor Ronals Maris, Published by Guildford Press.

Thanatology Abstracts, Biannual, Editor Otto Margolis.

Advances in Thantology, Quarterly, Published by the Foundation of Thanatology.

Archives of the Foundation of Thanatology, Quarterly, published by the Foundation of Thanatology.

Suicide Research Digest, quarterly, Editor David C Clark & Susan C Younger. Published by Center for Suicide Research and Prevention, Rush Presbyterian-St. Luke's Medical Center, 1770 West Polk Street Chicago IL 60612 (312) 942-7208.


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Psychological Autopsy

Suggestions for the Psychological Autopsy

The traditional medical pathological conference was adapted by Shneidman and colleagues in the early fifties (1961) to evaluate ambiguous modes of death reviewed by the LA Coroner's office. There is no one way to conduct an autopsy nor is it merely a collection of elicited facts. The psychological autopsy when carried out appropriately, is really a human process where health professionals attempt to identify the motives, life styles and feelings of the patients by reviewing their own deservations including private feelings towards the patient.

These data become available when health care teams seek to find an explanation for self injury behavior in a client in a context of professional observations, reviews, and of searching for one or more consensuses. In this process, new facts are created coming, from participants who have accumulated attitudes based on client's behavior. In the course of reviewing victim activities, one or more present begin to express these collective attitudes. Such themes became diagnostic of victim life styles, problem solving, and intentions to die.

The user of this guide line should be aware that there are levels of observation possible and that information or attitudes surfacing in the conference will have different meanings depending upon what source is perceived. These levels of observation are:

  1. The facts of death or self injury
  2. The chronology of these facts
  3. Inferred motivations by the observers
  4. Reactions of victim associates to the above
  5. Collective themes observed in survivors or assembled staff

There is no set way to conduct the autopsy, nor listing of facts to be obtained. It is rather a process, in which the whole is greater than the sum of its parts or the isolated facts elicited. The list attached is simply a guide to starting the process, which will proceed at its own pace and in directions never quite predictable. The guide is intended to help the chairperson keep some perspective on the events. There is no substitute for professional judgment and collegial review of ambiguous outcomes.

In addition, the facilitators should be aware that participants are experiencing a loss which varies in degree for each member of the staff, whether present or not. They will each be utilizing their own unique methods of managing these feelings. The person providing leadership to the autopsy conference needs to follow each person present sufficient psychological space to accomplish personal resolutions of great reactions.

Guide to the Psychological Autopsy

NB : The psychological autopsy should be separate from any medico-legal investigation. The chairperson should attempt to provide a non judgmental and supportive atmosphere.

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The essential ingredient to more effective prevention is more professional attention to the high risk victim before they become acutely suicidal. This can take the form of volunteers, family, additional health care personnel, or support groups. The methods for mobilizing additional attention are described in this chapter.

Other Chapters...


Chapter 6

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Copyright© FRED CUTTER, Phd.