This chapter describes new developments over the last decade that needed separate space and did not quite fit into other chapters all of which contain updates where available. Of these the most innovatyive seem to be the efforts to incorporate suicidology into computerlized programs. Positive reasons for living seems to be increasingly consistent as a correlate of survival and its absence is associated with efforts identify high risk people. The emergence of survivor and support groups mainly staffed by volunteers who themselves have suffered a loss is a major clinical resource which helps the leaders recover some balance as well as providing more resources for the "worried well".
Suicidology is participating in computer applications for clinical intervention but less so than other domains of mental health care. Some resistances to computer applications are preferences for human procedures, perceived low cost-benefit of any increased suicide prevention, human inertia to any new practice, or "protection" of clients from "machines". The advantage of computer assisted programs are optimal management of drudgery associated with:
Twelve focused suicide prevention programs are known to the writer and reported in a previous paper (Cutter, 1988). These are described here and grouped into similar functions. There are two community resource coordination programs (Abert, 1989 & Pagano, 1988); two more for training of medical students (Gentry & Woods, 1985); training of workers at the high school level (McKinnon, risk for students (Hickson, 1988), psychiatric patients (Griest et al 1873), and general population (Cull & Gill 1982); four interactive interviewing and recommendations (Colby, 1990; Cutter, 1990; Petrie, 1988; Kalb, Fehler, Grabisch, & Demling, 1988). Suicide Information and Education Center (1989) is a data base program of the world literature on suicide which can be accessed by modem or letter.
Computers have a role in suicide prevention on at lease three counts. The first is simply in some word or data processing function whether it be for administration, or research. The second is in direct clinical service to the client by professionally generated data in order to provide systematic evaluations and recommendations. The third potential is in client self help programs where software can give access for those high risk people who can use the terminals of computers.
Computers have already appeared in the office as word processing, accounting and appointment scheduling to name the most visible. Data processing for research is also relatively well known. The use of computer programs to interview clients for suicide risk have been reported, and subsequent efforts to predict out.
Come have been compared with the human experts who proposed the criteria. The results administrated that the computer predictions were significantly more accurate than the human counterparts (Griest et al 1972).
The burgeoning electrnic bulletin boards are starting to compete with call in radio shows and are potentially available as hotlines. A psychologist has provided a stress management bulletin board where callers received assistance in learning to manage their own programs of stress reduction (Walker, 1986).
The author suggests the creation of an electronic bulletin board oriented to gate keepers, volunteers, significant others, and self help. Public health education information could be accessed on any topic related to suicidology. An existing suicide prevention center is the most appropriate, although existing computer groups may well provide a more visible and available organization to the at risk user.
Among people with the equipment, those who have self injury ideation could access bulletin boards with programs that provide suicide assessmens and recommendations such a in the Suicide Prevention Triangle program. When this happens it will be a welcome additional resource that taps populations which might otherwise never call for help. The AAS has formed a computer committee which is exploring this and other options.
Readers interested in applying any of the programs or developing an electronic bulletin board approach are invited to contact the author for current status or assistance. A list of focused programs and the flow chart for the proposed bulletin board is added here.
Table 9
Computer programs in suicide evaluation and training May 1989
| SOURCE contact | ADDRESS telephone | DEVELOP started | USERS intended | CLIENTS access | PURPOSE |
|---|---|---|---|---|---|
| Crisis Clinic Peter Abert |
1515 Dexter Ave N, Seattle WA 98109 (206)461-3210 |
1980 | Counselors | No | Guide-caller types |
| Colby & Simon NPI, UCLA | Mallibu Artifactual, Intellig. Works, 25307 Malibu Rd, Malibu CA 90265 | 1987 | Clients | Yes | Patient educat |
| Cutter Private pract. | 290 Cypress Ave, Morro Bay CA 93442 (805)543-3575 |
1981 | Health prof clients | No | Evaluation & management |
| Psychiatry Greist et al | Med School U of Wisc, 1300 Univ Ave, Madison WI 53706 | 1970-1980 | Profess. | Yes | Risk access prediction |
| Gentry & Woods PHS-NIHM | Alco & Drug Abuse AD Rockville MD 20857 | 1983 | Med. students | No | Training |
| Dade Co Sch Joyce Hickson |
1550 N Miami Ave, Miami FL 33136 | 1985 | Teachers | No | Identify & counseling |
| Teen Suicide | Nat'l Ctr Youth Svcs, 125 N Greenwood, Tulsa OK 74120 (918)585-2986 |
1983 | Shelter | No | Training of staff |
| CPSAS Stella Pagano | Box 221 Ossining, NY 10562 (914)762-1839 |
1983 | Agencies | No | Coordination of informat. |
| Waikato Hosp Keith Petrie |
PO Box 58, Hamilton NZ | 1983 | Attempters | Yes | Self reports |
| SIEC | #201, 1615 10th AvSW Calgary, Alberta T3C OJ7 (401)245-3900 |
1978 | Suicidologists | No | Scientific information |
| West. Psychol. Services Cull & Gill |
12031 Wilshire Blve, Los Angels, CA 90025 (213)478-2061 |
1985 | psychologists | Yes | Risk assess. & prediction |
| Kalb, Fehler, Grabisch & Demling | Cur. Iss. Suicidol, Springer Verlag, Berlin, 1988 | 1988 | Mental health | No | Risk assess. & prediction |
For more information contact the author(s) or sources indicated above
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The suicidology literature tends to blur the distinction between self harm and suicide. The author has noted this in an earlier publication and proposed the use of language and separates between the wish to die, the act of self injury and the vital outcome (Cutter, 1972). However, this was not intended to include the least lethal range of incidents often labeled pejoratively as "hysterical, gesture, manipulative, and more recently as parasuicide. A list of typical self harm methods is given below.
Common Methods of Self harm
Modified from Kahan and Pattison, 1983.
Morgan (1979 and Ross & McKay (1979) have attempted to go further. They summarized the clinical and research literature and attempt to clinically differentiate between the two. Kahan & Pattison (1983) continue the delineation and argue that self harm is a specific subset a more general self damaging behavior. They present a schema for classifying the array of such behavior
Differential Classification of self damaging behaviour
| Behaviour | Direct | Indirect |
|---|---|---|
| High Lethality | Suicide Single episode |
Interruption of dialysis Single episode |
| Medium Lethality | Suicide repeaters Multiple episodes |
High risk events Multiple episodes |
| Low Lethality | DSH syndrome Multiple episodes |
Alcoholism, obesity heavy smokers Multiple episodes |
Modified from Kahan & Pattison, 1983
The specific category of self damage they call self harm is characterized by low lethality, repetitive incidents, not associated with chronic substance abuse. Kahan and Pattison then go on to propose a deliberate self harm syndrome (DHS) whose essential features are:
Other information that is relevant in recognizing the DSH syndrome is the an occurrence rate of 400-600/100,000 life people distributed equally between both sexes, and with peak incidence in the young, ages 16-25. It is especially likely in deviant and institutionalized youth. A primary diagnosis of schizophrenia, psychotic or affective disorders would pre-empt DSH and make it a secondary diagnosis. The clinical course if typically one of multiple low lethality episodes of physically self damaging behavior with some increasing lethality over the usual course of 5-10 years (Kahan & Pattison, 1983)
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"Reasons for staying alive when you are thinking of killing yourself" were generated by a sample of 65 individuals into an initial 72 reasons. These were reduced to 48 by factor analyses on two subsequent examples. The resulting inventory was further factorized into six scales or reasons for living. These are; survival and coping beliefs, responsibility to family, child related concerns, fear of suicide, fear of social disapproval, and moral objections. The RFL inventory was then given to Seattle area shoppers (n=197) and psychiatric impatients (n=175). Subsequent multivariate analyses separated suicidal from non-suicidal individuals in both populations. In the shopping center group, the fear of suicide scale differentiated between previous ideators and previous attempters. In the psychiatric impatients, the child related concerns scale differentiated current ideators from current para-suicides. Survival and coping, the responsibility, to the family and the child-related concerns scales discriminated bettween both population samples.
The reasons for living inventory represents a positive approach to assessing suicidal intent. Like the satisfaction scale it is the reduction of pleasure or reason for living that indicates the opposite, the readiness or intention to seek death. The RFL measures a range of beliefs that support continuation of on-going life and document impediments to self injury behavior. The inventory yields a profile of scores on six scales that permit classification of a person as belonging to one of several self injurious groups; past and current ideators, past and current para-suicides. Clinically, these profiles can be construed as reflecting increased wishes to die and presence of preferred methods of self injury.
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This chapter highlights significant developments in suicidology that represent some totally new approaches. These are the introduction of computer programs and incorporate available knowledge into software that are more accessible at least to those who are computer literate. Along the way, the authors are forced to become more precise and thus improve the quality of the writing and the associated research. Even more striking is the potential of converting existing electronic bulletin boards as new resources for those seeking help, comparable at least in potential to the introduction of hot lines in the late fifties. Reasons for living emphasis the positive, and are indeed associated with survival, this "self evident" idea is worthy of rediscovery. The deliberate self harm syndrome is also worthy of incorporation into the DSM, because conceptually it offers some order in the vast array self injury behaviors; direct and indirect, suicidal and para suicidal, along with the self mutilation, "only".
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