SUGGESTIONS FOR SUICIDE PREVENTION (quick summmary)
Fred Cutter,Ph.D.
San Luis Obispo CA

The wish to die may motivate an act of self injury, but a suicidal death is unpredictable!

The differences between the wish to die, an act of self injury, and death outcome must be noted in order to talk about, under- stand or prevent suicidal behavior.

Not all methods are equally lethal and even when they are very lethal, chance factors often aid or deter death outcomes.

Death means many things to different people and to the same person at different times. People choosing to kill themselves do not know what they are choosing, since none of them have ever died before.

All suicidal candidates want to change something in their aware- ness, even by ceasing it; they often hope to feel better in the next life. This is true for atheists as well as for believers.

The wish to die occurs to everyone and is no different than any other wish. It comes and goes very quickly. It often co-exists with the wish to live. Time often helps people to change their minds about the wish to die.

Many people are rescued from suicide by chance; e.g Sylvia Plath in her first attempt. Many others die accidentally after they change their mind during the course of a suicide attempt; e.g. Marilyn Monroe in her last of many attempts.

A person on the verge of a suicidal action needs different help procedures than one who is in between attempts, i.e. high risk for a repeat self injury.

People on the verge of suicide, need support, blocking of access to a chosen method of self injury, and time to help with the wish to die.

After rescue, victims continue to be vulnerable to the various psychiatric syndromes, especially addiction or self medication to allay distress. The best, and most universal resource here is NA or AA.

Two or more prior attempts increase the probability to one in ten survivors. Age (before 25 or after 65) is a second factor. Continuing or renewed substance dependence is a third.

Because self injury methods chosen by a victim are overdetermined by past history, selective blocking of access to that preferred method can be imposed more easily and for longer periods of time.

Professional attention is always a deterrent to self injury behavior; e.g. Psychotherapy or simple support.

The first issue for victims of a recent self injury event, is the question of the wish to die. Most will have changed their minds, and want very much to live. Even so the question needs to be asked. "Do you still wish to die?" All will need accept- ance, support, reassurance, and hope for tomorrow.

Psychotropic drugs are appropriate options. Antidepressants are a first thought in this situation, and more often right than not. Victims suffering from a psychotic diagnosis are best medicated by appropriate antipsychotics. With a confirmed bipolar history mood stabilizers become the treatment of choice.

Since the majority of suicide victims are either substance abus- ers or chemically dependent the use of any medication is a prob- lem. The immediate hazard is the prior ingestion of unknown or unmeasured amounts of chemicals.

Later, anxiolytics become problematic since these have an essen- tial role in preventing seizures during withdrawal, and reducing distress in the first hours following a rescue. As soon as the emergency is resolved these medications should also cease, and be replaced by more optimal prescriptions for the diagnoses contrib- uting the most to motivating distress, e.g. antipsychotics, mood stabilizers or antidepressants.

Victims with addictive histories will not be happy with anything except analgesics, hypnotics, uppers or anxiolytics and will complain until one of these is offered. The paradox is that it will make the person comfortable, but will reinforce suicidal behavior as a way of feeding the addiction.

The risk for suicidal events is aggravated by addiction. The best prevention is to achieve immediate abstinence. The most powerful motive for this end, and which is universally available, is the goal of helping other suffering addicts; especially those who are perceived as worse off.

Suicide is a very human behavior,that remains difficult to ex- plain fully. It is actuarially predictable for populations at risk, but can only be anticipated by human vigilance.

The triangle model can guide attention to the most accessible factors; the motivating distress, the wish to die, or the suici- dal plan. Intervention with any one of these three has a preven- tion effect for the short term.