-1

Harold I. Kaplan, M.D.P ro .e sso r o f P sych ia try , New Y ork U n ive rs ity S choo l of M ed ic ine ;A t.e n d in g P sych ia tr is t. U n ive rs ity H osp ita l o f the N ew Y ork U n ivers ity M ed ica l C enter. A tte n d in g P sych ia tr is t. Be llevue H osp ita l. New Y o rk . New York

Alfred M. Freedman, M.D,P ro fe sso r o f P sych ia try and C hairm an,D epa rtm e n t of P sych ia try . New Y o rk M e d ica l C o llege ;C ha irm an . C epa rtm en t o f P sych ia try , P sych ia tr ic Ins titu te .W es tch e s te r M e d ica l C enter, V a lha lla . N ew Y ork;C hairm an . D epa rtm en t of P sych ia try , M e tro p o lita n H osp ita l and B ird S. C o le r M e m oria l H osp ita l and Hom e, New Y o rk . N ew Y ork

Benjamin J. Sadock, M.D.P ro fe sso r o f P sych ia try , N ew Y ork U n ive rs ity S choo l o f M ed ic ine -A tten d ing P sych ia tr is t. U n ive rs ity H osp ita l o f the N ew York U n ive rs ity M e d ica l C enter.A tten d ing P sych ia tr is t, B e llevue H osp ita l. New Y o rk , New York

! a; '? s )( / D fs

WILLIAMS & WILKINS Baltimore/London

chapter

29-1 SuicideH. L. P. RESNIK, M.D.

Introduction Suicidal behaviors present as protean behaviors. A lthough

some suicidal people may be death seeking, others a ttempt to communicate pain, mitigate isolation, avoid the sequelae of status change, seek revenge, and transmit a host o f other meanings. Such behaviors constitute a problem in clinical practice" and are difficult to manage. Suicidal patients are probably the most frequent cause o f psychiatric emergencies and the 's ing le most frequent in terrupter o f the psychiatrist’s sleep, w hether he is a psychiatric resident or a seasoned clinical practitioner. Suicidal patients challenge the psychiatrist’s caretaking capabilities, bringing to his practice the confron ta­tions with d ea th tha t are seen more frequently by his medical and surgical colleagues. T h e suicidal person is difficult to identify w ith certainty; he is often u nm anageab le in an outpa-

’ tient setting and resistant to hospitalization; and he is subject to recurrent crises in m anagement.

DemographyAbout 22.000 suicides are recorded annually in the United

Sy' T h a t figure represents the lethal end o f attempted suruaes, which are estimated to exceed that n um ber by 8 to 10 times. Lost in the reporting process are the purposeful rmsclas- sification o f cause of death, “ accidents” o f undeterm ined cause, and w hat are referred to as forms o f chronic su icide— for example, alcoholism, d rug abuse, and consciously poor a d h e r ­ence to medical regimens for diabetes, obesity, and h yperten ­sion. T h e certif icati .m o f a person as a suicide is influenced by many factors an d varies extensively in different communities. Until there is a more standardized method o f evaluating and investigating suspected suicidal deaths, categories such as ac­cidental" and "und e te rm ined ” may be statistical repositories for probable suicides.

Certified suicides constitute a rate o f 1 1 deaths per 100,000 population, ranking suicide as the ninth over-all leading cause or death in the country. T h e economic impact o f suicide is Messed at S 16 billion lost yearly in victims’ earning power; the psychosocial imp.'.ct on the families o f victims is incalcu­lable hut is known to include psychological distress, social taboo, and. frequently, physical hardship.

In the m anagem ent o f any o n e suicidal crisis, the clinician s attentiveness, insight, experience, a n d professional judgm ent are far m ore valuab le than is familiari ty with aggregate statis­tics. Yet in their place, the d a ta are valuable clinical support-..For the administrative psychiatrist , they are political tools useful in bartering for em ergency an d prevention service p ro ­gram funds. For the dem ographer , they provide a foundation for p lanning and assessing m en ta l health emergency service needs. F or the clinician, they p rov ide an il luminating if abstract picture o f populations and persons at various levels o f need. In 1964, Mint/, reported a d o o r- to -d oo r public health survey in Los Angeles in which the n u m b e r o f living Americans with suicidal histories was es tim ated as 5 million persons.

Suicide rates in the U nited States rank at o r near the midpoint o f national rates repor ted to the U nited Nations by- industrialized countries. In ternationally , suicide rates range from highs o f more than 25 per 100,000 population in S can ­dinavia. Switzerland, West G e rm an y . Austria, and eastern E uropean countries (the suicide belt) and Japan to fewer than 10 per 100.000 in Spain, Italy, an d the Netherlands. Those variations are explained as functions o f religious orientation, rate o f culture change, and climate, but the explanations, likethe figures, are often controversial.

O ver the years, studies o f decedents and attempters o f suicide have provided a multifaceted picture o f subpopulations at risk for suicidal behavior. In light o f the many variables found within groups described as being at some level o f risk for suicide, it is useful to review a num ber o f characteristics individually.

SEX

M en com m it suicide m ore th an 3 limes as often as do w omen, a rate that is stable over all ages. W om en, on the other hand , are 3 times as likely to a t tem pt suicide a> are men.

AGE

T h e significance o f the midlife crisis is underscored by suicide Tates. A m ong men. suicides peak after age 45; am ong w om en, the greatest n u m b e r o f completed suicides occurs after age 55. Rates o f 40 per 100,000 population are found in men age 65 and older; the elderly a ttem pt suicide less often than younger people but arc successful more frequently, accounting foi 25 per cent o f the suicides, a l though the elderly m a*e up only 10 per cent o f the total population. A peak n>k ain.-ing males is found also in late adolescence, when death by suicide is exceeded only by d ea th a tt r ibu ted to accidents and cancer.

2 0 8 5

RACE

Suicide am ong whites is recorded at nearly twice the rate as nonwhites, but those figures are increasingly called into

question (Hendin . 196^). T he differences may have originally been a function of reporting procedures; conversely, closure o f the vap may indicate homogeni/.ution o f white arid nonwhite populations with regard to middle-class psychosocial stresses in con tem porary society. A m ong certain Native American and Alaskan Indian groups, suicide rates greatly e \ee ed the national rate.

REGION

D uik he im (1051) originally noted lower rates among rural than a m o n j u rban populations, a fact that seems to hold true todav. However, the reliability o f suicidal determination by o ther than medical exam iners m ay account for discrepancies.

RELIGION

Historically, suicide rates am ong Catholic populations have been recorded as lower than rates am ong Protestants and Jews, a truism that , if not disputed, is being refined. It may be that decree o f orthodoxy and integration within a religion are more accura te measures o f risk within this category than is simple institutional religious affiliation.

MARITAL STATUS

Marriage. reinforced by children, seems to significantly lessen the~risk o f suicide. A m ong married persons the rate is 11 per 100.000, in keeping with the national average. Single, never-marr ied persons register an over-all rate o f nearly double the married rate. Previously married persons show sharply h igher rates: 24 per 100.000 am ong the widowed, 40 per 100.000 am o n g divorced persons, with divorced m en registering 69 suicides per 100.000, as com pared with IS per 100,000 for d ivorced women.

HEALTH

T h e relationship o f physical health and illness to suicide is both predictable a n d inconsistent and, in either case, signifi­cant. T he inconsistency stems in part from the role o f the medical profession in suicide. T u ck m an and Y oungm an (1968) found prior medical care to be a negatively correlated risk indicator o f suicide; Motto and G reene (1958) found 42 per cent o f suicides to have had medical attention within 6 months o f death. D orpa t ct al. (1968) studied suicides and suicide attempts and found 70 per cent o f the victims to have been affected by one or more active— and, for the most part, ch ro n ic - illnesses at the time o f death. In 41 per cent ot the deaths, illness was viewed as a directly contributing factor. A m ong suicide attempts studied, more than one-th ird ot the persons were actively ill at the time o f the attempt, and more- than 90 per cent o f the a ttem pts were influenced by the illness. In both groups, psychosomatic illnesses constituted the m ajo r­ity o f diagnoses.

Factors associated with illness and contributing to both suicides and a ttem pts were loss o f mobility am o ng persons for w hom physical activity was occupationally or recreationally important; disfigurement, particularly am o n g women; and chronic, intractable pain In addition to the direct effects of

illness, the investigators noted the secondary effects o f illness—-, for example, d isruption o f relationships and loss or required change of occupational status.

OCCUPATION

A m onc occupational rankings w ith respect to risk for suicide, physicians h a w iradit ionall) been considered to stand out. and, am or .2 ph 'o icians. psychiatrists are considered to be at greatest risk. C raig and Pitts (1968) calculated the rate for suicidal death am o n g physicians to be roughly double the national rate per 100.000 population not at significant variance with age-adiustcd rates o f the male population. S tudying sui­cides among phvsician residents. Kelly (1976) found little evidence to support contentions that psychiatric residents dif­fered either from o ther medical specialties or from age-matched males in the general population. Blachly et al. (1963) did report that ps \chiatris :s h ad the highest rate among physicians. Per­haps the increased rate among psychiatric practit ioners is ex­plainable bv the increased and chronic exposure to the stress o f practice.’ The nu m b er o f suicides am ong physicians >•= a n ­nually equal to the graduating class in a large medical school.

T he fact that physicians often see their patients anywhere from the same day \ l per cent), week (23 per cent). 1 week to 30 days (27 per cent), or month (50 per cent) o f the s^%|Blal death (Motto and G reene . 1958) and usually for somatic de­pressive equivalents an d the fact tha t patients often use the physician's prescription to d ie—all argue strongly for increased attention in medical schools to the acute and long-term m a n ­agement ot suicidal patients.

Perspectives on Suicide

RELIGION

Chronologically, the earliest precepts and percepts regarding suicide are found in folkways, mores, and religious attitudes; those findings constitute a mixed assortment o f commendation, acceptance, and condem nation , the primary constant being the act itself. Earlv on. various mandates for suicide stemmed from the m aintenance o f honor, such as hara-kiri an d suitee, to the elimination o f dependency, such as going o ff into the winter snow — all tradit ions tha t have been subject to cultural reinter- pretation.

More frequently, suicidal death has been socially prohibited or at best ignored, with lack o f comm unity acknow ld^ .ent constituting a form o f censure. Addressed indirectly and rarelj in the Bible, a tt itudes toward suicide in the Judaic-Christian tradition h a w been a function o f social an d canon ruling, W h e r e a s J e w ish creed observed the value o f life, early Chris­tians so valued the a tta inm ent o f eternal salvation that suicide was seen— and accepted positively— as a m eans o f avoiding sinful distractions. More than h a l f a mitlenium passed after the establishment o f the Christian church before the opinions of St. Augustine were upheld by the Council o f Toledo in 639, b; w h i c h excom m unication was decreed for suicidal behavior Augustine viewed taking one’s own life as n i’cder. the usur pation o f the prerogatives of God, church, and state, each o which posse.-sed prior fealty on hum an life. T h e notions of sir and crime were mutually reinforcing and prohibit ive stricture found ir: both domains. Christians who died willingly by thei own h a n d ' -sere not to be buried in the grace of the churc! and their survivors were threatened with social taboo and eve

loss of property. Subsequent secularization o f Western thought emphssi7ecl civil, legal. a n J behavioral dimensions o f suicide while diffusing proscriptive church attitudes. Still, the legacy of religion' thought is yet to be found in the reported lower rales ol suicide in predom inantly Catholic countries.

SOCIOLOGY

Although religions passed ju d g m en t on suicide, they did not necessarily seek to unders tand the nature o f the act, its origins, or its implications. Such attempts were left to the enterprise o f <otial and behavioral science. Emile D urkheim (1951). in the publication o f Le Suicide in 1X97, gave a leading edge on the academic study o f suicide to sociologists. Although subject to ihe critiques o r century-after quarterbacks, the book today remains a sociological classic. D urkheim acknowledged the presence of extrasocial factors in suicide that ranged from insanity to race and heredity to cosmic influence, but the focus of his work was on social correlates. W ith tha t focus he set a path that was in returning to the biopsychosocial synthesis used

T ^ l u m a n disposition tow ard suicide was seen as a function of society's hold on people, which was exemplif ied most directly in suicide that Durkheim (195 1) described as altruistic, sacrifice of self for an ideal. Social integration was the hallmark. At the opposite end o f that integrative scale was egoistic suicide. Originating in a lack o f close ties to any and all social ins ti tu­tions—whether family, church, or c o m m u n ity —the category helped Durkheim explain high rates o f suicide found am ong unmarried persons, non-Catholics. and u rban dwellers, as com ­pared with their counterparts. T he sudden loss o f cultural £tiideposts characterized D urk he im ’s third type, anomic sui­cide: The loss was o f the norm. Although it may have been interpreted most com m only as descent into poverty or the death of a spouse, the potential for anom ie-inducing change is bidirectional, with gain and success equally unsettling.

The next three-quarters o f a century provided ample time for criticism, explication, modification, arid acclaim o f Durk- heim's theories. A major point o f criticism, noted by Douglas (1967) among others, was D urkhcim 's use o f statistical data as explanatory, rather than merely descriptive. D urkheim was judeed to have paid inadequate a ttention to o ther more specific

/ 'sonal motivating factors contributing to suicide, such kthe role ol status change in suicide.

Sainsbury (1956) examined the re lationship between suicide rates and poverty in the boroughs o f London. A rmed with the hypothesis that cohesion meant a satisfactory life style and that mutability — defined as loss o f economic s t a t u s - m e a n t dissat- I'laciion and was thus a putative causal factor in suicide. Sainsbury compared the economic status o f suicides with the ftonomsc status ol their neighborhoods. He coneludcd that 'wdiger.ous poverty dees not foster suicide.” Rather, he sug- cMed. it was the fall fr. ru affluence to poverty that indicated instability and potential f.ir suicide. A lthough the validity o f ■ t conclusion has been questioned. Sainsbury’s accom plish­ment was to move toward an unders tanding o f the suicide Process by focusing on individual patterns o f status change.

In a study of suicides in New Orleans, lireed ( l % 1 ; nioved ■he sociological assessment o f status change and suicide a step

toward the necessary psychosocial synthesis. He became J»are that official statistics on suicide- the traditional tool of ‘̂ sociologist - w e r e o f dubious accuracy with respect to such "''ails a, employment and piestigc ranking. O f most im por­

tance was B reeds a ttempt to address second- and third-level factors contributing to both s ta tus change an d suicide. A l­though his a ttention to individual factors was not sophisticated, it was sufficient for him to describe status change as only one factor am ong many in the com plex phenom ena o f suicide. An elaboration o f the theories on s ta tus change was offered by G ibbs and M artin (1964). T he g a p b e a c o n a sociostatis-ical evaluation and an appreciation o f intiapsychic variables had increasingly narrowed.

PSYCHOANALYSIS

Paralleling the developm ent o f sociological theories o f su i­cide through the 20th century have been the contributions o f the psychoanalysts . In 1917 F reu d (1957) conceptualized that melancholic or depressed patients h ad undergone an ego split in which part o f it (the superego) m ad e it difficult or impossible to express angry, hostile feelings tow ard loved ones. In 1927 A b ra h a m (1953) proposed tha t introjection and acting out o f such feelings against the se lf were the prims defensive m a n e u ­vers in suicidal behavior. The object o f that retrofle.xed energy was an internalized psychic representation o f the love object w ith in the ego.

As was the case with sociological theories, the psychoanalytic explanation o f suicide was for m a n y years unaffected by su b ­sequent critiques, interpretations, a n d amplifications, although Zilboorg (1937) pointed out the inseparable influence o f exter­nal social influences on personal motivations M enninger’s (1938) formulation o f the deadly tr iad— to kill, to be killed, and to d ie —was o f great practical help to the clinLLms in assessing their patients. L itman an d T abachnick (1966) offered a scheme o f fantasy systems tha t served as vehicles for the eventual resolution o f the inner conflict. Those fantasy systems included a tired wish for respite, for escape from the discord: a guilty wish for punishm en t and accepted apolosy for self- perceived shortcomings and failings: a hostile w ish 'for v indi­cation. for mastery and aggressive release o f pent-up emotion: an erotic wish for passionate masochistic surrender and the rea t ta inm ent o f lost loves; and a hopefu l wish for rescue that gives rise to the ambivalence frequently seen in suicidal people.

H end m (1951) observed that , once the potential suicides see those fantasies as offering a m ea n s o f gratification, a self­destructive act may be im m inent. T h a t promise o f "ratification provides some insight into the sense o fc a lm . o f purpose, that is often reported in the histories o f suicides.

LEARNING THEORY

A no th e r vantage point useful in gaining perspective on the nature o f suicide may be found in learning theory. Frederick and Resnik (1971) proposed that suicidal behaviors, like other pa tterns o f behavior, can be learned:

It would be difficult to support any notion dim self-destructive behavior uould be fully explained without employing 1 ern irm princi­ples. There is no evidence that such complex behavior ii'- one’s own selt-destruction resides in the genes. Behavior is motivated and it i> learned although social structure, unconscious conflicts, and neuro- biochemi'try d. affect the way in which it is learned. felt. and ex­pressed.

Ih e learning model o f behavior stem s from hvbrid i/ed roots o f American studies in functionalism and behaviorism and Russian reflexology research. Behavior therapies have been

increasingly applied in diverse forms to a variety o f clinical psychiatric and medical problems. T he focus ol behaviorally oriented learning models is the person in the environm ent o f here and now. A lthough past experiences are not denied sig­nificance. B andura (1969) stated:

When the actual social learning history of maladaptive behavior is know n. principles of learning appear to provide a completely adequate interpretation of psychopalhological phenomena, and psychodynamic explanations in te r m s of symptom-underlying disorder become super­

fluous

T h e ideological sap between psychodynamic and -.'Cial learning theories is narrowing. It is clear that self-destructive acts as part o f a depressive syndrome may be formulated and treated th rough learning theory concepts. Early on, in most cultural settings, infants perceive that expressions ol anger and a g r e s s io n are negatively reinforced. If. as psychoanalytical!) postulated, depression is a turning inward o f anger associated with early positive reinforcement, such behavior can become learned and subjectively perceived as depression. T he power to evoke reactions th a t is learned as a child in d,stress can be used later when, as an adult , anxiety, depression, and anger are experienced. As a child, the person learned to re turn to what h ad w orked before, with the expectation tha t it would work a«ain. T h a t is particularly true when recurrences o f behavior are reinforced by gratifications attendant to response or rescue. S e li°m an (1975) reported on learned helplessness derived from laboratory research with dogs struggling against the restrictions o f a harness. T h a t concept has relevance in unders tanoing h u m a n struggling against the restrictions o f a relationship and is identified as an im portan t clinical sign.

Similarly, suicidal behaviors can become reinforced by both physical and psychological attention. They can move forward in the sequence o f behavioral reactions and may be triggered quickly w ithout the prior appearance o f acute or prolonged anxiety. T o the person whose personal value has been sel - assessed and found w anting or missing, any response from the env ironm ent m ay be viewed as positive. Certainly, suicidal behaviors are d ram atic— even if equivocal and subinten- t iona l— and will almost always evoke responses w hen other cues have railed. Moreover, when cues are both attention eett ina and tension reducing, behavior patterns are doub y reinforced. For example, the prescription o f antianxiety agents provides a patient with a tangible means o f tension reduction while providing secondary gain in the form o f interpersonal

concern and sympathy.T h e concept o f positive reinforcement can be applied to a

n um ber o f suicide-prone and suicide-preventive activities. Se­vere punishm ent in childhood is an infrequently recognized precursor of suicide; the ability o f the child to reduce his own tension and his parents’ anger through his acceptance of p u n ­ishment is im portant. Later in life, self-imposed punishm ent, mediated by the parental surrogate or superego, m ay provide the reinforcement necessary to reduce tension stemming from intrapsychic conflict (Frederick and Resnik, 1971). In o ther instances. Frederick and Resnik suggested, responses provided by mental health professionals and s u i c i d e prevention centers may paradoxically reinforce suicidal behaviors insofar as a cry for help successfully elicits a real or fantasied change in in ter­personal relationships or env ironm ental surroundings.

If one has an awareness o f such dynamics, behavior analyses can provide therapists the information regarding the contm- pencies tha t p rom pt deviant responses. Alternative learne

C hapter 2S

behaviors, such as verbalizing hostile feelings, may be more desirable and effective than, for example, overdosing on an- tianxiety m edication. Productive physical activity and the seek­ing o f support d u r ing a crisis may be com m ended and re­warded with each positive response diminishing the likelinood o f the recurrence o f self-destructive behaviors. Associative learning principles emphasize the importance o f eliminating undesired responses in the same environment that evoked them and that will be the setting for newly learned and positively reinforced responses. F o r example, family therapy in the home may constitute a m ore effective response to suicidal threats or cries for help than w ould hospitalization.

Elements o f the notion o f learned behavior and reinforce- mer.t can be woven into the psychodynamic and sociological perspectives on suicide described above. L itman and Tabach- nick’s (1968) a rg u m e n t for the im portance o f separation anxiety as a precursor to suicidal behavior underscores the importance o f learned behaviors with respect to indivtdual differences in the expression o f such anxiety. Relearned adaptive behav.oris a part o f the insiaht sought in psychoanalytic psychotherapy In the context o f social theories, particularly as they involve individual stress reactions in the event o f b reakdow n o fe n w ronm ental supports , behaviors learned either in^ iv id ^ g |^ 01 collectively m ay be significant.(JiltXUYClY mcij ------

In other w ork on the psychology o f suicide, learning theory aoain promises applicability. H endin (1946) attributed suictd; rate differentials in Scandinavian countries to cultural; learned response pa tte rns based on psychoanalytic formulation Perhaps o f m ore im m edia te significance is the impact of sui­cidal behavior— w heth e r a ttempted successfully or no t— withn families on ch ild ren 's learning and development. Observing the process an d rewards o f such suicidal characteristics s manipulation , guilt in the wake o f hostility, an d solicit, dependency, the child is exposed to the positive reinforced!?:: p rom pted by the condit ions and may use the same behavio, at appropr ia te times in his own life.

A THEORETICAL SYNTHESIS

Several ra the r com par tm enta l ized theoretical formulate exist, each en deavoring to explain a complex h um an behaw within a un ita ry framework. H ow can the practicing psyc i. trist synthesize those concepts into a meaningful treatma approach? O n the suicidal e lephant rests the sociolog.^1 ha: focused on loss o f status, an attenuated suppor t syk ... ai the stresses o f poverty and dislocation. T h e psychodynaa palpation discovers early oral deprivation, split ego format., and the am b iv a len t introjection o f early objects. T he behavi istic exploration probes early exposure to su icidal behavior families that m ay provide early learning experiences. Beca each orientation , standing alone, allows only a truncated vt o f the prob lem , the clinician cannot afford to ignore any them, ra ther, he is well advised to include elements o f cad any m an ag em en t program.

Myths about SuicideM yths fallacies, and superstitions about suicide are roc

in time an d nur tu red by fear, folklore, taboo and » inaccuracy. F o r the public, they are misleading: for thep cian they are dangerous. Shne idm an and Farberow (1961) Pokorny (I96S) discussed and docum ented counterargu*to the mythology o f suicide.

1. People w h o act do not talk; suicide comes without wan

perhaps these myths stem from a need to insulate oneself against the signs o f an im pending crisis or to retrospectively rationalize an absence o f timely interv ention. T he fact is that g of overs 10 eventual suicides gave prior warning in clear lerms to the attentive listener. R o b in ; et al. (1959) identified 26 signals of in'.ent, ranging from direct statement (41 p e rc e n t of the communications) to morbid fascination with death to per­vasive disinterest. Suicide attempts, not threats, constitute the clearest predictor o f eventual suicide.

2. Broaching the idea plants the seed. A m ong the most potential!} dangerous o f the myths, this one mistakes genuine concern and discussions o f risk for unintended suggestions o f action. Studious avoidance o f the topic o f suicide, particularly with a depressed person, can reinforce the potential victim's feelings that no one really cares.

3. Suicide is a crazy act. Until the public and the mental health professions, particularly, agree on the definition o f crazy, this myth, too. is doubly dangerous. G iven rationality, is the life force irresistible? People can make a decision to kill th em ­selves and yet not be out o f their minds.

4. Suicide is an inherited trait. Suicidal behavior may result fr^lidentif ication o r be learned, bu t no evidence to date suggests heritability. In a study o f 2,500 twin sets, K allm ann and Anastasio (1947) d id not record a single incident o f c o n ­cordant twin suicides. However, to the degree that bipolar depression is genetically determined an d suicides are high in that group, there m ay be a relationship.

5. Weather (climate, cosmic phenom ena) influences suicide. Every conceivable meteorological, cosmic, and general physical environmental factor has at some time been implicated in the incidence o f suicides. N one has tested out. Ironically, the time of year that seern.s to be associated with a slightly higher than average incider.ce o f suicide is the aw akening and promising period of spring.

6. Passage o f the crisis means that the danger is over. Suicides are known to increase dramatically after the patient has ter-

‘ minated treatment, w hether as an outpat ien t or as an inpatient. Alternative explanations address the undistorted view o f real problems a person is facing and the increased energy and drive that may have been missing during a depressive or existential crisis.

dictionThe use o f demographic predictors in evaluating the suicidal

potential of any person is quite limited. Although comm unity- »iJe suicide prevention activities are best planned theoretically around demographic variables, it remains the task o f an indi­vidual clinician to assess an individual patient 's risk on the basis of a careful clinical examination. In this context. Lester's 11974) discussion o f false positives in suicide prediction offered J relevant introduction to the concept o f prediction. As he noted, the therapist, whether in private practice or in a clinic. On ihe predictors that allow errors in frequent positive suicide •dentificatious. Conservative erring is interpreted as sound clinical judgm ent by the psychiatrist himself, and responsive Patients only reinforce that sense o f caution. However, a psy­chiatrist in the emergency room of a general hospital or the admissions unit of a psychiatric hospital would soon flood his '"patient service by the use o f such conservative predictive techniques. l ie would quickly receive a conference invitation "ith ihe chief-of-service or the adm inis trator to discuss the :csuliant bed shortage. However, the fact rem ains that, al- though a single clinician may have large num bers o f patients

w ho present various signs predic ting suicidal behavior, any one clinician has relatively few patients who actually kill th em ­selves. Thus, the prediction o f such a rare event, based on actual clinical experience, is extremely difficult. It is u nder­standable that the responsible an d mature clinician prefers to overdiagnose false positives to avoid the responsibility for a misdiagnosis that results in a pa t ien t’s suicide.

C ognizant ol the clinician’s d ilem m a, a num ber o f research­ers have engaged in efforts to sharpen the validity and the utility o f predictive variables. L iim an et al. (1974) analyzed variables (see T able I) identif ied from two telephone-caller groups known to the Los Angeles Suicide Prevention Center; one group later com m itted suicide, and the o ther did not. Eleven items were found to d iscrim inate at the 0.10 level, the First eight o f them at 0.05 o r better. T h e most predictive items associated with high suicide risk are listed first in T able I, and in descending order the first eight are: age; presence o f alco­holism; no recent irritation, rage, or violence; high lethality o f prior suicidal behavior; male sex; not accepting help at the time o f evaluation; the longer the cu rren t suicidal episode the higher the risk; an d no prior psychiatric inpatient experience.

F o u r variables usually used to prcdict acute high lethality were opposite the expected d irection and may be more associ­a ted with the prediction o f suicide in a chronically suicidal person— namely, prior psychiatric hospitalization; presence o f irritation, rage, or violence; recent loss o f health; and a current loss.

T he last four items in T ab le I, variables 12 to 15, showed tendencies in the direction o f suicide but not at the 0.10 level. Ot those variables, by far the most important one to the clinician is depression, affective. T he authors suggested that tha t variable may be m ore predictive in chronically, rather than acutely, suicidal persons. T h e depression, affective vari­a b le— probably one ol the best predictors— is most reliably ob ta ined in a clinical interview. Thus, the reason for the lower ranking o f that variable m ay well be that the ratings were, perform ed by nonprotessional volunteers evaluating case rec­ords o f telephone calls.

T a b l e 1

Discriminant Function Analyse**

Variable in Rank Order

Content of Item Direction for Suicide

1 Age Older2 Alcoholism Yes3 Irritation, rage, violence No4 Lethal prior behavior Higher5 Sex Male6 Accept help now No7 Duration of current episode Longer8 Prior inpatient psychiatric No "

treatment9 Recent loss or separation No

10 Depression, somatic Yes11 Loss of physical health Less12 Occupational level Higher13 Depression, affective No14 Repeatedly discarded No15 f amily available Less

* from l.iimun. R. II. I arberow, N. L . Wolil. C. I . anJ Brown. T. R. Prediction models of suicidal behaviors. In II I'redictum o f Suicide. A. T. Beck. It. L. P. Resiiik, and D. J Leuieri. editors, p. 141 CTiarles Press. Bowie, Md„ 1974.

the study o f com ple ted suicides. Farberow and l.itnian (1975) offered guidelines for the emergency room physician. In mak­ing assessments, the clinician generally finds that age. sex. and marital status inf luence him little in comparison with the results o f a mental status evaluation, with its ability to reveal ideas of hopelessness and helplessness, mood disturbance, and history o f prior suicidal attempts.

Although the researchers, statisticians, and demographers continue to provide an expanding basis for understanding the suicidal behavior o f certain people with certain characteristics, two extraordinarily difficult tasks still confront the clinician. T he first is to app ly the knowledge from the patient's clinical history to a d em ograph ic profile and validate that with a mental status exam ination . Simultaneously, the clinician must assess the presence and the adequacy o f the pa tient’s relation­ship with him, so as to sustain the patient while appropriate medications in the optimal dosage are being instituted. All the while, the clinician should be attem pting to mobilize an outside support system. W h e n the task is broken into com ponent pans, it is, indeed, impressive.

T h e pertinent variables are sum marized in T ab le III. Predic­to r variables are those identified by researchers as m o s t^ ^ i - sistently helpful. In the table, the variables are groupe&jiS’lo three categories: (1) demographic indicators, ascertained by reading a simple in take sheet or reviewing the file and by speaking with the patient or his family directly; (2) menial status exam ination indicators, derived only from an interview with the patient and intended to give a sense o f dynamic processes, in all the i r subtlety or grossness, at work; (3) clinical history indicators, obta inab le from any so u rce—usually the

T abl f . IISuicide Rules' Measured M High-risk and Low-risk Categories o f Risk-related Factors among 1,112 Attempted Suicides}

Factor High-risk Calegor. SuicideRale Low-risk Category Suicide

Rale

Age 45 years and older 40.5 Under age 45 6.9

Sex Male : 33.8 Female 5.3

Race White 16.7 Nonwhite 9.0

Marital status Separated, divorced, widowed 41.9 Single, married 12.4

Employment statusi Unemployed, retired 24.8 Employed§ 16.3

Living arrangments Alone 71.4 With others 11.1

Health Poor (acute or chronic condition in the 6-month period preceding the at­tempt)

ISO Good§ 13.S

c-Mental condition Nervous or mental disorder, mood, or

behavioral symptoms, including al­coholism

17.6 Presumably normal, including brief sit­uational reactions§

11.7

Method Hanging, firearms, jumping, drowning 45.5 Cutting or piercing, gas or carbon mon­oxide. poison, combination of meth­ods. other

13.1

Potential consequences of method Likeh to be fatal",] 31.5 Harmless, illness producing 6.0

Police description of attempted sui- Unconscious, semiconscious 16.3 Presumably normal, disturbed, drink­ 13.0

cide's condition ing. physically ill, otherSuicidc note Yes 22.5 No§ 13.7

Previous attempt or threat Yes 22.6 No§ 13.1

Disposition Admitted to psychiatric evaluation cen­ 21.0 Discharged to self or relative; referred 11.6ter to family doctor, clergyman, or social

agency; or other disposition

* Although mental health statistics generally use rates per 100,000 population, here it is more appropriate to use per 1,000 population because ofthe small si/e of the sample.

t prom Tuckman. J., and Youngman. W. F. Assessment of suicidal risk in attempted suicides. In Suicidal Behaviors. H. L. P. licsmk. editor, p. 190. Little. ISrown. and Co.. Boston. I96S.

£ Does not include housewives and students.§ Includes cases for which information on this factor was not given in the police report.U Several criteria used in estimating whether the method used was likely to be fatal.

T u ck m an and Y ou ng m an (1968) developed a scale for the assessment o f suicide risk on the basis o f 1,112 attempted suicides reported to the Philadelphia police departm ent (see T ab le II). Fourteen characteristics o f the cohort were identified as high-risk or low-risk factors, with validity tested against a criterion o f subsequent death by suicide. High-risk character­istics included 45 and over in age (40.5 per cent versus 6.9 per cent); male (33.S per cent versus 5.3 per cent); divorced, widowed, or separated (41.9 per cent versus 12.4 per cent); lived alone (71.4 per cent versus 11.1 per cent); choice o f a highly lethal a ttem pt (45.5 per cent versus 13.1 per cent); and potential ly fatal consequences (31.5 per cent versus 6.0 per cent). Over-all differences between suicide rates o f the high- risk and low-risk groups were significant at 0.001.

T u ck m an and Y oungm an ( 196S) identified family disorgan­ization as a risk-related factor, measured by contact o f the a t tem pter or a family m em ber with a social service agency (12.3 per cent versus 9.2 per cent for those with no prior contact). Additional risk-related factors they cited included occupation, precipitants o f the attempt, elapsed time between the atteniDt and its discoverv. motivation, and diagnosis o f depression, termed a potentially powerful differentiating factor.

Ideally, indications o f suicidal risk should differentiate b e ­tween short-term, acute risk and long-term, chronic risk. Short­term predictors allow the determ ination o f criteria for interven­tion. which is usually successful; long-term predictors allow decisions regarding postinten.ention. long-term follow-up, and treatm ent. Clinical predictions require a com bination o f intui­tion derived from long-term experience and the knowledgeable use o f the research data that have identified key variables in

T M l! b I II

Key Variables i'i Suicide AssessmentI

Information toBe Pursued

lemographic1. Sex*

2. Age*

3. Racc

4. Marital statu;

5. ^ l o n

6. Occupational status

Mental Status Examination 1. Depression*

2. Thought disorder*KO s

Clinical History1. Family history

2. Previous attempts*

a. Lethality of attempt

b. Intention of attempt

F acts to Be A w are o fH igh

More women attempt suicide but men succeed, both in ratios of three to one

Suicide risk and age are positively correlated. Suicide rate rises steadily with age in men over 45: however, the rate for women levels off at about the sixth decade and declines thereafter. Suicide is rare among children. The rate rises rapidly in latency and early adolescence through the early twenties. Although the adolescent attempt rate is high, the number of suicides is not high.

On th e whole, suicide risk is greater among whites than among nonwhites e x c e p t for A m e r ic a n Indians and Eskimos. In urbi.n centers th e black rate closely a p p r o x i m a t e s t h a t of the w hite population rate.

Living alone is most important here. The suicide rate for single persons is twice that of married persons. Divorced, separated, and widowed persons who are living alone have rates 4 to 5 times those of married persons. In the widowed population, risks are greatest during the first year of widowhood. Suicide rates, are lowest among married persons, especially if they have children.

Suicide rates are lowest among Jews and Catholics. Protestants have signifi-j cantly high rates, as do those professing no religion.

In the United Slates one sees high rales at both socioeconomic extremes. What is probably most important is status change, cither up or down. Physicians when adjusted for education and age have no higher rates than do other "roups. Psychiatrists rank high among physicians in suicide risk.° Demographic Total

Suicide risk increases with depressed mood, especially if vegetative signs are ̂present, such as loss of appetite and weight, decreased libido, difficulty in | falling asleep, awakening during the night, and early morning wakening. Severe insomnia is associated with increased suicide risk. The absence ot future plans is ominous. Risk is greatly increased when depressed patients move to high-energy outputs manifested by anxiety, anger, or agitation, indicating sufficient mobilization to activate an attempt. The presence of psychomotor retardation and feelings of worthlessness, hopelessness, and helplessness are important. Primary affective disorder is a strong predictor.

Suicide risk is high when there is a thought disorder combined with a depressed mood. Cognitive distortions, such as a paranoid delusional system and auditory hallucinations to kill oneself or a loved one. are present. Risk is especially high , in patients with a psychotic depressive reaction or a postpartum depression, j

IMental Status Examination Total j

Risk is increased if there is a family history of suicide. Suicide risk is especially | high if a unipolar or bipolar affective disorder is know n. j

Almost three-fourths of those who ultimately commit suicide have a history of ; at least one previous attempt. Women tend to use ingestion or wrist laceration, j men use more active means. When women use more active means, the.subsequent risk is higher than in other women. |

i

If a person has made an attempt on his life that would have resulted in death if he had not been found and brought for treatment, his risk is much greater ( for another attempt than if he had ciied out for help.

Ingestion of great numbers of dangerous medicines, hanging, use or plastic bags, jumping K-m high places, and gunshot wounds are usually associated with quick deaths and represent, therefore, lethal attempts. Wrist, lacerations and minor ingestions are much less lethal. __________________ __________

200 I

Ta!!1.[. Ill — Continued

Patient's StatusInformal son to

Be l’ur>ueJiFacts to Be Aware of r

High Lo-*» j Not ! Helpful '• Nu

3. Alcohol and drug abuse* Suicide risk is high in alcoholics and drug abusers. Alcohol and tranquilizers, barbiturates, or antidepressants represent a particularly lethal combination.

!

-1 Recenl loss High risk is associated with the recent loss of a loved one through death or separation and the loss of status or of a job. a pet, or a body part.

5. Physical illness There is an increased risk w ith physical illness, especially a painful or disabling illness, such as cancer. Recent surgery may have taken place. Chronic pain may be at issue.

Clinical History Total IAggregate Total i l...♦ Predictor Total

I i

patient, frequently the family, and often the referring physician; here information can be cross-checked and distortions sorted out by evaluating several sources. T h e table is further organized bv specific variables to be pursued and key facts to assist in evaluating that variable’s contr ibution to the over-all picture. Since a valid formula to provide for weighting each variable is vet to be reported (Beck et al., 1974). the clinician’s synthesis o f all the in form ation is the instrum ental force propelling him to a decision. T h e last heading. “ Patient’s Status,” is calculated to force the clinician to make a decision on the contribution o f each variable to an over-all suicide status evaluation. It is im portan t to unders tand that a check in this colum n simply indicates that the particular variable, as it exists for a patient, is a h i”h, low. or unclear con tr ibu tor or noncontr ibu tor to the determ ination o f ’.he patient’s suicide risk. W hen cach subsec­t i o n - d e m o g r a p h ic . m ental status examination, and clinical his tory— is totaled, the presence o f three or more highs am ong the predictor variables, only one high in the mental status exam ination variables, or a total o f six or more highs in the entire th ree -p an evaluation points to a high suicidal risk.

If the essence o f T ab le III were to be presented as a handy clinical dipstick into the suicidal psyche, it might be arranged to allow the acronym " M a ’s salad.” W hoever cares to rem em ­ber tha t term can rapidly do a yes-no mental checklist during a clinical interview and come up with a good working eva lua­tion o f a patient's risk and need for hospital care.

M =■ Menial status. A clinical examination detects the presence of a primary affective disorder or psychosis. The presence of depressive symptom^, both vegetative and subjective, is of concern, especially when the terrible triad of hopelessness, helplessness, and worthless­ness is elicited This examination also gives the clinician a sense of the available energy —represented by agitation, anxiety, and anger— to carry out the suicidal ideation.

A = Attempt. A history of prior suicide attempts should always be explored, w .’h lethality and intention most important. A psychiatric hgspitah/.ui v. is an ominous predictor.

S = Support s', -iem. Who are the significant others, both at hand and distant'’ Can tl’c\ assist the patient? When the answer is negative, psychiatric hospitalization is warranted. The significant others should be interviewed to assess their own ambivalence concerning the suicidal patient.

S = Sex. fo r females, the risk is greatest between the ages of 25 and 55: for males, the risk increases above 45.

A = Age, The clinician should mandate hospital care in older age suicidal risks.

L = Loss. This variable reminds the therapist of the importance of a recent loss, probably within 6 months of the interv iew. The loss can range from the loss of a partner to the loss of status or reputation.

A = Alcoholism. Alcohol weakens the ego's ability to function, result- •in° in self-destructive behavior, both overt and disguised—c vsyample, aulo accidents.

D = Drugs. Drug abuse also weakens control and, at times, releases psychosis.

Crisis EvaluationAny patient w ho presents with a combination o f the above-

mentioned signs o r 'symptoms without specific mention of suicidal intent should be directly asked if he feels so bad that he would like to en d it all. Every therapist should feel com­fortable with those or similar words o f his choice. N o clinical evidence suggests th a t asking a patient that question inserts the thought or provides the psychic m om entum needed to act it out. Rather, the contrary occurs. T h e patient is. by inference, usually relieved by the invitation to talk about his self-destruc­tive feelings; tha t invita tion can reassure the patient that the psychiatrist is com fortab le with the subject and is experienced and com petent in treating suicidal patients.

I f the patient’s response is affirmative, he should be encour­aged to go on. D u r in g the interview, phraseology, tone, spon­taneity, and concern comm unicate reassurance. Suicidal thoughts and feelings are likely to require tem porary exf '- jgP support. As the patient indicates assent, the therapist should increase the specificity o f his questions to ask whether the thoughts involve a plan, the nature o f the plan, the timing, and the availability o f the means. It is useful to ask whether the suicidal preoccupat ion is a first-time occurrence o r if the patient has been struggling with such impulses for m an y years; if so. the therapist shou ld determine w hether the patient ever at­tem pted suicide. Typically , the clinician observes a progressive opening up on the part o f the patient.

A clinician w h o begins such an interview with the permissive first question m ust be prepared to take an active role, to the extent o f call ing in the patient’s family or friends or by directly hospitalizing the patient. Once high suicidal risk is determined, a patient must never be left alone until he is hospitalized. At times, a family m em b e r may have to be te lephoned while the clinician or so m eone from the support staff stays with the patient. Such behaviors on the part of the clinician often require m ore activity than traditional psychotherapy may dic­tate, bu t they are the ultimate expression o f the psychiatrists

Jisapproval of suicidal behavior. He is saying verbally and • ,\mbolicaUy. “1 can’t allow you to kill yourself.” Admittedly,

:hat statement is predicated on his own professional philoso­phy.

Before treatment, the patient often experiences a period o f solving suicidal ideation as the ego attempts to come to grips .vith stresses. The primary phase o f treatment begins at the Mint at which the clinician has made the diagnosis o f high -uicidal risk and has committed to engage the problem. F red ­rick and Resnik (1971) offered a variety o f therapeutic moves n the primary phase that may often be used in concert: (I ) a emporary gi\ing in to the patient's infantile, dem anding d e ­pendency needs, thus providing a strong and loving parental surrogate for support during the crisis; (2) being direct and authoritarian in order to take over decision making when the patient's decision has been based on faulty and illogical deci­sion making: (3) abandoning customary techniques o f reflec­tion, free association, and other nondirective procedures, thus allowing for direct questioning. T he clinician should obtain the necessary information about the suicidal plan, the lethality, and, in the event o f suicidal comm unications m ade by tele­phone, the patient's whereabouts. It is often useful to note the home work phone numbers o f suicidal patients for emer- sency vSPtrence: occasionally a patient hangs up unexpectedly during a late night call or provides only a name to the answ er­ing service.

A straightforward clinical ploy is to ask any patient consid­ered suicidal whether he will agree to call when he reaches a point beyond which he is uncertain o f controll ing his suicidal impulses. If a patient can commit himself to such an agreement, he is reaffirming his belief that he has sufficient strength to cry out for help. If a patient who is considered seriously suicidal cannot make that commitment, im mediate hospitalization may

. be indicated, and both the patient and his family should be apprised.

In return for the patient’s commitment, the clinician should •eciprocate. By agreeing to be available 24 hours a day through

I ananswering service and to be directly accessible during what !he patient understands to be usual consultation hours, the clinician reassures the patient. I f stronger measures o f a clini­cian's interest are warranted, unlisted home telephone num bers and out-of-town hotel locations in the event o f travel may be provided. The patient should unders tand that the clinician will not always be able to return the call immediately but that a fullyCjr.'fed alternate psychiatrist will always be available. Perhaps the only patients unable to honor such a com m itm ent contract are those who are struggling with alcoholism or d rug abuse at the time that they are actively suicidal. T hose patients should be hospitalized directly, without a ttempting to negotiate an agreement. Tl-.e clinician who tries to negotiate an agree­ment with them will not sleep well— and properly so.

Once a patient has been identified as a high suicidal risk ;md no contract can be struck, the alternatives to im mediate hospitalization are limited. T he clinician should discourage family resistance to hospitalization for reasons o f possible social 'tigma, poor insurance coverage, or a wish to provide a round- the-clock surveillance as a measure o f their love and care for 'he patient. Families rapidly lose their motivation, their am biv ­alence may come to the fore, and the psychiatrist lacks assur­ance that a nuiiient support system is accessible to the patient -■1 hours a day. Any psychiatrist so inclined to let the family he responsible for the patient must make his next appoin tm ent a house call to see what is going on.

An often helpful technique is to introduce the suicidal patient

into a psychotherapy group in w hich some o f his needs can be met by his peers. In group p sycho therapy the sharing o f suicidal ideation o r past behavior allows the pa tien t to feel less different and. thus, less isolated. And, ju s t as peer support is a helpful quality, so is peer confrontation.

Litm an (1968) succinctly discussed problems facing the psy­chiatrist 'h a l i n g with the suicidal patient. He pointed out that the therapist s anxiety and ap p reh ens ion may result from fear that the patient will, indeed, kill himself, despite the therapist 's efforts. A strategy for neutra liz ing tha t final one-up gesture may lie in the clinician s n<.;;tig his aw aieness that the patient can kill h im self any time he w ants but, as long as part o f him wants to live, that is all that is required at the mom ent. T he psychiatrist also must p lum b his osvn psyche regarding his interest in comm itting h im self to in tervention with all suicidal patients or with certain patients . Psychiatrists who attem pt to treat more than several suicidal pa tients at one time find their energies rapidly depleted. T h e psychiatrist must accept the concept o f direct intervention in any acute suicidal crisis and must be prepared to use a range o f treatm ent approaches, including pharm acotherapy , hospita l ization , and eiectrocon- vulsive therapy. Yet he must recognize that all or any o f those m eans canno t deter a patient w ho is chronically suicidal and determ ined to end his life. T h e therap is t must rem em ber that the state o f suicide prediction a n d , indeed, o f psychiatric care, is such tha t he cannot take full responsibility for any person’s life for long periods o f time w ithou t tha t person’s eventually accepting a share o f the responsibility. In a hospital, the responsibili ty is shared.

Hospital CareOn identif ication o f the high-risk patient, the clinical task

enters a second and often more difficult arena. T he admission ol .; suicidal patient to an inpat ien t psychiatric unit, whether it be at a general hospital or a private or slate psychiatric facility, constitutes an im portant therapeutic intervention. Danger to self is one o f the few clear-cut indica tions presently acceptable in all states for involuntary co m m itm en t . Implied in such an admission is an acknow ledgm ent tha t the therapist’s clinical skills, the family s ability to m ain ta in the suicidal patient, and the com m unity s resources are unab le to m anage the patient w ithout a high risk o f a successful suicide attempt. On the admission o f a suicidal patient to a psychiatric unit, the patient, his family, and society presume tha t he has gained entree to a system that is experienced in car ing for the patient at risk. Stafied by professionals skilled in suicide in tervention and prevention techniques, such a system is both physically and psychologically protective and supportive. T he attend ing phy­sician w ho coordinates the trea tm en t program is seen as the key resource. Such a p resum ption seems reasonable; how closely it reflects the actual clinical m anagem en t o f the acute o r chronically suicidal patient is an o th e r issue.

F rederick and Resnik (1970) described the inadequacy o f trea tm ent techniques, insti tutional procedures, and postdis­charge follow-up programs for the suicidal patient that con­tr ibute significantly to the suicide rate.

Even am on g high-risk groups o f hospitalized patients , su i­cide is a rare event. Lester (1974) e labora ted on Rosen 's (1954) observations that the annua l suicide rate am ong patients in psychiatric hospitals was approx im ate ly 0.003 per cent, or 40 suicides per 12,000 patients. If clinical techniques were able to identify correctly th ree-quarters ol the suicidal patients . 30 o f the 40 in a 12,000-patiem psychiatric hospital popula t ion would

Historical Papers, Wits University

http://www.historicalpapers.wits.ac.za/admin/cms_header.php?pid=98[2013/03/12 07:52:17 AM]

Collection Number: AK2216 AGGETT, Dr Neil, Inquest, 1982 PUBLISHER:Publisher:- Historical Papers Research ArchiveLocation:- Johannesburg©2013

LEGAL NOTICES:

Copyright Notice: All materials on the Historical Papers website are protected by South African copyright law andmay not be reproduced, distributed, transmitted, displayed, or otherwise published in any format, without the priorwritten permission of the copyright owner.

Disclaimer and Terms of Use: Provided that you maintain all copyright and other notices contained therein, youmay download material (one machine readable copy and one print copy per page) for your personal and/oreducational non-commercial use only.

People using these records relating to the archives of Historical Papers, The Library, University of the Witwatersrand,Johannesburg, are reminded that such records sometimes contain material which is uncorroborated, inaccurate,distorted or untrue. While these digital records are true facsimiles of paper documents and the information containedherein is obtained from sources believed to be accurate and reliable, Historical Papers, University of the Witwatersrandhas not independently verified their content. Consequently, the University is not responsible for any errors oromissions and excludes any and all liability for any errors in or omissions from the information on the website or any relatedinformation on third party websites accessible from this website.

This document is part of a collection deposited at the Historical Papers Research Archive at The University of the Witwatersrand.