Crisis of Lethality

Chapter Eight

Background of Suicide and Homicide

Edwin Shneidman is the founder of suicidology.

Working with suicidal and/or homicidal clients is always a possibility.

Instrumental vs. expressive Instrumental acts occur for a financial or concrete

gain. Expressive acts attempt to reduce psychological

pain. Feelings of depression, guilt, disempowerment,

hopelessness, etc.

The Scope of the Suicide Crisis

Worldwide1 million commit suicide annually (1 person

every 40 seconds) In the last 45 years, rates have risen about 60%

United States30,000-35,000 commit suicide annually (85

people per day) Conservative due to political, religious, emotional

issues or inconclusiveness of evidence Expert estimation is 60,000 suicides annually

The Scope of the Suicide Crisis Cont.

300,000-600,000 survive a suicide attempt. 19,000 of survivors are permanently disabled

10th/11th leading cause of death.

Caucasian men over 35 have the highest rate.

People ages 15-24 have the highest increase during the past 30 years.

2nd leading cause of death

25% of all suicides occur in people over 65 years of age.

Suicide and the Moral Dilemma

Complex moral, legal, ethical, and philosophical dilemmas.

Eastern vs. Western culture Eastern culture may see suicide as a means of relieving

dishonor, shame, or humiliation from oneself or one’s family. Western culture commonly sees suicide as a sin.

“Self-murder” “Death by murder carries no stigma and is seen as a tragedy.

Accidental death is fully condoned providing the person didn’t do something stupid or careless. Death by natural causes and resistance to the end allows grieving without animosity. Less forgivable is natural death by neglect or overindulgence. The least forgivable death is suicide, for which there is little sympathy and no absolution”-Everstine (1998)

Suicide and the Moral Dilemma Cont.

Euthanasia Assisted suicide vs. euthanasia

“Prolonged dying” 70-80% of adults will die in either a hospital

or nursing home most likely of degenerative diseases.

The dying process may be painful and financially draining to the individual, their family, and society.

Right to refuse medical treatment or artificial intervention?

Psychological Theories

Freudian Inward Aggression Suicide is triggered by an intrapsychic conflict

that emerges when a person experiences great psychological stress.

Developmental Views suicide in terms of life stages. If an

individual does not successfully navigate these stages, they may become unable to cope leading to suicide.

Deficiencies Mental deficiencies become risk factors that can

lead to suicide.

Psychological Theories Cont.

Escape Suicide is seen as a flight from a situation deemed

by the person as intolerable.

Hopelessness When an individual believes that highly desired

outcomes will not occur or that highly aversive outcomes will occur and there is nothing they can do to change the situation.

Psychache “The hurt, anguish, soreness, and aching pain of the

psyche or mind.” Cubic model combines psychache, perturbation, and

press.

Sociological Theory

Durkheim’s Social Integration (1897) Most important sociological theory on suicide. Societal integration and social regulation are

major determinants of suicidal behavior. Four types of suicide:

Egoistic Anomic Altruistic Fatalistic

Sociological Theory Cont.

Suicide Trajectory Model Considers the total constellation of risk

factors including: Biological Psychological Cognitive Environmental stressors

The more these stressors build-up, the greater the risk of suicide.

Interpersonal Theory

People commit suicide because they can and because they want to kill themselves.

Three central components: Acquire suicidal capability Perceive burdensomeness Failed belongingness

All three must be present simultaneously for suicide to occur

Existential-Constructivist Framework

Four corner posts of existence: Death Existential isolation Meaninglessness Freedom

Individuals respond to challenges to their worldview in three ways: Retain their original constructions Alter their original constructions to build new

ones Decide that neither response is an option and

consider suicide as a final construct

Other Explanations

Accident Biochemical or Neurochemical Malfunction Chaos Dying With Dignity/Rational Suicide Ecological/Integrative Interactional Ludic Oblative Overlap Model Parasuicide Suicide by Cop

Characteristics of People Who Commit Suicide

10 most common characteristics (grouped under six aspects)

Situational characteristics Stimulus is unendurable psychological pain Stressor is frustrated psychological needs

Motivational characteristics Purpose is to seek solution Goal is cessation of consciousness

Affective characteristics Emotions are hopelessness and

helplessness

Characteristics of People Who Commit Suicide Cont.

Cognitive characteristics Cognitive state is ambivalence between doing it and

wanting to be rescued Perception is a state of tunnel vision with no

alternatives Relational characteristics

Interpersonal act is communication of intention Action is egression

Serial characteristics Consistency is with lifelong coping patterns when

deep perturbation, distress, threat, and psychological pain are present.

Each suicide is idiosyncratic and there are no absolutes or universals.

Similarities Between Suicide and Homicide

30% of murderers committed suicide after completing a homicide.

Elderly couplesDomestic violence Infanticide by overwrought parentsMental illness

Myths About Suicide

Discussing suicide will cause the client to move toward doing it.

Clients who threaten suicide do not do it. Suicide is an irrational act. People who commit suicide are insane. Suicide runs in families (it is inherited). Once suicidal, always suicidal. When a person has attempted suicide and pulls out of it,

the danger is over. A suicidal person who begins to show generosity and share

personal possessions is showing signs of renewal and recovery.

Suicide is always an impulsive act.

Myths about Suicide Cont.

Suicide strikes only the rich. Suicide happens without warning. Suicide is a painless way to die. Few professional people kill themselves. Christmas season is lethal. Women do not use guns to kill themselves. More suicides occur during a full moon. Suicidal people rarely seek medical attention. Most elderly people who commit suicide are

terminally ill. Suicide is limited to the young. Suicidal thoughts are relatively rare.

Assessment

Suicide Clues Nearly all suicidal/homicidal people offer some kind

of clues (verbal, behavioral, situational, or syndromatic)

Warning Signs IS PATH WARM

Ideation Substance abuse Purposelessness Anxiety and agitation Feeling Trapped Hopelessness Withdrawal Anger Recklessness Mood fluctuations

Assessment Cont.

Assessment Instruments MMPI-2 Hopeless Scale Beck Depression Inventory Acquired Capability for Suicide Scale SAD PERSONS BASIC

Clinical Interview CAMS CASE RFL SRADT

Using the Triage Assessment Form in Addressing Lethality

Intervention Strategies

The goal is to change at least one of the “Three I’s.” Inescapable Intolerable Interminable

Explore existing problem-solving skills or generate new skills.

Recognize that emotional pain will not be constantly intense and interminable.

Cognitive behavioral therapy techniques are commonly used.

Cognitive restructuring Emotional regulation Changing destructive behaviors through psychoeducation

“No harm” contracts Controversial Traditional vs. alternative format

Older Adults

Suicide Rarely a “cry for help” or an impulsive act Percentage of completed suicides increases with age 75% of individuals who completed a suicide had been to

their physician within the previous 30 days but did not discuss their suicide plans.

“Chronic/passive suicide”

Homicide/Suicide Occurs at nearly double the rate of young adults. Perpetrator is typically a male who kills his partner and

then commits suicide. Three different types:

Aggressive Dependent-protective caregiver Symbiotic

Some "Don'ts"

Don’t lecture, blame, or judge. Don’t debate the pros/cons of suicide. Don’t be mislead by the client saying that the crisis is in

the past. Don’t try to challenge for shock effect. Don’t be passive or overreact. Don’t glamorize, martyrize, or deify suicidal behavior. Don’t forget to follow-up. Don’t be embarrassed to consult. Don’t rush. Don’t forget about countertransference. Don’t be manipulated into giving into a client’s demands.

The Psychological Autopsy

Examination of personal demographics, in-depth interviews, and examination of suicide notes in an attempt to determine:

Was the act a suicide? What were the triggers? Was psychopathology present?

Analyzing Suicide Notes Not commonly left Four categories:

Problems are not of their own making but they know what they are doing

Incurable physical or mental illness that has drained all strength Love scorned and the note is directed toward the significant other “Last will and testament” with instructions but little insight for

motivation When analyzed in conjunction with a detailed life history, it can

offer a lot of insight about why the individual committed suicide

Postvention

Emotional Toll Average suicide leaves 6-10 survivors (real

victims) who experience extreme grief Feel double binds of guilt and anger Generally receive less sympathy and encounter

more isolation and stigmatization than other bereaved individuals

Child/Parent Survivors Potential to suffer from severe pathological

problems is high

Postvention Cont.

Support Groups Active Postvention Model (Baton Rouge, LA)

Meetings 1-3 focus on prohibition of mourning Meetings 4-8 focus on doing grief work Meetings 9 & 10 focus on reminiscing about the

good times, becoming more future-oriented, and termination of the group.

Transcrisis Postvention Resuscitation Resynthesis Renewal

Losing a Client to Suicide

Essential to remember that if people really intend to kill themselves, despite our best efforts to intervene, they can manage to accomplish the task.

Guided debriefings lead by experts are necessary.

Supervision should be mandatory. “Vicarious traumatization”