1. Crisis of Lethality
Chapter Eight

2. 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.

3. The Scope of the Suicide Crisis
 Worldwide
1 million commit suicide annually (1 person every
40 seconds)
 In the last 45 years, rates have risen about 60%
 United States
 30,000-35,000 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

4. 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.

5. 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)

6. 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?

7. Psychological Theories
 Freudian Inward Aggression
 Suicide
is triggered by an intrapsychic conflict that
emerges when a person experiences great
psychological stress.
 Developmental
 Viewssuicide 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.

8. 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.

9. 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

10. 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.

11. 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

12. 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

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

14. 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

15. 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.

16. Similarities Between Suicide and
Homicide
 30% of murderers committed suicide after
completing a homicide.
 Elderly couples
 Domestic violence
 Infanticide by overwrought parents
 Mental illness

17. 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.

18. 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.

19. 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

20. 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

21. 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

22. 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

23. 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.

24. 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

25. 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

26. 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

27. 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”