Week 4: Discussion: Responding to Community Violence

CHAPTER EIGHT: CRISIS OF LETHALITY

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

 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

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 couples Domestic violence  Infanticide by overwrought parents Mental 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”