The Question of Intent in Suicide Attempts

Suicide Attempts
"The survivor of a suicide attempt act is regarded by the public as either having bungled his suicide or not being sincere in his suicide attempt intention. He is looked upon with sympathy mixed with slight contempt, as unsuccessful in an heroic undertaking. It is taken for granted that the sole aim of the genuine attempt is self destruction, and therefore the dead are successful and the survivors unsuccessful.", Erwin Stengel.

People who carry out acts lumped together as "suicide attempts" actually have a variety of motives, and combining various intents masks important differences. According to Louis Dublin, a respected statistician, almost a third fully intend to kill themselves; fewer than half of these succeed. Those that fail generally do so because of unexpected rescue, or, more often, mistakes in planning or knowledge. These people tend to use generally-lethal methods (guns, hanging, drowning, jumping) and are disproportionately older and male.

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Another third clearly do not want to die. Their suicide attempt, more aptly called a "suicidal gesture", is a cry for help or attention. They're trying to change their circumstances or to influence important people in their lives, usually parents, spouse, or lover. They make every effort to be saved, often scheduling the attempt to coincide with the expected return of a would-be rescuer.

Of course, rescuers are sometimes delayed--or uninterested. Forensic texts provide some charming examples. In one case a woman took an overdose of barbiturates and pinned a note to herself saying, "If you love me, wake me up." Her husband came home around 10 p.m., saw the note, tossed it into the trash, and went out to a bar. When he returned early next morning, she was dead. The official cause of death was suicide. Criminal charges of homicide were considered, but not filed.

These suicide "attempters" are more likely to be younger and female, and use less lethal means than the first group, most frequently drug overdoses and wrist cutting. Note that a "failed" suicide attempt in this group is one in which the person dies, which is the opposite of failure in the previous group.

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The last third are people tossing the dice. They are in such emotional pain, rage, or frustration that they don't much care if they live or die, as long as the pain stops. They tend to be impulsive, not plan carefully (if at all), and leave their survival to chance. In another study, of 500 suicide attempts, only 4% were described as "well-planned", but only 7% turned out to be more-or-less harmless.

The relationship between the seriousness of someone's intent to kill herself and the lethality of the attempt is controversial. While it would seem intuitively plausible that the more seriously one intended to die the more lethal the resulting suicide attempt would be, numerous studies have reached contradictory conclusions: some have found an association, others have not.

The debate is more than academic. If the connection between serious intent and lethality of attempt is real, it implies that suicide prevention strategies that focus on decreasing the availability of lethal methods (e.g. gun-control laws) will fail, because people wanting to die will simply switch to other, similarly lethal, methods such as hanging.

If, on the other hand, there is no good correlation between intent and lethality, then a decrease in the availability of lethal methods will be effective in decreasing suicides, because serious (but not fully rational) attempters will tend to switch to methods of lesser lethality.

Other evidence suggests a third possibility, that impulsivity or depression might have the best correlation with use of lethal methods; and that these in turn, are associated with neuro-chemical imbalance.

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Suicide Intent Scale

The suicide intent scale was developed by Aaron T. Beck and his colleagues at the University of Pennsylvania for use with patients who attempt suicide but survive. It is important to understand a patient's will to die in order to assess the severity of the suicide attempt. Some attempted suicides are carried out with little to no intention of cessation of life, while others clearly have no other goal. The suicide intent scale is an attempt to redefine the meaning of attempted suicide, placing them on a scale based on intent.

Another factor that plays an important role, but is not listed on the scale below, includes the chosen method of attempted death. Hangings and firearms is clearly more effective tools of suicide, the damages much more difficult to reverse. Suicide by poisoning, on the other hand, is less likely to be successful. This, however, is not the case in less developed nations, where access to emergency treatment is less possible and there is greater access to more deadly poisons such as pesticides. These factors must be also taken into consideration.

Objective Circumstances Related to Suicide Attempt
1.      Isolation
1.      Somebody present
2.      Somebody nearby, or in visual or vocal contact
3.      No one nearby or in visual or vocal contact

2.      Timing
1.      Intervention is probable
2.      Intervention is not likely
3.      Intervention is highly unlikely

3.      Precautions against discovery/intervention
1.      No precautions
2.      Passive precautions (as avoiding other but doing nothing to prevent their intervention; alone in room with unlocked door)
3.      Active precautions (as locked door)

4.      Acting to get help during/after attempt
1.      Notified potential helper regarding attempt
2.      Contacted but did not specifically notify potential helper regarding attempt
3.      Did not contact or notify potential helper

5.      Final acts in anticipation of death (will, gifts, insurance)
1.      None
2.      Thought about or made some arrangements
3.      Made definite plans or completed arrangements

6.      Active preparation for attempt
1.      None
2.      Minimal to moderate
3.      Extensive

7.      Suicide Note
1.      Absence of note
2.      Note written, but torn up; note thought about
3.      Presence of note

8.      Overt communication of intent before the attempt
1.      None
2.      Equivocal communication
3.      Unequivocal communication

Self Report
9.      Alleged purpose of attempt
1.      To manipulate environment, get attention, get revenge
2.      Components of above and below
3.      To escape, surcease, solve problems

10.  Expectations of fatality
1.      Thought that death was unlikely
2.      Thought that death was possible but not probable
3.      Thought that death was probable or certain

11.  Conception of method's lethality
1.      Did less to self than s/he thought would be lethal
2.      Wasn't sure if what s/he did would be lethal
3.      Equaled or exceeded what s/he thought would be lethal

12.  Seriousness of attempt
1.      Did no seriously attempt to end life
2.      Uncertain about seriousness to end life
3.      Seriously attempted to end life

13.  Attitude toward living/dying
1.      Did not want to die
2.      Components of above and below
3.      Wanted to die

14.  Conception of medical rescuability
1.      Thought that death would be unlikely if he received medical attention
2.      Was uncertain whether death could be averted by medical attention
3.      Was certain of death even if he received medical attention

15.  Degree of premeditation
1.      None; impulsive
2.      Suicide contemplated for three hours of less prior to attempt
3.      Suicide contemplated for more than three hours prior to attempt

Other Aspects (Not included in total score)
16.  Reaction to attempt
1.      Sorry it was made; feels foolish; ashamed
2.      Accepts both attempt and failure
3.      Regrets failure of attempt

17.  Visualization of death
1.      Life after death, reunion with descendants
2.      Never-ending sleep, darkness, end of things
3.      No conceptions of or thoughts about death

18.  Number of previous attempts
1.      None
2.      One or two
3.      Three or more

19.  Relationship between alcohol intake and attempt
1.      Some alcohol intake prior to but not related to attempt; reportedly not enough to impair judgment, reality testing
2.      Enough alcohol intake to impair judgment; reality testing and diminish responsibility
3.      Intentional intake of alcohol in order to facilitate implementation of attempt

20.  Relationship between drug intake and attempt
1.      Some drug intake prior to but not related to attempt; reportedly not enough to impair judgment, reality testing
2.      Enough drug intake to impair judgment; reality testing and diminish responsibility
3.      Intentional intake of drug in order to facilitate implementation of attempt

15-19 Low Intent
20-28 Medium Intent
29+ High Intent

There is also a greater risk of repeated attempts the higher the intent rating.

Sources and Additional Information:


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