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1. Marital Status. Divorced or separated people comprise a disproportionate percentage of suicides (Farberow et al. 1965) and widowed individuals show especially high rates (Sainsburg 1955). Their self-inflicted deaths cluster in the first years of bereavement (MacMahon). The lowest rates appear to be among the married, especially those with children. The rates for single people average twice those of the married, and the rates for the divorced or widowed are from four to five times higher than the married (Hendin 1967).
2. Presence of Physical Illness. There is a high correlation between physical illness and suicidal behavior (Dorpat et al. 1968). The presence of a disabling or painful illness, such as cancer, particularly in someone who was robust, presents a considerable risk.
3. Depression. All patients whose mood is depressed should be carefully questioned as to their suicide potential (Susser 1968).
4. Severe Insomnia. Regular early morning wakening with restlessness indicates a high risk.
5. Correlation to Gender. The risk of suicide is higher among men (Susser 1968), although women may gesture more. Men will frequently make more lethal attempts using violent means, whereas women seem to prefer to overdose. The percentage of males and females are 70 and 30 respectively for successful suicides, while the percentage for attempted suicides are nearly the reverse, 31 and 69 respectively (Farberow and Shneidman 1965).
6. Schizophrenia. Clinical experience suggests that suicidal behavior is much more difficult to predict in schizophrenics (Farberow and Shneidman 1957). A combination of a depressed mood, a thought disorder, and suicidal ideation is ominous. Especially ominous are "command" hallucinations telling the patient to kill himself, or the hallucination of the voice of a departed loved one beckoning the patient to join him in the world beyond.
7. Alcoholism and Drug Addiction. Clinical experience shows that suicidal behavior is difficult to predict in alcoholics (Farberow and Shneidman 1957) and in drug addicts. While an addict or alcoholic may not consciously elect to kill himself, his judgment may become impaired to the point where he might, for instance, take an excess of barbiturates in order to sleep. in susceptible individuals alcohol or drugs can also trigger violence aimed at oneself or at others. Alcoholism or drug addiction may, in addition, be an expression of an underlying neurosis or psychosis; these disorders may of themselves increase the risk of suicide. It is believed by some that any addiction, because of the incredible toll it takes on the individual both physically and emotionally, represents a form of chronic suicidal behavior.
8. Homosexuality. Homosexuals, particularly those inclined to alcoholism and depression, and those who entertain florid sadomasochistic fantasies, should be carefully assessed for suicidal potential. The aging homosexual whose physical attractiveness is declining constitutes a serious risk. Society still continues to treat homosexuals as outcasts, thus engendering situations where homosexuals are prevented from moving within the mainstream and have to depend for support on the homosexual subculture.
9. Previous Suicide Attempts. Studies have shown that 50-80 percent of those who commit suicide have a history of a previous suicide attempt (Susser 1968).
10. Lethality of Attempt. Shneidman and Farberow (1965) divide suicides into two groups: those in which the point of no return is rapidly reached and those in which it is gradually reached. Gunshot wounds, hanging, and jumping, which are associated with a quick death, are identified almost entirely with lethal attempts, whereas wrist cutting, throat cutting, and ingestions are associated with nonfatal attempts. The more violent and painful the method chosen, the greater the risk. The setting in which the attempt occurs (e.g., is there likelihood of immediate discovery?) and whether an attempt is made to communicate to others are important considerations. Suicidal ideas harbored by the patient and not communicated to his relatives constitute a grave situation. A suicide attempt is more serious when a note has been written. Szasz (1959) believes that suicidal behavior may constitute a form of communication, or as Shneidman and Farberow prefer, "a cry for help." A suicide attempt is less malignant when it can be determined that secondary gain is involved.
11. Living Arrangements. Suicide risk is greater among those who live alone (Susser 1968; McMahon et al. 1963).
12. Age. Advancing age and suicide rates are directly correlated. Suicides are virtually nonexistent before nine years of age and rare. In the ten to fourteen year old age group (less than one death for 200,000 children). However, the rate rises sharply from age fifteen to nineteen (an eight to tenfold increase); from age twenty to twenty-four the suicide rate doubles again. This trend continues to the very old adult (Shneidman and Farberow 1957).
13. Religion. Jews and Catholics seem to have lower suicide rates than Protestants (Durkheim 1897).
14. Race. It appears that proportionately more blacks attempt suicide than commit it. Shneidman and Farberow report that 95 percent of successful suicides in their group were white. Certain subgroups are atypical; while suicide among urban black males aged twenty to thirty-five is nearly twice that for white men of a comparable age group, in older age groups the white suicide is significantly higher (Hendin 1967).
15. Family History of Suicide. A history of suicide in the family must be asked about. In one series, 25 percent of those who attempted suicide had a history of suicide in the immediate family (Shneidman and Farberow 1957).
16. Recent Loss. The recent loss through death of a person close to the patient has also been found to be a precipitating factor in suicide (Shneidman and Farberow 1957).
Other factors cited as increasing the risk of suicide include hypochondriasis, recent surgery or childbirth, no apparent secondary gain, unemployment, and financial difficulty.
In evaluating a patient who has attempted suicide or is contemplating it, it is crucial to assess how depressed the patient is and to inquire specifically about guilt feelings, self-depreciation, or nihilistic ideas. The patient who persistently claims that he or others would be better off if he were dead constitutes a serious risk.
- Getz, William, Allen E. Wiesen, Stan Sue, and Amy Ayers; Fundamentals of Crisis Counseling; Lexington Books: Massachusetts; 1974
Personal Reflection Exercise #3
The preceding section contained information about a suicide risk assessment model for clients in crisis. Write three case study examples regarding how you might use the content of this section in your practice.