ASSIP - Attempted Suicide Short Intervention Program - A Manual for Clinicians

2 Suicide and Attempted Suicide (p. 5-6)

2.1 Definitions

Suicide is the act of deliberately killing oneself. This definition includes intentional actions such as overdosing, hanging, shooting, etc,, and omission of life-saving measures – for example, refusing dialysis in renal failure. The concept of suicide as a “willed” action stands in contrast to the close association of suicide with psychiatric disorders (Barraclough, Bunch, Nelson, & Sainsbury, 1974; Isometsä et al., 1995) as well as the reports of suicide attempters who say that during the suicidal crisis they were in an out-of-theordinary state of mind, acting like in a trance (Orbach, 1994). The so-called rational suicide, where a suicide is believed to be a rational decision by a mentally healthy person is generally thought to be a rare exception, if it exists at all (Dörner, 1993).

Attempted suicide (Suizidversuch) was defined by Erwin Stengel (1964) as a form of deliberate self-harm limited to a short period of time where the suicidal person cannot know whether or not he or she will survive. Stengel referred to suicide attempts with only limited intention to die, as parasuicide or parasuicidal acts. Wilhelm Feuerlein (1971) sought a further differentiation based on the seriousness and the motives of the self-harm and introduced the terms parasuicidal pause (interruption of an unbearable situation) and parasuicidal gesture” (with a communicative or appellative aspect). The WHO/EURO multicenter study on suicide and attempted suicide (Platt et al., 1992) defined attempted suicide as an act with non-fatal outcome, in which an individual deliberately initiates a non-habitual behavior that, without intervention from others, will cause selfharm, or deliberately ingests a substance in excess of the prescribed or generally recognized therapeutic dosage, and which is aimed at realizing changes which the subject desired via the actual or expected physical consequences. (p. 99)

The WHO working group intended this working definition to cover the whole spectrum of life-threatening behaviors (WHO, 1986). Long-term self-harming behavior such as anorexia or substance abuse are excluded from the WHO definition.

Silverman et al. (2007) defined attempted suicide as a “self-inflicted, potentially injurious behavior with a nonfatal outcome for which there is evidence (either explicit or implicit) of intent to die.” Suicide attempt is the term commonly used in German-speaking countries and in North America, while in the United Kingdom, the preferred terms are self-harm, deliberate self-harm, or parasuicide, terms encompassing all forms of nonfatal self-injury (Skegg, 2005). Attempted suicide usually includes episodes of self-injury with at least some intent to die; self-harm or self-injury are broad terms which range from habitual self-injury for emotional regulation without suicidal intent through to serious suicide attempts with high intent. Distinguishing between “seriousness of intent” and “assumed intent” is problematic (and not a distinction usually made in the German-speaking sphere). Intent is often characterized by ambivalence or even concealment. Often, the goal may be to initiate change, which can include finding release from an unbearable situation, finding a state of calm, ending overwhelming mental and emotional pain, and calling attention to one’s suffering, as well as a desire to put an end to a life that has become unbearable (Bronisch & Wolfersdorf, 2012; Hjelmeland & Hawton, 2004). Most people who consider suicide as an option do not go on to make a suicide attempt. In a population-based study, only 7.4% of those with baseline suicidal ideation reported a suicide attempt over the subsequent 2 years (ten Have et al., 2009).

The term attempted suicide, as we use it in this book, includes self-harm with at least some intent to die but excludes habitual self-harm, which is typical in borderline personality disorders. Suicidal behavior encompasses suicide and attempted suicide. Suicidality here means ways of thinking and behaving such that someone accepts death as the possible outcome of an action (based on Manfred Wolfersdorf, 2000).

Internal and External Attributions

When we explain the behavior of others, we make attributions (ascribing causes and effects of actions). If we assume that the explanation for a behavior lies in the person himself or herself, we speak of internal attributions. If we assume that an external event is responsible for a certain behavior, it is an external attribution (Heider, 1958). As outsiders we usually only have fragmentary information to explain the behavior of others. This is especially true in the case of completed suicide, when we can no longer question the person. External attributions are based on theories and models we create to explain the behaviors of others. For example, media reports may explain the suicide of an adolescent with poor marks at school (“Poor marks at school: Suicide!”), thus not only badly simplifying the mechanisms leading to suicide, but also providing a simple and sensational model that may result in copycat suicides. The medical model, in particular, has a tendency to use external attributions, based on its tendency to search for the cause of pathology, and with its emphasis on mental disorders as the cause of suicide.

Buss (1978) argued that there is a fundamental difference between explanations by an outsider and explanations by the acting person. Outside observers tend to use causal (“why”) explanations – for example, “Mr. B. took his life because he had lost his job.” By contrast, the individuals concerned (people who have made a suicide attempt, or a suicide note left by the dead person) generally explain their action with a motive or intention: a “reason” as opposed to “cause” – for example, saying, “At that moment I saw suicide as the only possible way of putting an end to unbearable mental pain.”

In suicide research, one way to find more person-centered explanatory models is by studying suicide notes (Leenaars, 1988) and through what is known as psychological autopsies (studies designed to do proxy-based diagnostic assessments). This method involves collecting all available information on the deceased via structured interviews of family members, relatives, or friends, as well as the attending health care personnel. In addition, information is collected from available health care and psychiatric records, other documents, and forensic examination.