Result

The results will be presented in the following manner.

First, the

demographic characteristics of the participants will be reported, followed by a

summary of the ideoaffective variables reported as occurring within the half hour
prior to the most recent attempt.

Second, the descriptive statistics including

means, standard deviations, and intercorrelations between all of the variables

used in the study will be presented.

The mean ratings of lethality of the

methods chosen and the time involved for the method to result in death,
provided by both the clinicians and the patients, will be reported.

In

addition, the frequency and percent distribution of responses given for items
on the Suicide Intent Scale and the Self-Rated Scale for Suicide Ideation,
and the frequency

and percent

distribution

Hopelessness Scale will be reported.

of the total scores

on the

Finally, the results of the predicted

relationships will follow: 1) clinician ratings of lethality (i.e., medical lethality

and the Lethality of Suicide
Attempt Rating) and the intent of the attempters, 2) patient ratings oflethality
(i.e., perceived lethality) and their reported

subjective intent,

3) clinician

ratings of lethality (i.e., medical lethality and the Lethality of Suicide Attempt
Rating) and patient ratings of lethality (i.e., perceived lethality), 4) clinician and
patient evaluations of the time involved for the chosen methods to produce
death (i.e., medical time and perceived time,

5) patient reports of suicidal

ideation and suicidal intent, 6) hopelessness and suicidal intent.

I. Demographic Characteristics
i) Characteristics of the Sample

Table 1 presents the demographic characteristics of the sample.

A total of23 patients participated in the study, 14 females and 9 males. The ages of
the participants ranged from 19 to 55 years of age, with a mean age of 39 years. Seventy
percent of the sample were single, and not more than 22% were regularly employed. The
majority of participants, 52%, had at least one year of post-secondary education. None of the
participants reported abuse of illicit drugs, and only one participant reported a history of
alcohol abuse.

Previous Psychiatric Diagnoses (DSM-IV)

In terms of lifetime prevalence ofpsychiatric disorder, 43% of the sample had been
diagnosed with depression, 17% with bipolar disorder, and 13% with borderline personality
disorder.

Nine percent of the sample had a diagnosis of dissociative disorder, 9% of

schizophrenia, 9% of other psychosis, and 9% of obsessive compulsive disorder

Family History of Psychiatric Disorders & Suicide

Disorders of mental health in first or second degree relatives were reported for 70%

Percent total exceeds 100% because of comorbid diagnoses.

Treatment
Ninety-six percent of the participants had current or previous psychiatric contact.
Twenty-two percent of the sample reported receiving treatment by a general practitioner, and
48% by a social agency. Ninety-six percent of participants had ongoing psychiatric treatment.
All of the participants reported taking antidepressants at some point in their
psychiatric treatment history, while 39% reported having taken antipsychotics or neuroleptics.

Previous Suicide Attempts

Thirteen participants (57%) had made between 2-6 attempts, and 7 (30%) had made
up to 15 attempts. Three individuals (13%) reported attempting 17 or more times. A mean
of 8.5 suicide attempts were reported for the entire sample, with a standard deviation of 6.9.

Method Used in Recent Attempt

In terms ofthe method employed in the attempt they were interviewed for, 17 (74%)

of the participants reported taking an overdose of pills (prescription and/or nonprescription).

Of these self-poisoners, 4 (17%) reported taking pills in addition to employing other methods
such as cutting and/or ingesting other substances (e.g., batteries, bleach). Three (13%) ofthe
participants reported jumping or attempting to jump from various heights.

Table 1 . Demographic Characteristics

ii) Ideoaffective State
N=23
Freq.
%
N=23
Freq.
%
Psychopharm.,
current states reported for the
Gender Figure 1 presents the frequency distribution
of the ideoaffective
male
Female
Age (X=39)

9
14

39%

benzodiazepines

9%

61%

antipsychotics/
neuroleptics

30%

22

96%

s30

17%

antidepressants

s40

35%

Psychopharm., ever

s50

35%

benzodiazepines

13%

16

70%

antipsychotics/
neuroleptics
antidepressants

9
23

9
23

married

9%

divorced

17%

16

16

separated

4%

10

10

Education
Previous Psychiatric
Diagnosis*
elementary

9%

highschool

college/university*

12

s60
Martial Status
single

Mental Disorders,
Relatives
Suicide, Relatives

depression

10

39%

bipolar

52%

borderline

(*at least 6 months)

dissociative disorder

Occupational Status

schizophrenia

regularly employed

22%

other psychosis

disability pension

22%

OCD

unemployed

30%

(*exceeds 100% due

to dual diagnoses)

welfare

30%

psychiatric

22

96%

# of Previous Suicide
Attemps
(M=8.5)

general practitioner

22%

<6

Ongoing Treatment

13

57%

social agency
ii) Ideoaffective State
Psychiatric Inpatient,

11

48%

<15

30%

<20

9%

Figure
1 presents the
distribution
the
96%
31 of the ideoaffective states1reported for4%
Previously
22frequency

(# of times, inpatient
M=5.1
Psychiatric Treatment,
Ever

Received Treatment
for Attempt

22

22

96%

96%

half hour before the attempt for which the participants were interviewed for the present study.
In response to how they were feeling in the half hour before their recent attempt, the
following results were obtained for the present sample.

Nineteen (83%) participants reported feeling that they had trouble concentrating or
thinking before and during the attempt, and almost half (44%; N=lO) of these individuals
indicated that they had felt this way for one month or longer,

Twenty-one (91%) participants reported feeling upset or agitated at the time of their
attempt, and 57% (N=l3) of these same individuals indicated that they had felt this way for
one month or longer. Fifty-seven percent (N=13) of the sample reported feeling ashamed
about something at the time of the attempt, and 78% (N=18) indicated that they felt that they
hated themselves; 70% (N=16) felt that they were to blame for something.

Twenty (87%) individuals from this sample indicated that they thought they would
experience excessive relief as a result of their attempt (a score of 5 on a 5-point scale), while
the remaining 3 participants indicated a great amount of relief (a score of 4). Interestingly,

twenty-one (91%) individuals indicated belief in some form of life-after-death experience,

ii) Ideoaffective State
such as the soul living on in heaven /Paradise or a reincarnation into another life form. This
Figure 1 presents the frequency distribution of the ideoaffective states reported for the

suggests that the expected experience of relief may have been in anticipation of a form of
continued existence after the physical suicide. Fifteen (65%) participants indicated that they
thought they would be very successful in their attempt to suicide (a score of 5 on a 5-point
scale), and the remaining 8 indicated that they thought they would more than likely be
successful (a score of 4).

62

Figure 1.

Frequency Distribution of
Ideoaffective States
upset/agitated

Count

10

12

14

16

18

20

22

63

IL Descriptive Statistics

I) Means and Standard Deviations

The means and standard deviations for all of the variables in the study are presented

in Table 2.

Table 2. Means and Standard Deviations for the Sample (N=23)

Variable

.sn

3.08

1.29

42.61

19.59

Psychiatrist Rated

L Medical Lethality
("How likely was the method the patient chose
to have caused his/her death?")
2. Lethality of Attempt Rating (LSARS)
Patient Rated
3. Perceived Lethality
("How likely was the method you used to have
caused your death?")

5.35

0.65

8.43
12.52
20.95

2.88
1.08
3.43

5. Suicidal Ideation

34.09

4.89

6. Hopelessness

18.26

4. Suicidal Intent (SIS)

Objective Circumstances
Subjective Intent
Total Intent

3.41

64

Mean scores indicated a low to moderate level on the dimension of lethality as rated
by clinicians. When asked "How likely was the method the patient chose to have caused
his/her death?" (medical lethality), on average, clinicians indicated that the most recent
attempt was not likely to have caused death. Similarly, the mean score for the Lethality of
Suicide Attempt Rating translates into "death being less than a 50-50 probability" and "death
improbable as long as first aid was administered", according to the descriptive anchors on the
LSARS scale.
The mean score for lethality as rated by patients when asked "How likely was the
method you used to have caused your death?" was high. On average, patients estimated that
the method chosen for their most recent attempt would almost definitely result in death. It
is apparent that the standard deviation for lethality is smaller for the patients than for the
clinicians. Within this sample, patients were consistent in providing high lethality ratings,
while clinicians tended to provide a wider range of scores. On the scale ranging from 1 to 6
in rating lethality, the scores provided by the 23 participants ranged from 4 to 6 with the
majority of ratings (91%) above a score of 5, indicating that the .method employed would
almost definitely result in death. For clinicians using the same scale, the lethality score ranged
from 1 to 5 and it was estimated that in 40% of the cases death was unlikely, with the
majority of ratings (70%) falling below a score of 4, indicating that death may have been
possible under certain conditions. The clinicians did not assign the highest possible lethality
rating for any of the participants in the sample, reflecting their assessment that none of the
methods employed by this sample would defmitely result in death.

65

The mean scores for the measures of suicidal ideation and hopelessness were generally
higher than those obtained in other clinical and nonclinical samples. The mean score obtained
on the Hopelessness Scale was above the cut-off score of 9, which is predictive of eventual
suicide.
Similarly, the mean score for the measure of suicidal intent was generally higher than
mean scores obtained in other studies. Reported results for total intent have ranged from
M=5.4, SD=7.5 in nonclinical samples (Wetzel et al., 1980) to M=l9.5, SD=3.5 in clinical
samples (Hamdi et al., 1991). In terms of assessing the relationship between the objective
circumstances and the subjective intent, these two components of intent first had to be made
comparable, since the total number of items for both subscales differed. In order to compare
the mean obtained for the objective circumstances subscale with the mean for the subjective
intent subscale, the subscale totals for each participant were divided by the highest possible
score that could be obtained for the subscale, and the mean was then recalculated In other
words, the objective circumstances subscale total for each participant was divided by sixteen,
and the subjective intent subscale total for each participant was divided by fourteen. This
yielded the average response to the objective items by an individual and the average response
to the subjective items by an individual. The means for both of these adjusted variables were
then compared. Table 3 presents the original and the adjusted means and standard deviations
for the sample.

66

Table 3. Original and Adjusted Means and Standard Deviations for the Objective and
Subjective Measures of Suicide Intent.
Objective
Circumstances

M
Original Scores
Adjusted Scores

8.43
0.53

Sl2
2.88
0.18

Subjective
Intent

Sl2

12.52

1.08

0.89

0.08

1
(df=22)

10.43*

*p<.Ol

The results indicated that there was statistical evidence that the mean of the average
response to the subjective items was significantly greater than the mean of the average
response to the objective items. In other words, significantly more items were endorsed on
the Suicide Intent Scale which represent the subjective intent to suicide, in comparison to the
items which inquired about the circumstances of the act, such as the amount of planning
involved and whether or not overt communication about the attempt was made prior to the
act

ii) Bivariate Intercorrelations Among the Variables

Table 4 presents the intercorrelations among the variables in the study.

Table 4. Intercorrelations between all of the variables in the study.

Variable

1. Medical Lethality
2. Lethality of Attempt Rating
(LSARS)

.96
(.00)

3. Perceived Lethality

-.14
(.52)

-.26
(.23)

4. Suicidal Intent (SIS)

-.17
(.43)

-.15
(.48)

.11
(.61)

5. Suicidal Ideation (SSI-SR)

.03
(.89)

-.14
(.52)

.17
(.43)

.43
(.04)

6. Hopelessness (HS)

-.01
(.97)

-.06
(.78)

-.08
(.71)

.09
(.68)

.66
(.09)

Note. 1. The Spearman rank coefficient (p) was used for correlations involving variables 1 and 3
which are scaled on an ordinal scale. The Pearson coefficient (r) was used for all other
correlations.
2. The two-tail significance levels are reported in parentheses directly below each correlation

The two clinician rated scales measuring the dimension of lethality (medical lethality,
LSARS), were significantly related, sharing 92% of the variance. This indicates that the two
scales are highly correlated, and are not mutually exclusive from one another in assessing the
actual lethality of suicidal activity. Thus, the use of either scale may be appropriate in

68

providing a measure of lethality for methods of suicide according to clinicians.

The

preconceptions held by patients regarding the lethality of the methods employed in their
suicide attempts were unrelated to the lethality ratings indicated by clinicians. In other words,
the measure of perceived lethality was not significantly correlated with either of the two
clinician rated scales of lethality (medical lethality, LSARS). Suicidal intent as reported by
patients was not significantly related to either of the two aspects of lethality, perceived or
medical. The measure of total suicidal intent, however, was significantly related to suicidal
ideation such that as patients' thoughts of suicide increased, so too did their actual desire to
engage in potentially self-destructive acts. The measure of hopelessness as rated by patients
was unrelated to any of the variables in the study.

iii) Mean Lethality Ratings

Table 5 presents the frequency of methods used by the sample for the attempt for
which they were interviewed, in addition to the mean ratings of lethality provided by clinicians
and participants according to the method employed. When clinicians and participants were
asked how likely the method chosen for the attempted suicide would result in death, the
following ratings were obtained.

69

Table 5. Clinician and Patient Ratings of the Mean Lethality for the Chosen Methods and
the Frequency of Each Method Used in the Sample.
Method Used

Frequency
(N=23)

MeanLSARS
Rating

Mean Lethality as
Mean Lethality as
Rated by Clinicians Rated by Patients

1. Drug Overdose

13

39

2.96
(SD=0.92)

5.23
CSD=0.75)

2. Jumping

62

3.83
(SD=2.02)

5.00
(SD=O.OO)

3. Cutting
4. Stabbing
5. Drug Overdose &
Cutting

1
1

10
50

1.00
3.50

6.00
6.00

28

2.00
(.SD=1.41)

5.50
(Sl2=0.71)

6. Jump in Subway
Tracks

60

5.00

6.00

7. Swallowed Batteries 1
8. Ingested Bleach
1

75
35

5.00
2.50

6.00
5.00

Combination with
Drugs & Cutting

The most popular method employed by the patients in the current study was selfpoisoning with prescription and/or nonprescription drugs. This is consistent with previous
studies (Hawton & Catalan, 1987; Farberow & Shneidman, 1965; Shneidman &
Greenblatt,
1976). At-test revealed that the mean lethality rating provided by patients for the attempts
involving drug overdoses was significantly higher than the mean lethality rating provided by
clinicians for this method, 1 (12) = 5.42, p<.Ol.

This indicates that patients tend to

70

overestimate the degree of danger to life associated with drug ingestion in comparison to
medical estimates. The difference between the mean lethality ratings for jumping and for drug
overdoses with cutting were nonsignificant.

iv) Mean Time Ratings

Clinicians and patients were asked to rate how long they expected the method
employed in the recent suicide attempt to take to result in death, in terms of seconds,
minutes, hours, or days. Whereas the clinicians' rated 35% (N=8) of the attempts as being
nonlethal, all of the participants believed that the method they chose would result in death
within a time-frame of a few seconds to a few hours. Table 6 presents the frequency and
percent distribution of ratings provided by both clinicians and patients with respect to time
expected for the method chosen for the attempt to result in death.

Table 6. Distribution of Clinician and Patient Ratings of "How long did you expect this
method to take to result in death?"

Time

Clinicians
(medical time)

a few seconds
a few minutes
less than one hour
a few hours
one day
a few days

(0%)
0
3 (13.0%)
(0%)
0
1 (4.3%)
10 43.5%)
1 (4.3%)

nonlethal attempt

8 (34.8%)

Patients
(perceived time)
1

(4.3%)

5 (21.7%)

4 (17.4%)
13 (56.5%)
(0%)
0
(0%)
0
0

(0%)

71

III. Frequency and Percent Distributions

I) Distribution for Suicidal Intent

In assessing the patient rated intent to suicide (SIS) associated with the attempt for
which they were interviewed, the following results were obtained.
Sixty-one percent (N=14) of the sample reported that although there was no one
present at the time of the attempt, someone was within visual or vocal contact, while 39%
(N=9) indicated that there was no one nearby or in visual contact. With respect to the timing
of the attempt, 52% (N=12) reported that intervention was not likely, and 30% (N=7)
reported intervention was highly unlikely. Sixty-one percent (N=14) reported making no
effort to communicate their intent to suicide, and 65% (N=15) did not leave a suicide note.
Almost all ofthe participants (95%; N=22) reported that the purpose of the attempt was to
escape or to solve their problems, and indicated that they expected their attempt to be a fatal
one. All participants (100%; N=23) reported that they seriously attempted to end their life
and that they truly wanted to die. The objective and subjective aspects of intent, and the
frequency of their endorsement, are presented in Table 7.

72

Table 7. Objective and Subjective Aspects of Suicide Intent at Time of the Attempt - The
Suicidelntent Scale
Frequency
Percent
(100%)
(N=23)
Objective Circumstances (items 1-8)
Isolation
somebody present
somebody nearby
no one nearby

0
14
9

0.0%
60.9%
39.1%

Timing
intervention was probable
intervention not likely
intervention highly unlikely

4
12
7

17.4%
52.2%
30.4%

11

5
7

47.8%
21.7%
30.4%

Acting fQr Help Aftr Att mpt

notified potential helper
contacted, but did not notify helper about attempt
no contact/no notification

1
6
16

4.3%
26.1%
69.6%

Final Acts
none
thought about/made some arrangements
made defmite arrangements

10
2
11

43.5%
8.7%
47.8%

Active Preparation
none
minimal to moderate
extensive

3
13
7

13.0%
56.5%
30.4%

PreQill!tions Against Discover:)!

no precautions taken
passive precautions taken
active precautions taken

73

Frequency
(N=23)
Suicide Note
absence of note
written & torn/note thought about
presence of note

15
1
7

Overt Communication
none
equivocal
unequivocal

14
5
4

Percent
(100%)

65.2%
4.3%
30.4%

60.9 %
21.7%
17.4 %

Subjective Intent (items 9-15)

Alleged Purpose
manipulate environment/get attention/revenge
components ofboth
escape/surcease/solve problems

0
1
22

0.0%
4.3%
95.7%

Expectations of Fatality
death was unlikely
death was possible, not probable
death was probable or certain

0
1
22

0.0%
4.3%
95.7%

Conception of Lethality
did less to self than thought would be lethal
wasn't sure if act would be lethal
equalled/exceeded that thought lethal

0
1
22

0.0%
4.3%
95.7%

Seriousness of Attempt
did not seriously attempt to end life
uncertain about seriousness to end life
seriously attempted to end life

0
0
23

0.0%
0.0%
100.0%

Attitude Toward Liying/Dying

did not want to die
components of both
wanted to die

0
0
23

0.0%
0.0%
100.0%

74

Frequency
(N=232
Medical Rescuability
thought death unlikely if medical attention received
was uncertain whether death could be averted
by medical attention
was certain of death even if medical attention
received

Percent
(100%)

0.0%

18

78.3%

21.7%

3
7
13

13.0%
30.4%
56.5%

Reaction to Attempt
sorry attempt was made/feels foolish, ashamed
accepts both attempt & its failure
regrets failure of attempt

0
8
15

0.0%
34.8%
65.2%

Visualization of Death
life-after-death; reunion with decedent
never ending sleep
no conceptions

7
12
4

30.4%
52.2%
17.4%

21

91.3%

0
2
0

0.0%
8.7%
0.0%

23

100.0%

0
0
0

0.0%
0.0%
0.0%

Degree of Premeditation
none; impulsive
suicide contemplated 3 hours or less prior
suicide contemplated more than 3 hours prior
Other Aspects (not included in total SIS score)

Relationship Between Alcohol Intake & Attempt

no alcohol use/did not apply
some alcohol, not related to attempt; not enough
to impair judgement
enough alcohol to impair judgement
intentional intake to facilitate attempt
Relationship Between Drug Intake & Attempt
(when drug was not the method used to suicide)
no drug use/ did not apply
some drug use, not related to attempt; not enough
to impair judgement
enough drug intake to impair judgement
intentional intake to facilitate attempt

ii) Distribution for Suicidal Ideation

The suicidal ideation reported by patients as occurring prior to the attempt for which
they were interviewed, and as measured by the Self-Rated Scale for Suicide Ideation (SSISR), is presented in Table 8. Almost all of the participants (96%, N=22) indicated that they
had frequent to continuous thoughts about suicide. This same percentage of participants
reported that their wish to die during the attempt for which they were interviewed was high.
Ninety-six percent (N=22) of the sample also reported that at the time of their attempt, they
had a moderate to strong desire to kill themselves, and in addition, their reasons for dying
outweighed their reasons for living. None of the participants indicated that their reason for
wanting to commit suicide was aimed at getting attention from others; rather, 96% (N=22)
of participants reported that they had engaged in suicidal behavior in order to escape
problems.
Table 8. Frequency Distnbution ofltems on the Self-Rated Scale for Suicide Ideation (SSI
SR)
Frequency
(N=23)

Percent
(100%)

0
3

Wish to Live
moderate to strong wish
weak wish
no wish

20

0.0%
13.0%
87.0%

Wish to Die
no wish
weak wish
moderate to strong wish

0
2
21

0.0%
8.7%
91.3%

76
Frequency
(N=23)

Percent
(100%)

Reasons for Living

outweighed reasons for dying
were equal to reasons for dying
were outweighed by reasons for dying

0
1
22

0.0%
4.3%
95.7%

Desire to Kill Self

no desire
weak desire
moderate to strong desire

0
1
22

0.0%
4.3%
95.7%

In a Life-Threatening Situation
would try to save own life
would take a chance on life or death
would not take steps necessary to avoid death

16

8.7%
21.7%
69.6%

Periods of Thinking About Killing Self

brief, passed quickly
lasted for moderate amounts of time
lasted for long periods of time

3
3
17

13.0%
13.0%
73.9%

Thoughts About Suicide

rare/occasional
frequent
continuous

13

4.3%
39.1%
56.5%

Idea of Killing Self

did not accept idea
neither accepted or rejected idea

1
3

4.3%
13.9%

19

82.6%

0
9
14

0.0%
39.1%
60.9%

accepted idea

Committing Suicide
could have prevented self from attempt
unsure as to whether could have prevented self
could not have prevented self from attempt

1
9

77
Frequency
(N=23)

Percent
(100%)

Because of family. friends. religion. possible

injury from unsuccessful attempt
would not kill self
somewhat concerned about killing self
was not, or was only a little concerned
about killing self

1
6

4.3%
26.1%

16

69.6%

Rs;asons for Wanting to Commit Suicide

primarily aimed at influencing others
(getting revenge/attention)
components of both
primarily based upon escaping problems

0
1
22

0.0%
4.3%
95.7%

Plan of How to Kill Self

no specific plan
considered ways; no details worked out
had a specific plan

1
12
10

4.3%
52.2%
43.5%

0.0%

AQc ss to Method or Opportunity to Kill Sdf

did not have access/opportunity
method wanted takes time, & did not have a
good opportunity to use this method
had access & opportunity

3
20

13.0%
87.0%

Courage & Abilit,)!: to Commit Suicide

did not think they had it
was unsure
had both courage & ability

0
7
16

0.0%
30.4%
69.6%

Exp Qtation of SuiQidAttempt

did not expect to make attempt
unsure as to whether or not to make attempt
was sure about making attempt

2
4
17

8.7%
17.4%
73.9%

78

Frequency
(N=23)

Percent
(100%)

Preparations for Committing Suicide

made no preparations
made some preparations
almost fmished or completed preparations

3
13
7

13.0%
56.5%
30.4%

Suicide Note
not written
thought about/started, but didn't complete
completed a note

15
1
7

65.2%
4.3%
30.4%

Arrangements for What Would Happen After Suicide

no arrangements mad
6
thought about only
8
defmite arrangements made
9

26.1%
34.8%
39.1%

Desire to Suicide
had not hidden it from others
held back telling others
attempted to hide, conceal, lie about it

17.4%
47.8%
34.8%

Attempted Suicide Prior to Last Attempt

none
once
two or more
Wish to Die During Last Attempt
low
moderate
high

4
11

0
1
22

0
1
22

0.0%
4.3%
95.7%

0.0%
4.3%
95.7%

ill) Distribution of Hopelessness Scores

The total score that can be obtained on the Hopelessness Scale (HS) ranges from 020, with 0 indicating the absence of hopelessness and 20 indicating the highest degree of
hopelessness, and with a cut-off score of 9 being predictive of eventual suicide. Ninety-six
percent (N=22) of the sample scored 16 or above on the scale, with the majority of
participants (52%; N=12) obtaining a score of 20. Only one individual generally endorsed
those items indicating an absence of hopelessness. Table 9 presents the distribution of total
hopelessness scores obtained by the sample.

Table 9. Frequency and Percent Distribution of Total Hopelessness Scores

Hopelessness
Score (0-20)
4
16
17
18
19
20

Frequency
(N=23)
1
2
3
2
3
12

Percent
(100%)
4.3%
8.7%
13.0%
8.7%
13.0%
52.2%

80

IV. Testing the Hypotheses

The following section presents the results for each of the six hypotheses tested.
The first hypothesis suggested that there would be a weak relationship or an absence
of a relationship between the two measures assessing the actual lethality of the methods
employed in the suicide attempts (medical lethality scale, and the Lethality of Suicide Attempt
Rating Scale) and the measure of intent of the attempters (total score on the Suicide Intent
Scale). The prediction was supported in the study, in that the clinician rated lethality of the
employed methods was unrelated to the intent to suicide as reported by patients.

This

indicates that the level of intent to suicide cannot accurately be inferred from the actual degree
of dangerousness of the method employed in the attempt. In other words, the consequence
of a suicide attempt is not an adequate indicator of the seriousness of the intent to die.
The next hypothesis to be tested involved the preconceptions held by patients
regarding the lethality of the methods employed in the suicide attempt, and their reported
level of intent to suicide. It was predicted that the perceived lethality of the attempt would
correlate positively with suicidal intent and furthermore, there would be a stronger
relationship between perceived lethality and the subjective intent of the patients, as measured
by the subjective items on the Suicide Intent Scale (SIS). This hypothesis was partially
supported in that the total intent of the patients was unrelated to their perceived lethality
ratings for the methods employed, however, there was a moderate relationship, 11

= .36

Eta-squared (112) is a coefficient of determination for nonlinear relationships.

This coefficient is used when one variable is nominal and the other is interval.

81
between the variables of perceived lethality and subjective intent. For the 23 participants in
the study, when asked "How likely was the method you used to have caused your death?"
(with possible scores ranging from 1 to 6), the resulting patient scores ranged from 4 to 6.
A rating of 4 indicates that the method chosen "probably would" result in death, a rating of
5 indicates that death was "likely", and a rating of 6 indicates that the method chosen "would
defmitely" result in death. Those individuals who indicated that the lethality of the method
they used in their attempt "probably would" result in death (score of 4) had an average level
of reported subjective intent ofM=l0.50, SD=0.71. This was significantly lower than the
average reported subjective intent of either those individuals whose perceived lethality was
"likely" (score of 5), (M=l2.86. SD=0.87), or those individuals who indicated that the
method used "would definitely" result in death (score of6), (M=12.80, SD=0.97), E (2, 20)=
5.57, p. < .05. This indicates that those individuals who report a strong intent to die also
believe that the method they use in their suicide attempt will prove to be fatal.
The next hypothesis to be tested predicted that the participants' perceptions of
lethality

(perceived lethality) would differ significantly from the evaluations of lethality

provided by clinicians (medical lethality), and this was confirmed in the present study. There
was no evidence of a significant correlation between the mean lethality rating provided by
clinicians and the mean lethality rating provided by patients. However, a paired samples t-test
was calculated on the dimension of lethality and revealed a significant difference between
clinicians' and patients' estimations of the degree of danger to life associated with the various
methods employed for the attempts in this study. On average, patients rated the lethality of

82
the methods employed higher than clinicians, 1 (22)

= 6.96,

p < .01. This is consistent with

other studies in the suicide literature which demonstrate that lay persons tend to overestimate
the probability of death associated with various methods of self-injury (e.g., Becket al., 1975;
Rhyne et al, 1995). Figure 2 presents the lethality ratings provided by clinicians and patients.
The fourth hypothesis of the study anticipated that in considering the time involved
for the

method employed to produce death, the mean evaluation provided by patients

(perceived time) would differ significantly from the mean evaluation made by clinicians, in
that patients would underestimate the time involved for the method to prove fatal.

In

response to "How long would you expect this method to take to result in death?", each of the
23 participants reported that they expected the method they had chosen for their recent
attempt to produce a lethal result within a period of time less than one day, whereas clinicians
made this estimation for only 4 participants.

A test of marginal homogeneity10 was

performed, comparing the distribution of times as rated by clinicians with the distribution of
times as rated by the patients, in terms of those methods which were rated as requiring

he test of marginal homogeneity was used in place of a chi-square. A chi-square

is used in comparing two different groups; the test of marginal homogeneity is used when
comparing 2 sets of ratings on the same group.

83

Figure 2.

Comparison of Medical &

Perceived Lethality
"How likely was the method chosen to result in death?"

:J

I\
\I

,//

--

4
il)

>

.>....-. .

....c..
.

il)

I.

'

-;:

,------

"

:1
1

I
\

,,
'

.. I
I

'.

:::l

----------

'
,'

_./

...

',
',

Perceived Lethality

/\

(participants)

'- '

\:

'.

"!

Medical Lethality
(psychiatrists)

Participant ID

11

i3 15

17

19

21

23

84
less than one day to produce death and those methods which were rated as requiring at least
one day to produce death. As expected, there was statistical evidence of a difference between
the clinicians' ratings and the patients' ratings of the time required for a given method to
produce death. The MH

11

statistic was 46, N=23, p< .01. On average, patients under-rated

the time they expected the method to take to produce death, relative to the estimates of
clinicians. This fmding of nonsuicidologists underestimating the length of time required for
a method to prove lethal is consistent with the research literature (e.g. Rhyne et al., 1995).
Table 10 presents the cross-tabulation for the clinicians' and patients' ratings.

Table 10. Cross-tabulation for Clinician and Patient Ratings of "How long would you
expect this method to take to result in death?"
Time

Less than one day

Respondent
Clinician

4
(17.4%)

At least one day

The attempt was nonlethal

Patient
23
(100.0%)

11
(47.8%)

8
(34.8%)

Total

11

23
(100.0%)

23
(100.0%)

MH is the accepted representation of marginal homogeneity, as there is no standard

symbol for this statistic.

85
In considering the frequency and duration of suicidal thoughts and the nature and
intensity of suicidal desires, it was hypothesized that there would be a positive relationship
between suicidal ideation and suicidal intent. As indicated in Table 4 this relationship was
supported in the current study, in that suicidal ideation was significantly related to suicidal
intent, with the two dimensions sharing 18% of the variance. This indicates that each
dimension measured different aspects of suicidal behavior but they were not mutually
exclusive from one another. As the frequency and duration of suicidal thoughts increased,
so too did the intensity of wanting to actually commit suicide. Thus, although thinking about
suicide and actually attempting it are two different dimensions of suicidal behavior, in the
present study, those individuals who indicated having a high degree of suicidal ideation prior
to their attempt, also reported a strong tendency to seriously end their lives. This fmding is
consistent with the research literature.
The final hypothesis of the study predicted a significant relationship between
hopelessness and suicidal intent. This relationship has been consistently demonstrated in the
research literature for individuals who have engaged in at least one suicide attempt, and it was
anticipated that the same fmding would be reported in the current study among multiple
suicide attempters. It was expected that those individuals who indicated a high degree of
hopelessness would have also reported a high level of suicidal intent at the time of their
attempt. This relationship was not supported in the current study, in that the measure of
hopelessness was unrelated to suicidal intent.

The failure to statistically confirm the

association between hopelessness and suicidal intent, however, was not surprising considering

86
the general lack of variability in the hopelessness scores, as can be seen in Table 9. The
homogeneity of the sample in terms of the overall high levels of hopelessness reported may
have contributed to the lack of a demonstrated positive correlation.
In summary, the results of the current study suggest that for the present sample and
the present test instruments, patients tended to exhibit high levels of hopelessness, suicidal
ideation, and suicidal intent. In addition, individuals reported that the method they had used
in their recent attempt was expected to be lethal and in a relatively short period of time, and
the ratings of both lethality and time tended to be inaccurately estimated in comparison to
ratings provided by clinicians. In general, it was demonstrated that patients and clinicians
hold different opinions regarding the dynamics involved in suicidal behaviors.

87

Discussion

The problem of frequent hospital admissions for attempted suicide is well

documented (e.g., Alderson, 1974; Appleby, 1993; Bille-Brahe, Schmidtke, Kerkhof, De Leo,
Lonnquist, Platt, & Sampaio Faria, 1995; Hawton & Catalan, 1987, Pallis & Sainsbury, 1976;
Weisman, 1974). The suicidal patient is often perceived as the most common and vexing
challenge presented to clinicians. Although it is acknowledged that not all suicidal behavior
is truly the pursuit of a deadly outcome, by the same token it is important to recognize that
a population does exist within the suicide subculture in which individuals have a strong
intent to suicide, however, they remain unsuccessful in their multiple attempts.

The

conventional view within the suicidology literature is that such individuals - the repeat
attempters - use potentially self-destructive behaviors as gestures, in order to benefit form the
post-crisis reactions of attention from others.

Within this 'cry for help' hypothesis it is

advanced that since the majority of chronic repeaters use methods of low lethality, they must
not be serious about their expressed desire to suicide. The present research has challenged
this line of reasoning by reexamining the relationship between lethality and intent.
Specifically, addressing lethality in terms of both medical and perceived definitions adds
immeasurably to the understanding of the process of a suicide attempt, by highlighting that
often the clinical view of lethality may differ from a suicidal individual's understanding of
the consequences of his/her attempt.
In the present investigation, in comparing clinicians' ratings of lethality with those
of the chronically suicidal, it was found that patients significantly overestimated the violence

88

associated with the methods they chose in their attempts and underestimated the time
required for the method to produce a fatal outcome. In effect, even those methods which
have traditionally been deemed as "low lethal'' by medical professionals, in this study and
in previous suicide research, were rated by patients as being highly likely to result in death.
Since the medical community has commonly relied on the lethality of an act to infer the
intent of the individual to seriously suicide, it is assumed that those attempts involving low
lethal methods are generally not aimed at producing death. The results of the patient ratings
of lethality in the present study, however, suggest that this proposed relationship between the
actual lethality of an act and the original intent of the attempter may be misleading. Instead,
in addition to assessing the medical seriousness of an act of attempted suicide, it may be more
informative to also consider the knowledge held by the attempter of the degree of danger
involved in the act. The level of accuracy of the attempter's conception of the lethality of
a suicide attempt has important implications for the assessment and management of suicidal
behaviors. Those individuals who repeatedly engage in potentially self-destructive behaviors
are at risk, particularly if their knowledge of the actual lethality of various methods increases.
In assessing this group of individuals, it is important to determine how accurate their
conceptions of lethality are, in addition to evaluating their level of intent. Aspirin, to an
uninformed individual who has had neither experience nor information about it, might seem
as a lethal mode of self-destructive activity. To dismiss such an individual as not being
serious about committing suicide is dangerous, particularly if the individual becomes
informed about the actual lethality of different methods. If clinical intervention occurs at that
individual's first hospital presentation, there may be a greater chance of reducing the

89

likelihood of that individual repeatedly engaging in further suicidal activity.

To address the potential contention that members of this population purposely
overinflate their ratings of lethality in order to deceive others for their own gain, it should be
pointed out that research which has used nonsuicidal lay persons to rate the lethality of
various methods, has also shown that all methods were overrated by lay persons in
comparison to pathologists (Rhyne et al., 1995). In this instance it may be effectively argued
that the lay raters did not have any reasons or would not benefit from any form of secondary
gain by inflating their evaluations of lethality. Rather, any overrated values assigned by
nonsuicidologists may be a function of poor knowledge of the actual degree of danger to life
associated with various methods. In the present study it should also be acknowledged that
the participants involved did not have reason to overinflate their responses. The patients
were informed that their participation would not affect their care at the hospital, nor would
their responses be shared with anyone involved in their health care. As such, the participants
would not benefit from purposely exaggerating their intent or from understating their
knowledge of the actual lethality associated with the method used in their attempts.
Consequently, the results of this study support earlier findings that the higher lethality ratings
given by patients may simply reflect an unrealistic or uninformed opinion about the true
danger to life involved with their chosen method in a suicide attempt. Thus by applying the
standards of the medical community regarding lethality in assessing individuals who
continually self-harm, the risk is taken of failing to understand the clinical characteristics
actually involved. The inherent danger, of course, is the increased chance of a successful
suicide.

90
In the present sample, the most prevalent method used for attempted suicide was an

overdose of prescription and/or nonprescription drugs. The traditional explanation of this

customary finding is that individuals with a low intent to suicide or those who are ambivalent
about committing an act of suicide, engage in low to moderate dosage drug use, to increase
their chances of survival and subsequently reinforce their attention-seeking behavior. Within
this perspective, it is argued that those who truly are committed to ending their lives will
choose a more lethal method which cannot be undone which medical intervention, such as
with the use of firearms. It is suggested here, that perhaps a more utilitarian way to view the
predominance of drug overdoses is in considering the availability of methods. Although
firearms are rated medically as highly lethal, access to guns is not as permissive as it is for
drugs.

Within the present sample, for example, all participants have had medications

prescribed to them at some time by their physicians, and over-the-counter drugs remain as
perhaps the most convenient method for the majority of the population. Smith, Conroy, and
Ehler, (1984) suggest that people tend to use the methods that are most readily available,
which in this increasingly drug-oriented society is likely to be drugs.

Furthermore,

concerning the dosage ingested, once individuals secure access to drugs, it has been shown
that few have an accurate conception of the amount required to produce death and the period
of uninterrupted time required for the method to take effect. This scenario can therefore
account for a great many of the perplexing cases in which individuals remain highly intent
in killing themselves and attempt several times, but are repeatedly saved by timely medical
intervention.
Another distinctive feature amongst repeat attempters is that in addition to their

91

fixation on attempting suicide, they seem to digress little in the method they use from one
attempt to the next. Unstructured interviews with the present sample revealed that the
majority of individuals would engage in the same method for each attempt, or would employ
a variety of methods all within relatively the same grade of lethality. The finding that over
eighty percent of participants in the present research sample reported feeling that they had
trouble thinking and/or concentrating both before and during their suicide attempt, is
consistent with previous findings of suicidal individuals operating from within a very narrow
range of cognitions and having difficulty entertaining new ideas or focusing on alternate
behavior options (Neuringer, 1964; 1976; Shneidman, 1976), and, in fact, entering into a
certain unique cognitive state (Neuringer, 1976). It is evident, in reviewing the results of
suicidal ideation among the present sample, that the majority of participants were involved
in extended periods of time thinking about suicide and about engaging in suicidal behaviors.
A similarly composed explanation is given by Beck, Rush, Shaw, and Emery, (1979) who
advance that suicidal individuals have a unique cognitive deficit in solving interpersonal
problems, in that when more commonly used problem-solving strategies fail, they become
paralysed and view suicide as the only way out. The attraction to suicide, in these cases, is
described as an 'opiate'. If this is indeed accurate, it may also be plausible to suggest that
this proposed 'cognitive deficit' may also cause suicidal individuals to become 'stuck' or
fixated on one particular method. It has already been established that nonsuicidologists, in
general, overestimate the lethality of most methods in comparison to psychiatrists. Thus,
these individuals 1) choose a method they have overrated in terms of degree of danger to life,
and 2) they then become fixated on this method. They are apparently unable to shift

92

cognitive sets - in other words the ability to shift to a new mental strategy - and this feature,
in addition to faulty assumptions held about the lethal effectiveness of certain methods, may
contribute to the chronic and repetitive behavior of the 'persistently suicidal'. The fixation
on suicide as a solution and the perpetual usage of the same method appear to be clinical
characteristics of this population.

It is suggested that treatment strategies focus on the

cognitive organization of suicidal individuals and areas of cognitive patterning such as

problem-solving.
In assessing the characteristics of the overall presuicidal environment for the present
sample, it may be suggested that the objective circumstances of the attempts may not be
entirely informative in terms of predicting or inferring intent to suicide. When looking at the
patterns of responses for the objective items, more variability was found, whereas a greater
homogeneity of responses existed for the self-report items of intent. For instance, greater
diversity was found amongst responses with regards to precautions taken against discovery,
making final arrangements, the presence of a suicide note, and the degree of overt
communication made prior to the attempt. Participants differed with respect to these aspects
of the attempt, however, greater agreement was found in assessing the subjective intentions
involved in each suicidal act. Items such as those inquiring about the alleged purpose of the
attempt, expectations of fatality, conceptions oflethality, the seriousness of the attempt, and
attitudes toward living and dying, tended to capture a similar pattern of response. Clinically,
the sample appeared uniform in their subjective intent, however, the same cannot be said with
respect to the circumstances of their attempts. In this regard, few parallels could be drawn
in their behaviours. In assessing the objective and subjective components of the Suicide

93

Intent Scale with psychiatric inpatients with a history of suicide attempts, Mieczkowski and
colleagues (1993) similarly concluded that the intent to make a lethal suicide attempt appears
to be distinct in some ways from the planning of the attempt.
In evaluating the medical lethality of the methods chosen by the present sample and

the intent to suicide, the finding of a lack of a significant relationship is consistent with
previous research outcomes. This suggests that the customary view held in clinical contexts
that individuals who use methods of low lethality are not serious about committing suicide,
may be misinformed. When patients incorrectly assess the lethality of the methods they use,
their intent cannot be reliably inferred from the actual lethality of the act. Intentionality is
not reflected in the method that the individual chooses for suicidal activity.

Beck and

colleagues (1975) similarly concluded that medical lethality is not a reliable index for
evaluating the seriousness of intent.
In assessing the preconceptions held by attempters about the lethality of their acts and

how serious they were about killing themselves, an important finding was made. There was
no evidence of a significant relationship between perceived lethality and the total intent
scores of the present sample. However, this result was not entirely unexpected given the
inclusion of objective items in the total intent score. When the objective items were removed
from the measure of intent and the relationship was reexamined, a significant positive
relationship was found between the participants' perceptions of lethality and their self
reported subjective intent.

In other words, those participants whose subjective intent

reflected the highest levels for such items as seriously wanting to die and expectations of a
lethal outcome for their attempt, also rated the method they had chosen for their attempt as

94

being highly lethal, with death as the definite outcome.

Hence, in determining the

relationship between lethality and intent it has been demonstrated here, as in previous
research, that it becomes necessary to distinguish medical from perceived lethality.
The claim that suicidal ideation serves as a marker for the risk of more serious
suicidal behaviors and/or completed suicide, and is positively related to suicide intent, was
supported in the present investigation. The participants in the present study indicated overall
high levels of both ideation and intent. In effect, these individuals had persistent thoughts
of engaging in self-destructive behaviors and expressed a strong desire to suicide. These
results are clinically relevant, in that they describe a group of individuals who confess to
incessant thoughts of killing themselves and then repeatedly engage in potentially life
threatening behaviors. This has implications for both assessment and cognitive treatment
strategies.
Although the dimension of hopelessness was not significantly related to any clinically
distinct aspects within the spectrum of suicidal behavior, this may be explained in terms of
the specific dynamics of the present sample. The participants in the present investigation
varied little in their reported level of hopelessness.

Except for one individual, the total

hopelessness scores for the participants fell within a narrow four point spread, and were in
the high range of hopelessness. Accordingly, the relative homogeneity of the sample may
account for the absence of a significant relationship. Although statistical evidence of the
proposed relationship was not obtained, the results are clinicaUy informative in that they
identify a distinct group that has expressed a very high level of hopelessness and a high level
of intent, who repeatedly express their suicidal tendencies in overt attempts. Although, for

95

the present sample, the level of hopelessness cannot be used as a predictor variable, results
do support prior research findings that hopelessness is a distinct characteristic among
multiple attempters of suicide.
hopelessness

Consequently, therapeutic interventions which reduce

most rapidly, may also lower suicidal potential (Beck, Steer, Kovacs, &

Garrison, 1985). There is evidence in the suicide literature that cognitive therapy acts faster
in lowering hopelessness than does pharmacotherapy (Rush, Beck, & Kovacs, 1982). Thus,
cognitive interventions, or a combination of cognitive therapy and pharmacotherapy may be
effectively used to reduce hopelessness and suicidal risk. The effect of cognitive intervention
as providing prolonged protections against suicide is supported by studies which show a
lower relapse rate among patients treated with cognitive therapy than with any other
antidepressant treatments (Kovacs, Rush, & Beck, 1981).

96

Limitations of the Present Investigation and Future Directions

The present investigation examined a limited sample of the spectrum of suicidality,

given the small sample size (due to the constraints of availability of, and access to, the
population under study), and the finding that most of the participants reported a drug
overdose as the chosen method in their attempt. Since the sample was small and relatively
homogeneous, there were no examples of individuals with low levels of intent and perceived
lethality for comparison.

The results of the present study, however, are supported by

previous research findings which involved larger sample sizes.

Another important limitation to this study, and in most research in suicide, involves
the possibility that patients may over-endorse on many measurement scales as a reflection
of their distress levels at the time they are being interviewed.

Those involved in the

assessment and treatment of suicide attempters can only speculate about how one's
judgement is impaired in times of crisis. Further, once the immediate crisis situation is over,
the level of distress experienced by the individual may affect their capacity to make rational
judgements and assume responsibility for their attempts. Although it is acknowledged that
distress levels at the time of the interview may have affected the responses given by some
individuals in the present study, certain measures were included to reduce the effect of this
inherent bias. For instance, individuals were not interviewed for the study until they were
stable and the medical personnel involved in their mental health care advised that they were
not at immediate risk of a suicide attempt. In addition, participants were asked that they refer
to the time period of the half hour before their most recent attempt in completing the

97

questionnaires, and refer to how they were feeling at that specific time as opposed to their
ideations and affect during the interview session. It was anticipated that these measures
would permit a more accurate depiction of the attempt. Even with the inclusion of these
measures, however, the design of the present study makes it difficult to differentiate those
who may have been influenced by a certain level of personal distress at the time of the
interview from those participants who provided a valid reflection of their intent to suicide.
It is proposed that future research designs be longitudinal to permit the retesting of suicide

attempters at different time periods following an attempt. This type of design could perhaps
more accurately assess the influence of current distress levels on response items.
An additional limitation to the present study concerns a current debate within the
suicidology literature involving trait versus state features amongst repeat attempters of
suicide. To account for the repetitive potentially self-destructive acts of this population,
several investigators have proposed that certain personality traits may precipitate this
behavior, such as trait anxiety and trait anger (e.g., Goldstein, Daniel, Reboussin, and Kelley,
1996; Yan-Elderen, Yerkes, Arkesteijn, & Komproe, 1996; Yerkes, Fekkes, Zwinderman,
Hengeveld, Yan-der-Mast, Tuyl, Kerkhof, & Yan-Kempen, 1997).

Although the present

investigation did consider the affective states of the participants prior to their attempts,
measures were not included which would address the possibility that the enduring nature of
their suicidal intent may suggest a trait relationship.
Chronic repeaters of suicide are a group for which there is a considerable dearth of
information, in terms of the nature and causes of their behavior, and the means for providing
effective intervention. Future investigations would certainly benefit from the inclusion of

98

a larger sample size to capture a greater range of the associated cognitions and behaviors of
this identified group.

Based on the findings that self-report subjective items may

communicate a distinct aspect of intent, it is suggested that the relationship between objective
and subjective measures of intent be explored in greater detail for this particular population.
In addition, an exploration of the aspects of ideation and intent for this particular population
may produce a more accurate portrayal of the dynamics involved in their repetitive behavior.
The present examination has highlighted the importance of relevant operational definitions
within the suicide discourse, especially in distinguishing medical and perceived lethality, for
"prevention rests on assessment; assessment rests of definition" (Shneidman, 1985; p. vi).
Notwithstanding the above caveats, it is proposed that the present findings add to the
clinical depiction of the persistently suicidal. It may be argued, at least for the present sample
of individuals and the present test instruments, that the actual violence associated with
certain methods of suicide is not a reliable measure of the seriousness of intent, and that the
main factor to consider when assessing suicidal intent, in this respect, is to what extent the
individual was aware of the likely medical consequences of the attempt.
It is recognized that the motives leading to suicide are both numerous and nebulous.
It is often unclear as to why individuals repeatedly inflict self-injuries or engage in potentially

life-threatening behaviors, and as such, it becomes more difficult to help such individuals.
Commonly believed notions have included the idea that certain people lack appropriate
coping resources to overcome their difficulties and may continually engage in suicidal
behaviors in order to avoid confronting their problems. An associated idea is that the actual
self-injurious behaviors are used to deal with intolerable feelings of tension. Alternately,

99

there is the view that a few individuals appear to obtain a level of excitement from the risk
taking entailed (Hawton & Catalan, 1987). Finally, and perhaps the most widely expressed
opinion, is that individuals who repeat several times may feel they need the attention of
family, friends, or the hospital staff that each episode brings. Although it is recognized that
not all suicide attempts are seriously aimed at producing death, and that certain individuals
do use suicidal behaviors for manipulative purposes, it is asserted that this should not serve
as a unitary explanation of repeated suicide attempts. It is argued that a distinct group does
exist in which individuals have a strong suicidal tendency and desire to suicide, however, the
lethality of the methods they choose to employ is often misconceived, or the circumstances
of their attempts permit timely interventions.

Differences in motivation between the

individual who takes a handful of barbiturates and the one who pulls the trigger of the gun
placed at his/her head cannot readily be assumed. The importance of examining the aspect
of perceived lethality is reflected in the attitudes held by mental health professionals. The
findings of the present study are not challenging the use of medical estimates of lethality in
assessing suicidal individuals. Rather, it is suggested that in addition to considering the
actual consequences of an attempt, it would be beneficial to assess the preconceptions held
by the attempters about the lethality of their acts. Similarly, in evaluating suicidal intent, it
is acknowledged that assessing the objective circumstances of the attempt is important, such
as precautions taken and degree of planning involved.

It is suggested, however, that

assessing the conditions of a suicide attempt is not sufficient in determining one's intent.
The conscious suicidal intent as reported by the individual should also be included in this
determination, in that obtaining qualitative information from those who have attempted

100

suicide regarding the nature and intensity of their suicidal desires, would add immeasurably
to understanding the process of a suicide attempt. Unless consideration is given to the unique
dynamics involved within this group, there is a danger that medical settings will not perceive
the attempts as serious ones and will ineffectually treat these individuals.

The real risk

involved is that the repetition of attempted suicide will increase the chances that an
individual will subsequently die from suicide.
While several competing theories have been advanced to account for the actions of
multiple attempters of suicide, consensus does exist on the point that suicide is epidemic
(Peck, 1986). Inevitably, the myriad of variables involved which motivate an individual to
continually self-harm, necessitate an analysis at a variety of levels, including both the
epidemiological - or population - level, and at the clinical - or individual - level, in addition
to the possible self-reinforcing nature of suicidal behavior.

Future investigations would

undoubtedly benefit from a comprehensive assessment of the overt behaviors, thoughts, and
feelings of those who deliberately self-harm, in an effort to understand the parameters of
repeated suicide. Until a better understanding is reached concerning the dynamics involved
with the persistently suicidal, within clinical settings the suggestion of Shneidman (1976)
should be heeded in that suicide attempts, "whatever their lethality, ought to be taken
seriously".

101

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Alvarez, A (1972). The Savage God: A Study of Suicide. New York, Random.
Angel, R., & Gronfein, W. (1988). Subjective information in statistical models.
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Angel, R., & Thiotis, P. (1987). The impact of culture in the cognitive struture of
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Appleby, L. (1993). Parasuicide: Features of repetition and the implications for
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Bancroft, J., Hawton, K., Simkin, S., Kingston, B., Cumming, C., & Whitwell, D.
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105

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Predictors of early suicide:
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Identification and

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10
6
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10
8
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2,

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11
0

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Appendix A

113

HO SPITAL
160 Wellesley Street E: st
Toronro. ON I\14Y 1]3
i Cnu'IL"'"111.\I

nf Tarunto

Commrltf'd to ItS

T tJCbtn Ho:fi'JU:Jl

Commw1u11r.r

CONSENT TO PARTICIPATE

Investigators: Dr. Ron Heslegrave, (416) 926-7758

Dr. Paul Links,
(416) 926-5053 ext. 3726
Polyxeni Kartakis

The study in which you have been asked to participate is intended to assess the circumstances
surrounding suicide.
The study is concerned with better understanding the factors that may or may not influence
suicide and self-harm behaviors. You will be asked to complete a series of questions regarding your
views about suicide and your thoughts and feelings around the time of your visit to The Wellesley
Central Hospital. The time asked of you to complete the interview and questionnaires will be less than
one hour. We will also gather some information about your visit to The Wellesley Central Hospital from
hospital records. This will include your hospital diagnosis, information about your treatment at the
hospital, and details on the reasons surrounding your visit to The Wellesley Central Hospital.
Any informat1on that you provide will be held in strict confidence, and will only be used by the
investigator for the purpose of the present study. However, if during the course of the interview
session there is any concern about your health by either you or the interviewer. a member of the
Wellesley Crisis Team will be notified. This measure wi!l necessarily be taken for your protection. You
will never be identified in any resulting presentation or publication.
Your participation in this study is voluntary, and you are free to withdraw from the study at any
time. If you refuse to participate in the study it will not influence your current or future health care; you
will continue to have access to quality care at The Wellesley Central Hospital. By signing this form you
are agreeing to participate in the study. As we will be conducting research in this area in the future,
we would like your permission to contact you at a later time.
Thank you for your time and cooperation.

I have read and understand the above conditions. I hereby consent to participate in the study.
Participant's Signature

Print Name

Date

I. the undersigned, ha,,e fully explained the relevant details of this study to the participant
named above and bel1eve that he/she understands the nature of the study.

Investigator's Signature

Print Name

Date

Appendix Bl

114

Date:
Number:
Wellesley#:
.IN:

------------_
-------

1. Gender:
M- 1
F-2
2. Age:
3. Marital Status:
single.....................1
married.................... 2
cohabiting................ 3
divorced...................4
widowed...................5
4. Education:
ementary................1
highschool................. 2
college/university....... 3
Years completed:
5. Occupational Status:
regularly employed.... 1 (Vocation:
student......................2
disability pension.......3
unemployed...............4
welfare....................... 5

--.) (full time_; part time_j

6. Ongoing Treatment
psychiatric.................. 1
general practitioner.... 2
social agency............. 3
other...........................4

7 Psychiatric inpatient treatment, previously

No...............................1
Yes .............................2 (Number of times

115

Appendix B2

8. Psychiatric treatment, ever

No.............................1
Yes...........................2

Describe

----------------------

9. Psychopharmacological treatment, currently

Benzodiazepines......1
Antipsychotics/
Neuroleptics.......2
Anti-depressal"lts......3
Other........................4
10. Psychopharmacological treatment, ever
Benzodiazepines......1
Antipsychotics/
Neuroleptics.......2
Anti-depressants......3
Other........................4
11. Mental disorders in relatives
i::Jo............................ 1
Yes..........................2

Describe

----------------------

Relation

---------------------

12. Suicide in relatives

No............................1
Yes..........................2

13. Previous psychiatric diagnosis

No...........................1
Yes......................... 2 Diagnosis ------------------14. Previous suicide attempts
No...........................1
Yes.........................2
(a) How many?-------(b) When was the last attempt?
(c) Treatment received for it?
No......1
Yes....2 Describe

Appendix Cl

116

Date:
Number:
IN:
Wellesley#:

_
_

-------_

For each item marked (a) in questions 1-5, please circle the number
which represents your choice, according to the following scale:
the most
I've ever felt
this way

the least
I've ever felt
this way
2

For each item marked (b). please circle the number which represents
your choice, according to the following scale:
all day- 1
one week- 2
two weeks- 3

1. Did you feel upset/agitated?

one month- 4
six months - 5
more than six months - 6

Yes_

No

(a) In the 1/2 hour before you hurt yourself, how would you rate this

feeling? ............................................................................. 1

(b) Overall, how long were you feeling this

way?.........................................................................1

2. Did you feel ashamed?

Yes_ No_

(a) In the 1/2 hour before you hurt yourself, how would you rate this

feeling..................................................................................1
(b) Overall, how long were you feeling this

way?.........................................................................I

11
7

Appendix C2

For each item marked (a) in questions 1-5, please circle the number
which represents your choice. according to the following scale:
the least
I've ever felt
this way

the most
I've ever felt
this way

For each item marked (b), please circle the number which represents
your choicaccording to the following scale:
all day- 1
one week- 2
two weeks- 3

3. Did you feel that you hated yourself?

one month- 4
six months - 5
more than six months - 6

Yes

No

(a) In the 1/2 hour before you hurt yourself, how would you rate

(a) In the 1/2 hour before you hurt yourself, how would you rate
this feeling..........................................................................1

(b) Overall, how long were you feeling this

way?........................................................................1

(a) In the 1/2 hour before you hurt yourself, how would you rate
this feeling...........................................................................1

(b) Overall, how long were you feeling this

way?........................................................................1

this feeling...........................................................................1
(b) Overall, how long were you feeling this
way?........................................................................1

4. Did you feel that you were to blame for anything?

Yes

No

5. Did you feel that you had trouble concentrating/thinking?

Yes_ No

11
8

Appendix C3
6. (a) How much relief did you think you would feel by attempting to hurt yourself?
very little
relief

excessive
relief

(b) Overall, how long were you feeling this

way?........................................................................1

7. (a) In the 1/2 hour before you hurt yourself, to what extent had you been thinking
abouUplanning to hurt yourself?
very little
planning

excessive
planning
2

(b) Overall, how long were you feeling this

way?........................................................................1

8. (a) How impulsive did you feel in the 1/2 hour before you hurt
yourself?
not at all
impulsive

very
impulsive
2

(b) Overall, how long were you feeling this

way?..........................................................................1

9 How successful did you think you would be?

not very
successful

very
successful

Appendix Dl

OBJECTIVE DESCRIPTIONS
SUBJECT: #001
METHOD: Overdose
SUBSTANCE: antidepressants, benzodiazepines, Tylenol (regular strength); 4 beers
DOSAGE: approx. 200 pills total
COURSE: approx. 2 hours

SUBJECT: #002
METHOD: Overdose
SUBSTANCE: Tylenol (reg. strength), Codeine
DOSAGE: approx. 75 pills total
COURSE: approx. 3 hours

SUBJECT: #003
METHOD: Overdose
SUBSTANCE: antipsychotics, antidepressants
DOSAGE: approx. 150 pills total
COURSE: approx. 2 hours

SUBJECT: #004
METHOD: Overdose
SUBSTANCE: Tylenol (reg. strength), antipsychotics, antidepressants, antiseizures
DOSAGE: approx. 100 pills total
COURSE: approx. 4 hours

SUBJECT: #005
METHOD: Overdose
SUBSTANCE: neuroleptics, mood stabilizers; 3 glasses of wine
DOSAGE: approx. 50-60 pills total
COURSE: approx. 2 hours

SUBJECT: #006
METHOD: attempted to jump off Bloor Viaduct at night
(passerby called the police)

119

AppendixD2

120

SUBJECT: #007
METHOD: jumped off bridge (40 feet high), with traffic below
(re ulting injuries: shattered knee, broken elbow, fractured pelvis, loss of
consciousness)

SUBJECT: #008
METHOD: Overdose SUBSTANCE:
anti-anxiety meds DOSAGE: approx.
100-120 pills total COURSE: approx.
2 hours

SUBJECT: #009
METHOD: Overdose
SUBSTANCE: antidepressants
DOSAGE: approx. 30-35 pills total
COURSE: approx. 1-2 hours

SUBJECT: #010
METHOD: Overdose & Cutting
SUBSTANCE: Prozac, Benadryl (cold med), aspirin
DOSAGE: approx. 200 pills total
COURSE: approx. 2 hours; woke up after 4 hours and cut both wrists with razor blade

SUBJECT: #011
METHOD: stabbed self with knife- lower chest, above abdomen

SUBJECT: #012
METHOD: Overdose
SUBSTANCE: benzodiazepines, antidepressants (has asthma & was aware of
depressing effect of antidepressants on respiratory system)
DOSAGE: approx. 20 pills total
COURSE: approx. 1-2 hours

SUBJECT: #013
METHOD: jumped onto subway tracks

Appendix D3

SUBJECT: #014
METHOD: Overdose & Cutting & Swallowed batteries
SUBSTANCE: Tylenol (extra strength)
DOSAGE: approx. 200 pills
COURSE: approx. 3 hours
Cut both wrists & throat with razor blade
Swallowed 2 batteries

SUBJECT: #015
METHOD: Overdose & Cutting & Ingested bleach
SUBSTANCE: antipsychotics, antidepressants
DOSAGE: approx. 50-60 pills total
COURSE: approx. 2-3 hours Cut
both wrists with knife Ingested
small amount of bleach

SUBJECT: #016
METHOD: Overdose
SUBSTANCE: antidepressants, antiseizure meds
DOSAGE: approx. 70 pills total
COURSE: approx. 2-3 hours
SUBJECT: #017
METHOD: attempted to jump off bridge (approx. 30 feet high)
(passerby notified police)

SUBJECT: #018
METHOD: Overdose & Cutting
SUBSTANCE: antidepressants
DOSAGE: approx. 15-20 pills total
COURSE: approx. 1 hour
Cut both wrists with dinner knife

SUBJECT: #019
METHOD: Overdose
SUBSTANCE: antidepressants, Tylenol 3
DOSAGE: approx. 50-60 pills total
COURSE: approx. 2-3 hours

121

Appendix D4

SUBJECT: #020
METHOD: Overdose
SUBSTANCE: antidepressants, Tylenol (reg. strength)
DOSAGE: approx. 100-120 pills total
COURSE: approx. 2 hours

SUBJECT: #021
METHOD: Cutting
Cut both arms in several places with razor - over 40 cuts total

SUBJECT: #022
METHOD: Overdose
SUBSTANCE: neuroleptics, antidepressants, Tylenol (reg. strength), Gravol
DOSAGE: approx. 60 pills total
COURSE: approx. 3-4 hours

SUBJECT: #023
METHOD: Overdose
SUBSTANCE: Tylenol (reg. strength), antidepressants, antihistamines, herbal pills,
heartburn liquid
DOSAGE: approx. 75 pills total; half bottle of heartburn med
COURSE: approx. 2-3 hours

122

123

Appendix El
Date:
Number:
Wellesley#:
IN:

------------_

For each item, try to think back to the 'lz hour before you attempted to hurt yourself and circle
the answer which best describes how you felt at that time.

1.

0.
1.

2.
2.

0.

1.
2.

3.

0.
1.
")

4.

0.
I.
")

5.

0.
1.

2.

I had a moderate to strong wish to live.

I had a weak wish to live.
I had no wish to live.
I had no wish to die.
I had a weak wish to die.
I had a moderate to strong wish to die.
My reasons for living outweighed my reasons for dying.
My reasons for living or dying were about equal.
My reasons for dying outweighed my reasons for living.

r had no desire to kill myself.

I had a weak desire to kill myself.
I had a moderate to strong desire to kill myself.
I would try to save my life ifl found myself in a life-threatening situation.
I would take a chance on life or death if I found myself in a life-threatening
situation.
I \vould not take the steps necessary to avoid death if I found myself in a life
threatening situation.

If you have circled the zero statements in both Groups

4 and 5 above, then skip down to Group 20. If you have
marked a 1 or 2 in either Group 4 or 5, then open here
and go to Group 6.

Subtotal Part 1

Appendix E2

6.

0.
1.

:2.
7.

0.
1.
2.

8.

0.
1.

:2.
9.

0.
l.
2.

10.

0.
l.
1

ll.

0.
].

2.

12.

0.
1.
1

13.

0.
1.
1

12
4

I had brief periods of thinking about killing myself which passed quickly.
I had periods of thinking about killing myself which lasted for moderate amounts
of time.
I had long periods of thinking about killing myself
I rarely or only occasionally thought about killing myself
I had frequent thoughts about killing myself.
I continuously thought about killing myself.
I did not accept the idea of killing myself.
I neither accepted nor rejected the idea of killing myself
I accepted the idea of killing myself.
I could have kept myself from committing suicide.
I was unsure as to whether I could have kept myself from committing suicide.
I could not have kept myself from committing suicide.
I would not kill myself because of my family, friends, religion, possible injury
from an unsuccessful attempt, etc.
I was somewhat concerned about killing myself because of my family, friends,
religion. possible injury from an unsuccessful attempt, etc.
I was not. or was only a little concerned about killing myself because of my
family, friends, religion, possibly injury from an unsuccessful attempt, etc.

My reasons for wanting to commit suicide were primarily aimed at influencing

other people, such as getting even with people, making people happier, making
people pay attention to me. etc.
My reasons for wanting to commit suicide were not only aimed at influencing
other people. but also represented a way of solving my problems.
My reasons for wanting to commit suicide were primarily based upon escaping
from my problems.
I had no specific plan about how to kill myself.
I had considered ways of killing myself, but had not worked out the details.
I had a specific plan for killing myself.
I did not have access to a method or an opportunity to kill myself.
The method that I wanted to use for committing suicide takes time, and I really
did not have a good opportunity to use this method.
I had access or anticipated having access to the method that I chose for
killing myself and also had the opportunity to use is.

Appendix E3

14.

0.
1.
2.

I did not think that I had the courage or the ability to commit suicide.
I was unsure as to whether I had the courage or the ability to commit suicide.
I had the courage and the ability to commit suicide.

15.

0.

i did not expect to make a suicide attempt.

1.
J

16.

0.

1.

2.
17.

0.
1.

18.

0.

1.
J

!9.

0.

1.

20.

0.
1.

I was unsure as to whether or not to make a suicide attempt.

I was sure that 1 would make a suicide attempt.
I had made no preparations for committing suicide.
I had made some preparations for committing suicide.
I had almost finished or completed my preparations for committing suicide.
I had not VvTitten a suicide note.
I had thought about Vvriting a suicide note or had started to VvTite one, but did
not complete it.

I had completed a suicide note.

I had made no arrangements for what would happen after I had committed suicide.
I had thought about making some arrangements for what would happen after I had
committed suicide.
I had made definite arrangements for what would happen after I had committed
suicide.
I had not hidden my desire to kill myself from people.
I had held back telling people about wanting to kill myself.
I had attempted to hide. conceal, or lie about wanting to commit suicide.
I had never attempted suicide.
I had attempted suicide once.
r had attempted suicide two or more times.

If you have previously attempted suicide. please continue with the next statement group.

21.

0.

l.
J

12
5

My wish to die during the last suicide attempt was low.

My \Vish to die during the last suicide attempt was moderate.
My wish to die during the last suicide attempt was high.
Subtotal Part 2
Total Score

Appendix Fl

126

ame---------------------------------------------------------- Dace
For all items in this scale, use code number "8" for " ot applicable."
"S's"
are not counted
hen
calculating the total score.

I. Objective Circumstances Related to Suicide Att ot

l. Isolation
0. Somebody present
1. Somebody nearby, or in visual or vocal contact
2. No one earby or in visual or vocal contact
2. Timing
0. Intervent:ion is probable
1. Intervention is not likely
2. Intervenc:ion is highly unlikely
3.

Precaut:ions against: Discovery/Int:ervent:ion

0. No precautions
I
1. Passive precautions (as avoiding others but: doing nothing to prevent their
intervention; alone in room with unlocked door)
2. Active precautions (as locked door)

4. Acting to Get Help During/After Attempt

a. Notjfied potential helper regarding attempt
1. Contacted but did not specifically notify potential helper regarding att pt
Z. Did not contact or notify potential helper
J.

Fi al Aces in Anticipation

a.

of Death (e.g.

vill

gifts, insurance)

None
- Thought about or ade some arrang ents
2. Made definite plans or completed arrang ents

6. Accive Preparation for Att pt

0.

None

2.

Extensive

1. Minimal to moderate

i.

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

8.

Overt Communication of Intent Before the Attempt

0. None
l. Equivocal communication
2. Unequivocal c munication
Self Reoort:

9. Alleged Purpose of Attempt

0. To manipulace environment, gee actention, revenge
l. Cm::ponents of "0" and "2"
2. To escape, surcease, solve proble s

Appendix F2

Lxpectations of
Fatality
0. Thought: chat: death was unlikely
l. Thought: chat death was possible but not: p_robable
2. Thought: that death was probable or cercain
10.

127

11. Concepcion of Method's Let:hality

0. Did less to self than he thought would be lethal
l. Wasn't sure if what: he did would be lethal
2. Equaled or e.-....:ceeded what: he thought would be lethal

12. Seriousness of Attempt:

0. Did not seriously attempt to end life
1. Uncertain about: seriousness to end life
2. Seriously attempced to end life
13. Attitude Toward Living/Dying

0. Did not: want co die

l. Componenc:s of "0" and "2"
Z. Wanc:ed to die

14. Conception of Medical Rescuability

0. Thought: that deach would be unlikely if he received medical attention

1. Was uncert:ain whether death could be averted by medical attention
2. Was certain of death even if he received medical attent:ion

15. Degree of Premeditation

0.

None; impulsive

1. Suicide contemplaced for three hours or less prior to at:tempt

2. Suicide contemplated for more than three hours prior t:o attempt:
III. Other AsDects (Not Included in Total
Score)

l6.

eaccion to Attempt:
Sorry that he made attempt; feels foolish, ashamed (circle which one)
l. Accepts both attempt and its failure
2. Regrets failure of attempt:

0.

17.

Visualization of Death
0. Life-after-death, reunion with decedents
l. Never ending sleep, darkness, end-of-things
2. No conceptions of, or thoughts about deat:h

18.

iu:nber of P::-evious Atce.mpts

:-lone
- One or wo
2. Three or more
0.

19.

el tionship becween Alcohol Intake and Attempt

0. Some alcohol int:ake prior eo but not relaced to attempt, reportedly not enough
to impair judgment, reality
testing
Enough alcohol incake to impair judgment, reality testing and diminish
responsibil:
2. Intentional intake of alcohol in order to facilitate implementation of attempt

20.

elationship between Drug Intake and Att:empt (narcotics, hallucinogens, etc.,

when drug is not the method used eo suicide)
0. Soce drug intake prior co but not related to attempt:, report:edly not enough
to i pair judgment, reality tescing
1. Enough drug intake to impair judgment:, reality tesr:ing and diminish responsibilit:
Intentional drug intake in order to facilitate implementation of attempt

12
8

Appendix F3

CLINICIAN'S ESTIMATE OF RELIABILITY

Estimated reliability of patient

0. Uncertain
l. Poor
2. Fair
3. Good

V& L BLES INFLUu CING RELIABILITY OF

PATIENT
Confusion as a
0. None

edical consequence of attempt

1. Some
2. Moderate
3. Severe

Disorientation at time of attempt due to alcohol or drug abuse

0. None 1. Some
3. Severe
2. Moderate
Disorientacion at time of attempt due to emotional state
0. None 1. Some
2. Moderac:e 3. Severe
Lack of truthfulness or reluctance to disclose information
1. Some
0. None
2. Moderate
3. Severe
Current me!:lory i:::pairment, amnesia, "blocking" regarding attempt
0. None
l. Some
2. Moderate
3. Severe
Current vithdrawal, partial mutism, inability to verbalize
0. None
1. Some
2. Moderate
3. Severe
"Objective" items ::hat patienr: didn't e.'Cplicitly

an::; er (list by i)):

Clinician's conr aence in his inferences about above questions:

0. N/A
Low
2. Moderate
3. High
"Self-report" ite!:ls that: patient didn't e.'Cplicitly answer (list by f.!):

Clinician's confidence in his inference about above questions:

0. M/A
1. Low
2. Moderate
3. Uigh

Clinician's overall est:imate of t:he Scale's validity as a measure of

suicidalit:y, in vieof all above factors.
0. Lov
l.
oderat:e 2. High

12
9

Appendix F4

SUPPLEMENT TO INTENT SCALE

Wny did the patient choose this particular method?

(Enter patient's
verbatim response and then enter appropriate category)
Patient's Response:

0.
l.
2.
3.
4.
5.
6.
7.

---------------------------------- -------------

ost immediately accessible.

Believed to be most lethal.
Least painful.
ethod suggested by another person.
Imitation of suicide attempt by another person.
ethod suggested or demanded by voices.
Method has particular psychological or symbolic significance
Other.

co this patient.

If ::he patient took a drug overdose and had ingested alcohol, was he or she
aware of the fact that the combined effects of alcohol and certain drugs are
greater than the total of their separate effects?
0.
l.
3.

Yes, patient was aware of it.

o, he (she) was not aware of it.
Question is not applicable to this case.

W.;ac is the relationship between alcohol ingestion and the attempt?

0.

o alcohol
ingestion.
Alcohol ingestion was normal for this patient, and unrelated to the
suicide attempt
2.
cohol ingestion was excessive and may have
paired judgment, bur
patient did not drink in order to facilitate the attempt.
3. ?atient drank excessively to gain courage for the attempt.
4.. ?atientdrank in order to add to the effects of an overdose.
S. ?atient took alcohol in combination tJith a drug overdose, knowing that this
would produce an extra lethal effect.
6. Alcohol ingestion was related to the attempt in another way.
(Specify)

Appendix G
Please indicate a rating of the objective
.lethality

LETHALITY OF SUICIDE ATTEMPT RATING SCALE

DEATH IS ALMOST A
CERTAINTY.

DEATH IS A HIGHLY
PROBABLE OUTCOME

100

90

DEATH WOULD
80
ORDINARILY BE CONSIDERED
THE OUTCOME

130

Date:

--------------

Nunber:
Wellesley # :
Clinician: ------

Cutting: Cuts as severe as in 90. except that the likelihood of intervention

is even more remote. Blood loss is severe and quick.
Ingestion: Because of the time involved before a toxin can lake effect,
there are few examples- furniture polish, paint thinner.
Other: e.g. jumping off a tall building, in front of cars, gunshot to the head.
Cutting: Severe, usually multiple cuts with severe blood loss.
Ingestion: Clearly lethal doses e.g. drinking several ounces of acetone.
Other: Highly lethal means e.g. plastic bag tied over head, gunshot to chest.

Cutting: Severe gashes with major & quick blood loss.

Ingestion: Clearly lethal doses with no communication made.
Other: Acts which may not succeed, but are done so that a calculated chance
of intervention could interrupt.

DEATH IS THE PROBABLE 70 Cutting: Cuts are severe e.g. slashing neck with razor, but seeks medical help.
OUTCOME UNLESS THERE
Ingestion: Potentially lethal medications & quantities.
IS IMMEDIATE INTERVENTION Other: lethal actions performed in a way that maximizes chances of intervention.

DEATH IS A 50-50
PROBABILITY

50 Cutting: Severe cutting resulting in sizable blood loss (more than 100cc).
Ingestion: Unknown quantities of drugs that are lethal in small doses.
Other: Potentially lethal acts e.g. putting bare wires into electrical outlet with
others present.

DEATH IS IMPROBABLE
SO LONG AS FIRST AID
IS ADMINISTERED

35 Cutting: Deep cuts involving tendon damage & possible nerve/vessel damage
Blood loss is usually less than 100cc.
Ingestion: Significant overdose e.g. fewer than 60 ASA or OCD's
Other: Possibly serious actions that are quickly brought by the patient to the
staffs attention e.g. tie shoelace tightly around neck but walk over to
staff immediately.

DEATH IS IMPROBABLE
20 Cutting: Relatively superficial cuts. May receive, but does not require medical
AS AN OUTCOME OF THE ACT
intervention to survive.
Ingestion: May receive, but does not require medical intervention to survive.
e.g. 25 Regular Strength Tylenol, 100 laxatives
Other: Nonlethal, usually impulsive & ineffective methods e.g. inhaling deodorant.
DEATH IS VERY HIGHLY
IMPROBABLE

10

Cutting: Shallow cuts without tendon/nerve/vessel damage; very little blood loss.
Ingestion: Relatively mild overdoses or swallowing of non-sharp glass.
Other: Tying a thread, string, or yarn around neck and then showing to others.

DEATH IS AN IMPOSSIBLE
0
RESULT OF THE "SUICIDAL
BEHAVIOR"

Cutting: light scratches that do not break the skin.

Ingestion: Mild overdoses and swallowing objects like paper-clips & money.
Rating:
Other: Clearly ineffective acts which are usually shown to others.

----

Appendix H

131

Date:
Number:
Wellesley#:
IN:

-------_
-------

Please circle the number which best represents your choice.

1. How likely was the method you used to have caused your death?

very unlikely

would definitely result in death

2. How long did you expect this method to take to result in your death?
a few seconds................................. I
a few minutes ..................................2
less than one hour........................... 3
a few hours......................................4
one day............................................5
a few days.......................................6

1\1 \e\tta.\

..............................................0

(Please describe:

--'

Appendix I

132

Date:------Number:
_
Wellesley#:
_
Clinician:
_

Please circle the number which best represents your choice.

1. How likely was the method the patient chose to have caused his/her death?

very unlikely

would definitely result in death

2. How long would you expect this method to take to result in his/her death?
a few seconds.................................1
a few minutes..................................2
less than one hour...........................3
a few hours......................................4
one day............................................5
a few days........................................6
N,ot\

l.e.\.-.h..o...l.........................................0
(Please describe:

_,

133

Appendix 11
Date:
Number:
Wellesley#:
IN:

_
_
_

-------

There are twenty statements below. Please read each statement and circle "True" if you
agree. or "False" if you do not agree.

I. I look forward to the future with hope and enthusiasm ...........................True

False

I might as well give up because I can't make things better

for myself................................................................................................True

False

3. When things are going badly, I am helped by knowing they

can't stay that way forever......................................................................True

False

4. I can't imagine what my life would be like in 10 years..........................True

False

5. I have enough time to accomplish the things I most want to do.............True

6. In the future, I expect to succeed in what concerns me most...................True
7. My future seems dark to me.....................................................................True

False
False
false

8. I expect to get more of the good things in life than the average
person .......................................................................................................True

False

9. [just don't get the breaks, and there's no reason to believe I will
in the future..............................................................................................True

False
False

10. My past experiences have prepared me well for my future.....................True

11. All I can see ahead to me is unpleasantness rather than
pleasantness..............................................................................................True

False
False

12. [ don "t expect to get what I really \Vant....................................................True

13. When I look ahead to the future. I expect to be happier than
I am no\v.................................................................................................True

False

Appendix 12

134

14. Things just won't work out the way I want them to................................True

False

15. I have great faith in the future................................................................. True

False

16. I never get what I want so it's foolish to want anything..........................True

!7. It is very unlikely that 1 will get any real satisfaction in the
future.........................................................................................................True

False

False
False

18. The future seems vague and uncertain to me............................................True

False
! 9. [can look forward to more good times than bad times.............................True
20. Thercs no use in really trying to get something I want because
I probably \Von't get it..............................................................................True

False