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Attitudes toward suicide among

mental health professionals
a a
Barbara J. Swain & George Domino
a
University of Arizona , Tucson
Published online: 14 Aug 2007.

To cite this article: Barbara J. Swain & George Domino (1985) Attitudes toward
suicide among mental health professionals, Death Studies, 9:5-6, 455-468, DOI:
10.1080/07481188508252537

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 wwwwwwwwmwmo~wwmwwwmmwwwmwmwwwmwmmmwwmwmmmwwww

ATTITUDES TOWARD SUICIDE AMONG

MENTAL HEALTH PROFESSIONALS
wwwwwwwmmmmoammmwwwwmmmwmwmwcewwwwmmwwmmwwwmwww

BARIBARA J. SWAIN and GEORGE DOMINO

University of Arizona, Tucson
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The Suiciak Opinion Questionnaire (SOW and the Recognition of Suicide Lethality
( R S L ) scale were trdministered to 141 mental health professionals representing seven
groups: f a m i b pructice physicians, psychiatrists, psychologists, psychiatric nurses
and aides, social workers, crisis line workzrs, and clergy. The results indicate
s@;f;cant differences among goups on 5 o f the 15 SOQ fnttors, on a clinical[y
derived empathic understanding scale, and on the R S L . Major findings of the study
include: (a) the complexity of attitudes towards suicide; @) substantial differences
between clergy and other mental health professionals; (c) differences between
physicians and psychologists on attribution of manipulative motivation to suicide
attempts; (d) a rehtionship between attitudes and personalfamiliarity with suicide;
(e) an ordering qf professional groups on the Empathic Understanding Scale
rejecting psycholoi$cal, medical, or rel&ious training; (f) group differences on the
recognition of suicide lethality signs; and (9)a relationship between knowledge of
lethality and several attitudinal factors.

Introduction

Societal attitudes toward suicide have varied considerably over the

centuries. Such c.hanges have been documented by philosophers, so-
ciologists, and other writers (1-5).
In the United States, suicide is a major cause of death, and
suicide attempts are a clinical phenomena encountered by most
health professionals (6). Yet little is known about the attitudes of such
professionals toward suicide and suicide victims. The studies that

Address correspondence to George Domino, Department of Psychology, University of

Arizona, Tucson, AZ 85721.

Death Studies, 9:455-468, 1985 455

Copyright @ 1985 by Hemisphere Publishing Corporation
 456 B. J . Swain and G. Domino

exist have used a variety of approaches, with little comparability

from study to study.
Personal interviews have been used to sample community atti-
tudes toward suicide (7, 8), to examine the motives attributed by
doctors and nurses for self-poisoning (9) and to explore the treatment
decisions of mental health center therapists when they work with
suicidal patients (10). A variety of questionnaires have been used.
Some have been oriented around a positive/negative or sympathy/
hostility dimension of suicide (9, 11, 12). Shneidman (13), Weis and
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Seiden (14) and Weigand (15) used a questionnaire that focused on

the respondents’ attitudes toward their own deaths or suicides in
samples of Psychology Today readers, suicide prevention center volun-
teers, and physicians.
Domino et al. (16) presented evidence to indicate that attitudes
toward suicide are rather complex and not to be viewed on a simple
positivehegative continuum. They also presented a 1OO-item Suicide
Opinion Questionnaire (SOQ as a standardized instrument with a
solid psychometric basis.
The present study was undertaken as part of a programmatic
effort to understand attitudes towards suicide (16-21). The aims of
this study were to examine such attitudes among mental health pro-
fessionals who have contact with suicidal clients and to relate these
attitudes to personal acquaintance with suicide and to recognition of
suicide lethality.

Method

Subjects

The 128 respondents in this study were recruited from members of

seven professional groups in Tucson that serve the suicidal: family
practice physicians (n = 17), psychiatrists (n = IS), certified psy-
chologists (n = 25), psychiatric nurses and aides (n = 13), social
workers (n = 23), crisis line workers (n = ZO), and Protestant and
Jewish clergy (n - 16). Although the sample was one of convenience,
an effort was made to reach those working in diverse settings and
locations. These settings included six inpatient and outpatient medical
or psychiatric facilities, three counseling or mental health centers,
 Attitudes Toward Suicide 457

two crisis-line organizations, and one correctional facility. Three of

these 12 facilities are privately funded, and 9 are supported by gov-
ernment funds, including 4 associated with the University of Ar-
izona. In addition, physicians, psychiatrists, and psychologists work-
ing in 18 privatle practice settings and Catholic, Protestant, and
Jewish clergy at 2 1 churches were invited to participate in this study.
Questionnaires were personally distributed to potential respon-
dents either individually or during staff meetings, by either the sen-
ior author or a staff member. In addition, every other psychiatrist
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listed in the membership rolls of a local psychiatric association was

mailed a questionnaire. Overall, 269 questionnaires were distrib-
uted; 141 were returned, with 13 not indicating occupational status,
for a total response rate of 52.4 percent.
The modal age range for participants is from 35 to 44 years, with
physicians tending to be older and crisis-line workers younger. The
groups also differ in gender composition: No female clergy or psychi-
atrists responded, while 70 percent of the participating crisis-line
workers are wornen. Overall, 41 percent of the participants are
women.
As a group, these professionals are intimately acquainted with
suicide, and report encountering an average of three suicide clients
per month (i= 3.11; SD = 8.3).
Approximately two-thirds knew someone personally (as opposed
to professionally) who committed suicide. Ten percent had a family
member or relative who committed suicide, 27 percent had a friend
who committed suicide, and 26 percent had an acquaintance who
committed suicide. Approximately one-third have seriously consid-
ered suicide, but there are significant group differences, from 14
percent for the cllergy to 58 percent for the psychiatric nursing per-
sonnel. Four participants in this study report that they have at-
tempted suicide.

Instruments

Participants were asked to fill out a 130-item composite question-

naire made up of the 100-item SOQ (16), the Holmes and Howard
(22) 13-item Recognition of Suicide Lethality Scale (RSL), and 17
items requesting demographic and biographic information.
 458 B. J . Swain and G . Domino

The SOQ requires the respondent to indicate agreement or dis-

agreement on a five-option response scale: “strongly agree,”
L < agree,” “undecided,” “disagree,” and “strongly disagree.” The

100 SOQ items were those that survived logical and statistical anal-
yses from an initial pool of approximately 3000 items derived from a
comprehensive survey of the literature (16). Representative items
are: “I would feel ashamed if a member of my family committed
suicide”; “most persons who attempt suicide are lonely and de-
pressed”; and “suicide is an acceptable means to end an incurable
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illness.” Studies with the SOQhave looked at the attitudes of college

students (20), the alteration of such attitudes through a course in
Abnormal Psychology (17), Jewish vs. Christian attitudes (19), the
attitudes of Mexican-American vs. Anglo youth (18), an assessment
of the SOQ through factor analysis (16), and a comparison of atti-
tudes among suicide attempters, contemplators, and nonattempters
(21).
The RSL scale (22) consists of 13 four-choice multiple-choice
items requiring the respondent to determine empirically and circle
the correct answer. An example is “Persons who are most likely to
succeed in committing suicide are (u) female and under 50 years of
age, or (b) female and over 50 years of age, (c) male and under 50
years of age, or (6) male and over 50 years of age.” Holmes and
Howard (22) administered the RSL to various groups of profession-
als and found that physicians and psychiatrists were significantly bet-
ter than other groups at recognizing suicide lethality.
Finally, the demographic and biographical items requested the
respondent to indicate sex, age, suicidal ideation and attempts, fa-
miliarity with suicidal clients, personal acquaintances with suicide,
occupation, and occupational setting. No names were requested, but
respondents were given the option of identifying themselves and re-
questing additional information from the authors.

Procedure
The first step was to submit the 141 SOQprotocols to a factor analy-
sis. Although Domino et al. (16) carried out such a procedure for a
sample of 285 heterogeneous adults, the specific nature of this sample
suggested the need to repeat the factor analysis.
 Attitudes Toward Suicide 459

A factor analysis using a principal component solution with nor-

malized varimax rotation (23) was performed, and fifteen factors
were derived on the basis of the Scree Test for the number of factors
(24). These 15 factors accounted for 53.1 percent of the total vari-
ance. An item wa.s selected for a factor when the absolute value of its
factor loading was greater than -30. Of the 100 SOQitems, 98 met
this criterion. No item was included on more than one factor. Dupli-
cate items were assigned to the factors for which they had the highest
loadings if those loadings were .05 or higher than the competing
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loadings. If the (competing loadings differed by less than .05, the

assignment to a factor was made on the basis of conceptual similarity
with other items in the factor. The factor names were developed
through inductive scrutiny of the items that comprise each variable.
An additionall variable assessing empathic understanding was
constructed from the S O Q items. Five S O Q items were deemed in-
dicative of an empathic response to suicidal crisis. Three of these
items loaded highly on Factor I and thus were excluded from Factor
I to avoid redundancy.
Each protocol was scored for the 16 S O Q variables (15 factors
plus empathic understanding scale) and for the RSL. Two-way
ANOVA were then performed to evaluate response differences on the
basis of occupation and personal acquaintance with a suicide victim.
Sex and age were included as covariates in the analyses to control for
any group differences that might be attributable to the groups’ differ-
ing sex and age composition.
Post-hoc multiple comparison tests using Tukey’s hsd test were
performed on those variables shown by the ANOVA to reflect group
differences on the basis of occupation or personal acquaintance with
suicide. Finally, a correlational analysis was undertaken to compare
with RSL scale with the SOQvariables.

Results

The 15 SOQ factors are presented in Table 1. The largest factor is I,

Acceptability, which involves the theme that suicide is an acceptable
and sometimes preferable act, particularly suicide in response to old
age, disease, or enduring problems in living. Factor 11, Manipulative
 460 B . J . Swain and G. Domino

Aspects, reflects the attitude that suicide attempts are attention-

getting or manipulative ploys. Factor 111, Impervious Drive, sug-
gests that humans have a self-destructive drive impervious to social
influence, akin to the death instinct proposed by Freud (25). Factor
IV, Harsh World, centers on the theme that suicide is a reaction to a
harsh world which transcends different cultures and time periods.
Factor V, Elderly, suggests that older people have a greater risk of
suicide, while Factor VI, Differential Aspects, suggests that those
who are “different,” such as minority members, the very rich and
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the very poor, the depressed, and the obese, present a greater risk.
Factor VII, Irrationality, reflects the attitude that suicide is an irra-
tional act often reflective of mental illness, while Factor VIII, Insta-
bility, reflects the attitude that suicide is more prevalent among those
who have enduring defects of character than among victims of exter-
nal circumstances. Factor IX, Hidden Suicide, centers on the notion
that dangerous or unhealthy lifestyles, such as automobile racing and
alcoholism, may represent a hidden or unconscious desire to die.
Factor X, Fatality, suggests that the desire to die, although rare, is
successfully fatal and not preceded by suicidal gestures. Factor XI,
Romantic and Common, centers on the dual notion that suicide is
romantic, that is, reflects heroism and/or unreturned love, and is
also common in the United States. The items of Factor XII, Cultural
Values, reflect the interplay of cultural values such as patriotism,
personal honor and family shame, with suicide. Factor XIII, Social
Institutions, centers on the theme that suicide reflects social institu-
tions because it has social consequences and implications. In Factor
XIV, Communication, suicide attempts are a form of communica-
tion, a “cry for help” from someone with disturbed interpersonal
functioning. Finally, Factor XV, Religion, assesses the attitude that
having religious beliefs is inconsistent with suicidal behavior.
Many of the above factors are identical with or substantially sim-
ilar to those obtained by Domino et al. (16) but there are sufficient
differences to support the utilization of the factors obtained with this
sample.
The results of the ANOVA indicate that five of the factors, the
empathic understanding scale, and the RSL scale show significant
differences between professional groups. These are presented in
Table 2.
On Factor 111, Impervious Drive, there was a significant rela-
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TABLE 1. Results of Factor Analysis for SOQ ( N = 141)

Number % of
of total
Factor items variance Sample items Loading

I. Acceptability 16 9.8 There may be situations where the only reasonable resolution is suicide. .76
11. Manipulative Aspects 7 3.3 Those people who attempt suicide are usually trying to get sympathy. .74
111. Impervious Drive 9 3.1 Suicide is clear evidence that mankind has a basically aggressive and
destructive nature. .50
IV. Harsh World 11 6.2 Many suicide notes reveal substantial anger towards the world. .64
V. Elderly 3 2.4 Most suicide victims are older persons with little to live for. .65
VI . Differential Aspects 6 2.9 The suicide rate is higher for blacks than for whites. .76
VII. Irrationality 4 2.7 Suicide among young people (e.g., college students) is particularly
puzzling since they have everything to live for. .69
VIII. Instability 4 2.5 People who commit suicide must have a weak personality structure .48
IX. Hidden Suicide 3 3.0 People who engage in dangerous sports like automobile racing probably
have an unconscious wish to die. .66
X. Fatality 4 2.3 John Doe, age 45, has just committed suicide. An investigation will
probably reveal that he has considered suicide for quite a few years. - .62
XI. Romantic and Common 6 2.1 The Japanese KamiKaze pilots who destroyed themselves by flying
their airplanes into ships should not be considered suicide victims. - .56
XII. Cultural Values 4 1.9 If a culture were to allow the open expression of feelings like anger and
shame, the suicide rate would decrease substantially. .43
XIII. Social Institutions 5 2.2 Suicide rates are a good indicator of the stability of a nation; that is,
the more suicides the more problems the nation is facing. .52
XIV. Communication 7 3.6 A suicide attempt is essentially a “cry for help.” ,516
xv. Religion 5 5.2 People who attempt suicide are, as a group, less religious. .69
 Downloaded by [Korea University] at 16:10 25 December 2014

TABLE 2. Results of ANOVA on SOQ and Empathic Understanding Scale, and RSL Scale
Ip
QI
N Variables Groups (differentiated by parentheses)"

(SOC.Work. Psychiat . Psychol. Crisis Nursing Physicians) (Clergy)

I. Acceptability x 2.89 3.02 3.02 3.05 3.34 3.57 4.31
F(6,99) = 9.31.. SD .75 .44 .54 .66 .49 .59 .32
(SOC.Work.) (Physicians)
(Physicians) (Psychol .)
11. Manipulative Aspect x 3.33 3.82
F(6,101) = 2.42. SD .34 .43
(Nursing) (Psychiat. Clergy Psychol. Crisis SOC.Work)
111. Impervious Drive x 3.12 3.63 3.67 3.69 3.73 3.76
F(6,104) = 3.78' SD .49 .36 .39 .52 .41 .34
(Psychiat . Psychol. Crisis Physicians) (Cleru)
IV. Harsh World x 2.13 2.22 2.32 2.34 2.79
F(6,lOO) = 4.59.. SD .25 .43 .39 .32 .45
(Physicians Psychiat.) (Cleru)
V. Elderly x 3.21 3.24 3.93
F(6,105) = 3.44" SD .69 .60 .42
(Crisis Psychol. SOC.Work. Psychiat. Nursing) (Clergy)
Empathic Understanding x 1.95 2.02 2.07 2.11 2.25 2.67
F(6,103) = 4.79'; SD .39 .40 .33 .24 .52 .62
(Psychiat. Physicians Crisis Psychol.) (Clergy)
Recognition of Suicide Lethality x 9.47 8.93 8.75 8.73 7.42 6.42
F(6,100) 33.93'. SD 1.20 1.75 1.68 2.45 2.71 1.56
(Psychiat.) (Nursing Clergy)

'p < .05.

" p It .01.
"Group differences based on Tukey's hsd test, with p < .05.
Note. Scoring guide on SOQvariables: 1 -strongly agree, 2 agree, 3
- - undecided, 4 = disagree, 5 = strongly disagree
 Attitudes Toward Suicide 463

tionship with personal acquaintance with suicide [F( 1,104) = 5.25,

p < .05]. Professionals who had a personal acquaintance (N = 77,
2 = 3.54, SD == .47) endorsed this attitude more than those with-
out such acquaintance (N = 43; = 3.75, SD = .40).
A significant relationship was also obtained on the RSL scale
[F(1,100) = 1O.li9, p < .05], with professionals who had a personal
acquaintance (N = 76; k = 8.71, SD = 2.08) scoring significantly
higher than those without such acquaintance (N = 40; X = 7.58,
SD = 2.17.
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Significant interaction effects were obtained on two factors. On

Factor IV, Harsh World, [F(6,100 = 4.58, p < .Ol] psychiatric
nurses and aides who had personal acquaintance with suicide
x
(N = 8; = 2.66, SD = .62) endorsed this attitude less than those
without such acapaintance (N = 4; = 2.14, SD = .17). In con-
trast, psychologists who had personal acquaintance with suicide
x
(N = 16; = !2.10, SD = .93) endorsed this attitude more than
those without such acquaintance (N = 6; .? = 2.52, SD = .42).
O n Factor VI, Differential Aspects, [F(6,102) = 2.24, p < .05],
psychiatric nurses and aides who had personal acquaintance with
suicide (N = 8; 2 = 3.10, SD = .44) were less likely to endorse
this attitude than those without such acquaintance (N = 4;
X = 2.21, SD == .80).
The results of the correlational analysis between the RSL Scale
and the 15 SOQ-variables yielded six significant coefficients: - .19
with Factor 111, Impervious Drive (p < .05); .34 with Factor IV,
Harsh World (p < .Ol); .51 with Factor V, Elderly (p < .Ol); -
.20 with Factor VIII, Instability (p < .05); - .26 with Factor X,
Fatality (p < .Ol); and .21 with Factor XIV, Communication (p <
.05).

Discussion

The first thing of note is a repetition of the point made by Domino et

al. (16) that attitudes toward suicide are complex and ought not to be
considered from a simplistic positivehegative viewpoint, as research-
ers and clinicians have often done in the past. The results of the
factor analysis underscore this complexity, as well as the heuristic
value of assessing the factor structure in differing groups. At the
 464 B. J. Swain and G. Domino

same time, however, there is considerable overlap among the 15 fac-

tors obtained in this study and the 15 reported by Domino et al. (16).
In both studies the first major factor was one of acceptability. Two
factors in the present study, Factor 11, Manipulative Aspects and
Factor VII, Irrationality, show substantial item overlap with Dom-
ino’s Factor 2, Mental and Moral Illness. The third factor in this
study, Impervious Drive, is represented by two factors in Domino’s
study: Factor 6, Lethality, and Factor 8, Irreversibility. Four other
factors in this study (Factor V, Elderly; VI, Differential Aspects,
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VIII, Instability and XV, Religion) are similar to four factors in

Domino’s study (Factor 10, Aging; 9, Demographic Aspects; 3, Sui-
cide as semi-serious; and 4, Religion). Finally, seven factors in the
present study (IV, IX, X, XI, XII, XIII, XIV) do not have clearly
parallel factors in the Domino study.
A second finding concerns the various group differences ob-
tained. Perhaps not surprisingly, the clergy differ singularly on five of
the seven significant variables. On the factor of Acceptability, the
clergy are significantly different from all other groups, and their
mean response of 4.31 shows strong disagreement with the attitude
that suicide is an acceptable act. Among the other six groups, physi-
cians are significantly different from social workers, and their mean
score of 3.57 also reflects disagreement. These results are in accord
with the belief espoused by Whalley (26) that physicians and clergy
are more resolute than psychologists about the value of life. The
acceptability of suicide represents a major ethical and philosophical
issue. Of the groups assessed, only the mean of the social workers is
in the agree range. These results are in contrast with the view pro-
posed by Kastenbaum (27) that suicide is becoming increasingly
more acceptable in our culture and that eventually, suicide will be-
come the preferred mode of death, chosen in the national interest by
the socially conscious.
A third finding is the significant difference between physicians
and psychologists on Factor 11, the attribution of manipulative mo-
tives to suicide attempters. Although both means are in the “unde-
cided” to “disagree” range, physicians tend to attribute manipula-
tive motivation to suicide attempts more than psychologists do,
results that agree with those of Ramon et al. (9).
Sifneos (28) coined the term “manipulative suicide” (1 1) to de-
scribe suicide attempts used to control or receive something from
 Attitudes Toward Suicide 465

others. Sifneos may not have intended the term to be pejorative, but
it has become so. Ansel and McGee (1 1) found that public attitudes
towards a suicide attempter are more negative when the attempter’s
motive is seen as a manipulative one rather than as a desire to die.
Similar findings were obtained by Ramon et al. (9) among a sample
of medical personnel.
A suicide attempter’s first professional contact is often with a
physician (12, 29) whose skills are best utilized in the resolution of
physical rather than emotional problems. The label “manipulative”
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may be a shorthand to distinguish between those who need medical

attention and those who do not. Sifneos (28) warns physicians that
they should not completely dismiss the nonlethal attempter with such
a label.
An interesting group difference arises on Factor 111, Impervious
Drive, with psychiatric nurses and aides being significantly different
in the agree direction than all other groups except physicians. These
results are not consistent with the observation of Reynolds and Far-
berow (30) that psychiatric aides emphasize intrapsychic causes in
suicide much less than other helpers do. Both psychiatric aides and
psychiatric nurses have almost identical mean responses on this atti-
tudinal variable (2= 3.18, SD = .52 vs. 2 = 3.08, SD = .50).
The question of attitude and experience is one that has not been
fully explored despite its obvious significance. Goffman (3 1) proposes
a deviance theory and hypothesizes that familiarity with deviance
tends to increase tolerance toward such deviance. The theory was not
supported in a study by Marks and Riley (32) of attempted suicide,
but other investigators (21, 33, 34) have found partial support. The
present study indicates that professionals who have personal ac-
quaintance with suicide are more likely to accept the notion of a self-
destructive drive and are better able to recognize signs of suicide
lethality.
Mention shaluld be made of the Empathic Understanding scale,
derived clinically rather than factorially. The issue of empathy in
psychotherapy is a key one (35, 36), and the results here support that
centrality. All of the psychologically and psychiatrically trained
groups score differently than the clergy. The ordering of the groups
themselves, while not statistically significant, parallels clinical experi-
ence. The first three groups (crisis-line workers, psychologists, and
social workers) are psychologically oriented. The next three groups
 466 B. J, Swain and G. Domino

(psychiatrists, psychiatric nurses and aides, and physicians) are more

medically oriented. The final group is the clergy, who again are sin-
gularly different in their philosophical and theoretical orientation.
Finally, the obtained results on the RSL scale are almost a dupli-
cate of those reported by Holmes and Howard (22). The only rever-
sal occurs in the first two groups: For Holmes and Howard physi-
cians scored highest and psychiatrists second (although the difference
was not statistically significant) while for the present study the two
groups are reversed. In both studies, clergy scored lowest.
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The correlational analysis with the SOQ variables indicates that

professionals who are more knowledgeable about the lethality of sui-
cide are less likely to impute a self-destructive drive or mental insta-
bility to suicide attempts, are more likely to see suicide as a reaction
to a harsh world, see the elderly at greater risk, have less of a fatalis-
tic outlook, and see suicide attempts as more of a “cry for help.” To
be sure, the obtained correlation coefficients are modest and need to
be replicated, but these results point to a relationship between knowl-
edge and attitudes that may have educational and clinical implica-
tions for the training of mental health practitioners.
There are, of course, substantial limitations to this study. The
sample is relatively small and not representative. The physicians, for
example, were all family practice physicians who may possibly be a
more psychologically attuned group than their medical colleagues in
surgery, pathology, and other specialties. The clergy represented only
some Protestant denominations and a portion of the Jewish faith. Yet
the results point to substantial differences between professional
groups, and to the utility of the SOQ.

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Received February 27, 1985