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Another caution: Do not allow the frequency of a sign’s occurrence
or long lists of warning signs lead you to the belief that suicide is a
common or acceptable solution to serious distress. Suicide, in my
opinion, is a totally unacceptable, not thought through, and misguided
solution to any troubling situation. Remember, a high percentage of
people prevented from killing themselves have gone on to live a
happy, productive life and were deeply grateful for having a full life.
Things change.
One more final comment about warning signs. Shea (1999) makes
this point very well. Because warning signs are easily identifiable and
countable, even clinicians may be prone to base their predictions
largely on warning signs. Shea reminds us that the decision to kill
ourselves comes from the mind’s perception of the psychological pain
we are suffering, not from a count of warning signs. Thus, the best
predictions (and the best help) are based on getting to know
intimately the reasoning and the feelings leading to the decision to die.
This decision often lingers on for days, weeks, months or years of
detailed thought about the various pros and cons and about the
consequences of using different methods (all this thinking pushed and
influenced by emotions). If the therapist is caring, lucky, and
understanding, the doctor may be invited by the patient to see the
complex and intimate journey the mind has taken and why. With that
insight, then, perhaps, better predictions can be made and, more
importantly, maybe alternative solutions can be tentatively discussed.
In his book, Shea provides a strategy for getting this process moving
and giving good therapy, called the Chronological Assessment of
Suicide Events (the CASE approach). These hours are precious for both
the helper and the helpee.
Too often there isn’t enough time for the “CASE” approach, even if
the patient has good health insurance. Much of the time, professionals
assessing the lethality of suicidal intentions have to rely on warning
signs and a brief mental health history.
The importance of Shea’s notion of understanding the person’s
thinking and intentions is underscored by a very thorough 12-year
follow up of 224 suicide attempters done by four Finnish hospitals
(Suominen, Isometsa, Ostamo, and Lonnqvist, 2004). Trained
interviewers asked the attempters 424 questions about their everyday
life, health, alcohol and drug use, suicide attempts, health care,
psychiatric treatment, and life events. In addition, a large test battery
was administered, including Beck’s Suicide Intention Scale, Beck’s
Hopelessness Scale, State-Trait Anger Scale, Self-Esteem Scale,
Motives for Parasuicide Scale, and Beck’s Depression Scale. The
Finnish investigators found that during those 12 years of follow up
22% of that group had died but only 8% had died from suicide. This
8% were found to have scored very high on the Suicide Intention
Scale when they first came to the hospital. This high intention (a
strong wish to end one’s life) was the best predictor of eventual
suicide perhaps years later, better than previous attempts,
hopelessness, gender, age, psychiatric disorders, health, or other
