In order for licensed health professionals to implement any suicide prevention strategy, they need a notion of cause-effect. The existing models have been reviewed in chapter III. This chapter presents the suicide prevention triangle model which addresses the logic of a necessary and sufficient cause for a self injury event to occur whether this outcome ends in death or continuation;i.e. suicide death or suicide attempt.
Since any explanation of the problem of suicide requires some attention to the meaning of death to the victim, this topic will also be addressed in a preliminary section. Cultural and regional differences of meanings are assumed to be incorporated in the unique significance each person gives to their life and its subsequent termination.
Camus (1955) has observed that the value and meaning of life can be related to the wish for death. He differentiates the worth of continuation from its significance. Camus goes on to argue that the only real choice available to modern man or woman is the implicit daily decision to reject suicide and continue with existence. This dramatic metaphysical assertion makes a point, but understates the individual's role in creating meaning and giving values to otherwise neutral or absurd events.
The value of a person's own life is assigned by the individual in a process of self evaluation which concludes that existence is, or is, not worth continuing. The meaning of the life that continues varies between self assessments and appraisals of others. When there is consensus the meanings are considered objective. When discrepancies exist subjectivity is inferred and questions of competence arise. Regardless of which, all persons assign a value to their existence, which reflect changes in meanings perceived or understood by each individual. While such values may not be explicit, pride and the wish to live carry a basically positive answer. "My life is worth continuing". Exceptions can occur with the assignment of zero or negative value and the subsequent choice or impulse to end that life. In contrast the negative choice is always explicit and based on a unique process, at an experiential level of observation.
A further description of this personal role can be made with the career of the public inebriate. Many of whom make the self assessment that their lives are purposeless and meaningless, but still cling to its inherent value by waiting for their existence to run its course. While death rates from natural and violent causes are high, the suicide rate is not known to be excessive compared to the depressed or most other high risk groups.
The exceptions occur with those who are forced to give up alcohol through medical illness or incarceration induced withdrawal. All alcoholics who continue to drink are at less immediate risk for self injuries than those who have been detoxified and are seeking rehabilitation through abstinence. The latter are vulnerable to the physical pathology of their age and neglected health, plus the duress of accumulated personal tragedies. When these are added to the demands of symbiotic spouses and the compulsions of their pre morbid personalities, perturbation reaches significant levels.
Since all alcoholics are also different, despite the stereotypes of behavior induced by addiction, they are capable of perceiving new experiences in ways that change meanings and allow them to assign positive values to their existence. The further example here would be AA participation, and the discovery that others can respect them by listening and personal support through small acts of friendship. These include points of mutual identification, offering new meanings to daily frustrations, and valuing self help behavior. A recovering alcoholic in this scenario would be more able to assign positive value to his or her life of continued sobriety. These would occur through helping others, making amends, expiating guilt, and finding small satisfactions in daily life. Others less fortunate would block mutual help, maintain cynicism, and miss the psychological vitamins of peer approval. The lack of perceived external support would fuel increasingly negative self values, which in the context of abstinence would facilitate the wish for death, and the seductions of an after life. The meanings they might assign would imply relief, peace, or as documented recently, respite (Parker, 1981).
This raises the question of how can death be desirable. What logic allows any victim to engage in actions that cause a dying process in order to achieve death, and whatever that may bring to the victim? Such a choice is made possible by the comparison with life and the conclusion that there will be more satisfaction after termination.
Each victim can specify a condition under which their life has no value and when they would prefer to cease. As subjective perceptions of their reality converge on this criterion, the victims experience a wish to return to an earlier state of existence which was more satisfying, or its equivalent, wishes for death. Implicit here is the assumption that after termination some awareness of increased satisfaction will still be present, i.e. continuation.
Carl G Jung (1964) has expressed this as well as any person:
"No one believes in his own death... our own death is indeed unimaginable and whenever we make an attempt to imagine it we can perceive that we really survive as spectators... in the unconscious everyone is convinced of his own immortality."
Shneidman (1981) has written about orientations to death and inferred the difference between interruption versus cessation of awareness as psychological conditions influencing the choice of suicide. The former refers to transitory states such as sleep and awaking, fainting and revival, anesthesia and recovery. Such interruptions of awareness are the only prior experience anyone can have in preparation for the final cessation of awareness implied in the termination of the living body.
It is a relatively universal experience to feel better after a sleep. People have written of positive experiences following a sudden interruption state, such as out of body experiences, or the varieties of religious conversions. The implication here is that victims of suicidal behavior believe they will feel better after termination and that it represents a way of changing their unacceptable awareness of current existence. They find the idea of interrupting consciousness through suicide is attractive. At least partly, they expect to re-awaken after death, like they do after sleep, refreshed, with new ideas, and unforeseen options. The possibility that any change will feel better is itself seductive.
The prospect that awareness will continue past the point of termination, permits potential victim to prefer death. The chance that death may result in cessation rather than interruption of awareness is given much less credence. Such beliefs about the meaning of the afterlife allow victims to consider termination as another option and to wish for its occurrence.
Reviewing the value of life, and the meaning of after life, is a prerequisite to explaining a victim's preference for death. The subsequent choice of suicide is only one of four mortal options. There are also accidents (on purpose or otherwise), victim precipitated homicide, and surrender of the body to life threatening illness. There are psychological reasons to believe that victims of each play some role in easing or aggravating their respective modes of dying.
The wish to die is experienced, and becomes clinically visible, when a potential victim perceives his or her existence as approximating an implicit criterion for when death is preferable. The convergence creates the perturbation associated with suicidal behavior. The emergence of a suicidal plan reduces acute perturbation while permitting action to continue.
This criterion implies some strongly held belief about the nature of an after life, which usually assumes a continuation of their awareness, past the point of termination and into a state where the awareness will change. Whether or not an after life is objectively possible, is irrelevant for the purposes of explaining suicide. It is sufficient that the victim believes he or she will feel better after death is achieved. This includes the idea that to feel nothing is also an improvement.
An assessment of the potential victim's notions of the after life are necessary. Open ended questions during an interview should be used, or structured with multiple choices including an 'other' category. From this, one must elicit a criteria for when the victim believes their life will be unlivable and death would be more preferable. Again an open ended question or multiple choice format would be appropriate. The two questions should be presented together in the above sequence in order to create a non pejorative set, given the taboo and stigmatized aspects of suicide today.
Once a preference is elicited it represents the criterion for when that victim might wish to die and therefore start considering a suicidal plan. This information allows the clinician to make a judgment about how close the person is to acting on a wish to die.
Such professional judgments are made frequently from the known facts.
Alternatively, the clients can be asked to make this judgment themselves.
Several ways are possible and will be illustrated next.
Other methods of assessing these issues are possible. Whatever the format, efforts to explain or prevent clinical suicide must start with the personal notions of the circumstances which make death preferable to a potential victim. Prevention can then be focused on the time period when perceived existence approaches this criterion and psychological efforts to alter one or both sides of the convergence can be attempted, i.e. the criterion and the perception.
The Suicide Prevention Triangle model is borrowed from fire prevention education, which is illustrated below..
Fire cannot occur with any one aspect removed or reduced sufficiently.
Similarly, one can juxtapose a triangle composed of three suicidal aspects: a wish to die, a suicidal plan, and sufficient distress to require relief. Together these provide a necessary and sufficient situation for self injury behavior. The relation is illustrated below.
Self injury behavior can be deterred if one or more aspects are reduced or removed from the social situation of the high risk person. Each is a necessary, but insufficient cause by itself.
The wish to die cannot be altered directly. Like high fever, it is the result of other conditions. It is experienced when the victim perceives existence as approaching or approximating some implicit standard for when death is preferable. Under some circumstances anyone would rather cease to exist. Given such a perception, the individual is expressing a need to leave an intolerable situation or state of existence. The wish to die when observed reflects a client's desire for an alteration of existence. The health professional can intervene in terms of changing awareness; by either restructuring the definitions of issues or working with perceptions of existence.
People will express the wish to die if they are given social permission by the authority figures in their environment, peers, or have some additional motives not fully recognized by either the victim or others. Regardless the licensed professional can elicit the current state of the wish to die by clinical inquiry. Simply asking, after rapport is established or as part of an ongoing clinical procedure, is sufficient.
The wish to die can come to anyone, although it is relatively rare and transitory compared to its opposite the more universal wish to live. Sometimes the two coexist and resulting conflict behavior is apparent. This is more familiar as ambivalence.
Deterring any self action has the value of providing opportunities for the wish to live to reassert itself. Because the wish to die can return again, the health professional needs to monitor the current state of the wish to die even after relative stability has recurred. The wish to die aspect is illustrated below.
Self injury methods are over determined by character, previous history and availability(Lester,1970). Thus one method is usually preferred over all those that are actually available. There are two exceptions to this rule of thumb. People early in the life cycle of their suicidal careers are less committed to one method. They tend to prefer two or more less lethal methods, such as wrist cutting and abuse of prescription drugs, often utilized as gestures or threats. The second exception is the behavior of more psychotic people who may act impulsively with methods of availability which provide more lethal opportunities for self injury such as jumping or hanging. The key difference is that there is very little planning and the sheer availability of the method determines the decision to use it by these highly distressed people. Intervention with the first group permits more margin for error. The second requires more vigilance than can be maintained over extended periods of time. Both require priority attention for the underlying distress as the major prevention strategy.
For the larger majority of high risk people who contribute the bulk of deaths by suicidal mode in the U.S., the methods are less random and approach compulsivity (Lester,1970). This permits the health professional to block access to specific methods rather than the more usual suicidal precautions where access to all methods is denied. The latter creates situations that merely increase the amount of distress experienced by the potential victim while providing protection for short durations of time only. Selective blocking of a preferred method takes less effort and is less stressful for the client. It can also be imposed for longer time spans than the usual emergency approach. The degree of planning aspect is illustrated below.
Distress and loss of hope is the most visible clinical source of motivation for self injury behavior. It is also the one for which health professionals have the most skill and experience in managing. While vulnerable individuals seem to be most prone for return of distress, over a short interval health professionals are able to do a great deal to reduce or control the experience of personal distress. Crisis intervention, tender-loving-care (TLC), problem solving, constructive listening and opportunities for catharsis, are the usual interventions when clients are identified as in need of emergency care. These are appropriate, short term responses for the prevention of suicide.
However, efforts oriented to distress focused on self injury, or perturbation, are highly restricted. These take the form of supervision and medications for the duration of the emergency. More effort is needed in examining and altering after death orientations, criteria for living, and developing suicide prevention plans that block access to methods. These relations are illustrated below.
The whole model is illustrated and developed further in the closing section called the suicide prevention classes.
The longer range perspective is also possible and necessary. The assumption here is that in between suicide attempts, high risk people need intervention that does something for recurring distress, especially when this threatens hope (Beck et al,1975). Usually this is accomplishable through cooperation and planning with significant others, health teams, and the device of a suicide prevention plan. The basic element is monitoring the high risk person over the first six months of post hospitalization, and the first year or two following a self injury incident. The use of suicide prevention classes after the acute phase, and letter follow ups during the one or two years post self injury represents longer term interventions that are cost effective. These yield increased support, observation, and stimulate hopefulness. The third figure illustrates the issues in managing distress.
Frequent assessment is implied in longer range interventions. The wish to die, the preferred method and the degree of distress experienced needs to be reviewed with every clinical contact and changes noted. These call for strategies that represent degrees of intervention to match the degrees of lethality and risk; rather than the all or none tactics currently in use.
The wish to die when explicit represents an acute stage calling for immediate steps to block preferred methods, and to deal with distress. The absence of the wish to die, that is the presence of the wish to live, returns the client to pre morbid, but high risk state, even though this may be moments after a self injury act.
The health professional needs to debrief the method used for its continuing availability and lethality. It should be removed or blocked from access. The source and nature of distress are longer term issues that need to be addressed as clinical resources permit.
This overall model permits various clinical skills and procedures to be used optimally over different time frames.
Alcoholism or addiction to other substances is universal in mental health treatment settings, and facilitate self injury behavior. However, distress cannot be managed nor prevention goals achieved without first achieving abstinence. The current state of knowledge does not permit both. The longer range goal of preventing acute recurring episodes of self injury incidents is not accomplishable with continued use of substances that are addictive or cross addictive. The higher treatment priority is to achieve abstinence, and hopefully a life of positive sobriety by whatever combination of treatment strategies it is possible to provide. While exceptions can occur, and the actual suicide rate of known alcoholics with previous attempts is somewhat lower than those without alcoholic addiction, long range effective interventions are impeded by episodes of ingestion. Paradoxically, successful abstinence, at least in the first six months increases experienced distress, and requires more vigorous suicide prevention efforts for the next 12 or 24 months. The cautionary statements in the preceding paragraphs are intended to emphasize priorities of effort. The primary diagnosis is addiction rather than suicide, and the major effort should address achieving abstinence as the most optimal method of preventing self injury behavior.
Suicidal events are initiated in order to change the contents of awareness of personal existence. Potential victims regard their lives as having unacceptable values, because their understanding of meanings converge on a self defined criteria for when death is preferable. As this convergence approaches congruence, the wish to return to an earlier more satisfying state is approximated by a wish to die. The facts of termination, and the occurrence of a physical death, are expected to change distressing awareness without causing cessation of all awareness. Even those who deny any continuation will imply that nothing will feel better than their present perturbation.
The necessary and sufficient conditions for the occurrence of a self injury event are a wish to die, an act of self and sufficient perturbation to motivate a lethal plan.
The time lag within each condition is variable, but additive. There can be long gaps as the potential victim struggles with and surrenders to the seductions of relief from a wish to die. Shorter gaps can occur in the choice and development of a lethal plan. There is an unknown period for the conversion of personal distress to an action oriented perturbation. The time frame for all of these processes is known only by post hoc inquiries or personal speculations of suicidologists. This lack of knowledge reflects the difficulty of accessing the data of victims. However, the sum of them all represents the window of opportunity to introduce prevention efforts.
This chapter presents the Triangle Model which addresses the scientific criteria of necessary and sufficient causes for a suicidal event.
The absence of one or more of these separate conditions can block the occurrence of self injury behavior. Their presence demands a suicidal act. This sequence is a restatement of the triangle model postulated to account for suicidal events. Whether or not these end in death depends on lethality of planning and accidental factors. More explications and applications of the model are described in this chapter including a statement attempting to resolve the problem of suicide; an answer to "Why?"