• TABLE OF CONTENTS
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 Title Page
 Acknowledgement
 Table of Contents
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Summary
 Appendices
 References
 Biographical sketch














Title: Suicide risk, self-injury risk, and expected intentionality for a population and its component sub-populations /
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Title: Suicide risk, self-injury risk, and expected intentionality for a population and its component sub-populations /
Physical Description: viii, 92 leaves : ill. ; 28cm.
Language: English
Creator: Wilson, Karl Eugene, 1946-
Publication Date: 1976
Copyright Date: 1976
 Subjects
Subject: Suicide   ( lcsh )
Psychology thesis Ph. D   ( lcsh )
Dissertations, Academic -- Psychology -- UF   ( lcsh )
Genre: bibliography   ( marcgt )
non-fiction   ( marcgt )
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Thesis: Thesis--University of Florida.
Bibliography: Bibliography: leaves 84-90.
General Note: Typescript.
General Note: Vita.
Statement of Responsibility: by Karl Eugene Wilson.
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Bibliographic ID: UF00099531
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
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Resource Identifier: alephbibnum - 000168877
oclc - 02891137
notis - AAT5277

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Table of Contents
    Title Page
        Page i
        Page ii
    Acknowledgement
        Page iii
    Table of Contents
        Page iv
        Page v
    Abstract
        Page vi
        Page vii
        Page viii
    Introduction
        Page 1
        Page 2
        Page 3
        Page 4
        Page 5
        Page 6
        Page 7
        Page 8
        Page 9
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        Page 11
        Page 12
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        Page 15
        Page 16
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        Page 21
        Page 22
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        Page 24
        Page 25
        Page 26
        Page 27
        Page 28
        Page 29
        Page 30
        Page 31
        Page 32
    Methods
        Page 33
        Page 34
        Page 35
        Page 36
        Page 37
        Page 38
        Page 39
        Page 40
    Results
        Page 41
        Page 42
        Page 43
        Page 44
        Page 45
        Page 46
        Page 47
        Page 48
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        Page 58
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        Page 60
        Page 61
        Page 62
        Page 63
    Discussion
        Page 64
        Page 65
        Page 66
        Page 67
        Page 68
        Page 69
        Page 70
        Page 71
        Page 72
        Page 73
        Page 74
        Page 75
        Page 76
        Page 77
        Page 78
    Summary
        Page 79
    Appendices
        Page 80
        Page 81
        Page 82
        Page 83
    References
        Page 84
        Page 85
        Page 86
        Page 87
        Page 88
        Page 89
        Page 90
    Biographical sketch
        Page 91
        Page 92
        Page 93
        Page 94
        Page 95
Full Text











SUICIDE RISK, SELF-INJURY RISK, AND EXPECTED
INTENTIONALITY FOR A POPULATION AND ITS
COMPONENT SUB-POPULATIONS










By

KARL EUGENE WILSON


A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL OF
THE UNIVERSITY OF FLORIDA
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE
DEGREE OF DOCTOR OF PHILOSOPHY










UNIVERSITY OF FLORIDA


































COPYRIGHT BY

KARL EUGENE WILSON

1976















ACKNOWLEDGMENTS


The data utilized in this study were collected for research sup-

ported in part by National Institute of Mental Health Grant MH-18911.

I wish to acknowledge the cooperation of Dr. George Murphy and Dr.

Richard Wetzel in permitting me use of the data for this study, and

Ms. Marcia Lange for her invaluable statistical and computer consul-

tation.

I wish to thank Dr. Richard McGee, Chairman of my Committee, for

his advice and guidance in this work and throughout my graduate career.

He has been an exceptional professional model, mentor, and friend. I

also wish to express appreciation to Dr. Benjamin Barger, Dr. Hugh Davis,

Dr. Everett Hall, Dr. Richard Swanson, and Dr. Joe Wittmer, who served

on the Committee, for the interest they have shown and the advice which

they have offered.

I thank Mr. Douglas Freeman for rating the reliability sample and

Dr. Joe Thigpen for his hospitality and facilitative efforts on my

behalf.

I reserve special acknowledgments and loving gratitude to my wife,

Jan, for her support and understanding.



















TABLE OF CONTENTS


ACKNOWLEDGMENTS . . . . . . . . . . . .

ABSTRACT . . . . . . . . . . . . . .


CHAPTER I INTRODUCTION . . . . . . .
Suicide in the United States . . . . .
Toward an Understanding of Suicide . . . .
Attempted Suicide . . . . . . . .
Intention-to-Die . . . . . .....
The Role of Intention-to-Die in Self-Injurious
Assessing Intention-to-Die . . . . .
The Relationship of Suicide Risk Components: A
Theoretical System . . . . . .
The Study: Purpose and Hypotheses . . .


Behaviors
. . .


Page

iii

vi

1
1
6
13
20
20
23

26
29


CHAPTER II METHODS . . . .
The Population. . . . .
The Sample . . . . .
Assessing Intention-to-Die . .
Revision of the Probability of
Reliability . . . .
Probability of Dying . . .
Correlates of Intention-to-Die.
Risks and Expected Intentionality
Hypotheses Testing . . . .
Hypothesis 1 . . . . .
Hypothesis 2 . . . .
Hypothesis 3 . . . . .
Hypothesis 4 . . . . .
Hypothesis 5 . . . .
Hypothesis 6 . . . . .


. . . . . .

. . . . ..
. . . . .
Intervention Scale.
Intervention Scale.

. . . . . .
. . . . . .
. . . . . .
of Sub-populations.
. . . . . .
. . . . . .
. . . . . .
. . . . . .
. . . . . .
. . . . . .
. . . . . .


CHAPTER III RESULTS . . . . .
Intention-to-Die Matrix . . . . .
Characteristics of Self-Injurers . .
Multivariate Analyses of Intention-to-Die
Self-Injury Risk, Suicide Attempt Risk, and
Hypotheses Testing . . . . . .
Hypotnesis 1 . . . . . . .
Hypothesis 2 . . . . . . .
Hypothesis 3 . . . . . . .
Hypothesis 4 . . . . . . .
Hypothesis 5 . . . . . . .
Hypothesis 6 . . . . . . .

iv


Suicide


. . .


Risk..

. .o
. ...
,,.

.,,,.


.
.
.
.
.
.
.

.
.









Page

CHAPTER IV DISCUSSION . . . . . . . . . 64
Hypotheses Testing . . . . . . . . .. . 64
Expected Intentionality . . . . . . . . .. 65
Assessing Intention-to-Die . . . . . . . . 65
Predicting Intention-to-Die . . . . . . . . 67
Developmental Life Crises. . . . . . . . . .. 68
Suicide Prevention . . . . . . . . . . . 71
Formulating Suicide Prevention Strategies . . . .. 71
Evaluating Suicide Prevention Services. . . . . ... 74
Parasuicide . . . . . .. . ......... 75
Significance and Prospects. .. . . . . . . . 76

CHAPTER V SUMn1ARY . . . . . . . . ... ..... 79

APPENDIX A REVERSIBILITY OF METHOD SCALE. . . . . ... 80
APPENDIX B PROBABILITY OF INTERVENTION SCALE. . . . ... 81
APPENDIX C PROBABILITY OF INTERVENTION REVISED SCALE. .... . 82
APPENDIX D INTENTION-TO-DIE MATRIX. . . . . . . ... 83

REFERENCES. . . . . . . . . ... ....... 84

BIOGRAPHICAL SKETCH . . . . . . . .... .... 91














Abstract of Dissertation Presented to the Graduate Council
of the University of Florida i- Pdrtial Fulfillment of the Requirements
for the Degree of Doctor of Philosophy



SUICIDE RISK, SELF-INJURY RISK, AND EXPECTED
IHTENTIONALITY FOR A POPULATION AND ITS
COMPONENT SUB-POPULATIONS

By

Karl Eugene Wilson

June, 1976

Chairman: Richard K. McGee
Major Department: Psychology

Although a number of good studies have been able to delineate

factors associated with suicide, only recently have researchers begun

to make epidemiological investigations of self-injurious acts which did

not directly result in the death of the victim. The investigation of

factors associated with self-injurious acts, both suicides and suicide

attempts, was the major focus of this study.

A schematization which was proposed earlier by Wilson (1974) and

Freeman, Wilson, Thigpen, and McGee (1974) was applied to self-injuries

reported for a general population and component sub-populations.

Specifically, the self-injuries were rated for intention-to-die, which

is the probability of dying given a self-injury. Suicide risk, suicide

attempt risk, self-injury risk, and expected intentionality were then

ascertained. Expected intentionality is a prediction statement of the

probability of dying of an individual given a future act of self-injury

and is derived from known average levels of intention-to-die of sub-

populations.









The subject population for this study consisted of all attempted

suicides (n = 692) and suicides (n = 115) reported by police for a two

year period in a majority of municipalities of St. Louis County, Missouri

These 807 reports were analyzed and rated utilizing a revised version

of the Intention-to-Die Scales developed by Freeman et al. (1974). The

expected intentionalities associated with the cells of the Intention-

to-Die Matrix were ascertained through Stepwise Regression Analysis of

suicide death as a function of scores on the scales. Suicide attempt

risk, suicide risk, and their sum, self-injury risk, were obtained for

each sex X social-status sub-population of interest by dividing inci-

dence by sub-population size times 2 years. For the overall sample

and for each sex, multivariate analyses were utilized to determine the

relationship of a number of variables, including age, health, living

conditions, marital status, and education, to intention-to-die.

A number of hypotheses were tested. The majority of self-injurious

behaviors were found to be associated with essentially no intention-

to-die. Self-injury risk and suicide attempt risk decreased signifi-

cantly over the life span for most sub-populations while suicide risk

increased for both males and females. The hypothesis that moderate

intention-to-die self-injuries would increase in age ranges associated

with developmental life crises was rejected. Intention-to-die was

found to increase steadily as a strongly significant function of age.

Living alone was found to lower intention-to-die in older females.

Although age and sex were the strongest factors relating to

intention-to-die, other personal factors were found to make minor, but

significant, contributions to the multiple relationships, which were

multiple r = .54 for the overall population, multiple r = .43 for








females and multiple r = .56 for males. Although social-status did

not relate to intention-to-die, lower social-status for both males and

females was found to increase self-injury risk, suicide attempt risk

and suicide risk. Actuarial type tables for these risks were reported

for each sex X social-status sub-population.

This study was the first to ascertain the role of expected inten-

tionality and self-injury risk in suicide risk. Findings are discussed

in terms of evaluating suicide prevention centers, formulating suicide

prevention strategies, and in the ongoing reconceptualization evolving

in the literature of acts presently labeled as suicide attempts.














CHAPTER I


INTRODUCTION


The subject of this study is the role of the victims' intention-

to-die in self-injurious behaviors, suicide and suicide attempts, for

a general population and relevant component sub-populations.


Suicide in the United States


Suicide has been a prevalent factor in civilized cultures through-

out history (Choron, 1972). Within the United States it ranks, from

year to year, as the ninth to eleventh leading cause of death: eighth

for white males, third for the 15-24 age group, and fourth in the 25-

44 age group. Officially reported suicides in the United States now

average between 22,000 and 25,000 annually, about one percent of all

deaths. Most investigations estimate suicide to be underreported by a

factor of one fourth to one third, increasing incidence to perhaps

30,000 annually. The overall suicide rate has remained fairly stable

in this country, ranging from 10-17 per 100,000 since the beginning of

the century, and averaging approximately 11 per 100,000 in each of the

years of the last decade. However, regional differences can range from

less than 7 for Newark or Providence, to over 17 for the Tampa, San

Francisco, and Los Angeles areas. Even larger differences in rates

between nations demonstrate both the effect of culture upon suicide,

and possible differential biases in the reporting of these phenomena









(World Health Organization, 1967; Massey, 1967; United Nations, 1967).

In the Western World, men commit suicide at a higher rate than

women. For the United States a consistent ratio of 3:1, men to women,

is found, although the female rate has been steadily increasing relative

to the male rate since 1950 (Dublin, 1963; flassey, 1967). The average

age of suicides is usually found to be around 50 while rates increase

steadily with age from 6.0 for the 15-24 age group, to 20.5 for the

45-54 age group, to 23.9 for the 75-84 age group (Tuckman & Lavell,

1958). Female rates, however, peak around age 50 and decrease steadily

into old age, while white male rates increase monotonically. Non-white

suicide rates are significantly lower than rates for whites. Negro

males commit suicide at a rate similar to that of white males until

the mid-thirties and their rates decline gradually, rising again to a

smaller peak in old age. However, non-white suicide rates, especially

among young males, have been increasing dramatically (Hendin, 1969;

Massey, 1967). Marital status hes also been found to significantly

effect suicide rates: for persons over age 15 rates are 11.9 for married,

20.9 for single, 23.8 for widowed, and 39.9 for divorced persons.

These patterns are consistent over age, with the exception that being

widowed increases suicide risk dramatically in younger groups, and

becomes less of a factor with increasing age (Massey, 1967; Durkheim,

1951; MacMahon & Pugh, 1965).

MacMahon, Johnson and Pugh (1963) found striking parallels between

suicide rates for white males in the United States and level of unem-

ployment, especially among 45-55 year olds. Sociological studies from

Durkheim's classic study of 1897 (1951) have concentrated upon

additional factors in differential suicide rates that include








occupation, socioeconomic status, and religion (Farberow, Shneidman,

and Neuringer, 1966). For example, Kennedy, Kreitman, and Ovenstone

(1974) found both suicice and "parasuicide" (i.e., suicide attempt)

rates to be highest in impoverished, socially disorganized slum areas.

Maris found that, for males, ". . the social-status hierarchy is

inversely related to the suicide rate" (1967, p. 249). He utilized

occupational-status as an indicator of social-status in one analysis,

and also utilized an index of socice:coomic tatuss based on occupation,

income, and educational level. Breed (1963, 1967) found decreasing

income and downward occupational mobility to be associated with in-

creased suicide risk. Loss of position, especially among men; loss

of another person, especially among women; and loss of mutuality, the

weakening of mutual social relationships over time, have all been found

to contribute to increased suicide risk (Creed, 1967, 1966). Humphry

(1974) reports that loss of social roles increases vulnerability to

suicide. In the case histories of 160 suicides he found prevalent

patterns of role-disturbances from childhood, through chaotic marriages,

to later loss of occupational roles.

Broken homes in childhood, loss or prolonged absence of at least

one parent before age 15, increase both the probability of suicide

attempts and suicide (Stengel & Cook, 1958; Batchelor & Napier, 1953/54;

Dorpat, Jackson, and Ripley, 1965). Loss of some kind is strongly

associated with suicide. Dorpat and Ripley (1960) and Murphy and

Robins (1968) found 27 and 26 percent respectively of suicides in a

consecutive series had suffered a recent loss of a love object. These

studies als) report 49 and 43 51 percent, respectively, to have a

medical or surgical illness. Murphy and Robins caution, however, that








base rates for these phenomena have to be taken into account: They note

that Burnight found 64 percent of a ". . random sample of noninstitu-

tionalized married white urban men aged 60-64 years (among the highest

suicide risk sub-population) reported the presence of one or more

chronic medical and/or surgical conditions" (Murphy & Robins, 1967,

p. 306).

Many psychological studies of suicide utilize case histories of

patients who subsequently commit suicide. Farberow, Shneidman, and

Neuringer describe patients who later commit suicide as exhibiting a

"characteristic pattern . the 'dependent-dissatisfied' person . ."

(1966, p. 42). These patients are more complaining, demanding, in-

sisting, controlling, inflexible, and unadapting. They would turn to

the staff for support but proceed in alienating them with insatiable

demands for special attention. Continual strokes were needed for self

esteem, which resulted in a "bind" where increased demands would exhaust

sources of gratification, leading to an acceleration of demands, despite

their negative effect. Prior to suicide, the most frequent behavioral

manifestations were: agitation; depression; withdrawal; sleep troubles;

complaints about health; and difficulty in thinking and concentrating.

In a longitudinal study, Fawcett (1969) found four characteristics

which differentiated high from moderate and low suicidal risk patients:

"interpersonal capacity;" marital isolation; distorted communication;

and "help negation."

In studies of consecutive series of suicides in general populations,

Robins, Murphy, Wilkinson, Gassner, and Kayes (1959b) found 21.6 percent

and Dorpat and Ripley (1960) found 33.3 had made a prior suicide attempt.

Studies with more bias in the selection of the sample report up to 62.5









percent prior suicide attempts in suicides (Dorpat & Ripley, 1967).

Most suicides have communicated their intent to kill themselves

(Dorpat & Ripley, 1962). Robins, Gassner, Kayes, Wilkinson, and Murphy

(1959a) found over two-thirds had made some, usually several, attempts

to communicate their concerns with death or suicide, usually for the

first time, recently, directly, and to more than one other person.

One-fifth of these were to physicians, although a higher percentage,

half of the suicides, had seen a physician within the previous year,

a frequent finding in the literature (Motto, 1958; Murphy, 1972; Robins

et al., 1959b; Dorpat & Ripley, 1960; McCarthy and Walsh, 1966).

The most frequently found psychiatric diagnosis in suicide is a

depressive illness, usually affective psychosis. Dorpat and Ripley

(1960) found 30 percent while Murphy and Robins (1968) found 45 percent

of suicides in this category. Both of these studies report a fourth

of the suicides as chronic alcoholics. Psychiatric disorders that

rarely occurred, and distinguished suicides from suicide attempters,

were sociopathy and hysteria. Within a patient population, Pokorny

(1960) found 26.5 percent of suicides to be schizophrenics. Farberow,

Shneidman and Neuringer (1966) had similar findings, but a difficulty

again occurs with base rates. Both patient populations were from V.A.

hospitals, where a high proportion of psychiatric patients are labeled

as schizophrenics.

Although depression has been found to be a prevalent factor in

suicide, most studies have imposed diagnoses retroactively. Some

studies have retrospectively diagnosed as many as 94 percent of

suicides as psychiatrically ill (Robins et al., 1959b), but are

methodologically weakened through the absence of psychiatric postmortem








of a control group. Patients diagnosed as manic-depressive are at great

suicidal risk, however, as most studies find that 15 percent will

eventually suicide (Diggory, 1967).

In summary, suicidal factors, although isolated in most studies,

work together to form patterns of suicide risk. For example, a fairly

typical suicide would involve a number of the following characteristics:

white male over 40 years of age; retired, unemployed or suffering

recent job troubles; living alone; divorced; having a history of

suicide attempts; somatic complaints; alcoholism, where the drinking

recently has become more uncontrolled; and, a recent loss or threat

of loss of a close relationship (Murphy, 1969). The picture isn't

completely clear, however, as young people and women also kill them-

selves and the majority of people with even the most suicidogenic

characteristics will go on living, and eventually die of other causes.


Toward an Understanding of Suicide


Until recently suicide attempters have been viewed as failed, or

bungled, suicides. In other words, attempters were viewed as belonging

to the same, or at least a similar, population as completed suicides.

While sociologists and anthropologists concerned themselves almost

exclusively with incidence and characteristics of suicides, psychologists

and psychiatrists were presented with methodological difficulties in

garnering generalizable information concerning the motives, dynamics,

and personality characteristics of suicides. Several approaches evolved,

including: retrospective psychiatric diagnoses of consecutive series

of suicides through perusal of public and medical records and interviews

with families (Robins et al., 1959b); the "method of residuals," the








study of notes and other clues which are left by approximately a third

of suicides (Shneidman & Farberow, 1957a); longitudinal follow up of

highly selected, at risk, psychiatrically hospitalized populations

(Farberow, Shneidman, and Neuringer, 1966); and psychological studies

of people who have attempted suicide and survived or who have threatened

suicide (Freud, 1925; Menninger, 1938; Stengel & Cook, 1958; Shneidman,

1963). The difficulty with the retrospective diagnostic approach is

one of base rates and the use of retrospective data. The difficulty

with longitudinal studies of selected populations or with the "method

of residuals" is in generalizing from what is known about a biased

population to all suicides. The difficulty with the last approach is

within the assumption that suicide attempters, threateners, and com-

pleters are interchangeable in characteristics (Neuringer, 1962).

Following the conceptual lead of Stengel (1952), more recent studies

have begun to find that suicide attempters and completers represent

two different, but overlapping populations (Dorpat & Ripley, 1967).

Sociological and psychological factors can be shown to covary

with suicide rates. However, they serve only as correlates of, rather

than explanations of the phenomena. Although an increase in unemploy-

ment is associated with increases in white male suicides, the vast

majority of the unemployed will not commit suicide. What does unemploy-

ment, or any other correlate of suicide, entail that it should raise

suicide rates? Or, why should increased unemployment lower a group's

collective immunity to this behavior, leaving a small but significant

minority vulnerable?

Freud (1925) outlined the dynamics of depressive suicide as the

turning inward of sadistic impulses, where the ego perceives itself as









deserted by the superego and permits its own demise. Suicide is seen

as an outcome of a strong ambivalent dependence on a sadistic superego

and the necessity of ridding oneself of an unbearable guilt tension at

any cost. Jackson (1957) sees motivational theories of suicide as

stressing suicide as a symptomatic act, and not a discrete entity,

which is motivated by either: self-directed aggression (thanatos); re-

birth and restitution, the doing away of the "bad me" to permit a new

beginning; or, loss and despair, loss of self esteem or a real or

imagined love object, or loss of health, prestige, or resources.

Menninger (1938) expanded on Freud and his postulation of a "death

instinct," or "thanatos." He proposes a triad of lethal wishes: to

kill; to be killed; and to die.

"Psychologists refer to social factors in their theoretical for-

mulations of the causation of suicide" (Farberow, Shneidman, and Neu-

ringer, 1966, 32). Economic, religious or political conflicts, de-

pressions in reaction to the loss of status, blows to the self-concept,

and dependency frustration in reaction to loss of a love object are

all seen as interactive factors in the dynamics of suicide. For

example, Jackson (1957) describes a typical suicide scenario advanced

by Davison: The victim, having reached the limit of his resources

(following a crisis situation) loses sight of his life goals. The

immediate situation acts as a "dominant" which restricts the field

of consciousness, resulting in an inattention to life and depression.

Higher brain centers are unable to comply with and control incoming

impulses to choose an action. The victim, losing perspective of his

problems, gives way to imagination, and loses the normal ability to

inhibit unhealthy impulses, resulting in suicide.








Neuringer (1964) and Neuringer and Lettieri (1971) stressed the

role of cognition in suicide. They found high risk groups to be

distinguished by rigid (i.e., simplistic and dogmatic) cognitive styles.

Life would have to be categorized as black or white, with greater and

greater discrepancy between extremes.

Shneidman and Farberow (1957) coined the term "catalogic" to

describe the fallacious thinking patterns in most suicides, especially

mistaking or fallaciously interchanging non-equivalent concepts. For

example, they outline two different concepts subsumed by the word "I":

I-self, or our conception of ourselves; and I-other, or our c ;'ceptions

of other persons' perceptions of ourselves. Through the study of

suicide notes they found a high incidence of concern on the part of

the victim with the I-other; of getting even with other people, etc.,

as if the I-self would be around to see these reactions: "They'll

feel different about me then."

Common to most theories of the causes of suicide is the inability

of the victim to cope with some perceived personal failure and to make

necessary decisions to resolve a crisis (Farberow, 1967). The crisis

can result in suicide as a function of sociological, interpersonal,

intrapersonal, and/or developmental factors. For example, one's in-

ability to solve an interpersonal crisis, such as threatened loss of

a love object, can be aggravated by the poor resolution of what

Erikson (1950) describes as a developmental life crisis. Of concern

to the study of suicide are: the "identity versus role confusion"

crisis of adolescence; the crisis of "intimacy versus isolation"

within the young adult; the crisis of "generativity versus stagnation"

of the young adult, and the crisis of "ego integrity versus despair"








of middle age and maturity. Specifically, the young adult, the middle

aged person and the older person face the life paradox of giving some-

thing up in order to get something of much greater value: the chance

to continue to grow, accommodate to life, and receive life's bounties.

Those who fail at these tasks are particularly vulnerable to other

factors, interpersonal and sociological, which correlate with suicide.

In these crises, what is given up are the old cognitions and accommo-

dative patterns. The cost of not rescinding them is increased vul-

nerability to failure of adaptation and, possibly, the final regression

from reality, suicide.

However, most investigators do not see suicide as a uni-dimensional

concept or discrete psychologic entity, but as a number of different

syndromes under one rubric. A number of different schemes for

categorizing suicide have appeared, beginning with Durkheim's

schematization of 1897 (1951). Durkheim classified suicides as a

function of sociological factors: "egoistic suicide," where the

individual is not sufficiently integrated into his society; "altruistic

suicide," where overintegration of the individual with society leads

to the individual's self-sacrifice, as with kamikaze pilots; "anomic

suicide," where the individual's adjustment to society is suddenly

disrupted (e.g., through a loss of wealth) combined with a lack of

sympathetic acceptance of the individual by his social group; and

"fatalistic suicide" as a reaction to oppressive authoritarian con-

straints.

Shneidman and Farberow (1957) list: "surcease suicides," where

the individual is making a rational choice to escape pain and no

reasonable future can be anticipated; "catalogic suicides," which have









already been discussed and which make up the majority of suicides;

"cultural suicide," which is similar to Durkheim's classification of

altruistic suicides; and "schizophrenic suicide," where the victim

utilizes "paleologic," making identifications in terms of predicates

rather than subjects, which may result in the cutting out of the "bad

me," although no intention-to-die exists.

Neuringer (1962), in reviewing classification schemes, found the

following different categories of suicidal acts: 1) intentional suicide,

which includes altruistic and surcease suicides, and Camus' classifica-

tion of "existential suicide," for reasons of the basic absurdity of

life; 2) psychotic suicide; 3) automatization suicide, where the victim

is a habitual abuser of sedatives and alcohol, and ingests one sedative

after another in order to reach an unobtainable desired effect, which

results in an accidental death; 4) accidental suicide, especially in

cases of "contra-intentional" attempts where the intention is not to

die, but to elicit a response from some significant other, and the

victim accidentally dies; 5) manipulative suicidal act, or a suicide

attempt where the motivation is a warning or plea, a "cry for help;"

6-9) chronic, neglect, probability, or self-destructive suicides, which

involve killing oneself slowly or increasing the probability of death

occurring early, as is more or less the case with smokers, drug-addicts,

race-drivers, or overeaters; 10) suicidal threats; 11) suicidal thinking,

and 12) test suicide, or persons giving suicidal or depressive responses

on psychological tests.

Shneidman notes the semantic confusion in the field and notes that

present concepts of death and suicide are too ambiguous to be either

scientifically or clinically useful. He defines suicide as ". . the








human act of self-inflicted, self-intentioned cessation." Further,

intention is defined as: ". . the role of the victim in his own

demise" (1969, p. 225). Only category 1 of those categories of suicidal

acts Neuringer found can clearly fit this definition. Category 2 is

also traditionally included as suicide in the literature, while

categories 3 and 4 are usually considered accidental deaths, categories

6-9 are considered self-destructive life styles rather than suicide,

and category 5 is considered a suicide attempt.

Stengel defined a suicide attempt as: ". . any non-fatal act of

self-damage inflicted with self-destructive intention, however vague

and ambiguous. Sometimes this intention has to be inferred from the

individual's behavior" (1968, p. 172). He justifies this usage, even

when there is no risk of death, because, from the victim's point of

view, ". . those attempts are risk-taking acts whose outcome is

uncertain" (1968, p. 173). He also justifies this usage from the

standpoint of the victim's higher future suicidal risk: ". . People

who tend to react to stressful situations with suicidal gestures are

more likely sooner or later to commit suicidal acts than people who

make no such gestures" (1968, p. 173). This view stems from an

assumption that suicides and suicide attempts are part of some continuum

of behaviors. Stengel (1960) had noted earlier that human behavior

usually is a function of multiple motivations, and both suicides and

suicide attempts are a mixture of many motives, including wanting to

live and not live.

Many investigators agree that: ". .. even the suicide gesture

should be considered a 'cry for help' which, if ignored, may later

lead to more serious and lethal self-destructive behavior" (Dorpat &








Ripley, 1967, p. 77). Freeman, Wilson, Thigpen, and McGee (1974) argue

that the use of the terms suicide gesture or suicide attempt in cases

of low probability of dying, is inaccurate, pejorative, and leads

treatment staff at hospitals and essential gatekeeper intervenors,

such as police, to deal with the victim in non-facilitative ways. They

cite studies of the negative attitudes and sometimes open hostility

of these essential caregivers toward low-intentioned suicide attempts.

They propose the use of the term "self-injurious behaviors" for both

suicide attempts and suicide. Similarly, Kessel and McCulloch (1966)

had utilized the terms "deliberate self-poisoning" and "deliberate

self-injury."

Kennedy, Kreitman, and Ovenstone (1974) suggest that omission of

the reference to the term suicide neglects the very real association

between attempted and completed suicide. They propose the term

"parasuicide" while Choron (1972) proposes "protosuicide." As a sub-

stitute for the term suicide gesture, where there is no intention-to-

die, Lennard-Jones and Asher (1959) propose the term "pseudo-suicide."

Kessel and Lee (1962) and Clendenin and Murphy (1971) utilize opera-

tional definitions for their studies. For the purposes of consistency,

this study will utilize the term suicide attempt as it has evolved

in the literature and as defined earlier by Stengel (1968). However,

implications of the empirical findings of this study will be discussed

in terms of a classificatory schematization of self-injurious behaviors,

acts presently labeled as suicides and suicide attempts.


Attempted Suicide


"Compared with groups that commit suicide, those who attempt








suicide are younger, use less lethal methods, include more women than

men, and more often include impulsive self-destructive behavior per-

formed in the presence of other people" (Dorpat & Ripley, 1967, p. 74;

Dorpat & Boswell, 1963). Although Dublin (1963) advances the notion

that women outnumber men in suicide attempts by 3:1, a lower ratio has

been found in most studies which utilize other than populations

selected towards particular sub-populations. Women usually are found

to outnumber mcn by ratios of from 2.1:1 to 2.5:1 (Shneidman & Farberow,

1961; Dorpat & Boswell, 1963; Edwards & Whitlock, 1968; Murphy, Clendenin,

Darvish, and Robins, 1971). In other woros, about two-thirds of suicides

are men while over two-thirds of attempters are found to be women. The

majority of suicide attempters are women under 40 (Hopkins, 1937;

Ettlinger & Flordh, 1955; Dahlgren, 1955; Gold, 1965; Sclare & Hamilton,

1963; Whitlock & Schapira, 1967). Non-white women have a high incidence

of suicide attempts in the United States (Davis, 1967). Dorpat and

Boswell (1963) found the average age of their Seattle sample of

attempters to be 35.1 years while 51.3 was the average age of completed

suicides. For Los Angeles, Shneidman and Farberow (1961) found modal

age of suicides to be 42, with age of attempters peaking at 32 for

males and 27 for females. Depressive and alcoholic psychiatric

diagnoses are represented frequently among suicide attempters, but the

high frequency diagnoses, which appear less often among completed

suicides, include hysteria, sociopathy, or character disorder, and

anxiety neurosis (Robins et al., 1959b). Suicide notes are left less

often by attempters than suicides, especially in low lethality attempts

labeled "gestures" (Dorpat & Boswell, 1963).

Tuckman, Youngman, and Bleiberg (1962) found a higher rate of









attempts in health districts of Philadelphia characterized by poor

housing, low income, high morbidity, and delinquency; factors associated

with social disorganization. They found interpersonal motives given

by over half while the most frequent reason given was disturbed family

relations. Shneidman and Farberow (1961) found marital difficulties

and depression given as reasons for both sexes with financial and

employment difficulties added for men. Ill health was given as a

reason less frequently than it was among suicides. Psychodynamic

studies reveal a higher proportion of "auto-plastic," or inner directed

motives in suicides, with more "alloplastic" motives in suicide

attempters ". . involving an appeal for help and efforts to manipulate

others in order to be rescued from their suffering" (Dorpat & Ripley,

1967, p. 74). Maris (1969) compared suicides and suicide attempters

in New Hampshire and found attempters were most frequently young females

who were divorced or separated, had problems with work, changed jobs

frequently, were not very successful and accomplished few life goals.

They were more likely to be from broken homes and were characterized as

more dependent personalities. They were more socially involved than

the suicides who were characterized as more often being socially

isolated, independent, held jobs longer, had accomplished more life

goals and were regarded by others as more successful.

In a study which matched hospitalized female suicide attempters

with depressed patients, Weissman, Fox, and Kerman (1973) found the

attempters were distinguished by manifest hostility, pervasive and

overly hostile relationships, poor long term work history, antisocial

behavior, and were demanding and hostile during the interview.








Lukianowicz (1973) studied a similar population of female attempters

and found that, with the exception of the psychotic and psychopathic,

they were "goal" and "gain" directed and the attempts were aimed at

changing the environment to the attempter's benefit. He found a

dramatic increase in suicide attempts in the last decade, as did

Weissman (1974) who reports hospital admissions for attempted suicide

rising, especially among youth. She speculates on a delayed increase

in suicide rates as this group increases in age.

Dorpat and Ripley (1967) reviewed 15 follow-up studies of suicide

attempters which report incidence of suicide and found that suicide

risk is highest in the first two years following an attempt. They

estimate the incidence of suicide among suicide attempters to be 10 to

20 percent. Tuckman and Youngman (1963a; 1963b) followed 1112

attempters for one year and found suicide rate to be 140 times the rate

of the general population for this period. Later follow up revealed

two percent suicide the first year and one percent the second year

following the suicide attempt (Tuckman and Youngman, 1968). Motto

(1965) estimated eventual suicide among attempters to be 80 to 100

times the rate of the general population. Therefore, although

differences can be shown when comparing suicide and suicide attempt

populations, it is important to any strategy of suicide prevention to

understand the overlap, or similarities in suicide and suicide attempt,

and to differentiate levels of risk among suicide attempters (Segal &

Humphry, 1970). Tuckman and Youngman (1963a) found that suicide rates

(per 1000) for attempters in the year following the attempt was a

compound function of three demographic characteristics: age, sex, and

race. Characteristics associated with higher suicide risk were: being








white, male, and/or over the age of 45 years. Those with none of these

characteristics had a 0.0 rate of suicide; those with one characteristic

had a rate of 8.55; those with two characteristics had a rate of 16.21;

and those with all three had a 44.12 suicide rate. The rate of the

general population was 0.14 per 1000 people. They conclude: ".

among the attempted suicides the more closely individuals approximate

completed suicides with respect to sex, race, or age, the higher their

suicide risk. The data also suggest that risk is accentuated by the

compounding or cumulative effect of the three characteristics" (1963a,

p. 587). In a follow-up study they found fourteen factors which were

combined into a scale. A cut-off score of four yielded two groups with

suicide rates of 0 and 35.20 per 1,000 population. The two most

differentiating characteristics besides sex and age were living

arrangements and method employed in the attempt (Tuckman and Youngman,

1958a and 1968b).

The incidence of suicide is a matter of public record; but the

incidence and prevalence of attempted suicide is difficult to ascertain.

Most studies of suicide attempters have utilized selective samples,

such as a consecutive series of medically treated attempters in a single

private hospital. One indication of the proportion of the population

of suicide attempters such a sample obtains is to take the ratio of

the sample to the number of suicides from the general population for

the same period. In the literature, estimates have been made of the

"true" ratio as being anywhere from 5:1 to 15:1 (Ruegseggar, 1963),

with most estimates around 10:1. Utilizing such estimates, prevalence

of suicide attempts is extrapolated by Dublin (1963) as being about

one percent. Stengel (1968) estimated the number of attempts in the








United States annually as up to 166,000 by 120,000 people, with per-

haps 2 million people having attempted suicide at some time in their

lives. Mintz (1970) estimated a prevalence as high as 2 1/2 percent,

or 5 million. Mintz bases his estimates on survey data from Los Angeles.

Other population sample survey studies have found high rates of claimed

suicide attempts, but too small absolute numbers to make generalizations

(Paykel, Myers, and Lindenthal, 1971; Schwab, Worheit, and Holzer, 1972).

Schwab et al. found approximately 12:1, suicide attempts to suicides,

in a sample survey of one Florida county. However, this is based on

only 10 positive responses in his sample of 1645 people. They found

2.7 percent claimed to have made an attempt sometime during their

lives, a prevalence similar to that which Mintz (1970) reports.

Locating suicide attempts is more difficult than determining

incidence through surveys, however. The first major effort to locate

all suicide attempts in one area over a period of time was made by

Shneidman and Farberow (1961). They obtained all public hospital

emergency room medical records for one year and also sent question-

naires to all physicians and osteopaths in Los Angeles County. From

their responses it was determined that approximately 5906 suicide

attempts had taken place in this community of 5 million,-where 768

suicides had occurred. This yields a ratio of 7.7:1, suicide attempts

for each completed suicide for this population. However, the total

number of attempts for which they had sufficient information to make

generalizations was 2652, yielding a ratio of 3.3:1. Parkin and

Stengel (1965) used all hospital admissions, both private and public,

and reports from general practitioners to find 820 attempts in two

years in Sheffield, England, a population of approximately half a








million. During the same period 86 suicides occurred, for a ratio of

9.5:1. However, 639 attempts had sufficient information for study, a

ratio to suicides of 7.4:1, the highest reported in the literature.

Both of the above studies concluded that the true ratio would be

higher by an unknown factor if attempts that did not come to medical

attention could be included. Other studies which utilized hospital

admissions include Gold who reports a ratio of 3.7:1 (1965) and Edwards

and Whitlock who found a ratio of 4.2:1 (1968). One study (Bergstrand

and Otto, 1962) of a sub-population of attempters found a ratio of

16:1 among adolescents. However, adolescents are known to have a

higher incidence of attempts to committed suicides than the general

population (Jacobziner, 1965).

Murphy et al., (1971; Clendenin & Murphy, 1971) took a different

strategy in compiling information on suicide attempts in a general

population. They devised a standardized police report form for suicides

and suicide attempts which was utilized in St. Louis County. For the

year 1968 they report 336 attempts and 58 suicides, a ratio of 5.8:1.

A similar ratio was found by Freeman et al. (1974) for a smaller county

in Florida over a 30 month period utilizing police reports and records

of the Suicide and Crisis Intervention Service. Tuckman, Youngman, and

Bleiberg (1962) found information for 1251 suicide attempts in Phila-

delphia, a ratio of 3.2:1, utilizing police reports. This is also the

only study which reports suicide attempt rates. The total population

of attempters was broken down by sex and race and suicide attempt rates

given per 100,000 population. These decreased as age increased for all

groups, and in a steep monotonic gradient for all but white males.









Intention-to-Die

The Role of Intention-to-Die in Self-Injurious Behaviors

From the above literature review one can conclude that suicide

and attempted suicides come from two separate, but overlapping, popu-

lations (Wilkins, 1967; Stengel, 1964; Freeman et al., 1974). Within

each category, researchers have attempted to further differentiate

these behaviors (Stengel & Cook, 1958; Herdin, 1950). The concept of

suicide attempt can lead to confusion when it is applied to widely

discrepant behaviors. For example, both of the following hypothetical

cases are presently labeled as suicide attempts: a case where the vic-

tim ingested ten aspirin in the presence of their spouse; and, a case

where the victim drove to an isolated spot in the country, severely

wounded himself in the chest with a firearm, and was subsequently

rescued through the chance intervention of a passing hunter. McGee

and Hegert (1966) underscore this conceptual confusion and conclude:

It is evident . that suicide is not a
dichotomous behavior by which the participants
in the act can be meaningfully separated into
categories denoting whether or not they actually
expired . It is important to note that the
populations of people who participate in various
types of suicidal behavior are in fact different
populations, which are graduated along a continuum.
Even within the total group that expires, there
are still degrees of 'suicidality' based upon
method of injury, and on demographic variables
of age and sex (1966, p. 9).

Stengel (1968) utilizes the concept of suicidal intent in evalua-

ting these behaviors. He concludes that many suicide attempts have no

intent-to-die and many have ambiguous motivation:

Many suicidal attempts and quite a few suicides
are committed in the mood of 'I don't care whether









I live or die,' rather than with a definite and
unambiguous determination to end life. Most
people, in committing a suicidal act, are just
as ambivalent and muddled as they are whenever
they do anything of importance under emotional
stress. This is why many people who honestly
deny that they really wanted to kill themselves
admit that they did not care whether they lived
(1968, p. 172).

Stengel further delineates factors which determine whether a

suicide attempt becomes a suicide: chance factors due to intervention

or the breakdown of the plan; the method employed; and the "social

constellation" at the time of the attempt. This uncertainty of outcome

is labeled the "gamble with life" resulting from the multiple, and

many times contradictory, motivations of the victim. Stengel labels

this ambivalence the "double vector" in suicide attempts (1968).

Shneidman and Farberow (1961) distinguish between: those who really

want to die; those who leave survival to chance; and those who definitely

expect to be saved. They were able to classify the attempters in their

study as being almost equally divided among the three groups. Shneidman

(1968) labels these three orientations towards one's own death as:

intentioned; subintentioned; and contraintentioned or unintentioned.

In relation to suicidal or self-injurious behavior, Freeman et al.

postulate that:

. Persons who make self-inflicted injuries do
so within a set of specially contrived circumstances
which they have deliberately -- perhaps not
consciously -- created for the purpose of either
providing for, permitting, or preventing their
own rescue. Thus, persons who provide for their
own rescue have low intentionality, those who
permit a rescue have moderate intentionality,
and those who seek to prevent a rescue may be
seen as having high intentionality (1974, p. 23).

Tuckman and his associates (Tuckman and Lavell, 1958; Tuckman and

Youngman, 1963a; 1968a; 1968b) have found that the self-report of the








attempter as to his or her intent-to-die is actually related negatively,

albeit weakly, to suicide risk. In other words, the investigator into

suicide attempts cannot rely on the self-report of the victim to

differentiate attempters in any meaningful way.

An alternative strategy is to utilize judged seriousness of the

attempt in order to categorize attempts. Dorpat and Boswell (1963)

developed a five-point rating scale to evaluate the seriousness of the

attempt. Ratings of "1" represented a suicide "gesture," "3" an

ambivalent suicide attempt, and "5" a serious suicide attempt. "Suicide

gesture was defined as behavior indicating a pretense of suicide in

which there was no intent-to-die" (1963, p. 117). They utilized both

the statements of the patient and an evaluation of the method in their

judgments and found 20 percent suicide gestures, 60 percent ambivalent

attempts and 20 percent serious attempts. When these groups and a group

of suicides were compared, the average age and the sex ratio of male:

female increased monotonically with increased seriousness. The "gesture"

group was described in relation to the serious group as containing fewer

isolated individuals, demonstrating less premeditation, and as being

with someone much more often at the time of the attempt:

In the gesture group the action was directed
almost entirely at effecting some change in
others. More serious self-destructive motiva-
tion was observed in the ambivalent group whose
action was meant to bring not only suffering
to the patient but rescue and help from others
. a kind of gamble with death . The
serious suicide attempt and completed suicide
groups showed little concern about rescue or
directing change in others (1963, p. 123).

This, and further studies (Dorpat & Ripley, 1967), led Lester (1970)

to his succinct conclusion that suicidal behaviors fall on a continuum

of seriousness and that extrapolations can be made on the basis of this

continuum.









Weisman (1970) and Weisman and Worden (1972) developed a procedure

for assessing the "lethality of implementation" in a suicide attempt

which is a function of two ratings: the degree of self-inflicted damage,

or "risk;" and the resources for "rescue" in the environment. Ratings

of these two dimensions were utilized in an arbitrary formula of risk-

rescue scores which ranged from 17 to 83. This total score is seen as

a representation of the continuum of lethality possible in suicide

attempts.

Weisman proposes that any suicidal event, a self-injury regardless

of whether the result is death, is composed of 1) ideation, 2) imple-

mentation, and 3) intervention.

Implementation refers to more than just the
instrument or agent that a suicidal patient
uses . We should be able to recognize the
options open to him, his style of communication
with others, and his available and accessible
rescuers within the inner sphere of his rela-
tionships . Consequently, the edge of life
and death that a person inserts in his suicide
attempt should express a singular relation
between the risk of death and the potential
rescue operations (1970, p. 17).

Assessing Intention-to-Die

Freeman et al. (1974) developed a scale designed to assess the

intention-to-die of the person in a suicide or suicide attempt. Their

assumption, which was discussed earlier, was that the victim chooses

the circumstances surrounding the event in order to provide for, permit,

or prevent his own rescue. "The specially contrived circumstances

which are of interest in making this assessment are: 1) the reversibility

of the method of self-destruction, and 2) the . probability of

intervention by others in the victim's environment" (1974, p. 23).









Intention-to-die, then, is advanced as the continuum upon which

self-destructive acts fall which is necessary for any understanding of

these events. Although seriousness of the attempt is a correlate of

intention-to-die, intention-to-die involves the state of the individual

immediately prior to the act and is inferred directly from behaviors

on the part of the victim over which the victim has some control. These

are rated on two separate scales, the Reversibility of Method Scale

(Appendix A) and the Probability of Intervention Scale (Appendix B),

which are each ". . 5-point ordinal scales designed to accommodate

and represent the circumstances surrounding an individual's suicide

attempt" (1974, p. 25). The Reversibility of Method Scale measures the

probability of stopping, or reversing, the action once set into motion.

An example of a method of "complete" reversibility is the ingestion of

small amounts of commercial drugs, while an example of a method of

"remote" probability of reversibility is a self-inflicted gunshot

wound to a vital area. Intermediate ranges include "probable,"

"questionable," and "improbable" reversibility. Both the method and

the degree to which it is employed are accounted for in the scale. The

Probability of Intervention Scale takes into account the degree to

which the ". .. victim can expect someone to become aware of the

event, to recognize it as an attempt, and to intercede . ." (1974,

p. 26), and is a function of the proximity and expected proximity of

other people. An example of a rating of "certain" intervention is

when the act is committed in the presence of one's spouse, while an

example of "remote" chance of intervention is when the victim makes

his attempt in an isolated, non-populated area where communication

with the rest of the world would be difficult. Intermediate ranges








include "probable," "ambiguous chance of,' and "improbable" intervention.

These two scales were combined as axes of the Intention-to-Die

Matrix (Appendix D) which is utilized in determining degree of intention-

to-die. A major contribution of the authors in this study was the

empirical validation and quantification of the concept of intention-to-

die. While Weisman and Worden (1972) arrived at an arbitrary index of

intention-to-die in order to quantify the concept, Freeman, Wilson,

Thigpen, and McGee defined intention-to-die as . the probability

that death will occur as a consequence of the circumstances in which a

self-injury event occurs" (1974, p. 39). Their sample of 243 suicide

attempts and 34 completed suicides were all rated and multivariate

analysis employed to ascertain the probability of dying, or intention-

to-die, given the ratings of the two scales. Each cell of the Intention-

to-Die Matrix was associated with a quantified index of intention-to-die,

the probability of dying given those circumstances. Low intention-to-

die was associated with cells with probability of dying approximately

0 (65 percent of the attempts and no suicides). Moderate intention-to-

die was defined for this study as between .05 and .30 probability of

dying (26 percent of the attempts and 21 percent of the suicides), while

high intention-to-die was associated with cells having greater than

.30 probability of dying (9 percent of the attempts and 79 percent of

the suicides).

All completely reversible methods were associated with .low intention-

to-die and all irreversible methods were associated with high intention-

to-die (Appendix D). In other words, at the extremes of the Reversi-

bility of Method Scale probability of intervention did not differentiate

as to overall intention-to-die. The probability of intervention score









was found to be important in differentiating levels of intention-to-die

at intermediate ranges of reversibility of method.

The Relationship of Suicide Risk Components: A Theoretical System

Wilson (1974) and Freeman et al. (1974) suggest that the intention-

to-die of self-inflicted injuries is an important variable in the

assessment of suicide risk. They suggest that an epidemiological study

of the role of intention-to-die in self-injurious acts would be an

important contribution toward developing an understanding of self-injury

and a technology of suicide prevention. They advance quantifiable con-

ceptualizations of the components of suicide risk and suggest these be

applied in epidemiological studies to ascertain incidence within sub-

populations.

Many epidemiological studies of suicide rate have been reported.

These have led to an operational definition of suicide risk (SR) as:

1. SR = frequency of suicide death for the population + chance factors
population size X time

A future event, suicide risk, is projected through the known suicide

rate. Only recently were good epidemiological studies of suicide

attempt rate accomplished. Only one, Tuckman, Youngman, and Bleiberg

(1962), goes beyond the description of incidence to utilize an opera-

tional definition for suicide attempt rate which can serve as an indica-

tor of suicide attempt risk (SAR):

2. SAR = frequency of suicide attempts for the population + chance
population size X time factors

If self-injuries are defined as any self-destructive act, then

self-injury rate can be determined by summing suicide rate and suicide

attempt rate. Therefore, self-injury risk (SIR) is the sum of suicide

risk (SR) and suicide attempt risk (SAR):









3. SIR = SR + SAR

or
frequency of self-injury behavior for the
4. SIR = population + chance factors
population size X time

Intention-to-die was previously operationally defined as the

probability of dying as the result of a self-injury. Expected

intentionality is a prediction statement of the intention-to-die of the

victim given a future act of self-injury. As suicide risk can be

ascertained through epidemiological use of appropriate data for suicide

occurrence within groups, so cculd the expected intentionality of sub-

populations of self-injurers be ascertained (Wilson, 1974). Expected

intentionality (Ex.In.) is projected directly from the average intention-

to-die found for a group, just as suicide risk is projected directly

from suicide rate. Freeman et al. (1974) propose:

frequency of suicide death for the
5. Ex.In. = population + chance factors
frequency of self-injury behavior for
the population

Expected intentionality and self-injury risk are each partial

statements, or components, of suicide risk:

6. SR = SIR X Ex.In.

By substitution:

frequency of self-injury behavior
7. SR = population size X time X

frequency of suicide death + chance factors
frequency of self-injury behavior

Solving yields:


1. SR = frequency of suicide death + chance factors
population size X time








This theoretical system has important implications both in dealing

with groups of people and in dealing with individuals. As all of its

major elements (suicide risk, self-injury risk, and expected intentionality)

are construed as probability events, it lends itself to more precise

prognostications of future behaviors based on past events. For example,

the clinician can reformulate his more general predictions of "high"

or "low" suicide risk to more precise probability statements of not

only suicide risk, but its components, self-injury risk and expected

intentionality. If the probability that a self-injury event of any

kind will take place for the individual "A" is 1 in 4 and the probability

that death will occur as a result of the occurrence of the event

(expected intentionality) is 1 in 5, then suicide risk is 0.05.

Individual "B,' with the same suicide risk of 0.05, may have very

different degrees of risk of self-injury and expected intentionality.

For example, he could have a self-injury risk of 0.10 and an expected

intentionality of 0.50. The clinician would base these predictions on

clinical and population base rates and would have a better conceptuali-

zation of the dimensions of risk associated with each individual.

Similarly, a program planner may find that different strategies

of intervention and prevention need to be employed with populations

that have been lumped together in the past as having near equivalent

suicide risks but which demonstrate very different degrees of intention-

to-die and rates of self-injury. Hypothetically, for the given locality

it may be found that middle-age Negro males and adolescent white

females have similar suicide rates. However, the former group may

have a very low self-injury rate and display a very high degree of

average intentionality, while the latter group had 100 times the








self-injury rate but with very low average intention-to-die. Given

these added dimensions, very different strategies would be called for

in any preventative programming.

The Study: Purpose and Hypotheses


Many studies have examined factors that differentiate suicide

attempters and suicides. The purpose of this study is: to assess the

levels of intention-to-die of the self-injurious acts of a general

population; to determine the expected intentionality, self-injury risk

and suicide risk for relevant component sub-populations; and to apply

multivariate analyses to assess the role of intention-to-die in self-

injurious acts as a function of demographic and personal variables.

Dorpat and Ripley recommended that: ". multivariate abstract

variance analysis methods be used to determine the patterns of attempted

suicide behavior that are related to suicide risk . (as previous)

research on attempted suicides has used only single-variable dimensions"

(1967, p. 78).

Hypotheses are derived from the cumulative suicidology literature

and through the application of the schematization of suicide risk,

self-injury risk, and expected intentionality which was reviewed and

advanced earlier.

The first hypothesis of this study is:

1) The majority of self-injurious behaviors found in a general

population will have essentially no intention-to-die associated with

these acts. Dorpat and Ripley (1967) and Shneidman and Farberow (1961)

judged intention-to-die of attempters to be distributed approximately

equally between low, moderate, and high levels. However, the only









study of quantified intention-to-die in a general population found nearly

two-thirds of attempters in their sample to have essentially no intention-

to-die associated with their attempts (Freeman et al., 1974).

2) Although suicide risk will increase with age, self-injury risk

and suicide attempt risk will both decrease as a function of age within

each sex X social-status subpopulation. Only one study has assessed

suicide attempt risk in a general population (Tuckman, Youngman, and

Bleiberg, 1962). They found that suicide attempt risk decreases with

age monotonically, with the exception of males, where the decrease is

less dramatic and less even. From the literature, self-injurious acts

contain a communicative function. This function should be especially

important in self-injurious acts of younger people.

3) Self-injurious behaviors, both suicide and suicide attempts,

which evince moderate intention-to-die will increase for each sex-age

group as a function of developmental life crises. This pattern has

not been demonstrated previously as no study has attempted to control

for the confounding factors of different types of self-injurious be-

haviors. Suicide is seen as a multi-modal concept within the literature.

However, the majority of suicides within this culture fall within

Shneidman's category of catalogical suicides, where the individual is

neither suffering from a schizophrenic state, nor is he "rationally"

committing a surcease suicide to avoid an inevitable and unrelieved

future of excruciation, nor is he committing an altruistic or cultural

suicide where the culture recognizes his suicide as an heroic and

socially beneficial act. It is hypothesized that developmental life

crises will increase the risk of suicide in an individual. High in-

tentioned self-injurious acts should more reflect all types of suicide;








moderately intentioned acts should reflect the ambivalence associated

with life crises; while low intentioned acts should most reflect inter-

personal crises and a breakdown in communication.

4) Average intention-to-die for each sex X social-status subpopu-

lation will demonstrate peaks in the under 25, and in age groups over

45. Overall increases will occur as a function of age. Related to the

third hypothesis is the effect of life crises on average intention-to-

die. Although confounding factors will obliterate some of the effects,

developmental life crises should be more reflected in changes in

average intention-to-die over the life span than in changes in suicide

rates. The cumulative effect of poor adaptation to developmental life

crises should increase average intention-to-die of self-injurious be-

haviors, with peaks immediately following the ages when they mostly

occur.

5) Subpopulations which are similar on one factor, either suicide

risk, self-injury risk, or expected intentionality, will be differen-

tiated by the other two factors as a result of the different functions

of each factor for each subpopulation. For example, it is expected

that middle-aged white males of different social-status will be found

to have similar levels of average intention-to-die, but will be

differentiated by self-injury risk, and as a result, suicide risk.

Although suicide is not taken as an option as often by middle-aged

and upper social-status white males, if they do decide to make a self-

injury it will be demonstrated by high intention-to-die, as would be

a middle-aged lower-social-status white male's, as this act serves

little communicative function for either group.

6) Living alone will increase expected intentionality, especially




32



in all but the older age ranges for each sex X social-status subpopu-

lation. Besides age, sex, and social-status, multivariate analysis

will reveal the living arrangement of the individual to be related to

suicide risk. This has been documented in the literature. However,

it will more effect intentionality than self-injury risk because of

the greater communication function of the latter.














CHAPTER II


METHODS


The subject population for this study consisted of all attempted

suicides and suicides for a two year period in a majority of the muni-

cipalities of St. Louis County, Missouri that came to the attention of

the police. "These reports include not only the cases the police are

called upon to handle but also those reported to them by hospitals"

(Clendenin & Murphy, 1971). This consecutive series of systematic

police reports were analyzed and rated utilizing a revised version of

the Intention-to-Die Scales developed by Freeman et al. (1974).

The expected intentionalities associated with each cell of the

Intention-to-Die Matrix were ascertained through Stepwise Regression

Analysis of suicide death as a function of scores on the Probability

of Intervention Revised Scale and the Reversibility of Method Scale

of all self-injury cases in the sample. Suicide attempt risk, suicide

risk, and their sum, self-injury risk, were obtained for each subpopu-

lation of interest by dividing the incidence found by the subpopulation

size times two years.

The subpopulations of interest were sex X social-status groups

over the age span. The non-white subpopulations were too small to

analyze. Expected intentionality and risk scores were derived for each

of these subpopulations for 5 year age groups over the life span. For

the overall sample and for each sex, multivariate analyses were utilized









to determine the relationship of a number of different variables to

intention-to-die. These independent variables included age, health,

living conditions, marital status, and education.


The Population


St. Louis County is comprised of nearly a hundred municipalities

and had a population of approximately 910,000 people during the period

of this study. It is an urban and suburban area of 406 square miles

which borders the three land sides of the City of St. Louis, which is

politically and administratively separate. St. Louis County has its

own commercial and governmental center and its population is diverse

in social class makeup, although it has an overrepresentation of the

upper end of the socio-economic spectrum. From the U.S. Bureau of

Census Classification of Occupational Status, 31 percent of the employ-

ment of county residents is in upper status occupations, 57 percent

middle status, and 13 percent lower status (1962, 1972). Just under

5 percent of the county is black.


The Sample


The standardized police report form was developed for the St.

Louis County Coroner's Office by Murphy et al. (1971) and adopted in

1967 for use by police in the investigation of attempted and completed

suicides. The form was designed to include social and personal items

that are known to be associated with suicide (Murphy et al., 1971).

In 1968, 408 reports, and in 1969, 459 reports, were forwarded from

the police (Clendenin & Murphy, 1971). Suicide attempts for the two

year period totaled 714 by 686 different people, while 126 completed









suicides and 25 suicide threats were reported. Two reports concerned

deaths judged as accidents by the author. Nearly all the attempters

and threateners were seen by a physician: For 1968, ". . 53 percent

(were seen) at a private hospital, 43 percent at a public hospital, and

2.3 percent at a . private office" (Murphy et al., 1971, p. 100).

These reports were earlier used in one article on the demographic

differences between wrist cutters and other attempters (Clendenin &

Murphy, 1971) and in an article describing the police report form, with

a demographic descriptive breakdown of the 336 attempters reported in

1968 (Murphy et al., 1971).

Not all municipalities in the county cooperated and consistently

reported self-injuries. Seven municipalities with a total population

of 23,210 did not adopt the standardized report form and did not report

any self-injuries during the two year period of the study. An additional

ten municipalities with a total population of 152,324 reported only

suicides, or grossly under-reported suicide attempts. Therefore, the

20 suicide attempts and eleven suicides reported from these municipalities

and two suicide attempts from the City of St. Louis were dropped from

the study.

The final sample consisted of 807 reports of self-injuries, 115

suicides and 692 suicide attempts, from a population of 738,904 for a

two year period. The ratio of reported suicide attempts to suicides

was 6.0:1. The area represented comprises 81 percent of the population

of St. Louis County and is approximately 3.7 percent black.








Intention-to-Die

Revision of the Probability of Intervention Scale


Freeman et al. (1974) noted that the Probability of Intervention

Scale contributes less than the Reversibility of Method Scale to the

variance of Intention-to-Die scores. After a sample of the reports

were rated for reliability purposes it was noted that several categories

seemed to arbitrarily combine behaviors that might be related very

differently to the probability of death given these behaviors. For

example, the third category contained cases where the victim called by

telephone to report the self-injury during or immediately following the

act, and cases where the victim was alone, but anticipated the arrival

of someone who could intervene. The former involves a more active role

in one's own rescue than the latter.

The second category contained cases where the victim was in his

own basement with the family upstairs asleep but did not initiate his

own rescue, and cases where the victim walked out of his bathroom to

announce to the family he had just attempted "suicide." These cases

demonstrate differences in the activity level of the victim which are

not reflected adequately in a scale that so heavily emphasizes actual

or potential proximity of others. Therefore, it was decided to revise

the scale to attempt to increase the variance attributable to the

probability of intervention in the self-injury.

The Probability of Intervention Revised Scale is a 6 point ordinal

scale designed to emphasize both the actual or potential proximity of

possible intervenors and the activity or passivity on the part of the

victim in mobilizing this intervention (Appendix C).









Reliability

One month of reports were picked for the reliability sample. An

additional person independently rated these 40 reports (8 suicides and

32 suicide attempts) without knowledge of the ratings of the primary

rater. Pearson correlations for agreement were obtained. For the

Reversibility of Method Scale, r = .938, while r = .898 for the

Probability of Intervention Scale, and r = .850 for the Probability

of Intervention Revised Scale. The latter two reliability scores

exceeded the r = .80 for the Probability of Intervention Scale reported

by Freeman et al. (1974). However, the revised scale demonstrated a

slight sacrifice in reliability from the original in this study.


Probability of Dying

Stepwise Regression analysis was utilized to ascertain the

probability of dying associated with each cell of the Intention-to-

Die Matrix. The occurence of death was the dependent variable while

the rating for each scale, their interaction, and quadratics were

submitted as potential independent variables. These were selected in

a stepwise fashion while overall F and F to add or delete remained

significant. The resultant regression equation was utilized to generate

values for each cell.


Correlates of Intention-to-Die


Stepwise Regression Analysis was utilized to determine the

relationship of dependent variables individually and as a group to

intention-to-die. Thirty dependent variables came directly from the

police reports and were recorded in the forms of ordinal or binary









variables. The nominal variable of marital status was reduced to three

values which each became a binary variable: single, never married;

divorced, separated, or widowed; and married, living with spouse.

Occupational-status was utilized as an indicator of social-economic-

status (i.e., social-status). This variable was derived from four

separate variables which were not independently included in the regres-

sion analysis: current occupational status; former occupational status;

current occupational status of the principal wage earner; and former

occupational status of the principal wage earner. The highest value

among these four derivative variables became the value of social-status.

Social-status could take three values: high, middle, and lower. These

were determined utilizing the U.S. Bureau of Census occupation categories

and occupational-status classification system (1962, 1972).

The Stepwise Regression analyses with intention-to-die as the

dependent variable were run for the entire population and for white

females (n = 522) and white males (n = 266). The dependent variable

list was reduced to exclude four variables with excessively small

standard deviations. These were race, where 97.6 percent of cases

were white, and three variables concerning types of police records.

Separate runs were accomplished excluding the variables of education,

occupational status, and living conditions. These variables each

had missing data which reduced the sample a total of 37 percent when

they were all included.


Risks and Expected Intentionality of Subpopulations


Subpopulations of interest were sex X social-status groups over

the age range. For each subpopulation the average (i.e., mean)








intention-to-die was determined at each age level. Suicide attempt

risk, suicide risk, and their sum, self-injury risk, were obtained

for each subpopulation of interest by dividing the incidence formed

by the subpopulation size times 2 years.


Hypotheses Testing


Hypothesis 1

The percentage of self-injurious behaviors in the sample found to

have low intention-to-die (i.e. less than .05) was determined to see

if it was a majority of cases.


Hypothesis 2

For each subpopulation the Kolmogorov-Smirnov One Sample Test was

applied to determine if self-injury risk and suicide attempt risk de-

creased significantly as a function of age for age levels over 15 years.


Hypothesis 3

Number of moderate intention-to-die self-injuries from two age

groups which should not be as typified by developmental life crises

(i.e. ages 30-34 and 35-39) were compared to the frequency among two

age groups that should more be typified by developmental life crises

(i.e. ages 20-24 and 40-44) using the X2 One-Sample Test. Moderate

intention-to-die was defined as greater than or equal to .05 and less

than .35 probability of dying.


Hypothesis 4

For each subpopulation average intention-to-die was plotted and

the curve investigated for peaks before age 25 and after age 45. The









correlation of age and intention-to-die was determined for each sex.


Hypothesis 5

Similar levels of factors which were demonstrated by different sub-

populations were noted and the groups compared on other factors. For

example, age groups among different subpopulations with similar levels

of self-injury risk were compared for average intention-to-die and

suicide risk.


Hypothesis 6

Analyses of Variance were executed for each sex to determine

whether living alone increased intention-to-die and whether any con-

tribution of living alone was significant in conjunction with the

factor of age. In addition Stepwise Regression Analyses with intention-

to-die as the independent variable and living alone and age as dependent

variables were executed for each sex.














CHAPTER III


RESULTS


Intention-to-Die Matrix


The frequencies of ratings corresponding to each cell of the

Intention-to-Die Matrix are shown separately in Figure 1 for the 115

suicide cases and the 692 suicide attempt cases. For example, cell

3-6 demonstrates that 5 suicide attempt cases and 6 suicides were

rated 3 on the Reversibility of Method Scale and 6 on the Probability

of Intervention Revised Scale. Figure 2 demonstrates the percentage

of suicides among the self-injuries in each cell. For example, for

the previously mentioned cell 3-6 there were 55 percent suicides, or

6 of 11 self-injuries.

Stepwise Regression analysis yielded a formula from the ratings

for the probability of death, or intention-to-die. Figure 3 demon-

strates the resulting intention-to-die associated with each cell of

the Intention-to-Die Matrix. Cells are grouped as to whether they

represent high, moderate, or low intention-to-die. High intention-to-

die cells are defined as those which demonstrate a probability of

death greater than or equal to .35, low intention-to-die cells demon-

strate probability less than .05, and moderate Intention-to-die cells

are greater than or equal to .05 and less than .35 probability of dying.

Over 60 percent of the self-injuries were classified as low intention-

to-die, confirming hypothesis 1. Over 47 percent of the total

41


























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of the Intention-to-Die Matrix.

























Probability of Intervention


Figure 3. Probability of dying for each cell of
the Intention-to-Die Matrix.


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self-injuries were in cells with 0 probability of dying. Only 1 suicide

was among the 490 low intention-to-die self-injuries.


Characteristics of Self-Injurers


Women made up 66.0 percent of the self-injuries: accounting for

70.4 percent of suicide attempts and 40.0 percent of suicide deaths.

Blacks, who made up 3.7 percent of the sample, accounted for only 2.3

percent of suicide attempts and 1.7 percent of suicides. Of the 65.6

percent of the sample where social-status could be determined, 32.7

percent of self-injurers were lower, 40.1 percent were middle, and

27.2 percent were upper social-status. This compares to base rates,

respectively, of 12.5, 56.8, and 30.7 percent. In other words, lower

social-status individuals have a greater probability of self-injury

than either middle or upper social-status individuals. This difference

is significant and is reported later with other results concerning

self-injury risk.

The following factors significantly differentiated suicide

attempters from suicides: being female; being younger; having some

high school, but no degree; having very acute problems; being lower

or middle social-status; and drinking at the time of the incident

(all X2 less than .025 probability). Being single approached signi-

ficance as did being employed for males, not being under recent

physician's care, and not having a recent hospitalization. These

factors non-significantly increased the likelihood of living given

a self-injury.

The simple correlations of each of the dependent variables to

intention-to-die are given in Table 1. These are ordered as to their









Table 1. Simple correlations of dependent variables and intention-to-
die for the total population and by sex.


White White
Dependent Variable Overall Male Female


Age .411** .461** .386**
Sex .301**
Single, never married -.129** -.197** -.184**
Acuteness of problem -.100** -.051 -.136**
Drinking at time -.096** -.228** -.058
Under drug therapy -.087* -.104 .005
Education level .069 .000 .079
Recency: Visit to physician .066 .070 .094*
Physician's care within month .065 .057 .120**
Married, living with spouse .064 .135* .094*
Divorced, separated, widowed .058 .063 .069
Living alone .057 .058 -.057
Social-status .057 .106 .035
Prior attempt .050 -.099 .019
Hospitalization within month .044 -.027 .081
Prior attempt or threat -.043 -.111 .040
Acute depression -.043 -.028 -.045
Recency: hospitalization .041 -.037 .103*
Police record: drunkenness -.030 -.081 -.042
Police record -.028 -.100 -.074
Recency: prior attempt -.027 -.106 .061
Recency: prior threat -.023 -.095 .040
Depression .023 .080 .017
Prior threat .022 -.090 .046
Police record: conduct -.018 -.096 -.052
Nervous condition -.006 .017 .020

**P<.025
*p<.005










magnitude for the overall sample. In addition, correlations are shown

for white males (n = 266) and white females (n = 522). Age and sex

demonstrate the greatest magnitude of correlations. Other variables

differentially relate to intention-to-die according to the sex of the

victim. The vast majority of factors demonstrate very low order re-

lationships with intention-to-die.

Multivariate Analyses of Intention-to-Die


Multiple relationships of the dependent variables with intention-

to-die were assessed utilizing a series of Stepwise Regression Analyses

for the overall population, white females, and white males. Table 2

shows the summary table of the Stepwise Regression Analysis for the

overall population. Although six variables each maintained significant

Fs to add or delete and a significant overall f6,800 = 54.92, two

variables contributed the greatest portion of the variance. Knowing

the sex and age of the victim accounts for 24.8 percent of the variance

of intention-to-die in a self-injury. The other four variables con-

tribute an additional 4.4 percent for a total of 29.17 percent explained

variance, which is the sum of r2 change. Being male, older, not

drinking at the time of the incident, not being under drug therapy, not

having a police record for a conduct offense, and having seen a physician

within a month increased probability of dying in the self-injury. The

additional contributions of other variables were insignificant. Table

1 shows a significant negative relationship for being single, never

married and degree of intention-to-die. Its relationship with other

variables, including age, make its contribution insignificant when

considered in a multiple correlation. In a separate Stepwise Regression









Table 2. Multiple correlations stepwise with
total population (n = 807).


intention-to-die for the


Dependent Variable Mult. r r2 Change


Age .411 .169
Sex .498 .079
Drinking at time .524 .026
Under drug therapy .534 .011
Police record: conduct .538 .004
Physician's care within month .540 .003



Table 3. Multiple correlations stepwise with intention-to-die for the
white males (n = 266).


Dependent Variable Mult. r r2 Change


Age .461 .212
Drinking at time .511 .049
Under drug therapy .539 .029
Recency: hospitalization .545 .007
Recency: visit to physician .559 .015



Table 4. Multiple correlations stepwise with intention-to-die for
white females (n = 522).


Dependent Variable Mult. r r2 Change


Age .386 .149
Drinking at time .399 .010
Recency: prior attempt .409 .008
Under drug therapy .414 .005
Acuteness of problem .421 .005
Police record .426 .004-









Analysis where only demographic variables were used, the three factors

of age, sex and single, never married were significant, explaining 25.22

percent of the variance, although being single and never married con-

tributed only 0.43 percent to the total.

Table 3 shows the summary table of the Stepwise Regression Analysis

for white males. Five variables each maintained significant Fs to add

or delete and a significant overall F5,260 = 23.60. The variance ex-

plained was 31.22 percent, although age accounted for over two-thirds

of this total. Being older, not drinking at the time of the incident,

not being under drug therapy, and not having been in the hospital

recently but having recently visited a physician, increased the prob-

ability of dying in the self-injury of a white male in this sample.

Table 4 shows the summary table of the Stepwise Regression Analysis

for white females. Six variables each maintained significant Fs to add

or delete and a significant overall 56,515 = 18.98. The variance ex-

plained was 18.11 percent while age alone accounted for over 82 percent

of this total. Being older, not drinking at the time of the incident,

having a more recent prior attempt, not being under drug therapy, prob-

lems being less acute, and not having a police record increased the

probability of dying in the self-injury of a white female in this

sample.

Self-Injury Risk, Suicide Attempt Risk, and Suicide Risk


Although social-status did not relate significantly to intention-

to-die overall or for either sex (Table 1), it was retained as a factor

in determining subpopulations because of its significant relationship

to self-injury risk, suicide attempt risk, and suicide risk. Table 5









Table 5. Self-injury risk (SIR), suicide attempt
suicide risk (SR), per hundred thousand
sex by social-status level.


risk (SAR), and
population for each


SIR SAR SR


Males

Overall 39.20 29.33 9.87
Upper 35.11 20.25 14.85
Middle 25.58 17.91 7.67
Lower 110.89 89.38 21.52
X2 92.83** 95.87** 10.09*


Females

Overall 68.44 62.54 5.91
Upper 60.29 52.42 7.86
Middle 50.37 48.24 2.13
Lower 170.30 155.84 14.46
X2 109.29** 97.59** 16.67**

**p<.005
*p<.025









shows the levels of these risks for males and females by social-status

level per hundred thousand population. The statistic X2 for differences

between social-status levels was significant in all cases. Actual

frequencies were used in computing this statistic, rather than the rates

shown in Table 5.

The significantly higher risks for lower social-status males and

females over either middle or upper social-status groups would be masked

if only raw frequencies were reported and subpopulation sizes were not

considered. Although lower social-status self-injury risk was demon-

strated as 3.4 times as great as that for middle social-status, more

middle social-status self-injuries occurred. However, middle social-

status individuals made up the majority of the base population, and

this base group was 4.5 times the size of the lower social-status base

group.

The other factors in determining subpopulations were sex and age.

Kolmogorov-Smirnov One Sample Tests were utilized to analyze the rela-

tionship of age with each type of risk, for age levels of 15 and over,

which are reported in Table 6. The difference between the cumulative

percentage of cases by age level was compared to the expected cumulative

percentage for each group. It was hypothesized that both self-injury

risk and suicide attempt risk would decrease over the age span for both

males and females (i.e. hypothesis 2). This is demonstrated in Table

6. However, the relationship was not significant for upper and middle

social-status males for self-injury risk, and for upper social-status

males for suicide attempt risk. In each instance, the relationship

was stronger for females, for the lower social-status, and with suicide

attempt risk. It was hypothesized from the literature (i.e. hypothesis








2) that suicide risk would increase, however. This was the case in all

instances except for upper social-status males, where suicide risk

actually decreased after middle age, but not significantly. When

analyzed by social-status groups, changes in suicide risk over age

groups were not found to be significant, partially as a function of the

smaller n of suicides.

Sex was also a significant factor in determining subpopulations.

The X2 for differences between male and female frequencies were 66.84

(p<.001) for self-injuries, 97.02 (p<.001) for suicide attempts, and

6.26 (p<.025) for suicides. Females demonstrated higher rates of

self-injuries and suicide attempts, but a lower rate of suicide.

Self-injury risk, suicide attempt risk, suicide risk, and expected

intentionality (average intention-to-die) by age level for each sex are

shown in Table 7. Self-injury risk, suicide attempt risk, and suicide

risk are expressed as rates per hundred thousand persons.

For males, expected intentionality, or probability of dying, in-

creases steadily and with increasing slope into old age. Only the 15-19

and 50-54 age ranges demonstrated slight declines over the previous age

range. For females, expected intentionality also rises steadily into

old age, but more slowly than for males. The slope increases in the

early forties. Only the 60-64 age group demonstrates a slight decline

over the previous age range. In the oldest age group, expected inten-

tionality approaches a one in three probability of dying for. females,

while it surpasses a three in four probability of dying for males.

For females, self-injury risk and suicide attempt risk are bimodal

curves with their greatest peaks in the 20-24 age range and a similar

peak in the 35-39 and 40-44 age ranges. The low point between the peaks





53



Table 6. Kolmogorov-Smirnov differences of expected and found cumulative
frequency percentages by age for self-injury risk (SIR),
suicide attempt risk (SAR), and suicide risk (SR) for each
sex by social-status level.


SIR SAR SR


Males

Overall .21** .23** .17*
Upper .14 .18 .15
Middle .10 .20* .23
Lower .23** .32** .28


Females

Overall .13** .24** .28**
Upper .22** .23** .25
Middle .28** .29** .25
Lower .24** .32** .30

**p<.05
*p<.01




















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is the 30-34 age group, with lower levels of self-injury risk and

suicide attempt risk that are not again reached until about age 50. In

other words, for both these factors there is a sharp rise into the

early twenties which declines rapidly until the middle thirties where

it rises into the forties, and then decreases sharply. These curves

continue to decrease gradually from the fifties into old age. Suicide

risk for females is very low until the early forties, where it peaks

and decreases, with a smaller peak in the late fifties. The suicide

risk peak in the early forties for females is a function of high self-

injury risk, while the suicide risk peak in the late fifties is a

function of increased expected intentionality.

For males, self-injury risk and suicide attempt risk reach a

sharp peak in the early twenties, decreases rapidly, and then more

gradually into middle age. A slight increase in self-injury risk was

demonstrated in the late forties, after which the curve again decreases.

Suicide risk increases steadily for males until it peaks in the

late forties where it plateaus into old age. Declines over the previous

age group take place in the late twenties and early fifties. For males,

suicide risk is primarily a function of high self-injury risk in the

younger age groups. The increase of expected intentionality is counter-

vailed by a similarly sloped decrease in self-injury risk, creating a

plateau in middle and older groups in suicide risk.

Social-status affected the magnitude of the curves for risk levels

over the age span for both males and females. Tables 8 and 9 show, for

males and females respectively, self-injury risk, suicide attempt risk,

and suicide risk for social-status groups by age level.

Because of the smaller frequencies within age groups when




















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social-status groups are considered, it would be misleading to utilize

Tables 8 and 9 as actuarial type tables, as Table 7 might be used.

Although some differences in pattern exist, it might be more accurate

to utilize items in Table 7 multiplied by a factor for the contribution

of social-status. This factor can be derived from Table 5. For example,

in Table 5 lower social-status male self-injury risk is 110.89 while

overall male self-injury risk is 39.20. Dividing yields a factor of

2.83. In order to estimate the self-injury risk of lower social-status

males in the 55-59 age range, the appropriate factor is applied to the

self-injury risk of males in this age range, 4.21 from Table 7, yielding

119.1 per hundred thousand. These factors appear in Table 10.

A drawback in the use of factors from Table 10 is that there are

some differences in patterns for the risk functions between age X

social-status groups. For lower social-status males, self-injury risk

is bimodal with a large peak from the twenties through the early

thirties, with a sharp decline to a nadir in the late thirties and

early forties age groups, and a rise to a smaller peak in the early

fifties. This pattern is most similar to female subpopulations, with

the exception that the nadir occurs earlier for middle and lower social-

status females. The other two male social-status subpopulations demon-

strate less clear cut patterns. Middle social-status males demonstrate

a peak of self-injury risk in the early twenties, declining to a nadir

in the late twenties and early thirties, which is followed by a smaller

peak and a saw-toothed pattern into old age. Upper social-status males

demonstrate a similar, but even less consistent pattern. The peaks in

upper social-status male self-injury risk are in the early twenties

and late forties.










Table 10. Factors for the contribution of social-status to self-injury
risk (SIR), suicide attempt risk (SAR), and suicide risk (SR)
for males and females.


SIR SAR SR


Males

Upper 0.90 0.69 1.50
Middle 0.65 0.61 0.78
Lower 2.83 3.05 2.18


Females

Upper 0.88 0.84 1.33
Middle 0.74 0.77 0.36
Lower 2.49 2.49 2.45








Hypotheses Testing

Hypothesis 1

The first hypothesis, that the majority of self-injurious behaviors

found in a general population would demonstrate no intention-to-die, was

confirmed. Low intention-to-die cells of the Intention-to-Die Matrix

in Figure 3 were those associated with less than .05 probability of

dying. Over 60 percent of self-injuries fell in those cells.


Hypothesis 2

The second hypothesis, that self-injury risk and suicide attempt

risk would decrease within each sex X social-status subpopulation

while suicide risk increased, was partially confirmed. Table 6 shows

Kolmogorov-Smirnov differences in cumulative expected from found per-

centages. Decreases over age in self-injury risk and suicide attempt

risk were significant for the overall male and female groups, and

significant for these risks for all female social-status subpopulations.

The decreases were not significant, however, for the male upper social-

status subpopulation or, for self-injury risk, for middle social-status

males. Increases in suicide risk were significant for males and females,

but not when divided into social-status subpopulations. The upper

social-status male subpopulation actually decreased, although non-

significantly, in suicide risk from middle to older age groups.


Hypothesis 3

The hypothesis that moderate intention-to-die self-injuries will

increase during developmental life crises is not confirmed. To test

this hypothesis two age groups, ages 20-24 and 40-44, were picked which









were thought to be more prone to developmental life crises, and two

groups, ages 30-34 and 35-39, were picked which should be less prone.

The One Sample X2 for the difference between frequencies within each

were 1.1 for males and 0.75 for females, both non-significant. For

males, the reverse of the hypothesis was actually found, more moderate

intention-to-die self-injuries were found among the thirties age groups.


Hypothesis 4

The fourth hypothesis was that: overall increases in average in-

tention-to-die for each sex X social-status subpopulation would increase

as a function of age; and peaks would occur in the early twenties and

late forties age groups. The first part of this hypothesis is confirmed

and the latter part is rejected.

The correlations of age to intention-to-diewere r = .41 (p<.001)

overall, r = .46 (p<.001) for males, and r = .39 (p<.001) for females.

No separate correlations were computed for social-status groups as

social-status did not turn out to be a factor which differentiated

intention-to-die for either sex. This was ascertained utilizing analyses

of variance which yielded F2,138 = 0.34 for males and F2,304 = .00 for

females (both p>.90) for the contribution of social-status to intention-

to-die, in two two-way analyses with age also a factor.

Intention-to-die for males increased steadily and increasingly

into old age. A small dip occurred in the early fifties age group,

but the curve was essentially smooth. For females, intention-to-die

increased for each age group until the late fifties. No peaks occurred

where hypothesized. Therefore, intention-to-die in self-injuries for

both males and females was shown to be highly and significantly age








related and not influenced by developmental life crises.


Hypothesis 5

The fifth hypothesis was that groups which were similar on any

one factor among self-injury risk, expected intentionality, or suicide

risk, would be differentiated by the other two factors. This hypothesis

is largely confirmed. From Table 7, males in their early forties and

females over age 65 demonstrate respective expected intentionalities

of .29 and .31. However, self-injury risk and suicide risk for the

middle-age males is over twice that of the elderly females. Males over

age 65 and females in their early forties demonstrated similar levels

of suicide risk. But self-injury risk is over 4 times as great for the

middle-age females as for the elderly males, while expected intentionality

levels are .14 for the former and .76 for the latter. Finally, females

in their late teens and males in their early twenties demonstrated

similar levels of self-injury risk. However, expected intentionalities

were, respectively, .02 and .12 while suicide risks were 9.4 and 2.9

for the two groups.


Hypothesis 6

The last hypothesis, that living alone would increase expected

intentionality, especially in all but the older age ranges, is rejected

for both males and females. For males, the correlation of intention-

to-die and living alone was non-significant, r = .06. Even this small

correlation is mostly a function of the small positive relationship of

living alone and age in males. A two-way analysis of variance yielded

a highly non-significant F1,113 = 0.001 for the contribution of living

alone to intention-to-die in males. In a Stepwise Regression Analysis,









F for living alone to be added following age was a similar F 176 =

0.152.

For females, the correlation of intention-to-die and living alone

was also non-significant, r = .057. However, because of the positive

relationship of living alone and age, the contribution of living alone

to explaining intention-to-die is significant for the multiple correla-

tion including age, F to add or delete living alone was 1,330 = 3.81

(p<.05). However, the contribution of living alone, beyond that of

age, was only 1.0 percent contribution to the variance that could be

explained (i.e. change in r squared). A two-way analysis of variance

yielded a significant E1,302 = 7.30 (p<.01) for the contribution of

living alone to intention-to-die with age and the interaction also

significant. However, the relationship of living alone and intention-

to-die was found to be the reverse of that hypothesized. It was

hypothesized that the relationship would be positive and effect younger

over older people. What was found was that living alone significantly

lowered intention-to-die in older females.














CHAPTER IV


DISCUSSION


Hypotheses Testing

The majority of self-injurious behaviors in this study were found

to be associated with essentially no intention-to-die. Self-injury risk

and suicide attempt risk were found to decrease significantly over the

life span for both males and females, and for most sex X social-status

subpopulations. Suicide risk increased significantly over the life

span for both males and females, but not when broken down into any sex

X social-status subpopulation. Expected intentionality increased

significantly over the life span for both males and females. Social-

status was not found to differentiate social-status groups for expected

intentionality.

Developmental life crises were not found to be a factor in expected

intentionality. The increases in intention-to-die were found to be a

function of its strong relationship with age. Nor did self-injuries

which evinced moderate intention-to-die increase in frequency for age

levels which were hypothesized as reflecting more developmental life

crises. Parenthetically, although no hypotheses were formulated for

these relationships, self-injury risk and suicide attempt risk both

demonstrated bimodal patterns for most sex X social-status subpopula-

tions which will be discussed later in tennis of possible developmental

life crises influences.








Living alone was not found to have the hypothesized positive rela-

tionship with expected intentionality. Rather, among elderly females,

those who lived alone, were found to have significantly lower expected

intentionality. This relationship, although significant, contributed

little to the overall explanation of the variance of expected intentionality

for females.

It was also hypothesized that populations that were similar for

either suicide risk, self-injury risk, or expected intentionality, would

be differentiated by the other factors, and this was demonstrated. This

hypothesis tested the utility of reconceptualizing suicide risk as a

function of self-injury risk and expected intentionality. If these

factors vary with some independence, then they add to the understanding

of suicide risk as a non-unitary phenomenon. For this sample, males

over age 65 and females in their early forties demonstrated similar

levels of suicide risk. But, for this age group of females, self-injury

risk was over 4 times as great as for the elderly males, while expected

intentionality was 5 times as great for the elderly males as for the

female group. This and similar comparisons between groups give the

researcher and program planner important insights into the varying

functions of self-injuries to different subpopulations. Important

differences between groups were demonstrated through this schematiza-

tion where previously the groups would be lumped together on the basis

of their similar suicide risks.


Expected Intentionality

Assessing Intention-to-Die

Freeman et al. (1974) found that about 20 percent of the variance









of intention-to-die could be explained utilizing stepwise regression

analysis. In this study the explained variance increased to over 29

percent. Over 31 percent of the variance of intention-to-die could be

accounted for in the male group, while, for the females, 18 percent was

explained.

Two factors might have increased this relationship for this study.

The first is the increased number of dependent variables and the second

might be a function of a more accurate assessment of intention-to-die.

This study utilized 26 dependent variables of which six were found to

relate significantly as a group to intention-to-die. However, age and

sex alone, with r2 of nearly .25, accounted for more total explained

variance than the total explained in Freeman et al. Having access to

data for more dependent variables than Freeman et al. added only 4.4

percent of explained variance to the total. Therefore, the increased

relationship found might be a function of increased sensitivity of the

assessment instrument. Although Freeman et al. do not report on the

correlation of intention-to-die and death for their sample, this was r

= .75 for this sample, or over 56 percent of explained variance. In

comparing the Intention-to-Die Matrices from both studies, a greater

range in scores is found in this study, especially as a function of

levels of probability of intervention. For example, from Figure 3,

intention-to-die can range from .31 to .98 as a function of probability

of intervention for self-injurers rated 5 for reversibility of method.

Freeman et al. (1974, p. 31) found a range of from .54 to .70 for these

cells, a little less than one forth of the range found for this study.

The Probability of Intervention Revised Scale therefore seems to be

more sensitive and may contribute more to overall intention-to-die than








did the original.


Predicting Intention-to-Die

The strong positive relationship of age and intention-to-die for

both sexes, especially for males, was reinforced by this study. The

personal variables that significantly increased intention-to-die for

both males and females were not drinking at the time of the incident

and not being under drug therapy. Although drinking problems are known

to increase suicide risk, the findings could indicate that self-injury

risk is increased by drinking, while expected intentionality decreases

because of the increased frequency of impulsive self-injuries. Being

under drug therapy could also increase the probability of self-injuries

taking place, through increased availability of the means. However,

drugs are usually associated with lower intention-to-die self-injuries.

A combination of these two factors, increased availability of means,

but the means usually having low-lethality, could explain the relation-

ship found.

While seeing a physician within a month increased intention-to-die

for males, being in a hospital recently had the opposite relationship.

Health problems are known to increase suicide risk, which is compatible

with the former but not the latter finding. Knowing why the individual

was in the hospital or seeing a physician could explain the apparent

discrepancy in the findings.

The pattern of relationships between intention-to-die and personal

variables, variables other than sex and age, do not lend themselves to

ready explanations. The dependent variables in this study could be

indicators of other factors which directly influence intention-to-die.

These variables could take many forms, but may be motivational. For








example, Dorpat and Ripley (1967) studied alloplastic, (i.e. other

directed) and autoplastic (i.e. inner directed) motives of self-injurers.

He found suicides as having more autoplastic motives while attempters

were more alloplastically motivated. Perhaps the relationships of the

personal variables in this study to intention-to-die could be a function

of their relationship to alloplastic or autoplastic motivation, which

was not studied. For example, having a police record for a conduct

offense had a small but significant relationship to intention-to-die

in the overall sample. Perhaps having this record is related to an

orientation of other directed manipulation, or alloplastic motivation.


Developmental Life Crises

Erikson (1950) conceptualized growth and development in terms of

a series of crises in life where the individual is confronted with a

shift in his basic social roles as a function of biological maturation.

Although he describes the ordering of the major developmental life

crises, he only roughly describes the timing of their onset as occurring,

for example, in the "young adult," etc. He speculates that, although

the major developmental life crises and their sequences are increased,

the culture determines, within some range, when particular crises will

occur. For example, the crises of "intimacy versus isolation" may be

usually confronted earlier in an agrarian than in an industrial culture.

As the United States, and especially its metropolitan areas, are

pluralistic in population make-up, it could be hypothesized that there

would be some variance between subpopulations and groups as to the

typical onset of these crises.

It was hypothesized that particular age groups should more repre-

sent developmental life crises and that expected intentionality would









increase as a function. This was not found to be the case. However,

Freeman et al. (1974) reported a bimodal curve for expected intentionality

among males with the smaller peak in the early twenties, a nadir in the

late thirties, and a steady and rapid increase into old age. Why the

discrepancy between the two studies? One possibility is the nature of

the population studied by Freeman et al., a small city with a major

university as the dominant industry. Student-status was found to in-

crease intention-to-die in self-injuries in their study, and a large

proportion of the male population was comprised of students in their

early twenties. It is harder to form any explanation for the discrepancy

between the .12 expected intentionality they found for males in their

late thirties, and the .25 found in this study.

Expected intentionality was hypothesized as relating most to

autoplastic motives in this study, while self-injury risk was thought

to be a function of alloplastic motives. Therefore, no hypotheses were

made as to a relationship between developmental life crises and self-

injury risk. However in both males and females and for the majority

of subpopulations, self-injury risk was bimodal with one peak either

in the early or late twenties, and a second peak anywhere from the late

thirties to the early fifties. For females the peaks were in the early

twenties and early forties with a nadir in the early thirties. There

was some difference in magnitude between the peaks for female sub-

populations and, within five years, where they would occur, but the

overall patterns were consistent. For males the first peak was in the

early twenties for all subpopulations, and was of greatest magnitude,

except for the upper social-status. The occurrence of the second peak

was not as pronounced in middle and upper social-status males as it was









for lower social-status males and all female subpopulations.

Self-injury risk varies as a function of age and generally declines.

However it rises and falls in definite patterns, which vary by sex and

social-status. These patterns could be a result of particular stresses,

which become crises, associated with maturational stages that vary as

to their onset of occurrence in different subpopulations and between

men and women. Exactly what form these stresses take could be the sub-

ject of a developmental study of normal people representative of

different subpopulations.

It is as much interest that a hiatus consistently occurs between

early adulthood and middle-age in self-injury risk as that there are

peaks of the phenomena. For female subpopulations this respite occurs

around the early thirties while for males its occurrence may be as late

as the early forties. The occurrence of this hiatus is consistent with

Erikson's theory. Evidently some difficult social role and inter-

personal adjustments occur before and after this hiatus. Once the

individual reaches a particular age within his/her culture, he/she

has made some accommodations which will permit at least minimal function-

ing until vectors for change in roles and relationships occur again in

middle age. From this study, the interpersonal and cultural environ-

mentsseem to put the greatest stresses and demands for change upon the

individual, rather than these stresses coming intrapersonally, directly

as a function of biological maturation. If the latter were the case

then expected intentionality would also demonstrate peaks and nadirs

and the relationship would not vary as a function of social-status.

It is hypothesized from the results of this study that developmental

life crises are expressed more interpersonally or alloplastically,









where the individual attempts to change his/her environment through a

cry for help. Developmental life crises are not related to autoplastic

motivation, as would be reflected in greater intention-to-die.


Suicide Prevention


Formulating Suicide Prevention Strategies

Many clinically oriented authors such as Murphy and Robins (1967)

acknowledge the existence of sociological and personal factors in

suicide, but disparage their significance, in that they give us ". .

little help in predicting, and thus preventing, the individual suicide"

(1967, p. 303). Rosen (1954) discusses the difficulty in predicting

a low frequency event, such as suicide, without incurring the high

cost of identifying large numbers of false positives. Both of these

attitudes, however, are based on assumptions that the individual has

to be identified in order to mobilize individual treatment, usually

medical in nature. If suicidal individuals are being located in order

to be hospitalized, it is true that we are being confronted with a

hopeless task. There are not enough hospitals to accommodate all the

people our best screening instruments would identify as high suicide

risks. Neither has this strategy of suicide prevention been demon-

strated as effective. However, there are other strategies of suicide

prevention that are possible, and alternative approaches to medical

intervention. For example, Diggory (1969) outlines a program designed

for increasing hit rates, optimizing suicide prevention programs by

directing resources to high risk populations. Any such suicide pre-

vention effort needs two components: the identification of subpopula-

tions which are at risk, or identifying points in peoples lives or









situations which raise suicide risk; and the development of alternative

strategies which can either be directed at groups rather than individuals

or which utilize intervention strategies which incur relatively low

cost. This study was addressed to the first of these two components

with the assumption that alternative forms of suicide prevention are

developing concurrently.

One such alternative strategy of suicide prevention is postventa-

tive work with suicide attempters. We know that, despite medical inter-

vention including hospitalization, suicide attempters will have about a

140 times greater chance of dying in the year following the attempt

than other members of the general population. It is also known which

factors will increase or lower this risk (Tuckman & Youngman, 1968b).

And yet only a few programs around the country will systematically

postvene non-medically following the release of the suicide attempter

from the hospital, emergency room, or physician's office. These pro-

grams work with the individual in the community setting to mobilize

resources to work through their crises and change the factors in the

situation which led to the suicide attempt. Good follow-up studies

are needed to evaluate the effectiveness of these programs. It would

be possible to assign suicide risk factors to these individuals using

a modified scale from Tuckman and Youngman (1968b) and compare these

at follow-up points with actual death rates. We know that from 10 to

20 percent of suicides have made prior attempts (Dorpat & Ripley, 1967),

which is the maximum degree to which overall suicide rates potentially

could be lowered through this one approach.

Suicide prevention services have not adopted alternative strategies

which are aimed at high risk groups, however. We have instead developed









technologies for suicide prevention and crisis intervention which take

the passive stance of responding to self-selected people in trouble.

We need to develop programs which are actively aimed at influencing

high risk groups prior to self-injuries. One form such programs might

take is in extending the accessibility of our crisis phone centers.

Although these centers are available to the troubled individual, these

individuals may not see the center as a resource. Therefore, crisis

centers need as a first step, to target messages to high risk popula-

tions which will educate as to their appropriateness as a resource in

time of crisis. This would, hopefully, improve the accessibility of

an already available service.

Many individuals may not use an available service in a suicidal

crisis, even if they know of its existence and its mission. Part of

the phenomenon of suicide is a cognitive inflexibility on the part of

the victim where resources are not perceived, even if others near the

situation perceive the resource as appropriate and accessible to the

victim. Our programs need to be aimed at those who are close to high

suicide risk individuals. These natural caregivers need to learn to

assess suicidal risk and to mobilize our intervention services. We

need programs aimed at the police, clergy, physicians, and bartenders

to mobilize our services on behalf of high risk individuals they meet

in the normal course of their professions. A few demonstration pro-

grams of this type have recently begun. We also need to educate

spouses and children to recognize suicide risk and to know when to call

a suicide prevention services on behalf of their loved ones.









Evaluating Suicide Prevention Services


When a service has taken "suicide prevention" in its name or as

part of its mission, it has incurred an obligation to evaluate the ex-

tent to which it prevents suicides and to structure its program to

optimize its impact on the suicide rate. This evaluation can take many

forms, but this study is directly applicable to one needed procedure:

The center can evaluate itself as to whether it is being utilized by

high risk subpopulations. Although the center undertakes an obligation

to people in any type of trouble who choose to utilize it as a resource,

it also has an obligation to evaluate its accessibility to those at

high suicide risk. For this purpose the center needs to know suicide

risk, self-injury risk, and expected intentionality. In other words

to apply the schematization of Freeman et al. (1974) and Wilson (1974)

which are demonstrated in Tables 7, 8 ard 9. If the service does not

have the resources to utilize the Intention-to-Die Scales, it can use

a near equivalent method of assigning the value of number of suicides

divided by number of suicide attempts for the group of interest as a

measure of expected intentionality. When dealing with smaller numbers,

this will be less accurate and the curve should be smoothed out to form

estimates.

One difficulty in using the schematization of self-injury risk,

expected intentionality, and suicide risk is in obtaining a complete

and unbiased sample from the general population. For this purpose

cooperation with hospitals, physicians and police are necessary. If

the estimate of 10 suicide attempts per suicide is accepted, then an

estimate can be made of the extent to which the true population of

self-injuries was tapped by comparing this theoretical ratio to the








ratio found. In this study a ratio of 6.02:1 was obtained. By dividing

this into the theoretical ratio, a factor of 1.66 is obtained. This

factor could be multiplied to find suicide attempt risk for an estimate

of the theoretical rates of suicide attempts. This procedure may or

may not be justified, depending on the size of the factor and the uses

of the results.


Parasuicide


Freeman et al. (1974) advance the argument that the term suicide

attempt should be stricken from the language. They point to the in-

accuracies of the term suicide in conjunction with an act where, in

a majority of cases, no intention-to-die exists. This reconceptualiza-

tion is seen as not just a semantic exercise, but needed because of

the sometimes insidious abuses created by the label. For example, a

self-injury that is labeled a suicide attempt sometimes evokes conno-

tations of the individual being hopelessly incompetent or a liar who

is trying to "put something over" on the caregiver (1974, p. 36).

They propose the term self-injury as a substitute. However, a term

is needed which includes both suicides and what are presently labeled

suicide attempts, and self-injury is a good fit. A term which was

advanced by Kennedy, Kreitman, and Ovenstone (1974) which conceptually

includes the relationship of the behavior with suicide, without the

pejorative inaccuracies of the term suicide attempt, is parasuicide.

Of all the alternatives in the literature this one seems to have the

most promise of offering a label which is useful and accurate, without

introducing new semantic or connotative difficulties. The prefix para-

denotes that these non-fatal self-injuries resemble suicide in some









ways, but also have important functional differences. It is suggested

that parasuicide be defined utilizing Stengel's definition of suicide

attempt: ". . any non-fatal act of self-damage inflicted with self-

destructive intention, however vague and ambiguous" (1968, p. 172), or,

as any non-fatal self-injury. Within the classification of parasuicides

are suicide attempts, which are defined as high intention-to-die para-

suicides, a quantified definition. In other words, for this study only

30 of the 692 parasuicides, about 4 percent, were suicide attempts. As

can be seen, suicide attempts are a relatively rare special case of

parasuicide, occurring only about a fourth as often as suicides.

An additional conceptualization is important which involves the

issue of self-definition. In survey work a larger magnitude of para-

suicides will be found than in the best case-finding study, as self-

defined cases will be included for which there was no intervention, or

only private intervention by significant others. In this study over

98 percent of the self-injuries involved medical intervention. It

would be important for the purpose of comparing results between studies

if survey studies also asked if any type of intervention occurred. This

would sub-classify parasuicides into those with and without caregiver

intervention, whether the intervention is by police, medical, etc.

Self-defined parasuicides and intervened parasuicides need to be

identified in survey research in order for results to be compared to

studies involving other methodologies.


Significance and Prospects


Probably the most important contribution of this study is its

naturalistic-descriptive function. Data from as thorough a sampling









of a large general population are intrinsically interesting and valuable.

They give a new picture of patterns of the phenomena in an area where

there were only partial pictures available previously. There are

limitations, of course, to the study and its generalizability; but

it represents a step forward in the empirical conceptualization of self-

injurious behaviors. This study is the first to ascertain the role of

intentionality in self-injuries in relation to population base rates.

In other words, this study puts it together, and demonstrates how other

researchers or program planners can determine a more vivid picture of

the phenomena in their own community.

Hopefully, this study and the conceptual framework it employs

will have heuristic value in that it stimulates hypotheses for future

research. The reconceptualized form in which the data are presented

in this study are seen as leading to more antecedent-consequent types

of research in the area. For example, a longitudinal follow up study

such as Tuckman and Youngman's (1968a) could add the factor of previous

intention-to-die of parasuicides in assessing not only suicide risk,

but self-injury risk and expected intentionality among prior parasuicides.

The relationship of developmental life crises and self-injury risk was

a serendipitous finding of the study and suggests further research.

A number of good scales of suicide risk have been developed,

including Litman's (1971). Perhaps it would clinically be valuable

to sub-scale these suicide risk scales into a self-injury risk scale

and an expected intentionality scale. It is important to know both

the probability of the event happening and the probable consequences

of the event if it does happen. It would also be of clinical use to

be able to assess prior parasuicides of clients for intention-to-die.








Weissman (1974) found the absolute number of young parasuicides

in one hospital to be rising and speculated that it could be a precursor

of later increases in suicide rates as the group ages. A more accurate

warning might come from a replication of this study in the same

community. From this study, does the high self-injury risk found for

lower social-status males indicate increased suicide risk of this group

as it ages? A follow-up study would show any changes in patterns that

would indicate later changes in suicide risk. If a trend in increases

in self-injury risk was ascertained it might precede a subsequent rise

in suicide rate, giving earlier warning for possible prevention efforts.

Although the results of this study will be of interest to people

working in suicide prevention they may have limited generalizability

to their own community. Patterns of the phenomena will vary over

time and between localities. Hopefully, suicide prevention centers

will begin to apply the schematization in order to monitor the pheno-

mena for their own community and to differentially program and evaluate

their suicide prevention efforts.














CHAPTER V


SUMMARY


As complete and unbiased a sample of self-injuries in a general

population were obtained and suicide risk, self-injury risk and expected

intentionality were determined and related for the population and sex

X social-status subpopulations over the age span. The 692 parasuicides

(i.e. suicide attempts) and 115 suicides were rated for intention-to-

die utilizing a revised version of the Intention-to-Die Scales developed

by Freeman et al. (1974). Although age and sex were the strongest

factors relating to intention-to-die, other personal factors were found

to make minor, but significant contributions to the multiple relation-

ship. Although social-status did not relate to intention-to-die,

lower social-status for both males and females were found to increase

each of the risk levels. Self-injury risk was found to relate to

developmental life crises for both males and females and for most sex

X social-status subpopulations. Findings are discussed in terms of

evaluating suicide prevention centers, formulating suicide prevention

strategies, and in the reconceptualization of acts presently labeled

suicide attempts as parasuicides.










APPENDIX A


REVERSIBILITY OF METHOD SCALE


Rating

1. COMPLETE REVERSIBILITY OF METHOD:

Ingestion of aspirin or other commercial drug items (such as
Excedrin, Bufferin, Midol, etc.); antihistamines, or other non-
toxic household substances (such as baking powder, mouthwashes,
etc.). Also slight cuts not requiring treatment.

2. PROBABLE AND EXPECTED REVERSIBILITY OF METHOD:

Ingestion of 10 or more tranquilizers or nonprescription
sleeping pills (such as Sominex, pep pills, etc.). Ingestion
of 10 or more stimulants (such as Serpasil, reserpine, Raudixin,
Thorazine, Compazine, Dartal, Mellaril, Permitil, Trilafon,
Stelazine, meprobamate; Librium, valium, Miltown, and Equanil).
Also wrist cuts requiring vessel and/or tendon repair.

3. QUESTIONABLE REVERSIBILITY OF METHOD:

Ingestion of 10 or more soporific medications, poisons, large
amounts or combinations of several drugs, narcotics (barbiturates:
phenobarbital, sodium butisal, Nembutal, Seconal, Sodium amytal,
tuinal; non-barbiturate hypnotics: bromides, chloral hydrate,
paraldehyde, bromural, Carbrital, halabar; narcotics: morphine,
Demoral, Darvon). Deep cuts requiring tendon or vessel repair
(except single wrist cuts) and multiple severe cuts.

4. IMPROBABLE AND UNEXPECTED REVERSIBILITY OF METHOD:

Attempted drowning, carbon monoxide suffocation, domestic gas
suffocation, suffocation. Deep cuts to the throat.

5. REMOTE OR NO CHANCE FOR REVERSIBILITY OF METHOD:

Gunshot in vital area (such as trunk of body or head). Jumping
from a high place (more than 20 feet). Hanging (feet above
ground).









APPENDIX B


PROBABILITY OF INTERVENTION SCALE


Rating

1. CERTAIN INTERVENTION

Act committed in the presence of another person.

2. PROBABLE INTERVENTION

Act committed with another person in the immediate vicinity
but not visibly present (such as in the same household).

3. AMBIGUOUS CHANCE OF INTERVENTION

Act committed by person alone, with no certainty of immediate
assistance; however, a reasonable chance for intervention exists
(such as the victim is aware of the impending arrival of others).
Telephone is available and may be used to call a significant
other person.

4. IMPROBABLE INTERVENTION

Act committed by person alone, with intervention by a passerby
possible although not expected (such as a motel room, an office
late at night, or home alone with no one expected).

5. CHANCES OF INTERVENTION REMOTE

Act committed by person in a solitary or isolated place without
access to telephone (such as a wooded area, cemetery, etc.).









APPENDIX C


PROBABILITY OF INTERVENTION
REVISED SCALE


Rating

1. CERTAIN INTERVENTION

Act is committed in the presence of another person who can
recognize it as self-injurious behavior and intervene immediately.

2. PROBABLE INTERVENTION I

Act is committed while the person is alone, but a person is
contacted to intervene (e.g. by telephone) so as intervention
should be almost immediate or with short delay; or, another
person is not present but is expected immediately or with
short delay following the act.

3. PROBABLE INTERVENTION II

Act is committed with another person in the immediate vicinity
but not visibly present (such as in the same household) who
is likely to intervene with little delay or who is put in or
who finds themselves in a position of recognizing the attempt
with little delay.

4. AMBIGUOUS CHANCE OF INTERVENTION

A potential intervenor is on the premises, in the vicinity,
or expected but intervention is expected to be significantly
delayed (e.g. several hours).

5. IMPROBABLE INTERVENTION

Act is committed by the person alone. Intervention is expected
to be significantly delayed (e.g. hours).

6. CHANCES OF INTERVENTION REMOTE

Act is committed by person alone and intervention is not
expected for at least 12 hours; or the act is committed in a
solitary or isolated place without access to a telephone (such
as a cemetery late at night; an isolated wooded area, etc.).









APPENDIX D


INTENTION-TO-DIE MATRIX



Probability of Intervention

1 2 3 4 5


--i


o
0
Il 2

0


, 4 3
-

(oJ


5 I -


Low
Intention-
to-die

Moderate
Intention-
to-die




High
Intention-
to-die


mI


------/-----














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BIOGRAPHICAL SKETCH


Karl Eugene Wilson was born June 14, 1946, at Wayne, Michigan.

He was graduated from a Detroit Public High School in August of 1964.

He immediately went to work as a laborer, for an automobile manufacturing

corporation, and completed several college courses before enlisting as

a private in the United States Marine Corps in February, 1966. He

completed two years of active duty, including a fourteen month tour of

duty in Viet Nam, and was able to travel around the world.

Mr. Wilson re-enrolled in Monteith College, Wayne State University

in April, 1968 and graduated with the Bachelor of Philosophy with high

distinction in June of 1971. During this period he worked at such

diverse jobs and positions as bartender, nursery school teacher, and

research assistant at the Merrill-Palmer Institute of Human Development.

He was married in December, 1969, to Rose Janet Goodman Wilson. Ms.

Janet Wilson is a psychiatric social worker.

Mr. Wilson has been enrolled in the graduate program in clinical

psychology at the University of Florida since September, 1971. He

received his Master of Arts degree in December, 1972. During his

graduate career he was associated with the Suicide and Crisis Inter-

vention Service of Gainesville, Florida and the Center for Crisis

Intervention Research. He completed his one year internship in

clinical psychology, with emphasis in community psychology, in

September, 1975, at Malcolm Bliss Mental Health Center in St. Louis,





92



Missouri. Mr. Wilson began his current position as Visiting Assistant

Professor, Department of Psychology, Washington University, in

January, 1976. Mr. Wilson has published articles in the areas of

child development, suicidology, and the utilization of paraprofessionals

in crisis intervention.




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