By effectively differentiating among certain characteristics of the suicidal
crisis, the clinician will be better able to manage the clinical conundrums so
common in the treatment of this patient population.
Versus Chronic Suicidality
Acute conditions are, by their nature,
state (transitory) disorders. The patient's symptoms are the product of an acute
process generated by biopsychosocial disturbances. Acute conditions (a) improve,
(b) become persistent or chronic (become trait phenomena), or (c) cause the sufferer
to succumb. Acute suicidality conforms to the definition of a state disorder-the
unfortunate convergence of mental disorder with personal and/or social vulnerability
that has inspired lethal intent. The patient will recover, will incorporate suicidality
into his or her adaptational style (become chronically suicidal), or will die
by his or her own hand (Havens, 1963). Inpatient units are particularly effective
in controlling acute suicidality by treating acute symptoms and by providing temporary
safety, support, and hope. Inpatient units are not particularly effective in controlling
chronic suicidality, especially in nonpsychotic patients. To paraphrase Gutheil
(1985), acute suicidality is a defect in the metabolism of despair, whereas chronic
suicidality is a defect in the metabolism of responsibility. I know of no short-term
inpatient unit that can significantly alter character or ingrained deficits in
Ideas Versus Actions
A cornerstone of psychiatric theory and practice is the uncensored expression
of ideas and affects. From the outset of hospitalization, the suicidal patient
must be told that staff are prepared and able to hear the disturbing ideas and
feelings that the patient cannot bear alone and that threaten his or her well-being
(Sederer & Thorbeck, 1991). At the same time, staff must convey-clearly and
firmly- that suicidal behavior cannot be tolerated. Patient safety is always the
first priority of the patient milieu.
Suicide ideation can be understood
as the product of despair, as a communication, or even as a form of self-soothing
(Buie & Maltsberger, 1983). In all cases, it serves a purpose. The clinician's
aim is not to try to take suicide ideation away from a patient, because this would
deprive the patient of a necessary mental operation. Instead, the clinician offers
the patient both the opportunity not to be alone in despair and the prospect of
altering illness and circumstance so that suicide ideation is no longer necessary
for psychic equilibrium.
Threats Versus Suicidal Ideation
A further distinction that the clinician should understand
is that between suicide threats and suicide ideation or intention. Suicidal ideation
and intention (acute) are symptomatic of illness, despair, or disequilibrium.
Suicidal threats are very different. Threats are interpersonal acts meant, consciously
or unconsciously, to manipulate someone. That someone, be it family, friend, or
the clinician, often cannot marshal empathy and support for the person making
the threats, because he or she feels resentment or aversion, the common by-products
of the experience of being manipulated. The clinician cannot be hostage to a patient's
threats and simultaneously provide what the patient truly needs. As Main (1957)
said, "sincerity by all about what can and cannot be given with good will
offers a basis for management (p. 145, emphasis added).
Parasuicide refers to behaviors that are equivocally
suicidal, such as gestures or self-destructive acts that are not lethal in intent
(Kreitman, 1977). Parasuicide is a "non-fatal act in which an individual
deliberately causes self-injury or ingests a substance in excess of any prescribed
or generally recognized therapeutic doses" (Kreitman, 1977, p. 3). Parasuicide
does not have death as its aim, which is what differentiates it from a completed
suicide that is not an accident and a serious suicide attempt that is foiled by
unexpected discovery and rescue.
Parasuicide has been understood
as manipulative, depersonalized, or both (Maltzberger & Lovett, 1991). Manipulative
parasuicide aims to control others and is generally inspired by rageful panic
or narcissistic shame and injury. Revenge may be the primary motive in manipulative
parasuicide. Depersonalized parasuicide aims to relieve the patient of an unbearable
numbness, alienation, or derealization. Its method is usually self-mutilation
through cutting, burning, banging, or biting.
not be an adequate indication for hospitalization. If a pattern of increasing
self-destructiveness develops, however, hospital-level care may be needed to avert
the progression to a lethal outcome. The treatment in such cases differs from
that offered in suicidal situations, because the aims and methods of parasuicide
do not merit the same safety considerations and therapeutic interventions that
apply to the suicidal patient.
- Leenaars, Antoon, Maltsberger, John T., &
Robert A. Neimeyer, Treatment of Suicidal People, Taylor & Francis: London,
Management of Major Depressive Disorder (MDD) in Adults
Primary Care Skilled Assessment and Diagnosis
- VA/DoD Depression Practice Guideline Provider Care Card. (2009). Management of Major Depressive Disorder (MDD) in Adults Primary Care Skilled Assessment and Diagnosis.
Reflection Exercise #6
The preceding section contained information
about differentiation of the characteristics of the suicidal crisis. Write three
case study examples regarding how you might use the content of this section in
Online Continuing Education QUESTION
20 How does a suicidal threat differ from an ideation? Record the letter
of the correct answer the CE Test.