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Half in Love With Death
Managing the Chronically Suicidal Patient

Half in Love With Death
Managing the Chronically Suicidal Patient

Joel Paris
McGill University
LAWRENCE ERLBAUM ASSOCIATES, PUBLISHERS

2007 Mahwah, New Jersey London
Copyright © 2007 by Lawrence Erlbaum Associates, Inc.
All rights reserved. No part of this book may be repro-
duced in any form, by photostat, microform, retrieval sys-
tem, or any other means, without prior written
permission of the publisher.
Lawrence Erlbaum Associates, Inc., Publishers

10 Industrial Avenue
Mahwah, NJ 07430
Cover design by Kathryn Houghtaling Lacey
Library of Congress Cataloging-in-Publication Data
Paris, Joel, 1940-

Half in love with death: managing the chronically suicidal
patient / Joel Paris.
p. cm.
Includes bibliographical references and index.
ISBN 0-8058-5514-9 (cloth : alk. paper)
ISBN 0-8058-6081-9 (pbk. : alk. paper)
ISBN 1-4106-1459-X (E book)
1. Suicidal behavior—Treatment. 2. Suicide. 3. Young
adults—Mental Health Services. 4. Chronic dis-
eases—Treatment I. Title.
RC569.P37 2006
616.85’844506—dc22 2006002686
CIP
Books published by Lawrence Erlbaum Associates are printed

on acid-free paper, and their bindings are chosen for strength
and durability.
Printed in the United States of America

10 9 8 7 6 5 4 3 2 1
This book is dedicated to my patients, who have taught me so much
about the human condition.
Contents
Preface ix
Introduction xiii
1 Suicidality and Suicide 1
2 The Inner World of the Chronically Suicidal Patient 18
3 Suicidality in Childhood and Adolescence 32
4 Chronic Suicidality and Personality Disorders 55
5 Myths of Suicide Prevention 78
6 Psychotherapy Research and Chronic Suicidality 103
7 Pharmacotherapy and Chronic Suicidality 117
8 Tolerating Chronic Suicidality 130
9 Managing Chronic Suicidality 147
10 Suicidality and Litigation 176
Summary: Guidelines for Therapists 187
References 191
Author Index 215
Subject Index 223

vii
Preface
Darkling I listen; and, for many a time

I have been half in love with easeful Death,
Call’d him soft names in many a mused rhyme,
To take into the air my quiet breath.
—“Ode to a Nightingale” by John Keats
The Problem of Chronic Suicidality
John Keats’s poem describes a state of mind we often see in

chronically suicidal patients. Life becomes so painful for these
people that they feel “half in love” with death.
Chronic suicidality is a difficult problem. I have written this
book to help clinicians with treatment. Many authors have
written about the clinical management of patients who
threaten or attempt suicide. Yet there is a surprisingly small
literature on chronic suicidality. Most books on suicide focus
on the assessment of patients with episodes of depression last-
ing a few months. But chronically suicidal patients can think
about suicide for years and often make multiple attempts.
Maltsberger (1994) described some of the problems in
managing these cases:
ix
x PREFACE
Patients who threaten suicide in all seasons, self-mutilate, and who

from time to time make serious suicide attempts tax and challenge
clinical workers. Every hospital has its legend about the exploits of
such a patient. When these patients die of suicide, a wave of sorrow
and guilt follows. Many therapists exclude them from their practices;
keeping clinical balance in working with them is difficult. Intractably
suicidal patients require much time and great energy from those re-
sponsible for their care. They draw forensic attention and excite hospi-
tal administrators to action. Much of the anxiety they arouse comes
from the question of whether they should be admitted to the hospital
and, once they have come into the hospital, from the reciprocal:
whether they should go out again. The increasingly litigious climate in
the United States makes the treatment of such persons extremely diffi-
cult. (p. 199)
Therapists lack guidelines for dealing with such problems.

And without guidelines, chronically suicidal patients are
frightening. Our greatest fear is losing a patient to suicide. We
try to do everything we can to prevent fatal outcomes, but
most of us will experience a completed suicide sometime in
our career.
It is, therefore, not surprising that some therapists attempt to
avoid treating this population. Yet no one can practice for long
without seeing chronically suicidal cases. And once patients are in
treatment, we are obligated to help them. Thus, most of us
struggle along, dealing with the situation the best we can.
On a purely human level, we care about our patients. It
would be painful to lose someone with whom we have spent so
many intense hours. On a professional level, suicide challenges
our feelings of helpfulness and competence. Last, we have to
be concerned about the consequences of a suicide. If a patient
dies by his or her own hand, what will our colleagues think?
Could we suffer a lawsuit by angry family members?
The following example illustrates some of these problems:
Colleen was a 25-year-old nurse who came to therapy after taking
a large overdose of pills. The immediate precipitant was a break-up
with a boyfriend. However, Colleen reported that since the age of 13,
suicide had always been an option for her. She had taken her first over-
PREFACE xi
dose, 20 aspirins, as a ninth-grade student, after an argument with

her mother. Colleen awoke the next morning feeling ill, but she went to
school and never told her family what she had done. Over the coming
years, Colleen continued to feel that her life was empty, although she
achieved some degree of outward success. Colleen did well in nursing
school and took on a demanding position at an intensive care unit. But
in her adult years, Colleen found herself unable to find intimacy and
happiness, and despair took command of her life.
Colleen was seen weekly in therapy over the next 3 years. Although
she did not make another attempt, both Colleen and her therapist were
always aware that she had the means to ensure that the next one would
be fatal. For example, Colleen had access to vials of potassium chloride
at work, which she kept at home, along with a syringe. Every session
dealt with the possibility of suicide. The therapist could never be sure
whether Colleen would survive to the next session. And if she did kill
herself, the medical community would know of it.
Although clinical problems like this are difficult, this book
suggests a way for therapists to approach such problems with-
out being paralyzed by fear. This book also challenges conven-
tional wisdoms about the management of suicidality. I
suggest that most of the “classical” approaches in the litera-
ture are mistaken and even counterproductive when applied
to patients who are chronically suicidal. But this book is not
intended to be simply a polemic against misconceptions and
bad practices. It offers a different approach to treatment, one I
hope readers will find both positive and practical.
Acknowledgments
The concepts in this book expand on ideas originally pre-
sented in two journal articles: Paris (2002a) and Paris (2004b).
Roz Paris and Hallie Frank read earlier versions of this
manuscript and made many useful suggestions for improve-
ment. Judy Grossman helped me to find obscure references.
Chapter 9 uses concepts developed by Deborah Sookman.
Introduction
Challenging Conventional Wisdoms

The conventional wisdoms about the management of
suicidality have misled us. We have long been taught that
when patients are suicidal, therapists should be highly vigilant
and intervene actively to prevent completion. This point of
view usually leads to hospital admissions, which are assumed
to save lives.
This book will show that there is little evidence for these as-
sumptions. There are no data to show that hospitalization pre-
vents suicide, even in patients who are acutely suicidal. Even if
it were true that admission to a ward can prevent some people
from committing suicide, hospitalization tends to be ineffec-
tive and unhelpful for chronically suicidal patients.
These ideas will probably encounter some resistance. Ther-
apists believe that it is their responsibility to ensure safety for
patients. This book suggests that “safety” is an illusion—and
a dangerous one, in that attempts to protect patients from sui-
cide cut them off from everything that makes life meaningful.
Instead, I suggest that giving up the idea of actively saving
chronically suicidal patients actually liberates us to understand
them and to work on their problems. Paradoxically, the most
xiii
xiv INTRODUCTION
important thing therapists have to do when treating this popu-

lation is to tolerate suicidality. This provides the basis for address-
ing the psychological issues behind suicidal ideas and behaviors.
The Four Major Points

of This Book
1. The inner world of the chronically suicidal patient is one of
pain, emptiness, and hopelessness; suicidality is an attempt
to cope with these states of mind.
2. Chronic suicidality is not usually accounted for by depression
alone but is associated with personality disorders.
3. Methods generally recommended for the management of
suicidality are ineffective and counterproductive in chroni-
cally suicidal patients.
4. Effective therapy requires that therapists tolerate chronic
suicidality while working toward healthier ways of coping.
The Inner World of the Chronically

Suicidal Patient
Planning any form of treatment for suicidal patients requires an
understanding of why they have become chronically suicidal.
The inner world of suicidal patients will be alien to most
people. At the center of suicidal patients’ experience is a para-
dox. Suicidality has become the center of their existence.
Death has become a way of life.
Although it may be hard to imagine, patients can actually
be comforted by suicidal ideas. These patients suffer a high
level of distress and can only tolerate that distress if they know
they can escape it. In this way, patients become “half in love
with easeful death.”
Chronically suicidal patients have only a faint hope that
their lives will ever be happy or that they can do anything to
change their situation. Yet because they can always choose not
INTRODUCTION xv
to live, they retain a strange power over their fate. That is the
main reason why patients can think about suicide every day.
When crises arise in their lives, they need not suffer passively
but can do things that give them a feeling of activity and con-
trol: making suicide attempts by overdose, or cutting and
burning themselves.
Behavioral patterns remain stable when they perform a
function. In this way, suicidality can be seen as a coping strat-
egy. In fact, most chronically suicidal patients do not end their
lives by suicide. Herein lies the paradox. The only way for
them to go on living is to maintain the option of dying. They
threaten to die in order to stay alive.
This book considers some of the unique psychological issues
that affect the emotional life of these patients. The first con-
cerns psychological pain. The feelings that the chronically sui-
cidal patient is trying to cope with are beyond the experience
of most people. Empathizing with these states of mind
requires some imagination.
We all know what it is like to be depressed and anxious. The
level of such feelings tends to be unpleasant but manageable.
Moreover, we generally anticipate that painful emotions will
go away with time. Imagine, however, what it must feel like to
experience severe and continuous distress. Chronically sui-
cidal patients are rarely happy for more than a few days. Most
of the time, their mood is depressed, anxious, or angry. This
level of suffering is quantitatively beyond our experience, and
that is what makes it qualitatively different.
The second unique emotion we see in chronically suicidal pa-
tients is emptiness. This state of mind is not the same feeling as
depression. Patients who are depressed have a sense of loss. Pa-
tients who feel empty describe a sense of having nothing inside
and of being nobody. As one of my teachers once put it, these
patients have a sense not of “having been” but of “never was.”
The third emotion associated with chronic suicidality is
hopelessness. This state of mind also occurs in classical depres-
sion, but the difference lies in the time scale. If one cannot re-
xvi INTRODUCTION
member ever feeling content, there can be little hope for a

return to happiness.
This is one of the reasons why chronic suicidality cannot be
accounted for by depression. Most people are “down” from
time to time. In the course of a lifetime, 1 out of 10 people will
meet criteria for a clinical diagnosis of major depression. As
long as this state lasts, nothing can cheer the patient up. But
depression tends to be temporary. If it is not too severe, pa-
tients may remember better times and realize they are not
quite themselves. Although many depressed people have
transient thoughts about death, only a minority will act on
these thoughts by making suicide attempts. And once depres-
sion lifts, suicidal ideation disappears.
What Kinds of Patients Are Chronically Suicidal?

At least half of chronically suicidal patients meet criteria for a
personality disorder. Yet patients who are suicidal are often di-
agnosed only with depression, and many clinicians go no fur-
ther in their diagnostic thinking. Actually, most people with
suicidal ideas of any kind, not to speak of suicide attempts,
tend to meet Diagnostic and Statistical Manual of Mental Disor-
ders (DSM) criteria for major depression. But that diagnosis
tells us little about why patients become suicidal.
Much of the confusion derives from the way depression is
defined. DSM (4th ed., text rev.) lists eight criteria for a major
depressive episode and requires that patients meet five of
them. It is not very hard to earn this diagnosis. Almost anyone
who is seriously unhappy for more than a couple of weeks can
be diagnosed with major depression. This definition is based
on too broad a concept and is particularly unhelpful in distin-
guishing chronically suicidal patients from depressed patients
in an episode of mood disorder.
The chronicity of suicidality requires a diagnostic concept that
reflects continuous dysfunction over time. Patients with major psy-
INTRODUCTION xvii
chiatric diagnoses, such as bipolar disorder, melancholic depres-

sion, substance abuse, and schizophrenia, can also be chronically
suicidal. I might have written another book about the problems
these groups present. But in the majority of cases, the most useful
diagnostic concept for understanding chronic suicidality is person-
ality disorder. One is not likely to develop chronic suicidal ideas and
actions in the absence of this kind of pathology.
Moreover, the largest literature on this clinical problem de-
rives from studies of Axis II disorders, most particularly pa-
tients who meet criteria for borderline personality. These are
the clients who give the most trouble to therapists and on
whom this book focuses.
How Not to Manage Chronic Suicidality
Suicidology is a discipline in its own right. It addresses an im-

portant clinical problem by inspiring a large body of empirical
studies examining the risk factors for suicide. Clinical guide-
lines for the assessment and management of risk identify pa-
tients who are, at least statistically, more likely to commit
suicide. For example, completion is more common in men
than in women, particularly among older men. Suicide is more
likely to occur when patients have poor social supports and
when they feel hopeless about the future. Patients who have
previously attempted suicide are somewhat more likely to die
by their own hand. Completion is an increased risk in a num-
ber of diagnostic groups, particularly melancholic depression,
bipolar illness, alcoholism, and schizophrenia.
However, these risk factors are not at all useful in predict-
ing whether any individual will die by suicide. This research
suffers from a very large number of false positives (patients
who have the risk factors but who never commit suicide).
Moreover, there is little evidence from systematic research
that identifying these risk factors helps to prevent completion.
xviii INTRODUCTION
Of particular concern, guidelines for managing suicidality

have been applied to all patients who think about, threaten, or
attempt suicide. Arguably, little harm will be done if one in-
tervenes unnecessarily in patients with acute suicidality, be-
cause that condition is usually temporary. However, methods
of assessment and treatment developed for acutely suicidal pa-
tients can be inappropriate, or even counterproductive, for
chronically suicidal patients whose symptoms are in no way
temporary. On the contrary, by providing reinforcement,
these interventions tend to increase chronic suicidality. It does
not make sense to treat all patients as if they were at immedi-
ate risk of losing their lives. Only a minority will eventually
end their lives, and there is little to go on in predicting which
patients are most likely to be completers.
To clarify these issues, this book makes some fundamental
distinctions between several patterns, all of which have been
called “suicidal.” First, suicidal thoughts, common in many
depressed states, must be distinguished from suicidal actions.
Second, self-mutilating behaviors are not usually suicidal in
intent. Finally, high-risk suicidal actions that are potentially
lethal have a different meaning from actions such as minor
overdoses. Although their functions overlap, each of these sit-
uations is different and needs to be managed differently.
Suicidal thoughts, given their high base rate in the popula-
tion and their common appearance in depression, are not use-
ful markers for completion. Suicide attempts, despite their
relationship to completed suicide, are also not strong predic-
tors of completion. Repetitive attempters and suicide com-
pleters are separate, albeit overlapping populations. Finally,
self-mutilation does not predict suicide. Repetitive cutting is
not even really “suicidal” behavior but rather a way that pa-
tients self-regulate dysphoric emotions.
In summary, this book will further argue that hospitalizing
chronically suicidal patients accomplishes little and can do
some harm. When patients are suicidal over long periods of
time, “safety” is an ephemeral goal. Treatment approaches de-
INTRODUCTION xix
signed to prevent completion tend to reinforce the very behav-

ior they are trying to contain. Hospitalization, however
unproductive, tends to be repetitive. A vicious cycle is created
in which therapy becomes virtually impossible.
This book maintains that treating chronically suicidal pa-
tients requires therapists to tolerate some degree of risk. Most
patients will not complete suicide, even if some do. Clinicians
are trained to believe that they must act to prevent suicide at
all costs. If one could identify who is at risk, perhaps focusing
on prevention would make sense. But we cannot identify these
patients. The most rational approach to the chronically sui-
cidal patient is to avoid unnecessary interventions and to
proceed with therapy.
Managing Chronic Suicidality in Therapy
This book explains why the backbone of management for the

chronically suicidal patient with a personality disorder is out-
patient psychotherapy. Unlike many of my medical col-
leagues, I am skeptical about the value of currently available
pharmacotherapy in this population. I will show that al-
though drugs can “take the edge off ” dysphoria, their thera-
peutic value has been both overrated and overstated.
Although the future may provide us with better agents, at
present one can only conclude that pharmacological treat-
ment fails to produce remission of the disorders that cause pa-
tients to be chronically suicidal. In fact, there is better
evidence of the efficacy of psychotherapy than for any phar-
macological intervention in this population.
A more general principle is that therapists should avoid
making unnecessary interventions and should focus their ef-
forts on addressing the underlying causes of chronic
suicidality. We have to address the real-life issues that make
lives unbearable. Until patients develop new skills, and have
new and more positive experiences, they will not readily give
xx INTRODUCTION
up their suicidality. The ultimate goal of treatment is to help

the patient to “get a life.”
Obviously, psychotherapy takes time. While awaiting an
improved quality of life, therapists need to tolerate suicidality.
Doing so is an essential part of the treatment strategy. Patients
may need to be allowed to maintain a suicidal option because
it is often their way to go on living. Later, when life satisfac-
tions become more available, they can move away from a pre-
occupation with death and begin to solve the problems of
living. In the meantime, patients can be taught to tolerate
dysphoric emotions, to stand outside of them, and to reap-
praise the circumstances that bring them on.
Many of the questions examined in this book do not have un-
ambiguous answers based on research data. I do not wish to join
the ranks of authors who offer dogmatic opinions based on expe-
rience alone (often drawn from a very limited and unrepresenta-
tive clinical case load). Yet clinicians and their patients must not
be expected to wait another 50 years for definitive answers to im-
portant problems. Thus, although I have not systematically
tested every idea in this book, my clinical recommendations are
informed by my experience as a researcher and are consistent
with what the empirical literature shows.
How I Became Interested

in Chronic Suicidality
As a young therapist, I often felt unsure about whether I was

helping people. But if my patients were suicidal at the begin-
ning of treatment, I would at least know if they were alive or
dead at the end. I was also fascinated by the inner world of
suicidality and energized by the clinical challenge it presented. I
began to collect chronically suicidal patients in my practice.
It took me several years to understand that these patients
could be diagnosed with severe personality disorders. I had
INTRODUCTION xxi
learned about this form of pathology in my training but did

not really understand it. Until the 1970s, there was little for-
mal research on personality disorders. Then the field saw a
dramatic growth, producing a large body of empirical data.
Although I had little formal training in research, I became
part of that movement, learning from colleagues how to con-
duct empirical studies and eventually publishing my own
work on borderline personality disorder.
Although research became a major part of my professional
life, it did not provide me with guidelines for treating chroni-
cally suicidal patients. But the findings of my studies of the
long-term outcome of personality disorders helped me to feel
more comfortable. Most of these patients, despite having been
seriously suicidal for many years, eventually recovered and re-
turned to a reasonable level of functioning.
These findings left room for a guarded optimism. I also
learned that those who did commit suicide had not done so at
the time when they were most threatening to their therapists
but rather ended their lives at a much later point, usually
when they were no longer in treatment. This observation
greatly reduced my anxiety about treating young suicidal pa-
tients. I hope to produce the same effect on the readers of this
book.
The Plan of This Book

Each chapter develops a theoretical perspective based on em-
pirical data, and most are illustrated by clinical examples.
Chapter 1 distinguishes between the various types of
“suicidality”: thoughts, attempts, and self-mutilation. These
distinctions help us to understand the relationship between
suicidality and completed suicide.
Chapter 2 examines the inner world of the chronically sui-
cidal patient, with particular focus on pain, emptiness, and
hopelessness.
xxii INTRODUCTION
Chapter 3 shows how chronic suicidality can originate in

childhood and adolescence, well before any clinical presenta-
tion. The chapter also presents a perspective on why the ado-
lescent years are usually the time when overt suicidal
behaviors first appear.
Chapter 4 examines the relationship between chronic
suicidality and personality disorders, most particularly the
category of borderline personality. The chapter questions the
concept that chronic suicidality is primarily the result of
depression.
Chapter 5 critiques the myth that suicide can be prevented
using current methods of intervention. This chapter shows
why hospitalization is not useful for patients with chronic
suicidality and examines some of the alternatives.
Chapter 6 reviews the effectiveness of psychotherapy for
chronically suicidal patients.
Chapter 7 reviews the effectiveness of pharmacotherapy for
chronically suicidal patients.
Chapter 8 focuses on the problems therapists have in toler-
ating chronic suicidality.
Chapter 9 offers an approach to management, in which
even the most alarming behaviors can be dealt with in a mat-
ter-of-fact, pragmatic fashion.
Chapter 10 discusses the risks of litigation in managing this
patient population
The book ends with a brief summary of its main arguments,
followed by an outline of their practical implications for treat-
ment as well as future directions for research.
1
Suicidality
and Suicide
What is Suicidality?
When therapists talk to each other, they may refer to a patient

as being suicidal. Yet it is not clear what using this term com-
municates. A single word can have many meanings. Under-
standing what is meant by suicidality is not just a problem in
semantics: Ambiguity in language leads to confusion in prac-
tice. At best, when clinicians describe people as suicidal, the
clinicians are expressing concern. It need not mean that pa-
tients are in mortal danger.
A standard text (Maris, Berman, & Silverman, 2000, p.
314) defines suicidality very broadly, including situations in
which patients consider suicide, cut their wrists, take mild
overdoses, or carry out life-threatening acts. The risk of com-
pletion is quite different in each of these situations, and each
has to be managed differently. This chapter reviews research
on these clinical problems and reviews to what extent suicidal
ideas and actions are related to completion.
1
2 CHAPTER 1
Suicidal Ideation
and the Risk of Completion
What Does Suicidal Mean?
Most of the time, when therapists use the word suicidal, they
are referring to thoughts that patients have of ending their
lives. Clinicians have been trained to assess suicide risk by ask-
ing patients if they are considering suicide and to raise their
level of concern if the answer is yes. Thus, the presence of al-
most any form of suicidal ideation can set off alarm bells.
Unfortunately, what therapists have been taught about sui-
cide risk has little or no scientific basis. As we will see, stated
intention has little relationship to completion. (Nor is the
presence of suicide attempts a reliable marker for risk.) We
should always be concerned about patients when they feel sui-
cidal and acknowledge the level of distress that makes people
think along these lines. But although there is nothing wrong
with concern, the presence of suicidal thoughts can lead to a
knee-jerk response, in which any suggestion that suicide is be-
ing considered is seen as life endangering.
Therapists are understandably anxious about losing pa-
tients to suicide. A buzzword that is often used to guide man-
agement is safety. Yet we do not really know what constitutes a
safe environment for patients who are thinking about ending
their lives. The answers suggested by empirical data do not
correspond to current clinical practice.
The High Prevalence of Suicidal Ideation

Suicidal thoughts are very common. A large-scale American epide-
miological study, the National Comorbidity Survey (Kessler et al.,
1994; Weissman et al., 1999), reported the lifetime prevalence of
suicidal ideation at all ages to be 17%. Thus, one of six people has
contemplated suicide at some time in his or her life. And it is possi-
ble that older people may forget that about thoughts they had
SUICIDALITY AND SUICIDE 3
when they were young. In our own research, the prevalence of sui-
cidal ideas in young adults was as high as 50% (Brezo et al., 2005).
This extremely high prevalence of suicidal ideation can be com-
pared with prevalence of suicide completion, which is 11 per
100,000 (Grunebaum et al., 2004). Thus, the presence of suicidal
ideas can hardly be a reliable way to assess the risk for completion.
To some extent, ideation raises the risk for attempts: Although
only 5% of the population will make an attempt of any kind over
their lifetime, about 30% of those with suicidal ideation have made
some kind of attempt (Kessler et al., 1994). Nonetheless, most
people who think about suicide never make an attempt.
The reason why suicidal ideas are so common is that depression
is common. Suicidal thoughts are very common when people are
depressed. Accordingly, lifetime rates of depression decrease in
much the same range as the prevalence of suicidal ideation: be-
tween 10% and 20% (Weissman et al., 1988). But because depres-
sion is an episodic condition, most suicidal thoughts are transient
and go away when the depression lifts. Of course, this does not
happen when patients are chronically suicidal.
Are Risk Factors for Suicide Clinically Useful?

Does suicidal ideation provide a better index of risk when
combined with other risk factors? Clinicians have been trained
to assess a set of predictors believed to increase the risk for
completion in patients who think about suicide. Maris et al.
(2000, p. 514) listed them, and they should not be unfamiliar.
They include specific types of psychological symptoms
(impulsivity, agitation, psychosis, violence), serious medical
problems, high levels of stress, poor functioning, lack of social
supports, and a family history of suicide.
Each of these risk factors is indeed associated with an in-
creased probability of suicide. But most patients who have any
one of these risks (or several of them) will never kill them-
selves. Thus, if we were to consider every patient who presents
4 CHAPTER 1
with these factors as being at risk for suicide, we would be

faced with an enormous number of false positives.
Thus, statistical data obtained from large populations gen-
erate associations that are not of any practical use in a clinical
setting. Applying these relationships to patients can be very
misleading. As chapter 5 shows, even when we combine all of
the risk factors in an algorithm and apply them to large
groups of patients who are known to be suicidal, it has proven
impossible to predict whether any individual patient will actu-
ally commit suicide (Goldstein, Black, Nasrallah, & Winokur,
1991; Pokorny, 1983). Although we sometimes have the im-
pression, at least in retrospect, that suicide could have been
prevented, we would have been unable to identify which indi-
vidual patients are at the highest risk for completion.
Clinical Implications of Suicidal Ideation

If suicidal ideation is not a useful predictor of suicidal actions, it is
actually misleading to refer to patients having these thoughts as
being suicidal. This way of using words might conceivably be de-
fended on the grounds that suicide is such a horrific event that it is
better to be vigilant than to miss such a serious consequence, how-
ever rare. Yet as chapter 5 shows, there is hardly any evidence that
clinicians can intervene in any meaningful way to prevent suicide.
Like preventive wars, attempts at suicide prevention can
have unintended consequences. Allowing a large number of
false positives can lead to improper management. As this book
shows, treating all who have suicide ideation as if they were at
risk of death is as likely to make them worse as better. This is a
particularly important problem for chronically suicidal pa-
tients, in whom suicidal ideation does not take the same form or
have the same meaning as in those who are acutely depressed.
Thus, suicidal thoughts, by themselves, should not be a cause
for alarm and anxiety. They reflect mental states that may or may
not be associated with actions. It is likely that anyone who suffers
a depression of some severity will, at some point, think about the
possibility of ending the pain. But if we were to treat all patients

with suicidal ideation as if their life were at risk, hospital wards
would fill up and would be unable to admit other cases. We
would also be mistreating a large number of patients on the un-
proven assumption that doing so would allow us to save a few.
Again, this point of view should in no way be understood as
encouraging clinicians to ignore suicidality. Even if suicidal
thoughts are not harbingers of mortality, they can never be
seen as unimportant. Ideas of death are a mirror of pain and
distress. For that reason alone they should always be attended
to carefully. Ultimately, suicidal ideation is a signal that some-
thing needs to be done to relieve psychological pain.
Suicide Attempts and the Risk

of Completion
The Prevalence of Suicide Attempts
About 1 in 20 people in the United States will make some
kind of suicide attempt during their lifetime (Kessler,
Berglund, Borges, Nock, & Wang, 2005; Weissman et al.,
1999; Welch, 2001). The ratio of ideas to attempts is therefore
about 6:1. But the ratio of attempts to completions is 500:1.
These statistics, based on community data, may be somewhat
misleading in that they include milder attempts (sometimes
called “gestures”) that may never come to medical attention. For
this reason, there is a stronger relation of attempts to completion
in hospital settings. Nonetheless, even in clinical populations,
most patients who make attempts never complete suicide.
Differences Between Attempters and Completers

Research has consistently shown that suicide completers and
suicide attempters are distinct populations (Beautrais, 2001;
Kreitman & Casey, 1988; Linehan, Rizvi, Welch, & Page,
2000). Completers tend to be older, to be male, to use more le-
6 CHAPTER 1
thal methods, and to die on the first attempt. In contrast, at-

tempters tend to be younger, to be female, to use less lethal
methods, and to survive (Maris et al, 2000, p. 285). Although
these groups overlap to some extent, most cases in practice are
distinct, and management draws on different principles.
Demographically, suicide attempters are more likely than com-
pleters to come from lower socioeconomic groups (Hawton,
Harriss, Simkin, Bale, & Bond, 2001), although it is not clear
whether that is a cause or an effect of their condition. Clinically, at-
tempters constitute a large percentage of visits to medical emer-
gency rooms, accounting for as many as 2.8% of all cases (Pajonk,
Gruenberg, Moecke, & Naber, 2002). There is also a broad rela-
tionship between impulsivity and suicide attempts; large-scale sur-
veys have found that attempters are highly likely to suffer from
externalizing disorders (Hills, Cox, McWilliams, & Sareen, 2005).
Thus, attempters often suffer from both depression and sub-
stance abuse, and Hawton, Harris, et al. (2003) reported that
problems with drugs have become more common among at-
tempters. In addition, up to half of cases who present with suicide
attempts also meet criteria for a personality disorder (Haw,
Hawton, Houston, & Townsend, 2001), most particularly the
borderline category (Forman, Berk, Henriques, Brown, & Beck,
2004; Suominen, Isometsa, Henriksson, Ostamo, & Lonnqvist,
2000). Because patients with borderline personality are highly
treatment seeking (Zanarini, Frankenburg, Khera, & Bleichmar,
2001), this diagnosis is very common among suicide attempters
seen in emergency rooms and outpatient clinics. About half of all
clinic patients can be diagnosed with a personality disorder
(Zimmerman, Rothschild, & Chelminski, 2005).
Of course, not every suicide attempter has a chronic mental
disorder. This is reflected in the important differences between
patients who make one attempt and those who make many. In
general, repeated attempts are more predictive of completion
than single attempts (Sakinofsky, 2000). Even so, most repeti-
tive attempters do not end up completing suicide. In fact, the
majority eventually give up this pattern of behavior. Maris
(1981) followed a cohort of repetitive suicide attempters and

found that the behavior did not continue indefinitely but usu-
ally came to a stop after a maximum of four attempts. Although
experienced clinicians will have seen patients who have made
10, 20, or more attempts, these cases are unusual.
How Often Do Attempters Commit Suicide?
Researchers have studied how often patients who are seen in

mental health settings for suicide attempts eventually complete
suicide. In a long-term, large-scale, follow-up study (ranging
from 3 to 22 years) of all patients who presented with attempts to
an emergency room in Oxford, England, Hawton, Harris, et al.
(2003) identified 11,583 patients who had presented to a hospi-
tal with attempts. Of these, 3% eventually died by suicide. The
rate for repeated attempters was twice that for single attempters
(Zahl & Hawton, 2004). Nonetheless, because only 300 partici-
pants in this cohort actually completed suicide, predicting death
from a repeated pattern of attempts would have led to a very
large number of false positives.
Another large-scale study from England (Cooper et al.,
2005) followed 7,968 patients with deliberate self-harm (a term
that includes both overdoses and self-mutilation) over a 4-year
period. The researchers reported 60 completed suicides (about
0.1% of the original sample). This is a very low rate, and the
discrepancy is most likely due to the use of a sample that ini-
tially presented with less dangerous behavior.
Surveys in other countries have yielded higher rates of even-
tual completion: 5% in a study of 1,052 patients presenting to
emergency rooms in Sweden (Skogman, Alsen, & Ojehagen,
2004), 6.7% in a follow-up of 1,018 emergency room patients
in Finland (Suokas, Suominen, Isometsa, Ostamo, &
Lonnqvist, 2001), and 5% in a Finnish follow-up of 1,198 pa-
tients with deliberate self-harm (Suominen, Isometsa,
Haukka, & Lonnqvist, 2004). Some of the higher rates might
8 CHAPTER 1
reflect the higher overall prevalence of suicide in Scandinavia

(England is more similar to North America).
A major methodological problem with these follow-up
studies is that mild attempts tend to be mixed with
life-threatening ones. If one begins with a sample with severe
attempts, the rate of completion is bound to be higher. For ex-
ample, Carter, Reith, Whyte, and McPherson (2005) found
that multiple attempts with increasing severity were associ-
ated with a statistically significant higher rate of eventual
completion (although the sample was too small for clinically
useful prediction).
Another way to separate serious from less serious attempts
is to focus on patients admitted to a hospital. In one of the first
systematic follow-up studies, carried out in a Swedish hospital
(Ettlinger, 1975), the overall completion rate for admitted pa-
tients was as high as 10%. Recently, a Finnish study
(Suominen, Isometsa, Suokas, et al., 2004) found a similar
rate: In a cohort of attempters followed for 40 years, as many
as 13 out of 100 patients eventually died by suicide. This re-
port noted that 8 of these died 15 years or more after the first
attempt, raising the question whether longer follow-up peri-
ods are needed to determine the true rate of completion. On
the other hand, Scandinavian rates of suicide could still be un-
usually high: In a well-designed large-scale study carried out
in New Zealand (Gibb, Beautrais, & Fergusson, 2005), the
rate of eventual completion for hospitalized patients after 10
years was only 4.6%.
The contradictions in this literature probably depend on
the nature of samples. Everything depends on who gets ad-
mitted to the hospital. If only the most severely ill and psy-
chotic patients are hospitalized, suicide rates will be higher. In
settings where most attempters are routinely kept for a few
days, rates will be lower.
Another way to separate patients at high and low risk is to
differentiate between life-threatening attempts and mild
overdoses. For example, in a 5-year follow-up of 302 patients
who made medically serious attempts, Beautrais (2003) found

that 6.7% had died by suicide. This rate is higher than that
observed in the wide variety of attempters studied by
Hawton, Harris, et al. (2003).
Perhaps the safest conclusion is that somewhere between
3% and 7% of attempters will eventually kill themselves. Yet
even if we accept the high end of this range as accurate, its
clinical application remains problematic. We cannot know
whether patients were in imminent risk at the time of any pre-
vious attempt. Also, attempters who eventually kill them-
selves may have sought help for a previous episode but not for
the one that actually leads to their death.
The Nature of Suicidal Intent

Assessing the nature of intent may be the best way to identify at-
tempters most at risk for completion. Aaron Beck developed two
scales for assessing suicidality, the Suicidal Ideation Scale (Beck,
Resnick, & Lettieri, 1974) and the Suicide Intent Scale (Beck et
al., 1974), to measure how seriously attempters intended to die.
In a follow-up of Finnish attempters by Suominen, Isometsa,
Ostamo, and Lonnqvist (2004), the Suicide Intent Scale was the
only predictor (among many others that were used in the study)
of completion; this finding was replicated in a study from Eng-
land (Hariss, Hawton, & Zahl, 2005).
Another scale that has been widely used in research is the
Reasons for Living Inventory (Linehan, 1983). This scale as-
sesses intent from a somewhat different perspective: factors
that make patients want to stay alive. However, none of these
scales, even those that have been shown to predict completion
with statistical significance, have been shown to be useful in
making clinical decisions about suicidal risk. In other words,
they identify populations at statistical risk, rather than the in-
dividuals who are most likely to die by suicide.
The most important factor in determining intent is the
method used (Maris et al., 2000, p. 285). A patient who shoots
10 CHAPTER 1
himself is obviously more motivated to die than one who takes

pills. But when patients overdose, the distinction between a le-
thal and a nonlethal action can be clouded by lack of knowledge
about the effects of drugs (Beck, 1974), because not everyone
knows which agents are most dangerous. Patients may over-
dose on benzodiazepines (which are rarely fatal), because the
fact that they are prescription drugs can make them seem more
dangerous than they really are. On the other hand, many peo-
ple see over-the-counter drugs as harmless. They may not real-
ize that a bottle of aspirin is enough to kill you.
Psychiatric Diagnosis and Suicide Attempts
Another factor in the risk associated with a suicide attempt is

psychiatric diagnosis. Many mental disorders are associated
with high suicide rates: Schizophrenia, melancholic depres-
sion, bipolar illness, and alcoholism all have completion rates
as high as 10% (Inskip, Harris, & Barraclough, 1998), and
borderline personality disorder (BPD) has a similar rate
(Linehan et al., 2000; Paris, 2003).
Yet although diagnosis should always be considered in as-
sessing risk, we are usually unable to determine whether the
chances of suicide are high in any individual case or at any par-
ticular moment.
Number of Attempts
Another predictor of completion is the overall number of sui-
cide attempts. A higher frequency of attempts has been con-
sistently associated with an increased lifetime risk (Welch,
2001). In the Oxford study (Zahl & Hawton, 2004), the risk
for completion after multiple attempts was 6%, twice that for
single attempts. Even so, 94% of the patients with multiple
attempts in the study did not commit suicide.
Can We Predict Completion From Attempts?

In summary, the findings reviewed here can be interpreted as
showing that the cup is either half full or half empty. The ma-
jority of people who make suicide attempts decide to live,
whereas a minority make a decision to die. Although one can
identify risk factors that make a fatal outcome more likely, it is
not possible to predict suicide completion from attempts in a
clinically useful way. Two large-scale studies (Goldstein et al.,
1991; Pokorny, 1983) that attempted to predict suicide, using
algorithms based on all the risk factors described in the litera-
ture, were unable to identify any individual case of comple-
tion. This failure was entirely due to false positives (patients
who have the risk factors for completion but who never actu-
ally commit suicide).
Why is prediction so difficult? The main reason is that com-
pletions are so rare relative to attempts. In addition, most
deaths by suicide occur at the first attempt and are not pre-
ceded by unsuccessful actions (such as overdoses). In a survey
by Maris (1981), the overall rate of suicide at first attempt was
as high as 75%, with 88% of all completions over the age of 45
being first attempts. A large-scale Finnish study (Isometsa et
al., 1996) obtained similar results, with 56% of completions
being associated with a first attempt.
Of particular relevance to chronic suicidality, attempts have
different meanings in different patients. In clinical popula-
tions, most occur during episodes of depression, which is usu-
ally either temporary or episodic. In chronic suicidality,
however, most attempts are not intended to cause death but
have an ambivalent motivation. Attempts that use nonlethal
means (e.g., an overdose of benzodiazepines taken after a
quarrel or a rejection) are particularly likely to occur in a com-
municative and interpersonal context in which significant
others find patients and/or escort them to emergency rooms.
These patients play a game of Russian roulette with fate, mak-
12 CHAPTER 1
ing death possible while leaving open the possibility that

someone will come and rescue them in time.
Why Self-Mutilation is Not

Suicidal Behavior
Of all the behaviors described in this chapter, self-mutilation
is the least related to completed suicide. In fact, this kind of
behavior should not be described as suicidal.
The literature has used multiple terms to describe this be-
havioral pattern, and this is a source of some confusion.
Favazza (1996) defined self-mutilation as the deliberate
nonsuicidal destruction of one’s body tissue. Self-injurious be-
havior (Stanley, Gameroff, Michalsen, & Mann, 2001), also
called self-injury (Osuch, Noll, & Putnam, 1999) or self-wound-
ing, is essentially equivalent. Deliberate self-harm (DSH) is a
term that has been widely used in the suicide literature. It is
defined as “the intentional injuring of one’s own body without
apparent suicidal intent” (Hawton & van Heeringen, 2000, p.
1501). Actually, DSH is a broader concept because it includes
both self-mutilation and overdoses, and this usage is a prob-
lem because it conflates nonsuicidal with suicidal actions. Re-
cently, Hawton’s group (Harriss et al., 2005) suggested
redefining the term more simply as self-harm (after consumer
groups complained that the term deliberate might be seen as
stigmatic!). Finally, parasuicide, defined as “any nonfatal,
self-injurious behavior with a clear intent to cause bodily harm
or death” (Comtois, 2002, p. 1138), is also a broader concept
that includes both self-mutilation and overdoses.
Self-mutilation is the narrowest and most clearly defined of
these concepts. It was first described in the psychiatric litera-
ture 40 years ago (Pao, 1967). Typically, the pattern involves
superficial cuts on the wrists and arms, actions not associated
with serious danger to life. Although one occasionally sees
dangerous slashes in patients who cut, most incidents consist
of either “delicate cutting” or skin-deep cuts without damage

to nerves, tendons, or blood vessels. Although the most com-
mon site tends to be the wrists, some patients will cut their
arms and legs in relatively invisible places to avoid
commentary from others.
The prevalence of self-mutilation in the general population
(including single incidents) is similar to that for suicide at-
tempts (i.e., about 4%; Klonsky, Oltmanns, & Turkheimer,
2003). But unlike attempts, this pattern does not have any
consistent relationship to suicide completion. In fact, this be-
havioral pattern can have meanings that lie outside any clini-
cal context. Thus, although self-mutilation in patients is
generally seen in young women, it has long existed in religious
groups and is also not uncommon in male prisoners (Favazza,
1996).
Although self-mutilators can go on to make suicide at-
tempts, the intent of these behaviors is distinct (Gerson &
Stanley, 2002; Winchel & Stanley, 1991). A study comparing
two groups of patients with BPD, one with suicide attempts
and the other with nonsuicidal self-injury (Brown, Comtois, &
Lineham, 2002), found that both stated that their behaviors
were usually intended to relieve negative emotions. However,
whereas suicide attempts were frequently described as in-
tended to leave others better off, self-mutilation was reported
as performing other functions: to express anger, to punish
oneself, to generate normal feelings, or to distract oneself.
This research, supported by other reports (Favazza, 1996;
Gerson & Stanley, 2002; Leibenluft, Gardner, & Cowdry, 1987;
Linehan, 1993; Simeon et al., 1992), suggests that cutting
serves a psychological function, by providing short-term regu-
lation of intense dysphoric affects. Its very success in achieving
this goal may explain why self-mutilation tends to be repetitive
and why chronic cutting can come to resemble addictive behav-
ior (Linehan, 1993). Because some patients are in a dissociated
state when they cut and feel little pain (Herpertz, 1995;
Leibenluft et al., 1987), cutting can be highly reinforcing.
14 CHAPTER 1
The main way that self-mutilation regulates dysphoria is by

providing a distracter, substituting physical for mental suffer-
ing (Linehan, 1993). This mechanism is not unique to hu-
mans: Self-injury as a response to stressful circumstances has
been observed in other species, such as dogs and nonhuman
primates (Crawley, Sutton, & Pickar, 1985).
Self-mutilation can also communicate distress to other peo-
ple (Paris, 2002a). Significant others (and therapists) will usu-
ally learn about the behavior and be alarmed by it. Although
patients may initially be secretive about self-injury or be so-
cially embarrassed by visible scars or burn marks (particularly
in the summer months), the pattern eventually comes to the
attention of other people. Gunderson (2001) also suggested
that self-mutilation can be used to express emotions in a sym-
bolic fashion: self-punishment related to guilty feelings, or a
way of expressing anger that cannot be communicated in an-
other way. Finally, self-mutilation is particularly associated
with BPD (Gershon & Stanley, 2002), a relationship that is
discussed in chapter 4.
Patterns of Suicide Completion

Completed suicide is the 11th most frequent cause of death in the
American population (Maris, et al., 2000). Although the overall
prevalence of suicide has not changed dramatically (van Praag,
2003), it does show some degree of variation over time. Thus, a
recent survey (Grunebaum et al., 2004) noted that the overall
rate of suicide in the United States increased by about 30% be-
tween 1957 and 1986 (from 9.8 to 12.9 per 100,000) and then
decreased by 13% (to 10.7) by 1999; this decrease was twice as
great in women than in men.
The explanation for changes in suicide rates over time is far
from clear, although there has been a great deal of speculation.
Moreover, responses to these statistics are not always disinter-
ested. When suicide rates go up, the press reacts with alarm,
and mental health professionals call for more action and more
resources. When rates go down (as they have recently), the

change may not even be reported in the press, whereas mental
health professionals tend to believe they reflect the
effectiveness of their work.
As discussed in chapter 5, the relationship between the
availability of treatment and the frequency of completion re-
mains controversial. We need to remain humble about the
value of our interventions: Although human resources in
mental health services have increased, making therapy more
available to the population, doing so has not markedly re-
duced the number of people who end their own lives.
From a long-term perspective, suicide rates are fairly stable
over time. One reason for this relative stability may be that
most patients who complete suicide tend either to not seek
help or to avoid it. This pattern has been identified by psycho-
logical autopsy studies in which family members are carefully
interviewed (Cavanagh, Carson, Sharpe, & Lawrie, 2003). As
already noted, most completed suicides occur on the first at-
tempt, usually because the means used are likely to be fatal.
Even among young adults, a large-scale study using psycho-
logical autopsies (Lesage et al., 1994) found that among 75
patients who died by suicide between ages 18 and 35, less than
a third were in treatment at the time of their death, fewer than
half had seen a therapist during the previous year, and a third
had never even been evaluated. In a review of 174 suicides in
young adults under age 25, Hawton, Houston, and Sheppard
(1999) reported very similar findings.
The demographics of suicide completion are notable. In al-
most all locations in the world, men are much more likely to
commit suicide than women (Maris et al., 2000). The main ex-
ception is China (Eddleston & Gunnell, 2006), where there
has recently been an epidemic of suicide among women in ru-
ral areas (related to the availability of insecticides, which are
often fatal when taken impulsively).
Suicide rates tend to increase with age, and the highest
prevalence has always been in the elderly. But in the 1960s,
16 CHAPTER 1
suicide rates in the cohort ages 15 to 24 began to increase in

several highly developed countries, including the United
States (Murphy & Wetzel, 1980), Canada (Solomon & Hellon,
1980), and Australia (Morrell, Page, & Taylor, 2002). This in-
crease in youth suicide was the subject of much discussion in
the media, and entire books (e.g., Sudak, Ford, & Rushforth,
1984) were written to explain it.
However, the overall relationship between age and suicide
completion continued to be largely linear. The increase in
youth suicide was a “blip” that has leveled out in recent years
(Maris et al., 2000). By the beginning of the 21st century, sui-
cide among the young was no more common than it had been
20 years previously, even if the problem was not going away.
Suicide completion is more common in lower socioeco-
nomic groups (Kreitman, Carstairs, & Duffy, 1991), although
this relationship may only hold for men, not women (Morrell,
Page, & Taylor, 2002). But almost all medical illnesses are
more common among the poor as opposed to the rich (Lynch,
Smith, Harper, & Hillemeier, 2004). Again, it is not clear
whether lower social class is a causal factor in suicide or the re-
sult of the mental disorders associated with completion.
The prevalence of suicide completion is definitely affected
by social context. For example, youth suicide is more common
in specific cultures, most particularly in indigenous societies,
where there have been dramatic increases in suicide and sui-
cide attempts over recent decades (Kirmayer, Brass, & Tate,
2000). These populations, which are undergoing rapid social
change associated with a disruption of traditional social struc-
tures, no longer provide meaningful roles for young people
(Paris, 1996). However, these relationships are not universal.
For example, African American populations have a surpris-
ingly low rate of completed suicide (Willis, Coombs, Drentea,
& Cockerham, 2003). Thus, the issue is not primarily one of
social disadvantage but rather one of the availability of social
roles and the strength of social networks.
Conclusions
Many types of behavior have been called “suicidal.” But few of
them are clinically useful predictors of whether people will kill
themselves. Thinking about suicide, no matter how intense
the ideation, is too common to be of any use for prediction of
risk. Attempts such as overdoses can range from the trivial to
the near-lethal, and most attempters never die by suicide.
Self-mutilation is usually more disturbing than dangerous and
should not even be thought of as suicidal behavior.
In summary, it is a mistake to treat all forms of suicidality as
if they were one problem. Nor can suicidal behaviors be man-
aged with any single tool. It has been said that if one has a
hammer, everything looks like a nail.
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Half in Love With Death

Managing the Chronically Suicidal Patient

LAWRENCE ERLBAUM ASSOCIATES, PUBLISHERS

Lawrence Erlbaum Associates, Inc., Publishers

Cover design by Kathryn Houghtaling Lacey

Library of Congress Cataloging-in-Publication Data

Paris, Joel, 1940-

Books published by Lawrence Erlbaum Associates are printed

Printed in the United States of America

Summary: Guidelines for Therapists 187

Author Index 215

Subject Index 223

Darkling I listen; and, for many a time

The Problem of Chronic Suicidality

John Keats’s poem describes a state of mind we often see in

Patients who threaten suicide in all seasons, self-mutilate, and who

Therapists lack guidelines for dealing with such problems.

dose, 20 aspirins, as a ninth-grade student, after an argument with

Challenging Conventional Wisdoms

important thing therapists have to do when treating this popu-

The Four Major Points

The Inner World of the Chronically

member ever feeling content, there can be little hope for a

What Kinds of Patients Are Chronically Suicidal?

chiatric diagnoses, such as bipolar disorder, melancholic depres-

How Not to Manage Chronic Suicidality

Suicidology is a discipline in its own right. It addresses an im-

Of particular concern, guidelines for managing suicidality

signed to prevent completion tend to reinforce the very behav-

Managing Chronic Suicidality in Therapy

This book explains why the backbone of management for the

up their suicidality. The ultimate goal of treatment is to help

How I Became Interested

As a young therapist, I often felt unsure about whether I was

learned about this form of pathology in my training but did

The Plan of This Book

Chapter 3 shows how chronic suicidality can originate in

When therapists talk to each other, they may refer to a patient

The High Prevalence of Suicidal Ideation

Are Risk Factors for Suicide Clinically Useful?

with these factors as being at risk for suicide, we would be

Clinical Implications of Suicidal Ideation

possibility of ending the pain. But if we were to treat all patients

Suicide Attempts and the Risk

Differences Between Attempters and Completers

thal methods, and to die on the first attempt. In contrast, at-

(1981) followed a cohort of repetitive suicide attempters and

How Often Do Attempters Commit Suicide?

Researchers have studied how often patients who are seen in

reflect the higher overall prevalence of suicide in Scandinavia

who made medically serious attempts, Beautrais (2003) found

The Nature of Suicidal Intent

himself is obviously more motivated to die than one who takes

Psychiatric Diagnosis and Suicide Attempts

Another factor in the risk associated with a suicide attempt is

Can We Predict Completion From Attempts?

ing death possible while leaving open the possibility that

Why Self-Mutilation is Not

of either “delicate cutting” or skin-deep cuts without damage