The suicide process and the act of suicide

Suicide is a mode of death usually consequent to a complex and multifaceted behaviour pattern. It is typically seen as the fatal outcome of a long-term process shaped by a number of interacting cultural, social, situational, psychological, and biological factors. Suicide is a rare, shocking, and very individual final act, which often leaves the survivors helpless. The suicide process model is used to organize and clarify the complexity of factors associated with suicide ( Fig 1).

Fig. 1 Risk and protective factors.

Suicide is usually preceded by years of suicidal behaviour or feelings, and plans and warnings. In about half of all suicides a previous attempt is found in the person's history, which offers, in theory, an opportunity for suicide intervention wherever suicide attempts occur. Male suicide attempts are more violent and the first attempt more likely to end in death. Particularly among males, suicide prevention ought to begin earlier in the course of the suicide process. Successful suicide prevention calls for sensitive understanding of suicidal intent and active early intervention. (3)

Various risk or protective factors underlie suicidal behaviour, and the changing balance of these helps to explain the fluctuation of suicide risk over the course of time. An appearance of suicidality means either an intensified effect of risk factors or a weakened effect of protective factors. For example, a separation from someone close may precipitate a suicidal imbalance in a vulnerable person due to the adverse life event as a stressor and the broken social network as a loss of social support.

The treating personnel and relatives of the suicide victim tend to overemphasize the meaning of the most recent events in the course of the suicide process. A precipitating factor may well be decisive in explaining the precise timing of suicide in the long course of a person's suicide process. Often, however, it also allows a simple and rational explanation in the face of the complexity of suicide. The guilt feelings of survivors are often dealt with by rationalization or projective accusations.

The choice of a specific method takes place at the very end of the suicide process and represents the last possibility to intervene. Availability is a major factor affecting this choice. Hanging is universally available and it is the most common suicide method globally. In many countries the ready access to firearms makes them potentially dangerous, especially among male adolescents and young adults. Restricting access to handguns might be expected to reduce the suicide rate of young people. Previously domestic gas was frequently used as a suicide method, and detoxfication resulted in a significant decrease in suicide rates. Restrictive availability measures may also be important in the clinical treatment of individual suicidal patients. Restriction in availability of dangerous means is a strategy based on the fact that suicidal crises are often brief, suicidal acts are often impulsive, and the long-term suicide rate of serious suicide attempts is remarkably low. (4,56,Z. and 8)

The lethality of the suicide act is related to the severity of the intent to die and the degree of mutilation caused by the act, and how quickly a method can cause death. Firearms, carbon monoxide, and hanging are active suicide methods with the highest potential to cause death. Jumping from a height or leaping in the front of a moving vehicle are more passive ways, but are also highly damaging in nature. Poisoning, drowning, or wrist cutting are typically methods which leave more time for help seeking and intervention.

Imitation means learning the use of a specific suicide method from a model which is overtly available in a culture, community, institution, or mass media. The risk of imitation emerges if an emotionally loaded suicide model is presented in detail on television. (9) Imitation may have a significant effect on the choice of a suicide method, especially at schools, in psychiatric hospital wards, and in the general population of young people. The most famous example of imitation is the effect of Goethe's novel The Sorrows of Young Werther, which was widely read in Europe about 200 years ago. The suicide of the hero was imitated to such an extent that authorities in several European countries banned the novel. The 'Werther effect' also appeared after the death of Marilyn Monroe; the suicide rate rose about 10 per cent over the next 10 days. Despite suggestions of media influence on suicidal behaviour, contradictory findings have also been presented. Recommendations for reporting of suicide have encouraged avoidance of repetitive and excessive reports, descriptions of technical details, simplified explanations for suicide, presenting suicide as means of coping with personal problems, or glorifying suicide victims. (1.0) Experiences from subway suicides in Vienna show that well-considered media guidelines changed the style of suicide reporting in Austrian newspapers, which probably led to a marked decrease in the imitation effect and consequently also in subway suicides/!1

Most suicides are solitary and private, but a few result from a pact between people to die together. Suicide pacts are exceptional, accounting for less than 1 per cent of all suicides, and their incidence seems to be declining.

Suicide always has a major impact on the survivors. Suicide is a threatening event not only among close family members, but also in the surrounding population, including treating personnel and the people at the victim's workplace. The major challenges after a suicide, in addition to a normal mourning process, are dealing with shame and guilt feelings, and the crisis of survivors. Sharing of the traumatic experience and social support should be arranged immediately and continued, if necessary, at least for the first 6 months after the suicide and with the help of mental health professionals.

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