US ARMY HEALTH PROMOTION RISK REDUCTION AND SUICIDE PREVENTION

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.d.The intention of the victim determines whether a death is classified as a suicide rather than an accident.In anequivocal case, it is difficult to evaluate the deceased s intentions, either because the factual circumstances of the deathare incompletely known, or because the deceased s intentions were ambivalent, partial, inconsistent, or not clear.e.At present there are at least two distinct questions that the psychological autopsy can help to answer(1) Why did the individual do it? When the mode of death is clear and unequivocal, the psychological autopsy canserve to enhance our understanding of the factors that lead to the act.When the mode of death is clear, but the reasonsfor the manner of dying remain puzzling, the psychological autopsy is a reconstruction of the motivations, philosophy,psychodynamics, and existential crisis of the decedent.(2) What is the most probable mode of death? When the cause of death can be clearly established but the mode ofdeath is equivocal, the purpose of the psychological autopsy is to establish the mode of death with as much accuracy aspossible.B 2.Operational criteria for the classification of suicideThe OCCS that follows were developed to provide a standard definition of suicide for purposes of conducting apsychological autopsy.a.Self inflicted.There is evidence that death was self inflicted.Pathological (autopsy), toxicological, investigatory,and psychological evidence, and statements of the decedent or witnesses may be used for this determination.b.Intent.There is evidence (explicit and/or implicit) that at the time of injury the decedent intended to kill self orwished to die and that the decedent understood the probable consequences of their actions.(1) Explicit verbal or nonverbal expressions of intent to kill self.(2) Implicit or indirect evidence of intent to die such as the following:(a) Preparations for death, inappropriate to or unexpected in the context of the decedent s life.26 DA PAM 600 24 " 24 November 2009(b) Expressions of farewell or desire to die, or acknowledgment of impending death.(c) Expressions of hopelessness.(d) Efforts to procure or learn about means of death or rehearse fatal behavior.(e) Precautions to avoid rescue.(f) Evidence that decedent recognized high potential lethality of means of death.(g) Previous suicide attempt.(h) Previous suicide threat.(i) Stressful events or significant losses (actual or threatened).(j) Serious depression or mental disorder.B 3.Motivation for suicidea.The psychological autopsy should address the motivation for suicide.The reasons, motives, and psychologicalintentions of suicidal persons are quite complex.Some of the prominent mental trends in suicidal persons are(1) A wish to escape from mental or physical pain.(2) A fantasy of eternal rest or life with a loved one.(3) Anger, rage, revenge.(4) Guilt, shame, and atonement.(5) A wish to be rescued, reborn, start over.(6) A wish to make an important statement or communication.b.Destructive ideas or impulses that are ordinarily well controlled or mostly unconscious can be activated orreleased under the influence of emotional stress, physical exhaustion, or alcohol.B 4.Role of intenta.The psychological autopsy should address the motivation for suicide.The reasons, motives, and psychologicalintentions of suicidal persons are quite complex.Some of the prominent mental trends in suicidal persons are(1) The victim s intention was ambivalent, with coexisting wishes both to live and to die.(2) The self destructive action itself was inconclusive.(3) Death followed the action after a considerable delay.b.Intention is variable in degree, not all or nothing.The concept of intention signifies that the individual under-stood, to some degree, his or her life situation and the nature and quality of the proposed self destructive action.B 5.Classification of suicides by intenta.One classification system that incorporates the notion of degree of intention and that may be used in the autopsyis as follows:(1) First degree suicide: deliberate, planned, premeditated, self-murder.(2) Second degree suicide: impulsive, unplanned, under great provocation, or compromising circumstances.(3) Third degree suicide: victim placed his or her life in jeopardy by voluntary self injury, but we infer theintention to die was relatively low because the method of self injury was relatively harmless, or because provisions forrescue were made.The victim was unlucky enough to die.b.The following are 2 other categories of self inflicted death that are not typically classified as suicide because theintention to die cannot be established.(1) Self destruction when the victim was psychotic or highly intoxicated from the effects of drugs or alcohol.Thesecircumstances suggest impaired capacity for intention.(2) Self destruction due to self negligence.This last category of death has been described as sub-intentioned death.A sub-intentioned death is a death in which the decedent plays some partial, covert, or unconscious role in his/her owndemise.Evidence for this ambivalence toward life may be found in a history of poor judgment, excessive risk taking,abuse of alcohol, misuse of drugs, neglect of self, a self destructive life style, a disregard of prescribed life savingmedication, and in other actions where the individual fosters, facilitates, exacerbates, or hastens the process of his orher dying.In terms of the traditional classification of modes of death (natural, accident, suicide, and homicide), someinstances of all four types can be subsumed under this category, depending on the particular details of each case.B 6.Lethalitya.The psychological autopsy should also address the issue of the lethality of the suicidal behavior.Although thevictim s intention to die is the factor used to classify his or her death as a suicide, the amount of lethality involved maybe used to discriminate among the various degrees of suicide.Lethality is the probability that the suicidal behaviorwould result in death.b.Consideration of the lethality involved permits an evaluation of the individual s drive to self imposed death.Allsuicides threats, acts of self harm, attempts, and completed suicides should be rated for their lethality.c.The lethality of the victim s behavior, whether or not it results in death, may be judged to be in one of fourDA PAM 600 24 " 24 November 2009 27classes: high, medium, low, or absent.This may be accomplished using the lethality Behavior Rating Scale of Suicidebelow.The numerical scale will be used to rate the lethality of the suicidal behavior of the victim.The lethality ratingwill be the number of the statement that best characterizes the suicidal act.Lethality will then be characterized as beinghigh, medium, low, or absent.d.The lethality rating derived from the scale below relates to the classification system based on degree of intentionas follows:(1) A first degree suicide would require a high lethality rating.There is no doubt as to the victim s intention to die.(2) A second degree suicide may be either rated as high or medium in lethality.The victim knew that the suicidalbehavior would likely result in death, however, the act was impulsive and unplanned.(3) A third degree suicide would be rated as being either medium or low in lethality [ Pobierz całość w formacie PDF ]

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