·

THEREACTIONS
Silverman
COUNSELING
/ RATIONAL
PSYCHOLOGIST
SUICIDE / July 2000

Rational Suicide, Hastened Death,

and Self-Destructive Behaviors
Morton M. Silverman
University of Chicago

One of the 15 major recommendations from The Surgeon General’s Call

to Action to Prevent Suicide (U.S. Public Heath Service, 1999) was to “insti-
tute training for all health, mental health, substance abuse, and human service
professionals (including clergy, teachers, correctional workers, and social
workers) concerning suicide risk assessment and recognition, treatment,
management, and aftercare interventions.” Therefore, I commend the editors
of this journal for presenting this special set of articles devoted to the topics of
suicide assessment, intervention, and prevention, as well as the role of mental
health professionals in deliberations concerning rational suicide and has-
tened death. These major contributions may well serve as the template for
other professional journals to educate their readerships about current contro-
versies, challenges, and opportunities for mental health professionals as they
engage in clinical encounters related to death and dying, dying with dignity,
and the assessment, treatment, and prevention of suicide and self-destructive
behaviors.
In this response article I will elaborate on some of the more controversial
issues raised by Werth and Holdwick (2000 [this issue]), as well as by
Westefeld et al. (2000 [this issue]). Both articles are rich in ideas, concepts,
and scientific data. I will comment on the implications of these overviews for
the training and clinical practice opportunities of counseling psychologists.
My goals are to critically analyze certain aspects of the state of the art in these
fields to stimulate and challenge thinking about working with patients who
choose to end their lives. My own training, experience, and expertise are
more focused in the fields of suicidology and the prevention of mental disor-
ders than in the areas of death and dying. Therefore I will direct more of my
responses and reactions to these areas.
Probably the most controversial area within the field of suicidology today
relates to the appropriate role for mental health professionals in decisions
about death and dying. Specifically, I refer to the concepts of rational suicide
and hastened death, and the meanings and connotations that these terms
engender. Many professional organizations have prepared statements and

THE COUNSELING PSYCHOLOGIST, Vol. 28 No. 4, July 2000 540-550

© 2000 by the Division of Counseling Psychology.

540
 Silverman / RATIONAL SUICIDE 541

guidelines in response to the need to clarify terms, concepts, professional

roles, and legal/ethical responsibilities. Among others, the American Associ-
ation of Suicidology commissioned a work group to make recommendations
to its membership regarding how to respond to this topic (Maltsberger et al.,
1996). As with many other consensus statements by professional organiza-
tions (Farberman, 1997), this committee maintained a neutral stance pending
more research, clinical experience, political action, and legal decisions.
The use of the term rational suicide to describe a rational decision and
action to end one’s own life stands in juxtaposition to the assumption that all
other lethal forms of self-destructive behavior are irrational. Until there was a
national debate about who had control and legal responsibility for a decision
to terminate life, it was generally accepted that almost all suicides were the
result of irrational thinking and behaviors (Mayo, 1998). After all, con-
sciously deciding to end one’s life is a rejection of Judeo-Christian teachings,
except in exceptionally rare circumstances. Hence, I have difficulty with the
merging of the two terms to describe a lethal behavior that is not necessarily
rational (Rogers & Britton, 1994).
Interestingly, the concept of rational suicide mainly has been discussed in
the context of chronic or terminal illness (i.e., in response to the presence of a
definable and measurable physical disorder or dysfunction). It is often the
case that these physical illnesses have altered an individual’s self-image,
self-concept, or ability to live a normal life. Some of the better known chronic
and debilitating illnesses that result in a shortened life span include, but are
not limited to, Huntington’s Disease, Alzheimer’s disease, amyotropic lat-
eral sclerosis (Lou Gehrig’s disease), AIDS, multiple sclerosis, and certain
forms of cancer. Of note is that many of these chronic, debilitating diseases
affect the central nervous system and hence can interfere with rational think-
ing, reality testing, decision-making processes, problem solving abilities,
and cognition. It therefore may not be so surprising that these diseases and
their effects on the total individual’s self-concept seem to be most often asso-
ciated with decisions regarding rational suicide and hastened death. Deter-
mining rational thinking in a potentially cognitively compromised individual
considering a rational suicide remains a challenge and a responsibility that
requires many checks and balances in the evaluative process (Rogers &
Britton, 1994).
The concept of rational suicide evolved in parallel with the incredible
technological advances within the field of medicine in the past two decades.
In short, if it were not for major advances in biotechnology, treatment modali-
ties, interventions that prolong life, and diagnostic approaches, we would not
be saving or preserving as many lives as is now routine and expected by the
general population. As more people live longer and are able to manage better
with their chronic and sometimes even debilitating illnesses, we have
542 THE COUNSELING PSYCHOLOGIST / July 2000

engaged new concepts and new emphases such as ensuring the “quality of
life.” As many of these formerly acutely devastating illnesses have become
manageable, and as more individuals have taken back “ownership” of their
own health and well-being, the healing professions have been challenged to
redefine their roles and responsibilities regarding the care and protection of
patients. Not only have the challenges come from within the doctor-patient
relationship, the need to redefine roles has been stimulated as well by rapidly
evolving technologies and scientific advancements.
We have entered an era of bioengineering, genetics, and biotechnology
that has revolutionized our understanding of susceptibility to illness, disease
progression, and our ability to effect treatment responsiveness, effectiveness,
and efficacy. In part due to an emphasis on quality of life and end of life deci-
sions, there has been renewed attention paid to the use of medication to allevi-
ate pain and the management of chronic pain syndromes. As a direct result of
individuals living longer with their illnesses and becoming more articulate
about their long-term needs in relationship to their illnesses, the field of med-
icine has broadened its traditional boundaries by incorporating approaches
aimed at better understanding the relationship between mind and body, the
role of spirituality in the healing process, and the use of alternative forms of
Western medicine.
Hence it is something of a paradox that as a result of major advances in
extending life, society is now preoccupied with ensuring that individuals
maintain full autonomy and control over decisions about prematurely ending
their lives. Of note is that the concept of rational suicide implies that the deci-
sion and action of self-inflicted death is a rational attempt to gain or perhaps
regain autonomy and control over one’s life. Are our attitudes toward death
and dying changing? (Stillion & Stillion, 1998-1999). If, in fact, we are rede-
fining our concepts of what constitutes life and what is the interrelationship
between life, living, and dying, then we may need a new vocabulary, classifi-
cation system, and nomenclature to talk with our patients and to talk with
each other about how to assess and treat our clients (O’Carroll et al., 1996).
Werth and Holdwick (2000) present suggestive survey data from many
different sources (suicidologists, clinical psychologists, professional coun-
selors, psychiatrists) that support their position that there is a “70% to 80%
acceptability rate for rational suicide and physician aid-in-dying” (p. 518).
As a clinician-scientist approaching this new challenge to traditional meth-
ods of caring for patients, I want to know how many individuals are actively
contemplating hastened death. In other words, I want to know how prevalent
the problem is and for whom the problem exists. Some studies suggest that
most individuals with terminal illnesses do not choose hastened deaths
(Lokhandwala & Westefeld, 1998; Marzuk et al., 1988).
 Silverman / RATIONAL SUICIDE 543

I want to know whether we can define the problem accurately and reliably
and what are its defining features. I want to know whether there are alterna-
tive approaches to addressing and solving the problem or whether the prob-
lem can be defined using different concepts and terminology. If, in fact, there
does seem to be a real public health problem, I want to know how many spe-
cialists need to be trained to adequately address the problem in a meaningful
way. In other words, is it necessary for all mental health professionals to be
trained as experts in the assessment and caring for those who are contemplat-
ing rational suicide or hastened death decisions? I am concerned that we need
better surveillance data and more elaborate reporting of the circumstances
surrounding requests for determining hastened death decisions to answer
these questions.
There needs to be a fuller discussion about the appropriate role of mental
health professionals as members of a broader team of health professionals
who would most likely be responsible for, or at least involved in, any decision
or action related to a hastened death. Werth and Holdwick (2000) seem to
suggest that psychologists should be trained extensively in matters related to
death and dying in order for them to participate in hastened death decisions.
The draft criteria for training and experience to be professionally competent
to act as a consultant or counselor in situations where hastened death is being
discussed encompasses general training in nine areas, specialized training
related to working with individuals who have a high incidence of morbidity
and mortality, 2 years of general postdegree counseling experience, and a
minimum of 6 months of one-half time mental health work with the popula-
tions for whom the professional will act as a consultant (Werth, 1999).
I am not convinced that it is in the best interests of graduate schools, clini-
cal training programs, practicum and internship sites, professional licensing
boards, or professional accreditation agencies to teach and train all students
and professionals for situations and careers that they probably will not
encounter on a regular basis. That is not to say that at certain times and under
certain circumstances there is not the appropriate place for the development
of expertise and experience in matters that have great importance to some
individuals. I would contend that rational suicide and hastened death deci-
sions may well be the exception rather than the day-to-day experience of
most mental health professionals.
One issue raised by Werth and Holdwick (2000) is that of who is to be the
“aid” in the aid-in-dying scenario. By definition, physicians are trained to be
healers and to treat disorders, diseases, and dysfunctions. The circumstances
surrounding rational suicide and hastened death decisions are ones that most
often fall within a medical context. Therefore, it only seems natural that the
development of expertise and experience in these matters should first fall to
the health and mental health professionals who more often interact with these
544 THE COUNSELING PSYCHOLOGIST / July 2000

patients as part of their daily professional lives. It might be prudent to seek

guidance and direction from these medical professionals regarding what
other members of the total health care team need specialized training and
expertise.
It has only been in the past quarter century that physicians have begun to
be more oriented to concepts of health promotion and disease prevention. At
a time when the public seems to be asking physicians to be more of a partner
and role model in maintaining health and promoting healthy lifestyles, it
seems somewhat ironic that physicians are being accused of not being at the
forefront of the movement toward facilitating hastened death. Nevertheless, I
believe that no one profession should seek ownership of this area of expertise.
It seems obvious from the literature that is developing in this field that multi-
ple disciplines have contributions to make in end-of-life decisions and
actions.

SUICIDE AND SELF-DESTRUCTIVE BEHAVIORS

The article by Westefeld et al. (2000) provides a comprehensive overview

of basic concepts and approaches that constitute the foundations of
suicidology. I wish to direct the interested reader toward other handbooks and
textbooks that provide fuller discussions of many of these topics. Currently,
there are a number of textbooks available that provide differing approaches to
the understanding of the suicidal process, assessing and predicting suicidal
behavior, and clinically approaching the treatment of individuals most at risk
for expressing self-destructive behaviors (Blumenthal & Kupfer, 1990;
Jacobs, 1999; Maris, Berman, Maltsberger & Yufit, 1992; Maris, Berman, &
Silverman, 2000). There are a number of professional journals that focus
almost exclusively on the topics raised in both articles (i.e., Suicide and
Life-Threatening Behavior, Crisis, Omega, Death Studies, Archives of Sui-
cide Research). In addition, there are a number of professional organizations
devoted to understanding and preventing suicide and self-destructive behav-
iors (i.e., American Association of Suicidology, American Foundation for
Suicide Prevention, International Association for Suicide Prevention). There
are also special interest organizations devoted to providing support for those
who have survived the suicide of a loved one (i.e., American Association of
Suicidology, American Foundation for Suicide Prevention, Suicide Preven-
tion Advocacy Network).
These and other organizations exist because suicide is a major public
health problem in the United States. In fact, the United States Surgeon Gen-
eral has declared suicide to be a major public health problem and one worthy
 Silverman / RATIONAL SUICIDE 545

of national attention and action. The magnitude of the problem is far greater
than the mere recitation of rates. The World Health Organization estimates
that approximately 1 million individuals worldwide die by suicide every year
(World Health Organization, 1999). It estimates that by the year 2010 there
will be 1.4 million suicides per year.
There are approximately 30,000 suicides per year in the United States.
But, suicide and self-destructive behaviors are a public health problem not
only for the United States and industrialized countries. The problem of
self-inflicted injury and death is an international public health problem
(World Health Organization, 1996). As pointed out by Westefeld et al.
(2000), there may be up to 25 times as many suicide attempts as there are
completed suicides per year (approximately 750,000 attempts per year). The
degree of morbidity associated with these suicide attempts and near-lethal
suicide behaviors is often underappreciated. What often are overlooked are
the costs to society when individuals become paraplegic, quadriplegic, brain
damaged, cognitively impaired, or physically challenged as a result of a sui-
cide attempt.
As noted by Westefeld et al. (2000), the emphasis within the field of
suicidology in the past quarter century has been on surveillance, epidemiol-
ogy, elucidation of demographics, and the statistical association of risk fac-
tors. Much work needs to be done on elaborating theories of why people
become suicidal and better understanding the immediate context that sur-
rounds the individual when they are imminently self-destructive (Jobes &
Mann, 1999; Joiner, Walker, Rudd, & Jobes, 1999).
We have just begun to develop and evaluate therapeutic modalities that
hold promise for certain individuals (Rudd, 2000). Much more needs to be
done in the development, implementation, and evaluation of effective thera-
peutic modalities (Rudd, Joiner, Jobes, & King, 1999). We need to develop
and evaluate more effective and efficient psychotherapy techniques and
interventions (Linehan, 2000). We need to better understand the dynamics of
transference and countertransference in the therapeutic setting with self-
destructive individuals (Maltsberger & Buie, 1974). More discussion needs
to take place regarding standards of care in the assessment, treatment, moni-
toring, and management of individuals at risk for self-destructive behaviors
(Bongar et al., 1998). The field of suicidology can surely benefit from the
infusion of new ideas, new approaches, and new challenges to accepted con-
structs and concepts (Silverman & Maris, 1995).
As a viable form of primary prevention, I wish to highlight the means
restriction approach (Öhberg, 1999). Empirical evidence exists to support the
notion that restricting access to lethal means of suicide does result in an over-
all reduction of deaths due to suicide (Kreitman, 1976). There does not seem
546 THE COUNSELING PSYCHOLOGIST / July 2000

to be “symptom substitution” when a specific lethal means of suicide is not

readily available (O’Carroll, Silverman, & Berman, 1994). A corollary
implication of this observation suggests that many suicides may be impulsive
and contextual. It may be that up to 30% of all suicides occur in individuals
with a history of aggression and/or impulsivity. From an injury control
model, one viable approach to preventing such a negative outcome for an
impulsive individual is to prevent access to the means by which a self-
inflicted injury will result (Silverman, 1996).
One of the most exciting research areas in suicidology today is the
neurobiology of violence and self-destructive behaviors. Not only are we
learning more about possible genetic predispositions for violent behavior; we
are learning about how environment and diet might influence how we inter-
pret and respond to external as well as internal stimuli. We are also learning
about the role of neurotransmitters and their influence on basic central ner-
vous system physiology and information processing (Stoff & Mann, 1997).
Furthermore, studies are now beginning to demonstrate the protective (and
preventive) role of medications used as primary therapeutic modalities for
the treatment of schizophrenia, bipolar affective disorder, and major depres-
sive disorder (Isacsson, Holmgren, Druid, & Bergman, 1997; Meltzer &
Okayli, 1995). These studies suggest that with the proper pharmacological
treatment of those major psychiatric disorders often associated with an
increased risk for suicide, there is a reduction in suicidal behaviors as com-
pared to those mentally ill individuals not receiving appropriate pharmaco-
logical treatment for their illnesses (Goldblatt & Silverman, 2000; Jamison &
Baldessarini, 1999).
In regard to postvention, much has been written about the role of the media
in reporting suicides. Guidelines now exist for the responsible reporting of
suicide within the community, and these guidelines are linked to protocols for
appropriate community interventions aimed at preventing the advent of clus-
ter suicides or copycat suicides (Centers for Disease Control and Prevention,
1994). I believe that it is our responsibility as mental health professionals and
public health advocates to help limit exposure of community members and
at-risk individuals to episodes of suicide in our communities. We need to
develop and implement protocols and procedures to respond empathically,
efficiently, and effectively when a suicide occurs. We need to be sensitive to
the effect that such a loss has on the survivors of the suicide and be prepared to
offer the necessary support and treatment to those most affected by the loss.
In this way postvention interventions can serve as primary prevention efforts
as well. Similar guidelines need to be developed in the future for the responsi-
ble reporting of rational suicides and hastened deaths.
 Silverman / RATIONAL SUICIDE 547

IMPLICATIONS FOR THE TRAINING AND

PRACTICE OF COUNSELING PSYCHOLOGISTS

There are multiple roles for counseling psychologists regarding the

assessment and intervention with suicidal and self-destructive individuals, as
well as with individuals struggling with end-of-life decisions. In addition to
the professional roles elucidated in the articles by Werth and Holdwick
(2000) and Westefeld et al. (2000), I believe that expertise in disease (suicide)
prevention and health promotion will prove to be highly sought-after areas of
consultation in the future. I specifically believe that an expertise in protective
factors for both suicide prevention and hastened death scenarios will prove to
be an invaluable contribution for counseling psychologists.
Measures that enhance resilience and spirituality are as essential as risk
reduction in preventing suicide, alienation, isolation, and mental illnesses.
Such measures include the following: (a) strengthening of community and
family support networks; (b) healthy family functioning and stability; (c)
religious attachment and social integration; (d) enhancing individual inter-
personal relationship skills and affect regulation (especially as it relates to
peers, coworkers, and significant others); (e) promoting positive body and
self-image; (f) fostering self-esteem and other ego strengths; (g) developing
risk assessment and risk management techniques; and (h) increasing learned
skills in problem solving, conflict resolution, assertiveness, self-control, and
nonviolent management of disputes and disagreements. Research has sug-
gested that certain coping styles are protective against self-destructive behav-
iors and promotive for interacting with one’s environment, especially in the
elderly (Botsis, Soldatos, Liossi, Kokkevi, & Stefanis, 1994; Plutchik,
Botsis, Bakur-Weiner, & Kennedy, 1996).
Prevention is predicated on prediction (Silverman & Felner, 1995a).
Much needs to be done to improve our ability to predict future violent and
self-destructive behaviors (Pokorny, 1993). We also need better screening
and diagnostic tools as well as therapeutic techniques to identify and inter-
vene with those at potential risk for the expression of self-destructive behav-
iors (Hawton et al., 1998). As Westefeld et al. (2000) point out, we need reso-
lution to our terminology and nomenclature in labeling and describing
individuals who express certain suicidal ideations and behaviors (O’Carroll
et al., 1996). Furthermore, we need to foster new insights into understanding
the suicidal mind and how individuals engage the process of death and dying
(Farberow, 1997).
Recent research suggests that certain personality disorders in adolescence
increase the risk for the development and expression of major mental disor-
ders and suicidal behaviors in early adulthood (Johnson et al., 1999). A chal-
548 THE COUNSELING PSYCHOLOGIST / July 2000

lenge is to develop techniques to modify these personality disorders and

teach individuals how to better control and modify those aspects of their per-
sonalities that can lead to negative outcomes. Counseling psychologists are
uniquely oriented to the application of preventive intervention techniques
and methodologies within a conceptual framework of growth and develop-
ment (Silverman & Felner, 1995b). It is also this framework that is invaluable
in evaluating individuals for therapeutic interventions. The appropriate diag-
nosis and treatment of mental disorders and behavioral dysfunctions may be
the best opportunity to prevent the development and expression of subse-
quent suicidal and other self-destructive behaviors as well as the circum-
stances surrounding rational suicide and hastened deaths.

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