Intoxicated Offenders and Suicide Threats: Is There a Connection?
Intoxicated Offenders and Suicide Threats: Is There a Connection?
By Tony Salvatore, M.A.
Mr. Salvatore coordinates suicide prevention and postvention at Montgomery County Emergency Service in Norristown, Pennsylvania.
State and municipal police officers often have encountered the co-occurrence of excessive drinking and suicide threats. Communication of suicidal thoughts, primarily from males, accompanied many of the 2.5 million alcohol-related arrests in the United States in 2009. Men accounted for the majority of these arrests and were more apt than women to engage in heavy use of alcohol. Statistically, males comprise 79 percent of suicides in the nation and are four times more likely to complete suicide than females.
Suicide threats, often contrived, sometimes are dramatic. Frequently, these threats occur in situations that result from consumption of large quantities of alcohol. They may emerge in conjunction with a traffic stop, in the course of an arrest, from the backseat of a patrol car, or from inside a holding cell. Certain key factors appear to be involved—individuals attain a high blood alcohol level affecting their mood, physical ability, and mental prowess, resulting in police intervention and restriction of liberties.
Repeated exposure to manipulative “suicide talk” often exhausts and frustrates law enforcement officers and sometimes leads to decreased vigilance. Agencies must educate their officers on the suicide risk involved with excessive drinking, the relationship between this risk and suicide threats, and the motivation for such threats.
Numerous individuals who commit suicide have high blood alcohol levels….
Numerous individuals who commit suicide have high blood alcohol levels; thus, some research has correlated alcohol abuse and suicide risk. It is estimated that 40 percent of alcohol- dependent individuals attempt suicide, and 7 percent complete the act. People with high alcohol use have a suicide risk factor five times greater than that of social drinkers. Seemingly, alcohol dependence may be a compelling contributor to completed suicide.
A suicide threat is “any interpersonal action, verbal or nonverbal, without a direct self-injurious component, that a reasonable person might interpret as...communicating that suicidal behavior might occur in the near future.” They may convey suicidal intention, involve no intent, or be unclear as to a plan. Spontaneous suicide threats tend to be verbal, direct, and unambiguous (e.g., I am going to kill myself), as opposed to indirect and ambiguous (e.g., I cannot take it anymore).
These threats have the power to evoke a response, whether or not suicidal intention is present. Often the goal is to alter the behavior of the information recipient. However, all suicide threats connote the possibility of suicidal behavior, and law enforcement officers must take them seriously. The nature of a threat indicates whether there also is intent. Two threats serve as examples: 1) I am going to kill myself tonight, and 2) I will kill myself tonight if I go back to jail.
The first is an unconditional statement with a definite timeframe. It is a noncontingent threat that is passive and does not include any demands. Noncontingent threats indicate a high risk of suicide. These tend to be associated with acute suicidality, while contingent threats often link to chronic suicidality.
The second declaration is conditional and sets the terms for implementation of the intent. This is a contingent suicide threat that may be dramatic and predicated on secondary gain to the individual. Often, there is a link between these threats and substance dependence, criminal justice contact, and low suicide risk.
Acute vs. Chronic Cases
Law enforcement officers often encounter individuals who are expressing suicidal thoughts or are attempting to commit suicide.
Many studies of suicidal behavior in individuals who abuse alcohol focus on acute suicidality—the near-term risk (i.e., minutes, hours, or days) of completing a potentially lethal suicide act. Less information is available on other types of suicidal behavior in alcohol abusers.
Acute suicidality often follows an overwhelming psychosocial stressor and indicates imminent danger. The Interpersonal Psychological Theory of Suicide provides insight into acute suicidality. This theory posits that a potentially fatal suicide attempt requires a strong desire to die and the capability for lethal self-harm. An intense volition for death comes from personal beliefs of burdening, not belonging to, or not connecting with family and friends. When individuals cannot fulfill expectations or obligations, they may develop a sense of burdensomeness and see themselves as a liability to others.
An unmet need for social relationships and the perception of not being cared about by others sometimes results in feelings of lack of belongingness. Alcohol abuse often contributes to this perception through weakened interpersonal relationships, hopelessness, and other stressors. Any combination of these factors may evoke a desire to die; however, more than a wish to end one’s life is necessary for a suicide to occur.
An individual must be capable of ending life, which requires overcoming fear, pain, and the instinct for self-preservation. This capability may result from abuse, victimization, trauma, or a history of violence. It also may stem from past attempts and repeated mental practice of a suicide plan. An alcoholic lifestyle provides opportunities to become acclimated to fear through physical threats and to pain from assault and other victimization. Alcohol influences judgment, impulse control, and consequence perception.
Chronic suicidality involves a range of behaviors, including repetitive suicide threats, with no evident intent to die. There may be a vague plan (e.g., I am going to hurt myself) or methods (e.g., I am going to take something) or no plan at all. These threats provide a sense of control.
Chronically suicidal persons usually experience a sense of burden. They feel abandoned, rejected, betrayed, or uncared for, or think that the world would be better without them. These individuals sometimes develop a desire to die. They acquire the capacity to complete suicide over time through recurring threats and thoughts given to developing such scenarios.
Alcohol use, combined with law enforcement contact, increases suicide risk, especially in men.
Various schemas attempt to explain why an individual in a stressful situation, created or aggravated by excessive drinking, resorts to dramatic suicide threats as a coping strategy. The premise of the Reactive Aggression Model is the interaction of four outcomes of alcohol abuse: 1) interpersonal relationships are at risk, 2) problem solving and the ability to foresee the consequences of behavior are impaired, 3) impulsivity and aggressiveness are heightened, and 4) angry responses to perceived threats are facilitated. Alcohol-induced contingent threats are aggressive acts committed in reaction to distress over a lost or threatened relationship.
The Entrapment Model alleges that an alcohol abuser is sensitive to external cues of humiliation, blame, or shame. These individuals believe that relief from these negative self-perceptions is impossible and that the situation will persist. This sets the stage for a “suicidal crisis” escape, consisting of contingent threats.
The Self-regulatory Model explains suicidality as rooted in a desire to escape negative self-awareness and unpleasant emotions. Adverse personal decisions or occurrences may cause individuals to see themselves as unacceptable or intolerable. Self-awareness is minimized to allow escape from self to avoid negative self-comparisons that weaken inhibitions against suicidality and are expressed as impulsive suicide threats.
According to the Looming Vulnerability Model, some individuals possess a cognitive style that creates scenarios of rising danger in response to anxiety. These people acquire a processing bias that leads to catastrophization of stress. The resulting emotional distress produces unbearable desperation and urgency that leads to drastic actions, such as contingent suicide threats.
Overall, alcohol narrows perception, reduces inferential thought, and decreases awareness of optional problem solutions. Individuals engrossed in “alcohol-induced myopia” focus on the immediate situation, with reduced sensitivity to the negative consequences of their actions. This is conducive to “all-or-nothing” responses, such as threatening suicide.
Law enforcement officers often encounter individuals who are expressing suicidal thoughts or attempting to commit suicide. Through training or on-the-job experience, many officers learn how to deal with suicidal people. However, heavy alcohol consumption by these individuals complicates the situation.
Using alcohol aggravates a suicidal episode by diluting the personal protective instincts necessary to prevent suicide completion and amplifying factors that heighten the risk. Drinking increases suicide risk by promoting depressive thoughts and hopelessness; removing psychological barriers to lethal self-harm; increasing impulsivity, fearlessness, and risk taking; inducing cognitive constriction (either/or thinking); limiting access to family support; and impairing understanding of behavioral consequences.
When officers encounter individuals who are threatening suicide during, after, or while recovering from heavy drinking, they should remember several important points.
1) Give the person the benefit of the doubt. The individual may only be making empty threats, but alcohol abusers possess several suicide risk factors and should be treated as high risk for potentially lethal self-harm.
2) Serious suicidal behavior is possible in the advanced stages of alcohol abuse when the person is becoming socially marginalized, suffering health complications of alcoholism, and experiencing a loss of important relationships.
3) Early sobriety is a high-risk period for alcohol abusers because cognitive clarity improves, and the potential to act on intent and plan increases. The danger of suicide may intensify as the individual becomes aware of the legal consequences of excessive drinking.
4) Basic intervention and negotiation techniques that rely on communication and questioning may prove ineffective. Acute alcohol use limits attention, comprehension, and the ability to follow through on coping and problem-solving efforts.
Officers should consider that chronic alcohol abusers have spent time thinking about suicide, may have attempted or planned it, and probably know others who have completed it. These individuals are “suicide ready” and quickly able to progress from low to imminent risk. They should be observed, denied access to anything they can use for self-harm, and quickly transported to a hospital emergency room or crisis center for evaluation.
Until specific tools for addressing contingent suicide threats exist, officers must use vigilance to ensure safety and minimize liability when encountering intoxicated offenders who voice such threats. Alcohol use, combined with law enforcement contact, increases suicide risk, especially in men. A study of suicide victims found that increased risk was associated with prior police encounters, even among those never convicted or incarcerated. It is important to note that even in the absence of intent to die, increased suicide risk may occur in individuals who repeatedly make contingent threats because this behavior progressively erodes their resistance to lethal self-harm. Finally, it is crucial to remember that the first rule of suicide prevention and intervention is to act.
 U.S. Department of Justice, Federal Bureau of Investigation, Crime in the United States September 2010, www2.fbi.gov/ucr/cius2009/data/table_37.html (accessed March 23, 2013).
 Substance Abuse and Mental Health Services Administration, Office of Applied Studies, The NSDUH Report: Gender Differences in Alcohol Use and Alcohol Dependence or Abuse 2004 and 2005 (Rockville, MD, August 2007).
 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, “Web-based Injury Statistics Query and Reporting System (WISQARS) 2007,” www.cdc.gov/ injury/wisqars/index.html (accessed March 23, 2013).
 L. Sher, “Alcohol Consumption and Suicide,” Quarterly Journal of Medicine 99 (2006): 57-61; and M. Pompili, G. Serafini, M. Innamorati, G. Dominici, S. Ferracuti, G. Kotzalidis, G. Serra, P. Girardi, L. Janiri, R. Tatarelli, L. Sher, and D. Lester, “Suicide and Alcohol Abuse,” International Journal of Environmental Research and Public Health 7 (2010): 1392-1431.
 L. Sher, “Risk and Protective Factors for Suicide in Patients with Alcoholism,” Scientific World Journal 6 (2006): 1405-1411.
 E. Harris and B. Barraclough, “Suicide as an Outcome for Mental Disorders: A Meta-Analysis,” British Journal of Psychiatry 170 (1997): 205–228.
 A. Beck and R. Steer, “Clinical Predictors of Eventual Suicide: A 5- to 10-Year Prospective Study of Suicide Attempters,” Journal of Affective Disorders 17 (1989): 203–209.
 M. Silverman, A. Berman, N. Sanddal, P. O’Carroll, and T. Joiner, “Rebuilding the Tower of Babel: A Revised Nomenclature for the Study of Suicide and Suicidal Behaviors Part 2,” Suicide and Life-Threatening Behavior 37, no. 3 (2007): 264-277.
 S. Goldsmith, Reducing Suicide: A National Imperative (Washington, DC: National Academies Press, 2002).
 M. Lambert, “Seven-Year Outcome of Patients Evaluated for Suicidality,” Psychiatric Services 55, no. 1 (2002): 92-94.
 T. Joiner, Why People Die by Suicide (Cambridge, MA: Harvard University Press, 2005).
 Sher, “Alcohol Consumption and Suicide.”
 Joiner, Why People Die by Suicide.
 P. Smith and K. Cukrowicz, “Capable of Suicide: A Functional Model of the Acquired Capability Component of the Interpersonal-Psychological Theory of Suicide,” Suicide and Life Threatening Behavior 40, no. 3 (2010): 266-275.
 N. Madhabika, A. Lown, J. Bond, and T. Greenfield, “Lifetime Victimization and Past-Year Alcohol Use in a U.S. Population Sample of Men and Women Drinkers,” Drug and Alcohol Dependence 123, no. 1-3 (2012): 213-219.
 J. Paris, Half in Love with Death: Managing the Chronically Suicidal Patient (Mahwah, NJ: Lawrence Erlbaum Associates, 2006).
 J. Paris, Half in Love with Death: Managing the Chronically Suicidal Patient.
 K. Conner and P. Duberstein, “Predisposing and Precipitating Factors for Suicide Among Alcoholics: Empirical Review and Conceptual Integration,” Alcoholism: Clinical and Experimental Research 28 (2004): 6S-17S.
 T. Ellis and B. Rutherford, “Cognition and Suicide: Two Decades of Progress,” International Journal of Cognitive Therapy 1, no. 1 (2008): 47-68.
 R. Baumeister and K. Vohs, Handbook of Self-regulation (New York, NY: Guilford Press, 2011).
 J. Riskind, N. Williams, and T. Joiner, “The Looming Cognitive Style: A Cognitive Vulnerability for Anxiety Disorders,” Journal of Social and Clinical Psychology 25, no. 7 (2006): 779-801.
 C. Steele and R. Josephs, “Alcohol Myopia: Its Prized and Dangerous Effects,” American Psychologist 45, no. 8 (1990): 921-933.
 Pompili, et.al, “Suicide and Alcohol Abuse.”
 D. Daley, Understanding Suicide and Addiction (Center City, MN: Hazelden Foundation, 2003).
 M. Hufford, “Alcohol and Suicidal Behavior,” Clinical Psychology Review 21, no. 5 (2001): 797-811; and D. Daley, Understanding Suicide and Addiction.
 R. Webb, P. Qin, H. Stevens, P. Mortensen, L. Appleby, and J. Shaw, “National Study of Suicide in All People With a Criminal Justice History,” Archives of General Psychiatry 68, no. 6 (2011): 591-599.
 Joiner, Why People Die by Suicide.
 P. Quinnett, Counseling Suicidal People (Spokane, WA: The QPR Institute, 2000).