Risk-Rescue Rating in Suicide Assessment
Avery D. Weisman, MD, and J. William Worden, PhD, Boston
The Risk-Rescue Rating is a descriptive and quantitative method of
assessing the lethality of suicide attempts. Its underlying hypothe-
sis is that the lethality of implementation, defined as the probability
of inflicting irreversible damage, may be expressed as a ratio of fac-
tors influencing risk and rescue. Five risk and five rescue factors
have been operationally defined, weighted, and scored. Illustrations
of typical high risk/high rescue, high risk/low rescue, low risk/high
rescue, and low risk/low rescue are presented, together with scoring
instructions and tables of values. Risk-rescue ratings correlate well
ONE
lethality.
OF THE urgent problems in the study of sui¬
cide is to find a reliable, quantitative measure of
Clinicians tend to divide suicide attempts into
those of patients who carry out a "serious" act and those
who "only gesture." The fact is that every suicide attempt
is serious, if we mean that a person has so few alterna¬
tives in solving problems that he must put his life in jeop¬
ardy by a self-destructive act. A second fact, however, is
that high-risk suicide attempts are not always carried out
by highly disturbed people who are, for example, suffering
from psychotic depression or schizophrenia. Nevertheless,
high-risk patients are usually sent to mental hospitals, if
their physical condition permits, while patients who un¬
dertake low-risk attempts are simply patched up, pumped
out, and sent home, especially if they deny or regret the
suicide attempt. As a rule, there is little effort to quantify
individual factors involved in the attempt, and, as a result,
clinical judgments of relative seriousness are apt to be
highly impressionistic.
There are many suicide attempts of intermediate lethal¬
ity which cannot be dichotomized easily into "gestures"
and "serious" attempts. They are difficult to assess ad¬
equately in themselves. Age, sex, self-reported intent,
psychiatric diagnosis, suicidal history, inflicted damage,
and the inherent danger of the agent or method used pro¬
vide substantive data for a judgment of seriousness but
fall short of some kind of a quantitative appraisal.
In our study of terminal illness and suicide, it became
necessary to assess the relative "deadliness" of individual
Accepted publication Aug 1, 1971.
for
From the Department of Psychiatry, Massachusetts General Hospital,
Boston.
Reprint requests to Project Omega, Suite 3F, Zero Emerson Place, Bos-
ton 02114.
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with the level of treatment recommended (none, emergency ward
only, hospital admission, and intensive care), with the subject's sex,
and whether the subjects lived or died. There is less decisive correla-
tion with age and little correlation with marital status and multiple
attempts. Taken by itself, the risk-rescue rating is not a predictive in-
strument. However, when considered along with other kinds of leth-
ality, such as that of intentionality and psychosocial involvement,
the lethality of implementation can add to the basis of individualized
suicide prognosis.
suicide attempts in order to compare the attempt of one
patient with that of another, and to establish a continuum
of lethality for several attempts made by the same pa¬
tient. Existing rating forms did not seem adequate, be¬
cause they called for information that was not always
available on intake.
There are various ways of defining lethality. Shneidman
talks about lethality as one's predisposition to kill himself
at any given time.1 For Beck, lethality is the degree of ac¬
tual physical damage one inflicts on oneself.- Others re¬
gard lethality as the intent to kill one's self while engag¬
ing in life-threatening behavior.' All of these definitions
of lethality have meaning. However, we found it useful to
distinguish three forms of lethality, instead of one. These
forms are (1) lethal intentionality, (2) implementation,
and (3) involvement. In this paper, we shall describe a
quantitative assessment of the second form, that of imple¬
mentation; this is the Risk-Rescue Rating.
A suicide attempt is a special form of life-threatening
behavior in which the probability of death is substantially
influenced by what the person does to himself and the con¬
text in which he does it. Any suicide attempt entails a cal¬
culated risk. But because any attempt must also take place
in a psychosocial context or within a specific set of circum¬
stances, survival may depend upon the resources for res¬
cue as well as upon the specific form of the attempt. For
example, jumping off a relatively high bridge into the
river beneath has about the same riskiness whether it is
done at 3 pm or 3 am. However, rescue factors are much
less if the attempt is made in the early morning hours
when it is dark and fewer potential rescuers are around
than during a busy afternoon. There are other reportable
rescue factors which may also change the calculated res¬
cue, and modify the lethality of the attempt further.
Calculations of risk and rescue factors are primarily re-
 lated to reportable observations of what happened, not to
inferences and reconstructions about what the subject in¬
tended or planned to do. Although one might presume
that a person with a high risk, low rescue attempt wanted
to kill himself more than someone with a lower rating,
this is still a conjecture which is open to dispute.
By risk, we mean the method used and the actual dam¬
age sustained during a single attempt. In our sense, the
term "risk" differs from its more general, prognostic
meaning, namely, the "riskiness" of future suicide.
By rescue, we refer to the observable circumstances and
available resources present at the time of the attempt.
Rescue, in our sense, does not include treatment. Measures
and means used to relieve a suicidal person's distress, to
restore him to health, and to thwart further attempts are
considered under the lethality of involvement.
The ratio of risk to rescue is a balance of calculated fac¬
tors related to the degree of irreversible damage and to
the resources that facilitate or hinder rescue. These two
factors, taken together, give one a judgment regarding
the lethality of implementation, ie, the estimated proba¬
bility of inflicting irreversible damage from a given at¬
tempt. From this one can assess the relative "seriousness"
or "deadliness" for a given attempt.
Risk-Rescue
Rating
Out of a number of possibilities we selected five vari¬
ables to go into an assessment of risk and five variables to
assess rescue. These variables and their definitions are
listed below.
Risk Factors.—migrent.—The agent answers the question,
"What did the person do?" We grade inherent danger of
different agents on the empirical basis that drug inges¬
tion, cutting, or stabbing, on the whole, is less likely to
cause irreversible damage than are gunshot wounds and
jumping from high places. Cases of drowning, asphyxia¬
tion, and strangulation are apt to cause intermediate de¬
grees of damage. Combinations of agents, such as ingest¬
ing drugs and leaping from a bridge, are graded according
to the most lethal agent.
Impaired Consciousness.—Impaired consciousness is
graded according to the impairment at or during the time
of rescue. Three levels of impaired consciousness are
scored: (1) None in evidence; (2) confusion and semicoma;
and (3) coma, deeply comatose. The first level means that
the subject is alert and oriented. At the second level, the
subject is somewhat disoriented, not wholly in contact,
and his verbal responses are apt to be reduced or in¬
appropriate. Coma, deeply comatose, occurs when the sub¬
ject does not respond to his surroundings, cannot speak,
and may barely react to painful stimuli.
Lesions and Toxicity Although lesions and toxicity can
be separately rated, because we are estimating only the
—
actual damage inflicted, we grade them together. Physical
lesions are scored as mild, moderate, or severe. Mild
means superficial, transient, and self-limited damage, ie,
wrist scratching without significant blood loss or abra¬
sions needing minimal care. Moderate lesions require
treatment by a physician, but are not life-threatening in
themselves. Examples are damage to smaller arteries, lac¬
erations that need sutures, and fractures of smaller bones.
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Severe lesions refer to extensive damage to larger blood
vessels, penetrating necrotizing lesions of vital organs,
or
fractures of large bones, the skull, or vertebral column,
with neurological changes.
We score ingestions, which are the chief agents produc¬
ing toxicity, according to a toxicity chart, devised by Rob¬
ert Sterling-Smith, for 30 drugs used most frequently in
suicide attempts treated at the Massachusetts General
Hospital. This chart takes into consideration what the pa¬
tient ingested and clinically calculates the potential dan¬
ger or toxicity as being mild, moderate, or severe.
Reversibility.—This factor properly belongs to the set of
intangibles called "clinical judgment." It refers to the
time of medical recovery that is anticipated when the per¬
son is first evaluated by a clinician. Good means that medi¬
cal recovery is expected to be complete within 24 hours.
Fair is a delayed recovery, but expected to be complete in
less than one week (one to six days). Poor means a ques¬
tionable recovery because significant impairment or resid¬
ual damage is likely. The six-day point was decided upon
because patients who are still in the hospital after six
days usually have damaged themselves severely enough to
require extended hospitalization and treatment. Minor
scars or fractures that will heal in time are not considered
signs of poor orquestionable reversibility.
Treatment Required—Although rescue ends when
treatment begins, we consider an assessment of the treat¬
ment required as a further judgment about the extent of
actual physical damage. Since this is a clue as to the de¬
gree of physical injury to which the patient has been ex¬
posed, it is included as an aspect of the risk assessment
rather than the rescue. Requirements may range from
first aid or other simple interventions, to hospital admis¬
sion for observation and general care, to the therapy and
management required by patients with the highest risk,
namely, special skills and facilities, such as an intensive
care unit provides.
Reversibility and treatment required apply only to
physical damage or toxicity, not to the estimated revers¬
ibility of psychiatric disorders. Concomitant psychiatric
disturbances are not included in the assessment of imple¬
mentation. As a rule, psychiatric disorders, such as psy¬
chotic depression and schizophrenia, belong to assessment
of the lethality of intentionality. Their responsiveness to
treatment also influences judgment about the lethality of
involvement.
Rescue Factors.—Although resources for rescue ob¬
viously affect a patient's chances for survival, hospital
records seldom document the circumstances of the rescue,
such as whether clues were given, the location of the at¬
tempt, or the probability of any rescue. The following five
factors were selected because they could be readily estab¬
lished, and require minimal interpretation and inference.
Obviously, there are many other factors influencing rescue
that are more subtle, but they do not lend themselves to
scoring with any degree of operational clarity.
Location— Location answers the question, "Where did
the attempt occur?" We found that three types of location
were likely to influence the Rescue: Familiar is a place
that is part of the subject's routine. Examples are resi¬
dence, office, shop, recreation site, anywhere that the sub-
 RISK-RESCUE RATING
Risk Score.
Rescue Score.
Risk-Rescue Rating
_

Patient. -Age_ .Sex_Previous Attempts.

Circumstances.

RISK FACTORS RESCUE FACTORS

1. Agent used: 1. Location:
_1 Ingestion, cutting, stabbing _3 Familiar
_2 Drowning, asphyxiation, _2 Non-familiar, non-remote
strangulation _1 Remote
_3 Jumping, shooting
2. Person initiating rescue :*
Impaired consciousness :
2. _3 Key person
_1 None in evidence _2 Professional
_2 Confusion, semicoma _1 Passerby
_3 Coma, deep coma
3. Probability of discovery by
3. Lesions/Toxicity : any rescuer:
_1 Mild _3 High, almost certain
_2 Moderate _2 Uncertain discovery
_3 Severe _1 Accidental discovery

4. Reversibility: 4. Accessibility to rescue :

_1 Good, complete recovery _3 Asks for help
expected _2 Drops clues
_2 Fair, recovery expected with _1 Does not ask for help
time
_3 Poor, residuals expected, 5. Delay until discovery :
if recovery _3 Immediate 1 hour
_2 Less than 4 hours
5. Treatment required : _1 Greater than 4 hours
_1 First aid, E.W. care
_2 House admission, routine Total Risk Points_
treatment
_3 Intensive care, special RESCUE SCOREt
treatment
1. Least rescuable ( 5-7 points)
rescue

Total Risk Points_ 2. Low moderate ( 8-9 points)

rescue
3. Moderate (10-11 rescue points)

RISK SCORE
4. High moderate (12-13 rescue points)
5. Most rescuable(14-15 rescue points)
5. High risk (13-15 risk points) *
Self-rescue automatically yields a Rescue Score of
4. High moderate (11-12 risk points) 5.
3. Moderate ( 9-10 risk points) t If there is undue delay in obtaining treatment af¬
2. Low moderate ( 7-8 risk points) ter discovery, reduce the final Rescue Score by one
1. Low risk ( 5-6 risk points) point.

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 suicide at home, but at a time when no one is expected to
Table 1.—Computation of Risk-Rescue Scores*
call, diminishes the probability of discovery, although he
Risk-Rescue uses a familiar location. Probability of discovery might
Risk Score Rescue Score Score have been greater, had he used a non-familiar, nonremote
17 location. There are three grades of probability. High, al¬
20 most certain means that rescuers are nearby, or are faced
25 with the attempt immediately thereafter. An example is a
33
50
person who cuts his wrists in the bathroom and then ap¬
29
pears in the living room where the family is sitting. Un¬
certain discovery refers to moderate probability of being
33
40
found. The attempter may not present himself to a poten¬
50 tial discoverer, even though he may be nearby. The rescue
66 is not certain; the discovery may not take place until it is
38 too late. Low, accidental is when the rescue takes place
43 only by chance, as if the subject took precautions to avoid
50 discovery.
60 Accessibility to Rescue— Risk-rescue rating does not at¬
75 tempt to determine whether a person intended to die or
44 expected to be rescued. Accessibility to rescue refers to
50 what the person did, rather than what he intended to be
57 done in response to his actions. We recognize three grades
66 of accessibility which imply some openness to rescue. Asks
80
50
for help is a clear-cut statement about despair and suicide
ideation. By calling upon another in a direct way, the sub¬
56
63 ject vastly increases his chances for rescue. Leaves clues
means that the subject has given a sign that he intended
71
83 to attempt suicide. The signs may be direct or indirect,
through notes, empty bottles conspicuously placed, even
* These
ratings have been computed on the basis of A X 100
where A risk score and = rescue score.
7<+B tangential statements to alert rescuers. Indirect signs
— such as staggering or appearing groggy might be con¬
strued as a clue. Letters mailed out but not deliverable be¬
ject would be recognized. Non-familiar, nonremote loca¬ fore the attempt are not considered clues. Does not ask for
tions are places where the person would not be recognized, help is what it suggests. Physical signs of an attempt,
but still might be identified as someone in trouble. Exam¬ such as a trail of blood, the sound of an automobile run¬
ples are subways, office buildings, bridges, public facilities. ning in a closed garage, or a pile of clothing near the rail¬
Remote places are sites where discovery cannot be counted ing of a bridge are not considered asking for help.
upon. Examples are alleys, rural roads, deserted beaches, Delay Until Discovery—This category refers to the time
and office buildings during the weekend. lapse between the suicidal act and the start of rescue oper¬
Person Initiating Rescue—A "rescuer" is someone who ations. It is an important rescue factor because treatment
initiates steps for rescue after discovering the attempt. often depends upon how promptly the person can be dis¬
People who merely transport the subject to a treatment covered. However, delay until discovery does not include
facility are not considered rescuers. Other than a self-res¬ the interval from discovery until treatment, because this
cuing person, one who delivers himself to medical treat¬ period is often determined by availability of trans¬
ment, we have three types of rescuers. A Key Person is portation, adequate treatment resources, and so forth. We
someone who knows and is known by the subject. The key use the periods of one hour or less, and four hours, as crit¬

person need not be a "significant other," ie, someone with
whom there has been a sustained and reciprocal relation¬
ship. The key person may be a professional, eg, a psy¬
chiatrist or clergyman, provided that the subject is well-
known to that person. A Professional is a person whose job
is such that he could be expected to initiate rescue oper¬
ations. This includes, generally, physicians, policemen,
bartenders, cab drivers, or telephone operators who might
be contacted by the subject. The third type of rescuer is
the passerby, someone with no regular obligation to ren¬
der service, or to initiate rescue. Examples are chamber¬
maids, parking lot or washroom attendants, and pedestri¬
ans.
Probability of Discovery by any Rescuer-This category
refers to the potential availability of any rescuer at the
time of the attempt. For example, a person who attempts
ical intervals, because less than one hour usually indicates
that available rescuers are nearby, while discovery de¬
layed beyond four hours often means that the context of
rescue is seriously compromised.
Scoring Risk-Rescue.—The risk-rescue rating is assessed
conveniently by using the form illustrated (Fig 1). The
form also includes identifying data, such as age, sex, and
prior suicidal history, and space for a brief description of
the attempt itself.
Each of the five risk factors is rated on a scale of one to
three points and the total risk points are then converted to
an overall risk score ranging from one to five. The highest
risk score is five; the lowest is one.
Similarly, each of the five rescue factors is rated on a
one to three scale and the total rescue points are con¬
verted into a rescue score ranging from one to five.

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 The risk-rescue rating is determined by the formula,
A X 100, in which A equals the risk score and
A+B
equals the rescue score. This formula provides for a trans¬
formation of scores which gives a more meaningful distri¬
bution of scores than the mere formula A. Consequently,
the lethality ratings for implementation run from a low of
17 (for a low risk score of one and a high rescue score of
five) to a high rating of 83 (for a high risk score of five,
and a low rescue score of one). Table 1 lists all the possible
risk-rescue ratings. Once a risk score and a rescue score
have been assessed, this table will provide the risk-rescue
rating according to the A x 100 formula.
A+B
Scoring Modifications.—Self-rescue, ie, delivering one¬
self to medical treatment, is automatically given a rescue
score of five.
Undue delay in obtaining treatment after discovery, re¬
gardless of how the subject is found, reduces the rescue
score by one point, ie, from five to four.
Agents not listed should be rated one, two, or three ac¬
cording to their estimated probability of inflicting ir¬
reversible damage. Combinations, eg, overdose of drugs
with jumping from a high place, are rated on the basis of
the most lethal agent.
Toxicity of commonly used drugs is derived from the
Sterling-Smith Toxicity Chart (available upon request).
In cases where there is an immediate likelihood of ex¬
tensive physical damage prior to any rescue action, ie,
jumping in front of a train or from a high building, the fi¬
nal rescue score should be reduced by one point. In sub¬
jects who are dead on admission or who are merely re¬
ferred for psychiatric appraisal, risk factor five should be
omitted.
Illustrative Cases
The following is a series of cases taken from a file of
suicidal patients to illustrate some possible combinations
of risk and rescue and to show how these modify the over¬
all lethality of implementation.
High Risk, High Rescue
Case l.-A 36-year-old woman had been drinking heavily and
arguing with her husband. She went into the bathroom and in¬
gested 25 to 90 mg of secobarbital as her husband was leaving for
the evening. Upon noticing the drugging effect, she went outside
and managed to hail a taxi and delivered herself to the Emer¬
gency Ward. Twenty minutes later she lapsed into a deep coma,
was sent to the Intensive Care Unit, and later transferred to the
general hospital for an anticipated stay of more than a week be¬
fore medical clearance.
Scoring
Risk score, 5
Rescue score, 5
Risk-rescue rating, 50
Case 2.-A 76-year-old widow living in a nursing home who
learned she had cancer stole a large knife from the kitchen. She
went out to the sun porch with the other patients, told them of her
plight, and proceeded to stab and cut herself in front of them. Al¬
though she was rescued at once she lost a great deal of blood,
lapsed into a coma, and required special care for more than a
week.
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Scoring
Risk score, 5
Rescue score, 5
Risk-rescue rating, 50
These two suicide attempts had the same score, although the
second woman's age and widowhood suggest that her intent to die
was higher than the first woman's. Regardless of these factors,
however, their lethality of implementation was the same.
High Risk, Low Rescue
Case 3.-A 21-year-old unmarried woman went to the home of
her boy friend while he was away. She ingested 70 to 100 phéno¬
barbital tablets of unknown strength and a few Doriden tablets.
During the evening, her boy friend's brother happened to call, and
noticed that she was becoming less responsive. He then brought
her to the Emergency Ward where she was admitted to the In¬
tensive Care Unit.
Scoring
Risk score, 4
Rescue score, 1
Risk-rescue rating, 80
Had high risk alone been assessed and rescue not been
considered, the ultimate seriousness of this attempt might
have been missed. The low rescue score adds to the overall
lethality of this attempt. This woman turned out to be, in
fact, quite depressed and diagnosed as a "borderline per¬
sonality." About one month later, she completed suicide in
another city.
Case 4.—A 38-year-old unmarried waitress ingested an un¬
known amount of sedative drugs, but went to a movie theater af¬
terward. Several hours later, patrons called the management's at¬
tention to her because she was in coma. Police brought her to the
Emergency Ward, where she was pronounced dead.
Scoring
Risk score, 5
Rescue score, 1
Risk-rescue rating, 83
Only four risk factors were assessed, since "treatment
required" was not applicable. Despite circumstances that
suggested a high rescuability, the actual rescue was very
low, thus increasing the lethality. Retrospective in¬
vestigation showed that she had made several previous at¬
tempts within the month prior to her death. She was di¬
vorced, lived alone, and was said to be extremely
depressed.
Low Risk, Rescue
High
Case 5.—A 48-year-old unmarried woman who lived alone in a
rooming house ingested 500 mg of phénobarbital, and then noti¬
fied friends. They came to her aid immediately and brought her to
the Emergency Ward; she walked in without assistance, and was
released within a few hours.
Scoring
Risk score, 2
Rescue score, 5
Risk-rescue rating, 29
On the surface, this attempt seemed to be a clear ex¬
ample of "suicidal gesture," or "manipulation." Actually,
she had been hospitalized several times previously because
of suicide attempts, and was diagnosed "borderline psy¬
chosis." There was a strong family history of suicide, espe¬
cially that of her brother, with whom she had a frankly in¬
cestuous relationship. She denied suicidal intention.
This case illustrates that the risk-rescue rating at a
 given moment may not accurately reflect the patient's in¬
herent "riskiness" and "suicidal disposition." However,
when the subject later made two subsequent attempts
that showed a rising lethality score, it was possible to
weigh the risk-rescue rating, along with factors related to
the lethality of intentionality such as prior attempts, de¬
fective reality testing, psychiatric diagnosis, and to send
her to a mental hospital for further management. None of
these factors alone would have been sufficient to disclose
the gathering urgency of her situation.
Case 6.-A 14-year-old girl became angry after a family spat
and ingested 14 aspirin tablets. She immediately informed her
parents who brought her to the hospital. There were no physical
symptoms, but she was offered a psychiatric appointment before
discharge.
Scoring
Risk score, 1
Rescue score, 5
Risk-rescue rating, 17
Seemingly, this was a straightforward, impulsive ges¬
ture designed to protest her parents' attitude. The lethal¬
ity score was approximately the same as in case 5, but
lacked the other lethality factors that made case 5 a far
greater suicidal risk. Once again comparison of cases 5
and 6 emphasizes that the risk-rescue rating does not
foretell the future, nor does it eliminate the necessity for
further investigation. It does permit a quantitative as¬
sessment of the immediate lethality.
'
Low Risk, Low Rescue
Case 7.—Following a barroom argument with a boy friend, a 24-
year-old woman went to a nearby beach, intending to "swim until
she couldn't swim anymore." However, a passerby noticed her in
the water and summoned the police who rescued her. She was abu¬
sive and combative, but because she had sustained no physical
damage was soon released.
Scoring
Risk score, 2
Rescue score, 1
Risk-rescue rating, 66
Low risk, low rescue cases are unusual. Most cases of
low risk are never brought to the hospital. This subject
was rated low rescue because she would not have been res¬
cued without accidental and opportune discovery by a
passerby. In short, she might have died, despite the low
risk. It is likely that people who habitually place them¬
selves in life-threatening situations may display lethality
of this kind.
Results
In order to evaluate the effectiveness of the risk-rescue
rating we applied it to 100 cases of suicide. These 100 cases
were selected at random from a total of 403 suicide cases
seen at the Massachusetts General Hospital during 1965.
The demographic characteristics of the sample were suf¬
ficiently like those of the total population to make the
sample representative (Table 2).
Ratings of these cases extended from a low of 17 to a
high of 83 with a mean rating of 40. The standard devia¬
tion was 14. Fifty percent of the cases received a risk-res¬
cue rating of 40 or below, giving a skewed distribution
around the lower end of the scale (Table 3). This finding
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concurs with our clinical judgment that the Massachusetts
General Hospital is used primarily for suicide attempts of
low and low moderate lethality, while cases of higher leth¬
ality are either taken to other hospitals or to the mortuary
as dead on arrival.
The risk-rescue rating significantly discriminated at¬
tempts by sex, in that men had higher scores than did
women (Table 4).
Of the two main variables, risk and rescue, risk is the
stronger discriminator by sex, in that men tended to carry
out riskier acts. Although there was more homogeneity
between men and women on the five rescue variables, men
also did things in a slightly less rescuable context.
The risk score taken alone was a better discriminator of
age than was the risk-rescue rating. This suggests that
older subjects carried out riskier attempts, a fact that cor¬
responds with other studies.' The rescue score did not sig¬
nificantly correlate with age, suggesting that the circum¬
stances of an attempt for an older person favor rescue
neither more nor less than those for younger people. Ob¬
viously, there are many other factors related to circum¬
stances, as well as to intentionality and psychosocial in¬
volvement, which are not measured by the risk-rescue
rating, and these might discriminate more clearly be¬
tween age groups.
The treatment received by subjects studied ranged
from none, to first aid emergency treatment only, to hos¬
pital admission for routine observation and treatment, to
special care in intensive care units. Risk-rescue rating cor¬
related significantly with the level of treatment received.
While the risk score correlated .56 with level of treatment
received and the rescue score only .07, a multiple R yields
a correlation of .67, suggesting that the rescue factor may
be acting as a suppressor variable with respect to risk. '
Risk-rescue rating also discriminated significantly be¬
tween those who were alive or dead after a suicide at¬
tempt, and did so better than either risk or rescue taken
alone. It did not, however, distinguish between those who
were known to be multiple attempters and those who were
not. In other words, multiple attempters did not cluster at
either end of the lethality scale. We are currently study¬
ing a subgroup of multiple attempters to distinguish char¬
acteristics of attempts whose risk-rescue ratings over
time tend to ascend, descend, remain on the same lethal
level, or show a mixed pattern.
Interrater reliability coefficients can be found in Table
5. Besides the common-sense appeal of the risk-rescue rat¬
ing, we found that scoring could be easily taught to un¬
trained people, and most important, is not subject to the
vagaries of overall clinical judgments and the idiosyncra¬
sies of different clinicians. Table 6 contains information
on item-total reliability.
Comment
The risk-rescue rating seems to be a good descriptive
measure for discriminating between suicide attempts, es¬
pecially those of intermediate lethality. It has face valid¬
ity and correlates with other clinical and empirical judg¬
ments. (A subsequent study of 25 patients admitted to the
MGH psychiatric ward in 1970 shows that the risk-rescue
ratings done on these patients correlates .66 with an inde-
 Table 2.—Characteristics of Patient Sample pendent clinical judgment of the intent to kill themselves,
made by a staff psychiatrist (rated high, moderate, low),
% (N =
100) and a .60 with Aaron T. Beck's Medical Lethality scale.
Sex For an of 25 cases, a correlation greater than .49 would
Male 34 discriminate significantly at the .01 level.) But what about
Female 66 its use in predicting future attempts?
Age No suicidal rating scale yet devised is applicable to all
0-10 0
10-19 populations." ' Naturally, rating scales are largely based
upon the patient population with which investigators are
20-29_30
30-39 23 most familiar. Patients who have been in mental hospitals
40-49 Ï8~ may have different predictive criteria than people who
50-59 Ï2~ have been working in the community prior to their at¬
60-69 5 tempts. Patients who have been in prior psychotherapy
70-79 ~T may also have different predictability for suicide than
80+_3_ people who have had no contact with health professions or
Ethnic
White 100
agencies. For large groups of attempters, age and sex are,
Black ( perhaps, the most reliable indices for predicting future at¬
Marital Status tempts. Yet these factors alone are unlikely to be helpful
Single 36 for the clinician who must deal with individual patients in
Divorced 7 specific situations. He needs information that will help
Separated him decide about an individual prognosis. He is less con¬
Widowed cerned about the predictability of selected factors for
Married 44 groups of suicidal subjects.
Type of Treatment The most important considerations in the diagnosis,
No medical treatment
52
management, and prognosis of suicidal patients are in¬
Emergency ward only
House admission 28
tentionality, implementation, and resources for post-
Special care 13 attempt correction. At the present time, we refer to re¬
Living/Dead
sources as "psychosocial involvement," or more tersely,
Dead 5 "involvement." Shneidman calls postattempt resources
Living 95 and activities "post-vention," analogous to "prevention"
Multiple Attempter and immediate "intervention."1 Taken by itself, the risk-
No_64_ rescue rating is a descriptive and quantitative assessment
36" of a specific attempt that correlates well with clinical
judgments and which requires the clinician to heed rescue
factors more carefully. When considered along with the
other two dimensions of lethality, those of intentionality
and involvement, the risk-rescue rating might acquire
more predictive significance. However, its chief impor¬
tance at present is that it enables the clinician or in¬
Table 3.—Risk-Rescue Ratings For 100 Suicide Cases vestigator to evaluate the lethality of multiple attempts
by the same individual over time, and to compare differ¬
Males Females Total ent subjects with respect to their actual attempts. For ex¬
Rating_% (N =
34) % (N =
66) % (N =
100) ample, a subject may make repeated attempts using
83 0_ 1 1 ~

short-acting barbiturates in approximately the same

80 0 0 amounts. However, if we have a means of assessing the
75 0 0 0 circumstances of successive attempts, the diminished res¬
11
66
2
0
0
1
2
1
cue potential might be clearer. An initial ingestion may
occur in a familiar place with a member of the family at
63 4 0 4
2~ 0 2
hand for rescue without delay. In a later attempt, the sub¬
60
57 1 4 5 ject might check into a motel under an assumed name,
56 112 and, while ingesting the same amount of the drug, vastly
50 5 8 13 diminish his chances of rescue and treatment.
44 1 3 4 We suggest that suicide prognosis might be expressed
~~43 6~ 7 13 as an integral equation, S„ =
1( + , + ,, where Sp =

40 2 4 6 suicide prognosis, , =
lethality of intentionality, , =

38 1 9 10 lethality of implementation, and ;, =

lethality of in¬
33 2 4 6 volvement. This formula is based upon the theory that sui¬
29_6_11_170 cide is a product of different kinds of lethalities or systems
25 0
_0_ of interaction between fields and forces. It is incorrect and
20_0_1 12
_113
misleading to speak of either suicidal choice or suicidal
17 1
caw.se, or to ask why someone chose to attempt suicide, or

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 Table 4.—Correlation of Demographic and Sociologie Variables With Risk-Rescue Rating (N =
100)
Variable Risk Score Rescue Score Risk-Rescue Rating Multiple R*
Sex(M =
0, F=l) -.30t .22 -.27t .23t
Age .24* .01 .19 .27t
Level of treatment! .56t .07 .71t .67t
Living/Dead (L = 1, D 0) .35t .35t .38t .40t
Multiple attempter
—

-.07 .12 .01 .19

*
Multiple R of risk score and rescue score against the criterion variable.
t P<.01.
<.05.
S Levels of treatment are (1) no medical treatment; (2) emergency ward only; (3) House admission; and (4) special care.

what caused him to do so." The many answers that are

Table 5.—Interrater Reliability Coefficient For
given often seem to reflect the investigator's preconcep¬ Risk-Rescue Rating
tions about suicide, rather than a careful assessment of
different contributor lethalities. Risk Rescue Risk-Rescue
We must emphasize that appraisal of lethality for an at¬ Score Score Rating
Between raters A and .90 .94 .95
tempt is only partially based upon the risk-rescue rating. Between raters A and C .88 .78 .93
A more comprehensive assessment of psychosocial in¬
volvements and personal intentionality is also required.
We are currently developing assessments for these other Table 6.—Item Total Reliability
forms of lethality. More subtle implementation factors,
such as the interaction between the subject and his res¬ Risk Rescue Risk-Rescue
Score Score Rating
cuers, or the significance of the agent used in his prior sui¬ .08 —.43 .17
Risk factor 1
cidal history, belong to additional assessments of in¬
Risk factor 2 ÜB2 -.41 ?79~
tentionality and involvements. Risk factor 3 ?75 -.18 !66~
How any clinician forms global judgments about sui¬ Risk factor 4 5 -.39 J9~
cidal ideation, implementation, and prognosis is difficult Risk factor 5 Hi -.14 .49
to substantiate without careful analysis of the kinds of Risk score 1.00 -.47 .91
symptoms and signs, latent and explicit, which the subject Rescue factor 1 —.06 .35 —.23
presents. Feinstein" has described how the so-called "art" Rescue factor 2 —.19 A3 —.37
of clinical judgment is a product of reasoning based upon Rescue factor 3 —.44 .63 —.64
experience and selective preference. Most clinical judg¬ Rescue factor 4 -.54 ?76 —.72
ments are both descriptive and prognostic, and their accu¬ Rescue factor 5 —.30 .66 —.54
racy depends upon sets of independent variables. Some Rescue score -.47 1.00 -.80
clinicians approach the problem of suicide prediction by
sweeping judgments based upon intuition, while others relates well, is not sufficient. Practical assessment re¬
confine themselves to only a few factors, such as presence
of psychosis, explicit wish to kill oneself, the method em¬
quires that we have operational methods for distinguish¬
ing lethal forces in living people. The risk-rescue rating is
ployed, or the extensiveness of the injury sustained. Our a step forward towards that objective.
impression is that overall assessment of prognosis, while
largely inferential, is usually based upon (1) explicit in¬ This study was supported by the Center for Studies of Suicide Pre¬
tent to die, (2) past history of mental disturbances or sui¬ vention, National Institute of Mental Health grant No. MH 15903.
Robert Sterling-Smith, MA, and Lee C. Johnston, MA, helped in data
cide attempts, (3) details and extent of physical damage, gathering, data processing and the coordination of material.
and (4) resources in community for providing appropriate
support and treatment. Nevertheless, there is little uni¬ References
formity in prognosis and management of suicide at¬ 1. Shneidman ES: Suicide, lethality, and the psychological au-
tempts, except for subjects on either end of the lethality topsy. Int Psychiat Clin 6:225-280, 1969.
2. Beck AT, Greenberg RL: The nosology of Suicidal phenom-
spectrum—subjects with very low lethality attempts are ena: Post and future perspectives. Bull Suicidology, to be pub-
sent back into the community, while subjects with very lished.
high lethality attempts are transferred to mental hospi¬ 3. Farberow NL, Shneidman ES: The Cry for Help. New York,
McGraw-Hill Book Co Inc, 1961.
tals. Yet there may be great discrepancy, as our examples 4. Prevention of Suicide, Public Health Papers, No. 35, Geneva,
indicate, between the degree of lethal intentionality and World Health Organization, 1968.
that of lethal implementation. 5. McNemar Q: Psychological Statistics, ed 4. New York, John
Our hypothesis about different kinds of lethality of Wiley & Sons Inc, 1969, p 210.
6. Neuringer C: Methodological problems in suicide research. J
which implementation is only one enables investigators Consult Psychol 26:273-278, 1962.
7. Rosen A: Detection of suicidal patients: An example of some
to separate the task of assessment into retrospective ex¬ limitations in the prediction of infrequent events. J Consult Psy-
amination of intentionality, and prospective appraisal of chol 18:397-403, 1954.
resources, involvement, that might help in forestalling 8. Weisman A: "Is suicide a disease?" Life Threatening Behav,
to be published.
later attempts. The unequivocal distinction between the 9. Feinstein A: Clinical Judgment. Baltimore, Williams & Wil-NN
living and the dead, with which the risk-rescue rating cor- kins Co, 1967.

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