IDAS process

1 hour awareness workshop

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Cécile Bardon, Ph.D.

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(c) Bardon C. 2025

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Objectives

• Increase awareness of MAS in students with autism or ID
• Introduce the suicide prevention continuum and IDAS process
• Briefly present screening tool
• Explore needs for Suicide prevention continuum implementation

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Understanding suicide risk in young people with autism or ID

The dynamic model of suicide

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Types of MAS

• Thoughts (not observable or communicated)
• Verbal communications
• Non verbal communications

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• Self-aggressive behaviours without injury
• Self-aggressive behaviours resulting in injury or death

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Specificities of MAS in youth with autism or ID

• Communication
• Understanding of death
• Cognitions (including restricted interests)
• Emotions (understanding)
• Role of parents and adults
• Recurrence

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Specificities of autism or ID

Youth with autism

• Memory of facts/thinking in images
• Hypersensitivity and intensity of émotions: all or nothing
• Rapid escalation
• Lack of understanding of emotions
• Neocortex (high-level abilities) communicates/connects little with the limbic system (primitive emotional brain)
• Consequence: less power to influence emotions when thoughts intrude
• Interferes with the “thinking and reflecting” brain’s ability to influence emotions
• Contributing factors
• Non-acceptance and recognition of diagnosis; Depression following anxiety symptoms; Avoidance of social situations and isolation; Control and rigidity ; impulsivity ; Obsessive routines and rituals ; Irrational beliefs (false ideas contrary to reason) ; Self-medication (alcool and drugs) ; Unsuitable environment ; History of depression/anxiety in the family ; Psychological/psychiatric comorbidities ;History and experience of repeated failure ; Sensory sensitivities ; Depressive symptoms described in 66% of people with autism ; Difficulties in naming and expressing émotions: alexithymia ; Difficulties in recognizing associated symptoms ;Tendency towards emotional escalation

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Youth with ID

• High rates of aggressive behaviour in people with ID and depressive symptoms
• Aggression is often the common final trajectory of distress expression
• Aggression or self-harm can be manifestations of distress
• People with ID may experience shame related to distress.
• Shame can contribute to the development and maintenance of psychological distress and mental health disorders in adults with mild to moderate ID
• Strong desire for “normalcy”
• Stigmatizing experiences can have a negative impact on their sense of self and emotional well-being

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Dynamic model of suicide in individuals with autism or ID

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The dynamic model of suicide

• Based on the integrated motivation-volition (IMV) model of suicide
• Based on existing research
• Validated with autistic-ID people in Québec

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O'Connor, R. C., & Kirtley, O. J. (2018). The integrated motivational–volitional model of suicidal behaviour. Philosophical Transactions of the Royal Society B: Biological Sciences, 373(1754), 20170268.

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Essential skills for suicide prevention in young people with autism or ID

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Understanding danger in people with autism or ID

• Distinguish suicidal planning from suicide attempts:
• Not so necessary,
• As long as the means envisaged to attempt suicide present a very low danger and there is time to interact with the person
• As long as we understand that the person is suffering and we deal with their distress with them

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• Precision – when we talk about danger:
• Danger of the behavior for the person’s safety
• Understanding the level of danger can affect the assessment (e.g., the person who eats grass thinking it’s dangerous)
• assessing danger: reference to the term used in short tools used for the general population
• Assessment of danger is important to ensure safety but absence of immediate danger does not mean low distress

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Additional clues for identifying people at risk

• When a person does not clearly express suicidal ideations or when verbal clues are difficult to understand
• When factors associated with suicide are present
• Can become indicators of suicidal risk in the absence of clearly identifiable behaviors/proposals
• When changes in the person’s usual behavior can be observed

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Changes and manifestations associated with suicide behavior in MAS :

• Behavioral: changes of behavior (for better or worse, agitation or lethargy, amplification of usual disruptive behavior, increase in substance use or compulsive behaviors, isolation, increased need of help, absenteeism
• Somatic : The appearance or worsening of physical or digestive troubles, back pain, headaches, etc.
• Neurovegatative: Degradation of sleep, of appetite, of the level of energy 
• Sign of hopelessness: Negative talk about the future, discouragement, resignation, devaluing of the self, cessation of treatment, refusal of follow up or absences, refusal of offered help

• Cognitive : confusion, difficulty concentrating, indecision
• Emotional : changing moods, mood swings, Manifestations of sadness, of anger, of irritability, increased worry towards future events, anxiety, increased aggressivity, dissatisfaction, disappointment, fears or insecurity about a situation, feelings of incompetence
• Psychiatric : increase in symptoms 
• Loss of abilities / knowledge and difficulties in adapting to the current situation : stagnation ou regression

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Ambivalence and suicidal intent

• It an be very difficult to assess whether there is intention or not
• The search for a clearly articulated intention may taint clinical judgment, encourages minimization of suicidal risk and failure to intervene adequately
• Even in the general population, the intention may not be clear, even to the suicidal person him/herself
• Ambivalence between living and dying is always present and modulates the intention
• High impulsivity may provoke a suicide attempt, without intention or perceptible planning

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Hope and hopelessness

Three triads of hopelessness

Suffering is:

• Interminable, unacceptable, unbearable (Shneidman, 1976)
• Interminable, unavoidable, intolerable (Chiles & Strohsahl, 1995)
• Negative perception of the suicidal person(Beck et al., 1975) :
• Of themselves
• Of those around them
• Of their future

Remember that:

• Ambivalence is always present between hope and hopelessness
• The person has reasons for living: explore reasons for living more than reasons to die
• It’s all about opening a breach in hopelessness through appropriate intervention!
• Hope ≠ distraction

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Collecting information

• Vary the sources of information and do not neglect direct observation of the person and his behavior (e.g. attitude, body language, emotions, observable changes)
• Remain cautious with the perceptions and analyses of cloe persons and caregivers
• Important to recap and summarize what the person is saying
• Allows for adding more details or clarifications
• Allows the person to agree or disagree with the care worker’s interpretation

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The care worker attitude towards the person

Facilitating MAS exploration

• Caring, warm, reassuring, patient, welcoming attitude
• Showing that you are available to hear and understand is crucial (welcoming and establishing a relationship of trust).
• Be fairly directive with the person (e.g., “It’s important, let’s sit down and talk about it.”)
• Adapt to the person’s emotional level, taking into account their understanding of their emotions and their level of disorganization
• Involve a familiar person with whom the person has a good contact (this may mean that the meeting is done with two people: the assessment “specialist” and the person's “specialist”).
• Note the terms used by the person to talk about their distress and MAS, then reuse them (e.g. “When you [term used by the person], tell me how you feel.”).
• Use a neutral tone when asking questions
• Pay attention to non-verbal communication (both from the care worker and the person)
• Remain open so as to fully understand without diverting thought with too many questions
• Tolerate silences, be patient
• Encourage the expression of distress that lead to suicidal ideation, listen to the person’s story from their perspective, whatever your analysis of the situation
• Use familiar methods of communication

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Hindering MAS exploration

• Conveying an impression of suggestion (e.g.: have you thought about suicide to stop suffering?) or disapproval of suicidal ideas (e.g.: I hope you’re not thinking about suicide?)
• Including answers (e.g.: did you hide that knife to kill yourself?)
• Cutting the person’s train of thought by asking too many questions
• Over-interprete, as the person may have difficulties finding out what he or she wanted to say
• Stigmatization and guilt-tripping (e.g.: have you thought about the pain you’d feel if you killed yourself?)
• Too many questions about suicidal intent (this is not reliable indicator of risk, and can change very quickly)
• Giving the person a pass because of MAS, or conversely, depriving them of an activity (this could be perceived as punishment and hinder the expression of their needs in the future)
• Questioning the person’s response (e.g.:“Are you sure?”), as this may aggravate the potential for acquiescence and may hinder, rather than help or clarify a problem.

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Introduction to IDAS process

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General structure – IDAS process

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Basic principles of the IDAS process

• Collaborative work
• Between stakeholders from different settings and expertise
• Along the suicide prevention continuum (promotion, prévention, intervention, postvention)
• With the young person and his entourage

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Effective collaborative suicide prevention

• Teamwork between:

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• Bulding a network / continuum

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Detection of distress

No

Screening of MAS

Yes

No

Suicide risk assessment

Short term risk for suicide attempt

No short term risk for suicide attempt

Who does what, when, how?

What is your role in this continuum?

What should be developed quickly?

Develop a suicide prevention continuum in your community / organisation

Evaluation of needs for long term support and care

Supporting protective factors

Postvention

Yes

Regular services

Intervention to reduce distress

Crisis and emergency intervention to ensure safety

Close follow-up

Regular follow-up

Current action plan

Intervention plan

SPP- Screening

SPP- episode

SPP – Follow-up

SPP- Risk

Screening and reference

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General structure – IDAS process

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Action following screening

• If the person presents MAS (ideations, means to attempt suicide, associated distress)
• Complete the screening section to correctly identify and describe the suicidal episode
• Assess suicide behavior danger
• If there is no MAS:
• Explore possible sources of change in usual functioning
• Identify distress and its sources
• Reduce distress

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IDAS process in school settings

Knowlwdge mobilization strategy

Mentors

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Structure of the KM strategy

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Key actors

Objectives

Tools and methods

Context

Expected outcomes

Mentors’ role and activities

• Increase awareness of colleagues on suicide prevention
• Identify beliefs / attitudes / prejudice regarding suicide and its prevention
• Orient colleagues towards available resources to develop abilities in suicide prevnetion
• Train to use IDAS process
• Apply IDAS process with clients when needed
• Support colleagues in learning suicide prevention
• Remind colleagues of IDAS process and to use it when appropriate

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Elements supporting IDAS process implementation

1. Benefiting from a strong organizational support
2. Naming a person in charge of the implementation
3. Implementing coordination processes
4. Clarify the role of mentors for all stakeholders
5. Identify good mentors
6. Support mentors in time
7. Plan intégration between UIDAS process and other suicide prevention protocols to ensure cohérence and continuity

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Implementing IDAS process in your organization

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• Based on the Toolkit :

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Identify the intervention team’s strenghts and needs

• Identify the following elements regarding your team:
• Its members (size, localised in one or several service points, contact methods, types of care workers, main objectives…)
• Its team work spaces (mutildisciplinary meetings, lunch talks…)
• Strenghts for suicide prevention
• Needs for suicide prevention
• Current roles in suicide prevention (awareness, screening, crisis management, intervention, follow-ups…)

• Your team?

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Identify strengths and needs of suicide prevention collaborators

• Identify the following elements regarding collaborators in the school system and outside:

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• Where and how are you working on MAS and associated factors within the service continuum?
• Who are your usual collaborators / partners in mental health and suicide prevention? (i.e. hospital, suicide prevention centre, families…)
• What are their objectives / roles in terms of social intervention / support and suicide prevention?
• How do you collaborate with service organizations within the servic e / suicide prevention continuum? What are your relatyionships? How can you develop / reinforce them?

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• Your team?

Identify barriers and facilitators to suicide prevention

• Identify barriers and facilitators observable in your setting:
• Éléments associated with individuals, teams, organizations that can affect changes in attitudes, beliefs, knowledge, practices
• Strategies and resources available in your setting to help reduce barriers and reinforce facilitators

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• Your team?

Identify and describe suicide prevention activities

• Identify the various suicide preventiona ctivities performed by members of your team (screening, management of MAS episodes, follow-ups, intervention…)

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• Your team?

Define the objectives of the KM strategy

• Based on the analysis you made, what are the priorities you need to address in your KM plan?

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• Objectives should be hierarchic (awareness – training – change of practice – sustainability)
• Define your objectives in term of :
• Awareness
• Training
• Change in practices
• sustainability

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• Your team?

Define KM activities to answer your objectives

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Implementation

• The plan should be well known by all involved parties
• Monitoring and adjustments should be made when expected outcomes are not met
• Support of management and direction is crucial to proper practice implementation

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• Your team?

Sustainability

• KM plan should be revised and updated at least once a year
• Use Communities of practice if available
• Mentors should be in contact with each other for support
• Management support
• Apply the KM plan to new teams when possible
• Integrate KM activities into usual team activities and processes
• Sense of competency increases in teams when new and emerging knowledge are regularly shared

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• Your team?

Conclusion

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Thank you!

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Reference list

Documents issus des projets de recherche ayant mené au Processus AUDIS

• Bardon, C., Morin, D. et Millette, L. (2020). Stratégie innovante de mobilisation des connaissances en prévention du suicide chez les personnes ayant une DI ou un TSA : collaborer avec le réseau pour améliorer les services. Centre de recherche et intervention sur le suicide, enjeux éthiques et pratiques de fin de vie, Chaire DITC, Montréal QC, 108p
• Bardon C, Morin D, Halmov X, Mishara BL, Morin D, Mérineau-Coté J, et al. Understanding suicide risk : developing a specific model of suicide risk for individuals presenting with an ID or an ASD.  2017 Annual Conference of the AAIDD; Hartford, CT2017.
• Bardon C, Morin D, Halmov X, Mishara BL, Morin D, Mérineau-Coté J, et al. Assessing suicide risk : developing a process to support clinical judgement for suicide risk assessment in persons presenting with an ID or an ASD.  2017 Annual Conference of the AAIDD; Hartford, CT2017.
• Bardon C, Morin D, Ouimet A-M, Mongeau C. Comprendre le risque suicidaire chez les personnes présentant une déficience intellectuelle ou un trouble du spectre de l’autisme. Revue francophone de la déficience intellectuelle. 2015;26:102-16.
• Bardon, C. and X. Halmov (2015). Mieux comprendre le risque suicidaire chez les personnes ayant une déficience intellectuelle (DI) ou un trouble du spectre autistique (TSA). XXVIII World Congress of the International Association for Suicide Prevention, Montréal.
• Bardon C, Morin D, Ouimet A-M, Mongeau C, Girard M-J. Comprendre et prévenir le risque suicidaire chez les personnes présentant une déficience intellectuelle ou un trouble du spectre de l’autisme : une consultation d’experts. Montréal, QC2014.
• Bardon C, Halmov X, Mishara BL, Morin D, Morin D, Ouimet A-M, et al. Comprendre et estimer le risque suicidaire des personnes ayant un TSA: les résultats d’une recherche menée au Québec pour le développement de nouvelles pratiques. In: Rousseau M, Bourassa J, Milette N, McKinnon S, editors. De l’enfance à l’âge adulte : pratiques psychoéducatives innovantes auprès des personnes ayant un trouble du spectre de l’autisme. Longueuil, QC: Béliveau éditeur; 2017.

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Suicide behavior and ID

• Benson BA, Laman DS. Suicidal tendencies of mentally retarded adults in community settings. Australia and New Zealand Journal of Developmental Disabilities. 1988; 14:49-54.
• Dodd, P., et al. (2016). "A Systematic Review of Suicidality in People with Intellectual Disabilities." Harvard Review of Psychiatry 24(3): 202-213.
• Hardan A, Sahl R. Suicidal behavior in children and adolescents with developmental disorders. Research in Developmental Disabilities. 1999 7//;20(4):287-96.
• Hirvikoski T, Mittendorfer-Rutz E, Boman M, Larsson H, Lichtenstein P, Bölte S. Premature mortality in autism spectrum disorder. The British Journal of Psychiatry. 2016 2016-03-01 00:00:00;208(3):232-8.
• Ludi E, Ballard ED, Greenbaum R, Pao M, Bridge J, Reynolds W, et al. Suicide risk in youth with intellectual disabilities: The challenges of screening. Journal of Developmental and Behavioral Pediatrics. 2012;33(5):431-40.
• Lunsky Y. Suicidality in a clinical and community sample of adults with mental retardation. Research in Developmental Disabilities 2004;25(3):231-43.
• Lunsky Y, Raina P, Burge P. Suicidality among adults with intellectual disability. Journal of Affective Disorders. 2012 11//;140(3):292-5.
• Menolascino FJ, Lazer J, Stark JA. Diagnosis and management of depression and suicidal behavior in persons with severe mental retardation. Journal of the multihandicapped person. 1989;2(2):89-103.

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Suicide behavior in ID

• Merrick J, Merrick E, Lunsky Y, Kandel I. Suicide behavior in persons with intellectual disability. ScientificWorldJourna. 2005;5:729-35.
• Merrick J, Merrick E, Lunsky Y, Kandel I. Review of suicidality in persons with intellectual disability. Israel Journal of Psychiatry and Related Sciences. 2006;43(4):258-64.
• Patja K, Iivanainen M, Raitasuo S, Lonnqvist J. Suicide mortality in mental retardation:a 35-year follow-up study. Acta Psychiatrica Scandinavica. 2001;103(4):307-11.
• Patja K. Suicide cases in a population-based cohort of persons with intellectual disability in a 35-year follow-up. Mental health aspects of developmental disabilities. 2004;7(4):117-23.
• Ruddick, L., et al. (2015). "Self-injurious, aggressive and destructive behaviour in children with severe intellectual disability: Prevalence, service need and service receipt in the UK." Research in Developmental Disabilities 45-46: 307-315.
• Sovner S, Hurley AD. Suicidal behavior in mentally retarded persons. Psychiatric Aspects of Mental Retardation Newsletter. 1998;1(10):37-40.
• Sturmey P. Suicidal threats and behavior in a person with developmental disabilities: effective psychiatric monitoring based on a fundamental assessment. Behavioral Interventions. 1994;9(4):235-45.
• Walters AS, Barrett RP, Knapp LG, Borden MC. Suicidal behavior in children and adolescents with mental retardation. Research in Developmental Disabilities. 1995;16(2):85-6.
• Wark, S., et al. (2018). "Suicide amongst people with intellectual disability: An Australian online study of disability support staff experiences and perceptions." Journal of Intellectual Disability Research 62(1): 1-9.

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Suicide behavior in autism

• Arwert, T. G. and B. B. Sizoo (2020). "Self-reported Suicidality in Male and Female Adults with Autism Spectrum Disorders: Rumination and Self-esteem." J Autism Dev Disord.
• Cassidy S, Bradley P, Robinson J, Allison C, McHugh M, Baron-Cohen S. Suicidal ideation and suicide plans or attempts in adults with Asperger’s syndrome attending a specialist diagnostic clinic: a clinical cohort study. The Lancet Psychiatry 2014;1(2):142-7.
• Cassidy, S. A., et al. (2019). "Is camouflaging autistic traits associated with suicidal thoughts and behaviours? Expanding the interpersonal psychological theory of suicide in an undergraduate student sample." Journal of Autism and Developmental Disorders: No Pagination Specified-No Pagination Specified.
• Cassidy, S. and J. Rodgers (2017). "Understanding and prevention of suicide in autism." The Lancet Psychiatry 4(6): e11.
• Conner, C. M., et al. (2020). "A Comparative Study of Suicidality and Its Association with Emotion Regulation Impairment in Large ASD and US Census-Matched Samples." J Autism Dev Disord.
• Dow, D., et al. (2019). "Anxiety, depression, and the interpersonal theory of suicide in a community sample of adults with autism spectrum disorder." Archives of Suicide Research: No Pagination Specified-No Pagination Specified.
• Hedley, D. and M. Uljarević (2018). "Systematic review of suicide in autism spectrum disorder: current trends and implications." Current Developmental Disorders Reports 5(1): 65-76.
• Hochard, K. D., et al. (2020). "Examining the Relationship Between Autism Traits and Sleep Duration as Predictors of Suicidality." J Autism Dev Disord.
• Hooijer, A. A. T. and B. B. Sizoo (2020). "Temperament and character as risk factor for suicide ideation and attempts in adults with autism spectrum disorders." Autism Res 13(1): 104-111.
• INSPQ (2017) Surveillance du Trouble du spectre de l’autisme au Québec https://www.inspq.qc.ca/sites/default/files/publications/2310_surveillance_trouble_spectre_autisme.pdf

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Suicide behavior in autism

• Kato K, Mikami K, Akama F, Yamada K, Maehara M, Kimoto K, et al. Clinical features of suicide attempts in adults with autism spectrum disorders. General Hospital Psychiatry. 2013;35(1):50-3.
•  Mayes SD, Gorman AA, Hillwig-Garcia J, Syed E. Suicide ideation and attempts in children with autism. Research in Autism Spectrum Disorders. 2013 1//;7(1):109-19.
•  Moseley, R. L., et al. (2020). "Links between self-injury and suicidality in autism." Mol Autism 11(1): 14.
•  Paquette-Smith M, Weiss J, Lunsky Y. History of Suicide Attempts in Adults With Asperger Syndrome. Crisis. 2014;35(4):273-7.
•  Pelton, M. K., et al. (2020). "Understanding Suicide Risk in Autistic Adults: Comparing the Interpersonal Theory of Suicide in Autistic and Non-autistic Samples." J Autism Dev Disord.
•  Raja M. Suicide risk in adults with Asperger’s syndrome. The Lancet Psychiatry. 2014 7//;1(2):99-101.
•  Raja M, Azzoni A, Frustaci A. AUTISM Spectrum Disorders and Suicidality. Clinical Practice & Epidemiology in Mental Health 2011;7:97-105.
•  Richa S, Fahed M, Khoury E, Mishara BL. Suicide in autism spectrum disorders. Archives of Suicide Research. 2014:null-null.
•  Shtayermman O. Suicide and suicidal ideation among individuals diagnosed with an autism spectrum disorder. In: Franklin. C, Harris. MB, Allen-Meares. P, editors. The school services sourcebook: A guide for school-based professionals (2nd ed). New York, NY, US: Oxford University Press; 2013. p. 261-71.
• South, M., et al. (2019). "Unrelenting Depression and Suicidality in Women with Autistic Traits." J Autism Dev Disord.
• Storch EA, Sulkowski ML, Nadeau J, Lewin AB, Arnold EB, Mutch PJ, et al. The Phenomenology and Clinical Correlates of Suicidal Thoughts and Behaviors in Youth with Autism Spectrum Disorders. Journal of Autism and Developmental Disorders. 2013;43(10):2450-9.
• Zahid, S. and R. Upthegrove (2017). "Suicidality in autistic spectrum disorders: A systematic review." Crisis: The Journal of Crisis Intervention and Suicide Prevention 38(4): 237-246.

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Distress and mental health problems

• Ali A, King M, Strydom A, Hassiotis A. Self-reported stigma and symptoms of anxiety and depression in people with intellectual disabilities: Findings from a cross sectional study in England. Journal of Affective Disorders. 2015;187:224-31.
• Bramston P, Fogarty GJ. The assessment of emotional distress experienced by people with an intellectual disability: A study of different methodologies. Research in Developmental Disabilities. 2000;21(6):487-500.
• Bramston P, Fogarty GJ. Measuring stress in the mildly intellectually handicapped: The factorial structure of the Subjective Stress Scale. Research in Developmental Disabilities. 1995;16(2):117-31.
• Fogarty GJ, Bramston P, Cummins RA. Validation of the Lifestress Inventory for people with a mild intellectual disability. Research in Developmental Disabilities. 1997;18(6):435-56.
• Hirvikoski T, Blomqvist M. High self-perceived stress and poor coping in intellectually able adults with autism spectrum disorder. Autism. 2015;19(6):752-7.
• Kellett S, Beail N, Newman DW, Frankish P. Utility of the brief symptom inventory in the assessment of psychological distress. Journal of Applied Research in Intellectual Disabilities. 2003;16(2):127-34.
• Mason J, Scior K. ‘Diagnostic overshadowing’amongst clinicians working with people with intellectual disabilities in the UK. Journal of Applied Research in Intellectual Disabilities. 2004;17(2):85-90.
• McKenzie K, Smith M, Purcell AM. The reported expression of pain and distress by people with an intellectual disability. Journal of Clinical Nursing. 2013;22(13-14):1833-42.
• Regnard C, Reynolds J, Watson B, Matthews D, Gibson L, Clarke C. Understanding distress in people with severe communication difficulties: developing and assessing the Disability Distress Assessment Tool (DisDAT). Journal of Intellectual Disability Research. 2007;51(4):277-92.

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Other

Concept of death

• Burke K, Obroin D, McEvoy J, editors. Teaching Death Concepts to Adults With Intellectual Disabilities Using Computer Games. Proceedings of the European Conference on Games Based Learning; 2014; Reading, USA: Academic Conferences & Publishing International.

Suicide and associated concept

• Beck, A. T., Kovacs, M., & Weissman, A. (1975). Hopelessness and suicidal behavior: An overview. Jama, 234(11), 1146-1149.
• Chiles, J. A., & Strosahl, K. D. (1995). The suicidal patient: Principles of assessment, treatment, and case management. American Psychiatric Association.
•  INSPQ (2020) Le suicide au Québec : 1981 – 2017 – Mise à jour 2020 https://www.inspq.qc.ca/sites/default/files/publications/2642_suicide-quebec_2020.pdf
• O'Connor, S. S., Jobes, D. A., Yeargin, M. K., FitzGerald, M. E., Rodríguez, V. M., Conrad, A. K., & Lineberry, T. W. (2012). A cross-sectional investigation of the suicidal spectrum: Typologies of suicidality based on ambivalence about living and dying. Comprehensive Psychiatry, 53(5), 461-467. 
• Shneidman, E. S. (1976). A psychologic theory of suicide. Psychiatric Annals, 6(11), 51-66.

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