A suicide rehearsal is a behavioral enactment of a suicide method, usually as part of a suicide plan. A mental suicide rehearsal is a process that evolves over time into a plan. Patients who are intent on attempting suicide usually do not reveal their plans. However, behavioral rehearsals display specific clinical characteristics that speak louder than the guarded patient’s denials, revealing the patient’s suicide plan (Table).
Suicide rehearsals may precede suicide attempts or suicide completions. The percentage of patients who stage suicide rehearsals before attempting or completing suicide is unknown; however, in my experience, suicide rehearsals are relatively common. This article describes suicide rehearsals, and offers 4 cases that illustrate what clinicians can learn from rehearsals to improve their patients’ safety.
Table
Clinical characteristics of suicide rehearsals
| Guarded patient |
| Behavioral enactment of a suicide method |
| Lethal means |
| Presumptive acute, high risk of suicide |
| Severe mental illness |
| Suicide attempt often within hours or days |
| Rehearsal usually covert |
| Rehearsal event or multiple events |
The psychology behind suicide rehearsals
Rehearsing suicidal behavior can lower the barrier to a suicide plan, thereby increasing a patient’s resolve and risk. Joiner1 notes that engaging in behavioral or mental suicide rehearsals increases the risk of suicide. Moreover, rehearsals diminish the prohibition against suicidal behavior and the fear of pain and dying. Examples of rehearsal psychology include:
- overcoming ambivalence about dying
- desensitizing anxiety about performing the suicide act
- testing or “perfecting” the method of a planned suicide
- firming one’s resolve to complete suicide.
Other non-lethal motivations include “a cry for help” and self-injurious behaviors motivated by external gains. Patients who do not intend to attempt suicide may openly rehearse low-risk methods, such as superficial cutting.
Rehearsal characteristics
Suicide rehearsals can be confused with aborted, interrupted, or failed suicide attempts. Suicide rehearsals usually are associated with severe psychiatric illness and high-risk lethal methods of attempting suicide. My experience is that suicide attempts or suicide completions often follow a rehearsal within a few hours or days. However, no short-term suicide risk factors—within hours, days, or weeks—can predict when or if a rehearsed suicide will proceed to a suicide attempt.2
A suicide rehearsal is presumptive evidence that the patient is at acute, high risk for suicide and immediate clinical intervention is necessary. A rehearsal allows the clinician to explore the various methods of suicide that the patient has considered, including prior rehearsals. Knowledge of prior rehearsals can inform the clinician’s management of the current suicide rehearsal.
Suicide rehearsals often are conducted covertly. On inpatient psychiatric units, the rehearsal usually is discovered by staff members or reported by other patients. In outpatient settings, the patient or a significant other may report a rehearsal.
The suicide method displayed in a rehearsal may change. A patient who is rehearsing a hanging may attempt suicide by overdose or a firearm. In a systematic review of prior suicide attempts (N = 1,397), Isometsä et al3 found that 82% of patients used 2 or more different methods in suicide attempts, including the completed suicide. However, in a cohort study of 48,649 individuals admitted to a hospital after an attempted suicide, Runeson et al4 found that patients who attempt suicide often used the same method in completed suicide (ie, >90% by hanging for both men and women). Therefore, when taking measures to restrict the patient’s access to lethal means, safety efforts should not be limited to the method used in the suicide rehearsal. Patients can always substitute methods.
Making overall preparations for suicide—for example, making a will, giving away valuable possessions, or putting financial affairs in order—could be confused with a suicide rehearsal, which displays the lethal method to be used in a suicide attempt, often after preparations are made. Suicide rehearsals tend to occur much closer in time to the suicide attempt than preparations for suicide. Similarly, a patient’s plan to hoard drugs for a suicide attempt is not the same as ingesting a sub-lethal dose of a drug to test his or her resolve to die.
By definition, impulsive suicide attempts are not rehearsed. However, an individual’s suicide rehearsal can impulsively segue into a suicide attempt. In a case control study (N = 153) Simon et al5 found that 24% of patients spent 6 found that 26% of individuals with lifetime suicide ideation transitioned from suicide ideation to an unplanned suicide attempt. In my experience, a suicide rehearsal before a suicide completion is presumptive evidence against an impulsive suicide.