Suicide Risk: Phenomenological Notion of the Threshold Effect

Sometimes suicide is committed suddenly and other times suicide is planned long time ago. This study aims to know about the background of the time effect for psychic life how the idea of suicide is growing up. Is suicide unpredictable or is there another factor like latency coming up for being acted out? Incarceration and prison environment has a very high risk for suicide in France. This study confronted observations of psychiatrists and psychologists having prisoners as patients. Their observations are compared too with psychiatrists and psychologists having a double professional experience in town and in prison. Interpretations of statistics about suicide risk complete information. This interpretation is helped by the phenomenological notion of the threshold effect (Zutt, Kuhlenkampf) coming from early experimental psychology (Th. Fechner). All results agree about the importance of being in contact with the prisoner from the very beginning of his incarceration. The incarcerated person has to get started when entering in prison by verbalizing about himself. Later he may have lost all motivation and may be tired by all interpersonal effort. The risk of hetero and auto-aggression will be high.


Introduction
Suicide seems to occur in an unpredictable way for physicians, friends and relatives. They wonder about the meaning and the circumstances. Sometimes, they realize evidence they did not pay attention before. For example, we know about the importance of the birthday factor of a traumatic event having been this day one, two or more years before (death, separation, violence, migration). This day the risk of suicide is very high and we should care specially for this person in looking after her all the day.
We may ask if it is constitutional that suicide occurs mainly for vulnerable or depressive persons. Even though if there is something true about it, other examples show that persons suicide in spite of success. Comic actors or clowns are risky too. We could argue that they were depressed anyway but they didn't show. But this argumentation is turning round. If every person who attempt suicide is defined as depressive, the question is to know when he started to feel depressive and how to know about the beginning. Does he know it himself?
So the question of latency becomes important, because somebody may suffer and it seems to him that nobody cares about him. The violence about the act could be the answer to violence experienced from others. Suicide could be a kind of victimization of oneself. The questioning is to know about the probability of suicide for someone and how to predict this act? Would somebody have commit suicide anyway one day or are there circumstances that pushed him to act?
As it is impossible to study risky moments of people all their life, this investigation has chosen prison as a frame of experience where the suicide risk is very important: French prisons. Prison is the loss of liberty and may somehow be experienced as throwing life when going to suicide. Furthermore, different observations complete each other to avoid the specialization of a clinical method (Psychiatry, Psychology, Psychoanalysis, etc.) or the special professional experience (only working in prison or working in town too) or the specificity of the place (two biggest prisons in France, smaller prisons in France, French Caribbean prison on an Island with another cultural background).

Prison Environment, Violence, Suicide Attempt and Suicide
The penitentiary establishment of Fleury-Mérogis is the biggest prison of Europe and therefore the biggest prison of France, near Paris. The risk of suicide attempt is nearly 70%. Aggression and violence are common every time in this very crowded prison [1][2][3][4].
Violence is directed to others, to oneself in auto-mutilation and in suicide attempt. Prisoners became incarcerated as aggressors and few time later they become victims of violence. They have to be protected to stay alive [5,6]. Fleury-Mérogis is very heavy to stay, even guardians suicide [1,5,7]. The study at Fleury-Mérogis during ten years leads to the conclusion that there is a risk factor from 5% to 15% that suicide attempt will finish by suicide. We are confronted with the ethical problem that the incarcerated person aims to commit suicide with "success". This action is directed against the punish-system and the guardians who felt that they failed [8].
Even the prison of Fresnes (second biggest prison of France near Paris) has the same problems. They are compared to other prisons in France in using the data of the Penitentiary Administration Office and of the Ministry of Health [1,6,[9][10][11][12][13]. These data help to examine the circumstances of the suicide risk. Smaller prisons in France and the French Caribbean prison Ducos of Martinique have the same problem of suicide attempts but the realization of suicide is rare compared to the two biggest prisons. or the psychologist as they want. Lacking time, prescribing drugs, prisoners are helped to sleep without finding any answer to their problems. Anti-depressants not really prevent from suicide neither. It is almost difficult to evaluate the suicide risk and to decide if a person suicides because of the drug or in spite of the drug. Prisoners succeed to get illegal drugs in all prisons. By this way, they resolve the psychiatrists' crisis of conscious but they are complicating diagnosis later.
The prison of Ducos, near Fort-de-France, opened at 1996. This place is for incarceration in obedience of the law of Martinique. The aim of the incarceration system is to preserve the relation to the families all the time when being in prison. The cultural and historical background of population makes to feel more comfortable in being together. Whereas, the Metropolitan Paris and other towns of France lead to individual way to live. Sharing any place there when being free may already be considered as a punishment. Nearly every town has a prison in France and a service of infirmary.
When entering into prison, the medical situation of the patient has to be evaluated. He might have been ill before coming to prison and the suffering may grow because of incarceration [14,15]. He might become ill in prison or show psychosomatic symptoms [16,17]. He will experience quickly that health and happiness is very antagonistic. Feeling unhappy when being healthy, this might be the starting point of depression [15]. So the passive way will seduce by taking drugs. Preventing from the worse, means preventing from death. But, our study realizes that the practice of psychiatry is not the same outside and inside. It is more radical, because the fear of the incarcerated patients' suicide is constantly present, or suicide attempts [18].
Interrupting medical treatment can harm. Followed by an evaluation when being incarcerated the starting point of the care problem, in prison, is to avoid misunderstanding and not to mistake the consequences of the interruption for care with another symptom [19,20]. Boissenin [18] said that prison is not a hospital but psychological care from the beginning may prevent from later damage and the risk of becoming completely asocial. Even if there are not many possibilities to care about the prisoner individually, it should be in the beginning and not later. Incarcerated persons show all kind of vulnerability and taking care in the beginning prevents from violence. Being a "patient" in prison is very ambivalent. We may consider that the incarcerated person "patients" comes out in reacting in a somatic way [21]. He is not the same "patient" as in liberty.
The first French study about incarcerated patients in 1997 realized by physicians showed that 30% of the arrivals combined the consumed alcohol, tobacco, illegal drugs and psychotropics; 10% of the incarcerated persons should see a psychiatrist. The DREES study (Direction of Research, Investigation, Evaluation and Statistics of the Ministry of Health) with the French Group of Psychiatric Epidemiology (GFEP) realized the study in 2001 (published in 2002) in all Regional Medical and Psychological Services (SMPR) with 2302 new arrivals [3]. This time, the evaluation comes from psychiatrists: 55% arrivals show at least one psychiatric disorder; 30% of men showed a depressive trouble and 45% of women; 54% (men and women) showed an addictive trouble; 20% had been treated in psychiatry before and 52% should be treated for the trouble that was detected. But finally, only 10% of them were treated in the infirmary. The suicide risk of 44% of those who are not treated is high. The study about arrivals shows a high score of pathological troubles: anxiety (90%), impulsion (63%), and addiction (35%). Prevention of suicide starts too in taking care of the troubles detected.
Incarcerated persons contemplating suicide becomes normal for psychiatrists working in prison. We change about what we will consider "normal" in prison [22][23][24][25]. In everyday life, a depressed and mentally ill person will think about suicide. In prison, it is the first thing coming up to mind. What about those who won't think about suicide? Are there monsters risking recurrence once in liberty? Is thinking about suicide the guarantee of conserving the quality of staying human in an environment difficult to bear? [26].
Prison has a kind of "magnifying-glass" effect: everything becomes bigger in prison. Information about the patient shows whether there is an influence of ancient problems or new problems appearing from outside (death of a parent, loss of somebody close, family quarrels) overwhelming the incarcerated person. In psychopathology, characters are considered to exist in a latent way. Only special situations will make them manifest. So people could possess a lot of unpleasant, unsocial or dangerous characters but they will never show them because life keeps them away from the conditions to show them. May be, unconsciously, they prevent themselves all their life to meet what they repress? [27].
This study was confronted with this methodological problem from the beginning: you cannot predict the future behaviour of a person. Analysis of the subject reflecting himself is also a philosophical problem [28]. That is the reason to look for phenomenological research.
The study of psychiatrists shows that depression is mainly represented (50% of the population) followed by psychotic troubles (25%). So, depression is included with other difficulties (personality disorders, addiction, and psychosis) in this study. By this statistics, we get the impression that each incarcerated person suffers from disturbances [29]. Many authors mention the frequency of incarceration of individuals with mental disorders [1,4,6,7,20,30,31]. We know that depression and schizophrenia may lead to suicide. We know too about the influence that psychopathic persons may have on vulnerable individuals. They can influence them to suicide too.
A patient with a diagnosis of depression and a diagnosis of schizophrenia too, it is not possible to know if it is a mixed expression about both entities (two nosographical entities create co-morbidity) [20,32]. Another difficulty concerns "reactional depression", directly linked to the loss of freedom. This diagnosis is very important for psychiatric epidemiology and will change the statistical evaluation [1]. Furthermore, the statistics may astonish when having a look at the time when suicide occurs during incarceration. The highest rate happens with new arrivals, just in the beginning before judgment. The number of arrivals suicide is nearly identical (varying, some years they are higher, others to 20% less). This high score is stupefying compared to those incarcerated after judgment. So the beginning of the prison time is the most risky for suicide. Another surprise is to realize that suicide happens also at the end of incarceration. It is easy to understand that the incarcerated person without hope of liberty wants to suicide, but those who suicide before the near liberation signify the loss of hope. Incarceration has been meant for life for them without any anticipation to move over in future.
This comparison between the suicide of arrivals, before judgment, and the suicide after judgment shows the importance of "going through" from one place to another. Patients mentioning suicide should be taken seriously. All people speaking about suicide might act. A person who gives up when liberty is so near, there is obviously a problem about meaning. It is puzzling that in both cases, for the arrivals as for incarcerated persons coming to the end of prison time the risk is the same. This makes us think about the "threshold effect". The DREES study showed too that any kind of changing places in the prison (another room, share with a new person, another wing of the building) is troubling a lot and leads to crisis. So the changement has a special mental effect we wanted to study.

The "Threshold Effect" in Phenomenology
Phenomenological studies after war were interested in the concept of "abnormal crisis" [32]. Psychiatrists discussed from a phenomenological viewpoint how to explain typical situations with patients behaving suddenly in an incomprehensible way [33]. For example, after a life event, a schizophrenic patient starts to feel well and might even looks like being cured. Or people, having been quiet normal up to now, will commit a totally stupid action. Every psychiatrist knows about this phenomenon impossible to grasp because the patient can't explain himself. Furthermore, it is not welcome to ask patients for the reasons of being well. Those phenomenological psychiatrists stated on abnormal crisis and found out the expression of what they called the "Copernician change": individuals will make up their mind in an unexpected way. In fact, psychotherapists notice when practicing with psychotic persons for a long time, that they change one day without being able to explain what happened to them and the reason for their illness. They make up their mind in the same way as Copernic changes the mind of people when explaining that the earth is round.
A case study helps for a better understanding of this kind of situation. A German emigrated to the United States of America during the war decided to see his family after war. So he came back to Germany to visit them. At the frontier, the officer asked him if "he has something to declare". At this moment, he got his knife out of his pocket and cut his throat. Fortunately, there were other officers and a doctor to help quickly. This German man got into hospital and could be safe. He must lie down to recover and his brother came to see him. Obviously, his family was not happy about the idea of having him any longer in the country or coming to their home. After the visits from his family in hospital and after recovery, he should travel back to the States. But all of the stuff was very afraid about his reaction about what might happen when crossing the frontier anew? What foolish idea will come up to his mind to hurt himself?
They wanted to prevent any harm. The suicide danger seemed to be obvious after those unhappy holidays. So the psychiatrist tried to speak with him and asked him carefully about the event that happened when crossing the frontier of Germany? What has happened, how explain that he took the knife? But he just moved his shoulders with a big smile, signifying that it was nothing. In other words, he had nothing to declare.
This is exactly the situation where every psychiatrist or searcher in psychopathology will feel stupid, doubting about his own observation.
The phenomenological discussion continued about searching to define the "threshold effect", meaning the moment when the appreciation of things changed. E Straus developed the impossibility to describe this moment because of the intellectual problem: the event is always before or afterwards, but meanwhile, there is the moment where the person performs. Straus gives the example that it is like jumping. It is difficult to define the moment when the decision to hop starts. There is just the result of having changed places. Somebody "jumped". Straus explained that this kind of situation is typical in criminology. The criminal is like a person who jumped and later, all the officers want him to explain his reasons. The problem is that he doesn't know the reason and he doesn't link the act to an effect. He doesn't ask this question to himself why and he answers « that is why ». Even the shock will make him produce answers that are not true but just a kind of logical. But the logic system is cut from his emotions. Therefore it will be difficult to find the logic of the real truth. Truth and law seem opposite to him.
The example of the German man coming back after war and after having been cut from his family, isolated, illustrates the citation of Beckett "words fail" in Happy Days. He opens his throat as if the declaration could come out by bleeding. This abundance shows that he has so much to say that this act will speak by itself, signifying and symbolizing the meaning of coming over. Certainly, he did not want to suicide, but he nearly succeeded by his gesture. Often suicides are the result of a gesture and it is less sure if it was an intention.
The concept of the "threshold effect" is ancient, introduced by Th. Fechner, at the beginning of experimentation in psychology. The studies were about perception and physics to evaluate perception in an objective manner (psychophysiology). These experimentations of subjective appreciations were verified by objective methods of measurement and mathematics. Fechner was named to the first chair of professor in psychology in Leipzig in 1897 because of this research. He showed that our appreciation about quality is not only proportional to quantity. It is subjective but measurable. The threshold effect pushes appreciation from one category into another. For example, he measured threshold effects about all sensual feelings as feeling cold suddenly after losing a half degree or the appreciation of something as being too heavy, whereas just before it was acceptable.
In matter of suicide the threshold effect has an importance for the symbolization of the person. Incarceration is synonymous of being isolated. The case study of coming back after war, emigration, is also isolation. So we may predict that suffering from isolation is a risk for suicide. At the same time, it is not easy to come out of a long isolation like in this example, coming over after war, or coming out after prison time. The person is overwhelmed and signifies meaning by actions. The immediate character of action, called ruptivity, puts the person in front of an existential situation. To exist, existere means etymologically being thrown outside into the world. The person is "out of him" and interprets this situation with leaving life.

Conclusion
To conceive prevention all kind of information's complete each other's: statistics completes the appreciation of the results, philosophy, psychology, psychoanalysis, psychiatry are linked. Therefore searching and working in a team in prison is very helpful for everyone to prevent suicide of prisoners and guardians. We have to keep in mind the "threshold effect" right from the beginning of incarceration and at the end too for the special time effect as the same as anniversaries of life events such as the death of a beloved person, separation, former suicide attempt, or all sudden changes in the persons' life. This trauma happening to the person may come up suddenly by the time effect as a threshold effect.
Paradoxically, the prisoner will repeat his judgment by aggressing himself or others. Without elaborating this mechanism, he will tend to make his own law. This mechanism has to be elaborated with the group of the prisoners, a kind of special coaching. It is important to prevent mass effects in prison making their own law and exercising their own justice. The threshold effect also shows that there are different kind of suicides occurring in prison (like in liberty but much more