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		<p>It is well established by now that suicidal individuals tend to be more<lb/> cognitively
			rigid than nonsuicidal individuals <ref type="biblio">(Levenson &amp; Neuringer,<lb/>
				1971; Newringer, 1964)</ref>. This phenomenon has been found both in<lb/> suicidal
			adults <ref type="biblio">(Patsiokas, Clums, &amp; Luscomb, 1979)</ref> and in children<lb/>
			<ref type="biblio">(Orbach, Rosenheim, &amp; Hary, 1987)</ref>. It is evident that
			suicidal individuals<lb/> have difficulty generating new alternatives in problem-solving
			situations.<lb/> It is contended that the inability to produce alternative solutions in
			a<lb/> problem situation serves as an intervening process between certain<lb/> stresses
			and suicidal behavior. When a stress situation interacts with<lb/> rigid thinking, the
			suicidal individual cannot produce alternative so-<lb/>lutions in problem situations,
			coping behavior becomes constricted, and<lb/> suicidal behavior prevails.<lb/></p>

		<p>In a recent study, <ref type="biblio">Schotte and Clums (1987)</ref> have elaborated
			and<lb/> extended the proposition about the connection between suicidal tend-<lb/>encies
			and rigid cognitive functioning. They studied the interaction<lb/> among life stress,
			cognitive rigidity, interpersonal problem-solving skills,<lb/> and depression and
			hopelessness in suicidal and nonsuicidal hospitalized<lb/> psychiatric patients. They
			found that suicidal patients, in comparison<lb/> to the nonsuicidal patients, tended to
			generate fewer alternatives to<lb/> interpersonal problems; they also tended to focus on
			the potentially<lb/> negative aspects of the solutions they generated. Moreover, the
			suicidal<lb/> subjects were observed to implement fewer of the alternatives that<lb/>
			they did generate.<lb/></p>

		<p>One of the important contributions of the <ref type="biblio">Schotte and Clums
				(1987)</ref><lb/> study is that it illuminates some of the qualitative and stylistic
			aspects<lb/> of the problem-solving process in suicidal individuals, rather than
			only<lb/> the quantitative aspects (number of alternatives). A similar emphasis<lb/> on
			qualitative aspects of cognitive functioning in suicidal individuals<lb/> is offered by
				<ref type="biblio">Shneidman (1985)</ref>. He points to the logic of the
			suicidal<lb/> person&apos;s thinking and shows its faults. The suicidal person&apos;s
			thinking<lb/> is categorical and abrogates the rules of logical deduction. The
			deductions<lb/> made by suicidal individuals are based on faulty premises and
			faulty<lb/> syllogistic conclusions. Shneidman demonstrates how such faulty
			rea-<lb/>soning processes may turn destructive to the logician.<lb/></p>

		<p>The purpose of the present study was to learn further about the<lb/> qualitative aspects
			of the problem-solving process in suicidal individuals.<lb/> Specifically, the study
			focused on the following question: Can suicidal<lb/> individuals produce alternative
			solutions that are qualitatively different<lb/> from each other? Do the alternatives
			consist of a direct confrontation<lb/> of the problem or an avoidance response? Are the
			solutions active or<lb/> passive in nature? To what degree are the proposed solutions
			relevant<lb/> to the problems? Other questions related to the degree of extremity
			of<lb/> the solutions, type of affect demonstrated in the solutions, and
			orienta-<lb/>tion to the future in the solutions. We sought out the qualitative
			aspects<lb/> of problem solving along three dimensions: the general coping style<lb/>
			(e.g., degree of versatility), the energetic/motivational dimension, and<lb/> the
			emotional/affective dimension.<lb/></p>

		<p>In this study, emergency room patients and outpatients, including<lb/> both suicidal and
			nonsuicidal individuals, were evaluated with regard<lb/> to degree of suicidal intent, a
			problem-solving task, a scale measuring<lb/> authoritarian, and a creativity test. The
			problem resolution task was<lb/> analyzed on a number of quantitative and qualitative
			aspects. The<lb/> present paper summarizes the qualitative/stylistic aspects
			only.<lb/></p>

		<head>Method<lb/></head>

		<head>Subjects<lb/></head>

		<p>Sixty-eight males and females, with an age range of 18-45 and an<lb/> average age of 31
			years, participated in the study. The subjects were<lb/> recruited from two sources.
			Forty-six subjects were in treatment in a<lb/> psychiatric outpatient clinic of a large
			mental hospital near Tel-Aviv.<lb/> The subjects were screened with the help of the
			clinic therapists, who<lb/> were asked to select patients known to have made a suicidal
			attempt<lb/> or who had suicidal ideations, but who were nonpsychotic. The
			therapists<lb/> were also asked t o refer other nonsuicidal, nonpsychotic patients.
			Most<lb/> of the patients referred to the study were diagnosed by their therapists<lb/>
			as suffering from depression (major or minor). The subjects were then<lb/> approached
			for an interview by one of the investigators (N. D.).<lb/></p>

		<p>The other 22 subjects were recruited from the psychiatric emergency<lb/> room (ER) where
			they were evaluated for suicidal behavior (attempts<lb/> or ideation). These subjects
			were identified by the attending psychiatrist<lb/> as suicidal or nonsuicidal depressed
			patients who were referred for<lb/> ambulatory care and who did not need immediate
			hospitalization. The<lb/> diagnosis of the patients was determined by the attending
			psychiatrist<lb/> in the ER. The psychiatrist then referred each appropriate patient
			to<lb/> one of the investigators, who was present in the ER for the purpose of<lb/>
			conducting the experimental procedure. The subjects were then redivided<lb/> on the
			basis of suicidal behavior by means of a questionnaire and<lb/> information from the
			admissions interview. This procedure yielded the<lb/> following groups: 31 nonsuicidal
			subjects and 29 suicidal subjects (16<lb/> subjects with suicidal ideation, 13 subjects
			who had attempted suicide).<lb/> Suicide attempts included acts of self-harm by
			ingestion of pills (71,<lb/> wrist cutting (4), jumping from a high place (11, and gas
			inhalation<lb/> (1). Suicidal ideation consisted of wishes to be dead (81,
			occasional<lb/> thoughts about suicide (5), and planning suicide without intentions
			to<lb/> carry it out in the near future (3). This information was obtained<lb/> through
			the questionnaire or evaluation in the ER.<lb/></p>

		<p>All subjects were Hebrew-speaking. Forty-eight were born in Israel<lb/> or in another
			Middle Eastern country; the rest were of European origin.<lb/> Most of the subjects were
			of low to middle socioeconomic status. The<lb/> range of years of education was 5-16 ( M
			= 10.2). This information<lb/> was obtained from a general information questionnaire
			that was filled<lb/> out by the patients.<lb/></p>

		<head>Instruments<lb/></head>

		<p>Depression and Suicide Questionnaire The scale used in this study<lb/> to assess
			suicidality is a modification and Israeli adaptation of the Zung<lb/> Depression Scale
				<ref type="biblio">(Zung, 19741</ref>, which measures both depression and<lb/>
			suicidality. The 3-point scale was modified and adapted by <ref type="biblio"
				>Bar-Joseph<lb/> and Tzuriel(1984)</ref>. They found this scale to be highly
			reliable in several<lb/> test-retest procedures (r&apos;s between .71 and .86). Validity
			was determined<lb/> through a concurrent administration with diagnosis of Depression
			by<lb/> DSM-III-R ( r = .42,p &lt; .05). Only that part of the questionnaire
			dealing<lb/> with information about suicidal behavior (ideation or attempt) was<lb/>
			utilized for the analysis of the recent study. The validity of this subscale<lb/> was
			confirmed in a previous study by means of a correlation between<lb/> the suicide
			subscale items and chart information about acutal suicidal<lb/> behavior ( r = .92, p
			&lt; .05; <ref type="biblio">Orbach, Apter, Gruchover, Tiano, &amp; Har-<lb/>Zahav, in
				press</ref>). In addition to this questionnaire, information about<lb/> suicidal
			behavior was obtained from admissions records of both out-<lb/>patients and inpatients.
			Thus, a person was defined as suicidal on the<lb/> basis of the suicide scale and/or
			admissions records.<lb/></p>

		<p>Problem-Solving Task The problem-solving task was devised for<lb/> the present study as a
			measure of the qualitative and quantitative<lb/> dimensions of the problem-solving
			process. The task consists of three<lb/> dilemmas that the subject is asked to resolve
			by giving as many possible<lb/> solutions as he or she can. The first problem deals with
			a young woman<lb/> who is driving her car, with her boyfriend sitting next to her. He
			decides<lb/> to take this opportunity to ask her to marry him. The young woman,<lb/> in
			her excitement, reaches out for a cigarette; at that moment, she<lb/> loses control of
			the car and an accident occurs. The young woman is<lb/> slightly injured, but her
			boyfriend is paralyzed for life. The dilemma<lb/> here is how to continue the
			relationship with the boyfriend, if at all.<lb/> The second dilemma deals with a
			university professor who has devoted<lb/> his life to his work, but unexpectedly
			receives a letter of termination.<lb/> The professor must ponder the options for
			response open to him. The<lb/> third dilemma deals with a problem of forbidden love
			between a man<lb/> and woman of different religious faiths. The woman is being
			pressured<lb/> by her family to leave her lover because of his different faith. The<lb/>
			woman is caught up in an extreme conflict between leaving her lover<lb/> and leaving her
			family.<lb/></p>

		<p>For each of the three dilemmas, the subjects were requested to respond<lb/> to the
			following questions:<lb/></p>

		<list>
			<item>1. If you were in the place of the protagonist (the girl who survives<lb/> the
				crash; the professor; and the woman who is pressured by her<lb/> family), how would
				you solve this dilemma? Please give as many<lb/> solution as you can.<lb/></item>
			<item>2. Indicate (on a scale from 1 to 3) the degree of satisfaction that you<lb/>
				would derive from each solution.<lb/></item>
			<item>3. Indicate (on a scale from 1 to 3) the degree to which you believe<lb/> that you
				would be able to carry out each of the solutions you have<lb/> indicated
				above.<lb/></item>
		</list>

		<p>The present study analyzed the responses to the first question only.<lb/></p>

		<p>A pretest yielded eight qualitative categories in terms of which the<lb/> various
			solutions were analyzed. The categories were as follows:<lb/></p>

		<list>
			<item>1. Versatility of the solutions-Do the various solutions seem to be<lb/>
				definitely different from each other? &quot; Yes &quot; was scored 1; &quot; no
				&quot; or only<lb/> one alternative was scored 0.<lb/></item>
			<item>2. Reliance on self or reliance on others-Does the solution represent<lb/>
				reliance on self or dependence on others? Reliance on self was scored<lb/> 1, and
				dependence on others was scored 0.<lb/></item>
			<item>3. Active versus passive solution-Does the solution reflect an active<lb/>
				initiative (through self and others), or is it a passive, giving-in type of<lb/>
				solution? Active solutions were scored 1, and passive solutions were<lb/> scored
				0.<lb/></item>
			<item>4. Confrontation versus avoidance-Is there a direct confrontation<lb/> of the
				problem (fighting, compromising, getting help, complaining), or<lb/> is there an
				avoidance of the problem (escape, denial)? Confrontation<lb/> was scored 1, and
				avoidance was scored 0.<lb/></item>
			<item>5 . Relevance-Is the solution relevant or irrelevant to the problem<lb/> at hand?
				A relevant solution was scored 1, and an irrelevant solution<lb/> was scored
				0.<lb/></item>
			<item>6. Positive versus negative (or no) affect-Does the solution contain<lb/> positive
				affect, negative affect, or no affect at all? Positive affect was<lb/> scored 1;
				negative affect and no affect were scored 0.<lb/></item>
			<item>7. Reference to the future-Does the solution imply a positive reference<lb/> to
				the future, a negative reference to the future, or no reference at all?<lb/>
				Positive reference was scored as 1; and negative or no reference was<lb/> scored
				0.<lb/></item>
			<item>8. Drastic solutions (extremeity) -Does the provided alternative consist<lb/> of a
				drastic solution (suicide, homicide, getting crazy, aggression), or<lb/> does it
				consist of a moderate solution? A drastic solution was scored 1<lb/> and, no drastic
				solution was scored 0.<lb/></item>
		</list>

		<p>The final score of each category consisted, for each subject, of the<lb/> mean score
			based on the number of solutions he or she offered. The<lb/> solutions were rated by two
			independent, experienced clinical psy-<lb/>chologists, and the correlation coefficients
			of the ratings (1 or 0 in each<lb/> dimension) were .68, .80, and .69 for the three
			dilemmas, respectively.<lb/> Whenever there was a disagreement between the two judges, a
			third<lb/> judge, also a clinical psychologist, determined the final score.<lb/></p>

		<p>The Creativity Test <ref type="biblio">(Milgram 82 Milgram, 1974, 1976)</ref> and the
			Au-<lb/>thoritarian Personality-F Scale <ref type="biblio">(Adorno, Frenkel-Brunswick,
				Levinson,<lb/> &amp; Sanford, 1950)</ref> were also administered as validity
			measures for the<lb/> rigidity measure of the problem-solving task. The F scale was
			negatively<lb/> correlated with the number of alternatives provided on the problem-<lb/>
			solving tasks ( r = .41, p &lt; .001). Similarly, there was a significant<lb/> positive
			correlation between the Creativity Test and number of alter-<lb/>natives provided on the
			problem-solving tasks ( T = .54, p &lt; .001).<lb/></p>

		<head>Procedure<lb/></head>

		<p>The study was presented to all subjects as an investigation of cognitive<lb/> processes
			in problem solving. Only the subjects who consented to the<lb/> procedure participated
			in the study.<lb/></p>

		<p>Outpatients were approached, with the help of their therapists, for<lb/> an appointment
			with the investigator. The ER patients were approached<lb/> when they were cleared for
			the study procedure by the attending psy-<lb/>chiatrist.<lb/></p>

		<p>All subjects were given the questionnaires in the same order; however,<lb/> the order of
			the three dilemmas was randomized. The procedure lasted<lb/> about 45 minutes.<lb/></p>

		<head>Results<lb/></head>

		<p>Three one-way analyses of variance (ANOVAs) were conducted in order<lb/> to detect
			differences among the three groups with regard to the depression<lb/> questionnaire, the
			Authoritarian Personality-F Scale, and the Crea-<lb/>tivity Test. None of the
			differences among the three groups (nonsuicidal<lb/> patients, suicide ideators, and
			suicide attempters) was significant.<lb/></p>

		<p><ref type="table">Table 1</ref> summarizes the means, standard deviations, and the
			one-<lb/>way ANOVAs for each of the eight content factors. All but one factor<lb/>
			significantly differentiated among the three groups of subjects. The<lb/> only
			nonsignificant factor was the drastic-solutions dimension.<lb/></p>

		<p>In general, suicide attempters and suicidal ideators came out lower<lb/> on versatility
			of the solutions, direct confrontation, relevance of solutions,<lb/> positive affect,
			and orientation toward the future. On the activity-<lb/>passivity dimension, attempters
			and normals were higher than the<lb/> suicide ideators. Eight 3 x 2 (groups x sex)
			ANOVAs were also carried<lb/> out to assess differences between men and women. These
			analyses<lb/> yielded no significant differences.<lb/></p>

		<head>Discussion<lb/></head>

		<p>The findings of this study clearly point out distinct differences between<lb/> the
			problem-solving processes of suicidal individuals (attempters and<lb/></p>

		<figure type="table">TABLE 1. Means, Standard Deviations, and ANOVA F Values for the
			Eight<lb/> Categories of Content Analysis in the Three Groups<lb/> Attempters<lb/>
			Ideators<lb/> Controls<lb/> ( n = 13)<lb/> ( n = 16)<lb/> ( n = 31)<lb/> Category<lb/>
			M<lb/> SD<lb/> M<lb/> SD<lb/> M<lb/> SD<lb/> F (2, 57)<lb/> Versatility<lb/>
			Self-other<lb/> Activity<lb/> Confrontation<lb/> Relevance<lb/> Affect<lb/> Future
			orientation<lb/> Drastic solution<lb/> .46<lb/> .46<lb/> .76<lb/> .24<lb/> .30<lb/>
			.06<lb/> .42<lb/> .54<lb/> .44<lb/> .33<lb/> .36<lb/> .44<lb/> .33<lb/> .36<lb/>
			.34<lb/> .43<lb/> .34<lb/> .34<lb/> .18<lb/> .35<lb/> .40<lb/> .25<lb/> .43<lb/>
			.16<lb/> .04<lb/> . l l<lb/> .50<lb/> .38<lb/> .46<lb/> .66<lb/> .31<lb/> 1.01<lb/>
			.74<lb/> .74<lb/> .74<lb/> .74<lb/> .78<lb/> .29<lb/> .90<lb/> .13<lb/> .25<lb/>
			.25<lb/> .28<lb/> .28<lb/> .31<lb/> .28<lb/> .28<lb/> .43<lb/> 8.75*<lb/> 8.75*<lb/>
			8.50*<lb/> 26.88*<lb/> 13.72*<lb/> 8.61*<lb/> 10.94 &quot;<lb/> 1.72<lb/> * p &lt;
			.01.<lb/></figure>

		<p>ideators) and those of nonsuicidal individuals. These differences appeared<lb/> in all
			dimensions of the problem-solving process: the general coping<lb/> style, the
			energetic/motivational dimension, and the affective dimension.<lb/> The general coping
			style (degree of versatility, relevance of solutions,<lb/> confrontation vs. avoidance,
			reliance on self vs. others) of the attempters<lb/> and ideators was a style of
			avoidance. These groups tended to escape<lb/> and avoid direct confrontation; they used
			denial; and their solutions<lb/> tended to be irrelevant to the nature of the problem.
			At the same time,<lb/> they tended to use the same solution repetitively. The following
			are<lb/> examples of escapism and irrelevance: &quot; She should not have started<lb/>
			such a relationship to begin with &quot; (the interfaith love affair); &quot; He<lb/>
			should become religious &quot; (the professor); &quot; She should leave everything<lb/>
			and go to Africa to help those in poor nations &quot; (the accident).<lb/></p>

		<p>The following are examples that show the massive denial used by<lb/> some of the suicidal
			subjects: &quot; Try to forget it and never see him again &quot;<lb/> (the accident);
			&quot; Try to take care of him until he has completely recovered &quot;<lb/> (the
			accident).<lb/></p>

		<p>Examples of the repetitiveness in the alternative solutions include<lb/> the following:
			&quot; She can take care of him &quot; ; &quot; She can continue to love,<lb/> she
			cannot think of leaving him &quot; (the accident).<lb/></p>

		<p>The energetic/motivational dimension is reflected in the categories<lb/> of activity
			versus passivity and reliance on self versus reliance on<lb/> others. The suicidal
			ideators and attempters tended to depend on others<lb/> in their solutions. The
			following are examples of these tendencies:<lb/> &quot; Maybe a better cure can be found
			someday &quot; (the accident); &quot; Hopefully<lb/> the parents will change their minds
			&quot; (the love affair); &quot; I will ask him<lb/> [the boyfriend] what he suggests
			&quot; (the accident). Such responses show<lb/> little commitment to dealing directly
			with the problem. This approach<lb/> no doubt reflects the sense of hopelessness and
			lack of self-esteem<lb/> known to characterize suicidal individuals.<lb/></p>

		<p>Paradoxically, suicide attempters and nonsuicidal individuals, com-<lb/>pared with
			suicide ideators, produced more active and energetic types<lb/> of solutions: &quot; He
			should ask his friends to organize a strike &quot; (the pro-<lb/>fessor); &quot; Get
			Social Security to provide him with funds &quot; (the accident);<lb/> &quot; Go away
			from everything &quot; (the accident). Suicidal ideators on the<lb/> other hand, tended
			to show more passivity, such as &quot; Let&apos;s wait and<lb/> see &quot; ; &quot;
			Maybe things will change &quot; ; &quot; Maybe it&apos;s not so bad as it looks.
			&quot;<lb/> This finding can be taken to mean, in general, that those who exhibit<lb/> a
			stronger suicidal tendency tend to be more active and more energetic,<lb/> albeit in a
			self-destructive fashion, in their approach to problem solving.<lb/> Although lethal
			suicidal behavior reflects more hopelessness than non-<lb/>lethal suicidal behavior <ref
				type="biblio">(Beck, Steer, Kovacs, &amp; Garrison, 1985)</ref>, it<lb/> requires
			more active behavior. This difference between attempters and<lb/> ideators is consistent
			with the well-known fact that suicide may occur<lb/> in the stages of recovery from
			depression, when the individual is more<lb/> active and energetic, rather than during
			the incapacitating and passive<lb/> state of the depression <ref type="biblio">(Arieti,
				1974)</ref>.<lb/></p>

		<p>There was also a distinct difference between suicidal and nonsuicidal<lb/> individuals in
			the emotional/affective dimension (positive vs. negative<lb/> affect, reference to the
			future). The suicidal subjects displayed a more<lb/> pessimistic, giving-up attitude in
			their solutions, as in these examples:<lb/> &quot; I don&apos;t think they can be happy
			again &quot; (the accident); &quot; They can expect<lb/> a lot of trouble &quot; (the
			love affair).<lb/></p>

		<p>Taken together, the findings of this study with this particular pop-<lb/>ulation show
			that problem solving is not a process limited to cognitive<lb/> aspects or to the number
			of alternatives produced. Rather, it is a complex<lb/> process that includes
			motivational, cognitive, and affective aspects.<lb/> This study does not describe the
			exact causal relationship between the<lb/> problem-solving styles and suicide. However,
			it is clear that therapeutic<lb/> interventions should take into account these deficits
			in problem solving<lb/> when working with suicidal individuals. Special attention should
			be<lb/> given to the active, energetic characteristics of attempters as opposed<lb/> to
			ideators. Changing the nature of their activity from destructive to<lb/> constructive
			may be a good starting point in intervening in their pattern<lb/> of problem solving.
			Further studies are required to confirm the gen-<lb/>eralizability of these qualitative
			characteristics of problem solving among<lb/> suicidal individuals. Special attention
			has to be paid to the diagnoses<lb/> of the subjects in terms of suicidality and
			depression.</p>


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