My Thoughts on the Language of Suicidology and the Tower of Babel
I finally read the “Language of Suicidology” by Morton Silverman (Silverman, 2006). Silverman has been in the suicide field for years. He has written countless books and articles on the subject of suicide. In this article, I found a few interesting things. One is there is no such thing as the language of suicide that encompasses the whole discipline or even the different disciplines that suicide falls into. Things like suicide attempt or suicide gesture mean completely different things to different people. There is no forward definition on the subject. In O’Carroll et al. work (O’Carroll et al., 1996), the Tower of Babel, state that “’attempted suicide’ is meaningless”. Does it mean someone intended to die with an act that put their life in danger, hurt themselves without the intent to die, or just thought about the intent to die? Everyone has their own opinion on what this term means. Dr. Silverman pointed out that there was a study with expert suicidologists and then general mental health clinicians to find out if they could identify among ten vignettes which were deemed an attempted suicide. There was no consensus among either the suicidologists or the clinicians!! How is this term used so frequently yet has no definitive markers or insights is beyond my thoughts. I am sure you, as a reader of my blog, has your own opinion as to what is deemed a suicide attempt. But is it what the next person will think? Even among self-reports, there are no guidelines as to what makes a suicide attempt. Is it a few extra pills of Tylenol? A deep slash on the wrist that required stitches and a hospital stay? Or an overdose that didn’t require medical attention at all?
The one thing that I can take away from this paper is that his idea of “died by suicide” is golden. It is gaining ground in the suicide community to replace “committed suicide” or completed suicide. Other than that, there is no other message in the paper to help the understanding of the terms of suicide or even suicidality, a term that he wanted to get rid of all together. I use suicidality a lot in my blog. It encompasses the whole suicidal thoughts, behaviors, cognition, and emotion that I feel when I want to end my life. It might not mean anything to anyone else, but it means something to me. But he states that this word is not going away anytime soon.
If the experts can’t figure out what is meant by attempted suicide, how can the rest of the world? It means so much to different people yet in the clinical world it hardly means anything if there isn’t a nomenclature about it. What I found interesting was the synonyms for suicide attempt (SA): cry for help, courting death, life threatening behavior, near fatal SA, suicidal manipulation, near lethal suicide, risk taking behavior. And what is meant by suicidality? There is no clear definition of it. To me, it encompasses the cognition, behavior, and emotion of suicide, but it might not be the same to someone else. Does it mean someone is suicidal? What is meant by that? There were fifteen different definitions of suicide. Fifteen! All were mostly similar. The shortest one was “self-initiated, intentional death”. There was a definition by the father of suicidology, Edwin Shneidman, but I found that the definition to be confusing and wordy. The author of this article also had a definition, “suicide is, by definition, not a disease, but a death that is caused by self-inflicted intentional action or behavior”. If so many people define suicide differently than someone else, how can there be any consensus?
The one take away from this article was “committed suicide” should be taken away and “died by suicide” should be used. I was happy to see that. Also was glad to see possible terms to be removed: nonfatal suicide, committed suicide, completed suicide, failed attempt, failed completion, and fatal suicide attempt.
Part 1 and 2 of Revisiting the Tower of Babel
Since O’Carroll’s paper in 1996, there have been no definitive terms for suicide, suicide attempt, suicide gesture, self harm, or suicide threat. Efforts have been made but no two researchers have consistently used the same term. In the following, I will give the background of what has been used and what was “taken away”.
Silverman et al. (Silverman, Berman, Sanddal, O’Carroll, & Joiner, 2007a) have stated “’suicide’ refers not to a single action but more broadly to a great many varied behaviors” (p248). And as such, no single term defines the complex set of behaviors that suggests someone being suicidal. Here are my thoughts on this paper and the outcome of their process that was made to be simple in mind but proved difficult.
The background for this is as follows:
“Measures of suicide and nonfatal suicidal behavior continue to be hindered by the lack of 1) standard nomenclature; 2) clear operational definitions; 3) standardized lethality measures” (p249). While this is true, my feeling is that if a researcher/clinician defines what is meant by these terms in their measurement in their study, it will be defined as such so no confusion exists in that paper. Though I understand the complexity it will have among different studies, there are no set guidelines. In the many papers I have read in over the past 11 years since this paper has come into print, O’Carroll (1996) has been cited as the standard definition of the terms of suicide and suicide attempt. He distinguished suicidal behaviors by three characteristic features: intent to die, evidence of self-injury, and outcome (injury, no injury, death). A number of researchers have adopted this nomenclature in their studies (see article for the list). Even the American Psychiatric Association has acknowledged and adopted the definitions set by O’Carroll et al. in their implementation of practice guidelines for the assessment and treatment of patients with suicidal behaviors. The only reason why this hasn’t been formally adopted is because of the new terms they have proposed. It should stop here but let us continue with their insight into the definitions of suicidal behaviors.
One of the new terms proposed was “instrumental suicide-related behavior (ISRB)”. O’Carroll et al. thought this would be a better term than suicidality. However, as we will see, suicidality has been used more frequently to describe the whole of suicide, suicide attempts, behaviors relating to suicide, and self-harm (NSSI).
As stated above with Silverman’s paper, there is still confusion about the terms suicidal behavior, deliberate self-harm, suicide-related behavior, parasuicide, and suicidality. It is important to recognize that suicide and its subsequent behaviors are not a disorder or diagnosis. The motivation to die and prepare to die by self-jury do not necessarily place an individual at either acute or high risk for suicide. There has been much debate about what constitutes intent. It has been suggested that “intent implies an action to change the future while “motivation” implies an effort to affect interpersonal relations and a change in social milieu”(p254). Their position is that “intent refers to the aim, purpose, or goal of the behavior” (p254). I believe the latter to be the simpler definition of intent and “connote a conscious desire or wish to leave (or escape from) life as we know it” (p254). We also need to bear in mind that intent is fluid and changes from minute to minute.
The authors also explored the relationship between intent and lethality. They concluded “the presence of intent assumes 1) a desire or wish to die as a conscious experience; 2) knowledge of risk associated with a behavior; 3) some perception that means or methods are available to achieve the desired outcome (suicide attempt); 4) some knowledge about how to use means or method” (p255). Without knowing intent, it becomes impossible to know the different types of suicide related behaviors and self-injurious behaviors. The end result of this was to reorganize to three categories: no intent, uncertain intent, and intent. Regarding lethality, most clinicians think that high medical lethality suggests high intent even though high intent doesn’t always suggest high lethality.
Another term they deemed not to include in their nomenclature was “suicide gesture”. It’s ambiguity about it being a threat with low intent or behavior that is self-inflicted but not suicidal in nature makes it a precursor to suicide attempt but not with intention (p256). The common theory is ultimately that it simply means an action was taken with the intent to die not withstanding. It implies a suicidal act but because the intent was low, it doesn’t mean it. It can just be termed as self-harm behavior.
The term suicidality is used to encompass a wide range of thoughts, behaviors, and ideation of suicide and related behaviors. The authors chose not to avoid the term even though some authors use the term to describe the “totality of suicide-related ideation and behaviors” (P257). It has become a popular term even though it is not yet in the dictionary. Therefore the authors decided to stick with suicide-related ideations, suicide-related behaviors, and added the ridiculous term, suicide-related communication. Now that is simplifying things!
Even though the term “suicide attempt” was chosen to be extinguished from the vocabulary but still remains in the literature, it still does not have a clear definition though it has been suggested to mean “a high likelihood of death as a well as a true intent to kill oneself” (p258). As there can be varying degrees of attempts, part 2 of this article suggests typifying them into categories of type I and type II. Suicide Attempt, Type I is when no injury occurs. Type II is when injury occurs. Suicide is when death occurs.
Part 2 of (Silverman, Berman, Sanddal, O’Carroll, & Joiner, 2007b) is utter nonsense and had no meaning in defining anymore than what is already known. The term they tried to typify are the behavior, threat, plan, and ideation of suicide. For example, terms such as accidental suicide becomes self-inflicted unintentional death, completed suicide becomes suicide, intentional self harm or injury becomes self harm type I and II. And the term instrumental self-related behavior becomes suicide threat type I-III. (see the exhaustive list in the paper for definition).
A suicide plan is a proposed method of carrying out a method that leads to a self-injurious outcome (p268). That is something that I can agree on.
In closing, the authors quote Dr. Jamison (Jamison, 1999) as stating “all suicide classification and nomenclature systems are to a greater or lesser extent, flawed; and all or most all will have points that are well or uniquely taken” (p27;275). I take that to interpret that people will take what they will as it suits them and leave the rest as it lies.
Jamison, K. R. (1999). Night Falls Fast: Understanding Suicide: Alfred Knopf.
O’Carroll, P. W., Berman, A. L., Maris, R. W., Moscicki, E. K., Tanney, B. L., & Silverman, M. M. (1996). Beyond the Tower of Babel: A Nomenclature for Suicidology. Suicide and Life-Threatening Behavior, 26(3), 237-252.
Silverman, M. M. (2006). The Language of Suicidology. Suicide and Life-Threatening Behavior, 36(5), 519-532. doi: 10.1521/suli.2006.36.5.519
Silverman, M. M., Berman, A. L., Sanddal, N. D., O’Carroll, P. W., & Joiner, T. E. (2007a). Rebuilding the Tower of Babel: A Revised Nomenclature for the Study of Suicide and Suicidal Behaviors Part 1: Background, Rationale, and Methodology. Suicide and Life Threatening Behavior, 37(3), 248-276.
Silverman, M. M., Berman, A. L., Sanddal, N. D., O’Carroll, P. W., & Joiner, T. E. (2007b). Rebuilding the Tower of Babel: A Revised Nomenclature for the Study of Suicide and Suicidal Behaviors Part 2: Suicide-Related Ideations, Communications, and Behaviors. Suicide and Life Threatening Behavior, 37(3), 264-277.