Tag: self harm

My Thoughts on the Language of Suicidology and the Tower of Babel

by Midnight Demon, posted in suicide, suicide attempt

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.

Preview of the nomenclature of suicide

by Midnight Demon, posted in suicide, suicide attempt

Preview of Tower of Babel, Part 2 article

I just finished reading this ridiculous article that is supposed to clarify terms but instead complicates them more than anything. I know I am not a clinician, but if I were, I doubt I would use their terms that state and I quote “self-harm type I, II, III, suicide attempt type I, II, III” etc. I have read research articles that have been written after this article and NO WHERE do they define their terms as such. I am appalled. I just had to write about this. It will be in my paper when I write it this weekend, once I calm down a bit.

What was interested was they omitted the term suicidality altogether. Instead they called it “suicide-related communications”. I am glad I have short hair, otherwise I would be pulling mine out right now. Obviously, this article is not meant to be reviewed by someone with lived experience. It was blatantly obvious this was for a clinician, researcher, or other type of professional in the suicide field (e.g., medical examiner, coroner, or public health person). I probably shouldn’t stick my nose in it but I am going to anyways because, like I said, no one has yet to use these terms in the literature so I am going to go to town on this. I am just glad they didn’t have subtypes to the self-harm or suicide attempt. And by the way, suicide attempt type III is suicide! I will have the definitions in the paper this weekend. I just wanted to blow off some steam about this now so I could be a little bit more clear headed while writing.

In the conclusion, the authors wrote that there should be studies, international and multi-centered nationally, to try and see if these terms fit. That would take some doing, though how to classify a death by suicide after it was indeed a suicide, I am clueless. And the authors did write that it would be difficult to ascertain intent with individuals who were intoxicated by drugs/alcohol or who were psychotic, delusional, or dissociated. They did mention the word “demented” but I am not sure I have ever heard that term in a clinical setting. The authors didn’t speculate on that term, which I guess means it is implied that what it is meant by.

Also in the closing paragraph, Dr. Kay Redfield Jamison was quoted about nomenclature being essentially rubbish when it concerns suicide classification. I fricken was laughing at that. I remember the line because I read the book so many times. The whole article is rubbish. More to follow…

random 694

by Midnight Demon, posted in Bipolar Disorder, blogging, chronic physical pain, depression, suicide attempt

From 1100 to 1600, I voted for Xander Bogearts via Twitter. The only time I was not voting was when I was meeting my psychiatrist. I have a lot of tweets today as I broke the 16,000 mark. I was at 15.8 before voting. I don’t know when the results are going to come out, maybe later tonight. I do hope he wins. He so deserve to play.

Met with my psychiatrist today. We mostly talked about the depression and how it seems to have lifted a little with the addition of vitamin D. I won’t say that I am “cured”, because I still have my down moments, but the heaviness that I was feeling seems to have lifted a little bit. She asked me about my date and if it was still on. I told her I don’t know. She still wants me to see her, regardless on how I am feeling, that day. I think if I don’t see her, I might be hospitalized. We also talked about pain and how it is shooting up my anxiety. I told her I don’t like it because it sometimes lead to agitation and that doesn’t mix well when you are suicidal. She said that it is a physiological fight or flight response. I guess the only thing I can really do IS take an Ativan. She didn’t say it, but implied it. She asked the reasoning of why I picked the date. I told her it was just out of a hat, but it had to be on a Friday so I could mess with statistics. She then told me that she doesn’t want me to be one. I could have argued that I already am one but I didn’t. She didn’t know about the whole suicides occurring more on Mondays than on any other days of the week. And I won’t be dying on a Monday.

I told her that I am going to feel defeated and lost because I didn’t go through with my plans. I already am feel dejected, and it’s still a week away. My life only lives to next week. I can’t see past it. My cousin invited us to his house for a lobster party in August and the first thought I had was that I couldn’t go because I would be dead. I don’t know what I am going to do. I feel so lost and disappointed in myself. I shouldn’t have told my therapist what I was planning. And I SHOULDN’T have told my psychiatrist either. I am such an idiot.

Last night, I was going through my Twitter feed and came across on of my BPD friends who tweeted that she took 26 pills of Tylenol 3. She said she should go to the hospital but she doesn’t want to because she has something planned for Saturday. I reported the tweet and she hasn’t tweeted since that message. I am kind of worried. I don’t know where she lives. I think she is in the UK, but I am not sure. There was no tweet before the one where she said she took the pills so it was obviously an overdose/suicide attempt. When I tried talking to her about the Tylenol damaging her liver, she seemed oblivious to the seriousness of what she did. She just blew it off as “it would take a long time”. I just hope the Twitter folks gets to her and she is in good care.

I got my Kati Kati coffee today. It was so good. I love it! I really got to get a bag. I just hope that by the time my next check comes, it is still around. I have never had this coffee hot before. I only make coffee at home hot because I don’t know how to make it iced. I know I got to double the amount of coffee and such but since I don’t have an ice mug, I kind of just been drinking hot coffee.

I am feeling low. My therapist wants me to write her a letter everyday. I haven’t done one today. I was too busy voting. I brought my tablet to today, thinking I would read while I waited for my doc but I voted then, too. It was too important not to vote. Now the voting has ended and I am blue. I hate when I don’t know what to do with myself. Game is on tonight, but I really don’t feel like watching it. A friend of mine called wanted to know if I was up to watching the game together. He would bring the snacks. But I am not up for company. I am in pain and I am kind of sleepy from the pain meds. I don’t think I will make it past the 4th inning.

Twenty-Three Years

by Midnight Demon, posted in Bipolar Disorder, depression, mental illness, suicidality

Twenty-three years

Today marks twenty-three years that I have sought help for my depression and self-destructiveness. I actually didn’t seek help straight out. My English teacher noticed I was upset and pulled me aside and saw the marks on my wrist that I had made the night before. She then told me to stay after class, something no teacher has ever told me to do before. She took me to the nurse’s office. We chatted. I told her about what happened at my house the last two nights and how much I just wanted to die. She called my mother, who then took me to the local counseling center. By then, I told them “nothing was wrong” and that I was “okay”. I declined treatment and went on with my day. Daily visits to the nurse’s office became more frequent. I just stopped in to check in and told her what was going on. She wanted me to see someone so the following week I agreed to see the school counselor. Thus started my official journey into psychotherapy.

It hasn’t been an easy road. For the first ten years, I had a different therapist nearly every year. I think the only time I had two years was with the psych resident that wanted to see me or I would still be in the hospital. I went through a lot with this psychiatrist in training. While in her care, I attempt suicide and ended up being in the hospital for two and half months. When she ended her residency, I went to another psych in training. He wasn’t as good as she was. In fact, he was terrible. I felt like he was more my brother than a therapist but when I told him I was procuring more medication to end my life, he asked me if I was suicidal. That is when I knew he was an idiot. I pretty much ended our relationship within a few weeks and saw someone else. She was good, had years experience. But after I had an argument with my sister and she wanted to know more about my sister’s social life than my anger, I ended things with her. I went about a month without seeing someone. I then decided to go back to my town’s local mental health center. I saw someone there for a year and again, she decided to move on after that year mark. We were finally connected and I felt so betrayed. I didn’t think I was going to see another person again. I don’t know what changed my mind. I knew I didn’t want to see someone else at the local mental health center. I wanted to see someone private. I figured they were less likely to leave their practice. And I luckily found my current therapist and we have been together for fourteen years. It is the longest relationship I have had, outside of my psychiatrist. I am lucky that I have had just one psychiatrist for my medication all these years. She does more than just prescribe my medication. She also does some therapy and is my sounding board for the various medical issues that I have. And I can’t wait to see her again in a week after not seeing her for four long months. It is going to be weird seeing her again.

I don’t know why I have stuck it out in therapy all these years, especially when things were at their worst. I have been beyond hopeless and yet my psych team (therapist and psychiatrist) always made me see another day, sometimes against my wishes.