Words Matter: The Language of Suicidal Self-Directed Violence

SIGNIFICANCE FOR PRACTICING PSYCHIATRISTS

In the wake of the unfortunate passing of several high-profile individuals, media headlines illustrate a long-standing and persistent challenge regarding how best to speak and write about suicidal self-directed violence. This includes both suicidal thoughts, or suicidal ideation, and behaviors including preparatory behavior, suicide attempt, and death by suicide. Despite the Centers for Disease Control and Prevention advocating for uniform definitions of self-directed violence, coupled with guidelines by leading suicide prevention experts and organizations (eg, American Association of Suicidology, American Foundation for Suicide Prevention) to facilitate understanding and reporting of suicidal self-directed violence in the media, idiosyncratic, even troubling, turns of phrase continue to feature in this context.^1,2

The incongruity between recommended reporting guidelines and the language often utilized by the popular press provides evidence of a significant disconnect between the field of mental health and the media. The problem is perpetuated in part by challenges faced within the clinical and research sectors in terms of widespread education and implementation of the preferred suicidal self-directed violence nomenclature. Indeed, a quick online search will produce a litany of headlines featuring what is now considered antiquated language for suicidal self-directed violence, such as an individual who “committed suicide” or experienced a “failed suicide attempt.” Unfortunately, similar language not infrequently still appears in clinical records and communications offered by mental health professionals.

Consequences of biased and negative terminology

Although at surface level these phrases may appear rather benign relative to other outdated terms, such as “suicidal manipulation” or “rational suicide,” these terms, as well as others that are inconsistent with the proposed universal nomenclature, risk maintaining stigma and bias. Illustrative is the Merriam-Webster dictionary definition of “commit,” denoting an action that is deliberate, with “crime” and “sin” being the referent of deliberate action. The use of “commit” (often unintentionally) thus imbues suicide with a sense of badness or moral infirmity. Similarly, a “failed attempt” suggests that dying by suicide equates with success. The use of such biased suicidal self-directed violence terminology may reinforce the negative quality and heighten stigmatization of suicidal thoughts or behavior.

The persistent use of suicidal self-directed violence terminology inconsistent with proffered universal nomenclature carries with it several additional concerns. First and foremost, utilization of nonuniversal suicidal self-directed violence terminology enables, or superficially makes okay, the use of such phrases within clinical, research, and public health settings. Of course, such language is then all the more likely to feature in the popular discourse among the general population. This sets up a cycle of continued use whereby mental health professionals, media, and lay persons mutually influence one another, normalizing terms and phrases that are inherently biased, vague, and at times detrimental to patients’ treatment engagement and recovery.

Suicidal self-directed violence is often a devastating event that touches both the patient as well as those within their social support system including family and friends.³ Lack of patient-centered wording in these circumstances thus has the potential to further exacerbate grieving and complicate the recovery process. For example, headlines reporting on suicidal self-directed violence in a manner that fails to adhere to the current reporting guidelines (eg, “actor uses knife in failed attempt to commit suicide”) not only sensationalizes such events but also has the potential to vilify an individual in crisis as being a “failure” for not “completing” the suicide attempt, or as morally defective for “committing” thoughts or actions involving suicide.² This likely results in further stigmatization around mental health, and suicidal self-directed violence in particular, which is especially alarming given the significant public health concern that suicide remains.

Toward an appropriate universal nomenclature

Taken in aggregate, the utilization of inconsistent and stigmatizing suicidal self-directed violence nomenclature may represent an additional (and needless) barrier existing among clinicians, researchers, policy makers, and the individuals with whom we are attempting to connect, better understand, and treat. Whereas multiple institutions, including the Departments of Veterans Affairs and Defense, have advocated for, validated, and implemented efforts to promote universal nomenclature around suicidal self-directed violence, to improve provider communication, and decrease inherent bias and stigma, such energies to date have largely been focused on relatively narrow clinical and research communities.^4,5 To the extent that such efforts have gained traction, this mostly has been within large-scale medical settings wherein infrastructure and oversite (a top-down approach) makes feasible the dissemination, mandate of, and oversite needed to realize the use of suicidal self-directed violence nomenclature.

Global use of appropriate suicidal self-directed violence nomenclature requires more than uptake and adherence within medical settings. Attenuation of use of antiquated suicidal self-directed violence terminology requires a multidimensional, multidisciplinary approach that reaches across multiple sectors of the community. Specifically, approaches that continue the public health dialogue among mental health clinicians, researchers, and media personnel are necessary to facilitate consensus. Extant research continues to suggest a significant gap between aspirational language and actual reporting of suicidal self-directed violence, with a 2010 study finding that approximately 36% of reported stories continuing to use repudiated language (eg, commit suicide, failed suicide attempt, suicidal gesture) identified by the recommended media reporting guidelines.^2,6

Continued attention to how suicidal self-directed violence is discussed, within both the clinical and media sectors, remains important if we are to understand how nomenclature may influence suicide risk, especially in terms of how biased or stigmatizing language may provoke stigmatizing and dysphoric reactions among patients and those bereaved by suicide. There is some progress: revisions by the Associated Press Style Book in 2015 advocated for discontinued use of the term “commit/committed suicide” in favor of “died by suicide, killed him/herself, took his/her own life,” reflecting a continued culture of change. Further, at the time of this writing, a recent media report described the passing of a celebrity singer due to death by suicide, doing so in accordance with the recommended media reporting guidelines (eg, “singer dies of suicide”). Thus, there remains room for hope, perhaps tentatively even optimism that continued progress toward patient-centered discussion of mental health, including suicide, is achievable. We may even come to collectively utilize a nomenclature that facilitates engagement by patients and compassion more broadly.

Disclosures:

Dr Holliday is Advanced Postdoctoral Research Fellow, Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, and Instructor, Department of Psychiatry, University of Colorado, Anschutz Medical Campus; Dr Wortzel is Director, Neuropsychiatry Consultation Services, Co-Director, Suicide Risk Management Consultation Program, Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, and Associate Professor, Departments of Psychiatry, Neurology, and Physical Medicine and Rehabilitation, University of Colorado, Anschutz Medical Campus; Dr Matarazzo is Clinical/Research Psychologist and Director, Clinical Services, Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, and Associate Professor, Department of Psychiatry, University of Colorado, Anschutz Medical Campus.The authors report no conflicts of interest concerning the subject matter of this article.

References:

1. Crosby AE, Ortega L, Melanson C. Self-directed violence surveillance: uniform definitions and recommended data elements, version 1.0. Atlanta, GA: Centers for Disease Control and Prevention; 2011.

2. Reporting on Suicide. Recommendations for reporting on suicide. http://reportingonsuicide.org/. Accessed November 6, 2018.

3. Cerel J, Jordan JR, Duberstein PR. The impact of suicide on the family. Crisis. 2008;29:38-44.

4. Department of Veterans Affairs. Memorandum re: standardized suicide nomenclature (Self-Directed Violence Classification System) policy. Washington, D.C.: US Government Printing Office; 2010.

5. Office of the Under Secretary of Defense. Standardized suicide nomenclature (Self-Directed Violence Classification System) policy. Washington, DC: US Government Printing Office; 2011.

6. Tatum PT, Canetto SS, Slater MD. Suicide coverage in US newspapers following the publication of the media guidelines. Suicide Life Threat Behav. 2010;40:524-534.

7. Associated Press. The Associated Press Stylebook 2015: And Briefing on Media Law. New York, NY: Basic Books; 2015.