The reason I have very little interest in focusing on "suicide threats" is because I do not view these statements as threats.  Some patients which have, in my opinion, been improperly labeled as having borderline personality disorder, make statements about their suicidal experience which others then interpret as "threats".  I suspect many of these people actually have what Dr. David V. Sheehan and I called "Impulse Attack Suicidality Disorder" (see chapters 6.1 and 6.2 in our recent book Suicidality: A Roadmap for Assessment and Treatment available from HarmResearch.org) where they experience unexpected, unprovoked attacks to make a suicide attempt or to plan for a suicide attempt (Unexpected Suicidal Impulse Attacks [USIAs]).  One patient described these USIAs as "60% the urge to engage in a compulsive behavior, 5% an obsessive thought, 25% panic attack, and 10% the urge to tic".  I believe many clinicians have become frustrated with patients not responding to usual treatments and then label their patients with borderline personality disorder in order to help the clinician cope with the patient not improving.  Many of the patients with this disorder have experienced an increased frequency of these attacks when taking an anti-depressant, hence their unwillingness to adhere to treatment (another sign of "borderline personality disorder"). 

I suspect that what clinicians are hearing as "suicide threats" are these patients reporting their Unexpected Suicidal Impulse Attacks and stating that they will make an attempt if not admitted because they do not feel they can keep themself safe and not act on these impulses.  I suspect a huge percentage of these "suicide threats" are people that are experiencing a suicidality disorder (either Impulse Attack Suicidality Disorder or one of the other 9 phenotypic disorders we describe in our book) that is not properly treated.  If these patient's suicidality disorders were properly treated with specific anti-suicidality medications, then these "suicide threats" would also disappear in these patients.  Unfortunately, the currently accepted view of suicidality as a response to a triggering life event or as a result of depression, prohibits these patients from getting adequate care and results in them making more of these "suicide threat" statements about their suicidality.

In the book is a case study of a subject with 25+ years of chronic Impulse Attack Suicidality Disorder that was always made worse using antidepressants, anti-epileptics, and mood stabilizers.  Lithium was not helpful, but did not make the suicidality worse.  Two courses of ECT, were unhelpful.  Years of DBT and CBT were also unable to eliminate this subject's suicidality.  However, we happened on a treatment for her suicidality and she has been completely free from suicidality for over a year now.  We believe this candidate treatment needs to be explored in other cases of Impulse Attack Suicidality Disorder and in the other phenotypes of suicidality disorders.

The book also has a structured interview to help clinicians identify the specific phenotype of suicidality a patient may be experiencing and a number of assessment tools which allow clinicians to document a thorough suicidality assessment and to get a more comprehensive perspective of the patient's suicidality.

http://harmresearch.org/

Book Suicidality: A Roadmap for Assessment and Treatment

Thank you for your detailed and informative answer which provides some perspective on "threats." However, while I now better understand the origin of some threats I still wonder why suicidal vocalizations do not rate at least a fraction of the attention given to suicidal thoughts which may be more innocuous though they may lead to more serious behavior. Of course, not every case of suicidality involves a threat anymore than a note. Nevertheless, I think that threats belong on any continuum of suicdal behavior. Also we need more knowledge so that we can better assess their meaning, if any, in regard to risk. Regards!

Dear Tony, 

It must be a hard work to daily deal with this issue. Nevertheless, some papers that may interest you: 

Article Correlates of parasuicide, suicidal threats, and suicidal id...

Article The characteristics of the suicide attempter according to th...

Article Five-Year Prospective Investigation of Self-Harm/Suicide-Rel...

Beatrice:

Thank you for the citations. I am familiar with the first and will check out the others. A big part of my concern about suicide threats being mostly "off the radar" as we in the US are fond of saying is that some may be stepping stones to acquired capability a la Joiner or to O'Connor's "volitional phase."  A threat is more active than a passive disclosure of ideation and they may be the only signs of rising risk in some cases. The lethality seen in suicide plans may first appear, perhaps less concretely, in threats.

Best!

Tony, 

I completely agree with you!

greetings from a very snowy Finland!

I did a bit more research into this.  Back in 1996 a nomenclature of suicidality terms were suggested by O'Carrol et al. (see first publication).  This was further revised and expanded in 2007 by Silverman et al. (see second and third publication).  The results of a reliability study were published this year using the revised nomenclature (see forth publication).  The results showed that the categories labeled "suicide threats" (referred to in the abstract as suicide related communication) had poor inter-rater reliability. 

I suspect that the type of training of the clinician (more psychological-based vs. more psychiatric-based) is having an impact on the inter-rater reliability of categories related to "suicide threats". 

Plus, it is very difficult to study something that isn't clearly defined; "A suicide threat is any interpersonal action, verbal or non-verbal, without a direct self-injurious component, that a reasonable person would interpret as communicating or suggesting that suicidal behavior might occur in the near future." (see publication 3 listed below).   First, there is the issue of how a reasonable person would interpret the situation.  Is this reasonable person the average person that assumes all self-harm has suicidal intent?  Is this reasonable person someone that has experience with suicidality?  Is this reasonable person someone that is trained in suicidality assessment?  All of these "reasonable" people examples would likely interpret the same situation differently.  Second, there is the issue of "communicating or suggesting".  Some people will believe that such a communication or suggestion must be more explicit (e.g. "I am going to kill myself") while others will believe even the faintest communication or suggestion is a "suicide threat" (e.g. "I want to go to sleep and not wake up" [which could mean not wake up for a long time due to physical exhaustion]).  Third, there is the issue of "might occur".  Is "might" any possibility greater than zero (>0) or does there need to be a higher possibility for it to be considered as "might" and, if so, how much of a higher possibility is needed?  Fourth is the issue of "in the near future".  Is the "near future" the next day, the next week, the next two weeks, or the next month?  Is it some other time frame all together?  All of these pieces of the definition are unclear which likely leads to the poor inter-rater reliability in this case.

Article Beyond the Tower of Babel: A Nomenclature for Suicidology

Article Rebuilding the Tower of Babel: A Revised Nomenclature for th...

Article Rebuilding the Tower of Babel: A Revised Nomenclature for th...

Article Interrater Reliability of the Silverman et al. Nomenclature ...

People who tell you they are suicidal are telling you two equally true things: 

1. I want to die

and 

2. I want to live

The dialectic is resolved by framing suicide as a solution (not a problem).....then helping the person to find the problem and find a better solution than suicide e.g. distress tolerance or problem solving.... Linehan (1993)in her DBT programme describes all this in minute detail. Incddentally she calls DBT a quality of life program not and anti suicide program. Even DBT does not claim to prevent suicide although it does reduce self harm dramatically.

There are no known individual interventions that prevent suicide. There are public health measure e.g. look up the british coal gas effect.

Declan

Declan:

Thank you for your responses to my question. Regarding the first, if you are saying, in effect, that (to paraphrase Pope) the proper study of suicide is suicide, I don't agree. All that a completed suicide leaves behind are the victim's demographics, some medical history, some memories, and a lot of grief. None of these necessarily shed light on how suicidality arises. Suicide is indeed thankfully rare in those with mental illness as in others, but suicide threats are not. Regarding your second response, I disagree with your opinion of "all that Silverman stuff" but you are certainly entitled to see that work as you do. If you are saying that some suicidal people are ambivalent then you are, of course, correct, but many are not and say nothing. They at least temporarily only want to die and are often passive and indifferent towards efforts to assess their risk or aid them in any way. Some do communicate their intent at some point and this may be in the form of a threat. However, they may later disavow the earlier statements, say "I'm okay now" or "I was just talking." Nonetheless, many they may be far from safe, and, yes, our means of helping them are far too limited.

Hi Tony,

Tx. I don't mean like the pope. I mean the proper study of suicide is to study suicide. The proper study of people who seem "suicidal" is the study or predicaments - in that people who seem suicidal are in a predicament they cannot solve so ending is all seems like a solution. There are always better solutions. I think we need to move away from the language of suicide - call it predicamentology or something else.....

Dec

Declan,

Interesting viewpoint and sorry that I misunderstood. No quarrel that terminology making up "language of suicide," scientific, clinical, and lay, could be much better.

Regards!

Tony

Declan,

I completely disagree. While researchers can choose to limit their focus to only studying the people that kill themself, having the entire field limited in this manner prevents so much information from being gained which may help in preventative efforts and prevents us from having information about the quality of life for the people that are experiencing these other suicidality phenomena.

This is like limiting cancer research to only those that die from cancer and completely ignoring any life saving efforts or focusing on improving the quality of life for those with cancer.

While I don't agree with the specific terminology by O'Carrol et al. or by Silverman et al. their efforts to create a common language in order to move the field of suicidality research further is to be commended. If we are all using different language to describe the same suicidality phenomena, then it makes it very difficult for researchers to share information and understand the specific implications of the results of various studies. A common language is needed.

Just imagine if every clinician treating cancer patients used different terms to describe the phenomena their patients experience or if they use different terms to describe the lab results. We would have never even identified that there are unique forms of cancer, each of which can be targeted to find a specific treatment. The lack of common terminology would result in everyone sitting around twiddling their thumbs letting every patient with cancer die until a trans-nosological treatment was found which treats all types of cancer.

Since we know that suicidality is not trans-nosological (i. e., some patients will respond to antidepressants while the same antidepressants make other patients worse), we need a common language for further research to move forward.

Jennifer,

We do need a common language but my point is that the the language of suicide being used is misleading as 99.9% of people who feel suicidal won't kill themselves and many people who kill themselves have never contacted any services or mentioned the word...some suicides are completely rational and not remotely pathological (still very

sad)....we need a new more appropriate language (I think!)

Dec

Jennifer,

Thank you for bringing the suicidology terminology efforts into the discussion. I was too impetuous to go back to them. Good operational definitions are essential to any type of research. Yet I do not see why “poor inter-rater reliability” should be a problem in studying suicide threats. After all suicide research’s “gold standard” is a non-observational and non-experimental methodology used with some regularity around the world to affix psychiatric diagnoses to the departed. If psychological autopsy researchers can unhesitantly claim reliability and validity for clinical findings derived from the recollections of profoundly bereaved people and eventually inputted to a diagnostician some layers removed from the source, let alone the decedent, than sorting out suicide threats made by the still available subjects manifesting this particular suicidal behavior should a snap.

Tony

Dear Declan,

I completely agree.  That is why Dr. David Sheehan and I created a set of definitions for such terms and published them in our recent book (cited in my first post to this question.)

If specific anti-suicidality medications can be found for the phenotypes of suicidality and if more open communication about suicidality can take place between clinicians and patients and between patients and their loved ones, the rates of people killing themself without reaching out for help should diminish.  If it becomes okay for people to talk about suicidal experiences and if we can effectively treat them, then there is little reason for those not reaching out to fear doing so.  There will always be some people that will kill themself, but that number can be greatly decreased with open communication and anti-suicidality treatments.

Tony,

Even if we are directly asking a patient "Did you make a suicide threat?" you will likely not have much reliability from the answers.  Some patients, like one of the ones with a history of suicidality in my recent case studies, will always say "No", because she doesn't view her statements as "threats", but more of statements of how difficult it is for her to control her suicidality.  Meanwhile, other patients that may have been told that any such statements are certainly threats from a prior clinician may then respond "yes", even if they were just attempting to communicate their suicidality to someone because some clinicians assume all of these statements are "threats" and that message gets imprinted onto their patients.  Without a clear definition to refer to, it is really hard to gauge if this suicidality phenomena did or did not occur.  

How do you code the following example.  If 20 years ago a suicidal subject decided to kill themself when their parents die and they told a friend about this at the time the decision was made. Yesterday, now 20 years later, both died in a car accident.  Does the statement made 20 years ago count as a "suicide threat"?  Or, does it only count if the subject now says something else about planning to kill themself (which is in closer time relation to when they plan to or actually engage in a suicide attempt)?

Maybe these things are clear in your head and you would be able to identify such a "suicide threat" when you see it, but I would have a lot of difficulty coding something as a "suicide threat" without having a clear definition for it.

Jennifer,

why would anyone who was suicidal  take an antisuicide drug?

The only person who would take an antisuicidal drug would be someone who didn't want to commit suicide.

Secondly suicide is so rare a trial would be impossible. Look at Pokorny's data (1983 and 1993) on the 20 best predictors of suicide....

What about the rational suicides?

what about the people who kill themselves without going near services.

Put the drug in the water?

Declan

Dear Declan,

I think that everyone assumes all people that are suicidal are willfully suicidal.  My experience with those experiencing suicidality is that many, if not most, of them are not willfully suicidal.  Many of these people are experiencing suicidal phenomena that they simply cannot control.  For example, in cases of auditory command hallucinations for suicide or particular medical illnesses / neurological conditions or other types of suicidality, the suicidality seems to have a life of it's own that the subject is not necessarily willfully engaging in.  If these types of suicidality continue for a longer term many of these subjects then begin to believe that killing themself is the only way to make the suicidality stop, but that is a later progression of the suicidality.  If given the option, many of these people would rather take a medication that would end their suicidal thoughts than to continue being suicidal or end up killing themself. 

This is similar to the fact that many Bipolar patients with suicidality willfully take lithium to control their suicidality.  They prefer life without the suicidality and are willing to take a medication to make it stop.

It is true, that some people are insistent on killing themself because of particular circumstances in their life (e.g. a recent diagnosis of ALS) and these people may not be able to be helped from an anti-suicidality medication, but the others, like the examples above, can be helped with such anti-suicidality medications. 

If its not wilful its not suicide.

Suicide is the act of deliberately killing oneself (WHO) If its not wilful its not suicide.

The point is that people who say they are suicidal are not suicidal. They can't cope and think ending their life is the only to end the pain and are asking for help. They are in a predicament and suicide seems like the only solution. Our job is to find out what the problem is and help them find a better solution. e.g. for bipolar lithium is a solution. for someone who is homeless housing is a solution. 

I appreciate this question and the discussion. A standard nomenclature and support for reliably implementing it is a critical step in improving suicide research and clinical care. Even when working with nomenclature systems that have fairly good operational definitions, there are still many instances in which it is difficult to clearly classify behavior. For more on a nomenclature system being used within the VA see: http://www.mirecc.va.gov/visn19/education/

The website has links to free online trainings and supporting materials.

The discussion about suicidal intent is also an important one. Intent is necessary in virtually all classification systems for self-directed violence that I am aware of, but does not need to be 100%. Typically any degree of intent is sufficient (e.g., Columbia-Suicide Severity Rating Scale). Most people (particularly those patients that we actually get to see) experience some degree of ambivalence. Another issue is that suicidal intent is often transient. I think that it would be dangerous to assume that if someone says they are suicidal, that they are not actually suicidal. I certainly have known patients who have made threats of suicide and then died by suicide. For this reason, I prefer the use of nomenclature that does not require 100% intent for someone to be considered suicidal.

Tony, I think your question is a great one and that more research on suicidal threats is needed.

If you assume someone is not suicidal (no matter what they say) you will be right 99.5% of the time. (Pretty accurate!). As we can't predict suicide we can't learn how to prevent it as we have no outcome measure. Helping people who feel suicidal is completely different - its common and we have interventions that help e.g.CBT and DBT (no evidence that these  prevent suicide though). Suicidal crises should be reframed for patients and families/friends as emotional crises and given the appropriate support.

Sean, 

Outstanding material! Thanks for sharing this web-site. Definitions and other tools are very helpful. PA's state MH law governing involuntary psychiatric evaluations uses term "furtherance" but not clearly defined in law. "Preparatory" fits exactly. I agree that threats warrant more attention. They may be hard to classify but the only truly black/white suicidal behavior is a fatal attempt.

Tony

This does not directly speak to why threat is not discussed very much, but it’s a summary of how I think about suicidality after nearly 4 decades in clinical practice. For any person who talks about suicide, it is important to conceptualize it in terms of the interpersonal context in which it takes place. I generally try to understand suicidality using the discussion by Lorna Benjamin (1996) in Interpersonal Diagnosis and Treatment of Personality Disorders, a text which has been influential in shaping my own personal approach to relational therapy. Some threats fit a pattern of manipulative suicidality, where “the suicidal activity will be well controlled and geared toward coercing more and better nurturance ... this type of suicidality is controlled and should be interpreted as an interpersonal event” (p. 173). General the suicidality will not go beyond threats and partial preparations.

One has only to look at the 9 pages of the online Suicide and Grief Glossary to confirm that suicide is not a simple phenonemon, and that both the intrapsychic and inter-personal contexts for suicidal ideation and behavior must be part of the clinician’s assessment. Whatever is behind the threat, the person should be able to talk about whatever is on their minds, including suicidal thoughts, and in the therapeutic setting that the therapist should be able to contain and remain attuned, to maintain empathy in the attitude Marbin Buber described as “imagining the real.” It is the therapist’s job to help the client articulate what Christopher Bollas in The Shadow of the Object (1987) termed “the unthought known,” to bring to language and thought that which for a variety or reasons remains unarticulated. That begins with empathic attunement to the client’s psychic pain (Shneidman’s “psychache”) as well as to very real physical pain. It continues with exploration of interpersonal context and social support systems, so that we can identify what is supportive and find ways to cope with that which isn’t.

I generally think of suicidality in clients as having several levels or dimensions: (a) the suicidal ideation and the psychic pain it represents; (b) suicidal intent, with varying levels of potential risk; (c) safety measures to be taken when risk is high; (d) the interpersonal context in which gestures and communication about ideation and intent take place; (e) the relational consequences of suicide attempts. It would be a form of therapist countertransference not to permit conversation about it. As Benjamin (2003) pointed out, a form “of countertransference distortion is a therapist’s inability or unwillingness to explore a given important concern with a patient because of a personal distaste for or fear of the subject that needs to be discussed” (p. 331).

I’ve found it very helpful in relation to suicidality to use the ideas in James Hillman’s Suicide and the Soul, a classic in the fields of thanatology and suicidology, which has been in print since it was first published in 1964. It was republished in a second edition in 1997 with a foreword by Thomas Szasz and an afterword by Hillman, placing it in the context of several decades of developments in analytic psychology. It has an excellent summary of the history of suicide prevention and also as an empathic descriptor of soul pain. Hillman clearly understands why Shneidman (1993) writes about Suicide as Psychache, because suicidal acts express the pain of the soul that has so far been inadequately understood by others in the clients’ life. For clients with psychic pain, I might recommend R. D. Laing’s The Divided Self (1960), which provides words for forms of pain, bringing them out of the unthought known into the realm of speech and thought. Or we might together think of popular songs or poetry that put such pain into words. We might also read Paul Tillich’s The Courage to Be (1952), which emphasizes various existential threats to the self and the importance of mustering “the courage to be,” which implicitly contains the courage to go on living. Hillman opens up a range of issues. Suicide survivors find it liberating in that they see that a loved one’s suicide “wasn’t about me,” but about the suicide’s inability to tolerate psychic or physical pain, and their failure to find a different solution. Persons with suicidal ideation find that someone has put into words their pain, while at the same time raising the question of whether such pain should be eliminated with bodily death, since that doesn’t really offer a solution. It opens up discussions about the client’s own values: how do they feel about religious attitudes towards suicide? are their own religious or humanistic values strong enough to control their behavior? Can they stand back from their moments of suicidality to see that there are times when they are not in psychic pain, and that for that alone they should make no irreversible decisions? It allows them to reflect on the legal concept of “self murder” and how they understand that to relate to homicide. It allows us together to think about the relationship between suicidality and mental illness. What is most important is that clients understand that suicidal feelings, like other feelings, can be explored and contained, that they like other feelings are separate from any action that might be taken on them. And that actions always have consequences for the significant others in a person’s life space. They come to recognize what David Bakan (1966) called The Duality of Human Existence and to find their own balance of agency and communion.

I do not have the references for this readily available at the moment, but would be happy to provide them if you have difficulty locating them.

Hendrika,

Thank you for your detailed and thoughtful comments. Both your experience and perspective are helpful additions to this discussion. I've printed out your response and will give it more attention this weekend as I expect to be snow-bound at a crisis center. What better setting for reflecting on suicide as suicidal behavior is pressing in from all sides.

As for suicide survivors being liberated from their anguish by coming to see that their loss “wasn’t about me.” I have not seen this very often. Their guilt and sense of responsibility are usually impenetrable and may abate over time but never really go away. Nonetheless, this may change as suicide comes to be thought of differently in the public mind.

Regards!

Tony

Great discussions all! Some thoughts from a snowbound mind:

"Willful" - Interesting term but not sure how well it applies to acutely suicidal individuals towards the end. Their brains seem to be operating on auto-pilot or cruise control. They may have set the course at some point but now it is locked. They have "checked out" of life. Some are almost robotic with a classic "blunt affect." I see suicide as the outcome of a process in which decision-making deteriorates as risk rises and intent builds. Decisions are made and implemented at the planning stage but thereafter ruminating on that plan seems to lead to it becoming the sole focus of their remaining existence. Efforts at verbal intervention are often ineffectual and rescue can only occur through physical restraint. 

You ask some very interesting questions Tony! And, very interesting input Hendrika!

Just thought I would add my two cents as this is a topic I have been moving into and hope to explore further. First, I don't care for the terms "threats" or "gestures." Yes, sometimes people do threaten suicide when they have no intention of doing so - making that term appropriate, but it is rare. Gestures is too vague a term, and I don't think it captures the interpersonal meaning that Hendrika speaks so well one. I prefer 'suicidal communications' - not very sexy but clear and accurate, or 'suicidal disclosures.'

Shneidman included communication of suicidal intent as one of his 10 Communalities of Suicide. Like the study linked to above, there is a good deal of empirical evidence that suicidal communications are a 'cry for help' an attempt to gather support or help-seeking. Some studies that have shown this are:

Chalker, S. A., Comtois, K. A., & Kerbrat, A. H. (2015). Impulsivity and suicidal behavior: How you define it matters. International Journal of Cognitive Therapy, 8(2), 172-192.

Harris, K. M., Syu, J.-J., Lello, O. D., Chew, Y. L. E., Willcox, C. H., & Ho, R. C. M. (2015). The ABC’s of suicide risk assessment: Applying a tripartite approach to individual evaluations. PLOS ONE, 10(6), e0127442. doi:10.1371/journal.pone.0127442

Kovacs, M., Beck, A. T., & Weissman, A. (1976). The communication of suicidal intent: A reexamination. Archives of General Psychiatry, 33(2), 198-201.

Misson, H., Mathieu, F., Jollant, F., Yon, L., Guillaume, S., Parmentier, C., et al. (2010). Factor analyses of the Suicidal Intent Scale (SIS) and the Risk-Rescue Rating Scale (RRRS): Toward the identification of homogeneous subgroups of suicidal behaviors. Journal of Affective Disorders, 121(1-2), 80-87, doi:10.1016/j.jad.2009.05.012.

Venta, A., & Sharp, C. (2014). Extending the concurrent validity of the Self-Injurious Thoughts and Behaviors Interview to inpatient adolescents. Journal of Psychopathology and Behavioral Assessment, 36(4), 675-682, doi:10.1007/s10862-013-9402-1.

Also, Hendrika, I find your suicidal attributes interesting. When we conducted EFA on numerous suicide questions, we found strong evidence that suicidality fits the ABC theory of attitudes, that it may be considered be comprised of: affect (feelings of wanting to live/die), behaviors (history of plans, attempts), and cognition (specific suicide-related thoughts).

cheers,

Keith

Hi Keith and others...

The definition of suicidal:

"deeply unhappy or depressed and likely to commit suicide.

relating to or likely to lead to suicide."

What does likely to commit suicide imply?

90%?    50%?      10%    .04% ?

The most at risk are bipolar men who have self harmed (Nordentoft et al 2011). They had a risk of about .04% per month.

Therefore no matter what a patient says or does they are unlikely to commit suicide. We need better terminology for patients who feel "suicidal" or self harm.

We need to assess the problems patients present with and regard all patients as at risk as most patients who commit suicide were assessed as not high risk. If we focus on hige risk we are ignoring most of those who will kill themselves.

What do you think?

For a fuller account of my delusions about suicide risk  see: http://bjpo.rcpsych.org/content/2/1/e1

Declan

Declan, you are right, there is too much emphasis on suicide death. That is, of course a hugely tragic event, and the number one behavior we want to prevent. But, as you rightly point out, it rarely occurs. For what its worth, colleagues and I have recently been defining suicidality as:  personal distress due to death-related affect (e.g., feelings of wanting to die), and/or thoughts of killing oneself, past suicidal behaviors (modified by intent to die), and the potential for future suicidal affect, cognition, and behaviors (Harris et al. 2015).

That definition was created for suicidality measurement purposes, with the caveat that suicidality is volatile and needs to be assessed often to be accurate.

I like your idea of focusing on patient's/client's problems first and foremost. That is a practical and helpful approach. However, I feel it is not good to ignore suicidality. It is a different form of personal distress. Although it may not result in death, it always results in pain, perhaps much worse pain than depression, anxiety or other mental problems.

My current goal is to improve the measurement of suicidality. With improved measures we can better understand related factors.

Your goal appears to be better treating people who are suffering - so that they never experience suicidal or other pains. Can't see any fault in that.

Hi Keith - the redefinition is unhelpful and inaccurate. People who present feeling "suicidal" as the problem should be helped reframe to see that suicide is not the problem it is the solution (bad solution) and trace back to find out what the problem is and find a better solution e.g. emotion regulation, treat addiction, solve relationship problems etc. this is in Linehan's DBT program. So don't ignore the "suicidal" feeling or behaviour - reframe and solve. There is evidence that Self harm and feeling suicidal can be treated (e.g. Linehan etc). Little evidence that individual assessment and treatment can reduce or prevent suicide.

Declan

Hi Declan, I think we have gotten off topic here. Sorry, but I strongly reject the 'don't assess suicidality' movement. Individual assessment is crucial. The problem is that it has been very poorly done over the years. Assessment doesn't treat or prevent, it helps us understand. As Shneidman said "our constant goal is prevention, but first must come understanding."

Hi Keith,

Prevention of what? We need accurate language to communicate effectively. We can reduce self harm and psychache with individual assessment and treatment.

Not so with suicide. 

Suicidal implies likely to commit suicide. My point is that not that we shouldn't assess suicidality but that we do not have the ability to do so so we should stop pretending that we can. estimating the likelihood of suicide and designating people as at high risk leads to the wrong treatment.

Suicide is very different from self harm and feeling suicidal. little overlap between them.

Have a look at Ryan and Large papers from australia.....very convincing.

Declan