Let's Talk About Suicide: #LanguageMatters

NOTE: This article has been awarded the 2016 NASW Media Award for best magazine article!  Thank you for reading and voting. Congratulations to Jonathan Singer and Sean Erreger.

by Jonathan B. Singer, Ph.D., LCSW, and Sean Erreger, LCSW

Q: How many social workers does it take to change a lightbulb?

A: None. The light bulb is not burnt out; it's just differently lit.

     It is a silly joke. But the punchline probably made you stop and think. Burnt out = useless. Differently lit = different, but still lit... and therefore still useful. Changing the description of the lightbulb changed the way you thought about the lightbulb. The way social workers think about the lightbulb is, of course, as a metaphor for the way social workers think about people. We fight for the dignity and worth of the person (NASW, 2008). And one of the ways we do it is through language.

     Researchers have shown that even subtle changes in language can change reality (Borowditsky, 2011). Every social work student has heard the phrase “person-first” language. Instead of saying, “He is schizophrenic,” we say, “He (the person) has a diagnosis of schizophrenia.” Why? Person-first language honors the dignity and worth of the person. And although some people confuse social workers’ use of language as being “politically correct,” we know the words we use to communicate to our clients and others have power. Words can construct a reality of hope and acceptance, or despair and rejection. And when we’re talking about suicide, those words can be a matter of life or death.

Preferred and Problematic Terminology

     Knowing which suicide-related words are preferred or problematic can be tricky. The language of suicide is the source of frequent debate and change (O’Carroll, 1996). Terms that were once widely accepted, such as “commit suicide,” “parasuicidal,” or “suicide gesture,” are now discouraged (Easter, 2015). Older terms, such as “survivor,” which referred to those who have lost a loved one to suicide, are being modified as a result of newer terms. A recent entry into the lexicon is the term “suicide attempt-survivor” (http://actionallianceforsuicideprevention.org/task-force/suicide-attempt-survivors/), which reflects the field’s very recent acknowledgment of the value and worth of people with a history of suicide attempts. To avoid confusion, the term “survivor,” is now being changed to “suicide loss-survivor.” To keep up with these changes, there are several useful lists of suicide-related terms and definitions (e.g. Hollis Easter’s Suicide-Related Terminology). In fact, this article was inspired by a tweet from Jaelea Skehan during the International Association of Suicide Prevention 2015 conference (#IASP15), in which she pointed out problematic and preferred terms for suicide.

Harry Dies by Suicide

     As an illustration, we constructed a hypothetical rant by an agency caseworker, in which the worker uses several problematic terms and concepts. As you read each term or concept, we’d like you to do two things: 1) Think about why it is problematic, and 2) Think of an acceptable term or concept:

What a week. First, Frequent Flyer Harry successfully commits suicide after years of failed attempts. I was shocked because just last week, he said “no” when I asked him if he had any thoughts of hurting himself. I always felt like he was just attention seeking.Then the associate director is like, “You have to review Harry’s chart for the past year.” And in my head, I’m like, “I’d rather kill myself.” Then the unit director shoots us an e-mail to be on the lookout for copycat suicides. I can’t say “no,” because that would basically be career suicide. The irony is that Harry found a permanent solution to a temporary problem, and my chart review is a temporary solution to a permanent problem....

     Let’s go over the problematic terms and concepts and identify preferable alternatives.

1. “Frequent flyer.” This is a demeaning term that refers to people who use services frequently. This is not specific to suicide. Preferred term: long-term client.
2. “Successfully commits suicide.” This phrase is a mess. “Successful suicide” emphasizes “success.” You wouldn’t say “the assailant successfully raped the victim.” A suicide death is a tragedy, not a success. The magnitude of that tragedy was studied by Julie Cerel from the University of Kentucky School of Social Work. She estimated that each suicide death affects 115 people, with approximately 25 people feeling devastated (Cerel, Maple, Aldrich, & van de Venne, 2013).
3. “Commits suicide.” The word “commits” is associated with crime or pathology. People “commit murder,” and mental health providers “commit” people to inpatient settings. The preferred term is “died by suicide,” because it emphasizes the death and avoids judgment. Once you get used to it, you’ll find that it works in nearly every situation.
4. “Hurting himself.” You cannot assess suicide risk by asking people if they want to hurt themselves. People who are suicidal are often in so much pain that they could legitimately say, “No, I don’t want to hurt myself - I have no interest in hurting more. In fact, I just want to end the pain.” Effective suicide assessment requires that you ask if they are thinking of killing themselves. (For more information on assessing for suicidal ideation and intent, please see http://www.socialworkpodcast.com/2012/09/the-chronological-assessment-of-suicide.html.)
5. “Attention seeking.” Few suicide-related concepts are more dangerous than the idea that suicidal behavior should be discounted as “attention seeking.” If Harry wants you to pay attention to him so badly that he is making attempts to end his life, pay attention to him. He is probably trying to communicate something that is hard to put into words, so he is communicating with his actions. Rather than labeling these behaviors, we should explore the meaning behind his multiple attempts.
6. “I’d rather kill myself.” This is an example of irresponsible and lazy hyperbole. The statement is false, because the caseworker didn’t want to kill himself. Because we train people to take the phrase “I’d rather kill myself” seriously, it leaves the listener in a bit of a bind. Either take it seriously and follow up, or ignore it. Neither works. More importantly, the flippant use of the phrase for dramatic effect minimizes the actual struggle and pain experienced by people who are suicidal. The caseworker was actually saying, “I’d rather do anything other than chart review.” Nothing wrong with that.
7. “Shoots us an e-mail.” This can be a trigger for folks who are attempt survivors or loss survivors. Just say “send.” 
8. “Copycat suicides.” The term “copycat” indicates that someone died by suicide in the same manner as someone else. One problem is that the term “copycat” is associated with children, as in, “Mom, Bart is being a copycat. Tell him to stop.” This suggests that the people who died by suicide were in some way immature or couldn’t think for themselves. Another problem is that it could suggest that someone who wasn’t suicidal was inspired to die by suicide. Finally, “copycat” emphasizes “how” a person died and minimizes the death. If you are worried about “copycat suicides,” you’re really worried about “other people who are suicidal.” Just say that.
9. “Career suicide.” Just like the statement, “I’d rather kill myself,” this is an inappropriate use of suicide terminology for emphasis (same goes for the term “political suicide”).  Instead, say “end of my career,” or identify the career move that might not be possible.
10. “Permanent solution to a temporary problem.” This oft-quoted phrase passes judgment by suggesting that someone is overreacting to a passing problem, or that their pain is temporary. Instead, acknowledge a person’s pain as real, that there might not be a solution soon, but that you will be by their side to help them find a life worth living.

     Here’s the same paragraph with the preferred terms and concepts in bold.

What a week. My long-term client, Harry, died by suicide after several previous attempts. Despite many efforts to explore the reasons for his past attempts, he still could not communicate his pain any other way.  I was shocked because just last week, he said “no” when I asked him if he had any thoughts of killing himself. Then the associate director said, “You have to review Harry’s chart for the past year.” And in my head, I thought, “I’d rather do anything other than chart review.” Then the unit director sends us an e-mail to be on the lookout for other people who are suicidal. I can’t say “no,” because then I wouldn’t be considered for the supervisor position. It is ironic that Harry killed himself in part because he thought no one cared if he lived or died, and yet his death has been devastating for so many people. Instead of reaching out to these folks, I’m stuck inside doing chart review.

     So, how did you do? If we’ve done our job, not only can you identify preferred suicide-related words and concepts, but you experienced how changes in language changed your perception of Harry and the caseworker - for the better. As social workers, we want to describe Harry’s suicide by using language that respects his dignity, as well as inspires hope and solutions. 

Some Additional Terms

     Some terms that are commonly used in professional conversations and documentation related to suicide and self-injury are listed below (Erbacher, Singer, & Poland, 2015):

Suicide

     The act of intentionally ending one's life.

Suicidal ideation

     Thoughts of ending one’s life

Suicide attempt

     Any non-fatal potentially injurious behavior with intent to end one’s life. A suicide attempt may or may not result in injury. (e.g., “She took seven ibuprofen hoping she would die.”)

Interrupted attempt

     Individual is stopped by an outside force (person or circumstance) before making an attempt. (e.g., “He took the bottle before she could take any.”)

Aborted attempt

     Individual stops him or herself before making an attempt. (e.g., “She put down the bottle before taking the pills.”)

Non-suicidal self-injury

     Deliberate direct destruction or alteration of body tissue without a conscious suicidal intent. (e.g., “She cut herself but had no intention to end her life.”)

Non-suicidal morbid ideation

     Thoughts about one’s death without suicidal or self-injurious content. (e.g., “He wondered if the roof would collapse on him tonight.”)

Keep Talking

     When it comes to suicide, language matters. Please keep this conversation going. What suicide-related concepts, words, or phrases do you use? If this article changes the way you think and speak about suicide, please let us know. Comment below or on your favorite social media outlet using #LanguageMatters.

References

Boroditsky, L. (2011). How language shapes thought. Scientific American, 304 (2), 62-65.

Cerel, J., Maple, M., Aldrich, R., & van de Venne, J. (2013). Exposure to suicide and identification as survivor: Results from a random-digit dial survey. Crisis, 34 (6), 413–419. http://doi.org/10.1027/0227-5910/a000220

Easter, H. (2015, March 29). Suicide-related Terminology. Retrieved from http://www.holliseaster.com/p/suicide-related-terminology/

Erbacher, T. A., Singer, J. B., & Poland, S. (2015). Suicide in schools: A practitioner’s guide to multi-level prevention, assessment, intervention, and postvention. New York: Routledge.

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 & Life-Threatening Behavior, 26 (3), 237–252.

Skehan, J. [JaeleaSkehan]. (2015, June 15). Preferred and Problematic Language for Suicide #IASP2015 from @MindframeMedia in Aus. [Tweet] retrieved from https://twitter.com/jaeleaskehan/status/610922940889231360

NOTE: This article has been nominated for the 2016 NASW Media Award for best magazine article!  Vote HERE until April 10, 2016.

Jonathan B. Singer, Ph.D., LCSW, is an associate professor of social work at Loyola University Chicago and the founder and host of the Social Work Podcast. He is the author of 40 publications, including the 2015 Routledge Press text, Suicide in Schools: A Practitioner’s Guide to Multi-Level Prevention, Assessment, Intervention, and Postvention.

Sean Erreger, LCSW, is a clinical mental health case manager for youth. He blogs about social work, mental health, healthcare, and education at Stuck on Social Work, and is a moderator for the Suicide Prevention and Social Media (#SPSM) twitter chat.