The need for clear and consistent use of terms has provided the impetus for efforts to develop standard operational definitions and nomenclature to classify suicide and self-injurious thoughts and behaviors (e.g., Centers for Disease Control and Prevention [CDC], in preparation; DeLeo et al., 2006
; Posner, Oquendo, Gould, Stanley, & Davies, 2007
; Silverman et al., 2007a
). Building on an earlier collaborative effort sponsored by the National Institute of Mental Health, the Center for Mental Health Services, and the American Association of Suicidology (O'Carroll et al., 1996
), Silverman et al. (2007a)
referred to the term suicide gesture as akin to a behavioral form of suicide threat, and they did not include the term in their recommended nomenclatures because of its imprecision and arguably dismissive connotations. Posner and colleagues (Posner et al., 2007
) cited similar reasons for deciding against use of the term “suicide gesture” in the Columbia-Classification Algorithm for Suicide Assessment (C-CASA; Posner et al., 2007
), developed for the Food and Drug Administration in response to the need for a consistent and appropriate means of classifying adverse suicidal events in pediatric clinical trials. In a forthcoming report published by the CDC (in preparation) describing uniform definitions to be used in suicide surveillance, the term suicide gesture similarly is not recommended because of the subjective and often negative nature of the term. Despite the fact that many current or proposed systems for describing self-harm behaviors do not recommend the use of suicide gesture as a label, the term has continued to be used widely in clinical practice and in research, as well as in training settings. The purposes of this paper are to briefly describe the history of the commonly used term suicide gesture, to provide an overview of the multiple and inconsistent ways in which this term has been used in the literature, to discuss the implications of the use of this term in clinical practice, research, and training, and to suggest alternatives to its use.
The Historical Origins of the Term Suicide Gesture
The process of developing a shared language for characterizing psychopathology and implementing a standard nomenclature for clinical and research purposes has long been recognized to be a complex task (e.g., Wakefield, 1992
; Wilson, 1993
). For example, in developing nomenclature, there have been numerous controversies related to what constitutes mental disorder, the assumptions that are associated with these designations, and what is conceptualized as normal, healthy psychiatric functioning (see Wakefield, 1992
for review). Moreover, the evolution of terminology reflects changing social norms and values. In particular, because of concerns related to social stigma and the negative connotations associated with certain terms, terminology may fall out of favor and be replaced by more appropriate and respectful language. For instance, in an effort to be more sensitive to the issue of labels, the American Psychological Association (2001)
has advised that written descriptions of individuals “put the person first,” rather than highlighting the label or descriptive phrase. In an example, individuals diagnosed as having the psychiatric disorder schizophrenia may be designated as “meeting diagnostic criteria for schizophrenia” or “with diagnosis of schizophrenia,” rather than as “schizophrenics.”
With specific reference to the term suicide gesture, a review of the literature confirms that use of the term dates back decades. For example, Prudhomme (1938)
described two types of suicidal behavior: “the hysterical (gestural) or relatively benign type in which attempts are made but rather rarely carried out . . . and the psychotic or annihilating type which is malignant; under this heading come the actual suicides of the depressives, praecoxes and involutionals.” Lewis (1933)
similarly differentiated between “ineffective gestures and bids for attention” and what were considered to be “serious, genuine attempts” (p. 270). In psychoanalytic interpretations of self-destructive behaviors, Davidson (1941)
suggested that suicidal behavior can be related to both the unconscious aspects of personality (e.g., when behavior has specific symbolic meaning), and to the conscious aspects of personality (e.g., in relation to feelings of guilt or unworthiness). As a specific example of the latter, he referred to suicidal behavior of “the psychopathic variety, as a gesture
to one's ends” (p. 42, italics added). Wilson (1942)
wrote specifically about “hysterical suicide” and contended that hysterical fugue states may arise when individuals initiate suicide behaviors. In these fugue states, an “altered personality” without suicidal intent can be “suddenly substituted” to protect the individual. The resulting self-destructive behaviors without full suicide intent were referred to as suicide gestures.
The term also has been used historically in military settings to characterize the behavior of military personnel who were thought to engage in self-harm behaviors for instrumental reasons (e.g., avoiding responsibility) and were therefore deemed to be malingering or not “genuinely suicidal” (e.g., Fisch, 1954
; Tucker & Gorman, 1967
). As Fisch (1954)
noted, “One is soon struck by the transparent insincerity of these attempts, which in the majority of cases, are more aptly termed gestures” (p. 33). Tucker and Gorman (1967)
went further when they said, “The suicide gesture is more frequently a communicative act directed at the patient's environment . . . .The person who makes a suicide gesture in the military can usually be typified as ‘the man nobody likes’” (p. 854). Additional descriptions cited by Tucker and Gorman (1967)
include ‘transparent insincerity,’ ‘manipulative,’ and ‘emotional blackmail’ (p. 854).
Among the earliest to point out difficulties in how we conceptualize suicidal behaviors, Eisenthal (1967)
described common clinical practice, when he noted that:
Among the first questions usually asked about the behavior of a suicidal patient is: ‘Was his attempt genuine or a gesture? Did he really mean it when he threatened to kill himself? If the attempt was genuine, the implication is that the patient will continue to be a serious risk, but that if it was a gesture, suicide is unlikely. (p. 987)
However, he then suggested flaws with this practice insofar as there are situational determinants of suicidal behavior that are important and may change over time, and because he found in his study that “seriousness” of suicidal behavior was not predictive of later suicide outcomes.
The term suicide gesture continues to be used contemporarily both in clinical practice and in research. For example, in the National Comorbidity Study, suicide gestures were defined as “self-injury in which there is no intent to die, but instead an intent to give the appearance of a suicide attempt in order to communicate with others” (Nock & Kessler, 2006
, p. 616). Suicide gestures were contrasted with suicide attempts, with the former being less common and evidenced more by females, and with fewer diagnoses of depression, less comorbidity, and less history of sexual or other physical abuse (Nock & Kessler, 2006
). Using a similar definition, the concept was included in a recently developed assessment instrument, the Self-Injurious Thoughts and Behavior Interview (SITBI; Nock, Holmberg, Photos, & Michel, 2007
). In this preliminary report on the SITBI measure, individuals never heard the term suicide gesture per se, but were asked “have you ever done something to lead others to believe you wanted to kill yourself when you really had no intention of doing so?” (Nock et al., 2007
, p. 310). Although both of these studies provided clear and concise operational definitions of the term, it is interesting to note that psychometric analyses of the SITBI suggested that, despite high inter-rater reliability in classification of responses to this query, the responses to this question had poor test-retest reliability over six months (Nock et al., 2007
). This low test-retest reliability for the lifetime presence/absence of suicide gestures contrasted with strong test-retest reliability for lifetime presence/absence of suicide ideation, plans, and attempts. Nock and colleagues (2007)
proposed several possible explanations for this finding, including the social undesirability of the construct and perhaps a lack of clarity regarding how participants interpreted the question. Velting, Rathus, and Asnis (1998)
similarly found that confusion about the term gesture contributed to discrepant reporting of past suicidal behavior by adolescents.
Findings from these and other studies raise questions about the subjectivity or clarity of the concept of suicide gesture, even when there are apparent unambiguous operational definitions. These studies also raise questions about the degree to which the negative connotations or social undesirability of the construct are recognized even by non-clinician respondents. Moreover, the possibility that respondents lack clarity in how to interpret the question of engaging in suicidal behaviors in the absence of suicide intent also may reflect the term's lack of consistency across studies.
Recommendations & Conclusions
To summarize, across studies and settings, the term suicide gesture has been used inconsistently and in various ways, some of which may negatively impact the quality of care provided to patients. As pointed out by O'Carroll and colleagues (1996)
, a lack of consistent usage of terms for suicidal behaviors also creates confusion and makes it difficult for clinicians to communicate clearly with each other. Moreover, inconsistent terminology impedes efforts to summarize data (e.g., in surveillance efforts) and ultimately prevent suicidal behavior insofar as the definitions of terms affect our ability to synthesize findings and measure outcomes consistently across studies. Finally, although these arguments do not presume that individual clinicians who currently use the term gesture in practice necessarily see the term as having pejorative connotations, it is the case that the term emerged from a history of often negative attributions about individuals who “gesture” suicide. In light of these multiple difficulties, it is recommended that the term suicide gesture no longer be used.
It is important to note that although various suicide-related terms (e.g., suicidal ideation, suicide attempt) in addition to suicide gesture have sometimes been used inconsistently in research and clinical practice, it is notable that these terms did not emerge from a history of negative attributions about individuals who engage in the behaviors. Efforts to improve the nosology (e.g., CDC, in preparation; Posner et al., 2007
; Silverman et al., 2007a
) and evidence-based assessment of suicide-related thoughts and behaviors (e.g., Nock et al., 2007
) are constructively advancing the field. Importantly, the CDC (in preparation), Posner et al. (2007)
in an effort sponsored by the FDA, and Silverman et al. (2007a
have all recommended against use of the term suicide gesture because of its inconsistent usage and history of negative connotations, while retaining use of terms such as suicide ideation and suicide attempts.
One alternative to the current inconsistent use of the term suicide gesture is to adopt more precise use of language. For example, Nock et al. (2007)
clearly operationally defined the term suicide gesture as referring to behaviors intended to give the appearance of suicidal behavior, in the absence of true suicidal intent. However, as noted previously, the term already has been used in multiple ways and acquired a history of negative, dismissive connotations, and its use has been recommended against by various groups and organizations because of these connotations. Given this context, widespread adoption of this precise use of the term suicide gesture might be difficult to achieve.
Another strategy for increasing precision in our language would be to more clearly differentiate suicidal and non-suicidal self-harm behaviors. For example, we would suggest that to prevent confusion, the term suicidal only be used to refer to behaviors in which there is at least some intent to kill oneself. While acknowledging that there are sometimes cases in which it may be difficult to establish intent (Freedenthal, 2007
; Posner et al., 2007
; Silverman et al., 2007a
), other terms such as non-suicidal self-injury can be adopted to refer to self-harm behaviors without any reported intent to die. Self-harm behaviors that are not associated with intent to die but are meant to give the appearance of being suicidal could potentially be considered a specific subset of non-suicidal self-injury. The clinical characteristics of suicidal behavior such as degree of subjective intent, medical lethality, and form could be noted separately from the label of suicide attempt itself (e.g., a suicide attempt by overdose with high reported intent, but low medical lethality). In this way, noting intent and medical lethality routinely with suicide attempts would be analogous to noting the clinical characteristics or features of diagnostic categories in DSM-IV-TR, e.g., clinical course specifiers and melancholic features for major depressive disorder. In addition, Posner and colleagues (2007)
included a category of behaviors referred to as “Preparatory acts toward imminent suicidal behaviors,” which could be used to refer to behaviors leading up to a suicide attempt. This purpose of this article is not to propose a specific nomenclature, particularly given the fact that several groups have already been involved in such efforts (CDC, in preparation; DeLeo et al., 2006
; Posner et al., 2007
; Silverman et al., 2007a
). Rather, we cite these examples to illustrate the fact that greater precision in our language for describing these behaviors is indeed possible. The use of more precise descriptors is consistent with the overarching goals of performing more competent suicide risk assessments and more clearly communicating the results to inform treatment planning, which are critical components of effective and ethical care for suicidal individuals (e.g., Jobes, Rudd, Overholser, & Joiner, 2008
Another alternative is to place greater emphasis on the functional assessment of suicidal and non-suicidal behaviors. Functional approaches emphasize the importance of classifying and treating behaviors based on the antecedent and consequent conditions that are thought to trigger and maintain the behaviors in question. As such, a functional approach to assessment moves beyond simply focusing on the topographical features of the suicidal behaviors and instead centers on the underlying functional processes. In this regard, it has been noted that non-suicidal self-injury may have both negative reinforcing functions (e.g., to relieve negative affect or distress) as well as positive reinforcing functions (e.g., attention) (see Nock & Prinstein, 2004
). Hence, if an individual is reportedly engaging in non-suicidal self-injurious behavior to make other people believe that he or she is at risk for suicide, an understanding of the functions of the behavior may lead the clinician to choose or focus on different clinical strategies. For example, treatment planning may focus on other approaches that the individual can take to elicit validating responses from others, and alternative methods for resolving difficulties or relieving or communicating distress. In considering functional assessments, it also is important to note that contextual issues regarding the precipitants, functions, and consequences of suicidal behaviors may differ depending upon gender and culture (Goldston et al., 2008
) and should be taken into consideration in conceptualizations of suicidal and non-suicidal behaviors and treatment planning.
In sum, the term suicide gesture has a long history of being applied in various and inconsistent ways in both clinical and research settings and continues to be part of our current professional vocabulary. In spite of its persistent usage, there is a clear and compelling rationale for discarding the term. Specifically, removing the term suicide gesture from usage will improve clarity of communication and promote respectful language among clinicians and researchers. Support of more precise language for describing suicidal and self-harm behaviors and greater emphasis on the functional assessment of suicidal behavior will provide an important foundation for improved treatment planning by increasing the consistencies in our use of terms, shifting attention away from dismissive labeling, and enhancing our ability to understand the context within which suicidal behavior is occurring.