Making Space to Speak the Unspeakable: Talking About Suicide

Nicole Dunn

Suicide can feel unspeakable because for many of us, being in a place where living no longer feels like an option is unimaginable. In conversation, you may have noticed that it is not uncommon for the word “suicide” to be whispered or mouthed as an acknowledgment that something here is taboo. It is an emotionally charged word, loaded with feelings of blame, anger, guilt, sadness, and shame. No matter your lived experiences, speaking about suicide in some way forces us to confront the existence of these complicated and often deeply uncomfortable emotions. And yet, we know that having conversations about suicide is important – in fact, lifesaving. In the interest of making the unspeakable speakable, the following discussion will unpack some common terminology used to talk about suicide and offer some alternative language.

To understand language and its relationship to suicide, it’s helpful to acknowledge that for 80 years in Canada, suicide was codified as a criminal offence. Then, in 1972, suicide was decriminalized. But the language commonly used to talk about this issue still tends to include criminal overtones. For example, it is common to hear someone say that “X committed suicide”. The consequences of using the term “commit” when referring to suicide lies in its ability to generate feelings of shame. According to Brené Brown, shame is “the intensely painful feeling or experience of believing that we are flawed and therefore unworthy of love and belonging [because of] something we’ve experienced, done, or failed to do...” [1]. Using the term “commit” thus likens a person’s unimaginable experience of pain to a crime. Acts we “commit” tend to be reprehensible and so you can imagine that this association might generate feelings of shame. Furthermore, the word “commit” conveys literally nothing about the fact that a suicide is the tragic outcome of someone’s personal struggle [2]. Nonetheless, we know that experiencing deep physical and/or emotional pain does not make someone a criminal. We don’t say things like “X committed depression” or “X committed post-traumatic-stress-disorder”. We recognize that these conditions are not chosen, but are instead, serious mental health concerns that deserve compassion and empathy. As an alternative, instead of saying “X committed suicide” a neutral approach might be to say, “X died by suicide”.  This strategy has two advantages. On the one hand, it is very matter of fact, and does not diminish or try to hide the gravity of the act. On the other hand, this approach eliminates shame from the conversation.

Other shameful terminology that exists relating to suicide includes phrases like “successful attempt” and “failed attempt”. Here, a “successful attempt” refers to someone who died by suicide and a “failed attempt” refers to someone who survived suicide. If you read that and felt something rubbed you the wrong way, you’re not alone. Indeed, it’s puzzling to associate success with death and failure with life. Using language that couples the notion of achievement with suicide is very far removed from the nature of the issue and does not do this public health concern the compassionate justice it deserves. In place of “successful attempt”, neutral language opts to use “died by suicide” and in place of “failed attempt”, “suicide survivor” can be used.

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Shame is seriously dangerous. It is an emotion that is highly correlated with addiction, depression, violence, aggression, eating disorders, and suicide [3]. Shame does have an antidote, however, and it is found in the empathic reception of this emotion. By defusing the shame that discussions of suicide provoke, empathic communication helps makes space for us to speak about suicide, and is thus an important way to support survivors. In one study, researchers found that parents of young adult children who died by suicide found joy in talking about their lost loved ones as a means to keep their memory alive and process their grief. But they also felt that before they could open up about their child, they had to test their listeners to avoid unsupportive reactions. For parents, this process had the potential to isolate them in the moments they most wanted support [4]. Overcoming this barrier means conveying empathy to survivors and a simple and survivor-centric way to do this is through our language use. In fact, demonstrating this kind of care is proven to have a meaningful impact as research has shown that reducing stigma can improve access to care for mental health [5,6,7]. In other terms, communicating from a place of empathy can be life-saving.

At the Hatching Ideas Hub, we recognize that using neutral language when talking about suicide requires both knowledge of the weight of words and a willingness to be conscientious about their selection – a task that is not always easy! In fact, when it comes to talking about emotionally charged content, there are no perfect ways to have these conversations. But do have them. Language use might appear to be a minor issue in the grand scheme of suicide prevention efforts. After all, “a change in the words we use will not immediately dispel deep-seated prejudices” [2] but it can help lay the foundation for addressing this topic from a place of empathy, and the power of this should never be overlooked.

References

[1] Brown, B. (2017, September 10). Shame v. guilt. Retrieved January 15, 2018, from https://brenebrown.com/blog/2013/01/14/shame-v-guilt/

[2] Sommer-Rotenberg, D. (1998). Suicide and Language. Canadian Medical Association Journal, 159, 239-40.

[3] Brown, B. (2012, March 16). Listening to shame. Retrieved January 20, 2018, from https://www.youtube.com/watch?v=psN1DORYYV0

[4] Maple, M., Edwards, H., Plummer, D. & Minichiello, V. (2010). Silenced Voices: Hearing the stories of parents bereaved through the suicide death of a young adult child. Health and Social Care in the Community, 18, 241-248.

[5] Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 59, 614–625.

[6] Scocco, P., Preti, A., Totaro, S., Ferrari, A., & Toffol, E. (2017). Stigma and psychosocial distress in suicide survivors. Journal of Psychosomatic Research, 94, 39-46.

[7] Perlick, D. A. (2001). Special section on stigma as a barrier to recovery: Introduction. Psychiatric Services 52, 1613–1614.

The Hatching Ideas blog contains discussions of mental health, suicide, social vulnerability and other, similar topics. The topics discussed may prompt unwelcome reminders, and we ask our readers to exercise discretion when reading. In case of an emergency, please contact your local health provider or dial emergency medical services (9-1-1).

Calling People What They Want to be Called

Craig MacKie

During our lab’s last Twitter live-chat, one of the topics that generated lively debate was that of language. Specifically, we asked what kind of language was appropriate to use when describing people who use mental health services. Opinions were varied, but I did like one response in particular: @MarkOneinFour suggested that, in terms of word-choice for a mental health service-user, “I think it might be more ‘call people what they want to be.’” A simple and elegant solution.

I like this approach. It’s a friendly principle, and one that I try to pursue in my private life. It makes respectful consideration the basis of the choice, and ensures that the power to define is vested with the person being defined. To use the language of psychiatry, it is a “person-centered” approach to naming. This said, the limit of this solution emerges when you try to apply it to a group, as when publishing a paper, blog, pamphlet, or other summary. When moving from the level of individual choice to that of the collective, the imperative suddenly becomes one of selecting the most widely accepted, or at minimum, the least offensive term.

This is the road that health bureaucracies must travel, and it has created a spectrum of terms that vary from country to country, from health system to health system, and, often, within research/health teams; with the preferred terminology generated often showing preference for the kind of bland language corporate structures gravitate towards. As we mentioned in our December 4, 2017 blog post, a systematic review of the literature shows that terms like ‘client,’ ‘service user,’ ‘customer,’ and ‘consumer,’ have gained currency in English-speaking countries[i], with a range of other terms also showing some prominence.

As I’ve already suggested, these are terms that have been largely chosen because they are (relatively) inoffensive. They also mirror the language of the marketplace, especially in cases such as that of the U.S., where the desire to distance healthcare language from that of business is less of a priority due to the nature of the privatized healthcare system. The Australian healthcare system appears to have opted for a middle-road with the term of choice being “consumer,” while Canada and the U.K. seem to have made room for a range of different, though similarly generic, terms, including “person affected by mental illness” and “person with lived experience.”

I’d also like to point out that there is still some support for the term “patient,” even while it is often poorly received and remains a contentious choice. As it was explained to me, a cancer patient is never described as a “person with lived experience of cancer,” and if someone afflicted with this disease were to be described as such, they would probably find the euphemism more than a bit inappropriate, if not reprehensible. From this perspective, it is worth asking ourselves if the decision to avoid describing people suffering with mental illness as patients is not itself a form of polite stigmatization, with the imperative to select a respectful term of address covering up the practical functioning of a system that nevertheless treats people affected by mental distress as patients. While the campaigns to combat stigma through language deserve our respect and support, if they are not accompanied by real changes to the functioning of the healthcare system, then we can probably point to all of these debates as the definition of “lip-service.”

As far as the Hatching Ideas Hub is concerned, our phrase of choice remains “people with lived experience.” This is influenced by our position within the Canadian healthcare system, our role as a research institution, and our commitment to patient-oriented research. When working with research partners who have struggled with their minds as with the Canadian healthcare system, we seek knowledge of this ‘lived experience’ to inform the work that we do. It is simultaneously a pragmatic choice and a euphemism, and though it remains more than a bit sanitized, it seems like the best option among a host of inadequate choices.  When working in less of a partnered capacity, and when speaking from more of a clinical perspective, the lab’s language favours the term “service-user.” Again, this choice, while imperfect, seems like an ideally generic option. It does not escape the language of the market, but I find it preferable to the alternatives. To be able to describe and advocate for the people who use mental health services, “service-user” works, though it may not be the term I would select for myself. If I were to choose what I want to be called, it would probably be “person,” but I realize that this is not exactly the most descriptive of terms. I also like “fellow traveler,” but I don’t exactly anticipate that medical journals will flock to this choice. In the end, we have to use the words that are expected by and accepted by the listener. Blandness and inadequacy may be the flip-side of incoherence, but it also may be the price that we have to pay in order to be heard.

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[i] Dickens, Geoff and Marco Picchioni. (2011). A Systematic Review of the Terms Used to Refer to People Who Use Mental Health Services: User Perspectives. International Journal of Social Psychiatry, 58(2), 115-122.

The Hatching Ideas blog contains discussions of mental health, suicide, social vulnerability and other, similar topics. The topics discussed may prompt unwelcome reminders, and we ask our readers to exercise discretion when reading. In case of an emergency, please contact your local health provider or dial emergency medical services (9-1-1).

A List of Terms Used to Describe People Who Use Mental Health Services

To kick-off our series on language in mental health, we thought it would be useful to compile a list of all the major terms used to describe people who use mental health services. This list is based off of a survey of the prominent academic and popular literature on the subject. If you see any terms missing, please get in touch with us and we'll be sure to add them. We welcome all comments and perspectives on this topic.  


A List of Terms Used to Describe People Who Use Mental Health Services: 

Attendee

Client

Consumer

Content Expert

Customer

Ex-Patient

Expert by Experience

Expert through Experience

Fellow Traveler

Human Being with a Psychiatric Disorder

Patient

Peer

Person Affected by Mental Illness

Person-in-Recovery

Person in Therapy

Person with Lived Experience

Person with Lived Expertise

Person with Mental Health Problems

Person with a Mental Health Disability

Psychiatric Patient

Psychiatric Survivor

Recipient

Service User

Sufferer

Survivor

User

The Hatching Ideas blog contains discussions of mental health, suicide, social vulnerability and other, similar topics. The topics discussed may prompt unwelcome reminders, and we ask our readers to exercise discretion when reading. In case of an emergency, please contact your local health provider or dial emergency medical services (9-1-1).

Inclusivity and Power: A Series on Language in Mental Health Research

Nicole Dunn

We know that language is powerful, and that when we speak about important issues, the weight of words has the potential to both empower and dispossess. We also know that this is not a simple or unambiguous topic, but is one that is deeply contested, and rightly so. The terms used to describe us can become our identity, and so the words we choose is something that deserves careful consideration.

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The challenge of choosing meaningful language becomes especially pronounced when engaging those who seek care for their mental health. To date, there are several terms available to describe this population with varying rationales. In the UK, phrases like ‘clients,’ ‘patients,’ ‘service users,’ ‘patients/clients,’ ‘clients/patients,’ ‘people affected by mental illness,’ and ‘user/survivor’ are popular. In the US the terms ‘customer,’ and ‘survivor’ have gained currency, and in Australia ‘consumer’ appears to have become the preferred usage.[i] In our work at the Hatching Ideas Hub, ‘person with lived experience’ has become a regularly used phrase, with both ‘content expert’ and ‘expert by experience’ recently appearing as contenders. While all of these labels refer to someone receiving support, they differ in terms of where they locate power. For instance, the terminology “person with lived experience” aims to be person-centered and strengths based, whereas the term “patient” acknowledges a power dynamic as being under the care of another.

At the Hatching Ideas Lab, our inclination is to draw on inclusive language, but we also recognize that not everyone identifies with the terminology we select. We recognize that for some individuals, these terms seem  ideological because they appear to mask existing power dynamics. In research, this raises the question to what extent inclusive language can be used without obscuring existing structures of power? And more significantly, whether or not it is disingenuous to use such terminology, if the structures behind them are not nearly so accommodating?

While it can be difficult to answer the above questions, we think there are some questions that can be posed to help researchers consider the language they use when working with individuals who have historically or are presently receiving support:

·         Who have I talked to from this population and what terminology do they prefer?

·         What power structures are currently at work?

·         In my engagement with this population, who holds the power? In what ways?

·         What advocacy groups exist that I can touch base with?

As part of a series of blog posts on the topic of language use in mental health research, we will be continuing to ask these and other questions over the next few weeks. These discussions will not only address the challenge of describing service users, but also extend to our current areas of interest, and provide critiques of phrases such as “committing suicide” and “intentional self-harm.”

To open the discussion, we encourage readers to join by commenting on their preferred terminology, and explain why that term is meaningful for them.

Follow this space and our Twitter page for updates. More coming soon!

[i] Dickens, Geoff and Marco Picchioni. (2011). A Systematic Review of the Terms Used to Refer to People Who Use Mental Health Services: User Perspectives. International Journal of Social Psychiatry, 58(2), 115-122.

 

 

The Hatching Ideas blog contains discussions of mental health, suicide, social vulnerability and other, similar topics. The topics discussed may prompt unwelcome reminders, and we ask our readers to exercise discretion when reading. In case of an emergency, please contact your local health provider or dial emergency medical services (9-1-1).

Nov. 28th Live Twitter Chat with The Mental Elf and We Mental Health Nurses

Craig MacKie

Some excitement over here at the Hatching Hub this week, as we prepare for a live Twitter chat being hosted by The Mental Elf (https://www.nationalelfservice.net/mental-health/) and We Mental Health Nurses (@WeMHNurses) on November 28th at 3:00pm (Eastern Standard Time)/ 8:00pm (Greenwich Mean Time). We’ll be discussing one of our lab’s most recent publication, A qualitative study of a blended therapy using problem solving therapy with a customised smartphone app in men who present to hospital with intentional self-harm, which was released earlier this month in the BMJ’s Evidence-Based Mental Health (EBMH) journal as part of a special issue on new technologies and digital innovation in mental health. We were privileged to receive the “editor’s choice” for this article, which means it can be freely accessed at this address: http://ebmh.bmj.com/content/20/4/118.

The chat is being run collaboratively with The Mental Elf team (@Mental_Elf), an evidence-based mental health review, and We Mental Health Nurses (https://twitter.com/WeMHNurses), who have an established series of chats aimed at health professionals in the United Kingdom. You can find their chat archive here: http://www.wecommunities.org/tweet-chats/chat-archive.

The Mental Elf will also be publishing a blog post on our paper, authored by Olivia Kirtley (https://www.nationalelfservice.net/author/olivia-kirtley/), to be posted the day of the live chat. The Hatching Hub’s primary investigator, Dr. Simon Hatcher, and two of the article’s other authors, Craig MacKie and Sarah MacLean, will be answering questions using the @HatchingHub Twitter handle (Dr. Hatcher), @Smacl007 (Sarah MacLean) and @CraigMacKie12 (Craig MacKie). To participate, logon to Twitter at the appropriate time (3:00 pm EST/8:00 pm GMT) and post questions or comments using the #WeMHNs hashtag for the duration of the chat.

This event will be occurring the week before Digital Mental Health Week (#DigiMHweek), a week of research blogs, live streamed expert webinars, tweet chats and podcasts being organized by the Mental Elf’s André Tomlin (https://www.nationalelfservice.net/author/andre-tomlin/) with the support of Lisa Marzano (@lisa_marzano) of the EBMH Journal and the National Institute of Health Research (NIHR) Mindtech team (@NIHR_MindTech).  The NIHR Mindtech group will be hosting their annual digital mental health symposium toward the end of the week’s events in London on the 7th of December (http://www.mindtech.org.uk/mindtech-annual-conference/149-nihr-mindtech-htc-mental-health-symposium-2017.html).

Please join us for what promises to be a very interesting discussion, and check out the National Elf Service website (https://www.nationalelfservice.net/) to see some of their fantastic work.

See you on the 28th!   

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The Hatching Ideas blog contains discussions of mental health, suicide, social vulnerability and other, similar topics. The topics discussed may prompt unwelcome reminders, and we ask our readers to exercise discretion when reading. In case of an emergency, please contact your local health provider or dial emergency medical services (9-1-1).