The question “Have you got thoughts…?” has again (and again) appeared in my Twitter timeline. It is proposed to be a way in which to ask about suicidal ideation, otherwise known as suicidal thoughts. I don’t like questions about thoughts; to be honest, I think they shouldn’t be asked.
I’ve always been suspicious of questions about thoughts. This is because I tend to think and not consider my thinking as consisting of individual thoughts. So, I never know whether I have ‘thoughts’, I am able to tell you whether I think about something, for example suicide. And this post is about ‘suicidal thoughts’, objects whose identification is apparently crucial in medicine, suicidology and suicide prevention, let alone suicide risk assessment. It’s also worth reminding ourselves that in the classical Farberow & Shneidman study of suicide letters, the authors use ‘thought units’ as a means of analysing text. I don’t even want to know how they did it.
I often protest against the use of ‘suicidal thoughts’, but I’m told that I’m nit-picking. This is somewhat surprising, as I am also told that language matters, but it seems that particular language doesn’t. So, let’s consider the thoughts. I want to show you what is wrong with asking about suicidal thoughts.
When I was preparing to write this piece, I did a quick search. I wanted at least to have an impression whether ‘suicidal thoughts’ were a default way of talking/asking about suicidal ideation. The impression (quite a strong one, in fact) is that thoughts rule. I also came across a Canadian website with best nursing practice guides which suggest the following questions if a person thinks about killing themselves. Here is a selection.
- When did you begin to experience these thoughts and feelings?
- How frequently have you had these thoughts and feelings?
- Do these thoughts intrude into your thinking and activities?
- How strong are they?
- Can you describe them?
- Can you stop yourself from having them by distracting yourself with an activity or other more positive thoughts?
- Do your thoughts command you to act upon them?
- Do you think you might act on these thoughts of self-harm or suicide in the future?
To be honest, I find these questions quite bizarre and if they were not about a very serious matter, I would just laugh. Who speaks like that? Moreover, the questions construct my thoughts as independent entities, in fact, having agentive power (thoughts can command!) independent of me. Do I still think the thoughts that command me, I wonder. Put differently, do I still count in all those questions or is it just ‘the thoughts’?
(Reservation. I fully understand that in their stories people can and actually do talk about their agentive thoughts. That doesn’t mean, however, that nurses, doctors or whoever else should emulate such narratives. This is because if you ask a question with thoughts as agents, you might get an answer constructing thoughts as agents. What you will not know, however, is whose language it is. Does your patient speak like that or do they simply follow you? This is, again, really uncontroversial stuff).
Yet, it’s not even the constructions of thoughts as agentive which is extraordinary. Have a look at the first of the questions:
When did you begin to experience these thoughts and feelings?
The need to talk about thoughts results in two verbs (‘begin to experience’) before you actually get to the point of your question! Surely that’s hardly helpful. I suspect nobody, outside clinical or academic contexts, talks about ‘experiencing thoughts’, do they? Surprisingly, we do have a nifty verb replacing this very strange phrase. The verb is, wait for it, ‘think’! Surprisingly cool, isn’t it? (I am not going to comment on the ‘when did it start?’ question (here is an earlier post) as this post will quickly change into a rant.)
Similarly, instead of asking
Can you stop yourself from having them?
why not ask the badly unmedical, still, seemingly intuitive question:
Can you stop thinking….?
I also don’t know what ‘strong thoughts’ are, I wouldn’t know what to say when asked to describe thoughts. Green and colourless? Incidentally, just because people do answer such questions, doesn’t mean they’re worth asking. I keep wondering about the extent ‘we’ deprive people of their stories. Stories which may well use medical language (whatever that is), if we choose to use it.
But it is the last of the questions which really made me despair:
Do you think you might act on these thoughts of self-harm or suicide in the future?
It’s a question that asks me to think about thoughts! Is there no limit to objectivising the ‘thoughts’? Is it really so bloody necessary to make them into symptom-objects that they simply cannot be rendered in terms of process, in terms of thinking? Is it really so necessary to pathologise them that thinking about suicide is way too normal, so ‘we’ construct ‘the thoughts’ and go on a quest to establish their existence? Presumably, one thought at a time, in the process creating an illusion of simplicity.
But all that is just for starters. Questions about thoughts are not really worth asking there aren’t any homogeneous suicidal thoughts to discover. The responses to such questions contain a variety of stories which cannot really be shoehorned into one category.
A few years ago, Justyna Ziółkowska and I published a discourse analytic study of suicidal thoughts. We wanted to see what people said when asked about them by psychiatrists. We were not surprised to see that people’s answers were hardly consistent. Some people talked about ‘thinking of suicide, others talked about ‘wanting to kill oneself’, yet others about ‘not wanting to live’? Even more importantly, I doubt very much that a patient who speaks of ‘reluctance to live’ means anything remotely similar to one who says ‘I don’t want to be alive’? Yet, all those stories get recorded as ‘suicidal thoughts’, even though, just commonsensically, they are very different accounts.
Let me put it differently. It is quite surprising that medicine/psychology still considers (I should probably add ‘implicitly’) questions about ‘suicidal thoughts’ as accessing the thoughts. In reality, however, you really are not getting insight into what I think, you really only get to hear what I tell you. And that is quite a difference.
Moreover, as you only get access to stories about what a person thinks (or not!), surely, you must understand that stories do not only have contents, they also have form. Here is one of the stories we quote (translation from Polish):
- Doctor: Now, please, tell me what these suicidal thoughts consist in?
- Patient: Reluctance to live. I feel like either hanging myself or, I don’t know, I think that I will pour water into the bathtub and drown myself. I can’t switch the gas on because I don’t have it in the flat, but when I lived in the old one such thoughts appeared sometimes.
- Doctor: You look for means?
- Patient: I look for means, yes.
The patient’s account of her thinking about suicide is far from uniform. She speaks of reluctance to live, feeling like hanging herself, thinking of drowning in a bathtub. Linguistically, these are three different constructions of suicide. Note first that the initial mention of suicide is done by an impersonal use of a noun ‘reluctance’. The patient is talking about a state of mind which is not predicated of anyone in particular, including herself. It is as if there is this ‘reluctance’ to live, existing in its own right. The other two explications of the suicidal thoughts are done personally – with the speaker taking ‘ownership’ of what happens. And so, she speaks of ‘feeling like’ and of ‘thinking’. Again these two actions differ from one another: one refers to the sphere of volition (probably like the negative ‘reluctance’), the other to cognitive skills. Anyone ready to tell me what exactly her suicidal thoughts are, let alone what they mean?
Incidentally, the psychiatrist completely blanks the story, he makes no attempt to understand it, or explore it. Indeed, the record of this conversation consisted in noting ‘existence of suicidal thoughts’. What is clearly a very complex account of a patient’s experience is reduced to a risk category, maintaining the notion of the uniform suicidal ideation. Exactly in the same way as the questions about thoughts do.
But, I hear you say, again, the patient coped well. She was able to overcome the silly thought-question and told her story. Indeed, she did. But what you must ask yourself is what you want to achieve. The patient who copes with your questions, being likely to understand the gap between how you and she talks, or perhaps opening space for a story you will listen to. The little snippet shows that the doctor and the patient speak through each other, they don’t really communicate. They barely listen to each other, wanting to do different things with what they say.
Over the years, I have lost any hope that such a study will stop psychiatry/psychology/suicidology in their tracks. No, patients will continue to be asked about ‘suicidal thoughts’, while more research will be done on suicidal ideation/thoughts. Why? Because you can. Because at the end of the day, it is so much more satisfying to identify and object, measure and assess it and then be proud of your success. And I’d better stop here, as my cynicism rises dangerously.