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Suicide and Life-Threatening Behavior 36(5) October 2006  2006 The American Association of Suicidology

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On “Intention” in the Definition of Suicide
Karl Andriessen, BSW, GCSuicPrevSt

The need for a comprehensive nomenclature in suicidology is now well recognized. In this paper the focus is on the issue of intention, which is identified as an essential aspect of any definition of suicide and suicidal behavior primarily because of its distinction from accidental behavior. The distinction between the retrospective perspective of motives versus the prospective perspective of intentions is highlighted, and I argue that the latter is more closely related to suicidal behavior. Finally, while motives and intentions tend to be used together in research, there is a need for sound research to clarify the roles of intentions in order to better understand suicide and attempted suicide.

The need for a classification system with uniform definitions and guidelines to classify suicide was early recognized and, subsequently, steadily discussed as an essential ground for the development of contemporary suicidology (Beck, Resnick, & Lettieri, 1974; De Leo, Burgis, Bertolote, Kerkhof, & BilleBrahe, 2004; Farberow & Shneidman, 1961; Linehan, 1997; Maris, 1981, 1992a; Maris, Berman, & Silverman, 2000; Marusic, 2004; O’Carrol et al., 1996; Silverman & Berman,

Karl Andriessen is Coordinator of the Suicide Prevention Project of the Flemish Mental Health Centres in Belgium and Vice-chair of the Flemish Working Group on Suicide Survivors. He is a Belgian IASP National Representative, Chair of IASP Taskforce Postvention, and recipient of the 2005 IASP Farberow Postvention Award. The first version of this paper was written as part of the course work in the first year of the Masters of Suicidology, with due thanks to Prof. Diego De Leo, dr. Karolina Krysinska and Mrs. Jacinta Hawgood at the Australian Institute for Suicide Research and Prevention, Griffith University, Brisbane, Australia. In addition, the author wished to thank the anonymous reviewers for their valuable suggestions. Address correspondence to Karl Andriessen, MHC Suicide Prevention Project, FDGG, Martelaarslaan 204b, 9000 Gent, Belgium; E-mail: karl.andriessen@telenet.be

2005). In the 1980s the U.S. Centers for Disease Control called together a broad working group of “coroners, medical examiners, statisticians and public health agencies” (Rosenberg et al., 1988, p. 1445) to identify criteria for a definition of suicide and to develop guidelines for certification. They put forward that suicide is a “(1) death arising from (2) an act inflicted upon oneself (3) with the intent to kill oneself,” the so-called Operational Criteria for the Determination of Suicide (OCDS). O’Carrol et al. (1996) countered that it was not yet possible to develop a clinical classification system of suicidal behavior due to the limited knowledge of the causal pathways relevant to clinical and prevention work. Instead, based on the OCDS, they elaborated a nomenclature—a set of precise, defined terms to facilitate clear communication. Recently, Marusic (2004) also proposed to use the criteria of Rosenberg et al. to formulate a nomenclature for all suicidal behaviors. Marusic stated that by applying the criteria “1) intention, 2) act of self-destruction, 3) death” (p. 145), it should be possible to formulate a nomenclature for all fatal and nonfatal suicidal behaviors, including suicidal ideation, call for help, and euthanasia. De Leo et al. (2004) evaluated the criteria and definition of Rosenberg as well as several other definitions. They found that

expecting to. Mayo (1992) referred to intentionality as the “most subtle feature of the definition” (p. To operationalize intention these authors proposed the use of measurement Rosenberg et al. do not have self-extinction as their goal” (Kubie... in an early discussion chaired by Shneidman the issue of intentions was addressed: “Many acts of self-injury.. to die or to inflict bodily harm. Marusic. p. alternatively. THE DISTINCTION BETWEEN ACCIDENTAL AND SUICIDAL BEHAVIOR Defining “Intention” more difficult to determine suicidal intention than to determine whether death was selfinflicted. “Sometimes. These building bricks of the definition are: (1) behavior with fatal outcome. or taking the risk. p. goal: cessation of consciousness. After thorough consideration they proposed the following modified definitions: “Suicide is an act with a fatal outcome which the deceased.. Thus it is essential in a definition of suicide (De Leo et al. 2004. Mayo. however. the notion of “potentially” was now included in the modified definition of suicide (De Leo et al. which includes self-inflicted acts. This means that there should be either positive evidence of suicide or. and (3) intention or expectation to die. and that the suicidal person can be ambivalent regarding the intent to die. 1969. 1992). Because the suicidal person has died. Farberow & Shneidman. However. 2004. accidental. which are lumped together under the concept of suicide. While the agent of the action allows to distinguish between homicide and suicide. 1984. 72). unreal and abstract concept” (Kubie. 83). Among others. 1961. and homicidal [and not determined]) can be excluded (O’Carrol et al. Shneidman’s work was later to culminate in the formulation of the “ten commonalities of suicide” (Shneidman. 2004. (2) selfinitiated. it is . p. Because of the uncertainty. Indeed. Nonfatal suicidal behavior was defined as “[A] non-habitual act with non-fatal outcome that the individual. however vague and ambiguous” (p. De Leo et al. suicide. As a help. and active/passive acts. (2004) called intention “the most contentious aspect of the definitional debate on suicide and non-fatal suicidal behaviours” (p. 2004). has initiated and carried out with the purpose of bringing about wanted changes” (p. that the other categories (natural. p. (1988) argued that. suicide has become the “residual” category in the so-called natural. 33). he recommended that clinicians should regard “all cases of potentially dangerous self-poisoning or self-inflicted injury as suicidal attempts” (p. and cognitive state: ambivalence. these included: purpose: to seek a solution. In addition. 461). In the recent history of suicidology Stengel (1964) formulated “a suicide attempt is any act of self-damage inflicted with selfdestructive intention. 131). elusive. Nobody knows what it is to be dead. it is now well recognized that suicidal people can have multiple intentions at the same time. 2004. the conscious and unconscious goals may be precisely the reverse” (p. Maris et al. it has been argued that “intention” does not reach scientific standards and that the concept would be too vague to be included in a definition. 30). and at the same time death can be the method to reach another goal. 72). homicide (NASH) system (De Leo et al. 29). 36). the concept of intention distinguishes between accidental and suicidal behavior. Death can be one of the intentions. Further.. Rosenberg et al. knowing or expecting a potentially fatal outcome. 1996. 1996). 1967. Independent from this source. provided a list of criteria to consider in the assessment of suicidal intentions. 82). So how can someone wish to be dead? “Contemplation of his [one’s] own death remains a remote. accidental. 95). Litman.534 most definitions of suicide share common aspects. of the different aspects of the definition. that intentions may evolve during the suicidal process of an individual person. initiated and carried out with the purpose of bringing about wanted changes” (p. it is not possible to identify fully his/ her intentions. in the perception of the person death can be “just a more appealing option than living” (De Leo et al. 2000)..

Beachler (1979) referred to the Austrian/ American philosopher Alfred Schutz (1899– ¨ 1959). 2002. Several authors have pointed to the fact that intentions are often confused with motives (Hjelmeland & Knizek.” and intentions are related to what the person wants while motives are related to “the reason for the desire” (p. and looks at what will be realized. As such. while the teleological perspective looks for an explanation in the future (the actor’s perspective). 1999). Barber. (2000) defined (the basically legal concept) motive as “the cause or reason that moves the will and induces action. not necessarily equal the intended outcome. 1999. The act is expressed by the intentions. suicide) to effect a result” (p. Understanding the intentions behind the behavior is possible via the “in order to” perspective. Though some authors used motives (or reasons) and intentions as synonyms. the population that does not die as a result of its suicidal behavior. In addition. This be–cause explanation is always retrospective. p.. the criteria and questionnaire of Rosenberg et al. And as long as there is no action. Interestingly. (1988) are useful in this context. however. The latter consist of the circumstances that have influenced a person’s decision to act. 1979. A crucial issue in the action theory that he developed throughout his life. Hawton et al.” and intent is “the purpose a person has in using a particular means (e. namely the “in order to” perspective. support for this distinction is found in another scientific field. medically serious suicide attempts are not necessarily equal with high suicide intent. to what is to be accomplished by the act (Hjelmeland & Knizek. and first presented in The Phenomenology of the Social World. . who became influential for phenomenological sociology. the easy availability of lethal means may influence the outcome (Hawton. Otherwise said. In line with the definitions of Maris et al. the “in order to” would be more closely related to understand the action. THE DISTINCTION BETWEEN BECAUSE AND IN ORDER TO Despite these observations there is little research that offers a more solid empirical view on the issue of intentions. Thus research on intentions (e. a person projects an action as completed in the future. the intentions of the latter may give some indication of intentions that can be present in the first group as well. generally the recommendation was to distinguish between the two. The first is the opposite. or the “past factors that preceded that past decision” (Barber. Silverman & Berman. Starting from the verstehende sociology of Weber. or psychological autopsy studies. to explain behavior intentions more than motives are closely related to the act. Schutz (1932) ¨ stated that social activities must be understood by the sense that subjects give to their EXAMPLES OF RECENT RESEARCH Bearing in mind that the population who dies by suicide is different to.Andriessen scales such as the Suicide Intent Scale. Barber (2002) correctly mentioned that the observed behavior or the outcome does. there is no because (Beachler. and partly overlapping with.g. Unforeseen influences may alter the course and the outcome of an action. Hjelmeland and Knizek (1999) reviewed the psychological literature on the meanings of intentions and motives. 2002). 277). however. 2002).. 1979). 535 actions. Hjelmeland and Knizek argued that “intentional acts satisfy motives. applying questionnaires or interviews) is needed in all at-risk populations. (2000). Also. be aware that the two populations are only partly overlapping (Farberow & Shneidman.. was the distinction between the um-zu-motiv and the weil-motiv (Beachler.g. 2005). Both perspectives can be applied to suicidal behavior. The causal explanation of behavior looks to the past (the external observer’s point of view). The “decision” to act suicidal is only one choice among many options when faced with unbearable experiences. We must. With this. 2001). 37). Also. Maris et al. 53.

2002). Also. and the risk is highest in the first year after a suicide attempt. “my thoughts were so unbearable. 1981. and “I wanted to escape (intention) from an impossible situation (motive)” (58%). 2004). rather. 385). the review above is not an exhaustive overview of the literature. I argue that. fatal or nonfatal. As such. the intentions of persons who didn’t die of their suicidal behavior could be present in suicide deaths as well. identifying risk criteria does not mean that suicidal behavior. Ambivalence was obviously present in this population. 2004). 1996). However. statistics of lethal and nonlethal suicidal behavior. Obviously. These answers. 76) included a table from a study of 1986 in the UK regarding twelve “reasons for taking overdoses. intention is an essential component of the definition of suicide and attempted suicide primarily because it enables one to distinguish between accidental and suicidal behavior. A major result from this study is that the “parasuicidal patients” across the different regions and countries reported similar intentions (Hjelmeland et al. 388). 391). Prospectively. Williams (2001.2% in men). and “I wanted to die” (intention) (59. the suicidal intention as reported in the 14-item list correlated with the results of the Suicidal Intent Scale (p. is predictable (Goldney.. echoing the seminal work of Stengel. The aim. together with a few others. reasons included both motives and intentions. “I wanted to die” (intention) (61%). 10% to 15% of the people who attempted suicide eventually die by suicide (Maris. prevention. research. Of course. 2001). The total number of percentages of the twelve items was 418%.” “influencing others. and maybe more in women than in men. In addition. Information was gathered on 1. Further it was found that intentions did not vary much Defining “Intention” across gender and age. and clinical work. little research has focused on this issue. there was a positive correlation between the national and regional suicide rates and the frequency of the reply “wanted to die” only in women.” and “final exit” (p.3% and 64.5%). it is noted that intentions in this study included motives as well. even indispensable. This means that the participants provided an average of four reasons for their suicidal behavior. ambivalence and multiple intentions (and motives) per person were found (p. The fourteen intentions could be grouped in “care seeking. Kerkhof and Arensman (2004) reported that 44% of those who died by suicide have attempted suicide before. interesting research has been done on nonlethal suicidal behavior. and not in men (p.” Each participant was allowed to mark all items that were applicable to their case. despite limitations of the concept. (2002) found that “patient-attributed reasons for nonfatal suicidal behavior (such as suicidal desire and preparation) predicted a number of suicide criteria” (p. Intentions of nonfatal suicidal behavior were also included in the large WHO/Euro Multi-Centre Study on Suicidal Behaviour (Hjelmeland & Hawton. 1992b). I could not endure them any longer” (motive) (67. Though intention is an important. the issue of intentions in the definition of fatal and nonfatal suicidal behavior is germane to death certification. In this perspective.3% in women. 71. element to understand suicidal behavior. In this study.536 1961). because . resemble well with the “ten commonalities of suicide” (Shneidman. Kerkhof & Arensman. 74). Again. Indeed. The top three intentions were: “the situation was so unbearable (motive) that I could not think of any other alternative” (76. a study cited by Hjelmeland et al. In addition. It is not a coincidence that the second and updated edition of Mark Williams’ 1997 book The Cry of Pain was renamed Suicide and Attempted Suicide (Williams. The top three reasons cited were: “the situation was so unbearable (motive) that I had to do something (intention) and didn’t know what else to do” (67% of participants). This finding supports the hypothesis that.646 persons aged 15 years or more.7% and 63. 390).6%). at least partly. As a whole. was to present a few examples of how intentions have been addressed in research.” “temporary escape. 2000. A list of 14 possible intentions and the Suicidal Intent Scale were applied in 14 regions. p.

(Eds.. (1997). H. Chichester: Wiley. New York: Guilford. Deeks. (2004).. .). In D. 17–39). A..Andriessen motives and intentions are related to different explanatory perspectives (e. K. A. Maris. retrospective versus prospective). D. J. Alfred Schutz. & A. D. S.. & Shneidman. & Knizek. Berman. The Stanford encyclopedia of philosophy (Winter 2002 ed. (Original work published 1975) Beck. Kerkhof. 32. M. Maris. ¨ Kubie. 65–87). and effects on suicide and deliberate self-harm. & Bille-Brahe.. Maris. In E. 5.). Mann (Eds. S. Kerkhof. Maltsberger. (2004). & A. De Leo. 275–281. (2004). A. Bille-Brahe. Baltimore: John Hopkins University Press. Goldney. (1981). Hjelmeland. New York: Science House. De Leo. In D. Maris. The theoretical component in suicidology. Suicide and Life-Threatening Behavior. Zalta (Ed. K. Comprehensive textbook of suicidology (pp.. Behavioral treatments of suicidal behavior: Definitional obfuscation and treatment outcomes. (Eds. Definitions of suicidal behaviour. New York: McGraw-Hill.).). A complex process. New York: Guilford. H. (1979). (2002). UK legislation on analgesic packs: Before and after study of long-term effects on poisoning. E. R. The prediction of suicide.). New York: Guilford. R. Marusic.). Accessed November 25. Kerkhof. Berman. Maltsberger. E. Bille-Brahe. Waters. Why people engage in parasuicide: A cross-cultural study of intentions. Shneidman (Ed. (2002). (1984). 67–78). O’Carrol. In E. D. Assessment and prediction of suicide (pp.g.. On the nature of suicide (pp. Suicidal behaviour: Theories and research findings (pp. (1967). Maris. 32. Bille-Brahe. K. M.). (1961). A. Maris. (1992b). Litman. Simkin. The international handbook of suicide and attempted suicide (pp. (1992a). & R.. What is being predicted?: Definitions of “suicide. Berman. Assessment and prediction of suicide (pp.). Yufit (Eds. Johnston. New York: Basic Books. D. 88–101). Yufit (Eds. Kubie.).. J. Conceptual confusion about intentions and motives of nonfatal suicidal behavior: A discussion of terms employed in the literature of suicidology.stanford.). Suicides (B.). & A. 111–124). Tanney. Cooper. (2000). Gottingen: Hogrefe & Huber. & Hawton. L.. Suicidal behaviour: Theories and research findings (pp. Cooper. Moscicki. and to a better understanding of the suicidal act... Hjelmeland.. & Lettieri. Schmidtke (Eds. rationale. Neurobiology of suicide (pp. Pathways to suicide. 380–393.. Stoff & J. A. Schmidtke (Eds. Kerkhof. (2000). De Leo.. In D.. K. United Kingdom legislation on pack sizes of analgesics: Background. L. 362– 380). Gottingen: Hogrefe ¨ & Huber.). Berman. U. Resnik.. Bowie: Charles Press Publishers. 145–146. Assessment and prediction of suicide (pp. H. Shneidman (Ed. R. In R. J.. Maris. 14..edu/entries/schutz Beachler. R. Linehan. A. Suicidal behaviour: Theories and research findings (pp. (1974). U. L. 1076–1080. & Silverman. In R. 329. M. U. De Leo. from http://plato. A. R. & R. In K. K. A. Archives of Suicide Research. Nordvik. Gottingen: Hogrefe & Huber. et al. Hawton. A. New York: Annals of the New York Academy of Sciences. M. R. & Silverman. E. Maltsberger. M. 302–328). Berman. (1992). J. 88–95. In D. & R. J. van Heeringen (Eds. 2005. H. Bille-Brahe. Berman. et al.. A. Schmidtke (Eds. Yufit (Eds. A... In E. U. & Arensman. 81– 86). British Medical Journal. The relationship of nonfatal suicide attempts to completed suicide... 455–462). Silverman (Eds. (1969). Fekete. Kerkhof. REFERENCES Barber. Burgis. Bertolote. Hawton & K. San Francisco: Jossey Bass. Suicide and Life-Threatening Behavior. Hjelmeland. A. H. J. Maris. How are suicides different? In R. (2004).” In R. Mayo. Toward a new definition of suicidality? Are we prone to Fregoli’s illusion? Crisis. S. B. De Leo. Hawton. (2004). Hawton. 25. A. (2002). but hard to predict. 223–229. (1999). U. B..). 26–61). The study of intentions then might contrib- 537 ute to a better understanding of the relation (continuum and/or group similarities/differences) between nonfatal suicidal behavior and suicide. Repetition of attempted suicide: Frequent. future research should clearly distinguish between them both with regard to suicides and attempted suicides. N. Prediction of suicide and attempted suicide.).. Multiple determinants of suicide. Psychological autopsies in court.. The cry for help. Suicide and LifeThreatening Behavior.). New York: Guilford.. Maris. J. Intentional aspects of non-fatal suicidal behaviour.). A. ¨ Farberow... P. 585–595). & M. Essays in self-destruction (pp. Trans.

1932. London: Penguin Books. Smith. (1988).. Gantner. Paper presented at the XXIII World Congress. et al. 33. Berman.. 237–252. A. Williams. (2001). Vienna: Springer. G.. Rosenberg. September). The suicidal mind. Buzbee. Durban. M. International Association for Suicide Prevention. J. (1964). L.. 26. 2005 Revision Accepted: December 30. 1445– 1456.. (2005. E. A. Harmondsworth: Penguin Books. Shutz. 2005 . Suicide and Life-Threatening Behavior. Journal of Forensic Science.. (1996). South Africa. & Berman. Suicide and attempted suicide. Oxford: Oxford University Press. Defining “Intention” Silverman. E. Manuscript Received: April 29. Suicide and attempted suicide. A. H. M. Beyond the tower of Babel: A nomenclature for suicidology. Stengel.538 (1996). What’s in a name? Advancing a nomenclature for Suicidology.. Davidson. (1932). Der sinnhafte aufbau der ¨ sozialen welt. Shneidman. Operational criteria for the determination of suicide. M.