Suicide and the continuum of self-destructive behavior.

Suicide and self-destructive behavior are strongly influenced by a negative thought process, referred to here as the "voice." The voice process represents a well-integrated pattern of thoughts, attitudes, and beliefs, antithetical to self and hostile toward others, that is at the core of a patient's self-limitations and self-defeating actions. The voice varies along a continuum of intensity ranging from mild self-criticism to angry self-attacks and even suicidal thoughts. Self-destructive behavior similarly exists on a continuum ranging from self-denial to accident proneness, drug abuse, alcoholism, and other self-defeating behaviors, culminating in actual bodily harm. The two processes, cognitive and behavioral, parallel each other, and suicide represents the acting out of the extreme end of the continuum. The authors provide a chart depicting the levels of increasing suicidal intent along the continuum. The chart identifies specific negative thoughts and injunctions typically reported by persons who attempt suicide, neurotic patients, and "normal" subjects. Understanding where an individual can be placed on the continuum of self-destructive thoughts and actions can assist clinicians in their diagnoses and help pinpoint those students who are more at risk for suicide.