Why Are We Not Asking About Suicidal Mental Imagery?

Abstract

Mental health nurses and clinicians frequently work with people experiencing suicidal distress and there are established ways of assessing and working with this suicide risk; however, the assessment of suicidal mental imagery is one area of risk assessment that is significantly underutilised.

Suicidal ideation is a critical area of concern for mental health professionals, encompassing a range of thoughts and mental planning related to self-harm. Traditionally, the focus has been on verbal expressions and cognitive patterns associated with suicide risk. However, an often overlooked but equally significant aspect of this assessment is suicidal mental imagery. Suicidal mental imagery consists of vivid, self-generated visualisations that can be as diverse as the individuals experiencing them. These images might include scenes of jumping off a building, drowning or lying in a coffin, often accompanied by a sensory richness that includes colour, sound and emotional undertones. The experience of suicidal mental imagery may increase a person's risk of suicide as it promotes suicidal behaviour more than verbal thought. Despite its potential impact on an individual's mental state, the assessment of suicidal mental imagery remains underutilised in clinical practice. Cognitive behavioural therapy (CBT) can be used to target suicidal mental imagery directly by identifying relevant suicidal images, grading their emotional and behavioural intensity and intervening by changing the image to offset suicidal behaviour and ultimately, to its end, develop stabilising lifeward goals, thoughts and action. This editorial aims to highlight the importance of incorporating the evaluation of suicidal mental imagery into standard suicide risk assessments and therapeutic interventions.

The concept of suicidal mental imagery was first highlighted by Holmes et al. (2007), who emphasised that these mental pictures are not mere thoughts but sensory experiences that can significantly influence an individual's emotional state. These images are idiosyncratic, varying widely among individuals in terms of content, detail and associated emotions. For instance, while some individuals may find these images distressing, others may perceive them as comforting, providing an imagined escape from their painful life experiences (Holmes and Butler 2009).

Current assessment methods predominantly focus on cognitive aspects of suicidal ideation, often neglecting the sensory and emotional dimensions captured by suicidal mental imagery. This oversight can result in incomplete risk assessments and missed opportunities for targeted interventions. Mental imagery generates stronger emotional responses compared to verbalised thinking and is integral to the maintenance of most psychological disorders (Paulik et al. 2023), often associated with being suicidal. Mental health nurses and clinicians need to be equipped with the tools and knowledge to identify and understand the nature of these images. By integrating questions about suicidal mental imagery into routine assessments, clinicians can gain a more comprehensive understanding of an individual's suicidal ideation.

A recent systematic review of the available evidence indicates a high prevalence of suicidal people picturing death by suicide, accounting for 73.56% experiencing suicidal mental imagery among clinical samples, including preliminary evidence suggesting suicidal mental imagery as a motivator to suicidal behaviour (Lawrence et al. 2023). As there are significant overlaps between perception and mental imagery, imagery-based mental simulations (e.g., picturing oneself crashing a car) can enable individuals to experience imagined situations as if happening in real life (Lang 1979; Mathews, Ridgeway, and Holmes 2013; Moulton and Kosslyn 2009), thus increasing likelihood of their action. Suicidal mental imagery is, therefore, implicated as having action rehearsal properties (O'Connor and Kirtley 2018; Ji et al. 2024), a most important feature for clinical assessment.

Though there is no agreed or universally accepted definition of suicidal ideation (Harmer et al. 2024), existing definitions do not routinely include the phenomena of suicidal mental imagery, as a feature of suicidal ideation, despite being present at the time people are most suicidal and evidence showing association with suicidal behaviour (Crane et al. 2012; Lawrence et al. 2023). Suicidal ideation is defined by De Leo et al. (2021, 7) as: ‘thinking of suicide with or without suicidal intent; hoping for death by killing oneself; and, stating the presence of suicidal intention without engaging in behaviour’. In practice, suicidal ideation and planning are clinically assessed by seeking out the presence of thoughts (or verbal cognitions) rather than by specifically asking about associated mental pictures a person may be experiencing (Schultebraucks et al. 2020), a largely common experience for suicidal people. The lack of clear definition (and indeed understanding) and sometimes conflation with the concept of externally generated suicidal imagery, has potentially impacted its use in practice and as a topic for research. This paper goes some way to help clarify the term suicidal mental imagery as a self-generated activity and may orientate mental health clinicians as to the potential of this in practice. A broader definition of suicide ideation that explicitly includes the presence of suicide imagery would be a prompt for mental health clinicians to include suicide imagery in risk assessments for suicide ideation, and for suicide researchers to incorporate suicide imagery in studies of suicide ideation thereby expanding the evidence base on suicide imagery.

There is an emerging body of evidence that suggests suicidal mental imagery is an important risk factor (Crane et al. 2012; Ng et al. 2016; van Bentum et al. 2017; O'Connor and Kirtley 2018; Paulik et al. 2023) and that by asking about it, we can improve the assessment process and decrease the risk of suicide. Imagery of self-injury or death can propel a person from thinking about suicide to acting on it but is largely unexplored in the treatment literature. Clinicians often do not enquire about suicidal mental imagery and instead focus on more verbal forms of cognition, as they may fear asking about it or lack sufficient treatment tools (van Bentum, Kerkhof, and Marcus 2023). Most routine mental health assessment tools do not explicitly prompt the clinician to ask about suicidal mental imagery and it is largely absent from mental health education or policy documents relating to suicide. It is not something that, to date, has been largely covered in suicide literature and instructional texts for clinicians but its potential as a possible factor that moves someone from ideation to action has been suggested by O'Connor and Kirtley (2018). The authors in this piece, therefore, keenly suggest that clinicians may not be aware of the urgency of suicidal mental imagery, as a risk factor, to ask about it in the first instance. If there is a lack of knowledge in practice about a phenomenon, it will not be asked about or if there is very limited understanding, a clinician may not feel comfortable in asking about it. What if we could start by simply asking about it, alongside what we normally do, and then consider it as a treatment potential in the stabilisation of risk alongside current risk assessment processes?

Understanding the comforting aspect of suicidal mental imagery is crucial. For some individuals, these images may serve as a coping mechanism, offering a sense of control or relief from their current distress. Recognising this dual nature—both distressing and comforting—can inform more nuanced and empathetic approaches to treatment.

Incorporating suicidal mental imagery into clinical assessments can enhance the precision of suicide risk evaluations and interventions. For instance, CBT and its specialised form, CBT for suicide prevention (CBT-SP), can be adapted to address these visualisations. Imagery interventions, which involve modifying the content and emotional response to these mental pictures, can be a valuable addition to existing therapeutic strategies. Identifying an image of death or dying is a picture that can give far more detail of intrusion and related planning than those of verbal thoughts alone as there is a richness of information that comes from asking about related images than simply asking about thoughts or behaviour.

Another important consideration is the measurement of suicidal mental imagery. Though questionnaires such as the validated suicidal imagery questionnaire (SIQ) have been tested in non-clinical populations (Ko and You 2020), van Bentum, Kerkhof, and Marcus (2023) sought to investigate suicidal imagery in clinical samples, by developing the suicidal intrusion attributes scale (SINAS) focusing explicitly on how compelling images are, their compulsiveness and intrusiveness. Self-report scales such as these can help normalise the experience of suicidal mental imagery, open up the discussion in routine clinical practice and provide rich information in relation to markers of severity, indicating areas for more targeted interventions. Therefore, in addition to asking directly about a person's own imagery experiences, suicide imagery should also be captured through the use of standardised assessment tools and measurement.

Clinicians can work with people to transform suicidal images, reducing their intensity and emotional impact, and ultimately helping develop healthier coping mechanisms. For example, when a suicidal mental image is identified, the clinician now has the opportunity to directly address its emotional and behavioural grip through deglamorisation of the image, imagery rescripting or imaginal exposure. For instance, clinicians can assist the person to bring forward an image, ‘play’ the image right through to the end (in a safe space) and adjust with new stabilising imagery. This brief process alone can be sufficient in changing feeling, behaviour and meaning of imagery. It is important to identify images that are most intrusive or that people typically spend much time fantasising about.

For those experiencing suicidal mental imagery, what if we could target the image directly as part of routine practice to stabilise risk?

If we know that suicidal mental imagery can drive people to complete suicide, then conversely it can also be modified or manipulated to help ‘offset’ a suicidal act. Research transcripts of suicidal imagery by Crane et al. (2012) conceptualised suicidal mental imagery in the domains of image content, associated effect and meaning. By asking about the content of suicidal mental imagery (what do you see), understanding what feeling it brings (comfort, distress or both) and examining the function (role, such as escape), there is potential to build capacity to more confidently assess and treat these important mechanisms—to identify imagery feeling and meaning thereby essentially considering other ways to prevent suicide.

Carey and Wells (2019) illustrate a treatment approach utilising imagery assessment and interventions through CBT-SP adapted imagery intervention, aligning to the ‘Flash-Forwards’ phenomena. Flash-forwards were coined by Ng et al. (2016) and are concerned with future violent daydreaming about suicide, in this instance. We know that seeing one's own death ‘in the mind's eye’ is an emotional and motivational amplifier or enhancer (Holmes et al. 2007), like ‘rocket fuel’ to thoughts, feelings and behaviour. Flash-forwards is a type of mental time travel—the brain receives the (suicidal mental imagery) information as though it is real and is really about to happen, therefore amplifying the ‘rightness’ or likelihood of an action. For instance, in everyday human experience, consider daydreaming about something much wanted in life, for example, a holiday. This brings about feelings of anticipation and pleasure, including mental pictures of the holiday, where one may even mentally plan booking the holiday—all events which not happened yet. This is mental time travel but in a life-goal orientated way. In suicide, if a person is comforted by ending a problem through suicide, this is conceptualised as death-goal orientated. This is consistent with emotional amplifier theory, as demonstrated in imagery enhanced cognitive therapy protocols for mood (Holmes et al. 2019). If it is known that suicidal mental imagery acts to accelerate thoughts, feelings and associated behaviours, we need to consider its treatment potential in our collaborative stabilisation endeavours. Therefore, understanding the mechanisms of what works in mental health care interventions is crucial. The associated effect and appraisal of an image can accelerate (or amplify the rightness of) behaviour and it is known that suicidal imagery can be present at the time when people are most suicidal (Holmes et al. 2007; WeBlau et al. 2015).

Though recognised CBT-based imagery intervention protocols exist, they have not been adapted specifically in the routine treatment of suicidal mental imagery. Such interventions include imagery modification, manipulation and rescripting interventions to collaboratively interfere with the image. For instance, suicidal people can have highly comforting imagery of loved ones at their funeral, being relieved that they have died, while looking over their coffin. This is potentially more dangerous as it is connected with perceived burdensomeness, for example, in depression, sometimes making it easier to engage in the suicidal act. In an effort to interfere and deglamourise the suicidal image, the suicidal person could be facilitated by the clinician to create an adjusted mental picture to include a loved one at the point of death. This loved one would present in the new picture as being deeply upset, or alternatively could be willing the suicidal person towards them, thereby reducing the person's desire to voluntarily engage in the image as it becomes less comforting.

Creating new hope-inducing imagery that directs life goals is also an important feature of suicidal imagery treatment. In a recent qualitative study, exploring acute suicidal mental imagery, Nilsson et al. (2023) found that it is important to make any personal goal-orientated imagery concrete, real and accessible. Toning down imagery to make it realistic is, therefore, important and speaks to the idiosyncratic nature of imagery, that is, particular to the life and experiences of the individual. A personal realistic goal may be to re-engage with an old hobby or start a new course that is of interest and enjoyment to them. This can be guided using short, medium and long-term goal setting—by helping the person to create new imagery of themselves in 1 week, 6 months or 5 years from now. Importantly, life affirming imagery is not created by the clinician for the individual—the work of the clinician is to assist its development, helping change the course from death to life-orientated imagery and stabilisation. Identifying the role of suicidal mental imagery during a suicidal crisis could, therefore, allow for the development of alternative flash-forward outcomes to suicidal ideation, which could then be employed within a safety plan (Cleare and O'Connor 2024). For example, CBT uses homework to assist and maintain therapeutic gains. ‘Imagery homework’ can include, purposeful daydreaming and self-generated imagery around life-orientated goals. This is a daily activity that the suicidal person can engage in (and at multiple times), to capture images that feel meaningful and hopeful. Naming this self-help homework activity in the safety plan is one such potential.

Longitudinal research that can capture idiosyncratic within-person changes as well as between-person differences in suicidal mental imagery, as a function of suicide risk, is needed. What images may serve to comfort one person may be distressing for another. Hjelmeland and Knizek (2016) have long called for a change in the direction of suicide prevention research to that of more qualitative studies, heralding their relevance to clinical practice. Understanding the qualitative nature of suicidal ideation and meaning making, including imagery, is therefore necessary in our understanding of suicidal motivations, feelings and behaviours. Education and training for mental health professionals need to be updated to include assessment of suicidal mental imagery. It should be incorporated into suicide risk assessment and intervention education for mental health professionals, and then for those taking specific suicide modules and courses, a more detailed educational provision on imagery should be included.

This could involve changing undergraduate and postgraduate University curricula and by adding a proposed Suicidal Mental Imagery assessment and CBT-SP adapted Imagery Intervention module, as a standalone, in the available suite of more targeted modular-based suicide assessment and prevention programmes, as part of continued professional development. Using the CBT-SP adapted model, including imagery intervention, it would reflect key CBT principles (e.g., vicious cycle of being suicidal, idiosyncratic case conceptualisation, functional analysis, collaboration, problem-solving and goal setting), safety planning intervention (SPI) and imagery modification and rescripting, to treat deep mental imagery. The CBT model, more generally, is well established and accepted by mental health nurses and clinicians in routine practice. Its adaptation to treat suicidal mental imagery would be a novel important tool for practice. However, an adapted model as proposed by the authors, requires testing in clinical populations.

This editorial is a call for clinicians to start actively assessing the experience of suicidal mental imagery in routine practice. It is the authors' purpose to demystify and simplify the concept of suicidal mental imagery for clinicians, to tune into associated feelings of both comfort and distress (and the implications of these) to build more comprehensive risk assessment and going forward, for mental health clinicians to learn practical skills to appropriately respond to suicidal mental imagery as a developing area of mental health practice. There is a rich opportunity to actively listen to the person about the mental pictures that do exist. Clinicians can simply start by asking about suicidal mental imagery.

The assessment and treatment of suicidal ideation must, therefore, evolve to include the rich, sensory experiences of suicidal mental imagery. By acknowledging and addressing these mental pictures, clinicians can provide more comprehensive and effective care. Future research should focus on developing standardised tools for assessing suicidal mental imagery and evaluating the efficacy of imagery-based interventions. By expanding our understanding and treatment of suicidal ideation to encompass these vivid self-generated mental images, we can better support individuals towards mental health and well-being.

In conclusion, while traditional assessments of suicidal ideation have focused on cognitive aspects, it is imperative that mental health professionals also consider the sensory and emotional dimensions of suicidal mental imagery. By doing so, we can provide more holistic and effective care, ultimately improving outcomes for individuals experiencing suicidal distress.

This paper clarifies the nature of suicidal mental imagery for mental health nurses and clinicians. It argues for more in-depth qualitative research into real-time suicidal ideation, emphasising the need to understand the mechanisms of the suicidal mind to include imagery and also recognising the dual nature of associated distress and comfort, the latter of higher risk potential. This paper provides practical suggestions for clinicians to inquire about suicidal mental imagery during routine assessments. By explaining the concept in simple terms and asking specific questions, clinicians can open a dialogue about this often-overlooked aspect of suicidal ideation.

The authors are engaged in qualitative research, The SUMI (Suicidal Mental Imagery) Study, exploring people's experiences of suicidal mental imagery and the potential role of CBT-SP imagery intervention, to further advance our understanding and promote skills for practice.

Marie Carey is the principal investigator of The SUMI Study and the main author of this manuscript. Prof Louise Doyle is the lead supervisor and Dr. Brian Keogh is the co-supervisor of the study and manuscript. All listed authors are in agreement with the manuscript.

The authors declare no conflicts of interest.