I am a physician, a urologist, and a survivor of multiple suicide attempts related to physician burnout. In dealing with my psychopathology, I experienced a devolution in my mental status, culminating in suicidal behavior. I can remember the exact moment when I acknowledged that suicide was a possible solution to my problems. At one moment, I felt revulsion at the idea of suicide but crossed over to accept it. This moment, etched in my brain forever, brought me to realize that there are four stages in the evolution of suicidal behavior or ideation.

Suicidal ideation is a clinical term used to describe thoughts of suicide or wanting to take one’s life. These thoughts do not occur suddenly but evolve in individuals who eventually attempt suicide. Generally, this evolution follows four distinctive stages.

1. Acknowledge. People are born with a sense of self-preservation. Upon hearing for the first time about an individual who has committed or attempted suicide, the natural sense is one of repulsion. The first stage in the evolution of suicidal ideation requires a loss of this repulsion. The person somehow acknowledges that suicide in some individuals is understandable and tragic.

2. Accept. Accepting that under overwhelming circumstances, suicide would be acceptable for him marks the second stage in the evolution of suicidal ideation. In many suicidal individuals, accepting suicide as a possible action in their own life never resolves. Even when this individual decides never to commit suicide, he still remembers feeling that this would be acceptable. It is my experience; these memories continue to haunt the individual even when clinically doing well.

3. Anticipate. The third stage in the evolution of suicidal ideation involves the anticipation that, at some time in the future, suicide is inevitable. As this individual decompensates, plans to commit suicide begin.

4. Action. The last stage in the evolution of suicidal ideation involves action, which takes two forms.

In the first form, the action involves a sudden decision and suicidal activity. This action occurs at the spur of the moment and shows little organization. The result is a poorly planned overdose or other possibly lethal action.

In the second form, the action takes the form of a plan. In this plan, the individual decides on a day and the action necessary to end his life.

We are born with mental reflexes designed for self-preservation, which makes the concept of suicide repulsive. The evolution of these complex ideas to those in which an individual carries out a suicide attempt does not occur in one step, but rather by a series of, in many instances, irreversible changes in thinking.

The suicidal individual first acknowledges that certain individuals are justified in attempting suicide. Secondly, this person accepts that if the situation becomes intolerable, suicide would be an acceptable response. Next, suicidal ideation anticipates that sometime in the future, the act of suicide will be carried out. The last stage in suicidal ideation involves action, either actively with a plan or as a sudden, poorly organized action.

In no way does the description of the stages in the evolution of suicidal ideation defend the act of suicide. The act of suicide is an irrational reaction to what is perceived as an unrelenting, overwhelming sense of pain. This is a complex set of thought processes that do not occur quickly but evolve over time. Recognizing the early stages in the development of suicidal ideation could benefit the individual by directing effective intervention early in this evolution.

William Lynes is a urologist.