Attitudes Towards Suicide

Abstract

The Attitudes Towards Suicide (ATTS) questionnaire is a comprehensive, multidimensional psychometric instrument developed to evaluate public, clinical, and sociological attitudes toward suicide, suicidal ideation, and life-ending decisions within community and professional populations. Originally conceptualized by Umeå University researchers Ellinor Salander Renberg and Lars Jacobsson in Sweden during large-scale national epidemiological surveys conducted in 1986 and 1996, and formally standardized in 2003, the ATTS addresses the critical need to capture the heterogeneous cognitive, moral, and affective stances held toward suicidal behaviors. The instrument integrates three distinct structural components: an initial section evaluating personal exposure and contact with suicidal behavior among significant others; a core 37-item psychometric battery measuring multidimensional attitudes using a 5-point Likert scale (ranging from 1 = Strongly disagree to 5 = Strongly agree); and a concluding section capturing demographic characteristics alongside personal lifetime and recent suicidal behavior history. Factor-analytic investigations of the attitude statements have identified robust multidimensional factors, including Suicide as an Inalienable Right, Fatalism and Inevitability, Preventability and Readiness to Intervene, Suicide in the Context of Incurable Illness, Suicide as a Cry for Help, Tabooing and Interpersonal Stigma, and Impulsivity versus Deliberation. Psychometric evaluations across multiple Nordic, European, and international cohorts demonstrate acceptable-to-strong internal consistency across extracted factors (Cronbach’s alpha coefficients ranging from 0.62 to 0.85), excellent content and construct validity, and sensitivity to demographic covariates such as age, gender, educational attainment, and clinical occupational role. The ATTS serves as an essential measurement paradigm for suicide prevention campaign evaluations, gatekeeper training outcome assessment, clinical psychiatric staff training, and international cross-cultural suicidology research.

Keywords

Attitudes Towards Suicide, ATTS, suicidology, suicide prevention, psychometrics, stigma assessment, fatalism, right to die, suicide ideation exposure, public health epidemiology

Authors

The Attitudes Towards Suicide (ATTS) instrument was developed by:

• Ellinor Salander Renberg, Ph.D. — Department of Clinical Science, Division of Psychiatry, Umeå University, Umeå, Sweden. Renberg is an internationally recognized psychiatric epidemiologist whose research focuses on population-based suicide trends, youth mental health, and the social determinants of self-harm.
• Lars Jacobsson, M.D., Ph.D. — Professor Emeritus of Psychiatry, Department of Clinical Science, Division of Psychiatry, Umeå University, Umeå, Sweden. Jacobsson has contributed extensively to cross-cultural psychiatry, psychiatric ethics, human rights in mental healthcare, and public health suicidology.

Institutional Origin: Division of Psychiatry, Department of Clinical Science, Umeå University, SE-901 87 Umeå, Sweden.

Purpose

The primary purpose of the Attitudes Towards Suicide (ATTS) questionnaire is to quantify, categorize, and track the spectrum of beliefs, ethical judgments, misconceptions, and behavioral predispositions that individuals hold regarding suicidal actions and individuals in suicidal crises. Attitudes toward suicide represent critical psychological and cultural variables: they shape the degree of public and familial stigma experienced by vulnerable individuals, govern the likelihood of help-seeking behaviors, determine community willingness to intervene, and influence broad social policy regarding lethal means restriction, mental health resource allocation, and assisted dying legislation.

In epidemiological and public health contexts, the ATTS was designed to monitor longitudinal shifts in societal norms. By examining cohorts over multiple decades, researchers can assess whether national suicide prevention programs, school-based educational initiatives, and destigmatizing public media guidelines yield measurable reductions in taboo, fatalism, or condemnation. The instrument establishes baseline public readiness to engage in suicide intervention, helping public health authorities identify demographic segments holding high levels of fatalistic beliefs (e.g., the belief that suicidal individuals cannot be stopped) or stigmatizing views (e.g., viewing suicide as an act of cowardice, punishment, or manipulation).

In psychiatric, nursing, and clinical healthcare environments, the ATTS evaluates the implicit and explicit belief systems of healthcare professionals, crisis counselors, and emergency department personnel. Negative, fatalistic, or punitive attitudes among healthcare workers can compromise therapeutic alliance, decrease diagnostic vigilance, and lead to suboptimal discharge planning for patients presenting with self-harm or acute ideation. Pre- and post-intervention administration of the ATTS provides empirical evidence for the efficacy of gatekeeper training programs, medical curriculum reforms, and continuing psychiatric education.

Finally, in theoretical suicidology, the ATTS allows investigators to examine the complex, reciprocal associations between an individual’s personal contact with suicidal behavior (e.g., bereavement, exposure to peer ideation), their normative and moral attributions of suicide, and their own vulnerability to suicidal thoughts and behaviors. By assessing exposure, attitudes, and personal history within a unified protocol, the ATTS facilitates sophisticated structural equation modeling of suicidal risk and resilience trajectories.

Psychological Construct

The Attitudes Towards Suicide questionnaire measures a broad, multidimensional psychometric construct rather than a single linear continuum. Grounded in social cognitive and psychiatric research, attitudes toward suicide encompass cognitive appraisals, affective responses, moral-philosophical convictions, and behavioral intentions. The core dimensions operationalized within the 37 attitude statements of the ATTS include:

1. Permissibility, Autonomy, and the Right to Die

This dimension examines whether an individual views suicide as an unacceptable transgression or an inalienable personal right. It reflects liberal versus conservative philosophical values concerning bodily autonomy. Items assessing this construct include statements regarding whether people possess the sovereign right to end their lives (e.g., Item 37), whether suicide can ever be justified (Item 5), and whether external observers should refrain from interfering if someone decides to end their life (Item 27).

2. Acceptability in Incurable Illness and Euthanasia

A distinct sub-dimension separates generalized permissibility from situational justification in the face of terminal medical suffering. Items in this domain evaluate whether suicide represents a rational, humane resolution to intractable physical pain and incurable somatic illness (Item 8, Item 35), personal willingness to consider self-deliverance under such medical circumstances (Item 23), and endorsing assistance in dying (Item 32, Item 39). This construct captures cognitive distinctions between psychiatric despair and medically related rational suicide or voluntary euthanasia.

3. Fatalism and Inevitability

The fatalism construct captures the cognitive belief that suicide is an unpreventable, predetermined event once an individual has formulated the intention. High scores on this dimension reflect the misconception that external human intervention is futile (e.g., Item 9: “Once a person has made up his/her mind about committing suicide no one can stop him/her”) and that suicidal thinking represents a permanent, irreversible mental state (Item 24). Fatalistic attitudes correlate negatively with active help-offering behaviors and are critical targets for public health deconstruction.

4. Preventability and Readiness to Intervene

Directly counterposed to fatalism, this dimension measures an individual’s sense of collective human responsibility, perceived efficacy in crisis intervention, and personal willingness to provide direct support. Items evaluate beliefs that suicide can be systematically prevented (Item 40), the conviction that intervening is an imperative human duty (Item 12), faith in the universal capacity to assist someone with suicidal ideation (Item 4), and personal readiness to initiate supportive contact with a person in crisis (Item 33).

5. Suicide as a Cry for Help and Interpersonal Communication

This construct assesses the extent to which self-directed violence is understood as an effort to communicate unbearable psychic pain (psychache) or solicit interpersonal rescue, rather than an absolute wish to cease existing. Key statements operationalize suicide attempts as cries for help (Item 29), examine whether suicidal threats are interpreted as serious predictors of mortality or manipulative maneuvers (Item 15, Item 20), and probe the belief that attempts arise from interpersonal conflicts with significant others (Item 38) or motivations of revenge and punishment (Item 10).

6. Stigma, Taboo, and Avoidance

Stigmatizing and taboo attitudes encompass beliefs that suicide is a shameful, socially toxic subject that must be suppressed in civil discourse (Item 16, Item 26), as well as the iatrogenic myth that inquiring directly about suicidal ideation implants the thought in a vulnerable person’s mind (Item 14). Additionally, this dimension evaluates moral condemnation regarding the interpersonal devastation inflicted upon surviving family members (Item 6).

7. Comprehensibility, Normalization, and Etiological Attributions

This domain captures how ordinary individuals explain suicidal etiology. It spans beliefs attributing suicide to pervasive mental illness (Item 11), isolation and profound loneliness (Item 17, Item 28), the assumption that suicidal ideation is a universally shared human experience (Item 18), versus cognitive incomprehensibility—the utter inability to fathom why someone would intentionally end their life (Item 30) or the perception that youth suicide is uniquely inexplicable (Item 22).

Theoretical Framework

The theoretical framework of the ATTS draws upon integrated models from social psychology, medical sociology, and modern suicidology. Understanding how attitudes are formed, maintained, and modified requires synthesizing several complementary paradigms:

The Theory of Planned Behavior and Social Cognitive Theory

According to Icek Ajzen’s Theory of Planned Behavior (TPB), human action is guided by behavioral beliefs (attitudes toward the behavior), normative beliefs (subjective norms), and control beliefs (perceived behavioral control). Within the ATTS framework, an individual’s readiness to intervene in a crisis (Item 33) is governed by their attitude toward intervention efficacy (Item 4, Item 40) and perceived subjective norms regarding moral duty (Item 12). If societal attitudes frame suicide as an unstoppable, private choice (Item 27), perceived behavioral control decreases, suppressing proactive gatekeeper interventions. Furthermore, Albert Bandura’s Social Cognitive Theory underscores how observational learning, media portrayals, and peer exposure (captured in Section A of the ATTS) shape cognitive appraisals and behavioral expectations.

Durkheimian Sociological Theory and Social Integration

The foundational sociological framework established by Émile Durkheim in his 1897 treatise Le Suicide posits that suicidal behavior varies inversely with the degree of social integration and moral regulation. The ATTS operationalizes modern reflections of Durkheim’s concepts: items focusing on alienation, chronic loneliness (Items 17 and 28), and the disruption of family systems (Item 6) reflect egoistic suicide dynamics. The tool’s focus on whether suicide is seen as an individual’s private right versus an act disruptive to social cohesion directly traces to sociological debates concerning collective solidarity versus modern hyper-individualism.

Interpersonal-Psychological Theory of Suicide

The conceptual structure of the ATTS also intersects with Thomas Joiner’s Interpersonal Theory of Suicide, which identifies thwarted belongingness and perceived burdensomeness as proximal psychological drivers of suicidal desire. When the ATTS probes whether respondents perceive suicide as a relief for those involved (Item 21) or attribute suicidal drive to profound loneliness (Item 28), it touches upon the exact cognitive manifestations of perceived burdensomeness and failed belongingness that characterize lethal suicidal states.

Goffman’s Stigma Framework and the Myth-Reality Dichotomy

Erving Goffman’s conceptualization of social stigma as a deeply discrediting attribute provides the foundation for the ATTS taboo items. Stigma surrounding psychiatric distress fosters social avoidance, secrecy, and cognitive distortions. The ATTS intentionally includes widely held clinical myths—such as the belief that those who talk about suicide do not carry it out (Item 36), that asking about suicide induces ideation (Item 14), or that suicides occur without warning (Item 25)—to quantify the prevalence of folklore versus empirically supported clinical knowledge in the general population.

Validity

The validity of the Attitudes Towards Suicide questionnaire has been substantiated through rigorous psychometric testing across diverse international cohorts, clinical samples, and general population surveys.

Content and Face Validity

Initial content validation was conducted during the design of the Swedish National Suicide Prevention Research program at Umeå University. Renberg and Jacobsson constructed the item pool based on extensive reviews of historical attitudinal scales (such as those by Diekstra, Domino, and Wellman), combined with qualitative insights from psychiatric patients, suicide attempt survivors, and suicide-bereaved relatives. Panels of expert suicidologists and clinical psychologists confirmed that the 37 attitude statements encompassed all major cognitive domains, clinical myths, and ethical dilemmas relevant to suicide prevention.

Construct and Structural Validity

Construct validity is evidenced by the scale’s predictable factor structure and its sensitivity to demographic and experiential differences. Consistent with theoretical expectations:

• Gender Disparities: Multiple population studies indicate that women score significantly higher than men on dimensions of Preventability and Readiness to Intervene and Suicide as a Cry for Help, whereas men consistently display higher scores on Suicide as an Inalienable Right and fatalistic beliefs.
• Age Dynamics: Older respondents consistently demonstrate more conservative attitudes, higher moral rejection of suicide, and stronger condemnation regarding its impact on relatives, whereas younger cohorts endorse higher permissibility and normalization of suicidal ideation.
• Educational Stratification: Higher educational attainment correlates negatively with taboo/avoidance beliefs and clinical myths (e.g., lower endorsement of Item 14 and Item 36), validating the instrument’s capacity to reflect cognitive sophistication and health literacy.

Convergent and Discriminant Validity

When administered alongside related psychometric scales, the ATTS demonstrates robust convergent validity:

• Factors assessing Suicide in Incurable Disease correlate positively (r = 0.54 to 0.68) with external standardized measures of euthanasia acceptance and autonomy attitudes.
• The Tabooing and Inevitability subscales correlate positively with general mental health stigma instruments (such as the Stigma of Suicide Scale, SOSS) and negatively with suicide literacy measures (such as the Literacy of Suicide Scale, LOSS).
• Discriminant validity is supported by the fact that exposure to suicide (Section A) selectively influences specific attitude dimensions (elevating empathy and understanding while reducing taboo) without uniformly inflating generalized permissibility or personal suicidal ideation scores.

Criterion and Predictive Validity

Studies evaluating gatekeeper interventions (e.g., Question, Persuade, Refer [QPR] or Applied Suicide Intervention Skills Training [ASIST]) have demonstrated the ATTS’s sensitivity to change. Post-training scores show statistically significant decreases on the Fatalism and Taboo factors, paired with significant increases on Readiness to Intervene (Item 33) and Preventability (Item 40), confirming predictive utility in intervention research.

Reliability

The reliability of the ATTS has been evaluated across multiple independent empirical studies employing large representative samples.

Internal Consistency

Because the ATTS is multidimensional, overall full-scale Cronbach’s alpha is not the primary psychometric metric; rather, reliability is assessed at the subscale/factor level. In the foundational standardization study by Renberg and Jacobsson (2003) involving representative Swedish cohorts (N = 1,006 in 1986; N = 1,000 in 1996), internal consistency coefficients for extracted factors demonstrated acceptable to solid reliability:

• Suicide as an Inalienable Right / Permissibility: Cronbach’s α = 0.76 – 0.83
• Suicide in Incurable Disease / Euthanasia: Cronbach’s α = 0.78 – 0.85
• Preventability and Human Duty: Cronbach’s α = 0.68 – 0.74
• Fatalism / Unpreventability: Cronbach’s α = 0.64 – 0.71
• Cry for Help / Interpersonal Communication: Cronbach’s α = 0.62 – 0.69
• Taboo and Stigmatization: Cronbach’s α = 0.65 – 0.72

Certain brief two- or three-item subscales generated across cross-cultural adaptations show lower alphas (0.55 – 0.62), a recognized psychometric artifact of brief subscale length, prompting recommendations to use composite factor scores or structurally verified shortened versions in cross-cultural comparative research.

Test-Retest Reliability and Temporal Stability

In stability trials assessing non-clinical student and community cohorts over intervals of two to four weeks, the ATTS subscales demonstrated intra-class correlation coefficients (ICCs) and Pearson stability coefficients ranging from 0.70 to 0.86, indicating high temporal stability in the absence of targeted educational or clinical crisis interventions.

Factor Analysis

The underlying latent structure of the 37 attitude statements (Items 4 through 40) has been investigated through both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) across several national populations.

Original Swedish Factor Model (Renberg & Jacobsson, 2003)

In the seminal psychometric validation paper, principal component analysis followed by orthogonal (Varimax) and oblique (Promax) rotations identified a 10-factor solution explaining approximately 52.8% of the total variance across the 37 attitude items. The 10 extracted factors were characterized as follows:

1. Factor 1: Suicide as a Human Right / Permissibility (Items 5 [reversed], 19, 27, 37; primary loadings 0.54 – 0.76). Captures the ideological stance that taking one’s life is a personal entitlement that should not be impeded.
2. Factor 2: Suicide in Incurable Disease (Items 8, 23, 32, 35, 39; primary loadings 0.61 – 0.81). Represents rationalization and personal acceptance of assisted suicide or self-deliverance in terminal medical illness.
3. Factor 3: Fatalism / Impossibility of Prevention (Items 9, 24, 25; loadings 0.51 – 0.72). Reflects beliefs that once suicidal intent forms, intervention cannot alter the fatal outcome.
4. Factor 4: Preventability and Intervention (Items 4, 12, 33, 40; loadings 0.48 – 0.74). Captures beliefs in the efficacy of psychological support and the ethical duty to rescue.
5. Factor 5: Tabooing and Interpersonal Discomfort (Items 14, 16, 26; loadings 0.56 – 0.69). Reflects avoidance of verbalizing or inquiring about suicidal thoughts.
6. Factor 6: Cry for Help (Items 20, 29; loadings 0.58 – 0.77). Focuses on non-fatal suicidal behaviors as urgent signals for interpersonal rescue.
7. Factor 7: Loneliness and Despair (Items 17, 28; loadings 0.53 – 0.70). Isolates perceived social isolation as the primary etiology of self-destruction.
8. Factor 8: Impulsivity versus Long Deliberation (Items 7, 13 [reversed]; loadings 0.50 – 0.68). Distinguishes sudden crisis behaviors from protracted planning.
9. Factor 9: Incomprehensibility (Items 22, 30; loadings 0.49 – 0.64). Reflects inability to cognitively or emotionally empathize with the suicidal mind.
10. Factor 10: Clinical Myths / Manipulation (Items 10, 15, 36; loadings 0.45 – 0.66). Encapsulates erroneous clinical tropes (e.g., that talking about suicide precludes acting upon it).

Confirmatory Models and Cross-Cultural Invariance

Subsequent psychometric studies—including large-scale cross-national adaptations in Norway, Lithuania, Italy, and Bangladesh—have tested both the original 10-factor model and more parsimonious second-order structures. Confirmatory factor analytic investigations evaluating a streamlined 6-factor core attitudinal structure (retaining approximately 20 to 24 salient items) have demonstrated solid model fit indices:

• Root Mean Square Error of Approximation (RMSEA): 0.042 to 0.054 (indicating excellent fit below the 0.06 threshold).
• Comparative Fit Index (CFI): 0.91 to 0.95.
• Tucker-Lewis Index (TLI): 0.90 to 0.94.
• Standardized Root Mean Square Residual (SRMR): 0.048.

Measurement invariance testing across gender groups has demonstrated metric and scalar invariance, confirming that cross-gender comparisons of latent means on the ATTS reflect genuine psychological differences rather than measurement bias.

Instrument / Measurement Tool

The complete Attitudes Towards Suicide (ATTS) questionnaire is a standardized, self-administered paper-and-pencil or digital psychometric instrument. Structurally, it is divided into three distinct modules:

• Structure: 44 primary numbered inquiry sequences organized into three sections:
  • Section A (Contact with the suicide problem): Items 1 to 3 evaluate personal exposure across 8 relationship categories (father/mother, brother/sister, child, partner, other relatives, friends, work-/schoolmates, others).
  • Section B (Attitudes): Items 4 to 40 comprise 37 declarative attitude statements spanning multidimensional evaluative domains.
  • Section C (Sociodemographics and Personal Suicidal Behavior): Items 41 to 44 capture biological sex, age, educational attainment, and lifetime/past-year personal suicide attempts.
• Administration Format: Self-administered (individual or group setting) or digitally via online survey platforms. Can also be administered as a structured interview in epidemiological field surveys.
• Completion Time: Approximately 12 to 18 minutes for the full instrument.
• Response Scales:
  • Section A (Item 1): 4-point categorical scale (Never, Some time, Often, Not applicable).
  • Section A (Items 2 and 3): 3-point categorical scale (No, Yes, Not applicable).
  • Section B (Items 4–40): 5-point Likert scale (1 = Strongly disagree, 2 = Disagree, 3 = Undecided, 4 = Agree, 5 = Strongly agree).
  • Section C (Demographics): Categorical and numerical responses; personal attempt history (Item 44) scored as Yes / No across two timeframes (past year, earlier in life), followed by integer count of total attempts.
• Scoring and Factor Computation:
  • Items within Section B are scored from 1 to 5. Negatively phrased items on specific subscales (e.g., Item 5 within the Right to Die factor) are reverse-scored (1 = 5, 2 = 4, 3 = 3, 4 = 2, 5 = 1) prior to mean calculation.
  • Subscale scores are calculated as the mean of their constituent items, yielding subscale score ranges of 1.00 to 5.00. Higher scores indicate stronger endorsement of that specific construct (e.g., higher permissibility, greater fatalism, or stronger intervention readiness).
  • No single total aggregate score is computed, as summing opposing constructs (such as fatalism and preventability) obscures the respondent’s distinct psychometric profile.
• Target Population: General adult population (aged 18 and older), secondary and university students, clinical healthcare personnel, psychiatric inpatients and outpatients, crisis line volunteers, and emergency response workers.

Permissions & Fee and Test Year

The Attitudes Towards Suicide questionnaire was initially conceptualized and piloted in 1986, refined during the 1996 Swedish national population survey, and formally published in peer-reviewed psychometric literature in 2003 by Ellinor Salander Renberg and Lars Jacobsson.

• Test Year: 1986 (development/initial survey), 1996 (revised survey), 2003 (formal psychometric publication).
• Copyright & Permissions: The ATTS is copyrighted by the original authors (Renberg & Jacobsson) and Umeå University. However, consistent with public health suicide prevention objectives, the instrument is generally made accessible free of charge for non-commercial academic research, clinical education, and public health evaluation purposes.
• Licensing Protocol: Researchers and healthcare institutions seeking to utilize, translate, or adapt the ATTS in formal academic investigations or clinical audits are advised to contact the corresponding author, Dr. Ellinor Salander Renberg (Department of Clinical Science, Division of Psychiatry, Umeå University, Umeå, Sweden), to obtain written approval, report intended modifications, and receive standardized administration guidelines.

References

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• Durkheim, É. (1897). Le suicide: Étude de sociologie. Félix Alcan. [English translation: Durkheim, É. (1951). Suicide: A study in sociology (J. A. Spaulding & G. Simpson, Trans.). The Free Press.]
• Joiner, T. E. (2005). Why people die by suicide. Harvard University Press.
• Knizek, B. L., Akotia, C. S., & Hjelmeland, E. (2011). A cross-cultural study of attitudes towards suicide: A comparison of young people in Ghana and Uganda. International Journal of Culture and Mental Health, 4(2), 130-142. https://doi.org/10.1080/17542863.2010.536965
• Paykel, E. S., Myers, J. K., Lindenthal, J. J., & Tanner, J. (1974). Suicidal feelings in the general population: A prevalence study. The British Journal of Psychiatry, 124(582), 460-469. https://doi.org/10.1192/bjp.124.5.460
• Renberg, E. S., & Jacobsson, L. (2003). Development of a questionnaire on attitudes towards suicide (ATTS) and its application in a Swedish population. Social Psychiatry and Psychiatric Epidemiology, 38(1), 52-64. https://doi.org/10.1007/s00127-003-0604-3
• Renberg, E. S., Hjelmeland, E., & Koposov, R. (2008). Building models for the understanding of suicidal behaviour: The role of attitudes. In D. De Leo, U. Bille-Brahe, K. Kerkhof, & A. Schmidtke (Eds.), Suicidal behaviour: Theories and research findings (pp. 53-70). Hogrefe Publishing.

13. Items of the Scale (Questionnaire)