I spoke today at the Mental Health Summit Ireland event in Croke Park about the topic of having a conversation with someone about suicide and this also coincided with World Mental Health Week with the theme being suicide prevention. I was delighted to take part because we have to be having these conversations if we are to continue to not only raise awareness about suicide but prevent it.
Why do we need to be having a conversation about suicide? Might seem blindingly obvious but it’s still worth stating explicitly, because even 1 death by suicide is still too many.
We have made very positive steps in Ireland to reduce the numbers of men, women and children dying each year. Despite stigma reduction campaigns and campaigns promoting help seeking we still had 352 people die by suicide in Ireland in 2018. The impact of each one of those tragic deaths will be felt deeply by the family, friends, work colleagues, neighbours and the communities of those people who died, such is the impact of suicide on our society.
I want you to think about how many much needed road safety and anti-drink driving ads you’ve seen and heard on TV, radio, newspapers, magazine, social media channels. They have been a fantastic resource to highlight the dangers on our roads and encourage people to drive in more responsible and safer ways. Can anyone remember the last time they saw an ad on TV with the same circulation as road safety does for suicide prevention? This is not about showing preference for one over the other, we need both, but when you have (at least) twice the numbers of people dying by suicide as road deaths, there is no rational argument for suicide prevention campaigns not having at least parity of coverage with road safety.
I understand it could be anxiety provoking to ask a friend, relative, colleague if they have been thinking about suicide. However, keeping with the road safety theme, if you suspected the person who was offering you a lift home from the pub had a few drinks on them would you be anxious about asking them if they’d been drinking before getting in the car? To protect yourself, the driver, and the public I suspect you’d find a way to ask the question.
A unfortunate legacy of mental health stigma is that some people will continue to believe in suicide myths. The biggest one of all? That if you ask about suicide you will put the idea in their head and suddenly they will be at risk of suicide. This is just not the case and in fact the opposite is the case.
The second myth that we need to highlight is around the belief that “but they don’t seem depressed so they’re probably not suicidal” . You don’t have to have a mental health difficulty / disorder / illness to feel so bad that you consider suicide. How many times have the words been uttered following a completed suicide “I don’t understand it, they seemed ok“? If we only watch out for what we believe are observable and obvious signs of poor mental health then we will likely miss people who are considering ending their lives. Again, if you’re worried, even if you’ve nothing concrete to back it up, just a gut feeling, ask the question.
One of the risk factors for suicide is the person feeling that they are a burden to others and that the world would be better off without the burden of their existence. This belief of burden can prevent the person who is in incredible emotional pain from sharing that pain or their thoughts with others because they don’t want to burden anyone else with their load. I don’t know of anyone who wouldn’t want to share this emotional load if it meant even one less death by suicide.
So when we have the conversation, when we ask someone if they have been thinking about suicide we are relieving the person of the (perceived) burden of having to find the strength to disclose how they have been feeling. Most people who have been thinking of suicide will report feeling relieved that someone started the conversation with them. If you ask and you’re wrong, that’s ok, if nothing else you’ve just proven to the person how much you care about them to check in on their well-being.
Sharing in someone else’s deepest, darkest emotional experiences, that sometimes has led them to the thought of ending their life is often a very difficult experience for the person who is asking. I should know, I’ve experienced it most days for the majority of the last 16 years. That can take it’s toll, but you know how it’s manageable? By viewing the disclosure as a privilege, by thanking the person directly for having the strength and courage to share their distress with you, to trust you enough to allow themselves to feel vulnerable, to feel the emotions that have led them to such a difficult place.
If you’ve decided that you need to ask the question then it’s important to consider the when and where. If possible it’s best to arrange to do something that you both enjoy, a walk, watching TV, going for a drive or eating together. In my experience sitting opposite someone, face to face is not always the most comfortable scenario for someone who might be considering suicide. Suicide is an act for which a person can feel incredible shame, just for contemplating it. When we sit face to face it’s difficult to avoid eye contact, or we don’t know where to look, and when we feel internal shame, it’s hard to feel like you’re under scrutiny, which can increase shame. I have found (inspired by the Collaborative Assessment Management of Suicide CAMS) that sitting beside someone is often best. They feel less pressure and scrutiny, hopefully less shame and I think just as important we are practically and symbolically showing that person that we are at their side, that they are not alone.
The first thing to remember about starting a conversation about suicide is that there is no perfect way to do it, there is no gold star script you should follow. There are however a couple of guiding principles we should all remember.
A person who has thought about or has made plans to end their life by suicide has in essence come to the ultimate in negative judgment about themselves, that they are unworthy of existence, that they don’t have the strength to cope with the pain that they are in. So in light of that the very last thing they need is anyone making more negative judgments of them.
So how do we ask? Directly. I’ve had feedback from teens that I see that I’m as “direct as a brick in the face” when it comes to asking about suicide. They’re right, I am and will never apologize for that, asking about suicide is not something that should be vague or misinterpreted, if someone’s life is at risk we need to know and know now.
Have you been thinking about suicide
Have you been thinking about ending your life
We can be direct but also show empathy and understanding at the same time. We need a balance of both. Someone who feels like ending their life needs to know that we’re trying to understand how much pain they’re in, for us to validate how hard it is for them. Validating their inner emotional turmoil is not the same as agreeing with their thoughts about ending their life through suicide. Completed suicide is the ultimate in disconnection from people and the world. By emotionally connecting with a person’s inner experience, however painful it might be (for both) gives a person who is thinking about suicide an a potential anchor in this world, something to hold onto, a reason to live. Contemplation of ending your life must be one of the loneliest places a person could ever find themselves in.
By asking the question, by being non-judgmental, empathetic, understanding, supportive we convey the message very powerfully that the person is not alone, that we are connected to them in that moment and that if they need it, in that moment, we can be their tether to hope.
Hope is an important part of any conversation about suicide. But we also need to be careful about how we try to convey hope. When a person is at a point of thinking of ending their life they are at one of if not the lowest points they could ever be at. Making well intention ed predictions about future happiness and fulfillment might feel like the right thing to say but to someone who is thinking about suicide it can feel like something very distant in that moment and unreachable. What it probably more important is that we can instill some hope that we can find a way, with support, to tolerate the current levels of distress and we can survive the next few moments, hours, days. That’s a reasonable target, to aim for safety in the first place and just feeling ok can be a target to look at another day with happiness something that we will bear in mind but won’t set that expectation too quickly.
Our colleagues in Jigsaw created the concept of #onegoodadult and it’s one of my favourite campaigns both for its simplicity and it’s relevance. The concept was aligned to remind everyone that just one good adult in a teenagers life can make a difference. I would argue that this can be extended to all of us, especially when thinking about suicide prevention. Whether it’s #onegoodadult or #onegoodfriend it doesn’t matter, once there is at least one person that we feel a safe, trusting sense of connection and understanding with it can make a huge difference to a person’s life who is struggling with thoughts of suicide. You may be that person, don’t underestimate the power of being that person.
We shouldn’t have this conversation without also acknowledging that there are ways in which you should not approach a conversation with someone about suicide. The one that irritates and frustrates me the most goes something like this “they’re just attention seeking”. Imagine being in such a lonely, isolated and dark place where if you felt that the only way you could get the attention you need at that moment from the world around you was to make an attempt on your life. My view on this is that if that was the function then you bloody well give the person all the attention they need in that moment to keep them safe.
We also should never tell someone that they are being “selfish“, that they must be “crazy, mental, stupid” or question them about “how could you even think of doing this to me / us?”. Comments like this are dripping in stigma, ignorance and judgement. As disconnected as the person already feels from the world around them, these comments only seek to reinforce and add to that sense of disconnection, the exact opposite of what they actually need.
If the answer is yes
In the scenario where you ask the question and your friend, colleague, sister, brother confirms that they have been considering suicide, what then? What you should not do is make any promises about confidentiality. It’s not safe or helpful for you or that person to keep that information to yourself. In this scenario it’s useful to consider what existing supports the person has that are available to them now to keep them safe. Once we know that there is a risk to the person’s safety we need to look at the range of options to bring additional supports, these could include:
Your GP / Out of Hours GP
It’s not if we should have the conversation about suicide but HOW are we going to have the conversation when it’s needed.