Is A Suicide Attempt A Type of Communication?
Zero Suicide Ambition
I am a member of the Zero Suicide Alliance. The aim is to have no suicides at all ever. What a great thing that would be. It’s some way from reality sadly, but it’s an aspiration. Just think about it — 0 suicides. It’s possible. Let’s try.
Over many years, I have worked in mental health crisis services for both children and adults. I have seen thousands of people who presented with thoughts of suicide over the years and sadly lost a handful of them — eleven to be accurate. Two of the eleven were eventually ruled not to be suicide by the Coroner, but make no mistake, I take suicide very seriously. I am 100% against it.
If you wander the Internet, you find a good number of communities are pretty for killing yourself, and encouraging others to do it. I think they are naive, misguided and downright dangerous.
It may not be an original thing to say, but it’s still true: suicide is a permanent solution to a temporary problem.
No matter how great and dark your problems seem today — next year, in five years, in ten years your problems will merely be a memory. Your life will still go on. But if you end your life now, that’s it: game over, no more chances.
The devastation suicide wreaks is never healed for those you leave behind you. It’s like getting everyone who loves you gathered together in a room and letting off a hand grenade.
Make no mistake, it devastates those who love you. For the people who don’t care; your suicide is just something they will comment on over coffee or a drink, but for those who loved you, it will break them.
And furthermore, we know statistically that if a person kills himself the risk of suicide for his or her children jumps exponentially.
My simple takeaway message about suicide is: don’t do it. Get help. Doesn’t matter where you get help or what it looks like, there are people desperate to help you at any time or night or day.
The Myth of Being a Burden
Suicidal people often tell me that no matter how desperate they were, they’d never ring anyone because “I don’t want to be a burden to them.”
Let me tell you, after having worked with the families and friends of suicide victims, I have never heard anyone say, “I’m glad they didn’t ring me. I was busy.” In fact, what they always say is, “I only wish now they would have contacted me.”
I understand that when you’re considering killing yourself, you’re in a dark place. I get it that you lose your perspective when you’re desperate, but drill it into yourself that those who love you want to help you. Even strangers want to help you. It may not feel like that, but there is so much help out there. In the midst of despair, please believe there is light.
A Word on Men and Women
Suicide statistics show that men overwhelmingly kill themselves more than women, but that women attempt overwhelmingly more than men. The reason for this apparent discrepancy is that men use more violent means such as hanging and shooting which give little opportunity for intervention. Women self-poison more which allows antidotes to be administered.
There are also discrepancies in age. Worryingly, suicides of people in their twenties are increasing and mortality rates of women in that age bracket are closer to those of men.
Overall, men in from 45–65 are the most likely to kill themselves.
Also rates are higher in those occupations with access to lethal means such as farmers, doctors, dentists and people who have firearms.
Process and Procedures
A lot of people who kill themselves have not seen a mental health professional, they just go and do it. But, if you do go and see someone, there is a process.
You may not realise it but the professional will be assessing your problem according to a structured model. The most popular one in general medicine is the Cambridge-Calgary Consultation Model. If you’re interested in that, there’s a good summary here. The upshot is the clinician needs to understand as efficiently as possible what’s going on and come up with their best guess at an effective treatment plan.
In Mental Health we tend to use a similar process but we call it the Psychiatric Interview or refer to it as taking a psychiatric history.
The idea is we give the person the “golden minute” for them to talk. The first things they say will generally be the ones we need to take notice of. Some people might tell you lies from the outset, but even then, the lies are probably the thing you should most attend to. After the free talk, we ask open questions to gather as much information as we can. Then we drill down to closed questions, being very specific. We need to know details.
We will take a history that includes current symptoms, past history, any physical ailments, social situation including money, relationships, substances, and trouble with the police or anyone else threatening violence like drug dealers.
From this, we come up with a hypothesis of what might be wrong. This will usually be a list and from that we draw up a differential diagnosis list. We should be able to whittle things down and come up with a formulation. The formulation is about what is going on and why. From this, we can derive a treatment plan.
This of course implicitly assumes that the patient is passive and the doctor is the active agent in the process. I say doctor because it was generally doctors doing this historically, less so now due to the fact that people like me are cheaper! Lots has been written about the power imbalance between patient and clinician but we have long taken it for granted that we the clinician is doing and the patient is merely receiving. The patient is passive, a simple recipient of our wisdom and beneficence.
I always knew this wasn’t correct, and then I read a book by Chris Voss called Never Split the Difference: Negotiating As If Your Life Depended On It. Voss used to work as chief negotiator for the FBI in hostage situations.
He came up with a concept called tactical empathy. The basic premise is that to negotiate effectively, you have to know what the person sitting opposite you wants. This goes for suicidal patients too. People always want something, even if it’s simply to get better.
How do you find out what they want? Surely it’s to die? But, it’s rare I see someone who actually wants to die.
I empathise with them, discover their true need and try to help them get it. However, what they think they want may collapse, when you work with them as a partner with them to explore what the suicidal impulse is actually about. They usually just want to get better. But not always.
People Don’t Want to Die
Like I said, the first thing I want to know, is what does the person sitting opposite me really wants.
More than half will say that they don’t want to die, but are very disturbed by the thoughts of suicide that are occurring to them. This is the most straightforward case. They don’t want to die, and I don’t want them to die, so together we work out a safety plan. You can think of this as Group One.
Group Two is just under half in numbers and they usually begin by saying they want to die. My first ploy is to explore what they understand about death, so I will ask them, “So what’s so good about death?” or “What actually happens when you die?”
Surprisingly, this approach stops people in their tracks, like they haven’t actually thought about what might happen if they do kill themselves. I would say that the majority, when prompted to consider what might happen respond that they want to die because they believe it will end their suffering.
If pressed, they say that death is like turning a TV off. They will simply stop.
Machines and Metaphors
In UK these days and probably across a lot of so-called Western Culture, a lot of people have a nihilistic view that after death their awareness simply ends, even though there is absolutely no evidence for this. There’s no evidence the other way either. We simply don’t know. All you believe is evidence is just a guess.
The people in my group two believe that death is like simply switching off the TV and making the programme stop.
It’s interesting how we use the technology of our time to understand our psychology. In his time, Sigmund Freud used the hydraulic or steam engine metaphor for his model of mental illness. His age was built by the steam engine. In a steam engine pressure builds up, and Freud envisioned libido as the force that built up in a person’s psyche and had to be released through a cathartic revelation. His metaphor is that if the stream pressure isn’t released the engine will blow.
We may find this steam engine model quaint now, but we are just as much prisoners of our current machine metaphors. For example, a current popular model for how people think is to compare the human mind to a computer with hardware (the brain) and software (concepts).
And a new machine metaphor for existence is developing. This latest one is that we are living in a computer simulation. Elon Musk believes this and increasingly so do others. I’m a bit persuaded myself in fact. But we simply couldn’t have had this model before we developed computer role playing games. This idea would never have occurred to us. It’s another culturally bound metaphor of existence.
Remember that the map is not the territory. These metaphors can be helpful but they can also be misleading.The truth is, the human mind isn’t a steam engine, or a computer or a TV.
So, if someone tells me that they want to kill themselves because suicide will simply switch them off, I ask them how they know? I then jokingly ask them if they’ve died before. You’d be surprised but people who are suicidal can still joke.
‘I’ve never died, or met anyone who has, so I can’t tell you what happens after you die, and whatever you think, you don’t know either.’
Then I refer to my grandmother, sadly gone, who was convinced that Heaven and Hell were realities. Lots of people still are. Different societies at different times have very different ideas about what happened after death. Like I said, this TV switching off metaphor is pretty recent — within the last fifty years — and related to the growth of atheism.
I gently suggest that however convinced they may be of their beliefs, a hundred years or a thousand miles away (this is getting longer with global intercommunication) people are equally convinced of something totally different.
So the idea that death is a switching off peace might be right and it might not. I’m reminded of Pascal’s Wager, where he bet on the existence of God. God, according to Pascal, may or may not exist, but if he does and you don’t believe in him, it won’t go well for you, but if he doesn’t exist and it makes no difference, so the safest course is to believe in him and avoid the chance of punishment.
Suicide as a solution is a hell of a gamble.
Even this Group Two, who think they want to kill themselves actually just want not to feel so shit. For these people I will suggest that we can do something about that and they generally all take me up on that offer.
Threatening Suicide as Bargaining Ploy
So we’ve considered Group One, the people who don’t want to kill themselves, but just want help, and Group Two, who think they want to kill themselves but really just want not to feel awful.
There is a Group Three too. This is a significant minority of people who use suicide as a bargaining ploy.
In the socialised healthcare system of the UK, you can get free drugs from the State. I have even had people tell me they come to me “to cut costs”. Mostly however, they are driven by addiction and their supply has run out, or they can’t afford the drugs their body needs.
You may think I am cynical, but a clinician has to be wise as a dove and subtle as a serpent. Not everyone who comes in the door tells the truth. Like I said, it’s a negotiation. Mostly they won’t be straight up about wanting drugs, but will try and make out the drugs are the thing that will stop them killing themselves. Eventually it comes out.
Another minority of people want to be admitted to hospital to escape from people who mean them harm. Sometimes, it’s the police that are after them and they’ve committed some crime. I’ve had all sorts of criminals, illegal CD copiers back in the day when that was a thing, not usually murderers but certainly paedophiles and drug dealers.
This is a kind of instrumental suicide threat. Usually it’s framed as “Unless you do X, I will do Y”.
So, “Unless you give me diazepam/codeine etc, I will kill myself,” or “Unless you admit me to hospital, I will kill myself.”
If they say this then I say, “Sounds like what you want is X, not to kill yourself.”
These conversations can be fraught and sometimes threatening (to me!). I’ve had knives pulled on me and once an old-fashioned cut-throat razor.
However, people who want these things are usually driven so they don’t give up easily. Sometimes, I have had to simply say, “I don’t believe you’re going to kill yourself.”
This is the nuclear option and people get very angry at this response. As far as they are concerned I’m not taking them seriously. There’s a kind of doublethink going on — they know they’re lying to me but they’re outraged I don’t believe them.
I have had people have video me on their phone for evidence so I get the blame “for when I’m swinging.”
I remember seeing a guy who wanted to be in hospital. He said he’d tried to hang himself but he had no ligature marks so I was suspicious. I asked him to show me the rope which he said had snapped. It was blue polypropylene that can hold an elephant’s weight. I remained sceptical. I asked him to show me where it had snapped. It was a clean cut so I said, “Doesn’t look like it snapped, looks like it was cut” to which he responded, “Who do you think you are — fucking Sherlock Holmes?”
Yes, I am Sherlock Holmes.
If I call their bluff, they either give up, or sometimes storm out, threatening to kill themselves. When that happens, I always cross my fingers. So far it’s worked out. I count on the fact that ending your life to piss off some guy you’ve never met before is probably not likely. Probably.
Personality Disorder is a special case, but because people with Borderline (or as we call it in the UK system, Emotionally Unstable Personality Disorder) try to kill themselves as a feature of the condition, we see people with this diagnosis a lot. More than any other group in fact.
A psychologist Joel Paris wrote a fantastic paper called Half in Love With Easeful Death, the title of which s a line from a poem by Keats. It explores the meaning of suicidality in Borderline Personality Disorder.
In the paper, Paris says that suicidality for patients with Borderline PD is more complicated than simply wanting to die. That isn’t to say the patients don’t feel like they do want to die. I am sure that most of them feel they do when they make a suicidal gesture. And I’m also sure that in these crises their negative emotions overwhelm them to the extent that death becomes a fantasy of escape.
The core feature of Borderline PD is a longing to be loved. I would say all patients I have come across with this condition have had aversive and often horribly traumatic incidents in their earlier life. Very often the people who were supposed to care for them didn’t, and let them down in a severe way.
People with Borderline PD come to feel that they are worthless and undeserving of love. I will say elsewhere that each of us uses different techniques to get other people to help us — some of us are charming, some of us are intimidating, some of us become doormats for others, but people with Borderline PD get others to do things by making them anxious.
They put anxiety into us with their behaviour. I think that this is an unconscious process, but their experience is that only by making caregivers anxious can they motivate them to do anything.
An example of this was a phone call from the patient saying, “I’ve got a bottle of vodka and a knife and I’m going to do it. Phone me back.”
When I phoned back, the phone was switched off. It always will be because of the need to keep others on their toes. People with this condition can never let you off the hook of anxiety because they are terrified that if you’re not scared, you’ll leave them.
People with Borderline PD need to test whether you care for them, because of course they can’t believe you really do. They do extreme things to see whether you can tolerate them. If you can, then you might really love them. However, this is ultimately a self-defeating strategy because no one, no matter how devoted initially, can tolerate endless tests of anxiety provoking behaviour.
There is lots to be said about this condition, but is a fact for those living and working with people with Borderline PD, you will always be anxious.
A conversation might go like this, “Do you want to kill yourself?”
I will then go through my techniques but they still say they want to kill themselves.
“Will you tell me your plan?”
I might say, ‘Then why are you talking to me? Some part of you must want to live, and that’s the part I need to talk to now.”
They can see this as a challenge, because they need me to take their threats seriously or I won’t be anxious. They seriously feel bad. They seriously want someone to help them. Mostly by the time they see me they will have been doing things to make people anxious for years and eventually it stops working, and people leave them, proving again that they are intolerable. So, they are hypersensitive to me not believing their threats.
So how do I help them? I validate their feelings. I tell them I am taking their need for care seriously. If they start to trust me, they will relax and we can talk about how to make them feel better without them having to attempt to kill themselves to prove how seriously bad they feel.
I will also tell them it’s not their fault, because it isn’t. If we talk about how they came to feel like this, I will reassure them that they were innocent victims.
But I’m not their saviour. It’s important neither I nor they fall into that trap. Ultimately, I need to convince them they can save themselves.
And my role in this front-line suicidal presentation is simple. I just need them not to kill themselves. I need them safe for now, longer if possible, but tomorrow, let alone next Thursday, is another day.
Even if what they really want is love and care rather than death, the fear of rejection and the need to keep others anxious can provoke them to do risky things. Taking overdoses, cutting, burning or standing on a bridge is dangerous and they may die anyway. Around 10% do.
If necessary, I will admit them to hospital. Not because hospital will help their condition in the long term, but it might just keep them alive during the short term when they are so emotionally overwhelmed they can’t think or act straight.
Suicide prevention is a huge subject with a huge literature. But in all the thousands of people I’ve seen, I’ve only met a handful who really wanted to die. Mostly they had terminal illnesses. Most people just want help, others want escape, but rarely do they want to die.
But I return to what I said above. Nobody wants you to die. If you feel suicidal reach out, let someone help you.