'Even the bleakest moments are not permanent'

The title of your book is When It Is Darkest: explain that one to me.

Well, the full title is When It Is Darkest: Why people die by suicide and what we can do to prevent it. It's trying to help people recognise what it feels like to be suicidal and understand the darkness that people who are suicidal often feel. We all have our own experiences: either having suicidal thoughts ourselves, or people we know have been suicidal or died by suicide. I am hoping that the book will help people understand this really complex phenomenon, but also what we can do to help; the evidence for what every one of us can do, not just clinicians.

For example, if you're concerned about somebody, then ask them directly whether they're suicidal or not and try to engage them in a conversation. Of course this is a scary thing to do. But what I try to do with the book is to talk people through the complex set of factors that lead to suicide, as well as helping people to ask those difficult questions. I also provide some guidance on how we can keep people safe in terms of safety planning, as well as other interventions and supports.

Is that quite a new evidence-based bit of advice, to directly engage with people and to say to them, 'Are you feeling suicidal?' And I know from talking to you before, actually, to go further and say, 'Have you planned how you would do it?'

I've been working in this area for 25 years, and definitely when I started out people were so frightened to engage with the topic… there was that fear, that myth that if you ask the question, you're planting it into somebody's head. And I would say in the last 10 or 15 years, the field has demonstrated not only that asking those questions does not cause harm, but actually there's evidence that they can get people the help they require. They start the conversation which will hopefully then lead to support.

To me, your book title conjures up images of 'the night is darkest before the dawn'.

Yes. When the person is in that depth of despair, they can't see the light. They're often so constricted in their thinking. It's trying to help people remember that the despair is not static. The dawn does and will come,
the brightness does and will come. Even the bleakest moments are not permanent. Even if someone has been through the worst of circumstances, things can improve; it is so important to hold on to that sense of hope.

But is there always light on the horizon? It might be that there are people in exceptionally bad circumstances that don't actually show that much sign of improving. What is it that you try to emphasise, that you try to find even in those circumstances?

Of course, nobody really knows in that moment what's in the mind of that individual. But the message I've heard from so many people over the years is that when somebody has intervened or asked them about suicide, it's given them space. It may act as catalyst to reconsider life. What you're trying to do is to create distance between a person's thoughts of suicide and any potential self-destructive actions.

We know from a range of psychological research that when you are in an acute crisis, you can't process information in an even-handed way. Whatever judgement you come to is likely biased. We know that in a depressive episode, negative thoughts are more likely to be over-general, and you're more likely to think of things as stable, that they will never change – and that things won't get better. You're not giving yourself a fair chance. Creating space for the person to breathe and to think, 'actually, there may be another way', that's what's so important. I have literally lost count of the number of people who have been acutely suicidal or have attempted suicide, and thankfully, they're still here, and they're so grateful that they're still alive despite being so determined to die when they were in acute distress.

I've reached out to you a few times myself in dark moments, and something that you've done with me 
is reminders of connection and adding things into my life or my vision of the future that I can aim towards. What I found interesting about that, is that it stands in contrast to how I tend to live my life. I once interviewed the author, Matt Haig, and he said 'it's about editing your life until it makes sense again'. As a natural editor, that always appealed to me, but potentially it takes me down quite a solitary path where I withdraw from people and from activities, because that's the way I can control things, I can make them perfect, I can protect myself, I can perhaps protect others. But that's quite a nihilistic, dark road to be on. Whereas what you tend to do is more about adding things in.

I think, in the short term, 'editing' probably works. But you need different strategies for different times. Anything which promotes your sense of control is a positive. But we still need to be careful because over time the editing approach could become problematic. Perhaps you are thinking 'I'm trying to edit my life, but it's not getting to the perfect place I want to be', then this could contribute to your sense of entrapment, which may not be very protective for your mental health.

However, in the moment of crisis, you're trying to do whatever you can to rescue the person, or to promote connection, to help them to hold on. So I think it's doing both of those things, but the line from John Donne – 'No man is an island' – rings so true. But in that moment when someone is at their darkest and they think that they're a burden on others, it can be difficult to do things that will promote connectedness. If in the short term, editing your life helps to focus your mind, that's great… but what happens when the editing stops working?

That makes sense. I think you're right that longer term, shrinking things down is only going to end up in an isolated place. We touched there on perfectionism. Is that a personality trait you can address in the moment of crisis?

We've done work over many years on this idea of socially prescribed perfectionism or social perfectionism, and its association with suicide risk. It's not necessarily you setting standards for yourself that's potentially risky, rather it's what you think others expect of you. If you think that you have failed to meet their expectations, you may internalise this as self-critical rumination, and for some, they get into a self-critical cycle of failure and despair. We have data that shows that people who are high on social perfectionism are much more likely to feel defeated, much more likely to feel ashamed and much more likely to experience a sense of loss and rejection. My fear is when we get into this cycle of perfectionism, increasing feelings of defeat and humiliation and then when defeat leads to entrapment it can be a cause for concern.

In the book, people talk about their own social perfectionism, and I mention my own. Of course, perfectionism in and of itself is not a bad thing, but it becomes problematic under periods of stress or distress or negative life events. Recognising that it can give rise to a pattern of negative thought helps to promote a sense of control. 'I know I'm doing that, so let's do a bit of hypothesis testing, or formulation about what's going on, why do I feel the way I do?' Then it might be a case of checking out with other people that they don't actually think that you're a failure!

But social perfectionism is really pervasive, it can affect all aspects of your life. It can drive us forward on one level. It's part of a fundamental process of social comparison. No matter what we say, we're all somewhere on this continuum of comparing ourselves to other people in our lives. For some of us, we place too much weight on that social comparison, and it gets out of control. Not only do you think that compared to others you're not doing very well, but then you think you're letting others down. It can be dangerous because it's a meta-cognition, it's not the reality. Usually, it does not reflect what a loved one or a friend thinks, it's what you think they think. But as it is going on in your head it feels like it is outside your control.

So talk me through safety planning, the practical steps involved in it.

One of the biggest questions I've seen in the field of suicide prevention is, how do we better understand those people who are more likely to act on their thoughts of suicide? We want to better identify what we estimate is a third of people who think seriously about suicide and make the transition to a suicide attempt. Safety planning is derived from evidence-based strategies, which we know work in the regulation of mood and help us to monitor escalating risk.

As an intervention it's relatively straightforward. There are six steps. First one is to help an individual to identify warning signs that they may be becoming suicidal. So it could be things like you get agitated, or your sleep is disrupted, or you drink too much, or you feel really trapped… it's getting a sense of what those triggers are for you. If you identify these triggers, safety planning then focuses on what you can do to help yourself respond or cope so that a crisis does not escalate. So then steps two and three are to do with internal coping strategies and people and settings that provide distraction. These can include things like mindfulness or going for a walk or run, some activity that's within your control, to help you distract and get through those critical moments of crisis. We know suicidal thoughts wax and wane, they come and go, so with safety planning we're trying to get people to keep themselves safe when they're in a window of real acute risk when suicidal thoughts are present.

Steps four and five shift the focus away from the internal to reaching out to others for help. Is there somebody you can phone or contact in a moment of crisis? It doesn't matter who that person is, it could be a friend or family member. It also includes identifying professionals or agencies who you can contact during a crisis: a GP, a mental health professional, adding in their details so you have them to hand. And then we move on to the sixth step, which is such a crucial one: making the environment safe. Working collaboratively with an individual to agree together to restrict access to a particular method, situation or location which they may have thought of as a way of ending their life.

Is it about literally filling in a form?

And so much more than that. There's a whole chapter on safety planning in my book. To complete a safety plan effectively, it is vital to establish a relationship with somebody and pretty quickly too. It's that trust, that collaboration, that sense of compassion, that you recognise and validate the pain that they're experiencing. That's so powerful. Also the collaboration sends out the message that they do matter. This is important as they often deal with a sense of worthlessness, believing that 'the world would be a better place if I wasn't in it'.

And when you say the person working with them, are you saying that doesn't have to be a mental health professional, the idea is that friends, colleagues, could know and understand about safety plans to the extent that they could do this work?

Usually it's a trained mental health professional who is co-developing the safety plan with the person in distress. However, safety plans are widely available online, and lots of people use them. But there is a move to train more and more non-mental health professionals and volunteers in safety planning. Sometimes when people present to clinical services they're given a safety plan to complete themselves. So my message is, we all have a role to play in safety planning, in keeping each other safe. And part of that might be talking through a safety plan with someone you're concerned about and supporting them in doing so. But the message always has to be, if you're really concerned for a loved one or a friend and you fear that they're at imminent risk of suicide, seek emergency support.  

Another thing to remember about safety planning is that you're trying to help a person talk through the pros and cons of, for example, the different steps. 
So if somebody says, 'next time you're feeling suicidal, how do you think you might respond to help you manage that acute crisis?'. They might say 'I'll go for a run', but it is important to check whether this is sensible, perhaps by asking 'when do you tend to 
get suicidal?'. If it's the middle of the night, you don't want to be recommending they go for a run then. So even if you are not trained in safety planning, 
any one of us could talk through all the pros and 
cons at each of the relevant steps as well as checking that they will actually use a strategy when in crisis.

Overall, though, I believe that any one of us can have conversations about keeping somebody close to us safe, and the safety plan is a tool to structure that conversation. However, the key message has to be if you're really concerned that a loved one is at imminent risk of harm, don't delay, seek help immediately.

Three quarters of all suicides in the UK are by men. Why is that, and what do we understand about male suicide?

This is such an important question. Although there has been a welcome growth in suicide research in recent years, surprisingly few studies have focused on male suicide risk specifically. Indeed, we highlight this is in a new systematic review led by Cara Richardson.

In terms of what we know, there is no simple explanation for such a large gender difference… 
but it is explained, in part, by men using more violent methods of suicide. It also relates to issues around masculinity and helpseeking, the male relationship with alcohol and the impact of relationship breakdown especially in mid-life. Moving forward, we really need to prioritise male suicide in terms of research.

Are we experiencing an epidemic of suicide?

I dislike the word 'epidemic' in the context of suicide; it isn't helpful. In the last couple of years, across the UK, the suicide rates have started to increase. And that was before the pandemic. Pre-pandemic, my concern was that increases in suicides among young people including among young women were stark. I think we don't understand enough yet about why that is. Sadly now though, with the pandemic, we suddenly have this perfect storm.

Although the data from the start of the pandemic were broadly reassuring, as they showed no marked increase in suicide in the UK, I am concerned about the longer-term impact. As we navigate 2021 and beyond, the economic consequences, the social consequences, the isolation, effect of home-schooling, the lack of access to mental health services, increases in domestic violence, all these factors and many 
more will adversely impact on our mental health. In the UK Covid-19 Mental Health & Wellbeing study we have already seen increases in suicidal thoughts especially among young people, those who are socially disadvantaged and those with pre-existing mental health problems. Also, there are data from Japan in the autumn which point to an increase in suicides after an initial decrease when the pandemic hit. We need to be really vigilant and put measures in place now to keep the most vulnerable safe. 

What one thing do you think needs to change in terms of the public policy response to suicide and the involvement of psychologists in that?

Every suicide is a tragedy, but with this increase in suicide among young people I'm really concerned about young people because they are not getting access to child and adolescent mental health support in a timely fashion. The waiting lists are too long, and I don't think the treatments are tailored to young people sufficiently. If I was to prioritise one thing, it would be to lobby all of local and national political representatives to properly fund mental health services especially child and adolescent mental health services. We need to do everything possible to mitigate the damage of Covid on young people.

- There will be more on suicide in our June edition, and you can find much more in our archive.

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If you are affected by suicide or you are worried about someone, Samaritans is available 24/7 on 116 123 or via email [email protected].