‘Suicide isn’t an inevitable outcome of suicidal thoughts. The minute you can talk about it is when you can do something to help'

Suicide is a catastrophic event for the people who die in this way, and the scores of people who knew and loved that person. At a conference organised by the Health Science Network North East and North Cumbria, researchers explored whether we're getting any better at predicting who will go on to die by suicide and whether prevention is possible.

Professor Rory O'Connor, who leads the University of Glasgow's Suicidal Behaviour Research Lab, spoke about the myriad genetic, psychological, socio-economical and biological risk factors for a person dying by suicide. The picture is deeply complex and researchers are still mystified by what makes a person go from thinking about suicide to taking their own life. Although suicide is more commonly seen in those who experience persistent negative life experiences, deprivation and in those who are more impulsive and have little hope or positivity when thinking about the future, our actual ability to predict who will go on to die by suicide is around chance levels. As O'Connor pointed out, suicidal thoughts and behaviour can affect anyone. 

Given this complex picture O'Connor developed a three-part model to be used clinically – the Integrated Motivational-Volitional Model (IMV). Part one describes the background upon which suicidality may emerge – this could be biological or personality vulnerabilities. A person's environment is also key. Part two describes the motivational phase, which co-exists with feelings of humiliation and defeat along with thoughts of suicide. In this phase it's also important to consider a person's feelings about their past and future and how they might ruminate. The third, volitional, phase describes the transition from thoughts of suicide to attempts. O'Connor said if a person has the means, or is impulsive, or has had a family member who has died by suicide, they will be more likely to act on those thoughts. 

Professor Ellen Townsend (University of Nottingham) said understanding self-harming behaviours are a key part of suicide prevention. Data from the National Confidential Inquiry into Suicide and Homicide revealed around 50 per cent of young people who die by suicide have previously self-harmed. 

There's a complex mix of reasons and triggers, thoughts, emotions and circumstances under which people go on to self-harm, but this complexity presents us with countless opportunities to intervene, Townsend said. Dealing with this complexity from a research perspective, however, presents a particular challenge. While research has looked into the effects of many factors, including self-esteem and attachment, much of the data isn't longitudinal and can't reveal much about causality. It seems likely that multiple factors can build and fluctuate over time, and Townsend wanted to looked more deeply into this through the development of a Card-Sort Task for Self-Harm (CaTS). Participants were asked to look through 117 cards which state certain thoughts, feelings, events and behaviours, and sort these over a timeline covering before, during and after their first and most recent episode of self-harm. Young people who had experience of self-harm were consulted in order to develop the content of these cards, and there were also blank cards for participants to write on and add to the experimental set. 

After participants (aged between 13 and 21, half of whom had experience of being looked-after) carried out the task, Townsend and her colleagues analysed the sequences of thoughts, behaviours and events which can lead people to self-harm. Some of the most commonly selected cards said: 'I felt depressed and sad', 'I couldn't speak to anyone', 'I hated myself', 'I isolated myself from others', 'I felt worthless', and 'I felt like a burden'. Some of these didn't change over time, between the first episode of self-harm to the most recent. 

Impulsivity and having the means available, both predicted a transition from self-harming thoughts to actual self-harming. After the first ever episode of self-harm people reported feeling better afterwards. However, when looking at the most recent episode, self-hatred emerged as an important factor. The 'feeling better' that many experienced after their first episode had subsided, and thoughts of wanting to die had become more prevalent. Townsend said this holds huge implications for practice: even if someone doesn't have suicidal intent during their first self-harming episode, this should be monitored over time. CaTS, she added, could help start difficult conversations with young people in clinical settings, and be used to track a person's thoughts and feelings over time. 

Townsend also explained that the evidence-base for self-harm protection is sparse: only 11 studies worldwide have investigated self-harm prevention in young people, and many of these are under-powered. Distressingly, a survey of looked-after young people asked them to rate a number of services in terms of how useful they were in reducing self-harm and distress. The bottom-ten rated items were largely services such as GPs, counselling, self-help books and psychiatrists – the young people just didn't find them helpful. So there is much to be done, but Townsend is now trying to develop CaTS for collaborative assessment and hopes to use it eventually as an intervention to prevent self-harm. 

Postdoctoral Researcher Dr Olivia Kirtley (University of Ghent) began with some frightening statistics: more than 804,000 people worldwide die by suicide each year. Each one of those suicides is estimated to effect 115 other people, and this exposure by itself can make a person more likely to go on and also die by suicide. It remains difficult to explain why some people act upon suicidal thoughts and others don't. We know, Kirtley said, that people who die by suicide are more impulsive, but exposure to the suicide of others, or social modelling, is another very important factor. In her own research Kirtley found that exposure to the self-harm of others is more strongly correlated with self-harm than impulsivity is. Kirtley suggested that while you share similar backgrounds or values with friends and family members who may have harmed themselves, it also might create a norm for individuals or 'legitimise' suicide or self-harm. 

It's important to understand that while there are well-known mechanisms that lead to self-harm, such as relieving emotional pain, feeling worthless or wanting to escape, reading about it or seeing it in the media can also be a mechanism. Kirtley suggested that promoting positive messages about recovery when a person is in distress could counter the effects of this exposure. Socially modelling better solutions than self-harm could also have a real impact. 

Dr Alys Cole-King, a Consultant Liason Psychiatrist and Clinical Director of Connecting with People, which provides training and awareness about self-harm and suicide, emphasised the desperate need for dismantling stigma around suicide and having those difficult conversations. She referred to stigma as a 'life-limiting condition' as it makes people feel unable to speak up. 

She said although healthcare professionals are sometimes thought of as uncaring for not openly talking about suicide or suicidal thoughts with clients and patients, the real problem is people are unsure of how to have those conversations and are fearful of doing something wrong or being blamed. The not-for-profit group Connecting with People provides training in having those conversations and what to do if someone comes to you with thoughts of suicide. 

Cole-King said there were inherent problems with identifying people as high or low-risk of suicide: while low-risk patients may get a referral to their GP at most, many very high-risk patients are sometimes even excluded from certain services. She argued that identifying and characterising risk shouldn't be seen as the most important thing, but that it is the diligent identification of risk factors, needs, protective factors, assets and intervention which is important in improving practice. We should also think about awareness, compassion and eradicating stigma. A small amount of compassion may help a struggling person to hold on, even if only by a thread. She also emphasised the importance of self-care among practitioners: 'The best resource the NHS has is us, the tool by which people's lives are saved… do we really look after ourselves as we should?' 

Cole-King also presented a comprehensive idea for a safety plan, co-produced by the person in distress to help them build up their cognitive, emotional and social strategies. It is a list of things they can do for themselves and people to contact on their next episode of feeling suicidal, or if they feel the need to self-harm. The list includes identifying reasons for living, how to make their homes safer (by getting rid of access to means), things that can lift the mood and distract them, as well as friends, family, community support, third sector and local support services for easy access during a difficult period. She and other experts in the field have created the SAFETool Triage, a short assessment and safety plan to be used within GP surgeries, which could easily fit into a 10-minute consultation. Cole-King even suggested that everyone could use a safety plan such as this, as suicidal thoughts and feelings can affect anyone. A sample of GPs who have used this short-version plan have said it's useful and so far has led to fewer referrals to crisis teams – although this work is in the early stages. 

Cole-King ended a very hopeful talk on an appropriate note: 'Suicide isn't an inevitable outcome of suicidal thoughts. You can save someone's life until the final moment. The minute you can talk about it is when you can do something to help a person.'  

- If you need support with any of the issues described in this article contact Samaritans on 116 123 or email [email protected] 

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