#88: Why Would Anyone attempt suicide? And what can we do about it?
🧠 A Q&A with suicide researcher Rory O'Connor
If you or someone you know is feeling suicidal, know that help is available. Contact your doctor, your local hospital emergency room, or a 24/7 suicide prevention hotline (I’ve listed resources at the bottom of the page).
Today is World Suicide Prevention Day1 and I’m grateful for the opportunity to write about it. Last year, a person close to me attempted suicide. They’re doing much better now! 💛 I’m sorry to admit it took several suicide attempts for me to actually see their pain—get my sad, angry, frightened head out of the sand, and learn about suicide in earnest. I’m writing this post so that if you’re ever in a similar situation, you can feel less ignorant and impotent, and find / provide help for yourself and the people you love.
What motivates someone to take their own life? How can people who feel suicidal or have attempted suicide be motivated to stay alive? I’ve found helpful insights in my interview with health psychologist Rory O’Connor (below), and in his heartfelt book When It Is Darkest: Why People Die by Suicide and What We Can Do to Prevent It.
O’Connor leads the Suicidal Behaviour Research Laboratory at the University of Glasgow in the United Kingdom. He speaks from decades of research knowledge, as well as from his own experience of losing friends to suicide. (As usual, I’ve edited the Q&A for brevity and clarity.)
Why is it important to study the motivations of people who attempt suicide, or die by suicide?
It's very rarely a single event or a single episode that leads to suicide, it's usually much more complex than that. Understanding that complexity is important because it helps you dispel myths around suicide. And crucially, it helps inform interventions or treatments. In the model of suicide that I developed, the Integrated Motivational-Volitional model, the guiding thing is the sense that people become suicidal when they feel trapped by unbearable pain—which is often driven by defeat, humiliation, primarily, but also by shame, loss, rejection. Although there are common features, the pathways for that mental pain are different for everybody.
When someone has suicidal thoughts and hears: “but you have wonderful children!”—or other external things to live for—can this make sense to a person who’s in acute pain?
In suicide notes analysis, we often make the distinction between intrapersonal communications and interpersonal communications. So many people know, or people keep telling them, that they have “so much to live for”. But actually, when a person is in that acute suicidal pain, they often will feel that they're a burden on others and that on balance, everybody will be better off [if they die by suicide]. Often their thinking is very black and white.
The torment is this ambivalence between living and dying, the internal struggle—your intrapersonal worth of staying alive versus the people around you—is so exhausting for many. That mental turmoil impacts your ability to make decisions or solve problems, especially social challenges. The research evidence suggests that people who are suicidal differ from people who are not suicidal in terms of social problem-solving—work relationships, family, friendships. They don't differ on intrapersonal problem-solving.
If someone is feeling suicidal, can we help them find an internal motivation to live? Is that what interventions should aim for?
I'm trying to do two things. One, I'm trying to understand the emergence of that pain: what leads somebody to become suicidal. That is obviously both intrinsic and extrinsic. We’re all individuals in a context: everyone has got a history, biology, social context, cultural context and psychological context. For example, often there is a history of trauma in people who've become suicidal. That will be an extrinsic event, but often that is internalised into shame or low self-worth. In those early stages in life, the person maybe hasn't developed the skills to navigate their emotions or build and nurture relationships, to feel valued in the world. That's part one […], then part two is understanding the transition from thinking about suicide to acting on your thoughts; in the book, I talk about crossing the precipice.
Some treatments or interventions will try to find reasons for living, and those can be both intrinsic and extrinsic. But—and that's a really important thing—if you think there's cognitive constriction [also referred to as tunnel vision], you're trying to un-blinker [the person who is feeling suicidal], so they can see alternatives.
“Asking somebody about suicide could be the start of a life-saving conversation.”
Could you tell me about the research you’ve done about future thinking?
[In some studies] we ask people to tell us what they're looking forward to, and what they're concerned or worried about in the future: it's called the future thinking task. If you compare people who are suicidal with people who are depressed but not suicidal, it's not that their future is so overwhelmingly bleak or negative, what seems to be going on is that they can’t generate positives.
[In studies], people may say they look forward to connecting for dinner with their partner or going on holiday. When we coded these positive future thoughts, we found a lot of things to do with other people or [external] achievements. But in one study, we find this peculiar effect that people who had more intrapersonal positive thoughts—such as not being depressed, having more self-esteem, being a better person: things that don’t involve anybody else—were more likely to attempt suicide over the next 15 months. This is an acute sample of people who've attempted suicide before. What we think is going on is they have these really powerful positive expectations, but if over the year things didn't really improve, they feel even more trapped.
Is that because they set an unrealistic bar, and then blame themselves?
That's one interpretation. But the point is the mismatch between their hopes and their actual reality, that gap feeds a sense of entrapment. So one treatment goal is acceptance. For example, mindfulness [techniques], trying to help you to focus on the present. Because if we spend all of our lives focused on anxieties for the future, or ruminating about the past, both of those are not good for us.
In your book, you talk about suicidal behaviour as a cry of pain2 rather than a cry for help.
Over the years, we have minimised the term “cry for help”. It's usually said in a pejorative way, prefaced with the word “only”, and it's usually associated with women who maybe have a diagnosis of borderline personality disorder, and have been engaging in self-cutting. Any act of self-destruction or self-injury has to be an expression of pain. So the reason I'm against the terms “cry for help” and “attention-seeking”, is because both of those terms are pejorative. Of course, the person is [truly] needing help.
In writing about suicide prevention, I worry that readers who have lost family or friends to suicide may feel awful because they couldn’t prevent the death of the person they loved.
[I thought about this too] when writing the book, and the feedback I've had has been universally positive—especially from those who have been bereaved, [who] are incredible advocates for the work that we do. It is possible to prevent suicide [in general] but it's so difficult to prevent an individual suicide. At a clinical level, at a research level, our ability to predict individual suicides is no better than chance. But we're trying to get a bit better at doing that, and help those people who are struggling. No one individual, none of us can be held responsible for the death of another human being [by suicide].
It's hard for loved ones to find a balance between “we're trying to keep this person alive” and at the same time, if something terrible happens, it’s not our fault. What would you say to people who are in that situation?
It's really difficult! I think that's the honest answer. And I've been there as well, it’s such a difficult place. I suppose all we can do is do our utmost to try and keep people safe in their moments of crisis, but understanding that all we can do is try our best. Recognising that they’re in unbearable pain, that they're not trying to inflict harm on you. Safety planning is key in this context. But also you need to support the person who's looking after somebody suicidal; your mental health has to be protected as well because it's awful.
In the book, you mention different interventions and treatments3 to help people who are suicidal. What’s your number one recommendation?
Without question, my message always is: if you think somebody may be struggling, ask them directly whether they're having thoughts of suicide. All the times that I’ve asked, people have been so relieved. It's given them an opportunity to talk about something that they may feel deeply shameful about, or often think that nothing can be done, and give somebody that [opportunity] to reach out and get the support that they need.
[Some] people are very frightened to talk about suicide because they think it will plant the idea in somebody's head. So it's important to get that message across: the evidence is the opposite. Asking somebody about suicide actually could be the start of a life-saving conversation. Historically, even in treatments, people didn't really try and tackle suicide head-on, separate from tackling the mental health problem that may underlie it. Of course, you get treatment for your depression, or your schizophrenia or anxiety, but suicide is not simply a byproduct of mental illness. Most people with mental health problems will never die by suicide.
Should we also talk about suicidal thoughts and plans with someone who has already attempted suicide?
Yes, in the case of somebody who has a history of suicidal behaviour, I would check in with them. Remind the person that they're valued, and that you're always there if they need to chat or get support.
The other [important thing we can do] is safety planning. [… ] My hope and aspiration are that everybody who is in crisis has a safety plan co-created [with health professionals], and access to immediate crisis support. For many people who attempt suicide [in the UK] and are admitted to the emergency department, the only treatment or support they'll get is a referral to their GP. That's just unacceptable. Supporting people in crisis through recovery is absolutely vital, especially in the immediate aftermath of a suicide attempt, when we know people are particularly vulnerable. And then providing support for those around the person who's suicidal, family members and friends.
More generally, [we must continue] to tackle the stigma of mental health problems. Although we have made some progress in the last 10 or 15 years, we've still a long way to go. There are still too many people who are frightened to talk about mental health problems. In the present context, my concern is that thousands, millions of people will be vulnerable [because of] the cost of living crisis. The pandemic, thankfully, was not associated with an increase in suicide [in the UK]4. But we know that in times of economic crisis, suicide rates tend to increase, so we need to be really vigilant that those people with pre-existing mental health problems are supported.
Even small things can make a difference to interrupt suicidal thoughts. In the same way that the devastation of suicide has a ripple effect, that pool of people around you can be protective as well. What we're trying to do is harness those ripples to save people's lives.
Resources
Helplines
These phone services can provide 24/7, free, confidential support:
Suicide.org publishes a list of US suicide hotlines (state by state) and in other countries.
In the UK, NHS 111 is available for urgent care and mental health support, and Samaritans volunteers offer support on the phone (116 123) and by email (jo@samaritans.org).
The US National Suicide Prevention Lifeline is available on the phone at 988.
Books
O’Connor’s book is full of empathy and hope. He explains the state of suicide research, dispels common myths and shares his own struggles, plus a list of specific resources (for young people, people bereaved by suicide, and mental health professionals, among other groups).
May I introduce you to Rory O’Connor
The Suicide Prevention Pocket Guidebook, by Joy Hibbins (founder of UK charity Suicide Crisis). As its name indicates, this guide provides practical tips, including how to broach hard suicide conversations and steps to support a loved one during a crisis.
For media folks
Different organisations have put together media guidelines and fact sheets to cover suicide responsibly and sensitively, and avoid suicide contagion. These can be useful for journos, editors, documentary filmmakers, fiction writers, lyricists, etc.
Reporting on Suicide has a convenient two-pager, also translated into French, German, Slovenian and Spanish.
World Health Organisation (PDF)
Samaritans has PDFs for specific topics and professions.
Johns Hopkins University offers a free online course on Responsible Reporting on Suicide for Journalists.
Different campaigns are raising awareness throughout the month until World Mental Health Day on 10 October.
O’Connor credits Mark Williams’ 1997 book Cry of Pain: Understanding Suicide and Self-Harm (which I haven’t read).
The book mentions research evidence about:
brief contact interventions such as clinicians sending brief follow-up “caring letters” after a hospital discharge
safety planning, i.e. creating a personalised document that lists
warning signs that a crisis may be developing (thoughts, images, mood, situation, behaviour)
internal coping strategies: things I can do to take my mind off problems without contacting another person (relaxation, physical activity)
People and social settings that provide a distraction (with their phone numbers)
People whom I can ask for help (with their phone numbers)
Professionals or agencies I can reach during a crisis (+ contact details)
Ways to make the environment safe
longer-term interventions, including dialectical behaviour therapy and cognitive-(behavioural) therapy, as well as online interventions
In a recent study of 33 countries, there was no increase in suicides in the first 9-15 months of the COVID-19 pandemic in most of the countries studied—but the longer-term effects are still playing out, O’Connor says.
*Correction note (10 September 2022 at 12:00 CET): This post was updated to correct O’Connor’s statement, who says that the pejorative term ‘cry for help’ is usually associated with women who may have a diagnosis of borderline personality disorder (not bipolar disorder).
Thank you for writing about this difficult but very important topic.