Updated: Feb 20, 2021
How to talk about suicide:
Opening up conversations on difficult subjects never gets easier. Even for me/us as mental health nurses. I have asked the question many times and the difficulty varies, depending on who we are speaking to.
In my personal experience, I have found that asking someone I love, who I know personally, has been the hardest. There are several reasons for this but perhaps a small explanation as to why this is so hard may serve as comfort to whoever reads this.
As humans we operate within a variety of environments and we are often many things to many people. I am a mother, a nurse, a lecturer, a friend, a partner and a colleague, amongst many other roles. As a nurse I am comfortable with looking after your loved ones; if I am honest, it is an honour. So, asking complex and challenging questions is part of my role; I do this within a care environment and the caveat is ‘it is my job to ask’. Though I care for the people I nurse, there is always a limit to the emotional attachment I have with them. Professional boundaries are in place to preserve the integrity of nurses and to assure that we adhere to a set of standards and policies that limit our relationships. I have asked people in my care about whether they have a history of sexual abuse, if they have an express intention to die, if they have a plan to complete suicide and whether they have the means to carry that out (more on this later).
At the end of my working day, I get to go home. Though this sounds like an abrupt ending to my day, it is good to point out that often as nurses we become desensitised to these types of enquiries as they are so frequent in our role. That is not to say that you do not reflect on or think about the conversations you have had, or that you go home and feel accomplished and that you have solved a problem or saved a human. Often the role of nursing leaves me/us feeling sad, upset, frustrated and profoundly powerless. But I am able to understand that I have done everything within my job to consider the risk a person poses to themselves, that I have assessed this, documented it and escalated this. If the person is in our care on a ward, for example, we sleep knowing that for the duration of their time with us, we have a real chance at helping them overcome the feelings of distress or trauma.
However, as a human who has faced this with someone they love, I know that there are complexities.
When my mum took her own life, she was on a respiratory ward and had been in hospital for over 12 months. The hospitals changed, the wards changed, and so did the nursing staff. So did the sympathy, the understanding and the compassion. My mum relied on oxygen to breathe. My mum was also very unwell mentally; her quality of life and her prognosis were limited. My mum once said to me that the kindest thing anyone could do would be to let her die. I remember her saying “you wouldn’t keep a dog like this”. I remember looking at her and hearing that she wanted to die; this was her telling me that she was ready. It is fair to say that when a person’s physical health is compromised, this type of conversation is common. My mum died a week later. She had concealed and stockpiled medication as overworked staff nurses simply left her tablets on her table. Though this decision to end life is objectively, logically, procedurally ‘a suicide’, I did not ever think about it in those terms. My mum had died. I had no guilt that I could have done more, and I never considered her actions to be selfish or untimely. It might be worth mentioning that, at this time, I was not a nurse.
When my friend rang me from hospital after an overdose, my response was markedly different.
All the things I knew about nursing evaporated from my brain. The A&E department discharged him whilst heavily sedated and his fitness to be discharged was clearly questionable. However, I could not find the words to articulate this; I could not think of the terminology, the processes, the policies or the interventions that I wanted to spout at the medics. Instead I went to pieces and cried. A person I love and a person who has such charisma, presence and energy was lying before us sedated, emotional, helpless and self-deprecating; not knowing how to access help or who to ask.
So, here we are: if I cannot manage a situation like this with someone I love, as a nurse, then why do you feel bad for thinking you should be able to cope? Why do you feel that you should be able to fix things, to look after the people you love and to keep them safe? Why do you feel that you should be able to do all of that whilst being part of other people’s lives and living within their expectations of you as a friend, family member, carer or any other role?
The vital starting point is to consider that the response you hear when you ask these questions is going to profoundly affect you, and then you have to think about what you do with that, ensuring that you get to talk to someone and make sense of this is vital. Even at times when you feel that sense cannot be made, talking and allowing yourself space to feel, whatever that feeling is, is essential.
There are three questions you need to come to terms with asking:
1) Are you suicidal?
2) Do you have a plan?
3) Do you have the means?
Research tells us that men of working age are the highest risk group for completing suicide. We also know that men use more violent means, hanging for example, whilst women tend to use poisoning by overdose.
By plan, we mean: Has the person started to prepare for their death? This could look like: getting their affairs in order, amending a will, selling off items that they may no longer need or giving away things in large quantities. Have they left a letter, or have they closed bank accounts? Some people book hotel rooms and leave a note on the door for housekeeping; I read one that said “please do not enter this room, please alert the police and please trust me, I do not want this to be something that you live with”. Have they posted something in public on social media that you consider worrying? For example a public apology, or a goodbye. We have read damning media reports on the use of social media as a method to say goodbye where it is labelled as ‘attention seeking behaviour’ rather than informing the population on what to do should you see this.
TO BE CLEAR: This is something you should take seriously! Any suggestion of self-harm, or suicidal ideation must be treated with seriousness. The message that a person is ‘attention seeking’ has cost lives that could have been saved. If you recognise this as something you have done or thought, please spend some time researching this beyond the realms of the neighbourly over-the-garden-fence chat that lacks any academic rigour or, well – FACT.
By means we think about: Does a person have access to a something (a method, location, or paraphernalia) that would help them complete suicide? This may include access to weaponry such as guns, or prescription medication – either theirs or belonging to someone that they live with or care for. Do they have blades or anything sharp to cut, or do they have things that could be made into a ligature? It is worth noting here that not all people who die by ligature are suspended; wherever a cord of some nature can be fixed securely, it is generally possible to find a way of standing or leaning to restrict your oxygen supply. Some people ingest sharp objects to puncture their organs or toxic items that breakdown in digestion and cause poisoning. Others may live near a location where suicide could be completed such as a station, bridge or cliff.
If someone discloses that they have a plan and means – it is important to remain calm. I know that this sounds hard, but removing the means is the next phase.
If a person does not explain the means or the plan you could shrewdly assess the environment and consider what Rethink list here: https://www.rethink.org/advice-and-information/carers-hub/suicidal-thoughts-how-to-support-someone/
It is important that the questions you ask remain limited to fact finding; remember that this is the first aid, basic safety phase. Often the temptation is to ask ‘why?’ and try to understand. Why would someone we love want to hurt themselves or end their life? Though ‘why’ is an important question, we need to make their immediate surroundings safe, or safer, so that they are safe long enough to get the help they need; you have all the time in the world to ask ‘why’ after that.
It is also vital to remove yourself from the ‘why’? It can be difficult to understand why someone feels that this is their only way to resolve their feelings. But please try not to assume that you are a failure or not enough to the person in this situation. Suicide is complex, and sometimes asking questions at this stage can put a barrier in the way. Please consider the three questions. Please collect facts, a location, a plan and the call for help.
Please access our help and support tab on the website.
Hazel Nash RMN
Gemma Jennison RMN.