‘How are you feeling?’… And other impossible questions to ask someone following a suicide attempt.

The period immediately after someone has made an attempt on their own life can be a very scary, confusing, and stressful time for all involved; one where friends. family, or even healthcare professionals might be wondering what to say and which questions to ask (or avoid). This can lead the people connected to someone who has made an attempt on their life to feel extremely anxious in the immediate aftermath of the event; a feeling only heightened by the fear that saying both the ‘wrong thing’ and ‘saying nothing’ might lead the person who has attempted suicide to try again. It is for this very reason – the not knowing how to respond – that some people might avoid engaging with the person at all, whilst others may turn to bombarding them with a million and one questions. Thus, at a time where people who have experienced suicidal crisis say that “honest and open communication is key“, not knowing what to say can, in this way, lead those closest to someone who has attempted suicide to subconsciously change the way they interact with said individual, or to avoid interaction altogether. It is this anxiety I hope to alleviate somewhat by writing this blog piece.

Notably, whilst much could be written on how to deal with someone in suicidal crisis (some of which I have written on here), this post focuses on the immediate aftermath of a suicide attempt, from the perspective of the person (the ‘patient*’) who has survived it. I hope it will shine some light on a sensitive and challenging period for those whom might experience it in the context of their professional lives (e.g. medical professionals), personal lives (e.g. via a loved one or colleague), or whom may simply wish to understand this important issue better for another reason.

Of course, if a person has attempted suicide, the first priority should be ensuring that the patient is stable (both physically and emotionally). This may require intervention by medical and/or mental health professionals, the emergency services (e.g. ambulance, police), or simply those nearby. Once the patient is no longer in a critical state and has been dealt with medically, however, it is likely then that a social worker, psychiatrist or other professional with training in mental health will come round to see the patient and ask ‘How are you feeling now?’. This may either be in hospital or the patient’s home, depending on the severity of their injuries. Ideally, the patient will be seen within just a few hours of stabilising after the event has occurred and they have regained lucidity.

The question ‘How are you feeling?’ is a seemingly innocuous one but this belies the true significance of the question, especially when asked by a medical professional. I understand why clinicians and social workers feel obliged to ask this question; they need to assess imminent risk, in order to make appropriate decisions about the patient’s future care and implement any safety measures that might need putting in place. As a result, however, the question ‘How are you feeling?‘ can feel like quite a loaded one in the patient’s eyes, especially if they are scared they might be detained under the Mental Health Act or prevented from leaving hospital. These power dynamics may be even more unequal if the patient is already in state care, such as in an inpatient psychiatric unit or prison, where they may fear losing even more of their liberties or being isolated from their peers if they express suicidal thoughts or feelings.

Of course, family members might also feel the urge to ask their loved one ‘How are you feeling?’ following a suicide attempt, possibly out of a sense of culpability, compassion, or a need for reassurance. Again, this might feel like a somewhat impossible question to answer for the person who has attempted suicide, depending on their relationship with their family members: If they are still feeling acutely sad or hopeless, for example, they may want to shield their loved ones from these feelings out of guilt or shame. Alternatively, if their family have particularly strong views on suicide, the patient might not want to fully involve them in what has happened out of fear of ostracism. This can then lead to further feelings of disgrace or isolation.

So, what on earth should I say?

Talking to people who have survived a suicide attempt, the one thing that comes across with a resounding thwack is that communication and transparency are key: “As someone who has been in the position a few times, I know the drill and exactly what to say to go home, so if I’m just having questions reeled off at me with no attempt to really engage or empathise I will shut off. What makes it harder is also the general lack of transparency about outcomes. I know that professionals who I have felt supported by in these situations are honest with me about the decisions they need to make and their concerns. In my area, the Crisis and Home Treatment Team work closely with Psych Liason at the general hospital, with one team member on shift there every night. That meant on one occasion I was able to speak to a lady I knew from working with her previously which made talking and being more honest easier. She herself is very frank about things which I find most agreeable. That approach makes me feel able to be honest and talk candidly – when they properly engage, they can take the whole conversation into account…. if they’re doing a tick box exercise they’ll put red flags next to honesty (about feeling suicidal) without any other reflection, when in fact honesty is a really positive sign”.

What really stands out from this person’s experience of talking to professionals following a suicide attempt is the need for clear and honest communication, especially about the decisions that might be made with regards to their future care. It is often the fear of consequences (e.g. detention under the Mental Health Act, losing one’s friends or family) or the shame of the stigma associated with suicidal thoughts and feelings that forces suicidal people into the shadows and discourages help-seeking behaviours. This is why transparent and empathetic communication between all parties is key.

Another thing that resonated among the people I spoke to for this blog was that coming out the other side feeling isolated or alone is not helpful; in fact, it may even be detrimental to that person’s recovery. Unfortunately, some people may consciously or unconsciously ostracise a person who has attempted suicide, due to fear, ignorance, confusion, anger, or even sadness over what has happened. Similarly, someone who has survived a suicide attempt may isolate themselves due to the shame, embarrassment or guilt over what has happened. The word ‘suicide’ itself is an extremely loaded term, with a lot of stigma attached to it. One of our last taboos, I find that most people (even clinicians and academics) ‘clam up’ when I tell them I am a suicide researcher; however, this shutting down of the conversation around suicide is the very opposite of what patients and those who lose a loved one to suicide really need.

So, to be clear, can I ask anything, or should I avoid questions altogether?

Of course, it is perfectly ok to ask a person who has survived a suicide attempt how they are feeling; in fact, it may even save a life by opening up the dialogue a little. The key here is how you ask the question, especially if there may be an unequal power dynamic between you and the other person involved. If this is the case, ensure you listen carefully and empathetically with the person who has attempted suicide; really engage with what they are saying and how they are saying it, paying attention to their body language. If you have to make decisions about their care, be honest about this from the beginning and be sensitive to the fact that this may make disclosure more difficult. No matter what you ask, or don’t ask, speak to the person candidly but with compassion. Above all, try not to reduce them to simply being someone who has survived a suicide attempt – they are still a human being with hopes and dreams, likes and dislikes, fears and worries. Treat them as whole.

*Although ‘patient’ is arguably a medical term and might be viewed by some as potentially reductionist or dehumanising as a result, I am in no way ascribing to the medical model of suicide and use the word ‘patient’ in a very loose sense here. 

Language… a) kills b) saves (Delete as appropriate)

This is a post about language; more specifically, the language we (especially GPs) use when confronted by a person who is in distress.

You see, language (be it spoken, sung, written, depicted, symbolised, gestured, or signed) is how we communicate our innermost thoughts and feelings to one another. Language is how we find connection; how we explore our ideas, beliefs and values outside the privacy of our own minds. Without language, we would all languish in our own individual realities, unable to tell if the people around us were seeing or thinking or feeling the same as us. In short; it would be a pretty cruel and lonely existence if we were to be without the means to communicate with those around us.

Language, therefore, is vital to our emotional, intellectual and spiritual well-being. It is essential if we are to learn, to question, and to develop our understanding of the world. Language allows us to confirm or deny our beliefs about what we see in front of us, by probing others’ perceptions of the same. Language not only provides existential affirmation, however; it allows us to cooperate, to collaborate, to accommodate, and to integrate. Arguably, it is the development of the human capacity for language that has allowed our species to develop capabilities beyond any other. Language enables us to grow, to advance, and to thrive.

Nevertheless, whilst it is important to recognise the advantages of our ability to communicate with each other, one must also bear in mind the ills that can be caused via one’s use of language: Due to its potency, language can also be harmful, especially if used if maliciously or injudiciously. Language can be used to insult, to label, to discriminate, and to ‘other’. Language can be used to inspire hatred or prejudice, to justify maltreatment, to excuse negligence or oversight, and to maintain systemic power hierarchies. Language can be used to enslave; to restrict, to contain, and to define the conditions under which one must subject their autonomy, their freedom, or their possessions to another. Furthermore, through censure, populist narratives and dogma, language can even be used to define reality; as opposed to simply describe it. Language can thus be used to control.

It is for all these reasons that the language we use when met with a person in distress is so important. It is vital that the words we choose in these circumstances are genuine, empathetic, and affirming. It is imperative that we do not trivialise that person’s suffering, or invalidate their feelings in their moment of distress. In this instance, it is paramount we allow the entire person into the room with us, and that we ‘turn in’ to their pain, rather than pushing it away. In these scenarios, our response in that moment can be life-saving or life-ending. It is our responsibility, therefore, to ensure we do our best to make it the former.

To give you one example of what not to say in these particular scenarios, especially if you are a gatekeeper (e.g. a GP, a psychiatrist, a social worker) to other services which that person may require, I give you this example from one person’s own lived experience: First, imagine that you are a GP, and a patient has come to see you during a routine assessment. In this assessment, the person appears to be outwardly cheery and optimistic, but you sense that this is relatively superficial and that there is more going on beneath the surface. Consequently, you decide to probe the patient in question for more information, until they reluctantly open up about the suicidal feelings they have been experiencing for several weeks. This does not come as a surprise to you; they have a long history with psychiatric services and have a complex trauma history, so you offer them some advice: You insist, sympathetically but repeatedly, that the patient simply needs to ‘enjoy life’. This is largely where the conversation ends.

If you have not yet grasped the problem with this scenario, let me explain it for you: Telling a person with a long history of self-harm/suicidality, who has reluctantly confessed to struggling lately, that they simply need to ‘enjoy life’, is not only deeply patronising, it is potentially detrimental to that person’s self-esteem and future help-seeking behaviour. In truth, the very fact that the person in question is feeling suicidal likely means that they simply cannot ‘enjoy life’; and, it is unlikely that this deep distress is due to the patient being want for trying. The issue here is that, by suggesting that the patient simply needs to try more to ‘enjoy life’, places blame at their feet and will likely compound any guilt they are already feeling at being unable to feel pleasure from anything at all; thus fuelling feelings of being a ‘burden’ to those around them, and exacerbating their suicidality. By using this statement, one has successfully invalidated everything that the patient is feeling – their anger, frustration and fear at being so acutely in pain – and disregarded all the potential contributors to their feelings in the very same breath (note that the GP was familiar with their trauma history). In this moment, the patient is likely to feel completely unheard, more lonely, and as if nothing can be done to help them; all from only two words.

So what can be done better? Well, the best thing you can do in moments like this one is to sit with the person’s pain; to recognise it, to bear witness to it, and to not push it away. In these moments, you need to allow that person to be truly honest about how they feel, without shutting them down or trivialising their feelings, whilst also offering hope that they can move out of this pain at some later stage. Most of all, offer them your genuine concern, not your pity, if true empathy is beyond your reach. Remind them that they can talk to you again if they are suffering or, if this is not possible or practical, refer them to appropriate services. No matter what you do or say, remember that your language can have a lasting impact on this person in their moment of vulnerability, and that is your responsibility to ensure it is not a harmful one. Language can kill, but it also saves: You decide the outcome.

Two Weeks In: Taking Stock (…& BREATHE)

As the first day of a new week, as well as the first day of a new month, today I am reflecting on the past couple of weeks since my PhD began, as well as the month as a whole.

To put it bluntly, the past month has been exhausting: I am physically and emotionally drained. September marked the end of a large and significant chapter in my life, as well as the beginning of an equally momentous one. In the space of just a couple of weeks, I packed up my life in York, where I’d been for half a decade, and moved to a new and unfamiliar city. I left behind friends and relationships, for somewhere I knew almost no one. I also finished a two-year Research Fellowship, saying goodbye to fond colleagues, handed in my 80-page Masters dissertation, the culmination of two years of work I’d completed part-time alongside my research job, moved house (twice), and started a PhD. Did I mention I am knackered…?

As anyone who has moved house/jobs/cities will well know, no matter how much planning and preparation you put in place in advance, there will always be things outside of your control that will inevitably go wrong. From an outsider’s perspective, some of these things may seem so small as to be trivial, such as not having your IT account set up in time for your first day or the furniture you ordered for your new flat going missing in transit, more than once… Yet, as these things slowly pile on top of one another, ever-increasing the number of things you have to worry about or deal with, they can begin to feel overwhelming. Unable to do much about many of these extraneous factors in the immediate term, this stress can then begin to put strains on your important relationships, as you instead vent your frustrations elsewhere; in particular, to close friends, family, or significant others. Finally, with your resilience strained to its absolute limit, you may find yourself being more impatient or short-tempered with these people than you otherwise would be; thus, creating fresh tensions between you. In turn, these tensions can then create more stress, as you may feel less able to emotionally depend on those whom usually support you; thus, leading to a vicious cycle. Ultimately, all of this can increase the likelihood of subsequent ‘burnout’, or the emergence of mental health issues, especially in those who have a history of poor mental health.

Given that many of us will experience stressful periods or changes at some point in our lives; albeit, not necessarily all at once, how can we best go about protecting ourselves and our wellbeing under such demanding circumstances? In my experience, one’s first priority should be simply to recognise the strain one is under, to appreciate that to feel tired and irritable is to have a perfectly normal reaction to the stress, and to understand that it is unlikely that these feelings will persist forever. It is important that we first acknowledge these things, as to fail to do so can lead us to blame ourselves for finding the scenario challenging, to feel weird or ashamed of our emotional reaction, or to mistakenly believe that things will not or cannot get better.

Once we have recognised the truth of these statements, our second priority should be to identify those things which are contributing to this stress, before taking proactive measures to try and mitigate, minimise or remove some or all of its causes. Of course, some of these things will not be subject to your control, such as when exactly your missing furniture will turn up, but you can still take steps to alleviate the anxiety that comes with this, such as contacting the company responsible for the delivery and rearranging or cancelling your order.

Alternatively, for those things truly outside of your influence, a helpful strategy for alleviating anxiety can be to try reframing those particular stressors in a more positive light: For example; telling oneself that, yes, it may be annoying that the furniture will not be arriving today, but it does mean that you instead have time to explore the local area and become more familiar with your surroundings. If action is not possible and reframing is not helpful, however, another useful trick for reducing stress can be to employ distraction techniques: This may involve solitary activities, such as listening to music or reading a book, but it can also be helpful to replace the stress with positive social activities, such as going to see a movie or getting a coffee with a friend. These activities will help remind you of the things you enjoy doing, and the positive relationships you have in your life; this is especially important if you are prone to what psychologists call ‘negative automatic thoughts’, or have low self-esteem. Bear in mind that distraction can take you away from important tasks that really do require you attention, however, and be careful not to procrastinate things which you do have control over but are causing you anxiety. This strategy is likely to lead to further stress in the long-run.

Of course, the maxims I have discussed above are all very easy to say, but can so often be much more difficult to do. Certainly, starting out on the stressful journey of PhD study, I am finding it difficult to remember all of these tips myself at times and often need to remind myself to take my own advice! However, no matter what you do when facing a stressful life period, I urge you to remember to be kind to yourself. Ask for help if you think you’re struggling, or simply talk to someone (anyone) about how you’re feeling. We all have our own personal challenges, and recognising your own and asking for help is a sign of strength, not weakness.

Till next time,
MentalAcademic xo

 

 

 

The Journey Begins

Hello friend,

Thanks for joining me!

I’ll be updating this blog very soon, I am currently just getting to grips with how this whole thing works! In the meanwhile, please feel free to check me out on Twitter (@MentalAcademic) or email me via the contact pages. I’d love to hear from fellow academics, professionals, people with lived experience of mental health issues, or just the curious individual with an interest in the area.

Till then,

MentalAcademic xo