The theme of this year’s World Suicide Prevention Day is ‘Creating Hope Through Action’. The IASP (International Association for Suicide Prevention) encourages us to consider that ‘action’ means the seemingly small actions of individuals – the difference a moment of kindness, of reaching out, of listening, might make to somebody who is struggling – as well as broader change which needs to be effected by education, workplaces, the third sector, and governments.
Awareness days generally seek to achieve improved understanding of the scale of a problem. In terms of suicide, the scale is immense – around 800,000 deaths globally every year, with an enormous ripple effect: the WHO estimates that 135 people are affected by each suicide. The eminent suicide researcher Prof. Rory O’Connor likens suicide to a ‘social bomb going off – and no-one knows how far the ripples will spread’. Other aims of World Suicide Prevention Day include encouraging more open conversations, and consequently – particularly important when it comes to suicide – reducing the stigma that is still perceived around suicide and suicide bereavement.
All of these goals are admirable, however, opening up conversations is most useful when those affected have somewhere to go for help. Yes, the support of friends and family can be a lifesaver for somebody experiencing suicidal ideation, but sometimes professional intervention is needed, and we know mental health services are stretched. Furthermore, when the aim is suicide prevention, there should be clear-eyed focus on those most at risk, and the delineation between ‘prevention’ and ‘postvention’ removed. The prevailing narrative is often on poor mental health, particularly depression, as a key risk factor for suicide, yet the statistics bear out that the majority of people who die by suicide are not known to mental health services. Other important risk factors, such as socio-economic status, poverty and health inequalities are often overlooked by policymakers, as these are the factors that government has failed to successfully address. However, it must be emphasised that any organisation or campaign seeking to reduce the number of suicides attempted and completed should put the needs of those bereaved by suicide at the forefront of their strategy.
A study published in the British Medical Journal in 2016 explored the hypothesis that bereavement by sudden and ‘unnatural’ means, including suicide, is a risk factor for suicidal ideation and behaviour, and the findings appear to bear the theory out. In fact, the study found that people bereaved by the sudden death of a friend or family member are 65% more likely to attempt suicide if the deceased died by suicide than if they died by natural causes, bringing the absolute risk up to 1 in 10 (UCL 2016).
Every bereavement and every individual is of course different, so there can be many reasons for this. A sudden death by suicide can raise unanswerable, often unbearable, questions (‘Why did they do it?’ ‘What more could I have done?’ ‘Why was I not enough?’), and with them, emotions of intense guilt, remorse and shame. Alongside the common feeling in deep grief that ‘things will never get better’, there may be additional existential crisis along the lines of: ‘if this can happen, anything can happen…the world as I knew it is no longer safe…what is the point of life?’. These perceptions of entrapment and instability can exacerbate the challenges faced by the grieving person in surviving and (eventually) accommodating their loss.
Then there is the question of stigma. The perception of stigma appears to be the greatest differentiator between those bereaved suddenly by natural causes as opposed to those bereaved by other sudden causes e.g. accident, murder and especially suicide. This is not surprising in a world where suicide is still illegal in at least 20 countries worldwide and where commons phrases such as ‘committed suicide’ still point towards the historical legal connotations attached to ending one’s life. As individuals, we can continue to work to reduce stigma, from simply changing our language to ‘died by suicide’ or ‘ended their life’ to actively reaching out and supporting those bereaved by suicide rather than avoiding them because we don’t know what to say, or fear making their grief worse somehow.
This is where professionals and the wider support of funders and policymakers have a large role to play, too. If we are serious about prevention, then timely, accessible, help for people bereaved by suicide is critical. This may take the form of peer support: understanding that you are not alone, that bereavement by suicide is sadly common, and crucially the knowledge that others have survived can be powerful in helping to alleviate both stigma and feelings of despair.
For some people professional counselling is appropriate. One of the ways in which a skilled counsellor can help is to allow space for the most uncomfortable feelings that come with suicide bereavement. A friend or family member might, with the best of intentions, respond to those feelings of guilt and perceived responsibility with continual reassurance (‘It wasn’t your fault’), which the bereaved person might find helpful or conversely, may have the effect of closing them down. On the other hand, a professional counsellor will sit alongside the bereaved person with whatever they bring, however difficult or dark; they will seek to normalise their experience and in doing so hope to diminish the sense of stigma.
Taking action to prevent suicide is a broad remit, one that can be adopted by individuals and organisations alike, and one of the first steps must be adequate consideration of those bereaved by – and in a wider sense, affected by – suicide. They are too large and too vulnerable a group to be ignored.
Written by Joanna Williams, Head of Counselling at Professional Help