As we mark World Suicide Prevention Day, Dr Fiona Pienaar, Senior Clinical Advisor at Mental Health Innovations, explores what we’ve learned about suicide de-escalation, taken from an analysis of anonymous conversations with children and young people experiencing suicide ideation who reached out to our text service, Shout, for support.
Gaining insight into suicide prevention
The impact of the pandemic over the past couple of years has seen a substantial increase in people experiencing challenges to their mental health and seeking support. At the same time, statutory services are struggling to meet the demand and non-profit charitable services, such as Shout, that offer mental health support 24/7 when people are in crisis, have become increasingly important in the general structure of available mental health support in the UK.
Every suicide is a tragedy and the numbers we see reported across the globe should be a concern for us all. Since Shout was founded in 2018, suicide ideation (having thoughts of suicide) has been the leading presenting issue on the platform - on average, suicide is mentioned in 39% of all conversations.
One of the most difficult, yet critical questions we are constantly exploring is ‘how can we successfully de-escalate each conversation with a texter so that we leave people feeling more grounded and less ‘at-risk’, having articulated who in their life they can seek support from, and with a plan to keep themselves safe?’
We recently analysed a set of anonymised conversations with children and young people (19% aged 13 years or younger, 60% aged 14-17 years old, and 21% aged 18-24 years old) who were experiencing suicide ideation and who reached out to Shout for support. We also conducted interviews with Shout Clinical Supervisors and trained volunteers. This has provided insight into what can be very challenging and delicate conversations with often extremely vulnerable individuals.
Asking about suicidal thoughts, a plan, access to means and a timeframe are all part of our risk assessment. This approach acknowledges the understanding that talking about suicide is unlikely to increase suicidal ideation and may in fact reduce it. Risk assessment provides us with important information about the level of danger and vulnerability a texter might be in, as well as giving a person in crisis the experience of connecting with someone who is not flinching in the face of their obvious distress.
Importantly, we acknowledge that, however skilled our trained volunteers are, a very small percentage of texters who are at imminent risk of suicide and who have taken steps to end their lives will struggle to work with the volunteer to de-escalate and will require us to contact the emergency services; a step undertaken by our experienced Clinical Supervisors who are constantly monitoring the conversations taking place on the platform. In spite of this imminent risk, we never lose sight of the fact that, even in a state of extreme distress, people have picked up their phone to text our service knowing that they can connect with someone, evidencing that there is always hope we can support them, even in their most vulnerable moments.
What are some of the challenges that children and young people are experiencing in their lives that may be contributing to their state of mind?
In the conversations that we analysed, the majority of texters experiencing suicide ideation identified deteriorating mental health and relationship issues as the main triggers for them reaching out for support.
Those who struggled to work with volunteers to de-escalate and whose risk we would consider immediate were more likely to report multiple risk factors including family conflict, peer-relationship problems, experiences of trauma, lack of professional support, and deteriorating mental health. Safeguarding vulnerable children, young people and adults is a critical part of our work and our dedicated and experienced safeguarding team follows up on any concerns that emerge.
Why do children and young people reach out to Shout when they are having suicidal thoughts?
Texters who managed to de-escalate were more likely to be looking for a way to distract themselves, or seek relief from their suicidal thoughts, while those who were not able to focus on de-escalating struggled to identify a goal for their conversation and, in some instances, just wanted to reach out to let someone know of their plans. However, the very fact that they have reached out for help, tells us that there is a part of them that wants to connect and that does want help and we focus on strengthening that connection and that hope.
Helping children and young people to identify who in their life they can turn to for support - parents, other family members, friends, professionals - is a key part of what we do in working to support somebody in crisis to leave the conversation with a plan as to who they can reach out to and how they can support themselves.
What do we know about texters who were able to de-escalate?
Texters who are experiencing suicidal thoughts when they first reach out to Shout but who are able to work with the volunteers to de-escalate are more likely to mention protective factors including social support, having access to professional mental health support (including school counsellors, doctors, psychologists, etc), and be able to describe their coping mechanisms.
What do we know about texters who struggled to reach a calmer state?
With all texters experiencing suicide ideation we focus on risk assessment and safety planning - essentially a plan, developed with the support of the volunteer, to keep texters safe and more in control, post the conversation, and beyond.
Those who are unwilling or unable to work with the volunteer to de-escalate were more likely to report having made a previous suicide attempt, to be engaging in self-harm, or to describe that they were actively taking steps to end their life. These emotions and behaviours are all factors that suggest a degree of acquired capability not as frequently present in conversations with texters that de-escalated, and also align with psychological states described in ‘ideation to action’ theories of suicide.
What was effective and less effective in de-escalating conversations with children and young people?
Conversations that volunteers were able to de-escalate were characterised by lower, less imminent risk factors, which gave volunteers the time to explore the challenges texters were experiencing in their lives, offering them non-judgemental validation, empathy and compassion.
Conversations with texters that did not de-escalate were characterised by increasing risk factors, for example, the texter having commenced taking an overdose, or letting us know they are walking towards a train station. Circumstances like this were more likely to lead to volunteers taking a more problem-solving approach to conversations, while the clinical supervisors are taking the necessary steps to involve the emergency services.
Focusing on trying to connect with someone in immediate risk can be challenging, and taking a more directive and solution-focused approach can be entirely appropriate and necessary. However, even under these circumstances, maintaining a connection and demonstrating compassion and empathy, are key to supporting a person to a place of psychological and physical safety.
Where there is imminent risk to life, physical safety must be prioritised. But, in these moments, what happens to emotional safety?
While it is challenging to emotionally connect with and de-escalate texters who are at imminent risk and who may already have taken steps to end their life, we continue to engage with them to attempt to bring them to a calmer state of mind, even while we involve the emergency services. With all texters, no matter their level of crisis, we aim to build rapport, listen, validate their experiences and emotions, show compassion and focus on each person as an individual in pain, who has reached out for connection and support.
What can we all do to prevent suicide?
Supporting someone who we suspect might be ‘at-risk’ in terms of their safety can be anxiety-provoking and stressful. We can worry about taking that step and asking them whether they are experiencing thoughts of suicide. This is totally understandable. It’s important, however, that it not get in the way of asking, listening and talking about suicide, and showing compassion, remembering that asking someone if they’re having thoughts of suicide is not going to precipitate them into taking action to end their life.
On the contrary it can be a huge relief to someone in crisis that their distress or their change in behaviour has been noticed, that someone cares and has reached out to connect with, and listen to them, offering them hope. Telling them about organisations such as Shout. Take a deep breath and reach out.
Everyone has a role to play in suicide prevention. It starts with self awareness and knowing what keeps us healthy - physically, emotionally and mentally. Noticing if we are struggling and reaching out for support before the situation deteriorates.
Of vital importance in life is knowing who is in our circle of support, from family and friends through to professionals, including school counsellors, teachers and family doctors, and other trusted adults. People we can connect with, who may notice when we are struggling, ask us questions, listen to us and offer the support we may need. We all need to have those people in our lives and we should all aspire to be that person in other people’s lives.