Unspeakable Thoughts: When staff think “If you were going to kill yourself you’d have done it by now”

Trigger warning – Suicide, Dismissive ‘care’

This phrase has popped into my head a few times over the years.  Mostly, when I was first starting out in the community mental health team and I had my first taste of doing ‘duty’. ‘Duty’ (I have no idea where this name comes from) involved being in the office and fending off phone calls; seeing someone who pitched up at the building; or leaping into a car to go on an emergency visit. It was here that I first came across people who were recurrently suicidal.   

Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through beamconsultancy.co.uk

The first time I listened to a detailed description of how someone had prepared their method of suicide and was now phoning me because it was in their care plan to ask for help, I was terrified. I felt it was my duty to keep them safe. I suggested solutions, I reassured, I tried to instil hope. I probably suggested hot baths and milky drinks. All to no avail. I remember the first conversation ending with no reassurance that they could stay safe, so I sent an ambulance round and crossed my fingers. They were suicidal. I was the last person to speak to them. Could I live with myself if they died? Would I be blamed for not doing better or not doing enough? I spent the weekend worried I’d find out they were dead on Monday and when all seemed well on the Monday morning I breathed a sigh of relief.   

Fast forward 3 years and I’d probably had the same conversation with the same person 50 times. When I heard their voice on the phone I started to feel less compassion and more annoyance. Rather than my first novel experience of trying to save someone, I think I was frustrated, bored and eager to get the conversation finished. My colleagues supported me by reassuring me this person would never kill themselves and while we would occasionally still send ambulances if ‘the right words’ came out in the conversation, it was always out of a sense of ticking boxes rather than doing anything that might be useful.   

During this period that I was fully immersed in stigmatising attitudes around ‘personality disorder’.  I remember my amusement when someone told me they were putting on a course for people with Borderline Personality Disorder to teach them how to kill themselves properly. The ‘joke’ here being that despite repeated attempts, by some chance people always live. The implication is that the statement “I’m going to kill myself” has no value when uttered by someone with that diagnosis despite the 1 in 10 suicide rate. 

As I’ve developed within mental health services I’ve found myself working more and more with people who are recurrently suicidal. They have the misfortune to be supported by people who have attitudes similar to those I had in the past. Those staff still harbour the idea that “If you were going to kill yourself you’d have done it by now”. It either stays in the head of the practitioner (and gets acted out in more subtle ways of dismissal) or said openly to insult or attack. Neither of these are helpful and over time I’ve learned that being able to articulate a more empathic version of that view is essential to be able to work with those who feel life isn’t worth living.   

I think we need to see suicidality (a word that I use a lot but which every spell check hates) as being on a spectrum. People are rarely 100% suicidal or 100% loving every moment life sends. People exist somewhere in between. For me, someone saying they feel suicidal is the beginning of a conversation.   

Because this conversation is happening, we can assume that someone isn’t at the 100% stage. I’ve listened to people tell me with absolute clarity, the method they will use to end their life once I have left them.  10 years ago I’d have been furious at them for ‘putting me in this position’ and ‘knowing I would have to react’. I can now be curious about why someone would say these exact words to me. This can lead us to a discussion about my anticipated reaction and the pros and cons of this for them.   

This might sound invalidating but its important to keep in mind here is that telling someone you are suicidal might be a way of keeping yourself safe.  This is to be celebrated.  All people working in mental health want those in their care to live.  We could consider being grateful when someone says they are suicidal because in some way, it’s an invitation to help.  It might not be the most effective invitation, but it is an invitation none the less.  We can explore what’s going on in more detail, rather than ignoring everything in pursuit of someone saying they can keep themselves safe until the next person comes along.   

This might sound invalidating too, but even attempting suicide might be a way of inviting help.

For me attempting suicide and not dying is something to celebrate.  Often something will have got in the way which was, to an extent, predictable.  Not always, but where these occasions occur, they are again an opportunity to be curious and something to be joyful for. Some force, conscious or unconscious has intervened to keep them safe. I suppose some examples of these are people who take “small” overdoses (if such a thing exists), people who begin their act after saying goodbye in a way that will alert people, or do something that is likely to attract attention (e.g. standing at the bridge, walking down the tracks).  In here, somewhere, is a communication about distress that gets in the way of dying.   

The trap (which I have often fallen into myself) is seeing all this as some ploy to ensnare an unwary clinician. Just because someone has taken 40 overdoses with the stated intention of dying doesn’t mean they’re only saying it to torture you. It’s a chance to wonder about what is happening in that pattern. Whatever it is, is useful in some way.  Equally, it’s ok to ask what has kept someone alive.  I’ll often preface this with “This might sound like I’m trying to catch you out or trick you, but I’m really interested”.   

This might be massive invalidation number 3, but it’s important is to hold onto the idea that what we say isn’t always what we mean.  If you disagree, consider how often you’ve told people you’re ‘alright’ when really your world has collapsed.  I’ve worked with many people who have learned that merely asking for help brings nothing.  I’ve worked with people whose life has taught them that if you don’t use volume 11 then you won’t get heard.  I’ve worked with people whose life has taught them that only actions make people respond.  

My argument is that we should always take people seriously.  This does not mean that we take them literally. I’ve seen people who have wanted to be dead in the community for the past 5 years be kept on a hospital ward because they wanted to be dead.  It made the staff feel better.  It meant the person lived in hell.  Sadly, a conviction that death is better than life is very common for people who have lived through shit.  We generally compound this if we respond to their words with dismissal or restriction.   

Curiosity about why suicidal people are still alive is an essential part of work within mental health.  It allows us to expose strengths that are difficult to articulate.  It can let us know what is going on in the minds of those we care for.  It can prevent us doing things that are deeply unhelpful.   

A colleague now passed away once described the work of the CMHT to me.  “We will get a barn full of notifications that people are suicidal every year. Within that barn is a desk. That desk has a drawer. In that drawer is an envelope and in that envelope is a piece of paper with a few names on.  The work is trying to sift through the barn to find the people who are going to kill themselves”.  I identify a lot with this analogy, but I’d add some research to it as well.  We can predict those who are at high risk of suicide, but we are useless at predicting which high risk people will go on to die.  We risk a brutal system of ‘care’ for hundreds of people to save one life.  This might be a price worth paying, but it might not be the view of those who lose their liberty.   

We work in a system that demands accurate risk assessment – a task that no one has been able to manage so far.  Until our organisational and political systems recognise this, our workers will be filled with anxiety. Anxious workers dismiss people or restrict lives.  The work isn’t easy, but we will serve people better if we can thoughtfully voice the thoughts in our heads rather than having to act them out.  We will always be more helpful if we’re honest with people that we want to trust us.

Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through beamconsultancy.co.uk

* There was someone I only ever met on twitter.  She was very kind to me and very supportive of a blog I wrote called Why Are People With Personality Disorder So Manipulative?  We talked of a follow up around Why Are People With Personality Disorder So Attention Seeking?  This isn’t that, but I think it touches on some of the issues that mean that accusation gets thrown around.  I hope she would have approved of this.

* This was originally part of a co-produced workshop delivered at the BIGSPD conference in 2019.  It was originally Published in Asylum Magazine Vol 26 Issue 3.

4 thoughts on “Unspeakable Thoughts: When staff think “If you were going to kill yourself you’d have done it by now”

  1. Very thoughtful piece. The topic of repeated suicide attempts/ “threats” is toxically emotive and as you say can create strong negative emotions in many mental health practitioners. It is therefore good to read a balanced intelligent assessment of this minefield of the often conflicting attempts to control and manage intense distress demonstrated by both caregivers and those needing care.

    Having been that “nightmare client” that engendered annoyance and worry in equal measure in numerous mental health professionals, was on first name terms with every local member of the emergency services and would have benefitted from an A&E loyalty card this is my take on the topic…

    Validation and clear honest communication is the key. Whatever you think of how the distress is being communicated please validate and don’t belittle the distress. I guess the reason I sometimes communicated my distress in emotive and unhelpful ways is that I grew up rarely having my feelings validated so felt I had to shout them in a way that was difficult to ignore in order to have them heard. If you feel you exist in a disconnected vacuum somewhere in outer space where no one can hear you scream you may feel you need to use behaviour and threat for your distress to actually reach those on Earth who might help you. Others responding back with calm kindness can help someone like me realise that their emotions can be heard without the need to scream them at the top of their voice in a frantic attempt to get someone, anyone to listen. Being asked “ I can hear you are suffering. What can I do to help?” Would have helped me.


    1. Katherine who vanished from Twitter!

      Thank you for your comments (which I might screenshot onto other media if that’s ok). Glad you’re still around. Totally agree about the validation.


      1. Yes feel free to use my comments however you want. I can’t deal with social media on any level for any purpose! Always keen to read your thoughts though.

        My training mantra for mental health professionals…

        Listen, validate, respond (repeat for as long as necessary)


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