The Comprehensive Toolkit Understanding Suicide and Self-harm

Foreword This course manual supports The Mental Health Toolkit course, Understanding Suicide and Self-harm, topics which may be a distressing for some people. If you experience suicidal thoughts or are concerned about self-harm, please contact your GP or emergency services straight away. Understanding suicide Suicide, when a person intentionally ends their life, is the biggest cause of death among men aged 20 to 49. While men are four times more likely to die from suicide, women are more likely to experience suicidal thoughts and feelings and to attempt suicide. The reasons for this difference - sometimes called the gender paradox in suicide - and the reasons why people act upon suicidal thoughts, are complex. However, if we understand that stress and distress arise from unmet emotional needs, we may be able to better support people who are experiencing suicidal thoughts, and those people affected by suicide.

What causes suicide? What causes people to become so distressed that they experience suicidal thoughts and then plan to act upon them? There are a number of risk factors which include: existing mental ill health, addiction, and self-harming behaviours; the loss of a job, financial hardship and worrying about debts; the loss of a relationship; and bereavement, particularly when it involves

suicide. Other people who are disproportionately affected by suicide include LGBTQ and those who have been or are homeless. What is common to all of these situations and circumstances, is that they can present barriers to a person meeting emotional needs. For example, bereavement and relationship breakdown, like divorce and separation, often result in an unmet need for emotional connection. By emotional connection, we mean a relationship where we feel accepted for who we are, either by a partner, a friend or, for some people, it could be a pet animal. Men are eight times more likely than women to die by suicide following relationship breakdown, and the period of time between separation and divorce is associated with the highest increase in risk. This may be because they are uncertain about the future and feel that they do not have much control over their lives. If there were children from the relationship, they may feel a loss of emotional connection or that they have let them down as a parent. They may also feel a lack

of confidence in their ability to find and establish a new relationship. If their needs for community are also unmet, both men and women may also have few people to talk to about how they are feeling, to share positive attention with or to take part in activities which meet needs in healthy ways. Although not all men conform to stereotypes, there is a widely held view that expectations about how men should behave prevent them from asking for help with suicidal feelings and thoughts. Research also suggests that men may place less value than women on developing supportive friendships, or community networks, which can help them to cope when relationships end. The loss of a job and income can result in unmet needs for status and security, but also unmet needs for achievement and meaning & purpose too. Worrying about unmet needs can also result in depression, low mood and feelings of hopelessness. When a person feels hopeless, it can be a sign that they are lacking meaning & purpose in their lives, which is a risk factor for depression and suicidal thoughts.

Insomnia and suicide There is evidence that disturbed sleep, especially nightmares and insomnia, increase the risk of a person having suicidal thoughts. In the case of nightmares which

continue over a period of time, these may be a symptom of post-traumatic stress disorder (PTSD). Most dreaming occurs during REM sleep as the brain is discharging emotions from the previous waking phase, to calm the brain down. Nightmares occur when the brain is trying to discharge the emotions which occur alongside flashbacks and memories of a traumatic event. Researchers have identified that insomnia is a risk factor for thoughts of suicide, even when we take other mental health conditions, like depression and PTSD, into account. Insomnia stops a person getting enough REM sleep to discharge emotions from the previous day. This leaves the brain’s ‘Security Officer’, the amygdala, overreactive to emotionally stimulating events and prone to acting upon impulse. This could explain why a person who does not appear at risk of suicide, even to those who know them well, might, after a short period of insomnia, become overwhelmed by suicidal thoughts and then act upon them. For these reasons, addressing poor quality sleep, insomnia, and nightmares caused by PTSD are essential steps in reducing the risk of suicide.

Suicide prevention guidelines Here are some essential steps we need to take, should someone express thought of suicide or plan to act upon them.

1. If someone discloses experiencing suicidal thoughts, it is essential that we ask if they have a plan to act upon those thoughts. We may be concerned that asking if they have plan may further raise their distress, but if we don’t ask the question, we risk missing the opportunity to intervene before the person feels compelled to act to end their life 2. If someone discloses that they have a plan to act upon suicidal thoughts, DON’T agree to keep their thoughts or plans a secret, and DO encourage them to seek professional help from a GP 3. If they are in the process of acting on a plan to end their life, keep talking to them and DON’T leave until emergency services arrive 4. Encourage and support them to make and attend an emergency appointment with their GP if necessary and out-of-hours 5. If they disclose suicidal thoughts, but do not have a plan, still encourage them to seek professional help by booking an appointment with their GP 6. Make sure they have numbers for support services like the Samaritans 116 123 and, in Suffolk, Suffolk Mind on 0300 111 6000 7. Ask the person how they are sleeping at the moment. If a person having suicidal thoughts is suffering with nightmares or insomnia this increases the risk of impulsivity and acting upon

suicidal thoughts. If you are a professional who is in a position to support the person in taking steps to address poor quality sleep, make sure it is part of the support plan 8. Identify any unmet emotional needs and work with the person to address those unmet needs. If there are circumstances which are likely to result in unmet emotional needs, such as relationship breakdown, bereavement, job loss, debt or financial hardship, encourage the person to seek support with these issues 9. Listen out for language which tells you that the person’s needs control and for meaning & purpose are unmet. This is a key risk factor for depression and suicide, and can be expressed in statements like: “There’s no point going on.” “The world would be better off without me.” “I can’t cope with life anymore.” If you’re able to build good rapport with them and you feel they’re engaging with you and appear calmer, you might ask them about times when they did feel that they had a stronger sense of purpose or felt more in control. You can do this indirectly, by asking them about their hobbies and interests, work or responsibilities, taking care to let them share their own examples and letting them lead the conversation.

Three sources of meaning & purpose to listen out for are learning, serving others and feeling connected to something bigger than ourselves. We can gently reflect these back when we hear people share information about themselves. Below is an example of a conversation, where the supporter listens, asks relevant questions and reflects their understanding back, to guide the supported person’s attention towards previous sources of meaning & purpose. Supported: “There’s nothing to look forward to anymore.” Supporter: “So, was there a time when you did have things to look forward to?” Supported: “I don’t know…perhaps when I was working. But that was a while ago.” Supporter: “What did you do for work?” Supported: “I was a quantity surveyor.” Supporter: “That requires some serious expertise. You must have good problem-solving skills to be able to do that.” Supported: “I don’t know. But I suppose so. Yes.” 10. Seek an agree a date and time to meet and talk again. This can help the person to focus attention on the future and build positive hope for change.

Understanding self-harm Self-harm may be defined as intentional damage to a person’s bodily tissue, which results in harm or injury to themselves. One way of thinking about selfharming behaviours is that, like mental health in general, they sit along a continuum or a spectrum. This self-harm spectrum includes commonplace behaviours like excessive eating or undereating, drinking too much alcohol, smoking, or excessive self-criticism. Most of us will have done one or more of these things in response to stress from unmet needs. Further along the selfharming spectrum, other behaviours might include self-injury, like biting or scratching oneself, head-banging, self-poisoning, overdosing on prescription or illegal drugs, and cutting or burning of the skin. If any of these behaviours become habitual, and we come to rely upon them as unhealthy coping strategies, then they pose a greater risk to our mental and physical health. ~

What causes self-harm? A common misconception is that people who self-harm are trying to meet a need for attention. But research shows that in 70% percent of cases, most self-harming begins as an attempt to get control over distressing feelings and thoughts, unpleasant memories, and flashbacks. These thoughts,

memories and flashbacks are often connected to existing traumas, adverse childhood experiences of neglect and abuse, the break-up of families and bereavement.

1 in 20 who will go on to self-harm ten or more times, their self-esteem, or sense of self-worth, is seriously affected, and this is when the risk of experiencing suicidal thoughts arises.

To begin with, self-harming gives a person control over feelings of stress and distress by releasing endorphins, a natural painkiller, in response to injury. But, like anything which makes us feel better for a while and gives us relief from pain, seeking the release of endorphins can become a habit. Becoming reliant upon self-harm to relieve distress can cause the person to feel low, ashamed or guilty about it afterwards. These feelings might then trigger the impulse to self-harm again, to block out guilt or feelings of low self-worth.

Having conversations about self-harm

Suicide and self-harm Self-harm is associated with an increased risk of suicide. One reason for this is that self-harm may unintentionally result in accidental death, but another is to do with the number of times self-harming occurs. The average age when selfharming behaviour first occurs is between 12 and 13. About 17% of the population, or nearly one in five of us, will resort to self-harm at some point and about half of those people will self-harm only once or twice in their lives. It may be that people have learnt alternative coping strategies by the time they reach adulthood, as rates of self-harm reduce to about 5.5% or 1 in 20 people. But for these

If you are thinking about starting a conversation with someone who may be self-harming, think about when and where to approach having the conversation. Choose a time when the situation at home or school is less stressful, and a place which is private when you are less likely to be interrupted. If you are a parent seeking to have a conversation with your child, remember that their bedroom is likely to be a space which meets their needs for privacy and control. They may feel that an attempt to start a difficult conversation is an invasion of privacy which they have no control over. Also, if their bedroom is where selfharming behaviour has taken place, conversations about this may trigger uncomfortable feelings and thoughts. Instead, you might suggest a more neutral space like the kitchen, a living room, or somewhere calm, like a park. If you are a teacher or other professional working in a school or club, you might try to find a space which is not a classroom, with comfortable seating and where you won’t be interrupted, and the

the goal, which consider their concerns and available resources

child or young person can speak confidentially. You might also suggest switching off mobile phones or other potential distractions, remembering to enable the child or young person to choose. If you are going to have a conversation which is potentially distressing, walking can help to lower distress because exercise burns off stress hormones like cortisol and adrenaline.

RIGAAR A useful acronym to follow when approaching challenging conversations is RIGAAR, which stands for: •

Rapport building – take time to listen and empathise. Use reflective listening skills to check your understanding of what they have shared

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Information gathering – ask questions about the person’s concerns and seek to identify unmet needs

•

Goal setting – agree goals which address unmet emotional needs. Goals should be collaborative in nature

•

Accessing resources – identify resources, including safe places, friendships, and hobbies and interests which meet needs, as well as techniques and strategies for calming distress

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Agreeing a strategy – agree the steps they will take to achieve

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Review – review what has been agreed to give the strategy the best chance of success

Reflection sheet

References

What have you learnt in the course that is going to be helpful in your role?

Association Between Suicidal Ideation and Suicide: Meta-analyses of Odds Ratios, Sensitivity, Specificity and Positive Predictive Value McHugh, C. M, Corderoy, A, Ryan, C. J, Hickie, I. B, & Large, M. M | BJPsych Open, 5(2), e18 2019

How will you apply what you have learnt?

Gender Differences in the Prevalence of Nonsuicidal Self-injury: A Metaanalysis Bresin, K & Schoenleber, M | Clinical psychology review, 38, 55–64 2015

What benefits are you expecting?

Once you have had the opportunity to practice what you have learnt, describe how you have used the RIGAAR model to ensure that an intervention was effective

What skills from The Mental Health Toolkit do you want to develop further?

Self-harm and Suicide in Adolescents Hawton, K, Saunders, K. E & O’Connor, R. C | Lancet (London, England), 379(9834), 2373–2382 2012 Deliberate Self-Harm in a Nonclinical Population: Prevalence and Psychological Correlates Klonsky, E. D, Oltmanns, T. F & Turkheimer. E | American Journal of Psychiatry. 160:8, 1501-1508 2003 Measuring Self-harm in Adults: A Systematic Review Borschmann, R, Hogg, J, Phillips, R & Moran, P | European psychiatry: the journal of the Association of European Psychiatrists, 27(3), 176–180 2012

Fatal and Non-fatal Repetition of Self-harm Owens, D, Horrocks, J & House, A | Systematic review. The British journal of psychiatry: the journal of mental science, 181, 193–199 2002 Reducing Suicidality Through Insomnia Treatment: Critical Next Steps in Suicide Prevention Hamilton, J. L and Buysse, D. J | American Journal of Psychiatry. 2019 176:11, 897-899 2019 Sleep Disturbances as Risk Factors for Suicidal Thoughts and Behaviours: A Meta-analysis of Longitudinal Studies Harris, L. M, Huang, X, Linthicum, K. P, Bryen, C. P & Ribeiro, J. D | Scientific reports, 10(1), 13888 2020 The Role of Sleep Disturbance in the Relationship Between Post-traumatic Stress Disorder and Suicidal Ideation. Betts, K. S, Williams, G. M, Najman, J. M & Alatic, R | Journal of Anxiety Disorders. Volume 27, Issue 7, October 2013, Pages 735-741 2013

The Mental Health Toolkit’s website, thementalhealthtoolkit.co.uk provides a range of resources on available support and advice

Notes

Notes

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