You might think we’re heading into a low time of year for suicides because they peak during the cold, dark months of winter. But, in fact, suicide peaks during the spring and early summer.
This is just one example of the popular beliefs around suicide that turn out to be myths. Here to unpack more of these myths, as well as the truths around this poorly understood subject, is Rory O’Connor, the leader of the Suicidal Behaviour Research Laboratory and the author of When It Is Darkest: Why People Die by Suicide and What We Can Do to Prevent It. Today on the show, Rory discusses possible reasons for why suicides go up in the warmer months and why men die by suicide more often than women. He explains that suicide doesn’t happen without some warning signs and why someone’s improved mood might be one of them. In the second half of the show, Rory walks us through the real reasons people move from having suicidal thoughts to acting on them, and what works to prevent suicide.
Resources Related to the Podcast
- The Suicide and Crisis Lifeline
- The Suicidal Behaviour Research Laboratory
- Atlantic article: “The Troubling Link Between Springtime Allergies and Suicide”
- AoM Podcast #585: Inflammation, Saunas, and the New Science of Depression
- AoM Podcast #886: What the World of Psychology Gets Wrong About Men
- AoM Podcast #756: How the Desire for Status Explains (Pretty Much) Everything
- “Why Men Kill Themselves” by Will Storr
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Read the Transcript
Brett McKay: Brett McKay here, and welcome to another edition of the Art of Manliness podcast. You might think we are heading into a low time of year for suicides because they peak during the cold, dark months of winter but in fact, suicide peaks during the spring and early summer, this is just one example of the popular beliefs around suicide that turn out to be myths. Here to unpack more of these myths, as well as the truths around this poorly understood subject is Rory O’Connor, the leader of the Suicidal Behavior Research Laboratory and the author of When It Is Darkest: Why People Die by Suicide and What We Can Do to Prevent It. Today in the show, Rory discusses possible reasons for why suicides go up in the warmer months and why men die by suicide more often than women. He explains that suicide doesn’t happen without some warning signs and why someone’s improved mood might be one of them. In the second half of the show, Rory walks us through the real reasons people move from having suicidal thoughts to acting on them and what works to prevent suicide. After the show’s over, check out the show notes at aom.is/suicide.
Alright, Rory O’Connor, welcome to the show.
Rory O’Connor: Thank you, I’m delighted to be here, Brett.
Brett McKay: You are a professor of psychology who researches suicide and suicide prevention. I’m curious, what led you down this career path?
Rory O’Connor: Well, that’s an interesting question. Like many things in life, this path was serendipitous. As an undergraduate student in Belfast in Northern Ireland, I’d been studying depression, and I thought I was going to continue my undergraduate work into looking at depression rather than suicide itself. But then as things happen, I got a call in the summer of… I think it must have been the summer of 1994, so quite a while ago, and the person who turned out to be my PhD supervisor told me that there was an opportunity for a funded scholarship PhD program on suicide, and so that’s where it all began, just that phone call and I decided that that’s the direction I would go. And I suppose what’s quite interesting to my point of view is that, well, clearly suicide is the most devastating of outcomes from depression and other mental health problems. But I suppose I didn’t quite envisage where that journey would take me, and in particular, that man, that phone call, my PhD supervisor, the person without whom I wouldn’t have done the research on suicide, sadly, some years later, he took his own life. And I often think back to that phone call and really, I often wonder what was in his mind at that time, why did he ask me? He wasn’t a suicide researcher. So it’s just funny how these things happen. But I’m incredibly grateful to him because it genuinely was like a sliding doors moment which changed my life.
Brett McKay: What did your family think when you told them, “I’m gonna do my PhD in suicide?”
Rory O’Connor: Well, my mother in particular, she was quite concerned because she knows me as a person and she just knew that everything I would do, I would put me heart and soul into, and so her big concern was the impact on me, on my own mental health. And yeah, one of the first questions she asked me was, “My God, you’re not gonna kill yourself. Are you?” That was her genuine fear that if I was so immersed in this… And I suppose that question was really an important question to ask and something I remind myself of daily, of reminding myself to look after my own mental health, as well as now the mental health of the people I work with here in my team in Glasgow.
Brett McKay: You’ve written a book called When It Is Darkest: Why People Die by Suicide, and What We can do to Prevent It, which is a book where you’ve taken the research you’ve done on suicide and suicide prevention and presented it for a lay audience. We’re gonna talk about this book but before we do, I think it’s important to talk about how to talk about suicide. I’m sure a lot of people have noticed maybe in the past decade or so, when we talk about suicide or someone who has taken their own life, you hear people say, “He died by suicide,” instead of, “He committed suicide,” why that shift?
Rory O’Connor: Yeah, it really has been a marked shift I would say in the last 20 years, and the reason for the shift is because the term “committing suicide,” it harks back to a time in many countries where suicide was illegal. And so it harks back to that criminal undertone, that it was seen as a criminal offense. And indeed in the United States and in the UK, thankfully, suicide is no longer a criminal offense but there are still many countries in the world in which it is a criminal offense. And I just know from speaking to countless people who are bereaved by suicide or people who’ve been suicidal themselves, they often are quite upset about that criminal over undertone. So for that reason, I think we shifted and been much more careful in our language because to my mind, we can talk about people dying by suicide, it conveys the same message and it’s not going to cause distress to those who are bereaved. So in all the work that I do, I avoid the term “committing suicide” for that reason.
Brett McKay: What’s the state of suicide in the West today? Are rates increasing or decreasing?
Rory O’Connor: In some sense, there’s no simple answer to that question, so maybe I’ll try and answer it in a couple of ways. If I look at the suicide rates, say, over the last 40 years… Now, if I take a global perspective first. So on a global perspective, the suicide rates have decreased by about 30% or thereabouts over the last 40 years or so. However, if you try and disentangle then where the decreases have happened, you see that much of the decline in suicides happened in Asian countries, in India and in China and other Asian countries, largely in China. And so that tells you a pattern, yes, on a global context, in those lower, middle income countries historically, the suicide rates have been decreasing. Now, if I take then the last 20 years and focus in on, say, the United States or the United Kingdom, you see a different pattern. Indeed in the United States, you’ve seen this upward trend in suicides. And then if I look in the UK, say over three or four years before the pandemic hit, similar to the United States, the suicide rates were increasing. And in Australia, New Zealand, other western countries, in those recent years, suicide rates have been on the increase.
Now, when the pandemic hit, many of us working in the field of suicide research and suicide prevention were really, really concerned about the potential impact of Covid 19 on the suicide rates. Now, thankfully, our concerns were not realized because the suicide rates broadly speaking did not increase basically in a global context. And indeed with a colleague, Jane Pirkis from Melbourne University, she led this big international initiative of 33 countries across the globe, and it covered the first, I think it was 15 months of the pandemic, and within those first 15 months, broadly speaking, the suicide rates did not increase. Now, there were some exceptions. For example, Japan, there are some signals now that the suicide rates might be increasing in Japan but the broad picture is that the pandemic did not see the increase that we feared. But now my concern is, and we’re starting to see this in the United States, in the UK, and in other countries, is now with the cost of living crisis and the potential economic turmoil and the Ukraine crisis and other things going on in the world, our concern is that suicide rates are starting to go up again. So we had this period when they didn’t increase during the pandemic, we need to be really, really vigilant moving forward.
Brett McKay: Are there demographics, groups that are more susceptible to suicide, say, by age or sex?
Rory O’Connor: Yes, well, if we just focus on Western countries or high-income countries, suicide rates are significantly higher in men than a women. In the United States and in the UK, about three quarters of all suicides are by men, but then if you look to other countries to lower middle income countries, you see less of a disparity between males and females. But I think in every single country in the world, men outnumber women in suicide. Now, if you look down at age profiles, again, you have the nuances, there’s slightly different patterns in different countries but broadly speaking, suicide is rare before puberty, and then when puberty hits and those periods through from puberty right up to your mid-20s, you see this increase in suicidal thoughts, behaviors, and deaths by suicide. And again, there are slight differences in countries, but in the UK, for example, the leading middle-aged men are the group most at risk of suicide.
And in other countries, older-age men are at increased risk or the highest risk group but the concern many of us have is that we are starting to see this increase in young or youth suicides again. And that really reminds me of when I first started researching this field in the 1990s, the biggest risk group were young men. And if we think back to the 1990s, we had just all emerged from a recession or real economic turmoil. And my concern now here is we’ve a similar pattern, we’ve gone through a recession a few years ago, we now have this cost of living crisis and the broader uncertainty in the world, and my concern is that young people are being maybe even more at risk and that their suicide rates may start to increase faster. So we need to be so, so careful and protect our young people.
Brett McKay: Speaking to the sex breakdown, something that I’ve read, and I want to see if this is true. Is it true that women attempt suicide more often than men but men are more likely to actually take their lives because they use more lethal means?
Rory O’Connor: Yes, broadly speaking, that’s a correct statement, I agree with that, is that yes, women are more likely to engage in nonfatal suicidal behavior. However, the explanation for that differential isn’t as straightforward as saying it’s all down to the method that has been used. That’s certainly part of it, we know that men are more likely to use more lethal methods and obviously therefore more likely to die, say, on a first attempt but it is more complicated than that. And I think we need to look at issues around masculinity, what it means to be a man in today’s society, issues around the way we structure and tailor treatment. So the question I often ask is, “We know there are effective treatments, psychological treatments, which reduce risk of suicidal behavior but the question is, do they work for men, and are they tailored for men?” And that is linked to the fact that the way men help-seek is perhaps different from women.
And we know that men are less likely to seek help for mental health problems. And so what we should be asking is… Instead of blaming men for not seeking help, which sometimes is part of the narrative, we should be saying, “Actually, perhaps the treatments and support coupled with the stigma around help-seeking, mental health, masculinity, these are all contributing to a situation, and like a perfect storm of factors, together with the increased use of more lethal methods of suicide. And that’s really, the complexity, is the answer to the question of why there are more male suicides than female suicides.
Brett McKay: What are some of the biggest myths around suicide, and how can those myths get in the way of helping people who are susceptible to suicide?
Rory O’Connor: To my mind, probably the single most common myth that I have come across is that if you ask somebody whether they’re suicidal, it will plant the idea in their head, and it’s really important that we squash that myth because there is no evidence at all that by asking somebody whether they’re suicidal that it actually will make them suicidal, there’s just no evidence. However, there’s now quite a bit of evidence showing the opposite, showing that actually if you ask somebody that question, and I agree it’s a difficult question to ask, but if you ask that question, ask somebody directly whether they’re suicidal, there’s evidence showing that actually it can get them the help that they need. And I often describe that question as being potentially the start of a life-saving conversation. So that would be myth number one.
Then another myth I often think is important to highlight, Brett, and that is this idea that… And it comes from a place of real sadness and heartbreak, is that the number of people that I have encountered over the years, both loved ones as well as health professionals, who have come up and told me the story that the person who they’ve lost to suicide had seemed okay, had seemed well in the days and weeks before they died. And so the myth is that if there’s this improvement in mood that’s associated with reduced risk, that’s a myth because it’s the opposite in too many cases. And I suppose to clarify it, I’ll make it clear what I mean in a second. What the work or the research and evidence suggest is that if there is an unexplained improvement in mood, it could mean that the person has resolved to end their life, and because they’ve resolved to end their life as a way of dealing with their pain, their mood lifts because they found a solution to their pain, a solution to their problems.
And the reason it’s concerning is, as a person’s mood lifts, their cognitive capacity, their motivation, their ability to plan and carry out the suicidal act increases. So the message on that myth is, if there is any unexplained improvement in mood, if somebody has been in a depressive episode, please check in with them to try and understand why their mood is lifted. Now, of course it could be their mood has lifted because their treatment has kicked in, either their medication or their psychosocial treatment has kicked in or their crisis has abated but the concern is if somebody seemingly improves in mood, in emotional wellbeing and you don’t know why, always, always check in to ensure they’re doing okay.
Brett McKay: Okay. So if someone’s mood improves, it can actually be a danger sign because they may just be feeling relieved that they’ve made the decision to stop struggling and take their own life. And another related myth is that someone will always be depressed before they die by suicide. Mental illness is correlated with suicide but sometimes someone hasn’t been depressed, and we’re gonna talk more about this later, but they haven’t been depressed but then they experienced some sort of a big setback or humiliation that leads them into this spiral of suicidal thoughts. And these things relate to another myth, which is that there aren’t any warning signs before a suicide. A lot of times, when someone takes their own life, their friends and family, they’re shocked and they say they didn’t see any signs it was coming, but your research shows that there are typically signs, they can just be hard to recognize.
Rory O’Connor: The sad reality is that warning signs for suicide are difficult to spot, but there are warning signs. And so the things I would often highlight are changes in behavior, that could be changes in eating, sleeping, drinking. Like sleeping in particular, because we know that disrupted sleep, sleep problems are associated with suicide risk because obviously if your sleep is interrupted, that’s a basic… In biological terms, we would describe it as a basic homeostatic function. You don’t sleep well, your problem-solving is affected, your mood is affected, your self-regulation is affected. So changes in these basic processes are important to look out for. But other things like… And this certainly only probably applies to some cases, people who are starting to get their life in order, their life affairs in order, that would be another warning sign that the person may have resolved to die by suicide.
And then obviously if somebody has been bereaved by suicide themselves or they’ve experienced a marked loss either in status or in relationships, things like that, those marked changes can have an impact. So again, I would be checking in with somebody as well. Also, people who are talking about feeling trapped and hopeless and feeling a burden on those around them because we know that sense of burdensomeness is at the heart of the suicidal thinking. The person feels, “Actually, if I end my life, the people around me would be better off if I was dead.” And so those are the sorts of things I would highlight as warning signs, but the reality sadly is our ability to predict suicide is no better than chance, it’s no better than the toss of a coin, it’s really difficult to predict who will die by suicide, but we should be still checking in with people if we are concerned, of course.
Brett McKay: Is there a seasonality to suicide? Because I think maybe there’s a common belief out there that a lot of suicides happen in the winter because it’s dark and cold, maybe the holidays make people feel sad. Is that true?
Rory O’Connor: Well, the holidays bit is probably true but not necessarily the winter bit. Again, the best evidence… If you try and bring together all the evidence from across the world, the best evidence suggests that suicides actually peak in spring, summertime, so the increase in that period… And actually in December, they’re actually lowest on Christmas day, but then they peak on new year’s day. And so the question is, Well, why do you see this seasonal effect? And the short answer is, we don’t know for certain. Part of it could be due with, as we move seasons, there’s a change in our sleeping patterns and our physical activity, it could be maybe linked to… If we look at occupations at risk of suicide, as you move into spring, perhaps there’s increased work-related stress, say, if you’re working in the agricultural sector, if you’re a farmer or whatever it may be, so you can see increased stress and risk there. But it could also be the fact that as we move into spring and summer and the brightness and vitality of spring and summer, if you’re struggling with your mood, there’s that mismatch or that dissonance between your internal world and your external world, and perhaps that’s part of the explanation as well. So yes, there are seasonality effects but we need to do more research to understand why they persist.
Brett McKay: I saw this article in the Atlantic, this is speculative, but a factor that might contribute that seasonality is… In the spring, there’s allergies, and inflammation can potentially contribute to depression and mental illness. Again, this is speculative but I thought that was interesting, I saw that a couple months ago.
Rory O’Connor: No, absolutely. And I may have read that same article in the Atlantic actually. No, I think we need to look at the allergens and the role of allergens because, as you say, there’s growing evidence that the impact on how they can activate some of the obviously biological systems which are associated with mental health problems like depression. So I think that’s an area we need to look at in much more detail because remember, one of the things certainly I’ve recognized more and more as I’ve studied suicide and suicide prevention is… And I often describe it as, historically, we’ve either been too focused on the individual or too focused on the context in which an individual lives without bringing those together. Those people who do work on brain imaging and biology, that’s all great. And those people who do work on social contexts and cultural factors, that’s brilliant as well. But ultimately, as John Donne said… That idea of “no man is an island,” we need to recognize it each… If we’re to understand suicide risk, we have to understand the individual in their context, and that context includes these wider environmental factors that you’ve mentioned, as well as of course things closer to home, like obviously relationship crises, mental health problems, bullying, unemployment and on. We need to look at the environmental context as well.
Brett McKay: And we’ll talk about some of these factors ’cause you’ve developed this model, the integrated motivational volitional model of suicide behavior. Maybe we can talk about some of those factors in that model but just broadly speaking, big picture, why do most people decide to take their own life?
Rory O’Connor: Well, the answer to that question I often give is, people end their life as a way of managing unbearable pain. And so for whatever it is, 703,000 people who die by suicide each year, there’s a whole complex set of reasons which will lead to each one of those individuals dying by suicide. But I think the common thread is that those people feel trapped by unbearable pain, which can be caused by a whole range of factors, it could be caused by the fact that your relationship ended or the fact that you had experienced trauma as a child or the fact that your mental health problems are really, really unbearable, but the key driver is seeing suicide as the ultimate solution to your pain. And for Edwin Shneidman, who’s a founding father of suicide prevention from the United States, often talked about this idea of seeing suicide as a permanent solution to our often temporary problems. And so for me to answer the question of why people die by suicide, the answer to that question is, we need to understand, What are the drivers to the mental pain by which an individual feels trapped by? And they see no alternative, no way to end their pain, no solution to that pain, and the only solution is the ultimate solution, that is, to take their own life. So it’s like the person in essence doesn’t want to die, they just want the pain to stop, they just can’t bear the pain.
And maybe we’re gonna go on to talk about my model of suicide, that’s at the heart of my model, that sense of entrapment. And then just say the key premise of the model is that suicidal thoughts emerge, they come out of this sense of entrapment but that sense of entrapment is triggered by feelings of defeat and humiliation. And those feelings of defeat and humiliation are often triggered by loss, by shame, or by rejection. And although that’s the common spine to understand the emergence of suicidal thoughts, then the question goes, For every one of us who become suicidal, the pathways to defeat, the pathways to entrapment are unique.
Brett McKay: We’re gonna take a quick break for a word from our sponsors.
And now back to the show. Let’s dig into the integrated motivational volitional model of suicide behavior that you developed that can help practitioners but also other people, loved ones or even individuals who might be experiencing suicidal ideation, help them figure out where they are in that path towards suicidal behavior. And the first part of the model is the premotivational phase. What are the factors there that can influence whether someone decides to take their own life?
Rory O’Connor: Yeah, the premotivational phase is part one. There are three parts to the model: The premotivational phase, the motivational phase, and the volitional phase. The premotivational phase is like the background context in which suicidal thoughts or behaviors may emerge, the motivational phase is a central… The middle bit of the model, and that’s really trying to understand the emergence of suicidal thoughts, and then the third bit of the model is called the volitional phase, and that’s trying to understand who is more likely to cross a precipice, from thinking about suicide to acting on their thoughts. Going back then to the premotivational phase, the premotivational phase is really trying to understand, What vulnerabilities do we all carry? For example, we all have different vulnerabilities, they could be biological vulnerabilities, for example, there’s evidence that people with low levels of serotonin and other metabolites. And [0:26:14.8] ____ metabolites and other neurotransmitters are associated with suicide risk, that’s a potential vulnerability factor but it’s never an inevitability, it is just a vulnerability factor.
Another vulnerability factor we’ve done quite a lot of work on is on different types of perfectionism, and there’s one type of perfectionism which is described as socially prescribed or just simply social perfectionism. And what that is is if you’re high on social perfectionism, and I speak as somebody who is also high on social perfectionism, is that we’re overly concerned about the expectations of others such that we continually live our life thinking that we’re letting others, important people in our lives down. And I describe it in the book When It’s Darkest, I describe people who have this high social perfectionism as basically having thin psychological skin such that when the bows and arrows of life come at us, when negative events occur, our skin is much more likely to be pierced metaphorically. And so let’s say it’s our premotivational phase because the concern is that people who are high in social perfectionism are much more likely to feel defeated or humiliated when stuff happens to them.
Brett McKay: The social perfectionism is interesting. Will Store, we had him on the podcast talk about his book about social status. He wrote an article about male suicide and he talked a lot about this social perfectionism and the role that plays, as well as status defeat in men can play in a man susceptibility to suicide.
Rory O’Connor: Yeah, no, absolutely, I know Will, Will’s a good guy, and actually Will Store interviewed me as part of that article, and then obviously initially, it was an article in the book or one of his books. And he’s exactly right, which is, that social perfectionism is a really useful framework for us to try and understand as Will has done, understand male suicide. But the way I’ve tried to conceptualize it is, try to understand, Well, how does it increase risk, in my case from a psychological perspective? And I think that idea of the thin skin-ness is a useful way to think about that. So we’ve got that vulnerability aspect, and then the other two bits are environmental influences and negative life events, they’re the last two parts of that premotivational phase. And the environmental influences are really recognizing that this idea that we know that there’s a socioeconomic gradient to suicide and that basically people from more socially disadvantaged backgrounds are much more likely to die by suicide. Some estimates are you’re three times more likely to die by suicide if you’re from a socially disadvantaged background compared to a more affluent background. And now, that’s not to say that people from more affluent backgrounds don’t take their own lives, because they do, but the risk is higher when there’s more social disadvantage.
And then the last bit on the premotivational phase is we know that people who die by suicide or attempt suicide have experienced a disproportionate number of negative life events, and that’s both in childhood as well as across their lifespan. And actually, when you look at the psychophysiology of suicide risk, we also know that people who attempt suicide or die by suicide, their stress system, their cortisol system… Remember cortisol is like the fight or flight hormone we need to help us either defend ourselves or flee a threatening situation. The people who are suicidal, their cortisol system is dysregulated, it’s not working as well, so it adds to the vulnerability.
Brett McKay: Okay. So the premotivational face, these are just the background factors that are already in place in someone’s life that could make them more vulnerable to suicidal thoughts, they won’t necessarily lead to suicide but they’re potential vulnerabilities. You move into the motivational phase of this, this is when ideation and intention formulation occurs. And I think you said what usually kickstarts the ideation is some sort of defeat, whether you lose a relationship, you lose a job, etcetera.
Rory O’Connor: Yeah, absolutely. I’ve touched on the motivational phase when I was answering one of the previous questions, that central idea that suicidal thinking is driven by or it grows out of feelings of defeat and humiliation from which you cannot escape. And it’s that sense of mental pain and entrapment which drives the emergence of suicidal thoughts. And again, when we think about what then drives or causes defeat or humiliation, that’ll be unique for all of us, it’ll be different for every one of us. And defeat and humiliation, again, are often also driven by loss, rejection, or shame. So I think when we’re trying to understand risk at an individual level, that’s a really helpful way to think about it, is asking ourselves, Well, what are the potential drivers to somebody feeling defeated or humiliated? And ultimately, what are the drivers to them feeling trapped? And then if we can identify those drivers, the causes of defeat, the causes of humiliation, we can hopefully intervene either to change the thing that’s leading to the defeat or humiliation. Or if we can’t change that, thinking of ways to support the individual through that crisis time.
Brett McKay: Well, in this part of the model, you have this idea of, I think it’s a threat to self-moderators and motivational moderators. What are those?
Rory O’Connor: Yeah, they are psychological factors. We’re trying to understand… If we think about the model as a horizontal line going from… On the left-hand side, you’ve got defeat and humiliation, and then if you move from left to right, you move from feeling defeated to feeling trapped. And then you move from feeling trapped to suicidal. The threat to self moderators and motivational moderators are psychological factors which we hypothesize facilitate or impede the movement from left to right. That includes things like if you’re a really good problem solver, social problem solver, and you’re feeling defeated… Well, actually if I’m feeling defeated and I can solve the problem, I’m less likely to feel trapped. So let’s take an example of where good problem solving will arrest or stop the movement from left, from defeat to entrapment. Or for example, if you’re feeling trapped, what increases the likelihood that you might become suicidal? Well, if I’m feeling trapped and I’m really socially isolated or I feel that I’m a burden on those around me or if I feel disconnected, I’m much more likely to feel suicidal.
And so that sense of being a burden, that sense of support or isolation, they are these motivational moderators which help us understand who is more likely to move from feeling trapped to suicidal. And although often in the model, we frame it as risk, the presence of all these factors lead to risk, the motivational moderators and the threat to self-moderators help us identify what we describe in psychological terms as targets that we could focus on which will hopefully protect somebody from moving from defeat to entrapment to suicidal thinking.
Brett McKay: There’s the motivational phase, you have the defeat or humiliation which leads to entrapment, which then could lead to suicidal ideation and intent. What causes someone to start shifting over from just ideation to, “I’m actually gonna do something?” We’re moving to the volitional part of this.
Rory O’Connor: Yeah, the volitional phase is the third part of the model, and it’s our attempt to try to identify what we think is about 30% of people who have thoughts about suicide, we think about 30% move from thoughts to suicidal acts, and that includes fatal as well as nonfatal suicidal behaviour. According to the model, there are eight key factors, which I call “volitional moderators” or “volitional factors” which increase the likelihood that you make that transition, you act on your thoughts. And they include things like having access to the means of suicide.
It stands to reason, if I’m suicidal and I’ve ready access to the means of suicide, well, I’m more likely then to act on my thoughts because if it’s ready access, it means that the environmental constraints on you accessing that method are reduced or low, then anything which leads to reduced constraints on access to means increases the likelihood that you’ll engage in that behaviour. And indeed, if you look at the evidence for what works at a public health level to prevent suicide, it is interventions which are focused on restricting access to the means of suicide. That’s like for example having barriers in places of concern, not having ready access to medication and so on. That’s one of the volitional factors.
Others include exposure to suicide. What we mean by “exposure” is that if you know somebody else who’s died by suicide. And again, it stands to reason that if I have having thoughts of suicide and I know somebody who’s died by suicide, I’m more likely to act on my thoughts. And that’s because the mechanism could be that if somebody close to you has died by suicide, that method of death is potentially more cognitively accessible. Or it could be that if that person is like you, you’re modeling their behavior or it could be that it legitimizes the behavior for you because if a loved one uses that method of coping with a distressing situation, well, maybe that’s something you would consider. That’s one of the volitional moderators.
I’ll just say there’s eight of them but I won’t go through all eight, I’ll do a couple more. Impulsivity is one of the volitional moderators. Again, the idea that if you’re having thoughts of suicide and you’re impulsive, it stands to reason you’re more likely to act on your thoughts. And then just maybe two last ones. Second last one in the list, if you read the model, is basically this idea that having mental imagery around dying or death. What we think happens is, if somebody is having thoughts of suicide and they’re picturing themselves either dying or dead, that’s perhaps like a rehearsal mechanism or it could act as a habituation of making death less scary. So then the presence of both thinking about suicide and imagery around death increase the likelihood that you’ll act on your thoughts.
And then one very last one is past behavior. The single best predictor of any future behaviour is whether you’ve engaged in that behaviour in the past, it’s exactly the same for suicidal behaviour. The evidence shows that if you’ve engaged in suicidal behaviour in the past, you’re statistically more likely to engage in suicidal behaviour in the future or sadly die by suicide. It’s important to put that in context because although past behaviour is one of the strongest predictors of future suicidal behaviour, the majority of people who say are suicidal or have attempted suicide in the past won’t do again in the future and will never die by suicide.
Brett McKay: Okay. So that’s the integrated motivational volitional model of suicide behaviour. And what this allows you to do as a practitioner or anybody, there’s points where you can see where you can start doing some preventative things. I’m going to start working here in the motivational part… Or I’m going to start working here in the volitional part. So based on your research, not only do you research suicide, but you research suicide prevention. What’s the best thing that works in suicide prevention?
Rory O’Connor: I’ll answer that in two ways. Large-scale public health interventions have been shown to be effective, that’s things, as I mentioned earlier on the restricting access to the means of suicide, anything which restricts access to the means of suicide has been shown to be effective in reducing suicide. So that’s good news, that’s really good news. Now, that’s challenging, for example, in the United States, that’s challenging when we think about firearms, that’s a really complicated topic to address, given the constitutional implications and so on. That’s a big public health-type example. But if I focus in on the individual level, over the last 20 years, there’s been growing evidence that psychosocial interventions, these are like talking therapies, things like cognitive behavior therapy have been shown to be effective in reducing suicidal behavior over time. So that’s good news. There’s a growth in the evidence base for those sorts of talking therapies.
There also has been a lot of interest and focus on brief interventions, things like safety planning. And safety planning is an intervention that we’ve done some work with ourselves over here in the UK, but safety planning was developed by Barbara Stanley and Greg Brown in the United States. It’s an effective intervention, but it’s a simple intervention, and it really focuses in on the volitional phase. If you think about cognitive behavioral therapy or CBT, it’s more focused on the motivational phase, it’s trying to understand the complex factors that lead to defeat and entrapment and suicidal thinking and so on. But a volitional phase intervention like safety planning is trying to interrupt suicidal thoughts so that somebody doesn’t cross the precipice from suicidal thoughts to suicidal acts.
And it’s very, very simple, the intervention basically has six steps. Step one is you work collaboratively with somebody who’s suicidal to try to identify the warning signs that a suicidal crisis might be escalating. So hopefully, if you can identify in advance, you can intervene and do something to keep yourself safe. And then in steps two, three, four, and five, it helps the individual identify people or places or organizations that they can go to either to distract themselves as the suicidal thoughts might be escalating, or if they feel they cannot keep themselves safe, somewhere to go in crisis or somebody to contact in crisis.
And then step six is the last step of this intervention, and it’s working again collaboratively with the person to help them keep their environment safe, and by keeping their environment safe, what we mean is basically to increase the distance between them and a method of suicide. If they thought about how they might end their life, what can we do to ensure that when that crisis escalates again, they do not have ready access to the means of suicide. So something like that I would really focus in on, that safety planning, it’s only one example as a brief intervention, but a really important one because it’s something which intuitively makes sense, Brett, but something we can all be thinking about.
Brett McKay: And then also on an individual level, if you know someone who you’re worried about, we talked about this earlier, don’t be afraid to ask them if they thought about taking their own life because it’s not going to implant that idea in their head to do it, it’s just that could actually be the thing that could kickstart them getting the help they need.
Rory O’Connor: Yeah, absolutely. And really, we cannot emphasise that enough, if you are concerned, please ask somebody directly whether they’re suicidal. But I appreciate that that’s a difficult thing to do, and again, I describe some tips in the book. But in essence, if the person answers “yes,” that I am suicidal, in many respects, that’s your biggest fear… If you ask that question, and somebody says, “Well, yes, I am suicidal.” Your biggest fear is, “Well, what do I do next?” What you do next is you just validate how they’re feeling and say, “That must be really difficult for you.” That’s all we mean by “validation.” “That must be really difficult for you.”
It’s not about trying to solve their problems, it’s trying to acknowledge, be alongside them in their distress and then encourage them to think about how they might be able to get support if they think they cannot keep themselves safe. And that sense of common humanity, that sense of connection and treating an individual as worthwhile, as somebody who’s valued in this world, because many people who are suicidal don’t think that they have a role in society anymore and feel that they are a burden. So anything which promotes connectedness and then encourages them to maybe reach out, speak to their physician, their general practitioner, somebody else in their life who can help keep themselves safe. I would really encourage people to do that. Please, please reach out.
Brett McKay: Let’s talk a little bit… You talk about this in the book, about those who are bereaved by suicide, so family members who had a loved one that took their own life. How does their grief differ from someone who might have just experienced someone who died by other causes? And any advice for them on how they can navigate that? And I guess the other question there too would be, What can people do to help those who are bereaved by suicide?
Rory O’Connor: Yeah, again, really important questions. The grief associated with a suicide is complicated because, of course, any sudden death is devastating, but on top of the sudden death, there’s often shame and guilt and, “What could I have done differently?” And again, I speak as somebody who’s twice bereaved by suicide, and in particular, with a close friend of mine who took her own life. I still ask myself today what I could have done differently and I felt in part responsible for not being able to save her life. And many people bereaved by suicide feel the same. So part of it is trying to be more self-compassionate. No one of us should ever be held or can ever be held responsible for the actions of another person. Recognizing that the prediction of suicide is so, so difficult, and as I said earlier, it’s no better than chance, our ability to predict suicide. And so recognize that every day is different, every day is different and it’s the pain, anger, the steps of bereavement, that people go through them differently. And probably the only certainty about bereavement by suicide is its uncertainty, is its unpredictability, some days you might feel okay and other days not, and it can come on such unpredictably obviously.
And I suppose it’s also recognizing that although as days become weeks and weeks become months, it’s all about moving forward, it’s not forgetting, it’s just you’re moving, step forward, step forward, step forward. You’re changed as an individual, of course, you are, and it’s just trying to recognize that, and things do become a bit easier.
In terms of advice for those who are around those who have been bereaved, again, it’s just recognizing that the person is going through unbearable pain. Don’t be frightened because one of the big fears, again, is, “I’ll say the wrong thing.” And again, the advice that I would certainly give, and I know from speaking to countless others who have been bereaved, is as long as somebody treats you with humanity and compassion, you’re unlikely to say the wrong thing. And don’t judge. It’s nonjudgmental. Don’t try and tell the person how they’re feeling, just be alongside the person and let them know that you’ll be with them, you’re there if they need them at any stage. And please don’t cross the road because that still happens, that idea of people who are bereaved by suicide and people cross the road instead of speaking to them, and that’s often out of fear of saying the wrong thing. Please, please support each other.
Brett McKay: Well, Rory, this has been a great conversation. Where can people go to learn more about your work in the book?
Rory O’Connor: To find out more about our work, we have a website, the website is www.suicideresearch.info that’s suicideresearch.info, and the book is available I think everywhere, so wherever you tend to get your books, in Amazon or wherever, or other obviously booksellers, the book’s widely available.
Brett McKay: Well, Rory O’Connor, thanks for your time, it’s been a pleasure.
Rory O’Connor: Thanks so much, Brett, I really enjoyed our conversation.
Brett McKay: My guest today was Rory O’Connor. He’s the author of the book, When It Is Darkest: Why People Die by Suicide, and What We Can Do to Prevent It, it’s available on amazon.com and bookstores everywhere. Check out our show notes at aom.is/suicide, where you can find links to resources, we delve deeper into this topic.
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