My Twitter timeline regularly contains messages urging people to engage in conversations with people they suspect of suicidality. One of the most recent tweets contained reference to an article of ‘caring conversations’. I continue to think that urging untrained people to have such conversations is unethical and shouldn’t be done. But, I thought, perhaps I am wrong and close-minded. I decided to look for evidence, after all, with so many urging messages, there must be loads, it must be screaming at you!
Let me start with the article. It is a story as many others like that. You must recognise the warning signs and then engage in a conversation, after all, as the title says:
A caring conversation can save lives
And as I keep seeing these exhortations, I keep wondering whether they are based on anything apart from, I fully accept it, an earnest wish to help people. Well, the article doesn’t provide any evidence, but it refers to an earlier article, from the Center for suicide prevention. I thought, surely, if the Center for Suicide Prevention urges lay people to engage in what must be dreadfully difficult conversations, it must be based on some evidential base. Mustn’t it? Well, it’s another article which shows suicide prevention by bystanders as beautifully easy. All you must do is recognise the warning signs and then do a ‘thoughtful’ conversation. Interestingly, the article’s author does support this simplicity of life with research. Except, extraordinarily, none of the research quoted refers to ‘caring conversations.
And just to add, the article on caring conversations has a subtitle: What suicide can look like. Let me say to this – no, it can’t.
Undeterred, I decided to look further. After a few moments, I came across a number of statements from the Samaritans *).
Small talk saves lives
says one of the pages on their website. That’s quite a statement, isn’t it? Linguistically, this is certainty at its highest, you cannot make a statement which tells someone that you are more certain than that. It’s worth noting that the first article I quoted does have the modal ‘can’, at least there is some hesitation, an implication that it might not happen. The Samaritans do away with it – that’s a title showing a natural law.
But, I kept repeating, is there any evidence? Well, no, there isn’t. But the Samaritans do say they are engaged in research with the rail industry (a link here) and Middlesex University on bystander campaigns. Great, I thought, I seem to be getting somewhere. And so, off I went to see the research on bystander campaigns.
When you look for information on bystander suicide prevention, you will come across a number of references, for example from the Mental Health Foundation (link), Cornell University (link), Network Rail (link). These are but a few. Unfortunately, none of those pages makes any reference to the foundation of their claims – that bystander suicide prevention works. Moreover, where is the research the Samaritans refer to on their webpages? Well, I haven’t found it. The Samaritans pages are not dated, but the document from Network Rail says that the research was started in 2017. That’s four years ago.
However, the 2019 suicide prevention report, authored by Louis Appleby does mention the campaign and the research. The research was called Qualitative Understanding of Experiencing Suicidal Thoughts and explored suicidal thoughts and why people choose particular methods of suicide. How that relates to evidence for small talk saving lives, I have really no idea. The result of the research was a bystander campaign. That’s it. I still haven’t found any evidence for bystander interventions. Prof. Appleby’s latest report makes no mention of the research.
So, to make the point again: none of the documents urging people to engage in conversations provides any evidence that bystander interventions work. None!
But I did find one piece of research. A qualitative study on effective interventions by lay people. It is usefully reviewed on the Mental Elf website by Ioana Crivatu and Dafni Katsampa. Let me offer a somewhat tendentious summary of the Mental Elf summary for you. It’s something like: we really have no idea. I would add that while qualitative research is great in getting stories of such interventions, it cannot and must not be used as evidence of effectiveness or even as a pathway to effectiveness. And I am afraid the reviewers are way too optimistic saying that the study “adds new evidence to the body of literature and highlights details about the process of intervening in a suicide attempt”. In fact, it doesn’t do anything of the sort. It doesn’t because this is not what qualitative research can do. A qualitative study can only offer us stories and experience of such process. Useful as such stories are, they do not offer any insight into what happened, only to what people tell us today about what happened in the past. Moreover, the abstract of the study itself is seriously overreaching in what it can deliver.
It’s also worth adding qualitative research cannot even claim that the interventions were in fact successful. That is to say, they were experienced as successful at that particular moment in time, but we have no idea whether the success lasted beyond the moment. And what disappoints me even more is that the Samaritans’ guide to such conversations includes issues such as not getting any response, saying wrong things, the person not being suicidal, or the person starts crying. Is there really nothing to say about the well-being of the helper. Nothing at all?
And so, I remain unconvinced. We actually continue not to know much about members of the public offering suicide prevention. And I continue to think that before people or organisations recommend people’s launching into what must be extremely difficult conversations we need to know considerably more. Here is a rough and ready list what we should know.
1. How many lay conversations were unsuccessful and resulted in suicide? I find the unspoken assumption that the moment you will open your mouth, all will be hunky-dory objectionable. Indeed, the above-quoted guide, as an answer to the question of no response says:
It can take a while for someone who is having difficult thoughts to realise, they are being spoken to and interrupt their thoughts. They might seem distant or may not seem to hear you. Be patient; stay in their line of sight if you can and just let them know that you’re there. When you feel ready, you can try and talk to them again. Just letting someone know you are there can help.
To which I can only say, bloody hell, that’s just dishonest. No, there is no guarantee that people will respond, there is no guarantee at all you will be successful. Yes, despite your best effort, the person can still jump under the train. And you will have to live with this. Do you really still want to do it?
2. What were the consequences (e.g., psychological, social, economic) for those who tried to help and failed.
3. What were the consequences of not helping for those who didn’t. I find the campaigns to pressure people. People should not be pressured to be ‘heroes’.
4. What are the consequences for those who actually were successful? Is all happiness and bliss and riding into the sunset? Or can post-event reflections be somewhat more troublesome?
My final point is about venting my irritation with this simplistic account of warning signs. Is it really so nice and simple? How do you see the ‘thwarted belonginess’ as one of the articles I quoted above suggests? If it were all that simple, we would all be saving lives daily. As Tyler Black, a suicidologist, suggests, no, you haven’t missed anything. Suicide is unpredictable.
To any survivors of those who died by suicide:
The incorrect and stigmatizing messages of "warning signs" & mental illness made you feel guilt you shouldn't bear.
You did nothing wrong.
You didn't miss anything.
The death you grieve was complex and unpredictable.
— Tyler Black, MD (@tylerblack32) April 7, 2021
The constant banging about learning the signs does little more than put people in shackles of guilt feeling, racking their brains wondering what they had missed or whether they could have done more. You probably couldn’t.
I also know that, again, I am the awkward sod who is not enthusiastic about things and doesn’t want to help out (I’ve been accused to personally support all world evils, so I hardly care). But I am writing out the experience of trying to shoulder the weight of someone’s suffering and in situations way less dramatic than what’s at stake in making ‘small talk save lives’. My experience literally almost killed me. I don’t want to go there again. And I would like someone to look out for me when I don’t jump to help, when I say nothing. I would like someone to (say they) understand that I am scared of saying a word.
Of course, I do realise that this blogpost will fall on deaf ears. I will continue to get messages urging me to reach out. But what bothers me more than anything is that these messages seem not to be supported with any solid grounds on which to make them. And it’s that nonchalance that really bothers me.
*) I’ve been told a number of times one doesn’t criticise the Samaritans. I want to stress that I do think the Samaritans’ people do a wonderful job, they truly do. But they are trained to do it. Encouraging people to simply help can result in putting them in harm’s way.