The Art of Manliness - The Myths and Truths Around Suicide

00:00:00.000 barrett mckay here and welcome to another edition of the art of manliness podcast

00:00:10.800 you might think we're heading into a low time of year for suicides because they peak during the

00:00:15.040 cold dark months of winter but in fact suicide peaks during the spring and early summer this

00:00:21.380 is just one example of the popular beliefs around suicide that turn out to be myths

00:00:25.120 here to unpack more of these myths as well as the truth around this poorly understood subject

00:00:29.500 is rory o'connor the leader of the suicidal behavior research laboratory and the author of when it is

00:00:34.800 darkest why people die by suicide and what we can do to prevent it today on the show rory discusses

00:00:40.480 possible reasons for why suicides go up in the warmer months and why men die by suicide more

00:00:44.860 often than women he explains that suicide doesn't happen without some warning signs and why someone's

00:00:49.780 improved mood might be one of them in the second half of the show rory walks us through the real

00:00:54.600 reasons people move from having suicidal thoughts to acting on them and what works to prevent suicide

00:00:59.180 after the show's over check out our show notes at aom.is slash suicide

00:01:03.200 all right rory o'connor welcome to the show thank you i'm delighted to be here brett so you are a

00:01:25.460 professor of psychology who researches suicide and suicide prevention i'm curious what led you down

00:01:31.200 this career path well that's an interesting question like many things in life this path

00:01:37.620 was serendipitous so as an undergraduate student in belfast in northern ireland i've been studying

00:01:44.400 depression and i thought i was going to continue my undergraduate work into looking at depression

00:01:50.380 rather than suicide itself but then as things happens i got a call in the summer of i think it

00:01:57.560 must have been the summer of 1994 so quite a while ago and the person who turned out to be my phd supervisor

00:02:05.060 told me that there was an opportunity for a funded scholarship phd program on suicide and so that's where

00:02:14.180 it all began just that phone call and i decided that that's the direction i would go and i suppose what

00:02:19.780 it's quite interesting from my point of view is that well clearly suicide is the most devastating of

00:02:25.400 outcomes from depression and other mental health problems but i suppose i didn't quite envisage

00:02:31.520 where this that journey would take me and in particular that man that phone call my phd supervisor

00:02:38.340 the person without whom i wouldn't have done the research on suicide sadly some years later he took

00:02:45.320 his own life and i often think back to that phone call and really what i often wonder what was in his

00:02:51.360 mind at that time why did they ask me he wasn't a suicide researcher so it's just funny how these

00:02:57.320 things happen but i'm incredibly grateful to him because it genuinely was like a sliding doors moment

00:03:03.840 which changed my life what did your family think when you told them i'm gonna do my phd

00:03:08.320 and suicide well well my mother in particular um she was quite concerned because she knows me as a

00:03:17.680 person and she just knew that everything i would do i would put my heart and soul into and so her big

00:03:23.200 concern was the impact on me on my own mental health and so yeah so one of the first questions

00:03:28.840 you asked me was my god you're not going to kill yourself are you that was her genuine fear that if i was

00:03:34.480 so immersed in this and i suppose that question was really important question to ask and something

00:03:40.260 i remind myself of daily of reminding myself to look after my own mental health as well as now the

00:03:47.200 mental health of the people i work with here my team in glasgow so you've written a book called when

00:03:53.340 it is darkest why people die by suicide and what we can do to prevent it which is a book where you've

00:03:58.560 taken the research you've done on suicide and suicide prevention and presented it for a lay audience

00:04:03.360 we're going to talk about this book but before we do i think it's important to talk about how to talk

00:04:07.380 about suicide i'm sure a lot of people have noticed maybe in the past decade or so when we talk about

00:04:12.920 suicide or someone who's taken their own life we say you hear people say he died by suicide instead of

00:04:19.920 he committed suicide why that shift yeah i mean it really has been a marked shift i would say in the

00:04:27.640 last 20 years so and the reason for the shift is because the term committing suicide it harks back

00:04:36.260 to a time in many countries where suicide was illegal and so it harks back to that criminal sort of

00:04:43.840 undertone that was seen as a criminal offense and indeed in the united states and in the uk

00:04:48.700 thankfully suicide is no longer a criminal offense but there are still many countries in the world

00:04:55.180 in which it is a criminal offense and i just know from speaking to countless people who are bereaved

00:05:02.200 by suicide or people who've been suicidal themselves they often are quite upset about that criminal

00:05:09.420 over undertone so for that reason i think we shifted and be much more careful in our language because to my

00:05:17.120 mind we can talk about people dying by suicide it conveys the same message and it's not going to cause

00:05:23.780 distress to those who are bereaved so in all the work that i do i avoid the term committing suicide for

00:05:30.220 that reason what's the state of suicide in the west today are rates increasing or decreasing

00:05:35.620 in in some senses there's no simple answer to that question so maybe try and answer it in a couple of

00:05:42.880 ways if i look at the suicide rates say over the last 40 years now if i take a global perspective

00:05:50.160 first so on a global perspective the suicide rates have decreased by about 30 percent or thereabouts

00:05:56.960 over the last 40 years or so however if you try and disentangle then where the decreases have happened

00:06:04.380 you see that much of the decline in suicides happened in asian countries in india and in china and

00:06:12.300 other asian countries largely in china and so that tells you a pattern yes in a global context in those

00:06:19.640 low and middle income countries historically the suicide rates have been decreasing now if i take then

00:06:25.560 the last 20 years and focus in on say the united states or the united kingdom you see a different pattern

00:06:32.600 so indeed in the united states you've seen this upward trend in suicides and then if i look in

00:06:38.600 the uk say over the three or four years before the pandemic hit similar to the united states the

00:06:46.200 suicide rates were increasing and in australia new zealand other western countries in those recent

00:06:52.580 years the suicide rates have been on the increase now when the pandemic hits many of us working in the

00:06:59.020 field of suicide research and suicide prevention were really really concerned about the potential

00:07:05.240 impact of covet 19 on the suicide rates now thankfully our concerns were not realized because

00:07:14.020 the suicide rates broadly speaking did not increase in basically in a global context and indeed with a

00:07:20.580 colleague jane perkis from melbourne university she led this big international initiative of 33 countries

00:07:28.120 across the globe and it covered the first i think it was 15 months of the pandemic and within those

00:07:34.380 first 15 months broadly speaking the suicide rates did not increase now there were some exceptions for

00:07:41.340 example japan there's some signals now that the suicide rates might be increasing in japan

00:07:45.660 but the broad picture is that the pandemic did not see the increase that we feared but now my concern is

00:07:53.680 and we're starting to see this in the united states in the uk and other countries is now with the cost of

00:08:00.560 living crisis and the sort of potential economic turmoil and the ukraine crisis and other things going on in

00:08:06.680 the world our concern is that suicide rates are starting to go up again so we're at this period of sort of when

00:08:13.720 they didn't increase during the pandemic we need to be really really vigilant moving forward

00:08:17.980 are there demographics groups that are more susceptible to suicide say by age or sex

00:08:23.560 yes well if we just focus on western countries or high income countries suicide rates are significantly

00:08:31.740 higher in men than a woman in the united states and in the uk about three quarters of all suicides are

00:08:39.960 by men but then if you look to other countries to low middle income countries we see less of a disparity

00:08:46.020 between males and females but in i think it's like every single country in the world men outnumber women

00:08:53.720 in suicide now if we look then at age profiles again you have the nuances there's slightly different

00:09:01.160 patterns in different countries but broadly speaking suicide is rare before puberty and then when puberty

00:09:09.660 hits and those periods through from puberty right up to your mid-20s you see this increase in

00:09:15.880 suicidal thoughts behaviors and deaths by suicide and again there's slight differences in countries

00:09:22.560 but in the uk for example the leading middle-aged men are the group most at risk of suicide and then

00:09:30.940 other countries older age men are increased risk or the highest risk group but the concern many of us

00:09:37.760 have is that we're starting to see this increase in young or youth suicides again and that really

00:09:46.140 reminds me of when i first started researching this field in the 1990s the biggest risk group were young men

00:09:55.140 and if we think back to the 1990s we just all emerged from a recession or real economic turmoil

00:10:03.200 and my concern now is we have a similar pattern we've gone through a recession a few years ago

00:10:08.420 we know of this cost of living crisis and the sort of broader uncertainty in the world and like my

00:10:15.800 concern is that young people are being maybe even more at risk and that their suicide rates may start

00:10:21.540 to increase faster so we need to be so so careful and protect our young people speaking to the the sex 1.00

00:10:27.660 breakdown something that i've read and i want to see if this is true is it true that women attempt 1.00

00:10:32.520 suicide more often than men but men are more likely to actually take their lives because they use more

00:10:38.440 you know lethal means yes that broadly speaking that's a correct statement i agree with that is

00:10:44.180 that yes women are more likely to engage in non-fatal suicidal behavior however the explanation for that

00:10:51.840 differential isn't as straightforward as saying it's all down to the method that's been used that's

00:10:59.700 certainly part of it we know that men are more likely to use more lethal methods and obviously

00:11:04.580 therefore more likely to die say on a first attempt but it is more complicated than that and i think

00:11:11.060 we need to look at issues around masculinity what it means to be a man in today's society issues around

00:11:17.860 the way we structure and tailor treatment so the question i often ask is we know there are effective

00:11:26.000 treatments psychological treatments which reduce risk of suicidal behavior but the question is do

00:11:32.720 they work for men and are they tailored for men and that's linked to the fact that the way men help

00:11:38.300 seek is perhaps different from women and we know that men are less likely to seek help for mental health

00:11:44.320 problems and so what we should be asking is instead of blaming men for not seeking help which

00:11:50.220 sometimes is part of the narrative we should be saying actually perhaps the treatments and support

00:11:55.620 coupled with the stigma around help seeking mental health masculinity these are all contributing to

00:12:02.860 a situation i think a perfect storm of factors together with the increased use of more lethal methods of

00:12:10.060 suicide and that's really the complexity is the answer to the question of why there are more male suicides

00:12:16.560 than female suicides what are some of the biggest myths around suicide and how can those myths get in

00:12:22.420 the way of helping people who are susceptible to suicide to my mind one of probably the single most

00:12:29.160 common myth that i have come across is that if you ask somebody whether they're suicidal it will plant

00:12:38.100 the idea in their head and it's really important that we scorch that myth because there is no evidence at all

00:12:46.240 that by asking somebody whether they're suicidal that it actually will make them suicidal there's just no

00:12:53.080 evidence however there's no quite a bit of evidence showing the opposite showing that actually if you ask

00:13:00.720 somebody that question and i agree it's a difficult question to ask but if you ask that question ask

00:13:08.300 somebody directly whether they're suicidal there's evidence showing that actually it can get them the help

00:13:14.440 that they need and i often describe that question as being potentially the start of a life-saving

00:13:20.180 conversation so that would be myth number one then another myth i think i often think it's important

00:13:25.720 to highlight brett and that is this idea that and it's just it comes from a place of real sadness and

00:13:33.160 heartbreak is that the number of people that i have encountered over the years who both loved ones as well as

00:13:41.760 health professionals who have come up and told me the story that the person who they've lost to suicide

00:13:48.560 had seemed okay had seen well in the days and weeks before they died and so the myth is that if somebody

00:13:57.400 if there's this improvement in mood that's associated with reduced risk that's a myth because it's the

00:14:03.580 opposite in too many cases and i suppose to clarify and i'll make it clear what i mean in a second

00:14:09.700 so what the work or the research and sort of evidence suggests is that if there is an unexplained

00:14:17.440 improvement in mood it could mean that the person has resolved to end their life and because they've

00:14:26.320 resolved to end their life as a way of dealing with their pain their mood lifts because they found

00:14:33.660 the solution to their pain a solution to their problems and the reason it's concerning is as a

00:14:40.660 person's mood lifts their cognitive capacity their motivation their ability to plan and carry out the

00:14:48.820 suicidal act increases so the message on that myth is if there is any unexplained improvement in mood if

00:14:58.660 somebody has been in a depressive episode please check in with them to try and understand

00:15:05.120 why their mood is lifted now of course it could be their mood has lifted because their treatment has

00:15:12.940 kicked in either their medication or their psychosocial treatment has kicked in or their crisis

00:15:18.680 has abated but the concern is if somebody seemingly improves in mood and emotional well-being and you

00:15:26.220 don't know why always always check in to ensure they're doing okay okay so if someone's mood improves

00:15:33.080 it can actually be a danger sign because they may just be feeling relieved that they've made the decision

00:15:39.760 to stop struggling and take their own life and another related myth is that someone will always be

00:15:46.820 depressed before they die by suicide mental illness is correlated with suicide but sometimes someone

00:15:53.880 hasn't been depressed and we're going to talk more about this later but they haven't been depressed

00:15:58.100 but then they experience some sort of you know big setback or humiliation that leads them into this

00:16:05.400 spiral of suicidal thoughts and these things relate to another myth which is that there aren't any

00:16:12.420 warning signs before a suicide and you know a lot of time when someone takes their own life their

00:16:18.720 friends and family you know they're shocked and they say they didn't you know they didn't see any

00:16:23.560 signs it was coming but your research shows that there are typically signs they can just be hard to

00:16:29.280 recognize the sad reality is that um warning signs for suicide are difficulty spots but there are warning

00:16:38.840 signs and so the things i would often highlight are changes in behavior so that could be changes in

00:16:46.060 eating sleeping drinking like sleeping in particular because we know that disrupted sleep sleep problems

00:16:52.780 are associated with suicide risk because obviously anything if your sleep is interrupted that's your

00:16:58.600 that's a basic and biological terms we would describe it as a basic homeostatic function if you don't sleep

00:17:04.760 well your problem solving is affected your mood is affected your self-regulation is affected so changes in

00:17:10.680 these sort of basic processes are important to look out for but other things like and this is certainly

00:17:16.800 only probably applies to some cases people who are starting to get their life in order their life affairs

00:17:22.820 in order that would be another warning sign that's something that person may have resolved

00:17:27.660 to die by suicide and then obviously if somebody has been bereaved by suicide themselves or they've

00:17:34.620 experienced a marked loss either in status or in relationships things like that who's marked

00:17:40.660 changes can have an impact so again i would be checking in with somebody as well also people

00:17:46.680 who are talking about feeling trapped and hopeless and feeling a burden on those around them because we

00:17:53.340 know that sense of burdensomeness is at the heart of the sort of suicidal thinking the person feels

00:17:59.420 actually if i end up my life the people around me would be better off if i was dead and so those are

00:18:06.180 sorts of things i would highlight as sort of the warning signs but the reality sadly is like our

00:18:12.240 ability to predict suicide is no better than chance it's no better than the toss of a coin it's really

00:18:19.100 difficult to predict who will die by suicide but we should be still checking in with people if we are

00:18:24.760 concerned of course is there a seasonality to suicide uh because i think maybe there's a common belief

00:18:31.260 out there that a lot of suicides happen in the winter because it's dark and cold um you know maybe

00:18:40.260 the holidays make people feel sad is is that true well the holidays bit is is probably true but not

00:18:48.020 necessarily the winter bit so that again the best evidence if you try and bring together all the

00:18:53.040 evidence from across the world the best evidence suggests that suicides actually peak in spring

00:18:59.580 summer time so the increase in that period and actually in december they're low and actually

00:19:05.680 lowest on christmas day but then they peak on new year's day and so the question is well why do you see

00:19:12.880 this seasonal effect and the short answer is we don't know for certain part of it could be due with

00:19:18.080 as we move seasons there's a change in our sleeping patterns and our physical activity it could

00:19:24.580 be maybe linked to if we look at sort of occupations at risk of suicide as you move into spring perhaps

00:19:31.740 there's increased work related stress say if you're working in the agricultural sector if you're farmer

00:19:37.120 or whatever it may be so you can see increased stress and risk there but it could also be the fact

00:19:43.060 that as we move into spring and summer and the brightness and sort of vitality of spring and summer

00:19:50.140 if you're struggling with your mood there's that mismatch or that dissonance between your internal

00:19:56.400 world and your external world and perhaps that's part of the explanation as well so yes there are

00:20:02.540 seasonality effects we need to do more research to understand why they persist you know one i saw this

00:20:08.780 article in the atlantic this is speculative but a factor that might contribute to that seasonality is

00:20:13.860 in the spring there's allergies and inflammation can contribute potentially contribute to depression and

00:20:19.640 mental illness again this is speculative but i thought that was interesting i saw that in a

00:20:23.320 couple months ago no absolutely and i may have read that same article in the atlantic actually

00:20:28.440 and no i think we need to look at the allergens and the rule of allergens because as you say there's

00:20:35.400 growing evidence that impact on how they can activate some of the obviously biological systems which

00:20:42.180 are associated with mental health problems like depression so i think that's an area we need to look at

00:20:47.060 in much more detail because remember like one of the things that certainly i've recognized more and

00:20:53.200 more as i've studied suicide and suicide prevention is is and i often describe it as historically we have

00:21:00.700 either been too focused on the individual or too focused on the context in which an individual lives

00:21:07.500 without bringing those together so so those people who do work on brain imaging and biology that's all

00:21:13.860 great and those people who do work on social contexts and cultural factors that's brilliant as well but

00:21:19.820 ultimately as john sort of done said that idea of no man is an island we need to recognize that each if

00:21:27.520 we're to understand suicide risk we have to understand the individual in their context and that context

00:21:34.300 includes these wider environmental factors that you've mentioned as well as of course things closer to home

00:21:41.020 like obviously relationship crises mental health problems bullying unemployment and so on we need

00:21:47.100 to look at the environmental context as well and we'll talk about some of these factors because you've

00:21:52.020 developed this model the integrated motivational volitional model of suicide behavior maybe we can

00:21:57.180 talk about some of those factors in that model but just broadly speaking big picture why do most people

00:22:03.020 decide to take their own life well so the answer to that question i often give is people people end their life

00:22:10.900 as a way of managing unbearable pain and so for whatever it is 703 000 people who die by suicide each year

00:22:21.760 there's a whole complex set of reasons which will lead to each one of those individuals dying by suicide

00:22:28.900 but i think the common thread is that those people feel trapped by unbearable pain which is can be caused

00:22:37.920 by a whole range of factors it could be caused by the fact that your relationship ended or the fact that

00:22:43.100 you were had experienced trauma as a child or the fact that your mental health problems are really

00:22:47.520 really unbearable but the key driver is seeing suicide is the ultimate solution to your pain and for

00:22:54.700 like edwin schneidman who's like a founding father of suicide prevention from the united states often talked

00:23:01.600 about this idea of seeing suicide as a permanent solution to what are often temporary problems and so for

00:23:10.580 for me to answer the question of why people die by suicide the answer to that question is we need to

00:23:16.160 understand what are the drivers to the mental pain by which an individual feels trapped by and they see no

00:23:23.880 alternative no way to end their pain no solution to that pain and the only solution is the ultimate

00:23:31.440 solution and that is to take their own life so it's like the person in essence doesn't want to die

00:23:37.900 they just want the pain to stop they just can't bear the pain and and maybe we're going to go on to talk

00:23:44.240 about my model of suicide that's at the heart of my model that sense of entrapment and and then just say

00:23:50.920 the sort of key premise of the model is that so suicidal thoughts emerge so they come out of

00:23:58.220 this sense of entrapment but that sense of entrapment is triggered by feelings of defeat

00:24:04.500 and humiliation and those feelings of defeat and humiliation are often triggered by loss by shame

00:24:13.940 or by rejection and so although that's the common spine to understand the emergence of suicidal thoughts

00:24:20.800 then the question goes for every one of us who becomes suicidal the pathways to defeat the pathways

00:24:28.760 to entrapment are unique we're going to take a quick break for your words from our sponsors

00:24:33.680 and now back to the show so let's dig into the integrated motivational volitional model of suicide

00:24:46.420 behavior that you develop that can help practitioners but also other people loved ones

00:24:52.000 or even individuals who might be experiencing suicidal ideation help them figure out like where

00:24:58.200 they are in that path towards suicidal behavior and the first part of the model is the pre-motivational

00:25:04.760 phase what are the factors there that can influence whether someone decides to take their own life

00:25:10.080 yeah so the pre-motivational phase is part one there are three parts to the model so the pre-motivational

00:25:17.980 phase the motivational phase and the volitional phase and so the pre-motivational phase is like the

00:25:26.060 background context in which suicidal thoughts or behaviors may emerge the motivational phase is a

00:25:34.360 central the middle bit of the model and that's really trying to understand the emergence of suicidal thoughts

00:25:40.600 and then the third bit of the model is called the volitional phase and that's trying to understand

00:25:47.720 who is more likely to cross the precipice from thinking about suicide to acting on your thoughts

00:25:54.700 so going back then to the pre-motivational phase the pre-motivational phase is really trying to

00:26:00.640 understand what vulnerabilities do we all carry so for example we all have different vulnerabilities

00:26:06.520 they could be biological vulnerabilities so for example there's evidence that people with low levels

00:26:11.440 of serotonin and other metabolites and its metabolites and other sort of neurotransmitters are

00:26:18.400 associated with suicide risk so that's a potential vulnerability factor but it's never an

00:26:23.060 inevitability it's just a vulnerability factor like another vulnerability factor we've done quite a lot

00:26:29.420 of work on is on different types of perfectionism and there's one type of perfectionism which is

00:26:36.640 described as socially prescribed or just simply social perfectionism and what that is is that if you're

00:26:44.920 high on social perfectionism and i speak as somebody who is also high on social perfectionism is that

00:26:51.240 we're overly concerned about the expectations of others such that we continually we live our life

00:26:59.620 thinking that we're letting others important people in our lives down and i describe it in the book when it's

00:27:06.360 darkest i describe people who have this high social perfectionism as basically having thin psychological skin

00:27:14.420 such that when the bows and arrows of life come at us when negative events occur our skin is much more

00:27:22.340 likely to be pierced sort of metaphorically and so that's a sort of pre-motivational phase because

00:27:28.000 the concern is that people who are high in social perfectionism are much more likely to feel defeated

00:27:34.340 or humiliated when stuff happens to them the social perfectionism is interesting is that uh will store we had

00:27:41.440 him on the podcast talk about his book about social status he wrote an article about male suicide and he

00:27:47.600 talked a lot about this social perfectionism and the role of that plays as well as status defeat in men

00:27:54.620 can play in a man's susceptibility to suicide yeah no absolutely i know will will's a good guy and

00:28:02.140 actually will store interviewed me as part of that article and then obviously initially it was an article

00:28:08.280 and then and then the book or one of his books and he's exactly right which is that social

00:28:13.540 perfectionism is a really useful framework for us to try and understand as will has done understand

00:28:19.440 male suicide but the way i've tried to conceptualize it is try to understand well how does it increase risk

00:28:25.580 in my case from a psychological perspective and i think that idea of the the thin skinness is a useful 1.00

00:28:32.400 way to think about that so we've got that vulnerability aspect and then the other two bits are

00:28:37.560 environmental influences and negative life events they're the last two parts of that pre-motivational

00:28:43.720 phase and the environmental influences are really recognizing that this idea that we know that there's a

00:28:50.080 social socioeconomic gradient to suicide and that basically people from more socially disadvantaged

00:28:56.780 backgrounds are much more likely to die by suicide some estimates are you're three times more likely to die by

00:29:03.900 suicide if you're from a socially disadvantaged background compared to a more affluent background 1.00

00:29:09.720 and now that's not to say that people from more affluent backgrounds don't take their own lives because

00:29:15.420 they do but the risk is higher when there's more social disadvantage and then the last bit on the

00:29:20.920 pre-motivational phase is we know that people who die by suicide or attempt suicide have experienced a

00:29:27.760 disproportionate number of negative life events and that's both in childhood as well as across the

00:29:34.580 lifespan and actually when you look at the sort of psychophysiology of suicide risk we also know

00:29:41.660 that people who attempt suicide or die by suicide their stress system their cortisol system remember

00:29:47.960 cortisol is like the fight or flight hormone we need to sort of help us either defend ourselves or flee

00:29:54.340 a threatening situation the people that who are suicidal their cortisol system is dysregulated it's

00:30:01.960 not working as well so it adds to the vulnerability okay so the pre-motivational phase these are just sort

00:30:08.000 of the background factors that are already in place in someone's life that could make them more vulnerable

00:30:14.140 to suicidal thoughts they won't necessarily lead to suicide but their potential vulnerabilities so you move

00:30:20.240 into the motivational phase of this this is when ideation and intention formulation occurs yeah and i think

00:30:25.900 you said what usually kickstarts the ideation is some sort of defeat whether you know you lose a

00:30:31.740 relationship you lose a job etc yeah absolutely so i touched on the motivational phase when i was

00:30:38.340 answering one of the previous questions that central idea that suicidal thinking is driven by or it grows

00:30:47.160 out of feelings of defeat and humiliation from which you cannot escape and it's that sense of mental

00:30:53.860 pain that entrapment which drives the emergence of suicidal thoughts and again when we think about

00:31:00.700 what then drives or causes defeat or humiliation that'll be unique for all of us it'll be different

00:31:06.840 for every one of us and defeat and humiliation again are often also driven by loss rejection or shame

00:31:15.500 so i think when we're trying to understand risk at an individual level that's a really helpful way to

00:31:21.880 think about it is asking ourselves what are the potential drivers to somebody feeling defeated or

00:31:27.960 humiliated and ultimately what are the drivers to them feeling trapped and then if we can identify

00:31:34.020 those drivers the causes of defeat the causes of humiliation we can hopefully hopefully intervene

00:31:42.280 either to change the thing that's leading to the defeat or humiliation or if we can't change that

00:31:48.660 thinking of ways to support the individual through that sort of crisis time well in this part of the

00:31:54.840 model you have this idea of i think it's threat to self-moderators and motivational moderators what are

00:32:01.260 those yeah so they're psychological factors so we're trying to understand so if we think about the

00:32:08.120 model as a sort of horizontal line going from on the left hand side you've got defeat and humiliation

00:32:14.720 and then if you move from left to right you move from feeling defeated to feeling trapped

00:32:20.080 and then you move from feeling trapped to suicidal now so what the threat to self-moderators and

00:32:27.660 motivational moderators are psychological factors which we hypothesize sort of facilitate

00:32:34.400 or impede the movement from left to right so that includes things like if you're a really good

00:32:41.660 problem solver social problem solver and you're feeling defeated well actually if i'm feeling defeated

00:32:47.980 and i can solve the problem i'm less likely to feel trapped so that's like an example of where good

00:32:53.860 problem solving will sort of arrest or stop the movement from left from defeat to entrapment or for

00:33:02.060 example if you're feeling trapped what increases the likelihood that you might become suicidal well

00:33:06.820 if i'm feeling trapped and i'm really socially isolated or i feel that i'm a burden on those

00:33:13.500 around me or if i feel disconnected i'm much more likely to feel suicidal and so that sense of being

00:33:20.540 a burden that sense of support or isolation there are these motivational moderators which help us

00:33:26.580 understand who is more likely to move from feeling trapped to suicidal and so although often in the

00:33:34.120 model we frame it as risk so the presence of all these factors lead to risk the motivational moderators

00:33:41.000 and the threat to self-moderators help us identify what we describe in psychological terms as targets

00:33:47.720 that we could focus on which will hopefully protect somebody from moving from defeat to entrapment to

00:33:55.060 suicidal thinking so there's the motivational phase you have the defeat or humiliation which

00:34:00.540 leads to entrapment which then could lead to suicidal ideation and intent what causes someone to start

00:34:07.540 shifting over from just ideation to i'm actually going to do something so we're moving to the volitional

00:34:12.460 part of this yeah so the volitional phase which is the third part of the model and it's our attempt

00:34:18.220 to try to identify what we think is about 30 percent of people who have thoughts about suicide we think

00:34:26.200 about 30 percent move from thoughts to suicidal acts and and that includes fatal as well as non-fatal

00:34:34.900 suicidal behavior and so according to the model there are eight key factors which i call volitional

00:34:41.780 moderators or volitional factors which increase the likelihood you make that transition you act on

00:34:48.160 your thoughts and they include things like having access to the means of suicide so it stands to reason

00:34:54.120 if i if i'm suicidal and i have ready access to the means of suicide well i'm more likely than to act

00:35:01.380 on my thoughts and because if it's ready access it means that the environmental constraints

00:35:07.540 on you accessing that method are reduced or low and anything which leads to reduced constraints

00:35:15.280 on access to means increases the likelihood that you'll engage in that behavior and indeed if you

00:35:21.060 look at the evidence for what works at a public health level to prevent suicide it is interventions

00:35:27.200 which are focused on restricting access to the means of suicide that's like for example having

00:35:34.860 barriers in places of concern not having ready access to medication and so on so that's one of the

00:35:42.320 volitional factors others include exposure to suicide so what we mean by exposure is that if you know

00:35:49.880 somebody else who's died by suicide and again it stands to reason that if i have having thoughts of

00:35:56.140 suicide and i know somebody who's died by suicide i'm more likely to act on my thoughts and that's because

00:36:03.580 the mechanism could be that if somebody close to you who has died by suicide that method of death

00:36:10.380 is potentially more cognitively accessible or it could be that if that person is like you

00:36:16.380 you model you're modeling their behavior or it could be that it legitimizes the behavior for you

00:36:24.200 because if a loved one uses that method of coping with a distressing situation well maybe that's

00:36:30.240 something you would consider so that's that's the one of the that's the volitional moderators i'll just

00:36:34.860 say there's eight of them but i won't go through all eight i'll do a couple more impulsivity is one of

00:36:41.400 the volitional moderators so again the idea that if you're having thoughts of suicide and you're impulsive

00:36:47.160 stands to reason you're more likely to act on your thoughts and then just maybe two last ones

00:36:53.820 second last one in the list if you if you read the model is basically this idea that's having mental

00:37:01.420 imagery around dying or death so so what we think happens is if somebody is having thoughts of suicide

00:37:08.640 and they're picturing themselves either dying or dead that's perhaps like a rehearsal mechanism or it

00:37:16.440 could be it could act as a sort of habituation of making death less scary so that so then the presence of

00:37:23.300 both thinking about suicide and imagery around death increases the likelihood that you'll act on your

00:37:30.400 thoughts and then one very last one is past behavior the single best predictor of any future behavior

00:37:38.920 is whether you've engaged in that behavior in the past it's exactly the same for suicidal behavior

00:37:45.580 so the evidence shows that if you've engaged in suicidal behavior in the past you're statistically

00:37:51.580 more likely to engage in suicidal behavior in the future or sadly die by suicide it's important to

00:37:58.860 put that in context because although past behavior is one of the strongest predictors of future suicidal

00:38:05.760 behavior the majority of people who say are suicidal or have attempted suicide in the past won't do

00:38:12.980 again in the future and will never die by suicide okay so that's the integrated motivational volitional

00:38:19.260 model of suicide behavior and what this allows you to do as a practitioner or anybody there's points

00:38:26.060 where you can see where you can start doing some preventative things i'm going to start working here

00:38:31.060 in the motivational part or i'm going to start working here in the volitional part so based on your

00:38:34.980 research not only do you research suicide but you research suicide prevention what's the best thing that works

00:38:40.740 in suicide prevention so i'll answer that in two ways so you've got large-scale public health

00:38:48.040 interventions have been shown to be effective that's things that as i mentioned earlier on the

00:38:52.800 restricting access to the means of suicide anything which restricts access to the means of suicide

00:38:58.660 has been shown to be effective in reducing suicide so that's good news that's really good news

00:39:04.040 that's challenging for example in the united states that's challenging when we think about

00:39:09.860 firearms that's a really complicated topic to address given obviously the constitutional implications

00:39:16.560 and so on so that's a sort of big public health type example but if i focus in on the sort of

00:39:22.160 individual level so over the last 20 years there's been growing evidence that sort of psychosocial

00:39:28.260 intervention so these are like talking therapies things like cognitive behavior therapy have been shown to

00:39:34.580 be effective in reducing suicidal behavior over time so that's good news there's a growth in the evidence

00:39:42.000 base for those sorts of talking therapies there also has been a lot of interest and focus on sort of brief

00:39:48.760 interventions things like safety planning and safety planning is an intervention that we've done some work

00:39:55.240 with ourselves over here in the uk but safety planning was developed by barbara stanley and greg brown in the united states

00:40:03.280 and it's an effective intervention but it's a simple intervention and it really focuses in on the

00:40:09.040 volitional phase so if you think about cognitive behavioral therapy or cbt it's more focused on the

00:40:15.020 motivational phase it's trying to understand the complex factors that lead to defeat and entrapment and

00:40:21.160 suicidal thinking and so on but a volitional phase intervention like safety planning is trying to

00:40:27.580 interrupt suicidal thoughts so somebody doesn't cross the precipice from suicidal thoughts to suicidal acts

00:40:36.200 and it's very very simple so the intervention basically it's it has six steps step one is you work

00:40:44.580 collaboratively with somebody who's suicidal to try to identify the warning signs that a suicidal crisis

00:40:51.740 might be escalating so hopefully if you can identify in advance you can intervene and do something

00:40:58.080 to keep yourself safe and then in steps two three four and five it helps the individual identify people

00:41:07.680 or places or organizations that they can go to either to distract themselves as the suicidal thoughts

00:41:16.220 might be escalating or if they feel they cannot keep themselves safe somewhere to go in crisis or somebody

00:41:23.940 to contact in crisis and then step six is the last step of this intervention and it's working again

00:41:31.780 collaboratively with the person to help them keep their environment safe and by keeping their environment

00:41:38.400 safe what we mean is basically to increase the distance between them and a method of suicide

00:41:45.160 if they thought about how they might end their life what can we do to ensure that when that crisis

00:41:51.280 escalates again they do not have ready access to the means of suicide so something like that i would

00:41:57.800 really focus in on that safety planning it's only one example as a sort of brief intervention but a

00:42:03.800 really important one because it's something which intuitively makes sense brett but something we can all

00:42:08.680 be thinking about and then also on individual level if you know someone who you're worried about

00:42:14.440 we talked about this earlier don't be afraid to ask them if they've thought about taking their own

00:42:19.460 life because it's not going to implant that idea in their head to do it it's just that could actually

00:42:24.320 be the thing that could kickstart them getting the help they need yeah absolutely and really we cannot

00:42:29.720 emphasize that enough if you are concerned please ask somebody directly whether they're suicidal

00:42:35.360 but i appreciate that that's a difficult thing to do and again i described sort of some tips in the book

00:42:41.720 but in essence so if the person answers yes that i am suicidal i mean in many respects that's your

00:42:47.860 biggest fear if you ask that question and somebody says well yes i am suicidal so your biggest fear is

00:42:53.480 well what do i do next so what you do next is you just validate validate how they're feeling and say

00:42:59.440 that must be really difficult for you that's all we mean by validation that must be really difficult for

00:43:04.760 you it's not about trying to solve their problems it's trying to acknowledge being be alongside them

00:43:10.380 in their distress and then encourage them to think about how they might be able to get support

00:43:16.080 if they think they cannot keep themselves safe and that sort of sense of common humanity that sense of

00:43:22.520 connection and sort of treating the individual as worthwhile as somebody who's valued in this world

00:43:29.940 because many people who are suicidal don't think that they have a role in society anymore and feel

00:43:35.980 that they are a burden so anything which promotes connectedness and then encourages them to maybe

00:43:42.040 reach out speak to their physician their general practitioner somebody else in their life who can help

00:43:47.360 keep themselves safe i would really encourage people to do that so please please reach out let's talk

00:43:53.620 about a little bit you talk about this in the book about those who are bereaved by suicide so family

00:43:58.100 members who had a loved one that that took their own life how does their grief differ from someone who

00:44:03.400 might have just experienced you know someone who died by other causes and any advice for them on how

00:44:09.360 they can navigate that and i guess the other question there too would be what can people do to help

00:44:14.960 those who are bereaved by suicide yeah i mean again really important questions so the grief associated with a

00:44:23.480 suicide is complicated because of course any sudden death is devastating but on top of the sudden death

00:44:30.760 there's often shame and guilt and what could i have done differently and again i speak as somebody who's

00:44:38.180 twice bereaved by suicide and in particular with a close friend of mine who took her own life i still ask

00:44:45.280 myself today what i could have done differently and i felt in part responsible for not being able to

00:44:51.540 save her life and many people bereaved by suicide feel the same so part of it is trying to be more

00:44:58.600 self-compassionate no one of us should ever be held or can ever be held responsible for the actions of

00:45:05.140 another person recognizing that the prediction of suicide is so so difficult and as i said earlier

00:45:11.180 it's no better than chance our ability to predict suicide and so recognizing that every day is different

00:45:18.500 every day is different and it's and that's the pain anger the steps of bereavement that people go through

00:45:25.820 them differently and probably the only certainty about bereavement by suicide is its uncertainty is its

00:45:32.760 unpredictability it's some days you might feel okay and other days not and it can come on in such a

00:45:39.560 unpredictably obviously and i suppose it's also recognizing that although as days become weeks and weeks become months

00:45:47.780 it's all about moving forward it's not forgetting it's just you're moving step forward step forward

00:45:53.540 step forward you're changed as an individual of course you are and it's just trying trying to sort of

00:45:58.900 recognize that and things do become a bit easier in terms of advice for those who are around those who have

00:46:06.080 been bereaved again it's just recognizing that the person is going through unbearable pain don't be

00:46:13.220 frightened because one of the big fears again is i'll say the wrong thing and again the advice that i would

00:46:20.040 certainly give and i know from speaking to countless others who have been bereaved is as long as somebody

00:46:24.340 treats you with humanity and compassion you're unlikely to say the wrong thing and don't judge it's non-judgmental

00:46:32.880 don't try and tell the person how they're feeling just be alongside the person and let them know that you'll be

00:46:38.720 with them you're there if if they need them at any stage and please don't cross the road because that

00:46:46.020 still happens that idea of people are bereaved by suicide and people cross the road instead of

00:46:51.760 speaking to them and that's often out of fear of saying the wrong thing so please please support each

00:46:57.320 other well rory this has been a great conversation where can people go to learn more about your work in

00:47:02.260 the book so to find out more about our work we have a website the website is www.suicideresearch.info

00:47:11.480 so that's suicideresearch.info and the book is available i think everywhere so wherever you tend

00:47:18.140 to get your books in amazon or wherever or other obviously booksellers the book's widely available

00:47:23.540 well rory o'connor thanks for your time it's been a pleasure thanks so much brett i really enjoyed our

00:47:28.180 conversation my guest name is rory o'connor he's the author of the book when it is darkest why people

00:47:33.560 die by suicide and what we can do to prevent it it's available on amazon.com and bookstores

00:47:37.900 everywhere check out our show notes at aom.is suicide where you find links to resources where

00:47:42.540 you can delve deeper into this topic well that wraps up another edition of the aom podcast make sure

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The Art of Manliness - May 31, 2023

The Myths and Truths Around Suicide

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