Without question, the hardest thing about training to support people struggling with their mental health is unlearning almost every instinctual response you have (particularly if you’re British and are predisposed to attempt to solve every problem with a cup of tea).
I am by nature a problem-solver. Apparently, I get this from my dad – people used to queue at his market stall in the late 1970s not to buy his bargains, but to ask for his advice, which he’d dispense in his trademark, no-nonsense manner.
I’m similarly pragmatic and proactive, so if someone comes to me with a problem, every fibre of my being wants to respond with, "here’s what you should do...". I can then walk away with a feel-good sense of satisfaction, knowing I have solved their conundrum.
But years of working in the field has taught me you can’t treat mental health in the same way you would a flat tyre, or a tricksy boss. What might have issued from my mouth as well-meaning, practical instructions have probably reached the ears of whoever I’m talking to as judgement.
Similarly, people who base their sense of the world on an optimism deriving from comparison (the knowledge that other people "have it worse") tend to apply this strategy to others. They will implore friends or colleagues weighed down with depression to "count their blessings" and be grateful to live in a country where life is not a daily fight for survival.
The mentor in this dynamic neglects to understand that depression often feels like a struggle to remain alive and in the process: what began as an attempt at cheer succeeds only in belittling the feelings of the mentee.
I have experience of the receiving end of this type of conversation and it’s incredibly frustrating. I’ve told people I am having a difficult period with anxiety and they have responded that I "shouldn’t worry" because "everything’s going really well for me at the moment" (basing their comments on the erroneous assumption that anxiety is in any way a logical illness). Yet I also know that they aren’t dismissing my condition deliberately: they simply haven’t been schooled in the correct way to handle it.
Facing the question
Perhaps the most counter-intuitive of all is the correct way to respond to a person who is potentially suicidal. The Samaritans, Mental Health First Aid England and specialist suicide charity ASIST all recommend asking the question direct – “are you thinking about killing yourself?”.
It is difficult enough saying these words aloud in a training role play scenario, let alone when actually dealing with a person who’s life is in jeopardy. Yet the general consensus amongst experts is that it’s crucial to ascertain whether a person is a risk of suicidal behaviours as early as possible, and the only way to do this with any certainty is to ask outright.
Incidentally, if the answer to the question above is “yes”, further, direct enquiry is necessary, which takes you into even more uncomfortable territory. So-called "suicidal ideation", which is used to describe a person who thinks about suicide but has not concocted a detailed plan, is surprisingly common.
While it can be an indicator of depression, suicidal ideation doesn’t necessarily mean the person in question is at immediate risk of death. To assess the urgency of the situation, mental health first-aiders are advised to ask “have you thought about how?” and then “have you thought about when and where?”
The Samaritans charity, which leads the field for research on what does and doesn’t cause suicide, are absolutely adamant that direct, non-emotional questioning of this kind cannot place suicidal thoughts in the mind of a person who was not already thinking them. (Interestingly, according to a lecture I attended by a senior instructor at Samaritans, there is evidence to show that press reporting on suicide, which tends to romanticise the act and use euphemistic language, can induce suicidal thinking in vulnerable people).
In a scenario between a teacher, parent or counsellor and a person who is exhibiting symptoms of depression, however, the question "have you thought about suicide?" is likely to have one of two responses: "Oh my God. No. Absolutely not," in which case you have eliminated that particular risk and can move on, or "yes", in which case you’ll be very glad you were brave enough to ask.
In my opinion, guidance from Samaritans, MHFA and ASIST on suicide is absolutely spot on – I do not believe harm can come from talking about suicide in the correct way, within specific guidelines. However, advice to ask has been known to contravene school safeguarding protocol, which presents a serious potential conflict for staff.
Clarity would help
Part of the issue in addressing this is that, while all safeguarding protocols contain broadly the same guidelines, institutions tend to tailor them, meaning it's difficult to obtain a centralised, national document.
According to safeguarding documents I found on one school's website, staff should not “interview a child, young person or adult at risk of harm. Question normally and without pressure and only to confirm what you have just heard. Never ask leading questions or act as an investigator. Do not put words into their mouth”.
This is, I believe, pretty standard safeguarding advice and it’s completely understandable for the vast majority of applicable scenarios. In the case of suicide risk, however, it might increase risk or allow a vulnerable young person to slip under the radar.
With schools across the country being offered free Mental Health First Aid training and the growing call for teachers to be trained in responding to emergency mental health situations, there is an obligation for government to issue crystal clear instructions on when the general rules of safeguarding might not apply. Thus, they give school staff the green light to respond to those at risk of suicide in what is generally acknowledged to be the right way.
After all, to avoid direct questions, in certain scenarios, can be deadly.
Natasha Devon is the former UK government mental health champion for schools and founder of the Body Gossip Education Programme and the Self-Esteem Team. She tweets as @_NatashaDevon
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