A call to health policymakers for new directions in suicide prevention and research

Konrad Michel, Professor Emeritus and suicide researcher, argues for a shift away from the traditional medical model of suicide prevention and emphasizes the need to reach the many who don’t see their suicidal thoughts as a mental health issue

The WHO reports over 720,000 suicides worldwide each year. Suicide rates are declining in some countries; in others, they keep rising. National suicide prevention programs have been established in low, middle, and high-income countries. Still, it is virtually impossible to evaluate their effect, apart from specific public health-directed measures, such as means restriction and improved reporting of suicide in the media. ⁽¹⁾

At-risk individuals are not seeking help

Fifty percent or more of those who die by suicide do not seek help prior to their deadly suicide action. ^(2-3) This equates to over 400,000 individuals worldwide each year, despite decades of public-oriented prevention projects aimed at spreading information about suicide and the importance of seeking help. This phenomenon is found even in countries with high-quality services for suicidal people and a long tradition of national suicide prevention and research, such as Denmark. ⁽⁴⁾ There are barriers to seeking help, such as stigmatisation, the fear of not being understood, the fear of being admitted to a psychiatric institution, and being treated against their will. However, an eye-opener are qualitative studies about the personal attitudes of suicidal individuals. In a survey with 8,400 individuals who reported episodes of suicidal ideation in the past year, three-fourths said that they did not feel they needed mental health treatment. ⁽⁵⁾

In our own follow-up study of patients who had attempted suicide, 52% said that nobody could have helped, and only 10% mentioned a healthcare professional. ⁽⁶⁾

The disconnect between medical interventions and the inner experience of the individual

Traditionally, suicidal behaviour is conceptualised as a mental health disorder. However, this frame of practice has serious drawbacks. For example, we expect people who suffer from problems with mental health to seek help, similar to somatic problems. The reality is that they don’t seek help. Another issue related to the medical model is that health professionals are the experts in identifying, assessing, and managing individuals at risk. However, risk assessment based on suicide risk factors doesn’t work. ⁽⁷⁾ Different from somatic disorders, suicide does not proceed in a linear development, which would allow for the formulation of a short-term or long-term prognosis. Furthermore, people often do not disclose their suicidal ideas and plans even under psychiatric care, and even when the issue has been addressed on the day of their suicide.

Clinical approaches to suicidal patients with psychological treatment models, such as CBT, BCBT, CAMS, DBD, and ASSIP, reveal an inside view of the suicidal mind, which stands in blatant contrast to the medical model of suicide. Suicidal behaviour is inherently individual and personal. Psychological approaches rely on narrative interviewing and a collaborative working alliance. In this context, certain key psychological issues have emerged, particularly in the clinical practice of ASSIP ⁽⁸⁾ where the patients’ narratives are video recorded for joint reflection:

• Suicide as a goal is ego-syntonic; that is, it is consistent with the experience of the Self. It offers an escape from suffering and a solution to an unbearable mental condition. It is not experienced as a mental disorder.
• Personal suicidal dynamics are fluid. ⁽⁹⁾ They are related to individual vulnerability and specific suicide triggers.
• Acting on suicidal impulses is characterised by dissociative symptoms such as “acting like a robot” and “as if in autopilot mode”. In research, this experiential aspect of suicidal behaviour is badly neglected.

The suicide narratives reveal that, generally, patients do not have a useful concept of suicidality. This leaves them vulnerable to future suicidal crises and actions of self-harm. Drawing from the clinical experience with ASSIP, we found that with the acquired knowledge of suicide and personal safety planning, people learn to recognise the warning signs and interfere effectively with the suicidal development. In an RCT, ASSIP resulted in an 80% risk reduction of suicide reattempts over two years.

The answer lies in insights gained from patient-centred clinical interventions

An increasing number of clinical studies have investigated the effect of narrative interviewing and therapeutic alliance on suicidal behaviour.^(10-11) Qualitative studies have focused on patient satisfaction.⁽¹²⁾ Numerous meta-analyses on the effect of patient-centred psychological treatments on suicidal behaviour have been published. However, considering the limited resources in mental health care, suicide prevention must move beyond clinical work with patients and reach the general public with the goal of disseminating person-centred knowledge of suicide.

A call for action: Suicide health literacy as a way forward

Suicide literacy is related to measuring specific knowledge and health competencies. ⁽¹³⁾ To develop and promote suicide health literacy, we first need information on suicide health literacy in different populations and cultures, including barriers to seeking help, such as stigma, using instruments such as the Literacy of Suicide Scale (LOSS). Projects need to define goals, target groups, and the means of dissemination. The content should be easy to understand and meaningful to the general public, patients, and health professionals. Projects need to be culturally tailored. This new direction of research will require planning and steering by multidisciplinary task forces.

Summary

The vast number of people who die by suicide without seeking help is one of the major, so far unsolved problems of suicide prevention. Models of suicide health literacy based on patient-centred models of suicide derived from clinical work have the potential to reach the general public and, above all, to reach people who are at risk but would not normally seek professional help. Suicide health literacy projects as a new and promising direction of prevention should be on the agenda of concerned health policymakers.

Konrad Michel is the author of ‘The Suicidal Person. A New Look at a Human Phenomenon, Columbia University Press, 2023. https://konradmichel.com/.

See also the January 2025 Edition of Open Access Government

References

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