Wednesday 28 June 2023

How Are You, Really? Eight Things I've Learned About Suicidality and Self-Harm

Suicidal ideation has less power when it is verbalised. — Fran Houston

I’ve written a few “things I’ve learned about” articles, including Three Things I Wish People Knew about Loving Someone with Mental Illness, Three Things I’ve Learned About Mental Health Medication, and Four Things It’s Hard for a Mental Health Ally to Hear. This time, I want to talk about two of the most challenging topics of all, suicidality and self-harm. In doing so I’ll draw on my experience with Fran and other friends over the past dozen years or so, as well as training I’ve undertaken including Mental Health First Aid (MHFA), ASIST, and a range of other suicide prevention and awareness courses. I’ll close with a selection of relevant articles we’ve shared previously, and links to crisis lines and other support resources.

1. You know someone who lives with thoughts of suicide or self-harm

According to suicide prevention charity Grassroots, one person in four in the UK experiences mental ill-health in their lifetime, one in five thinks about suicide, and one in fifteen attempts suicide. Young Minds, a UK charity working for children and young people’s mental health, says that in 2018-19 almost a quarter of seventeen-year-olds reported having self-harmed in the previous year, and seven per cent reported having self-harmed with suicidal intent at some point in their lives.

I struggle to get my head around numbers like this, but most of my friends live with a diagnosed mental health condition. Many have experience of suicidal thinking or self-harm. Some have hurt themselves or attempted to take their life. I know this because we’ve talked about it. Whether you realise it or not, whether they mention it to you or not, you know someone who lives with thoughts like these. Probably more than one. That may or may not be an easy realisation, but it’s true.

2. There are many kinds of suicidality and self-harm

I have no first-hand experience of suicide or self-harm. Before talking with Fran and others, I had only the most naive idea of what these terms represent. If I thought of them at all, I thought only of desperation and crisis. I’ve learned how dangerous such naivety can be, and how important it is to appreciate the variation in people’s experience.

In our book Fran and I explore five kinds of suicidal thinking: relentless thinking, suicidal thoughts triggered by situations and stress, hopelessness and despair, suicide by proxy, and focus on suicidal methods. Our discussion is based on how suicidality presents for Fran, but every person’s experience is different. The same is true of self-harm. There are many ways someone might hurt themself, and a wide range of motivations for doing so.

3. Focus on what’s happening not the labels

The distinction between suicidality and self-harm isn’t always clear-cut. As described by the Centre for Suicide Prevention, some researchers place all forms of self-injury on a “suicidal continuum” whilst others consider suicidality and self-harm to be completely different behaviours.

Part of the problem with labeling someone’s behaviour or actions as suicidality or self-harm (or both, or neither) comes down to intention. That’s never easy to gauge. Is my friend suicidal or just having a really rough time? Are they handling suicidal thoughts and feelings with no intention of acting on them, or do they have a plan? Was my friend’s injury self-harm, an attempt at suicide, an accident, or a symptom of something else? It’s important to respect the perspective of the person concerned. I’ve written about this previously.

When it comes to something as complex as suicidality and self-harm, the best approach is to start from the individual person’s perspective, experiences and needs. And if we cannot guess what those are — and we cannot — we need to be prepared to ask the questions.

This is important because while labels have their uses, they can also get in the way. A few years ago I wrote a blog post that explored how I felt when one of my friends hurt themself badly. I was proud of the article. It was raw and honest, and paid due regard to my friend’s experience and mine. We agreed to publish it, but at the last moment we clashed over my labeling it self-harm. By insisting on my interpretation of events, I lost the opportunity to share my experience of a challenging, but ultimately valuable, episode in our relationship as friends.

However we label them, these thoughts, feelings, and impulses arise in situations characterised by distress. I wrote the following notes while taking Carolyn Spring’s online course Dealing with Distress: Working with Suicide and Self-Harm:

The assumption that suicidality is driven by mental illness (rather than by distress) leads to a focus on treating the illness (medical model). The suicidal person doesn’t want diagnosing and treating. They want relief from their pain, and the hope that their pain can get better in the long run. So the focus should be on relieving their pain.

I’ve learned to pay attention to what my friend is going through, and what that means for them, rather than worrying too much what we call it.

4. Holding a safe space is profoundly protective

It’s easy to react out of fear if someone tells you they have thoughts of suicide or self-harm. Knee-jerk responses are unlikely to help, though, and can be unhelpful. As Fran told me recently, “[t]he worst thing someone can do is to be shocked. A much better response is ‘tell me more about how you feel.’” If we’re prepared to listen without judgment we open a space in which both people can feel safe.

It’s hard to overstate how important this can be. Fran’s told me many times over the years that she wouldn’t be here if it wasn’t for our friendship. I take her at her word. We all have a role to play in normalising talking about suicide and self-harm. I agree with Fran when she says, “[t]he most important message is not keeping suicidality in the dark, because when it’s kept in the dark people either have to shut down or shut up. Suicidal ideation has less power when it is verbalised.”

If you’ve never been in so dark a place, think about it this way. If there was something that was always or often in your mind, a part of your lived experience, and there was no one you could mention it to or talk to about it, how alone would you feel?

5. It’s not easy to hear but it’s harder to live with

It’s not easy to listen as someone we care about shares thoughts of suicide or self-harm. It’s okay to acknowledge this. Our feelings are valid. But if it’s difficult for us, imagine how much harder it is for them. What your friend or loved one is going through may be a one-off. It may be the first time it’s happened, or a repeat of something they hoped was behind them. It might be something they deal with all the time or on a recurring basis. Whatever it is, this is part of their reality. If they trust you enough to tell you about it, that says a great deal about your relationship. How you respond says a great deal about you.

6. It’s not selfish and it’s not a failure

This one divides opinion but for me there is no moral component to suicide or self-harm. People who live with suicidal thoughts and feelings, people who have attempted to take their lives or have hurt themselves in the past, are not worse for having done so. They haven’t committed a sin. They’re not being selfish. They’re not attention-seekers. They’re not weak or failing at life.

I’ve always told Fran I’d do anything I could to help her stay alive, but if she took her life, I wouldn’t hate her for it. My promise may seem naive but it was instinctive and heart-felt. I feel the same to this day. I explored my response to friends telling me about self-harm or other “failings” a few years ago, in a post titled I Wasn’t Disappointed in You When.

I wasn’t disappointed in you when you told me you cut yourself. Although maybe it seemed that way when I said remember I’m here. Don’t ever feel you’d be a burden or that I’d be too busy or asleep. As though I can make the demons go away.

Although I’m not disappointed in my friends if they experience a set-back, they might well be. Their feelings, be they of frustration, anger, or shame, deserve my respect, whether I agree with them or not. As I’ve written elsewhere, “[i]t takes enormous courage to acknowledge you’ve resorted to behaviours you’re trying to leave behind, to pick yourself up, and continue the journey. That’s the hallmark of a hero, not a failure.”

7. Don’t assume it’s a crisis

Suicidality and self-harm come up regularly when I’m talking with friends. They’re not in danger. They’re simply sharing what’s going on for them, the way any of us might discuss issues we’re dealing with. In my view, this aspect is overlooked in almost all public discussion and awareness training. As valuable as these are, they tend to treat any mention of suicide or self-harm as requiring intervention. I believe people need to feel safe sharing their thoughts and feelings without it leading automatically to someone pulling the emergency cord.

I’ve had friends wary of talking to me at all because they were scared I’d escalate things and call the police or an ambulance. Fran expressed this perfectly in a recent conversation. “People seem to want to fix us,” she said. “We don’t need fixing. We need acceptance, just as we are.”

8. Be prepared in case it is

That said, sometimes it is a crisis, and we need to know what to do. Supporting someone in crisis can take many forms, from calling an ambulance, giving them a ride to hospital, or keeping them company in person or online. It helps if you’ve discussed in advance what your friend or loved one might need in such a situation. They might have a crisis plan they’re happy to share with you. Examples include Fran’s travel wellness plan which we describe in our book, and the Wellness Recovery Action Plan (WRAP) developed by Mary Ellen Copeland.

It’s a good idea to keep a few emergency contact details close to hand, such as those listed on our resources page. I have a number of local hospitals in the GPS (satnav) app on my phone in case I need to drive there at a moment’s notice. Consider taking some self-harm or suicide awareness training. Many such courses are low cost or free to access online.

Once the immediate crisis is past, let them know you’re there for them if they want to talk about what they’ve been through. Respect the fact that they might not wish to do so, at least not immediately. Being there when things were desperate doesn’t give you an automatic right to an explanation.

Further Reading

We’ve shared a number of articles dealing with suicidality and self-harm over the years.

Selected Articles for World Suicide Prevention Day 2020

17 Online Suicide Awareness Courses and Podcasts

A Heap of “S” Words and an Aitch: Stigma, Suicide, Self-Harm — and Hope

She Is So Not OK: Being There When Your Friend Is Suicidal

Self-Harm, Addiction, and Recovery: Thoughts Inspired by My Friend’s 365 Day Milestone

How to Take Care of Yourself When Your Friend is Suicidal

Attending a Self-Harm Awareness Session at ReCoCo

Our resources page includes links to suicide crisis lines / support organisations, training resources, and books. UK mental health charity Mind offers a range of help and information if you need support or are concerned for someone else.

Over to You

In this post I’ve shared some of the things I’ve learned about suicidality and self-harm. I’d welcome your thoughts and experiences on these subjects, whether in the comments below or via our contact page.


Photo by Finn at Unsplash.



  1. I love this post because it does tackle a very real and challenging issue. Over the last seven months I’ve grappled with suicidal ideations, but I refuse to go into our psych ward because it scares me. I’d rather tough it out then deal with the hospital we have here. I couldn’t tell you how many times I’ve called the hotline this year so far. Too many and in reality, I’d rather have a friend or family member to call. Unfortunately my mom doesn’t know how to help, and flat out doesn’t want to. That’s a big ouchie for me. This is a great post. Thank you for writing it.

  2. This post is very pertinent, I think. I can certainly relate to it. I’ve been suicidal a lot these past seven months, and to be honest, I’d rather talk to a friend or family member. But that’s not viable for me at this time. Great post. Glad you tackled it.