This article is all about death and suicide. It may not be an easy read.

The first time I thought about suicide was when I was eight. Leeds Utd had just lost to Chelsea in the FA Cup Final and the shame of trying to beat up my big brother’s cocky friend and collapsing in tears was too much. I was in the garden afterwards trying to focus on the beautiful cloud of butterflies landing on the purple buddleia.

And then this quiet voice wafted over me, landed, and drilled into my forehead: “Why bother?”

This question has haunted me ever since. And it probably haunts you. But we are not allowed to ask it.

In 1990, in the thick of my six year long 24/7 obsessive anxiety state, I thought much more about dying than living. It was not a cry for help. It was a wanting to be free of pain. The fantasy of dying was an escape valve—I assume a little like self-harm is for some people, though I wouldn’t know.

The Dabbler

I dabbled with suicide. I took some overdoses. I remember sitting on a bed washing down half a dozen paracetamol with half a bottle of whisky and calculating how much more would do the job. But what scared me more was the double pain—the stomach pump and possible liver damage, plus the shame of coming round in A&E with my mother frowning down. What if I did not succeed? Why bother? Oh, irony.

I also remember wandering up and down Union Street in High Barnet for hours burning with anxiety about living and dying and eventually wandering into the path of a white van that had turned into the side street. But it was only doing a maximum of 20mph. I think the police that came were chortling at my half-hearted attempt. And I had messed up the nerves of the poor van driver. I had brought one more sorry soul into my sick circle. This proved it.

And then there was the shame of thinking I was not even decisive enough to kill myself properly. I was a dabbler who was fortunate to stay alive in hindsight.

The Decisive

Back on the ward, one man went off and hung himself. Another stole off one night and drowned himself. Decisive.

So, there is my first learning about suicide—that there are different types of folk. Even in the mists of pain and suffering, there are different “styles” of suicidal behaviour. Is anyone studying this? Or are we stuck in our simplistic “suicide prevention” models—the “let’s talk” or “breaking stigma” approaches that allow us all to be smug—that raise Twitter awareness—that conflate “hits” on a website with true analytical thinking about what works and what doesn’t?

If we truly understood what’s going on with folk as they near the brink, maybe we could have more subtle approaches, based on involving users in that work. Maybe this sort of work is happening—I’d love to know about it.

The vulnerable time

Lesson two about suicide came later. I was “recovering,” and the volume, intensity, and frequency of “intrusive” thoughts were receding. So much so that my psychiatrist wanted to prescribe pills to prevent me from being too high. He thought I might turn psychotic.

When he realised that this was a positive turn of events, he “discharged” me. I spent a few weeks popping back into the day centre. Then I was “discharged” from that limbo-land. I was in the “real” world that I had spent six years away from.

In that vulnerable state, with fewer lifelines, I was “getting better.” I was doing more, but still feeling awful. This gap between behaviour and feelings—where to “act as if” precedes the nervous system re-wiring—is surely the most potentially risky in terms of suicide. This time I had the energy to do it. I was stronger in some ways, and more vulnerable in others.

I went swimming again (I had been a competitive swimmer in my younger less fat with drugs years). But when I realised I wasn’t “enjoying” it, I thought “why bother?” Those buddleia days returned with a vengeance. I projected into the future. If I can do things, but they don’t bring me emotional reinforcement, truly why bother? What is the point of life? What nobody told me—what all the myriad psychiatrists (and later psychologists and self-help authors) never did—was that feelings follow behaviours. That the “act of will” (read more about “psychosynthesis” please) can help re-wire sensation, emotion, feeling.

But I didn’t know that, and was both recovering and feeling worse at the same time. I wonder whether anyone is seriously looking at this. In the widening gap between the NHS and seriously under-funded social care, my guess is that suicide figures for this segment of the population may be increasing—anyone know whether this is true? Are the stats there? Anyone looking?

Ambivalence

My third lesson about suicide is how it feels when a loved one or friend does the deed. Many people reading this will know of Rosamund Snow’s calculated insulin overdose. I almost admire her deliberate act (careful David—taboo thought, you’re not allowed to say that. What the hell. I’m too old to pretend). But I am also angry with her for what she did, how she deprived us all of her talents. And I also hate myself for not being able to help.

It is this swirl of ambivalent and confusing feelings that is also not allowed of people close to those who decide to die. I hear people telling others who have been bereaved to “stay strong.” What? How? The need for strong support for the bereaved is my third lesson in coming to terms with suicide. And for those who have tried to kill themselves, to witness someone else doing it leads inevitably to comparison, to guilt of all sorts, and the questions about “could I do it”? The answer is obvious to me now: Don’t. Just don’t. Trust me: Don’t. But boy the mind can weave some wearying diabolical pathways before you come up with that conclusion.

Four Lessons

So here it is, if anyone feels like taking the “mental health awareness” message seriously and putting money where mouths are:

Lesson One: Recognise the different “attitudes” of those who want to die. Let’s learn to approach support in nuanced ways.

Lesson Two: Acknowledge the danger of the “recovery” period. We need people not to fall into the gaps.

Lesson Three: Don’t tell people who have lost folk to suicide to “stay strong.” Go find them and give them space to share their feelings and words. Support them for more than a week or two.

Lesson Four is the one that has been slowly taking root since Dave Webb scored a late Wembley winner that I still think was a foul. And my buddleia experience. That it is OK. Repeat: OK to think about ending it all. That is part of our life experience. We cannot control our thoughts, merely be mindful of them. Stop listening to the shiny positivist “let’s be happy” brigade. It’s OK to think about death, to think about life being futile, to recognise existential doubt.

And when it gets to a bad patch, when these thoughts become heavier in volume, frequency, and intensity, it’s OK. Repeat it’s OK. This too shall pass—slowly, painfully, slowly, painfully. But they can and they will.

I am glad I did not kill myself. But I think of death a lot. As my lovely uncle Robin once said: “what else is there to think about. Cucumber sandwiches?” If we don’t consider death, life is not worthwhile. Think about that. Those who don’t think about it, may well find themselves more prone to the kickback later of emotional suppression.

Good luck. Be gentle, wherever you are, and whatever your tricky mind is doing.

David Gilbert, Patient Director, Sussex MSK Partnership (Central). This blog was written in a personal capacity.

Competing interests: None further declared.

David writes at futurepatientblog.com and can be found on Twitter at @DavidGilbert43.

Patient consent: obtained from next of kin.