Introduction 'You're not going to kill yourself, are you?' That was one of the first things that my mother said to me, 25 years ago, when I embarked on a PhD on suicide. She was concerned about the emotional toll that working in the field of suicide research would have on me and would regularly check in to make sure that I was looking after my own mental health. 'Of course not,' I replied. 'Are you sure?' she pushed, seeking further confirmation. To be honest, I didn't know how to answer her question. It wasn't something that I had really thought about. As a 21-year-old, I felt indestructible and had never really invested much time in looking after my own mental health. Also, I had no direct experience of suicide at that stage. I had always been intrigued by mental health, although my decision to study suicide wasn't planned; it was serendipitous. As an undergraduate psychology student at Queen's University Belfast, I had been researching depression and I had intended to continue this work into my PhD. However, in the summer of 1994, just after my graduation, out of the blue, one of my professors, Noel, telephoned me, asking whether I'd be interested in doing a PhD on suicide. I jumped at the chance. When I thought about it, it was the obvious next step for me. Suicide is the most shocking outcome from depression and, although the suicide rates among young men across the UK in the early nineties were on the increase, there had been little relevant research in Northern Ireland. That day, when I agreed, I couldn't quite envisage what a PhD on suicide would look like, but I grabbed the opportunity with both hands and just ran with it. And there it began - suicide research was to become my life's passion. Little did I know, though, that many years later Noel would lose his own mental health fight by his own hand. I often think about him reaching out to me, it was like my Sliding Doors moment; although I'll never know for certain, I doubt I would have become a suicide researcher without him, I think my life would have taken a very different path. For this I am eternally grateful. To this day I wake up every morning with as much drive and enthusiasm (if not more) to make a difference as I did in my twenties. Perhaps I should have reached out to Noel in his hour of need. I really wish I had. I'll always regret that I didn't do more for him. Guilt and regret are such commons emotions after a suicide. Returning to my mother's question, I hadn't anticipated the emotional toll of doing a PhD that involved interviewing people who had attempted suicide and learning, at first hand, the intimate details of those who had died by suicide. I don't know why, it was obvious. Of course it would be draining. To this day, I vividly remember the first person I interviewed as part of my PhD: Greg, a man in his forties who had been admitted to hospital after a suicide attempt. He had taken a massive overdose hours before. He was lucky to be alive, but he seemed so angry when I clapped eyes on him from across the ward. Although I had role- played in advance what I might say, I was still petrified as I approached his hospital bed. I was starting to sweat, hoping I wouldn't say the wrong thing. 'Hello, I am a psychologist who is carrying out research and I'd like to ask you some questions about what happened last night. Is that okay?' I enquired. I expected him to say no, but to my surprise, and as I would learn, like most patients who I approached following a suicide attempt, he agreed. We talked about his life, his mental health, his recent long- term relationship breakdown, his distant past and how he came to attempt suicide the night before. He wanted to be heard. Although he was older than me, he was no different from me - no different from any one of us; he was someone going through a bad patch, struggling to get through each day. Also, I had misjudged him; he wasn't angry, but despondent - he was stuck, trapped, feeling a burden to loved ones. When I asked how he felt now, after his suicide attempt, and whether anything had changed for him, he told me, tearfully: 'No, nothing has changed. I don't care. I feel the same way as I did last night. I feel as depressed and as useless as I did yesterday.' And he was right, nothing had changed - his relationship was still broken and he was no closer to getting the support for the trauma he had experienced as a child. He had been diagnosed with an adjustment disorder and would soon be discharged, receiving no more support beyond a letter sent to his GP. I felt so helpless; it was my first experience of the emotional impact of seeing someone in such acute distress but not being able to help. He was leaving hospital with more problems than when he had arrived barely conscious in an ambulance hours earlier. Now he had to face his family. 'They're ashamed of me, they think I am so bloody selfish. How could I do this to them?' he said at one point. There wasn't much I could say in response. At the end of the interview, he thanked me, and, while I was wondering why, as if reading my mind, he added, 'thanks for listening'. I learned so many valuable lessons that day and in those early days in the observational ward linked to the emergency department at Belfast's City Hospital. I learned about the importance of listening and the power of silence. I learned about the potency of my own fears as well as the pain of suicidal distress. I learned the value of being alongside someone in their own distress and the shame so often linked to suicide. I knew then that I had made the right decision that summer and I resolved to do whatever I could, no matter how small, to tackle suicide. Still, my mother's words have stayed with me; with others - my wife, family, friends and colleagues - now adding to the self-care chorus. And, ever since then, I've been having the will-I-die-by-suicide conversations with myself intermittently, usually when grappling with sleep or if I have been working late at night, or when something is really troubling me. It's as if they just sneak up on me. They've also become much more frequent in my forties, waxing and waning, coming and going with the ups and downs of life. Even when I am not having the 'will I, won't I' conversation, never a day passes when I don't think about suicide, its causes or consequences. I live, breathe and, quite literally, dream about suicide. It is not that I have ever been acutely suicidal, but since the mid- to late nineties, I've spent all of my working life studying suicide; trying to get inside the mind of someone who is suicidal and striving to understand the complex set of factors that leads to suicide. I am a Professor of Health Psychology at the University of Glasgow where I direct the Suicidal Behaviour Research Laboratory, a research group dedicated to understanding and preventing suicide. In addition to my research at the university, I work with many national and international organisations tasked with preventing suicide. I also travel up and down the country delivering talks about suicide to the general public. This is easily one of the most rewarding aspects of my job, seeing first-hand how our research is helping others understand their own or their loved one's distress. It is so important that scientists communicate their research findings as widely as possible, especially when they genuinely relate to issues of life and death. In the course of my work, I am privileged to talk to people who have been bereaved by suicide and to those who struggle to stay alive, as well as to those who have recovered from suicidal crises. I am continually humbled by the trust people place in me and my research team when they share their most private life stories. Late one night, while on a recent holiday with my family in Crete, I experienced the will-I-die-by-suicide thoughts again. I might add that this is no reflection on the holiday, which was idyllic - 30-degree heat, turquoise sea and copious amounts of food and drink, and great company. Such holidays feel like a distant memory now as I write this in the midst of the COVID-19 pandemic. I think it was the combination of the humidity, difficulty unwinding from work (my summer holiday is the only time of the year when I turn off my email) and Catholic guilt, which takes hold when I am not working. That night and for the previous few weeks, this goddam book, yes, this one, had rarely been far from my waking and nocturnal mind. For several years I had wanted to write a book on suicide for the general public, to reach those who do not read scientific papers. Something that would speak to those who have lost loved ones to suicide, who have been suicidal or work with people in crisis, as well as the wider public trying to understand this complex phenomenon. Also, I wanted the book to be personal, to convey something of my own experiences, but I was concerned, as a private person, about giving away too much about myself. I suppose I was paralysed by self-disclosure anxiety. As someone who has spent all of my adult life endeavouring to portray myself as competent and self- assured, I kept asking myself why on earth I would risk exposing any vulnerabilities, uncertainties and neuroses in a book. After many attempts, I just couldn't settle on a way forward. I had a breakthrough though, at around 4am that night on holiday, unable to sleep, just focusing on the whirr of the air conditioning and trying to silence my mind. As had happened so often in the past, the will-I-die-by-suicide thoughts surfaced one by one, though, this time, they were pretty intrusive: 'Will I die by suicide?', 'Could I kill myself?, 'Am I frightened of dying?' . . . But what was different that night was that for the first time I stayed with the thoughts, trying to make sense of them, asking myself, 'What do they mean?', 'Why do they keep coming back?', 'What's wrong with me?'. In the past I'd bat them away as soon as they entered my conscious awareness, finding them uncomfortable and disconcerting. I pondered whether it was my immersion in suicide research that triggered such thoughts, or whether it was because, with almost every passing year, someone else I know dies by suicide and I cannot help but compare myself to them. My reasoning continued: 'Surely, therefore, it isn't surprising that I am preoccupied with my own vulnerability and possible suicide?' What is more, since the age of 23, when my father died suddenly of a heart attack at 51, I've been fixated on my own mortality. I wondered whether I was unconsciously planning my own death, but by suicide rather than a heart attack. Also, I considered the fact that I'd been having these thoughts much more frequently recently, which coincided with my own personal discontent with life, agitation and general malaise in the past few years. Indeed this triumvirate, which has marred much of my forties, led me to start personal therapy five years ago. Unexpectedly, though, the puzzling over my own thoughts of suicide led to a sea change in my thinking that night; confronting them allowed me to acknowledge and accept that it was okay to have such thoughts. This step forward also had echoes of what happened to me a few years earlier when I started therapy. At the age of 42, for the first time in my adult life, I had reached out for help because I was struggling to cope. I was incredibly unhappy, perhaps depressed, but I couldn't understand why. Thankfully, undertaking weekly psychodynamic psychotherapy helped me immensely and still does. Initially, it was upsetting and disconcerting. I felt extremely exposed and vulnerable. As a result, I kept my visits secret, telling only those closest to me. I have come a long way since my first session in May 2016. I've a better understanding of who I am, I'm more accepting of my own flaws and I'm definitely happier, much, much happier. It has also helped me professionally. It has given me a deeper appreciation of the darkness of despair, the nothingness of living and the unbearable loneliness even when surrounded by others. Without doubt, therapy has been a turning point for me and for my mental health. For most of my adult life, I'd been so driven by making my career a success that I'd largely ignored my emotional and mental health needs. I was the upbeat extrovert, always positive while concealing, for the most part, my nail- biting neuroses. I had to do everything at a million miles per hour. Metaphorically, I'd be running as fast as I could from one thing to another. I didn't make the time or space to nourish my own mental health. The irony isn't lost on me, given the focus of my working life! I remember an early session with my therapist, when she asked whether my constant running represented me running away from something. We also explored whether I feared that if I slowed down, then I might have to deal with my own discontent and emptiness. Or was it the death of my father? I've spent the last few years trying to make sense of this. I think that, initially, my efforts to cram in everything were driven by my preoccupation with dying young. But latterly I believe that my fear of slowing down was because I didn't want to confront my own emotional needs. This is reflected in a diary entry I made not long after starting therapy: It is so easy to burst my 'externally-facing' confidence and self-esteem. In therapy recently, I talked about how, sometimes, when I am ruminating heavily, I'll try to picture myself in a box - and for some reason that gives me some comfort and assumed protection. I wish I wasn't so psychologically thin- skinned, if I just keep going, then the rumination will be blocked out and I'll be able to relax. One of the reasons I am disclosing my own struggles here is because reaching out for help has been transformative for me. So I hope that my experience will encourage others to consider doing the same, especially if they are reticent. Although I still have regular battles with myself and my mental health, I have found a way that works for me that is much more healthy and manageable. Also, the idea of psychological thin skins is something I return to later as I explore the factors that can lead to suicide. Excerpted from When It Is Darkest: Why People Die by Suicide and What We Can Do to Prevent It by Rory O'Connor All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.
