No. 1: suicide is not an accident

The causative factors in any individual suicide are complex and multifactorial. Some suicidologists believe that around 30–50% of the risk is genetic, and the aetiology then may start in the womb.^{Reference Coon, Darlington, DiBlasi, Callor, Ferris and Fraser7} Contemporary psychoanalysts such as Campbell, Hale and Maltsberger conceptualise suicide as resulting from complex unconscious* mental mechanisms* that we do not yet fully understand.^{Reference Campbell and Hale8,Reference Maltsberger and Buie9} In their view, the destructive pathway is set in motion as a response to loss where the capacity to mourn is overwhelmed. The failure in this process causes a split* within the personality structure (ego*), which allows the body to be treated as a separate object*, projected* into and experienced as the source of the pain which cannot be digested. In this state, the mind is perfused with ‘suicidal fantasies’, which are a ‘quasi-delusional psychic retreat’ from unbearable anxiety. The core belief of these fantasies is that liberation from the body will allow a ‘survival self’ to continue life in a pain-free ‘bodiless way’,^{Reference Campbell and Hale8} allowing for an avoidance of the awareness of the finality of death.^{Reference Gibbons, Adshead, Gibbons and O'Reilly10} These fantasies can be seen on occasion in the symbolic nature of the suicidal acts. For example, people travel from all over the world to jump from the Golden Gate bridge in America (or Beachy Head in the UK), perhaps in a bid to transition through a portal or ‘Golden Gate’ to a pain-free heavenly world where their life can begin again.

No. 2: we will never know why someone died by suicide

The true reasons why someone has died by suicide will never be known. The person who could shed some light on the situation is no longer present, and even when people have been interviewed after making very serious attempts on their life, they are frequently unclear as to why they did it and can be as shocked and surprised as everyone else by their actions.^{Reference Van Orden, Wiktorsson, Duberstein, Berg, Fässberg and Waern11,Reference Richardson, Dickson, Robb and O'Connor12} Only around a quarter of people who die leave a suicide note, and they very rarely give any good reasons for their death.^{Reference Paraschakis, Michopoulos, Douzenis, Christodoulou, Koutsaftis and Lykouras13,Reference Pestian, Matykiewicz and Linn-Gust14} As a result, those bereaved are left in a state of unbearable pain and uncertainty. This can be temporarily mitigated by generating simple narratives where the death is conceptualised as an accident, or the result of their own or others’ negligence. These narratives allow the preservation of the memory of the person who is lost, and enable their role in their own death to be temporarily obscured.

No. 3: the ‘act’ of suicide: suicide is an ‘acting out’ behaviour that results in death

Campbell, Hale and Maltsberger describe suicide as an ‘acting out’ behaviour aimed at ridding the self of pain.^{Reference Campbell and Hale8,Reference Maltsberger and Buie9} ‘Acting out’ is an unconscious defence mechanism* where action takes the place of feeling. For many who make serious attempts on their life, the first sign that they feel in such overwhelming distress is that they act.^{Reference Vandevoorde16}

If the attempt is survived, the underlying distress can be recognised by the individual themselves and those around them. With this can come the development of concern and an opportunity for development and growth.^{Reference Richardson, Dickson, Robb and O'Connor17}

No. 4: everyone is shocked by the death

There is much discussion about the predictability of individual suicide; however, many deaths are not preceded by warnings, and frequently those who die have hidden their intent from those around them.^{Reference Friedlander, Nazem, Fiske, Nadorff and Smith18,Reference Skerrett19} For the bereaved, it is important to recognise the death is a ‘bolt from the blue’ (a phrase often used by those bereaved) because very quickly narratives are constructed, as described above, where the death could have been foreseen, mistakes made and blame apportioned. The National Confidential Inquiry finds each year that around 73% of people who die by suicide have not been in touch with mental health services in the year preceding their death. For the 27% who have and have had a risk assessment tool filled in at their last contact, 83% have been rated as no or low risk.²⁰ Even in the small group with recognised serious ongoing suicidality, there is often no expectation of the attempt at that point in time. Some are reported to appear to improve before their death.^{Reference Tillman, Stevens and Lewis21}

No. 5: suicide appears to be either impulsive or premeditated

Deaths by suicide appear to be either impulsive or premeditated.^{Reference Tillman, Stevens and Lewis21} There are numerous examples of apparently impulsive deaths, with many occurring in the middle of an argument or after a physical fight. In some cases, the suicidal act occurs within 5 min of the decision.^{Reference Simon, Swann, Powell, Potter, Kresnow and O'Carroll22,Reference Deisenhammer, Ing, Strauss, Kemmler, Hinterhuber and Weiss23} Many deaths, however, have been clearly premeditated, often over long periods of time, without even the closest people to the deceased having any awareness of this preparation. In some cases, people can be very determined, secretive and inventive about how to end their lives.

No. 6: suicide is part of the human condition and is not just related to a mental health condition

The relationship between suicide and mental illness is complicated and poorly understood. Data indicates that a significant number of people do not have a diagnosed mental illness at the time of death, and some have no known history of mental distress.^{Reference Coope, Donovan, Wilson, Barnes, Metcalfe and Hollingworth24–Reference Kafka, Moracco, Taheri, Young, Graham and Macy29} Whether this group has an underlying mental illness therefore cannot be established. The incapacity to mourn loss is thought to be an aetiological factor in both mental illness and suicide;^{Reference Gibbons30} however, the assumption of a direction of causality may be erroneous. Research shows that suicide follows antecedents that can be broadly categorised as life events including: significant physical illness, bereavement (particularly bereavement by suicide), relationship breakdown, being charged by the police (particularly with child sex offences) and domestic violence (for both perpetrator and victim).^{Reference Coope, Donovan, Wilson, Barnes, Metcalfe and Hollingworth24–Reference Kafka, Moracco, Taheri, Young, Graham and Macy29}

Thinkers about suicide such as Durkheim,^{Reference Durkheim31} Hillman,^{Reference Hillman32} Sartre and Camus^{Reference Camus6} do not see mental illness as a primary cause of suicide. Durkheim considers suicide as a social phenomenon (egoistic, altruistic, anomic, fatalistic); Hillman regards to drive to suicide as a transformative impulse, as an attempt to go through the death experience with meaning, Sartre as an assertion of authentic human will in the face of absurdity, and Camus as a rational response to life's lack of meaning.

If we just focus on those who have a known mental illness, there will be many who are at risk of suicide that are not attended to. If we put the location of disturbance* in the mental health and not the social arena, we can then make suicide solely the responsibility of mental health services and we can turn away and think no more about it.

No. 7: we cannot read other people's minds

With time to reflect, the ‘truth’ that we cannot read other people's minds seems undeniable. We don't know what is going on in our own mind much of the time, as around 90% of its functioning is unconscious. In mental health services, however, there is an underlying omnipotent belief, supported by societal expectations, that we have a special intuition about others’ minds and can predict an action someone else is going to make in the future.

Sometimes the death occurs shortly after being seen by family, friends or clinicians. Understandably, those in most recent contact can feel that they missed something or were misled. However, mental states change rapidly. The person themselves may not have been feeling suicidal at the time of meeting or may not have been aware of their level of distress, or, as described in the case example below, a loss event may have happened in the intervening period.

No. 8: no one is to blame for someone else's death by suicide

When affected by suicide, the capacity to mentalise*, to think and symbolise*, is lost.^{Reference Bateman and Fonagy33} In this non-mentalising state, the only option is to think concretely, and shades of grey cannot be conceptualised. ‘Blame’ is a word that comes out of this non-mentalising state of mind. It implies that there is one aetiological factor, and that we know what this is. In reality this could not be further from the truth. Suicide is multifactorial and complex. ‘Responsibility’ is a mentalising word and allows for many different factors to be involved. We can then think about what our responsibility was, and different narratives can be explored, including the part the deceased has played in their own demise.