Living with chronic suicidality

I have lived with suicidal thoughts stemming from complex mental illness for the most part of two decades. There are times when I want to die more than anything else. There are also times when I desperately want to live but can’t feel any hope. In between, there are long periods where I survive more than I live and have very few days without some kind of ambivalence between wanting (and not wanting) to live (or to die).

Awareness campaigns encourage us to ‘reach out’, ^{Reference Henderson, Robinson, Evans-Lacko and Thornicroft5} but I’ve only ever been able to access clinical care after a crisis. Even then, I have often felt blamed for my symptoms by professionals who have labelled them as ‘attention seeking’ or used the abstract word ‘behavioural’ to explain them. Conversations about suicidality, on the few occasions when they have taken place, have rarely been compassionate.

The right kind of suicidal

The debate around assisted suicide both highlights and reinforces a persisting divide in how society regards physical suffering versus mental suffering. ^{Reference Behan and Kelly4} The person whose body is failing owing to terminal illness has their pain acknowledged as legitimate. They are not seen as irrational; their death is part of the natural order, and their decision is met with empathy. New services for them have been modelled at pace in Parliament, with the promise of all the funding they need.

This lies in stark contrast to the lack of progress in providing understanding and support for those who feel suicidal as a result of mental illness. Many of us wait years for any meaningful response at all. The services we need are under-resourced, or do not exist. The message this sends is clear: there is a ‘right’ kind of suicidal, and ours is not it.

This hierarchy has significant clinical consequences. When mental illness is seen as a form of suffering that is less worthy of attention and support, this reinforces stigma and hopelessness, creating a damaging cycle in which people are discouraged from seeking help or seeing their struggles as valid.

Compassion as a safeguard

Assisted suicide is framed as a compassionate act, preventing the distress of a painful death. But compassion is not always about alleviating suffering, nor it merely a sentiment. Compassion is something that is enacted – through empathy, presence and kindness. ^{Reference Gilbert6} These practices depend on the structures of healthcare, including sufficient training and resources that equip clinicians with the skills and space to offer compassion ate responses sustainably. ^{Reference Harwood3,Reference Baguley, Pavlova and Consedine7}

In my own experience, I am grateful for the times when clinicians enacted compassion in ways that were not necessarily ‘soft’ – for being fiercely protective of my life when I have wanted to discard it. I am here today because of professionals who have held a firm line with me, even when I have pushed them away, and have understood that the kind thing to do doesn’t always feel kind for the patient, or for themselves.

If we’re going to talk about assisted dying with the language of compassion, then we need to talk about compassionate responses to mental illness with the same depth and nuance. ^{Reference Malhi8} For someone like me, who isn’t dying but often wants to, I need the law to protect me: from under-resourced systems, from clinicians afraid to talk about suicide and from myself on the days when I am convinced that dying is the answer. That, to me, is compassion.

The same nuance is needed when considering patients’ rights to make decisions. Achieving parity of esteem between mental and physical illness is not about offering the same outcome. Although patients have rights, that doesn’t mean that our views are always right, especially when we are in the grip of suicidality. This is when our right to life must take priority, even if it is not our own priority at the time.

Making space for suicidality

Too often, clinicians have either treated my suicidality as a pathology to be controlled and a risk to be managed, or ignored, trivialised and dismissed it as something I’m not really that serious about. In both cases, the reality of my suffering has been sidestepped, either by being erased or denied. Between these two forms of avoidance has been my unmet need for attention, presence and listening. What I have needed most has been someone to sit with me in my suffering and to listen without trying to change, minimise or deny my experience.

Being alongside those who are suicidal is not about agreeing with their thoughts or actions; it is about embedding listening and presence as central components of compassionate care, especially in the context of systems where these practices can easily be overshadowed by excess pressures and efficiency demands. ^{Reference Gilbert6} Public discourse and clinical practice alike need to make recognise that the suffering of mental illness deserves to be met with just as much resource, respect and compassion as terminal illness.

If dying well matters, so should living

I want people who are dying to have as much support as possible to die well. But I also want people who are suicidal to have the chance to live well. Part of this is being able to speak about wanting to die without being met with fear or avoidance. It also requires clinical environments in which staff have the time, training and support to respond with empathy and presence, so that compassion becomes a lived reality rather than an aspiration.

If our politicians can fast-track services to assist those with terminal illnesses to die, they must also act to improve the healthcare that is offered to those who are choosing, every day, to stay alive.