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Stigma: A major barrier to prevention


Stigma surrounding suicide is the theme of this year’s World Suicide Prevention Day taking place on September 10.

And it isn’t simply the fear patients have in approaching healthcare professionals that needs to be tackled – it’s also the apprehension that nurses and GPs have in exploring their patients’ mental wellbeing. They are usually too scared to ask.

“A lot of people don’t seek help, or if they do, they don’t actually say that they are experiencing thoughts of suicide,” says psychiatrist Dr Alys Cole-King.

Dr Cole-King is the founder of Connecting With People, a not-for-profit organisation that provides suicide awareness and prevention training to professionals acrossa range of disciplines.

“For suicide prevention to work you need to change the culture across all sectors.  People need to be inspired to personally make a difference in saving a life,” she explains.

Three quarters of people who die by suicide were not in contact with specialist mental health services in the year before their death but many of them were attended hospital and in particular emergency departments or visited their local surgery for other reasons in the days and weeks prior to their death.

“The first step is to remove the fear and secrecy – tackling the stigma,” she says.

People affected by depression and suicidal thoughts find it hard to approach anyone for help. Research has shown that young people especially do not think their local health professionals will be interested. But people will often seek medical help for other problems in the hope that someone will then approach them, however this doesn’t often happen.

“It may be vague symptoms like tiredness, lethargy or unexplained pain. Sometimes the nurse or GP will find it difficult to then ask about the patient’s general wellbeing. They need to break the barriers and ask questions like, how are you coping at the moment? How is this affecting you? How is life generally?” she says.

Noticing the signs of depression and having the courage to investigate them will improve early intervention with those contemplating suicide.

“People need to be aware of the signs and know how to compassionately respond, and if they can’t deal with the problem themselves they need to know where to find people that can. Our mission is to make sure this happens,” says Doctor Cole-King.

Nurses and GPs providing health services are just as fearful of mental health issues as the public, but many lives are saved when healthcare professionals take a risk and reach out.

“There are some fantastic examples of compassionate care, but some of the research also shows us that healthcare professionals don’t always respond as we would wish because of their own fear and stigma. We need to raise the confidence of healthcare professionals,” she explains.

World Suicide Prevention Day is an internationally recognised event that seeks to raise greater awareness of suicidal thoughts and feelings and their consequences.

“For World Suicide Prevention Day we will be collaborating with all sectors to spread the message that the stigma of suicide is often the biggest enemy. We need healthcare professionals to realise it’s not a ‘them and us’ situation. You never know what life will throw at us. Suicidal thoughts are more common than we realize and it’s important to know that we can get through them and where and how to find support” For more information regarding the Connecting with People World Suicide Prevention Day campaign please see


How you can help

Do not be frightened to ask your patient if they have suicidal thoughts – this is the first step in reducing their risk of dying by suicide.

Suicidal thoughts are far more common than people realise. Stigma stops us talking about suicide but talking about it helps break down stigma.  

All suicidal thoughts, however ‘minor’, require a response that needs to be compassionate, proportionate and timely.

Listen to carers - nurses can gain useful and important information from third parties such as family, friends and colleagues in addition to objective evidence - particularly if someone has self-harmed, or has attempted suicide.

Connecting with People have developed a range of practical and compassionate self-help resources with their collaborators on behalf of the Royal College of Psychiatrists - available to anyone in need of advice and support. They promote appropriate self-help and inform people regarding useful strategies, how to create a ‘safety plan’ and how they can access help and support:

  • ‘Feeling on the edge helping you get through it’ - for people in distress attending A&E following self harm or with suicidal thoughts
  • ‘Feeling overwhelmed and staying safe’ - for anybody struggling to cope when bad things happen in their life
  • ‘U Can Cope’ - originally designed to help younger people develop resilience and cope with any current/future difficulties in their life. Just as helpful for adults of all ages

‘U can Cope’ film and all resources available:



Follow World Suicide Prevention Day on twitter: @AlysColeKing



Readers' comments (72)

  • Katie Sutton

    Wonderful post, I said some of the same things in my own:

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  • big joke. please don't forget suicide ideation and completed suicide can and does also affect healthcare professionals as much as the rest of the population.

    organisations like Samaritans are only volunteers and not mental health professionals and the ones i have phoned for help always have to deal with any other incoming calls as well. you may be in the middle of pouring your heart out and thinking you have found somebody to listen to you when they suddenly have to attend to another call which is urgent leaving you with the thought that somebody else's needs are more important than you own.

    this has also happened to me in mental health services when the on-call doctor or nurse suddenly gets called away to an emergency and ends the chat - again other patients are more in need than i am although I might easily have gone away and attempted suicide.

    recently a mental health social worker told me she had asked the mental health team of the local hospital what to say if a patient threatened suicide. the reply was tell the patient I hope you won't kill yourself and if you need further help i will refer you to the mh services.

    an intern responsible for looking after in patients on the mh ward told me that if I wished to take my own life that was my responsibility and my own choice and nobody could do anything to prevent it when all I wanted was a talking therapy and some words of reassurance. On the phone on occasion I have had the same response from other on call staff members when I had been told to call the service day or night if I felt the need of a professional in a service who knew me well. Fortunately, more often than not I did get some doctors or nurses who were very understanding and gave me the time and reasurancce I needed.

    I once took an overdose when i was in a locked unit and feel into a deep slumber for 24 hours before I had finished taking the rest. I got as far as 7 Lorazepam 1,5mg which was no big deal but nevertheless not the best idea. All they could do when I awoke the next day was express their anger.

    Fortunately i am still here ten years later but have lived through some very dark moments. My named nurse said such thoughts would always return and unfortunately they do but I have learned up until now to manage them uncomfortable and unwanted thought they often are.

    The upshot of all of this 'treatment' was I carried out a very thorough literature search over several years to try and find out how to support patients with suicide ideation and threats of suicide to determine what i should realistically expect from these specialists services in terms of understanding and support and whether my exceptions and demands of the service and fellow human beings were far too high. I now conclude that they were not and every trained hc professional and especially those working in mh services should be able to meet such demands.

    often my threats and pleas for help were ignored and once i was so desperate I expressed them in front of a group of patients whilst in a day clinic and was immediately hospitalised in a locked unit but there I felt secure and cared for. I think basically I was in a desperate situation but deep down I did not wish to end my life and found many different reasons not to such as failure which could end in severe damage to an otherwise very healthy individual. I was often scared i would make a dangerous attempt and had plenty of opportunities in my environment to do so.

    I eventually found the work of the Aeschi Conference a group of suicidology experts who meet regularly and notably the work of the late Orbach who really understood how to get inside the mind of the suicidal patients he was treating and where they were coming from.

    My apologies this is rather long and written in a rush but I hope my personal experiences may be of some interest or help and i hope i will be able to extend my help to others who might find themselves in a desperate position.

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  • Anonymous | 10-Sep-2013 6:20 pm

    I meant to add to my above comment that there were often times when I openly expressed my suicidal ideation to mental health professionals in whose care i was that I was not being heard or taken seriously. they often did not respond or changed the subject which in my mind did not help me to solve my problems and often exacerbated them and my frustration.

    Apart from the one episode above when I disclosed my feeling in front of other patients, I have never talked about these feelings to anybody apart from those in mental health who were responsible for my care. I did attend a self help depression group but it was more focussed on other things than one's own feelings and I found it of little support.

    I once or maybe more sent an e-mail to Jo at the Samaritans and there I did get very good and supportive replies within 24 hours. I think this is an excellent adjunct but not a substitute for one to one professional contact. After 10 years of psychotherapy at £85/hour only partially reimbursed by insurance I have now decided to go it alone preferring to save for some excursions and holidays instead. My therapist is always there for any hiccups and is great to talk to but all I do there is ramble on about anything I wish and he says very little. Although we have an excellent rapport I sometimes found it rather disconcerting that he is blind so cannot observe my facial expressions or posture but I imagine he has plenty of other means such as tone of voice, etc. He is a clinical psychotherapist working in the hospital and is very highly thought of and seems to have a great understanding and grasp of all I have told him and I am sure would not be there is he was not an expert in his field.

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  • Anonymous,

    Please stay alive.
    The world needs you.
    You are totally amazing and thank you for posting.

    I sometimes talk to people and what I find is listening. Just listening and knowing you are being heard is important

    Will post tomorrow


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  • Good article & much needed. Even if you ask for help the stigma within services can be humiliating/degrading and just add to the despair you're already feeling. So degrading I won't recount them here.
    Having recently had a horrible experience following my own suicide attempt, including being told by the nurse when asking for painkillers (headache from hypertensive crisis) to "shut up, we're busy with people who are really ill".
    Apart from the fact that we are duty bound in our code of conduct to treat people without discrimination, if a nurse is unable to control her prejudices, or feels out of his/her depth dealing with such a situation then, at least until those issues are addressed, surely s/he should also follow clause 28 of the code ("You must make a referral to another practitioner when it is in the best interests of someone in your care.") rather than risk harm to the patient?

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  • Anonymous | 11-Sep-2013 2:29 am

    a nurse who replies to a patient in this manner should be reported and punitive measures taken or the problems of his/her own stress sorted. the difficulty however is often who to report it to as either nobody listens or they politely listen but no action is taken as the staff all stick together to defend on another.

    I reported on nurse who responded very poorly in a similar manner when I was in a critical situation in mental health. I told my psychotherapist who said we could arrange a meeting with her but when I saw this would cost me another £80 odd for the session I dropped the matter.

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  • Anonymouses,

    I think a lot of people in society cannot really cope when giving help and support to someone who has tried to kill themselves.

    Its all about listening and understanding.
    Its just being there for people and loving them as much as you can. Its all about saying "I know what you are going through and I can help".

    Hugging helps. Its all about being in contact and knowing, just knowing someone out there wants you.

    World Suicide Prevention Day? That just stops you from dieing, it doesn't start you living again. You need courage and strength to start living again, otherwise you just existing, waiting for something else to come along.

    I am proud of both of you, so really proud as you are still here with us.

    I am on other chat forums and whenever anyone asks for help, we always support and if I knew you, I would hug and start talking to you and strat listening.


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  • PDave Angel | 11-Sep-2013 8:42 am

    that is all very well and sweet and thank you for your support there is plenty of room for that as well but a serious clinical discussion is needed here on the failings of the services and how they can be improved to support patients like myself and others in need and on the expectations one has from our highly qualified mental health colleagues.

    the purpose of my comment was to cite my own experiences and see how they can be used to stimulate debate for professionals and how we can help others. just because someone such as myself has lived through such experiences does not mean we totally understand others and their needs but we need to research as much as we can, gather experience from others and do our very best.

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  • Anonymous | 11-Sep-2013 6:25 am

    "a nurse who replies to a patient in this manner should be reported and punitive measures taken or the problems of his/her own stress sorted."

    Or perhaps, it might be an idea to discuss it with the nurse and give him/her the right of reply, before the firing squad are marched in.

    I am a research nurse and today I watched a patient accuse a mental health colleague of saying a variety of things (during a session where I was an observer) which she didn't say at all. This gentleman is deeply unwell and I was impressed by the RMN's calmness and genuine concern for him in the face of some outrageous allegations. For the nurse, this is not an unusual part of her job. It is not always as straightforward as we would all like to think.

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  • michael stone

    Suicide is a hugely complicated issue: beyond it almost always being tragic that a person is contemplating suicide, and that suicide is not illegal and (for attempted suicide) not under English law an automatic proof of mental incapacity, I can't really comment much on this.

    But obviously anyone who approaches HCPs because of suicidal feelings, should be dealt with in a sensitive and appropriate manner - exactly what that means, however, varies a lot with 'the circumstances'.

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