When it is Darkest
Author: Rory O’Connor

Overview

This book’s declared objective is to ‘promote the conversation around suicide’, a tragedy that the author portrayed as ‘one of the last remaining taboos‘. Asserting that it is a phenomenon that is ‘plagued by stigma, myth and misunderstanding‘, the book set out to dispel ‘14 commonly reported myths’ about suicide which range from ‘suicides occur without warning‘ and ‘suicide is inherited‘, to ‘thinking about suicide is rare’ and ‘suicidal people clearly want to die‘. Citing harrowing statistics that show that suicide affects 800,000 people annually, and it accounts for 1.5 per cent of all mortality, the book paints a heartbreaking picture of suicide as an epidemic that ‘can affect any one of us‘. Whilst the book’s narrative highlights the gloomy facets of suicide, it also conveys the optimistic message that ‘suicide is never inevitable‘ because it is ‘preventable right until the final moment’. Even more cheering is the book’s declaration that ‘for most people who contemplate suicide, the risk is usually short-term and linked to a specific situation’, and that ‘the vast majority…will never attempt suicide and will not die by suicide’. Written by a psychologist who said he has ‘spent all my working life studying suicide’, the book also benefits from the author’s personal experiences of mental illness (pages 1-2,  6-7, 11, 16, 22, 36-37, 48-49 and 55).

Synopsis

In exploring the seemingly inexplicable reasons why people set out to take their own lives, the author highlighted the urgent need of some people with depression to end ‘unbearable‘ psychological or mental pain which they feel ‘no one else can understand’. Because they are unable to imagine ‘a time when things will be different‘, the author explained that suicidal people see death as ‘an urgent and permanent’ escape from their sense of ‘entrapment‘. Many suicidal people also ‘think they are a burden to others and that if they kill themselves then their loved ones will be better off’; therefore, rather than seeing suicide as a selfish act, they actually ‘feel that they are doing their loved ones a favour‘. Dispelling the idea that suicide attempts are attention-seeking acts, the author stressed that self-injurious behaviour ‘is a marker of distress‘ which requires ‘a compassionate, human response’ (pages 13, 35-39, 42-43, 56-57 and 61).

A major theme of the book is its detailed exploration of the manifold risk factors for suicide, what it refers to as ‘a complex set of biological, psychological, clinical, social and cultural determinants’. For example, the author reviewed the relationship of suicide to gender, pointing out that whilst the risk is higher in males, ‘women tend to attempt suicide more frequently‘, and ‘more females have switched to more lethal methods of suicide’. Similarly, he discussed how parental suicide heightens the risk of offspring suicide, noting that this is greater following maternal than after paternal suicide. The book also discussed the risk of suicide following childhood trauma, which the author said was present in about 80 per cent of suicide attempts, and the risk in people of low social class, a situation that increases the likelihood of suicide about ten fold. Other major risk factors the book highlighted are the personality profiles that increase the capability of carrying out the suicide act, and these included higher impulsivity, low physical pain sensitivity, and the fearlessness of death. Perhaps more worrying are the more banal risk factors for suicide which included sleep disturbance, bullying, bereavement, divorce, and ‘everyday failures, everyday crises and everyday losses‘ (pages 12, 22-26, 36, 40-41, 51, 124-125, 152, 165-171).

The impact of suicide on those left behind to mourn was a very touching theme of the book which portrays every suicide as ‘an unbearable personal tragedy‘ whose vast ‘ripples‘ extend ‘well beyond our immediate families’. Depicting suicide as ‘the most shocking outcome from depression’, the book describes how it leaves in its wake shock, disbelief, family and relationship strain, feelings of resentment and isolation, and ‘overwhelming’ stigma and helplessness. Metaphorically illustrating the wide ramifications of suicide, the author likened each event to ‘a social bomb exploding, with the extent of the devastation impossible to predict’. The author also used his experience of suicide to illustrate the other emotions that a suicide evokes, for example the guilt that tormented him for not reaching out to his suicidal friend Noel ‘in his hour of need‘. He also narrated the devastation he felt after the suicide of another friend Clare, an experience which he said ‘changed me as a person’ and ‘made me question my professional life’. Other relevant concepts the book explored in this theme were suicide contagion and suicide clusters (pages 2, 10, 15, 161-164 and 242-243).

The author’s recommendations on dealing with the suicidal person formed the most practically helpful theme of the book which emphasised the need ‘to do whatever we can so that people around us don’t feel such emptiness and meaninglessness, don’t feel so disconnected that they see suicide as the only way to be free‘. Arguing stridently that ‘anything that interrupts suicidal thoughts can give someone the chance to reconsider the decision of life versus death‘, the book urged people to consider even such simple acts as smiling, a ‘social connection‘ that can be ‘life-saving’ because ‘it is an acknowledgement that we do exist, that we are sufficiently valued by another person, that we are worthy of a smile’. Further underlining the ‘powerful suicide-protective effect’ of social contact, the author advised that ‘if you think someone is struggling, reach out, drop them a message, check in with them’. And in dealing with people considering suicide, he counselled that all suicidal utterances should be taken seriously and explored ‘directly and compassionately‘ with ‘active listening‘ to uncover ‘what is driving the thoughts of suicide’; this, he explained, could ‘give people the opportunity to consider their options and rethink their decision to end their life’ (pages 43-45, 50-53, 190, 225 and 229).

Beyond individual-level acts that help to prevent suicide, the book also reviewed the policy-level interventions that are effective at the societal level. In this regard, amongst the measures the book advocated were ‘restricting access to the means of suicide’ such as by limiting paracetamol retail quantities; discontinuing non-toxic domestic gas supply and car exhausts; and putting barriers on bridges. At the healthcare level, the processes the book advocated included the use of ‘brief contact interventions‘ for suicidal people; safety planning after suicide attempts; and long-term psychological interventions such as dialectical behaviour therapy – a form of cognitive behaviour therapy that the author said aims to ‘resolve contradictory problems in people’s lives by finding the balance between achieving acceptance and the need for change‘. And at the academic level, the author introduced his integrated motivational-volitional (IMV) model of suicidal behaviour, explaining that this concept covers ‘the processes that lead to the formation’ of the suicidal intention, and ‘the transition from thinking about suicide to attempting suicide’, and arguing that it helps in the development of better interventions for suicide (pages 144-145 and 187-226).

Opinion

This book conveys an enlightening perspective of suicide as the desperate act of people who see no other way out of their unbearable pain. It portrays suicide in a sensitive and understanding manner, using this approach to highlight the practical and humane strategies of managing it. The book is also an educational resource replete with information and statistics that highlight the diverse facets of this disturbing phenomenon. A few themes were unnecessarily dragged out, such as the chapter on making sense of suicide, whilst others were a rehash of previously covered subjects, such as the chapter on what suicide is not. Otherwise, the book’s content are comprehensive and exhaustive, and it successfully achieved its educational objectives.

Overall assessment

This book is a handy tool which provides accurate information about a subject that is little understood within and outside healthcare. Just as it dispels the prevalent false impressions of suicide that abound, it also documents the risk factors that are largely preventable. Most importantly, it gives invaluable recommendations on simple measures that individuals and society can implement to mitigate the risk of suicide. The author presents his arguments in simple language, and his tips in practical terms. Whilst many of the recommendations the book makes are aimed at the general public, several are professional interventions which benefit the public and healthcare providers. The book is a rare insight into a complex problem that blights healthcare and I recommend it to all doctors.

Book details

Publisher, Place, Year: Vermilion, London, 2021
Number of chapters: 14
Number of pages: 346
ISBN: 978-1-78504-343-7
Star rating: 4
Price: £11.69