Suicide Prevention and Service Failure in the U.K.

Waking up, I knew it was the day – it just had to be. The voice in my head had spent weeks getting louder: “Die, just die, you deserve to die.” It was so overwhelming that at times I would scream it to the four walls of my bedroom, my most constant companions. It was a radiant, cloudless day as I set out from my house, first to the local supermarket’s pharmacy, where I asked for “a pack of 32 co-codamol please,” and there it was in my shopping basket with no questions asked. Once I had paid for it and then bought some vodka and grapefruit juice (having read that the latter exacerbates overdoses by inhibiting cytochrome p450), I left. You see, I had done my research. I headed to another pharmacy, walking purposefully in a state of happiness—no, make that contentment. As I headed to the next pharmacy, due to limits on purchasing co-codamol, I should really have thought up an excuse for all those painkillers: when a diligent assistant asked, I offhandedly complained of back pain. As I look back now, how bizarre I must have looked skipping back down the street toward home, gripped by a very different kind of pain, excited by the imminent pharmacological vanquishment it, and I, faced.

A Dread of Failure

It had been a tumultuous few months until I reached that point in May 2017. The previous October, I had become estranged from my abusive father; in January, I’d met my first serious girlfriend, soon after I’d received an offer to study medicine at the University of Oxford, and by April I had had my first heartbreak. By the beginning of May, the cracks had begun to show: I became increasingly obsessed with failure. Failure has always dogged my thoughts, from my first childhood memory of being beaten right through to the university application process. Indeed, I became so afraid to fail that I simply couldn’t countenance sitting my A-Level exams; I felt certain that it would go badly. I knew so, and I knew I couldn’t cope with failure.

At age 18, I’d tried speaking to doctors about it, obtaining an anti-emetic for my nauseating panic attacks, but the 14-week waiting list for cognitive behavioral therapy (CBT) just felt too much; I had already tried therapy at age 16 and –whilst it had been the first time that I disclosed the beatings I had endured— it didn’t work for me. I didn’t want to talk about going to the police, and I didn’t want to see my Dad punished. I wanted to tell someone that when I was 14 I’d begun to cut myself, or that at the time I was burning myself with hot metal straight from my oven, but I was scared.

Looking back, I’d spent much of my life feeling scared of someone or something. Scared of being alone, scared of talking to others, scared of my Dad, scared of horses, scared of anything that felt threatening. All that talk of the police and punishment made me frightened that maybe I, too, would be dealt with punitively. That’s certainly how psychiatric hospitals seemed: places where mad, bad people got sent to be reformed.

Overdosing on Pills

Barely a month before the most important exams of my life thus far were due to begin, crucial to determining my place at medical school, I took an overdose. Sitting at my kitchen table, I popped each pill one by one, laying them out: 64 co-codamol, 35 sertraline, 20 prochlorperazine; my entire stash, laid out beside the vodka and grapefruit juice. By this point, it was midday, my Mum and Stepdad were at work, and I reasoned that I could swallow all of the pills, tidy the house, make it to bed, and die all before they returned.

I wrote a note, apologising for what I had done, offering closure to my Mum, and I found myself crying for the first time in years. By that point, as the dripping tears caused the ink to run, I poured a drink and the pills went down the hatch as I wrote further apologies. The great irony was that in my hurry to acquire (what seemed like) enough drugs to overdose, I forgot writing paper, and so my suicide note was written in a notebook with “Thoughts and Dreams of an Undiscovered Genius” on the cover.

I had taken the prochlorperazine thinking that it would stop me from vomiting; it always did during my daily, nauseating panic attacks. This time, it didn’t work. Barely half an hour after ingesting the mammoth supply of pills, I found myself in a daze, vomit pooling across the laminate flooring in the hallway of my childhood home. “It’s begun,” I thought, “death is but hours away.” As I crawled up the three flights of stairs to the top of our house where my bedroom lay, I vomited yet further and collapsed, facedown in a shallow pool of my own effluence.

The story gets a bit hazy for the next few hours as I drifted in and out of consciousness. I remember calling the National Health Service non-emergency helpline; I didn’t want to be alone, feeling frightened, and knowing that I had failed. Pulsating pains launched through my head as I sat and waited for an ambulance, uncertain what damage I had done to my body. I lay on the floor again and drifted back to sleep.

The crew came a couple of hours later and took me to my local Accident and Emergency Department. By this time, my Mum had returned home, too. She thought initially that I had accidentally taken a double dose of antidepressants; little did she realise that I wanted to die. As I lay on a gurney, cardiac monitors bleeping in response to the arrhythmia and hypotension induced by the prochlorperazine and surrounded by sick bowls, I told my Mum for the first time about my life growing up a hundred miles away from her, of the smacking I’d endured whilst screaming apologies for my inadequacy. I told her of the smashed furniture, the smashed plates, and my smashed self.

Failed Interventions

Mine, you see, is a story of failed interventions. I misbehaved a bit at school and then I was referred for counselling, aged 14, to a charity-funded therapist. We developed something of a ritual; For weeks, my first sentence would always be “I’m very well, thank you, how are you?” Sometimes we got close to what hurt, but I could never find a way to express it, lacking the vocabulary to describe a decade filled with pain and insecurity. One day, though, I arrived for our session looking appallingly dejected, short of breath, and unable to even say, “I’m very well, thank you, how are you?” My perennial platitude had failed, and I was exposed as troubled, but still unable to say by what.

Jane, as I shall call her, took me home in her car immediately, putting me to bed and updating my Dad on my evidently faltering state of mind. I didn’t leave that room for a week, as terrified by the homophobic abuse I always received at school (and the isolation I felt when walking near it) as I was of facing my Dad. At our final therapy session, when the funding had run out, Jane had cried and told me that she wished she had called the local authority to take me into emergency foster care. She must have known something was wrong at home, but I still hadn’t told her. Moreover, it wouldn’t have crossed my mind to do so: He was my world, the only person I knew in the town. To be hit by someone who loves you is better than to feel unloved, I reminded myself.

That the money ran out without Jane’s and my ever exploring what hurt most was cruelly mirrored years later in the trigger for my suicide attempt –that too-long wait for a CBT session. Looking back, I wonder whether, had Jane been given more funding, I could ever have told her what she needed to know in order to have me taken into care. I wonder, too, whether that CBT list would have been so intimidatingly long had the local mental health services had more funding.

My story ends somewhat brightly, though. I sat my A-Level exams whilst I remained an inpatient in hospital; when the results came out in August 2017, I had missed my offer for Oxford by one grade and was denied the place I so coveted. Instead, I found myself whisked off by my Mum to the University of Bristol for a tour. I loved it— the city and the university— and took up a place at its medical school a few weeks later.

New Problems, Same Old Solutions

A year later, though, after my inpatient stay, the absence of any therapy in the community began to hit me hard and the same morbid thoughts began to creep into my mind. I found a new way to cope, however: self-starvation. Starvation gave me a focus, a purpose, and a way to cope when things went wrong. It was comforting when my emotions felt out of control, but starvation wasn’t sustainable; I found myself facing university disciplinary proceedings for the many absences caused by my psychological distress. During a routine appointment with my GP regarding anaemia, she picked up on my demeanour and probed, suggesting that I might have anorexia nervosa. She referred me for an assessment but forewarned me that the clinic waiting list was four-to-five months long. That was a turning point: I knew I needed to help myself in the absence of professional support (other than carrying an unhelpful label that I resented) and so over the next three months, I regained and maintained 10 kg.

I made this decision for the same reason I wound up hospitalized the first time, namely the NHS’s failure to provide follow-up care. After I had been deemed clinically stable following my suicide attempt, I was transferred to an inpatient psychiatric unit. I’d received a provisional diagnosis of “emotionally unstable personality disorder”, and was advised that psychologists would be reluctant to work with me. However, I didn’t expect to hear nothing from my local mental health service upon discharge. Once the community nurses had spent a week visiting me daily at home, that was it – I would be abandoned by mental health services once again.

When I moved to Bristol, I visited my new GP to discuss this and the transfer of my “care” to a new NHS trust. This led to the only outpatient appointment I have ever been offered with a psychiatrist: He confirmed “emotionally unstable personality disorder” and added “cyclothymic disorder.” Reliving, for the first time, those memories of my suicide attempt was deeply distressing; I forgot all the questions I had planned to ask about therapies. In keeping with the advice I had earlier heard, no specific service for either diagnosis reached out to me; in fact, nobody has discussed wither with me since I gained those labels.

Earlier this year, three years after my attempted suicide, I was offered a therapy programme for anorexia nervosa. I had maintained a BMI > 22 for 16 months and therefore no longer needed it. This strikes me as exemplifying the problem of a care system that lacks not only funding but also holistic, dare I say sensible, organisation. There are services for people with eating disorders, people with personality disorders, child-abuse survivors, and self-harmers; what good are they, though, if you have all of those issues? Truly holistic care cannot be possible if mental health services are this stretched and this pigeonholed into categorisations that do not reflect the complex, multifactorial development of distress within those who becomes their patients. It seems like common sense, too, to posit that attending each of these individual clinics, even if you could get the necessary referrals, would never solve all of your problems. A different professional looking at each one discretely means none of them would see the whole of you.

Now in my third year of medical school, I try to look after myself. Carrying diagnoses of emotionally unstable personality disorder, cyclothymic disorder, and anorexia nervosa is a huge burden and sometimes I feel angry, — like I was failed by a system that didn’t care about me. Mostly, though, I don’t think much about it; I try to stay busy and fill each moment of my day with something to occupy my wandering mind. When I do think properly about it, though, the story has a simple moral: Maybe if the charity had been better funded and I had had enough counselling at age 14 to find the words to say “I don’t feel safe,”…maybe if the local mental health services had enough funding to reduce their waiting times or to offer me post-inpatient therapy… maybe if I’d had lessons at school about accessing healthcare openly and supportively, then maybe, just maybe, I wouldn’t have found myself starving and unable to move, effectively paralysed by malnutrition before having to put all that weight back on again.

The truth is, it’s really hard to talk about suicide. We are constantly constrained by the notion that our mental health is our individual responsibility to manage, told to “live our best lives” by a never-ending campaign of exploitative wellness fads. A more collective conversation is needed, rejecting this liberal individualism, so that those people who aren’t immediately able to access specialist support can talk to the people around them. For too long, psychiatrists have controlled the discourse on mental health –they create the diagnoses, then profit from treating those who meet their criteria – and this really isn’t working: Suicide remains a leading cause of mortality worldwide. A more collective discourse, in which thoughts of suicide can be talked about openly (such as in this article) may be the first step not only to help those who are suicidal to navigate healthcare services, but also to deinstitutionalise “mental illness,” creating a more accepting culture in which certain behaviour patterns (from hearing voices to wanting to die) are no longer taboo.

I bear the mental and physical scars today of years of abuse and neglect, much of it self-inflicted. If we are to prevent that happening to future children, even future doctors like myself, then properly resourced mental health services are needed, alongside an open culture around suicide. And to anyone who may be feeling similarly to the thoughts described above, I shan’t offer advice or comfort, because I know that “it will get better” feels hollow and mendacious. For those people, know that –like me—there are academics, activists, artists, students, clinicians, and survivors of suicide fighting for you and with you, though we will likely never meet you. If only we could just talk about it; so far, this has been a very one-sided conversation.