Bipolar disorder Pendulum: stories and information suicide prevention toolkit Suicide is the single biggest killer of men aged under 45 in the UK. In 2015, 75% of all UK suicides were male. Bipolar increases an individual’s risk of suicide by up to 20 times. We estimate 3 people living with bipolar take their own lives every day. But with the support we can help change this. Jeremy shares his thoughts on suicidal ideation and how to prevent it. What is suicidal ideation? I am sure there are suicides that occur due to a sudden perceived catastrophe such as a stockbroker realising a plunge in the FTSE has wiped out their holdings, or someone who's failed their A levels and has the immediate prospect of studying at the local agricultural college instead of university. But my experiences of suicidal ideation were far more sustained. It typically started with a slide over a number of weeks into depression, then deeper down to a point where my thinking became fixated on self-destruction. In this state, my mind seemed to focus exclusively on ways to take my life with an exhausting drip, drip, drip of repetitive suicidal thoughts. It was quite simply my brain telling me over and over again to kill myself. Sometimes the only relief was to consider different suicidal methodology and how comforting it would be not to exist anymore. This could go on for weeks and was exhausting. I think I should point out that the majority of the time I'm in a normal range of mood and these thought patterns were episodic. I haven't been affected for a number of years and I'm fine today. I think it is interesting to consider the first time I experienced these thoughts. I was 17 years old and still at school, recovering from my first manic episode that had thrown my academic life into disarray. It took 10 years for me to get a diagnosis of bipolar (about average) and I had no idea at the time why my erratic behaviour had damaged relationships with teachers and students alike. During the depressive episode that followed the mania, and which included suicidal ideation, I had no psychological tools to manage what I was experiencing. I concentrated on salvaging my A levels and in time was lucky that the extreme negative thought patterns subsided, despite a level of residual depression lingering for several years. So, what stopped me? Probably the most important thing is the fact I grew up in a family. My dad had bipolar so there were times when our lives were anything but stable, but we stayed together as a family despite some lean times. I consider that to be a strong protective factor. However, if a friend comes to you feeling suicidal, an observation about the benefits of stable family life isn't going to be much help. Are there practical things we can suggest beyond the usual, sound advice of going to a GP and calling a helpline if you're desperate? I believe so. There are protective thought patterns that I have developed that now enable me to beat suicidal ideation almost before it starts. When I was grappling with bipolar in the early noughties, I found a psychotherapist who specialised in Neuro-Linguistic Programming (NLP), a branch of Cognitive Behavioural Therapy (CBT). A few sessions of NLP helped me establish a greater awareness of my inner voice and observe the way my mind told me all sorts of unhelpful messages. Developing an ability to spot self-sabotaging thought patterns, and to consider alternative ways to appraise myself and the world around me helped me significantly. I have since used the techniques I learned to develop a toolkit, which I apply when I spot the early warning signs of a manic or depressive episode occurring. There are specific things I do to prevent mania, but I will focus here on techniques to prevent the depressive phase and suicidal ideation. My suicide prevention toolkit: The anti-depression spanner set This consists of all the things I do to turn around a developing depressive episode – increasing exercise, coming off alcohol and coffee, telling my wife and trusted friends/colleagues that I'm at risk, and ensuring adequate but not excessive sleep. I apply the CBT techniques I have learned and pay more attention to my mental 'monitoring programme' that observes my thoughts and challenges irrational perceptions. Listening to 70s funk helps, rather than intensifying my low mood with someone like Leonard Cohen. Fresh air, sunlight and a good diet are also key. Antidepressant medication can be useful for some, but it can precipitate mania in people with bipolar and for that reason I don’t take it. The hammer of experience People who make attempts on their lives run a significant risk of completing on the second and future attempts. But this is where a key protective thought pattern can be introduced. I tell myself that I survived last time, so this state-of-mind is temporary and will pass. I've managed to get out of the hole before and will be able to do it again. Explaining this to someone who is suicidal is tough and they simply aren't going to comprehend easily. Their mind may be telling them that a perceived catastrophe or situation they are facing is final and can't be solved, and that the only logical way to deal with it is self-destruction. They may believe they will always feel this bad. If done sensitively, however, it is possible to plant the kernel of an idea of the eventual transitory nature of these thoughts. The screwdriver of positive memories I list the positive things that have happened since I was last feeling suicidal – what would I have missed if I'd gone through with it? When I first applied this thinking, it was things like becoming an uncle, making some new friends, and learning salsa dancing, all of which I would have missed. Between each episode, there will be a number of positive memories, so extending that to imagine all the good things I would inevitably miss in the future is another useful tool. Thinking back on all I would have missed in the 27 years of life since my first episode of suicidal ideation is quite sobering. The pliers of blessings Someone experiencing suicidal ideation may feel that they have exhausted all their resources, that they have nothing to count on. However, even in what appears a desperate situation, it is possible to count your blessings and to do it systematically. I have water, I know where my next meal is coming from, my shoes are keeping my feet dry, I have somewhere to sleep tonight, I have a brother and can call him anytime, and so on. Suicidal ideation can stem from an underestimation of the resources we have at our disposal, so listing what we have can be helpful. Saying to someone 'how can you be suicidal when you have so much, you should count your blessings' is unhelpful. But helping them to realise how much they do have can be beneficial, if done sensitively. You may not be able to convince them in the moment, but again, you may be able to establish the seed of a positive thought. The electric drill of other people's grief Thinking how people would react to my suicide is helpful. In the past, I have pictured the despair and grief that my family and friends would experience. It was hard to think of putting them through that pain and enough to make me think twice. Now that I am married, the thought of my wife having to cope is simply unthinkable. Sometimes people who are suicidal feel that the world would be better off without them. They may believe they have created a catastrophic situation and their friends and relatives would benefit from them not existing anymore. Again, this thought pattern is not borne out by reality. We know that families and friends suffer intense grief related to suicides and it even increases the risk of further suicides within the group. Considering the psychological impact on the person who would discover me is also a thought that has held me back. The workbench of community I have facilitated peer support groups for people with bipolar for ten years. Once a month, 20-30 people with the condition, carers and family members come to the group and talk for two hours, developing practical self-management techniques, and finding advice on how to help loved ones. It is common for people who have attempted suicide or who are experiencing suicidal ideation to attend the group. Managing a response effectively is a key part of my role, not least because the group needs to feel that the right support is being given. Failure to manage the situation adequately creates anxiety within the group and people might then be prompted to take action they are not trained for, which could involve risk. When someone in a suicidal frame of mind comes to the group for the first time, I start by talking of my own experience as this creates a permissive environment where suicidal thoughts can be discussed openly. I stipulate that methodology is not a topic for discussion, neither is recounting historical attempts. Instead, I get the group to focus on practical techniques to deal with the ideation. The group is overseen by Bipolar UK, who provide insurance, manage background checks for facilitators, develop policies, train the 450 volunteers who run the 123 groups countrywide and manage the group's finances, which in our case is simply ensuring our room hire is paid. If someone is suicidal when they come to the group, we offer to pass their phone number to the charity's staff, who will contact them, helping them engage with statutory health services and other support. People develop their own networks of friends within the group and it can be the cornerstone of someone's journey to rebuild their lives. In the 10 years I have facilitated the Central London group, over 500 people have attended and I am not aware of us having lost anyone to suicide. The sense of belonging to a group, finding a new set of supportive friends and sharing experiences has no doubt contributed to these and other success stories. This is corroborated by feedback in Bipolar UK's annual surveys in which service users report a reduction in suicidal ideation in each of the charity's service delivery methods: peer support groups, the helpline, the e-community, and information on the website. The monkey-wrench of meaning I have found self-help books useful in the past and one that I often recommend is 'Man's Search for Meaning' by Victor Frankl. He built a career in psychiatry having survived life in a concentration camp. He observed that some of his fellow prisoners had been more resilient than others and concluded that the difference was because they had found meaning in their lives despite the obvious horror of their surroundings. Volunteering to help others and the sense of purpose that comes with it, has a very distinct benefit and can be extremely useful in rebuilding self-esteem. Helping others with suicidal thoughts has helped me find meaning in the experiences I have been through. The anvil of language I think it's important to pay attention to the language I apply to myself but also the messages I receive socially. Is it helpful for example to point out that groups of the population are more at risk? In the warped logic of a suicidal mind this can become a justification. I have thought to myself in a suicidal phase 'I'm male, in the risky age range and I have bipolar so people will forgive me if I do this – it's almost pre-destined'. Equally, someone may feel that resources are being unfairly targeted at certain groups that they don’t belong to, and it is therefore important not to focus on men at the exclusion of the 25% of suicides that are female, for example. There is no doubt a balance to be struck in how we communicate about people at risk. However, it is important that we try to be more open about this issue. As a society, I think we need to normalise talking about suicidal ideation when it occurs, and abnormalise acting on it. The chisel of a compassionate listener I’ve described my toolkit, which I apply when I notice the first signs of my mind heading in a self-destructive direction, but having a friend or relative on your side can be extremely helpful. If someone tells you they are experiencing suicidal thoughts, I would suggest listening to them. Don’t panic. Let them explain to you how they are feeling and try not to judge. Although the thoughts are irrational, what they are thinking feels real to them and it will take time to get out of that mode of thinking. The most powerful message to try to convey in my opinion, is that these thoughts will pass. You can also signpost to support either through a GP, local mental health crisis service or through the third sector with phone lines and online information provided by Sane, Samaritans, Mind and Bipolar UK. If you have been affected by anything in this series that upsets you, please talk to someone you trust. If you encounter someone at risk, please encourage them to seek help. These are my personal thoughts and you may not agree with everything I've written, but I'm hoping it helps open up the subject for discussion. I appreciate it is a challenging subject. We have provided some information on who you can contact if you are in need of urgent help or crisis support.