An overview of findings
It was clear from the review of available literature that there is insufficient robust evidence across services for people in suicidal crisis to recommend a single effective model of crisis intervention, care and support for the whole of Scotland. This is not to say that there are no effective models currently operating, rather that there has been little work done to evaluate most of these. Many operate locally and are not well known outside their immediate locale. In addition, having considered potential touchpoints for help-seeking or intervention at the point of suicidal crisis, these recommendations, rightly, go beyond the scope of formal health and care services.
While the research and evidence are not available to recommend a single suicidal crisis service model, there were clear messages from engaging with those with lived experience and those working in the field of suicide prevention which, if translated into an approach across settings, could transform the response to those in suicidal crisis.
In the stakeholder survey, stigma and discrimination, a fear of being a burden and a lack of compassion were identified as the top barriers to help-seeking. Respondents also highlighted the importance of having sufficient time to talk about their feelings and of support being available at the time they need it, including out of hours. Respondents felt that access to confidential safe spaces where people would be seen quickly and privately would encourage people to seek help. They also expressed the view that people providing support at a time of crisis should be suitably trained to respond to suicidal ideation and should be equipped with the knowledge and ability to signpost to appropriate onward support. These messages were reinforced through further discussion with the Lived Experience Panel.
Research conducted by Samaritans into their caller outcomes also supported this, with callers reporting reduced levels of distress following the calls and particularly valuing the 24/7 nature of service, the time to talk things through, someone really listening, offering confidentiality and anonymity and a human connection.
Quotes from the Action 5 questionnaire
"If they knew they would get a human response, empathy, kindness, someone to listen and help them overcome the difficulties they are facing. If they feel like they have an ally, not necessarily to solve all of their problems for them but someone who can provide support." (Professional stakeholder)
"I'd like someone kind and friendly, maybe in my GP practice but not my GP. I would like to be able to spend time talking about my problems." (Person with lived experience)
"Being able to be seen quickly and privately." (Person with lived experience)
"Adequately trained staff who have the time, skills and compassion to support such individuals." (Professional stakeholder)
"I want to speak to someone kind who will just listen to me and try to really understand. I don't want to be patronised or made to feel stupid." (Person with lived experience)
It is these voices of people with lived experience, and those working on the frontline, which have shaped our approach which sees suicidal crisis response as a human reaction, not a service model, and which sets out the principles of Time, Space and Compassion as the basis of improvement in support for those in crisis, wherever it is available.
Building on what we have heard, the next section sets out what we understand by Time, Space and Compassion.
At a point of suicidal crisis, people need the time to discuss their feelings and to tell their story about what has led them to feel that acting on their thoughts of suicide is their only option. People in suicidal crisis need the undivided time and attention of those providing support, those working in service settings need to be resourced and trained appropriately to deliver this support, and suicide awareness-raising and listening skills need to be made available more generally to the public.
"I would like to spend time talking about my problems" (person with lived experience)
There is also the need to ensure a response to someone contemplating suicide is available when it is needed. Suicidal crisis is not restricted to the hours of 9-5 Monday to Friday. When someone is at imminent risk of ending their life, they need to be able to get support without delay.
"I think many...people [in suicidal crisis] struggle to access appropriate support quick enough. Waiting times for appointments, counselling are often long and delayed and people struggle in the meantime to cope." (Professional stakeholder)
Physical spaces for people who seek support in suicidal crisis should be accessible, quiet, comfortable, pleasant and take account of emotional and physiological needs. There are strong links with the work to raise awareness of the impacts of trauma, it is therefore critical that spaces where support for those in suicidal crisis are trauma informed. People should feel they have the space to explore the thoughts in their head and the reasons behind their suicidal crisis in the course of a confidential therapeutic conversation.
"If they feel listened to and given appropriate time to talk openly and honestly about their thoughts and feelings without fear or judgement. They need a safe space to talk." (professional stakeholder)
Not all "space" needs to be provided in a physical location. Anyone in suicidal crisis should be able to access support remotely by phone, text or online. The use of approaches through digital technology allow people in crisis access to Compassionate support at any Time and from any Space.
There are a range of crisis services which are not face to face and which provide support to large numbers of people:
From the start of lock down on 23 March 2020 until the 20 December 2020 Samaritans provided emotional support over 1,700,000 times to people struggling to cope, via phone and email.
Over the course of the financial year 2020/21, Breathing Space answered 112,975 calls and the NHS 24 Mental Health Hub answered 102,950 (this service became available 24/7 from July 2020. Suicidal ideation is the highest reason for calling with around 25% of callers expressing this as their main call reason.
Since May 2019, SHOUT have responded to over 550,000 text messages from people in need of immediate support.
Anyone seeking support should have choices available so they are able to access the type of space that suits them best.
The definition of compassion used by the Compassionate Mind Foundation is "...a sensitivity to suffering in self and others with a commitment to try to alleviate and prevent it." A compassionate response to someone in suicidal distress requires meeting the person where they are with attention, empathy and a desire to assist on their terms.
The stakeholder survey responses identified compassion as being the most important characteristic of support services, with 92 references to compassion, empathy and emotional understanding from 62 participants.
Research into compassion [published as a supporting document alongside this report] has identified that, in the short term, those who experience a compassionate response when in suicidal crisis are more likely to disclose details which, in turn, can inform more effective support than those who receive a non-compassionate response. In the longer term, a compassionate response also increases the likelihood of help-seeking behaviour if future suicidal crises are encountered. It will aid the development of trusting relationships with services and lay the foundations for self-compassion, which in turn will reduce the need for support from frontline services in the future.
Connecting people with and supporting them to access support can provide emotional holding which alleviates distress. An example would be Distress Brief Intervention where the person is connected to support within 24 hours of initial referral.
A clinician who is sensitively seeking to understand the causes of self-harm and suicidal thoughts is likely to foster empathy, and so help to contain distress (Smith et al 2015)
In addition, our principle of compassion covers support offered to those who engage with people in suicidal crisis to avoid compassion fatigue, burn out and contagion. This can be achieved by providing direct support for staff for example sufficient staffing, supervision and debriefing / postvention interventions and also ensuring there are well connected, accessible services that are able to share information safely for those they are supporting and caring for, where appropriate.
"…the experience of responding to a suicidal person…can be emotionally disturbing for staff, and its effects can have widespread repercussions." (Smith et al 2015)
Time, Space and Compassion: Recommendations for improvements in suicidal crisis response
Embedding the principles of Time, Space and Compassion across responses to suicidal crisis in Scotland will require concerted action across national and local government, and services across sectors, communities and citizens. It is also essential that our evidence base is strengthened so that future action on suicidal crisis, including targeted investment, can benefit from a better understanding of what works. Our recommendations focus on developing a framework that will support mainstreaming these principles, as set out above, into a wide range of suicidal crisis responses and using it to improve our understanding of good practice.