Investigating factors leading to suicide de-escalation in imminent risk youth: Insights from a national crisis text-based service
An introduction to this Emerging Minds funded cross-sector placement with Mental Health Innovations by Carolina Guzman Holst, DPhil student in Experimental Psychology at the University of Oxford
Suicide is a serious public health issue
Suicide is one of the leading causes of death among young people aged 15-29 (WHO, 2019). It refers to death caused by self-injury or self-poisoning with the intent to die. Within suicide statistics we also include deaths where the intent is undetermined since it may be challenging to establish or ambivalent. Suicide often represents an extreme endpoint for poor mental health. In England, a quarter of 11-16 year olds, and nearly half of 17-19 year olds with a diagnosed mental health condition reported that they had engaged in self-harm or attempted suicide at some point in their lives (NHS Digital, 2018). Unfortunately, although suicide in young people is relatively rare compared to other ages, the rate of young people ending their own life has increased substantially across the UK since 2010 in both sexes, with young men three times more likely to take their own life than young women (ONS, 2021).
Who is at risk of suicide?
Many factors can increase the risk of suicide or protect against it. In fact, it is rarely caused by a single factor, but rather by a complex range of factors interacting to increase risk. These may include individual factors and circumstances, such as experiencing hardship, violence, abuse, neglect, loss, chronic illness, persistent mental health difficulties, limited access to care and support. Other family and social factors such as bullying, relationship breakups, family conflict and certain forms of social media may also increase risk. Suicide rates are also higher among vulnerable and minority groups such as mixed ethnic groups, LGBTIQ and prisoners. Additionally, different theories and research studies found that hopelessness, depressive symptoms, history of suicidality and self-harm are the most important factors that distinguish youth with suicidal ideation from those considering action (Mars et al., 2018; O’Connor & Nock, 2014).
Many factors can also protect young people against suicide. For example, having a supportive family environment, quality friendships, school engagement and involvement in extracurricular activities are all very important protective factors. Similarly, good problem-solving skills and coping skills can really help young people cope with suicidal thoughts. Lastly, availability and access to mental health care can also prevent young people at high risk of suicide. For a review of risk and protective factors see Bilsen (2018) and Hawton, Saunders & O’Connor (2012).
How can we prevent suicide?
Suicide can have a profound effect on communities. To reduce the risk of suicide, it is essential to implement a comprehensive public health approach that integrates low-cost evidence-based interventions in schools and the community, raise awareness and reduce stigma around suicide, learn about the warning signs of suicide, train professionals, families, and teachers to detect and help young people at increased risk of suicide, and promote factors that may protect individuals and increase resilience. Importantly, researching novel approaches to understand suicide and enhance interventions is also key to preventing suicide.
How can a national crisis text-based service help us understand and prevent youth suicide?
Mental Health Innovations (MHI) is a digital mental health charity which uses data digital innovation, data driven analysis and the experience of clinical experts to improve the mental health of the UK population (MHI, 2022).
MHI’s first service, Shout 85258, is the UK’s first, free, 24/7 crisis text support service. Since its launch in May 2019, Shout 85258 has had over 1.5 million text conversations with over 500,000 individuals presenting with anxiety, stress, depression or feeling overwhelmed, unable to cope and who need immediate support. Texters who message the platform engage in conversations with volunteers who are being supported by clinical supervisors. Around 35% of individuals who text Shout are 18 years old or younger, and from this age group, 35% of conversations deal with texters reporting thoughts of suicide.
To address the problem of youth suicide, it is important to understand what causes it. Indeed, while studies and theories of suicide contribute to our understanding of which groups of people are vulnerable to suicidal behaviour, they will not always accurately predict which specific individuals will engage in suicidal behaviour nor how they translate to real-time situations. It is young people’s own lived experiences and explanations that is crucial for understanding these behaviours and incorporating them in prevention strategies. The Shout 85258 platform presents a unique opportunity to join these perspectives and understand what personal and contextual factors in real-time text conversations, including characteristics of the texters and features of the conversation, are associated with de-escalating suicidal behaviours. This information could offer important insights on how real-time factors can help us succeed in the fight against suicide.
Emerging Minds x Mental Health Innovations Placement Project
The purpose of this project was to understand what factors contributed to suicide de-escalation in young imminent risk texters. This project used anonymised information from young people who initiated a text conversation with the Shout 85258 service and were considered at imminent risk after expressing they had a wish, plan, means and timeframe to attempt suicide in a ladder up risk assessment with the volunteer. Half of the conversations we examined reflected a de-escalating trend, in which the texter ultimately agreed to a safety plan. The other half reflected an escalating trend, in which texters did not agree to a safety plan, resulting in clinical supervisors having to notify emergency services so they could attempt an active rescue. Separately, we conducted interviews with clinical supervisors and volunteers to get their perspective on what works and does not work in de-escalating suicidal behaviours and preventing them through the platform. We anticipated that the findings from this project would help us enhance training and support for volunteers and generate knowledge that is of broad interest to those working in suicide prevention.
This project revealed several key findings which overall suggested the importance of assessing risk factors and promoting protective factors in conversations. While texters with deteriorating mental health, troubling relationships, past traumas, prior suicide attempts and a history of self-injury were at a greater risk of an active rescue, texters with social support, coping skills and professional mental health support were more likely to de-escalate and become calmer whilst texting with a volunteer. Notably, texter’s emotions and behaviours aligned with our knowledge of existing theories of suicide and known pathways from suicidal ideation to action, highlighting the importance of evidence-based practice. Lastly, we found that exploring feelings, behaviours, and goals was an essential part of the conversation structure and might aid in de-escalating imminent risk texters. Indeed, our findings suggest that building rapport, maintaining connectedness, and validating an individual’s experience so that they feel heard and understood is essential for emergency suicide prevention and intervention, especially when following protocols that are required to ensure that someone’s physical safety is prioritised.
From a personal perspective, it was a great experience to work at Mental Health Innovations. I witnessed the effort and dedication that volunteers, supervisors, and dedicated teams at MHI devoted to Shout, and their commitment to help support thousands of individuals across the nation struggling with mental health issues. MHI is not only actively engaging in conversations with the government, agencies, and academics about important issues such as suicide, but they are also informing research and policy, promoting public engagement, fundraising new mental health initiatives, and finding new ways to improve training and awareness for their volunteers to provide potentially life-saving support. I feel very lucky that I had the opportunity to take part in an Emerging Minds x Mental Health Innovations placement and experience first-hand the impact of Shout. As a doctoral student in psychology, it was an invaluable opportunity to learn from this collaboration how to integrate clinical practice, evidence-based research, and digital innovation to understand unique aspects of young people’s mental health.
Find Out More
For more information about Shout 85258 please visit their website.
You can also read a short blog by Mental Health Innovations about the placement over on their website.
Bilsen J. (2018). Suicide and Youth: Risk Factors. Frontiers in Psychiatry, 9, 540.
Hawton, K., Saunders, K. E., & O’Connor, R. C. (2012). Self-harm and suicide in adolescents. Lancet (London, England), 379(9834), 2373–2382.
Mars, B., Heron, J., Klonsky, E.D., Moran, P., O’Connor, R.C., Tilling, K., Wilkinson, P. and Gunnell, D. (2019). What distinguishes adolescents with suicidal thoughts from those who have attempted suicide? A population-based birth cohort study. J Child Psychology and Psychiatry, 60: 91-99.
NHS Digital. (2018). Mental Health of Children and Young People in England, 2017. Accessed on September 19th at: https://digital.nhs.uk/data-and information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017#key-facts
Office of National Statistics. (2021). Suicides in England and Wales: 2020 registrations. Accessed on April 11 2022 at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsand
O’Connor, R. C., & Nock, M. K. (2014). The psychology of suicidal behaviour. The Lancet. Psychiatry, 1(1), 73–85.
WHO Mental Health Geneva: World Health Organisation; (2018). Available online at: https://www.who.int/news-room/fact-sheets/detail/suicide