Rethinking Mental Health Approaches to Suicide
- Rachel Gibbons, MD
- Aug 28
- 6 min read
August 28, 2025
Rachel Gibbons, MD, Author & Consultant Psychiatrist
Tom O'Connor, Editor & Publisher
Despite decades of effort, suicide rates remain stubbornly high. Mental health professionals like Dr. Rachel Gibbons are now rethinking mental health approaches to suicide, questioning long-held assumptions that shape prevention strategies. By examining the limitations of prediction, the role of psychiatric care, and the deeper emotional dimensions of self-harm and suicidal ideation, Dr. Gibbons invites us to engage with suicide prevention more compassionately—and more effectively.
Author Rachel Gibbons, MD, has been researching the nature of suicide and suicide bereavement for over 16 years. Dr. Gibbon's focus is on applying psychoanalytic and psychodynamic concepts to complex topics in mental health care and psychiatry. Her goal is to foster open and honest dialogue. Rachel is currently contemplating the nature of self-harm, prejudice, and discrimination among individuals diagnosed with a personality disorder, assisted dying, and suicide, as well as the defensive processes clinicians, use to deny their vulnerability. Dr. Gibbons is a psychiatrist, psychoanalyst, and group analyst. She resides in Brighton, England, United Kingdom.
Rachel draws much of her research in this article from:
According to Rachel Gibbons, MD:
Over the past two decades, suicide prevention efforts have expanded significantly; however, deeply held assumptions continue to shape policy in ways that may limit effectiveness.
Can We Predict Suicide?
Despite decades of research, our ability to predict individual suicides has not improved. Yet, belief in prediction persists, shaping discourse, research methods, and the conclusions drawn from them. Suicidal behavior arises from a complex interplay of genetic, psychological, and social factors. Some acts are impulsive, while others are carefully concealed. Survivors of serious attempts often report uncertainty about their motives, many showing no clear warning signs. If suicide is inherently unpredictable, does an overemphasis on predictive risk oversimplify its complexity, hindering understanding and prevention, and paradoxically increase 'risk' by fostering fear-driven rather than therapeutic responses?
Suicidal Ideation: A Warning Sign or Something More?
Suicidal ideation is widely recognized as a predictor of suicide; however, most individuals who experience it do not die by suicide, and around 60% of those who do never express such thoughts. Its low positive predictive value highlights its limitations as a risk assessment tool. Far from being rare, suicidal ideation can be part of grief and mourning and reflects an ability to symbolize distress—a capacity often absent in those who die by suicide. When someone expresses suicidal thoughts, they articulate somatic and psychic pain, offering a crucial opportunity for therapeutic engagement. Yet, once again, anxiety-driven interventions can obscure this, prioritizing immediate risk management over a deeper understanding.
Are Self-Harm and Suicide Two Sides of the Same Coin?
Self-harm, which is a common and rare suicide, is often mistaken for different expressions of the same issue. However, this misconception disregards their distinct functions, motivations, and underlying dynamics, undermining the validity of research that examines them together. Self-harm often serves as a coping mechanism—a way to express distress, regulate emotions, or seek connection.
Suicide, in contrast, generally signifies a retreat from connection and an attempt to escape unbearable emotional suffering, often accompanied by fantasies of a life free from pain after death.
Although self-harm is the strongest predictor of future suicide, this may reflect shared mechanisms: the loss of mentalization, the collapse of symbolic processing, and the crossing of the body boundary, where psychic pain becomes physically enacted.
Does Mental Illness Cause Suicide?
The assumption that suicide is caused by mental illness has influenced prevention efforts, placing primary responsibility on mental health services, narrowing the scope of suicide prevention, and leaving many deaths unexamined.
In England, only 26–27% of people who died by suicide had contact with mental health services in the preceding year. Similarly, the CDC reported that 54% had no diagnosed mental illness. With one-sixth of the UK population experiencing mental illness at any time and 25% facing a common mental health problem each year, this overlap is unsurprising and inevitable in large-scale studies. Correlation may be mistaken for causation, reflecting Western assumptions that suicide is inherently irrational and linked to mental illness, with a focus on the individual over social, cultural, or spiritual factors.
Mental illness is frequently identified in those who die by suicide; however, research relying on retrospective diagnoses is susceptible to bias and may exaggerate causation. Some suggest that mental illness may serve as a defense against suicide, with risk increasing during recovery. Others propose that both mental illness and suicide may arise from an inability to mourn, with significant losses—bereavement, illness, or relationship breakdown—often preceding both.
Does Psychiatric Hospital Admission Ensure Safety?
It is widely believed that psychiatric admission ensures safety for individuals at risk of suicide, but evidence is limited. Large and Kapur (2018) identified only two studies on this matter and concluded that neither could determine whether hospital admission saves lives or increases the risk of suicide. Suicide rates during admission are estimated to be 50 times higher than in the general population, with the post-discharge risk soaring to 133–300 times higher in the first month.
Hospital Admission May Increase Rather than Reduce Suicide Risk.
Restrictive environments, stigma, and loss of autonomy can heighten distress. Institutionalization may induce regression, weakening psychological defenses and fostering dependency, which increases vulnerability upon discharge. Individuals may feel exposed and unable to care for themselves until they regain their internal resources. Given the strong influence of hospital safety on policy and practice, this warrants further investigation.
Removing Ligature Points is a Key Public Health Strategy in Many Countries.
Yet its impact on hospitals remains largely understudied. Ligatures are objects used for hanging or self-strangulation, while ligature points serve as anchors. Inpatient environments contain numerous potential ligatures, making the complete elimination of them nearly impossible.
Achieving this level of environmental control has required substantial resources, rebuilding, and significant changes to inpatient care. A cost-benefit analysis is necessary to assess whether these measures improve safety or compromise the therapeutic environment. The failure to eliminate all risks has, at times, led to serious organizational consequences.
Many Self-Injurious Acts are Impulsive.
It occurs during an emergent personal crisis. Limiting access to lethal means, particularly through environmental modification and engineering, is one of the few interventions with proven effectiveness in reducing suicides.
For instance, studies from different countries have shown that installing physical barriers in bridges could reduce suicides in these hotspots by over 90%. Interventions targeting suicide hotspots, however, are often hindered by two concerns: the potential substitution effect and the economic costs. The substitution effect refers to the possible shifting of suicides from treated hotspots to untreated neighboring sites or other means.
Why We Must Rethink Mental Health Approaches to Suicide
Rachel Gibbons Concludes:
The suicide prevention movement stands at a crossroads, navigating assumptions that may limit its effectiveness. These include the belief that suicide can be reliably predicted, the conflation of self-harm and suicide, the assumption that suicidal ideation leads to death, and the conviction that mental health services ensure safety. Although well-intentioned, these perspectives risk oversimplifying a complex and deeply personal phenomenon shaped by cultural and social forces.
A focus on certainty and control risks reinforcing blame, fear, and scapegoating rather than fostering understanding and support. Suicide remains complex and often enigmatic—acknowledging this is not a failure but a step toward more meaningful, compassionate prevention.
Clinicians, researchers, and organizations struggle with the tension between expectations and reality as they are pressured to provide certainty in the face of uncertainty. But rather than viewing uncertainty as a barrier, could it be an opportunity? By broadening its focus beyond risk reduction to explore the existential, moral, and philosophical dimensions of suicide, the movement can encourage deeper engagement with what it means to be human. Embracing the complexity of suicide may not only refine prevention but also deepen our understanding of suffering, resilience, and meaning.
Dr. Rachel Gibbons can be reached at https://www.drrachelgibbons.co.uk/. Dr. Gibbons
Worked as a consultant in the NHS, privately, and in national leadership roles, Dr. Gibbons has researched suicide and suicide bereavement for over 16 years. Her focus is on applying psychoanalytic and psychodynamic concepts to complex mental health and psychiatry topics. She is currently exploring self-harm, prejudice, and discrimination in personality disorders, assisted dying/suicide, and clinicians' defensive processes.
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