Professor Ella Arensman:

Over more than 30 years, we have conducted different types of research including interview studies with people who have survived an act of self-harm, present to the emergency department and obtain a mental health assessment. We have done some of this work in a standardised way with other countries in Europe and with Australia and one of our findings went against what we would have expected. We expected a subgroup of people who had survived a highly lethal act of self-harm to record a wish to die as their only motive. That was our hypothesis. However, that is not what came out. The same type of interview was used across all of these countries. They took place a week to three weeks after a person had survived a suicide attempt. We did not detect anybody reporting a wish to die as his or her only motive. It was always reported with temporary relief from an unbearable situation, seeking attention, to use the interviewees' own words, or self-punishment. We were struck by the finding that, while more than 80% reported death-oriented motives, it was never the only motive around the time they undertook highly lethal acts of self-harm.

This brought us to the concept of ambivalence, which, to some extent, was a surprise to us. It also appeared to be absolutely unknown to those doing the assessments in the emergency department. It is almost hard to believe that, 30 years on, we are still educating people in this construct in the training for emergency department staff, clinical nurse specialists, trainee psychiatrists and psychologists. Why is this construct so important? First, it opens up the communication and allows people to talk not only about death but about whether there is a small glimpse of light in the darkness where they have some hope that things may change. What then becomes important is the offer. Where do we see equality in the offers being made to these people? It is absolutely striking. The figures are also supported by striking cases of people who are now active in suicide prevention advocacy.