"He seemed fine this morning," his GP commented, when I phoned to let him know that his patient was having suicidal thoughts. He seemed to doubt that it was possible that Josh, who he had seen that morning for a physical ailment, could be having these thoughts.
I explained to the GP that a significant percentage of clients at our Suicide Crisis Centre, particularly men, are able to present to everyone as if they are "fine". We are sometimes the only people who they are telling about their suicide risk.
Many of us become very adept at presenting as though we are okay when extremely distressing things are happening in our lives. We get used to putting on a professional front at work when the most deeply painful events are taking place in our lives outside it. We feel under an obligation to be able to function well at work. That can extend to appearing fine to friends and family, too, if we choose to hug the difficulties we are having to ourselves. It may be one reason why some of us are able to appear "fine" when having suicidal thoughts. We may have become skilled at covering up pain.
We know that men in particular may find it difficult to open up to friends and colleagues about suicidal thoughts. However, there is less awareness of how difficult some men find it to tell their GP. After all, a GP is a trusted individual who we talk to in confidence about health matters, perhaps sometimes about deeply personal health issues. Why couldn't men be equally open to the GP about having suicidal thoughts?
Josh, who the GP thought had seemed "fine" that morning, had told me that he had wanted to tell his GP about his suicidal thoughts in the appointment. He just hadn't felt able to, when he got there. It was really hard to say it in the time-pressurised environment of a ten-minute GP appointment. He had to build up to it. When he called us that afternoon, my impression was that he had waited some time before picking up the phone. When he spoke, his first words to us were "I don't know how to start this. I don't know how this works or what happens now I have phoned you."
For some men, picking up the phone to start accessing a service or walking into a crisis centre straight away can feel too much. They need to take more tentative steps to start building a connection before they have verbal contact. They may send a series of texts or emails. This is not about accessing an anonymous text or email support service. These are the first steps in making a connection and building trust with a team who will ultimately support them face to face. Sometimes they may want to tell you deeply personal things in writing so that it's known before they come in and they don't actually have to say it.
Some of our male clients avoid telling anyone else, including their GP, about their suicidal intent because that would mean disclosing the reasons why they are feeling this way. This was the case with Mark. "I was simply too ashamed," he told me. Mark's wife had left him, and her parting words included references to his manhood which struck at the very core of his identity and sense of self-worth - and his sense of being a man. "When I told my GP that my wife had left me, he told me that I had been a good father and husband - a good man. Man? I felt ashamed to be called a man. I felt inadequate and so full of shame for not being 'manly' enough. I felt like a shamed lost little boy. I felt I wasn't a man at all. How could I tell my GP, who believed me to be a good husband, father and a good man?"
Mark said that he could have gone to see his GP about the most intimate and embarrassing physical health problem. But he couldn't tell him the things his wife had said to him on leaving him for another man.
We know that there are other reasons why men (and women) may not disclose suicidal thoughts to their GP. Some believe that it will impact adversely on their current or future job prospects. Some fear that they might be sectioned. This happens rarely though, usually when all other forms of community support have been tried.
After my phone conversation with Josh's GP, I thought of everything Josh had disclosed to me earlier that afternoon. A serious accident, then a criminal conviction which led to the breakdown of his marriage and the loss of his job and which created distance in his relationship with his children. This was a series of major life events in close proximity and his GP surgery was aware of most of these.
It would be helpful if GP surgeries could monitor the emotional and mental health of patients who disclose that they have been affected by major life events. There certainly seems to be a case for closer questioning to check how deeply affected the person is.
A high percentage of the men we see at our Suicide Crisis Centre tell us that the loss of a partner, either through death or relationship breakup, is a strong contributory factor in their suicidal crisis. As well as being proactive in asking questions to determine the impact upon a person, GPs can make sure that the person knows that the doctor's surgery is available for support afterwards if they need it, even if the patient discloses nothing initially. A caring, concerned approach and a professed wish to be supportive - this makes disclosure more likely.
"Mark" hopes that other people may be helped by hearing about his experience.
For information about the Suicide Crisis Centre: http://www.suicidecrisis.co.uk