Participant characteristics
There were 35 participants in the current study who were interviewed between 2017 and 2021. The ages of participants ranged from 18 to 60 years (Mean = 36.03, SD = 12.92). Most of the sample were female (n = 21; 60%), White British (n = 31; 88.57), had a diagnosis of schizophrenia (n = 26; 74.29%), and were unemployed/exempted from work through disability (n = 28; 80%). All participants had current or recent suicidal thoughts and/or behaviours (ASIQ: M = 77, SD = 39, range = 14–143, possible range = 0–150). Most participants were currently experiencing positive psychosis symptoms, with many reporting at least mild hallucinatory experiences, paranoia, or delusions.
Due to the current study being nested within the overall CARMS project, over half the participants interviewed had received, or were currently receiving, suicide-focused CBT therapy (CBSPp) (n = 21; 60%). Almost half of the participants reported having engaged with CBT in the qualitative interviews (n = 18; 51,43%), but other therapies that they had previously received included dialectical behaviour therapy (n = 5; 14.29%), person-centred counselling (n = 3; 8.57%), cognitive analytical therapy (n = 2; 5.71%), and voice dialogue (n = 1; 2.86%). Ten participants (28.57%) indicated that they were unsure about the type of therapy they had received prior to CARMS. Just under two-thirds reported having received multiple types of psychological therapy across their lifetime (n = 21; 60%).
Overview of key findings
At the outset, it is worth highlighting two aspects of participants’ personal narratives. First, they all lived with suicidal experiences. For many, these experiences were ever-present and often co-existed with unrelenting hallucinations, paranoia, and persecutory thoughts and feelings, and were often linked with past trauma and abuse. Despite this, they were present in the interviews. They had not died by suicide, despite feeling horrified, exhausted, worn down, and despairing. This in itself attested to their resilience:
“It’s erm, it’s not a very nice kind of abuse, it’s the most horrific abuse you can think of. And I’m still here, I can’t believe it [laughs]” (Participant 17).
Second, for most participants, their daily lives were taken up with profound and elongated struggles, for example, to find money for food, to secure housing, to manage caring responsibilities, to get medication, and so on. Again, this attested to their resilience.
Four psychological processes were identified by participants as being central to the development and maintenance of resilience to suicidal thoughts and behaviours in tandem with psychotic experiences: 1) a sense of control; 2) a sense of hope for the future; 3) a sense of self-worth; and 4) acceptance of suicidal thoughts (see Fig. 1).
Theme 1: Sense of control
Theme 1 had two sub-themes which were about developing different kinds of control in relation to i. Persistent and powerful voices and ii. Overwhelming feelings and emotions. Participants described the unrelenting and powerful nature of voices. For many participants, the perceived power of the voices and perceptions of a lack of control over the voices led to suicidal thoughts and attempts. Other participants did not directly link voice hearing to suicidal experiences and, instead, viewed suicidal thoughts and behaviours as resulting from overwhelming feelings and emotions that they felt unable to control. Participants described how engaging in psychological therapy was instrumental to them developing a sense of control over the voices and overwhelming emotions, which enhanced resilience to suicidal experiences. However, some participants did not necessarily report feeling in control of voices and emotions, but instead no longer felt under their control, and it was this feeling of no longer being hijacked by the voices and powerful accompanying emotions that aided their resilience. For individuals who had limited experience of therapy, there was the expectation that they wanted to learn how to gain control of their voices and emotions and/or be relinquished from their hold.
Subtheme i: Persistent and powerful voices
Many participants reflected on the perceived uncontrollability of distressing, relentless, and hostile voices, which had often been present for many years. Delusional interpretations of voices as related to external entities often exacerbated perceptions of the control and power of the voices:
“I hear Satan speaking to me and he wakes me up in the morning and he controls me all day. He attacks me, you know verbally, or physically… He freezes me to the chair… and controls my mind” (Participant 5).
The longevity of the voices and perceived powerful nature meant that participants often viewed suicide as the only option to escape, stop, or appease the voices:
“and that’s when I start thinking of taking my life, because I can’t handle these voices I hear, just can’t handle them” (Participant 2).
Indeed, a key aim for many participants when entering therapy was to explore different ways to control their voices:
“talk about the voices and get more techniques on how to control [them]” (Participant 33).
Through engaging with psychological therapy, participants described how they began to gain more understanding of their past and current difficulties and how psychosis and suicide-related experiences were often linked to previous traumas:
“[My voices came from] childhood history. I’ve learnt that through therapy… it’s made me understand why I’m hearing voices and how to deal with them…” (Participant 16).
For these participants, an increased understanding of the voices facilitated a shift in their perception of how much agency and personal control they had over their voices. One participant described how they learnt that their voices represented different aspects of themselves which meant that they became able to confront the once seemingly unyielding and powerful negative voices but also embrace protective voices:
“He’ll [voice] say, “Why don’t you pour that hot kettle on your hand?” Or he’ll make me paranoid to the point where I think I can't carry on. But what I have found is my other voices… they’ll stop me. And what I've learnt as well, each voice is a represent of me. So it's me, but all different… I find having them more beneficial since I've been having therapy instead of a burden… I have the strength to tell him [the voice] off” (Participant 11).
Increased understanding of the voices, and subsequent feelings of control and/or agency, were often facilitated in therapy by co-creation of diagrammatic representations of past and current experiences i.e., formulations. Participants viewed these formulations as simplifying what had originally felt complex and confusing:
“It [formulation] sort of made it more simplified for me, to look at, and think, oh actually it’s not quite as complex as I thought it was because I couldn’t understand certain things… it made me feel more positive that I could understand myself a little bit more” (Participant 30).
Moreover, challenging the reality of voice content in therapy sessions and recognising that the voices could not physically harm them, was viewed by participants as illustrating that the voices could not control them, thus combatting suicidal behaviours. Importantly, for some participants this was beneficial as they no longer felt controlled, whilst other participants developed active control over the voices. Participants continued to use their abilities to challenge and affect control in their day-to-day lives:
“It’s just knowing that I’m in control, even though I have voices in my head, it’s knowing that I’m in control, because nobody can hurt me only me. You know, the voices in my head they might be there, they might be saying negative things and to do bad stuff, but there’s only me that can actually do it to myself… Because I used to say the voices are in control. They tell me to do it, so I do it. I listen to them, but I don’t always act on what they’re saying, you know, because I know it’s not them, they can’t hurt me, they might be saying horrible things, but they can’t actually hurt me. But as I went through therapy and talking about it, you know, it’d be do I want to do it [suicide]? I’d question it. I don’t know, sort of carried on since therapy I question it now” (Participant 32).
Subtheme ii: Overwhelming feelings and emotions
Participants described how their emotional difficulties could often feel overwhelming and coupled with a feeling of vulnerability when talking about emotions:
“Er, vulnerable. Because it [talking about difficulties], it taps into that … it's like being a child again, essentially, because your emotions are some of the most powerful things that we have to deal with on a day to day basis. So keeping control of your emotions, especially as a man in this society. As a cis white male living in 2019” (Participant 25).
For one participant, therapy was described as bringing up emotions that they had repressed for years. Whilst this was not viewed as distressing by the participant, they acknowledged that they were somewhat wary due to fears of negative consequences:
“It [therapy] brought them back up after being repressed for about twenty years… I wouldn’t say struggling [with those], but they’re there. And it’s like just trying to readjust. I don’t want to regress to how I readjusted because I buried all those shitty emotions under a mountain of drugs and alcohol. And I can’t be eased spending all the money on drugs and alcohol again” (Participant 28).
Participants relayed how these feelings were often exacerbated because their attempts to talk and share had been met by off-putting reactions and extreme or invalidating responses from friends and family members:
“I don’t talk to anyone about things regarding my BPD [Borderline Personality Disorder] and my delusions, my paranoia… I won't talk to any of them [relatives] about that because… it causes uproars and things like that” (Participant 22).
Participants reflected that because of these types of reactions they tended to keep overwhelming emotions to themselves, and felt that they had no outlet for relief. It was in these situations, that suicidal thoughts, urges, and behaviours came to the forefront of their minds with some participants using self-harm behaviours to provide a release and give a sense of control. Additionally, for one participant, emotions were described as a physical feeling rising through them, which subsequently led to voice-hearing:
“I get a feeling that comes through my body and I can feel it rising and as its rising through
my body my brain starts to overload and then by the time this feeling I get reaches my head, my head just feels like it’s going to explode and I start hearing the voices” (Participant 2).
Participants explained how engaging in psychological therapy empowered them to share difficult thoughts and feelings with therapists. Participants described a sense of relief when they felt able to release feelings that they had kept to themselves for a long period of time.
The relationship that was formed with therapists was viewed as important in helping participants to build autonomy by determining the focus and direction of therapy and contributing to them feeling empowered. When therapists were viewed as understanding, non-judgmental, and trusted, then it helped promote participants’ confidence in talking about their overwhelming experiences, feelings, and emotions. Moreover, when therapists were perceived as explicitly working collaboratively with participants in discussing issues and content that they felt were important, then this engendered participants’ feelings of ownership and control during therapy sessions. This also applied to practical arrangements such as when therapists offered choices over the timing, duration, and location of therapy:
“I like the fact when he [therapist] comes in, he asks how long do I want it and stuff, and I really appreciate that… I feel like it’s, I’m in control of the therapy, it’s my therapy so I’m in control of it” (Participant 11).
Feeling a collaborative partner in these kinds of decision making was both empowering and enabling because it allowed participants to gain confidence in their abilities to navigate and live with difficult emotions and experiences outside the therapy room in their day-to-day lives.
Theme 2: Sense of hope
This second theme captured how participants often had an enduring and recurring set of perceptions and beliefs that nothing could help them when they faced, and had to live with, exceptionally distressing experiences, for example hallucinations which vividly re-enacted abuse. This, in turn, led participants to feel hopeless because nothing could or would change, and to feel that they were completely trapped with no reason to keep going. Suicide was seen as the only alternative:
“ It just feels like, just like no matter what way I turn or no matter what way I try to do anything that it's not going to change anything” (Participant 3).
During the interviews, participants explained how psychological therapy initiated in them a recognition that positive changes were possible and that aspects of their lives carried a felt value worth living for. These changes were perceptible and tangible, and elicited a sense of hope in participants which had previously been absent. It is important to note that for some participants, they did not necessarily develop a sense of hope, but stopped feeling so utterly hopeless. An important part of these transitions away from hopelessness was the recognition that a bad day was just a moment in time. Hence, this theme comprised two sub-themes of iii. Bad days do not last forever, and iv. There are positive things in life worth living for.
Subtheme iii: Bad days do not last forever
Participants described how they learnt to recall multi-sensory positive memories in therapy which immersed them in an emotional and sensory warmth evoked by those memories, but also imparted a knowledge that they had felt positive in the past, and so could have those positive experiences again. Participants were guided by therapists in using extensive imagery techniques to aid positive memory recall. With this guided imagery, participants brought the memory to life vividly and interactively through all five senses. The resultant emotions in-the-moment felt positive, and palpably so:
“Thinking of a positive memory and going over it in my head. And imagining yourself there and thinking like, what was the smell and different senses…it makes me smile… And it shows that you don’t have to be in a dark place forever” (Participant 24).
Some participants relayed how talking with therapists led to them recalling traumatic life experiences, particularly child abuse, fed into a process of increased understanding of their current day-to-day problems and experiences. Domestic abuse, grieving for the loss of loved ones, children being taken into care, relationship breakdown, substance use, and criminal activities were just some of the life events viewed to be impacting current situations. Whilst recalling these past traumatic experiences could be distressing, participants also described a process of reflection where they were able to recognise how far they had come in their lives despite the challenges and barriers that they had encountered. This recognition fostered participants’ beliefs that change was, and is, possible for them which elicited hope and countered suicidal thoughts and plans:
“Maybe we have to look back to be grateful to where we are now…. If I look back then I’m more grateful to – that I’m much better than I used to be. So, that felt positive” (Participant 33).
For some participants, the realisation that negative thoughts and feelings could improve over time and would not last forever was promoted through completing thought records introduced during therapy, used to capture thoughts and feelings about a situation and evidence for and against negative thoughts. Participants could see how their thoughts and feelings changed and fluctuated throughout any one day, and from one day to the next. For example, one participant used a mood rating scale of 0–10 during therapy, which helped them observe how low mood, hopelessness and suicidal thoughts could come and go and were not static, thus making them feel less hopeless:
“So that [thought record] was interesting to look at to go… even though the days are different… tomorrow it might be a ten, today it’s a three” (Participant 22).
Subtheme iv: There are positive things in life that are worth living for
Participants explained how therapists often encouraged them to identify and acknowledge the positive aspects of their day-to-day lives, no matter how brief or seemingly small, which could act to off-set suicidal thoughts. These “moments of joy” (participant 18) could replace an excessive focus on negative aspects of their lives. Taking time to stop and notice such moments could help participants recognise there were experiences that were worth living for, which buffered suicidal thoughts:
“He [the therapist] taught me to try and look for a moment of joy. There’s not many moments of joy when you have paranoid schizophrenia. But if you can look for a moment of joy it can be worth so much… A different thought, just for a second. That’s all it takes. Suicide takes a second… but if you just replace that second with a positive second” (Participant 18).
Similarly, participants indicated that identifying and naming protective and/or preventative factors with therapists augmented the recognition that there were positive aspects of their lives that were worth living for, providing reasons to disengage with suicidal thoughts and an incentive to continue living:
“When I discussed suicide with them [the therapist] they asked me questions like what’s preventing you and we went through like the reasons, so I listed those reasons, it gave me more desire, more ambition, more reason to live” (Participant 33).
Whilst identifying positive moments was a valued strategy amongst many participants which had the effect of amplifying hope, one participant described feeling “devastated” when the therapist suggested this as a technique. For this participant, their life seemed so hopeless that the therapist’s suggestion led to the perception that they were not being listened to:
“It was just the way that he [the therapist] said think of three nice things and I just snapped inside… I’ve got no washing machine, as you can see. I’ve got no fridge freezer… I’m in trouble… So you know my life’s upside down… he wasn’t listening” (Participant 17).
The participant reflected that this perceived dismissal of such difficult life circumstances led to them disengaging from therapy and no longer trusting the therapist, highlighting that for them, focusing on positives could not nullify negatives.
Theme 3: Sense of self-worth
Participants articulated that feelings of low self-worth were linked to thoughts of being better off dead. Low self-worth was often exacerbated by negative voice content through accusations and insults:
“They tell me to, that I'm not worthwhile and I should just do the world a favour and stop breathing… it makes me feel like I agree with them” (Participant 6).
Moreover, participants’ sense of self-worth, and subsequent suicidal thoughts, were negatively impacted by self-comparisons, often connected with their beliefs that others around them were achieving more based on societal expectations and comparisons:
“I just used to keep punishing myself, it was like, well that's not enough, look you should be doing a job, you should be learning how to drive, you should have been having a degree, you should be doing this, you should be doing that, and none of it felt enough” (Participant 22).
Participants discussed how psychological therapy increased their self-acceptance and their ability to perceive their positive qualities. This subsequently fed-into to a sense of evolving self-worth. These experiences have been represented by two sub-themes of v. Finding self-acceptance and vi. Finding positive qualities.
Subtheme v: Finding self-acceptance
Participants narrated that one of the ways that they connected difficult past traumas with current psychotic and suicide-related experiences was through psychological therapy. The ensuing increased awareness of the origins of psychosis and suicidal thoughts stimulated in participants an appreciation that their severe and enduring mental health problems were not only immensely understandable, but could also be rationalised, given the traumatic experiences that they had lived through. This subsequently led to reduced feelings of self-blame conjoint with increased self-acceptance, which in turn, promoted perceptions of self-worth and counteracted suicidal thoughts:
“I understood things a bit more as well… I found it got easier to sort of understand how I felt and, you know, why I’d maybe felt like that… realised… it’s okay to… feel a certain way and I shouldn’t feel bad” (Participant 27).
Gaining an understanding of past experiences and their effects on their current lives during therapy also promoted self-compassion amongst participants for behaviours and decisions that had previously elicited guilt feelings, such as suicide attempts. For example ‘forgiving’ themselves for past behaviours could enable participants to feel they could carry on living:
“he's [therapist] helped me to understand some of my behaviours, like when I took that overdose and everything… I understand why I did it. And then it makes me kind of forgive myself a little bit… I feel more confident that I can keep going” (Participant 11).
Subtheme vi: Finding positive qualities
One of the skills developed during psychological therapy which participants cited as being important, was the ability to challenge negative thoughts about themselves and, instead of being hijacked by that negativity, to affirm their own value, and their own self-worth. This was particularly valued by participants who viewed themselves as being unworthy due to perceived failures in their lives. Encouragement to recognise, and endorse, their qualities in therapy sessions helped participants to develop a sense of “happiness” and appreciation of the person that they were, without needing to put excessive demands and pressures on themselves, which had historically contributed to suicidal thoughts:
“I’ve got to appreciate myself as I am in a simple sense [since therapy]… keep things simple and not to think about like doing too much… I was caught between massive ambitions and just being young and happy… being young and happy and just being myself is more important than being like a guy who’s accomplished a lot in life” (Participant 33).
Many participants indicated that low self-worth had led them to have thoughts that others would be better-off if they were not alive, and no one would care if they died. For these participants, challenging these thoughts during therapy sessions and recognising that they did matter to others was pivotal in interrupting the suicidal thoughts-to-action pathway:
“It’s like if I kill myself who’s going to miss me? Who’s it going to affect? And the more you think about that, actually I’ve got my mum, I’ve got my dad, I’ve got my sister, I’ve got the animals… All the people that I’ve made a decent impact on” (Participant 25).
For some participants, feeling able to embrace their positive qualities was viewed as so fundamental in reducing and eradicating suicidal experiences that they set this as a therapeutic goal. One participant told us how therapy encouraged them to make a note of the positive things that other people had said about them to help reinforce their realisation and ownership of their own qualities:
“we had homework to change one thing and I thought, I’m going to change how I see myself. Because I’ve always seen myself negatively, but, this sounds big headed, but I do have some really nice qualities about myself… people… keep telling me how proud they are. So I’m starting to listen and take on board what they have to say” (Participant 11).
When therapists genuinely appreciated and acknowledged the achievements of participants during therapy then this was seen by participants as crucial for improving their sense of self-worth. Participants recounted how it could often be challenging for them to identify and recognise their achievements themselves. Therefore, therapists noticing and naming these helped participants to notice them themselves subsequently:
“I think I was putting too much pressure on myself, thinking I had to be this amazing person… And he [the therapist] really like turned the whole situation round. I was like, oh yeah, I should be proud of myself, I'm going to college, I'm doing something” (Participant 11).
Theme 4: Acceptance of mental health problems and suicidal thoughts
The interviews revealed different aspects of acceptance which comprised this fourth theme. For example, acceptance could represent a kind of reconciliation about having mental health problems, specifically schizophrenia. This was sometimes accompanied by a change of perspective which involved embracing aspects of the condition:
“It's made me accept my schizophrenia, and that this is a long-term condition. But I've also learnt the positives about it, like I mentioned before. So I feel like it's changed my viewpoint on myself and what I'm going through” (Participant 12).
Participants also spoke about two slightly different, but nevertheless inter-related, aspects of the processes underlying acceptance which were represented by two sub-themes of vii. Stopping the battle and viii. Living alongside suicidal experiences.
Sub-theme vii. Stopping the battle
Participants referred to fighting suicidal thoughts and urges which was both exhausting and ineffective and led to feelings of being defeated. Feelings of defeat further aggravated suicidal experiences in a downward spiral. This could be even more exacerbated by the effects of medication:
“Yeah ‘cos it had – I do get moments where I contemplate it [suicide] because I think I can’t – but mainly because I don’t want to live the rest of my life as I am now. Especially with the side effects. And the medication. So my suicidal thoughts are based around that. And also the low motivation. And the weight gain and stuff like that. And so my suicidal ideation is based upon those things” (Participant 29).
This same participant further explained how, when they were at a really low point, they found that acceptance helped them get through that period:
“Er [short pause], that I’m going to be like this for a while and then I’ll be better again, kind of. So, instead of like, trying to fight it, just like, [short pause] stay with it and like, there’s no point in trying to like, battle it, just do whatever makes you like, happy. So, if like lying there, if I was happy lying there, then there’s no point in not lying there” (Participant 29).
For this participant, learning to use distraction was an important part of being with, rather than fighting, their psychotic and suicidal experiences. When asked by the interviewer “what worked for you at that point?” the participant responded:
“Distractions. Distractions ‘cause whenever I feel like that, I just can’t–, I just hate thinking because it’s like–, it’s like nothing’s going right, so–, erm, [short pause] if I’ve got like–, like I was saying, I’ll sit there and watch TV, but I didn’t have the energy to play games, so I’d just sit there and watch TV and just like, use that as a way to stop myself from thinking. ‘Cause like–, I don’t know [laughs]--, but that’s what I found helpful” (Participant 29).
The functionality of distraction was echoed by other participants, although not as clearly juxtaposed with acceptance. In contrast, others found distraction as an isolated technique unhelpful:
“So I used to try and help, try and do all the distraction things, but they just didn’t work” (Participant 7).
viii. Living alongside suicidal experiences
An alternative type of passive acceptance was revealed when participants described learning to be able to live with, and live alongside, psychotic and suicidal experiences This type of acceptance- based resilience manifested as not trying to get rid of, or diminish suicidal thoughts, but letting them be and letting them pass:
“Well, I’d normally just be… lying down on the settee watching TV and then it [the suicidal thought] would just wash over me. Then I’d just have to go, “oh god here we go again” and just let it disappear” (Participant 26).
A different approach that helped participants establish this type of acceptance was through a cognitive diffusion technique that involved creating a visual image of the suicidal thoughts floating away:
“[The therapist] took me through a YouTube video where I have to focus negative thoughts onto a leaf which is flowing down a stream, and imagine that the thoughts have been transferred” (Participant 35).
This technique enabled participants to recognise that they did not have to focus on the thoughts, and they could let them be and allow them to pass, and that this did not result in negative repercussions. This ability provided an alternative to feeling forced to concentrate on, give attention to, and engage with, the thoughts, thus reducing their impact:
“So I just try – I try and just let it [suicidal thought] pass, I just let it pass… It’s not overwhelming anymore” (Participant 33).
Acceptance was not portrayed as neutralising the gravity of living with suicidal and psychotic experiences. Rather, it represented a different way of viewing those experiences and learning to be with them despite the concomitant distress.
It should be noted that acceptance could feel impossible for some participants. For example, one person who we interviewed described a voice as constantly nagging, sometimes with a mocking tone. This person had heard from other people around them that attempting to accept and connect with the voice could help, but they found it impossible:
“And I found that–, a few times I tried talking to it 'cause I know some people do that to try and, erm, accept it a bit more. And I've tried engaging with the voice and it repeats everything I say. If I talk to the voice then it will repeat what I say…So I can't even do that” (Participant 12).