Better serving suicidal men: rethinking “under the radar”

HOW do we understand a phenomenon that remains hidden? More specifically, how do we understand individuals whose suicidal thoughts and/or behaviour remain hidden?

Fifty per cent to 60% of individuals who die by suicide did not receive formal mental health care or treatment before their suicide, and we consider them “under the radar”. Perhaps a more pertinent question we must ask is if under the radar individuals are not engaging with professionals, how can we reach them before it is too late?

With little known about this hidden population – other than that most are male – our team at the Black Dog Institute conducted a multimethods study to understand the experiences of Australian men who experienced suicidality in the past 12 months and had not engaged with any formal mental health services. The study aimed to discover why these men were not engaging with services. Surveys were completed by 415 Australian men with past-year suicidal thoughts, half of whom were identified as “under the radar” and half of whom were not.

Three papers have been published about the project so far – in the Journal of Affective Disorders, in Frontiers in Public Health, and in the International Journal of Environmental Research and Public Health.

In addition to these quantitative surveys, we conducted 50 qualitative interviews – for their richly textured and detailed data. Stories or narratives can contribute to knowledge in more nuanced ways than surveys alone, especially with people who may not yet fully comprehend how their suicidality has presented itself in their own experiences. Through our qualitative approach to understanding these men’s individual experiences, it became clear that the relatively straightforward “under the radar” definition ascribed to these men was much more complicated. Indeed, it did not wholly reflect who they are or their experiences.

We assumed that our “under the radar” definition and the men’s self-identification with the definition were aligned because the recruitment materials were codesigned with men with a lived experience of suicide. However, the interviews revealed a greater nuance to the “under the radar” meaning. Further to revealing broader, more encompassing descriptions of their experiences, their interviews offered greater insight into their activities and actions.

Some men actively sought information and informal help from friends, family, community and/or online resources for their experiences but still considered themselves “under the radar”. Some men revealed that they attempted to access formal mental health help without successfully receiving it and were reluctant to re-enter that space.

These two findings highlight that the definitional binary of “suicidal and engaged with help or suicidal and not engaged with help” was not congruent with their overall experiences. The findings highlight that some “under the radar” men are not resistant to help seeking and some are not finding the proper support for them at the right time. Perhaps most importantly, our definition of “under the radar” seemed to have missed the mark with our participants. This, in turn, prompted us to examine our definition and interpretation.

The response rate of over 400 men who chose to participate in the survey indicates a desire to connect and to have their suicidal thoughts and/or behaviour understood, contradicting the assumptive premise that “under the radar” is an active choice to stay hidden. Moreover, at least 18 survey respondents offered to participate further by taking part in interviews, losing anonymity in the process. As the interviews progressed, some men provided further insight into the grey areas of suicidality. Here, some men did not report passive suicidality but had suicidal thoughts and knew “something was not quite right”. Similarly, other men experienced active suicidality but did not have the language or critical awareness of what was occurring.

Furthermore, in our interviews, we asked the men to imagine what could potentially have helped them in their time of need. Unsurprisingly, many answered “I don’t know” to this initial question.

However, with some further clarification, sensitive inquiry, and time, this question elicited a conversation that sparked a sense of possibility. Interestingly, many men reported that the acknowledgement that existing services may not always get it right was a validating experience – an unexpected yet positive outcome. In addition, the men indicated that through the interview process, talking through their experiences with someone led to hope for the future.

These insights point to the diversity of experience and the importance of beginning a conversation in whatever manner it may take. We learned from the men we interviewed that suicidality is full of complexities. These complexities render neat labels, for the most part, potentially misleading and unhelpful. We argue for inserting an additional step when researching hidden phenomena. That is, to interview people who have lived experienced first to determine the definitions for recruitment and inclusion criteria.

Dr Ally Nicolopoulos is a Postdoctoral Research Fellow at University of New South Wales and the Qualitative Lead of the Under the Radar project at Black Dog Institute.

Dr Diane Macdonald is a postdoctoral researcher and program manager for Culture Dose for Kids at UNSW Sydney and Black Dog Institute.

Veronica Sheanoda is a PhD graduate from Macquarie University with research experience in cyberbullying, intersectionality, and suicide prevention.

Stephanie Habak is a research officer with expertise in virtual reality interventions at the Black Dog Institute.

Professor Katherine Boydell leads Knowledge Translation, Evaluation and Qualitative Inquiry at the Black Dog Institute. Her program of research focuses on advancing the use of innovative arts-based knowledge translation strategies.

Acknowledgements: This research study is intended to inform the design of a better-serving approach to suicide prevention. Our research adopted a codesign and an integrated knowledge translation approach, the underpinnings of which involve pertinent stakeholders (including people with lived experience of suicide) throughout the research project. The investigative team represents a diverse group of nearly 50 lived experience advisers, practitioners and researchers. However, this article is a reflective piece by qualitative researchers from the larger team. We extend our gratitude to Kathryn McLachlan for her tireless contributions.

Funding: Funding for this research was provided by the Medical Research Future Fund, Australia (grant number: 1200195).

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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