A qualitative study of young people’s lived experiences of suicide and self-harm: intentionality, rationality and authenticity

Background: Suicide is a leading cause of death amongst young people and a major public health concern. Although increasing research has identiﬁed contributory and protective factors affecting youth suicide, less is known about how young people make sense of suicidal distress themselves. Methods: Using semi-structured interview methods and reﬂexive thematic analysis, this study explores how 24 young people aged 16 – 24 in Scotland, UK made sense of their lived experiences of suicidal thoughts and feelings, self-harm, and suicide attempts. Results: Intentionality, rationality, and authenticity formed our central themes. Suicidal thoughts were categorised by participants dependent on their intention to act on them; a distinction often used to downplay the signiﬁcance of early suicidal thoughts. Escalating suicidal feelings were then described as almost rational responses to adversities; whereas suicide attempts appeared to be described as more impulsive. These narratives seemed to be somewhat shaped by dismissive attitudes participants experienced in response to their suicidal distress, both from professionals and within their close networks. This impacted how participants articulated distress and asked for support. Conclusion: Suicidal thoughts that participants articulated as lacking the intention to act could represent key opportunities for early clinical intervention to prevent suicide. In contrast, stigma, difﬁculties communicating suicidal distress and dismissive attitudes could serve as barriers to seeking help, and, therefore, additional efforts should be made to ensure young people feel comfortable seeking help.


Introduction
Suicide is a leading cause of death amongst young people aged 15-29 and a major public health concern for politicians, policy makers, practitioners and the public alike (World Health Organization, 2021).The relationship between mental illness, self-harm and suicide is complicated and contested.Although some studies have suggested that the majority of young people who die by suicide had a diagnosable mental illness prior to their death (Nock et al., 2013), others have questioned the validity of post-mortem diagnoses (Hjelmeland & Knizek, 2017).It has been argued that pre-existing mental illness, previous suicide attempts and self-harm may contribute to future suicidal feelings (Hawton, Saunders, & O'Connor, 2012).However, this relationship is non-linear and often cyclical (O'Connor & Kirtley, 2018), with self-harm sometimes understood as a method of self-care or self-soothing during times of distress (Chandler & Simopoulou, 2020).
Although extensive research has been conducted on the contributory and protective factors influencing young people's suicidal distress (Grimmond, Kornhaberid, Visentinid, & Cleary, 2019;Hawton et al., 2012), less research has explored how young people themselves experience and make sense of self-harm and suicide (Gilmour, Ring, & Maxwell, 2019).This is particularly the case in the UK (Grimmond et al., 2019).Emerging literature has begun to explore how young people can conceptualise suicide and self-harm as selfdestructive shame responses to social and structural stigma (McDermott & Roen, 2016), and furthermore suggest that such experiences of stigma and shame can produce barriers to seeking help and support (Chandler, 2017;Gilmour et al., 2019).

Understanding suicidal distress and self-harm
Self-harm is considered to be an increasing concern amongst adolescents (Townsend, 2014), with studies suggesting that self-harm may be associated with an increased likelihood of future suicide attempts (Whitlock et al., 2013).However, a growing body of evidence has suggested that self-harm can also be understood as a tool for emotional regulation, allowing individuals to cope with distress (Paul, Tsypes, Eidlitz, Ernhout, & Whitlock, 2015); self-soothe and regain control over over-whelming emotions (Chandler, 2016b); and care for one's self (Chandler & Simopoulou, 2020).Further to this, it has been reported that people experiencing disassociation can find that self-harm disrupts dissociative feelings, acting as a sensationseeking practice when feeling numb (Paul et al., 2015) and as a grounding technique to reconnect the mind with the body (Hunt, Morrow, & McGuire, 2020).It has also been argued that similar soothing effects may be associated with suicidal thoughts and visualisations, functioning as a cognitive respite for individuals experiencing unbearable emotional pain (Kleiman et al., 2018).Thus, subsequent to thinking about or visualising one's suicide it may be possible to feel an uplift in mental health due to an increase in positive affect, at least in the short term (Crane et al., 2014).However, in the long-term such thoughts may serve to cognitively rehearse suicide, increasing the future risk of suicide attempts (O'Connor et al., 2018).

Feeling suicidal
Whilst suicidal thoughts and attempts have been given much attention, qualitative explorations of suicidal feelings are lacking, with complex emotions tending to be reduced to quantifiable measures (Burkitt, 2014).Here, we use 'suicidal distress' to describe the feelings and emotions underpinning suicidal thoughts and attempts.Some theoretical positions have been offered: Kovacs & Beck's (1977) 'internal struggle hypothesis' for example, describes how suicidal distress can be experienced as a moment-to-moment internal conflict between wanting to live and wanting to die (Bergmans, Gordon, & Eynan, 2017).Others have suggested that at times of suicidal crisis, individuals may experience a type of tunnel vision, termed a 'suicidal mode', in which all other thoughts and feelings are restricted as the individual becomes increasingly focussed on suicide (Br€ udern et al., 2018).There is, however, a lack of research exploring the ways in which young people who feel suicidal make sense of their own experiences of suicidal distress (Gilmour et al., 2019).This gap may in part be due to concerns that talking about suicide could increase or intensify young people's suicidal feelings (Berman & Silverman, 2017), although evidence suggests that this is not the case, at least amongst adult populations (Blades, Stritzke, Page, & Brown, 2018;Polihronis, Cloutier, Kaur, Skinner, & Cappelli, 2020), and indeed that participating in qualitative suicide research can have a cathartic effect (Biddle et al., 2013).Alternatively, the lack of in-depth discussion of suicidal distress may be due to suicide-related stigma, which can position people experiencing suicidal distress as 'sinful', 'dangerous', 'attention-seeking', 'selfish' and 'contagious' (Oexle et al., 2019), rendering it a topic that can be difficult to talk about.This could be further impacted by a lack of clearly defined, consistent language used to describe suicide (Silverman, 2006), although others propose that this semantic challenge accurately reflects the inherent messiness of articulating suicidal distress (Marsh, 2016).This study aims to understand the messiness of these experiences.To do so, we draw on data from a qualitative study with young people aged 16-24 years in Scotland, UK to examine their lived experiences and sense making of suicidal distress to better identify opportunities for intervention.

Recruitment
We recruited 24 young people aged 16-24 (mean age 19.6) from across Scotland using adverts social media, at community events, and through community organisations (both charitable sector and grass-roots).Ethical approval was granted through the University of Glasgow's College of Social Sciences Research Ethics Committee, and safeguarding practices were employed throughout for both researchers and participants.In brief, this included opportunities for both researcher and participant debriefing; pseudonymisation; signposting participants to local and digital support services; and ensuring that opportunities for breaks were highlighted and restated throughout research interviews.

Sample
Participants described their gender as follows: men/male (7); women/female (11); non-binary (2); and 4 participants described their gender in another way.All participants had experienced suicidal thoughts; 10 had attempted suicide, all had done so more than once; 14 disclosed previous experiences of self-harm.The sample included representation from across urban and rural regions of Scotland and all deciles of the Scottish Index of Multiple Deprivation [an index of 6976 areas according to seven domains: income; employment; education; health; access to services; crime; and housing (Scottish Government, 2020)].Three participants had experienced homelessness, and two were careexperienced.The majority of participants were white; three participants were Black, Asian or Minority Ethnic (specific identities are not detailed for the protection of participants' anonymity).Participants were invited to describe their sexual and romantic orientation using as many terms as they felt were appropriate.Eighteen people used non-monosexual terms: pansexual (seven); bisexual (six); queer (three); bi (two); biromantic (one), whilst seven people used monosexual terms: lesbian (three); gay (three); homosexual (one).One participant described themselves as ace, one as asexual and one as aromantic.

Interviews and analysis
Narrative semi-structured interviews were conducted by Marzetti and took place between May and October 2019 in locations chosen by participants.One of the key benefits of qualitative methodologies is their explorative nature (Testoni,  & Zamperini, 2021), affording the research team the opportunity to learn from participants and be surprised by the research data (Riessman, 1987).To make use of this flexibility, the interviews had a loose structure to allow participants to share the experiences they felt were most pertinent.To open the interview, we asked the question 'how has suicide affected your life?' and then provided visual representations of prompt questions the participant could (although were not obliged to) address through their narratives (see Figures 1 and 2).With participants' permission, all interviews were audio recorded, transcribed in full and pseudonymised.Consistent with our constructionist epistemology, transcripts were analysed using reflexive thematic analysis (RTA), which we selected as we felt it facilitated a 'Big Q' qualitative analysis, in which the subjective, constructed nature of both interview data and researchers' interpretations were explicitly engaged with (Braun & Clarke, 2022).We were therefore guided by Braun (Braun & Clarke, 2006, 2022).
To begin the analysis, all transcripts were read in full whilst listening to the recording of the interview and making contemporaneous analytical notes, with Marzetti writing summaries of each participant's interview and her preliminary interpretations of them as a reflective task.Following this, each interview was individually coded, creating a large volume of codes that were written up and grouped under preliminary themes in a report that was then discussed by the whole research team.This process allowed the team to reflect upon both the descriptive content within the data and to go beyond this semantic content, to consider more latent, theoretical interpretations reaching across the data.Through the process of description and discussion, themes were defined, refined, and combined, before returning our analytic gaze back to the data to consider whether the centrally organised themes captured participants' experiences.The results were then written up in full.Although this study looked more broadly at suicidal distress, helpseeking, and contributory and protective factors as part of a PhD project (Marzetti, 2020); this paper focuses on a single research question: how do young people make sense of their own experiences of suicidal distress?

Results
All participants in this study had suicidal thoughts beginning aged 14 or younger.In describing the development of suicidal distress, participants often articulated chronological narratives that presented suicide as an almost rational response to long histories of adversities causing a deterioration in their mental health.Within these narratives, participants drew boundaries between types of suicidal thoughts, self-harm and suicide attempts; unpacking these gives unique insights into the phenomenological experiences of young people's suicidal distress and illuminates possible opportunities for intervention.Through our analysis, we constructed themes centred on intentionality, rationality and authenticity: organised around a central concept of disrupting binary understandings of suicidal thoughts, attempts and selfharm explicitly attending to blurriness and liminality.

Beyond binaries: Intentionality and categorical blur
Some participants described binary understandings of suicidal thoughts; separating those they intended to act on from those they did not; at times using somewhat clinical terminology such as 'intrusive' or 'passive' to describe suicidal thoughts which had been present throughout their adolescence.However, the lack of intention to act upon them was used by participants to suggest that they were 'not serious', 'not legit [sic]', 'not real' and not 'that big of a deal'.Despite this, over time the majority of participants went onto experience suicidal thoughts they did intend to act upon and that they had found more concerning.For example, Euan: I would say it's always been there.It's been like a very young age, so I remember being 12 years old and thinking, god, I have to go through another 80. . .70 years of this, it was just a bit like. ..so it's always been. ..I mean, it's like moments of. ..it wasn't serious back then, it was kind of like, ugh, and it's not real at that point but it's still like that thought is in your head now, like I wish I was dead.And then it kept going up and it's slowly just more consistent, it's more. ..like the first thing you think of when something bad happens, but, you know, you don't see a future, you just see, like, you're going to get to a point where it's either going to suddenly be better and something you're not going to think about anymore, it's going to be something you wouldn't even imagine doing, or it's eventually going to get you.Young people's experiences of suicide and self-harm 3 Within Euan's narrative, we see a sense of progression through his suicidal thoughts.Although at first, he articulates a desire to die that he does not think is serious, he presents this as part of an escalating trajectory in which suicidal thoughts are called to mind quicker, more easily, and in response to less stimuli, consistent with O'Connor & Kirtley (2018).We, therefore, argue that although suicidal thoughts without intention may not be of immediate concern to clinicians or young people alike, they could act as an important early warning sign of the need for support.
For some participants, actions that put them at risk of death, without a clear, intentioned suicide plan were not classified as a suicide attempt.Laura described how on her way to school she would cross the road with her eyes closed, defining her actions as 'reckless' and describing them as part of her experience of depression.
Laura: I didn't really feel joy in my life at that point, like I didn't feel like I wanted anything else.But I wasn't going to actively do anything, I was just going to set up situations that something could happen, hence the closing my eyes and stuff.
Laura recognised that the setting up of these situations was related to her suicidal feelings and articulated this as the first time she was affected by suicide.However, it appeared important for her to make the distinction that she was not actively trying to attempt suicide.Another participant, Damian, reported making three suicide attempts by drowning; picking the location, travelling there, and beginning to make preparations to attempt suicide, but had changed his mind and aborted the attempt.In contrast to this, two other participants, Leo and Euan, reported making clear detailed suicide plans with some preparations, but both had also decided not to go through with the attempt and explicitly described these incidents as plans, not suicide attempts.In drawing attention to such differences in the terms used to describe their experiences, we do not wish to question the validity or accuracy of participants' definitions.Instead, we wish to illustrate the diversity of individual understandings, and thus the importance of explicitly clarifying language use and working with young people to co-construct shared meaning.

Blurred boundaries between self-harm and suicide attempts
Fourteen participants disclosed having previously selfharmed using a range of practices including, but not limited to, cutting, poisoning, scratching, the restriction of enjoyable activities and bruising.For some, self-harm was presented as distinct from, although linked to, suicide attempts; for example, using self-harm to selfsoothe when feeling suicidal to alleviate distress.
Andrew: At the time I think it was like it let me cry.It kind of made everything I was feeling in my head almost feel visible, which for me at least I'd convinced myself it made me easier to feel it and get rid of it; because when it was all just locked up in my head it would just build; so it almost felt like a way to convert that mental energy into physical energy and be able to be upset about it, cry about it, and then call it a day.In this quote, Andrew demonstrates a type of mind-body dualism that has been previously remarked upon in selfharm research (Chandler, 2016a), in which self-harm practices are presented as an embodied way of expressing internal, psychological pain.Andrew went on to describe this as an undesirable coping mechanism.
Although some participants were comfortable with selfharm as a tool for managing suicidal distress, for others such as Andrew, tension was expressed between feeling that self-harm effectively managed suicidal distress, and feeling that self-harm itself was a problem.
Other participants reported that self-harm could blur and become part of a suicide attempt.Amber: So, the times that I do have suicidal thoughts, I tend to self-harm.So, I guess I have a more unconventional way of self-harming, through scratching.Like, it's not the usual way.But again, when it came to those two times of actually trying to commit suicide [sic], the scratching didn't work, it was like, I properly cut up my arm, through just constant scratching.I then tried other ways of self-harming, and again, the pain just, it didn't bring anything, I was still far too numb [. ..]And then I thought, you know what, this is not how to live life, and that [suicide attempt] felt like the only option.
For participants such as Amber, suicidal feelings were expressed as almost cyclical.At first, there was an experience of intense, often over-whelming emotional distress, followed by a period of numbness that self-harm aimed to disrupt, and although at times this was effective, where it was not there could be an escalation of selfharming practices that ultimately amounted to a suicide attempt.
Two participants described being unable to distinguish between self-harm and a suicide attempt due to an ambivalence about their desire to live or die.One participant, Ayla, described two incidents: one of self-cutting and one of self-poisoning: Ayla: I had another attempt, but it wasn't an attempt.There was this time where it was very blurry for me whether I wanted to do self. ..likeI wanted to do self-harm but at the same time I would sometimes test out the waters to see how far I could go [. ..] now that I look back I realise, wow, like the blurriness between those two [self-harm and suicide attempts] is really scary because it's maybe. ..like maybe that day I only woke up because I didn't take like one more pill, like maybe there was like a tipping point, like how stupid could I be?Like. . .But I just didn't care.It didn't matter to me and the fact that it didn't matter is very saddening.
These types of accounts sit in contrast to the proposal that people attempting suicide may enter what has been termed a 'suicidal mode' in which they experience tunnel vision (Br€ udern et al., 2018), restricting their ability to think about anything else.For participants such as Ayla, an ambivalence about the desire to live or die was maintained before, during and after the incident.Therefore we join other researchers who have argued for a more nuanced understanding of the relationship between selfharm and suicide (Chandler, 2016b;Chandler & Simopoulou, 2020;Hunt et al., 2020;Paul et al., 2015).We suggest that self-harm should neither be understood as necessarily contributing to, nor protecting young people from, suicide and instead a person-centred approach must be taken to better understand an individual's own experience of and relationship to self-harm.

The ir/rationality of suicide attempts
Narratives about suicidal thoughts that participants had the intention to act on were described by the majority of participants as responses to a series of adversities, presented as a causal chain, from which suicide appeared to them the only possible escape.These narratives seemed to position suicide as a rational option given the ways their lives felt unliveable.
Damian: I think it would probably be best to start with what happened, because it's kind of, cause, and then effect.
For some, there was also a critical incident that catalysed a suicidal crisis.It was at this time that participants changed the ways in which they described a suicide attempt, moving away from describing a causal chain leading to a rational suicide, and instead presenting their suicide attempt as shocking, sometimes impulsive, and often as if the consequence of a momentary loss of control.
Isabel: I had these, like, moments. ..I don't know, it's just where I don't feel like I'm myself, like I'm watching over myself.
Amber: I struggle to, like, I can recognise that I'm going down a dark path and I need to do something, but once I step over the threshold, it's very hard to then stop myself, because I have, it's like you don't have control of your own body after that.
Such accounts appeared to represent a suicide attempt as a moment in which the rational mind lost control over an unruly body, demonstrating again a type of mindbody dualism.Thus, despite stories of escalating suicidal distress tending to preserve the participant as a rational narrator, presenting complex clusters of contributory factors leading to suicide, interspersed by methods enacted to protect their wellbeing; the act of attempting suicide was, in contrast, presented as shocking, irrational, and somewhat out-of-the-blue.It is possible that this disconnect could be a type of disassociation in response to intense emotional distress; however, it may also have been a narrative device to create distance between the participant as a rational narrator of their story and the past actions of their somewhat unruly suicidal body, attempting in some ways to avoid stigma or shame.

Articulating the authenticity of suicidal distress
Although there are many reasons why participants constructed the boundaries discussed (between un/intentionality, ir/rationality, as well as between the mind and body), we questioned whether it might have been somewhat influenced by social attitudes to suicide.Participants in this study reported many ways in which the significance of their suicidal distress was diminished by others.For example, Lewis: My old GP, when I was registered at home, I was like, I am depressed, and they're like, you're just a hormonal teenager and did nothing about it.
Lily: [Her mum] was like, you can't have been suicidal, you've not actually thought about actually ending your life, you've not planned it [. ..]She was like you can feel low but there's differences between feeling low and suicide.And I was like if I feel like ending my life doesn't that mean that I feel suicidal.Such comments, whilst perhaps not intended to cause harm, could serve to reinforce wider narratives that position young people in distress as "attention seeking" (Chandler, 2017).For one participant, Eilidh, resistance to being labelled attention-seeking was explicitly articulated.
Eilidh: when I was at school a lot of my friends had problems with self-harm and I did as well for years and years but a lot of them were just like. ..I wouldn't say doing it for attention but like a lot of them did it in a very different way to me.A lot of my friends were doing it and then they would immediately tell someone and I was not like that at all.
For Eilidh, privacy around self-harm and suicide were crucial elements of validating her self-harm as authentic in contrast to attention-seeking.Through the use of the apophasis 'I wouldn't say', she introduces the idea of another who indeed would say that her peers were selfharming for attention, constructing a distinction between herself as someone who was authentically selfharming in contrast to other young people who were seeking attention.Pressure to authenticate self-harm and suicidal distress due to external invalidation was evident through the ways that participants discussed help-seeking.Consonant with existing literature (see Gilmour et al., 2019), participants in this study reported proactively seeking help for suicidal distress both from within their own personal networks of friends and families and from professionals.However, many had not received the support they wanted or expected.Some participants described learning not to seek help subsequent to dismissive experiences, due to concerns they were not 'bad enough' to receive support for suicidal distress.
Harley: I don't know if I'm bad enough for that [seeking help from her GP] yet.Like I don't know if it's got that bad, which I think is kind of strange considering that I'm talking about suicidal thoughts.
In contrast, other participants described the ways in which they felt pressured into disclosing suicidal distress and self-harm in order to access support, due to a perceived obligation to demonstrate their need.
Yasmin: I had to be like I'm going to kill myself if you don't refer me [for mental health support].Like I had to say that to her [Yasmin's GP] more than once and I had to talk about like self-harm and things like that I didn't really want to talk about with her, because she had already been dismissive, but I felt this is the only way.You know, I feel like it's like that at the doctor a lot.So, she was quite, you know, snippy and looked down her nose at me, but she referred me in the end.
In turn, we questioned whether experiencing dismissive responses might have been internalised, leading young people to downplay the seriousness of suicidal feelings, as discussed in the first part of our findings section.In contrast here, we wish to draw attention to young people's early experiences and disclosures of feeling suicidal, regardless of intention to act, as an opportunity for intervention to prevent escalating distress.

Discussion
This article contributes to a growing literature seeking to understand youth suicide.Whilst this research area has focussed primarily on identifying contributory factors to youth suicide (Hawton et al., 2012), this study extends the existing evidence to an analysis of young people's own understandings and articulations of their lived experiences of suicidal distress.Through our analysis, we were able to unpack how young people used language to describe their experiences of suicide, in particular paying attention to boundaries constructed between un/intentionality, in/authenticity and ir/rationality.Participants in this study were careful to downplay the significance of early suicidal thoughts due to their perceived lack of intention to act upon them, perhaps also reflecting clinical distinctions made around 'intrusive' or 'passive' suicidal thoughts as well as the perceived seriousness of suicidal distress.However, over time the majority of participants developed suicidal thoughts that they either intended or did act upon.This appeared consistent with previous research that suggested that thinking about suicide can become a self-perpetuating cycle, habituating suicidal distress by cognitively rehearsing suicide attempts, thus increasing the risk of future suicide (Crane et al., 2014;Kleiman et al., 2018;O'Connor & Kirtley, 2018).We, therefore, argue that although suicidal thoughts that were explicitly articulated as lacking intention may be considered of less importance (both to young people and clinically), they could provide an important opportunity for early intervention to prevent escalating suicidal distress and future suicide attempts.
On the whole, intentional suicidal thoughts were constructed by participants as somewhat rational responses to life adversities, whilst suicide attempts were often described as a momentary loss of control during a time of crisis.Both in their descriptions of the un/intentional suicidal thoughts and the ir/rationality related to suicidal distress, participants' narratives demonstrated extensive boundary work, in which they were careful to distinguish between thoughts and practices that they did, and did not, need support with.In some ways, this appeared to respond to and at times pre-empt the stigmatisation that young people anticipated and experienced from those around them both in their informal networks such as friends and family, and from professionals they attempted to access.
Whilst the negative effects of the stigmatisation of suicide, self-harm and mental health more broadly, particularly amongst young people, are established (Oexle et al., 2019), in this study, we argue it somewhat shaped how participants articulated their suicidal distress and sought help, particularly after attempting to proactively seek help and experiencing what they reported as dismissive attitudes towards their distress.Within our study sample, there was a high level of diversity such as geographical location (rural-urban), gender, sexual orientation, social class and disability, and thus young people might have experienced multiple, intersecting experiences of stigmatisation, additional to experiences of suicide, self-harm and mental health stigma (for greater exploration of this please see Marzetti, 2020;Marzetti et al., 2022).
Accessing mental health support is viewed as essential to young people's recovery from deteriorating mental health and it is therefore crucial that young people feel comfortable seeking help (Gilmour et al., 2019;Hart & O'Reilly, 2018).However, in a perverse paradox, helpseeking for self-harm and suicidal distress can also be subject to stigmatisation, re-cast as attention rather than help-seeking (McDermott, Hughes, & Rawlings, 2018).Therefore, although there can be a perceived need to demonstrate sufficiently severe distress to be granted support when suicide or self-harm is made visible to others in demonstration of such need, this can be misunderstood by others as seeking attention (Chandler, 2016a).We argue that this perverse paradox played out amongst our participants, creating a kind of scarcity mindset in which they felt it was necessary to downplay any suicidal distress they felt it was possible to manage autonomously, only seeking help when absolutely necessary due to crisis.One strategy used for autonomous self-management of suicidal distress, used by some participants in this study, was self-harm.Although self-harm has been conceptualised in research literature as a risk factor for suicide attempts (Whitlock et al., 2013), our findings support the emerging body of research that complicates and reframes the relationships between suicide and self-harm (Chandler, 2016b;Chandler & Simopoulou, 2020;Hunt et al., 2020;Paul et al., 2015).Some participants reported that self-harm could be used during times of intense suicidal feelings to manage emotions and self-soothe.However, although this was effective at times, self-harm could also escalate, becoming part of a suicide attempt; whilst for others, it was impossible to distinguish between self-harm and suicide attempts.Given the increasing concern about self-harm amongst young people (Townsend, 2014), understanding the variety of roles that self-harm can play may be both an important topic for future research and contemporary practice.Therefore, clinicians and practitioners should pay particular attention to developing an understanding of the role that self-harm is understood to play by individual young people; taking a person-centred approach rather than assuming that self-harm is necessarily a risky behaviour that should be immediately stopped (Chandler & Simopoulou, 2020).

Limitations
First, although this paper reports on a small sample, participants were purposively recruited, facilitating an in-depth, narrative analysis to facilitate enhanced understanding of this under-researched topic (Braun & Clarke, 2020;Smith, 2017).Second, as all participants in this study reported beginning to think about suicide aged 14 or younger, future research may wish to explore lived experiences of suicidal distress amongst people aged under 16, particularly given increasing concerns about suicide and self-harm in younger age groups (Bilsen, 2018) and noted differences between the suicidal thoughts and attempts of children and adolescents (Marraccini et al., 2021;Sarkar et al., 2010).Finally, our research design required relatively high labour from participants: attending research interviews that on average were over an hour in length.As a result, this study is likely to have primarily recruited participants that had high levels of comfort and confidence in discussing their suicidal distress.Therefore, future research may wish to incorporate anonymous methods (such as online interviewing or qualitative surveys) to reach participants who are less comfortable discussing suicide in a face-to-face setting.

Conclusions
This study extends current understandings of youth suicidal distress, offering insights into the lived experiences of young people's suicidal feelings, exploring opportunities for early clinical intervention and suicide prevention, and discussing uses of language to narrate suicide experiences.Understanding how young people make sense of suicidal distress has important clinical implications: highlighting opportunities for interventions to prevent youth suicide and explicitly addressing how dismissive attitudes to help-seeking can have long-lasting impacts on young people's ability to articulate distress and seek help.Furthermore, this study highlights the variability in the language used by young people to describe their suicide experiences, highlighting the need to clarify language use, develop shared understandings, and not assume shared meanings.
De Vincenzo, Ó 2023 The Authors.Child and Adolescent Mental Health published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.
and Clarke's six phases of RTA; (a) familiarisation; (b) coding; (c) generating initial themes; (d) developing and reviewing themes; (e) refining, defining and naming; (f) writing up; accompanied by a reflexive journaling practice to further develop our analytic lens and offer moments for reflection

Ó
2023 The Authors.Child and Adolescent Mental Health published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.

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2023 The Authors.Child and Adolescent Mental Health published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.