Abstract
No one factor can be held to account for the decision a person makes to take their own life. Suicide prevention is complex, and is too often overshadowed by a focus on mental health. Certainly ill health has a significant place in many peoples decision, but it is not the only factor. The proposed amalgamation of the suicide prevention and the mental health promotion strategies, “whilst there are clear elements of crossover, one is a behavioural outcome and the other is an illness”[1]. As a result the predictors for both are different. To date 28 countries worldwide have implemented a National Suicide Prevention Strategy. Assessing the evidence against UK counterparts who have all seen a reduction in rates from their 2002 strategy figures, none of these documents have a combined strategy. Scotland have seen the greatest reduction with 18%[2]. Their commitment to suicide prevention is evident in decisions to have mental health at the core of each cross departmental strategy and separate suicide prevention and self-harm strategies.
Methodology
This briefing paper sets out to provide an evidence base which supports separate Suicide Prevention and Positive Mental Health Promotion Strategies for Northern Ireland. Literature has been accessed through a range of sources including online journals, books and publications by various researchers in the area of suicide prevention. Other supporting documentation has been acquired via correspondence with globally renowned experts in the area with a specific interest in Northern Ireland.
Introduction
Every death by suicide is ultimately a tragic and profoundly devastating event that can impact on the lives of so many more. There are rarely simple or single reasons as to why someone decides to end their own life; the causes of suicide are both multi-faceted, complex and are shaped by many different aspects of a persons’ life.The proposal for a joint strategy has many negative impacts, some of which will be discussed below.
Stigma and Taboo
Stigma comes in a number of ways – most destructively as shame; and reduces contact between support people and the vulnerable individual.A review of recent literature (PsycINFO and Ovid Meadline) revealed a total of 13 papers published between 2001 and 2013 that have examined whether asking about suicide induces suicidal ideation. Systematic reviews of both adolescents and adults and in general at risk populations, none found a statically significant increase in suicidal ideation in participants as a result of being asked about their suicidal thoughts[3]. Given the widespread stigma around suicide people with ideation often do not know who to speak to. Rather than encouraging suicidal behaviours, talking openly can give an individual other options or the time to rethink his/her decision, thereby preventing suicide.[4]The amalgamation of both strategies could potentially see this focus being lost with the inclusion of positive mental health promotion.
The stigma of suicide has a profound impact on suicide prevention[5]. It contributes to reduced community awareness of the issues related to suicide and suicide prevention. It restricts help seeking behaviour’s for people with suicide ideation, impacts the resourcing of appropriate services, inhibits the grieving of those bereaved by suicide, and adds to the burden of those with lived experience. Stigma embraces both prejudicial attitudes and discriminating behaviour towards individuals with mental health problems, and the social effects of this include exclusion, poor social support, poorer subjective quality of life, and lowself-esteem[6].Challenging stigma requires confidence in the public stage yet we still do not know how to talk safely and effectively about suicide. The decision to amalgamate our positive mental health promotion and suicide prevention will only add to this existing stigma.
Language is power
The way we use language has implications for how we think and how we act with regard to suicidal behaviour and suicidal people. This in turn has implications for how we approach suicide prevention. Unless and until the field of Suicidology speaks the same language and approaches the classification of suicidal behaviours in a clear concise, and consistent manner, communications between and among all those who work for the goal of suicide prevention will remain clouded. Language is powerful and influences thoughts and actions. Suicide behaviours are complex. There are multiple contributing factors casual pathways to suicide and a range of options for its prevention. Usually no single cause or stressor is sufficient to explain a suicidal act. By joining two such strategies, suicide prevention and positive mental health promotion, we are creating an additional barrier to the difficulty already experienced by those in crisis. People suffering with mental ill health do not as a consequence take their own life. In fact 72% of our population in Northern Ireland have not accessed mental health services prior to taking their own lives[7].Suicide prevention continues to be seen as an adjunct to mental health rather that a cross-sectoral responsibility. If we continue to pursue this ideology through the development of this new strategy, we are creating an environment that is not conducive to our population. Reducing suicide rates requires action at population level, targeted interventions in high-risk groups and settings, and appropriate and effective responses to individuals at imminent risk.
Biological View Point
The philosophical point in the suggestion for the amalgamation of both strategies, is that viewing suicide as a mental health keeps suicide sitting within a medical and biological realm, when we are aware that social influences are often more important, than the mental health concerns of some people who experience suicidal ideation, behaviours, attempts and death. The dominance of the medical model has not helped us reduce suicide rates across the globe, so it is imperative to do something differently. “This does not include incorporating suicide prevention in positive mental health strategy”[8].
The increased domination of biological approaches in suicide research and prevention, at the expense of social and cultural understanding, is severely harming our ability to stop people dying[9]. According to Geertz[10], “there is no such thing as a human nature independent of culture . . . We are . . . incomplete or unfinished animals who complete or finish ourselves through culture” (p. 49). And, in the words of Markus and Hamedani[11] “biological beings become human beings through their engagement with the meanings and practices of their social world . . .” (p. 32). Thus, the sociocultural context is crucial to peoples’ lives, which inevitably means that it also plays a crucial role in suicide. If we want to understand suicidal behaviour and suicidal people, it is absolutely essential to take the cultural context into consideration.
It is also important to remember that human beings are not biological/mechanical machines, and suicidal behaviour is not an automatic/mechanical response to certain biological and/or environmental stimuli. Human beings are complex, reflective beings, and suicide is by definition a conscious, intentional act. Intentionality is often overlooked in biological research when, in fact, “a choice can invalidate a genetic influence[12]” Intentional behaviour cannot be reduced to the deterministic cause-and-effect level of some biological factors. Barrett et al. (2010) maintain that “By focusing on a mental state or behaviour in isolation, it is easy to miss its embeddedness in a larger system that gives it its nature. It is easy to miss the forest for the trees”. Biological research alone can therefore contribute relatively little to the understanding of suicidal behaviour. For instance the strong relationship between mental disorders and suicide, namely that more than 90% of those who die by suicide, suffered more than one mental disorders established as a ‘truth’ in the West (is not found in other parts of the world)[13] Perhaps the weaker relationship between depression (and other mental disorders) and suicide found outside the West is not the anomaly? No one has ever been able to show how depression and other mental disorders are related to suicide. In fact the evidence for this western truism is rather weak[14]. The vast majority, around 95% or more of people with a diagnosis do not kill themselves[15]. What separates those relatively few depressed people who do kill themselves from those who do not? It is certainly not depression. Perhaps this relationship in the West is overemphasised as psychiatry has such a strong position in Suicidology. Perhaps in the West we are looking in the wrong places for the solution to the ‘enigma’ of suicide[16].
Northern Ireland in Context
Northern Ireland has seen national mental health and suicide prevention strategies published and the Northern Ireland Self-harm Registry has also been established[17][18]. These progressions are welcomed. They havestimulateddiscussions with key stakeholders, guided service development and helped to highlight how the legacy of the conflict may continue to impact upon the vulnerable. However, the association between the Troubles and mental health is complicated, with many questions as yet unanswered. In addition, much more needs to be done to promote connectedness, engagement and resilience[19] among those who are disenfranchised with the current peace/political processes. The mental health needs of this sizeable minority (who present with multiple vulnerabilities and) who have suffered a lot as a result of the Troubles, require urgent attention[20]. Otherwise, these needs will continue to emerge in the form of low educational attainment, high rates of unemployment in deprived communities and social disadvantage. They are also likely to contribute to Northern Ireland’s high suicide rate as well as the transmission of mental disorders to future generations[21]. In conclusion, it isbelieved that the key challenges for mental health promotion and suicide prevention in Northern Ireland relate not only to mental health care and tackling stigma but also to limiting the impact of austerity, recognising the changed social context in Northern Ireland and increasing connectedness and engagement among vulnerable groups20.One of the concerns about combining preventative and promotional programmes in positivemental health with those in public health is that the relevance of mental health may get lost in the area of suicide or indeed the wider area of health. Although we know that suicide most often occurs within the context of mental health problems, it is crucial that government approaches to suicide prevention are cross departmental.
The WHO proposes strategic actions for suicide prevention[22]. This does not include the promotion of positive mental health. A national strategy indicates a government’s clear commitment to dealing with the issue of suicide, not a combined one that may dilute the issue. While links between suicide and mental disorders are well established, broad generalisations of risk factors are counterproductive. Increasing evidence shows that the context is imperative to understanding the risk of suicide.[23]
In addition to this research, contact has also been made with Professor Rory O’ Connor to establish perspectives from global experts in the field of suicide prevention. Rory commented “As an international researcher and current President of theInternational Academy for Suicide Research I support a call to ensure that suicide prevention and positive mental health strategies are kept separate in Northern Ireland”[24].
Suicide prevention requires so much more than an exclusive focus on positive mental health. Almost without exception, to be effective, suicide prevention requires cross departmental prioritisation and collaboration[25].
Bibliography
Barrett, L. F., Mesquita B., & Smith, E. R. (2010). The context principle. In B. Mesquita, L. F. Barrett, & E. R. Smith (Eds.), the mind in context (pp. 1–22). New York: Guilford.
Colbert, T. C. (2001). Blaming our genes: Why mental illness can’t be inherited. Tustin, CA: Kevco.
Geertz, C. (1973). The interpretation of cultures. New York: Basic Books.
Livingston JD,Boyd JE (2010) Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and meta-analysis.Soc Sci Med.71(12):2150-61.
Markus, H. R., & Hamedani, M. Y. G. (2007). Sociocultural psychology: The dynamic interdependence among self-systems and social systems. In S. Kitayama & D. Cohen (Eds.), Handbook of cultural psychology (pp. 3–39). New York: Guilford
National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). Manchester: University of Manchester (2014). Suicide in primary care in England: 2002-2011.
1
[1] Correspondence with Professor Siobhan O’ Neill (Professor of Mental Health Sciences. Chartered Health Psychologist. Member of the World Mental Health Survey Initiative (MPsychSc PhD)
[2] Suicide Prevention 2013-2016
[3] Dazzi T, Gribble R, Wesely S. and Fear N.T (2014)
[4] Preventing Suicide: A global imperative. WHO 2014.
[5]Young IT, Iglewicz A, Glorioso D, Lanouette N, Seay K, Ilapakurti K, Zisook S (2012)
[6] Livingston and Boyd (2010)
[7] The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (2014)
[8] Correspondence with Dr Myfawney Maple (PhD, GCTE, GradCertAdolHlthWelf, BSW(Hons1)
[9] Hjelmeland, H. (2010). Cultural research in Suicidology: Challenges and opportunities. Suicidology Online, 1, 34–52.
[10] Geertz, C. (1973). The interpretation of cultures. New York: Basic Books.
[11] Markus, H. R., & Hamedani, M. Y. G. (2007). Sociocultural psychology: The dynamic interdependence among self-systems and social systems. In S. Kitayama & D. Cohen (Eds.), Handbook of cultural psychology (pp. 3–39). New York: Guilford.
[12] Colbert, T. C. (2001). Blaming our genes: Why mental illness can’t be inherited. Tustin, CA: Kevco
[13]Chan K. P. M., Hung S. F., Yip P. S. F. Suicide in response to changing societies.Child and Adolescent Psychiatric Clinics of North America.2001;10:777–79
[14]Hjelmeland H, Dieserud G, Dyregrov K, Knizek, BL, Leenaars AA. Psychological autopsy studies as diagnostic tools: Are they methodologically flawed? Death Studies 2012 June;36(7):605-26
[15].Blair-West GW, Mellsop GW, Eyeson-Annan ML. Down-rating lifetime suicide risk in major depression.Acta Psychiatr Scand.1997;95:259–263
[16]Hjelmeland. H (2013) Suicide Research and Prevention: The importance of culture in “Biological Times”.
[17] DHSSPS (2012). Protect Life. A shared vision. The Northern Ireland Suicide Prevention Strategy 2012-2014.
[18] DHSSPS (2015). Northern Ireland Registry of self-harm Annual Report 2013/14. Belfast: DHSSPS.
[19]O'Connor, R.C., Nock, M.K. (2014). The Psychology of Suicidal Behaviour. Lancet Psychiatry, 1, 73-85.
[20] O’Connor R.C. and O’ Neill, S.M (2015) Mental Health and Suicide Risk in Northern Ireland: A Legacy of the Troubles? Lancet.
[21]O’Neill, S., Armour, C., Bolton, D., Bunting, B., Corry, C., Devine, B., Ennis, E., Ferry, F., McKenna, A., McLafferty, M., & Murphy, S. (2015). Towards a Better Future. The transgenerational impact of the Troubles on mental health. Belfast: Northern Ireland Commission for Victims and Survivors.
[22] Preventing Suicide: A global imperative. WHO 2014.
[23] Preventing Suicide: A global imperative. WHO 2014.
[24] Correspondence with Professor Rory O’ Connor (PhD CPsychol AFBPsS FAcSS,)
[25] Correspondence with Professor Rory O’ Connor (PhD CPsychol AFBPsS FAcSS,)