Of all taboos and all stigmatised words, suicide is one of the more provocative. Death is no discussion for polite dinner parties but suicide is spoken of in hushed tones and alluded to by cinematic gestures. Why wouldn’t a family whose loved one was found hanged, with their hands and feet bound by cable ties, suspect that this was murder, and not suicide?
We have a greater understanding of suicide than ever before. Only decriminalised in 1961, the language of suicide remains fixed in the concept of a positive act, the ‘committing’ of suicide. More dangerously, the assumptions we make about suicide also remain. Suicide is inevitable, and attempted suicide is a ‘weak person’s cry for help’ or deliberate self-harm is ‘attention-seeking’. ‘I wouldn’t have the guts to kill myself,’ or ‘I couldn’t do that to my family,’ reinforce those assumptions and beliefs about suicide.
The Zero Suicide movement, the brainchild of Dr Ed Coffey from Behavioural Health Services in Detroit, USA, is blowing those myths out of the water. The aim is to reduce the number of deaths by suicide. But how low is low enough? Is a goal of one suicide acceptable? Dr Coffey doesn’t think it is.
So what if suicide were preventable? How would we do things differently? A suicidal person talking about their suicide plans does not increase their risk of suicide. The myth persists that talking about suicide might give the person an idea they don’t already have. Studies show the opposite: if the person really was thinking of suicide, there’s often a sense of relief in having it out in the open. And if they weren’t thinking about death, you haven’t planted a seed but instead conveyed you’re caring and concerned.
Suicide is about escape, it’s about ending the turmoil, ending the pain of mental illness, it’s about having no energy left to cling on. Sometimes, your hands are tired, the bars are slippery, and you just fall off because you tried as hard as you could not to fall. David W Covington, Psychiatrist and international speaker for the Zero Suicide movement, uses this metaphor when talking about suicide.
At a West Yorkshire Vanguard Zero Suicide Event in February 2016, I was privileged to hear David’s latest version of his widely-shared TED talk, Spreading a different courage (2015), in which he asks us to change our attitude to people thinking or talking about dying by suicide. He talks about the precious resource of people with ‘lived expertise’; those who’ve been there, clinging on, and survived. He does not accept the inevitability of suicide. He does not accept the ‘attention-seeking’ label given to people who self-harm. With the right interventions, people who have self-harmed can significantly reduce or end their self-harming behaviour. They are then much less likely to die by suicide as a result. Attitudes and conversations are key.
In Leeds, where I am Mental Health Lead for Leeds North CCG, we are undertaking our second suicide audit. The first, funded by Public Health England, was recognised as a gold-standard approach to measuring suicide and therefore providing the raw data to effect change.
Middle-aged men in the most deprived parts of Leeds are the most likely to die by suicide, usually by hanging in woodland. Projects such as Men in Sheds and more community support have emerged from the background of this alarming audit. Nationally, young female suicide is on the rise, apparently driven by the pressures of social media. The Leeds Suicide Prevention Strategy group has, with the help of journalists, devised a set of national media guidelines for how suicide is reported. In Leeds, the new service for supporting people bereaved by suicide has been overwhelmed by referrals.
There is a long way to go. Risk of suicide is greatest just after discharge from mental health services, particularly in the first 7 days. More than 60% of people who die by suicide will have had contact with their GP in the months before they die. Conversely, 75% of those who die by suicide are not under the care of specialist mental health services. Eliciting suicidal ideation and intent in 10 minutes remains challenging, especially when it is not the presenting problem.
Safetalk and Asist (Applied Suicide Intervention Skills Training), specific training for those who may be in contact with suicidal people, has been particularly effective for the police and for railworkers. Network Rail, in a partnership with the Samaritans (who provided training), believes it has successfully intervened to prevent more than 1000 suicide attempts over the past 3 years. I believe this training is as necessary as Basic Life Support. A bold claim, but on a background of making mental illness as much of a priority as physical illness, I stand by that claim. We take it for granted that 999 ambulance services go to people directly to assure immediate life-saving care. This approach has transformed stroke and heart attack care, with emergency medical services in every area of the UK. We can do the same for other brain health crises.
Zero is a near-impossible, lofty and idealist goal; however, a change in attitude will save lives.