A psychiatric doctor who helps suicidal teenagers says the Ministry of Health’s suicide reduction plans miss much of the wider issue. We need to listen to affected communities, and equip them to make the changes they need, he writes.
Last week, as I left yet another 3am crisis interview in ED as a psychiatric doctor for a suicidal teenager, I felt drained and weary. This was partly due to the time, but mostly something else: although I felt I had helped keep the young person safe in the imminent future, I was frustrated that I was unable to meaningfully address the reasons why they felt that way.
I thought I’d look through the recently released Ministry of Health authored Suicide Prevention Strategy, a 10-year suicide prevention strategy coupled to a five-year suicide prevention action plan. I wanted to see if there was some hope for how to help people get better. I was disappointed.
Before I get into the document itself, however, I should outline my understanding of suicide.
Trying to understand suicide
The factors that lead to people taking their own lives are varied, complicated, and always individual. Yet there are frequent themes. When we learn to recognise these, we can know better when to act – but only once an individual’s story and unique situation is understood.
One way of looking at suicidal thoughts is as a see-saw. We have the protective factors on one side – such as hope and resilience. These will counterbalance the imminent risks on the other side – including ease of access to means, practice and planning of a method, and disinhibition through the intoxication of alcohol and drugs. The pivot in the middle can be an event in life, which causes the see-saw to go one way or another. This pivot can move depending on how much the event affects the person. For example, someone with lots of hope for the future can be floored by a catastrophic event, such as an accident causing the loss of a loved one. If they have enough protective factors, and few of those risk factors, the see-saw tips in favour of the protective factors. Absent those, and with risk factors prevalent, the outcome can be very different.
Extensive research has gone into reducing the risk factors for suicide, and with fantastic results. Reducing access to means (locking guns away, barriers on bridges, limiting supplies of potentially lethal medication, fitting catalytic converters to cars) has had a significant impact on suicide rates worldwide. We can stop people buying guns, however, but stopping people buying DIY supplies is much harder. We can reduce access to the tops of buildings, but we can’t block off people’s garages and gardens. We as a country also have high rates of binge drinking, which increases our risks of doing things we wouldn’t do if we were sober.
The other half of the equation is hope and resilience, which are becoming more widely studied and understood. A healthy and supportive whānau and a safe and loving upbringing provide people with an abundance of resilience and hope. A more difficult upbringing including parental abuse, parental mental health and addiction problems, poor quality housing and poverty (collectively known as adverse childhood experiences) along with currently experienced physical illness, mental disorders and addictions, poverty, lack of purpose in life and experiencing suicide can reduce this hope. Combine such factors with a tendency to use alcohol when feeling low and we have a rough, generic way of seeing who might be at higher risk of attempting suicide.
Not everyone fits these explanations, of course. My job is to see where a person sits on the seesaw, and then to try to rebalance it if it’s looking precarious – removing risk factors, treating mental health and addiction problems and trying to return hope.
Misuse of coronary statistics
When the preliminary 2018/2019 figures were released, I read multiple reports in the media and from the government about how dire the stats were: a 2.5% increase from the previous year, and one of the highest rates in the world. This surprised me as in my clinical experience of working on call for the crisis team for the last three years in Wellington, as well as stints in child and adult community teams and inpatient units, I have met hundreds of suicidal people – but none has died of suicide while under my care.
How is my experience so different from what we see in the news? I don’t think I’m luckier than the next doctor and I’m certainly no better at risk prediction than my peers. Most of my highly skilled and respected senior colleagues have had a handful of their clients tragically end their lives in mostly unpredictable circumstances, and I know that it’s only a matter of time before I experience this too.
I believe there are two reasons why it’s rare for us. Firstly, suicide does not only occur to people in the mental health service. Nationally, roughly half of all completed suicides have had contact at least once with a mental health service in their lives, and of these a third had contact once or more in the year preceding. This means that the majority of people who end their lives are not engaged in our services. Suffering from mental health difficulties is significant, but it is only one of many risk factors for suicide.
Secondly, any suicide is one too many – but this doesn’t detract from the fact that it is rare: 14 in 100,000. I am not privy to the number of people currently in our service for suicidal thoughts or actions, but I see hundreds a year, as do the hundred or so other psychiatrists and trainees I work with. This means those who tell us they’re suicidal and then go on to end their lives is fortunately a very small amount. This makes it very hard to predict who is at risk, and very hard to study – the numbers are too small to be analysed for meaningful trends without looking at a minimum of five years of data at a time. A yearly national increase 0f 2.5% is not statistically significant.
When I talked to a few of my senior colleagues – who had worked through clusters of suicides through their years of practice and been on mortality review boards – they made consistent observations from two or three decades of trends. They described individual communities at risk, and these communities tended to be highly deprived and over represented by Māori, Pasifika and non-cis gendered persons.
Suicide is a local phenomenon, and is intensely personal – every suicide is a tragic loss of a life. Yes, large youth suicide numbers make New Zealand look bad on the international stage, and it demands inspection, but who it really hurts are the communities it takes place in. In my view, these tend to be marginalised and overlooked by government – even though we have huge amounts of quality evidence that should raise a flag. These communities often have less access to quality housing, less access to good education and jobs, less access to hope for the future. They also have higher rates of addiction, chronic physical and mental health illness, and tend to have higher rates of family violence and other adverse childhood experiences. This provides less resilience to a loss of hope, and less resilience to the effects of a suicide on the community – which significantly increases the risk of it happening again.
Because suicide can in many ways be used as a proxy for the health of a community, it annoys me that governments continue to merge multiple local data sets – which should be looked at in isolation and over time – into meaningless larger ones. This misses the subtlety of what is actually happening – the majority of people are unaffected by the rare tragedy that is suicide, but individual and normally vulnerable communities, whānau and hāpu are strongly impacted. Instead, we compare statistics to other countries, which have different ways of collecting the statistics, different ways of classifying what a suicide is, and different means. We are often comparing apples to oranges.
Looking at the latest guidelines
Emile Durkheim was one of the first people to move from thinking suicide was an individual’s internal problem to considering it an individual’s problem in the context of their society. He explained this in his book, aptly called Le Suicide, in 1897. If this has been known about for over 125 years, why do we still try to fix individuals rather than their surroundings?
This is not lost on the publishers of the 10 year strategy, who wish to implement increased support in affected communities. It also recognises that the current system of only addressing mental health and addiction risk factors at the time of crisis isn’t working. It is right to observe that mental health services have a limited part to play before the emergence of a crisis or mental health need – the loss of resilience and hope in a community starts well before suicidal thoughts emerge.
However, the five year plan does not reflect this. The first four out of eight points the plan outlines say we need a better plan, and the last three points boosting recognition and treatment of early suicidal thoughts and care for those bereaved by suicide are valid but address a problem that has already taken root. Only one point addresses promoting resilience and hope in people, and does so through support in schools. This is important, but does not address the first few years of life which are seen to be the most important in developing resilience. From this, it is hard to believe that promotion of wellbeing in communities is a priority for this government in a meaningful way – no matter how much it acknowledges the need to do so in its 10 year strategy.
This plan seems to continue to focus on things after they’ve already started to go wrong.
What would I like to see? Simply put, I’d like to have less work – fewer people presenting as suicidal. Returning hope to a community should not be through appointed working groups and setting up advisory boards by the government, We do not need outside eyes to identify the problems a community has; we need to trust that they know themselves. We need to listen to communities, and equip them to make the changes they need themselves.
There is a feeling among the Child and Adolescent teams that I currently work in: that the knowledge of how to successfully parent has been lost from some communities. This is a skill that is well enshrined in indigenous knowledge, but has been diluted in part due to colonisation, urbanisation and parents having to divert energy into surviving material hardship. This is an opportunity for the government to intervene – for example, resourcing communities to access their own tikanga and reintegrate it through marae governed parenting groups and childcare. I am a huge fan of the Incredible Years courses and believe that western research and approaches can still be valid, but need to be made relevant and taught by communities, for communities.
In the recent Wellbeing Budget, a vast amount of money seems to be allocated to mental health services for our target population. This is admirable, but I’d rather people not need our services at all and for us to focus on those who have complex mental health needs. Whānau Ora, a service where Māori who are identified as having social needs get to decide how the money allocated to them is spent (rather than having predominantly Pākehā bureaucrats decide for them) has been seen to be successful in its pilot form and could have lasting multigenerational effects by reducing adverse childhood experiences. It and other kaupapa Māori services only received a token increase in funding.
I would like our society to try to stop people becoming suicidal by equipping communities to nurture resilient and hopeful lives. I am constantly amazed by people’s ability to recover from terrible circumstances, but would love to see them not need to be there in the first place.
Where to get help
Need to talk? Free call or text 1737 any time for support from a trained counsellor.
Lifeline – 0800 543 354 or 09 5222 999 within Auckland.
Samaritans – 0800 726 666.
Suicide Crisis Helpline – 0508 828 865 (0508 TAUTOKO). Open 24/7
Depression Helpline – 0800 111 757 or free text 4202. This service is staffed 24/7 by trained counsellors
Samaritans – 0800 726 666
Healthline – 0800 611 116
Counselling for children and young people
What’s Up – 0800 942 8787 (for 5–18 year olds). Phone counselling is available Monday to Friday, midday–11pm and weekends, 3pm–11pm. Online chat is available 7pm–10pm daily.
Kidsline – 0800 54 37 54 (0800 kidsline) for young people up to 18 years of age. Open 24/7.
For more information about support and services available to you, contact the Mental Health Foundation’s free Resource and Information Service on 09 623 4812 during office hours or email firstname.lastname@example.org