Said Shahtahmasebi and Caroll Aupouri-Mclean

Much has been written about Suicide. The literature is complex and yet confused and is often based on a presumption that there must be a mental illness for a person to take such a drastic action as killing oneself. In other words, a person’s decision making process falters only in the presence of mental illness. This is in direct conflict with the Western belief “to err is human”!

Throughout our lives we make so many decisions that appear to us as appropriate at the time they were made, not to mention risk taking behaviour including dangerous sports, smoking, drinking and drug taking. However, most commentators agree that suicide is an unnecessary and preventable death. But, how can suicide be prevented if we do not understand it. Suicide is highly politicised with a forceful drive for a medical (psychiatric) solution. The problem with adopting a single model to prevent suicide is that the majority of cases that the model cannot explain are made to fit. The consequences of such an approach will be a health care service that does not fit the problem, no prevention and no cure, a lack of service uptake, and social taboo. It is not surprising that the Chief Coroner Judge Neil MacLean stated “These statistics clearly show that what we have done in the past is not bringing the toll down so we must look for new solutions”.

On the other hand “new solutions” sounds like a shopping list where items can be taken off the shelf. It is not clear what is meant by new solutions. Do commentators, past and present who have emphasised a need for new solutions mean to advocate a move away from a medical model that lumps all suicide cases into a category and brand it mentally ill? Thus far, the trend suggests that this is not the case. Suicide prevention funding allocation almost entirely is allocated to mental health services. Historically, suicide rates appear to follow a cycle and we have not been able to break the cycles. When suicide rates fall, the authorities cheer the effectiveness of their suicide prevention schemes and demand more funding to sustain the schemes and fund research. But when the cycle ends and suicide rates go up, they cry that suicide is such a complex issue and depends on many socio-economic and environmental variables and more funding is required to research suicide.

The problem with researching suicide is that the key informant can no longer inform us of the dynamics of their decision making. Furthermore, mental illness (depression) has been firmly established in the public mind-set. Comments by a third person on a relative after the event of suicide will emphasise and highlight mental illness by association. The question would then be why mental illness was not picked up before the final outcome? Therefore, most studies of suicide are based on information gained from the survivors (family and friends left behind) and psychological autopsies which lead to mis-information and bias.

Most suicide research and prevention schemes follow a top-down and authoritative approach. Over the last decade proponents of the medical model concentrated on tackling depression as one of the main causes of suicide. The strategy included depression awareness campaigns. From these investments we would expect a reduction in suicide rates, or at least no change, but did not expect the result that suicide is on the increase and we need new solutions. If the search for new solutions follows the current trend then it would only mean one thing: more of the same!

Of course, the strategy of “more of the same” is the result of a top-down approach that has far reaching consequences beyond suicide. In 2010, the Waikato Institute of Technology (Wintec) in New Zealand, organised and hosted youth suicide prevention workshops in the Waikato Region. The workshops were presented by Professor Hatim Omar, the Chairman of the stop youth suicide campaign in Kentucky, USA. These workshops received considerable interest from the public and grassroots, including community, health and social workers, police, those concerned about what suicide is doing to their community, those who had lost a loved one to suicide, and teachers. Ironically, no academics, no one from the medical profession, and no politicians attended the workshops. Some groups attended the workshops in spite of being advised not to attend by their suicide prevention peers. These are indications that suicide is highly politicised which prevents us understanding suicide and its prevention. Until the public demand a change in suicide prevention policy there will be more of the same: the same solutions, the same services, the same decision makers, the same evidence provided by the same group of advisers/researchers. It is not surprising that there is mistrust between the public and care providers, in particular suicide survivors (family and friends). Current estimates suggest that between two-third and three-quarters of suicide cases do not come into contact with mental health services/psychiatric units.

One of the interesting issues that arose from the workshops was the will of suicide survivors to survive. But they would like to be heard, and are desperate to contribute to the debate to make the general public aware and potentially prevent it happening in other families. However, the top-down approach has the Associate Minister for Health Peter Dunn caused anger and concern amongst suicide survivors by leaving them out of his review of suicide. This supports the view that survivors are not important and cannot contribute or inform the process of policy formation. Why then the authorities interfere with the grieving process by imposing restrictions on survivors to maintain secrecy: a code of secrecy that is of the policy makers and not the public.

Anecdotal evidence arising from a study currently being carried out at Wintec suggests that there are untapped needs that may be employed for suicide prevention strategy development. The project allows volunteers to tell their stories from their perspective. Suicide survivors are not treated as experimental units in an interview session. The story telling sessions are referred to as ‘korero’, thus, removing the ‘top-down’ effect from developing any theories or policies. There is a lot of insight to be gained about suicide prevention services when the researchers are told that they were the first person to listen to suicide survivors’ since the event. There is a lot of insight in being told they had no idea how to respond to suicidal behaviour or ideation or when told directly by a loved one that they intended to end their life. There is a lot of insight in being told they (suicide survivors) are unsure how to advise other parents or adolescents who approach them for advice. There is a lot of insight in being told that the main reason the suicide survivors are approached for advice is that they are considered to be ‘more understanding’ and in a much better position to help. There is a lot of insight in being told that the only contact with the authorities was with the police. There is a lot of insight to be gained when the same old message that there were no suitable youth mental health services is repeated by recent suicide survivors. There is a lot of insight to be gained in being told that the services are not suited to the needs of the Maori. There is a lot of insight in the realisation that at least one person in the family puts grieving on hold in order to support family members and prevent family breakdown. And yet research continues to enforce the idea of suicide survivors’ vulnerability to severe physical and mental ill health, social and economic pressures, and a different grieving process, and ironically the need for mental health services. The irony appears to be that any services received by survivors have been of their own instigation. They just want the opportunity to grieve knowing there is support in the community.

Suicide can affect anyone in the community and therefore requires a fast-track depoliticisation and collective community collaboration without prejudice at the grassroots.

The good news is that Wintec has been awarded Fulbright funding to host Professor Hatim Omar in 2011 and plans are being drawn at grassroots level for more workshops. Interested? Contact Associate Professor Said Shahtahmasebi via this link.