Podcast – Theresa May’s Speech, Mental Health and Suicide Prevention

The audio for this podcast can be found here.

Hello and welcome to discussions in Tunbridge Wells and the podcast produced by the Salomons Centre for Applied Psychology in Kent.  My name is John McGowan and I’m a Clinical Psychologist working in our sector.  This week it’s been a very busy week in mental health, there’s been a House of Commons Select Committee report on suicide.  There has also been an update on the Department of Health’s Suicide Prevention Strategy and also a major speech by the Prime Minister signalling the Government’s direction of travel around mental health issues.  To chew over all of this in more detail I am joined by our regular panel of Anne Cooke, Angela Gilchrist and Rachel Terry.  We will drill a bit more deeply in today’s podcast into the developments on the Suicide Prevention Policy and talk to one of our colleagues who particularly specialises in this area over in Canterbury to help us with that.  First of all though Theresa May made an attempt to get away, I think, from her considerable headaches such as rail strikes, resignations in Northern Ireland, whatever is going on with Brexit and make some trumpeted announcements on mental health policy:-

Theresa May speaking:

‘We live in a country where if you are born poor you will die on average 9 years earlier than others, if you’re black you’re treated more harshly by the Criminal Justice System than if you’re white.  If you’re a white working class boy you’re less likely than anybody else in Britain to go to university.  If you’re at a state school you’re less likely to reach the top professions than if you are educated privately.  If you’re a woman you’re likely to be paid less than a man.  If you suffer from mental health problems there is not enough help to hand.’

(John McGowan) So first of all Angela, as I said last time about the issue, I just wondered if you might want to take us through some of the main points of what Theresa May said.

(Angela Gilchrist) Ok, well this has arisen, I think, out of what she is now calling her vision for the shared society and that in itself seems to have come out of something that she said in her inaugural speech as Prime Minister whereby she said if you suffer from mental health problems there is not enough help to hand.  She says that there is inadequate treatment that demands a new approach and it seems that she herself became interested in mental health as she was keen on improving the Police response to people with mental health needs and felt this was a top priority because she had direct experience of that when she was Home Secretary.

(John McGowan) Well she was Home Secretary for a long time I guess, so I in some way I wonder if that colours the way that she’s looking at it.

(Angela Gilchrist) Well I think it definitely does and we can get into that in our discussion. I wouldn’t say that it’s necessarily a good motivation for being interested in mental health although it might be one of them, but we are also looking at how this intersects with the third Progress Report of the cross-Government Outcome Strategy to save lives.  It has been found that suicide is now the biggest killer of men under 50, a leading cause of death in young people and new mothers and the central driver of the National Strategy that has arisen as a consequence of this is stated to be that suicide is preventable and that the rate of it must be reduced by 10% by at least 2020 or 2021.  So that’s the background really to what we’re talking about today.

(John McGowan)  I have to say Theresa May has a number of headaches on her slate every day I think but she has yet to face the scrutiny of the Salomons’ podcast grilling!  Thanks for going through that Angela.  As I say, we will come maybe to the Suicide Prevention Strategy which is an updated, bigger document, 2012 document, shortly but just first of all I wonder what do we think of what Theresa May is saying?  She is clearly trying to have a different conversation about something else and it is quite possibly very welcome actually focusing on mental health but what do we think about what she said?

(Anne Cooke)  I think the focus on mental health is hugely welcome as is the focus on parity between mental health and physical health because we know that mental health services are hugely under-resourced and hugely stretched so it’s wonderful to hear her talking about that.  Whether funds follow is a different matter, we’ll see and the emphasis again on social justice as well which was very refreshing to hear from a Conservative prime minister in particular.

(John McGowan)  Well she quite likes talking about social justice actually, she is not averse to talking about those kinds of issues and shared society, clearly not the big society – her antipathy towards David Cameron and many aspects of his agenda is well known.

(Rachel Terry)  I was going to say though, I agree it’s extremely positive that she was focusing on mental health, however I felt that her words were fairly shallow given the massive cuts under a coalition and then Conservative Government that we’ve seen to mental health services.  I think it’s all very well to talk about the importance of mental health services but at the same time whilst your Government (is seen as and being destructed?), it’s kind of quite difficult to hear really, I’ve found.

(Anne Cooke)  Yeah, that was certainly one of the main criticisms on social media and I think she can talk the talk but what’s the walk when they have actually overseen the decimation of the health service.

(Angela Gilchrist) It is obviously hugely welcome to hear her talking about mental health but I suppose there was part of me that was a little bit cynical about what she’s calling the ‘shared society’ and if I cast my mind back to David Cameron when he became Prime Minister, I think the first Monday of his first parliamentary week was the day on which he launched the so called ‘big society’ and this sounds similar but different but with something of an emphasis on mental health.  Obviously it is hugely welcome but it’s more about how we do it.  While there is some emphasis on prevention here it’s more about treatment and coming in after the event and what can be done afterwards although it’s heartening that there is some emphasis on prevention, there is also some emphasis on public health initiatives which is welcome but I guess it’s to be seen how all this comes out in the wash really.

(John McGowan)  There are a couple of points there, one is the issue of cuts and I said in the last podcast, I do think it’s really easy as soon as you’re in charge of a Twitter feed just to criticise the government for making cuts.  As it happens actually George Osborne was printing money, you know, quantitative easing, like Jeremy Corbyn actually in some ways though he maintained quite an austere reputation.  I wonder sometimes if the issues with NHS funding more broadly are actually quite so party political.  If you think about it, many more of us are surviving birth, we’re living longer, there are new treatments.  As a percentage of GDP I think I am correct in saying spending on the Health Service is rising, it does keep rising but how do we deal with the fact that there are more of us around and we have different kinds of illness loads and our expectations of the Health Service continually rise.

(Anne Cooke)  Well a cynic might say don’t sell it off so that we then have to pay the money to shareholders of the companies that actually deliver the services.

(John McGowan)  Well I’m not sure, I think that Labour and the Tories, I mean this is a broader discussion really about the absolute fundamentals of Health Service funding, they are trying to apply market efficiencies in the NHS in the attempt to drive cost saving and you know markets are very efficient tools in some ways, I mean there’s all sorts of question marks about the kind of way the incentives are set up within markets, some of the mess that you have when you start to locate different bits of service with different providers, do people really know how much things are going to cost, you know that we sometimes have under-costed bits and things like that.  These are tricky and quite complicated questions and I think they do transcend whether it is hived out to third sector providers or not.  In our field  some of the most innovative things in mental health, some of the most innovative things come from third sector providers these days.

(Rachel Terry)  You’re saying that the money that’s going into the NHS is rising but I would say that that’s not proportionally going to mental health services so the way that commissioning groups are spending that money which is to some extent outside of central Government control at the moment is not being spent in mental health services at the moment, I would say, fairly, we are talking about parity between mental and physical health services and at the moment that’s a very long way off I would say.

(John McGowan)  And that was one of the more explicit elements of Theresa May’s speech.  I think there’s a reality to mental health services being a kind of Cinderella and she seemed to be meeting that and I was quite struck that there were some quite eye-catching initiatives in it, things like school initiatives and things like that.  What do you think of those, I know that you were involved in some social media exchanges about things like mental health, first aid and…..

(Anne Cooke)  Yes, well I think the first thing I’d like to say about that is I think it’s again hugely welcome, the support for schools and teachers because I did some recent research with a former trainee here which has attracted quite a lot of attention which basically found that there are no conversations in classrooms usually about, well from our small sample of teachers that we interviewed, that teachers completely avoid the subject of mental health because they feel anxious about talking about it so any support I think is great.  I think the concerns that some of us had about this proposal to train all teachers in something called Mental Health First Aid really depends what you mean by Mental Health First Aid because there is a danger I think that it can be training in spotting symptoms of disorders and labelling children and then the risk is then that it actually disempowers the teachers that they feel that they don’t know how to help the children and need to pass them onto specialists and of course because of the cuts in services they can’t get anybody to see them so where does that leave you?  But I think the idea of perhaps psychological first aid training in understanding the psychology of distress and the kind of distress that young people are likely to experience and what can help would be hugely helpful. So I think there is potentially a real opening for psychologists here to help with that.

(Rachel Terry)  And even just opening up conversations of talking about how you’re feeling and we all get stressed sometimes because I think stigma reduction is a key thing actually and that should start from in our schools.

(Angela Gilchrist) I think that the training in schools is in principle to be welcomed because I do think we need to break through this idea of only professionals can deal with this.  I did my own research on suicide although it’s a long time ago now but I interviewed 47 people who’d made quite serious suicide attempts and one of the things that came through in that when I asked the question, ‘what could have prevented this?’, one of the things that came through was that very many of them said if only there had been somebody who really understood how I had felt, that might have made a difference and so, you know, and peers I think are always very, very important with the younger age groups, kids and teenagers, there is far more impact when a peer is able to share things with them sometimes than when an adult tries to attempt to do that.

(John McGowan)  Hold that thought Angela because actually this goes very much into something that I want to talk about later which is you know the balance between a focus on just preventing people taking actions and supporting them and supporting that kind of autonomy and choice but it does seem to me that you’re giving a kind of qualified welcome to the notion of school intervention and it does seem to me to be a good thing in terms of picking up distress which can be hidden and unacknowledged and I do wonder if there’s a sense in which Theresa May like many, many politicians before is slightly falling into the trap of assuming that you can sort of triage things and make demand go down.  You know, the founders of the NHS thought that we would solve the big health problems of the age and that demand would go down and that’s why you started laughing because in one way it does seem laughable really.

(Angela Gilchrist) And I think that is true and it’s because of the way it’s pitched as mental illness as opposed to distress per se although obviously they are on a continuum.

(John McGowan)  So if it’s distress it can potentially be handled in school, if it’s mental illness it has to be by definition almost handed over to somebody else in some other service.  I do think there is a point in there Anne whether you think, you know, identifying things under a banner of mental health problems or not is a good or bad thing or a complicated thing in the sense in which ultimately there is a danger of creating more demand for services that aren’t necessarily there really.

(Rachel Terry)  We are going to go on to talk about what we started talking about, suicide, and I wonder if feeling suicidal or having suicidal thoughts is automatically a mental health issue in itself or not and I think that’s quite a complex issue.

(John McGowan)  I am wondering if this would perhaps be a good moment to go to our interview with our colleague over in Canterbury, Ian Marsh, whom I spoke to earlier today.  He was hoping to be with us but the snow put paid to that, we’re at quite an elevated level here, both intellectually and physical!  (Laughter). Unfortunately Ian couldn’t get across and we had better not go too long with this discussion or we may not be able to get home!  So we will go over to the interview with Ian now.

(John McGowan)  Okay, I’m here with our colleague who is an occupational therapist and member of our Allied Health Faculty, Ian Marsh, who is the author of a number of papers looking at aspects of suicide, suicidal policy and a book, Suicide: Foucault, History and Truth.  Ian, we’ve had a Select Committee Report looking at Suicide Prevention Policy in the last week or so and we’ve had a Government update on the 2012 Suicide Prevention Strategy.  You and Anne Cooke wrote something on the Select Committee Report for our blog a few days ago but I’d be grateful if you could walk us through what some of the mains points of these two documents are and some of the features that we should be looking out for.

(Ian Marsh)  Yeah, well the Select Committee Report came about I think via the Health committee because there was a concern that the suicide rates were remaining high, particularly after the 2008 financial crash and then Theresa May’s speech was in relation to that but also in relation to, like you said, the revamped National Suicide Prevention Strategy and the main points that came out of the House of Commons Health Select Committee were actually around how the Suicide Prevention Strategy is being implemented which is now the responsibility of Local Authorities.  So locally it is Kent County Council and Medway County Council and there was concern that many counties didn’t have local suicide prevention plans in place and local suicide prevention groups set up so that’s part of the context of that.  Theresa May’s speech was also generally about mental health and how we look at mental health at the moment and stuff about stigma and then the revamped Suicide Prevention Strategy is not a huge departure from what was done before but what’s interesting at the moment is it seems to have risen up the political agenda.  Now that’s quite interesting in itself that it’s kind of come to the political agenda because it’s the sort of thing that politicians don’t often want to highlight, the fact that suicide rates are rising.  I was actually at a Suicide Prevention Steering Group for the Kent and Medway yesterday and it was very interesting that someone quite senior from NHS England was also present and it seems to be a top priority for NHS England at the moment as well.  So it’s interesting times I think.

(John McGowan)  So the reduction of the suicide rate is a very high priority for NHS England, yes?

(Ian Marsh)  Yeah.

(John McGowan)  One of the things I was quite struck by looking through the report was an idea that suicide rates at the very least haven’t reduced and possibly actually have risen slightly but within services they seem to have reduced and I was wondering about that.  It’s something that you mentioned in your piece that you wrote for us about the degree to which suicide risks could actually be controlled by services and just how useful contact with services actually was for reducing rates.  It doesn’t necessarily seem to be having the desired effect more widely in society.

(Ian Marsh)  Yeah and it’s about 28% of people that end their own life are known to Services and that rate’s been pretty constant.  What has gone down are in-patient suicides and that’s mostly to do with removing ligature points from in-patient wards rather than any new kind of risk assessment or management kind of stuff.  The suicide rates have gone up so have people who contact the crisis teams but that’s mostly because of crisis on treatment teams are seeing many more people but again that’s something that’s been flagged up about whether crisis teams are seeing the right people and have the capacity to manage people deemed to be high risk.  But it’s a broader point around risk assessment which we touched upon in the blog which is around whether risk factors and risk assessments and kind of approaches are the right way to go about reducing suicides really and there’s a paper in the British Journal of Psychiatry, the bulletin section, that kind of summarises some of the recent research that is suggesting that actually there is not that strong a link between people with a history of suicidal thoughts and suicidal plans and actions and actually eventual suicides and that throws into doubt the whole risk assessment process.  There’s a couple of things on the risk assessment and one, it kind of tends to be based on large population studies, it’s epidemiological and it’s kind of useful at highlighting that more men than women kill themselves but actually when you get down to an individual level that population level of epidemiological data isn’t that useful in predicting suicide risk, like if you are seeing someone clinically and you have a male in front of you, the fact that men are more than three times more likely to end their lives than women doesn’t actually tell you whether that person in front of you is likely to kill themselves in the next week, next month, next year and in fact none of the risk factors are particularly useful at that and that’s what the article is highlighting, actually those risk factors and risk assessment procedures aren’t good predictors of eventual suicide.

(John McGowan)  Well I had wondered about that for a number of years actually.  Obviously we work in a training capacity here in Tunbridge Wells and certainly practising clinically but also looking at our trainees going out into services there does seem to be some anxiety, which is I think quite understandably directed towards clinicians including them, that they have to be able to at some level almost look into a crystal ball really and see who is going to potentially be at risk and who is perhaps going to be less risky and it was quite salutary. I have always wondered just how realistic that was and it was quite salutary to find that in a research study suggesting that may be completely unrealistic actually and I wonder where that leaves services in terms of looking at the expectation that they have.

(Ian Marsh)  It’s interesting, I mean the other kind of new idea that’s around the suicide prevention is the zero suicide approach that has come out of the Henry Ford Hospitals in Detroit in the United States and it is complicated and the claims made I don’t think stand up to a huge amount of scrutiny but they do seem to have reduced suicide albeit in a population that isn’t necessarily representative of a broader population but they didn’t organise their suicide prevention around degrees of risk or levels of risk, they offered good care to all people that presented to their service, like with a mood disorder so they weren’t categorising people as high, low or medium risk, they were saying all people would be offered the same kind of opportunities to get in touch if they are feeling suicidal, we give them a number to contact and then we’re following up quite assertively over the first few weeks after assessment.  So there is something actually about the clinical utility of saying this person is high, medium or low risk because of what they’ve said or their gender or previous history is, maybe that’s not the key, maybe the actual approach is that which again I suspect most people who work clinically know, it’s actually the relationship, it’s the connectivity, it’s the sense of kindness and care that is around that context and around how that service is engaged rather than some score sheet or some assessment tool so the assessment is a way into relating to someone in a humane and kind way rather than a tool that objectively measures something that is clinically useful.  I know many clinicians like tools and forensic services particularly, they maybe have some utility in predicting violent behaviour but I think around suicide there is not a lot of evidence that it is effective really.

(John McGowan)  Well I was wondering about what you’d say about the notion of not necessarily categorising people according to risk but just actually thinking a little bit more about how you care, really, how you offer care.  I mean again, I think, a very strong experience for me certainly working in clinical services and I know that this is one from discussions that we have had before, that this is one that you also relate to, is the idea that actually categorising people according to their risk and then trying to prevent the risk, well it can sometimes take you into some slightly odd places in the sense that you are all about stopping them and stopping their behaviours rather than about trying to think in a more broadly caring way.

(Ian Marsh)  Yeah, yeah, and I’m sure you know from your own experiences that once someone mentions suicide in a conversation under the current set up of services it’s kind of almost inevitable that you become slightly defensive in your questioning, you try to elicit information, you are thinking about recording that information, passing it on, with half an eye onto, oh my goodness, if this person does end their life then that’s bad, not just for them but it’s also the questions that will be asked about whether the assessment you did was okay, whether you acted in the right way when you should have prevented that suicide.  So there’s almost an inevitability that the conversation moves away from one that would be seen as therapeutically good towards one that’s more around that kind of risk management stuff that again many service users that I’ve talked to and read say that it’s not helpful that those conversations become defensive and you kind of try to objectively categorise.

(John McGowan)  It seems to me that you’re kind of drawing a distinction here between a more broad stance of help in a way that ultimately you hope will address the risk posed by somebody but you’re drawing a distinction by implying that sometimes if you are too, I think you used the word defensive, or too driven by the risk then you may potentially be moving into places that people might actually perversely or somewhat against what may be good intentions actually find less than helpful.

(Ian Marsh)  Yeah, and I was just reviewing one of your qualified trainees, Lucie Nalletamby’s, kind of research project she did whilst at Salomons which talked to clinicians and that’s some of the conclusions she drew that the kind of ways of thinking around suicide in terms of risk assessment and management can lead to clinicians thinking quite defensively and acting quite defensively and the implication would be that that’s also experienced by service users as not being helpful.  It’s not something that I am saying people should be very laissez faire about and I think it is important, your response, and to take it seriously when people are talking about suicide but you have got to keep in mind what their best interests are and that kind of institutionally backed defensive behaviour, I would say isn’t always useful.

(John McGowan)  I mean it’s interesting and again I suppose a lesson that may bring one up short really, I mean we can see the pressure to avoid any death actually and I think I can see how people find the notion of zero suicide appealing and the notion of avoiding any such tragedy but ultimately it seems to me that you are saying that we may struggle to predict, and prevention may not necessarily always be within our power and the things that we may do to prevent something in a very short term window, hospital or taking steps to control, actually may sometimes end up taking us somewhere where we don’t want to go, with somebody or something that they may experience as less caring and less helpful.

(Ian Marsh)  Yeah, and I think that the British Journal of Psychiatry bulletin article was also arguing that because we rely on these risk assessment kind of processes and tools we often end up detaining people against their will under the Mental Health Act far more than maybe is useful and actually that can cause distress to people, that you question the preventative kind of aspects of in-patient care sometimes and that’s why crisis and home treatment teams are partly set up but again if they are coming under more pressure and there’s an implied criticism that crisis home resolution teams aren’t able to manage suicide risk then the pressure becomes to admit more people. It’s not necessarily a straightforward equation that you assess someone as higher risk, you admit them to hospital that that’s necessarily something that long-term people find beneficial or safe.  I mean the wards are safer because it’s the access to means so the negative points are being removed but psychologically in amongst them over a period of time are an awful lot of people who are saying to me, I am not going back into hospital under any circumstances, an awful experience, and I don’t think that’s an uncommon report from people.  Not to say that hospital can’t be but generally what I remember is that they weren’t perceived as being very helpful.

(John McGowan)  Well it seems that the best will in the world can sometimes betray us.  We will have to bring it to a close there but I just want to say thanks very much for talking to us Ian, I know you were supposed to be coming across here to speak to us today but we have been thwarted by the snow and so hopefully a Skype conversation will be an adequate substitute.  Okay, thank you Iain.

(Ian Marsh)  Thanks John, that was brilliant.

(John McGowan)  That was Ian Marsh.  Just thinking about some of the things he said and what we were mainly focusing on was the part of Theresa’s May’s announcement which tied in to an updating of the Government’s main flagship Suicide Prevention Policy. It’s clear that the Suicide Prevention Policy has been in place. It’s clear that suicide rates are something that politically are taken quite seriously.  And one of the things that Ian was saying there obviously was about the notion of the degree to which mental health services can realistically a) predict and b) prevent suicide and we’ve all had experience of working with people that have really, really despairing thoughts and for a variety of different motivations made attempts on their own lives.  What would you think of the overall strategy which we’ve all had a look at but also the kind of updating as well because I know you wrote something about the interim Select Committee Report that came out a few days before Theresa May’s speech.

(Anne Cooke)  I think it’s a bit like Angela was saying just now, it’s about how you think of suicide. The problem with both Theresa May’s approach and the approach of the Health Select Committee is that suicide is almost taken as a given that it is something that just happens, the psychology of suicide is sort of missing, what you were talking about Angela, about the very complex reasons that lead people to be so desperate that they take their own lives and I can think of several people actually that I have worked with clinically who did take their own lives and the reasons for those were very different for each person and very complex and I do worry slightly about this zero suicide culture where it’s almost assumed that it’s the job of clinicians, because it’s a symptom of mental illness, it’s the job of clinicians to be able to predict it, and to prevent it and that leads to a kind of blaming of us, of clinicians when it does happen. I was really lucky that that wasn’t around at the time when these things happened.  For me my colleagues were very understanding and that enabled me to cope with it and I worry about the culture that says we should be able to, that we are almost hoisting ourselves by our own petard, saying that we should be able to prevent people taking their own lives.

(Rachel Terry)  I mean, that was very much my experience working in in-patient services.  I think that was something that the staff group were terrified about happening.  We were working with very high risk people and I think that staff were terrified that if somebody did take their own life that they would be blamed, they would lose their job in some way but the impact of that meant that that was almost the main priority when working with people so it would be almost one of the first things that you would ask if there was a hint that somebody might be expressing suicidal thoughts then perhaps they would be put on massively high levels of observation, deemed to be extremely mentally unwell, and perhaps their medication would be reviewed and increased and so on and I think there was a negative of that in that it then meant that people were perhaps reluctant to talk about how they were feeling or experiencing things which is potentially the most important role that we have so I think sometimes risk assessment of suicide risk was actually backfiring and meaning that we weren’t offering the best service but I can understand why staff were doing that because they were so anxious about what would happen to themselves and their jobs or the service if somebody did kill themselves.

(Angela Gilchrist) Well, I think you have hit the nail on the head there with regard to the impact on service users that when there is going to be negative consequences for genuine distress in that sort of way they are going to be unlikely to come forward when they need to, they are going to be unlikely to discuss their feelings with professionals for fear of what might happen to them, you know, not just in forensic services that you are talking about, I heard on the radio the other day of a lady who was feeling suicidal and phoned 999 for help and police came and arrested her.  She was stripped naked, put in a police cell, restrained, the whole bit, why on earth would anybody want to seek help if that is going to be the response?

(Rachel Terry)  I mean, I think that’s an extremely extreme response which obviously sounds terrible but certainly a regular response would be okay, you feel suicidal, I’m going to have to take this further, speak to a psychiatry colleague, there was no then discussion about why might you be feeling like that, what support can we be putting in place, more sort of in-depth thinking and planning.

(Anne Cooke)  So it’s really ironic that Angela said a few minutes ago that the one thing people said would’ve helped is somebody really listening and understanding and our own way that we think about suicide within services is actually stopping us doing that very thing.

(John McGowan)  Well this is very much what Ian was saying in our conversation and I find that hugely resonant for me in services working in in-patient acute mental health services which I did for many years and in some sense I can really, as somebody who has also been touched on a personal level as well as a professional, I can really see the pull of zero suicide policies profoundly.  It feels like any death in someone should be something that we try to avoid.  I suppose where it really begins to worry me though is again as Ian was saying, it’s when we just start to focus on risk and trying to assess the degree of risk, a) the paper that we were talking about in the British Journal of Psychiatry recently suggesting that the predictability of that is a lot less than we would wish and I’ve certainly heard people aspire to, you know, having a very perfect model of predicting and knowing what’s going to happen.  But I suppose the other side of it is, even if you are able to predict that’s not the same as what you should do and if you’re only focused actually on just sitting on, containing, squashing out the risk it certainly seems to lead to places that for me are really not where I want to be as an effective psychologist, or in fact as a human being.  To be honest really, just controlling people, taking them away, bringing them into hospital which may be distressing, leaving things so that they can’t actually confide and get support because, you know, it would be action stations, and this a tough dilemma for services I think and you really struggle with it.

(Angela Gilchrist) Well I think what’s missing from this prevention strategy is the voice of the service user, the voice of the survivor.  Instead it is all about control and management and in a very paternalistic way, you know professionals are saying we know what’s good for you and this is what we’re going to deliver.  Whereas the service user in this, saying what they would like to happen in situations like this, what would be helpful, what would have enabled them to feel better about what was occurring, be less distressed by it as ultimately we want to stimulate somebody’s own resources to manage better in future and that is exactly what gets squashed in this very controlling process.

(John McGowan)  I don’t know if anyone is really necessarily intending for that to happen because I think that the will behind the suicide prevention strategy is good but I suppose it’s just thinking about the reality of it on the ground, I mean sometimes there’s a big assumption that mental health services are necessarily a good place to be with those people. They may or may not be, it depends on how……

(Angela Gilchrist) The person may not have a mental health problem, not everybody who kills themselves is depressed or has a so-called mental illness.

(Rachel Terry)  The figures suggest up to a third of people who have killed themselves have been in contact with mental health services in the last year, doesn’t it, so that’s two thirds that haven’t been.  That’s not to say they haven’t had a mental health problem but they haven’t been in contact with mental health services and we do know that lots of the factors that have been associated with completing suicide are things like unemployment, debt problems, relationship breakdown so it’s not just associated with being depressed or mental illness as such.

(Anne Cooke)  One of the figures that Ian and I quoted in the piece we wrote on the blog was really, really striking to me that nearly half of people on employment and support allowance have attempted to take their own lives. Wow! What a figure.

(John McGowan)  Well I mean that, I guess, brings me to the other bit of the discussion I suppose which has been on my mind a lot since reading your article which is the notion of the extent to which the MP Select Committee Report which is what you were writing about, you know Theresa May’s speech, and the Suicide Prevention Strategy are touching on something that we actually discussed extensively in the last episode which is a notion of something… thr lens through which we see suicide rates as being quite an individual one inside people’s heads rather than thinking about sometimes broader factors like unemployment or social inequality.  I think there’s an attempt actually to look across populations a bit, focus on new groups like middle aged men or groups that are perceived to be at risk but this was something that you felt yourself, and Ian I think Anne, felt was really lacking in the MP’s report for all the good things in that but also I’m guessing in the Suicide Strategy and its updates.

(Anne Cooke)  I think in a way it’s a kind of side effect of our construction of suicide as a symptom of mental illness.  It has the potential to close down curiosity then, you know that’s the answer, it’s just a symptom, rather than encouraging us to look at the things in the person’s life that may have led them to feel so desperate and look at a more general level when we are thinking about suicide prevention for example at the groups in society that may well have real difficulties and think about what might lead people to feel so desperate because suicide doesn’t arise in a vacuum.

(Angela Gilchrist) I’m kind of thinking as well that in the current economic climate, if you really can’t make it economically, if you can’t feed your kids, you can’t turn the heating on in the cold, you have no idea what the future may bring, you have inadequate housing, you feel as though you have failed as a parent because you can’t help your family, why wouldn’t you become desperate actually.  That’s not mental illness that’s a human response to appalling circumstances and we are reading about these things in the papers every single day.

(John McGowan)  And we see it everywhere, certainly even in leafy old Kent and Sussex, you know, just the number of people who are around who are homeless is noticeably large. I mean it’s touching us everywhere, not just the bald statistics, it is touching us.

(Rachel Terry)  But there are statistics aren’t there because suicide rates are ten times higher in the most deprived area than the least deprived area so there are statistics to be backing this up and that is a bit of a gap in the current Government strategy.  I think there are lots of great ideas and actually lots of new and interesting ideas around internet use and things, I think there are lots of good ideas and strategies there but I think in terms of disadvantage they have got less ideas about strategies.

(Anne Cooke)  To be fair, Theresa May did name that but needs to go beyond that.

(John McGowan)  Just on that point about use of the internet and the sharing of information, I am just wondering how we understand that because it is clear that we are in a different world really from 20 years ago to when any of us were teenagers or in our 20’s, for example just thinking about young people and internet use it is a very different world and you can get access to all sorts of things that may not simply just remain thoughts in your head but it turns out there are YouTube people with YouTube channels about their eating issues or about self-harm or about suicidal feelings, and anyway how do we feel about that?

(Rachel Terry)  Well in some ways I think there’s positives because there’s also an online support network so some people who wouldn’t want to present to mental health services are accessing support through an online community so there’s some positives but also there’s lots of very dangerous groups and websites, aren’t there, about how you can kill yourself and so on which are obviously very dangerous and worrying.

(Angela Gilchrist) Yeah, I don’t think I can add to that really, I think there’s an upside to the internet, I think the internet has had a role in reducing stigma in so-called mental illness because I think people feel far less lonely with it than perhaps they had used to but, yes, there’s some very dicey stuff on the internet as well and we know that young people are only too keen to access it.

(Rachel Terry)  And also online bullying, things like that which we know are factors in leading people to feel suicidal.

(Anne Cooke)  I suppose one of the things just to move it away from that slightly, that’s been missing for me from this discussion a bit is what can we do to help people.  We’ve talked a lot about a vicious circle whereby the ideas we draw on in mental health services often paradoxically stop us being helpful but what can be helpful, I was very struck by something I heard years ago, a guy from The Samaritans said that he thought that mental health professionals make the worst Samaritans and I think that’s probably because of what Angela was saying about the paternalistic idea that we ought to be able to solve problems actually stops us listening but of course there are services like that where they’re not based on the assumption that suicidality is a symptom of mental illness but it is part of normal human experience and they don’t have the assumption that they ought to stop it, you know…..

(John McGowan)  They are immediately trying to save you which I think, I’ve found, is a trap.

(Anne Cooke)  You mean mental health services are, yes.

(John McGowan)  They immediately move to save which is the most natural thing in the world, I think, in another human being in pain.

(Anne Cooke)  Indeed.

(John McGowan)  But in some sense, the awareness of it sometimes stops them doing what you need to do.

(Anne Cooke)  Exactly, and there are crisis services as well, crisis houses which are run on the principle that people can make their own decisions, we are not going to take them away from them but we need to be there for people and listening and providing that understanding we were talking about and I think we need way, way more of those and we are far too focused on beds and in-patient facilities, okay we need those, but we need many, many more crisis houses, crisis facilities. I think it’s really ironic that one of our local crisis houses in Sussex, its closure has just been announced the same day or the day after Theresa May’s speech.

(Angela Gilchrist) I’d agree with that Anne and I think you know that the normalisation of distress could play a huge role in that, that if people could become more confident about talking to others about their distress instead of immediately cutting it away and saying, ooh gosh, you are talking about things that are really frightening to me now, you must go and see a mental health professional.

(Anne Cooke)  Exactly.

(Angela Gilchrist) That could go a long way towards helping.

(Anne Cooke)  I agree, and this figure that’s bandied about, Theresa May used it again, 1 in 4 of us have mental health problems, well nobody wants to be that 1 in 4.  There’s a risk that it becomes a bit divisive, that it says that the people who have mental health problems aren’t us, you know, we’re the normal people, whereas actually we all have psychological distress, we all have psychological problems and I guess that’s the normalising framework you were talking about and that is a much more enabling framework, to me anyway, in terms of encouraging you to talk about it because it’s okay, it’s normal.

(Angela Gilchrist) Well, and I think you know, lay people are often very afraid of discussing something as potentially frightening as suicide because they think that doing so will encourage the person to kill themselves.  We know from research that’s exactly the opposite actually, that the more those difficult feelings are spoken about, the less likely it is the person will act on them.  I mean, that’s the very first message that needs to be put across really.

(John McGowan)  Of course that can be an absolutely massive challenge for, well we train mental health workers here, and that can be a huge fear, especially in the early parts of your mental health career.  How do you find the words? It seems to me that what we are asking for here is at least first stop and think around what we are doing as a society, are we all out for prevention, does that allow room for a kind of care, a kind of connection, a kind of respect for where people are and I don’t know how we change that, that seems difficult to change because as a society it seems to me that we are certainly going through a phase at the moment of, perhaps we make some very unrealistic expectations, that so many things should be preventable or that we should be able to do things about, so many things should be controllable.  Is that real?  I don’t know, I don’t think so.

(Rachel Terry)  But when it’s a matter of life and death the pressure is sort of higher, I think, given that if someone does die it’s a tragedy.

(Angela Gilchrist) Well of course it is, every suicide is a tragedy but we do need to have a different framework around it, a different way of thinking about it.

(Anne Cooke)  One that enables us to listen

(Angela Gilchrist) Well not only that, I suppose I am thinking also, if you insure your house against roof leaks or subsidence or something, obviously you hope it’s never going to happen but you can’t guarantee that it won’t happen and not every suicide is preventable, you know, that’s not a message that can easily be heard but it is true unfortunately.

(Anne Cooke)  And in our attempts to prevent we sometimes do harm as well.  I am reminded again of the paper that we are citing in the British Journal of Psychiatry that found that a lot of people would have to be locked up to prevent one suicide and we don’t actually know that suicide would be prevented anyway and meanwhile all those people are being locked up against their will, medicated perhaps so we have to think about the harm as well.

(John McGowan)  So think about the harm of what we do now as well as seeing it as being about safety, we can get so focused on this as the safe way to go that sometimes we can neglect the risks of this very cautious strategy that we often adopt.  And on that note of qualified hope I think that we are going to have to end there.

(John McGowan)  The best way to follow the podcast is to subscribe.  You can do that on iTunes by searching for ‘Discussions in Tunbridge Wells’.  Also, you can find links to some of the things we’ve talked about on the show page on our blog, ‘Discursive of Tunbridge Wells’.  As well as that you can follow us on Twitter at CCCUAPPPSY and on Facebook if you look for Canterbury Christ Church University Applied Psychology there will be links to the Twitter feeds of all our panel on the show page too.

(John McGowan)  All that remains for me to do is to thank all of our contributors and hopefully we will be back soon.