Life is a risk. Each action we take, outside the home or indoors, is associated with some degree of danger. Risk is an ever-present feature of human existence that each of us manage effectively, routinely deciding upon an acceptable balance between a rewarding lifestyle and the potential for harm. Yet there is one scenario where this collective wisdom is abandoned, replaced by a radically different, less rational approach: the situation where a person is perceived to be considering suicide.
Western psychiatry displays a perverse approach to risk. In the context of a society that craves reassurance that extreme violence (to self or others) is predominantly the domain of a ‘sick’ minority, psychiatry acts as a willing accomplice by asserting that some inherent biological disturbance – a ‘mental illness’ – underpins these acts of destruction. Acceptance of this assumption allows the general public to sleep easier in their beds, soothed by their belief that these extremes of behaviour of a disturbed minority can be effectively eradicated by psychiatric treatment. However, such conjecture is inaccurate and unhelpful.
The negative consequences of a medicalised approach to suicide
A medicalised approach to suicidal behaviour is associated with a number of important disadvantages.
First, it misleadingly suggests that people at risk of killing themselves will typically meet psychiatry’s diagnostic criteria for a ‘mental disorder’, yet the reality is that between two-thirds to three-quarters of those who complete suicide have neither a recognised psychiatric ‘illness’ nor any previous contact with mental health services [see previous blog]. And given that it is widely recognised that most of the mainstream diagnostic labels are devoid of explanatory power, offering little to identify a cause nor a helpful intervention, it would not get us very far even if those people at risk did meet these criteria.
Second, and perhaps most significantly, the claim that there is an underlying ‘mental disorder’ prevents us from searching for the real reason why a person has decided to die rather than to live. Life stories – the nuances of a person’s past and present life experiences – are ignored or de-prioritised, not seen as relevant, trumped by assumptions about the impact of a faulty brain.
Third, the medicalisation of our approach to suicide leads to the unfounded conclusion that psychiatric treatment deters people from killing themselves. As described by David Webb (in his excellent critique of ‘suicidology’, Webb ), few of us with an interest in the subject will not have heard a psychiatric expert espousing the mantra that, ‘suicide is primarily an outcome of untreated depressive illness’. Such a claim, unsupported by any research evidence, is often deployed to encourage more reliance on antidepressant drugs, thereby contributing to the rampant overprescribing currently witnessed across the Western world.
Fourth, the medicalisation of suicide, with the unsubstantiated claims that psychiatric ‘treatment’ can avert it, is commonly used to justify compulsory detention and enforced drug regimes. As powerfully stated by Webb (2016), ‘Suicidal people, like everybody else, do not want to lose their liberty and be assaulted by medical violence’ (p89). Consequently, mental health provision is often avoided by the very people it is meant to help.
Fifth, the assumption that a ‘mental illness’ underpins suicidal intent shifts responsibility for whether someone lives or dies from the individual sufferer to the mental health professional; if a curable brain disorder is the cause of the suicidal state of mind, it follows that only psychiatric expertise can rectify it. As well justifying the human rights violations, this responsibility grab contributes to the stifling level of risk aversion apparent throughout psychiatric services, where professionals often act to cover their own backs against a future risk of censure rather than in the best interests of the people they are paid to serve. One consequence of this focus on blame avoidance is the inordinate time devoted to bureaucratic risk assessments, an extended paper exercise that achieves very little other than to act as evidence to any subsequent serious incident review that the professionals did all they could to prevent a catastrophic outcome.
Why our approach to risk might be a barrier to a paradigm shift
The bio-medical approach, with its focus on ‘mental illness’ and corresponding drug treatments, continues to dominate the Western world’s approach to human suffering despite widespread recognition that this paradigm is both relatively ineffective and often harmful. One important reason for this odd state of affairs is the way society makes sense of, and responds to, people who are contemplating suicide. Our perverse approach to risk (as described above) may contribute to the maintenance of the status quo in two ways: by colluding with ‘internal deficit’ explanations of emotional distress and by acting as a cornerstone for the discriminatory Mental Health Act.
Society’s perception of suicide risk, as being the exclusive domain of a mentally disordered minority, dovetails with psychiatry’s ‘illness like any other’ approach to emotional distress and thereby perpetuates the idea that an internal defect, residing within the individual sufferer, is the primary cause. An ‘explanation’ of this type will often crush hope, induce passivity and encourage the gross overuse of psychiatric drugs currently evident across the Western world [see here].
Crucially, our perception of risk and its assumed underlying causes can be used to justify our prejudicial mental health laws. The Mental Health Act, currently active in England and Wales, fundamentally discriminates against those deemed to be suffering from ‘mental disorders’, legalising the incarceration of people who have committed no crime and forcing often-toxic psychiatric drugs on those with the capacity to make their own decisions. The erroneous assumption that extremes of emotion and/or behaviour (including suicidal crisis) are always indicative of someone who has lost the ability to make autonomous decisions is a significant reason why such flawed legislation persists, a legal framework that acts as an engine-room for much that is wrong with Western psychiatry [see here].
Furthermore, these two processes – the Mental Health Act and internal deficit explanations – are both highly stigmatising, construing suicidal people as second-class citizens who are intrinsically flawed. Consequently, people who are contemplating ending their lives will likely feel discouraged from speaking about their intentions. It is hardly surprising, therefore, that many suicidal people are reluctant to seek help.
Five recommended changes to the way we respond to suicidal people
1. Easy access to crisis centres
Instant access to a local, 24/7 crisis house should be available to anyone who needs it, offering temporary asylum from the everyday demands of life and an opportunity to share personal stories of distress in a supportive environment. The crisis house should be a non-medicalised facility, away from hospital settings, staffed by people displaying the core human qualities of genuineness, empathy, respect and compassion [see here].
2. Listen to people’s stories
The focus should be on discovering the real reason why a person is contemplating suicide, rather than assumptions of insanity. Normalising the experience by construing suicidal feelings as a ‘crisis of self’ (Webb, 2016) would form the bedrock of a less stigmatising approach.
3. Utilise the experiences of suicide survivors
Society’s approach to suicide prevention should be informed by the untapped testimonies of the many people who have survived a suicidal crisis. The experiences of those who pulled back from the brink of self-destruction should be at the centre of service planning, service delivery and research (as opposed to the current reliance on the views of psychiatric experts).
4. View self-injury as a survival strategy
Recurrent acts of self-harm (such as self-mutilation and drug overdoses) should be construed as ways of staying alive rather than as pathological behaviours, as no different from other, more socially acceptable coping strategies such as smoking, drinking or comfort food (Shaw, 2016). Adoption of this normalising approach would avoid unhelpful service responses (for example, coercion and derogatory labels like ‘borderline’) that can often make completed suicide more likely.
5. Develop mentally health communities
Although how we respond to those already in a suicidal crisis is important, any progress in suicide prevention will be realised primarily through the development of mentally health communities. As with all forms of emotional distress and overwhelm, our focus should be on the promotion of wellbeing rather than the ‘treatment of mental illness’. Encouraging sensible conversations about suicide across our society would be one way of achieving this aim.
And finally … the rallying call of David Webb (himself a suicide survivor) neatly captures the essence of what is urgently required:
‘We need to reclaim our personal power, both individually and collectively, and take ownership and responsibility for suicide prevention’ (Web, 2016, p93).
Webb, D. (2016). Thinking (differently) about suicide. In: Russo, J. & Sweeney, A. (eds.), Searching for a Rose Garden: challenging psychiatry, fostering mad studies. PCCS Books (pp 86-96).
Shaw, C. (2016). Deciding to be alive: self-injury and survival. In: Russo, J. & Sweeney, A. (eds.), Searching for a Rose Garden: challenging psychiatry, fostering mad studies. PCCS Books (pp 77-85).
Photo courtesy of Stuart Miles at FreeDigitalPhotos.net