The Gloucester group of the charity Survivors of Bereavement by Suicide (SOBS) and the 2gether NHS Trust, Gloucestershire’s mental health trust, held a joint conference on September 9th. It was part of an annual series of conferences on topics related to suicide and its prevention.
The best thing about these conferences, I think, is the breadth of participation, although this year’s seemed a little less broad than last year’s. Even so, it was good to mix with students, NHS staff, police, volunteers, and others.
Another good thing about the conferences is that the speakers are not just the usual suspects plodding through standard presentations. They always have different perspectives that provide much food for thought.
This year’s theme, On the Edge: Averting Crisis, was addressed by presentations on opportunities for suicide prevention in the community and an alternative to psychiatric hospital admissions. There were also workshop sessions from a team who work with homeless people, from police negotiators, and from the local NHS Crisis Resolution and Home Treatment team.
In the introduction Trish Thomas, who chairs Gloucester SOBS, pointed out that a crisis is a turning point if you take the word literally. However, none of the speakers really seemed to agree. It seems to me that the modern interpretation of crisis is that it’s a time of somewhat increased risk that might not be a turning point at all, but just a temporary peak in a pattern of recurring risk. Indeed, Trish herself went on to use the word crisis in reference to various minor difficulties she’d had while preparing for the conference.
Gordon Benson, Assistant Director of Governance and Compliance at 2gether, pointed out that the following day would be World Suicide Prevention Day, but almost no one in the audience was aware of it. To me, that is a good indication of just how important these world days are — not at all.
As before, some aspects of the way the conference was organized were less then ideal. The audio-visual support was patchy and some questions from the audience were inaudible. Presenters should know to repeat questions so that everyone knows what’s going on.
It was a pity that the workshop sessions were mostly filled with presentations leaving little or no time for workshop activity. The whole point of breaking up into smaller groups is to allow for interaction.
Interrupting the suicidal process
Christabel Owens, Head of Research for Devon Partnership NHS Trust, outlined an approach to suicidality based on public involvement, remarking that:
Nobody seems to be doing very much about it.
One of her starting points was that 75% of people who take their own lives are not in contact with specialist mental health services. That certainly makes it seem sensible to focus on suicide prevention in the community.
Gloucestershire’s current Suicide Prevention Strategy, however, contains quite different figures. For example, on page 21:
Over sixty per cent of people that [sic] died by suicide had been in contact with [specialized mental health services] and/or primary care within the preceding month
This figure makes it seem sensible to focus on suicide prevention in the NHS. At the end of her presentation I asked Dr. Owens how she accounts for the difference, but she found the question difficult to answer clearly. I suspect both parties may be quoting statistics that support their pre-determined conclusions.
Much of this presentation was based on a graph of a person’s suicidal tendency that showed it rising and falling over time, with an overall rising trend. The peaks were crises, but in the early stages the crises are not severe enough for other people to notice.
As things get worse for the person, the crises do become severe enough for other people to notice. It’s at these times that other people could intervene and help, but often they don’t do anything. Eventually there is a crisis so bad that the person really does commit suicide.
It wasn’t clear that this model is actually true, although aspects of it may be true. However, like the statistic I quoted above, the model supports the pre-determined conclusion that there are times when people can intervene in the long process leading to suicide.
The reasons why people don’t intervene are complicated. Often, the people who notice are family members who are themselves caught up in the problem. They might be the problem. Also, people want to believe that things are OK. They don’t like to interfere and they don’t know how to listen and help.
Dr. Owens recommended more education for the general public on how to respond to signs of distress in others. She suggested Mental Health First Aid or ASIST training for lay people, not just for clinicians.
She also supported more conventional means of reducing suicide numbers, like restricting access to high places and ensuring that people who may be vulnerable are not left alone.
Not all the questions were audible from my seat near the back of the hall, but I did hear one member of the audience remark that healthcare professionals sometimes ignore the signs too.
Leeds Survivor Led Crisis Service
Fiona Venner, from Leeds Survivor Led Crisis Service, described a multi-award winning approach to providing a place of sanctuary as an alternative to hospital admission for people in acute mental crisis. The service has NHS and council funding, which is ongoing despite cuts in other areas because of the service’s outstanding effectiveness.
The key elements seem to be that the service is led by people who have personal experience of mental illness, that its counsellors are trained in a person-centred therapeutic approach, that it is set apart from statutory services and has no powers of compulsion, and that its work is based on trust and engagement rather than aggressive risk-assessment. Their approach is similar to that at Maytree in London.
There is a focus on warmth, kindness, respect and sanctuary without diagnosis or assessment, even though many visitors (as they are called, instead of ‘patients’) are chronically very suicidal. They have had no on-site violent incidents or suicides:
We believe this is entirely because of the way we treat people.
Two of the centre’s visitors told their stories. One described how being a psychiatric in-patient had felt like being a prisoner. The other described how she had previously been labelled with a diagnosis, but this service doesn’t do that. She added:
There should be one in every town.
At the end of this impressive and moving presentation, Trish Thomas took the advice rather literally and announced a project to create a similar service in Gloucestershire. Quite a few people signed up to get involved, so it looks very possible that it could actually happen.
Homeless Healthcare Team
Members of the team from the Vaughan Centre for the homeless in Gloucester ran a workshop, although most of it was taken up with presentations. The day centre provides access to all kinds of health and social care services, and there is also a night shelter.
A user of the centre told his story and praised the work of both the centre and Narcotics Anonymous in helping him after many suicide attempts. There was a group task and a rather rambling discussion about suicide risk factors.
Two police negotiators ran a workshop on the work they do to save people who threaten to kill themselves, for example by jumping off bridges over motorways. The workshop was almost entirely taken up with presentations but they were very interesting with plenty of anecdote.
Intriguingly, the approach is not to talk them down but to “listen them down”. The emphasis is on creating rapport, understanding the suicidal person’s point of view, being empathic and being honest. There’s no attempt at diagnosis, even when the person is clearly mentally ill. The parallels with the work at Leeds were striking.
NHS Crisis Intervention
Members of the NHS Crisis Intervention and Home Treatment Team ran a workshop on the work they do. Again, the workshop was almost entirely taken up with presentations.
Although the workshop was entitled, Responding to crisis in the community, the team has been considering getting rid of the word “crisis” in their title. They don’t really respond to crises, and although they do provide an “emergency” number it’s not always manned and they may take an hour to “respond”.
It was difficult to understand the focus of their work. It seemed to be very broad. They estimate that 30% of people referred don’t have any severe mental illness, though they may be suicidal and have social problems. At one point it was remarked that:
We’ve become a massive assessment machine, in a way.
Again this confirmed the view of the Leeds service that conventional mental health services are far too focussed on assessment. It was surprising and disappointing that this team didn’t seem to have any good definition of crisis as their starting point.
The presentation went on to cover the process for dealing with people who present a risk in a public place. Under Section 136 of the Mental Health Act, police can forcibly take them to a place of safety to be assessed, and a special unit in Gloucester is provided for the purpose. The average time people spend there is 4½ hours, even though the Act allows up to 72 hours. Around half are discharged with no follow-up.
Before last year’s conference I volunteered to set up a stand and hand out information about Gloucestershire Local Involvement Network (LINk). Too few people, I suspect, even amongst those who work in health and social care, know what the LINk is and what it does. In the event there was no stand and no information. This year I offered again, but this time I received no reply at all to my offer. Again there was no LINk stand at the conference.
Things were worse than last year for the LINk, though, because there was someone in the audience who continually described himself in a way that made it seem he represented the LINk, and who made several remarks throughout the day criticising various presenters on matters of political correctness. Although I challenged him on one occasion, it didn’t deter him one bit.
One of the bees in his bonnet was about the phrase “commit suicide”, which some people don’t like because they think it implies suicide is a criminal act. But “commit” doesn’t really imply criminality at all. It only implies something that cannot be undone. A commitment is an act or an intention that you cannot go back on. So what the phrase “commit suicide” really implies is only that suicide is final, which it is.
Everyone has their own point of view about this kind of thing. It’s not for the LINk to go around telling people what they should think and how they should speak, and certainly not for an individual member of the LINk to go around doing it on the LINk’s behalf.
Right at the end of the day the same chap criticised the conference organizers for holding the conference on a Friday because it’s a holy day for Muslims. He was publicly rebuked for saying such a silly thing. It was an embarrassment for the LINk. So, while last year the LINk had no publicity at the conference, this year it had negative publicity.