The politics of suicide prevention

In the twelve years since my last suicide attempt, I've been active – some would say an activist – in the overlapping areas of suicide prevention, mental health and disability rights. When asked to report to Santa on whether my "area of expertise" has earned its annual Xmas presents, I regret that my report is once again rather grim.

During my PhD research, I saw myself as working within the academic discipline of suicidology. I now see suicidology as just one component of a larger suicide prevention industry, which in turn is a branch of a larger mental health industry. As I approach my retirement from this industry, I now also see much more clearly the politics of suicide prevention. I'm embarrassed at how naive I was ten years ago. But I am also shocked by the political machinations of an issue that should be above such tacky, self-serving, vested interests. I'm shocked by the politics of power that controls and seriously constrains the public discussion of suicide in Australia – the self-appointed gatekeepers not only of suicide conferences and journals but also of the discussion of suicide in the mainstream media. And I'm shocked that the understanding – and prevention – of suicide is constantly thwarted by ignorance, prejudice and ideological dogma.

The politics of suicide prevention is the major obstacle to progress in reducing the suicide toll. My sad assessment is that the suicide prevention industry – and its mental health daddy – contributes to rather than reduces the suicide toll. This is a very serious charge which requires some justification. The short summary here of my report to Santa presents the two major reasons why I come to this grim assessment – the excessive medicalisation of suicide and the institutionalised discrimination of suicidal people. These are both political issues, not academic or scientific, nor are they funding or resources issues. The only resolution of them will be broad public debate.

Medicalisation

These days most people think that suicide is caused by mental illness, and in particular see Depression as the major cause. This is the most damaging of many harmful myths about suicide. Why has this belief become so popular when there is in fact no scientific evidence to support it?

The reason is that the last 20-30 years has seen a massive public relations exercise by the medical profession and the pharmaceutical industry to promote the belief that Depression is a genuine medical condition that requires medical treatment, most notably antidepressant medications. In Australia, the exemplar of this PR machine is beyondblue but it also includes a few influential individuals that today we might call Team McGorry. This campaign has been so successful that the myth of the "chemical imbalance in the brain" has colonised our cultural understanding of suffering and poisoned the public discourse on mental health and our emotional wellbeing.

The marketing rather than scientific origins of the "chemical imbalance" myth has now been thoroughly exposed so the medical spin doctors rarely utter it these days. But the damage has been done, the medical colonisation is virtually complete. The psychology of the mind has been thoroughly reduced to the biology of our brains and mental "illness" has become a biological malfunction of the brain. Neurotransmitters are in, emotions are out. As Francis Crick once famously said, "we are nothing but a pack of neurons".

The dehumanising medicalisation of suffering – and indeed of the human condition in general – diminishes us all. It also contributes to the suicide toll. The most serious consequence of the assumption that suicide is caused by Depression (or any other medical illness) is that we then stop looking for the deeper causes of why some people choose to die. Instead, superficial, ineffective and often harmful medical interventions have become the first line of "treatment". The massive antidepressant experiment of the last 20-30 years has been a demonstrable failure, at least for suicide prevention, and it's long overdue that we call an end to it.

One alternative is to resurrect the concept of "psychache" pioneered by one of the founding fathers of modern suicidology, Professor Edwin S Shneidman. Suicide is caused by psychache, says Shneidman, which he defines as unbearable psychological pain (not illness) due to frustrated or thwarted psychological needs. A few suicidologists are keeping Shneidman's great legacy alive, most notably the Aeschi Group, but psychache remains marginalised by the medical juggernaut of contemporary suicidology.

Psychache is a useful concept with rather more intellectual credibility and integrity than the mental illness myth. But I think we can do better. I argue that suicide is best understood as a crisis of the self, which accommodates not only the psychology of psychache but also the social, cultural and spiritual dimensions of any suicidal crisis. A truly holistic approach to understanding – and preventing – suicide must consider the whole person in their social, cultural and historical contexts. The current enthusiasm for blaming suicide on the brain is contributing to the suicide toll.

Discrimination – aka 'stigma'

Stigma is recognised as a fundamental obstacle to suicide prevention, though it should be called by its correct name, which is discrimination. Stigma is not an attribute of the stigmatised individual but comes from the stigmatising attitudes and prejudices of the society in which these individuals finds themselves living – i.e. just like racism, sexism, homophobia and other forms of discrimination. Discrimination (stigma) is a political, human rights issue.

Despite all the hoopla of "stigma-busting" campaigns (which many people actually find patronising and indeed stigmatising), the single greatest source of the stigma around suicide, and mental health in general, rarely gets mentioned. The most severe discrimination occurs when it is enshrined in legislation, such as the racism of the White Australia policies, the homophobia that criminalises homosexuality, and so on. Most of these legalised forms of discrimination have now been abolished, at least on paper, but not yet in mental health. By far the major source of the toxic discrimination against suicidal people is mental health laws that make second-class citizens of people labelled as "mentally ill".

I think most people believe that one of the reasons we have mental health laws is to help prevent suicides. This noble aim is used to justify depriving people of their liberty and, furthermore, to force unwanted medical treatment on them. So let's assume, cautiously, that these laws come from good intentions, keeping in mind though that so did the Stolen Generation policies. But are these laws effective? Or do they possibly make things worse for (some) suicidal people? To use the medical jargon, what are the efficacy and safety of these laws? Do mental health laws help or hinder suicide prevention?

The first extraordinary thing about this question is that nobody seems to (want to) ask it. There is no research at all on the efficacy and safety of incarceration and/or medical force for the purpose of suicide prevention. This really is extraordinary. If we applied medical standards of evidence, then such an intervention with zero evidence of its efficacy or safety would never be permitted. All we have are status quo assumptions that detention and force are necessary to prevent suicides. But does this stand up to scrutiny? In the absence of any contrary evidence, I say there are powerful arguments against such laws, at least for the purpose of suicide prevention.

Suicidal people, just like everybody else, do not want to lose their liberty, nor do they want to have medical treatments forced upon them against their wishes. So we find that mental health services are often deliberately avoided by the very people they are supposed to help. At the very least, this contributes to the suicide toll by failing those in need of help. But even worse, some suicidal people are finally pushed over the edge into suicide by the violence they encounter from these services. And even worse again, detention and medical violence can actually trigger suicidal feelings in people who have never previously been suicidal.

Glimmers of hope ...

Although the medicalisation of suicide and its collaboration in the legalised discrimination against suicidal people seem deeply entrenched, it is possible to detect some faint glimmers of hope for the future. Most notably, we can look to our disability cousins for a clear, comprehensive and very good roadmap of a way forward.

The UN Convention on the Rights of Persons with Disabilities (CRPD) was adopted by the UN General Assembly in 2006 and ratified by Australia it in 2008. It represents a huge milestone and an outstanding achievement of the disability rights movement over the last generation or so. At the heart of the CRPD is a shift away from the paternalistic "father knows best" medical model of disability to a social model based on human rights and social inclusion, which is precisely what is needed in mental health and suicide prevention.

A core feature of the CRPD is a move away from substituted decision-making, such as involuntary psychiatric treatment, to a model based on supported decision-making. Space does not permit a full discussion of what this might mean for our mental health system, other than to say that it entitles an individual to have access to whatever supports they need to ensure their rights and their wellbeing. There is currently debate whether the CRPD actually prohibits substituted decision-making entirely but, at the very least, it requires that those who wish to maintain it are obliged to present very compelling reasons in order to justify it. Status quo assumptions can no longer govern our mental health laws.

We can no longer hide from the politics of suicide prevention. The CRPD was born through years of political struggle by people with disabilities. A similar struggle is required, now with the help of the CRPD, if we are to make meaningful progress in reducing the suicide toll.