When I am asked the simple question, "What is your most valuable possession?", the answer is obvious: "My life!" The simple truth of this response has helped to make suicide a taboo subject until recent times. Suicide is a fundamental challenge to this truth and to the fabric of society, which until recently responded with suppression and denial.
If life itself is so precious and the will to live normally so strong, how can it be that the leading cause of death in Australia for people under 40 is suicide, and self-harm and suicidal behaviour is widespread? Over 3000 Australians die this preventable death every year and there are many hundreds of thousands more who have attempted suicide or harmed themselves.
Acknowledging a role for health as part of the explanation allows room for a more compassionate and expert response.Credit:Tamara Voninski
Our Prime Minister has been grappling with this question. Since the election, he has pledged to end the "scourge" of suicide, and in a brave and inspired move has set the only appropriate target of "zero suicide". He has conducted a series of deep dives to help him understand the national crisis in mental health care, and earlier this month convened a national summit on suicide prevention in Canberra to which I was invited. It is clear to me that he is trying to understand what would bring someone to the threshold of ending their own life.
Suicidal thinking does not occur when people are in a normal and mentally healthy state. It comes about through the cumulative effect of a number of risk factors, especially when key protective factors – such as social support – are missing. The suicide prevention field has recently emphasised the role of "social determinants", meaning social and environmental factors such as poverty, childhood trauma, family violence and financial stress. These are what we call contributory causes and all have their role to play, as have background mental illness, addiction and chronic physical illness. However, since not all people exposed to these influences become suicidal, these forces are not determinants but merely influences. The word "determinant" implies that the result is "determined", and yet suicide is by no means inevitable, even under extreme conditions.
I know this through working for many years with torture survivors who have experienced the most extreme stress imaginable. So there must be another element that explains why some people exposed to powerful social "determinants" are able to hang on to the sense that life is worth living while others do not. In the past, those who succumbed – even if the pressures of life were severe and unremitting – were regarded as weak, and suicide was proscribed and even viewed as a sin or a crime. This implied a level of choice or free will. While these social and economic forces do substantially increase the risk, they are neither necessary nor sufficient for suicide. Some people die by suicide in the absence of any of these adverse life circumstances, and many more do not do so even in the wake of great adversity. Something extra is required.
The necessary element is a descent into a particularly lethal state of "mental ill-health", a stepping stone, which may involve varying combinations of emotional pain, hopelessness, guilt and anger, often fanned or triggered by substance use and immediate stressors or losses. This does not mean that the person is suffering from a narrowly defined or classical "mental illness" reflected in the traditional stereotypes, though serious mental illness can result in suicide even in the absence of social influences – for example, through hallucinations commanding the person to self-harm. It also does not mean that the social forces, perhaps interacting with other vulnerabilities to mental ill-health, have not created this potentially lethal mental state. The causal pathway is not binary but complex.
Yet unless we all accept that an intense state of mental ill-health, however brief or transient it may be in some cases, is a necessary pathway for suicide to be attempted or completed, there is a risk we will re-embrace the old prejudices of weakness of character as a reason for the rejection of our greatest gift and possession. Acknowledging a role for health as part of the explanation allows room for a more compassionate and expert response. These days we do try to offer decisive and timely intervention from health professionals as well as peers, recognising that this mental state is typically a temporary one even if longer-term mental illness has been present, which can resolve with support and expert help.
Through his personal advisor, Christine Morgan, the PM is fortunate to have access to the best possible evidence on suicide prevention. However, I must admit that we in the mental health and suicide prevention field have not been as helpful as we might have been in providing guidance to the PM. We have given the impression that there is a tension or dichotomy between the social and economic determinants of mental ill-health and suicide, and mental ill-health itself. In fact, both aspects usually play a causal role as I have explained. We need to be much more sophisticated in our thinking and our design of health care. We also need to look at the feasibility and time scale of reducing some of the risk factors for suicide, such as prevention of cyclical economic crises and what can be done to mitigate the effects of social and economic forces that we cannot deny, but that may be challenging to defeat.
It was very encouraging to hear the PM exhort our field to "get granular" and provide him with solutions he can fund that will make deep in-roads into the unacceptable death toll from suicide. Avoiding false dichotomies and prioritising feasible strategies will be crucial.
Patrick McGorry is a professor of youth mental health at the Centre for Youth Mental Health, University of Melbourne.
Support is available for those who may be distressed by phoning Lifeline 13 11 14; Mensline 1300 789 978; Kids Helpline 1800 551 800; beyondblue 1300 224 636.
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