HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
31 January 2008
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mrs Carmel Hanna
Ms Carál Ní Chuilín
Mr Mike Tomlinson
Mr Iain McGowan ) University of Ulster
The Chairperson (Mrs I Robinson):
I now welcome Mr Mike Tomlinson of Queen’s University Belfast and Mr Iain McGowan of the University of Ulster. You will have five minutes each to make an introductory presentation, which will be followed by questions.
Mr Mike Tomlinson:
I thank the Committee for allowing us to give evidence and for taking an interest in this subject. I am not here on behalf of Queen’s University; I am here because of research that I conducted personally, and which was commissioned as part of the suicide prevention strategy. The Department asked me to take an overview of established research evidence about the relationship between our conflict — and war in general — and suicide. What evidence do we have to show that what we are dealing with in relation to suicides is past trouble? Are there legacies that, in some senses, explain what appears to be an increase in trends? I am pleased to table that report and to be able to come here to present it.
The report is wide-ranging and deals with global trends, international and domestic conflict situations, and a variety of consequences of conflict situations. Some of those have already been touched on today, such as child abuse and the impact of sexual violence on women, and how that, in turn, translates into poor mental well-being and can result in suicide. My memorandum simply highlights some of the key points from the research that I think may be of interest to the Committee, particularly in its examination of the suicide prevention strategy, Protect Life.
I was particularly interested to hear discussion focusing on the data on suicide and the processes that produce the figures that we all depend on to shape our basic understanding of what is going on in society. Much of the report deals with those issues. I do not intend to talk very much about the data and the processes of recording and registration. However, when it appears that the suicide rate is getting out of control, it is worth reminding ourselves that the last set of figures produced by the Northern Ireland Statistics and Research Agency (NISRA) registered 291 suicides for 2006. Only 72 of those suicides actually occurred in 2006. I am quite prepared to believe that there were more than 291 suicides in 2006, but we will not know whether that is the case for at least another two years.
It is important for the Committee to focus on what is happening with processes of registration and recording. Everything that has been said so far about the role of coroners, the reporting structures, the early warnings, how that information gets registered and the delays in the system is very important. We must move towards the Scottish system, whereby an approximate figure is published much more quickly, which gives a much better sense of the real trends.
At the moment, our understanding of changes in trends comes from the experience of communities, which is why I remarked on the importance of funding the groups that support parents and communities. Very often, the politicians and community representatives are the first to hear about suicide. NISRA is the last to hear, in a sense. That involvement provides an important detection service. Nonetheless, we could improve the data to develop an early warning system about what is going on, not just in terms of prevalence, but also the age groups that are affected, broken down by sex and so on.
Much of the work in my report is not useful as regards front-line prevention activity. It is not about psychiatric interventions or explaining people’s psychological states of being. Rather, it focuses on the evidence on social circumstances, social structures and social change, all of which can lead to poor mental health and contribute to suicide rates. The report is pitched very much at a level that involves the kinds of factors that the other groups have mentioned today — for example, prevention, and an understanding of the issues that contribute to depression. There is very good population-based evidence to show that people who were closest to the conflict — who either were in the front line or lived in communities where they witnessed murders, shooting and mayhem, or who were personally affected by bereavement, injury or disability — have much poorer mental health than others. That is a very important starting point in any effort to move forward and deal with some of the legacy of the past.
Finally, it is not easy, or, in fact, possible, to distinguish completely between Troubles- and non-Troubles-related effects. That is simply impossible. We must accept that those are the circumstances in which we have lived and which have shaped our society: we must deal with that in whatever way we can.
Mr Iain McGowan ( University of Ulster):
Thank you for the invitation to address the Committee. I am present on behalf of the dean of the faculty of life and health science, Professor Hugh McKenna.
I will briefly explain my background and why the professor has asked me to be here. Ten years ago, I qualified as a mental-health nurse. I started work in the Mater Hospital in Belfast and was fortunate enough to set up and run its Assert (action on suicide, support, education, research and training) project. It was a fairly well-evaluated and successful project which operated primarily in north and west Belfast. I joined the university in 2002. During the 10 years that I have worked on suicide, the vast majority of my research has been on suicide in Northern Ireland.
I am currently working with Professor Marlene Sinclair, who is professor of midwifery research at the University of Ulster, on a book for midwives that examines suicide during pregnancy and the first post-partum year. That is currently being developed. Recently, I have also been invited to join a Europe-wide group of academics who seek to understand suicide in areas that are experiencing, or have recently come through, conflict. The group includes colleagues from Serbia, Bosnia, Kosovo, and Israel. We aim to develop that international group on suicide in conflict areas.
I will not go through my written submission. However, I will refer to three points, if I may. The first salient point to come through is the idea, which was referred to earlier, of the complexity, multifaceted nature and multidimensionality of suicide. My colleagues and friends Dr Paul Miller, who gave evidence to the Committee in July, Dr Philip McGarry, who gave evidence in October, and, I believe, Dr Deeny, have all pointed out that suicide is not simply a mental-health issue. To a certain extent, even though there is recognition that there are multifaceted underlying causes of suicide, the discussion always seems to return to mental-health services. We want that discussion to be widened.
I was heartened to hear Mrs Hanna talk about the anti-poverty strategy and the effect that poverty can have on an individual’s choice to take his or her own life. It is very much my belief that the causes of suicide are wider than mental health. The ongoing research that the university has presented has been along the lines of how analytical chemistry — examining hair fibres, and so on — could be used. One of my supervisors is a theoretical physicist. Through my PhD, I seek to determine whether some of the models that are used by theoretical physicists can be transferred across to the study of complex human behaviour. There is wider scope for study than just the consideration of the mental-health aspect of suicide.
Talking therapies have been discussed previously. It is to be welcomed, although, again, not necessarily for the sake of therapy and for being seen to provide something: it must be relevant to the individual’s needs and appropriately resourced. We have suggested other therapies in our submission. Several of my colleagues and I — Dr Derek Loughlin, Dr Paul Miller and Dr Michael Patterson — are currently putting the finishing pieces to a case study on psychological therapy for trauma and eye movement desensitisation and reprocessing. A side effect for one individual who was working through her trauma is that she stopped cutting herself. We are writing that up as a case study, because it was an unexpected bonus. There must be an innovative approach when we seek to develop the type of services that we can provide.
There has been a lack of local academic input into the suicide prevention strategy. As far as I am aware, no one from any of the three higher education institutes was a member of the strategy group. We accept that there were eminent academics and suicidoligists providing quality assurance, but it would have been useful to have had someone with local knowledge as a member of the group.
I am interested in this subject. It has, quite rightly, taken up much of the Committee’s time. Mr Tomlinson, Committee members and the Chairperson have all referred to the responsibility on doctors to record accurate information on death certificates. Due to the stigma, even after death, relatives have asked me not to register suicide as the cause of death. As Carál mentioned earlier, they do not want depression or alcoholism put down as causes. It is almost as if the family still, even after death — it is shocking. It is something that we are going to have to face up to as a society.
I agree with Mr McGowan; I have also come across situations where I could not honestly say. I am delighted that you said that. We have mentioned before how important it is for education facilities to be involved. I am shocked to hear that there was no higher education involvement in the strategy. Schools and churches must also be involved, because suicide affects our entire society.
I have been working in the Health Service for a long time, and it seems to me that the older generation were able to cope much better. Perhaps they had it harder, and were more used to dealing with hardship. People now seem to find it extremely difficult to cope. I will not mention any names, but there was some young fella from in and around these parts whose brother committed suicide in the past week. He could not get over breaking up with his girlfriend, but relationship break-ups have been going on since time began.
Are we all at fault, providing too much for young people, so that they cannot cope when anything goes wrong? I wonder whether I am as guilty as everyone else in that as society becomes more affluent, we provide more and more for young people, and they get everything that they want. Do we spoil our kids, so that when they grow up they have not been used to hardship and cannot cope when they encounter it? I am interested in your views on that.
There are Church representatives due to appear before the Committee. Is the message not getting through to young people that life is precious? As I said earlier, I have seen the effects of suicide on the families who are left behind.
The traditional age profile of suicide in most countries has been that the highest rates of suicide are among elderly people: the further up the age range, the higher the prevalence of suicide. Therefore, I do not know whether it is a question of people becoming less resilient. The global trend suggests that suicide rates are increasing in some parts of the world. That is partly explained, as in Northern Ireland, by greater prevalence of suicide in the younger age groups.
However, it does not go down that far. There is a tendency to focus on teenagers and the horrendous tragedy of 10- to 14-year-olds committing suicide — and I made the point in my submission that there is evidence of a trend. However, the basic pattern is that elderly people are most likely to commit suicide.
I want to make a broader point about concealment and revelation. Some people, particularly the closest relatives, have a propensity to want to conceal suicide, and they want it to be turned into an accidental death, through poisoning or whatever. The data shows a direct association between suicides through poisoning and accidents through poisoning. Therefore, there is a relationship that is to do with exactly the phenomenon that you are talking about.
There are certain social circumstances in which a lot of publicity has been given to the tragedy of individual cases. The very idea of suicide was unknown to me until I was 18 years of age, but now there are kids of 11 who understand what suicide is. We must ask: where does that idea come from? Where are they getting this concept? Who is reproducing it, and who is giving them ideas about how to put the idea into operation? Those are very relevant questions.
We have talked about the media. We must make use of all the new forms of communication that are available to young people these days, such as texting and Internet chat rooms. We do not know the half of it when it comes to the ways in which young people transmit ideas within their youth clubs, schools and peer groups, and internationally, in chat rooms and so forth.
Much of this is to do with the ideas that people have and the stigma that may or may not be attached. The trends reveal some interesting information. As communities become more emboldened in explaining suicide among their closest relatives in terms not of family dynamics but of the legacy of conflict, they are more prepared to come out and say, “That was suicide, it was not my fault”, recognise it, register it, and even campaign for more mental-health services. I am trying to make a point here: the social and political circumstances shape the willingness of individuals to come out about suicide — there are processes of concealment and revelation, which change according to social circumstances.
Chairperson, you made a point about the Churches’ role in this subject. If suicide is illegal, if it is a sin, if you are not going to get a burial, and if you are going to have your goods and chattels taken away from you, then that is not conducive to admitting that a suicide has taken place in your family.
Absolutely. I could not agree more.
I concur with Mr Tomlinson. However, there is another issue around stigma. It may be that an individual who feels like taking his or her own life, or makes an attempt to do so, does not seek help because of the stigma. That is the other side of the coin; the family of that individual says that it does not want the stigma. If that individual feels suicidal and is looking for a way out, but cannot do so because of the associated stigma, perhaps it is time to examine some of the more innovative interventions. If you turn up at an accident and emergency centre and say that you are suicidal, you will be assessed by a healthcare professional who will determine whether or not that is the case. If you say that you do not want to go into hospital, you are likely to be detained. To go back to my original point, it may not be just a mental health issue, and that intervention may not be the most appropriate one. The stigma has something to do with it, but it must be addressed in the overall context of how we provide help and support for people who feel vulnerable.
People who are determined to kill themselves will do so. However, there is a group of people who are determined to kill themselves, but it turns into a cry for help. They do not succeed, and they are very glad of that. There are some people who self-harm quite seriously — to the point of being hospitalised — who never really intended to carry it through; that is also a cry for help. There is a whole spectrum of behaviours, but, for the most determined, it is too late. They should have been helped years and years ago in order to interrupt that process and that determination. If one is really determined to end one’s life, one does not talk to anybody — one just does it. That is what is so distressing about —
Mike made some good points. Perhaps this is an appropriate point at which to make the Committee aware that Professor Hugh McKenna, Dr Joanne Jordan and I are currently working on the research and development of a funded project at Queen’s University Belfast. The project examines the service needs of young men in the four groups that Mike has outlined. They include: groups that are engaged in services; those who have engaged in services and have dropped out; those who engage with voluntary services; and those who have not talked to anyone but who are suicidal. I hope that some of Mike’s points will be addressed through our research findings.
I disagree with Mike that people who are intent on taking their own life do not necessarily communicate with other people. I accept that they may not outwardly say to someone that they are thinking of taking their life. I would argue that — from my experience of working with people who are suicidal and who access psychiatry, from reading and from my own work — that, in some way, shape or form, they will communicate their intent. It may be communicated by their returning gifts or returning items that they borrowed two or three years ago, after the original owner has given up on their return. Then suddenly the object is returned. Why has the object been returned, and why has it been returned now?
A case study has been published — and I am happy to provide the Committee with a reference to it — of a girl who borrowed a kettle from a friend. The original owner had considered it as lost. However, the kettle was returned 30 months later. The girl said that all she really wanted, at that time, was for someone to ask her why she was returning the kettle. Unfortunately, the friend was busy and simply thanked her for its return. Fortunately, the girl survived that particular suicide attempt. Subtle changes such as that can communicate that, perhaps, something out of the ordinary is happening.
There are also cases where people start to explain their endearments — such as “I really do care about you” — and telling the children that, whatever happens, they care passionately about them.
Ms Ní Chuilín:
There is a saying that suicide is everyone’s business. It is not simply a matter for health professionals. That view is supported by the Bamford Review — which was cross-departmental — which examined issues that affect people with mental-health needs or learning difficulties, because those groups are particularly vulnerable. Older people were included in those groups.
During the Committee’s visit to the Scottish Parliament, an MSP who represented the Lowlands said that there is a high incidence of suicide among doctors, vets, farmers and older people. Perhaps we do not know enough about those older people, because the media can more easily sensationalise the deaths of younger people. Most deaths of older people by suicide are not reported. During the past 30 years, people stuck together and worked together. They had to live, work and survive, despite what was happening around them. When those times ended, the survival instinct started to erode.
People become older, and families are displaced because they cannot afford to buy a house. All those issues matter. People move away and communities are broken up, which is quite different to how it used to be. Most of us no longer live cheek by jowl. When one speaks to older people about anything — perhaps they are complaining about something — they often recount their entire life experiences. Although one knows that they are vulnerable once one leaves their home, those people will never say that they are vulnerable. Therefore, it is not simply about stigma but pride.
The Bamford Review refers to living fuller lives. However, C difficile has affected many older people. The attitude seems to be that older people are affected, but they are sick, anyway. An attitude and a culture exist in which only services for younger people, such as youth clubs, teachers and parenting, are considered. In my community, young people do not go to Mass unless they are dragged there. Older people do go to Mass, but they do not get the comfort that they expected. They realise the stigma, which relates to a time when people died in questionable circumstances, no candle was lit at the altar and they were buried in unconsecrated ground. Older people know all that, but it is still hard for them to access services. Therefore, how will a person who is depressed and has come through a lot go about accessing services that they feel are appropriate to them, most of which are not available? How will they be able to talk about how they are feeling when they are proud and do not know how to describe their feelings? Many more services and initiatives are directed at younger people.
It is easier to cover up the deaths of older people by saying that they did not end their own lives or that they died through a mistake because they were doting. If an older person took an overdose, it might be described as being unintentional. From talking to colleagues in Dublin, I know that until the National Office for Suicide Prevention was set up and specifically considered the issue of the deaths of older people not being reported, such deaths were always viewed as mistakes, and suicide was never viewed as being intentional. A job of work must be done on that issue, and as you are involved in research, that is your bread and butter. The social aspect must be examined.
I was reared to look after my neighbours, and they would look after me. I have great neighbours of all ages, and if I had not seen one of them for a couple of days, I would knock on their door, because that is the way in which I was reared. My neighbour is grand; she has a big family and is very lucky. However, the break-up of communities definitely has an impact on older people, as does the lack of available services.
The removal of centres offering advice on welfare rights has had an impact, because there is no longer much money available for community groups. Those advice centres, especially when people needed some help with pensions or housing benefits, were a great gateway that allowed the opportunity to suss out what people were going through. The removal of that gateway prevents an opportunity to tune into what else that person might need, other than getting their cracked window fixed or having their pension aligned. That is a big gap, which you should also consider in your research. The removal of advice centres for welfare rights has definitely had an impact.
You are right, although I do not know whether I would use the term “survival instinct”. It is more to do with social cohesion, and I agree that that has started to fragment over the past five, six to seven years. When you raise the issue of older people taking their own life, you highlight one of the problems of having a specific population-based suicide-prevention strategy. Older people are not one of the populations that were included in the strategy. The reason for that is, perhaps, historical. I published a paper with Stephen Hamilton and Paul Miller in 2005 — ‘Contrasting Terrorist-Related Deaths with Suicide Trends over 34 Years’; it showed that the suicide rate dropped after the age of 54 and that Northern Ireland is only one of two countries in the world where that has happened. Anecdotal evidence suggests that the suicide rate among the older population is starting to rise. Mike mentioned that, and that is starting to reflect global trends. That suggests to me that something has changed over the past seven or eight years. I take Ms Ní Chuilín’s point that perhaps we need to take some risks in the funding that we need for research. That is not a direct plea for money, but it is a massive area and work needs to be done locally on that issue. We also have a role to play internationally in saying that we have come through the Troubles, and we are a changing society that is moving on. We can share our experience and how we dealt with the Troubles, and people can learn from us.
Do you want to say anything about that, Mike?
Psychiatrists will tell you that more psychiatrists are needed, and, of course, social researchers will say that more social research is needed. A study was conducted in areas of Scotland, and many places in Scotland are among the top 20 areas throughout England, Scotland and Wales for suicide rates. The Shetland Islands tops the bill, which says something about rurality and rural isolation.
One of the best pieces of social research, rather than psychological research, on suicide was done by social geographers. They were able to predict the suicide rate precisely in every parliamentary constituency in Britain on the basis of three variables, which they said were the most important markers of social isolation.
As we were talking about elderly people, I was reminded of that study, because one of the major factors in relation to suicide is single-person households, and many elderly people live on their own. The second factor is population mobility, where there is much inward and outward migration and communities are mixed up and unstable. Immigrant populations create change, which means that areas are dynamic. The final factor is detachment from the labour market, which is a huge problem, because many of us derive our social networks and supports from our place of work.
Those are three important background variables. Social isolation affects elderly people along with all the changes that are taking place. They are also detached from the labour market, and they may go to a local advice centre or post office only to collect their pension and meet people. If the post office closes down and those older people have no family, there is no other framework or basis on which to meet other people, and they become socially isolated.
The Northern Ireland suicide prevention strategy refers to the relationship between suicide, deprivation and poverty, and so forth, but they are not the main causes. The main problem is social isolation, which is connected to the other factors. Detachment from the labour market also plays an important part, because a lack of income shapes poverty.
That was fascinating. The statistics are very interesting.
Mike, is there a possibility that antidepressants have contributed to some suicides, perhaps because of misdiagnosis or the wrong type of drug being prescribed?
I urge the Committee to consider that issue in more detail. We are going through a period of major change, socially and politically, and people have to come to terms with massive changes in the way that they think about others. There is evidence of mass medication, whether that is with alcohol or antidepressants, and the Committee must seek an explanation. Are pharmaceutical companies using doctors to push their products because of the new generation of drugs? Are people presenting with more mental distress, anxiety and depression because of changes in social circumstances? What is the cause? That is a big question, because I am alarmed by the increase in prescriptions.
I have examined studies relating to Northern Ireland, and the results are contradictory. On the one hand, it could be argued that the more medications that are in people’s cupboards, the more likely it is that they will get into the wrong hands for the wrong purpose, and we end up with attempted, or actual, suicide. On the other hand, some studies defend the medications and conclude that they prevent suicide. There is no clear-cut answer, but it is an important question.
Some of the issues have already been touched on, but, on glancing through your two submissions, I notice that Iain referred to low-skilled workers, people in temporary or unstable employment and people with low educational attainment and material status — all of whom can have suicidal tendencies. That crosses many Departments: Education; Employment and Learning; Enterprise, Trade and Investment; Finance and Personnel; and Health, Social Services and Public Safety. Mike’s submission refers to areas that have an above-average rate of suicide. It mentions Omagh and Strabane among other places. Recent and not-so-recent reports identify those places as areas of high deprivation, and so forth. You also spoke about social isolation. Are you saying that a lack of skills and areas of high deprivation affect people with suicidal tendencies?
That is my belief.
We have spoken about the factors that build up people’s esteem. If people have a sense of direction and a future, if they are well educated and can escape the confines of a traditional community and have a future in that sense, those factors will contribute to a sense of ambition, esteem and progression. If a person feels trapped, he or she is isolated in a different way. He or she will feel isolated from all the things that other young people seem to be getting, from progressing or from the idealised lives that surround us in every way. One can be isolated in that sense. One might be living with one’s family in a rural community but might feel isolated in that other sense.
No doubt there is a huge job of work to be done in those areas.
I suppose it is a matter of getting the right balance of prevention, intervention and postvention. Should there be less focus on the general population and more focus on specific groups, such as people who self-harm? One of the NICE (National Institute for Health and Clinical Excellence) guidelines recommends targeting people who self-harm. That is one element of the strategy, and trusts are seeking to ensure that there is proper follow-up for people who present with self-harm. However, many people slip through the net. A person might attend an accident and emergency unit with self-inflicted injuries, but he or she might not be seen again until the same thing happens again. Should there be more focus on specific target groups, as opposed to a general approach, or should there be a balance between both?
There must be a balance. I can see the value in highlighting particular “high-risk” groups. However, there would always be a risk of alienating other people or missing a group, such as older people, pregnant women or new mothers. My colleagues Wendy Cousins and Sharon Milner and I are publishing a paper next week that will show an increase in the rate of suicide attempts and self-harm in children living in state care in Northern Ireland. That is another target group. Although I can see the value of interventions with specific groups, there must be a balance in order to take account of those people who do not fall into groups.
Self-harm covers such a spectrum of behaviour. The self-harm that presents as a suicide attempt in a hospital is very different to 15-year-olds scratching themselves with a pen in school, which is no more or less distressing for teachers. We need an understanding of where the pressure points are.
Everyone has now had an opportunity to speak. I thank Mike and Iain for attending the Committee. As Alex said, this has been a very interesting session. There are so many complications in the entire process that one wonders where to start in helping to solve the issues. Thank you for the work that you are doing. We appreciate that you have given of your time to come to the Committee.