Dee – Bristol Suicide and Self-harm Research Group

The language of suicide – time to pause and think?

Posted on October 15, 2018 by Dee

In a recent open letter, campaigners have urged the media to lead the way in using sensitive language when it comes to talking about suicidal behaviour. A similar request has been put forward to researchers and health professionals. There have been several phrases that have been suggested to be unhelpful (primarily from anecdotal accounts from people with lived experience), but the phrase that has gained the most disapproval is “commit suicide”.

You might be asking yourself, “what is the big deal?”. I certainly did when I first started writing about suicide and was consistently corrected. After all commit is a verb indicating that a person was determined to carry out a certain course of action. Yet I soon realised the most common use of the verb commit is in relation to someone committing a crime or an immoral act. People don’t “commit suicide” (i.e. a crime). Suicide has been decriminalised in the majority of countries worldwide. But this phrase has unhelpful undertones, which might further stigmatise this behaviour. With this understanding I’ve been in support of any drive to encourage more appropriate language use, and with the help of my colleagues have been actively encouraging academic journals and conference organisers to dissuade professionals using this language.

As professionals we don’t want to further stigmatise suicide, and as language matters we should be trying to help reduce the associated stigma. Stigma, we know, is a barrier for accessing health care, so in my opinion any effort to reduce stigma should be pursued. Some argue, however, that our push to move away from the term “commit suicide” is over simplistic, and that changing language does not change reality. The evidence being quoted here is weak, and in my view the question remains, does changing our language help? Does it reduce stigma? We simply don’t know. But a small change may help. Getting people to question their language brings into their consciousness the importance of the words they use, and the impact their words might have on others.

An argument has however been made for not moving away from the term “commit suicide”. Perhaps the alternative phrases (i.e. “die by suicide”) remove a person’s agency. I can see this argument, and I know that some use the term “commit suicide” without any understanding of implications of criminality. Take me for example, I certainly didn’t know about the link. But once I did, there was no going back. A friend of mine died by suicide in 2016, and for me reading about him “committing suicide” in the media felt wrong.

For professionals there are two things to consider. The language used to talk to an individual regarding an experience (in this case related to suicide) should be guided by the language that the person feels comfortable using. This should be assessed on a case by case basis. However, when talking to the public about suicide, professionals should use the language that is most acceptable to the greatest number of people. But here is where we stumble. At present we don’t know what phrase the majority of people with a lived experience of suicide find the most sensitive and appropriate. There simply is no empirical evidence to guide us. So perhaps, this is the time to push the pause button on the current drive for us to drop the term “commit suicide”.

As a researcher, evidence-based decision-making is important to me. With the help of fellow colleagues at the University of Bristol, University of Nottingham and the Samaritans, we launched an anonymous online survey for those who have experience of suicide. We hope that this evidence will help inform the debate and plan to release the results of this survey as soon as possible. A copy of the report will be hosted on this website, so stay tuned!

Dee Knipe is a Vice Chancellor’s Postdoctoral Research Fellow in the Department of Population Health Science, University of Bristol. She is an an epidemiologist with a special interest in suicide and self-harm in low and middle income countries.

You can follow @dee_knipe (group account @SASHBristol ) on Twitter.

If you or anyone you know is affected by the issues covered in this blog, you can contact the Samaritans for free from any telephone on 116 123 in the UK. Alternatively you can email jo@samaritans.org for details of your nearest branch, where you can talk to one of their trained volunteers face to face. The International Association for Suicide Prevention (IASP) has details of support organisations in other countries.

Student mental health, suicide and media reporting

Posted on May 29, 2018May 29, 2018 by Dee

By Professor David Gunnell

In the last 18 months, Bristol has been in the eye of a storm of concern about student mental health following the tragic deaths by suicide of a number of our students.

First and foremost our thoughts are with the families and friends of all those who have lost a loved one. They will quite rightly want to know what could have been done to prevent each death. It will be important that lessons are learnt and widely shared across the university sector.

What do we know about the mental health of the UK’s 2.3 million students and what lies behind the recent tragic deaths? It is widely recognised that levels of depression and self-harm in young people are increasing in the UK and internationally. UUK’s recent analysis highlighted a six-fold rise in the number of UK students disclosing a mental health condition to their university since 2007. Data recently presented to the National Suicide Prevention Advisory Group show rises in suicides in 15-19 year olds in England. The rises in levels of distress seen by UK universities likely mirror those seen in the wider population of this age. There are several possible additional contributors to student mental health problems. These include:

Concerns about the high levels of debt students incur because of course fees in excess of £9,000, in addition to their costs of living. This increases the pressure to perform well at university
Difficulties establishing new friendship groups and support networks as they transition to a new geographic location after leaving home for the first time
Loss of continuity of medical and mental health care for those previously under specialist care for mental health conditions in their home town
Loss of the sense of community provided by friends, families and schools, with students being increasingly able to access course materials on-line and so avoid attending lectures. Furthermore, pressures on university finances have resulted in larger year-group sizes and an associated sense of anonymity. When I studied medicine at Bristol in the 1980s my year group size was 120; now it is closer to 300.

Concern about student suicide and mental health dates back at least to the 1950s, following the identification of a high incidence of suicide amongst Oxford undergraduates. In 2015-16 York University was the focus of similar concerns and informal conversations with colleagues elsewhere in the UK points to similar worries about student suicides.

The research literature highlights “clusters” of student suicide deaths in the USA and elsewhere around the world. Such clusters have also been reported in secondary schools and communities.

We don’t know what causes these clusters. Psychological theories suggest risk may “spread” by social contagion, social learning, suggestion or imitation. But research such as Madelyn Gould’s elegant analysis of clusters in the USA tells us clusters are more common in young people and may be precipitated by news reporting. Reporting practices were recently criticised in relation to another UK cluster. For this reason Public Health England’s guidance for media reporting in relation to suicide clusters makes 10 recommendations (see page 24); these include:

avoid re-running details of each death in every report, re-reporting previous stories and making links to other suicides
do not give undue prominence to a story, such as front cover splash and dramatic headlines and use of photographs and memorials of people who have died – specifically repeated use of image galleries should be avoided

Whilst most news organisations, including our student news groups, have followed this guidance, several, most recently the Sun (Saturday May 19^th) have not. Some media organisations have repeatedly published picture galleries of the students who have died, taken in happier times, each time a further death has occurred. These may re-trigger grief in family and friends recovering from their loss. They may make other students feel vulnerable – “if this happy looking person took their own life, then am I too at risk?” It is possible that news coverage may have contributed to some deaths.

Research suggests that the proportion of students experiencing suicidal thoughts in a 12 month period is around 17%, and 9% have made suicide plans. If these thoughts and plans occur in an environment where models of people taking their lives in similar situations exist, suicide may become a more tenable option.

Furthermore, news reports linking the suicides with long waiting times for support and inadequate service provision, whilst rightly shining a light on important challenges across the university sector, may also deter people from seeking help, the last thing we wish to happen at times like this.

The impact of the deaths on students is exemplified by the 60% increase in referrals for counselling following deaths in Bristol in 2017. These will reflect both heightened concerns amongst students themselves as well as the staff they interact with.

Support, administrative, teaching and other academic staff too are profoundly affected by the death of a student in their care.

These are tough times for young people and universities. We need to better understand the most effective approaches to improving student mental health and support those experiencing difficulties, as well as learn lessons from the recent deaths. Furthermore, we need to understand the drivers behind recent rises in young people’s distress to inform prevention. We also need to review reporting guidance. Perhaps it is time the Independent Press Standards Organisation’s (IPSO) code of practice for reporting on suicide deaths is extended to include avoiding repeatedly publishing pictures of those who have died.

David Gunnell is Professor of Epidemiology in the Department of Population Health Science, University of Bristol. He has a long-standing research and policy interest in the epidemiology and prevention of suicide in the UK and internationally.

You can follow @SASHBristol on Twitter.

Can suicide media awareness campaigns sometimes backfire?

Posted on March 28, 2018March 29, 2018 by Dee

By Professor David Gunnell

There have been some truly moving suicide prevention media campaigns recently. For example, Samaritans “Small Talk Saves Lives” campaign tells the story of a woman whose life was saved (from suicide) because someone took the time to talk to her when she was planning to kill herself.

Project 84: CALM’s recent high-profile campaign, based around the sobering statistic that 84 men die by suicide in the UK every week, however, has raised concerns amongst a number of people in the suicide prevention community.

The campaign, which tells the real life stories of 84 men who died by suicide, was launched with a haunting display of 84 life-sized statues of men on the edge of the roof top of ITV studios in London. Friends and families of the bereaved, working alongside a sculptor took part in making the statues. The display reminds one of the moment before someone jumps from a high building.

Over the years CALM have done a huge amount of work raising awareness about the major public health problem of male suicide. However this particular campaign raises concerns. There is a large body of research evidence concerning the impact of reporting / media portrayal of suicide methods on subsequent imitative suicides and the uptake of suicide by populations.

It is thought that raising awareness of suicide methods can increase their “cognitive availability” and might influence method choice. A number of research studies – including work by @SASHBristol’s Dr Lucy Biddle – have drawn attention to how the media (print / on-line) may influence people’s preference for particular suicide methods and provide them with knowledge about how to use these. And if this influences them towards more lethal methods, this may result in a rise in suicide rates. Most people who survive a suicide attempt do not repeat the act. Importantly, people don’t have to be suicidal to be affected by the images and reporting. Information may be stored away at the back of someone’s mind and perhaps retrieved later at the time of a suicidal crisis.

Pictures of the statues in the Project 84 campaign have been widely reported by news websites in the UK. The display, which is on the top of a tall building in central London, is highly visible. Samaritans and WHO guidelines on responsible reporting of suicide are clear. Samaritans guidelines state “Avoid giving too much detail. Care should be taken when giving any detail of a suicide method” .

A series of recent studies have shown rises in method-specific (and sometimes overall) suicide incidence may follow high profile media attention given to a particular method of suicide, most often following a celebrity’s suicide. A recent research paper indicated that in the 6 months after Robin Williams’ death by suicide there was a 9.8% rise in suicide deaths (1841 additional fatalities) in the USA over and above expected levels based on recent trends. The excess in deaths was largely due to a rise in deaths using the very method used by Williams.

Jumping from a tall building is a highly dangerous suicide method (and in some parts of the world is one of the most frequently used methods). Here in the UK, suicide deaths by jumping account for approx. 250 deaths per year (around 4% of all suicides). The risk of the Project 84 campaign lies in increasing awareness of this method in the wider population. More deaths might follow as a result of increasing the “cognitive availability” of the method. Indeed these concerns led Australia’s Mindframe Media Advisory Group, putting out a call to Australia’s media advising against sharing imagery from Campaign84.

In many parts of the world suicide prevention teams work closely with local media to reduce risk associated with their reports of deaths from local landmark sites. For the same reason, here in Bristol, we work with our local media on their reporting of suicide deaths from a local site which has in the past often attracted considerable publicity. Of course, it is possible that some reports / approaches to reporting deaths by particular methods may actually deter some people from using those methods. One of our PhD students, Helen Fay, is working on this very issue.

Whilst it’s good to see the important issue of male suicide highlighted, it would be tragic if it were to inadvertently backfire and lead to a rise in deaths by jumping. Of course, as with any public health intervention such as a media campaign, we must careful weigh up the benefits and potential risks. Research on public awareness campaigns is in its infancy. Professor Jane Pirkis and team’s recent systematic review identified relatively few studies that looked at their impact on the incidence of suicide. Whilst there is some evidence of their effectiveness the authors caution about the importance of taking care “to ensure that campaign developers get the messaging of campaigns right, and further work is needed to determine which messages work and which ones do not, and how effective messages should be disseminated.”

You can follow @SASHBristol on Twitter.

Thanks to @dee_knipe @LucyABiddle @HelenAmyFay for their input