Five Reasons Why Suicide Prevention Programs Are Ineffective

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Five Reasons Why Suicide Prevention Programs Are
Ineffective Angus H ThompsonAlberta Centre for
Injury Control Research the Department of
Public Health Sciences University of
Alberta Canadian Association for Suicide
Prevention Edmonton October
2004
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EFFECTIVE SUICIDE PREVENTION

• Educating Physicians in Detection
  Intervention (Gotland, Sweden)

• Gun Control (Canada)

• Individual Interventions

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REASON 1 AN ORGANIZATION WITH SUICIDE IN ITS
TITLE CANNOT PREVENT SUICIDE!
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WHY DOES EARLY INTERVENTIONMATTER?

• To Make A Difference During the Formative
  Years

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WHY DOES EARLY INTERVENTIONMATTER?

• To Make A Difference During the Formative
  Years

• Canadian Children Are More Stressed Than
  Children From Many Other Countries

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RANKINGS OF CANADIAN 11-13 YEAR-OLDS ON SELECTED
HEALTH-RELATED QUESTIONS (VS 7-11 COUNTRIES)
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WHY DOES EARLY INTERVENTIONMATTER?

• To Make A Difference During the Formative
  Years

• Canadian Children Are More Stressed Than
  Children From Many Other Countries

• Childhood Stress is Increasing in Canada

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Figure 3 THE PREVALENCE OF TWO OR MORE TRAUMATIC
CHILDHOOD EVENTS BY COHORT YEAR AND SEX
Cohort Year Date when the youngest person in
each group would have been about 15 years of
age Source Thompson AH, Cui X (2000). Increasing
Childhood Trauma in Canada Findings From the
National Population Health Survey, 1994/95.
Canadian Journal of Public Health, 91(3), 197-200.
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REASON 2 SUICIDE IS NOT SEEN AS PART OF A
CLUSTER OF HUMAN PROBLEMS
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THE CANADIAN SOCIAL PROBLEM INDEX COMPONENTS Mur
der Attempted Murder Assault Sexual
assault Robbery Suicide Divorce Alcoholism
Source Thompson AH, Howard AW, Yin J (2001). A
social problem index for Canada. Canadian Journal
of Psychiatry 46, 45-51.
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THE CANADIAN SOCIAL PROBLEM INDEX 1956 - 1996
Source Thompson AH, Howard AW, Jin Y (2001). A
social problem index for Canada. Canadian Journal
of Psychiatry 46, 45-51.
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THE ASSOCIATION BETWEEN SOCIAL PROBLEMS AND
PSYCHIATRIC DIAGNOSES IN THE EDMONTON AREA
EPIDEMIOLOGICAL STUDY OF PSYCHIATRIC DISORDERS
Source Thompson A Bland RC (1995). Social
dysfunction and mental illness in a community
sample. Canadian Journal of Psychiatry 40, 15
20.
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(r 0.81)
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REASON 3 THE MAJORITY OF SUICIDAL INDIVIDUALS
EXHIBIT A MENTAL ILLNESS, BUT MOST OF THESE DO
NOT RECEIVE TREATMENT
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The Proportion Of Persons Who Had Completed
Suicide Who Showed Evidence Of A Mental
Illness Depressive Any Authors Country Diso
rders Disorder Robins et al. 1959 USA 45 94 D
orpat Ripley 1960 USA 29 100 Barraclough et
al. 1974 UK 70 93 Beskow 1979 Swe 45-48 97
Chynoweth et al. 1980 Aust 55 88 Rich et al.
1986 USA 46 95 Arato et al.
1988 Hung 58 81 Åsgård 1990 Swe 58 95 Henr
iksson et al. 1993 Finl 59 93 Cheng
1995 Taiw 88 98 Conwell et al.
1996 USA 47 90 Foster et al. 1997 N
Ire 36 86
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• BUT
• Psychological autopsies are retrospective in
  nature

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• BUT
• Psychological autopsies are retrospective in
  nature
• Treatment is far from perfect

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• BUT
• Psychological autopsies are retrospective in
  nature
• Treatment is far from perfect
• There is an environment by mental vulnerability
  interaction i.e.

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EXPRESSION OF SOCIAL PROBLEM BEHAVIOURA
Threshold Model
High Stress
Social Problem Behaviour
Stress Threshold
No Social Problem Behaviour
Low Stress
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EXPRESSION OF SOCIAL PROBLEM BEHAVIOURTwo
Components
1. ENVIRONMENTAL STRESSORS 2. INDIVIDUAL
DIFFERENCES IN REACTIVITY
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THE INTERACTION OF CONSTITUTIONAL AND
ENVIRONMENTAL FACTORS A MODEL
The Disabled
The Vulnerable
SOCIAL PROBLEMS
The Resilient
NO SOCIAL PROBLEMS
The Invulnerable
Social Disintegration
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THE INTERACTION OF CONSTITUTIONAL AND
ENVIRONMENTAL FACTORS A MODEL
The Disabled
The Vulnerable
SOCIAL PROBLEMS
The Resilient
NO SOCIAL PROBLEMS
The Invulnerable
Social Disintegration
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THE INTERACTION OF CONSTITUTIONAL AND
ENVIRONMENTAL FACTORS A MODEL
The Disabled
The Vulnerable
SOCIAL PROBLEMS
The Resilient
NO SOCIAL PROBLEMS
The Invulnerable
Social Disintegration
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REASON 4 SUICIDE PREVENTION PROGRAMS CANNOT
LEARN
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• SUICIDE PREVENTION PROGRAMS RARELY EVALUATE
  THEIR IMPACTS
• Several years required to show an effect

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• SUICIDE PREVENTION PROGRAMS RARELY EVALUATE
  THEIR IMPACTS
• Several years required to show an effect
• Avoidance of personal evaluation

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• SUICIDE PREVENTION PROGRAMS RARELY EVALUATE
  THEIR IMPACTS
• Several years required to show an effect
• Avoidance of personal evaluation
• Not knowing what ones job is (i.e. focus on
  process, not outcome)

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REASON 5 WE DONT KNOW WHY THE SUICIDE RATE IS
SO LOW
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• If depression and hopelessness are considered to
  be essential components of suicide, and
  considering that
• We all will die
• We will lose loved ones
• Most wont be in the career of choice
• Our abilities will decline as we age
• Then, why is the suicide rate not higher - in
  fact, much higher - than it is?

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WHY DO WE GO FORWARD?
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WHY DO WE GO FORWARD?
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• Strengthening Behaviour (Skinner)

• Control over one's environment

• Optimism (Seligman)

• The family

• Traditions (Frankl)

• Social skills

• Rose Coloured Glasses

• Social Support

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WHAT TO DO
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WHAT TO DO
AN ORGANIZATION WITH SUICIDE IN ITS TITLE
CANNOT PREVENT SUICIDE!
Focus on Early Intervention Child Development
prior to the onset of serious suicidal behaviour
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WHAT TO DO
SUICIDE IS NOT SEEN AS PART OF A CLUSTER OF HUMAN
PROBLEMS
Create a continuity of services that reflects the
inter-relatedness of suicide other social
problems
Create a social fabric that weakens the
determinants of suicide and enhances resilience
and social cohesion
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WHAT TO DO
MOST SUICIDAL INDIVIDUALS EXHIBIT A MENTAL
ILLNESS, BUT THE MAJORITY DO NOT RECEIVE TREATMENT
Improve detection, referral and access to
treatment for those with a mental illness
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WHAT TO DO
SUICIDE PREVENTION PROGRAMS CANNOT LEARN
Create Self-Regulating Suicide Prevention
Initiatives, most of which would not have
suicide in the title
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WHAT TO DO
WE DONT KNOW WHY THE SUICIDE RATE IS SO LOW
Ensure that every child has experience with
success and defer experiences with the traumatic
realities of the World - until it is too late!
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FIN
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• Questions arising
• How will we know if prevention programs are
  effective?
• Why do we have separate programs for each
  definable social problem? Can/should we change
  this? How?
• How is suicide similar to other social
  problems?How is it different?
• How can we integrate suicide prevention with
  other intervention programs?
• Why do so many social/health programs persist
  without evidence of effectiveness?
• Do treatment programs reach the people that need
  them?
• How can we integrate suicide prevention with
  other intervention programs?

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DETERMINANTS

• Depression
• Hopelessness
• Marginalization
• Competitive Disadvantage
• Childhood Trauma
• Development of Confidence

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• Overview
• There is little evidence that Suicide Prevention
  Programs work.
• Five reasons Why they dont
• Most suicide prevention interventions are
  provided after the onset of suicidal behaviour
  after the formative years
• Suicide is treated outside of its social and
  personal context
• The majority of suicidal people show evidence of
  a mental illness, but only a minority receive
  treatment
• Suicide prevention programs have difficulty
  learning from their successes and failures
• Perhaps we dont know why people like living. If
  we do know we rarely apply it in suicide
  prevention programs.