The Scottish Government

Listen

Reducing Suicide and Deliberate Self-harm (National Framework for the Prevention of Suicide in Scotalnd) Exploring Experience: Summary
July 2002

Prepared for the Scottish Executive by Scottish Development Centre for Mental Health

This document is also available in pdf format (28k)

Background

In October 2001, the Scottish Executive Health Department issued for consultation the Draft Framework for the Prevention of Suicide and Deliberate Self Harm in Scotland. The Scottish Executive also commissioned the Scottish Development Centre for Mental Health to undertake two interlinked pieces of work:

• 'Exploring Experience': a series of discussions with groups and services directly affected by suicide and self harm issues and with the media, summarised here

• 'Laying the Foundations: Identifying Practice Examples': a compilation of a range of practice examples, using a variety of different approaches, with different client groups

'Exploring Experience' gathered ideas, information and perspectives to enhance the Framework and to inform the process of implementation. It looked at:

• What protects against and what increases risks of suicide and of self harm

• Experiences of what helps and the routes to sources of help and support

• The challenges services face in working in these areas

• The role of the media in reporting events and in shaping public views and perceptions

Three main groups were involved in discussion:

• People affected by or with experience of issues relating to suicide and/or self harm

• Services - mental health services, local health services, prison, police, education

• Media: national and local print and broadcast media

What influences mental health and well being and the risk of suicide or self harm?

Many different influences improve our mental health and well being. People's circumstances and experiences can make them more vulnerable to mental ill health, to the extent where suicide may be a potential risk. Pressures and vulnerabilities were various:

Young people

• Traumatic experiences of loss or abuse

• Family relationships which can be both a source of support and of stress

• Issues of identity (culture, gender and sexuality)

• Lack of supports e.g. among isolated young men or young people leaving care

• Pressures to achieve and succeed, academically, socially and materially

People from minority ethnic communities

• Tensions between the values and ways of life of different cultures and different generations

• Conflicting perspectives on the role of women and on arranged marriages

• Experiences associated with being a refugee or asylum seeker

Men

• Difficulties relating to how men express emotions and 'show passion'

• Pressures associated with debt and child support

• Isolation

Women

• Self harm becomes a strategy for some to cope with pain and strong feelings

• For minority ethnic women, perceived lack of choice and control over one's life and one's future

Family members of a person with a mental health problem

• Physical ill health of carers, arising from long term anxiety and stress

• Men may be less willing to seek help or rely on mutual support networks

• Carers often find themselves at odds with or unsupported by mental health services, particularly in crisis situations

Offenders

• Loss of familiar supports and surroundings

• Pressures at key transition points: admission, pre-release, transfer

• Prison procedures which can be experienced as intrusive and as alienating

Understanding self harm

Self harm can be both an expression of powerful feelings of pain, anger, distress, sometimes self loathing and a way of coping with these emotions. Self harm should not automatically be seen as attempted suicide.

Access to help and support

People often do not know where to get help when required. Health and social care services could do more to enable people to find sources for the help they need, such as debt counselling or marriage guidance and to act as broker or mediator on their behalf.

Blocks

• Men tend to be reluctant to seek advice and support from health services (occupational health may offer untapped possibilities)

• Young people can be deterred from consulting the family doctor because they are concerned about confidentiality

• Ethnic minority communities may not perceive services as acceptable or as culturally competent. Language barriers can further impede use

• Carers report frustration and anger at being turned away and not listened to. Confidentiality can block communication

• Workers in many key front line services (welfare benefits, primary health care, police, residential child care, support workers) lack mental health awareness to be able to support people or to direct them into specialist services

• Services are not geared up to be able to work effectively with people who are in distress, lead disorganised lives and find it hard to keep to appointments

What helps?

In crisis

• Help that is not judgemental

• Somewhere to feel safe and protected

• Listening to what those close to the person say

• Support for families

• Support for workers

Preventing problems developing or becoming worse

• A trusting relationship with someone who understands and respects you

• Coping with and expressing emotions by enabling people to 'give shape to their pain'

• Help to understand the causes and the triggers that lead to self harm

• Persistence, not just short term support

• Finding or rebuilding hope of recovery and pleasure in life

Promoting well being and capacity to cope

• Developing the emotional literacy of children and young people

• Reviewing the pressures and expectations on young people to achieve

• Actively pursuing social inclusion - valuing diversity, whilst fostering belonging

• Building / protecting social networks and informal supports

Service perspectives

Prison service

Achievements

The strategic approach taken by Scottish Prison Service to address the risk of suicide aims to achieve a change in the culture in prisons:

• Responsibility for prisoners' well being rests with all staff, not just with 'specialists'

• Training programmes support this reorientation in practice, promoting multi-disciplinary working

• Capacity has been strengthened to 'spot' people at risk and to support them

• Listener scheme enables prisoners to access peer support with confidentiality assured

• Declining proportion of prisoners are 'at risk' and placed on special procedures

Challenges

• Building on work in prisons to achieve through and after care support

• Further development of therapeutic work with people who repeatedly self harm

Police and courts

Achievements

• The police service has strategies in place, but still struggles in practice to know how best to deal with individual situations where someone is at risk of harm

• Developments such as Glasgow Court Liaison service help identify people with mental health needs, ensure access to help and diversion from custody if appropriate

Challenges

• Although a regular feature of police work, suicide and attempted suicide do not arouse the level of public attention or concern given to drug related deaths

• Developing training and awareness raising in mental health for frontline officers

• Creating closer working links with local health services to establish agreements on accessing psychiatric assessment and hospital admission and to train together

• Finding alternatives to police cells to hold intoxicated people who may be disturbed or distressed

Education

Achievements

• Renewed emphasis on integrated approaches to address the needs of pupils, families and communities, through New Community Schools

• Growing attention to the emotional health and well being of young people and of schools' responsibilities to address these issues, in conjunction with other agencies

• Actions to promote access to health advice, information and services and to identify problems earlier

• Focus on approaches that develop skills, confidence, resilience and capacity to cope

Challenges

• Sustainability of integrated approaches beyond pilots and short term initiatives, from the margins to the mainstream

• Reconciling an education system focused on exam-based achievement and with one which nurtures and values young people, and builds their resilience and confidence

• Reinforcing existing examples of good practice to promote mental health and well being: consolidating what works and sharing information and learning

Mental health services

Achievements

• Developments in liaison psychiatry, providing specialist help in crisis

• Better links between primary health care and specialist mental health services

Challenges

• Dismantling barriers that impede access to services

• Ensuring people are linked more effectively into sources of help and advice

• Developing capacity to offer sustained support and treatment - more than 'first aid'

• Devising more sensitive, respectful responses to people who self harm

Achieving change

To make a difference by improving mental health and well being and by reducing risks of suicide and self harm will require:

Leadership and co-ordinated effort

Many of the issues identified lie beyond the responsibilities of a single service or agency. Reducing suicide and self harm needs senior commitment and leadership: at national policy level to give a steer and at local level to give focus and legitimacy to work on the ground, to sustain effort and to support 'joined up' action.

Shifts in culture, attitudes and awareness

Tackling suicide means we have to be prepared to

• Reconsider the values and the aspirations we have for ourselves and our children

• Become more aware of our own mental health and well being and developing an emotional currency that we are comfortable using in our relationships with others

• Harness the media as a key force in shaping ideas and making it possible to discuss topics such as emotional distress

Starting by getting the basics right: we can begin by establishing clear priorities and responsibilities for action, giving attention to service access and quality for people at risk or in distress

Building local alliances and networks: by improving this we will be better able to share information and practice and to create capacity for collaborative action

Taking the long term perspective: to build the confidence and self worth of individuals, families and communities will require action over many years on many different fronts