Talking about Suicide

The Tyranny of Silence

When my son Bruno killed himself in January 2007 my first impulse was to talk about it. I, my partner, and the rest of my family, came up immediately against the press guidelines that do not allow mention of suicide as a cause of death in the mainstream media. Naively we thought that since the Labour Government had reformed the legislation and suicides were now designated as “accidents” with burial costs covered by ACC, that suicide was a disease like any other. When someone dies suddenly it is only natural that people want to know why. To say that the death was “sudden”, “tragic” or an accident” leaves them guessing and perpetuates the “tyranny of silence” that surrounds suicide. I got around that partly by publishing a tribute to my son on Aotearoa Indymedia two days after his death.

My instinct was to share the knowledge of his life and death with many of those I had met, discussed and debated with on Aotearoa Indymedia as a “community”. Here was a politically engaged, mainly youthful audience that was actively concerned about social issues. I wasn’t aware at that time suicide has a ‘profile’ that should not be raised. The discussion that followed this posting reinforced for me the disconnection between the official code of silence and the openness of the internet where suicide is spoken of in all of its aspects from the sublime to the horrific. I discovered that the press guide lines were designed to stop copycatting.

The question then arose: why if silence was supposedly “evidence based” and therefore a “best practice” designed to stop copycatting, had no one at various Ministries surfed the social sites frequented by young people where hundreds of Youtube or Bebo tributes to dead young people are watched and commented on profusely and sometimes profoundly and realized that their social policy prescriptions are on a different planet?

I then looked for evidence in the published research that backed up the claim that silence was a means of suicide prevention. I couldn’t find it. Nor I discovered could others like Keith Newman who have been active in documenting suicide and its prevention over many years and who runs the internet site SOSAD (Save our Sons and Daughters). Newman saw the government’s policy of clamping down on suicide “awareness” as “politically correct”, an attempt to “censor” youth, stopping “open and sensible dialogue” and undermining youth initiative.

“Surely this should be a matter for youth to decide themselves. Youth are far more broad in their thinking than we give them credit for. Putting the right information in their hands and encouraging them to talk about their hurts and frustrations can be an important part of getting their thinking back on track and realising they are not alone.”

Newman also pointed to Australian evidence that showed that “raising awareness” caused suicide was a “myth”.

I was by this time very suspicious of the counter-intuitive claim that “talking” about suicide makes it “contagious” as if it were a virus. What made things even more strange was the fact that no evidence was cited to prove that talking about suicide would ‘normalize’ it or increase the danger of copycatting. It seemed that in the place of evidence there were patronizing assumptions that young people are impressionable, easily influenced and even uncritical consumers of fashion. This week it is this band, next week its cluster-suicide. Who at the Ministries knows anything about youth culture and why this model of youth consumption of death is supposedly held in such high regard? (McGorry and Robinson)

All the evidence of copycatting shows that its incidence is low (less than 5% of suicides) and that it may have nothing to do with “awareness” or “profile” or “contagion” but may be part of modern consumer capitalism. This research finds that those who suffer suicides of close friends or family tend to try suicide themselves more often than those who do not. However when other social factors such as alcoholism are considered, the “contagion” factor disappears, leaving other social and psychological factors as the most likely cause. In fact, the only significant finding is that knowledge of friends’ suicides after a period of at least a month is more immunizing than contagious as it leads to less “copycatting”. This high quality ‘anecdotal’ evidence supports the argument that the best suicide prevention for those affected by suicide may be active involvement in suicide prevention (Mercy et al, 2001).

In the age of the internet and global roaming the cat is out of the bag and pretending otherwise will not prevent suicide. Knowledge of suicides spreads like the ozone hole among peer groups and throughout the wider society despite the code of official silence. There is something unhealthy about adults pasting on ultra suicide block when their sons and daughters are grieving or morbidly fascinated by the latest suicide online. Internet bullying is now cited as a growing threat and cause of youth suicide. But like copycatting there is no way that the internet can be silenced or policed by parents and schools, nor should it as an important site of freedom of expression.

Internet bullies cannot be silenced on the internet but they can be exposed by identifying them publicly and building support in schools against the competitive culture that promotes bullying.

So logically, if silence doesn’t stop the talk of suicide, then maybe shouting might. This was the view of Maria Bradbury whose son Toran Henry committed suicide on March 20 2008. Ms Bradbury organized a march up Queen St, Auckland, to promote her view of the need to raise public awareness of the causes of suicide. Metaphorically speaking, this is what the Youth Suicide Prevention Trust and its Yellow Ribbon program in schools did between 1997 and 2005 when it was forced to shut down.

Who Killed Yellow Ribbon?

Yellow Ribbon was a self-help suicide prevention group founded by parents and friends of youth suicides who formed the Youth Suicide Awareness Trust in NZ 1997. Its basic approach was to enlist and train young people as ambassadors in schools to promote the Yellow Ribbon message that “It’s OK to ask for help”. Its members handed out yellow cards with the words “Its OK to ask for help” and referred young people who asked for help to health workers and counselors. Each school had a procedure for referral and for keeping their ambassadors safe from risk. Yellow Ribbon was initially modeled on the organization of the same name which was founded in the US in and which has since spread to many US states and to Australia, Canada, Scotland and Africa. By 2002 Yellow Ribbon NZ had over 1400 ambassadors in more than 140 schools.

Yellow Ribbon’s existence, however, was strongly contested. In NZ, Yellow Ribbon was consistently opposed by a number of academics and researchers in the field mainly associated with the New Zealand Youth Suicide Prevention Strategy, formed in 1998 after Yellow Ribbon, who argued that it could not prove that it did not ‘harm’ young people. Endorsements on the US Yellow Ribbon websites from suicidal young people who said they owed their lives to Yellow Ribbon and the many personal testimonies made to those involved in Yellow Ribbon in NZ did not fit with the orthodox “evidence based” approach to suicide prevention. Yet the case of a young Yellow Ribbon ambassador who committed suicide was cited informally as evidence of “harm”. The Minister in charge of NZYSPS, Jim Anderton, stated categorically:

“The literature is very clear – if you raise the profile of youth suicide, you get a higher rate of suicide”

(Collins).

As a result Yellow Ribbon had to look elsewhere for funding. When it went to ‘Fight or Life”, a charity boxing contest which featured “celebrity” matches, for funds it was heavily criticized for promoting a violent sport that could lead to bullying a recognized cause of suicide. Yet many of the ‘celebrities’ such as former league personality Tawera Nikau have a strong record in youth work. Another was the current Deputy Prime Minister, Bill English, who has yet to be shown up as a playground bully.

The question as to why Yellow Ribbon was closed down has yet to be answered. Those who were involved argue that it was deliberately shut down. They point to the claim made by the leading NZ suicide researcher Anne Beautrais who stated correctly that there was no evidence to prove “beyond doubt” that Yellow Ribbon did not cause harm.

In the face of this official criticism, Yellow Ribbon was more than ready to evaluate its approach to suicide prevention and correct any shortcomings. It commissioned Professor Ian Evans and Dr Narelle Dawson to design and implement a research project precisely for that purpose. This was the most advanced and robust study of Yellow Ribbon devised that I have seen anywhere. It was specifically designed to meet the requirement that: “the programme must demonstrate that it is “safe, effective, and evidence based, in a rigorous and scientific way.”

Thelma French wrote in response to Government concern that the Yellow Ribbon programme “lacked a robust evaluation framework”:

“Government is very aware of the evaluation design prepared by Prof Evans and Narelle Dawson in August 2002, the implementation of which we have been asked to delay, despite our seeking specific ring-fenced funding for evaluation studies. In order to ensure our evaluation plan would meet Ministry requirements, we initiated several meetings in which Yellow Ribbon requested from the Ministry representatives more detailed specification as to what in their view would be minimally required for a sound evaluation. To date they have been unable to provide any such guidelines. That safety issues have not been dismissed and are taken very seriously by Yellow Ribbon.”

However this was followed by a more serious criticism in a draft report of the IPRC at Auckland University:

“… the lack of evaluation evidence makes it extremely difficult to substantiate the impact of the program, and the level to which programme aims have been achieved. Consequently, respondents strongly questioned the probable contribution of the Yellow Ribbon program to young people’s help seeking behaviours and in particular to preventing suicidal behaviours among young people. Yellow Ribbon has no right whatsoever to claim that they make any positive contribution to suicide prevention.”

Yellow Ribbon replied:

“This type of comment places Yellow Ribbon in a classic double-bind. Obviously a programme cannot produce outcome evidence until it has been implemented for a period of time. Clearly the general thrust of the Yellow Ribbon programme is based on reasonable principles, and as already explained, work is under way to evaluate both process and outcome. Some initial efforts at review of processes have been initiated, for example in the above-mentioned questionnaire to ambassadors in January 2003, the majority (45.5%) said the training increased their knowledge a lot; and 27.5% said the training increased their knowledge somewhat. The majority of ambassadors said training increased their knowledge of where to seek help a lot (40.9%) and 29.6% ambassadors said the training increased their knowledge somewhat. In addition Youthline has recorded a 500% increase in calls and relationship services have also seen a marked increase. Whenever asked if we believe we have contributed to the drop in youth suicide we state that our belief is that education and awareness is very important, but we always reiterate if there is a significant decrease, it is due to the efforts of many organisations and strategies.”

In fact, as the reference to the survey of ambassadors points out, despite claims to the contrary, Yellow Ribbon was responsibly cooperating in an evaluation by the Injury Prevention Research Centre at Auckland University to establish an ‘evidence base’. This survey found a large majority of the ambassadors strongly approving of, and supporting, the work of Yellow Ribbon. A small number expressed doubts about its value, but these were of not sufficient ‘concern’ to warrant being followed up by the research project. A larger minority thought there should be more professional backup and support. However, as the researchers point out, most of those who responded (in fact a very low response rate of 37%) had been ambassadors for less than one year. This reflects the fact that Yellow Ribbon was by 2002 barely 3 years into its operation and was feeling its way and very willing to learn from the “evidence”. Moreover, the concerns of the researchers expressed in this report (lack of training, reported failure to refer young people at risk to adults or professionals etc) were clearly echoing the concerns of those ambassadors who wanted better training and more professional backup. Overall, the project endorsed Yellow Ribbon as a sound approach to youth suicide prevention.

However, the “concerns” that surfaced in the survey of Ambassadors were then used in the Ministry funded research on peer based programs as “evidence” that Yellow Ribbon’s program was “potentially harmful”. The results of this research were leaked to the Sunday Star Times which sensationalized YR as “dangerous”. Yellow Ribbon had its own evaluation of the research done by Professor Ian Evans and Dr Narelle Dawson, who found it to be “unscientific” and “unprofessional”.

The Evans/Dawson critique makes it clear that Yellow Ribbon is under attack by Government agencies. I would add that it was “unscientific” to misuse the survey of ambassadors based on a small sample in which an overwhelming endorsement of Yellow Ribbon by its ambassadors as cause for “potential harm” where suicides may results from promoting “awareness”, and Ambassadors put at risk in taking too much responsibility for counseling suicidal peers. It is clearly “unprofessional” in its cynical misrepresentation of Yellow Ribbon as lacking a theoretical base, and not interested in evaluating its methods, when it had initiated, designed and planned a world beating outstanding evaluation project and willingly collaborated with the University of Auckland Injury Prevention Research Centre to do the survey of its ambassadors.

While the survey of ambassadors was a world first in actually asking ambassadors (and not gatekeepers) to at least talk about their role, the obvious next step was not taken. Young people at risk were not asked if Yellow Ribbon had reduced their suicide attempts. Nor were those who did commit suicide tracked to see if their suicide was in any way caused by the “awareness” generated by the Yellow Ribbon program. Such critical questions were addressed by the Evans and Dawson evaluation plan. Moreover, the anecdotal evidence of testimonies of both ambassadors and young people helped by Yellow Ribbon and conveyed to the organizers was ignored as invalid and unreliable.

Yet, during the years of its existence from 1996 to 2005, suicide rates for the younger age groups (15-24) showed a decline of around a third. This was no doubt due to a combination of factors the most important of which is social inequality. But on the face of it, the “evidence” speaks for the efficacy of Yellow Ribbon rather than against it. So why did the IPRC researchers base their evaluation of Yellow Ribbon on the opinion of professionals (teachers and health workers) and not ask the young people who “talked” to the ambassadors, whether they thought suicide “awareness” prevented suicides or not? If Yellow Ribbon was at risk of doing “harm” why not ask the very people thought to be at risk? Why not fund the very good research project initiated by Yellow Ribbon that would have answered all these questions?

Suicide Prevention orthodoxyy

New Zealand has the third highest (behind the Russian Federation and Finland) suicide rate for young males, and the third highest for young females. The male rate is high because of the rate for Maori males in the youth age group 15-24 is up with Australian Aboriginal youth at 3 or 4 times more than non-Maori and non-Aboriginal respectively. The 2006 statistics