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Our Submission to Ministry of Health Concerning Suicide Prevention Strategy

Filed under: General — Ministry of Men's Affairs @ 7:48 am Tue 27th June 2017

MoMA asked Hans Laven to prepare a submission and we post it here with thanks for his hard work. It’s not short but hopefully worthwhile.

We draw attention here particularly to Section 2, Section 3 and Section 6.1. And the sentence that pretty well sums up the previous and the currently proposed Suicide Prevention Strategy: “While partnering with Maori, Pacific and other groups is justified, partnering with men’s groups and men’s services is more justified, indeed essential, and excluding men from mention here amounts to appalling sexism.”

Submission Regarding Proposed Suicide Prevention Strategy 2017
Hans Laven, Clinical Psychologist 26/06/2017

1. The proposed strategy (hereinafter referred to as ‘the Strategy’) has little focus on reducing suicide. Its focus is much more towards reducing intentional self-harm. Indeed, on page 7 it states “The purpose of the strategy is to reduce the suicide rate through reducing suicidal behaviour”. Surely the purpose of a suicide prevention strategy should be to reduce the suicide rate through all effective means?

The Strategy goes on to state “Reducing suicide behaviour for all people means fewer people hurting themselves intentionally, thinking about suicide and dying by suicide”. Although a history of self-harm has been shown to be one of many risk factors for suicide, like most other risk factors its particular contribution towards suicide risk is small. Further, most intentional self-harm is not suicide behaviour, so targeting intentional self-harm will tend to divert resources and attention away from reducing suicide. I may have missed it but I am unaware of research supporting the notion that targeting intentional self-harm is an effective way of either preventing individual suicides or reducing suicide rates. There is no scientific basis for estimating any degree of impact on suicide rates that might be achieved by targeting self-harm behaviour. There is no such estimation mentioned in the strategy and there is no explanation of how reducing self-harm behaviour might reduce suicide rates.

The same applies to suicidal ideation. A huge proportion of people have thought about suicide at some time in their lives yet only a tiny proportion act on those thoughts. Targeting ‘thinking about suicide’ will therefore tend to divert resources away from the task of reducing suicide. Greater impact on suicide rates will be achieved by targeting warning signs shown to be more highly correlated with actual suicide.

A history of suicide attempts is a significant risk factor for actual suicide and is more justified as a target as part of reducing suicide. Yet even there only a small proportion of people who commit suicide have a history of suicide attempts. Further, only a minority of people attempting suicide go on at some stage to commit suicide. One reason for this is that many events defined as ‘suicide attempts’ do not involve genuine intention to die. For example, the statistics for suicide attempts (and intentional self-harm) disproportionately reflect repeated events by a small group of personality disordered people who express their deep distress and need for support through suicide threats, gestures and apparent attempts in which they almost always ensure they will be rescued. If the Strategy is to target suicide attempts, the first step will be to assess and categorize true suicide attempts separately from those that are more accurately seen as help-seeking gestures or self-harm that probably did not involve any intention of dying. Until that happens, targeting the range of what are recorded as ‘suicide attempts’ will divert resources away from reducing suicide.

In its present form the Strategy should be called a ‘Self-Harm Prevention Strategy’. That may be a worthwhile enterprise but inconsistent with the role required of the Ministry regarding suicide prevention, and it leaves the area of suicide prevention inadequately addressed.

2. The Strategy acknowledges that males commit suicide at around 3 times the rate for females but then fails to provide one single plan targeting male suicide specifically or tailored to males. To achieve significant reductions in suicide rates it seems obvious that a priority focus would need to be on male suicide. Suicide rates justify approximately 75% of efforts and resources to be devoted to male suicide, both generally and within other special target groups such as Maori and Pacific peoples. The fact is that all differences between groups based on any other demographic do not come close to the gender difference. From the Ministry’s own figures, the Maori:non-Maori ratio is about 1.4:1, the highest deprivation:lowest deprivation ratio is about 1.7:1; the youth:’adult to middle age’ ratio is only about 1.1:1. The male:female ratio is about 3:1, this being the average ratio over the last 10 years of figures published by the Ministry.

Official suicide rates are likely to be an underestimation because some suicides will be recorded as road accident deaths, workplace deaths, police shooting deaths etc, while other suicides by slower processes of self-neglect, substance abuse and risky lifestyles will also be left out of suicide statistics. What we know about male driving, offending, work-roles, homelessness, substance abuse and other factors relevant to unrecorded suicides suggests that if including those statistics would maintain or increase the gender suicide disparity.

The Strategy states on page 11:
“It is also important to tailor activities…to address the needs of individuals in other groups or sub-groups with markedly higher rates of suicidal behaviour, such as males, LGBTI and the Rainbow community, and disabled people.”

However, there is nothing then recommended in the Strategy that is tailored to men. For example, on page 22 it states:
“Improve understanding of how to prevent suicidal behaviour in New Zealand, particularly among
– Maori
– Pacific Peoples
– young people
– LGBTI and Rainbow community”

Why is the most prominent group in suicide left out?

The Strategy states on page 7 that its intention is
“… to reduce and remove the differences in the suicide rates between different groups.”

It’s difficult to understand then why the Strategy avoids considering men and male suicide specifically and avoids any focus on reducing and removing the gender difference. Instead, it focuses heavily on reducing Maori suicide and reducing and removing racial differences even though they are less than half that for gender. The Strategy avoids giving any attention or priority to men as a group but disproportionately favours other groups including women on the basis that they show more suicidal gestures and potential attempts but don’t actually kill themselves as often. It is difficult to avoid a conclusion that the Strategy favours groups according to political correctness, and as such is deliberately sexist against men.

Is this related to attitudes to men as disposable and to traditionally lower empathy for men’s suffering? The traditional and continuing sacrifice of males in war and in male work roles (e.g. almost 100% of workplace deaths year after year) is hardly mentioned in media or in official reports and the gender issues are studiously ignored; the same pattern is evident regarding suicide and in the Strategy.

There have been in news media and the literature various suggestions and some examples of approaches that might be expected to impact on male suicide (e.g. Poole, 2016). Firstly, research is needed to gain better understanding of male suicide specifically, and why in ‘western’ but not in Muslim and some other non-western countries male rates rose significantly over the last few decades of the 20th century while female rates remained relatively stable (Phillips, 2011, in ‘Suicide – Suicide rates’, Te Ara – the Encyclopedia of New Zealand, http://www.TeAra.govt.nz/en/suicide/page-2). Research has looked at numerous factors correlated with male suicide yet when the known factors are controlled for, a large proportion of male suicide remains unaccounted for (Mann et al, 2005).

A theme apparent but not specifically explored in research on risk factors for male suicide is that of men’s need to feel useful and valued. For example, Danish research by Qin et al (2000) found that unemployment, retirement, sickness absence rate and being single were all risk factors correlated with male but not female suicide rates. Shiner et al (2009) analysed coroners’ files including suicide notes in the UK and found that relationship breakdown was more likely to be identified as the main trigger for males than for females, while work-related problems and financial debt were each cited at twice the rate for males than for females. Historically, a good proportion of men who saw themselves as not being useful or valued would readily fall on their swords and that appears still to be the case. It may be that many men are struggling to feel useful and valued in the face of gender-role changes over the last 50 or so years, and this is reflected in increased male suicide rates. Research is needed to clarify such matters and to allow solutions to be developed.

Other male-oriented approaches to reduce suicide have been proposed but are totally absent from the Strategy. For example, advertisements in male-rich employment places, bars and sports clubs are likely to reach men. Screen advertisements during male sport broadcasts and during male-oriented movies at theatres and on television could convey messages likely to reduce suicide. Depictions of men seeking support and being heard and understood would be helpful, as would depictions associating worthy masculinity with seeking help and staying alive in the face of humiliation etc. It is not difficult to think of approaches likely to be effective for men but there is a conspicuous absence of such effort in the Strategy.

3. The Strategy provides insufficient emphasis on researching suicide and approaches likely to reduce it. Not much in New Zealand or elsewhere has changed since the following was published in 2011 in The British Columbia Medical Journal:

(Bilsker D, White J. The silent epidemic of male suicide, BCMJ, Vol. 53, No. 10, December 2011, page(s) 529-534)
‘It is remarkable how little we have learned about causal factors and preventive strategies specifically relevant to male suicide. One would think that the hugely elevated rate of suicide in men compared with women would have sparked a substantial investment of resources into systematic research and enhanced clinical practice. Instead, the high rate of male suicide has been treated as somehow natural and inevitable. The time has come to give this problem high priority.’

There is no such priority in the Strategy. Where is the interest in finding out and addressing the reasons men are much more prone to seeing themselves as so worthless or to feeling in so much emotional pain that they kill themselves in such large numbers?

Areas needing research include
– More accurate categorization of suicide attempts vs manipulative gestures vs deliberate self-harm.
– Risk assessment instruments, both for screening purposes and for more intensive intervention purposes.
– Specific management and intervention programs for reducing suicide. There are promising options but none have been tested, researched and developed sufficiently to provide confidence as a routine pathway, and even those with some support have not been researched or adapted for the New Zealand situation.
– Social factors contributing to suicide rates, possibly including the devaluation and demonization of men and maleness in the feminist era; and specific strategies to address any such factors.
– Understanding why psychiatric treatment and hospitalization are associated with such high subsequent suicide rates.

4. The ‘Potential Areas for Action’ have merit but it is unclear why those 10 were chosen and numerous others ignored. Other Action Areas such as promoting physical exercise and family integrity, encouraging respect for men in our society and countering hate-speech and unbalanced propaganda that unfairly disparages men, and targeting male suicide specifically all deserve to be in this list and are more likely to have a beneficial impact on suicide rates than are many of those currently included.

There are approaches that have some research backing regarding reducing suicide, such as various forms of psychotherapy, and an approach called the ‘Collaborative Assessment and Management of Suicidality (CAMS)’ (Jobes, 2012). Such evidence-based approaches should be prioritized in the Strategy.

Subjectively uncontrollable emotions have been shown to predict imminent suicide attempts better than any other risk factor or warning sign (Hendin et al, 2010). Encouraging awareness of this and of using screening and risk assessment instruments concerning this should be part of the Strategy.

Dealing with suicidality as a stand-alone intervention in DHB and other services may be useful, as opposed to dealing with suicide risk as simply a symptom of some psychiatric diagnosis.

Avoiding coercion in treatment is likely to be important, and working to develop alternative approaches to forcing medication and ECT on suicidal people would be a meritorious inclusion in the Strategy.

5. The Strategy’s recommended approaches are vague and fail to identify who is responsible for bringing them about, how this will be done and funded, or how it will be determined that they have or have not been achieved.

6. Comment on each of the strategies:

6.1 Support positive wellbeing throughout people’s lives

This is a laudable aim and the recommended activities may well help to achieve this.

Male-specific approaches should be included. For example:
– Working to achieve gender equality in sentencing, prison conditions and likelihood of Mental Health Act coercion;
– Providing facilities in prisons and psychiatric wards conducive for fathers to spend quality time with children;
– Working to achieve a presumption of equal shared care of children following separation. If separating fathers were confident that their role as equal parent and their bonds with children were going to be protected by the state, this would have an immediate impact on reducing suicide rates;
– Working to achieve gender equality in how we manage all areas in which men are disadvantaged including hate-speech, homelessness, addictions, family law, support for victims of violence and crime, workplace deaths and injuries, health care and suicide prevention;
– Reforming our system of ‘child support’ taxation to overcoming the financial destruction of separated fathers;
– Reforming relationship property laws to reduce inequities and injustice mainly towards men;
– Recognition of the heavily disproportionate sacrifice men make with their lives and health in the dirtiest, most dangerous, most uncomfortable and health-damaging jobs that men overwhelmingly provide to maintain the infrastructure of our privileged lifestyles;
– Increasing recognition of men’s huge contribution historically to developing our civilization and privileged lifestyles;
– Developing a rite-of-passage for transitioning teenage boys into men, involving respect and obligations in relation to the adult male role.

6.2 Build social awareness of and well-informed social attitudes to suicidal behaviour

This seems to be a confused recommendation. It wants to make it easier for people who have lost someone to suicide to seek care and support; that is laudable but of limited relevance to suicide prevention.

This Action Area refers to ‘common myths’ about suicide but does not elaborate. Suicide myths have been suggested (e.g. Joiner, 2011) but those suggestions are poorly supported by research regarding the extent to which these myths are held. Further, it has not been established whether countering any such myths (even assuming we are able to do so confidently based on good research) will reduce suicide rates and if so to what extent.

There is no good scientific basis for ‘running a campaign to reduce the stigma around suicidal behaviour’ as a method to reduce suicide. Indeed, historical evidence suggests that suicide rates vary in correlation with beliefs concerning the acceptability of suicide and the individual’s right to commit suicide (Saul, 2014). While we may not wish to return to criminalizing suicide or punishing families of those who committed suicide, it may well be that a more effective way to reduce suicide would be to increase stigma around suicide and to increase its perceived moral unacceptability.

Reducing stigma concerning depression, mental illness and especially psychotic conditions may increase people’s likelihood of seeking help for themselves or others and thereby avoiding suicide. However, we first need to be confident about how such help is best provided. Some guidance would be desirable in the Strategy. For example, people with depression, grief or adjustment issues should not be too quick to engage with psychiatric treatment because that does not result reliably in suicide prevention, whereas participation in counselling and psychotherapy services is more likely to be helpful. However, severe psychosis should be managed by medication if suicide prevention is the goal, because we know such treatment will reduce suicide risk despite the downsides and inadequacies remaining in that approach. It would be helpful in the Strategy to include an Action Plan to highlight some of the risks of participation in our psychiatric and ‘mental health’ services and to provide some advice about managing such participation.

Raising awareness of ‘signs of distress’ is likely to involve excessive sensitivity and grossly insufficient specificity. Instead it would be more effective to raise awareness of suicide warning signs such as subjectively uncontrollable emotional arousal, preparatory actions towards suicide and large changes in personality or presentation.

While partnering with Maori communities will be important in reducing suicide, partnering with men and men’s groups will be even more important yet there is absolutely no mention of men.

6.3 Encourage responsible conversations about suicidal behaviour and preventing suicidal behaviour

The recommendation to encourage media to report on stories of people overcoming distress and avoiding suicide is a good one.

Teaching people how to discuss suicide and to support suicidal people ‘responsibly’ is commendable but there is a lack of specifics or explanation about this. It is difficult to rely on evidence-based guidance regarding this because the research is unclear and contradictory.

The Strategy could usefully include some specific guidance regarding ‘responsible’ discussion about suicide. For example, supportive listening skills, avoiding unnecessary blame, normalizing people’s errors, imperfections and distress, expressing how much the suicidal person is valued and highlighting the person’s qualities and strengths. Specific guidance on avoiding male-blaming, male-demeaning attitudes and other maleness-disparaging comments would be especially important.

The emphasis on ‘suicidal behaviour’ is appropriate in this Action Area but it would be desirable to include some guidance regarding what would be ‘responsible’ in the case of serious warning signs versus vague suicidal ideation, and some guidance on how to tell the difference.

Again, this Action Area focuses on ‘reducing stigma’ for which there is not good evidence as a suicide-reduction strategy, and on helping those bereft through suicide to seek help which is to some extent a distraction from actual suicide prevention.

6.4 Increase mental health literacy and suicide prevention literacy

‘Mental health literacy’ is not defined. Unfortunately, this will be assumed by many to involve increased readiness to submit to psychiatric diagnosis and treatment, and this believed to prevent suicide. The control of psychotic symptoms through antipsychotic medication, and the control of bipolar disorder through mood stabilizers are supported by most research as bringing significant suicide reduction; however, relying solely on such treatments will only avert a relatively small proportion of suicides, and many people who commit suicide are being treated with medications at the time. Regarding SSRI’s, meta-analyses of Randomized Controlled Trials did not detect reliable suicide-reduction benefit of antidepressants in mood and other psychiatric disorders (Mann et al, 2005). Indeed, SSRI medication has been associated with increased suicide risk for some populations. While several antidepressants have been associated with reduction in depressive symptoms, suicidal ideation and suicide-related behaviour, this did not extend to reducing the rate of completed suicides (e.g. Gibbons et all, 2012), emphasizing that targeting suicide behaviour of vaguely defined nature is not justified as the main focus of a suicide-prevention strategy.

This Action Area implies that addressing mental illness will significantly reduce suicide risk, and this is widely believed in our society. Many media articles conflate the two issues as though suicidality only arises because of mental illness. It will be important in the Strategy to counter that particular myth, and any idea that being diagnosed with something and medicated is a reliable way to avoid or to prevent suicide. Instead, an emphasis on seeking counselling and psychotherapy, and increasing funding and support for telephone counselling services, should be included in the Strategy.

6.5 Support and partner with communities to develop and carry out activities that help to prevent suicidal behaviour

Providing spaces for community groups to meet is a very good idea.

Providing access to sources of funding to support community initiatives to prevent suicide is a very good idea, but such initiatives should be evidence-based as far as possible and at the very least should include requirement and funding to undertake outcome research showing reduction in suicide rates. The very real danger otherwise is that resources will be wasted on ineffective approaches such as drug company profits.

The focus on suicidal behaviour as opposed to genuine suicide attempts or completions is not justified, and substantial diversion of resources into the range of behaviours that might be categorized as ‘suicidal behaviour’ will tend to detract from actually reducing suicide.

While partnering with Maori, Pacific and other groups is justified, partnering with men’s groups and men’s services is more justified, indeed essential, and excluding men from mention here amounts to appalling sexism.

6.6 Strengthen systems to support people who are in distress

The suggested activities are good ideas but the glaring omission here as in the rest of the Strategy is an emphasis on men and systems tailored to men in distress and at risk of suicide.

6.7 Build and support the capability of the workforces in the education, health and police sectors and in the wider justice and social sectors

This is a laudable aim but relies first on knowing what capability to build specifically that is supported by good research as achieving risk reduction. For example, how will one provide suicide prevention training likely to be effective? It would be helpful for the Strategy to provide some real guidance here. For example, it will be important to avoid:
– an over-emphasis on diagnosing and medicating mental illness;
– a reliance on suicide contracts, the use of which has not been shown to avoid suicide;
– a reliance on removing guns and medication, which has been shown to reduce suicide by those means but not overall (i.e. people simply use other means that usually carry greater risk of failure, permanent disability, or additional suffering in the process of dying).

The focus on Maori and Pacific ‘workforces’ assumes an apartheid system, and the wording should perhaps be more cautious in that regard.

Again, there is a glaring absence of focus on men. Male-tailored approaches will be essential for any substantial reduction in suicide. Justice and police sectors particularly will deal overwhelmingly with men in ways that will impact on those men’s suicide risk, so male-specific suicide prevention training (e.g. knowledge of male-specific and male-predominant risk factors, and knowledge of how to influence men against suicide) will be important. For other sectors it will be important to train front-line staff to address male-denigrating attitudes and to build skills for listening and understanding of men’s situations and reactions.

6.8 Strengthen systems to support whanau, families, friends and communities

While supporting those bereaved by suicide is warranted as part of the Strategy, the emphasis here is overdone relative to actual suicide prevention. The contribution of suicide clusters and suicide contagion to overall suicide rates is minor.

Extending that emphasis to include families supporting someone who has ‘ongoing suicidal behaviour’ runs the risk of diverting suicide-prevention resources into managing too wide a range of behaviour, unless ‘suicidal behaviour’ is carefully defined to distinguish it from self-harm, fleeting or uncommitted ideation and manipulative threats. That is not to say that behaviour that may be more broadly categorized as ‘suicide behaviour’ does not deserve attention in the Strategy, but that attention does not deserve to be so emphasized at the expense of addressing real suicide.

The list of ‘Activities in this area’ should include as a priority some male-oriented initiatives, for example:
– funding and re-establishing the Men’s Line as part of the Lifeline service,
– training male-rich workplace supervisors and HR people to recognize and effectively work with men at risk of suicide.

6.9 Strengthen and broaden collaboration among those working to prevent suicidal behaviour

These suggestions are good ones except that it will be important to provide some distinction between the broad notion of ‘suicide behaviour’ and warning signs of impending suicide, in order to avoid diverting too much resource and attention into behaviour that does not carry high risk of actual suicide. The amount of resource should be allocated according to risk levels of behaviour for actual suicide, as far as we can measure them.

In such collaboration it will be most important to increase awareness of men’s issues and to address the anti-male sexism apparent in many of our state and NGO services. For example, Women’s Refuge should be discouraged from making public statements that falsely claim or imply that all domestic violence is committed only by men and suffered by women, and other agencies collaborating with Women’s Refuge should be discouraged from colluding in such anti-male false propaganda which is likely to contribute to men’s sense of worthlessness and thereby to men’s high suicide rate.

6.10 Strengthen systems for collecting and sharing evidence and knowledge about suicidal behaviour and for tracking our progress

This in general is very sensible and commendable. The glaring omission again is any focus on men, the most significant group regarding suicide. We know so little about why men are killing themselves in such large numbers, yet men are totally ignored in favour of other groups that do not have such large relative elevation in suicide numbers. Why is this?

The suggested Activity for Maori to ‘lead’ research on preventing suicidal behaviour among Maori is an apartheid policy with many dangers. Specifically in this case, the Strategy should not have a policy that discourages other groups that are not necessarily identified as ‘Maori’ from initiating and leading research into Maori suicide. It may be that other groups, state organisations etc have research skills and resources not readily available to Maori groups. The Activity would be better worded more carefully, for example, ‘Maori leading or advising research on preventing suicide among Maori’.

Again, without clearer definitions the focus on ‘suicidal behaviour’ runs the risk of diverting resources away from actual suicide reduction in favour of all manner of distress behaviour.

REFERENCES

Beautrais AL, Fergusson DM, Horwood L J (2006). Firearms legislation and reductions in firearm-related suicide deaths in NZ. Australian and New Zealand Journal of Psychiatry, 40; 253-259

Borschmann R, Hogg J, Phillips R, Moran P (2012). Measuring self-harm in adults: A systematic review. European Psychiatry, 27; 176-180

Braun C, Bschor T, Franklin J, Baethge C (2016). Suicides and Suicide Attempts during Long-Term Treatment with Antidepressants: A Meta-Analysis of 29 Placebo-Controlled Studies Including 6,934 Patients with Major Depressive Disorder. Psychotherapy and Psychosomatics, Volume 85, No 3; 171-179

Gibbons R D, Hendricks Brown C, Hur K, Davis JM, Mann J (2012). Suicidal thoughts and behaviour with antidepressant treatment; Reanalysis of the randomized placebo-controlled studies of Fluoxetine and Venlafaxine. Arch Gen Psychiatry, 2012 Jun; 69(6): 580-587

Harris KM, Goh MTT (2017). Is suicide assessment harmful to participants? Findings from a randomized controlled trial. International Journal of Mental Health Nursing, Volume 26, Issue 2, Pages 181–190

Hendin H, Al Jurdi RK, Houck PR, Hughes S, Turner JB (2010). Role of intense affects in predicting short-term risk for suicidal behaviour. Journal of Nerous and Mental Disease, 198(3); 220-225

Ilgen M A, Zivin K, Austin KL, Bohnert A S B, Czyz EK, Valenstein M, Kilbourne AM (2010). Severe pain predicts greater likelihood of subsequent suicide. Suicide and Life-Threat Behaviour, 40: 597–608

Jobes DA (2012). The Collaborative Assessment and Management of Suicidality (CAMS): An evolving evidence-based clinical approach to suicidal risk. Suicide and Life-Threatening Behaviour, 42(6); 640-653

Jobes DA, Wong SA, Conrad AK, Drozd JF, Neal-Walden T (2005). The Collaborative Assessment and Management of Suicidality versus treatment as usual: A retrospective study with suicidal outpatients. Suicide and Life-Threatening Behaviour, 35 (5), 483-497

Joiner T (2011). Understanding and overcoming the myths of suicide; What goes on in the minds of those who attempt suicide. UBM Medica Psychiatric Times; 28(1), 1-5

Large M, Smith G, Sharma S, Nielssen O, Singh SP (2011). Systematic review and meta-analysis of the clinical factors associated with the suicide of psychiatric in-patients. Acta Psychiatrica Scandinavica, 124; 18-29

Luoma JB, Martin CE, Pearson JL (2002). Contact with mental health and primary care providers before suicide: A review of the evidence. American Journal of Psychiatry, 159:6; 909-916

Mann et al (2005). Suicide Prevention Strategies: A Systematic Review. JAMA, 2005; 294(16):2064-2074

McMillan D, Gilbody S, Beresford E, Neilly L (2007). Can we predict suicide and non-fatal self-harm with the Beck Hopelessness Scale? A meta-analysis. Psychological Medicine, 37; 769-778

Madsen T, Erlangsen A, Nordentoft M (2017). Risk Estimates and Risk Factors Related to Psychiatric Inpatient Suicide—An Overview. Int. J. Environ. Res. Public Health, 14; 253

NZ Ministry of Health (2003). Best Practice Evidence-Based Guideline: The Assessment and Management of People at Risk of Suicide.

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Poole G (2016). ONS suicide statistics: 10 ways we can stop men killing themselves. The Telegraph, 04/02/2016

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Web-based References:
http://ebmh.bmj.com/content/ebmental/8/4/114.full.pdf

We Can All Prevent Suicide


http://www.sprc.org/sites/default/files/migrate/library/RiskProtectiveFactorsPrimer.pdf
http://www.health.govt.nz/publication/suicide-facts-deaths-and-intentional-self-harm-hospitalisations-2013
http://www.health.govt.nz/publication/new-zealand-suicide-prevention-action-plan-2013-2016
http://www.police.govt.nz/sites/default/files/publications/crime-stats-national-20141231.pdf
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Saul P (2014). Do people really have the right to a rational suicide? The Conversation, 28/07/2014, at http://theconversation.com/do-people-really-have-the-right-to-a-rational-suicide-29658

15 Responses to “Our Submission to Ministry of Health Concerning Suicide Prevention Strategy”

  1. MurrayBacon says:

    Thank you very much for making a comprehensive and wide ranging submission. I strongly support your points.

    My submission was very much last hour, so not as comprehensive or well organised.

    What do you think about these pathways? Do you have any comments or suggestions about these pathways?

    These suggestions are easy to make, but harder to do in ways that are useful to the person in question.

    NZ has a human rights act. But it isn’t explicitly written to include trans* and gender queer or fluid people. Neither major party wishes to been seen to support such marginalised groups of people, so the situation is left in limbo.

    Canada has just included human rights protections for trans*, queer and gender fluid people. NZ and Australia and parts of USA are the last remaining western countries not to protect these people as if they were human. So the people who need such protections are left with largely ineffective human rights protection. This lack of protection then flows into equitable access to healthcare, access to jobs and accommodation.

    In some ways, men are a similarly unprotected group. The courts are erratic in offering human rights protections to men, eg DV is tilted to allow women to use allegations to manipulate custody of children. The familycaught$ acts in the manner of a mindless moron with such allegations. Not only does this help drive suicides, it also fails to properly protect the children, in their right to a good quality relationship with their father. This then leads to hampered school performance for such alienated children. Our society pays a huge cost for this stupid approach to DV, not just the fathers involved.

    Many men receive a lot of affirmation and support in workplaces. If they have a relationship separation, maybe loss of access to children and maybe child and spousal support hassles, they often suddenly find they receive no positive support at work. Another stressor, is that the previously mentioned stresses usually reduce workplace efficiency and capability. Thus their job becomes at risk too.

    Likely they receive victim blaming. This becomes a sudden and very sharp transition from affirmation, to social distance and exclusion, often with predictable outcomes. This illustrate how consideration of intersectional effects may be critical, if we intend to reduce suicides.

    Men are often hit with very obvious disrespect in many Government Departments eg WINZ, Family Court, IRD Child Support, CYFs. Despite paper mention of equality, reality bites hard, especially if these problems were not expected.

    When suicide decisions are usually made by how many straws does it take to break a camel’s back, then intersectional issues are likely to be particularly critical. One example is men losing custody of their ex-wife’s children. This stress, perhaps combined with any LGBT stigma or childhood abuse, is a potent suicide driver.

    I believe that coroners cannot access Family Court and/or Inland Revenue (Child Support especially) files. Bullying in the Departments can be a significant suicide driver, that Coroners are unable to observe most of the time. Statistics should cover which lawyers, registrars and judges were involved, so that suicide statistics can draw attention to individual Government employees who are causing the most deaths. This would make it possible to eventually take remedial action, if this was chosen.

    Similarly WINZ provided accommodation for women in Ashburton. But one man saw that he would be left forever sleeping in his car. In his frustration at being treated so obviously differently to women, feeling that there was no hope of improvement by complaining or humanitarian appeals for help, he shot two WINZ staff. I am not condoning extreme violence. But neither am I condoning WINZ’s clear and ongoing breaches of human rights. In essence it appears that this man responded appropriately to Government incentives, as he then gained satisfactory accommodation in jail. Even if this is what the Government incentivised, is it really what the public want?

    Faith based organisations should be allowed to operate with overt prejudice. There is no way to stop these types of people. But they should have to publicly declare their numbers of LGBTIQ members, so that there is some public visibility of prejudice levels within these organisations. This data should be assembled outside of the organisation, to ensure its honesty.

    GP practices should be required to declare their LGBTIQ patient numbers, training regarding LGBTIQ patient’s medical and social needs and their willingness to treat LGBTIQ patients. Almost all GPs lack such training in their medical degrees. LGBTIQ patients often have to make an appointment, just to find out if this doctor is able and willing to offer treatment. This cost is inequitable, as generally these patients are in NZ’s lowest socioeconomic group. These costs are a serious barrier to healthcare.

    Medical School in Auckland has a LGBT poster in foyer. But I have never seen a visibly LGBT person in med school. Maybe my eyes are not very good? This may be for fear about later employment? The important thing is that the Med School seem to be blissfully unaware that their students don’t appear to be safe to be out. This really does not suggest even the lowest level of LGBTIQ patient awareness in Auckland Medical School, or even a satisfactory attitude to caring for their own students?

    Prioritising actions
    The section on ‘Turning the shared vision into action’ describes 10 potential areas for action (see pages 10–12 in the draft strategy).
    Do you think these are the right areas for action to prevent suicide (eg, are any areas missing; are the areas identified the most important areas)?

    Giving working human rights protections to NZers who are not rich, whether they are men or women, or LGBTIQ.

    The plan focus seems to be around what doctors see in hospitals, rather than on the number of deaths by suicide ie men are relatively ignored in the “plan”. This leaves the plan looking as though it is just ticking boxes in reports to UN, but not meant to do anything on the ground in NZ.

    LGBTIQ are ignored in statistical data gathering.

    “accidents”, such as

    Workplace Drug poisoning
    Shooting accidents
    Falls
    Road Deliberate risk taking, intended to have a chance of death like Russian roulette in film The Deer Hunter.

    It is likely that these deaths may exceed suicides presently recorded by the coroner.

    Stigma in workplaces and Family Court regarding custody of children are large barriers to people, especially men, seeking help from mental health services. Additionally, mental health services don’t always have a good record of helping people.

    Stealth Rainbow people may particularly value these ways of dying, as it spares family from having to face the suicide.

  2. Downunder says:

    An admirable contribution to bullshit castle. (Read that as the determination to sit at the table when the cards are stacked against you)

  3. Downunder says:

    @1 with all due respect to the authors academic contribution, what you have written shows a more comprehensive understanding of male suicide, from my observations ‘in the field’ to clarify that.

    For that reason regardless of the academic contribution we will not see a reduction in male suicide.

  4. Evan Myers says:

    @1 Dear Mr Bacon

    You made reference to the Ashburton WINZ shooting. Can I add:

    There was scant coverage of the subsequent suicide of the office manager.

  5. hornet says:

    And of course this all ties in with Parental Alienation, the deliberate destruction of a father, destroying his income earning ability, taking away his assets and property, and leaving him high and dry. Add to this the deliberate distribution of METH across our nation, increases in alcohol sales outlets and we have all the ingredients to encourage suicide. In fact disturbingly some in the St Johns and Police have admitted to me that they like METH – since most people suicide on it, meaning they don’t have to deal with them – they go direct to the undertaker.

    The police were able to shut down legal party pills in NZ which NEVER killed anyone, and yet they cant for some reason shut down METH………..similar to the US military NOT being able to destroy ISIS, despite having the largest military in the world…….most young kids moved onto METH after party pills – who does this to a society?

    I also note for record here – Psychologists in the family court are not having a good time, they are being scared away from dealing with the SECRET family courts by way of COMPLAINTS about what psychologists are presenting. Are our psychologists presenting evidence of parental alienation by nasty MOTHERS – who then complain when the TRUTH is presented.

    An important study would be to find out from the Justice system – what are these COMPLAINTS towards PSYCHOLOGISTS are about – are they primarily from irritated narcissistic mothers who are not getting their way ALIENATING kids from DADS?

    Psychologists might well be on the side of good fathers, since they see the alienation first hand during their investigations and have to report on it as professionals. Something corruption hates – Professional, EXPERT TESTIMONY of the TRUTH.

    Alienating dads from their kids is something the state has been happy to also encourage to keep good dads away from their kids as I have seen over ten years. Using lawyers for child to LIE to the courts and suppress psychological evidence, perverting the course of justice and deliberately harming the child in the process – a Crime.

    State Care, foster homes – kids subject to psychological abuse and sexual assault – deliberately removing kids from parents, alienation of kids from dads, and the use of Drugs with heavy criminalisation to destroy those in society that are targeted – are all tactics that have been used before. We have a massive cover up on this issue right now in NZ.

    Nixons corrupted and impeached governance did this prior to the Vietnam WAR = they admitted to linking Hippies with Weed, and Blacks with Heroin and then targeted both groups criminally to shut down anti war protest.

    We are seeing the same again today in NZ.

  6. MurrayBacon says:

    #4 Thanks Evan, I was certainly unaware of that suicide.

  7. Downunder says:

    @5 In the days of UOF the psychological reports to the courts were a bone of contention.

    The courts held that the report was paid for by the administration for the benefit of the court. While it was available to officers of the court, which included your solicitor, your individual participation entitled you to know what was in the report but not to a copy of the report.

    While the report was available to those engaging by self representation at the decretion of the court, it was not available to those being assisted by UOF.

    The means at our disposal to balance the equation, was to equip our father with photography equipment, as the general procedure was to place the edited file, who knows what was redacted, in a room, to read by himself.

    While the reader was meant to be actively supervised, what we found was that if one of us went with the father, there was a presumption of appropriate behaviour.

    Whether anyone worked out what we did, who knows, but that is not the point, rather that the use of and affect of the contents cannot be determined, without knowing the contents.

    A disadvantage we covertly overcame, but in absence of a remedy, leaves today’s investigation, facing the same problem.

  8. hornet says:

    7 and 8 , thanks down under, I attended these free counselling sessions and what I found was the Councillor was NOT INTERESTED in the CAUSE of the CONFLICT and had no desire to help RESOLVE CONFLICT at all.
    We walked away dismayed by the total waste of time this was.

    My wife and I attended jointly, we were concerned with alienation by the mother, this was the CAUSE of the CONFLICT – the Independent Psychologist supported our concerns in her INDEPENDENT report to the FAMILY COURTS who requested it – so the psychologist was performing an independent report for the Family court on both parents and the child. The Psychological report identified the harm to the child.

    I have evidence that it was the LAWYER FOR CHILD who then deliberately withheld this evidence – he did not want the courts to hear evidence of the mothers mental health concerns, where the Psychologist had direct concerns for the mothers mental health, and the severe harm this was causing the child by way of parental Alienation.

    So the lawyer for child, LIED, withheld this evidence, perverted the course of justice and refused to protect his client – my daughter from harm – harm that he was directly made aware of.

    I asked the police to prosecute this lawyer for perverting the course of justice, and they refused. The evidence is all there.

    You are correct, this is why they are so secretive, the Psychological report which the family court had in front of them detailed the harm the child was being subjected to, and they DID NOTHING to protect the child as they are required to do by LAW.

  9. Downunder says:

    #9 did the police officer you spoke to point out that they would not prosecute an officer of the court – remember that this is a civil court.

    The ethos of the court, even though this wasn’t written in Piglet Mahoney’s report to parliament, was to not find fault with the mother but supply the court with a remedy, which generally found fault with the father, but did not supply a remedy for him.

    If this process wasn’t obvious in the psychological report, the management of that process as you describe, transferred to the council for child.

    Nothing unusual about this in the courts chain of command, and their intended outcome.

    Some of us weren’t so stupid (or are not) but the worst case of misplaced trust in fellow academics that we came across, cost the father $500,000 in legal fees, and that didn’t even get him access.

  10. Evan Myers says:

    If there’s a single thing that grates my back teeth in this submission it’s the use of Disposable Male.

    This analogy is historically based in the concepts of war and progress.

    In peace we have a case of justified casualties. Yes, we all want to drive on our roads, but there will be deaths.

    This is not a case of justified casualties of peace. It is disposed of males.

    Disposed of because they can be replaced.

    Disposed of because we do not account for their death as we normally would.

    Disposed of, because it suits the desires of others.

    In military theory there is a case for the justification of casualties, but there is not a case or justification for the disposed of male in peace.

    Except in the preservation of Feminism.

  11. Downunder says:

    @11 we were discussing transfer of purpose in the recent post Finding my Child – resulting in the alienated child, but does the transfer of purpose in the broader sense, result in the alienation of men, and in the death of the father.

  12. hornet says:

    10. Civil court or not, perverting the course of justice by withholding evidence and lying is still an offence.
    Alienation leads to extreme distress on fathers, as they have to sit and watch their kids being deliberately harmed – by the very system we go to for help seeking help and asking that they are protected. Thats twisted.
    A fathers role is to protect his children, but what happens when fathers are prevented from protecting them, enticed into conflict, provoked to violence and then as you rightly detail are flushed of all their wealth and assets trying to do the right thing.

  13. voices back from the bush says:

    Murray @6,
    Yes John Tully shot 3 WINZ workers that day in 2014. He Killed Two.
    I remember it all well as I was in Ashvegas that day.
    Three days later the Christchurch a regional manager involved with Tully’s case committed suicide in Christchurch.
    Perhaps she felt responsible in some way, Perhaps she was feeling despair herself for the way the system was incapable of protecting staff who were no doubt her friends.
    Other staff were extremely traumatised also.
    Inter-agency communications were woeful.
    There were so many homeless that year, all men according to the chch herald studies.
    There was no shortage of houses in fact there were many entire suburbs with almost adequate homes laying redzoned. Men found to be squatting in these homes were given non association orders against eachother which meant many couldn’t access food & clothing assistance from caravans and city mission and st vinnies as if they were found near the others they’d be arrested. I met several men who had been imprisoned for no other crime than trying to find a place to sleep.
    But in Tullys case, he’d had a reasonably normal life, returned to NZ after working overseas and struggled to settle. He expected our welfare state would provide for his needs, obviously he’d been gone for some time. For a time he lived in his car under a bridge, when he couldn’t afford upkeep on the car he tried to draw attention to his plight by camping in a park, The Asburton domain which is more or less Ashburton’s botanical gardens, there were many complaints from nearby residents, winz had offered him some basic shelter, probably in a mission, he stayed in one for 4 nights at one point. But he expected that he would be provided a house -just for him.

    The whole region in general was suffering greatly following Christchurch earthquakes.

    There was so much stress, homelessness and despair that social services weren’t coping and many were without help which lead to hopelessness.

    Tully also believed he had a rare skin condition that he was dying from.
    He had written to several politicians with complaints.

    After three weeks in this freezing cold park which is directly below Mt Hut, and not getting the help he believed was his right he got a gun from the home of a farmer he knew.
    He got 27 years minimum.
    So we will be paying all Tullys expenses for at least another 24 years yet.

    From that day Winz, Ird, cyfs, etc all have permanent security which many find intimidating.
    Apparently since the security has been installed staff feel more in danger than before and the incidences of irate customers has increased.

    The government decided this was the best way to solve the issue.

    http://www.stuff.co.nz/national/10541197/Devoted-Winz-worker-found-dead

  14. MurrayBacon says:

    Dear voices,
    thanks for the careful background. I try to keep an eye on suicides, women’s as well as men’s. m.

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