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 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, soon after Yellow Ribbon, they 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”
As a result, Yellow Ribbon had to look elsewhere for funding. When it went for funds to ‘Fight for Life”, a charity boxing contest which featured “celebrity” matches, 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 in the world. 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.” (Injury Prevention Research Centre)
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 of Health (MOH) 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 Yellow Ribbon as “dangerous”. Yellow Ribbon had its own evaluation of the MOH funded 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 was under attack by Government agencies. I would add that it was “unscientific” to misuse the survey of ambassadors based on a small sample, which had an overwhelming endorsement of Yellow Ribbon by its ambassadors, as cause for “potential harm”, namely suicides that may result 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 leading 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 would have been 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 1997 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 are social factors. 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 Orthodoxy
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 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 showed 2868 hospitalized for attempted suicide. According to the Canterbury Suicide Research Project, 1 in 6 think about suicide, 1 in 10 seriously, and nearly 1 in 30 attempt suicide. Many who try but fail will try again and some will succeed. Most youth suicides occur after school age but we don’t know how many of these tried while at school. On such a critical question there is a black hole of official ignorance. So there is no way of knowing whether or not a successful suicide prevention program in the schools would have reduced the risk of youth suicide later.
Suicide trends in New Zealand show a distinct increase in suicide rates from the late 80s to late 90s corresponding with the period of economic restructuring and social destruction that came with it. The Maori suicide rate went up fastest showing a strong correlation with SES or social class. Despite an increasing death rate, suicide prevention policy over the period of the Fourth Labour Government and National Government was notably missing in action. The country was still in a state of denial of mental health problems, let alone suicide, which challenge the standard label of individual ‘failure’ to question the ‘failure’ of society itself.
The public policy response to suicide was wholly inadequate:
“The Ministry of Youth Affairs was given $2 million in 1998 to take a lead role in youth suicide prevention. They produced a national strategy, commissioned some resources including the SPINZ comic and a guideline for General Practitioners put together by the Mental Health Foundation. That money ran out by mid-2001.”
In 2000 the newly elected Labour government campaigned on a promise to make good the “social deficit” left from the 1980s and 1990s. “Closing the gaps” for Maori was short lived when met by a racist reflux, but suicide was seriously addressed. Jim Anderton, himself a father who lost a daughter to suicide in 1993, was made Minister in charge of its new policy. Anderton put a lot of thought and energy into suicide prevention policy. He was committed to what he frequently stated was an “evidence based” approach to suicide prevention. In this he relied upon a small group of senior researchers with established research and publishing records in this field.
This body of research is not large in New Zealand, but what it lacks in this country is made up for by referring to a bigger body of literature overseas, particularly in the USA. From this literature a very clear message has emerged that is repeated constantly in a suitably bland and neutral language of the research establishment that carries the weight of official authority. That message is that suicide is a multifaceted, complex illness that is treatable by the health professionals, and that the public at large, and in particular activists who enter into this complex field, are amateurs, risk prone, and should stay out.
Most of the US evidence happens to be in the field of evaluating suicide prevention programs. The reason for this is that suicide prevention in the United States is largely in the private sector, as is the Health system in general. Funding is based on measures which purportedly show that prevention programs work. Of those who compete for funds, almost all are “education” oriented, or at the end of emergency phone lines or referral chains. The evaluations are rather trivial, usually amounting to questionnaires filled in by those who have had some ‘education’ about the causes of suicide and its symptoms. If the respondents say they are better informed or prepared to deal with identifying those at risk, this is evidence of efficacy.
There is no attempt to match these programs with any independent evidence of subsequent suicide attempts, or successful interventions to prevent suicides. In other words there is no evidence that such publicly funded private programs change the rates at which young people “harm” themselves. For example, the best research available of the evaluation of the SOS program in the US was done by Aseltine and de Martino. While the 1000s of subjects were school aged youth, who verbally reported a decline in suicide attempts, no attempt was made to track them to see what effect these programs had on suicide rates, compared with a control group of their peers.
Against these programs, the Yellow Ribbon and other youth-based peer group programs of suicide prevention are generally not publicly funded and have not been subject to any proper evaluation. The “common sense” evidence used by Yellow Ribbon is that of the success of self-referral or referral by ambassadors arising out of the face to face “It’s OK to ask for help” card. Prevention in these methods can only be evaluated by asking the ambassadors/peer counselors to report on their direct experience, and to ask those who have asked for help if their suicidal thinking or actions have been reduced as a result?
The New Zealand survey of Yellow Ribbon ambassadors found that most thought that the more serious problems reported to them were resolved by discussion among peers or by referral to adults (family or school counselors). But there was no specific questions designed to elicit reports of success or failure in preventing suicides. This was precisely the ‘black hole’ of official ignorance surrounding suicide prevention that the Yellow Ribbon evaluation project would have filled. This ‘black hole’ is no more evident that in the debate on “copycatting” already briefly referred to above.
Talking about “copycatting”
As we have seen it is almost an article of faith of the “evidence based” official line that talking about suicide, raising its profile, raising awareness, can cause suicide. The supposed causal mechanism is that awareness of suicide may make it an option that young people will act on. This claim reaches alarmist proportions on the issue of “copycatting”. This happens when the death of a friend or celebrity prompts others to kill themselves, often using the same method. There is plenty of evidence of friends or family of a suicide victim, also committing suicide. The loss of a friend or close family member is a known trigger of depression which is the major direct cause of suicide.
However, it doesn’t follow from what is known about copycatting that silence is the answer. If the copy cat identifies with the victim, they do so because that relationship is more important than those with other people. It is their social isolation and the stigma and the silence surrounding suicide that creates the conditions for copycatting not the “awareness” of suicide as such. Besides in the age of the internet it is impossible to keep the “cat in the bag”.
First, official silence such as banning the use of the world ‘suicide’ in death notices does not stop those close to the victim from knowledge of the manner of death. The campaign by the Dominion Post to break the media guidelines on reporting suicides argues correctly that ignorance not knowledge is the killer. While the paper continues to editorialise on this issue, it has taken its earlier articles offline.
The debate around the film “The Bridge” that filmed people jumping off the Golden Gate Bridge raises similar issues. The film maker argued that far from encouraging copycatting, watching the film acted to inform and motivate people to become aware of the causes of suicide. The UK Samaritans after taking a position against the film now sells DVD copies of the film as an aid in suicide prevention.
When families of suicide victims call for public discussion, clearly they see action on suicide prevention also as a means coping with the suicide. This is just as true of the close friends of those who die. Many of those who lose close friends or relatives to suicide are highly motivated to prevent it happening to others. This motivation on the part of the survivors of suicide helps explain the drive and energy of those who set up peer support groups like Yellow Ribbon, lifelines and mentoring. It explains that almost all of the positive evidence reported by young people that their lives have been saved results from such direct interventions. Not only that, the existence of peer support groups actively alters the youth culture towards solidarity with those in need, and can counter the more competitive, bullying culture found in varying degrees in every school.
Second, the power of the internet to communicate knowledge of suicides cannot be stopped other than by draconian bans on freedom of expression. Young peoples suicides are emblazoned all over the social sites like Facebook and Bebo and their friends, acquaintances and complete strangers, express their grief by talking about missing them, wanting to see them again, or meet them, again or soon. We have to assume therefore, that there is no point trying to maintain the code of silence in the face of the power of modern communications.
Moreover, far from being a cause, it seems that communication is an active preventative. The evidence that celebrity suicides cause rashes of copycatting seems only to apply when the deaths are “celebrated” or romanticized. But where the internet is used to expose the tragic futility of suicide it can work to prevent copycatting. An Australian study showed no increased incidence of suicide after the death of Kurt Cobain by gunshot. This study suggests that the “celebrity” effect of the suicide was cancelled out by the rejection of Cobain’s suicide by his girlfriend, Courtney Love, another “celebrity”. A US study found an increased number of calls for help – labelled the “Cobain effect”.
The logic of this is that full on, unrestricted peer to peer discussion and awareness of suicide can be the most powerful deterrent to “copycatting” and active suicide prevention. Instead of “shutting up” to silence awareness, “shouting” on the internet about suicide, and talking freely wherever young people met socially about its causes, is potentially much more effective in stopping suicides.
How do we know what causes suicides?
To summarize the “best practice” based on evidence: the suicide prevention orthodoxy, drawing heavily from publicly funded private suicide prevention programs overseas cannot show any “evidence based” efficacy in reducing the suicide rate in young people since 1997. The main drivers of suicide are social and economic factors such as low income. There are absolutely no grounds for claiming that the orthodox opposition to suicide awareness is capable of reducing the suicide rate independently of changes in the economic conditions, or changes of government policy. In New Zealand the single most important correlation of the rise in the suicide rate between 1987 and 1997 and its decline between 1997 and 2005 was income inequality. While the suicide rate has been trending down since 1997, the country has entered a new recession and is likely to face a rise in the rate of suicides that typified the period of the late 80s and 90s.
Similar concerns are expressed by Professor Graham Martin, who says there is no real evidence that the Australian LiFE (Living is For Everyone) program that began in 1995 contributed to the 25% decline in suicide in the 15-24 age group by 2005. He speculates that like wars, which reduce suicides, suicide bombings over this period might be a cause. In the light of lack of evidence that official suicide prevention works in New Zealand and Australia, I would say that the actual “evidence base” supports a suicide prevention strategy in a period of recession, of providing secure, well paid jobs for all, and a supportive social environment.
However, a more narrow focus is evident in the NZYSPS review of the evidence of suicide prevention strategies. Beautrais et al claim:
“A national suicide prevention strategy for New Zealand was developed in 2006… The available evidence thus far suggests that the most promising interventions likely to be effective in reducing suicidal behaviors are medical practitioner and gatekeeper education, and restriction of access to lethal means of suicide. This evidence also suggests a clear agenda for research…”.
This is an extremely narrow agenda. Of course we need better ways of gatekeepers and general practitioners identifying and treating young people at risk. But this assumes that those at risk will visit their doctors or come to the attention of a ‘gatekeeper’. The “evidence” on general practitioners is drawn from overseas studies and is based on older people who visit their doctors. The evidence on the effectiveness of training gatekeepers is drawn from a study of the US Air Force where young people are under military discipline! In New Zealand family doctors and gatekeepers are known to have contact with young patients who go on to commit suicide. The same could be said for the wider Mental Health system since many suicides occur under its care or supervision.
Of course these health professionals need to improve their performance in suicide prevention. Yet they can do this only if young people come to them first. This is the missing link! The official orthodoxy opposes the pro-active building of suicide “awareness” through Yellow Ribbon-type programs to empower peer group interventions to identify youth at risk and refer them to health professionals. This leaves the initiative with the suicidal young person who may be incapable of making that leap over the wall of silence. It ignores the powerful networks of youth friendships and support that can provide this missing link.
Recognising such solidarity networks exist and can be a force in suicide prevention, fills in the ‘black hole’ of individual isolation. Fielding High School has recently formed a “Yellow Tie” suicide prevention group to take up the work formerly done by Yellow Ribbon. Senior students are trained and supported by the school counselor, but actively promote lunch-time group meetings where students can bring up their problems. Similarly, some schools hold assemblies where the suicide of a student is spoken about frankly and faced collectively.
On the contrary, the official reliance on overseas research that has little relevance to young people in New Zealand establishes a false “evidence base” as a sort of “Catch 22” against which youth centered developments to suicide prevention can be discounted. The “no harm” rule expects youth provider approaches to prove they do no “harm”. But to prove this they cannot use anecdotal evidence to show that talking about suicide, and suicide prevention education, not only does no “harm”, but on the contrary by harnessing the goodwill and concern of young people, many of whom have lost members of family or close friends, is successful in reporting those at risk, befriending them, and in response getting flooded with testimonies of those who survive or are ‘rescued’.
Among the few evaluations of Yellow Ribbon type programs, a Canadian study based on interviews with students showed slight but positive gains in students’ willingness to seek help. In the US a more robust evaluation of the SOS program found a significant reduction in reported suicide attempts.
Given some ‘evidence’ of significant gains in suicide prevention from suicide “awareness” programs, why not do the research in NZ to see if there is a positive relationship between “awareness” and suicide prevention? The only research actually done on Yellow Ribbon in New Zealand questioned the ambassadors on their role but did not raise the need to evaluate changes in reported self-harm. In the absence of such crucial evidence then, why discount the anecdotal evidence of the success of Yellow Ribbon as reported by those directly involved as ‘invalid’ or ‘unreliable’? In this context when young people report to Yellow Ribbon ambassadors that “asking for help” did save them, why should we question the validity of such statements unless we don’t trust youth to know their own minds?
Here we see the catch 22 in operation. The evidence based on United States medical practitioners and gatekeepers does not relate to youth while the direct evidence of the statements of young people about intervening to stop suicides is ‘unscientific’.
Here we have a Foucaultian problem: perhaps the issue of “evidence” is masking something deeper, such as a relationship between those with power and those without power. Is the “scientific method” that poses as objective and neutral, actually the result of historical practices of those with power use to keep others powerless? Perhaps it is a matter of preserving the power and authority of the bureaucracy which hides behind a veil of ‘political correctness’. Perhaps it goes deeper still and is an attack on youth empowerment in which “science” is used to legitimate the power to judge “harm”? And as Foucault argues, such power relations are always contested.
Yellow Ribbon did not go away. It did not agree that it was “harmful”. It was convinced that young people could fight suicide by empowering themselves. It cooperated in adopting “best practice” and compromised to meet official objections to its program. It proposed its own comprehensive evaluation program. It abandoned the Fight for Life and lost the $400,000 it needed to function. It responded to criticisms of exposing its ambassadors to risk and agreed to more training and mandatory referrals to health professionals. It even stopped talking about suicide in its publications. This was not enough for the officials. Rather than work cooperatively with it Yellow Ribbon was hounded out of existence. But in the process, the official position proved that it was not a failure to adopt “best practice” that was the problem but the very existence of a successful competitor.
The professionals vs the amateurs
The competition between the professionals and amateurs began with the formation of the Youth Suicide Prevention Trust in 1997. Yellow Ribbon quickly became the pace setter in youth suicide prevention. It was ably promoted and managed and was rapidly adopted in a growing number of schools. By 2003 there were 140 schools and over 1400 ambassadors working with youth at risk. What is more they were using celebrities to flaunt the Yellow Ribbon “brand” of “talking about suicide”.
‘Health Central’ was alarmed. The amateurs were threatening to take over the profession. The Ministry of Youth Affairs set up the New Zealand Youth Suicide Prevention Strategy in 1998. Suicide Prevention Information NZ (SPINZ) was formed shortly after in 1999 with the main purpose of “providing accurate, up-to-date information on youth suicide prevention”.
I can only speculate that Jim Anderton who had suffered a tragic loss of a daughter to suicide must have found this public “celebration” of suicide prevention repugnant. Official hostility to the Yellow Ribbon leadership style and what was perceived as putting youth at risk now became Anderton’s cause.
Government funding had always been insufficient so the Yellow Ribbon founders used their advertising expertise to raise money on the Yellow Ribbon “brand” successfully. This must have put YR in the “more market” ideological camp for Anderton, and potentially out of control of the state. Moreover the “market” was very “downmarket”. Yellow Ribbon was forced to raise funds from less salubrious sources such as gambling and most controversially the ‘Fight for Life’ boxing charity. The sourcing of their funds in gambling and boxing gave the bureaucracy the ammunition they needed to cut off Yellow Ribbon funds. They said boxing was a form of organized bullying which was a known cause of suicide. How inappropriate to use it as a source of funds in suicide prevention. Not only that, Dean Lonergan who ran the “Fight for Life” was accused of taking an excessive share of the proceeds of the event and Marco Marinkovich was forced to try to justify this making Yellow Ribbon look like it was part of some rorting of the public.
If that was not enough, Government published policy documents on suicide prevention where the risks associated with Yellow Ribbon’s frontline youth on youth contact were criticized. It was claimed that making ambassadors responsible for making the initial contact without sufficient professional backup put them at risk of harm. Three Government Departments put out a policy edict to schools to disassociate themselves with Yellow Ribbon type programs. Attempts at compromise were made and some health professionals in the field sympathetic to Yellow Ribbon attempted to get it to back off the “risky” frontline peer group contact and confine itself to an educational role in suicide prevention and support provider for survivors of suicide. But this was in effect destroying the “value” of the “brand” whichvwas its upfront “talk about it” approach. The coup de grace came when Marco Marinkovich was pressured into backing out of Fight for Life leaving Yellow Ribbon with insufficient funds to keep operating.
Health Central had won, and their monopoly of suicide prevention incorporated into an integrated health “whole school” curriculum rather than a specific campaign on suicide, pushed aside that of YR as too risky, and potentially itself a cause of suicide. But as I have argued the issue was not really about the risks associated with Yellow Ribbon since these remained unproven. The official orthodoxy based on what was an already discredited US approach to suicide prevention was the official position backed by Anderton and the Labour Government. Moreover, the anecdotal evidence of many thousands of endorsements from young people who claim that Yellow Ribbon “saved their lives” on numerous websites in the US and elsewhere, was never acknowledged let alone proven to be invalid or unreliable.
This leaves us with only one conclusion at this point, which is, that if Health Central could not prove Yellow Ribbon to be a risky approach to suicide prevention, and didn’t want to support the Evans/Dawson research proposal to evaluate that risk, what was really at stake was its control of suicide prevention and its defence of that monopoly of control against a potentially successful non-state, more-market, advertising-led rival.
Yellow Ribbon challenges the health bureaucracy
As a sociologist I have some knowledge of theories of the bureaucracy. Max Weber, perhaps the all-time popular champion sociologist, developed a sophisticated theory of the bureaucracy. For him its originates as a means of administering society as it becomes more complex or “rational” and the industrial division of labor specifies a number of areas in which training in specialized knowledge is necessary. The state bureaucracy therefore develops to administer the increasingly complicated areas of social service provision including health. The body of knowledge becomes a source of authority i.e. authoritative knowledge that is unquestioned.
Weber went on to question the legitimacy of such authoritative knowledge because he feared that it took on a life of its own (his fear was that a socialist state would usurp all individual freedom in the market and use the state to impose a totalitarian regime) and hence threatened the very rationality it was supposed to serve in market capitalist society. Without agreeing with all of Weber’s fears about the bureaucracy, he was correct to point to its potential to usurp the rights of individual citizens in advancing and protecting its special powers and privileges. In this sense is the bureaucracy the basis of the Foucaultian ‘power relation’?
Thus the health bureaucracy protects its monopoly of knowledge as the source of its power and prestige. This knowledge or expertise in the field must be protected from any devaluation by non-knowledge. The bureaucrats’ expertise parallels that of the professions as a scarce commodity which commands a high monetary market value. This knowledge is rational because it causes efficient outcomes. It is not funded unless it can demonstrate this rationality.
In this case the outcome is the prevention of suicides. Any challenge to this monopoly by outsiders is resisted because it undermines the authority of the received wisdom about [mental] health, and challenges the assumption of rationality of outcomes. Similarly, health professionals, like bureaucrats, collectively defend their authoritative knowledge by forming professional bodies to protect their standards. Health is a field of knowledge that requires professional practitioners who have undergone a lengthy period of advanced training and practice. The body of knowledge is therefore the “property” of the professionals and any attempt to substitute some other knowledge, devalues that knowledge and the privileges of rank and status of the health profession.
What Yellow Ribbon did was to threaten these founding assumptions of the health bureaucracy. First, how could complete amateurs outside the field of advertising, and whose only claim to expertise was to suffer the loss of a loved one from suicide, pretend to know anything about suicide prevention? In fact the professionals view the loved ones of suicides as a suicide “risk”, that is, more at risk of suicide than capable of preventing it in others.
Second, such dangerous ignorance was compounded by putting the very people that Yellow Ribbon wanted to help at more risk of suicide by empowering them to talk about suicide openly, and in an informed way. No wonder the officials never commenting on the endorsements of thousands of young people in several countries commending YR for saving their lives. That is after all only “anecdotal” evidence. Yet proponents of the official orthodoxy can claim that Yellow Ribbon was risky because one of the Ambassadors killed herself. There is a double standard in the selective use of anecdotal evidence. Those who die are assumed to be the victims of Yellow Ribbon, but those who survive cannot be allowed to credit it with saving their lives?
The patronising attitude towards youth is evident. The vital role of youth in identifying their peers at risk is rejected as too risky. Yet this is the missing link that is needed to get those at risk “talking”. Young people do not trust adult authority unless it has earned their trust. You cannot impose gatekeepers and health professionals, especially when they are underfunded and unprofessional in their actions.
About the same time Yellow Ribbon closed down, a University of Auckland study was published that actually asked young people what they thought caused suicides. The “most commonly cited causes of suicide were: pressure to conform and perform, financial worries, child abuse and neglect, and problems with alcohol or drugs. (Only 1% cited mental illness.) Dr John Read, senior lecturer in psychology at Auckland University and one of the authors of the study, said: “Explaining suicide in terms of ‘depressive disorders’ medicalises what is a social problem, and begs the question of why so many people are depressed these days. The increase in the percentage of New Zealanders taking psychiatric drugs is a cause for concern not celebration (except for drug companies).” Dr Read explains that international studies indicate that mental health problems are caused by social rather than biological factors. The study recommends solutions that include “crisis support services located in schools and youth centres, more youth activities, educational programmes to assist young people to discuss feelings and to bolster self-esteem, and financial aid. Neither increasing mental health services, nor reducing media coverage of suicides, were considered solutions.”
But is the bureaucracy’s defence of its power and privilege sufficient to explain the euthanasia of Yellow Ribbon? I don’t think so. Unlike Weber I don’t think that the bureaucracy’s power and privilege is the end of the story. I think that modern capitalist society needs a strong centralized state with a powerful bureaucracy for a more important purpose and that is to regulate and reproduce each youthful generation as fully functioning, compliant citizens of capitalist society. The power of the bureaucracy is designed to disempower youth. Or to put it more correctly, since youth are already disempowered, the bureaucracy functions to prevent youth from empowering themselves. And what can be more critical for youth than the power over their lives.
Foucault or Marx: Dis-empowering Youth
For Foucault capitalism is about power relations. Those who have power have to constantly fight to keep it against those who contest it. There is always a spontaneous rebellion among youth against the normal institutions of family, school and the state as authorities regulating or disciplining their bodies and their lives. Capitalists live in fear of youth rebellion that gets out of control and have devised ways and means of preventing that by regulating and disciplining their lives. As the disparities of wealth and power become more evident the fear of youth rebellion is even more pronounced. Why? Because youth openly question social institutions especially those that create and reproduce alienation, powerlessness and despair in the face of social and environmental crises of life threatening proportions.
While ostensibly concerned with the wellbeing of individuals, the function of the state serves to regulate and reproduce individuals’ “well-being” as defined by the social relations of capitalist society seen as power relations. A critical function is that of defining and “treating” the “mental health” of individuals to minimize harm to the self and to the wider society in terms of economic costs. Funding mental health provision is therefore a contested field where the social and economic costs are weighted up against the social and economic benefits. The optimum outcome is the reproduction of individuals with a level of mental functioning that enables them to fulfill their expected social roles as members of families and as workers or self-employed in the economy.
Efficiency is therefore a function of an economic cost/benefit analysis. This usually means referral from a general practitioner to a mental health profession where symptoms of mental illness are “treated” and the patient “managed” if not “cured”. The knowledge required to fulfill this objective becomes a bureaucratic code of practice which amounts to the power to control the lives of patients and shape their behavior. A major aspect of this is the prescribing of unsuitable anti-depressants to young people.
Resistance to state surveillance, regulation and control poses a risk to the system of a breakdown in its reproduction. Behavior resistant to treatment and patients who are recalcitrant threaten the functioning of mental health treatment. Patients or their caregivers who reject the system or seek alternative treatments threaten the bureaucratic monopoly of the state to regulate individuals. The cost of controlling recalcitrant patients may be such that patients are left to deal with their problems in unsatisfactory circumstances. In Mental Health, and suicide in particular, underfunding and inadequate care are chronic reflecting the low social priority assigned to individuals who are expensive to rehabilitate and unlikely to be economically cost-effective in employment.
But the cost of Yellow Ribbon cannot explain its demise. The young people taking responsibility for talking to their peers at risk are volunteers and not themselves a cost. Society normally welcomes volunteer unpaid labour as a subsidy to its reproductive costs. Therefore, it was young people acting independently of the state structure that posed a threat to the state. Why is it necessary for capitalism to disempower youth and to prevent their empowering? What purpose does the subordination of youth as passive subjects serve?
I think that the answer to this takes us to the fundamental question of the alienation of the individual within capitalist society. When it comes down to it, the officials are not just protecting their authority and denying any power to youth, they are preventing the empowerment of youth to challenge alienation and the hegemony of the exploitative social relations of capitalism. Young people in taking control of their personal lives and confronting suicide directly are also in “at risk” of also taking control of their working lives and confronting the ultimate cause of suicide, alienation itself.
Developing the Foucauldian approach then, the bureaucracy is in the final analysis a means of state control of social disorder, of surveillance, and of the reproduction of social relations that ensure the continuity of capitalism. For Foucault, capitalism exists on the basis of maintaining the wealth and power of the ruling elite. This fact in itself is transparent because of obvious gaps in wealth and power.
Yet this approach to power does not recognize an even more fundamental source of power in capitalist society based on the ownership and control of private property. Hence the reproduction power relations serves the reproduction of a deeper set of social relations, that of capital and labor whereby capital alienates the value produced by labor as its own private property. Empowering youth to deal with matters of life and death not only threatens capitalist power relations but beyond that the reproduction of alienated social relations.
Alienation as a cause of Suicide
I am suggesting that the most important cause of suicide, and the depression and mental disorder that is usually associated with it, is social alienation. This is in effect a powerlessness or lack of control over one’s life. Alienation is usually talked of in a sense of absence of social relationships, more in the sense of Anomie as in Durkheim’s discussion of suicide. A discussion of youth and alienation and anomie in Australia talks of similar concerns to get the social stressors on youth recognized and acted in the face of the “medicalisation” of youth depression:
“In a recent article, Sharon Wright, a highly respected senior mental health nurse in charge of Out of the Blues, an innovative unit at the Flinders Medical Centre in South Australia which is dedicated to working with young people suffering from acute depression and suicide ideation, said the ‘age of individualism’ stops young people reaching out for help.”
Thus what is recognized as “individualism” is really a marker for something bigger called ‘alienation’ or ‘anomie’ at the societal level. US sociologist Thomas Scheff proposes “alienation”, the product of “individualism”, as a cause of depression:
“If it turns out to be true that alienation is an immediate cause of depression, how could virtually all of the earlier studies have missed the cues? One possibility is that the human sciences are just as rooted in the institution of individualism as the lay public. Elias pointed toward this institution as “the myth of homo clausus” (the self-contained individual). In Western societies, social relationships are all but invisible because our perceptions are dominated by the concept of individuality.”
For Scheff alienation results from individualism: “I take alienation to mean lack of connectedness (intersubjectivity), that is, failure to understand, and be understood by, the other, and failure to accept that which is understood about the other.”
But this begs the big question what causes the “institution” of individualism? Thus Scheff draws on Elias rather than Marx in his theory of alienation. Elias in turn was influenced by Durkheim, so that the process of ‘individuation’ or isolation is seen as shift away from community with the development of modern industrial society.
Overcoming the causes of such individualism therefore means a return to a form of moral community. This is an important practical question because we need to know how to build such a ‘community’ if we want to prevent alienation, depression and suicide. But we need to get to the root of the cause otherwise our practical efforts will be limited to treating the symptom only.
The Marxist tradition within sociology explains ‘individualism’ as the product of the rise of capitalism. It is not the cause of alienation but its effect. It arises with the market where commodities are bought and sold. Initially, producers buy and sell their own commodities. However traders emerge and grow wealthy so that they can employ others to produce for them. A capitalist class emerges when it is able to dispossess the producers of their land and means of subsistence. They then have no choice but to sell their labor-power as a commodity and the surplus-value produced is expropriated as the private property of the owner. Marx calls this the “commodity fetishism” as the value produced by labor now appears as the inherent property of the commodity itself.
Marx explains this process as the alienation of one’s labor (which now appears as the value in the commodities produced and owned by the employers). This in turn causes an alienation from one’s “natural” self [i.e. separation from nature] as one no longer controls one’s capacity to labor or directly benefit from its product. Alienation from others follows as we relate to one another as individual buyers and sellers of commodities and not as part of a productive collective. Finally, one is alienated from society because society is now constituted of alienated “individuals” whose only value is in the value of the commodities one can buy or sell (Marx, 327-334).
The “individual” that appears in daily life is the product of an historical process of alienation in capitalist class society. The symptoms of the “individual” prone to suicide are the result of a powerlessness, a lack a sense of self worth and of hope to change the situation one is trapped in, tall of which are causally rooted in the social structure. This helps explain the one empirical finding that is unchallenged, the relationship between suicide and low income which is compounded by social isolation. This is not to suggest that genetic or chemical changes in the brain are not part of the causation, but rather that they are contributing factors, sometimes predisposing factors activated by social stress, and acting as feedback factors, which interact to make the social trap more difficult to escape.
Therefore logically, of course it is necessary to support all methods that improve identifying those at risk of suicide and helping them to prevent their suicide, which includes GP diagnosis, drug therapy, counseling, etc. Yet the evidence shows that does not get at the roots of the problem. The most effective prevention of suicide is to empower young people to understand and act collectively to eliminate the most important causes that are pushing them towards suicide.
This means in the first place demanding the right to work and a living income as a means of survival, and in the second place understanding alienation as the root cause of alienation in creating powerless individuals. The way out of this trap is then to act collectively to progressively challenge the power relations and the underlying social relations of capitalism themselves. For young people the main institutions that reproduce them as powerless workers are the family, education and the workplace itself. In each of these institutions young people must organise collectively around a program for youth empowerment.
The Yellow Ribbon program and other youth based methods of suicide prevention reveal the willingness and enthusiasm of young people to fight suicide themselves. Not only does this fill in the black hole into which many young people disappear, it builds a culture of youth empowerment to combat the competitive individualism and bullying that is a major cause of youth suicide. It also builds the friendship networks that survive school and act as supports to young people in the workforce. Before it was killed off Yellow Ribbon responded to research that exposed weaknesses in its operation and was prepared to work on improving referrals of those at risk and the safety of the ambassadors. It had planned a comprehensive research project to evaluate its approach to suicide prevention.
This is the “least harm” approach that needs to be re-activated so that young people are encouraged to talk to their peers. But this approach should be widely extended into a public campaign to “breaking the tyranny the silence”, not only to “talk”, but to “shout”, to raise “awareness” and to rally youth in their own groups and organizations to actively campaign against suicide.
Conclusion: Empowering Youth to Fight for Life
The bureaucracy uses its power to monopolize knowledge and prevent any challenge to capitalist hegemony. The biggest challenge is young people who may revolt against what they see as the worst features of capitalism. Knowledge is power. One critical form of knowledge is the cause of suicide and the high rate of youth suicides. But to question and challenge capitalism means not only knowledge, but communicating and organizing, that is, talking about and acting on your beliefs. Talking about suicide at school face to face or texting on mobiles as now a manifestation of power many times more potent than the whole official code of silence backed by prohibitive laws an the sanctions of state authority. Texting to organise demonstrations and strikes is testimony to instant communication as a means of empowering young people. This not a virtual power or virtual reality; real mobilizations on real streets against real state and corporate authorities are the ends of such means of communications.
When mobiles merge with the internet an even more potent force will confront the power trip of the state and the bureaucracy. Every suicide is accompanied by a wave of shock, guilt, sadness and love. These are powerful emotions that must not be straightjacketed by the officials or grieving family and friends. Moreover, the internet while dependent upon private supply of hardware and telecoms, is an important source of income for the private sector. There is no way that the owners of the big social sites like Facebook, Myspace or Bebo will cut off or censor free speech without also cutting off their big profits. Indymedia can have its servers seized but they pop up elsewhere. The power of young informed people will simply divert around such puerile barriers and spread into new areas of communication.
We can see that on the many sites where people talk openly about suicide. The majority of responses are painful, confused and fatalistic – symptomatic of alienation. But there is also much expression of love, sympathy and hope for the future. While these sites are helping to talk about suicide they lack direction towards organized systematic prevention. We need not only suicide prevention groups on the internet but the mobilization of young people in schools, the workplaces and in the wider society to actively intervene in the causes of depression and suicidal behavior.
The Yellow Ribbon peer based approach has the potential of providing the missing link and filling the black hole in the official orthodoxy. Young people need young people to talk to and to support one another. It is a terrible indictment on our society that we do not act on the strongest evidence that we have, that young people talk to young people. An estimated 1 in 30 young people attempt suicide before they are 24, and many will try again as young adults. During these critical years most will talk to their peers. We have to seize that time spent in the schools to empower youth to fight for their lives. The silence has to be broken by talking, and to be heard, we all need to shout.