(The Guardian) The bold new fight to eradicate suicide
“We didn’t attach any particular significance to it,” said Steve of what he saw as merely a musical pause. “I think we just thought, ‘Well, the poor lad’s been at the piano for years and years. He’s so busy … ’ But these are the small things – the ripples in the fabric of normal life – that you don’t necessarily notice, but which, as I know now, can be very significant.”
Three months after Edward stopped playing, and just two weeks after he handed in an English essay that his teacher would later describe as among the best he had read, police knocked at the door of the family home in Meldreth, a village 10 miles south of Cambridge. Steve was at home, alone. “You become painfully aware that something appalling has happened,” he recalled. “You go through the description, they offer commiserations and a booklet, and then they leave. And that’s it. Suddenly you are staring into the most appalling abyss you can ever imagine.”
The next time Steve heard his son play the piano, the music filled Holy Trinity parish church, a mile from the station where Edward caught the train to school every morning, and where he died by suicide on 9 February 2015. Steve said 500 people came to the funeral. Friends had organised a soundsystem to play a performance by Edward that had been filmed on a mobile phone. “My son played the music at his own funeral,” he told me as he remembered that day over a mug of tea in a cafe in central London. “You couldn’t dream this stuff.”
I first talked to Steve in November, 21 months to the day since Edward’s death. He was 52. His hair was white; his blazer navy. He wore a white shirt and a remembrance poppy. He talked in perfect paragraphs and had a businesslike manner, but it was clear that the abyss was still falling away before him. He said it always would.
But life had also become a mission, and in the two years since his son’s death by suicide, Steve, a commercial property consultant, had turned into a tireless campaigner, a convenor of minds. He had earned the prime minister’s ear, and given evidence to health select committees. The study at his home was filled with files and research papers.
“As a father, I had one thing to do and I failed,” he said, his voice faltering for the first time. “My son was dying in front of me and I couldn’t see it, despite my education, despite my devotion as a father … So, you see, this is coming from an incredible sense of guilt. I suppose what I’m trying to do is save my boy in retrospect. I stood next to his coffin in the church. It was packed with people – a shattered community – and I made him a public promise. I said that I would investigate what had happened to him, and that I would seek reform for him, and on behalf of his generation. Quite simply, I’m just a guy honouring a promise to his son. And that’s probably the most powerful motivation that you could imagine, because I’m not about to let him down twice.”
Edward’s suicide was one of 6,188 recorded in the UK in 2015, an average of almost 17 a day, or two every three hours. In the UK, suicide is the leading cause of death among women under 35 and men under 50. The World Health Organisation estimates that 788,000 people died by suicide globally in 2015. Somewhere in the world, someone takes their life every 40 seconds. And despite advances in science and a growing political and popular focus on mental health, recorded suicides in the UK have declined only slightly over the past few decades, from 14.7 per 100,000 people 36 years ago, to 10.9 in 2015.
A simple belief drives Steve: that Edward’s death was preventable – at several stages during the rapid onset of his depression. Moreover, he and a growing number of mental health experts believe this applies to all suicides. They argue that with a well-funded, better-coordinated strategy that would reform attitudes and approaches in almost every sector of society – from schools and hospitals to police stations and the family home – it might be possible to prevent every suicide, or at least to aspire to do so.
They call it “Zero Suicide”, a bold ambition and slogan that emerged from a Detroit hospital more than a decade ago, and which is now being incorporated into several NHS trusts. Since our first meeting, Steve has himself embraced the idea, and in May of this year held talks with Mersey Care, one of the specialist mental health trusts already applying a zero strategy. His plans are at an early stage, but he is setting out to create a Zero Suicide foundation. He wants it to identify good practices across the 55 mental health trusts in England and create a new strategy to be applied everywhere.
The zero approach is a proactive strategy that aims to identify and care for all those who may be at risk of suicide, rather than reacting once patients have reached crisis point. It emphasises strong leadership, improved training, better patient-screening and the use of the latest data and research to make changes without fear or delay. It is a joined-up strategy that challenges old ideas about the inevitability of suicide, the stigma that surrounds it, and the idea that if a reduction target is achieved, the deaths on the way to it are somehow acceptable. “Even if you believe we are never going to eradicate suicide, we must strive towards that,” Steve said to me. “If zero isn’t the right target, then what is?”
Zero Suicide is not radical, incorporating as it does several existing prevention strategies. But that it should be seen as new and daringly ambitious reveals much about how slowly attitudes have changed. In the 1957 book The Uses of Literacy: Aspects of Working-Class Life, a semi-autobiographical examination of the cultural upheavals of the 1950s, Richard Hoggart recalled his upbringing in Leeds. “Every so often one heard that so-and-so had ‘done ’erself in’ … or ‘put ’er ’ead in the gas-oven’,” he wrote. “It did not happen monthly or even every season, and not all attempts succeeded; but it happened sufficiently often to be part of the pattern of life.” He wondered how “suicide could be accepted – pitifully but with little suggestion of blame – as part of the order of existence”.
Hoggart was writing about working-class communities in the north of England, but this sense of expectation defined broader societal attitudes to suicide, too. And at that time, suicide was a crime: in 1956, 613 people in England and Wales were prosecuted for attempting to “commit” suicide, 33 of whom were imprisoned. The law changed in 1961, but the stigma endured; the Samaritansand mental-health experts advise against the use of the term “commit” in relation to suicide, preferring “to die by suicide”, but “commit” still regularly appears in newspapers. The same voices have strongly opposed the view that suicide is “part of the pattern of life”, ultimately giving rise to the idea that its eradication – or at least a drastic reduction – might be possible.
Traditionally, suicide has been viewed as a deliberate action, a conscious choice. As a result, mental health systems have tended to regard at-risk patients in one of two ways. “There were the individuals who are at risk but can’t really be stopped,” said David Covington, a Zero Suicide pioneer based in Phoenix, Arizona, when I spoke to him. “They’re ‘intent on it’ is the phrase you hear. ‘You can’t stop someone who’s fully intent on killing themselves.’ So there is this strange logic that individuals who die couldn’t be stopped because they weren’t going to seek care and tell us what was going on. And those who do talk to us were seen as somehow manipulative because of their ambivalence. You heard the word ‘gesturing’. So we have this whole language that seemed to minimise the risk.”
Covington is president and CEO of RI International, a mental-health service provider based in Phoenix, which has more than 50 crisis centres and other programmes across the US, as well as a number in Auckland, New Zealand. A prominent and energetic speaker, he is also president-elect of the board of directors of the American Association of Suicidology, a charitable organisation based in Washington, DC, and leads an international Zero Suicide initiative. When he started in mental health more than 20 years ago, he was dismayed by the gaps in training and thinking he found in the system. Breakthroughs have come only recently, long enough for Covington to have observed and promoted a shift away from a fatalism – and a stigma – that was preventing any progress in reducing death from suicide while we eradicated diseases and tackled other threats, such as road accidents and smoking.
Covington credits a book and a bridge with accelerating that change. Why People Die By Suicide by Thomas Joiner was published in 2005. Joiner, a professor of psychology at Florida State University, drew on the testimony of survivors, stacks of research and the loss of his own father to upend minds. He recognised the myriad pressures on a suicidal mind – such as substance abuse, genetic predisposition to mental illness, and poverty – but identified three factors present in all of those most at risk: a genuine belief, however irrational, that they have become a burden to those around them; a sense of isolation; and the ability, which goes against our hard-wired instincts of self-preservation, to hurt oneself (this combines access to a means of suicide with what Joiner describes as a “learned fearlessness”; Covington calls it an “acquired capability”). “[The book] gave an architecture to what was going on that we had not seen before,” Covington told me. “It was like a crack through the entire field.”