68 Suicide prevention by education and the moulding of attitudes

In this chapter the challenge of influencing the attitudes to suicide prevention in key individuals or gatekeepers, such as clinicians, school personnel, social planners, and researchers in mental health and suicide prevention, is addressed. Based on experiences from several training programmes, the importance of a psychological perspective on suicidality is seen as relevant, even in population-based research and prevention. One focus in the discussion is on the distinction between having an immediate impact on conscious attitudes and the more difficult challenge of influencing less conscious, individual and cultural ambivalent attitudes to suicide prevention. In light of the universal stigma of and taboo against the topic of suicide, the ability of prevention specialists to withhold judgement and reflect on their own emotional responses to self-destructiveness is considered as an aspect of a scientific attitude. In addition, an anthropological elucidation of mental ill-health and suicide is called for as a supplement to the biopsychosocial, stress–vulnerability paradigm in suicide-preventive training programmes.

What is high-quality education in suicide prevention? The complexity of this question derives from its elements ‘education’ and ‘suicide prevention’, both of which continue to be universal social and scientific challenges. In a critical review of national suicide-preventive programmes, DeLeo (2002) recommended multidisciplinary education as the most relevant prevention strategy today. Mann et al. (2005), in a review of published prevention studies worldwide, similarly found that education was an effective strategy, particularly when directed to gatekeepers, for example, primary care physicians. One can conclude from these reviews that the severely distressed individual's susceptibility to wishing his or her own death may be counterbalanced—and suicide prevented—by better knowledge and by attitude change in gatekeepers, and that education of suicide-prone individuals as well as of caregivers, other gatekeepers, and those in power to shape society, may contribute to making suicide an ‘unnecessary death’ (Wasserman 2001a).

Attitudes to suicide on the one hand represent conscious ideas and self-reported behaviours, that is, phenomena that in evaluation studies might be measured on attitude scales. However, attitudes also have unconscious underpinnings, which can only be inferred retrospectively from complex narratives and from manifest action in real-life situations. An example of an unconsciously shaped attitude is the universal taboo against suicide, which does not solely denote a cultural, religious, or instinctive prohibition against killing oneself, but also a phobic attitude to approach—in deed or in thought—anything that has to do with suicide, suicide research and prevention included. Whereas the prohibitive function of the suicide taboo may protect people from taking their lives, the phobic aspect may, in interaction with other factors, contribute to promoting suicides.

A methodological challenge in population-based suicide prevention, including education, is that results reflecting the effects of a given prevention strategy are often not obtainable for statistical reasons, for example, when large enough cohorts or samples aren't available. Moreover it is often essential to supplement robust information on suicide rates, however reliably this information may reflect changes in health in a given population, with experience-near narratives and coherent theoretical descriptions of what has been achieved and how.

The Gotland study, a clinically based yet public-health oriented suicide-preventive intervention (Rutz et al. 1989; Rutz 1992; Rutz et al. 1995), which was the brainchild of the Swedish Committee for Prevention and Treatment of Depression (Eberhard et al. 1992), is an example of how to combine qualitative and quantitative approaches in evaluating the effects of attitude moulding; this project provides real-life illustrations of some of the questions and didactic challenges that are addressed in this chapter.

The principal intervention in this project was a training program given to all of the eighteen general practitioners working in the Swedish island of Gotland, the population of which was about 55,000 when the project was initiated in 1980. The main focus of the two days of lectures and discussions they took part in during the first year of the project was on contemporary methods of diagnosis and treatment of depression; a year later there was a follow-up day of lectures on other themes related to depression and suicidality. An immediate effect of the intervention was that the prescription rate of antidepressants increased and that suicide rates decreased from an annual average of 22 suicides per 100,000 inhabitants in 1979–1982 to 15.5 in 1983–1985.

However, in a follow-up study three years after the project period, the total suicide rate in Gotland had returned to its original, baseline level. One explanation may be that the half-life of attitude change in health-care organizations is short, and that continuous education in psychiatric practices are required to achieve sustainable results. In a subsequent commentary, Rutz and Wålinder (2000) noted that the fact that at follow-up the prescription of antidepressants remained stable at its new, higher level indicates that medication alone did not account for the intermittent reduction of suicides. The most obvious other variable that might explain the decrease of suicides during the project period was the patient–doctor relationship, which in the typical case was intensified while the project was running, or this relationship in interaction with the changed prescription practices. Either way, Rutz and Wålinder concluded, intense, empathic doctor–patient relationships contribute to reducing suicide rates among patients seen by general practitioners.

Improved doctor–patient relationships in general health care and psychiatry may be included among the salutogenic educational and attitude-related targets of individual-based prevention as well as of prevention directed towards vulnerable groups. Related goals are to advance openness to individual differences in the community at large or in social milieus other than clinics, for example, in schools, work places, and military settings, and to counteract the stigmatization of suicide attempters or other vulnerable individuals or groups.

A number of relatively recent studies (Oyama et al. 2004; Samuelsson and Åsberg 2002; Szánto et al. 2007; Valentini et al. 2004) in agreement with Rutz's work as well as with many of the studies reviewed by Mann et al. (2005), for example, Hannaford et al. (1996), Kelly (1998), Lin et al. (2001), Naismith et al. (2001), Pfaff et al. (2001), Rihmer et al. (2001), Takahashi et al. (1998), all bear out that education may have suicide-preventive effects.

Ultimately aiming at reducing suicide rates in the population, the training programmes at NASP, the Karolinska Institute, Stockholm, Sweden where both authors are active, have the objective of disseminating scientific knowledge and inspiring a science-based attitude to suicide prevention. The mental health professionals, social planners, administrators, and researchers who are students in the programmes are also regarded as suicide-preventive key persons who in turn are expected to influence the attitudes of others.

The programmes include arrangements in which students reflect on their personal values and attitudes to suicide. This emphasis, which in part derives from the clinical orientation and training of the NASP faculty and has evolved from the encounters with students from different professional and cultural backgrounds, does not exclude a parallel focus on the importance for mental health or ill-health of medical, physical, economical, and social conditions. These and other aspects, such as the availability of means for taking one's life, or cultural and social pressures, may play a role similar to that of attitudes in tipping the scale of the complex interaction of factors that in the end may either elicit or prevent a suicide.

The mixed professional background of the students is in harmony with the assumption that suicide can be fully elucidated only with a multidisciplinary approach. Although there is consensus on this view among researchers worldwide, implementing a multidisciplinary framework when teaching suicide prevention can be difficult. Not only do lecturers and seminar leaders need to be skilled in their respective subspecialties, but, in order to communicate effectively with students with heterogeneous professional backgrounds, they also need to be able to present their work in a theoretically integrated way and to place it within a framework of a complex stress–vulnerability model of mental health and ill-health. Taking into account that students will have emotionally coloured attitudes not only to suicidal patients or individuals, but also to competing theories on suicide, we face a challenge in promoting reflection and openness to the complexities of topic(s).

A particular facet of suicidal behaviours, which almost paradoxically has come to light in the research-oriented programmes rather than in the clinical ones (in which this perhaps is taken for granted), is that the real-life interface between the prevention specialist or researcher and the real or imagined beneficiary of the prevention efforts, for example, an individual member of a population cohort, is psychological. Depressive affect, anxiety, and the wish to die all belong to subjective experience, even when these phenomena are studied in terms of neurobiology, epidemiology, anthropology, or some specialized causal hypothesis in psychology. The prevention worker's attitudes to suicide prevention are affected by actual experiences, which may have been gratifying or disappointing, as well as by privately motivated and envisioned expectations, hopes, and fears about influencing—ultimately saving—suicidal individuals. Whether a clinician or a researcher, the engaged professional may empathize, neglect, outright reject, or directly or indirectly expose the vulnerable individual to mixtures of these attitudes. Clinicians usually appreciate the opportunity to address countertransference issues, i.e. their emotional response to suicidal individuals (Maltsberger and Buie 1972). It is a recurring experience that our research and master students, too, ask for seminars in which their personal values and views on suicide may be discussed.

This programme is a one and-a-half-year, part-time course for physicians, nurses, social workers, and psychologists working in psychiatry, child and adolescent psychiatry, general medicine, and social services. It has been given as a specialization single-subject course at Karolinska Institutet on a regular basis since 1993 (Wasserman 1993). The first programme, which was organized as a part time, 200-hour course covering two years, but condensed into a one-and-half year, three-semester programme in 2003 (with the same number of hours), gives an orientation on neurobiological, epidemiological, social, psychological, philosophical, and historical perspectives on suicide. Lectures are given on pharmacological and psychotherapeutic treatment strategies and on prevention programmes for near-suicide patients as well as for non-clinical vulnerable groups such as refugees and immigrants, the aged, and the young.

In closed small-group seminars that run throughout the entire course, students have the opportunity to relate their newly acquired theoretical knowledge to previous habits of thought and to clinical experiences. Through role playing the students also learn to lead a psychological autopsy after a suicide or a suicide attempt. The seminars are lead by clinically experienced and psychotherapeutically trained group leaders.

In addition to attending lectures and seminars, the students in this programme carry out a suicide-preventive research and development project in their workplaces with supervision from the NASP faculty, and describe it in a written report. Examples of topics for such projects are: writing local guidelines for the care of psychiatric patients at risk for suicide, or routines for the support and follow-up of individuals hospitalized after a suicide attempt; organizing courses in suicide prevention and support of trainers and supervisors; local epidemiological or small-scale treatment studies; carrying out and evaluating psychological autopsies; writing a qualified research plan, for example, for a doctoral dissertation in suicidology or suicide prevention. Together with the reflection and dialogue in the seminar groups, the implementation of a suicide-preventive project constitutes an accommodative element of the programme, aimed at fostering integration of the material given in the lectures (Piaget 1958; Wasserman 1993).

In a doctoral dissertation, Ramberg (2003), using questionnaires, studied the impact of the programme on the students' and their workplaces (Aish et al. 2000; Ramberg and Wasserman 2000, 2003, 2004a, b). The respondents, all from Stockholm, were 617 psychiatric co-workers who filled out the questionnaires before, immediately after, and one-and-a-half years after the completed programme. Half of the respondents worked in training units from which personnel were sent to the programme. The other half worked in non-trained units and served as controls. The main findings were that the respondents in the training units were to a significant extent more positive about working with suicidal patients after the programme than were those working in control units. Another observation was that the wish for training was greatest among psychiatric nurses and assistant nurses, whereas physicians and psychologists either tended to believe that they were already sufficiently knowledgeable in the field, or state that they did not wish to study it. The strengthening of the psychiatric personnel's motivation and sense of security in working with suicidal patients was significant in the training units regardless of which treatments methods they believed to be the best. In a subsequent study Ramberg and Wasserman (2003, 2004a, b) found that programme graduates often encounter organizational or other difficulties that stand in the way of implementing their suicide-preventive expertise. We conclude that, although an immediate impact on the conscious attitudes of psychiatric co-workers—participating students as well as their colleagues—was documented, further studies are called for to clarify the organizational obstacles and personal inhibitions that often stand in the way of suicide-preventive initiatives in the psychiatric workplace. The role of unacknowledged ambivalent attitudes to suicide prevention should also be studied in this context.

This is the name of a three-day training programme for teachers and other gatekeepers, including clinicians in child and adolescent psychiatry, who are accessible for young people for discussing important but difficult existential issues. The name of the programme is the same as that of a 46-minute documentary film, jointly produced by NASP and the Swedish film director Göran Setterberg. Four young adults are portrayed in the film. All four, two men and two women, have survived a suicide attempt during adolescence and they describe the struggle, each person in their own way, to find a new orientation and a stable identity as an adult in the years following the suicidal crisis.

The participants in this course learn to use the film to stimulate discussions with young people. Basics of adolescent psychology are included in the programme, as is the importance of creating a psychologically safe and respectful setting for the intended discussions. Participants who complete the programme receive a copy of the film, teaching materials, and a certificate authorizing them to use the film in schools, youth centres, and other appropriate settings.

The impact on young persons who watch the film and take part in a guided discussion was evaluated by Alin-Åkerman (2002). The specific focus of the evaluation was whether this experience strengthens the youngster's awareness of and ability to deal with the life challenges they are facing. Two groups of secondary school students were compared. Both groups included individuals with suicide-related problems and others without known problems. Participants in the intervention group saw the film, took part in a group discussion, and were interviewed and tested with psychological tests before and after the intervention. Those in the control group were interviewed and tested at the same intervals without having seen the film or having taken part in an organized discussion.

The young men and women in the intervention group, whether they were known to have suicide-related problems or not, appreciated the opportunity to talk about important issues about life and death in a safe context. They all underscored that there was little room for such exchanges in their everyday lives and that they would normally hesitate to burden others with their concerns, or to openly expose these thoughts to others. It was clear that the film worked a catalyst for these discussions.

As to the attitudes of school staff and mental health professionals who take part in the training programme, the encounter with the personal fates of the four young adults featured in the film usually has an immediate and rather dramatic impact. In course evaluations the participants report that they left the programme wanting to do more to help the young. However, as the empathic identification with a suicidal person individual is easily offset by a simultaneous impulse to withdraw from him or her (Titelman 1997; Wolk-Wasserman 1985, 1986), there is a great need to support those who make themselves available as partners for serious conversation and relationship-building with the young. Again, attitude ‘maintenance’ is a necessary supplement to mere inspiration.

Love is the Best Kick—the film, the course, and the study manual—works well as a tool for communicating with adolescents. The programme adds structure and motivation to those who work with the young in schools and other relevant locations and provides opportunities to discuss issues that may otherwise remain secret and drive a lonely young person to destructive acting out.

This annual, one-week research course was initiated in 2000 as a mental-health module of the World Health Programme, a postgraduate scheme supported by the Karolinska International Research and Training Committee (KIRT) at the Division of International Health (IHCAR) at Karolinska Institutet. The focus of the course week is primarily on epidemiology, although there has been some variation in content. The course attracts PhD students and established researchers from all over the world, who are given the opportunity to present their own work during the course week. Some participants return year after year to what in effect has evolved as an international network of researchers in suicidology and suicide prevention.

In 2006 the course had a clinical perspective that included the evaluation of psychotherapies with suicidal patients (Hendin et al. 2006) and presentations of psychoanalytically informed experiential as well as group-based studies focusing on the interaction of psychological development, traumatization and biological, social, and psychological vulnerability and protective factors.

In their evaluations of the course in 2006, students reported that it was meaningful to reflect on the experiential dimensions of their research subjects when these were envisioned men or women in risk of suicide in an otherwise relatively anonymous research context. To mention one example where the added psychological dimension was rewarding, a project on the role of the media in instigating suicidal behaviour among adolescents was dramatically enriched by the opportunity for the project leader to reflect on group psychology and identification phenomena with the aid of psychoanalytic theories.

The master programme was first given as a one-year programme, which in addition to applying the stress–vulnerability paradigm, included an orientation in public health science as well as courses in quantitative and qualitative research methodology. Specific courses focusing on population-based suicide prevention were also included, for example, ‘The environmental fraction in the causation of suicide and how it can it be controlled’, ‘The role of the media in facilitating or preventing suicide’, and ‘Clinical and nonclinical population groups vulnerable to suicide.’

The programme attracted students with academic backgrounds in medicine, psychology and sociology. Although the principal focus of the programme was on research and public health perspectives, as the programme advanced, the students' interests gravitated towards clinical and philosophical issues, foremost questions about the right to choose death, and on their own emotional responses to the topic. In line with these interests, a two-week course on ethics in research in mental health and suicide research was perceived by the students as a high point in the programme. Questions that were addressed in the ethics course were, for example: Is suicide ever acceptable? Should it always be prevented? What are our own values and fears towards suicide and towards talking openly about it? In the generally positive student evaluations of this programme one complaint recurred: it was felt to be too condensed, too intense.

A new, two-year master programme, which replaced the one-year programme in the autumn of 2007, is designed according to the principles of so-called Bologna Declaration, an agreement on synchronizing higher education in Europe, signed by forty-six countries. The two-year programme is open to international researchers, research-interested clinicians, social planners, and other qualified professionals with an interest either in the training programme in its entirety or in topics addressed in single-subject course modules within the programme.

The content of the previous master programme is extended in the two-year programme with course modules on psychophysiological stress research and on salutogenic perspectives on mental health, including cultural and anthropological aspects. The fourth term is devoted to an advanced level, 30-credit (European Credit Transfer and Accumulation System, ECTS) master thesis.

In the context of the mentioned methodological and epistemological challenges—the complex nature of attitudes to suicide, the centrality of psychological dimensions of suicidal behaviours, the overlap between individual- and population-based approaches, and the multifactorial, biopsychosocial explanatory perspective—it is relevant to underscore a particular element of a scientific attitude: the ability to suspend judgement when faced with the complex causation and the phenomenological ambiguity of suicide-nearness and suicide. This ability complements other aspects of a scientific approach, such as separating observations from inference and otherwise safeguarding the reliability and validity of one's work. It must sometimes be upheld in the face of pressures to provide simple answers, although, in clinical situations, when the immediate task is to save a life, direct and unambiguous action is usually necessary. The following example of being pressed to take action in an extreme situation, yet able to think clearly enough to postpone acting, was given by a student in one of our programmes who unexpectedly found herself in a situation in which she was pushed not to save a life, but to promote a death:

As an unplanned effect of his treatment, a somatically ill, elderly patient in our unit had lost consciousness and was given life-sustaining treatment. His family agreed with the head of the unit that it would be appropriate and in agreement with the patient's own wishes to discontinue his life-sustaining treatment. There was little reason [except for a sound scepticism about the objectivity of any close relative of any individual] to question that the family's assessment was made in earnest. I could not, however, make myself carry out his recommendation and instruct the staff to ‘pull the plug’, I just couldn't do it. After some time, the patient came to and was grateful for hav-ing been restored to life. I, too, was grateful for having had the presence to think about the fragility of the wish to live under such difficult circumstances, and about the possibility that the patient had other wishes simultaneously to wishing to die, as we had discussed in the programme. I felt strengthened by what I had learned about the risk for drawing quick conclusions with regard to an allegedly unambiguous wish to end your life.

(Student's personal communication. Words within brackets added).

When confronted with what is destructive in life, our inclination to oversimplification or avoidance may in part be caused by anxiety. Life's destructive sides include physical decay and mental disintegration in old age, but also the self-destructiveness seen in serious psychopathology. Is not anxiety, in fact, generally at work behind a phobic attitude to both suicide and suicide prevention? Miscalculated ideas and actions on the part of close relatives, medical staff, social workers, and psychotherapists are in any case not uncommon in interactions with suicidal individuals, particularly, perhaps, with the young, whom we simply do not wish to perceive as suicidal (Laufer 1995). As noted, in clinical work, such responses are understood as reflecting countertransference difficulties, sometimes including unconscious hate of the suicidal patient (Gabbard 2003; Kernberg 2004; Maltsberger and Buie 1972; Winnicott 1958; Wolk-Wasserman 1985, 1987).

We have emphasized that suicidality in real life is always presented as a psychological event: the conscious wish to die is consciousness, or, more specifically, a self-consciousness disorder. As such it is something distinctly human, related to, among other things, the capacity for guilt feelings. It is noteworthy in this context that Kandel (2005), whose focus is neurobiological, has pointed out that malignant self-destructiveness (of which inordinate self-punitive tendencies may be a derivative) is a response to severe stress that is specifically human, a reaction not found in other mammals. The therapist's or scientific investigator's—or the suicide-preventive gatekeeper's—emotional response to the suicidal person, which can shift between engagement and indifference and which probably always includes an element of identification (sometimes in the form of aggressive, ‘projective identification’), is a similarly human reaction in the service of ridding oneself of anxiety as well as of finding a way of remaining open to the patient to be helped or to the scientific question to be explored. Whatever applies in the individual situation, the aversion against suicide merits being approached with caution and reflection; it, too, is an aspect of the human predicament and may even reflect a human potential for suicide.

In trying to strengthen the capacity of students for intellectual and emotional containment of the challenges of suicide and suicidal behaviour, the timing of didactic interventions is critical. When we have invited students to reflect on their own attitudes too early, they have sometimes responded with discomfort and an unwillingness to open up to the questions. A typical disavowing a reaction has been: ‘Why this? We are here to learn science, not discuss philosophy.’ When, on the other hand, we have postponed such discussions too long, we have received evaluations such as ‘Great programme, but too little time to reflect on the “philosophy of suicide” and on our own attitudes’. Our overall experience is that students, struggling to understand suicide and developing their professional skills in working with suicide prevention, gradually appreciate that suicidality always has multiple meanings and causes, which, particularly in the case of a complete suicide may not be knowable, and that epistemological and practical–philosophical reflection, including disciplined self-reflection, are essential in the quest to understand these phenomena.

Educational efforts in the mental health field need to be renewed and repeated continuously. As assimilative learning needs to be supplemented by accommodative activity in cognitive development, training events of different kinds need to be followed by new in- or output—inviting students to generate knowledge actively is crucial—to maintain and fortify the effects of teaching programmes (Wasserman 1993). Students, further, probably need to achieve a personal identification with their teachers or mentors to carry on as influential teachers themselves.

Education frequently has an impact on the conscious attitudes to suicide and its prevention, but it is difficult to gauge the effects of educational programmes on deep-seated and relatively fixed attitudes and on the students' character-grounded anxieties and defences related to the topic of suicide.

The question remains whether the influence of education is lasting and whether educational programmes affect unconscious, ambivalent attitudes to suicide prevention at all. The challenge of addressing this and other questions in suicidology and suicide prevention will hopefully fall upon researchers who combine scientific specialization with an ability to reflect on socially, culturally and individually varied perceptions of the suicidal predicament as well as of the ways in which we try to counteract it.