Our new government is making the elimination of youth suicide a focus of health policy under Minister Greg Hunt. However, billions of dollars of investment over the years has failed to reduce the numbers of those taking their own lives. Business as usual is not an option and radical ideas are required for treating suicidality in both in-patient and out-patient settings.
In a post-election rush of optimism the returned health Minister Greg Hunt said that one of his first priorities was the elimination of youth suicide.
This commendable ideal would take nothing short of (another) miracle; Suicide rates have actually increased in the last five years with 2017 reaching a new height of 3128 deaths, of which 444 were people under the age of 24. (https://www.lifeinmindaustralia.com.au/about-suicide/suicide-data/suicide-facts-and-stats).
Practically speaking how should we join in Mr Hunt’s quest to eliminate 444 deaths by suicide each year.
As a child and adolescent psychotherapist I work on the front line of youth suicide prevention. Suicide is a toxic, alarming topic that activates all of our defences and anxieties. It is very difficult to talk about – especially with young people – and overwhelms parents and carers who feel responsible for keeping the child alive, but totally confused about what they can do. Added to that, young people’s brains are hyper-impulsive, making the risk of suicide much higher as they are without the reasoning powers to break down the consequences of their actions, before it is too late.
Terrifying as it is with young people, it is mostly a temporary mental state which if appropriately supported and contained can be survived.
In my experience, what many suicidal young people need to have are conversations that allow them to explore the idea of suicidality without necessarily doing anything about it. When your mind is telling you that ending your life is the only way out of unbearable pain and anguish, being told that it’s the wrong thing to do is totally ineffective. Exploring the root of the thoughts and feelings of hopelessness and working with the person to understand why they are in such despair is key to reducing suicidal risk.
Suicidality has a broad spectrum of severity. The majority of people with suicidal thoughts sit at one end where they might think that being dead is easier than being alive because of difficult thoughts and feelings, but have no intention to act – this is the lower end of suicidal ideation and is relatively common amongst young people who present with mental health issues. At the other end of the spectrum are those with a suicide plan who will kill themselves unless they are stopped and at the very end of this spectrum are those that actually suicide. Depending on where the young person is on the spectrum, different services are required.
Understanding the difficulty in discussing suicide, along with the fact that suicidality is a dynamic state – not one condition– should inform policy around suicide prevention.
Why is this understanding important?
Firstly, so that suicidality is not treated as an illness within a medical model of crisis management and life-preservation in psychiatric wards of public hospitals. This treatment may be necessary to treat a bi-polar or schizophrenic patients (who may also be suicidal), but it is not necessarily the right environment for a suicidal young person with no other co-morbid states. Currently there is huge pressure on the medical system to take in suicidal cases to keep these people safe, but within an institution that is not geared towards long term care and will often discharge patients because of lack of symptoms or pressure for beds regardless if there is a treatment plan or systems in place to keep the young person safe.
This is assuming you can get a suicidal young person admitted in the first place – a problem compounded in Australia where there are only 279 beds available nationwide for children and adolescents for all mental health related issues. (https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/specialised-mental-health-care-facilities)
One alternative idea for treating suicidal youth at the far end of the spectrum is a network of “Safe Houses” designed for young people who are at immediate risk to themselves. These residential spaces would be separate from a hospital environment, be dedicated to both containing and treating young people and their families, and accessible to all. This approach means young people are contained in a specific environment that is protected from the broader mental health population where they can work on their issues in a specialised setting over a longer period of time than would be possible with an emergency hospital admission.
These spaces could also be adapted to cultural requirements in each region of Australia, changing modalities and programmes to the specific needs of the local population.
The second critical point is open-ended service provision to suicidal young people that recognises the acute nature of their condition and is not limited by blanket policy decisions that regulate overall mental health service provision in Australia.
Billions of dollars have been poured into this problem over the past decade, but, as reported by the Grattan Institute in April, the suicide figures refuse to move anywhere but upwards.
Much of that money goes to Headspace which was set up in 2006 to tackle the youth suicide problem and the overall treatment of youth mental health. Although Headspace is a world leader in gathering youth mental health services under one roof, it is also a generalist in approach because of its mandate is to treat all mental health issues such as addiction and sexual health issues amongst the nations under 24 year olds. As such Headspace is dealing with over 24,000 client presentations a year across its 90 centres.
The Headspace programme receives most of its funding via the MBS (Medicare Benefits Schedule) which restricts the number of psychological sessions a young person can receive to 10 per annum.
This is nonsensical. A suicidal young person needs open ended psychological support, that they know will be available to them until they are no longer a risk to themselves. Limiting the number of sessions they can receive creates more pressure on the suicidal person as there is an expectation of recovery within the mandated number of sessions, regardless of how effective the therapy is. This cap on treatment provision is unique to mental health – for instance, you are not discharged from the Oncology department if you are half-way through your treatment and not yet cured – why is this the case with mental health?
Once a suicidal young person has taken the brave step of asking for help, they need to know that help is there for as long as it takes, and as long as they are at risk to themselves.
Headspace and the public hospital system both have to operate within the confines of their budgets delivering services to the broadest spectrum of patients possible.
Suicide, however, is a highly specialised and dangerous subset of what Headspace and the Public Hospital System treat and they may not be the right places for suicidal young people.
Specialisation of both in-patient and on-going therapeutic care in a Safe House model for the relatively small number of people on the critical end of the suicidal spectrum, could address this problem and provide a meaningful strategy to reduce youth suicide alongside the various prevention and early-intervention programmes in place that seek to reduce the number of young people who enter an actively suicidal state in the first place.
The issue of cost will be key but if youth suicide is a priority, then the funds should be made available.
The return on investment of creating world-leading suicidal treatment centres for young people is not just an economic calculation. A solution to youth suicide, and particularly the disproportionate number of Indigenous suicides of young people, will have immeasurable returns for our society as well as for the thousands of people who are touched by suicide each year.
Bernard Macleod is a Child and Adolescent Psychotherapist in Private Practice in the Eastern Suburbs. He is also President of the Couple, Child and Family Psychotherapy Association of Australasia.