The illness model of suicide has failed

Suicide involves a decision by a person to take their own life. Many factors may be involved in that decision, and that includes mental illness. There are similarities between suicide and Illnesses such as schizophrenia, cancer, and heart disease. Like these illnesses, some of the factors that contribute to suicide can be studied, and to some extent measured. But unlike the diseases above, suicide involves a personal decision to bring about the event itself. People do not contract cancer or schizophrenia own decisions. Therefore, for all their similarities, suicide and mental or physical illness are distinctively different in terms of how they come about.

I read a recent article in the British Journal of Psychiatrists in which the author expressed the hope that adopting into suicide research the techniques used in cancer research might improve our ability to predict suicide. I rather think the opposite; that the reason we have made little progress in predicting suicide may be because we have banked too much on these techniques; trying to predict suicide as if it were a disease. We have not paid enough attention to the uniqueness of suicide as an event; the fact that the single most important factor in suicide is the decision by its victim to bring it about.

Our approach to suicide studies also translates into difficulties with the way we manage suicide risks. Even when the risk factors for suicide in an individual have been identified, we still dwell on the form of those factors and pay little attention to their contents. For example, depression is often easily recognised and diagnosed and the link to suicide made early in the treatment. But the link between depression and suicide is rarely ever a direct one. Depression affects our judgment in different ways. We tend to minimise our achievements, or fortune and our abilities while maximising our misfortune, our deficiencies, and our failures. However, behind the maximisation and minimisation lies personal issues over which the would-be suicide victim may feel completely helpless, unjustifiably as that may be.

In my job as a consultant psychiatrist, I have been involved in many suicide investigations. What has particularly struck me about those cases is that the team involved in treating each victim seemed to have correctly identified the risk factors for suicide in each case. However, despite the victim enjoying frequent, sometimes daily, contact with mental health professionals, little, if any, time was spent on discussing with the victim why suicide may make sense to them. Such a discussion would have meant moving our attention from discussing how the patient’s condition has changed, to discussing the real contents of their thoughts. It would have challenged the patient to bring out deeply personal issues of their past and present, and to rationalise their thought of suicide.

In psychiatry, as we practice in the western world, there is a tradition that doctors must respect people’s private lives. It seems to me that in upholding this tradition, we have conveniently avoided engaging the patient in a discussion about the real reason they are contemplating suicide. I use the adjective real here, because, for the depressed patient, the real reason for suicide is not depression, but their very personal conclusions about some deeply personal matters including their perceived hopelessness. Even when the main rationale for suicide is their fear of not recovering from depression, it is important to recognise the difference between the depression and the patient’s own beliefs. We know that one does not always match the other.

On the surface, we avoid discussing our patients’ personal matters out of respect for their private life. But there is a more selfish reason for this both for the doctor and the patient. We feel uncomfortable talking about people’s personal lives. The patient feels ashamed to talk about them. One could say that there is unwitting collusion between the psychiatrist and the suicidal patient to avoid talking about the very reason they are contemplating suicide.

The feeling among psychiatrists seems to be that the kind of discussion that challenges the patient’s thoughts, assumptions and beliefs, is better left for the psychologists and psychotherapists. But most suicidal patients in the community and even in the ward, are seen by psychiatrists, mental health nurses and social workers. In fact, a high risk of suicide if often an exclusion criterion for psychological therapy. Most patients who took their own life would have had their last mental health service contact with a community mental health nurse or social worker. These are the frontline workers in suicide prevention, and any new interventions and approaches must be delivered with them.

Even in the most confused and disorganised mind there is a rationale for every action. The rationale may be shaped by mental illness. Unlike the symptoms of depression and other associations of suicide, the rationale for suicide is highly personal. Effective suicide prevention must seek to understand and challenge the rationale for suicide every suicidal individual.

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