BACP Response to the Health, Social Care and Sport Committee
Inquiry on Suicide Prevention
The British Association for Counselling and Psychotherapy (BACP) is pleased to respond to this important inquiry on suicide prevention in Wales. BACP is the UK’s leading body for counselling and psychotherapy, we have over 45,000 members in the UK, of which 1,900 are based in Wales working across a range of settings. Evidence clearly demonstrates the important role that talking therapies play in helping to alleviate symptoms which lead to suicide and self-harm.
A significant public health challenge
Suicide remains a significant social and public health problem. Each year in Wales between 300 and 350 people die from suicide, about three times the number killed in road accidents[1]. According to the latest data from the Office of National Statistics, the suicide rate in Wales is the second highest in the UK, with a rate of 11.8 per 100,000 people, compared to Scotland’s rate of 15 per 100,000 people[2]. This has fallen from a high of 13.0 in 2015. There are also concerns around the erratic suicide rate for Wales, particularly for males, as clearly demonstrated in the Figure 1. A number of commentators have theorised that this is due to rurality impacting on the accuracy of data collection, placing doubt over the accuracy of the picture. BACP would welcome an examination of this issue by the committee.
Figure 1: Age-standardised suicide rates by country, for males, 1981 to 2016
Source: Office for National Statistics, National Records of Scotland, Crown Copyright, 2017
Analysis shows that men are around three times more likely to die by suicide than women. Women are more likely to engage in non-fatal suicidal behaviours that require hospital admission. It is thought that up to 19 people in every 100 will have thoughts of suicide at some point in their life[3]. These thoughts are distressing and can further isolate an individual, creating additional barriers to seeking help.
Whilst this inquiry is focused on suicide prevention, there is a strong relationship with self-harming behaviour which cannot be ignored. A 2015 study found that self-harm patients had a 49 times higher risk of suicide than the general population (Hawton, 2015). Self-harm behaviour regardless of intent is also a serious public health problem in its own right. It is one of the top five reasons for medical admission in the United Kingdom and results in significant social and economic burden due to the utilisation of health services, particularly with respect to unscheduled hospital care, to treat the injury/ overdose. It also has a big psychological impact on the individual, friends, family and professionals who treat them.
Which groups are at more risk?
Earlier this year, Samaritans UK published ‘Dying from Inequality[4]’, which evidenced the critical relationship between higher individual deprivation and increased suicidal behaviour. This showed that suicide rates are two to three times higher in the most deprived areas. This also identified five groups most likely to be impacted by suicide.
1. Those living in areas of higher socioeconomic deprivation
2. Men are more vulnerable to the adverse effects of economic recession, including suicide risk, than women.
3. People who are unemployed are two to three times more likely to die by suicide than those in employment.
4. Those in least skilled occupations (e.g. construction workers) have higher rates of suicide.
5. A low level of educational attainment and no home ownership increase an individual’s risk of suicide.
We share Samaritans UK’s view that suicide prevention strategies should recognise the strong association between suicidal behaviour and area-level socioeconomic deprivation, targeting efforts on both people and places. BACP believes that more should be done to target interventions at these vulnerable groups and to more effectively measure outcomes by these groups.
Psychological therapies for suicide and self-harm
Though both suicidal intent and self-harm usually result from severe psychological distress, BACP believes that neither are in themselves mental illnesses. However, given the link between mental health disorders and an increased risk of suicide it is clear that psychological therapies are an effective intervention for those with an intent to commit suicide or self-harm.
The evidence base demonstrates that a range of psychological therapies can be used to treat the mental distress underlying suicidal tendencies and self-harm, and dialectical behaviour therapy has proven particularly effective in reducing self-harm (Feigenbaum, 2010). Research has shown that Dialectical Behaviour Therapy (DBT), Cognitive Behavioural Therapy (CBT) and problem solving therapy are effective interventions for people at risk of suicide (Winter, 2013). Evidence has also shown that psychosocial assessment forms an important aspect of the management of self-harm in hospitals, and is associated with a decreased risk of repeat self-harm (Gunnell, 2013). Problem solving therapy (Bannann, 2010) and DBT (Hawton, 1999) has been shown to reduce repetition and further self-harm. Patients receiving counselling and psychotherapy after deliberate self poisoning showed greater improvement, including a reduction in suicidal thoughts. The positive impact of counselling and psychotherapy was also maintained at six-month follow-up, with nine per cent of those receiving counselling and psychotherapy repeating self-harm compared with 28 per cent of those receiving usual treatment (Guthrie, 2001).
NICE clinical guidelines regarding the use of psychological interventions for the longer-term management of self-harm suggest interventions could include cognitive-behavioural, psychodynamic or problem-solving elements (NICE, 2011). A report by the Royal College of Psychiatrists (2010) has also outlined research evidence which suggests that CBT is effective in reducing levels of depression and incidents of self-harm, and that problem solving therapy can lead to improvements in mood and social adjustment. Research evidence suggests that psychological therapies can also be effective in the prevention of suicide, along with a range of approaches to psychotherapy and counselling (Winter et al, 2013).
We are fully supportive of efforts being made in Wales to improve access to psychological therapies, as this will have a positive impact on tackling suicide and instances of self-harm. Timely access is critical, and BACP, as a member of the We Need to Talk Wales coalition[5], are calling on Welsh Government to commit to parity of access so that people of all ages to access psychological therapies within 28 days, in primary and secondary care. Dignity and choice are also critical and we support the We Need to Talk Wales call for people to have a choice of therapy, where they want it and when they want it, underpinned by effective information.
Strategic opportunities and challenges
BACP welcomes the Welsh Governments’ strategic approach as set out within Talk to Me 2[6], and its aim to reduce suicide and self-harm in Wales. This recognises that efforts to tackle this issue are intertwined, and emphasised that improvements will only be achieved through concerted effort, the commitment of all Welsh Government departments and partner bodies. Together for Mental Health and the Mental Health (Wales) Measure 2010 (the Measure) also play a critical role in addressing the treatment and management of mental health disorders, and the rights, responsibilities and duties assigned to individuals and to services.
A key area of concern is the sustainability of the Time to Change Wales programme, which is a critical component in helping to tackle stigma. Funding for the programme runs out in December 2017 and no communication has been made on what will happen to the programme going forward or plans to replace it. We would welcome an examination by the committee into this matter.
Summary of recommendations
This section highlights the recommendations we have proposed throughput our written evidence.
1) We call upon the committee to urgently examine concerns with the accuracy of suicide data collection and reporting, ultimately to help secure improvements and confidence in the data.
2) There is a strong association between suicidal behaviour and area-level socioeconomic deprivation, targeting efforts on both people and places BACP believes that more should be done to target interventions at vulnerable groups and to more to effectively measure outcomes by these groups to measure success.
3) Tackling Stigma is central to tackling suicide, however, BACP is concerned that funding for Wales’ flagship programme, Time to Change, runs out this month, and no communication has been made on what will happen to the programme going forward or plans to replace it.
4) We call on Welsh Government to commit to parity of access so that people of all ages can access psychological therapies within 28 days, in both primary and secondary care. Dignity and choice are also critical and we support the call for people to have a choice of therapy, where they want it and when they want it, underpinned by effective information.
Annex A: References
Bannan, N. (2010) Group-based problem-solving therapy in self-poisoning females: A pilot study. Counselling and Psychotherapy Research, 10(3), 201–213
Bergen, J., L. Hawton, N. Kapur, J. Cooper, S. Steega, J. Ness and K. Waters (2012) Shared characteristics of suicide and other unnatural deaths following nonfatal self-harm? A multicentre study of risk factors. Psychological Medicine, 42(4), 727–741
Brown, G.K., C.F. Newman, S.E. Charlesworth, P. Crits-Christoph and A.T. Beck (2004) An open clinical trial of cognitive therapy for borderline personality disorder. Journal of Personality Disorders, 18(3), 257–271
Cooper, J., S. Steeg, R. Webb, S.L.K. Stewart, E. Applegate, K. Hawton, H. Bergen, K. Waters and N. Napur (2013) Risk factors associated with repetition of self-harm in black and minority ethnic (BME) groups: a multi-centre cohort study. Journal of Affective Disorders, 148(2–3), 435–439
du Roscoät, E. and Beck, F. (2013) Efficient interventions on suicide prevention: A literature review. Revue d’Épidémiologie et de Santé Publique, 61, 363–374 (p372)
Gunnell, D., K. Hawton, D. Ho, J. Evans, S. O’Connor, J. Potokar and N. Kapur (2008) Hospital admissions for self-harm after discharge from psychiatric inpatient care: cohort study. BMJ 2008; 337:a2278 doi:10.1136/bmj.a2278
Gunnell D, Hawton K, Bennewith O, Cooper J, Simkin S, Donovan J, et al. (2013) A multicentre programme of clinical and public health research in support of the National Suicide Prevention Strategy for England.
Guthrie, E., Kapur, N., Mackway-Jones, K., Chew-Graham, C., Moorey, J., Mendel, E., Marino-Francis, F., Sanderson, S., Turpin, C., Boddy, G. and Tomenson, B. (2001) Randomised controlled trial of brief psychological intervention after deliberate self poisoning. British Medical Journal, 323, 1–5
Hawton, K.K.E., Townsend, E., Arensman, E., Gunnell, D., Hazell, P., House, A. and van Heeringen, K. (1999). Psychosocial and pharmacological treatments for deliberate self harm.
Hawton, K., H. Bergen, K. Water, J. Ness, J. Cooper, S. Steeg and N. Kapure (2012) Epidemiology and nature of self-harm in children and adolescents: findings from the multicentre study of self-harm in England. European Child and Adolescent Psychiatry, 21(7), 369–377
Hawton, K., C. Casanas I Comabella, C. Haw and K. Saunders (2013) Risk factors for suicide in individuals with depressions: a systematic review. Journal of Affective Disorders, 147(1–3), 17–28
Hawton, K., H. Bergen, J. Cooper, P. Turnbull, K. Waters, J. Ness and N. Kapur (2015) Suicide following self-harm: Findings from the multicentre study of self-harm in England, 2000–2012. Journal of Affective Disorders, 175, 147–11
Horrocks, J and A. House (2002) Self-poisoning and self-injury in adults. Clinical Medicine, 2(6), 509–512
Luoma, J.B., Martin, C.E. and Pearson, J.L. (2002) Contact With Mental Health and Primary Care Providers Before Suicide: A Review of the Evidence. American Journal of Psychiatry, 159, 909–916
McLean, J. M. Maxwell, S. Platt, F. Harris and R. Jepson (2008) Risk and Protective Factors for Suicide and Suicidal Behaviour: a literature review.
Meltzer, H., D. Lader, T. Corbin, N. Singleton, R.Jenkins and T. Brugha (2002) Non-fatal suicide behaviour among adults aged 16–74 in Great Britain.
Morrison, L.L. and D.L. Downey (2000) Racial differences in self-disclosure of suicidal ideation and reasons for living: implications for training. Cultural Diversity and Ethnic Minority Psychology, 6(4), 374–386
NICE (2004) CG16 Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care.
NICE (2011) CG133 Self-harm: longer-term management.
Office for National Statistics (ONS) (2017) Statistical bulletin: suicides in the United Kingdom
Oude Voshaar, R.C., J. Cooper, E. Murphy, S. Steeg, N. Kapur and N.B. Purandare (2011) First episode of self-harm in older age: a report from the 10 year prospective Manchester self-harm project. Journal of Clinical Psychiatry, 72(6), 737–743
Saunders, K.E.A and K. Hawton (2013) Clinical assessment and crisis intervention for the suicidal bipolar disorder patient. Bipolar Disorders, 15(), 575–583
Scottish Government (2008) Risk and Protective Factors for Suicide and Suicidal Behaviour: A literature review.
Winter, D., Bradshaw, S., Bunn, F. and Wellsted, D. (2013) A systematic review of the literature on counselling and psychotherapy for the prevention of suicide: 1. Quantitative outcome and process studies. Counselling and Psychotherapy Research, 13(3), 164–183