Learning points from Churchill Fellowship Research for National Suicide Prevention Alliance

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Last year I was privileged to be awarded a Winston Churchill Travelling Fellowship to visit Australia, New Zealand and Ireland to meet with organizations and individuals who support families after they have been bereaved by suicide. As a child bereavement practitioner, and until recently a manager of services for bereaved children, especially those bereaved by suicide, I have long been aware that children are often overlooked in the quest to provided better services for those bereaved by suicide.

Children are affected by the death of a family member, especially when the person has died by suicide, with all the added complications that brings. Adults, both parents and professionals, often feel at a loss as to how to talk to children about suicide. Children need to be involved in the processing of what has happened in order to develop into resilient adults. Children bereaved by suicide are more vulnerable as they grow up, so it makes sense to put in place services for children that may prevent mental health issues in adulthood.

There are many developments in relation to support after suicide in the countries I visited that are cited as good practice. My Fellowship looked at how children are supported within these different models and services, and how specialist child bereavement services relate to these. I hope it will increase the understanding of what will most benefit suicide bereaved children in the growing partnership of organizations that are seeking to develop a national response for support after suicide in the UK.

Funding

Funding is obviously vital to the development of every service and across the range of my visits I saw how proper funding can enable services to become well grounded and grow. In Australia there is substantial government funding for services related to suicide prevention and bereavement, and I wanted to know why. Jaelea Skehan, Director of the Hunter Institute of Mental Health in Newcastle, Australia, doesn’t think funding is necessarily obtained through the logical way of running a pilot, evaluating it, showing its worth and applying for funding. It’s as much to do with developing relationships with the right people in government or other positions of influence and convincing them of the need for services, so they can apply pressure or influence where policies are made and funding decided.

Those who have been most influential in driving the agenda forward have had a personal interest in, or experience of, suicide. In the most recent Australian elections the Prime Minister Malcolm Turnbull said that ‘addressing suicide and mental illness would be a “vital national priority” for a re-elected coalition government.’ This statement was in response to a challenge by an alliance of leading mental health advocates to all political parties to announce what they would do to address the rising toll of suicide and self harm.

In NZ the Travellers programme for the prevention of suicide was funded by the New Zealand government and the Mental Health Foundation. At the time the minister was Jim Anderton, whose daughter had died by suicide, making him sympathetic to funding.

Headspace’ is a youth mental health initiative which was established by the Australian government in 2006 and is fully funded by the Federal Government. It emphasised evidence based intervention and was founded by Patrick McGorry, who as Australian of the year gave a big push to youth mental health.

Australia, New Zealand and Ireland have all run successful campaigns to highlight that deaths by suicide are often greater than road deaths. In New Zealand road deaths have been greatly reduced by a big campaign of posters along roads, proving that funding can be effective. Organizations related to suicide prevention are now using this as an argument for funding. Estimates of the total cost of road deaths to New Zealand society were put at around $3.6 billion each year. The national road safety campaign is based on a high level of research.

In Ireland the 3Ts( turn the tide of suicide) charity lobbies governments, raises awareness of suicide and provides grants and funding for research and support, highlighting that 3 times more people die by suicide in Ireland than die in road traffic accidents. Recognizing the need for research into suicide to help inform national suicide prevention strategies it funded the ‘Suicide in Ireland Survey’.  It states that ‘If adequate state funding for suicide prevention is unavailable, then we need a Suicide Prevention Authority similar to the Road Safety Authority, an independent authority to oversee a dedicated National Suicide Prevention Programme.’

The following example shows how, with commitment from those in government, a real difference can be made to the support available after suicide. Working in partnership in the UK is therefore vital in order bring maximum pressure to bear on those in government who can influence financial decisions.

In Australia an audit of 28 electorates between 2009 and 2012 found suicide rates exceeded the road toll in every seat. Between 2004 and 2014 suicide rates rose almost 20%.

Electorate 2009-2012                        Suicides                                Road toll

Canning WA                                          90                                             54

Longman, Qld                                      162                                             68

Cunningham, NSW                                91                                             37

Boothby, SA                                         64                                             13

Corangamite, Vic                                 111                                             65

The shadow Mental Health minister, Katy Gallagher, stated labour’s commitment to a 50% suicide reduction target over the next 10 years and the establishment of 12 suicide prevention pilot projects.

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In July 2010 the Prime Minister Julia Gillard said a labour government would spend $277 million to help Australians at risk of suicide, with a priority on providing services for men.

  • The Lifeline counselling hotline would be expanded
  • The Beyond Blue organization would be given funds to target men with depression Programmes would be made available to students through schools.

Money was given for research and a proposed service model was drawn up and launched in 2012, initially as a recovery programme, which then led on to a recognition for the need for preparedness. There is now a coordinator in every state and territory.

In Dec 2014 Julia Gillard joined the board of ‘Beyond Blue’. She said “as the daughter of a psychiatric nurse, I have always understood the need to talk openly about mental health and respond to those in need”.

Funding and Services

It is not surprising that large well organized agencies attract more funding. Australia has well developed mental health services and a lot of government funding has gone into organizations like Headspace, Beyond Blue and MindMatters, all of which seek to address the mental wellbeing and resilience of young people, either as a preventative to suicide or as a support after suicide. Headspace in particular has grown rapidly with its full government funding, with 100 Headspace centres nationally, 200+ staff in the head office and 2000 schools it has worked with. But these large services are often about facilitation and information and there is a lack of services to refer on to for direct support. One person I met in New Zealand commented that there are ‘leaflets, leaflets, loads of glossy leaflets, but no one actually works with families’. Large national organizations are better funded and often highly manualized. They have less understanding of direct work and less ability to connect with the local community, although they attempt to overcome these by referring on and by embedding the service in local organizations.

Those organizations that do work directly with children and families, such as the Jesuit Social Services Support after Suicide, and the Centre for Childhood Grief in Australia, Barnardos in Ireland and The Grief Centre in New Zealand, have a wealth of knowledge and experience in supporting children, but are small and find it difficult to attract funding.

It was striking that where Government funding has continued, albeit on a year to year basis, in Australia and Ireland, suicide support services have thrived, whereas in New Zealand promising initiatives and projects have floundered through lack of funding, and experienced staff have become demoralized or lost their jobs. The Ministry of Health is presently discussing the next 10 years for the Suicide Prevention Strategy in New Zealand and many professionals are waiting for the outcome of this. It is problematic that in New Zealand there is a political argument between government departments as to whether suicide is social or a mental health issue. I was told that no government department wants to be responsible for suicide prevention. They have done the research, written a document and an action strategy, but leave District Health Boards to put this into practice, which has led to a fragmentation of suicide support services in New Zealand.

What I have learnt from this is that in the UK we need to try and get a balance between large scale facilitation, which can co ordinate services at the national level but will be less responsive to local needs, less personal and more bureaucratic; and small scale direct work, which can provide very good practice,  expert knowledge and a high level of satisfaction for both those who receive and deliver services, but which find it hard to attract funding or offer services over a wide geographical area.

I was informed by a number of people that the Australian government is keen to fund e-programmes. One example of these is eHeadspace, which enables young people equal access to a service where they can email, phone or skype with qualified mental health professionals. Similarly in New Zealand 185 of 300 secondary schools are signed up for the ‘Travellers’ resilience programme developed by the child bereavement organization ‘Skylight’. Schools are trained to run the training and the whole cohort of year 9 pupils complete an online survey. On the basis of this high scoring pupils are offered counselling, medium scoring pupils are offered the Travellers course and low scoring pupils have anything of concern addressed.

Academic Rigour

Governments need convincing with evidence and good collection of data and successful projects are often evaluated by external bodies, such as universities or research institutes and have research evidence to highlight the need and show that costs of preventative services are less than the costs of doing nothing, e.g. hospital admissions, working days lost, and mental health. A good example of this is an influential study in Australia that did exactly this and helped deliver funding to the national organization StandBy. (‘Cost Effectiveness of a Community Based Crisis Intervention Program for People Bereaved by Suicide’. Tracy Comans, Victoria Visser and Paul Scuffham). In Ireland the National Suicide Research Foundation in Cork is an independent research unit which undertakes research into topics relating to suicide to provide the knowledge base for suicide prevention, intervention and postvention strategies.

In Australia there is a strong connection between research and practice, this makes the sector very vibrant and services well grounded in evidence and theory. The Hunter Institute of Mental Health in Newcastle, Australia focuses on research on the development of services that have a practical application in mental health, developing projects in relation to organizations on the ground that can carry them out. Jaelea Skehan, the director, is passionate about translating evidence into practice and finding better connections between research and practice. She believes there should be a middle ground between practitioners and researchers with a constant flow in both directions. The Institute of Suicide Research and Prevention at Griffin University in Brisbane has a taught Masters degree and Diego De Leo, it’s Director from  1998-2015, has been influential for a number of practitioners in their work in suicide pre or postvention. Griffin University in Brisbane Directs the WHO Collaborating Centre on Research and Training in Suicide Prevention.

This has also been true of the Irish National Suicide Research Foundation, which has worked in conjunction with those who are developing services for support after suicide in Ireland, while In New Zealand Chris Bowden, lecturer and researcher at Victoria University of Wellington  worked with Skylight to develop the Waves psycho-education programme, while also completing his own PhD on young men’s experiences of losing a close male friend to suicide, and Annette Beautrais and Prof David Fergusson at Otago University were joint authors of the New Zealand Suicide Prevention Strategy 2006-16 and were involved with the Christchurch Suicide Project.

On the service side in Australia there is a high academic level among practitioners, with many having Masters in Suicidology or a PhD related to their work in suicide. Some are working towards professional doctorates at the same time as working. Several PhD students are being supervised by Dr Myf Maple, associate Professor in the School of Health at the University of New England (UNE). The UNE works with four other universities and a local health district as part of a Collaborative Research Network (CRN) on mental health and well being, which has attracted $4.8 million funding from the Australian government. This means that research is joined up and has a strong profile. As mentioned in the blog of Sharon McDonnell, Honorary Research Fellow at Manchester University and Churchill Fellow, on April 4th 2014, ‘it is possible to suggest that Myf’s postvention department is a virtual one, in that many of her staff are PhD students and study via distance learning. It is commonplace to hold meetings via a video link’. This is a practical response to the vast distances in Australia.

I believe this interrelationship between research and practice, with movement in both directions has greatly helped practice to be grounded in research and research to be based in practice, and has given credibility to both. Governments are more likely to fund joined up working and more likely to be convinced of the importance of funding research that leads into the development of services that are effective, and the efficacy of funding practice that is evidenced by research.

Working in Partnership

I came across many examples of collaborative working which must inevitably aid the development of good joined up services for those who are seeking support after a suicide. Organizations working at a national level, such as StandBy and Headspace, do so by having a Memorandum of Understanding with local partner organizations and arrangements whereby coordinators of services meet together and train together. In the district around Melbourne Headspace do more general work in schools but refer children to the Jesuit Social Services Support after Suicide for direct work with individual children. This not only encourages cooperation but also develops an understanding of each other’s services. In Australia information about The Centre for Grief and Bereavement is given to families by funeral directors.

In all three countries the fact that coroners report deaths by suicide to those organizations providing services makes an enormous different to their ability to offer services, as people are less likely to fall though the net.

  • The Centre for Childhood Grief in Australia works together with the local coroner to run a ‘Support after Suicide Group’ with social workers from the coroner’s office. This group is funded by the coroner, who also provides the venue.
  • StandBy was initiated by the coronial service and the police, which has meant an ongoing positive working relationship between the different agencies.
  • The Department of Forensic Medicine in Newcastle works closely with coroners.
  • As a Regional Suicide Postvention Coordinator in Wellington New Zealand Jennie Jones is informed of every suicide by the coroner, who gives basic information, and by the police who share more details through an encrypted site.
  • Victim Support, who offer a service to those bereaved by suicide in New Zealand, also commented on the enormous advantage of being informed of deaths by the coroner.

This is an area that clearly needs a lot of attention in the UK, where contact with local coroners is patchy and sensitive.

Many different professionals are involved after a suicide, e.g. fire service, police, ambulance service, clergy, GPs and funeral directors. The most successful organizations had worked to get each profession onboard at a high level, in order that cooperation and good working relationships percolated down throughout the organization, and maintained these by good networking, joint training, clear guidelines and protocols. These are often brought together in manuals. Having a facilitator whose task it is to put all these things into practice seems also to be the mark of a successful service.  Prime examples of this are StandBy, the Mayo project in Ireland and the work of the Suicide Postvention Coordinator in Wellington.

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Developing a Model

Those organizations that have been most successful in growing and attracting funding have developed clear models of working based on research and evidence.

Services for the prevention of suicide and support after suicide are gradually being coordinated and strengthened in the UK through the coming together of different working partnerships, some in local areas and some nationally. Decisions need to be made on finding models of working that are most effective in our own circumstances in the UK.

As the provision of support after suicide in the UK is developed it is vital that the partnerships of organizations involved have clarity around the models that evolve from their collaboration, with clear theoretical underpinning, evidence for the efficacy of the model from pilots or other examples, and hold fast to best clinical practice as far as possible.

I saw several different models in the course of my Fellowship.

Direct work with families and children

For example,

  • Jesuit Social Services Support after Suicide in Melbourne.
  • The Centre for Grief and Bereavement, Melbourne
  • The Centre for Childhood Grief, Sydney
  • Skylight in New Zealand
  • Barnados in Ireland
  • The Mayo Project, Ireland

The mark of these organizations is high quality work, long standing experience and a real knowledge around suicide and it’s affect on individuals, families and society. These organizations are small and find it difficult to grow because of precarious funding and are fearful they may lose out to other organizations ‘that are better funded, better marketed and more glossy.’

The use of professionals who have another main job but an interest in suicide

These professionals are paid to offer counselling or run groups. This enables organizations to get input from professionally qualified people, but sometimes means these professionals have less experience in working with those bereaved by suicide.

StandBy refers children who need a level of expertise beyond what they can offer to specialist child counsellors they have an ongoing working relationship with. They provide training around the impact of suicide for these counsellors. They provide similar training to those who provide supervision to staff.

Chris Bowden, lecturer at Victoria University of Wellington, helped Skylight develop their group programmes and supervises students who are doing Masters on the work of groups. He co facilitated the Waves adult grief education programme for many years and now conducts research on the programme and its impact. He is now researching similar programmes for children. He will also work with individual families if needed.

The Grief Centre in Auckland contracts self employed counsellors to work with bereaved adults and young people.

Offering qualified professionals internships

This is a model used by The Centre for Grief and Bereavement in Australia. Professionally qualified interns go through an accredited grief training which is run by the paid counselling team of the organization. It gives interns access to training and 80 hours of supervised individual work, and it gives the organization a stable, qualified workforce, especially as many of those trained stay on with the organization to work as volunteers.

Through the use of volunteers

This seemed to work well where volunteer numbers were small, well trained, well supervised and integrated into the team. e.g. Barnardos in Ireland.

It appeared to provide a poor experience for those receiving a service when there was an unmanageable number of volunteers who were not sufficiently trained, prepared or supported, or given appropriate work, e.g. Victim Support, where volunteers may attend the scene of death and families report poor experiences.

Setting up national Drop In Centres

This is a model used by Headspace designed to offer easy access for young people to local services. It is often run by a local lead agency that is familiar with the local area and resources.

Community Postvention Response Model

These are services specifically set up as a community response to a suicide and is their main aim and function. StandBy in Australia, the Regional Suicide Postvention Coordinators in New Zealand and the Mayo project in Ireland are all examples of this type of model.

Features of this model are:

  • a clear protocol for responding to a suicide
  • the coming together and coordinating of all responders to a suicide
  • the gathering and sharing of information in order to make a coordinated response
  • a coordinator to drive forward and coordinate the response to avoid duplication or confusion.
  • work with the local community to train and support those around the bereaved e.g. families, workplace, neighbours, community, school, local professionals
  • a standardised information pack for the bereaved
  • a clear structure that is replicable

Observations

Each organization that tries to address the needs of those bereaved by suicide has grown from different roots and has a different emphasis, and all are influenced by the level of funding they can attract. Some approach it from the angle of mental health, some are influenced by their geographical location, some have evolved into a specialised service from other more general services and some have developed an area of expertise within a specialization of working with children. The Community Postvention Response Models stand apart in being set up with the sole aim of providing postvention support, and drawing in all the different agencies and professions to provide maximum support at the grass root level. Because it has protocols and a coordinator it can respond immediately with an ever increasing knowledge and experience base. It has the capacity to provide training at different levels and support to those who respond, and because it is embedded in the community knowledge is hopefully disseminated and resilience is built up.

My Fellowship was primarily aimed at researching how children are supported within the models that have been developed in Australia, New Zealand and Ireland. Those who had most knowledge and experience of supporting children after a suicide were small specialist organizations undertaking direct work with children. Large national organizations felt they lacked the expertise to support children, although may have specialist counsellors or therapists who work with children to refer on to. Most interventions were aimed at adults, with the hope that it would percolate down to benefit any children in the family. More organized responses are available for schools after a death.

In New Zealand there is a worrying acknowledgement of lack of skills to support children, and lack of confidence to develop these skills. One centre said they wouldn’t know who to refer children to and that it is difficult to maintain standards as there is no solid base of training. In Ireland it appeared that better support is available for children after a suicide in organizations orientated towards children e.g. Family Centres and Barnados, where there are specialist children’s therapists. Family Centre therapists in Mayo who work in the same venue as the Suicide Liaison Officer (SLO) have agreed to prioritize suicide bereavement referrals, and the SLO is confident in their work.

As a result of my visits to a large number of different organizations I am now convinced that in developing services that support people after a suicide in the UK we need to work towards more interaction between adult and children’s services, so that the learning embedded in children’s bereavement services can be utilized by those supporting adults, to the benefit of the many children who may be part of those families but not receiving a service in their own right.

Liz Koole

Churchill Fellow 2015

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