Deconstructing the First WHO Suicide Report

  • Over 800,000 people die by suicide each year, around one person every 40 seconds. 
  • 75% of suicides occur in low and middle income countries, although the actual rate of suicide is greater in high-income countries. 
  • Suicide is now the second leading cause of death in 15-29 year olds. 

In time for World Suicide Prevention Day, the World Health Organisation has released its first international suicide report, calling for large-scale strategic action to address a “global imperative”.

Its central advice is that all countries ought to have a national suicide strategy that focussed on restricting access to the ‘means for suicide’, equipping health services to better identify and respond to suicidal risk, and influencing culture to challenge stigma and increase ‘help-seeking behaviour’.

Perhaps surprisingly, given that the report divided nations by income, there is no substantial analysis around global socio-economic factors, or even why the suicide rate appears to be greater in high-income countries. Nor is there analysis of why so many young people should be suicidal.

The report steers clear of discussing current economic situations, unemployment levels, and global conflicts, despite each of these being strongly linked to suicide. Its recommendations are principally concerned with intervention at the point between suicidal ideation and the act of suicide, and not with prevention of suicidal ideation and related illnesses and conditions.

Necessarily, the report has to limit its focus. But in ignoring global events that may be increasing the risk of mental illness and suicide, the report seems to be in conflict with the whole-systems approach to health that the World Health Organisation has been advocating since the 1980s.

On the selfishness of suicide

“I cannot make you understand. I cannot make anyone understand what is happening inside me. I cannot even explain it to myself.”

Let’s say sweeping leaves is ‘leavish’. And chopping wood is ‘woodish’. In the same way, we might say suicide is selfish. The action necessarily involves the self.

But the word ‘selfish’ has moral connotations. It doesn’t just imply paying attention to the self, it suggests a kind of self-interest and disregard for others that exceeds moral norms, even by the narcissistic standards of the West.

From a logical point of view, it makes no sense to describe suicide as selfish. Suicide extinguishes the self. What could be more at odds with the interests of the self than its annihilation? To the degree that the action achieves nothingness from self, it’s better described as non-selfish.

But those making moral judgments about suicide are not speaking from a logical point of view, just as those suffering from suicidal depression can find themselves caught up in beliefs that defy reason. And those that hear such claims, and feel hurt and angered by them, would do better to consider that such judgments may be coming from a place of deep anxiety and trauma rather than careless ignorance.

Many of those who make moral claims have witnessed the pain that suicide can cause to those left behind, and find it hard to understand why anyone would inflict this upon others. To live is seen as the easiest of things, and to die by one’s own hand, the most destructive to others. In this respect, the biases of those making such a judgment are a mirror image of the biases of the suicidal.

Those making moral judgments may look at the suicidal or clinically depressed and deplore their preoccupation with self, but such self-occupation comes not from volition but compulsion, as if, like the protagonist in Kafka’s Metamorphosis, we have woken up to find ourselves suddenly set apart from others by some hideous and shameful peculiarity. No cause is more desperate than to diminish this uncompromising sense of differentiation. Suicide follows when all other attempts to return things to a sense of natural order fall short.

Speak to someone bereaved by suicide and, in spite of their grief and confusion, more often than not they will describe the deceased as having been someone who was exceptionally concerned for the feelings of others. Clinical depression feeds on the compassionate. It latches onto a concern for others and uses it as a weapon with which to bludgeon the self into submission.

Suicide necessarily concerns the self, but it is the least self-interested of acts. As in other areas, the person left most exposed to criticism by ill-founded moral judgments is the judge.

The rise of 'hapitalism', and what can be done

Hapitalism (hap-i-tal-ism)
noun (portmanteau of ‘happy’ and ‘capitalism’)
An economic system based on a state measuring collective happiness in a way that encourages a level of individual competition and inequality typical of unregulated, free-market capitalism.

Yesterday, I wrote something for the Huffington Post exploring the correlation between happiness and suicide rates in US states (and nations). In it, I raise concerns over a developing ‘hapitalism’ in which average happiness levels are raised by sacrificing the happiness, and, in some cases, lives, of a minority.

A central principle behind capitalism is that free markets allow for economic growth and that this benefits all of us on condition that interventions such as taxation and public services exist. In the same way, happiness advocates argue that an increase in gross national happiness will benefit us all. The problem is that, as the happiness-suicide correlate indicates, conditionals are also needed to ensure that a rise in GNH benefits all. I’ll look more at these conditionals shortly.

The importance of conditionals in a happiness economy risks being overlooked due to happiness being seen as an intrinsic moral good. On the surface, an increase in the happiness of a group seems like a good thing, but the problem is that an increase in average happiness can be attained even if one member of the group has come to find themselves in extreme suffering. The tendency to assume that we can draw conclusions about individuals from the condition of a group is known as an ecological fallacy.

The appropriateness of equating a capitalist economy with a happiness (‘hapitalist’?) economy depends on the way in which individual ‘growth’ occurs in the two types of economy.  In my blog post, I explore the idea that the happiness of some may be directly enhanced by the suffering of others, and that those who are suffering may feel worse by comparing themselves to happy people (hence a correlation between happiness and suicide)*. If this is an accurate description, then, just as capitalist societies tend to favour the wealthy and may widen inequalities of wealth and income, a happiness economy may widen the wellbeing gap between the happy and unhappy unless interventions are in place to help encourage the reverse.

Interventions

1. Improving happiness indicators
For happiness indicators to be a measure of the wellbeing of all, they need to focus on more than just aggregating individual happiness. The economist Sagar Shah suggests that this might be done by also looking at the ‘features of a society’, or by giving higher weight to those with ‘lower well-being’. Discrediting simplistic aggregated measures of happiness may also be an important step.

2. Improving communication
Those writing, speaking and teaching about happiness ought to appreciate the degree to which suffering is unavoidable, and to be mindful of the impact of their words on those who are suffering. Proponents of positive psychology tend to use Martin Seligman’s theories of learned helplessness and learned optimism to argue that we all have influence over our wellbeing. This can be a message of hope and encouragement to some, but it may also dishearten those with poor wellbeing. Whilst our perception of suffering may influence our ability to move on from the situation, the presence of suffering is often a normal and healthy reaction to adverse stimuli. (Try being happy when you’re repeatedly being subjected to electric shocks.) If we deny this, we risk stigmatising something that we will all experience at some point in our lives.

3. Improving policymaking
All official happiness policy should factor in public health principles, and any messages or interventions designed to boost collective happiness should consider implications for mental health and suicide-prevention. Economists and policymakers should be liaising with public health professionals — and also vice versa; as the World Health Organisation reminds us, “Health is created and lived by people within the settings of their everyday life; where they learn, work, play, and love.”

 

*This may only be the case for people, communities and societies that are driven by competition and comparison. In fact, research from Japan suggests that happier people are kinder.

Higher Education Propaganda: Bringing Lobbying Groups to Task

Originally published as ‘How Propagandists Manipulate the Facts to Sell the University Dream’ at HuffingtonPost.com.

It was the blog‘s lackadaisical attitude towards student wellbeing that got to me. The way it claims that higher education has “been shown” to benefit the ‘health and well-being’ of students, without providing a shred of evidence (and in the face of thisthis, and this). But it’s the misleading employment claims that show how far propagandists are prepared to go to sell university places.

For those that are unaware, Universities UK is a membership charity that (as you might guess from the name) acts on behalf of the majority of the UK’s universities. The aims of the organisation (which recently came under fire for its stance on gender segregation) include to “support universities in their primary aims of educating students, carrying out research and innovation, and strengthening civic society”.

The blog post in question was written by the Universities UK ‘Policy and Data Analyst’ and uses new ONS data to make a number of claims, including that those with a degree have a lower unemployment rate than those whose highest qualification is an A-level. Unfortunately that’s not what the data shows.

The first page of the ONS report states that the graduate figures refer to all those who have been through higher education, including recipients of diplomas and certificates typically awarded to those with professional experience. For instance, the Chartered Management Institute offers a Level 7 Award to senior managers. It’s not really surprising that for those with such an award unemployment should be low. We can assume, then, that had the unemployment figure only related to those with degrees, it might have been considerably higher. Of course, those casually reading the blog won’t know this. They’ll assume that the author of such an authoritative blog has got the facts right.

For an organisation that describes itself as “the voice of UK universities” it’s embarrassing that their official blog features such an obvious misuse of data. At best it’s carelessness, at worst, a deliberate attempt to foil the public. Let’s give them the benefit of the doubt.

Further claims in the blog relate to average salaries. Glancing at the impressive graph gives the illusion that graduates in their forties have average earnings twice as high as non-graduates, and that the data is a good prediction of what today’s graduates can expect in the future. Neither is true.

In his bestselling book, The Black Swan, statistician Nassim Taleb discusses the problems with using averages, warning, “don’t cross a river if it is four foot deep on average”. Those university candidates looking at average earnings data as an indicator of their future prospects should be just as wary – not only because of the issues with averages, but because of the changes in the jobs market over the past twenty years.

The highest earning university graduates, who are in their early-forties according to the graph, graduated at a time when the jobs market and economy were completely different. The proportion of the labour force with a degree has (according to the Guardian) doubled in twenty years, slashing the usefulness of a degree as a way of differentiating between job candidates. Additionally, economic turmoil and the shift towards a ‘knowledge economy‘ have created a skills gap that has forced almost half of graduates into non-graduate roles. The effect on average earnings is that, according to the same ONS report, 21-year-olds with an apprenticeship are earning more than 21-year-old graduates.

None of this is to say that university is not worthwhile for many. Of course it is. But to judge the value of a degree based on the success of those who graduated twenty years ago is like using a 1993 edition of the Financial Times to pick investments. Those considering university would do far better to ignore the propaganda and do their own research.

Even China admits that its schools have been damaging students. So why is the UK trying to emulate them?

‘The grass is greener on the other side’, or so Minister of Education, Elizabeth Truss seems to think. Next week she will be travelling East to see what can be learned from Shanghai’s schools.

In the latest PISA report into maths and science education, Shanghai once again topped the global charts, with children performing approximately 3 years above the international average for maths. By all statistical measures, Shanghai students seem to be “streets ahead” of their Western peers (as Truss puts it). But it’s far from being that straightforward.

The success of Chinese schools has come at a heavy cost. Student suicides, linked to long hours and intense pressure, are rife, and measures to try and curb the issues have been being gradually introduced for the past few years – such as with the rolling out of student counselling services and mental health education.

After broad reviews under the new Chinese government, involving examining education systems in 10 countries, last year the Ministry of Education announced plans for root-and-branch education reform. Long hours would be cut back, free time extended, focus would move away from standardized testing and a more holistic, softer flexible evaluation framework would be introduced; one that placed greater emphasis on the emotional and social skills of young people.

Concern over the mental health of young people wasn’t the only reason for the reforms. For a nation that boasts some of the world’s most important inventions, the last century or two has been a barren period for innovation; something that the current regime is keen to address. As the country gradually opens itself up to the rest of the world, China wants to have more to offer than just manufacturing – a function that will become increasingly redundant as incomes rise and sources of cheap labour diminish.

China’s review of education systems worldwide concluded that in order to boost innovation, it needed to pull back on productivity, and reorientate towards an appreciation of free time and spontaneity. That these should underpin creativity might seem obvious. But as China recognizes the role of soft power in the global economy, it seems strange that the UK seems so intent on moving things in the opposite direction, apparently oblivious to the impact that a pressure cooker education system has on the wellbeing and creativity of young people. So why are they doing it?

The paranoid might claim that the British government’s intentions are to decrease youthful dissent and create a more compliant generation, more willing to submit to authority – attributes that many associate with Chinese citizens. But the apparent intent on mimicking Shanghai’s education approach seems more like a lack of imagination on the part of the British Department of Education, and a confusion over what role they expect British graduates to play in global society. The relationship between China and the West, that, for decades, could be described as China copying a ‘visionary’ West, seems to have come full circle.

If we follow Shanghai into pushing rote learning of maths and science before all else then it seems that the only hope for Britain’s artistic, creative and entrepreneurial legacy is with those who manage to escape the education system early. As for the health and wellbeing of young people, well, we’d better start training more therapists now.

Is Higher Education an "Excellent Investment"?

In November, Universities UK, the higher education advocacy group, published a blog post entitled ‘Higher education is an excellent investment, even in an economic downturn’. The post is basically an advert for university, albeit with a number of questionable, and, at times, frankly, embarrassing claims.

Yesterday their social media team tweeted the post as the deadline for applications approaches, presumably aware that November applications were down on the previous year. I wouldn’t normally be critical of a blog post, but let’s take a look at its main arguments:

1. “Those with a degree are more protected from the recession than those without.”

The author refers to data from the ONS indicating that graduates enjoy a higher employment rate (87% versus 83%) and lower unemployment rate (4% versus 5%) as compared to those whose highest qualification is A level standard. Leaving aside the fact that the percentage differences seem pitifully small (particularly considering that graduates are more likely than non-graduates to have middle-class parents who are in a position to help them find work), a simple bit of background reading appears to show that the evidence doesn’t support the conclusion.

The ONS report clearly states on the first page that its definition of a graduate isn’t just those with degrees (as the author suggests) but also “those with higher education”, which covers all sorts of vocational awards and certificates that can be granted to those who are already established within a field. It’s not hard to get work after graduating if your employer is paying for the qualification.

Looking more closely at the ONS report, a crucial piece of information that the blog post doesn’t reveal is the nature of the employment. According to the ONS report, almost half of recent graduates were working in a non-graduate role (i.e. one that didn’t require higher education or a degree). They might, for example, be pushing trolleys in a warehouse. (Use of warehouse safety helmets is probably not the kind of “protection” the author wanted us to have in mind.)

2. “The profile of earnings for graduates is rising much more quickly than for non-graduates, and graduates are earning more than non-graduates over their lifetimes.”

The author displays the difference in earnings through an impressive adaption of the ONS’s chart, which – by narrowing the x-axis, starting the y-axis at £10,000, and removing apprenticeships from the chart altogether – makes it look as though graduates are very quickly earning more than twice as much as non-graduates annually. The problem with the graduate earnings data is that it’s largely meaningless. Not because it’s untrue, but because it’s based on the average earnings of graduates.

If there are four recent graduates in a room, each struggling on £10,000 a year, and a fifth graduate earning £110,000 a year walks in then the average earnings of the group will jump from £10,000 to £30,000.  This is unlikely to console them. As Fraser Nelson points out, the highest-earning professions – including law, medicine, and dentistry – tend to require degrees, skewing average earning figures for other graduates. Then there is the discrepancy between institutions, and the impact of unusually wealthy graduates.

The other reason why those thinking of applying to university should be extremely sceptical of the average and lifetime earnings data is that those at their peak earning age (of around 40) graduated in a completely different economic environment. University degrees were still relatively unusual, with 12% of the UK population having degrees in 1993, compared to 25% in 2010 (according to the Guardian) and only 19.3% of students participating in higher education in 1990 (according to this parliamentary report) compared to almost 50% today. The earnings data also doesn’t account for the negative impact of struggling to find work during a recession (which has been known as the ‘scarring effect‘). In short, the data is virtually useless as an indicator of what today’s graduates can expect their average earnings to be in twenty years.

The ONS’s average earnings data does have some use, though. It shows that a 21-year-old graduate earns on average less than a 21-year-old with an apprenticeship – a fact that’s unclear from the blog post’s chart due to it conveniently leaving out apprenticeships.

3. “There is personal benefit in attaining higher education, which has been shown for many aspects of life, including health, well-being and personal development.”

This is the part that really got to me. At least with the other claims, the author refers to some evidence rather than resorting to saying only that it has “been shown”. Let’s look at what’s been shown for a moment.

  • – Demand for support services has risen by nearly a third since 2008.
  • – Student suicides rose by 49% between 2007 and 2011.
  • – In an NUS survey of 1200 students last year, 80% reported feeling stressed and 13% claimed to have had suicidal thoughts.

Evidently the well-being benefits of higher education are not as clear-cut as the author might like to think.  The author’s half-hearted attempt to suggest otherwise, which reads more like an afterthought than a genuine point, is an indication that Universities UK does not see the wellbeing of students as a priority issue (despite its relevance to the ‘lost generation‘ claims that the author refers to).

Although Universities UK hosts a Working Group for Promotion of Well-being in Higher Education, the group receives no funding or advocacy support and is run by charitable university support staff in what little time they can find around very demanding university roles.

4. “Society as a whole also benefits by greater engagement through civic engagement, citizenship and lower crime rates, as described in the recent BIS report. It is clear that higher education is not only a good investment for those individuals who directly go to university, but it is a good investment for the UK’s economy and society too.”

Actually, most of this is probably true. Having more young people in university probably does increase ‘civic engagement’ and deter people from questioning authorities and institutions. And it probably does support the economy, at least in appearance (and until the next financial crisis).

But for those weighing up whether or not to go to university, these factors should be completely irrelevant. You should dismiss them, just as you should all the other misleading claims about higher education being a good investment. If you decide to go, go because it’s what you really want, not because you think it’s a safe option or that it’s expected of you. And certainly not because it will make you a ‘good citizen’.

For ideas about alternatives to university, take a look at www.notgoingtouni.co.uk

Edit
The Universities UK blog post was edited after this post was published, and now includes the following: “(chapter 3 of the supporting analysis for the higher education White Paper 2011 summarises some of the studies done on the wider benefits from higher education).” Unfortunately for Universities UK, the White Paper contains no evidence of the benefits to “health, well-being, and personal development” that the blog post claims have “been shown”. They have not responded to a requests for comment.

How China is addressing student wellbeing

The Chinese government has been taking major steps to protect the mental health of its students, an investigation has revealed.

Interviews with the Ministry of Education and a leading figure in student counselling have revealed that since 2011 all universities have been expected to start providing their students with compulsory mental health classes. The policy was introduced after more than a decade of lobbying from student support staff and ministry officials, and is aimed at helping students cope with academic pressures and to manage the transition into the working world during a period of global economic unrest.

In a story published in the China Daily earlier this year, Guirui Lin, Head of Counselling at Capital Normal University, raised concerns about the resources available to student counselling services. But a meeting in Beijing last month painted a more optimistic picture: “The majority of university students in China now have access to classes in mental health, and faculties are being trained to care for the psychological health of their students. Many students are also being trained to be peer counsellors, and every year on May 25th we hold a Mental Health Day which features a wide range of mental health education activities.”

At Guirui Lin’s institution, Capital Normal University, students are required to participate in 18 hours of mental health training per semester. Documents received by mwproject.org show that the classes cover a wide range of areas relating to student wellbeing including the Signs and Symptoms of Mental Illness, Managing Emotions, Adapting to College Life, Sexuality and Gender Issues, Dealing with Perfectionist Tendencies, Suicide Prevention, Healthy Relationships, Dealing with Setbacks, and Career Planning. Guirui Lin insisted that it was important that mental health classes be compulsory in order to reach all students and not just those with a pre-existing interest in the subject.

Wang Dinghua, China’s Director General for Basic Education, reiterated the importance that the government is placing on students’ mental health as part of reforms designed to shift emphasis away from standardised testing in schools: “We are providing funding and technical assistance to improve mental health in schools in 20 pilot areas…Within 5 years, we expect all schools to be providing mental health education.”

‘Student mental health not our responsibility’, says British government

In response to a letter enquiring into how the government is ensuring that students receive adequate support, the Department for Business, Innovation & Skills advised that the responsibility for determining student support rests with educational institutions.

The department’s response, received by email on July 18th, stated: “HEIs are autonomous bodies, independent from the Government.  They have legal responsibilities under the Equality Act 2010 to support disabled students in higher education, including those with mental health conditions but it is for the HEIs themselves to determine what welfare and counselling services they need to provide to their students to offer that support.”

The letter had been sent to David Willetts, minister for universities and science, and called on the government to provide funding for a national body to monitor student support and advise institutions, in light of the recent increase in student suicides, and an NUS survey earlier this year. The department replied, “Whilst we have noted and appreciate your suggestion, this is not something we can consider at the present time.”

The response also noted that, despite the independence of HEI’s, the government was providing a “comprehensive package of financial support to ensure that Higher Education (HE) students with disabilities, including those with mental health problems, receive the best possible support”. According to the department, this amounted to £109.2m being allocated to English students claiming Disabled Students Allowance in (2010/2011), and £13m to HEIs (2011/2012).

The total amount allocated in 2011/2012 by HEFCE to FE & HE institutions was £6507m.

Canada: Huge survey into student mental health forces action

In a survey of more than 30,000 post-secondary school students in Canada, across 34 institutions, 9.5% of respondents stated that they had “seriously considered taking their own lives in the past year”, The Province and The Star reported. A guide has been released to help institutions take action.

The survey, which was led by the Canadian Organization of University and College Health, also indicated that 89% of respondents reported feeling overwhelmed by “all they had to do”, 54% reported feeling hopeless during the last 12 months, and 64% had felt lonely. The survey findings echo a similar survey from NUS in the United Kingdom, in which 13% of the 1,200 respondents reported having had suicidal thoughts.

Following the release of the survey, the Canadian Mental Health Association (CMHA) and the Canadian Association of Colleges and University Student Services (CACUSS) has launched a guide to help institutions take action to address student mental health using a “systemic” approach. The guide is based on three years of work, and input from hundreds of professionals and students.

Openness By Whom And Of What?

In preparation for a talk last week entitled, ‘Mental Health: How Do We Encourage Openness And Meet Higher Demand For Services?’, there were two questions that seemed particularly topical. The first was, should we encourage openness around mental health if services can’t meet demand?

I had put the title of the talk to my Twitter followers, and one student suggested that we shouldn’t encourage openness if services are inadequate because we’ll “just be letting students down”. The assumption seems to be that the only reason for openness is to encourage use of services; this might be one reason, but if we’re talking about openness in a general sense, then there are many more that are just as important — some of which follow.

As another Twitter follower noted, there is a need for more understanding of self-care – something which openness ought to encourage through the sharing of information and resources. Openness can also improve the fit between students and services by educating students about the most appropriate service for their needs. Openness means services get more of those most in need, and less of those that would benefit from other services or that can figure out a solution themselves.

If openness increases demand for services, it also puts more pressure on those in a position to fund services. More shameful than an inability to meet demand is the concealment of insufficiencies, because it lifts pressure from those tasked with allocating resources.

I noted in my talk that the term ‘openness’, as used in the context of student mental health, needs to be unpacked. There are different things we might be open about – namely our mental health, or mental health in general; and there are is openness with different people – our friends & family, or institutions & authority figures. Then there is, of course, the matter of who’s being open. In this case, we’re mostly talking about the need for students to be open, but it’s equally as important that institutions are being open so that students can make informed decisions.

It’s the under-appreciated complexity of openness that leads into the second question: Why should students be open? (I’ve addressed this question before in the context of disclosure rates.)

Since the Royal College of Psychiatrists’ report on student mental health in 2011, there have been calls for institutions to be more honest and open about their support provision and commitment to students’ welfare by publishing a formal and publicly available mental health policy. (Annie Grant of MWBHE is currently surveying universities to find out how many have policies in place, and hopefully the results will be available before the end of the year.) The most important reason for such a document is that, without one, it’s very difficult for institutions to be held to account; not just by those outside of the institution but by themselves.

A mental health policy is also a statement of intent and a commitment to being open and transparent. If institutions are not being open about what they can and cannot do, it’s hardly surprising that their members might also want to withhold information about themselves.

The powerpoint presentation from my talk can be downloaded here, and an action plan for building a ‘whole-institution approach to wellbeing’ is available here.