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The event brought together people working with and affected by suicide to discuss and develop the approach.
In line with our focus on the social and cultural contexts in which suicide is embedded, I presented some reflections on the relationship between forms of social-political and cultural ‘crisis’, including austerity, the cost of living crisis, transphobia, and suicidal crisis. I asked what the use of the term ‘crisis’ might conceal, particularly in relation to how many people’s experiences of distress and suicidality are bound up with longstanding, slow and more ‘unspectacular’ forms of violence, including being slowly ground down by unfeeling or uncompassionate structures, day by day.
Drawing on the idea of “creating a radically different cultural landscape”, as highlighted in the Time Space Compassion report, my presentation focused on some examples from ongoing ethnography with a community-based organisation, which I have pseudonymised as In the Open. In the Open provides support for people with enduring mental health challenges, through what I argued is a socially compassionate approach.
This included examples of:
forms of accompaniment offered by In the Open staff, though which they support people to access health and other forms of care
how In the Open operates as a space of inclusion and belonging for people who, for various reasons, are socially excluded and may even be positioned by other institutions and social structures as ‘burdensome’
how the long-term nature of the support that In the Open offers allows for the development of supportive, caring and trusting relationships between the members of the group, as well as with staff members
I also shared an example of the systematic denial of compassion to certain people, based on our analysis of the Fatal Accident and Sudden Deaths Inquiries (FAIs) of deaths by suicide that occur in Scottish prisons. My presentation reflected on how in these reports, many people who have died by suicide in prison are constructed as ‘difficult’, ‘non-compliant’ and ultimately ‘unhelpable’. I argued that many of these inquiries fail to engage with the broader uncompassionate environment of the prison and how this contributes to people’s distress and even death.
My presentation ended by asking people to think about and share examples of other socially compassionate or uncompassionate spaces and how these may be related to suicide or suicide prevention. This was taken up in smaller group discussions following my presentation.
Later in the day, I was in conversation with Haylis Smith, discussing the Time Space Compassion approach:
In this post we continue with a discussion of some of the ethical challenges we are encountering as part of the Suicide Cultures project. Here we will focus specifically on the ethical challenges of working with the Fatal Accident and Sudden Deaths Inquiries (FAIs) of people who have died by suicide in prison. This post is intended as an explicit and transparent reflection on the complexities of issues of anonymization and an ongoing thinking project about issues of care, privacy and critiques of institutional framings of suicide. The reflections we present here have been born out of many discussions within the Suicide Cultures research team, as well as consultation with Sarah Armstrong, Linda Allan and Betsy Barkas, who are also working with FAIs.
As part of the Suicide Cultures project we are conducting an analysis of all the FAIs of deaths in prison due to suicide in Scotland from 2016 until the present. Prisons have been identified as having high rates of suicide (Tomczak, 2018; Zhong et al., 2021). Scottish prisons record higher rates than those in England and Wales, although there are a number of issues which make comparisons problematic (Armstrong & McGhee, 2019). Given that prisons are significant sites of suicide, it is important to explore how suicide is understood and responded to within these contexts. Our analysis focuses on how suicide is constructed within FAIs and the implications of these constructions for understanding the role of the prison environment in deaths by suicide.
When we say ‘how suicide is constructed’, we mean that the ways in which suicide is talked about and portrayed creates particular social ‘truths’ about suicide. These include ‘truths’ about what causes suicide and how it should be responded to. These ‘truths’ come to be taken for granted and regarded as the only explanation for suicide. For example, one of the dominant ways in which suicide is often constructed in research, as well as public policy, is as an individual mental health problem (see Marsh, 2020). This is done through explaining suicide as being caused by mental illness such as depression and proposing that the best way to prevent suicide is through individual therapeutic and pharmacological interventions. These constructions tend to focus solely on the ‘suicidal’ individual, neglecting the broader context in which the individual lives. In contrast, research which focuses on the social contexts in which people live highlights “the heart-rendering suffering, daily indignities, and desolation many people struggle with” (Reynolds, 2016, p.169), including poverty, homophobia, racism and other forms of social exclusion and violence (White, 2017). This kind of work constructs suicide as an issue of social justice rather than an individual mental health issue and proposes that suicide can only be ‘prevented’ by making lives more liveable for all people. It is important to note that these social constructions of suicide are not static and that they change and shift over time[1]. In our analysis we are interested in the kinds of truths about suicide that are presented in the FAIs.
These reports are publicly available, to facilitate transparency and public accountability, and include full names and many other personal details of the person who has died, and in some instances of their family, partners and friends. In light of the public nature of these reports, the issue of anonymization to protect people’s privacy is complicated. Normally in qualitative research, we pseudonymise participants – changing people’s names, and sometimes key details, in order to protect their privacy. This allows people to participate in a research project without necessarily exposing personal details about themselves. However, as Betsy Barkas noted in our discussion about working with FAIs, people’s anonymity has already been violated by the state in the case of FAIs, making it difficult for researchers to preserve people’s privacy.
As a research team we have found ourselves asking: how we can present a critical analysis of the FAIs, which explores the often-problematic ways in which people who have died by suicide are constructed, while preserving, as far as possible, the dignity of those who have died, as well as their loved ones who have been affected by their deaths?
We feel that a critical analysis, which draws directly on quotes from the FAIs, is important to be able to both highlight and disrupt the decontextualized ways in which prison suicides are understood, as well as the ways in which the systems and environment of the prison are implicated in people’s deaths. We have all been deeply moved, distressed and angered by what we have read in the FAIs and we hope to be able to draw on some of these feelings in our writing, to communicate in more affective ways about the people who have died by suicide in prison. We recognise that each person who has died by suicide is a human being, deserving of dignity and respect, whose life cannot and should not be reduced to the details of their deaths as recounted in the FAI. We aim to make this point clear in our writing about the FAIs, as well as, as far as possible, not to reproduce harmful constructions of those who have died. We hope that through presenting a critical analysis of the institutional frameworks through which suicide is presented, we can challenge dehumanising representations of people who have died by suicide.
We also recognise that our analysis of the FAIs, which includes potentially recognisable information about the person who has died, may be distressing for their loved ones. We have, therefore, decided not to use people’s real names. We will be using pseudonyms for all participants, as well as removing or altering demographic information in order to reduce, as far as possible, identifying information. However, as we have highlighted above, the publicly available nature of the FAIs mean we cannot guarantee that people will not be identifiable.
It was mentioned in our discussion with Linda Allan, Betsy Barkas and Sarah Armstrong that some families may want their loved ones explicitly named, as this may be an important way of honouring them and the conditions under which they died. It is possible that some of the families of the people represented in the FAIs we are analysing may feel similarly. However, after long deliberation we have decided not to reach out to families. The FAI process is, more often than not, very drawn out and so many of the deaths we will be analysing occurred many years ago. We recognise that some families may find it intrusive to be contacted by researchers after so many years and that they may not wish to revisit the death of their loved one in this way. This is in line with our original ethics application, where we proposed that we would not contact the families. After having seen the reviews, it has also become clear that in many instances the families are not named and therefore finding and contacting them would itself be intrusive and something we feel is ethically questionable.
There are no easy ethical answers when it comes to doing research on suicide, which becomes even more complicated when working with publicly available data collected by the state. The institutional environment of the prison removes certain rights from prisoners, while the FAIs construct their lives backwards through their final act of suicide. In our work we want to take care to avoid creating further suffering for the families of those who have died by treating the subjects of FAIs as whole human beings caught within complex institutional, legal, social, and economic forms of oppression. We hope that by more explicitly articulating our own ethical position, we make ourselves more ethically accountable as we continue this difficult work.
References:
Armstrong, S., & McGhee, J. (2019). Mental health and wellbeing of young people in custody: Evidence review. The Scottish Centre for Crime & Justice Research. https://www.sccjr.ac.uk/publication/mental-health-and-wellbeing-of-young-people-in-custody-evidence-review/
Marsh, I. (2020). Suicide and social justice: Discourse, politics and experience. In M. E. Button & I. Marsh (Eds.), Suicide and social justice: New perspectives of the politics of suicide and suicide prevention. Routledge.
Reynolds, V. (2016). Hate kills: A social justice response to “suicide”. In J. White, I. Marsh, M. Kral, &. J. Morris (Eds.), Critical suicidology: Towards creative alternatives. University of British Columbia Press.
Tomczak, P. (2018). Prison suicide: What happens afterward? Bristol, Bristol University Press.
White J. (2017). What can critical suicidology do? Death Studies, 41(8), 472–480. https://doi.org/10.1080/07481187.2017.1332901
Zhong, S., Senior, M., Yu, R., Perry, A., Hawton, K., Shaw, J., and Fazel, S. (2021). Risk factors for suicide in prisons: a systematic review and meta-analysis. Lancet Public Health, 2020(6), e164-74.
[1] For example, in many contexts suicide was historically regarded as a criminal act. In contemporary societies this ‘truth’ has been replaced by the ‘truth’ that suicide is caused by mental illness.
In this post I reflect on an instance of interrupting a discussion about suicide. I explore how asking different questions about the relationship between suicide and social inequality allows for different kinds of engagements with suicide. These kind of interruptions are simultaneously challenging, uncomfortable and necessary.
On the 17th of March, my colleague Sarah Huque and I attended an online roundtable discussion hosted by the Psychological Society of South Africa (PsySSA) entitled Suicide in South Africa: An Intersectional Dialogue. I was looking forward to the discussion, both as a researcher who works on suicide and as a research psychologist who previously trained and worked in South Africa.
I was particularly looking forward to the ‘intersectional’ focus of the discussion. The roundtable brought together the Operations Director of the South African Depression and Anxiety Group (SADAG); a mental health journalist who had lost her son to suicide; a psychiatrist; and a journalist who has survived “suicidal ideation/experimentation” (their words). The panel was attended by nearly 250 people, from across South Africa.
However, I was disappointed to discover that the discussion was dominated by a narrow, individualised, medicalised understanding of suicide. Someone repeated the phrase “the most dangerous kind of depression is an unmedicated one” and the psychiatrist proclaimed that “90% of those who die by suicide have a mental illness”[1]. The panelist from SADAG mentioned that since the beginning of the COVID pandemic they were experiencing a dramatic increase in calls to their crisis hotline but in the panel discussion there was no connection made between this increase and the particular social realities of South Africa, which has often been described as “the most unequal country in the world”. For me this was a clear and problematic missed opportunity to explore how the COVID-19 pandemic has intersected with existing social inequalities to make lives unliveable for millions of people in South Africa. This was but one example of the failure to engage with issues of inequality during the discussion.
By the end of the session I was feeling extremely frustrated and angry. In conversation with my colleagues in the Suicide Cultures project the next day, we reflected on how these kinds of discussions perpetuate decontextualised understandings of suicide. Spurred on by my colleagues’ shared concerns, I decided to write to the organisers of the event and express my disappointment. In my email I explained how I was especially disappointed by the lack of reflection on and engagement with the structural conditions which produce distress, in light of South Africa’s various intersecting legacies of inequality. I also noted that I felt PsySSA, as the representative body of psychologists in South Africa, had a responsibility to promote more holistic, ethical and contextually-relevant understandings of suicide rather than merely perpetuating individualised, psychiatric ones. I felt slightly better having, at least, articulated my frustration in this way but I did not have high hopes of a constructive response.
I was pleasantly surprised to receive a response a few days later acknowledging my concerns and inviting me to participate in a follow-up question and answer session. I was invited, during this session, to share my reflections on the initial discussion and to pose some questions to the panellists. I was both pleased and daunted at this opportunity to interrupt the discussion about suicide, especially as someone who is not a clinical professional. But I also felt a sense of responsibility to insert issues of inequality into the discussion of suicide, so I accepted the invitation.
I began my reflection by noting that the initial session had focused predominantly on identifying “signs” that people may be suicidal; promoting medication as the most effective treatment of suicidal distress; as well as suggesting that people who are experiencing suicidal distress can be protected using (coercive) forms of surveillance. I reflected on how these kinds of discussions are part of dominant ways of thinking about suicide, not only in South Africa but across the globe. I noted that it was important to expand understandings of suicide beyond these narrow focuses in order to more meaningfully contextualise people’s distress. Informed by many of the discussions we have had as the Suicide Cultures research team, as well as engagement with work of others in critical suicidology, I then posed the following questions:
How can we talk about ‘mental health’ and suicide in South Africa without centring issues of inequality and justice? By this I do not mean merely mentioning ‘social determinants of health’ or how some people’s distress may be caused by a lack of sense of safety in their communities, but rather what would it mean to reframe suicide as a social and political issue that is produced by social injustice, which demands social and political rather than merely individual responses?
What would it mean to shift from thinking about suicide as a mental health problem caused by depression to thinking about it as an expected and reasonable response to socioeconomic disadvantage or other kinds of social exclusion?
How do medicalised understandings of suicide and distress normalise social contexts which make life unliveable for many people?
How can we develop psychopolitical approaches which make connections between social inequality, injustice, and the emotional impact this has on people?
How can we shift from individual to collective efforts to repair ongoing social injustices?
Unfortunately, two of the previous panellists were unable to join the question and answer session due to load-shedding[2]. However, it seemed the questions I posed spoke to many of the challenges that South African psychologists and counsellors were facing, with many of them sharing their frustration about the difficulties of supporting people struggling with distress. There was also much discussion about inequalities in terms of being able to access mental health care, particularly for people living in rural areas. In this way, the critical interruption that I posed appeared to open up ways to talk differently about suicide. This was an important reminder of the power of interrupting normative conversations about suicide and how these interruptions can reframe suicide in relation to issues of social inequality. This is part of the work that we as the Suicide Cultures research team are doing through a variety of channels, including our seminar series, podcast and this blog.
[2]Load-shedding refers to scheduled rolling blackouts due to an insufficient supply of electricity, which is a relatively frequent occurrence in South Africa.
