Thinking Allowed - Suicide, Society and Liveability

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This is a Thinking Allowed podcast from the BBC. And for more details and much, much more about Thinking Allowed, go to our website at bbc.co.uk.

Hello, and a warm welcome to this new series of Thinking Aloud. Actually, today's topic rather forcefully reminds me of the welcome to sociology, which I typically extend to first year students in my opening seminar at York University. Look. Let's begin, I'd say, with a topic which on the face of it would seem like the very last 1 to have a sociological explanation, the highly individualistic topic of suicide. But that, I then point out, was exactly the phenomenon which exercised Emile Durkheim, 1 of the founding fathers of sociology way back in 1897, over 100 years ago.

I mean, he asked not about the psychology behind the individual act, but about why certain social or religious groups have higher incidences of suicide than others. And he concluded that the answer depended on their relatively high or low levels of social integration. Well, in today's program, I'm gonna be talking to 2 social researchers who, while they both thoroughly accept Durkheim's social interpretation of suicide, what they do, they're seeking to extend and refine his analysis. Those researchers are Alexander Oton, who's senior lecturer in social and political science at the University of Lincoln, and Sarah Huck, who is senior research fellow in the School of Health in Social Science at the University of Edinburgh. They're co investigators on a project entitled discovering livability, co producing alternatives to suicide prevention.

Alex, before we hear a little about your own approach, can you just tell me a little bit more about how really the value of what Durkheim had to say?

Yes. Absolutely. So Durkheim writes a book, suicide, in 1897. So Durkheim looks and it takes a a statistical approach to trying to understand and and explain suicide rates. So less interested in the individual, more interested in suicide rates at a population level.

And, essentially, what Durkheim is saying is that suicide rates are proportional or linked to a group social integration within society. Integration is the the structural elements of social relationships, so shared beliefs and rituals in terms of people bonding together. And so Durkheim is really interested in understanding population level suicide rates and explaining that using statistical positivist statistical approach.

And this is really quite an outstanding thing to do because on the face of it, why people commit suicide would seem to have only psychological explanations. But as you're pointing out, here is an intervention which establishes that the race vary according to the degree with which individuals are socially integrated. How does the project that you and Sarah are both involved in discovering livability connect, if you like, to what Durkheim was talking about? And tell me a little bit more about this term. I feel always welcome new sociological terms.

This is a new 1 on me, livability.

I see Durkheim was considering the belief in in the social causes of suicide rather than the psychological approaches to understanding suicide located within the individual. Hence, he's using statistics. I think we also need to understand in terms of what we do in our project as well, the context in which Durkheim was operating within. So essentially, when Durkheim was writing new forms of of government, new forms of governmentality were emerging. Governments are interested in effectively managing their populations, using statistics, using public health approaches.

Durko isn't actually the first person to do this, but he's the person who gained the most traction. So livability is attempting to consider the social factors are relevant when we think about suicide, so try to move away so working within the tradition of Durkheim to a certain extent, try to move away from seeing suicide as purely a problem of the individual, as individual pathology, and instead recognizing that there are context and environments that can make people more vulnerable to suicide. And we are thinking about how we can create livable lives rather than simply working to try and prevent death. And so we think we're kind of trying to flip the question that's often happened within suicide prevention. So instead of thinking about why do people die by suicide, instead, we're thinking about how can we create context and environments that make people's lives more livable.

What we're talking about here is a more sensitive analysis of the social conditions surrounding suicide, something which hasn't really been so sensitively done in the past?

Yes, and because even within a lot of the sociological research it tends to be that big number, quantitative data mixed voices don't get heard. And I think when we think about preventing death, we know how we can prevent biological death, and that's what tends to come through in the suicide prevention policies. We just prevent somebody from dying at that moment. However, if we've saved somebody from taking their own life, but we've not addressed the causes that have got them to that point and created that vulnerability, then just preventing them at that time and then putting them back in the same social economic context that has made them vulnerable, made their life unlivable, then we're just gonna continue going round and round. So livability makes us attuned to these broader contextual, structural, environmental facts that can have an impact on our fellow citizens' lives.

So, Sarah, what we're saying is that livability makes us look in more detail about the circumstances surrounding suicide and surrounding those people who are inclined to commit suicide.

Yes. Livability is about all of the things that make life livable, but not from a, we all have to be happy all the time kind of perspective. It's about the things that make you able to want to stay alive, to engage in your daily life. It's about thinking about suicide as a journey that is based in experience, embodiment, interaction with people, organizations, services, places, rather than thinking about it as the point of crisis. We prevent a suicide, and we go back to the same circumstances.

And, Alex? I just think probably a

a pertinent example for that is the Royal College of Psychiatrists have released immediate updates saying that if you're recent mother and you die by suicide, you're far more likely to live in a deprived area. And, that is what is that telling us? That is telling us that this is not just about pathology. It is about lives that, through the environment we're creating as a society, are not livable, that those people struggle, that those people end up potentially taking their own lives. And I would argue that is why we are talking about livability rather than just preventing death.

What can we do to make those new mothers' lives better?

Sarah, when I started looking at this, I thought, inevitably, suicide is a very difficult terrain, difficult area in which to go emotionally, ethically, and I should imagine methodologically as well. Tell me about how you navigated these challenges.

Yes. So our project is very qualitative in nature. So the work that led into discovering livability involved long term ethnographic work. It involved in-depth interviews with people who had experienced suicide, either been bereaved by suicide, had attempted suicide, or were professionals working in that space. And really, most of the people we spoke to fit into more than 1 of those broad categories.

And we also conducted a modified sociological autopsy of suicide deaths in those areas, which entails looking at NHS or multiagency reviews of deaths using a sociological lens to see what they say and don't say and what we can learn from them. So we were continuously navigating and adjusting how we went about the work for both the participants and our research teams well-being. I think a key point to this was the time scale of this. We had a lot of time. So the 1 and a half to 2 years we spent doing the ethnographic work, that happened simultaneously and in the same areas as we were doing the other methods.

So we were able to build trust gradually. We were able to have slow conversations and make sure people really understood what they were participating in.

You're bringing in people who've experienced suicide.

Yes.

And you're sitting them down. Whereabouts are you? In the university or in special meeting room?

No. So all over the place. So so we, the 3 research fellows on that project, were embedded in the communities we worked in. So we lived and we we worked there. And so our interviews happened wherever the person was most comfortable.

So we did interviews in community centers, in people's homes.

Whereabouts were the community centers?

So these were in 3 broad areas of Scotland. So you know, obviously, our ethical commitments, I can't tell you exactly where, but we had 1 research fellow in each area. And we worked with 11 community organizations in those areas. And I even did an interview in my car once because that's where the participant was comfortable.

And what would be a typical question you'd begin with? How would you get the discussion going?

We usually would ask people to just actually introduce themselves however they see fit. It's important to know that we never interviewed someone the first time we met them. So usually, we had had 2, 3, 4 conversations with someone before we sat down to do a formal interview, which is I think the benefit of that embedded ethnographic approach. And then we would kind of go from there. So we had an interview guide, but it was very much led by people's stories.

So you're trying to find out, get an understanding of how suicide is embedded in the social lives of people. But the idea really that you want to do something to make their lives, if you like, more livable so that in fact suicide, what is less likely to occur? Doctor.

That's the aim of discovering livability, yes. And that comes out of this previous project where we were actually collecting experiences. And so in that project, we were looking at what does suicide look and feel like in a particular place at a particular time? How does this compare how we talk and how people experience it? And so we built this kind of really locally embedded knowledge base about how suicide was being experienced in these communities and the contributing factors to that, and that's led us into discovering livability.

It's an enormously important undertaking. This isn't the idea of suddenly saying I'm going to improve your livability, so therefore to make you less amenable to thoughts of suicide. Alex, how in concrete terms do you begin to intervene?

I think just as preface this with, we're not telling people what livability should look like to them. So we, as a project, are working with this concept of livability, but it is a very open concept because we don't want to tell people what their life would look like. But, essentially, I guess we're doing this in 3 different ways. So we're using this concept of livability to work with policymakers and policy processes. So we're taking a critical approach to a lot of policies that already exist that are very much focused in terms of suicide prevention on this intervention at the point of crisis.

And then we try and prevent somebody from dying, and then we just put them right back into the same context that maybe created that those feelings of suicidality. So I think we can help intervene on that level, but also changing how suicide research itself is being done. So we're centering the lived and living experience. Often, that's been ignored. So people who have experience of suicidality in their own lives have often been marginalised within suicide research, because either that research just looks at statistics at a population level, or it's because it comes from more psychological approaches where the person is seen as mentally ill, and therefore they're marginalised and often their voices aren't heard.

So we're working with people with lived and living experience, rather than just doing research on somebody, actually engaging them in the research process with us. And then thirdly, we're working with communities. So people who are out there working with people who are at risk of suicidality, we're doing work to try and help them to understand what good practice looks like.

Sarah, that prompts a question. I mean, this community dimension. I mean, tell me a little bit more about how the community fits in here.

That is something, again, that emerged from suicide cultures. It came through in a lot of ways, but I'll give you 2 key examples. So 1 of the key ways is that community groups of all shapes and sizes are filling a gap in services. They're doing suicide prevention even if that's not in their remit. In some places, this looks like suicide specific support groups, but also community centers, organizations supporting veterans, disability organizations, therapy gardens.

These groups are recognizing that what they are doing is suicide prevention, and so do the people they support, but they're not often included in suicide prevention strategy or supported with enough funding to keep up that work. Although Scotland's suicide prevention strategy in particular and their action plans are moving towards this. The other example is an element of kind of individuals within services going above and beyond that's involved in this type of work. And this comes through when we talk about, especially the community of people who work in statutory services such as the NHS, inpatient settings, or the police service. And the actions of those individuals that felt to people experiencing suicidality as going above and beyond the norm of that service are the actions that make a huge difference in people's journeys.

And I think this is because that personalized, often more caring, localized approach is no longer something people expect from statutory services. So they notice it when they experience it. And so

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Both aspects of this kind of community centered approach point to the importance of real connections of local knowledge and peer and lived experience led approaches that actually meet people's needs where they are.

I must say this concept, I've indicated already, livability was a new 1 on me. So to what extent, Alex, is this discovering livability project fit into some other established intellectual tradition, or is it something completely new?

Well, I think what we're doing in terms of our specific actions on the project is new. However, we do also fit into an emerging trend of, I guess, we call it an approach to studying suicide, which is called critical suicide studies. So that's been going for since sort of the February. And, essentially, critical suicide studies, people within this approach come from a whole range of different disciplines, and they ask a range of different questions. So things like who are the experts when it comes to suicide?

Again, that feeds into our interest in lived and living experience. They're asking where does power reside within suicide research? Whose voices are being heard? Whose aren't? And who is suicide research for?

Is it for the government to help effectively manage its populations, or is it to actually help individuals? And so critical suicide studies have attempted to address that and to challenge that. Critical suicide studies and and our project don't see suicide and suicide prevention as a neutral act. Instead, it's wrapped up with other injustices such as race, gender, collality. Where we're different is in the size of a project.

In fact, we're using this concept of livability and thinking about alternatives to how suicide prevention works at the moment, very much in the sense of being there to prevent somebody from dying at that moment of crisis. I think where we're novel on the Discovering the Privilege project is we're coming at from from both a top down and a bottom up approach. So we're looking at how deliberate political decisions can make people more or less vulnerable to suicide. But then at the other side, we're also working with communities, working with people who've lived with

a living experience to center those voices through a research agenda. Let me move on to another aspect here because this is an important 1. It's the actual size of the issue, the scale. I mean, I should imagine for many people, it's still quite secret, almost a hidden phenomenon. You know, the silence, taboos about it.

We don't speak about it very much. I mean, what do we actually know about the numbers? Can I come to you on this, Sarah?

I will preface this by saying that suicide deaths are important to understand, but they are very rare, which makes using deaths as an outcome measure challenging, and that is really all our statistics at the moment capture. So in looking at the statistics, what they show depends on where you put your line. So since the 1980s, there was a general decrease in the suicide rate until 2008, when we start to see an increase again, but also the standard of proof changed in 2017. So it can be hard to say. If we look at the most recent year to year statistics as reported by Samaritans, there was an increase in suicide deaths recorded in England, Wales, and Northern Ireland from 2023 to 2024.

In England, that means the actual rate stayed the same, but in Northern Ireland, suicide rate increased. In Scotland, over the same period, both suicide deaths and the suicide rate decreased. However, for example, we need to look at this with a more intersectional lens. So in that same sort of set of statistics in Scotland, the most deprived areas in Scotland were 2.5 times as high probable suicide mortality as in the least deprived areas in Scotland. So 1 of the things we really try hard to do is question the statistics and also what they obscure.

So for example, we think about often a gender paradox in suicide of women attempting suicide at a higher rate, but men dying more. And this is often attributed to the lethality of the means used. So this gender paradox often means women's distress isn't taken as seriously because their attempts are seen as quote unquote less lethal. But we can complicate that data in a number of ways. So if you add race to the mix, you can complicate that.

We've only had statistics about race and suicide in England and Wales beginning in 2021, and we actually still don't have these numbers for Scotland. But work by a scholar called Dean Knapp has highlighted that mixed race women had higher rates of suicide compared with the white British population. Additionally, the National Confidential Inquiry into Suicide and Self Harm reported an increase in hanging deaths by women from an average of 39 of all female deaths in 2012 to 2015 to 46 percent in 2019 to 2022. So the idea that women use less lethal means, for example, as an explanation might be getting less relevant, but you kind of need to look beyond the over overall rate. And we really would like to suggest that we need to move away from looking at suicide statistics since probable deaths measure who dies, but not who attempts suicide or who experiences suicidal ideation or who self harms.

So we're moving from Durkheim looking at suicide as a social fact, which we can measure quantitatively towards more recent sociological work that questions if quantitative data is factual or objective. And that data is really important and shows us potential trends and inequalities, but we need to be careful with it and avoid flattening and homogenizing everyone's experiences to the point where our efforts at prevention can't actually impact people's lives.

Let me continue on that sort of theme for a moment, Alex. I mean, talking about statistics on suicide. We just heard some concerns about the statistics that are available and what they might mean. But are you generally happy with such statistics with the way they're assembled?

I think they have an important role to draw attention to issues. However, the politics to all of this, and, again, this is where this idea of livability and focusing on political decisions is really important. So, for example, if, you know, the average general population suicide trend is about 11 per hundred thousand, the latest sort of Samaritan statistics. Whereas in England and Wales, the number of people in prisons dying by suicide is 10.8 per 10000. So the statistics are telling you something really important, such as the huge increase in deaths within prison compared to general population.

Nothing's been done about it.

And let's stay with this point about the way in which suicide is handled in different environments. I mean, Sarah, tell me about some of your findings on the way in which, for example, suicide is handled in prisons.

Yeah. So there is a lot of critical social science that's highlighted sort of the hierarchies of lives in Western countries. And folks who are imprisoned are often placed lower on that hierarchy because of their perceived badness. So we conducted a sociological autopsy of fatal accidents and sudden deaths inquiry reports on suicide deaths in prisons in Scotland. And we found that most of the time, these reports argue that there was no learning to be done by the system in relation to these deaths, because the deaths were either unforeseeable, as in there could have been no way to predict the death, or inevitable.

This person was so mad or so pathologically suicidal that there was nothing that could have been done to prevent this death. And sometimes both, which is inherently contradictory. And you see that is a very different message from the 1 that's used in suicide prevention campaigns in the general public. Those often take a 0 suicide approach or an approach that says there is hope for everyone. All suicides are preventable.

It's interesting, isn't it? Trying to have conversations about suicide. I mean, Alex, let me turn to you. I mean, you do encounter resistance when you start to talk about suicide to people, don't you?

On an individual level, people are often actually very happy to discuss. So when when people ask me what I do, very rarely does that shut the conversation down. Very often, they even if they don't know somebody who's personally died by suicide, they've got an opinion. I think where it becomes problematic is at the political level, because the way that suicide is constructed and framed at the moment by government, essentially, that it is this pathological problem of the individual. That means that it's very hard for us to see where responsibility for these deaths lie.

And so just to go back to the prison example, in policy and in practice, the prison is seen as a neutral environment. The reason that prison suicides are so high is because prisons are full of ill people or violent people. The prison regime is hidden in the shadows. I think, politically, when you start talking about suicide, very often you come up against this approach, this discourse that says it's the individual. If it's an ill individual, we need to help them.

We don't need to think about the systems and what we're doing politically.

I want to stick with this question about people's readiness to talk about suicide because in a way people's readiness to talk about suicide is fundamentally important to your project. Am I wrong, Sarah, to say that people don't want to talk about suicide? Or have you found ways to make them talk about suicide?

You know, it's interesting. I have rarely encountered resistance or reluctance on an interpersonal level. I've once had someone say, no, don't talk about suicide. Accepted that, and I didn't ask them about it again. I think because the methods that I use, I think, again, this is goes to that.

I spend deep time with people. And so I often get to build relationships that mean that if there is hesitation, it does eventually fall away. And I think more broadly in life, as Alex said, I also experience that thing. As soon as someone finds out you're a suicide researcher, everyone has something to say about suicide. And I think that shows there's a real hunger to talk about this issue.

But because it's taboo or fraught or seen as very distressing, people are reluctant to bring it up unless they feel like you're in a job or a role that means you can handle it. So I think we get a lot of conversation about suicide very easily from people because they feel like this is what we do for our job so we can handle it. Whereas in their everyday lives, it's harder to have those conversations because you don't know what you're gonna be then putting on someone else.

That sounds very positive. And, Alex, are we seeing positive changes when we begin to talk about reducing the possibility of suicide when we're talking about the way in which suicide is perceived?

I think there is more of a willingness and more awareness of the issue of suicide now, and we see that in the setting up of men's sheds and, you know, these kind of groups who

Men's sheds? Sorry. That's right.

So men's sheds are a movement, a group of different organisations who essentially bring men together to talk about general well-being and and and health and things like that. So there is this, I think, this shift in that it's okay for people to talk about suicide, but I think at the same time, we focus very heavily on men's suicide and the suicide of a certain group of people, and that means that other groups are marginalized, other groups don't get that chance to discuss it. But in terms of my interest in politics and policy, I think we see a very different picture depending obviously, suicide prevention is a devolved issue, so we've got all 4 nations of The United Kingdom. Some are doing better at trying to address suicide and suicidality. Others lag behind a bit.

There's also a significant difference, I think, in terms of the local and national. So we have some local authorities that are fairly progressive in in thinking about suicide and suicidal ide. There's some reason to be optimistic.

Yes. Talking about progress and so I mean, Sarah, coming to you, I think it's true to say, isn't it, that this idea of livability, this concept we began today's discussion with, that's already being attended to by the Scottish government.

Yes. So that has started to be incorporated in the Scottish government's suicide prevention action plan related to the suicide prevention policy. And actually, just within the last few weeks, we had a really great workshop supported by our funder. And I think that's another important thing. So we're funded by Wellcome, and they fund a lot of really novel research that's pushing us because they give us the ability to then engage with the folks working in the Scottish Government and the third sector on these suicide prevention action plans.

So we don't wanna enable governments to abdicate responsibility for that. But we do wanna simultaneously figure out how we work within the constraints of our current politics, And increasingly, the role of communities, local approaches, and lived experience leadership is being recognized and embraced. And again, it's already being done regardless of support for it. Communities are doing the work. And so we are hoping to be part of helping policymakers continue to recognize that resource before it burns out.

And that passion and dedication there is the thing we return to when we find the hope that kind of helps us think about livability as opposed to all the despair.

Let me pick up on that positive note and thank you very much, Sarah Huck and Alex Oton. Thank you both very very much. And as usual I'd enormously welcome any comments at all on this topic. You'll find me at thinking aloud at bbc.co.uk. Let me conclude with 1 aspect of the suicide that we've not considered.

It's it's moral standing. The manner in which it's historically being condemned as wrong by mainly monotheistic religions. It was a condemnation which I remember it infuriated the the atheist philosopher Schopenhauer, and I still remember the little phrase he used. Surely he wrote, there's nothing in the world that man has more incontestable right to than his own life and person. That was a Thinking Allowed podcast from BBC Radio 4.

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