5,691 people lost their lives to suicide across England and Wales in 2019 – the equivalent of 11 deaths per 100,000 people[1].
A heart-breaking and largely preventable statistic.
Across the North East, there is a reassuring determination to reduce the rates of suicide, and we, at MMC Research & Marketing, were commissioned to support on an Association for the Directors of Public Health (ADPH) Sector Led Improvement project focussed on Suicide Prevention.
It has long been assumed that one of the causal factors of suicide is financial debt. Recognising this as just an assumption, the North East Public Mental Health Network wished to explore the relationship between debt and suicide risk to gain a better understanding of the links between the two. The aim being to improve the regional evidence base informing the work of all North East Local Authorities.
Research began with an assessment of local needs where a distinct correlation between suicide rates and area level deprivation emerged in a way that was impossible to deny.
People living in the most deprived areas and within the most deprived groups have a ten times higher risk of suicide than those in the most affluent areas[2].
This correlation is, arguably, particularly important for the North East due to entrenched levels of deprivation within this area.
As research continued, a common theme resurfaced time and time again.
Suicide is a complex issue that is extremely difficult to strip back and simplify as to having been caused by just one, single factor.
The Samaritans eloquently summarised the importance of understanding suicide as a deeply complex phenomenon:
‘Suicide is a complex and multi-faceted behaviour, resulting from a wide range of genetic, psychological, psychiatric, social, economic and cultural risk factors which interact to increase vulnerability to trauma and adversity in individuals, communities and society as a whole.’
The Samaritans [3]
Our academic literature review reinforced this notion – not least because we found only eleven studies pertaining to debt and suicide specifically.
The literature review evidenced that attempts to establish causation within the relationship between debt and suicide are highly problematic.
Debt must be considered within the context and meaning of people’s lives.
What is deeply problematic debt to one may cause another very little psychological distress.
It is also very difficult within research to delineate the impact of debt from the range of other financial problems, i.e., job loss may not cause problematic loss of income but rather lead to deeply felt loss of empowerment and autonomy that in turn leads to poor mental health.
It’s necessary to acknowledge the elephant in the room at this point: the COVID-19 pandemic.
At the time of writing (December 2020), it is worth noting that the full impact of the pandemic’s effect on mental health and wellbeing and/or financial solvency remain to be seen.
Having said that, common sense allows us to infer that the deleterious economic consequences of the pandemic response during 2020 will likely deepen levels of deprivation across the North East, and thus potentially contribute to the inequalities associated with an increase in suicide rates.
It can, therefore, be argued that nationally, and specifically within the North East, there is a pressing need to address the societal and structural causes of suicide, making the research findings here all the more pertinent.
The final phase of our research consisted of a service mapping exercise to identify existing services dealing with debt and/or suicide risk, the referral pathways between these services and any areas of best practice.
The service maps were developed iteratively, and the process was governed by the principles of snowball sampling.
The mapping began by conducting qualitative in-depth interviews with the three Suicide Prevention Co-ordinators operating across the North East, before contacting both health and financial support services (from publicly funded, charitable and voluntary sectors), within each Local Authority area.
As you can imagine, the subject matter discussed during these interviews was heavy going at times, but throughout the process, we were reminded of the inherent kindness of humanity, especially when talking with suicide prevention charities such as If U Care Share and RT Projects.
As someone on the outside looking in, we can feel empathy towards those experiencing suicidal ideations, but it’s impossible for us to truly grasp the depths of their despair.
It is for that reason that we felt it was important to include the opening lyrics to NEVER GIVE UP.
NEVER GIVE UP is a song written by Beano, the founder of RT Projects. It is based on his own experience of suicidal thoughts and he believes that those who find themselves in a similar situation will find some sense of hope and solace upon hearing it.
His words so beautifully capture how those experiencing suicidal ideations feel, and how they must be encouraged to see that there is – even just a glimmer of – hope.
What if?
What if?
What if?
What if we stumble, what if we fall?
If the world we exist in makes no sense at all.
What if the weight becomes too much to bear,
And we can’t really function and we’re so full of fear?
And what if in darkness we can’t see the light,
And we start to consider to give up the fight?
Never give up
Please don’t ever, ever let go
In the darkest night, you must find the light
This time is not right for you to go
If U Care Share describe suicide as a permanent solution to a temporary problem, and the first step on this journey to start solving the problem is to remind someone that they are not alone and there is emotional and practical support available to them.
Reassuringly, our qualitative in-depth interviews revealed the extent of the support present in the North East.
The region is covered by a comprehensive network of suicide prevention work, and there is a determined effort to proactively identify suicides in order to introduce preventative measures in a timely manner.
The mapping exercise revealed a consistent recognition of the potential links between debt and suicide.
When these issues were experienced concurrently, they tended to be addressed by signposting partnerships between relevant specialist agencies. For example, Citizens Advice Bureaus in the region relied upon signposting to the Samaritans.
Signposting in this manner ensures that professionals with the relevant specialist skills can help. However, it could be argued that for signposting to be effective the individual must have the capacity and resilience to autonomously make contact with a new service and establish a working relationship with them.
People who are experiencing problematic debt and suicidal ideation are undoubtedly living in crisis and are less likely to have the capability to manage signposting as well as people living in less stressful circumstances.
It is for that reason, that areas of best practice that were identified looked at those services who aim to provide more than just signposting for those experiencing debt and complex mental health needs.
The crisis and inpatient services at West Park Hospital in Darlington hold a Service Level Agreement with the local Citizens Advice Bureau to enable a debt advisor to give in-person advice at one of the inpatient mental health wards. This is a long-standing relationship with proven outcomes, ensuring that patients are supported prior to discharge which also reduces the rates of reattendance.
Middlesbrough Citizens Advice Bureau and Middlesbrough and Stockton Mind also have a long-standing referral pathway between them.
If someone presents to Citizens Advice expressing suicidality (or any other complex mental health difficulty) it is acknowledged that it would be very difficult to get them to engage effectively in debt advice. As a consequence, the Citizens Advice Bureau work to ensure that no immediate consequences of debt are experienced (i.e., negotiating to prevent eviction or legal action) and the person is referred either to the NHS crisis team or Middlesbrough and Stockton Mind to undertake work to stabilise and improve their mental health.
At this point, they re-engage with the Citizens Advice Bureau as it is hoped that they would now be in a position to effectively engage in debt advice.
Critically, in this re-engagement, the person works with both Mind and Citizens Advice Bureau jointly. If the person wishes, a Mind mental health worker attends the Citizens Advice Bureau meetings to both support and advocate for the person.
This increases the likelihood of vulnerable people being able to work with the services that are able to help them to end a period of crisis in their lives.
Upon seeing the value of partnerships such as these, a key recommendation to emerge from the research was to examine how more partnerships of this nature can be introduced across the North East.
As we come to a close, it’s important to acknowledge that this research project is only the starting point – a baseline from which to work.
Here, MMC Research & Marketing supported Public Health North East in beginning to delve below the surface of this subject matter and prompt the start of inter-agency conversations.
The discussion following our presentation of the findings to over 80 stakeholders was the perfect example of the drive that agencies, irrespective of sector, have to learn from one another and improve the experience for their service users.
This research will contribute to driving improvement through increased awareness of the impact of debt-related issues, increased competency of the workforce, adoption of best practices across the region, and improved service user safety, and we look forward to seeing the initiatives that are developed as a result.
