Note: contains discussion of suicide and mental illness.
Recent weeks have seen a spate of celebrity suicides, resulting in mainstream news coverage, resulting in social media commentary and reactions.
Remember 2008? Kevin Rudd and Barack Obama had just been elected, and there was a huge enthusiasm for Third Way politics. Put together, lefty social values plus business know-how were going to change the world. Social entrepreneurship was the next big thing: open data, social investment, participatory democracy, design thinking, fresh ideas, young people, seed funding, problem solved. Out of this mix came a bright idea for a strategy to tackle suicide rates: ‘RU OK?’ day, launched in 2009.
Each year, in the week leading up to RU OK day in September, I start to get hinky. I get the idea behind it, I really do — it’s a day to promote asking that question on any day of the year. But inevitably it comes as a reminder of mental illness to people who don’t live every day of the year with mental illness. As someone who does, and who works in and researches methods of peer-based health promotion, I struggle with RU OK day.
There are both formal and informal methods of health promotion. Methods can be proactive or reactive (or a combination). A campaign encouraging people to call Lifeline is a formal, proactive approach. Including the number for Lifeline at the end of every article touching on suicide is a formal, reactive approach. Formal approaches have their limitations, but one of their advantages is it’s easier to get the execution right — to pick a wording that will work in a campaign and to train up staff who answer Lifeline calls.
The RU OK campaign promotes an informal and proactive approach. Their tagline is ‘a conversation can change a life.’ And here’s where I get uncomfortable. A saying in evaluation research is that every program or initiative is a theory — it is a guess about what the problem is and how it could be fixed. The theory might be explicitly stated or implicit (unstated), and it can be made ahead of time, or emerge with the program. Taken together, we call these guesses the program’s theory of change.
And this is where it gets tricky: if either guess is wrong, you’re not going to have much effect, or worse, you could have unhelpful effects. For example, if a particular theory of the problem is (a) very widely held, (b) not explicitly stated, and (c) not a good fit with the actual complexity of the issue, then it can be a barrier to the promotion of more effective strategies.
The RU OK campaign was developed in response to a particular kind of suicide: an older man, whose loving family were totally blindsided. The scenario is so well-understood it’s captured in an idiom, ‘suffering in silence’. We implicitly understand that men of a certain age weren’t brought up with skills to seek help and talk about their emotions.
(This is why I lose my shit when that generation attacks kids who were brought up with those skills as ‘snowflakes.’)
This kind of suicide is devastating. It shocks the community. We ask ourselves ‘why?’ And we conclude that it could have been prevented if they’d only talked to someone. If they’d reached out for help, seen their GP and got a script for an SSRI.
But the group most at risk of suicide doesn’t fit this picture. It is — we are — people living with chronic mental illness. So the problem part of the RU OK theory of change doesn’t actually fit the complexity of suicide as a social phenomenon.
Likewise, as a proactive, informal strategy, the RU OK approach is vulnerable to variations in the quality of implementation. If you ask someone how they’re doing, and they’re quietly in a huge mess and tell you that, how you respond really matters. If you’re taken aback and freeze up, if all you’ve got is ‘please talk to someone’, ‘it’ll be ok’ or ‘it’s important to stay positive’, your intervention could have the opposite effect. So the solution part of the RU OK approach is also questionable.
Just talk to someone and please call the hotline
In the wake of the news of Anthony Bourdain’s suicide I’ve seen countless tweets encouraging people going through hard times to please just talk to someone or call the hotline it really helps. And inevitably, there’s debate about whether hotlines help.
(As usual, the correct answer is probably ‘sometimes’. What matters, from an evaluation researcher’s point of view, is not ‘do they work?’ but the realist question: ‘who do they work for, under what circumstances, and why?’)
I want to make a few observations about this response to celebrity suicide.
It puts responsibility back on the person with mental illness to take action. The immediate response is to tell people with mental illness to do something — an imperative that, repeated and multiplied, becomes a norm.
It assumes you know better than a person living with mental illness how their condition works and what might be helpful when they’re doing it tough. Please, take a seat. People with treatment-refractory depression don’t need to be exhorted to ‘talk to someone’ or to be convinced ‘treatment works!’
The odds are pretty good that we understand both the potential and the limitations of treatment a lot better than you do — and if we could find and afford good treatment services, we’d be there without prompting.
It’s tokenism. It focuses on the conduct of the person with mental illness rather than the systems that make our lives more difficult than they need to be. Studies show that suicide rates increase when the economy is in recession, and they increase more in societies whose governments adopt austerity policies.
We need to raise Newstart, make the Disability Support Pension easier to access, improve public mental health services and expand the Better Access program because ten counselling sessions per year doesn’t cut it.
What could we be doing instead?
I’m not in any way suggesting we should leave people to tough it out on their own. But how we engage matters. Rather than being proactive (asking ‘RU OK?’ without any signal this is wanted) or reactive (celebrity suicide 👉 ‘please talk to someone!’), I want to suggest being responsive. This means listening for cues that someone wants to have that conversation, approaching it gently and with curiosity, and following up afterwards.
Two programs I have done and recommend:
- Applied Suicide Intervention Skills Training (ASIST) provides an easy to remember framework for asking someone directly, ‘are you thinking of suicide?’ and then having a structured conversation about reasons for dying and for living.
- Mental Health First Aid (MHFA) offers more intensive training on a wider range of mental health conditions, and provides skills for identifying and responding to cues that someone might need some assistance.
It is also totally fine to say, particularly on social media, ‘I’m available if anyone wants to talk.’ This (a) doesn’t command anyone to do anything and (b) doesn’t promise anything other than companionship.
Secondly, right this minute, in Australia, we’re having a debate about tax cuts versus social spending — join the Australian Union campaign to Change the Rules and the ACOSS campaign to Raise the Rate.
And if the mental health sector in Australia ever manages to launch an advocacy campaign for improved services, rather than the broad ‘awareness’ campaigns that we’ve known for fifty years don’t work, I’ll be happy to refer you to that, too.
For the love of dogs, please don’t ‘RU OK’ me after reading this. But I’m really happy to discuss the practical questions raised in the post in the comments, or you can find me @engagedpractx on twitter.
If you want to speak with someone about experiences of mental illness or suicidal feelings, please contact Lifeline anytime by calling 13 11 14, or online chat from 7pm to midnight (AEST) 7 days per week.
If you need it, see also this great twitter thread of cute and tiny animals.