Suicides were prevented thanks to more than one influence:
first the influences of chosen confidants,
then those of other family,
finally those of trained helpers.

Revision: 06.08.2012

Updated in French and automatically translated

This Page includes two parts:

• Part 1: "Prevented suicides: thanks to whom?"

• Part 2: "Preventing suicide"

• Part 1:

Prevented suicides: thanks to whom?

One young person in five said they have had a serious suicide project (Brener, Krug & Simon 2000, Choquet & Granboulan 2004). As this project was rejected, at least temporarily, an estimated 8 million French adults benefited from prevention. A survey was therefore set up to find out thanks to whom.

Method. Through e-mail, it contacted 15,233 persons aged 18 to 40 and 3.8% agreed to answer about this project: 243 had attempted suicide and were excluded; 330 others had and rejected this project. The questionnaire asked if the rejection of the suicide project only resulted from a personal reflection or a change in living conditions. If not, thanks to whom : friends, spouses or partners, other family members, physicians or psychologists, nurses, teachers, social workers, prison staff, clergy, others. The helplines were not on the list. The influences were rated in three levels.

Results. Most of the respondents benefited from more than one influence (703 for 330); and more from the influence of people rather than from a change in living conditions (41) or personal reflection (20). The influence of trusted people was said to be far more important than that of professionals. The influence of chosen confidants, that is friends (161), spouses and romantic partners (116) was deemed to exceed that of unchosen ones, such as other family members (172). The physicians and psychologists were mentioned 109 times and other gatekeepers 84 times.

The discussion includes the validity and limitations of the survey, the results and the implications in postvention and prevention. As the friends ranked first, the first goal of prevention may be to help friends becoming better friends. I related a school action by Befrienders International in Denmark : helping small scholars to increase their coping skills. The hypothesis was to decrease their suicide risk twenty years later. My hypothesis is distinct : that these scholars will later become efficient to prevent suicides of their friends.

Conclusion: The main points were : more than one influence and chosen confidants.This survey promotes behaviour which is hardly scientific. Seeking how to help friends becoming better friends. Facing suicidal ideas, feeling loved in order to regain one's confidence; and initially turning to people other than professionals to share one's distress.

N.B. An article is submitted for publication.

Abstract

The family and friends of suicide victims are appalled when they are bereaved.

Yet the effectiveness of family and friends in the prevention of suicide is attested in seven publications:
1, The low suicide rate in women classed as black (Nisbet 1996).
2, The low suicide rate when there are very strong social ties (Durkheim 1897).
3, The interactions with friends (Curtis 2003; Salleh 2003).
4, An investigation on the declared motives for refusing suicide (Besan�on 2001).
5, Education on suicide prevention for parents of Australian adolescents (Toumbourou 2002).
6, The advice given to the families and friends of men after suicide attempts (Mishara 2005).

Instead let us identify three classes of suicide preventers : family and friends, trained helpers and communities.
Family and friends have the advantage of numbers and availability. They are able to create an atmosphere, to guess that a suicide attempt is imminent and to intervene before and after seing the physicians.
Trained helpers include telephone helpline operators, gatekeepers and physicians.
Communities reach people in the media and on the Internet through their programmes for preventing suicide and alcohol abuse.

Summary

Introduction
Are families and friends effective?
How effective are family and friends?
Trained helpers preventing suicides
Communities preventing suicides
Preventing suicides: methods of evaluation
References

Introduction

This page has a place amongst the “tools for families” to show that the prevention of suicide is everyone's affair.

The age range where there are most suicides is the 80-plus age group, but this age range represents the smallest proportion of the population.
The greatest number of suicides takes place among the middle-aged, primarily men, often widowers, often invalid or long-term unemployed.
Teenage suicides number about 600 a year.
Expressing these figures in lost years gives us a sense of the scale of the problem.

With regard to attempted suicides, the annual figure is estimated at about 160,000. Their seriousness is shown by the number of repeated attempts. The associated hospital costs are considerable, even though only a third reach hospital.

Are families and friends effective?

This effectiveness is shown in five studies: that of Nisbet on American women classed as black, that of Durkheim, ours on the conscious motives for refusing suicide and finally those of Toumbourou and Mishara with regard to families trained in the prevention of suicide. There are no survey figures for the population in general to estimate the number of suicides or attempted suicides considered as preventable by family and friends.

Suicide is even less frequent when social links are very strong, as Durkheim showed as early as 1897. Durkheim proposed to reinforce social groups including families.

In Australia, more than 300 parents of 14 year-old adolescents accepted training in suicide prevention. The subsequent results were expressed in terms of signs of suicide risk, drug use and delinquency. These results were then distributed to families other than those who had been directly trained (Toumbourou and Gregg 2002).

Are close families and friends the most effective? At least they have the advantage in both numbers and availability. This is particularly true, given that the proportion of impulsive, unpremeditated suicides that are not readily accessible to professionals is much higher than previously thought (O'Carroll 2002).

How effective are family and friends?

Are family and friends able to create a good atmosphere and to guess an imminent suicide attempt, whilst paying close attention to the warning signs rather than the indicators of risk, and finally able to intervene before and after the professionals in this field without usurping their roles?

• Creating a good atmosphere?

Certain family atmospheres are unfavourable.

Many traditions, poems, songs and shows all repeat that to be loved and to love give a meaning to life. This is consistent with the maxim “health is the capacity to love and to work” (Freud). It also follows on from the two reasons for living as cited above - namely “someone (at least) cares for me” and “I love someone (at least)” On a day to day basis, is this affection actually expressed?

• Guessing the imminence of a suicide?

The warning signs are changes in behaviour, which are obvious to family and friends. These changes are quite different from the indicators of risk, which come within the competence of professionals.

The predictors, in other words the indicators of risk, and not of fatality, include a history of suicide attempts, alcohol or drug dependence, mental problems, character traits, an atmosphere or a context; or an event which was perceived as a loss: loss of a loved one, or of an ideal image of oneself, of a friend or a group; loss of an achievement or position; or the childish dreams of being all powerful or that providence will make all wishes come true, or a dream of the future.
A loss that is not objectively serious can be enough to trigger the impulse when the subject is vulnerable or intolerant of any frustrations, or if the atmosphere is unfavourable (Yang).

• Intervention before and after the professional

Before the professional, the best trump cards remain availability and friendship, without mocking, moralising or challenging. It is important to listen at length before speaking. So proving that the distress of the potential suicide is understood, that you are worried and above all that you care for them. This comes back to the two
Reasons for living (in French): someone (at least) is cares me and I love (at least) someone.
The details are set out in
Speaking to the adolescent in persistent crisis (in French).

At times, a young person's parents are not best placed to be taken into his or her confidence. Then it is up to grandparents, other family members, friends and teachers to listen. All the better if the adolescent enjoys a network of friends within a youth group.
Helping men, who take their own lives far more often than women, to get over their reticence to talk about their possible distress and to say who they trust, and from this point to get them to seek help (Goldney).

When the potential suicide refuses diagnosis by a psychiatrist, which is commonplace, family and friends try and go through a GP, a nurse, or an association belonging to the UNPS (National Union for the Prevention of Suicide), whilst giving the telephone number for
SOS Amitié
or an association such as the Samaritans, as an alternative.A diagnosis or treatment by a psychiatrist is all the more indicated by recent progress in medication that has been announced (Lauterbach), but is yet to be confirmed.
In the event of a suicidal crisis, the GP tells the family and friends how to take the person concerned to a safe place, namely a hospital psychiatric emergency ward.

In day to day life, talking within the family about drugs and alcohol can contribute to the prevention of suicide, given that drugs and alcohol abuse can lead to suicide.Are the elderly helped to prepare their life in retirement (Range)?
It is up to each and every one of us to check that no firearms or ammunition (Grossman) or poisonous substances are accessible in their homes.
In Finland (Upanne 1999) and Sweden, families help one another “to stay in good mental health”, particularly in times of crisis. This is also true in Australia (Appleby, with Leenars 2001), Canada and the United States.

It is also up to each and every one to contribute to public opinion with regard to professional training, unemployment, harassment in the workplace, and the day to day management of justice and prisons as well as the reception of immigrants and the internet content on the subject of suicide.

Further prevention after a suicide attempt needs to take the risk seriously, whilst maintaining an atmosphere of mutual trust. Close friends and family will be tempted to want to “get them out of the mad house”, without understanding of the risk of relapse.They will also want to research into “Why?” this happened. They will also feel some responsibility for having failed to recognise such and such a warning sign or indicator of risk.

Trained helpers preventing suicides

Those who become close by means of the telephone, such as SOS Amitié volunteers, receive 600,000 calls a year. Their training is of high quality.
As the call goes on the caller gradually realises that “someone cares for him or for her”: the number 1 fundamental motive in Table 1 of the enquiry suicide the
Reasons for living (in French).

Suicidal people often do not consult a psychiatrist. Moreover, the warning signs are often concealed from the psychiatrist (Busch 2003), whilst they are noticeable to those they see every day.
In a rural environment such as the Canadian north where psychiatric resources are largely insufficient, the psychiatrist can use video-conferencing with great efficiency (Jong).

At a half way house between volunteers and doctors are gatekeepers in the social field, namely teachers, nurses, social workers, psychologists, members of the clergy, lawyers, prison guards and people caring for alcoholics (Sher) etc. In Canada, the United States and Finland, wide scale programmes have kept them informed of the indicators of suicide risk and the warning signs, but there is no proof that suicides are less frequent as a result (Chagnon 2004, de Leo 2004, Burgess 2004).

Communities preventing suicides

In France the “National Strategy for the Prevention of Suicide” places the highest priority on the promotion of mental health. However, numerous national prevention programmes have not clearly shown their effectiveness (Chagnon, de Leo, Beautrais, UN and Tanney). The prevention of alcohol abuse indirectly contributes to the prevention of suicide, bearing in mind that this abuse is involved in about half the suicides as well as in homicides: whether it is a question of alcohol dependence or mere intoxication (O'Connell).

Limiting access to the means to kill oneself seems to be the most promising measure.
This includes regulating firearms and ammunition (Bridges) and restricting the delivery of medicines and agricultural pesticides. When the instructions for pesticides stop mentioning their fatal effects, farmers use them far less to inflict suffering on themselves followed by death (Lim). In Hungary, restrictions on the delivery of medicines and other toxic substances coincided with a reduction in the number of suicides (Berecz). In Quebec, barriers have been erected on the Jacques Cartier Bridge, from where many people used to jump. This proved so successful that other bridges over the Saint Laurence River were not used by people to kill themselves.

The Australian Government (Youthlink) and the Governor of the American State of Maine (O'Halloran) have distributed excellent brochures to the majority of their citizens. Their evaluation will be discussed later in this document.
In Quebec, many programmes target schools. It was pointed out that suicidal behaviour at the age of 18 was foreseeable from suicidal ideas at the age of 8. Haavisto proposed a detection of these thoughts by teachers.

School nurses would be the best placed to detect and advise children who are victims of physical or sexual abuse. This would reduce the risk of suicide at an older age, as underlined by Corcoran.
In nursery schools in Denmark, Lithuania and Iceland, children are helped to overcome their sorrows and to face up positively to any major blows (Bale 1999, Mishara 1999). An initial evaluation of this policy has shown excellent effects on the ability of children to handle frustrations (Zippy's Friends).

In teaching establishments, after a suicide or attempted suicide, a suicide survivor from another school or a volunteer such as a suicide victim's relative could lead discussion groups in classes other than the one concerned with the suicide. They would work on the conscious reasons for refusing suicide as a solution as was said in our discussion groups.
See Postvention

Other programmes are aimed at prisoners, the bereaved and the police.
Projects are under way for soldiers, immigrants, Native Americans, gamblers, young homosexuals, the chronically ill and the elderly.

Companies and company medical officers are well placed to identify and eliminate overwork which is responsible for suicides (Amagasa).
In retirement homes, group activities combined with self-assessment of depression have significantly reduced the incidence of suicide amongst women (Oyama).

Resorting to the media is a must, without fear of repetition, as does the National Union for the Prevention of Suicide.
One of their member associations, Phare Enfants-Parents (Lighthouse Children-Parents), has published two remarkable guides: A reference for an educational attitude and Difficult adolescence, Signs and symptoms of malaise.

Journalists are for the most part in agreement to report suicides without glorifying or trivialising them. The results have been excellent.
See Suicide: preventing contagion

The Internet is another useful tool. It gives access to many websites aimed at prevention. This website contributes,
Suicide prevention; talking about suicide with an adolescent at risk (in French)
but its effectiveness cannot be evaluated:
Sharing grief after suicides; self help groups (in French)
Working towards mental health; prevention by the internet (in French)
There are seven times more websites inciting suicide. A better self-discipline by search engines could contribute to preventing suicides.

By getting families and friends to become trained helpers bit by bit, you can reach the population as a whole, if we calculate that we need to reach about 13 million people to reduce the annual number of suicides by 15%. These statistical arguments were put forward by Rosenman in 1998. There are far fewer suicides in the limited group of high-risk people than in the rest of the population.

Preventing suicides: methods of evaluation

How to evaluate the effectiveness of family and friends, telephone help lines, public campaigns and the Internet, while taking into account ethical issues?

The preventive effectiveness of telephone help lines is difficult to prove due to the essential principle of anonymity for both caller and listening volunteer. Effectiveness is likely when the caller shows a change in attitude.
This is probably true in the UK, where the Samaritans have been a model for SOS Amitié. Samaritans are much more widely developed. In UK, there are half the number suicides there are in France. Some help lines have enabled the listening volunteers to offer psychotherapy and show a success rate (Rhee).

When distributing brochures, governments have neglected to their cost to make up control groups, i.e. they should initially have sent brochures to just half the population. By not doing this, they have been prevented from assessing their effectiveness. In Australia, it seems that the incidence of suicide hardly declined after the distribution of brochures. This is also true in Quebec after the campaigns (Chagnon, Chambers). Have friends and family been properly informed of what is expected from them.

Evaluating these programmes raises numerous ethical issues linked to the diverging interests of prevention and evaluation organisations and the assessors themselves, by informed consent and by confidentiality (Mishara).

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