Dr Alex discusses male suicide, social isolation and educating young people about mental health

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Transcript

Ella Marchant: Hello and welcome to the Royal College of Psychiatrists' podcast with me Ella Marchant. Joining me on the podcast we have Dr Alex George discussing male suicide, social isolation and educating younger people about mental health needs. Alex is a doctor, author and mental health ambassador for the UK government. 

Since starring on Love Island in 2018, he has campaigned for more attention and funding to go towards young people's mental health, especially in the wake of the Covid 19 Pandemic. In the UK, men are three times more likely to die by suicide than women. And in the Republic of Ireland, they are actually four times more likely, we will also be discussing the mental health of new fathers, since our last episode on Daddy Blues last month. 

This podcast contains frank discussions about suicide and may not be for everyone. 

Thank you so much for being on the podcast today. We're here today to talk about world Suicide Prevention Day. And I just wanted to get your opinion on the change in language surrounding suicide because we used to say 'commit suicide' and now we say 'death by suicide' or you know, someone's killed themselves. Why do you think this change in language is important?

Alex George: Well, first of all, thank you so much for having me on the podcast. It's obviously a huge honour, and I think the Royal College of Psychiatrists do an amazing job. And I think you're great advocates for this space, in a really positive way. So, just wanted to say thank you. First of all, I think the language is incredibly important and I think we should talk about it on different levels, not just around the word 'suicide,' but actually emotional literacy, I think in mental health language in general. When we look at the term suicide in the past, saying 'committed suicide,' now changed to 'death by suicide' or 'died by suicide,' it's really important because it's such a heavily laden word to say 'committed,' you know. 

In 1961, they changed The Suicide Act, they changed that language, because previously it was seen to be a crime, to attempt to take your own life, and if you were found to of attempted to take your own life, it was something that could be punishable by prison. It's kind of really, really shocking, I think a lot of people don't realise that that is the case, and that's really what it means we're saying committed suicide. The message that can send to people who feel suicidal or feel really low or have suicidal ideation is really, really profound. I have had patients say to me, in A&E, they've said that they felt kind of suicidal, they said that they've heard healthcare professionals using the word committed and the way that that can make them feel. 

So, it's really important that we're aware of what we're saying and the impact that can have. If you extend it and use it in different scenarios as well, you know, people saying things like, 'a patient is bipolar,' 'that patient is bipolar,' or 'x, y, z name is bipolar.' They're not defined by the illness, they are this person who has a diagnosis of bipolar and just categorising makes people feel laden by that diagnosis. It just simply isn't fair. You know, it's like saying 'diabetic patient,' it's not, it's a patient who has diabetes, for example. And I think it's just really important to do that. 

A big part of stigma around mental health is this kind of labelling, I think that happens a lot of times, feeling that you become a diagnosis, which is not true. I guess the big thing about that, as well as the feeling that okay: 'Am I now this diagnosis? I can't be successful or be happy or do things in life achieve my goals.' Well, actually, a lot of people do manage to do that. 

I've got a colleague who works for me, a consultant who I'm very good friends with, and she has a diagnosis of bipolar disorder. She's an incredible consultant. She's very open about having that, but she's not defined by it. That's what's really important about language, and particularly when we're talking about the word, you know, committed suicide. For me personally, my brother took his own life just over a year ago he didn't commit a crime, he suffered with an illness, and there's a big difference.

EM: So, language and medicine actually have a much deeper relationship than we think?

AG: Yeah, I think usually, and if you look at what we're trying to do at schools now, it's to start integrating emotional literacy in an early age, a very, almost basic literacy of: What are thoughts? What are feelings? What's emotion? Why do behaviours sometimes link to inner feelings and emotions? And what's the connection? What do we do about it? Starting at a young age and helping people understand how to vocalise in the right way, what they're experiencing and expressing, is so important. 

A big part of some of the issues that we have around mental illness in particular is vocalising and expressing them, in a more broad sense, how we feel in terms of health and wellbeing. The barriers of emotional literacy are a huge issue. I wouldn't be doing the role I'm doing if I didn't believe strongly that education is a very powerful tool. Through education, we can change things like the way that we use language and help people use the right language and understand what words mean, and how to convey what they're feeling really well.

EM: Absolutely. I couldn't agree more. I also did an English degree. So, I always feel like if English and medicine can get together and have a good time, that's great.

AG: Yeah and I also think, just another brief point, I think it's like evolution in some ways. I mean, a lot of medical words and terminology we use, it just creates barriers. Sometimes we use fancy words for things when you can just explain them in much more simpler terms. When we speak to patients, the way that we talk about things, and talking on a level with someone is very important. So, from that perspective, just that doctor-patient relationship. You know, let's level with people and speak to them in a way that's understood, that people can understand, and I say, avoid labelling terms.

EM: Absolutely, and also, some medical literature, a lot of medical literature was created a really, really long time ago, and it hasn't kind of reached that modern level yet. 

AG: Agreed. 

EM: Today, we really want to talk about male suicide especially and how there's just such a dramatic difference between male suicide and female suicide rates in the UK and in the Republic of Ireland. So, men are three times more likely to die by suicide than women and in the Republic of Ireland it's actually four times more likely. It's just such a dramatic difference in those levels. And why do you actually think that is?

AG: There's been a huge amount of work in this area. I think it's fair to say it's very complex. And there's a lot of factors. One of the factors that we can tangibly look at and potentially change, is the kind of cultural expectations and cultural factors around what a man should be and how a man should be in modern society. Because it's an area that is playing a big role into why we see men take more violent forms of suicide. When it comes to, I think the stigma side of things, I feel that's a really big issue still, for men in particular. If you think of the societal norms, and maybe culturally, the British culture of like; a man should be, stoic, resilient, bullets bouncing off them. Men don't talk about feelings, you know, that showing emotions as a sign of weakness. This is actually real stuff that people have kind of been passing down the generations, you know, for a long time. And although I think we're making really good progress, that stuff doesn't dissipate overnight. You still see young people coming through with that feeling that they must be stoic, they can't share. And actually, you know, looking at what happened to my brother, he never said how he felt he never reached out at all to anyone around him. 

There's obviously a huge conversation around things like funding and we want to see CAMHS funded better, psychiatry, mental health as a whole, you know, I'm with you all on that. But if people don't feel able to reach out, then even the best funded services in the world can't save them. In my brother's situation, unfortunately, he didn't feel that he could reach out and I think a big part of that is around this feeling of shame. There's a shame associated with it, and being able to vocalise it. There's a big element, of course, when we go back to the emotional literacy and using the right words for how you're feeling and finding the words or finding the way to express yourself. That's a big, big aspect of it as well. We can't we can't ignore the issue. The fact that three times, four times more men die by suicide, it's just shocking and we've got to think about the potentially preventable causes of death. 

A big part of the answer comes down to education from a young age, getting people comfortable talking about the way they feel, understanding their feelings and emotions know how to manage those and feeling comfortable about accessing support, knowing where to go because a lot of people don't know where to go when they need help. And, as I said, we need more funding. We need more money into it, but actually there are a lot of amazing organisations doing a fantastic job that are there to help other people aren't aware of them. I'll take, for example, school children, the charity Shout is amazing. It's a tech service that you can text in and have a response via text by someone who is trained to respond and help you through that process. Why is it amazing? Because a lot of young people don't want to pick up the phone, they don't want to speak to their teacher or walk into the GP practice. Shout is a fantastic service, but if children aren't aware that that exists, they're not able to access it. So, potentially missing out on a group of people that we can help. And that's why I think education not just for stigma, but helping people understand the different ways that they can reach out and get support is very important. Particularly with, let's say a young boy, a young man. Maybe with my brother, what if he'd been aware of Shout, that you could have access in different way? Would he have accessed it? I don't know, maybe. But we've got to give these people the chance.

Particularly, we know that some of the highest rates of suicide are amongst farming communities. You can see in Wales, look at the way that culture is, I mean, you want to see a stoic culture? The kind of traditional male attitudes of what men should be? Look at farming. There's specific charities that work with farmers and try to connect with them, because often, they can be quite isolated in their work and their lifestyle. And the opportunity, I guess, for expression is different. Looking at different parts of the country, we're in different stages. I feel like in the last year, knowing all the terribleness of the pandemic, I think we're talking a lot more and I know some people feel...is talking the answer? I think part of it is, I think talking is part of realising that the problem exists. Through talking and through educating people, young and old, that's a big part of the solution.

EM: And our last podcast that we did was called Daddy Blues and that was basically looking at a short film that one of our psychiatrists made called Daddy Blues. We don't speak about the mental health of fathers very often, what kind of pressures do you think there is on dads?

AG: If you look around, if you want to look at an area that stigmatises it's a really big area, you know, you're a new dad, you should be tough, and should be strong. And if you're affected, how can you be? You didn't have to have the pregnancy? How can you be finding things hard? It's the mother of the child that's gone through the trauma. There's so much around that, that men are sometimes made to feel, not intentionally, but sometimes unintentionally. 

When you actually look at it, it's a lot more common than we realise. I mean, Tommy’s the charity, Tommy’s, there's a lot of research into this and it's believed up to 1 in 10, could be affected by daddy blues, and at the severe end of the spectrum; postnatal depression. We need to recognise that a little bit more, that any big change in your life can impact you and the way that you feel. If we look at it in a certain way, when we step back from this scenario, for a second, imagine you've got a new job. You're moving from Newcastle down to London, you're moving to the big city, it's a great opportunity, you've got a new job, but it's a massive change you're leaving your regular contact, probably with your family and friends, you're going to new places you don't know, you've got new added pressures with the stress of the job. There's all sorts of change in your life. 

We know that when you're experiencing big change, even if it's something that's perceived to be good, can actually have a profound effect on your mental health and your wellbeing. We talk about transitional points of going to school, going to university, leaving University, a job, the workplace, changing jobs, these are all transitional points. And a clearly big transitional point is fatherhood. So, having a new child, the financial pressures that come with that responsibility, you may be not going to do the same social things, you may become more isolated. It's a huge change. 

I think and I feel really passionate that we need to understand that it's fathers that are affected too. If you imagine even in the story of where, you know, the mother might have postnatal depression, that's probably going to have an impact on the mental health of that father as well. It's really great that that podcast highlighted the issue and was really powerful.

EM: So, just going back to education, we touched on this a little bit before. Some doctors do experience the death of a patient by suicide, do you feel when you're training to be a doctor that there is enough education around this?

AG: I went to med school at Peninsula Medical School, which is now Plymouth and Exeter and I must say we have quite a modern approach to patient interaction, into these kinds of issues. And I think we did have quite a bit of training around dealing with death, not so much around specifically suicide. I've actually been speaking a lot with med students from across  various medical schools, I think the general consensus is that we probably need to more around mental health.

I had a shift the other day, I'd say half the patients I saw, either the presenting complaint was related to mental health, or was a significant component of why I was seeing that patient. Even if the reason that there isn't about the mental health, often it's tied in. So, if someone comes in with a heart attack, they've had a cardiac incident, they've had a myocardial infarction, it may well be that the problem is physical, but the impact on their mental health could be huge. That connection, between the two, I do feel that it's important that we're trained, properly prepared for that, to realise that the two are so interconnected. 

When we look back at talking about suicide, I don't think we do enough, I think we probably should do more preparing because it's such an emotionally difficult situation. I have seen a few patients who have died by suicide, either before or at the time they presented to the A&E department. And it's really traumatic. It's really, really hard. And it's something that we all find really difficult to kind of get over. I think something really important that we've learned, is the importance of realising how tough it is, and talking, and we've been debriefing. And I think we're getting better, certainly at dealing with dramatic situations like that. But, we need to do more than that, especially for new doctors coming through, I think it's a real shock when it happens.

EM: Maybe there isn't any amount of education that can actually prepare you for it happening?

AG: Yeah, I think that, to me, it's more about how to deal with it afterwards. And the kind of looking after yourself and debriefing more than being prepared. I don't think anything can really prepare you for that fully. You're only human to be shocked by it and be upset by it. But it's how you handle that, knowing who to go to in the department, how the department's going to handle that situation happening, what the debrief process is. Or if your support services and counselling services are available to talk about that. Particularly the last year, we've seen so much death, I mean, there's no two ways around it, right? It's been really bad. And in that sense, and I think now more than ever, we've actually realise how much we need to care for our staff and look after our staff. 

Being aware of where to go when these things happen, don't just shrug it off and think you know what, I just need to crack on, you know, this resilient A&E doctor or doctor you're human. You shouldn't expect yourself to just shrug it off. You know, it's perfectly normal to feel what you feel and and I think knowing where to go and get getting support for that is vital.

EM: When do you think we can start to teach kids about suicide? Because perhaps it should start earlier than high school?

AG: Yeah, I think this is an area where there's been a lot of conversation around this. Truly the best person to answer that will be education psychologists, really looking into the most appropriate time and ages. I'm very keen that we particularly focus around the emotional literacy understanding, the kind of basic principles and wellbeing and what is mental health? What's mental illness? What's wellbeing? What's self-care? Learning the principles of how someone should look after themselves. And as they get older, I think we do need to teach because sadly we know that 11/12 year olds are taking their lives by suicide. If these are happening, we need to have the education to go alongside it. There's been a lot of fear in the past, people worrying if we talk about suicide, then children will take their own lives, well we actually know that the evidence doesn't support that theory. There's got to be an element of, 'When is it appropriate?' I hope this gets looked at intently over the next couple of years because I think we probably need to review it.

EM: This year due to COVID. A lot of university students were very isolated in halls. That was really difficult to cope with for anyone who's just moved away from home. Do you think there's something that universities could do to reach out to students and make them feel like they're included if there is another pandemic or another form of grand isolation that happened last year?

AG: I have done a lot of work with university over the last year, I speak to as many as I possibly can and students. Their a group that I've really been worried about. When I was working with Number 10 around the groups that have disproportionately been affected by the Pandemic, I think no one would argue that students are certainly among that group. Young people have moved to a new area that they don't know, and maybe don't even have friends yet, especially when their starting at university. And I think that's been so hard for them. We shouldn't for a second, ignore that. I think that a lot of universities did make some mistakes, I think errors have been made. 

A lot of universities have really tried hard to support their students in what is really a very difficult circumstance. One of the things I hear is that students would like to be included amongst communication and decision making more often. That's something a lot of universities agree and accept, it's an obvious point that if we're looking at the welfare of students, then let's involve the students in the decision making in that process. I hope, God forbid, we don’t go back to one of those situations. But I think that should be something really considered as time moves forward, for sure.

EM: Yeah, I definitely think if you're sitting alone in your halls, and you're having all your decisions made for you, and you're feeling extremely isolated, you'd feel like you've lost a lot of control.

AG: That's a huge aspect. I think a lot of us feel that way about control, but particularly if your movements are controlled to that level. I really feel for students through that, and what they've been through it has been really tough. That's why I spent so much time actually talking to students around how to look after themselves. Where they can go, what sort of support services have they been to. I've tried to speak to them as much as possible, to get that message across, see what more we can do to support them and also what's available. 

I'm really passionate about making sure that access to support should be easy, it should be drop-in, it should be available to anyone that needs it. One of the projects that I'm working on in my role with the government is an Early Support Hub set up across all communities in the UK. This is a project I'm working on in collaboration with the whole Mental Health Coalition, including all the charities and everything that's involved in the Mental Health Coalition. What we're calling for is the government to fund the hubs. These will be under 25 walk in services, whereby, you self-refer, you see a youth worker who'd go through why you're there, how are things, what things are going on in your life, and then they will be able to triage into the appropriate support. So, having access to counselling, therapy, talking therapies, educational advice, career advice, citizens bureau, sexual health, we're considering all will be an important aspect. A wraparound service, and I think we know from comparing to other services that are out there already, that the evidence is really good. The Y X Youth Access Model, has an improvement rate of psychological distress of around 60 to 70%, you know, across the board for those who present, which is actually really good when you compare it to other interventions. 

And so, when we move forward, we need to think about these community based things that provide support to all people, especially universities. That could be really important moving forward, those students that have been affected, they need somewhere to go that they can walk in, and the places are clinical. They won't be judged, of course, they can reach out to the university but some people don't feel comfortable doing that. And I think that's why something like this project could be really powerful.

EM: I feel like the concept that you're speaking about there for self-referral is also really important because it brings the control back to the service user. We know when our own mental health is severe enough to need to speak to someone.

AG: I think so. And the other aspect as well is that even when looking at GPs, they of course can refer to services, but a lot of people in the early stage with mild to moderate mental health illnesses or needs, that might not be the appropriate place to send them. Therefore they've referred a young person to the Child and Adolescent Mental Health Services, it might not be the appropriate place for that person at the time. But if we can intervene at an earlier point and in a wraparound service that is much more immediate, that could actually, for some people, prevent them requiring such services. I believe that is an area that we really should look into of course. CAMHS, the Child Adolescent Mental Health Services were developed and designed for the 5% right? It's not designed for the 100% that's currently being sent out there and we can't always expect those to fix everything. We need to look at the community as a whole and look at how various services can plug in and actually help different people at different points in their life. Really?

EM: Yes. It's not a one size fits all. 

AG: No, absolutely not. 

EM: So bringing it back to you, how do you personally look after your own mental health?

AG: I think it's been something that's become more important. Over the years I first experienced some difficulties with my own mental health at university. I became quite lost with myself. I lost interest in studies, I stopped eating well, I was sleeping terribly, wasn't exercise, and I recognised that I was going into a place really. Luckily, I spoke to my mum actually and she was a fantastic source, a lot of mums are. She helped me, kind of dragged me into the right kind of support and direction, which made a huge difference. Actually, it's my own mental health, and that was my first interest. And a lot of the ways that I felt better was actually by practising the wellbeing that we talked about. 

For a long time we've underplayed rather than overplayed the impact and power of what we can do in each day. I feel very strongly that the small changes individually can add up and make quite a significant difference. I mean, if you look at the treatment for most mental illness, an element of lifestyle change is in almost every single one. It's not just down to just one treatment, it's a combination. I look at everything in my life and how things can impact. So, am I sleeping well, am I rundown or tired and what's going to affect my mood, am I eating well and energising my body throughout the day. Not having peaks and troughs of energy which will affect the way I feel. Am I getting enough natural light, have I gone for a walk to be around nature and that calming effect, when's the last time we did some exercise. 

What I've tried to do is build a routine in my day, when I wake up in the morning, first thing to do is go outside have a walk. And the benefits for sleep, your circadian rhythm, morning sunlight is great for setting a circadian rhythm and sleeping in the evening. Going outside. Movement we know is great for mood and for calm, being around nature. Then during the day, I make sure I have breaks. I'm working with home a lot and having breaks; I can move and get up. I practice self-care. I love my bath bombs, which people might find quite funny, but it's great for me because it makes me stop. It just chills me out, put some music on, it's a really good unwind technique for me after a stressful day. I do that. I talk a lot as well. I speak to my family, or friends with my girlfriend. And all those aspects come to play. They all seem as little small things. But if I stop doing all those little things, I noticed a huge difference in the way that I feel. And I'm not saying these things are there to cure illness. That's not what I'm saying, of course, but they are they an important part of your general wellbeing? I think so.

EM: I love speaking to my mam and dad, daily life would not be the same and they're both occupational therapists. So, that's also very, very handy as well. 

AG: Give you sound advice. 

EM: Yeah, exactly. Very practical advice. 

AG: Yeah, I'm sure. 

EM: The theme of this year's World Suicide Prevention Day is creating hope. And it's 'Creating Hope Through Action,' so how can we create hope within our own communities, on a small level?

AG: This is something I'm really passionate about. Talking about mental health is very important and raising awareness, but it's also about tangible action. We can all do something that can help this movement of improving the country's mental wellbeing and health. We can all do something and even when it's big or small. I'll take for an example what we're doing at A&E, in Lewisham, we have one of the consultants as the Wellbeing Champion for the department. I'm not being the champion because I can't take on any more roles at the moment. There's a Wellbeing Champion and then we're having Mental Health First Aiders, so we've got volunteers who will be working in the trust who are going to be Mental Health First Aiders. Between them they will be running wellbeing sessions, thinking about creating wellbeing rooms, looking at staff wellbeing as a whole, looking at the working environment. So, what we're talking about is individuals who're actually trying to do a little bit, even it's just something small to help that community. 

Take that example and look at any stage in life, whether it's school, university, what can you do to get involved in a project that helps both your mental health and the wellbeing of people around you? It may well just be being more aware at work to check in with people, check in with your colleagues. You know, the Ask Twice Campaign as part of Time to Change. We ask people, 'How are you today?' British answer: 'Yeah, I'm fine.' Take that moment if your gut instinct, the social cues and behavioural cues make you think, 'Oh, they're not, they're not themselves.' Take action and ask them in a time and a place that's appropriate. 'I get the feeling that you're not yourself. Are you sure you're okay?' It's amazing how often in my working day, I noticed that we don't check in on people that much. It's not about running around all the time and checking in. But when's the last time you asked your two colleagues that you sat next to how they're really doing and what's going on in their lives? There's lots of little ways you can do it. Just think of an action that you can take, a tangible thing that you can do that might help yourself and other people.

EM:Yeah, it's a bit like what we were talking about before with new dads thinking that they have to be a big breadwinner. I imagine that people in who work in health, who work in the health sector, think they have to be really strong all the time, mentally and physically, they probably think, I can't get sick. I can't, I have to be strong because I'm in a caring role, I'm in a caring, giving role.

AG: Yeah and this is something that's huge. To be honest, it's a problem amongst the NHS. We are seeing huge and rising rates of burnout amongst the whole spectrum of health care providers and health professionals within the NHS. We need to really wake up to what's happening and realise that we need to look after the carers, we've got to care for the carers in order for them to be able to perform their jobs well. In some sectors of medicine, rates of burnout are up to nearly 80% can you believe? Which is absolutely huge and for the workforce and the provision even, forget the human level, in providing and doing the work that we're doing. It's a real worry. So, we need to focus on that and it's another area that I am hoping to push more. To force us to think a little bit more about how we look after our staff you know, what tangibly can we do? Tokenism is one thing. We don't want to be tokenistic about things we need to tangibly make a change and support people in a way that's meaningful. You know, it's a difficult space, but it's a really exciting one as well. I think there's going to be big changes in the years to come. I really hope that we can bring it forward into the 21st century.

EM:  A huge thank you to Dr Alex for coming on the podcast for World Suicide Prevention Day, which is on the 10th of September. If you would like any more resources on suicide, please visit our website www.rcpsych.ac.uk/. You've been listening to the Royal College of psychiatrists podcast with me, Ella Marchant.