Date: 8th December 2017. Health, Social Care and Sports Committee Inquiry into Suicide Prevention, Wales
This submission is made on behalf of the Royal College of Occupational Therapists (RCOT), the professional body for occupational therapists across the UK which supports 1880 occupational therapists in Wales, 300 of whom work in mental health services. The submission is made in response to the Inquiry into Suicide Prevention in Wales. Further information on any aspect of this response can be gained by contacting the RCOT.
Executive Summary
Key points to note from this submission include:
Ø Occupational therapists can lead innovative approaches to suicide prevention by focusing on the roots of emotional distress
Ø Occupational therapist believe more focus is needed on survivor legacy as they experience higher rates of suicide
Ø The value of meaningful occupation as a form of suicide prevention needs better recognition.
Submission
1. Innovative approaches to suicide prevention
An innovative and progressive approach to suicide prevention, with the potential to transform mental health services and generate significant social and economic impact, would be for the Welsh Government to support the introduction of a capacity test for suicidality.
For decades mental health services have been attempting a paradigm shift from the paternalistic medical model to a more holistic user-focussed recovery model – with only partial success. The impact of austerity has been a dramatic increase in poverty, homelessness and hopelessness, whilst at the same time funding for public services has been endlessly cut back.
This combination of undersupply and over demand has led to the tacit rationing of services, with criteria for access being set ever higher. Add into the mix spiralling public expectation and a culture of risk-aversion, and it is small wonder that the medical model has maintained its dominance.
The culturally-encoded concept of illness is so deeply embedded in society that in times of harsh austerity, to be labelled as sick becomes tolerable or even desirable if it means being cared for in an uncaring world.
Services have responded by fixating on risk rather than need to such a degree that the era when mental health services were focussed on severe and enduring mental illness (SMI) is long gone. Services have become a battleground for entitlement, a merry-go-round of assessment, and to a lesser extent management of risk, with precious little to offer in the way of rehabilitation or recovery.
In this socioeconomic context, suicidality has become a unit of currency, tradable for access to services. As the height of the bar rises so do the risks some people feel compelled to take, and so the focus of mental health services has become critically and unsustainably distorted.
Our members suggested solution is to stop treating suicidal ideation as necessarily a sign of illness, but rather a metaphor for emotional distress. By doing so we would free up services to address the root causes on an individual, needs-led basis – be it lack of meaningful occupation such as employment, accommodation, coping skills, social networks, all of which are the focus for occupational therapists. That is not to say that an individual’s cognition can never be impaired by SMI that they can see no alternative to ending their life. Indeed these are the very cases towards which services should in future, be orientated. The capacity test tells us if this is the case. Occupational therapists leading this type of approach would enable people to learn to deal with emotional distress and use meaningful occupation as an effective coping strategy.
2. Survivor legacy
A strong theme for our members is survivor legacy. Partners, parents and children present to mental health services with trauma symptoms such as guilt, anger, emotional volatility, alcohol and substance misuse that can be attributed to a critical trigger event such as suicide of a loved one.
Many of these survivors will manage with time but never fully recover. In many of these stories our members see pre-morbid behaviours of high expressed emotion, substance / alcohol misuse, dysfunctional relationships and abuse histories in both those who take their own life and survivors – in summary, vulnerable people with poor coping skills and little support. Our members feel that this group needs more policy focus and support. Occupational therapists can effectively support the survivors of suicide by focusing on how to use hope and goal setting to move forward positively with their lives.
3. Value of occupation.
Occupational therapists delivering occupation focused interventions can lessen suicidality. Participation in meaningful occupations or activities will have a positive impact on mental health and wellbeing and is often neglected as an effective intervention. A short film about Matt who tried to end his life and worked with an occupational therapist to regain meaning and motivation can be found here: https://www.youtube.com/watch?v=lVX_h-OroF0
Case study – Adult Community Mental Health Services - Hywel Dda University Health Board.
A 25 year old man had been suffering from severe depression with suicidal thoughts and self-harm. He had been in hospital for about 6 weeks and was discharged back into the community where he started working with the occupational therapist. There was little improvement in his mental health, he had not responded to CBT and had been off work sick. When the occupational therapist met him, he did not want to get out of bed and was voicing suicidal ideation. He lived in a rural location and was worried about losing contact with his two young sons because they were distressed at seeing their father so depressed.
By working with the occupational therapist he was able to identify that he hated his job and was constantly worried about making target sales. He was worried about paying his mortgage and providing security for his sons. He felt hopeless about the future. By working in collaboration with the man, the occupational therapist developed a care plan focused less on medication or talking therapies and more about re-engaging with everyday tasks such as self-care, work and leisure.
The man demonstrated that he had been a creative person who enjoyed making things out of wood and metal and was extremely good at DIY. His activity levels improved with activity scheduling and he began walking his dog on the beach every day, collecting driftwood and beginning to make things in his workshop. With the support of the occupational therapist, he began to sell his work on EBay and it sold quickly which improved his confidence and self-esteem. As his mood and sleep improved he made the decision not to return to the job he hated but to set his own business up as a handyman. After seeing the occupational therapist over a six month period he was discharged saying he felt like a different person with a vision and hope for the future.
Three months after his discharge he wrote the occupational therapist a thank you letter saying he had regained his driving license, had an improved relationship with his sons, was enjoying being self-employed and still sold his creative sculptures on the internet. The total cost of the occupational therapy intervention was approximately £1251 but the value to this man and his family is priceless.
About the College
The Royal College of Occupational Therapists (RCOT) is pleased to provide a response to this inquiry. RCOT is the professional body for occupational therapists and represents over 31,000 occupational therapists, support workers and students from across the United Kingdom. In Wales there are approximately 1880 occupational therapists, 300 of whom work in mental health services. Occupational therapy enables people of all ages to participate in daily life to improve health and wellbeing. The philosophy of occupational therapy is founded on the concept that occupation (participating in activities) is essential to human existence and good health and wellbeing.
Occupational therapists are regulated by the Health and Care Professions Council (HCPC), and work with people of all ages with a wide range of occupational problems resulting from physical, mental, social or developmental difficulties. Occupational therapists work in the NHS, Local Authority social care services, housing, schools, prisons, care homes, voluntary and independent sectors, and vocational and employment rehabilitation services.
Contact
For further information on this submission, please contact:
Genevieve Smyth
Professional Advisor
Royal College of Occupational Therapists
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