Examination of Witnesses (Questions 403
- 419)
WEDNESDAY 7 JULY 2004
PROFESSOR KEITH
HAWTON AND
PROFESSOR SIMON
WESSELY
Q403 Mike Gapes: Good afternoon everybody.
This is the fourth evidence session in our Duty of Care inquiry.
The aim of the inquiry is to examine how the Armed Forces look
after their people at the very beginning of their service, recruits
in Phase 1 training establishments and trainees in Phase 2 training
establishments. I should like to welcome Professor Hawton and
Professor Wessely this afternoon, who are two eminent psychiatrists
and then at half past four we are going to hear from the Health
and Safety Executive. I should like to thank you for coming to
give evidence to us and also for your written submission. Would
you like to introduce yourselves before we get into questions?
Professor Hawton: I am Keith Hawton.
I am a Professor of Psychiatry at Oxford University and, a Director
of the Centre for Suicide Research at the university. I am also
a consultant psychiatrist.
Professor Wessely: I am Simon
Wessely. I am Professor of Psychiatry at King's and Maudsley and
I am also a Director of the King's Centre for Military Health
Research and an advisor in psychiatry for the Army.
Q404 Mike Gapes: Could I begin with
a general question? On the basis of what psychiatrists know about
young people in general and the young recruits who have harmed
themselves in particular, is it possible or even helpful to consider
constructing profiles of vulnerability?
Professor Hawton: Perhaps I might
say first of all a little bit about the nature of suicide and
then come onto the question of profiling. One important point
is to recognise that suicide rarely results from a single event;
it is often a complex process where a series of factors over time
may lead to suicide, although there may be a precipitant. A wide
range of factors can be relevant. I will go through these briefly,
if that is okay. First of all, starting with the family and family
history of mental illness. We do know that a family history of
suicide is more common amongst people who commit suicide or self-harm.
Various types of life stresses are going to be relevant in young
people, particularly broken relationships, bereavements, abuse,
bullying, work problems, loss of status through work or in society
and so on. We know that psychiatric disorder is very common in
people who either self-harm or commit suicide. The vast majority
have a diagnosable psychiatric problem, although it is often only
diagnosed in retrospect rather than being known to others at the
time. This can be particularly depression, anxiety disorders and,
less commonly, manic depressive illness, and schizophrenia. Alcohol
and drug problems are also important contributory factors and
drug abuse is becoming an increasingly common factor in suicide
in young people. We know that certain personality types may be
more vulnerable and the sorts of characteristics which seem to
be particularly relevant here are a tendency towards being aggressive,
acting impulsively and generally having poor coping skills or
poor resiliency. Various psychological processes may be relevant
to someone getting into a suicidal crisis, such as feelings of
hopelessness, pessimism that nothing will change in the future,
feeling trapped in a situation and feeling powerless to do anything
about it or to escape from it, loss of self-esteem, shame, isolation,
which may either be in reality, in the sense of being actually
isolated from people around, or feeling isolated in a psychological
sense and, for whatever reason, being unwilling to share problems
with other people or approach other people for help. Probably
less relevant to young people, but not entirely so, is physical
illness which can be a contributory factor, particularly where
it is life-threatening or involves chronic pain. Another important
factor which we have become increasingly aware of is that exposure
to suicidal behaviour in other people may be very important; so
exposure to suicidal behaviour, such as through a family suicide
but also amongst an individual's peers. This can lead to clusters
of suicidal acts which it is well recognised can occur in young
people. We also know that there is good evidence that exposure
to suicidal behaviour in the media may in certain circumstances
also be a vulnerability factor. Then, crucially, there is the
availability of methods for suicidal behaviour and awareness and
knowledge of them and how to use them. It is not by chance that
the highest occupational groups for suicide in the United Kingdom
are all ones where there is access to means. They are: farmers
and vets, with obvious access to firearms; female doctors, dentists,
pharmacists, all having access to drugs, and anaesthetics in the
case of anaesthetists who are particularly high in this group.
We know less about what protects people against suicide, so-called
protective factors, such as having close, supportive relationships,
having good coping skills or resiliency as it is increasingly
termed and being willing to use sources of help. So a wide range
of factors can actually contribute to suicidal behaviour and it
is important to recognise that and in any one individual there
is likely to be more than one of these factors which is going
to be relevant.
Q405 Mike Gapes: Professor Wessely,
do you want to add anything to that?
Professor Wessely: No, you have
the world authority on the subject next to me, so I am not going
to add to that.
Q406 Mike Gapes: That is very useful.
There are many strands there which we shall no doubt take up.
I asked you specifically whether we needed to construct a profile.
If you had a profile which could include all those different categories
that is very, very wide, is it not?
Professor Hawton: Yes.
Q407 Mike Gapes: It could be a very
large cohort of the population.
Professor Hawton: Absolutely.
Q408 Mike Gapes: How could you narrow
that down to focus on vulnerable young recruits?
Professor Hawton: I think this
is very difficult. If we are addressing the question of whether
you can screen people at the point of application to join the
Force or as they enter the Force, to pick out those who are really
likely to engage in a suicidal act, fatal or otherwise, it is
difficult, if not verging on impossible, or at least has the potential
for very serious consequences. What one is talking about here
is trying to predict what is a very rare event, at least in the
case of suicide; self-harm of course is much more common. Trying
to predict something which is going to happen months or years
in the future is the first problem; predicting something which
is rare is another. I have been through all these factors, but
in terms of what we call their specificity for predicting suicide,
they are all very crude. They are also, as you were hinting, relatively
common in the population generally. I can give you an example.
A history of deliberate self-harm is the best predictor of suicide
and yet we know on the basis of a study we conducted recently
of 6,000 schoolchildren in England, that over 13% of them reported
an act of self-harm at some time, most of which had not come to
medical attention incidentally. In the girls it was 22% and the
boys around 6%. So you are talking about something which is relatively
common and yet very few of these will go on to commit suicide.
In terms of how specific that factor is, it is clearly not. The
other thing was that as I went through those factors it was obvious
that some of them are environmental and unpredictable; for example,
broken relationships and bullying. If you are screening somebody
at one particular point, how do you predict? You cannot predict
that they are going to experience these things. Another important
point, particularly in young people, is that you are talking about
the period when all the major mental health problems are most
likely to develop, to have their onset. Very often there will
not be any precursors to those illnesses which you can pick up.
Another important point to recognise is that it is a dynamic situation.
An additional factor is many people who die by suicide will actually
not have these clear risk factors which you can detect at a certain
point. The result of all this is that if you screen out people
using the sort of factors I went through earlier, if you take
those out of your population within the Force, you are going to
lose many, many individuals who will not develop problems, some
who will, a minority of whom will actually go on to develop problems
and you will also be losing a lot of people who may make a significant,
positive contribution to the aims and responsibilities of the
Force. This is not just speculation. There have been numerous
studies of risk factors for suicidal behaviour where people have
tried to look at what does predict it within a population
and these have all produced disappointing results without exception.
There were large numbers of false positives, in other words people
who showed the characteristics which are risk factors, but who
did not go on to show the behaviour you were trying to detect
and large numbers of false negatives, in other words people who
appeared to be okay when you screened them, but subsequently carried
out a suicidal act. Overall, I personally would not favour this
approach of screening at a certain point; there is a different
question about what happens over time subsequently.
Professor Wessely: We have done
quite a lot of work for screening on psychological vulnerability
in the military and if you look at the criteria used for establishing
a screening programme in the NHS, there is no shadow of doubt
whatsoever that this particular instance would fail on every single
one of the criteria which the NHS use. There is really complete
unanimity of opinion there, that screening for vulnerability to
mental disorders is ineffective and counter-productive. That is
in the general population. It becomes even worse in the military.
If you just take simple risk factors, for example coming from
a broken home, and if you say no-one can join the military who
comes from a broken home, that would eliminate nearly the entire
Army; 70% on the figures you have. It would not matter to the
RAF so much, but it would certainly affect the Army and that is
just on one factor. All these factors are very common anyway;
they are particularly common in the population the Army traditionally
recruits from and each of them is rather weak. You could construct
a profile which would eliminate everything Keith has said. The
statistics really do work like that and of course that would eliminate
the problem. However, you also have the other side, which I am
very, very keen on, which is that a lot of these people, who are
quite clearly risky—you meet them and you know these are
customers with somewhat dubious backgrounds—who can be a
bit scary to the average psychiatrist, nevertheless the research
we are doing at the moment shows that the vast majority of them
seem to do well and the military actually does very well by them
and there are winners from that game as well as losers. You would
lose completely that kind of social aspect. I know that is not
the purpose of the Army, but it is a side effect of the Army;
it does address a socially excluded group which very few other
people can tackle. They would go at a shot.
Q409 Mr Hancock: I am interested
in the profile you can get and whether or not people grow out
of the profile and how that emerges. Once you are in it and you
fit the criteria you have built up, is it possible for someone
to grow out of it or are they always a potential risk? The key
issue is that nothing has ever taken them over the edge.
Professor Hawton: May I take self-harm
as an example, going back to this school study I talked about.
What we know is that only a minority of these people who report
self-harm will go on to serious suicidal behaviour later on in
life. Maybe this is trivialising it, but for many this will represent
almost a developmental phase, a way of coping with difficulties
at a certain phase in their life. Having said that, once somebody
has crossed that boundary into harming themselves, they will always
carry some potential, increased risk. That is the current state
of knowledge. However, for some it will be an incredibly low risk
and they would have to be faced by certain overwhelming circumstances
for them to resort to this behaviour again. For a small minority,
it is a serious omen in terms of subsequent risk, but it is the
small minority; that is the crucial point.
Q410 Mr Hancock: If you were looking
at a group of young people at school, fifteen-year-olds at school
and you recognised in that cohort of youngsters some who met your
profile of people who were potentially self-harming, who were
actually self-harming, would they, according to your recollection
of the youngsters you have met like this, be the type who would
want to join the Armed Forces? That is the other issue, is it
not? Do people who meet these criteria, somebody who self-harms,
actually want to put themselves deliberately in harm's way?
Professor Hawton: This is a very
good question. I think the honest answer to that is that I do
not think we know, but, it leads really onto a complex question:
are the factors which are associated with risk of self-harm also
associated with an increased likelihood of wanting to join the
Armed Forces? In that case I would say yes, partly because of
the associations with self-harm, maybe with some difficulties
in following certain occupational routes and the Army or forces
might be more available to people of that kind. I would be loath
to say that people would want to put themselves at risk because
they had had a tendency to self-harm. I think that is highly unlikely;
there may be a very, very rare case.
Professor Wessely: There is good
evidence that that association you described does exist, through
risk-taking behaviour. For example, the studies we have done after
a war show you have an increase both in suicide, a transient increase,
and in accidental injury. The predictors of both are almost the
same; they are rather similar. Sometimes I have been involved
in looking at individual cases and it is very hard to know whether
or not that was suicide or it was just a completely stupid piece
of driving or risky behaviour which went hideously wrong. I think
you are right that there is an overlap between those characteristics
of danger-seeking, excitement-seeking and risk-taking.
Q411 Mr Hancock: I read that paper,
but it was based on the American experience, was it not?
Professor Wessely: No, it was
our paper; it was very British.
Q412 Mr Hancock: Is there a suggestion
that is something which is a pattern among young soldiers in the
UK?
Professor Wessely: We do not know.
The study we are doing at the moment will hopefully be able to look
at issues, but we do not know. We do know about the coming
together of self-harming behaviour and risky behaviour in general
and we know that both go up in the military after deployments.
The final bit of the jigsaw is that we do not specifically know
for the UK. I suspect that it will probably hang true, but you
are right, we do not yet know it. The paper we were describing
is a UK birth cohort, which includes very few, hardly any military
people.
Q413 Mr Jones: You mentioned that
the reasons for suicide are wide-ranging and there is no one reason
and in some cases there might be several reasons for suicide.
Is there anything either of you have actually seen in terms of
military training which is likely to exacerbate those problems
or lead to problems which people bring in from civvy street being
exacerbated by the way the training is done in any of the services?
Professor Wessely: The obvious
one is guns, access to firearms, which is major issue which is
clearly military specific. That is the immediate response to that.
Professor Hawton: I suppose the
fact that the very young people are away from their family situation
and if they are then involved in adverse experiences like bullying,
the impact of that may be more damaging for them when they do
not have their a family available. They may feel far more insecure
under those circumstances than someone who experiences bullying
under other circumstances but has their family support or their
usual friends around. In that way, these young people may be more
vulnerable.
Professor Wessely: Yes, I would
agree with that.
Q414 Mr Hancock: I just want to go
back to the profile and your experiences of people who fitted
into this profile going potentially from self-harm to suicide
or maybe even to harming others. Is it your experience that the
ultimate, the suicide or the harming of somebody else in their
lives, occurred while they were relatively young or is it something
which is liable to appear at any age? The issue we have here is
that we are dealing with very young people who have come from
maybe the sort of home lives you have talked about into a service
environment, many of them in the first year of their service lives
and they are still under 20 years old in the main. Would you recognise
that that is the potential risk time for them?
Professor Hawton: One of the issues
is that in the general population that is a time of particular
risk, particularly for non-fatal suicidal behaviour, self-harming
behaviour. Having said that, suicidal behaviour can appear at
any stage throughout the lifecycle, although the risk becomes
less as people get older, particularly for self-harm, not so much
for suicide. So the suicide risk is something which does not change
greatly. There has been a big change in the United Kingdom in
the last few years in that suicide rates have come down in older
people and gone up in younger people, so that now, what was the
traditional pattern of suicide risk increasing with age, is no
longer the case, particularly in males. Across the lifecycle you
see suicidal behaviour occurring and quite often with no previous
suicidal acts.
Q415 Mr Hancock: How effective would
it be for the Armed Forces in the UK to develop from your profile
of young people into an effective screening mechanism, not at
the training stage, but at the recruiting stage, so that there
was an effective measure for the Armed Forces to be able to exercise
some form of—
Professor Wessely: I go back to
the previous question. I do not think that is possible. It has
been tried occasionally and it has failed. It is just not possible.
You would eliminate too many people who would make good members
of the Armed Forces for the small number you would not recruit
in. The disadvantages for those people you have removed who would
have done perfectly well are profound. You label them as being
mentally unstable, vulnerable, etcetera and someone's constituent
had that problem, but I cannot remember who it was. When the Americans
did that in the Second World War, that was repeated on a vast
scale and there is lots of evidence of people who were denied
the chance of military service whose lives were stigmatised ever
after. When later in the war they were recruited into the military
because the Americans had run out of people, most of them made
perfectly good soldiers. The negative consequences for the people
who are falsely labelled are enormous.
Q416 Mr Hancock: If you cannot do
it at the initial recruiting stage, how soon into the training
phase could you do it?
Professor Wessely: In terms of
screening, you have a higher respect for psychiatry and its powers
of prediction than we do.
Q417 Mr Hancock: Let us not say "screening"
then. Let us say identifying the vulnerable person in training.
Professor Wessely: Spotting the
people in trouble is a very different strategy. That is not screening,
that is where you are observant for the signs of people in trouble.
Neither of us is expert on military training, but it is their
policy that they know their people and they spot people in trouble.
That is a perfectly reasonable strategy. The question of how good
they are at it is a different question.
Q418 Mr Hancock: But that is only
good if they are good at spotting them, is it not, and people
are trained?
Professor Wessely: Sure.
Q419 Mr Hancock: The evidence we
have is that the average life of a trainer is a two-year deployment,
somebody who is coming out of a unit, is sent as a trainer with
very little educational support for the initial stage or developmental
work during his or her time as a trainer.
Professor Wessely: As a strategy
I quite agree with you. My experience there is certainly that
knowledge of behavioural characteristics and of the issues we
are talking about could be increased. That would be a strategy
which would not impact in the way that screening would impact
on people who are not at risk and are falsely labelled. I suspect
strongly that could be improved, particularly if the situation
is as you say it is. Neither of us is expert in how the military
train people.
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