Alcohol Stories: Exploring accounts and practices of alcohol use, suicide and self-harm

Blog written for the Institute for Alcohol Studies Blog, in advance of a talk I gave summarising some of the findings from the Alcohol Stories project, at Alcohol Concern Cymru’s Saving Lives event on 22nd September 2016.

There is a complex, but significant, relationship between alcohol consumption, suicide and self-harm. Alcohol use is associated with completed suicide and self-harm in the short term – with over 50% of cases of suicide, and hospital treated self-harm, occurring in the context of alcohol use (Ness et al., 2015; Sher, 2006). In the longer term, individuals who are alcohol dependent are more likely than those who are not to die by suicide (Hawton, Casañas i Comabella, Haw, & Saunders, 2013; Sher, 2006). A conference, organised by Alcohol Concern Cymru on 22nd September 2016, dedicates a whole day to exploring this issue.  As part of this event, I will be speaking about my ongoing, qualitative research addressing cultural and social understandings of alcohol use, self-harm and suicide. Despite a growing body of evidence pointing to a statistical relationship between alcohol use and suicide; qualitative research addressing this issue has been scarce.

Of particular interest with regards alcohol use and suicide, are men in mid-life, from poorer socioeconomic backgrounds. This group are at heightened risk of both alcohol related harm (Fone, Farewell, White, Lyons, & Dunstan, 2013), and suicide (Shiner, Scourfield, Fincham, & Langer, 2009; Wyllie et al., 2012). Existing literature has suggested that alcohol use – among many other factors – may partly explain the higher rates of suicide observed among men currently in mid-life (Parkinson, Minton, Lewsey, Bouttell, & McCartney, 2016). Additional factors suggested include economic change (recession, economic restructuring, deindustrialisation); family breakdown; expectations of masculinity which may inhibit help-seeking; and the failure of mental health services to cater for men (Wilkins, 2010, 2015; Wyllie, et al., 2012). Alcohol use may emerge as part of, or in response to, each of these factors. In particular, it is proposed that men  are more likely to use alcohol ‘to cope’, as opposed to seeking formal help, or talking about problems with others (Canetto, 1991; Cleary, 2012).

However, while there are numerous proposed mechanisms by which alcohol use may contribute to suicide or self-harm among particular demographic groups, there is a distinct lack of qualitative research exploring such issues. In 2015 I was funded by Alcohol Research UK (http://alcoholresearchuk.org/alcohol-insights/alcohol-stories-a-lifecourse-perspective-on-self-harm-suicide-and-alcohol-use-among-men/) to carry out a small pilot study, to explore the possibilities of collecting qualitative data with a group of particularly ‘high risk’ men. These were men who embodied a number of risk factors for suicide, including their gender (male); age (‘mid-life’); previous experience with self-harm/suicidal thoughts; and socioeconomic background.

A number of compelling themes were identified, pointing to the importance of exploring these issues with more people, and the potentially vital role of cultural meanings associated with alcohol use and suicide in better understanding the complex relationships identified in quantitative studies.

Alcohol as a form of ‘coping’

Unsurprisingly, alcohol was often described as a method of ‘coping’ with life’s problems. The way in which this emerged in men’s accounts differed, however. For some alcohol was described as something they had used since early adulthood to ‘cope with’ low self-esteem and poor confidence; for others alcohol was a way of forgetting traumatic events or – more prosaically – “the shit that I’m going through” (Brad). However, a narrative of using alcohol ‘to cope’ was not always present, with other accounts talking about a drift into ‘heavy drinking’ that was not so neatly explained.

Alcohol and the act of suicide

A particularly important finding related to the use of alcohol in both planned suicides and ‘impulsive’ suicides. Men spoke of ‘others’ who had died by suicide following drinking, reflecting on the extent to which this was about alcohol reducing ‘inhibitions’ or facilitating a pre-existing, long standing desire to die: “they may have been suicidal and then had the drink and it’s just given the courage to do it” (Mike).

Relatedly, alcohol was described as being a way of getting the ‘courage’ said to be needed to go through with a suicide, and this emerged in accounts of men with – and without – identified alcohol problems. “There are ways of doing it. It’s the doing it that’s the problem. It’s the getting yourself to that point of doing it. And alcohol would certainly help” (Robert)

Alcohol and (non-fatal) self-harm

Among men who described past hazardous drinking, incidences of self-harm whilst drinking were described in a common-place manner: “I took overdoses, aye. Not that many, three or something” (Paul). This is important – and might be related to the ‘impulsive’ suicides of others that men referred to: many cases of ‘non-fatal’ self-harm could well have turned out to be suicides had men not been ‘discovered’, had they not vomited, had their bodies responded to a particular overdose in a different manner.

Listening to ‘difficult’ stories

This was a small, pilot study designed to test out whether it was possible and meaningful to investigate alcohol and suicide using qualitative methods. The rich and complex stories generated by the pilot project suggest that it is possible, meaningful and important to listen to the accounts of individuals regarding their use of alcohol and practices relating to self-harm and suicide. Attending to such ‘stories’  is vital if we are to more fully understand the diverse roles alcohol might play in practices of self-harm or suicide among different social groups.

For more information see:

https://alcoholstories.wordpress.com/

http://www.samaritans.org/about-us/our-research/research-report-men-suicide-and-society

Contact: a.chandler@ed.ac.uk @dramychandler

Canetto, S. S. (1991). Gender Roles, Suicide Attempts, and Substance Abuse. The Journal of Psychology, 125(6), 605-620. doi: 10.1080/00223980.1991.10543323

Cleary, A. (2012). Suicidal action, emotional expression, and the performance of masculinities. Social Science & Medicine, 74, 498-505.

Fone, D. L., Farewell, D. M., White, J., Lyons, R. A., & Dunstan, F. D. (2013). Socioeconomic patterning of excess alcohol consumption and binge drinking: a cross-sectional study of multilevel associations with neighbourhood deprivation. BMJ Open, 3(e002337).

Hawton, K., Casañas i Comabella, C., Haw, C., & Saunders, K. (2013). Risk factors for suicide in individuals with depression: A systematic review. Journal of Affective Disorders, 147(1–3), 17-28. doi: http://dx.doi.org/10.1016/j.jad.2013.01.004

Ness, J., Hawton, K., Bergen, H., Cooper, J., Steeg, S., Kapur, N., . . . Waters, K. (2015). Alcohol use and misuse, self-harm and subsequent mortality: an epidemiological and longitudinal study from the multicentre study of self-harm in England. Emergency Medicine Journal, 32(10), 793-799. doi: 10.1136/emermed-2013-202753

Parkinson, J., Minton, J., Lewsey, J., Bouttell, J., & McCartney, G. (2016). Recent cohort effects in suicide in Scotland: a legacy of the 1980s? Journal of Epidemiology and Community Health. doi: 10.1136/jech-2016-207296

Sher, L. (2006). Alcohol consumption and suicide. QJM, 99(1), 57-61. doi: 10.1093/qjmed/hci146

Shiner, M., Scourfield, J., Fincham, B., & Langer, S. (2009). When things fall apart: Gender and suicide across the life-course. Social Science & Medicine, 69(5), 738-746.

Wilkins, D. (2010). Untold Problems: A review of the essential issues in the mental health of men and boys: Men’s Health Forum.

Wilkins, D. (2015). How to Make Mental Health Services Work for Men. London: Men’s Health Foundation.

Wyllie, C., Platt, S., Brownlie, J., Chandler, A., Connolly, S., Evans, R., . . . Scourfield, J. (2012). Men, Suicide and Society. London: Samaritans.

 

 

Mental Health and Reflexivity: Presentations and Plenaries

Agenda, Mental Health and Reflexivity 7th June 2016

Final list of speakers and titles for our upcoming event on Mental Health and Reflexivity in (mostly) medical sociological research. Really pleased to have contributions from colleagues at different stages in their career, speaking from a range of disciplinary perspectives, including: sociology, user-led research,  medical humanities and history of psychiatry.

It promises to be an interesting day with lots of opportunities to reflect critically on the uses and challenges of reflexivity in this area of research; as well as the contributions, and blurred boundaries between different disciplinary perspectives, positions and identities.

Keynote speaker 1: Diana Rose (King’s College London) ‘On personal epiphanies and collective knowledge’

Anaïs Duong-Pedica (University of York) ‘Can the (academic) “suicidal” speak? Personal reflections on depression, suicide and research’

Ali Hutchinson (University of Chester) ‘On being insane in sane places: Researching, writing and experiencing ‘madness’’

Sarah Chaney (Queen Mary, University of London) ‘A Personal History of Self-Harm: Countering the Myth of Objectivity’

Brigit McWade (Lancaster University) ‘Was it autoethnography? The classificatory, confessional and mad politics of lived experience in sociological research’

Chris Millard (Queen Mary, University of London) ‘Catharsis, community or asbestos gloves? Reflexivity and the history of psychiatry’

Keynote speaker 2: David Pilgrim (University of Liverpool/University of Southampton)
‘Between neuro-reductionism and radical social constructionism: a critical realist perspective on subjectivity and mental health’

Funded by the Foundation for the Sociology of Health and Illness

Hosted by the University of Edinburgh, Institute for Advanced Studies in the Humanities, Centre for Research on Families and Relationships

Organised by Tineke Broer, Martyn Pickersgill (University of Edinburgh), and Amy Chandler (University of Lincoln)

Mental health and reflexivity: The role of personal experiences of mental ill-health in medical sociological research

Blog co-authored with Tineke Broer, University of Edinburgh

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Reflexivity is framed as an important aspect of rigorous sociological research. Critically reflecting on the position, role and influence of the researcher, and how this shapes the knowledge they create, provides a way of navigating epistemological threats to research practice. Sociological (and anthropological) research on mental ill-health has – for some researchers – entailed drawing productively on personal experiences. This is seen in Jackie Orr’s (2006) study of panic, subtitled ‘a genealogy of panic disorder’. She draws explicitly on her own experiences of panic and of participating in a clinical trial, critically considering her experiences in the light of a normalizing and in some ways disciplining psychiatry. Similarly, anthropologist Emily Martin (2009) uses her experiences of manic depression as a source of data, and a way in, to a wider ethnography of depression in the US.

More directly, ‘mad studies’ and user-led mental health research contributes to debates about the impact of experience on research and knowledge production. Standpoint epistemology in mental health research and mad studies has offered further ways of thinking through and with subjective experiences understood by one’s self or others as pathological (Rose 2003; LeFrançois, Menzies, and Reaume (Eds) 2013). This re-positions and reconfigures experience within a research context; and this movement can in part be seen as a reaction against power imbalances in psychiatry. There are, then, significant political implications to methodological and theoretical reflections on reflexivity.

These political aspects are evident in Alain Ehrenberg’s (2009) work, which argues that ‘admitting’ one’s mental ill-health in a public place relies on and constructs a particular notion of the self: one that confesses its disturbances in order to promote a social cause. Thus, conceptualisations of knowledge (production) and those of selfhood are intricately linked, and are reflected in the way in which researchers use (or do not use) experiences of mental ill-health in their research.

In a forthcoming symposium, funded by the Foundation for the Sociology of Health and Illness, we aim to provide space to critically interrogate the role of personal experience of mental ill-health in medical sociological research. What are the implications of researchers’ experiences with mental health when they set out to investigate sociological aspects of mental ill-health? What are the risks and benefits of researching experiences which may be close to our own? Are there dangers in researching experiences which we cannot share? What does it mean to draw on our own experiences when writing up the research, or when the research draws almost exclusively on our own experiences such as in auto-ethnography? Reflecting on these issues raises important wider debates regarding the nature of knowledge and the world.

The symposium will be held on 7th of June 2016, and aims to explore in depth what it means to draw upon one’s own experiences of mental ill-health in sociological knowledge production. The two confirmed speakers are Professor Diana Rose and Professor Dave Pilgrim. Diana Rose is Professor of User-Led Research, King’s College London, conducting research in her identity as (former) service user. Dave Pilgrim is Professor in the School of Social Work, University of Central Lancashire, and is co-author (with Anne Rogers) of the book A Sociology of Mental Health and Illness.

There are several spaces for papers from other researchers working on mental health, who would like to contribute reflections, analysis or findings relevant to the topic of reflexivity in mental health research. We are especially interested in hearing from sociologists, but welcome those working in other relevant disciplines (psychology, social work, anthropology, STS).

Details about abstract submission can be found here. Deadline for abstract submission is 6th March 2016.

Registration for the event is open, follow this link.

Organising committee: Tineke Broer (University of Edinburgh), Amy Chandler (University of Lincoln) and Martyn Pickersgill (University of Edinburgh). This symposium is generously supported by funding from the Foundation for the Sociology of Health and Illness.

References

Ehrenberg, A. (2009). Weariness of the Self: Diagnosing the History of Depression in the Contemporary Age. McGill-Queen’s Press.

LeFrancois B.A., Menzies R. & Reaume H., eds (2013) Mad Matters: A Critical Reader in Canadian Mad Studies. Canadian Scholars’ Press Inc., Toronto.

Martin, E. (2009) Bipolar Expeditions: Mania and Depression in American Culture. Princeton University Press

Orr, J. (2006). Panic diaries: a genealogy of panic disorder. Duke University Press.

Pilgrim, D. and A. Rogers (2010). A Sociology of Mental Health and Illness. Open University Press.

Rose, D. (2003). ‘Having a diagnosis is a qualification for the job’. BMJ. 2003 Jun 14; 326(7402): 1331.

Self-harm in (General) Practice

Reflections on diagnosis, self-harm and suicide; and how the complexity of defining self-harm relates to a new (open access) paper addressing General Practitioners’ accounts of responding to self-harm.

Sociology has a long history of engagement with the meanings of suicide (Douglas 1967), and a more recent history of critically exploring the meanings of self-harm (Adler and Adler, 2011; Brossard 2014). Emile Durkheim (1952/1897) famously used an analysis of official rates of suicide to demonstrate the then new science of sociology. Durkheim’s analysis rejected attempts to identify the ‘motives’ of people who appeared to have died by suicide – accounts of motivation were, he argued, untrustworthy, and changeable; while the rates themselves could be viewed as ‘social facts’.

Suspicion of motivational accounts of self-harm is preserved in many contemporary discussions of self-harm and suicide in psychiatry and health policy. For instance, the UK’s National Institute for Clinical Excellence (NICE) defines self-harm as “self-injury or self-poisoning, irrespective of the apparent purpose of the act”. This approach contrasts starkly with the proposal in the latest Diagnostic and Statistical Manual of the American Psychiatric Association, that ‘Non-suicidal Self-Injury’ (NSSI) be treated as a distinct psychiatric disorder.

Contrary to initial impressions, ‘self-harm’ – like NSSI – is defined in part by its relationship to suicide; though the key difference here is the outcome, rather than the ‘stated or inferred motivation’. Further, while self-harm is defined by the absence of suicide, it is also understood as closely related; people who are treated in hospital for self-harm (the minority) are statistically more likely to die by suicide in future, though still in very small numbers. The relationship between self-harm and suicide is further complicated by qualitative research with people who have self-harmed, which reports diverse and contradictory motivations. In some cases, self-harm is framed as having nothing to do with suicide – indeed it is the ‘opposite of suicide’; while other reports suggest more ambivalence or variation in their motives when self-harming (Solomon and Farand 1995).

To date, very little research had addressed how clinical practitioners – especially those working in General Practice, rather than psychiatry – navigate the complex, and contested, relationship between self-harm and suicide. In a project completed in 2014, and recently published in Crisis, myself and colleagues Caroline King, Chris Burton and Steve Platt, set out to explore just that. We interviewed 30 General Practitioners working in Scotland, exploring their experiences of treating patients who had self-harmed, and their accounts of addressing potential ‘suicide risk’ for these patients.

stethoscope

Potentially important differences in how self-harm and suicide risk were conceptualised emerged in the interviews. Our sample of GPs worked in diverse areas: cities, semi-rural and remote locations; areas of affluence as well as those characterised by significant socioeconomic deprivation. Those GPs who had experience working with patients who were marginalised and poor provided accounts of self-harm and suicide which addressed ambiguity and complexity: there was no clear distinction, self-harm could be suicidal, non-suicidal, neither, or both. This was related to what were termed the ‘difficult lives’ of patients living on the margins of society, many of whom indicated ambivalence about life and death. These findings reflect quantitative work which has highlighted significant inequalities in rates of suicide and self-harm between people living in affluent and deprived areas (Hawton et al 2003).

In contrast, GPs working with more affluent populations were more likely to describe self-harm and suicide as separate issues. In particular, patients who self-harmed were in some instances framed as highly unlikely to die by suicide – an account which reflects what some individuals who self-harm say (that self-harm is about ‘release’ or ‘coping’ rather than death) and official statistics which indicate that suicide is a (comparatively) rare occurrence, whereas self-harm is more frequent. What this distinction underlines is that how GPs respond to and work with definitions about self-harm and suicide may be affected by the socioeconomic contexts in which they work. For GPs working in more deprived areas, death of all kinds – including suicide – is more common, including among younger patients. In contrast, GPs working in more affluent communities are more likely to see suicides as a ‘one off’, ‘unpredictable’ event. In the paper, we argue that these different experiences, and different ‘working definitions’ of self-harm, has implications for the training of GPs around mental health, self-harm and suicide prevention.

Acknowledgement

The research was funded by the Chief Scientists’ Office of the Scottish Government, with research support from the Scottish Primary Care Research Network.

 

References

Adler, P. and P. Adler (2011). The Tender Cut: Inside the Hidden World of Self-Injury. New York, New York University Press.

Brossard, B. (2014). “Fighting with Oneself to Maintain the Interaction Order: A Sociological Approach to Self-Injury Daily Process.” Symbolic interaction 37(4): 558-575.

Chandler, A., et al. (in press, 2015). “General Practitioners’ Accounts of Patients Who Have Self-Harmed A Qualitative, Observational Study.” Crisis The Journal of Crisis Intervention and Suicide Prevention.

Douglas, J. (1967) The social Meanings of Suicide. Princeton University Press

Durkheim, E. (1952). Suicide: A Study in Sociology. London, Routledge & Kegan Paul.

Hawton, K., et al. (2001). “The influence of the economic and social environment on deliberate self-harm and suicide: an ecological and person-based study.” Psychological Medicine 31(05): 827-836.

Solomon, Y. and J. Farand (1996). ““Why don’t you do it properly?” Young women who self-injure ” Journal of Adolescence 19: 111-119.

 

 

Turning the light on male suicide

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The gap between male and female suicide rates has increased over the last 30 years; currently four out of every 5 deaths by suicide in the UK are men. Numerous explanations have been put forward, one of which suggests that men are less likely than women to a) share problems with friends; and b) access talking therapies.

For instance, a campaign earlier this year by the Self Esteem Team aimed to ‘inspire’ men to open up about their problems and worries; implying that if men stop ‘swallowing [their] feelings’ and ‘just soldiering on regardless’ then perhaps they might kill themselves less often. The campaign received a lot of media coverage, was supported by celebrities including Steven Fry and included a social media campaign where men were encouraged to name their worries publicly.

light-switch-944129_1280 (2)

For many reasons, this type of campaign is to be welcomed. It is refreshing to see distress and suicide being addressed in a non-medical, non-judgemental manner which is aimed at tackling widely held cultural beliefs about men and masculinity. However, there are also a number of concerns about the discursive link between male openness about feelings and high suicide rates. Focusing on talk, for instance, does not necessarily address structural inequalities, or other aspects of masculinities, which might also contribute to the discrepancy between male and female suicide rates.

As part of an on-going pilot study, funded by Alcohol Research UK, I have been interviewing men who have experienced suicidal thoughts or actions. Their stories provide some support to the idea that men find it difficult to ‘open up’ about their worries and problems. However, participants in the study have also told of thwarted attempts to ‘seek help’ – where services have not responded or simply not been there.

The worries articulated by (mostly successful, rich) men in the #switchonthelight campaign concern important issues regarding fear of failure, experiences of panic, feelings of inadequacy. To a certain extent these declarations normalise the discussion of negative feelings among men. However, in contrast, the concerns that emerge for men in the Alcohol Stories study go beyond this. Crucially they include extremely difficult experiences and feelings: job loss, relationship breakdown, prison sentences, abusive interpersonal relationships, suicide attempts and thoughts, dysfunctional family relationships.

These findings raise significant challenges for explanations for male suicide which focus overly on ‘talking’ and ‘open-ness’. Rates of suicide are much higher for men from lower socioeconomic backgrounds, for those who have insecure or no housing, for those who are unemployed. I would suggest that it may be much less possible for men who do not embody ‘successful’ masculinity via professional status or economic security to ‘open up’ about their problems in the manner suggested by the #switchonthelight campaign. As such, we need to remain cautiously supportive of such initiatives, whilst maintaining a close eye on the significant structural inequalities which shape problems like male suicide.

Cross posted with: CRFR October Newsletter;

Based on a paper given at the Annual Meeting of the Society for the Study of Symbolic Interaction, August 2015

Further information/support: Samaritans; CALM (Campaign Against Living Miserably).

Male suicides rising: exploring the role of alcohol and community support

This is a very much a ‘work in progress’ blog – reflecting on recent statistics on suicide in the UK, and thinking through how this relates to issues I am addressing in a new research pilot project (cross posted to the CRFR Blog).

New figures released by the UK Office for National Statistics show that suicides among men have risen, with levels now the same as in 2011 – a potential reversal of what had been a downward trend. Rates among younger men are often highlighted, since suicide in men aged 15-29 is the leading cause of death. These latest figures show that suicides among older men, aged 45-59, are now higher than any other age group.

guardian stats suicide rates

[Image from The Guardian]

I am currently at the start of a pilot project, funded by Alcohol Research UK, which is using biographical methods to study the life-stories of men in this older age group. The study will focus especially on men’s accounts of the complex interplay between alcohol use, self-harm, suicidality, and mental health.

The men I am speaking to are in some ways ‘lucky’ – they are all being supported by community-based mental health and substance use support services. Despite this, their accounts (so far) highlight difficulties they have faced in accessing and using support at various points across their lives. News stories about the latest suicide statistics were accompanied by coverage of one particular suicide, with a bereaved family keen to highlight what they see as limitations in current mental healthcare provision in the UK. The story of Martin Strain was, sadly, familiar when I read it – elements of his struggle are reflected in the accounts of the men I have spoken with so far. In particular, Martin’s history of drug and alcohol misuse is said to have resulted in him being denied access to one-to-one psychiatric support. This highlights a significant challenge in tackling mental ill health in general, but especially for men, who are more likely to turn to alcohol to manage distress.

Around 50% of deaths by suicide occur in the context of alcohol use; and those who are alcohol dependent are at increased risk of suicide. Despite this, those identified as having alcohol use problems are – like Martin Strain – in some cases, diverted away from psychological support, into alcohol use services. Unless appropriate community based support is available (which is patchy, and will be reliant on the whims of local authority funding), people who have both mental ill-health and alcohol problems may not receive any kind of ‘joined up’ support. One of the issues I am investigating in the current study is the extent to which mental health is supported by substance use services; and conversely, how well alcohol misuse is responded to by mental health services.

In a limited way, I will also be exploring the role that community based support can have for men, who are often framed as ‘hard to reach’ and ‘hard to engage’. Yet clearly, some are reached, and some do engage – how do men account for this? In particular, I will be building on existing research which has examined the accounts that men provide when they engage in potentially ‘un-masculine’ practices, such as accessing a talking therapy. Studies have suggested that there are important differences between men in how they deal with such issues: with some men more able than others to frame ‘talking’ or ‘connecting’ with others as a responsible reaction to depression and thoughts of suicide (Oliffe et al 2011).

Additionally, I am looking at the way in which men themselves talk about their use of alcohol in the context of mental ill-health. Not all suicides are related to alcohol, and not everyone who uses alcohol will have problems with mental health, self-harm, or suicide. Already, variations are emerging in how men talk about alcohol use, and this study will provide useful insights into the diverse ways in which alcohol and mental health are understood.

Self-harm and the media – unpicking the ‘rise’ in self-harm among young people

Several articles were published yesterday and today in the UK media regarding an apparently dramatic rise in “the number of children who self-harm”:

“The number of children who self-harm has increased by more than 70 per cent in the past two years to record levels, according to new figures” Ian Johnston, The Independent, Sunday 10th August 2014.

The piece in the Independent was originally illustrated with a picture of someone scratching their arm with a pair of scissors (this was replaced later in the day), while the Times ran with a picture of a young person with numerous cuts on their arms. These images are problematic for many reasons, not least that viewing such images may be experienced as ‘triggering’ or traumatic for people who have or do self-harm, or that websites containing similar images have been shut down for ‘promoting’ self-injury. There are other problems with the way this story has been reported, and below I offer a few reflections on these, based on my experience of carrying out sociological research into self-harm for the last 10 years.

Firstly, the ‘dramatic’ increase in self-harm that is described in the articles is based on hospital statistics. Thus, the articles should have stated (and some did, but not in the strapline, with the notable exception of the Daily Mail) that there has been a dramatic increase in hospital treated self-harm. Hospital treated self-harm can be used as a proxy for looking at wider rates, but among young people especially we know that the vast majority of self-harm is not treated in hospital (Hawton et al., 2002). What these increased treatment rates might reflect is that people are more aware of self-harm, more willing to seek help, or more willing to take children and young people to hospital. It might be a response to greater levels of fear about young people self-harming. The reasons that people present to healthcare services for any type of condition or injury can be complex, and certainly do not reflect a straightforward increase in ‘rates’.

We know a lot about hospital treated self-harm, research centres in Manchester, Derby and Oxford have been collecting data about this for many years. From these studies we know that the majority of people treated in hospital for self-harm have taken overdoses of medication (Bergen et al., 2010). Few people will be treated in hospital for scratches inflicted with a pair of scissors, underlining another problem with the images used in the Times and the Independent – both of which depicted cuts which would be unlikely to have been treated at hospital. Those who are treated in hospital for self-cutting are more likely to have used razors, glass or knives, to have created wounds that the individual (or someone else) is worried about and feels unable to self-treat. Again – most of those treated in hospital for self-harm have taken overdoses, with only around 15-20% having cut themselves or used other forms of self-harm such as hanging, jumping, drowning or suffocation.

While it might not be clear whether overall rates of self-harm have increased, we can be fairly certain that awareness of self-harm has risen in recent years. Stories such as those run by the Times, the Independent, and the Daily Mail are reflective of a particular way of reporting self-harm among young people – these articles emphasise the ‘worrying’ rise in rates, largely focus on a particular form of self-harm (cutting) and present an analysis of the reason for the rise: young people use self-harm to cope, and they do so in response to ‘pressure’, especially from ‘the internet’[1]. Such stories have appeared intermittently in the UK press for the last 10 years.

This form of reporting presents an inaccurate view of self-harm, one that is complicated by research, particularly qualitative, interview studies which have spoken with people who self-harm (Adler & Adler, 2011; Chandler, 2013). Self-harm can often involve cutting, but it also takes many other forms. My own research with young people aged 14-16 found that most reported engaging in ‘other’ forms of self-harm, as well as cutting and overdosing. These included: scratching, burning, biting, restricting eating, self-criticism, hitting, and punching objects. Crucially, while not all of these practices are formally understood to be ‘self-harm’ they were described as such by young people themselves.

By emphasising ‘worrying rises’ in statistical data on self-harm, news reports present a potentially exaggerated view of how ‘common’ self-harm is. Reports in 2012, for instance reported another ‘worrying rise’ based on increased calls about self-harm to Childline. Again, these do not necessarily reflect rising rates, but perhaps a greater willingness to talk about or ‘name’ self-harm. There were similar discussions of an ‘epidemic’ of self-harm in 2005.

The emphasis on particular reasons for self-harm, which highlight the role of the internet, ‘pressure’ and the use of self-harm as a coping mechanism presents a narrow view of why people might self-harm.Research with people who self-harm finds that a very wide range of explanations can be given: self-punishment, experimentation, expression of emotion, self-care, generating feelings, ending dissociative states, communicating distress – as well as ‘coping’ with life, or emotions (Adler and Adler, 2011; McDermott et al., 2013). What ‘coping’ means in individual cases can vary widely (Chandler, 2012). Similarly, proposed ‘reasons’ for self-harm are diverse, reflecting the range of people who self-harm and the complex and multi-faceted factors that might contribute to self-harm, including, but certainly not limited to: socio-economic disadvantage, family contexts, childhood abuse, and homophobia.

In conclusion, I urge caution when reading news coverage about self-harm, and particularly when making inferences from statistical evidence. Statistics are extremely useful, but must be treated with care. I suggest that these public accounts of what self-harm is, and what it means, underline the need for further research with young people about how they understand the ‘pressures’ they face, how they experience life in a ‘24/7 online culture’. Finally, what other, structural, social and economic factors might be shaping the experiences of young people? Self-harm is not ‘just’ an individual, psychological problem – it is shaped by social and cultural contexts; analysis of these must go further.

[1] Last year I supervised an MSc Childhood Studies dissertation project carried out by Caroline Plaine. Caroline carried out a discourse analysis of print media coverage about self-harm among young people, which we are currently writing up for publication. These reflections are based in part on Caroline’s analysis, which found self-harm being described as an ‘epidemic’ in newspaper reports from at least 2003.

 

References

Adler, P. and Adler, P. (2011), The Tender Cut: Inside the Hidden World of Self-Injury, New York, New York University Press.

Bergen, H., Hawton, K., Waters, K., Cooper, J. and Kapur, N. (2010), ‘Epidemiology and trends in non-fatal self-harm in three centres in England: 2000–2007’, The British Journal of Psychiatry, 197, 6, 493-498.

Chandler, A. (2012), ‘Self-injury as embodied emotion-work: Managing rationality, emotions and bodies’, Sociology, 46, 3, 442-457.

Chandler, A. (2013), ‘Inviting pain? Pain, dualism and embodiment in narratives of self-injury’, Sociology of Health & Illness, 35, 5, 716-730.

Hawton, K., Rodham, K., Evans, E. and Weatherall, R. (2002), ‘Deliberate self harm in adolescents: self report survey in schools in England’, British Medical Journal, 325, 1207-11.

McDermott, E., Roen, K., & Piela, A. (2013). Explaining Self-Harm: : Youth Cybertalk and Marginalized Sexualities and Genders. Youth & Society.

Mother’s Little Helper?

“Mother needs something today to calm her down
And though she’s not really ill
There’s a little yellow pill
She goes running for the shelter of a mother’s little helper
And it helps her on her way, gets her through her busy day”

Songwriters: JAGGER, MICK / RICHARDS, KEITH

Mother’s Little Helper lyrics © ABKCO Music Inc.

One of the things that I find fascinating about substance use is that the meanings attached to it can vary so widely, and with such far-reaching consequences. One example of this can be seen in the different policy, legal and social responses to alcohol and tobacco use, as compared to, for instance, LSD, heroin or cannabis. David Nutt, formerly a member of the Advisory Council on the Misuse of Drugs, for the UK Government, was famously sacked for challenging inconsistencies in legislation which did not, he argued, reflect the ‘objective’ harm caused by different substances. Social scientific work has a rich history of highlighting and challenging the variable ways in which substances are understood and given meaning both within and between different social and cultural contexts.

My own research draws on perspectives which address the diverse cultural meanings attached to substances, with a particular focus on opioids and opioid substitution – heroin, methadone, buprenorphine, subutex. An example I have used often in teaching is to encourage students to compare social responses to a morphine user who is in hospital, recovering from an operation, and one who is using heroin ‘recreationally’ at home. One is legitimate, the other illegitimate – but why? A more developed version of this is found in Helen Keane’s recent analysis of the stark differences in how medical literature approaches the same substance (methadone) when used in treating a) chronic pain and b) opioid dependence (Keane, 2013). Discourse addressing methadone use for chronic pain has to do a lot of work to try to avoid stigmatising patients, attesting to the highly negative meanings that methadone has come to imbue, associated as it is with: dependence, lack of control, lack of self-worth, epitomised in the cultural image of the underserving ‘junkie’.

Questions about the social construction of substance use often fade into the background in discussions about the impact of parental drug use on children. However, both parenting and substance use are clearly socially mediated, and given meaning in different ways according to a range of factors (social class, cultural background, religious belief etc.). Social scientific work on the dominance of middle-class models of ‘good’ parenting are one example of how this can play out in policy and practice (see e.g. Gillies, 2007).

In research completed in 2013 I was part of a team that explored accounts about parenting support among a group of opioid-dependent parents living in Scotland. A paper that has just been published in Drugs: education, prevention and policy, explores how parents accounted for their use of benzodiazepines compared to methadone. While policy often frames all drug-use as problematic among parents, in our research it became clear that some drugs were worse than others. In particular, while a range of problems can be associated with both methadone and benzodiazepine use; the latter was almost universally framed as unproblematic by parents who took part in the research. In particular, this applied to mothers – and several participants quoted the Rolling Stones song, Mother’s Little Helper (above), to support this view.

Benzodiazepine was described as helping parents to: sleep better, socialise, manage anxiety – so as not to impact negatively on children, and cope with traumatic histories. In contrast – methadone was associated with a range of difficulties, and almost all participants suggested they were committed to ‘coming off’ their methadone prescription. Though it was acknowledged that it was helpful in abstaining from illicit and/or injecting drug use – methadone was also framed as contributing to unpleasant physical symptoms, stigmatising identities (‘the junkie’), and the services connected with it (prescription pick-ups, monitored consumption) got in the way of ‘normal’ family life. Many of these constraining features were explored in more detail in an article published last year in the International Journal of Drug Policy (Chandler et al., 2013).

Different cultural images of drug-use and parenting (and especially mothering) highlight the importance of social context in shaping how we understand the impact of substance use on how we act, and who we are. For the parents we spoke to, these images had far-reaching impacts on their lives and on how they talked about parenting in the context of dependent drug-use. Those who continued to use methadone were tied in to services which monitored them and their children closely, as well as leaving them open to negative judgements from themselves and others. Benzodiazepine dependence was not seen as attracting the same level of scrutiny or stigma, and therefore stopping use seemed less pressing.

What I was left wondering when considering these findings, was whether methadone treatment could ever be viewed as benignly as benzodiazepine treatment seemed to be. I am far from an expert in the pharmacological make-up of these substances, but both can be ‘addictive’, both have psychoactive qualities, both have the potential (but not the promise) of impacting negatively on parenting. Yet one substance is imbued with (almost) positive qualities while the other has the opposite effect. Our research – and that of many others – has highlighted that these negative, stigmatising attitudes towards opioid treatment and dependence are ultimately damaging to both parents and their children: constraining help-seeking, leading to social isolation and lack of self-esteem. Can it ever be any different?

Chandler, A., Whittaker, A., Williams, N., McGorm, K. Cunningham-Burley, S. and Mathews, G. ‘Mother’s little helper? Contrasting accounts of benzodiazepine and methadone use among drug-dependent parents in the UK’ Drugs: Education Policy and Prevention

Chandler, A., Whittaker, A., Cunningham-Burley, S., Williams, N., McGorm, K. and Mathews, G. (2013), ‘Substance, structure and stigma: Parents in the UK accounting for opioid substitution therapy during the antenatal and postnatal periods’, International Journal of Drug Policy, 24, 6, e35-e42.

Gillies, V. (2007), Marginalised mothers: exploring working-class experiences of parenting, London, Routledge.

Keane, H. (2013), ‘Categorising methadone: Addiction and analgesia’, Int J Drug Policy, 24, 6, 12.

 

Narrating the self-injured body

Re-posted from the CRFR Blog

Recent media reports have highlighted an apparent rise in the numbers of young people reporting self-harm. These reports should be treated with caution: surveys may well have identified a rise in the number of people who are harming themselves, but findings might also reflect an increased awareness of what self-harm is; meaning that self-harm can be more easily identified and named.

Naming self-harm can be a tricky business, and the recent debates about including ‘non-suicidal self-injury’ in the latest edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (American Psychiatric Association, 2013) is just one example of this. My research, with people who have self-harmed, and General Practitioners, suggests that the type of practices self-harm is understood to involve, and the meanings they have, can vary widely. While for some people, ‘self-harm’ is taken to mean skin-cutting; for others it might refer to overdoses; misusing drugs and alcohol, attempting suicide, risk-taking, or maintaining an abusive relationship.

Surveys that collect data about rates of self-harm provide important information; but they do not tell us the whole story about how someone understands self-harm, what kind of practices self-harm involves, how self-harm affects and contributes to their day-to-day life. Even a particular type of self-harm, say, self-cutting, can be used and experienced in many different ways (Chandler, 2012; Chandler, 2013).

In a paper that was published recently (online first) in the BMJ journal Medical Humanities, I explore narratives about living with bodies scarred or marked by self-cutting. The paper uses Arthur Frank’s typology of illness narratives (Frank, 1995): restitution, chaos, and quest, to demonstrate the different ways in which people talked about the impact of scarring on their lives.

  • Restitution: For some participants, a focus of their story was to emphasise removal of scars, and attempts to ‘fix’ the problem of the scarred body.
  • Chaos: More rarely, people spoke of their scarred bodies as chaotic, indicating feeling out of control of their body and the scars.
  • Quest: A more optimistic account was given by others, who talked about the role of scars in ‘telling a story’ – to themselves and to others. Importantly, the story was one of hope, and of overcoming difficulties.

If rates of self-harm are increasing, there are likely to be more people living with scarred bodies in future. It is important to acknowledge that these scars may have very different meanings, and be experienced in different ways. Indeed, a common theme across the research I have done with people who have self-harmed highlights the pain caused by other people’s assumptions about what self-harm, or self-harm scars, might mean.

EDIT: The paper, Narrating the self-injured  body, is now open access in BMJ Medical Humanities.

American Psychiatric Association (2013), Diagnostic and statistical manual of mental disorders: DSM-5, Arlington, VA, American Psychiatric Association.

Chandler, A. (2012), ‘Self-injury as embodied emotion-work: Managing rationality, emotions and bodies’, Sociology, 46, 3, 442-457.

Chandler, A. (2013), ‘Inviting pain? Pain, dualism and embodiment in narratives of self-injury’, Sociology of Health & Illness, 35, 5, 716-730.

Frank, A. (1995), The Wounded Storyteller; Body, Illness, and Ethics Chicago, University of Chicago Press.

 

Ethics, Embodiment Re/Production and the Lifecourse

Written following a symposium I was involved in organising, held on June 6th 2014 at the University of Edinburgh.

“[B]ioethics is out of touch. It is out of touch with bodies themselves” (Shildrick 2005; p. 2)

Feminist theorists such as Margrit Shildrick have been prominent in critiquing bioethical discussions which take for granted bodies and embodiment. In Ethics of the Body: Postconventional Challenges, an edited collection by Shildrick and Mykitiuk, this is explored via papers addressing a range of topics which both invoke bioethical engagement, but also unsettle and question notions of embodiment and what bodies are. For me, the book has been a useful and enduring resource, since different chapters within it address areas of empirical research or teaching I’ve been involved in: addictions (Helen Keane), mental health (Nancy Potter), disability (Jackie Leach Scully), and sex/gender (Katrina Roen).

On 5th June 2014, a symposium, Ethics, Embodiment, Re/Production and the Lifecourse, at the University of Edinburgh, interrogated questions about the relationship, and potential for mutual collaboration between, theories of embodiment and bioethics. The symposium was part of a Wellcome Trust strategic award, The Human Body, its Scope, Limits and Future, on which Sarah Cunningham-Burley, my co-organiser, is co-investigator.

What can theoretical work on embodiment contribute to discussions about the ethical implications of biomedical innovations? What can bioethics contribute to theoretical work on embodiment?

The focus of the symposium on re/production and the lifecourse reflected an attempt to look at embodiment and ethics in terms of reproduction, and especially the challenges raised by new reproductive technologies, but also to consider how biomedicine increasingly works across the lifecourse to produce different types of bodies. Such biomedical innovations and interventions raise significant ethical questions. They also raise important questions about the nature of bodies and embodiment.

My own interest in embodiment and bioethics, and what the two might contribute to one another, led from work I undertook during a postdoctoral fellowship at IASH (Institute for Advanced Studies in the Humanities). While there I was working broadly on ethics and self-harm, but I focused especially on exploring the ways that academic discourse about the ethics of treating self-harm addressed embodiment. Perhaps unsurprisingly, most of what I found, which was itself limited, tended not to engage much with self-harm as an embodied practice. Indeed, this is reflective of the vast majority of academic work on self-harm – it tends to gloss over the messy, lived, corporeal aspects of being or caring for someone who self-harms.

The relative lack of engagement in (some) bioethical work with embodiment, and especially fleshy, lived bodies, was raised by many of the speakers who contributed to the symposium. I’ll be writing a more detailed blog and report of the day; but here is a brief overview of the speakers and their talks:

Session 1: Reproduction, ethics and embodiment

  • Elizabeth Ettorre, opened the day sketching out the need for an embodied ethics, which is open to and engages with bodily, embodied diversity; is empathic; and attends to embodied emotions as a part of ethical reflection.
  • Danielle Griffiths followed, taking an embodied perspective to ethical debates about new reproductive technologies; particularly those that have been proposed but not yet realised: male pregnancy and ectogenesis.

Session 2: Ethics, medicine and disabled bodies

  • The second session addressed disability and medical treatments or ‘fixes’. Fadhila Mazanderani discussed the role of patient’s embodied experiences in guiding their decision making regarding controversial treatments for MS; contrasting this type of evidence with, for example, Randomised Control Trials that are often prized in clinical decision making.
  • Jackie Leach Scully raised a series of provocative arguments regarding the development, use and representation of prosthetics. She suggested that the use of prosthetics contributes to the normalisation of certain types of disabled body; and the marginalisation of others.

Session 3: Biomedical innovations and enhancements

  • Next, Gill Haddow addressed a different type of assistive device (ICDs), though this one designed to prolong/extend/save life; discussing the embodied and relational consequences of being a ‘cyborg’.
  • Finally, Sarah Chan addressed bioethical debates about enhancement, using this discussion to problematize dominant bioethical discourse about normality, especially as applied to gender and disability.

The third session was also to have included a paper from Anne Kerr, discussing body work and emotional labour in biomedical innovation. Anne couldn’t present on the day unfortunately, but her paper would have been a great addition.

There were a number of common themes and threads running throughout the day, which I need more time to think about in order to do them justice. What was very clear was that there is a great deal of scope for further work which engages with bioethics and embodiment, especially when this explicitly includes attention to emotions.

References

Shildrick, M. (2005), ‘Beyond the Body of Bioethics: Challenging the Conventions’, in Shildrick, M. and Mykitiuk, R. (eds.), Ethics of the Body: Postconventional Challenges, London, MIT Press.