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)

Turning the light on male suicide

candles-492171_1920 (2)

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).

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.

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.