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.

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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.

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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.

 

 

Personal troubles and public issues: Suicide among disadvantaged men in mid-life and the importance of sociology

Suicide and society

BBC Newsnight ran a story on 5th March 2013 exploring the reasons why men in the UK are around three times more likely to complete suicide than women. As well as gender, other social factors affect suicide rates, particularly age and socio-economic position. While suicide is the leading cause of death for men aged 30-44, the suicide rate among men aged 45-59 has been “increasing significantly” since 2007 (ONS 2013) becoming almost equal to the 30-44 year old rate. The group of men most likely to die by suicide is men in mid-life (aged 35-54) in the lowest socio-economic group, a fact highlighted in a report published by Samaritans last year.

The Newsnight programme featured the work of both Samaritans and CALM (The Campaign Against Living Miserably), as well as including powerful testimony from men who had experienced suicidal thoughts, and the family of a man who had completed suicide. Much of the discussion focused on the difficulties faced by men in acknowledging distress and seeking help. Barriers include ‘masculine’ ideas about appropriate behaviour, especially around communicating about distress; the design of mental health services; and wider stigma about mental ill-health. In light of these barriers, it was heartening to see suicide among men discussed so openly and in such a public setting. It was encouraging also to see the involvement of a range of professionals, perspectives and views.

What the programme also showcased (albeit not explicitly) was the importance of sociological perspectives in contributing to understanding suicide. The discussion demonstrated the extremely wide-ranging factors that impact on suicide among men including: economic hardship, changing labour markets, relationship breakdown, drug and alcohol use, socially proscribed expectations of what men and women should do, as well as mental ill-health. Many of these issues are explored in detail, using sociological approaches, in a report from Samaritans, which I contributed to: Men, Suicide and Society (2012). The report argued that the complex nature of suicide necessitates wide-ranging attempts at explanation, which go beyond clinical or psychiatric perspectives which – while important – have historically dominated suicidology.

Suicide research, policy and practice should incorporate a similarly wide disciplinary lens; and suicide prevention strategies too need to be wide-ranging. Although suicide is very much a ‘personal trouble’ it is also an inherently ‘public issue’ (Mills 1959). As such, policy and practice in a range of areas can and do impact on suicide. It already appears that the current economic climate is impacting negatively on rates of suicide, particularly among men living in areas with high rates of unemployment (Barr et al., 2012). These ‘public issues’ will not be solved by improvements in mental health services alone; but require bolder action in terms of addressing gender inequalities and gendered expectations of men and women, tackling socioeconomic inequalities, reducing social isolation, and improving the chances that men and women have of living fulfilled and content lives.

References and Resources

Barr, B., Taylor-Robinson, D., Scott-Samuel, A., McKee, M. and Stuckler, D. (2012), ‘Suicides associated with the 2008-10 economic recession in England: time trend analysis’, BMJ, 13, 345.

Mills, C. W. (1959) The Sociological Imagination New York, Oxford University Press

ONS (2013) Suicides in the United Kingdom 2011

Samaritans (2012) Men, Suicide and Society, why disadvantaged men in mid-life die by suicide
 

The social contexts of suicide: sociological contributions to understanding suicide

Blog originally published on the Institute of Mental Health blog in 2012. I’ve edited this a wee bit, but not much. I was asked to do the blog following a book review I wrote that was published in the BSA magazine, Network, in 2012.

Suicide is a complex issue that touches many lives, and is the concern of a range of social and health-care professionals. It is also an important public health problem, being the “tenth leading cause of death worldwide” (Windfuhr & Kapur 2011: 28). While suicide is strongly related to poor mental health; it is widely understood that suicide often occurs in the absence of a psychiatric diagnosis. Although psychiatry and related mental health professionals have an important role to play in suicide prevention, the complexity of suicide necessitates the involvement of multi-disciplinary researchers and practitioners.

Published in 2011, Understanding Suicide: A Sociological Autopsy (Fincham, Langer, Scourfield & Shiner 2011) presents research from a broadly sociological (though incorporating other social scientific approaches) investigation of 100 suicide case files from a coroner’s office. The study incorporated both qualitative and quantitative analysis of the files, in an adaption of the more well established psychological autopsy approach to studying suicide. The research findings illuminate important, but often overlooked, social factors relating to suicide:

  1. That the group of people most at risk of suicide are men in mid-life.

Fincham et al combine a quantitative analysis of the 100 case files they studied, with official statistics on suicide rates. Through this, they highlight that suicide rates for men peak between the ages of 35 and 45, with suicide being a relatively rare occurrence among young men. However, many suicide prevention programmes have focused on reducing suicide among young men. This reflects an increase in the suicide rate among young men; but obscures the fact that the men in mid-life complete suicide in greater numbers. Fincham et al’s analysis examines the ways that age and stage of life might be implicated in suicides. In particular, they highlight the varying strength and importance of social relationships and social bonds in youth, mid-life and old-age.

  1. The importance of social relationships in understanding suicide.

A commonly held understanding of suicide is that it is related to social isolation – leading from Emile Durkheim’s pioneering work on the sociology of suicide, which argued that social isolation increased the chances of suicide. However, Fincham et al argue that social relationships – or more accurately, unravelling social relationships – might be a more appropriate way of explaining suicide. Their research found that the deceased in the case files had often recently experienced a break-up in a relationship or had lost contact with their children. This approach to understanding suicide provides one way of explaining the connection between suicide and unemployment, with work being an important source of social relationships – particularly for men, particularly men in mid-life. A related finding was that suicide can be seen as a way of trying to work on social relationships. Analysis of the suicide notes included in just under half of the case files studied suggested that the notes were often used to attempt to heal, create, or sever social ties. Fincham et al suggest that “[r]ather than seeing death as the end … suicide notes can be a means to continue or even to initiate relationships through which agency can be exerted” (p. 89)

  1. The role of gender in understanding suicide

In an earlier paper, Jonathan Scourfield (2005) highlighted the importance of gender in seeking to better understand suicide. Scourfield’s approach emphasised the problematic way in which much previous research on suicide had addressed gender: that is in a rather straightforward way, looking at ‘males’ and ‘females’ as two separate, largely similar groups. In Understanding Suicide, a more nuanced gendered analysis is presented. This takes account of the importance of differences within men and women, rather than focusing on the differences between men and women. Thus, in Understanding Suicide, greater attention is paid to the complex interactions between gender, life stage, and employment, family-life, and intimate relationships.

Each of the above points serves to improve our understandings of why people die by suicide. By examining the role of life-stage, social relationships and gender on individual suicides, Fincham et al propose novel ways of explaining why certain groups of people are more vulnerable to suicide. Additionally, their approach further confirms the usefulness of qualitative approaches to researching suicide. Perhaps most importantly, Understanding Suicide demonstrates the need for wide-ranging approaches to suicide prevention, which incorporate social interventions alongside medical and psychological treatment (p. 185).

This blog draws on an earlier review, published in Network, the magazine of the British Sociological Association (Chandler, 2012).

Chandler, A. (2012), ‘Understanding Suicide: A Sociological Autopsy, by Ben Fincham, Susanne Langer, Jonathan Scourfield and Michael Shiner, Book Review’, Network, 111, 37.

Fincham, B., Langer, S., Scourfield, J. and Shiner, M. (2011), Understanding Suicide: A Sociological Autopsy, London, Palgrave Macmillan.

Scourfield, J. (2005), ‘Suicidal Masculinities’, Sociological Research Online, 10, 2.

Windfuhr, K. and Kapur, N. (2011), ‘International Perspectives on the Epidemiology and Aetiology of Suicide and Self-Harm’, in O’Connor, R.C., Platt, S. and Gordon, J. (eds.), International Handbook of Suicide Prevention: Research, Policy and Practice, Chichester, Wiley-Blackwell.

 

 

Self-injury and embodied emotions

This is a slightly edited version of the first blog I ever did, reproduced from CRFR’s blog, which you can see here. This post was originally posted in 2012, when the first article from my PhD research on self-harm was published in the BSA journal: Sociology.

Self-injury is an under-theorised and little understood behaviour, despite reports that rates of self-injury are on the increase. Measuring the prevalence of self-injury is notoriously difficult: the number of people who present at a hospital reporting self-harm and self-injury are only a small proportion of all cases. Studies that have sought to measure prevalence have tended to focus on adolescent groups, and to date, there is no data on the incidence of self-injury and self-harm among the general adult population in the UK.

This blog on self-injury and emotions, is based on an article published in 2012, in Sociology.

Self-injury is usually studied from a clinical perspective: however, sociological approaches have the potential to greatly improve understandings of the practice. Recognising the emotional aspects of doing self-injury or understanding more about the societal and life factors that might lead someone to injure themselves can be an important way of exploring self-harm. Such approaches challenge some clinical psychological and psychiatric perspectives which tend to frame self-injury as ‘a problem’ located within the individual.

I undertook research to explore the ‘lived experience’ of self-injury, gathering the life stories of 12 people who had self-injured. People involved in the study were identified from non-clinical community sites, to increase the chances of including people who had not engaged with formal support services. Participants were aged between 21 and 37 years old from mixed backgrounds, although the majority were studying for, or had gained, higher educational qualifications.

Self-injury was defined as the cutting, burning or hitting the outside of the body, resulting, in most cases, in visible, lasting and sometimes permanent marks on the skin. As part of the study people frequently explored the reasons they had self-injured and, in most cases, they referred to how it enabled them to ‘work on’ their emotions through their body:

Control and Release: Release, relief and control were used by many participants when describing their self-injury. For some it allowed them to regain ‘control’ over their emotions, and their lives, while for others it was about controlling otherwise uncontrollable feelings.

“when the situation seems to spiral and I’m whooo losing it. Em and it was like right, regain control, this is what I’m gonna do, I’m going to cut myself…and it’s like, releasing something…and then when that whatever it is is released then your sortie regaining control…” (Anna)

Participants in the research suggested that when they felt they had little or no control over their body or life, control enacted through self-injury could be experienced positively. These explanations for self-injury reflect tensions between being ‘in control’ whilst at the same time needing to have a ‘release’. Similar language is used when people describe other embodied practices such as drinking, smoking and exercising.

Eliciting or Creating Emotions: Others suggested that they had used self-injury to bring out emotions that were ‘missing’. Self-injury in these cases generated a feeling of ‘something’ in response to ‘emotional numbness’:

“I wasn’t pretending that I wasn’t upset but I would just, I wasn’t letting people to know I was upset, if you see what I mean…I wanted to be able to feel I wanted to, you know, live or experience stuff, or… and so, self-harming was, you know a way of, feeling, pain, you know feeling pain ‘cos it was something.” (Francis)

In contrast, some participants talked about self-injury generating positive feelings:

“I think the first time it was associated with kind of a rush and, and a buzz.” (Justin)

These accounts, by indicating that ‘work’ is done on the emotions, through the body, demonstrate the interconnected nature of mind and body, challenging idea that they are, or could ever be, separate.

Reference to the article below, and clicking will take you to the article itself. A pre-pubulication version is available via my academia.edu profile. The research was supported by an ESRC funded PhD studentship, at the University of Edinburgh (2005-2010).

Chandler, A., (2012) Self-injury as Embodied Emotion Work: Managing Rationality, Emotions and Bodies, Sociology, 46 (3).