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.

 

 

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.

Publication of Men, Suicide and Society

Another CRFR blog I wrote, this one in September 2012, reflecting on the media coverage following the publication of the Men, Suicide and Society report. For some reason (?!) I don’t think I ever submitted this, so nice to have somewhere to put it now. The experience of having academic work I’d spent months on interpreted for the mass media was certainly interesting, to say the least. The response I liked most was a column by Catherine Bennett in the Guardian, which you can see here.

On 20th September 2012 a report was published by the Samaritans titled Men, Suicide and Society. This report was co-authored by a group of economists, psychologists and sociologists, including myself and Julie Brownlie, a CRFR associated researcher. In the report, we set out to explore the reasons why men in midlife, from deprived backgrounds were more likely than any other group to complete suicide. The report was partly designed to highlight the greater risk faced by this group of men, in contrast to the more usual focus on suicide among younger men. Findings from the report were covered widely in the media, with articles appearing in the Telegraph, Guardian, Daily Mail, on the BBC, and on ITN.

My section of the report examined how social scientific work on masculinity might help to explain why this group of men are so vulnerable to suicide. However, the overall report was multi-faceted, developing a number of potentially important explanations including: psychological aspects; the impact of relationship breakdown; differences in emotional communication; and the impact of socio-economic disadvantage, recession and unemployment.

I drew together a range of qualitative research which had examined the particular experiences and accounts of men, often living in conditions of economic disadvantage. I argued that these accounts indicated that for men, in mid-life, from lower-socioeconomic groups, the constraints and rigours of hegemonic masculinity (or a ‘gold standard’ of masculinity as in the media-friendly press release) might be particularly damaging. I was more cautious as to why this might be the case, though I suggested that a lack of material and cultural resources might contribute. The group of men who are currently in mid-life, as argued in Julie Brownlie’s section of the report, might be especially vulnerable because a) they have lived through huge changes in the nature of the labour market (crudely, the move from ‘masculine’ heavy manufacture and industry, to ‘feminine’ service professions); and b) they have lived through a change in expectations about emotional literacy (caught between the stoicism of their fathers, and the –apparently – greater openness of their sons).

One issue that was overlooked in most (though not all) of the media coverage, was that the restrictive masculinities discussed in the report impact negatively on everyone, not just men in this particular social group. For instance, although we characterise young men as relatively more emotionally liberated, there is evidence that men and women of all ages have different attitudes towards emotional expression and help-seeking; and men of all ages are more likely to complete suicide.

The implications of the report are far-reaching, suggesting that restrictive gender identities in general should be challenged, among people of all ages. Boys and girls should be encouraged and supported to explore diverse ways of being and becoming men and women. While including gender awareness teaching on the curriculum in schools would be a good start, changes need to be made across society (2014 edit: so, not really asking for much then?!).

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.