Working With Self Harm and Suicidal Behaviour

Louise Doyle, Brian Keogh, Jean Morrissey

• Éditeur: Bloomsbury Academic
• Année: 2015
• ISBN:
  9781350310742
• Édition: 1
• Sujet: Psychologie
• Sous-sujet: Bewegungen in der Psychologie

Suicide and self-harm are world-wide public health issues that can have devastating effects on families, friends and communities. They are both a priority for anyone working in mental health, social work, emergency departments and related fields, however suicidal and self-harming behaviour can take place anywhere anytime - it may be a pupil in a school, an inmate in a prison or a colleague or family member. For this reason, this book has been written in a clear, accessible and practical style for anyone who wants to learn more about working with and preventing suicidal and self-harming behaviour. - It identifies common risk and protective factors as well as specific warning signs of imminent suicidal behaviour - It provides essential communication skills for undertaking a risk assessment, illustrating how each skill can be used in real-life practice. - It looks specifically at the issue of self-harm and suicide in prisons, schools and emergency departments
- It lays out clear strategies for identifying and addressing issues of self-care when working with people who are suicidal or who self-harm - It identifies how we can assist those who are bereaved following the death of a loved one by suicide Packed with learning outcomes, case scenarios and reflective questions, this book acts as a toolkit for anyone working in this difficult field.

CHAPTER 1

Understanding Suicide and Self-Harm

Brian Keogh

Introduction

Drawing on biological, psychological and sociological perspectives, the purpose of this chapter is to introduce the reader to the main theories that attempt to explain suicide and self-harm. Biological perspectives will examine the role of age, gender, genetics as well as altered neurotransmitter functioning such as decreased serotonergic activity. Psychological components will briefly explore psychoanalytic theories and the role of interpersonal communication. Sociological perspectives will examine social integration and social regulation, drawing mainly from the work of Durkheim. It is acknowledged that this subject is very complex and that the information presented in this chapter is not exhaustive. Many other interpretations of suicide and self-harm are available within the extensive literature on the subject. In addition to introducing the theories, the chapter will provide examples of how they might inform our understanding of the subject. It will begin though by defining suicide and self-harm.

LEARNING OUTCOMES

By the end of this chapter, you should be better able to:

1. explain the complexities associated with defining suicide and self-harm;

2. outline the importance of having a theoretical understanding of suicide and self-harm;

3. differentiate between the biological, psychological and social approaches to understanding suicide and self-harm;

4. appreciate the importance of having an integrated approach to understanding suicide and self-harm.

Defining suicide and self-harm

According to O’Carroll et al. (1996: 246), the term ‘suicide’ refers to ‘death from injury, poisoning, or suffocation, where there is evidence (either explicit or implicit) that the injury was self-inflicted and that the decedent intended to kill himself/herself’. However, other concepts related to suicide such as self-harm or attempted suicide are less clearly defined or understood. This has meant that they are often used interchangeably to mean the same thing and are value-laden resulting in negative perceptions of people who engage in them (Doyle, 2008). Because there is a strong correlation between self-harm and completed suicide, it is preferable therefore to conceptualise them as a continuum rather than as distinct entities. Although the numbers of people who engage in some form of self-harming behaviour are much higher than those who go on to complete suicide and they have varying levels of intent (from no intent to strong intent), they remain a very high-risk group. Many terms describe the spectrum of suicide and self-harm and suicidal behaviour, and some of them are listed in Box 1.1:

BOX 1.1 CONCEPTS ASSOCIATED WITH SUICIDE AND SELF-HARM

Suicidal Ideation: Thoughts about engaging in suicidal behaviour (O’Carroll et al., 1996).

Suicidal Intent: Actively considering a plan to die by suicide (Doyle, 2008).

Suicidal Threat: A verbal or non-verbal action that suggests that the individual might engage in suicidal behaviour in the future (O’Carroll et al., 1996).

Deliberate Self-Harm (DSH): The various methods by which people deliberately harm themselves, including self-cutting and taking overdoses. Varying degrees of suicidal intent can be present and sometimes there may not be any suicidal intent, although an increased risk of further suicidal behaviour is associated with all DSH (HSE et al., 2005).

Suicide Attempt: A potentially self-injurious behaviour for which there is evidence that the person intended at some level to kill himself/herself (O’Carroll et al., 1996: 247).

Non-Suicidal Self-Harm (NSSH): Now included as a distinct condition within The Diagnostic and Statistical Manual of Mental Disorders 5^th Edition (DSM V), NSSH refers to self-harming behaviours not aimed at ending life (APA, 2013).

A theoretical understanding of suicide and self-harm

According to the Cambridge online dictionary, a theory can be defined as ‘a formal statement of the rules on which a subject of study is based or of ideas that are suggested to explain a fact or event or, more generally, an opinion or explanation’. Theory tries to help us understand complicated concepts such as self-harm and suicide by attempting to explain why they occur. In addition, they influence how we care for and treat people who present with these problems. While there are many different perspectives and some of them will be touched on in this chapter, the three dominant theoretical perspectives are the biological, psychological and sociological approaches to understanding why suicide and self-harm occur. An overview of these three approaches is presented in Table 1.1

Suicide and self-harm have tended to fall within the biological interpretation of mental distress as an illness. This means that hospitalisation and the use of psychotropic drugs are the dominant strategies in terms of care and treatment. However, the rates of suicide and self-harm have steadily increased in the Western world, which suggests that social and psychological issues may be more influential over the individuals’ biological or genetic profile. Furthermore, the often sudden and unexpected act of suicide may further suggest that psychological and social issues may be dominant. Confusion and lack of agreement about how suicide and self-harm are understood have led theorists to examine more integrated ways of approaching the subject. This is often articulated as a biopsychosocial approach, and it attempts to see suicide and self-harm not as having one explanation but several. This approach attempts to capture the complexity of suicide and self-harm by suggesting that there are many inter-related ways of understanding it. Therefore our understanding of suicide and self-harm can be drawn from biological, psychological and social perspectives.

Biological perspectives

The biological approach can be examined in two ways: firstly, as in the example earlier, it can be viewed in terms of structural, genetic or neurochemical influences that can contribute to suicide or self-harm. Secondly, components of our being, which we have no control over, can predispose us or increase our risk for suicide or self-harm. In this section, the main biological perspectives will be discussed briefly. It is important to reiterate here that the biological components should not be looked at in isolation and other factors, not just these alone, influence individuals’ decision to engage in suicide and self-harm.

Gender and Age: A person’s gender and age may predispose them to suicide and self-harm. While suicide across the lifespan is discussed in a later chapter of the book, the relationship with age and suicide and self-harm is discussed briefly here. According to the World Health Organisation, approximately 80% of the people who complete suicide each year are male. In the past, older men were more vulnerable to suicide; however, in recent times the rates among younger men (between the ages of 15 and 24) have increased making them the most vulnerable in some countries. In terms of worldwide figures for completed suicides, the highest rates are in men aged 70–79 years and in men over 80 years (Varnik, 2012). Suicide rates in women are lower in all countries except China where female deaths from suicide outnumber male deaths (Varnik, 2012). While women are overrepresented in terms of suicidal ideation and self-harm, they are less likely to die by suicide, a phenomenon described by Canetto and Sakinofsky (1998) as a gender paradox. For self-harm, while the age of onset is similar for men and women (early to mid-teens), the National Registry of Self Harm in Ireland (2012) found that rates of self-harm peak for males between the ages of 20 and 24 years, and gradually decrease thereafter. However, for women, the rates of self-harm peak at the age of 15–19 years, and they remain relatively constant into middle age (Griffin et al., 2013).

Table 1.1 Overview of the theoretical approaches to suicide and self-harm

Theoretical approach	Example	Influence on treatment approaches
Biological approach	Suggests that physical or structural problems can cause or contribute to suicide and self-harm. For example, a deficiency of the neurotransmitter serotonin is believed to cause depression which may lead to self-harm or suicide. Suicide and self-harm are often seen as an illness or disease.	Within the biological sphere, often the treatment revolves around the restoration of the deficient neurotransmitter (in this example, serotonin) usually through taking medications, especially anti-depressants.
Psychological approach	The psychological or psychodynamic approach attempts to move away from the idea of suicide and self-harm as an illness. Often they are seen as the result of struggles between mental processes or as a response to anxiety. In addition, suicide and self-harm can sometimes be viewed as responses to early childhood experiences.	The wide variety of interventions that are used within the psychological or psychodynamic sphere falls under the large umbrella of the ‘talking therapies’ or ‘psychotherapies’. There are many different schools of thought on the nature of mental distress from this perspective, and this influences the type of therapy that is used. For example, traditional psychoanalysis emerged from Freud’s work on the unconscious mind. Consequently, therapy focuses on the unconscious unresolved conflicts that are causing problems.
Sociological approach	The sociological perspective looks at the social determinants of health and illness and proposes that individuals’ social circumstances are influential and can contribute to suicide and self-harm. For example, poverty, access to healthcare and education may lead to suicide and self-harm.	Interventions from a sociological perspective focus on improving communities in terms of health and mental health outcomes. This is achieved through mental health policy and practice, education, etc. For example, the fear of being stigmatised often prevents individuals from seeking help. Strategies to de-stigmatise mental distress may reduce the level of suicide and self-harm as individuals may access mental health services earlier.

Genetics: The study of suicide and self-harm from a genetic point of view tends to consider family history, twin and adoption studies. According to Mann and Currier (2007), there is evidence that genetics plays a role in suicide and self-harm. Qin et al. (2003) found that a family history of suicide significantly increased suicide risk. However, a family history of suicidal behaviour may be explained by an increased genetic predisposition to mental health problems generally rather than suicide and self-harm specifically (Nock et al., 2012). In addition, Brent and Mann (2005) found in their review about adoption studies, that there was some evidence to suggest that the incidence of suicide among adoptees supported a genetic effect.

Altered Serotonergic Activity: According to Van Heeringen et al. (2004), the majority of biological research has concentrated on the role of the neurotransmitter serotonin. Neurotransmitters are chemical messengers that are responsible for communication at a biochemical level in our brain and throughout our body. Serotonin is one of these neurotransmitters, and it is believed to contribute to how we feel on an affective level (mood). Alterations in serotonin levels therefore are believed to impact negatively on our mood and our sense of well-being, resulting in depression and low mood. According to Opacka-Juffry (2008), the role of serotonin in contributing to depression has become widely acceptable, and there are many research studies to support this stance. However, serotonin’s mode of action and its role in contributing to depression, suicide and self-harm is complex and not fully understood. For example, depression is a very common phenomenon, but not everyone who is depressed is suicidal or engages in self-harming behaviour. It may be that other neurotransmitters are involved as well as the person’s social and psychological circumstances, which are influential in the decision-making process. Furthermore, many people who die from suicide are not known to be depressed from a clinical depression point of view, furthering the viewpoint that other factors within the social and psychological domains are important determinants in the decision to engage in self-harm or attempt suicide. Specific to self-harm, McGough (2012) suggests that the release of endorphins and adrenaline when the skin is cut may contribute to a sense of pleasure or excitement consequently perpetuating its use.

In summary, from a biological point of view, suicide and self-harm are generally believed to emerge from discrepancies in the transmission of serotonin, although other neurotransmitters are also believed to be involved. Factors like genetics, age and gender are fixed, so consequently, in terms of suicide prevention, an awareness of these factors coupled with additional support for people who are vulnerable from an age and gender point of view is an important preventative strategy. While the use of antidepressants may be helpf...

Table des matières

• Cover
• Title Page
• Copyright
• Contents
• List of Figures and Tables
• Acknowledgements
• Introduction
• 1. Understanding Suicide and Self-Harm
• 2. Self-Harm, Suicide and Stigma
• 3. Risk and Protective Factors for Self-Harm and Suicide
• 4. Suicide and Self-Harm Across the Lifespan
• 5. Understanding and Responding to Self-Harm
• 6. Communicating with People Who Are Suicidal
• 7. Self-Care: Professional and Personal Considerations
• 8. Suicide and Self-Harm Prevention and Reduction
• 9. Postvention
• 10. Self-harm and Suicide in Prisons, Schools and Emergency Departments
• Index