Introduction: It’s good to welcome you here today – I hope that by the close you will feel that your valuable time here was invested wisely in observing the genesis of a productive and appreciating asset. And what is that potential asset?
An accessible knowledge base for the study of suicide – suicidology – in Northern Ireland, in Ireland and in Great Britain.
The absence of such a resource, readily accessible by students, researchers – including conscientious journalists – and professional practitioners, means most people rely almost exclusively upon the print and electronic media.
Suicide and the media: With a few honourable exceptions, media today specialise in opinion. In the post-Murdoch era, tabloid print media and a significant proportion of electronic media, are potentially corrupted by questionable profit maximising priorities. Before the Dirty Digger got to work, it was possible to distinguish ‘editorial’ and ‘opinion’ in media content. Not so today. Unfortunately, opinion-loaded reporting of suicide here does not always comply fully with Irish Association of Suicidology / Samaritans media guidelines:
“In the case of suicide there is an added reason for discretion and restraint in that research shows that explicit descriptions or pictures can provoke imitative behaviour and lead to so-called copycat suicides” (IAS/Samaritans 2009: 3).
In New Zealand (NZ) for 25 years, reporting of suicide without the coroner’s permission has been a criminal offence (Hollings, 2013). Most NZ suicides are unreported. Editors in UK and Ireland can choose to follow advice in the media guidelines or not since they involve a voluntary commitment. It appears though that circulation, profit and, capitalism being what it is, commercial survival often come first. You’ll recall a couple of years ago in a trashy Sunday scandal sheet – it does not warrant the name of newspaper – publication on the front page of a photograph of a deceased suicide suspended from a road bridge not far from here.
My point is that consequently, much that non-specialist lay people “know” about suicide is based upon media distortion disguised as opinion. Yet opinion only becomes knowledge when evidence confirms its validity. Here I would commend the “Irish News”, for their current “Mind Matters” column which has facilitated more considered views of suicide and self-harm presented by professionals in straightforward language. Even in plain English (or Irish/Ulster-Scots) such considered views of a complex subject like suicidology need to be underpinned by study and research.
Study and research: I’m arguing that a wide gulf separates knowledge from opinion about suicide. But that divide can be bridged by study and research. I would think that, although Alvarez (1971) is probably right that everyone has an opinion on suicide [‘nearly everyone has his own ideas about suicide’ p14], opinion without evidence is of little value [except perhaps to a bookmaker]. Alvarez (1971) felt that while reliable evidence-based information about suicide is plentiful, little if any of it [other than sensationally, in circulation boosting front-page splashes] is aimed at or written so as to be capable of being read and understood by the non-specialist or ‘ordinary’ reader. Unfortunately 40 years after Alvarez’s key text this remains the case. And addressing this divide, this gulf, is one of the key reasons for our meeting today.
Modern pioneers: Modern studies on suicide date back around 100 years ago when Freud (1917) and Durkheim (1897) published original texts each of which continues to exert considerable influence on current thinking about suicide. Freud postulated a psychoanalytic perspective [‘the ego sees itself deserted by the superego’ (Jackson, 1957:11)] upon a conflict within the mind of an individual – while Durkheim approached the problem of suicide from a sociologic point of view: his interests were not in the mind of the individual but in the forces of society influencing that individual.
Menninger (1938) and Zilboorg (1936) developed Freud’s notions: the former visualized suicide as the winning out of destructive tendencies over constructive tendencies while the latter relied upon Freud’s theory of depression (‘melancholia’) and his concept of a death instinct (‘Thanatos’) to postulate suicides as ‘victims of strong aggressive impulses that they failed to express outwardly and [that] were, as a result, turned inward’ (Jackson, 1957: 15).
Twenty years after these writers, in 1957, a seminal US text (Shneidman and Farberow (Eds),1957: flysheet) noted that ‘few books have been written on suicide . . [adding] this aspect of human misery has been a relatively neglected area of scientific research and study’.
Local input: I have been able to find only one recent textbook (O’Connor and Sheehy, 2000) devoted to suicide with a Northern Ireland/Ireland connection. Both authors worked in the School of Psychology at Queen’s University Belfast although they were living and working in GB when their text was published. I hasten to add that Dr Rory O’Connor has subsequently published widely in academic journals and contributed chapters to many academic textbooks. He is a frequent guest speaker at seminars and conferences in Northern Ireland/Ireland. My point is to signal Rory’s uniqueness as a published author and locally ‘born and raised’ expert in suicidology.
The question is: why are there no, or very few, others?
How many of us, for example, are aware of his finding (O’Connor et al., 1999b) that only 15% of Northern Ireland suicides had a history of psychiatric illness. In other words 85% - or almost 9 out of 10 – suicides are what Dr O’Connor calls ‘normal’ people. And why has this seminal study that examined inquest files for 1994/95 not been repeated to check what our situation is nearly 20 years on and 15 years into post-conflict Ulster? And if it was repeated, I’m not aware of any results [but see after-note below about published (Oct 2013) research findings based on coroners’ files.]
I’ll say a word now about US and UK/Irish perceptions of suicide.
UK/Irish psychology challenges US psychiatry: If you cross the pond you’ll find that the dominant (fashionable?) theory on suicide is based on the work of American psychologist Dr Thomas Joiner: he calls it the interpersonal psychological theory of suicidal behaviour (Joiner, 2005). Dr Joiner, a popular (Thomas can be seen on the “Dr Phil” show on YouTube) and influential teacher and writer argues that “virtually everyone, approaching if not 100%, who dies by suicide had a mental disorder ... at the time of death” (Joiner, 2010: 188). This conflicts with and is directly opposed by Rory’s findings. I checked the index for Joiner’s text but found no reference to O’Connor et al. (1999b).
Dr Joiner’s statistical certainty is related to how mental health is practised in the States. The basis for psychiatric diagnoses there is the psychiatry profession’s ‘bible’: the Diagnostic and Statistical Manual (5th Ed.), published by the American Psychiatric Association (DSM 5, 2013). Dr Joiner relies more than somewhat uncritically upon its previous edition, DSM 4-TR (2000).
Although UK and Irish psychiatry uses an alternative manual, the International Classification of Diseases (ICD) published by the World Health Organisation, the influential and recently published American DSM 5 architecture has come under heavy criticism here.
For example, Dr Lucy Johnstone, a consultant clinical psychologist, cast doubt on the DSM 5’s reliance upon the biomedical model of mental illness. She said it was unhelpful to see mental health issues as illnesses with biological causes. She said:
"On the contrary, there is now overwhelming evidence that people break down as a result of a complex mix of social and psychological circumstances – bereavement and loss, poverty and discrimination, trauma and abuse" (Doward, 2013).
Dr Johnstone prefers the psycho-social model of mental health to the biomedical model although she is clearly in a minority. The study of suicide worldwide has, in my view, been polluted by what has been described as ‘the chokehold’ that psychiatry has on theory and practice. This tight grip is unlikely to be relaxed anytime soon.
Only by peer-reviewed research into alternative paradigm/s, or ways of understanding suicide, will fundamental changes occur through development of new theories to underpin counselling and psychological and psychotherapeutic practice with people at risk of suicide, including survivors of bereavement by suicide.
I do not know whether such research is underway here in Ireland, north or south. Nor have I any easy way to find out. It could well be that acknowledged Irish experts in suicide, such as psychiatrist Prof Dr Kevin Malone (Malone, 2013), is already working hard on alternative ways of understanding suicide other than through the strange, unscientific lens of psychiatry. But I doubt it.
However I want to say something now about how we’re getting on with our next door neighbours in the Republic.
Cooperation and collaboration: And unsurprisingly we don’t appear to be working well together. I would much rather that it was otherwise.
This lack of a close working relationship is evident for example, in two valuable research studies (Jordan et al., 2011; Richardson et al., 2013) investigating young men and suicide in Ireland, north and south that were published recently.
Amazingly, neither study referenced Mike Tomlinson’s important study of the Northern Ireland conflict, mental health and suicide (Tomlinson, 2007). Our Northern Ireland Public Health Agency sponsored both studies. Unfortunately the 2013 study included in its list of references no mention of the 2011 study.
And neither study referenced O’Connor et al. (1999b) nor a key US study (Crosby et al., 2011) that addressed the lack of uniform definitions in suicidology: not a lot of people know that this deficiency is a serious drag factor on understanding and sharing suicide research findings.
No doubt these obvious omissions were not deliberate. And if I have missed out on good news about our cooperation and collaboration with colleagues in the Republic regarding reduction of suicidal behaviour on the island, then of course mea maxima culpa. But it seems to me that our joint failures – because it takes two to refuse to tango – in Northern Ireland and the Republic to work together and to deliver “the potential for mutually beneficial co-operation” in addressing the scourge of suicide on the island, are considerable. One example will suffice to make the point. In October 2007 a Stormont press release said:
“An All-Island action plan has subsequently been developed in order to harness this potential [for mutually beneficial cooperation], and the launch of the new mental health promotion campaign is one of the key elements of the North/South co-operation on suicide prevention.”
I tried but failed to locate a copy of this plan. And I can find little evidence of any results of implementing this mythical all-island action plan. One wonders, for example, what the plan had to say about the 85% of local suicides that O’Connor et al. (1999b) found lacked evidence of the influence of ‘mental health’ issues.
I fear that this no doubt well-intentioned and sincerely adopted all-island action plan has been gathering dust on shelves north and south for at least six years. And for two major but obvious reasons:
1. Most importantly, suicide is much more than a mental health issue, whatever that might be thought to mean; and
2. Unfortunately, suicide reduction is not now a priority for either government.
And if it were in 2007, I’m afraid other more immediate issues that I don’t need to elaborate have overtaken it. Based upon a key learning principle – trial and error – those of us who want to work effectively in this field should therefore move beyond that negative experience and secure independent status so as to develop a healthy but arms length relationship with governments, north and south, and elsewhere.
I want to say a few words now about how an independent Study Centre, such as I envisage, working at one remove, but amicably with government bureaucracies and their staff, might become a living reality out of the framework of words offered today and in the Centre’s mission statement.
Study Centre 1: In my days long ago in corporate planning, I learned of the axiom that strategy precedes structure. In short you need to know where you’re going before you buy the ticket. The Centre as I imagine it will be engaged in study and research but not necessarily in the transmission of research to practice. The latter task would be for practitioners and their paymasters rather than the Study Centre.
What therefore needs to be done – and I mean as soon as possible – is the first step towards a strategy, i.e. a feasibility study into a Belfast Centre for Study of Suicide. Two primary questions are:
1. Is a Belfast Centre for Study of Suicide needed? and
2. If yes, is it needed now?
You can advise me about what your views are about that, including what you might be able and willing to contribute personally and professionally.
Further questions immediately arise some of which have been addressed in information sent to you earlier:
1. What is the proposed Study Centre’s mission?
2. Is this mission being met at present, in full or part, by any other organisation/s?
3. Are any similar organisations being planned in N Ireland and at what stage of development are they?
4. What are the proposed Study Centre’s objectives?
5. What will the proposed Study Centre’s legal status be? Charity? Limited company? Etc
[Regarding the Centre’s legal status: I asked a local expert to draw up a document based on the same information that you received about today’s meeting. I’ve been advised that a ‘company limited by guarantee’ might be the best option. More on that in due course.]
Only when these questions are satisfactorily addressed might a strategy be developed and an organisational structure devised and erected.
I now want to say a few words about the actualité of a Study Centre as I imagine it to be. In other words what activities might it engage in and with what outcomes?
Study Centre 2: At the outset I mentioned the productive and appreciating asset that we were considering today
an accessible knowledge base for the study of suicide – suicidology – in Northern Ireland/Ireland and Great Britain.
This resource would be the essential reservoir that served and facilitated the raison d’être for the Study Centre.
It might immediately be argued that each of the Northern universities has a resource located within their libraries that might be thought to be similar to what’s proposed here. Unfortunately these resources are accessible only by university staff and registered students and it’s not known how comprehensive or up-to-date they are. However a feasibility study would be free to consider if, how and when these resources might become accessible to Study Centre affiliates following negotiation and agreement with the universities. I would be sceptical about either university agreeing readily to an external body accessing their costly resources.
But however access to these resources are obtained, a central obligation for an independent Belfast Study Centre would be to make readily available to students, researchers and practitioners, relevant material about human suicidal behaviour, including any relatively inaccessible evidence, e.g. online documentation, dissertations, books, journal articles, academic and governmental reports, strategies and the like, that currently exists. Alvarez described this as ‘a huge mass of material on the topic [that] grows larger every year’ (Alvarez, 1971: 12). The quantum of suicide-related publications has continued to grow in the 40+ years since then. [I checked Mr Google lately and under ‘suicide’ he generated 129 million results.]
So an objective of our Centre would include the application of modern technology to the establishment of a dynamic, accessible suicidology knowledge base, structured and maintained by exploration, investigation, organisation and dissemination of available evidence about suicidal behaviour here and in neighbouring jurisdictions.
Textbooks and journal articles etc: In the 56+ year period since Shneidman and Farberow (1957) lamented the apparent neglect of scientific research and study of suicide, Alvarez’s ‘huge mass’ of published material includes many textbooks, dissertations, biographies, and novels as well as several academic journals devoted to publishing peer-reviewed writing about suicide. Inter alia these include:
Suicide and Life-Threatening Behaviour (AAS);
Crisis : The Journal of Crisis Intervention and Suicide Prevention (IASP);
OMEGA : Journal of Death and Dying;
Archives of Suicide Research (IASR);
Death Studies; and,
Suicidology Online (Open Access) – within the last four years.
In addition, a plethora of academic and professional journals specialising in law, medicine, psychiatry, psychology, sociology, philosophy, nursing, counselling and psychotherapy and many more, publish occasional articles where content regarding suicide fringes upon or overlaps with the journal’s specialism.
Online access to the outputs of specialist journals, including back issues, would be essential. Orders from the British Library in London for copies of one-off journal articles can already be placed through your local library at minimal cost.
Study Centre 3: We’re talking about study and research: study of the current knowledge base supported by research at and beyond the edge of that knowledge base.
I’ll look briefly now at the issue of how accredited study of suicidology from certificate (level 1) upwards to degree (level 3) and beyond might be organised and delivered under the aegis of the Centre with active co-operation, if this is available, of academic institutions, including universities, in Northern Ireland and elsewhere.
I’ll use my own experience but only as a guide to what services and products the Centre might provide.
My own study in suicidology began almost randomly – I was doing a postgrad counselling diploma at Jordanstown 15 years ago in 1998 that included a research methods module and assignment. This practical exercise launched me into a counselling master’s degree course which included a research dissertation. After finishing that I enrolled to do a doctorate by research. Both dissertations (MSc 2001; PhD, 2010) concerned aspects of suicidology.
I may not be believed but I think that anyone can use that route – but only if they’ve got the interest, the desire, the time, the resources and the commitment to deliver quality dissertations.
Most people have not used that route. Suicidology doctorates in Ireland, north and south are scarce. But an initial unmet ‘market’ may exist right now for ‘ordinary’ courses, e.g. at certificate and diploma level, as opposed to ‘advanced’ courses at first degree level and above.
Comparison with counselling courses might illuminate the issue further. For example, most students who achieve a certificate in counselling do not proceed to diploma level work but many do. Most diploma graduates do not proceed to degree level studies but some do. Most first degree graduates do not proceed to master’s level courses while only a fraction of master’s degree students proceed to doctoral level work. The actual stats on this might be interesting.
But I conclude that the critical mass of the Centre’s educational work would be at certificate and diploma levels. Development of course structure and content would need to be undertaken so as to achieve recognised accreditation.
However, all of that work awaits completion – if the man from Del Monte says the results of a feasibility study are positive. But that remains to be seen.
Conclusions: Personally I have no doubt that a need exists for organised accredited education courses for volunteers and professional practitioners in suicidology. But I don’t know if anyone agrees with me.
And I thank you for attending today and for giving me a hearing.
Alvarez, A., (1971) The savage god: a study of suicide. London: Penguin
DHSSPS Media Centre (2007) McGimpsey launches All-Island mental health promotion campaign. Published 9 Oct 2007. [Accessed on 18 Aug 2013 at http://www.northernireland.gov.uk/index/media-centre/news-departments/news-releases-_dhssps-september-2012/news-dhssps-october-2007/news-dhssps-091007-mcgimpsey-launches-all.htm]
Crosby, A.E., Ortega, L. And Melanson, C. (2011) Self-directed violence surveillance: uniform definitions and recommended data elements. Atlanta, Ga: National Center for Injury Prevention and Control
Doward, J. (2013) Mental health psychiatrists under fire in mental health battle. Sunday 12 May 2013. London: The Observer.
Durkheim, E. (1897/1950) Suicide. Glencoe,Ill: Free Press
Freud, S. (1917/1925) Mourning and Melancholia. London: Hogarth Press
Hollings, J. (2013) Expert opinion divided on suicide reporting. Marlborough Express (NZ) 15 July 2013
Irish Association of Suicidology/Samaritans Ireland (2009) Media guidelines for reporting suicide and self-harm. Dublin/HSE-Belfast/PHA
Jackson (1957) Theories of Suicide. In E.S. Shneidman and N.L Farberow (Eds) Clues to Suicide. 11-21. New York, NY: McGraw-Hill Book Company, Inc.
Joiner, T. E. (2005) Why people die by suicide. Cambridge, Mass: Harvard Univ Press
Joiner, T.E. (2010) Myths about suicide. Cambridge, Mass/Harvard Univ Press
Jordan, J., McKenna, H., Keeney, S., and Cutliffe, J. (2011) Providing meaningful care: using the experiences of young suicidal men to inform mental health care services. Belfast: Public Health Agency
Malone, K.M. (2013) Suicide in Ireland 2003-08. Dublin: 3 Ts Foundation
Menninger , K.A. (1938) Man against himself. New York, NY: Harcourt, Brace and Company, Inc.
O’Connor, R.C., Sheehy, N.P. and O’Connor, D.B. (1999b) A classification of suicides into sub-types. Journal of Mental Health. 8, 6, 629-637
O’Connor, R.C. and Sheehy, N.P. (2000) Understanding Suicidal Behaviour. Leicester, UK: BPS Books
Richardson, N., Clarke, N. and Fowler, C. (2013) Young men and suicide: a report on the all-Ireland young men and suicide project. Ireland: Men’s Health Forum
Shneidman, E.S. and Farberow, N.L. (Eds) (1957) Clues to Suicide. New York, NY: McGraw-Hill Book Company, Inc.
Tomlinson, M. (2007) The trouble with suicide. School of Sociology, Social Policy and Social Work, Queen’s University, Belfast.
Zilboorg, G. (1936) Differential diagnostic types of suicide. Archives of Neurology and Psychiatry, 35, 270-291.