11th Annual Conference
Women’s Health and Suicide
West County Hotel, Ennis
29th – 30th September, 2006
Board Members of the Irish Association of Suicidology
President
Mr. Dan Neville, T.D.
Dail Eireann
Chairperson
Professor Michael Fitzgerald
Consultant Psychiatrist
Secretary
Dr. John F. Connolly
Consultant Psychiatrist
Directors
Dr. Justin Brophy
Consultant Psychiatrist
Dr. Anne Cleary
Sociologist
Mr. Michael Fahy
‘Solace’ Suicide Support Group
Mrs. Mary Hutchinson
Student N.I.
Dr. Margaret Kelleher
National Suicide Research Foundation
Paul Kelly
Console, Bereaved by Suicide Foundation
Anne Kilgallen
Public Health Consultant
Prof. Kevin Malone
Consultant Psychiatrist
Mr Barry McGale
Suicide Awareness Co-ordinator
Ms. Eileen Williamson
National Suicide Research Foundation
Executive Officer – Ms. Josephine Scott
Clerical Assistant – Ms. Angela Coleman
THE IRISH ASSOCIATION OF SUICIDOLOGY
AIMS AND OBJECTIVES
The Association was founded in 1996 and among its aims and objectives are the
following

To facilitate communication between clinicians, volunteers, survivors and
researchers in all matters relating to suicide and suicidal behaviour

To promote awareness of the problems of suicide and suicidal behaviour in the
general public by holding conferences and workshops and by communication of
relevant materials through the media

To ensure that the public is better informed about suicide prevention

To support and encourage relevant research

To encourage and support the formation of groups to help those bereaved
President:
Mr. Dan Neville, T.D.
Chairperson:
Prof. Michael Fitzgerald
Consultant Psychiatrist
Secretary:
Dr. John Connolly
Consultant Psychiatrist
Conference Objectives
 To develop an understanding of the management of deliberate self
harm
 Insight into the relationship of developmental factors and suicide

Awareness of the growing problem of suicide in young women
Welcome Note
Dear Delegates
The 11th Annual Conference of the Irish Association of Suicidology has as its theme
“Women’s Health and Suicide”.
The male to female differential in suicide rates holds in all countries suggesting that
culturally defined gender roles and expectations may be important variables both across
and within different societies. It varies from 1.1 in China to 6.7 to 1 in the Russian
Federation. In European terms, Ireland ranks second to the Russian Federation having an
overall male to female differential of 4.7 to 1 in 2002. In Ireland the total rate of female
suicide has remained fairly constant since 1990. However, the number of young women
aged 15 to 24 who have died by suicide has trebled from 1990 to 2004.
Prior to 1980 the Irish female suicide rate was stable, at 2 deaths per 100,000, when there
was a marked increase to a figure of 7 per 100,000 in 2001. A modest decrease in
suicide rates in females over 65 years of age has been reported in Ireland since 1990,
possibly due to improved attitudes toward retirement; improved social services; enhanced
psychiatric care for older people; greater economic security and greater socio-political
activism for the elderly (de Leo 1998) –suicide among the over-75s being an indication of
inadequate support and poor medical care.
In 2004, there were 5,850 episodes of self harm of women presenting at accident and
emergency which was 37% higher than the male rate. There were 58 incidents of females
self harming for each completed suicide. The figure for males was 13. The complexities
and challenges of female suicide will be explored in depth during the course of the
conference. The bereavement seminar which is presented in conjunction with
CONSOLE, the suicide bereavement support organisation which was set up by families
that experienced the grief on loosing a loved one through suicide, will take place on
Saturday and will add to our knowledge of the traumatic experience of families of those
who take their lives.
It is now 10 years since the Irish Association of Suicidology was incorporated. It is a
time to take stock and plan for the future development of the organisation. I welcome
delegates’ views on this and look forward to ideas on how the association will contribute
to suicidology into the future and to reflect on how it has met with its aims and objectives
as set out in 1996.
We welcome you to Ennis and I am confident that the conference will add to our
knowledge of suicide and in particular in relation to women’s health and suicide.
Dan Neville TD, President, Irish Association of Suicidology
OPENING ADDRESS
Ms. Brid Clarke
CEO Mental Health Commission
Thank you for the invitation to attend your 11th annual conference. This year is the 10th
anniversary of the formation of the Irish Association of Suicidology (IAS). In these ten
years, the Association has taken the lead in raising awareness about the incidence of
suicide and factors that contribute to suicide and suicidal behaviour, in supporting groups
and communities affected by suicide and in promoting research. This year’s conference
on Women’s Health and Suicide will add to our knowledge and awareness of this
important area.
The Mental Health Commission was established in 2002 pursuant to Section 33 of the
Mental Health Act 2001. The overarching statutory functions of the Mental Health
Commission are twofold:-
 to promote, encourage, and foster the establishment and maintenance of high
standards and good practices in the delivery of mental health services and
 To take all reasonable steps to protect the interests of persons detained in approved
centres.
I will be focusing in my address on certain aspects of our mental health services.
The risk factors for suicide are multiple and typically people who die by suicide
experience more than one risk factor. While acknowledging the prevalence of mental
illness among those who die by suicide it is important to recognise that the vast majority
of people with a mental illness will not die by suicide. Most persons with a mental health
problem do not experience the life stresses or
other risk factors that contribute to suicide risk or they receive appropriate support and
interventions.
In recognition of the fact that mental illness is an import factor that can predispose people
to suicidal behaviour especially in western countries, the World Federation for Mental
Health has designated the theme for this year’s World Mental Health Day – 10th October
– as “Building Awareness – Reducing Risk: Mental Illness and Suicide”. This theme was
picked in recognition that suicide is a key public health problem in many countries. The
World Health Organisation estimates that there are one million deaths by suicide each
year, representing 1.4% of the total global burden of disease. The World Federation of
Mental Health has collaborated with the International Association for Suicide Prevention
to jointly promote World Suicide Prevention Day which was held on September 10th and
World Mental Health Day which will be held on October 10th. It is hoped that this
collaboration will promote awareness, reduce stigma and promote service and policy
advocacy.
The Mental Health Commission, since 2003 has marked World Mental Health Day with a
public seminar (free of charge) on the theme selected by the World Federation for Mental
Health. This year’s seminar will have two key speakers: Mr. Dougie Paterson, National Operations Manager
Choose Life National Strategy and Action Plan to prevent Suicide in Scotland.
Theme: “Suicide Prevention in Scotland – Raising Awareness to Reduce Risk”
 Mr. Gareth O’Callaghan – Author and Broadcaster
Theme: “Being Kind to your Mind”
There is a greater awareness and consciousness of World Mental Health Day in Ireland
and this is to be welcomed.
To return specifically to the theme of this year’s conference, Women’s Health and
Suicide, it is acknowledged that mental illness affects woman and men differently – some
mental illnesses e.g. depression are more common in women. WHO estimated that 121
million people currently suffer from depression with 5.8% of men and 9.7% of women
experiencing a depressive episode in any given year. The presentation of the illness
varies between men and women and treatment outcomes also vary.
Research studies have identified the risk and protective factors for mental health for
women and how to improve treatment outcomes. We know that women are more likely
to experience low social status, isolation and poverty. Frequently women have multiple
roles as members of the workforce and assuming major responsibility for child care and
caring for other family members. These factors can have an impact on women’s mental
health.
Research studies have also identified a number of areas which are important to ensuring
positive outcomes for women availing of mental health services. One of the most
important is ensuring the safety, privacy and dignity of the mental health service user.
Mental health care in Ireland is generally provided in mixed sex environments. Access to
women-only services and activities is very limited. Although some studies have
advocated the development of single-sex units and single sex provision, exercising choice
and ensuring the safety and dignity of women while availing of mental health services are
recognised as effective strategies. Factors that protect women’s safety, privacy and
dignity especially while receiving in-patient treatment include facilities/rooms that can be
designated as access for women only during certain periods of time, bathroom facilities
that are single-sex and appropriately located, providing information about the service in
advance of admission and assigning responsibility for women’s safety, privacy and
dignity to a senior staff member.
Research studies both here and abroad have also reported on service users’ wish for
choice in treatment interventions and choice of therapists. In the consultation process
undertaken by the Mental Health Commission in 2004 to ascertain stakeholders’ views of
what constitutes a quality mental health service, people availing of mental health services
talked of the importance of having a choice and a range of treatment interventions.
This included access to psychological, occupational and social care programmes as
well as to medical care programmes, access to counselling, involvement with support
groups and a holistic service which takes account of diet, social skills, education, work
training. A recently published study commissioned by the Mental Health Commission
from the Department of Applied Psychology, University College Cork, on the views of
Adult Users of Public Sector Mental Health Services also echoed these views.
We are moving from what has been called a paternalistic mental health service to one
where service users are now advocating an active involvement in their own care and
treatment programmes. Women have been to the forefront in expressing their wish to be
listened to, be involved, be accepted as partners in their treatment. There is increasing
evidence to support the recovery model within our mental health services. The recovery
model emphasises personal growth, building self-esteem, autonomy, empowerment and
having a meaningful role in society.
The Association for Suicide Prevention has identified a number of strategies for suicide
prevention which include improving mental health treatment and management. Mental
health services in Ireland are facing a most significant period of change, with the
commencement in full of the provisions of the Mental Health Act 2001 on 1st November
2006 and the implementation of the Government policy on mental health “A Vision for
Change”. Mental health services will be based on the multidisciplinary team communitybased model with the service user central to the treatment programmes. The Mental
Health Act introduces key protections for patients availing of mental health services,
especially those who are involuntarily admitted. As you are probably aware, all people
involuntarily admitted will have an automatic independent review of their admission.
The review includes an examination by an independent consultant psychiatrist,
appointment of a legal representative and a review of the admission order (or renewal
order) by a three person mental health tribunal. These provisions bring Irish mental
health law into conformity with the European Convention on Human Rights and
Fundamental Freedoms. The Act also provides for the registration of all approved
centres, the introduction of regulations for approved centres and rules for certain
treatments. The Mental Health Act also places considerable emphasis on promoting
quality and best practice in the mental health services. The Mental Health Commission
will be rolling out the quality framework for the mental health services over the next few
years, which will support continuous improvement in the quality of our mental health
services. The quality framework will identify the essential attributes of a quality mental
health service, describe how standards outlined in the framework can be attained and how
these standards of care will be monitored and evaluated internally and externally. An
exciting and challenging time faces us all in mental health services.
To conclude, I wish to again acknowledge the work of the Association during the last ten
years, wish you a successful and productive conference and look forward to ongoing
partnership with the Association.
Ms. Brid Clarke, CEO, Mental Health Commission, St. Martin’s House, Waterloo Road, Dublin 4
MICHAEL KELLEHER MEMORIAL LECTURE
WOMEN AND SUICIDE
ANNETTE BEAUTRAIS
Principal Investigator, Canterbury Suicide Project, Christchurch School of Medicine
Abstract
Gender plays a glaringly predictive role in suicidal behaviour: In Western
developed countries women are more likely to report suicidal ideation and
suicide attempt while men are more likely than women to die by suicide.
However, in a number of countries there are growing concerns that rates of
suicide in females may be starting to increase, particularly amongst younger
women. This trend suggests that suicidal behaviour in women should be a
more significant focus for research and prevention than it has been thus far.
Surprisingly little research to date has explored the risk, and protective,
factors for suicidal behaviour in women. This paper examines the
epidemiology of suicidal ideation, suicide attempt behaviour and suicide in
women and explores the risk and casual factors which are associated with
female suicidal behaviour. In particular, the role and contributions of
exposure to childhood adversity (including sexual abuse), mental illness,
marriage, pregnancy, postnatal depression, motherhood, social contact and
support, substance abuse, domestic violence and personality disorders are
discussed, particularly in the light of recent trends in suicidal behaviour
among women. The implications of these findings for assessing, treating and
managing suicide risk in women are examined. Implications for suicide
prevention strategies are discussed.
Prof. Annette Beautrais, Principal Investigator, Canterbury Suicide Project, Christchurch School of
Medicine, PO Box 4345, Christchurch 8001, New Zealand
CONSEQUENCES OF UNDER-TREATMENT OF PSYCHIATRIC
ILLNESS DURING PREGNANCY AND THE POSTNATAL PERIOD:
MATERNAL SUICIDE AND INFANTICIDE, DEPRESSION AND
SUICIDE IN OFFSPRING
VERONICA O’KEANE
Head of Section Perinatal Psychiatry, Institute of Psychiatry, London
Abstract
I am a Perinatal Psychiatrist: a term that unfortunately many of you will not
be familiar with because of the general absence of this specialty psychiatric
service in Ireland. I run a service in London for the treatment of women with
serious mental illness during pregnancy and in the first year following
childbirth. This service is largely in-patient based: we have a 10-bed unit
accepting referrals from all of the UK and we also run an out-patient clinic
and an advisory service. An integral part of the service is to disseminate
information to psychiatrists, GPs and obstetric colleagues about the
identification and management of mental illness during the perinatal period.
In this lecture I will address key issues in perinatal psychiatry: what
psychiatric disorders occur during the process of reproduction? Are these
disorders specific to this period? What are the treatments for these disorders?
What are the consequences of these disorders for the mother and the family
unit? What are the consequences of parental mental health problems for the
developing baby and into adulthood? What are the consequences of parenteral
mental ill-health on society at large and could this influence the rates of
suicide? What service do we require in Ireland to address these problems?
Psychiatric Disorders during the Perinatal Period
Postpartum Psychosis
Although suicide rates in women are significantly reduced compared to men, the risk of
a serious mental illness and suicide is hugely increased during the period immediately
following childbirth, known as the puerperium. This is largely because of the occurrence
of a mental illness specific to the puerperium called Postpartum Psychosis. This is a rare
disorder occurring in approximately one in a thousand live births. A family or personal of
Bipolar Disorder predicts the onset of this psychosis but about half of these cases occur in
women with no history of mental health problems. This dramatic illness was first
formally described in the mid-19th century by Victor Marce, a French physician and the
causes are generally attributed to hormonal fluctuations altering brain function, leading to
a psychosis. If treated effectively, women make a rapid recovery and the psychosis
completely resolves but if un- treated or under-treated, there is a high rate of suicide and
infanticide. Before the introduction of modern medicines for the treatment of psychoses,
there are accounts of women, such as the Mary Shelly (author of “Frankenstein”) who
developed a puerperal psychosis and died of the consequences of this “malady” within a
few years. In spite of the dramatic nature and frequently fatal consequences of this
illness, I have never treated a woman who developed this illness for the first time who
was aware of its existence. The identification of this illness appears to be subsumed under
the generic catch-all title of “post-natal depression”, perhaps reflection the stigma
surrounding serious mental illness.
Perinatal Depression
Depression is a spectrum disorder, and for this reason it is now operationally defined; that
is, it is said to exist when a certain range of symptoms are present for a fixed period of
time. Briefly a diagnosis of depression requires the presence, for at least the previous two
weeks, of consistent lowering of mood or inability to experience pleasure, along with a
fixed number of biological (disruption of sleep, appetite, motor activity, energy levels) or
cognitive (reduced concentration, guilt or suicidal thoughts) symptoms. The definition of
depression during the perinatal period does not differ from that of depression in general.
Rates of depression in women in general are about twice to three times as high as men
and are higher during, than outside, of reproductive years. Although rates of moderate
depression do not appear to be increased during the post-natal period there is emerging
evidence that some women are genetically vulnerable to developing a form of depression
characterised by anxiey and/or obsessional symptoms following childbirth. The
epidemiology of post-partum depression is similar to Post-partum Psychosis in that
women with a past history of depression are the most vunerable group but some women
will develop post-partum depression without any apparent vunerability factors,
suggesting a hormonal-brain interaction causation. Although excellent studies published
from the 1980’s onwards uncovered significant mood disorder during pregnancy, these
findings have been largely ignored. Findings from the main studies examining mood
symptoms and/or mood disorder during pregnancy and the postpartum period are
consistent in their findings and demonstrate high levels of depressive symptoms,
particularly from the second trimester of pregnancy through to the postpartum period.
Whether these high levels of depressive symptoms in women during pregnancy are
paralled by the occurrence of a specific pregnancy-related depressive disorder has not
been examined but in my clinical I have treated many severe pregnancy-related
depressions that remitted on delivery of the baby. What is certainly established beyond
doubt is that the perinatal period is a time of increased risk for the development of mood
disorder and that some of these disorders are specific to this period.
In many ways the risk factors for developing depression during the perinatal period are
similar to those outside of this periofd. In addition there are some specific risk factors
relevant to this state. Depression must be viewed as a stress disorder which arises in
response to external stresses and life events. Women will be individually susceptible
both to developing depression in the context of general stress, and in response to the
specific stressor of pregnancy and motherhood. Women who are socially vulnerable are
more prone to becoming depressed: a fact that is consistent across all studies of
depression regardless of age, gender or culture. Poverty, poor housing, exposure to
violence or racism, unemployment, lack of education, and an unplanned pregnancy or an
unsupportive or absent partner are specifically associated with pregnancy-related
depression. Ethnicity is also an important issue in perinatal depression as in many
cultures depression is not recognised as an illness or a disease and there is no language to
describe these pathological emotional states. For example, African women tend to
somatise their symptoms of depression and more commonly present with medical
symptoms (e.g. pains in their stomachs), rather than a lowered mood state. It would
appear that when depression is enquired after in a culturally sensitive way, that rates of
depression are similar across diverse countries and cultures. An important point with
regard to this is that women are more prone to becoming depressed when removed from
their familiar environment and culture, which is clearly protective.
Perinatal depression is similarly responsive to treatment as is depression outside of this
period: approximately 70% of women respond to standard antidepressant medication.
There has been limited experience with using antidepressants during pregnancy, but the
evidence to date does not suggest that antidepressant use is associated with significantly
higher rates of foetal malformation or complications of pregnancy. The problem with
most of the studies examining antidepressant use during pregnancy is that they fail to take
into account the fact that being depressed results in high levels of complications during
pregnancy and poor baby outcome. Many women prefer to manage their depression with
psychological therapies, and would appear to be as effective as medication for the milder
forms of depression, but in general these therapies are not available.
Consequence of Perinatal Mood Disorder
There has been much emphasis placed on recognition and treatment of postpartum
depression and this relates to the body of knowledge demonstrating that children born to
women who suffer from postpartum depression are disadvantaged relative to their peers.
They are disadvantaged in a range of areas including emotional development, intellectual
development and they also have higher rates of childhood psychiatric disorders, such as
conduct disorder and anxiety disorders. More recent follow-up studies of children born
to women who were mildly depressed, and certainly anxious, during pregnancy indicate
that at 4 years of age these children suffered more behavioural problems than their
counterparts born to women who did not have significant psychiatric problems during
pregnancy. A 16 year follow-up study of a group of 200 women and their babies from a
deprived area of south London from my research group has demonstrated that all
adolescents who were depressed at 16 years of age had a mother who suffered from
depression: 74% of whom had perinatal depression whereas among the women who had
never been depressed, none of their children became depressed.
There is also strong evidence that depression during pregnancy is associated with preterm
birth and/or low birth weight. My research programme is investigating the way that
mental stress can influence fetal growth and baby outcome, through the action of stress
hormones. Preterm birth and low birth weight are the leading causes of perinatal
mortality and illness and are the leading costs of disease burden world wide across
cultures. The role of psychosocial stress in determining baby outcome is being
increasingly recognised. Not only is low birth weight and preterm delivery the leading
cause of perinatal disease, it is also a significant determinant of adult health problems.
Low birth weight is associated with a range of diseases in adulthood including high blood
pressure, diabetes, ischaemic heart disease and major mental illness such as
Schizophrenia and Bipolar Disorder. Low weigh at birth is also associated with death by
suicide in adulthood.
The Future
In Ireland there is no means of identifying women who die by suicide as a consequence
of perinatal mental illness. In the UK, however, the most recent “Confidential Enquiry
into maternal deaths 1997-1999” has identified suicide as the second leading cause of
maternal death after cardiac disease. The report also suggests that many of the
unidentified deaths are likely to result from mental illness, making suicide the leading
cause of maternal mortality. More generally, it is now established that the seeds for
mental ill health are laid down before a baby is born and much of adult mental health is
determined by parental mental health, particularly during the perinatal period. If we wish
to address the public health problem of adolescent and adult suicide we need to target
these high risk children, who could be easily identified by screening programmes during
pregnancy and the postpartum.
Lastly, there has been an increase in the deaths of children by their parents in Ireland in
recent years: at least 18 children have died at the hands of their parents in this country
since 2000. In many of these cases, the parents then took their own life. It would appear
that many of these cases occurred because parents were psychotically depressed,
believing that it was in the best interest of their children to die rather than live a life of
disgrace, despair and eventual impoverishment. Experts call this “altruistic filicide”, a
phenomenon that I have followed in the national press because of the absence of official
information on the topic. Many of these case involved very young children with the onset
of depression occurring during the peripartum period. A project to investigate infanticide
and filicide in Ireland involving Barnardos, the National Children’s Office and the
Central Mental Hospital, and commenced by Dermot Aherne in his capacity as Minister
for Social, Community and Family Affairs some years ago has been abandoned because
of internal difficulties.
In addition to perinatal mental health service deficits, this official denial of the
phenomenon of infanticide, filicide and maternal death is leaving our children vulnerable
to an ongoing cycle of mental ill health and possible suicide.
Relevant website (created by a research worker in my team with personal experience of
perinatal depression): http://www.pregnancy-depression-help.com/index.html
Book: “Psychiatric Disorders in Pregnancy: Obstetric and Psychiatric Care” Eds,
O’Keane V, Marsh M, Seneviratne G. Martin & Dunitz: Feb 2006.
Dr. Veronica O’Keane, Senior Lecturer, Perinatal Section, Institute of Psychaitry, London SE5 8AF
WOMEN AND SUICIDE FROM A WOMEN’S HEALTH
PERSPECTIVE
ANNIE DILLON
National Women’s Council
Abstract
This presentation examines women’s mental health from a gendered
perspective taking account of women’s continued inequality, the impact on
women’s mental health and women’s experience of suicide and deliberate
self-harm. Women’s particular experience including diversity of women is
highlighted in the context of mental ill health and treatment and their own
preferences are put forward. Firstly some background information on NWCI
is presented.
National Women’s Council of Ireland (NWCI)
The NWCI was founded as the Council for the Status of Women (CSW) in 1973
following a recommendation by the Report of the First Commission on the Status of
Women. The name was changed to the National Women’s Council of Ireland in 1996.
NWCI is a Non-Government Organisation located within the Community & Voluntary
sector and is the national representative organization for women and women's groups in
Ireland. There are currently over 160 women's organisations and groups from all parts of
Ireland affiliated to the NWCI. It is estimated that the NWCI represents over 300,000
women through its combined affiliate membership.
NWCI Work on Women’s Health Policy and Issues
Since its foundation NWCI has worked on women’s health issues and policy, e.g. in 1995
NWCI was appointed by the Department of Health and Children to undertake wide
ranging consultation with members on the Green Paper on women’s health and
subsequently made significant contribution to the development of the Government’s
Women’s Health Policy ‘A Plan For Women’s Health 1997-1999’
Currently NWCI collaborate with our members to inform policy based on their work and
experience including e.g. NWCI annual pre-budget submission and other submissions1
such as to the Mental Health Commission on Recovery Model (Mar. 06)
NWCI have participated in Partnership through the Community and Voluntary (C&V)
Strand and also participate in the National Economic and Social Forum (NESF), most
recently in relation to the NESF Mental Health & Social Inclusion Project Team.
Work of NWCI Affiliate Members on Women’s Health2
Many NWCI member organisations work on women’s health at a variety of levels
including service provision, advocacy and lobbying:
 Locally and Regionally e.g. Provision of services such as counselling, mental health
promotion, well women services and adult education in response to local women’s
needs (Organisations include Longford Women’s Link, Letterkenny Women’s
Centre, North Leitrim Women’s Centre)
1
For NWCI Submissions see http://www.nwci.ie/publications.html#3
For further information on the work of NWCI and NWCI affiliate members see: www.nwci.ie and
http://www.nwci.ie/membership.html
2

Provision of community development approaches to health, health education, primary
health care projects (Organisations include Pavee Point, Cáirde, Clondalkin Women’s
Network Women’s Health Forum)
 Nationally, e.g. Bodywhys and Action Breast Cancer
In September 2006 NWCI published aReport ‘Women’s Health in Ireland; Meeting
International Standards’. The report recommends that policy take account of gender,
including the health impacts of women’s continued inequality, women’s diversity and
particular health needs and experience of ill health.
Health Impacts of Women’s Continued Inequality
‘Women’s Health is inextricably linked to their status in society.
It benefits from equality and suffers from discrimination’3
The WHO notes that the impact of gender on health is determined by women’s
subordinated status in society.4 The UN Convention on the Elimination of
Discrimination Against Women (CEDAW) stresses the broad range of risks to mental
health to which women are disproportionately susceptible as a result of gender
discrimination, violence, poverty, armed conflict, dislocation and other forms of social
deprivation.5
In Ireland, women continue to experience economic inequality. The gender pay gap
persists, with women currently earning 14% less than men. The Institute of Public Health
has noted that for women the gender pay gap is a pathway to poverty and ill health.6 An
increasing number of people living in poverty are working. In 2004, 6.2% of women
working were at risk of poverty in comparison to 7.2% of men. In 2004, 23% of women
were at risk of falling below the 60% poverty line in comparison to 18% of men. Women
aged 65 and older have a 45% risk of being below the 60% poverty line in comparison to
34% of men. Lone parents, the majority women, have a 42% risk of living on an income
below the 60% poverty line. Women do not have equal access to social welfare
allowances, defined within the system as ‘qualified adults’; which also affects the level of
state pensions.
As a result of women’s ascribed roles, women undertake the majority of unpaid care
work, which can have an impact on women’s mental health. While there is limited data
available in Ireland, there is evidence to suggest that unpaid care work negatively impacts
women’s mental health, including through lack of sleep, increased anxiety, lack of social
life and higher rates of illness generally7.
Overall women’s continued unequal position means that more women experience
poverty, a determinant, which negatively effects mental and physical health.
3
4
WHO (1998) World Health Report
WHO Europe (2001) Strategic Action Plan For Women In Europe
5 http://www.un.org/womenwatch/daw/cedaw/recommendations/recomm.htm#recom24
6 IPHI (2005) Health Impacts of Employment, A Review
7 Canadian Women’s Health Network
Impact of Violence and Sexual Abuse on Women’s Mental Health
It is increasingly recognised that violence against women is a major contributor to the
burden of mental and physical ill health experienced by women.8 According to the WHO9
women who have been exposed to violence are at greater risk to developing a range of
health problems including stress, anxiety, depression, pain syndrome, phobias and
medical symptoms. An overview of studies on domestic violence and depression in
women found an average prevalence rate of 47.6%.10
In Ireland the SAVI Report (2002) found that of the 42% of women who have
experienced sexual abuse or violence over their lifetime, including child sexual abuse,
25% reported symptoms consistent with a diagnosis of Post Traumatic Stress Disorder
(PTSD) at some time in their lives following and as a consequence of their experience of
sexual violence. Those who had experienced sexual violence were significantly more
likely to have used medication for anxiety or depression or to have been a psychiatric
hospital in-patient than those without such experiences. For example, those who had
experienced attempted or actual penetrative sexual abuse were eight times more likely to
have been an in-patient in a psychiatric hospital than those who had not been abused.
A Canadian study suggests that the impact of violence, abuse and trauma on women’s
mental health is not generally taken account by treatment services. When it is recognised,
as a causative factor a biomedical treatment approach is the norm.11
Women’s Mental Health
Women have a particular experience of mental ill health, and therefore specific mental
health needs. In 1997 the Government acknowledged that mental health services did not
meet women’s needs.12 Women’s mental health is affected by various factors relating to
women’s inequality and multiple discriminations in Irish society. In order to respond to
women’s experience and needs, mental health provision requires a gendered approach to
both policy and service provision as highlighted in the recent report by the Women’s
Health Council,13 borne out by the WHO’s acknowledgement that gender is a
determinant of mental health14 and recommended by NWCI (2006). With recent
developments in the area including the work of the Mental Health Commission NWCI
hope that the situation will soon improve.
Women’s Experience of Mental Ill Health.
8
Victorian Health Promotion Foundation (2004) The Health Costs of Violence, Measuring the burden of disease
caused by intimate partner violence. Melbourne, VicHealth: Victorian Health Promotion Foundation.
www.women.vic.gov.au
9 WHO (2000) Women’s Mental Health An Evidence Based Review. Geneva, WHO.
http://www.who.int/mental_health/media/en/67.pdf
10 Golding, J (1999) Intimate Partner Violence as a Risk Factor for Mental Disorder: A Meta Analysis
11 Morrow. M (2002) Violence & Trauma in the lives of women with serious mental illness.
http://www.bccewh.bc.ca/PDFs/violencetrauma.pdf
12 DoH&C (2007) A Plan For women’s Health 1997-1999
13 WHC (2005) Women’s Mental Health, Promoting a Gendered Approach to Policy & Service Provision.
14 WHO (2001) Gender Disparities in mental health.
The UN Convention on the Elimination of Discrimination Against Women (CEDAW)
stresses the broad range of risks to mental health to which women are disproportionately
susceptible as a result of gender discrimination, violence, poverty, armed conflict,
dislocation and other forms of social deprivation.
There are significant gender differences in the experience of mental illness.
For example: Depression, including postnatal depression is considered the most common
form of mental illness amongst women. Eating disorders are more common among
women and women are more likely to be diagnosed with anxiety related disorders and
post-traumatic stress than men.
Suicide and Deliberate Self Harm (DSH)
It is well established that suicide is less common amongst women than men although in
Ireland the Central Statistics Office (CSO) has noted that the overall female rate is
increasing with the rate of suicide amongst young women more than doubled during the
1990’s. Deliberate Self Harm (DSH) is higher amongst women than men, peaking
amongst 15-19 year old girls (more than twice that of boys).A recent Canadian report15
notes that women who self harm have frequently experienced family disruption and
trauma in their lives. The onset typically occurs in adolescence and often linked to
childhood abuse and violence including sexual abuse.
This report draws on research, which suggests that, the relationship between self-harm
and suicide is contested with self harm seen as a coping mechanism for dealing with
emotional pain and distress while suicidal acts are viewed as oriented toward ending pain.
The report notes that those who self-harm may still be at risk of suicide and recommends
particular women centred responses including:
 Community Services including crisis intervention
 Education including to reduce stigma
 Treatment that includes a woman centred therapeutic approaches, peer support
 Overall a non-punitive responses and harm reduction are recommended
 Policy development, that is women centred, focused on causes rather than behaviours
and research to establish prevalence, evaluate interventions etc.
Women’s Experience of Treatment
In relation to treatment women are generally more likely to be prescribed psychotropic
drugs by their GPs, while men are more likely to be referred for specialist treatment.16
Women with experience of mental ill health have expressed concern to the NWCI about
the use of medication and the lack of availability of services such as counseling and
therapy.17 This concern is borne out by a recent Canadian review, which indicates that
women are more likely to be prescribed psychotropic drugs such as SSRIs rather than the
15
Prepared by the Canadian Centre on Substance (2006) Abuse 'Self Harm Among Criminalized Women' Available
from www.ccsa.ca
16 WHC (2005) ibid.
17 NWCI (2004) In From The Margin
use of non-drug methods such as counseling, support, nutrition and exercise.18 Women
mental health service users have identified further issues to the NWCI19 including:


The gender specific experience of mental ill health
Stigma attached to mental ill health, lack of optimism and the impact of long term
medication
 The need for a person centred approach to treatment and mental health promotion
 The lack of availability of services such as counseling and self help groups.
Through NWCI membership women have also raised the need for more holistic and
empowering options such as counselling and support groups needs.
Promoting a Gendered Approach
In conclusion NWCI believe that in order to respond to women’s experience and needs,
including in the area of Suicide and Deliberate Self Harm, mental health provision
requires a gendered approach to both policy and service provision as recognized in the
recent report by the Women’s Health Council and borne out by the WHO’s
acknowledgement that gender is a determinant of mental health. We stress that ‘Womencentred’ includes involving women, particularly those who experience mental ill health
and is responsive to needs and recognises diversity. Finally in relation to Suicide and
Deliberate Self Harm NWCI acknowledges the need for further developments
particularly services which target young women.
Ms. Annie Dillon, NWCI, 9 Marlborough Court, Marlborough St. Dublin 1. Tel: 01 8898472. e-mail:
annied@nwci.ie Tel: 01 878 7248. E-mail: info@nwci.ie Website: www.nwci.ie
Chairperson: Anne Cleary - Comments
Session 2 of the programme consisted of two papers. The first paper, given by Dr.
Veronica O’Kane examined the health consequences of under-treatment of psychiatric
illness during pregnancy and the postnatal period. Dr. O’Kane’s job title – that of
Perinatal Psychiatrist - is, as yet, unusual and her talk began with a moving story of a
tragedy which underlined the need for this specialisation and the screening of pregnant
women for psychiatric symptoms. This need is crucial in the context of certain forms of
psychiatric illness – notably bipolar disorder – when screening may save lives. More
generally the identification of psychiatric symptoms has hugely positive repercussions for
both mother and children. The service which Dr. O’Kane provides in a special unit
attached to the Maudsley Hospital in London is unique in the UK and not available in
18
Currie, Janet (2005) The Marketization of Depression: The Prescribing of SSRI, Antidepressants to Women.
Women and Health Protection., Canada http://www.whp-apsf.ca/pdf/SSRIs.pdf
19
NWCI In From the Margin Project (2002/4), Feedback from Schizophrenia Ireland Women’s Group
Ireland. She therefore sees part of her role as disseminating information on this area of
need to other clinicians. The discussion which followed focused on the need to publicly
identify this problem and to provide appropriate care for such women.
The second paper examined suicide from a women’s health perspective and was
delivered by Annie Dillon of the National Women’s Council of Ireland. Using a
women’s health policy context the speaker reviewed issues relating to suicide and
parasuicide in Ireland and addressed prevention in the context of locally based groups.
The fact that the NWCI represents approximately 300,000 women through a network of
women’s clubs underlines the preventive potential of this organisation. Ms Dillon
emphasised the need to understand women’s health in a socio-economic context and this
approach underlines a recent report on women’s health from the Council. Economic
factors have a major influence on women’s health and women they are also affected by
gender-specific difficulties. Thus women have specific mental health needs and these
need to be addressed to prevent distress, mental illness and suicidal behaviour.
BORDERLINE PERSONALITY DISORDER: COMPLEXITY AND
CHALLENGE FOR SUFFERER AND SERVICE
ANGELA MOHAN
Consultant Psychiatrist, St. Vincent’s Hospital, Dublin
Abstract
This presentation will cover some of the complexities and challenges in the
diagnosis management and treatment of women with borderline personality
disorder. It aims to highlight the particular suffering of women with this
condition which is poorly understood and the difficulties experienced by their
families and society. The high incidence of self harming behaviours and the
links with completed suicide will be explored. Some suggestions for a more
compassionate understanding, treatment frameworks and service
development will be discussed.
Borderline Personality Disorder is a uniquely challenging mental health problem.
 It is difficult to define, is separate from mental illness but is commonly associated
with it.
 The cause is unclear.
 It lacks specific treatments.
 It causes much suffering for the individual, their family and society.



It challenges the health service providers due to the dramatic and demanding
presentations, the social rule breaking, the intense emotions stirred, the disruption
and the sense of powerlessness evoked in others.
There are also high maintenance costs of the individuals involved, as they are high
users of health services often with questionable benefit.
There is high morbidity, general ill health and high mortality with suffers dying from
accidents and physical ill health as well as having a rate of suicide of one in ten.
These clients are damaged and damaging, challenged and challenging.
Diagnosis
While not considered mental illness, personality disorders are defined in ICD-10 (WHO,
1992), as deeply ingrained and enduring patterns of behaviour manifesting themselves as
inflexible responses to a broad range of personal and social situations. They represent
either extreme or significant deviations from the way the average individual in a given
culture perceives, thinks, feels and relates to others. They are frequently, but not always,
associated with various degrees of subjective distress and problems in social functioning
and performance.
Borderline personality (BPD) is categorised under the group of emotionally unstable,
borderline type characterised by disturbed self-image, aims and preferences, chronic
emptiness, intense unstable relationships, self-destructive behaviour. (*3 criteria)
This disorder is grouped in the ‘Cluster B’ group of personality disorders.
Incidence
The incidence varies according to the study but there is general agreement that severe
forms of the disorder occur in 1% of the population. There is a four times greater
incidence in females (Gunderson, 2001).
Clinical Features
The core features are of unstable mood with frequent shifts sometimes within minutes or
hours. Depression is common but mostly of a reactive type. There is frequently a state of
emptiness. Patients describe this as feeling ‘blank’ or ‘being like a zombie’. They are
frequently bored and crave company. There is what is described as ‘a morbid fear of
abandonment’ and intense anxiety at separation. These unpleasant feelings are so
distressing that clients often use binge eating, substance misuse, engage in kleptomania,
promiscuity and self-cutting to relieve and break the cycle.
There are frequent episodes of intense rage and anger directed towards others as in
aggressive outbursts or towards themselves often resulting in self-harm.
With the frequent shifts from one mood state into another, the identity disturbance can be
understood, resulting in difficulties in interpersonal functioning and in work and
occupational functioning. Impulsivity is marked with recurrent threats, repeated
overdoses and self-cutting, running away and aggressive acting out.
There is frequent co morbidity with other types of personality disorders, dysthymia,
major depression, substance misuse, eating disorders, anxiety disorders and psychotic
disorders.
The repeated presentations to the A+E or the psychiatric services of these patients in
crisis either considering self harm or having cut themselves or taken an over dose leads
often to a negative rejecting and even hostile reaction. It is not unusual for those with the
most severe disorders to present up to 10 or 15 times a year in such a crisis. Doctors and
psychiatrists regularly describe these behaviours and patients as “wilful” “manipulative”
and “attention seeking”. Sometimes these patients are treated as if they are deliberately
trying to make life difficult for services and that their behaviours are under their full
voluntary control. There are no studies, which fully explain the motivation for the
behaviours (Browne, 2002). There appears to be a mixture of motivations, which can
vary between patients, and between the same patients on different occasions. One of
these is the relief from unbearable feeling of dysphoria. Patients describe a build of inner
tension, which is immediately dissipated, on cutting or on swallowing a foreign body.
This may be due to the release of brain endorphins, which help regulate other brain
chemicals (Leibenluft, 1987). Patients may be dissociating during the episodes as they
describe a lack of pain even during deep cutting. Other patients want to punish them
selves or distract themselves and some may indeed be motivated to illicit care and
attention. Patients with this condition are frequently admitted to acute wards in
psychiatric hospitals. After the first few days of admission as the crisis is resolving,
destructive dynamics (splitting) get played out where the patient manages to set other
patients and the staff against them and against each other, creating confusion and crisis.
The admission becomes counterproductive and the patient is frequently hastily
discharged feeling rejected and abandoned. The patient self harms to relieve the distress
or to gain support or attention, again repeating the cycle.
Causes
This is a disorder where both nature and nurture have roles to play. There is a strong
association with sexual and physical abuse (Fonagy, et al 1997) but a great many with
childhood abuse do not present in this way. Several studies have shown the strong
association between personality disorder and child hood adversity (Fonagy et al,
1997)(Johnston et al, 1999). There is also evidence of a genetic component (Torgersen,
2000) but the size of the contribution is unclear. Family members of patients with
borderline personality disorders frequently have high rates of personality disorders-not
just BPD. Other biological factors may be involved as the neuroendocrine function may
be damaged by chronic stress or trauma). There also may be neurotransmitter dysfunction
resulting in impulsivity and affective instability (Sarkar, 2006).
Self Harm and Suicide Risk
It has been described that there is “chronic” suicidal risk with borderline patients and the
risk becomes more “acute” with even slight interpersonal or environmental stressors.
There is a relatively low level of completed suicide given the number of attempts. Others
have described the high rate of self-injurious behaviour as the “behavioural specialty”
(Gunderson, 2001) of borderline personality disorder and this tendency as “multiple
suicide attempts of low lethality”. However the risk of completed suicide doubles after a
suicide attempt (Gunderson, 2001) .The risk of suicide increased with comorbid major
depressive disorder, with comorbid substance misuse and when there is co existing
antisocial personality disorder (APA Guidelines, 2001) The higher risk with co morbid
substance abuse maybe accounted for by impaired judgement and even low suicidal
intent can combine to produce a fatal outcome.
Personality disorders are estimated to be present in more than 30% of individuals who die
by suicide, about 45% of individuals who make suicide attempts (Haw, 2001), and
around 50% of psychiatric outpatients who die by suicide. In clinical populations, the rate
of suicide of patients with borderline personality disorder is estimated to be between 8%
and 10%, a rate far greater than that in the general population (Oldham, 2006). However,
since 60%–70% of patients with borderline personality disorder make repeated suicide
attempts, unsuccessful suicide attempts are far more frequent than completed suicides in
patients with borderline personality disorder
The risk factors most readily recognized by clinicians include a history of multiple
suicide attempts, especially those with high potential lethality, and the presence of
significant, persistent substance misuse. Despite the ability to identify meaningful risk
factors in patients with borderline personality disorder, we cannot with certainty predict
future completed suicidal behaviour in an individual patient. Impulsivity has been shown
to be related to suicidal behaviours (Brodsky, 1997). In a major prospective study,
affective instability the criterion most strongly related, in BPD, to both suicidal
behaviours and suicide attempts (Yen, 2004). It is interesting that this is more of a
predictor for suicidal behaviour than major depressive disorder. This suggests that
reactive mood shifts associated may account for suicidal behaviours more so than
negative mood
Ways of Understanding BPD
Freud’s concept of personality development proposes that early traumas disrupt
personality development and the patient becomes fixed at an immature level. Melanie
Kline suggests that there is regression to a stage of the infant within the first months of
life, with the use of primitive defences such as splitting where the sufferer separates and
divides people sharply in their mind into good and bad and projects these states out to
others. There is lack of the integration, which characterised more mature states of
development. I will spend some time describing Cognitive Analytic Therapy as this
gives a framework for the understanding of this condition, which I find useful in my
practice. Cognitive Analytic Therapy (Ryle, 1991) holds the theory that the mind is
socially formed and the infant learns about relationships and the social values and
customs through an intense intimate relationship with the chief carer usually the mother.
Observational experiments on neonates only a few minutes old have concluded that the
infant is primed to relate from birth and both responds to the mother and elicits responses.
The early relationships are internalised into the child’s mind .The child learns two roles,
the role of the caretaker and the role of the care receiver. These roles are seen to be
connected as the poles of a reciprocal relationship. The child is then able to apply either
of these roles in any future relationship either with another person or to themselves. In
other words, a baby who has experienced caring and nurturing will be able, throughout
their life to be in a caring and nurturing relationship with others and will be able to care
and nurture itself. When one is in one pole or role of the reciprocal relationship the other
pole or role is invited from others. Usually psychologically healthy people have a large
range of roles and they can move smoothly between these roles. The damaged child who
has been the subject of abuse is usually limited to a small number of harsh reciprocal
roles e.g. abusing to abused victim and abandoning to abandoned The abuse hinders the
development of reflective capacity (Ryle, 1991) and the client switches abruptly between
mood states. This is often then how they relate to them selves and others. They abuse
themselves in many ways, as has been described, but they also by their actions invite
abuse and neglect from others. These individuals also have the victim role, which invites
the other to be in a rescuing or be ideally caring. So on a ward some staff can be invited
into the ideally caring role and others can be invited into the rejecting abusive role and
this can change from day to day and hour to hour. This can cause the splitting between
staff, which reflects the chaotic destructive inner world of the client.
The role of Cognitive Analytic Therapy is to bring to the client’s awareness their roles
and how they operate and help to them integrate the different parts of their inner worlds.
This is usually done through diagrams to draw out the patterns and to help them develop
new ways of dealing with their lives. The diagram can also help staff to avoid colluding
in the invited roles.
Another way of understanding BPD is that there is a failure of regulation of emotions
resulting from insecure attachments to carers in childhood (Sarkar, 2006). This
hypothesis is gaining ground. It combines a psychotherapeutic understanding with a
biological model. I will go into this in more detail.
Emotions and affects have been described as bodily experiences as a result of an external
or internal cues (Damagio, 1994) The states are expressed through the autonomic nervous
system, the endocrine system and the sensory and motor responses e.g. speech and
through behavioural reactions. The systems in the body are linked together in a complex
arrangement and the whole system is in a delicate balance designed to assist the human in
survival behaviours. Humans are a uniquely social group and each individual requires a
long time to become independent from others. The capacity to regulate emotions is
advantageous to interpersonal functioning and to fostering higher levels of social
adaptation. Animal research (Suomi, 1999) has shown the links between the animal’s
temperament and the social environment and the development of the brain’s architecture.
A distressed infant has a raised level of noradrenalin, the fight/ flight/freeze hormone.
Crying elicits the care of the caretaker and when the baby is soothed the parasympathetic
nervous system is recruited and this brings the baby’s hormone system into balance. The
primary care giver has acted to regulate affects. In earliest infancy from around two
months of age there are short intense bursts of interaction of between the child and carer
centred on feeding changing bathing and holding. These critical interactions set the scene
for the development of cognition and interpersonal development. The right side of the
brain is involved in regulating the autonomic system and the right brain is also involved
in the social and biological functions of attachment. Any experience disrupting
development at this critical time is likely to impact on the development of this regulating
system and lead to difficulties with emotional regulation throughout life. Children around
the age of 5 have learned to regulate their own emotions internally and do not now need
an adult carer for this.
When there has been insecure attachment between a child and caregiver the emotional
regulatory system is not functioning. Slight signals or cues in the environment can switch
on an alarm response, which had difficulty being managed or contained. With very
overwhelming response the person can switch rapidly into ‘freeze’ mode as in a
dissociated state or there could be rapid cycling between states with depression and fear
(fright) and intense switches into aggression (fight) which can be directed towards others
and towards the self.
Treatment and Management of Borderline Personality Disorder
The main plank of treatment is psychotherapy. However the research into what works is
still at an elementary stage. Dialectic behavioural therapy, a type of cognitive therapy
with skills training in affect management using mindfulness, has shown promising results
on a reduction of self harming behaviours. This needs an especially trained team and
team support (Blennerhassett 2005).
In a funded study with the National Institute of Mental Health (NIMH) has found that
Dialectical Behaviour Therapy (DBT) reduced suicide attempts by half compared with
other types of psychotherapy available in the community in patients with borderline
personality disorder (Linehan2006). This study showed that DBT also excelled at
reducing use of emergency room and inpatient services and more than halved therapy
dropout rates compared to the mostly traditional approaches. Psychodynamic
psychotherapy has also been shown to be helpful as well as Cognitive Analytic Therapy
and Interpersonal Therapy. Group therapy and therapeutic communities (Dolan, 1999)
and psychotherapy day hospital care (Bateman and Fonagy, 1999) have demonstrated
value and benefit.
Psychotherapy especially relational therapy probably acts to contain emotion, acting
through the ventral precortex of the brain (Sarkar, 2006).
Medication can also be of benefit when targeted to specific symptoms. The newer
antidepressants, SSRIs, can help with impulsive aggression and anxiety symptoms and
low dose antipsychotic medication can help with perceptual distortions. Anticonvulsants
can help with mood stabilisation and with aggression.
Managing the suicidal behaviours is given the first priority and is commonly undertaken
by setting up a safety contract with the therapist .The patient is supported and encouraged
to contact the therapist (in the case of DBT by phone on 24 hr basis) but at least to
contact a day hospital or A+E before acting on an impulse to self harm. The therapy
sessions are used to work through triggers and to explore and seek alternative ways of
coping.
The role of inpatient hospital admission is controversial (Paris, 2002). The consensus is
emerging that hospitalisation is best avoided apart from brief stays which are sometimes
required for acute suicidal crisis. This may include discharge before the threats of self-
harm have subsided. It helps to balance the risk if the psychiatrist knows the patient’s
form over a long period is psychologically minded and has a good therapeutic
relationship with the patient. It can help also if the patient is referred to a day
psychotherapy service and if they have a therapy session within a few days of discharge.
Community day treatments with assertive outreach will most likely be the model of
service delivery in future for this group (Links, 1998).
In recent years there are increasing efforts to understand the pathology and the treatments
in borderline personality. This coupled with encouraging reports of positive results from
a number of studies of psychotherapy treatments is changing the views of service
deliverers .In Ireland a number of teams have been trained in DBT and in CAT (White,
2006) but there are no Irish dedicated psychotherapy day hospitals or therapeutic
communities serving this patient group. These services will probably develop in time as
the evidence base strengthens and hopefully these patients will have more comprehensive
humane and compassionate treatment.
References available from IAS
Dr Angela Mohan, St Vincent’s Hospital, Fairview, Dublin 3.
BRAIN, GENDER AND SUICIDALITY
MICHAEL FITZGERALD
Henry Marsh Professor of Child and Adolescent Psychiatry, Dublin
Abstract
This talk focuses on brain gender and suicide. It puts particular emphasis on
the major organic differences between male and female brains. It puts
forward ‘an amygdale theory’ of suicide. It also examines the psychological
differences between males and females and how these impact on suicide.
This paper focuses on brain gender and suicide. It puts particular emphasis on the major
biological differences between male and female brains. It describes the “amygdale
theory” of suicide. It also examines the psychological differences between males and
females and how these impact on suicide.
In Ireland in 2005 there were 19 female suicides and 360 male suicides. The suicide rate
of females in Ireland has increased for 2/1000,000 in 1980 to 7/100,000 in 2001.
Differences between Male and Female Suicide: Male and Female Brains:
The male brain has a larger coupus callosum that is the linkage structure between the
right and left hemispheres. There is therefore more information passing between the right
and left sides of the brain in females. Females use more of their brain to accomplish
tasks. The female brain peaks in size at 11 ½ years while the male peaks in size at 14 ½
Years. The female brain matures faster than the male brain. There is an exception in
that, boys mechanical and spatial reasoning matures four to eight years earlier in boys
than girls. Female brains are 8% smaller but are more integrated and more connected up.
In the female brain digust is processed by the left amygdale while in the male it is the
right amygdale. The amygdale is the part of the brain that processes fear, hate, love and
anger. It is involved in emotional processing. It is involved in a very quick form of
emotional processing. A slower form of emotional processing is when the amygdale
connects with the prefrontal cortex which is the executive part of the brain. These
connections are more elaborated in females and this is the reason why the female brain is
more connected up. This gives a protective factor to females in relation to completed
suicide. Females also have better connections between amygdale and language centres of
the brain. In addition female brains have less white matter in their brains that is the white
myelin sheets of nerve fibres under the microscope. Language is also more bilaterally
processed in female brains. In females the hippocampus is larger than in males. The
hippocampus deals with learning and memory. Very importantly female hippocampal
cells are less damaged by chronic stress in females than in males and it is possible that
sex hormones play a role here. In mice and we have to be careful in extending these
differences to humans there are 12,000 genes which behave differently in females than in
males. Females have 11% more nerve cells in the area of the brain devoted to emotion
and memory. This appears to be protective against suicide. It is going too far to say that
men are ‘construction failures’. Female babies are exposed to much less testosterone in
the later stages of pregnancy. This fact leads to better eye contact and earlier language
development.
Neuropsychological Factors:
Because of the above females have much greater capacity for empathy and have much
better verbal skill. From a purely human interpersonal point of view they are more
advanced evolutionarily than males. They have better social intelligence. They are better
at communication and care taking. They prioritise family over work even if working
both inside and outside the home. They are better at reading body language and nonverbal behaviour, better at emotional processing, more interested in people than objects
and they engage in less crime and physical aggression. They are better at seeing textures,
colours and have a better sense of smell. At the same time women have twice as much
depression as men and engage in self harm or attempted suicide far more commonly than
men.
Increasing Rates of Female Suicide:
It would appear that the increasing rates of female suicide are due to environmental
factors as the female brain would not change over the course of 20 years to any
significant degree. The factors related to increased suicide in females appear to be
alcohol particularly binge drinking, relationship breakdown, bullying in the workplace,
abuse of drugs, lack of social support, copycat situations.
The Need for Gender Specific Treatments for Men and Women in Relation to Self
Harm and Attempted Suicide:
It is important now that we begin to develop gender specific treatments for self harm and
attempted suicide based on the above differences in male and female brains. It is critical
that Psychotherapists are fully aware of the structural biological and neurochemical
differences between male and female brains in their treatment. If they are not aware of
this they will have greatly reduced capacity to be empathic and to understand the sex
specific issues of their clients.
References available from IAS
Prof. Michael Fitzgerald, Ballyfermot, Child and Family Centre, Ballyfermot Road, Dublin 10
WORKING WITH YOUNG WOMEN WHO SELF HARM – THE
SCOTTISH EXPERIENCE
PAT LITTLE
Development Manager (young people) Penumbra
Abstract
Penumbra is a leading Scottish Voluntary Organisation working in the field of
mental health. Since 1994 Penumbra has pioneered community based mental health
projects for young people. Penumbra provides an extensive range of person centred
support services for young people with mental health problems and a diversity of
support needs and issues throughout Scotland. Penumbra has been working in the
field of self-harm, particularly with the 16-25 year age group over a period of
several years. In 2001 Penumbra published a report on a piece of research carried
out in Edinburgh with young people who self-harm called “No harm in Listening”
that detailed gaps in the current service provision. At present Penumbra run 6
projects across Scotland funded by Choose Life (Scottish Executive National
Strategy for Suicide Prevention) to tackle self-harm issues. Many have experience
of both self-harm and attempted suicide. Penumbra’s aims to provide people who
self-harm with a safe and non-judgemental environment in which they can explore
their feelings and worries in confidence.
Structure of Presentation
I plan to cover Penumbra’s work with young people and then go on to look at working
with young women who self-harm exploring:
 What is it?




Why do they do it?
What are their needs?
What are the issues for agencies and workers?
Young people’s experiences
About Penumbra
Penumbra is a leading Scottish Voluntary Organisation (NGO) working in the field of
mental health. It provides a extensive range of person centred support services for adults
and young people. It also campaigns to raise awareness of mental health issues, promotes
the Recovery approach and is part of an anti stigma campaign called see me. Since 1994
Penumbra has been providing community based support services for 16-25 year olds and
in recent years increasingly working with all secondary school ages.
During this time Penumbra has become the leading agency in Scotland working with
young people who self-harm. Between 30-50% of the young people coming to our
mainstream projects self harm. In 1998 in conjunction with the British Medical
Association in Scotland we organised an Open Space conference to highlight experiences
of young people who self harm, their parents, carers and friends, and professionals who
come into contact with them.
In 2001 we published an Action Research Report carried out with young people in
Edinburgh who self harm called “No Harm in Listening”. This involved testimonies of
young people’s experiences of self harm- what led them to do it, what types of self-harm
they used, what they got from it, what were their experiences of services and finally what
types of support services they wanted to see developed.
In the past two years Penumbra has developed 6 dedicated Self Harm Projects funded by
local Choose Life groups- Choose life is the equivalent of the Irish Reach Out- tackling
suicide agenda. The main aims of these projects are to :
 Offer support and advice to young people who are engaging in self harming
behaviour
 Provide advice and support to carers, families and friends
 Provide information, training, support, advice and consultancy to professionals in
contact with young people who self harm
 Provide individual and group support which explores underlying issues leading young
people to self-harm
 Engage with young people and provide services that listen to and respond to their
perceived support needs
 Educate the general public in relation to self harm in order to reduce stigma
experienced by people who self harm
Penumbra’s Learning in Working with Young People who Self Harm
The history of Penumbra’s work with young people goes back to 1994 around the time
when there was a huge increase in young people being referred and admitted to
psychiatric hospitals in Scotland. What became clear was that the more young people
came into hospital the more people recognised that adult services could not meet the
needs of the growing numbers of young people being admitted to adult wards.
The Scottish Borders Local Authority asked Penumbra to examine what was going on in
their local area and to think about developing services which young people might use.
Penumbra set up a Drop-in service for young people and began to advertise a community
support service for young people affected by mental health issues.
Over the next few years through working with young people who came to the project we
began to develop a knowledge and expertise of working with this group. Some the
significant lessons learned were:
 Many of the young people had severe problems to deal with
 Very few had single issues with most having a range of problems
 Most had histories of deteriorating health and could clearly remember where things
had started to go wrong for them
 Most were reluctant to accept help from adults
 Once Penumbra managed to develop their trust we discovered they had great insights
into their own experiences which were often not recognised by professionals in
contact with them. This was particular evident when we began to work on one of the
main presenting difficulties- self harm.
What Penumbra Tries to do
 Acknowledge young people’s suspicion to accept help
 Recognise their expertise and knowledge about their lives
 Offer them help “on their terms”- they decide the level of engagement with the
projects
 Encourage young people to develop skills and confidence to
- discuss and deal with difficult issues in their lives
- take control and responsibility for their own lives
- break the pattern of negative experiences and recognise achievements and
progress
Moving then onto our Work in the Self Harm Field
The information gained through this level of engagement with young people allowed us
to build huge knowledge and experience in relation to self harm.
In 1995 Penumbra organised a conference on suicide and self harm and asked young
people to contribute their thoughts and experiences on the issue. Through this we began
to realise that the experts on self harm were the people who did it. They had lived with
this problem for years and the people who needed to become informed and educated were
the people who came into contact with them.
To people who have no experience of self harming this behaviour can be a very difficult
thing to understand. The first thing we learned is that the vast majority of self harm is
done in private. Hospital admissions for self harm appear very high- 16-17000 people
every year in Scotland. The information we received from young people indicated that for
every self harming episode that required hospital treatment, they had self harmed
numerous other times without needing medical attention. They had either learned to self
harm to the extent of being able to treat their own injuries or, because of the way they had
been treated when they went for medical attention in the past, were very reluctant to
return for treatment again. This is also supported in three large scale community based
surveys of self harm in adolescents in England and quoted in the recent National Self
Harm Inquiry into Self Harm among Young People. Green et al, 2005; Hawton et al,
2002; and Meltzer et al 2001 reinforce the point that the prevalence of self harm is much
higher than is indicated by hospital admissions.
Why do People do it?
Most people have mixed and complex feelings about their self harm. On the one hand
they feel frightened and ashamed. They hate the secrecy and isolation involved. The
thought that they may be harming themselves for years appals them. On the other hand
self harm may have become a valuable tool for survival.
Communication
Many young people do not have or have lost the skills to communicate and through self
harm are attempting to let people know the inner pain they are experiencing.
Feeling Real
Many young people describe feelings of numbness due to the pain they are dealing with
and describe self harming as a way making themselves feel alive again.
Self Punishment
Many people blame themselves for past experiences and feel they may have been
responsible for the death of a parent, for their parents breaking up or particularly for
contributing to their sexual abuse. This can cause feelings of self hatred and loathing.
They may believe they “deserve to be punished” and self harm may help a person feel
they have atoned for their past behaviour which they feel have contributed to these
events.
Control
Often when the rest of their lives are out of control self harm may be the only way they
feel they have control i.e. what happens to their own body.
Managing Moods and Feelings
Self harming can be a way of releasing anger and internal pain. While some people can
externalise pain through perhaps targeting their anger at other people by getting into
fights etc, people who self harm have learned that self harm can help them manage these
types of feelings.
Dissociation
Many young people describe how they use physical pain to distract themselves from
emotional pain effectively making their pain physical rather than emotional.
Coping
The primary reason described by young people for self harming was as a way of coping.
There are many complex reason why someone might self harm but it is generally
described as being in response to painful and difficult events in their lives. The feelings
and pain around these can build up and become unbearable. Self harming can have a
cathartic affect and significantly reduce the pressure that has built up inside them. This is
why self harm for many people can become a coping strategy and sometime reduce their
feelings of suicide.
It is therefore important to look behind the circumstances that lead people to self harm
and not necessarily focus on the self harming behaviour itself.
Suicide and Self Harm
Having worked with this issue for many years we are clear that self harm and suicide are
two distinctly different things. Solomon and Farrand (1996) say that although the self
injurious and suicidal acts may blur, their meaning does not…one (self injury) is an
alternative to the other (suicide).
Figures quoted in the Scottish Executive report on tackling suicide “Choose Life”
indicate that only 1% of people admitted to a hospital for a self harming injury will die by
suicide or undetermined death within a year. Only 3-5% of those people will die in
similar circumstances in the next 10 years. Bearing in mind Penumbra’s information that
most self harm does not result in a hospital admission then the risk of suicide is relatively
low in relation to all self harming episodes.
However there is a link which is important and which warrants further engagement and
investigation with people who self harm. Of actual completed suicides 40-60% come
from people who have been admitted to hospital for a self harming injury (Keith Hawton
Oxford University).
There is a piece of research funded by the Scottish Executive going on at present with
young people in contact with Penumbra who have experience of both self harm and
suicide. Within the group of people who self harm there appears to be groups of people
who have a higher risk of drifting into a “suicidal space”. We feel that engaging with this
group of people will shed more light on why, when most self harm can primarily be a
way of coping some people who self harm can end up feeling suicidal.
Gender Issues
Ongoing research indicates that self harm is more prominent among females that males.
The recent National Inquiry into Self Harm Among Young People quoted a number of
studies which indicated the prevalence of self harm is significantly higher among young
women than men. Many reasons have been suggested for this.
It can sometime be related to the role and expectations of women in society. Often
women are the main carers either for their children or parents putting other people first
and denying their own feelings. Unfortunately their own needs do not go away and can
contribute to great internal pain and subsequent self harm in response to this pain.
Pressures around body image can lead to young women in particular loathing their
bodies. Often women who have been sexually abused feel they have contributed to the
abuse and use self harm as I mentioned earlier to punish themselves. They may also use
self harm as a way of distracting any further male attention.
Penumbra sees a higher number of young gay, bisexual and transgender young women
than expected in its self harm projects and many of these young people have been on the
receiving end of bullying for many years due to being seen as “different”.
It is well documented that young women from black and minority ethnic communities are
more likely to self harm than their white counterparts. Bhardwaj (2001:55—56) says that
cultural beliefs can both legitimise gender violence (such as domestic abuse) and
oppression whilst also silencing women from discussing or seeking help because by
doing so would bring shame and dishonour to themselves their families and community.
This may be contributing to young women resorting to coping in private and may explain
the higher prevalence of self harm among this group.
Education, Training and Support
While having dedicated self harm projects has helped Penumbra to continue to reach out
to young people who self harm and learn from their experiences we believe that there
should not need to be projects that specifically work with this issue. Penumbra believes
that the most important people who can help and support people who self harm are
people who have day to day contact with them.
Therefore we feel that anyone who is working in an environment which may bring them
into contact with this issue should have access to good quality information, training and
support. Agencies should be looking to develop policies and guidelines for working with
people who self harm which state clearly how they expect staff to support and respond to
people who self harm and Penumbra also feel that it is important to involve people who
self harm in developing these policies and guidelines.
Patrick Little, Scottish Development Manager (Young People), Penumbra, Norton Park, 57 Albion Road
Edinburgh, EH7 5QY, E-mail: patrick.little@penumbra.org.uk
MAINTAINING INTEGRATY WHEN LANGUAGE FAILS
HELEN MACWHITE
Communication Officer, Bodywhys
Abstract
In this presentation I will explore self harm as a means of expressing
something that it does not feel safe to express in words – either because the
language has never been learned or because those at whom the message is
aimed are unable to hear it. I will draw on my experience of providing
support to people with eating disorders, many of whom self harm, some of
whom will complete suicide. I will also draw on my experience of providing
support for family members and friends struggling to find constructive ways
of supporting a person towards recovery. I will briefly put forward some
ideas that can be helpful in supporting a person towards more helpful coping
strategies and that might also play a role in prevention strategies for both self
harm and suicide.
Both suicide and self harm are realities that anyone working in the area of eating
disorders needs to be prepared for.
Living with an eating disorder and struggling towards recovery from an eating disorder
can be overwhelming experiences, not just for the person with the eating disorder, but
also for partners, parents, siblings, other family members and friends on whom the eating
disorder will inevitably have a significant impact. In fact, in many ways, eating disorders
are about overwhelm.
Eating disorders have the highest mortality rate of all psychiatric disorders. The most
common causes of death related to eating disorders are due to complications of the
disorder such as cardiac arrest or electrolyte imbalance, and to suicide.
Where death has resulted from completed suicide the contributing factors are most likely
to include a combination of
 depression
 intolerable levels of anxiety
 the cumulative effect of intolerable feelings of hopelessness , of ineffectiveness, of
inadequacy, of isolation
 feelings of total battle weariness, of being unable to ‘keep up the fight’
 no longer feeling able to carry the double burden of one’s own pain and anguish and
the pain and anguish inflicted on others
 coexistence of other psychiatric problems
Within the context of the services provided by Bodywhys the interface with suicide
occurs in a number of different ways. Typical examples might include
 disclosure of suicidal intent
 disclosure of suicidal thoughts (present or historical)
 disclosure of and reaction to the completion of suicide by a significant other
 disclosure of and reaction to a significant other’s suicidal intent or thoughts
These events can occur during a call to the helpline service, in an email communication
to the email support service, during the course of an online meeting or a face to face
support group.
Interface with self harm occurs in much the same way but is much more common as a
significant percentage of people with eating disorders engage in self harm. Indeed, the
relationship between self harm and eating disorders can be viewed as intimate. If we
adopt as a definition of self harm “the act of doing anything knowingly damaging to
yourself for a reason” this would include harming oneself by means of self-injury (e.g.
deliberate cutting, bruising, burning, tearing out of hair) and it would also include binge
drinking, smoking and drug taking, as well as many of the behaviours associated with
eating disorders (self-starvation, self-induced vomiting, misuse of laxatives, excessive
bingeing, excessive exercising).
Some sources estimate that approximately 25% of people with eating disorders engage in
self harm by means of self injury (Eating Disorders Review 2002; 10:205).
At this point it may be helpful to clarify that although many people believe that there is a
direct link between suicide and self harm, this is in fact inaccurate. While many people
who have completed suicide may have self harmed at some point, the majority of people
who self harm are not attempting to end their lives or even to communicate that they are
entertaining thoughts of wanting to end their lives. In order to be able to respond
effectively to self harm, it is essential to understand that self harm is an attempt to
preserve life rather than to destroy or end it. It is used as a survival strategy and as
such it should not be regarded as an attempt at suicide.
There are many parallels between eating disorders and self harm that can provide us
with clues in our quest to find better ways of responding to and, ultimately, of developing
prevention strategies for self harm (and many of these could also be applicable in the
context of suicide): As with an eating disorder
 self harm develops as a coping mechanism. It is a means of coping with distress/ of
surviving one’s emotional states/ of avoiding the direct experience of one’s
emotional states
 modulation of affect is achieved through the body
 the behaviour patterns are habit forming
 the person comes to rely on the behaviour in order to cope with feelings (there is a
significant element of dependency)
 there is a huge amount of guilt and shame associated with the behaviour (and the
emotional states induced by the behaviour) which breeds secrecy
 fear and anxiety around how the person will cope if they cannot self harm makes it
very difficult to tell someone about what they are experiencing
Other similarities that might offer insight relate to the psychological make up of the
person such as
- low self esteem and experiences of feeling inadequate
- difficulties coping with stress/ frequent or continuous sense of overwhelm
-
difficulties around assertiveness (the person feels disempowered and anticipates
disempowerment)
difficulties dealing with conflict
problems with separating from the family and normal individuation
difficulties discerning, establishing and maintaining boundaries
difficulties identifying and expressing needs
marked tendency to be other referrant (locus of evaluation placed outside of the self)
significant experience of pressure to perform
A close look at the above lists highlights two very important factors. Firstly, many of the
characteristics listed above are related to a fragile sense of self and secondly, they are
related to difficulties or disturbances at the level of communication. These two factors
can themselves be seen as very intricately linked and can be used to inform our response
to the person who self harms.
For many of the people who reach out to our services it has taken a huge amount of
courage to make that call or write that email, or decide to attend that support group. It
may be the first time that they have spoken about their eating disorder or any related
issues and they will be very apprehensive about the reaction they will encounter. For
some, the very act of making contact might prove too overwhelming for oral
communication to be possible. They might remain on a helpline call in silence or attend a
group without actively participating. How this first contact is met is crucial.
Given the nature of our services, this may be the only contact we have with them. For this
reason it is our job first and foremost to ensure that the contact has been one that will
enhance rather than hinder the person’s willingness and capacity to reach out again,
whether that be to our services, or to someone else.
Part of my work over the last number of years has been to help develop information
resources and training for the volunteers who provide our services – those who take the
calls on the helpline, or who respond to emails on our email support service, and those
who facilitate either online meetings or face to face support groups.
I will look here at some responses that can lead to the building of resilience and that will
in turn enhance the person’s capacity for the communication of distress and for more
effective communication generally.
In Bodywhys training for volunteers, a huge emphasis is put on active listening skills that
are underpinned by an attitudinal stance based on the core conditions of person centred
work, i.e. Acceptance (unconditional positive regard), genuineness (realness or
authenticity), and empathy. The presence of these qualities alone will help to create the
potential for healing to occur.
Active listening involves being able to hear on several levels simultaneously, picking up
not just on the content but also on the way it is being conveyed, tuning into how the other
is feeling, to how they are experiencing and viewing what is happening to them. The
quality of presence brought to an encounter will be felt keenly and will determine to what
extent a person will feel able to say what they need to say, and to say it as fully as
possible. It will also determine how well they are able to hear their own words in a way
that will empower them to acknowledge ‘where they are at’ so that movement forward
becomes more possible.
Accepting the person as they are without putting any expectation on them to change their
mind state or behaviours is essential. Change can only occur if it has been preceded by
acceptance of what is. This is not easy when we are in the presence of someone who is in
deep distress and who is engaging in behaviours that carry a risk.
Acceptance involves a caring response that is uncontaminated by judgement or
evaluation of the thoughts, feelings or behaviours of the other person. It is about valuing,
respecting, accepting a person unreservedly no matter what they have done or are doing,
no matter what their opinions are, what decisions they may decide to make. It serves to
create a climate within which the person can feel safe and free to express themselves
without judgement. Acceptance does not always have to be voiced. It can be
communicated through shared silence, through taking care not to interrupt, through
withholding criticism or comment.
Developing acceptance involves developing an awareness of our own assumptions and
prejudices which can impose conditions of worth on the person with whom we are
interacting. An awareness of how our own needs might come in the way of a supporting/
helping relationship is also essential. Are we allowing the person to really be as they are
or is our need to fix things, to make things better, to know that we have made a difference
getting in the way of our capacity to remain focused on the needs of the person who is in
distress and to offer full acceptance?
Genuineness is simply about being real, about just being yourself and not assuming a
role or façade of any kind. When I am genuine or congruent, I am who I am. I am being
real. I am in touch with my own flow of experiencing. I am able to own the thoughts,
the feelings and attitudes flowing through me. It is not necessary for me to express these
– an awareness of them is enough to increase my capacity for both acceptance and
empathy.
It is said that genuineness is ‘contagious’. Being genuine encourages the person with
whom you are communicating to be genuine too. Your being just yourself has the effect
of giving them permission to be themselves and not to be over-concerned with notions of
how they should be. Through your genuineness you are providing them with an example,
a model. They will be less likely to pretend, to deny, to hide, to conceal thoughts and
feelings, to be defensive. Genuineness allows for the development of trust and facilitates
disclosure.
Empathy refers to our ability to experience the other person’s world as if it were our
world, but without losing the ‘as if’ quality. Empathy is different from sympathy which
has its roots in our own thoughts and feelings about what is happening. It involves
entering into the private world of the other person in order to understand it, irrespective
of whether we feel sympathy. It is different also from identification (‘I know how you
feel because something similar has happened to me’). With empathy, the uniqueness of
the other’s experience is fully respected and the frame of reference remains that of the
other person.
A prerequisite to being able to bring these qualities to our response to an individual in
distress is self awareness.
Active listening involves listening to the other while simultaneously listening to yourself.
This practise of inner listening (listening to yourself, being aware of your own thoughts
and feelings in the process) can be vital to the quality of your outer listening (listening to
the other and tuning into their experience of the process).
The benefits of good active listening skills when interacting with a person who is in
distress are that they help to

establish rapport (a sense of a relationship in which the speaker feels the listener is
available and willing to focus on his/her needs)

establish and build trust (a belief in the honesty, integrity and reliability of the
other which will also increase openness to further contact)

create feelings of acceptance, safety, and understanding (helps to dispel any fear
of rejection or ridicule or of being pressured to make changes beyond what is
perceived as tolerable)

facilitate disclosure
 increases self esteem (a sense of both self worth and self competence)
This last point is of immense significance as every experience of the self being affirmed
is helping in the task of building resilience and slowly opening the person to a healthier
way of relating to themselves, to others, and to the world around them.
Research into the etiology of both eating disorders and of self harming behaviours often
focuses on very early development and its impact on the separation and individuation
processes.
Coming into the world is an overwhelming and potentially traumatic experience by any
standards and the subsequent task of learning to be in the world is a highly challenging
and complex business. We are not in control of it. Our survival is continually dependent
on a feedback loop between our internal world and the external world. Whether or not a
person experiences the world as a hospitable, accepting, safe place in which they can be
themselves freely and fully is dependent on a myriad of factors related to the functioning
of that feedback loop.
There are many things that can cause the feedback loop to contain a surcharge of anxiety.
Surges of anxiety are a natural aspect of the feedback loop. It is the way in which these
surges of anxiety are mediated within the feedback loop that sets up a pattern for dealing
with overwhelming emotions. If a surcharge of anxiety is continuously sustained this can
ultimately lead to an incapacity to express emotions appropriately and to integrate
experience and the individual will develop behaviour patterns that will display a
dominance of anxiety relieving strategies that do not involve a mediating factor that
elicits a response from the world around them.
Self harming behaviours can be seen as fulfilling this anxiety alleviating function in this
way. What cannot be communicated in words or actions is mediated through the body
and directed at oneself. This type of behaviour also ensures that distress remains hidden
from others and the integrity of the self is further protected from anticipated
disintegration. Of course, the relief is short lived because the underlying factors that have
led the person to respond in this way have not been modified.
When a person is coping with life in this way, the journey through life becomes a
constant struggle to survive and this can lead to a sense that life is not being lived but is
being bypassed. There is no sense of effectiveness, no sense of one’s capacity to shape
one’s world. Discernment of objective reality is problematic. The self harming
behaviours provide a means of coping with the intolerable sense of alienation that ensues.
Unfortunately, the energy that is put into coping in this way also serves to perpetuate a
vicious cycle of withdrawal and isolation from the objective world thus compounding the
isolation and increasing the distress.
Self harming allows the person to maintain a ‘window of tolerance’ that insures survival.
Respectfulness of this window of tolerance is essential and can be achieved through the
attitudinal skills outlined above.
A significant key to improving our response to mental distress and to building resilience
in those who resort to self harming behaviours in order to survive is rooted in self
awareness and effective communication skills. Each one of us can contribute to both the
alleviation and prevention of mental distress by developing these skills for ourselves and
thus improving our capacity to meet those in distress in a way that makes them feel
valued and safe. Each time that they experience such an encounter, it creates the potential
for them to move from a fear based response to life to a more trust based response.
Ms. Helen MacWhite, Communications Officer, Bodywhys Central Office, PO Box 105, Blackrock,
Co Dublin, E-mail: communications@bodywhys.ie
Chairperson: Seán McCarthy - Comments
It was a privilege and a pleasure to chair session 4 at the Irish Association of
Suicidologys’ 11th Annual Conference. The session provided an opportunity to the
presenters to share both their experiences and research findings. These presentations
were extremely relevant and insightful and contributed in a meaningful way to the
dialogue around the issues around self-harm and the whole area of communication with
people in distress.
Mr. Pat Little who is Development Manager with the Penumbra services in Scotland
presented us with an overview of their services. They currently run 6 projects across
Scotland and are funded by Choose Life (Scotland Executive National Strategy for
Suicide Prevention) to tackle self-harm issues. Findings of research conducted by
Penumbra called “No Harm In Listening” were presented. I was particularly taken with
this as it acknowledged the insights of young people when designing
programmes/interventions for young people. Many of the young people who contributed
to this research had experienced self-harm and attempted suicide.
Helen McWhite is Communications Officer for Bodywhys. This is a voluntary support
organisation for people with eating disorders their family and friends. Their services
include a network of support groups throughout the country, a helpline and an education
and awareness programme. During this presentation, the self-harm event as a mean of
expressing something that it does not feel safe to express in words was presented. The
reasons behind the difficulty with the communication, be it either an inability of the
individual to express their distress with appropriate language or the inability of the person
at whom the message is aimed at to hear it were discussed. Ideas that can be helpful in
supporting a person towards more helpful coping strategies and that might also play a
role in prevention strategies for both self-harm and suicide were discussed.
POSTERS
THE EXPERIENCE OF PATIENT SUICIDE AMONG GENERAL
PRACTITIONERS
MS MARY MOORE-CORRY¹²³, MS ELAINE MCMAHON²³, DR MARGARET
KELLEHER²³, PROF COLIN BRADLEY³4, DR ELLA ARENSMAN²³.
1 Doctorate in Clinical Psychology, University of Limerick, 2 National Suicide Research
Foundation of Ireland, 3 Cork and Kerry Alliance for Depression and Suicidal Behaviour
(CKADS), 4 Department of General Practice, University College Cork
The General Practitioner (GP) is the first, and sometimes the only, health professional
that individuals, who die by suicide contact within the health and social services. There is
a clear lack of research in the area of the personal and professional impacts of such a
client group on the GP. This study set out to elicit and explore GP views of the impact of
patient suicide among General Practitioners. A qualitative study using in-depth
interviews were conducted with a GP sample varying in gender, age, years in practice,
urban/rural location, public/private patients, and specific psychiatric training was carried
out. Eight GPs who had shown an interest in being involved with the Cork and Kerry
Alliance for Awareness of Depression and Suicidal Behaviour (CKADS) run by the
National Suicide Research Foundation (NSRF) were interviewed. Interviews were
transcribed and analyzed using thematic analysis. Professionally, suicides for the GP can
mean a great deal of self analysis of their work. The analysis revealed that GPs generally
felt that although the effects of a suicide was devastating, there was a certain amount of
acceptance in that as being all part of their profession. Personally, GPs found that
suicide, as with any patient sudden death, was difficult to cope with in terms of dealing
with one’s own emotions while trying to deal with the relatives and family. There was a
huge sense of loss when the GP knew the patient well. A number of GPs reported the
feeling of shock at the news of a suicide being related to the lack of any suicide ideations
or serious intent during their consultations with them. Concern was noted with respect to
the levels of support available for GPs to get through the death of a patient by suicide.
Training and educational issues were also identified and implications for the provision of
personal therapy, reflective practice group model and supervision were discussed.
SUPPORTING THE SUICIDE BEREAVED
OWEN O’MAHONY
P.R.O. Clare Living Links
Abstract
The feelings and reactions to suicide bereavement have aspects in common
with other bereavement. There is shock, disbelief, denial, sadness, loss,
anger, blame and the need to come to terms with the event. Friction within
the family unit is often a major problem and some families become totally
dysfunctional. Grief is a different levels within the family unit and this leads
to accusations of “you have forgotten very quickly” to “you were always the
selfish one”. Circumstances such as this prevent conversation and prohibit
the exploration of feelings.
In general, after a death, neighbours and friends offer support and help. This support
tends to die our after a short period and individuals and families have to deal with the
event on their own. There is also mutual avoidance. Neighbours and friends feel
incapable and are unsure what to say or do. For various reasons, the bereaved avoid
speaking about what happened. At this stage many people do not know where to look for
help and support. Prior to the bereavement little attention was paid to the existence of the
available support and now in the aftermath of suicide, with the resultant emotional
confusion, many people feel isolated, not knowing that help is available or where to look
for this help. Being aware of these factors those involved in Living Links are conscious
of the need to use any available means to inform people that help and support is
available.
What is Living Links?
Living Links is a groups of trained volunteers providing a listening/support service which
is free of charge and available to any person in the community including emergency
personnel, gardai, clergy etc. and anyone who has been in any way effected by suicide.
The group is supported and guided by an executive committee and the Organisation is
under the auspices of the HSE.
In each area a group of people are interviewed as regards suitability and then asked to
undertake a training programme specifically designed towards suicide bereavement
support. The training programme is comprised of formal lectures and workshops relating
to the immediate needs of the bereaved, exploration of grief and how to deal with it, the
role of the gardai and the coroner’s court.
Trained volunteers are now available in a number of areas to offer confidential practical
support and advice to families who have experienced a death by suicide. At the request
of the family or individual, the Suicide Outreach Support Person can call to the home or
meet at an agreed location. The outreach worker can provide information and practical
support concerning the following areas:
The funeral
The inquest
Entitlements
What to say to children
How to deal with the neighbours
Help the person to clarify their personal grief
Connect the person to other support services in the area
Provide information on suicide and attempted suicide
Be there as a friend for the person
Living Links Objectives are:
 To provide support and outreach to those bereaved by suicide.
 To increase awareness and understanding of suicide and its effects on individuals,
families and communities.
 To liaise and exchange information with similar support groups nationally and
internationally.
 To support and encourage relevant research.
 To produce leaflets and associated literature for the survivors.
 To liaise with and provide families with information on health services available in
the region, and the referral pathways to such services should professional counselling
or other help be required.
 To provide and facilitate a group healing programme, on a needs basis for the suicide
bereaved.
 To encourage the suicide bereaved to establish and foster an ongoing support group
among themselves.
In addition to one to one support for individuals and families Living Links volunteers
provide and facilitate a group Healing Programme on a needs basis for the suicide
bereaved. The programme consists of eight two hour sessions which include three to five
people in each group with one facilitator. Families are separated in the small groups
where possible. Each group has a lighted candle as a symbol of confidentiality.
The Aims of the Healing Programme are:
 To help adults, who have experienced a death by suicide, to find healing and support
in a safe and caring environment.
 To provide an opportunity of meeting others who have experienced loss through a
death by suicide.
 To provide healing through talking and listening in small groups.
 Mutual help is received and given through sharing.
Living Links Nationally
East Cork
087 1370792
Galway City & County
091 565066
Limerick City & County
087 7998427
North Tipperary
087 9693021
Co Clare
086 0565373
Co Kerry
087 9006300
Co Meath
046 9021407
Co Wicklow
01 2868413
Mr. Owen O’Mahony, P.R.O. Clare Living Links, E-mail: abomahony.ennis@eircom.net
SAMARITANS
GERRY DOBBIN
Abstract
Samaritans was founded in 1953 and provides confidential emotional support,
24 hours a day for people who are experiencing feelings of distress or despair,
including those which may lead to suicide. Samaritan support is provided by
phone(08457 90 90 90 in the UK and Northern Ireland and 1850 60 90 90 in
the Republic of Ireland);through visits to individual branches; by letter and email (jo@samaritans.org.) There is also a Samaritan presence at major
festivals. People who contact Samaritans are listened to in confidence and
treated in a non-judgemental way. Suicidal feelings are explored at every
opportunity.
Samaritans are there for those who are experiencing feelings of distress or despair, people
who may feel lonely and isolated and those who have come to a point when life is getting
too much to bear. Samaritans are prepared to listen regardless of how trivial or disturbing
a problem appears to be. Our message to our callers is: no matter what you are going
through, you're not alone. We're here to listen to peoples concerns, worries and anxieties
any time, day or night. We don't judge people, nor do we tell people what to do. What
we will do is give people time to think things through, listening with an open mind and in
complete confidence. People who contact Samaritans can share their innermost feelings
without fear, criticism or judgement and be safe in the knowledge that it is confidential
and also anonymous.
Samaritans believe that simply talking about feelings and being really heard can make a
difference- sometimes the difference between life and death. It is part of our vision for
society that if people are free to explore their feelings in a safe and non-judgemental way
and if people are able to acknowledge and respect the feelings of others then fewer
people will die by suicide.
Samaritans volunteers befriend people who feel they have no where else to go: people
who may feel betrayed by life and are desperate, lonely or suicidal. Volunteers are the
Samaritans greatest resource. There are approx. two thousand such volunteers manning
twenty branches in Ireland, 24 hours a day, seven days a week. Samaritans volunteers are
ordinary people who are open minded and who have natural listening skills; People who
respect confidentiality and who have care and compassion for other human beings.
Samaritans volunteers do not invoke religion, philosophy or personal view points when
engaged with callers, nor do we give advice or direction.
Recruitment and training take place annually. The initial training is intense and
comprehensive. Volunteers also have to attend ongoing training on an annual basis while
they are with the organisation.
Samaritans are continually developing our service to meet the needs of our callers. As
well as our twenty four hour phone service, people may visit our branches during
specified daylight hours. In recent years an e-mail contact service has been provided jo@samaritan.org -and this year a new text service has been launched -text phone at 1850-60-90-90. Samaritans also provide our service in various prisons. In addition,
volunteers attend major festivals around Ireland during the year befriending people at
such events.
Samaritans work in partnership with local and national government, businesses, local
organisations and the media in order to raise awareness of suicide and the importance of
listening to others.
Samaritans school talks programme is particularly relevant given the high number of
young people who self harm and who take their own lives. We talk to young adults about
the issues that concern them and offer them a forum to discuss these issues in a real and
open way and also raise awareness and understanding of the service that Samaritans
provide.
Samaritans......when needed we are there; when it would help to talk to someone who
cares, someone who will stay with you, contact Samaritans. What ever you are going
through, we'll go through it with you.
Mr. Gerry Dobbin, Samaritans. E-mail: dobcat@eircom.net
PAPER PRESENTATIONS
REACH OUT, THE NATIONAL STRATEGY FOR ACTION ON
SUICIDE PREVENTION
DEREK CHAMBERS, GEOFF DAY, ANNE CALLANAN AND
KAREN MURPHY
National Office for Suicide Prevention
Abstract
Reach Out, the national suicide prevention strategy, was launched in September
2005 following nationwide consultation. Implementation (in three phases) of this
broad-based ten year strategy is being coordinated by the National Office for
Suicide Prevention (NOSP). Actions are being implemented across four levels of
suicide prevention as follows:
 General population actions
 Targeted (risk group) actions
 Responding following suicide
 Information and research
Implementation Plan
Monitoring of implementation will be facilitated by the identification of broad time
frames, lead agencies and ‘deliverables’ for each action in the strategy. In the first year of
implementation, the NOSP appointed an advisory group and established a national forum
of stakeholders. In addition, a 12-point service plan was agreed for 2006, based around
Phase 1 actions, addressing the following issues and actions:
Making it Happen
1. To establish a national forum of key stakeholders (Reach Out p.17, 18 (Making it
Happen)
Level A – General Population
2. To deliver agreed training programmes (e.g. Action 7.3)
3. To work with the media (Reach Out Action Area 9)
4. To launch a national mental well being campaign (Reach Out Action Area 10)
5. To pilot a ‘gateway’ service post to inter-face between Primary Care and Secondary
Services in responding to suicidal crises (Reach Out Action 11.5)
Level B – Targeted Actions
6. To develop services to respond to presentations to hospital following deliberate selfharm (Reach Out Action 12.3)
7. To develop a travellers suicide prevention project (Reach Out Action Area 15)
8. To complete research into the link between institutional abuse and suicide (Reach Out
Action Area 19)
Level C – Responding following Suicide
9. To review and develop bereavement support services (Reach Out Action Area 23)
Level D – Information and Research
10. To review and improve suicide mortality data collection (Reach Out Action 25.2)
11. To develop methods of reaching people (especially young people) through
Information and Communications Technology (ICT) (Reach Out Action 25.4)
12. To agree a national programme of research on suicide prevention in Ireland (Reach
Out Action 26.1)
This paper presents an overview of progress in relation to the 12-point plan outlined
above.
Process in Implementation
Making it Happen
1. Establish a National Office for Suicide Prevention and Convening a National
Forum of Stakeholders (Making it Happen)
The National Office for Suicide Prevention (NOSP) was established by the Minister for
Health and Children at the launch of Reach Out in September 2005. The NOSP held its
first National Forum Meeting in March 2006. The Forum was attended by over 100
representatives from a wide range of suicide prevention and mental health promotion
agencies. Plans are underway for the next Forum in 2007.
Level A – General Population
2. Training & Awareness Programmes (e.g. Reach Out Action 7.3)
Reach Out sets a challenging agenda for the development and delivery of training and
awareness programmes for communities, organisations and professionals. Such training
will need to be delivered at both local and national levels. Some training in suicide
prevention is already undertaken at local HSE level and through voluntary organisations.
Mental health promotion training also takes place through HSE health promotion
services. The NOSP secured approval for one National Training and Development
Officer and three Regional Training Officers. The HSE is currently recruiting for these
posts on behalf of the NOSP.
The NOSP will continue to coordinate delivery of the ASIST (Applied Suicide
Intervention Skills Training) programme which has already trained over 70 trainers and
delivered nearly 100 workshops to ‘gatekeepers’ around the country.
3. Media (Reach Out Action Area 9)
Revised Irish Association of Suicidology (IAS) /Samaritans media guidelines were
launched in June 2006 simultaneously in Dublin and Belfast. The IAS are also planning
an awards event in 2006 to acknowledge journalists who have demonstrated sensitivity
and understanding in reporting on suicide prevention issues. These awards will be partfunded by the NOSP.
A print media monitoring study was finalised in 2006 and published by the NOSP. This
monitoring study will be used in the development of training modules for students of
journalism.
Headline is a new media monitoring campaign being developed by an alliance of
voluntary support organisations and the NOSP under the management of Schizophrenia
Ireland. Staff have been recruited to lead the campaign which, it is intended, will
facilitate improved working relations with the media in covering issues around suicide
prevention and mental health.
4. National Mental Health Promotion Campaign (Reach Out Action Area 10)
The NOSP has prepared a detailed project plan for the development of a major national
mental health awareness campaign which will be developed in partnership with the
National Office for Social Marketing of the HSE. The aim of this campaign is to launch,
in conjunction with voluntary organisations, a national multi media campaign to impact
on the stigma of mental health and to encourage help seeking. The campaign will be
developed through a professional advertising/media agency (engaged by HSE) with a
view to launch in late 2006. The campaign will be whole population based initially but
as it develops over time more targeted/local campaigns will be initiated. A public
attitudes survey will be conducted prior to launch in order to generate baseline
information that will facilitate evaluation of the campaign at a later stage.
5. Pilot ‘gateway’ worker between Primary and Secondary Care (Reach Out Action
11.5)
A pilot service to inter-face between primary care and secondary services in the
management of suicidal crises is being developed as a partnership between the Cluain
Mhuire Service in Dublin and the NOSP. The service will be lead by an experienced
mental health professional and will be evaluated with a view to informing such service
development throughout the HSE. This mental health professional has been recruited and
the evaluation methodology is currently being agreed.
Level B – Targeted (Risk Group) Action
6. A&E response to deliberate self harm (Reach Out Action 12.3)
Additional resources were made available in 2005 to put in place experienced psychiatric
nursing staff in A & E departments to respond to deliberate self harm presentations.
Further investment will be made in 2006 to ensure that all A & E departments have a
service to respond to such presentations by the end of the year.
7. Travellers Suicide Prevention Project (Reach Out Action Area 15)
The NOSP has worked with an alliance of travellers support groups to develop a project
worker post to support suicide prevention activities among the traveller population in
Ireland. The project is due to commence in the coming weeks.
8. Institutional Abuse and Suicide Risk (Reach Out Action Area 19)
There is some anecdotal evidence that those who have suffered institutional abuse have a
high rate of suicide. The National Suicide Research Foundation have been commissioned
to examine the risk associated with suicide for victims of institutional abuse and to advise
on service needs. Interviews with survivor support groups and staff of the National
Counselling Service have taken place. Seminars with victims of abuse have been attended
throughout the country and a Phase One report on the project has been finalised. The
findings of Phase One were accepted for presentation at the 2006 IAS Conference on
Suicide Prevention (September, 2006).
Level C – Responding following Suicide
9. Support the Development of Bereavement Support Services (Reach Out Action
Area 23)
A major national review of bereavement support services has been commenced on behalf
of the NOSP, involving statutory and voluntary service providers in the area of general
and suicide-specific bereavement support services. As part of the review a detailed
directory of support services will be completed and made available online. The results of
the review will be used to inform a national bereavement support care plan.
In the meantime, the NOSP has provided existing services in the area of suicide
bereavement support with funding of over €200,000 to ensure ongoing and expanded
service provision while the national review work is being completed.
Level D – Information and Research
10. Data collection on Suicide Mortality (Reach Out Action 25.2)
Recording practices in relation to mortality from ‘external causes’ is currently being
reviewed and a report will be made available in late 2006 highlighting current practice
and making recommendations for future developments in recording practive to ensure
accuracy of mortality data. A specific target in relation to the reduction of suicide rates in
Ireland will be set if the accuracy of suicide mortality data can be determined. It is
intended that a system of data collection will be developed that will allow more in-depth
information on trends in suicide mortality so that more effective prevention strategies can
be developed.
11. Reaching Young People (Reach Out Action 25.4)
The NOSP is exploring ways of reaching young people through email and text messaging
in order to develop a sustainable programme of action which can be funded in late
2006/2007 onwards. We will be consulting young people, voluntary organisations and
those using technology in innovative ways to provide services for young people. To date,
some support has been provided to one such service based in the north west but targeting
young people nationally, i.e. www.spunout.ie.
12. National Research Programme (Reach Out Action 26.1)
There is much research on suicide/self harm being undertaken at local/national and
international level. It is important to ensure a coordinated approach to funded research
and in particular to use such research to influence future suicide prevention activity. A
national research meeting was held in June 2006, bringing together all of those involved
in research in order to seek agreement on a national research plan. It is planned that a
national research network will be developed comprising participants at this inaugural
national research meeting.
Future Developments
Progress is being made in implementing Reach Out, and this progress can be clearly
monitored in the context of the Action Plan that was incorporated into the strategy. By
assigning something ‘deliverable’ next to each of the 94 actions in the strategy process
evaluation has been facilitated. Therefore, the NOSP can answer the question “did we do
it?”. However, the question “did it matter?” is more complex and will require an
independent outcome evaluation of the implementation so that we can answer the
question “did it matter?”. In 2007, the NOSP will be commissioning this independent
evaluation of Phase 1 Reach Out implementation.
Mr. Derek Chambers, Mr. Geoff Day, Ms.Anne Callanan and Ms. Karen Murphy
National Office for Suicide Prevention, Room G29, Population Health, Dr. Steevens Hospital
Kilmainhan, Dublin 8. Tel: 01 6352179
MATERNAL SUICIDE: A TWENTY YEAR REVIEW OF SUICIDES
IN THE UNITED KINGDOM BY NEW MOTHERS AND
PREGNANT WOMEN
IAIN W. MCGOWAN, MARLENE SINCLAIR
School of Nursing, University of Ulster
Abstract
In the United Kingdom suicide has recently been noted as the main cause of
maternal death. This paper will outline preliminary results of on-going
research into the prevalence and characteristics of maternal suicide in the
United Kingdom since 1985. The prevalence of maternal suicide in the UK
will be presented followed by the characteristics of the completed suicides, to
include age of the mother at death, the outcome of the pregnancy, marital
status of the deceased, method of suicide and the length of time from birth.
Finally, the implications for paediatricians, midwives, general practitioners
and health visitors will be discussed.
AN INVESTIGATION INTO THE RISK AND PROTECTIVE
FACTORS FOR SUICIDAL BEHAVIOUR AMONGST PERSONS
WHO HAVE EXPERIENCED INSTITUTIONAL CHILD SEXUAL
ABUSE
MARTINA O’ RIORDAN, ELLA ARNESMAN
National Suicide Research Foundation
Abstract
Studies examining the relationship between childhood trauma and adult
suicidal behaviour have reported evidence that the two are frequently linked.
Preliminary results from this qualitative study indicate factors associated with
suicidal behaviour most frequently cited by specialist support professionals
were alcohol/substance abuse (13 out of 15 counsellor/therapists) and social
isolation (6/15). Other factors included a lack of experience of forming
attachments or developing coping skills by those who had entered the
institutions as babies (4/15), a feeling of anti-climax following their
settlement from the Redress Board or ill-advised spending of their award
(3/15) and impulsive behaviour (3/15). The most frequently cited protective
factors were the ability to form lasting relationships or marriage (12/15) and
having children (7/15). Other protective factors included education (4/15),
being in employment (3/15) and having the support of a survivor group
(3/15). This information provides a valuable basis for a study comparing
persons who experienced institutional child sexual abuse and who died by
suicide versus those with a similar experience but who did not engage in
suicidal behaviour.
Introduction
Following the Industrial Schools Act of 1868, the Irish state developed a system of
institutional care for children which continued for over one hundred years. These
industrial schools were run by religious orders and funded by the public, their remit being
to care for ‘neglected, orphaned or abandoned children’ (Rafferty & O’Sullivan, 1999).
Children were placed in institutional care either by referral from the Health Board, by
private arrangement or by order of the courts. The number of children in industrial
schools peaked in 1900 with 8,000 children in 71 schools. By 1969 there were under
2,000 children in 29 schools as the suitability of the institutional care system came into
question. In response to growing criticism, the Government commissioned District
Justice Eileen Kennedy to enquire into the industrial school system. The Kennedy Report
was published in 1970 and recommended that institutional care was not appropriate for
children. Schools began to close during the 1970s and eventually in 1984 the Government
decided that foster families were a more suitable place for children in the care of the
state.
However, it was not until media attention in the late 1990s with documentaries such as
Dear Daughter and States of Fear that the horrifying picture of widespread abuse,
deprivation and neglect in the former institutions became evident. On the 11th May 1999,
An Taoiseach Bertie Ahern apologised on behalf of the Irish government to its citizens
who had been abused in institutions as children. Following this apology the National
Counselling Service (NCS) was established in September 2000 to cater for survivors of
child abuse, with priority given to those with a history of institutional child abuse (NCS,
First Report, 2002). The Commission to Inquire into Child Abuse was also established in
2000.
Studies examining the relationship between childhood trauma and adult suicidal
behaviour have reported evidence that the two are frequently linked (Brodsky et al, 2001;
Peters & Range, 1995). Consequently, the Reach Out National Strategy for Action on
Suicide Prevention, 2005-2014 has identified survivors of abuse, particularly those from
state institutions, as a group that should be prioritised for suicide prevention and mental
health promotion initiatives.
This paper reflects the first phase of a larger research project. It consists of a detailed
literature review into institutional child sexual abuse and suicidal behaviour, along with
the primary results of a qualitative study with specialist support service personnel. The
qualitative study seeks to highlight the factors associated with increased risk of suicidal
behaviour amongst persons with a history of institutional child sexual abuse along with
protective factors.
Part I: Literature Review
Studies included:
The literature search yielded three primary studies and forty-five secondary studies,
thirty-six of which met the inclusion criteria for review. Four government reports were
also included. Studies were matched against four quality criteria, thus the possible range
of quality scores was between 0 and 4. The actual range of scores was from 0.5 to 3.66.
The inclusion criteria were one or both of the following:
1) The study investigated the nature or long-term effects of institutional abuse or child
sexual abuse
2) The study examined the relationship between institutional abuse/child sexual abuse
and suicide, deliberate self-harm and/or suicide ideation.
The quality criteria were as follows:
1) Operationalization/definition of institutional abuse or child sexual abuse or suicide
ideation, suicide attempt or deliberate self harm
2) Selection of the sample
3) Measures of institutional abuse or child sexual abuse used
4) Appropriate statistical analyses
The studies were rated independently by the two authors and then cross-checked to
ensure reliability.
Main outcomes:
 There is a lack of studies addressing the relationship between institutional child
sexual abuse and suicidal behaviour and related mental health difficulties.

Studies focusing on the consequences of child sexual abuse in general reveal
consistent evidence for an association with adult suicidal behaviour, in particular nonfatal, as well as suicide ideation (Ystgaard, 2004; Brodsky et al, 2001; Vajda &
Steinbeck, 1999; Silverman et al, 1996).

Research indicates that the consequences of child sexual abuse by peers are similar
compared to abuse by adults in terms of suicidal behaviour and mental health
difficulties (Shaw et al, 2000; Sperry & Gilbert, 2005).

There is consistent evidence that child sexual abuse is associated with Post Traumatic
Disorder (PTSD) in adulthood, with the severity of the abuse linked to the severity of
the PTSD symptoms (Hetzel & McCanne, 2005; Peleikis et al, 2004; Schaff &
McCanne, 1998; Briggs & Joyce, 1997).

Research indicates that people with a history of child sexual abuse are at risk of
developing mental health problems (incl. depression, sexual difficulties and decreased
self-esteem) in adulthood (Modestin et al, 2005; Tanskanen et al, 2004; Zlotnick et al,
2001; Cheasty et al, 2000).
Recommendations:
 Further research into risk and protective factors for suicidal behaviour among persons
with a history of institutional child sexual abuse.

Research into consequences of institutional child sexual abuse should focus on abuse
by both adult perpetrators and by peers.

Further research into consequences of institutional child sexual abuse among men.
Part II: Qualitative Study
A total of fifteen professionals offering specialist support services to survivors of
institutional abuse participated in the study. A manager and a member of frontline
counsellor/therapist staff from seven of the ten branches of the National Counselling
Service took part. When saturation was reached amongst the NCS staff, no further
interviews took place, although there was a 100% response rate from the ten branches.
The MASC (Male Abuse Survivors Centre) in Galway also participated. A semistructured interview schedule was prepared by the NSRF, the recorded interviews were
later transcribed and a thematic analysis was undertaken.
Main outcomes:
 Factors associated with suicidal behaviour most frequently cited by specialist support
professionals were alcohol/substance abuse (13 out of 15 counsellor/therapists) and
social isolation (6/15). Other risk factors included a lack of experience of forming
attachments or developing coping skills by those who had entered the institutions as
babies (4/15), a feeling of anti-climax following their settlement from the Redress
Board or ill-advised spending of their award (3/15) and impulsive behaviour (3/15).


The most frequently cited protective factors were the ability to form lasting
relationships or marriage (12 out of 15 counsellor/therapists) and having children
(7/15). Other protective factors included education (4/15), being in employment
(3/15) and having the support of a survivor group (3/15).
Recommendations:
The risk and protective factors identified in this study provide a valuable basis for
further research directly involving survivors of institutional child sexual abuse.
This study is supported by the National Office for Suicide Prevention
Ms. Martina O’ Riordan, Dr. Ella Arnesman, National Suicide Research Foundation, 1, Perrott Avenue,
College Road, Cork. Tel: 021 4277499
BASELINE CHARACTERISTICS OF DELIBERATE SELF-HARM
PATIENTS RECRUITED IN A RANDOMISED CONTROLLED
TRIAL OF GROUP PROBLEM-SOLVING SKILLS TRAINING
COMPARED WITH STANDARD CARE
CARMEL MCAULIFFE1, BREDA C. MCLEAVEY2, PAUL CORCORAN1,
BERNIE CARROLL3, BRIAN O’ KEEFFE3, MARY O’ REGAN1, EVA
FITZGERALD1, LOUISE RYAN3, PORTIA HICKEY1, ELLA ARENSMAN1,
ANTHONY P. FITZGERALD1.
1
National Suicide Research Foundation, 2 HSE Southern Area, 3 HSE Mid-Western Area
Abstract
This study describes baseline characteristics and treatment satisfaction of
DSH patients recruited in an RCT to determine the efficacy of a group
interpersonal problem-solving skills training programme (IPSST) versus
standard care. Consenting DSH patients meeting inclusion criteria were
interviewed within three days of their index episode. Of the 2,654 DSH
patients screened, 1,151 (43%) were eligible, of whom, 441 (38%) were
randomised to IPSST or standard care. From analysis of baseline interviews
64% had previously self-harmed, while the following mean scores were
obtained: (Suicide Intent Scale mean 13; Beck Depression Inventory mean
36.3; Hopelessness Scale mean 10.8). Only 32% felt they could solve their
main problem. IPSST clients attended 67% of sessions and were more were
satisfied with treatment (91% v 60%, p<0.001) compared with standard care
clients. Higher attendance and greater satisfaction with IPSST indicate that
this treatment approach is suitable for a high risk sub-group of DSH patients.
Deliberate self-harm (DSH) is the most important risk factor for suicide (Hawton &
Sinclair, 2003) such that those who engage in DSH are 20 to 40 times more likely to
eventually kill themselves (Gunnell & Frankel, 1994; Harris & Barraclough, 1997).
Deliberate self-harm among young men and women poses a significant challenge to the
health system in Ireland (Corcoran et al., 2003). A total of 10,347 hospital presentations
due to deliberate self-harm were made by 8,055 individuals in the Republic of Ireland in
2004 (National Suicide Research Foundation, 2005). More than one-fifth of these
presentations were due to repeat acts and the proportion of presentations in Ireland due to
repeat acts - as in other countries - is thought to be increasing (Hawton et al., 2003;
Henriques et al., 2004; National Suicide Research Foundation, 2005). Over one-in-five of
all hospital treated presentations with deliberate self-harm in the Republic of Ireland in
2004 were due to repeat acts and approximately 14.9% of deliberate self-harm patients
made a further repeat attempt during the calendar year in which they presented to
hospital. There is also evidence that many more individuals engage in repeat episodes,
without presenting for medical treatment (Guthrie et al., 2001; Tyrer et al., 2003).
There has been a longstanding lack of research evidence of effective treatment
interventions in reducing repetition of DSH (Hawton et al., 1998; Arensman et al., 2001).
Poorer problem-solving ability has been found among people engaging in DSH in general
(Linehan et al., 1987; McLeavey et al., 1987; Rotheram-Borus et al., 1990; Pollock &
Williams, 1998; Pollock & Williams, 2004), and particularly among those who self-harm
repeatedly (Kehrer & Linehan, 1996; Rudd et al., 1996; Dieserud et al., 2003; McAuliffe
et al., 2006) and promising results have been found for problem-solving therapy in
reducing repetition of DSH (Hawton et al., 1998; Arensman et al., 2001). A recent trial of
cognitive therapy that included a problem-solving component reported a significantly
lower re-attempt rate (Brown et al., 2005). The failure of a recent trial - using a manual
assisted cognitive therapeutic approach - to demonstrate a reduction in repeat episodes
(Tyrer et al., 2003) in which over one-third of the active treatment sample received a
treatment manual alone without any treatment sessions, suggests that reliance purely on a
self-help approach among repeaters of deliberate self-harm is ineffective in reducing
repetition (Arensman et al., 2004).
Aside from repetition, a number of other important treatment outcomes should be
considered using standardised measures (Arensman et al., 2001) for two reasons: Firstly,
in trials of problem-solving and other psychosocial therapies, including those where a
significant reduction in repetition has not been achieved, other important outcomes have
been found, such as the alleviation of depression and hopelessness (Guthrie et al., 2001;
Raj et al., 2001; Townsend et al., 2001; Brown et al., 2005;), improvements in problems
or problem-solving ability (Raj et al., 2001;Townsend et al., 2001), and a significant
reduction in suicidal ideation (Guthrie et al., 2001; Raj et al., 2001). Secondly, trials that
achieve a consistently positive effect across several outcomes (e.g. depression,
hopelessness) in addition to repetition, provide stronger evidence that the significance of
the results is not just due to a small shift in the number of repeat attempts during a
follow-up period (Brown et al., 2005).
There is an urgent need for the development of effective treatments for this group of
people. This presentation describes the baseline characteristics and treatment satisfaction
of deliberate self-harm patients recruited in a randomised controlled trial (RCT) to
determine the efficacy of a structured group interpersonal problem-solving skills training
programme (IPSST) compared with standard care. Consenting DSH patients meeting
inclusion criteria were interviewed within three days of their index episode. A total of
441 DSH patients in Cork and Limerick were randomised to IPSST or standard care. The
IPSST programme consisted of weekly two-hour sessions of group problem-solving skills
training over six weeks at a community based venue, using clients’ own problems for
training sessions and practice at home. Outcomes including coping skills, symptoms of
mood disorder, and repeated self-harm were measured following treatment and again six
months later. Information on repeat episodes of DSH was collected up to one year
following entry to the study. This is one of the first such large-scale studies undertaken in
any country, and findings will have far-reaching implications for the treatment of DSH,
which is known to have poor follow-up attendance rates at mental health services and to
lack effectiveness in terms of repetition rates. The interpersonal problem-solving training
is expected to significantly improve psychological and social functioning, and to reduce
repetition rates.
Results are currently being analysed, and preliminary outcomes are encouraging with
regard to attendance at problem-solving group training and satisfaction with treatment.
From analysis of baseline interviews of those randomised 64% had previously selfharmed, while the following mean scores were obtained: (Suicide Intent Scale mean 13;
Beck Depression Inventory mean 36.3; Hopelessness Scale mean 10.8). Only 32% felt
they could solve their main problem. IPSST clients attended 67% of sessions and were
more were satisfied with treatment (91% v 60%, p<0.001) compared with standard care
clients. Higher attendance and greater satisfaction with IPSST indicate that this treatment
approach is suitable for a high risk sub-group of DSH patients.
Carmel Mcauliffe1, Breda C. Mcleavey2, Paul Corcoran1, Bernie Carroll3, Brian O’ Keeffe3, Mary O’
Regan1, Eva Fitzgerald1, Louise Ryan3, Portia Hickey1, Ella Arensman1, Anthony P. Fitzgerald1
1
National Suicide Research Foundation, 1, Perrott Ave, College Rd, Cork, 2 HSE Southern Area, 3 HSE
Mid-Western Area
Chairperson: Sheila Dalton - Comments
This part of the conference had a poor attendance unfortunately. It provided some very
valuable research and information on what is happening on all fronts in the area of
suicide prevention.
Derek Chambers opened the session outlining the 12 point plan of Reach Out, the
National Strategy for Action on Suicide Prevention. Much work has been done in the
past year. It is heartening to hear of the liaising and development of professional,
statutory and voluntary bodies across all sections of society.
The networking of all involved in research to agree on a national research plan was good
to hear. Derek said that their aim is achievable and deliverable and an independent
evaluation of Phase 1 will be carried out in 2007.
Iain McGowan had prepared a paper, which, in his absence was read by Mark Owens
from Derry. This was a 20 year review of suicide among new mothers and pregnant
women in the UK. It was a statistical study and complemented an earlier paper presented
by Dr. Veronica O’Keane. It raises questions and issues. A multidisciplinary health
professional approach is vital in this area.
Martina O’Riordan presented her findings on the factors that influence suicidal behaviour
among those who have experienced institutional C.S.A. This was interesting in the light
of current media coverage. While the Redress Board makes financial settlements, further
counselling and survivor groups are needed.
The final paper was from Carmel McAuliffe. She compared the treatment satisfaction in
those who participated in combined group solving skills along with standard treatment.
There was a lesser degree of recurrent self-harm with those who participated in both. An
interesting aspect of this study which was carried out in Limerick and Cork was that
Limerick had a much higher degree of self-harm and repeated self-harm. It poses
questions!
It is not easy to remain focussed on research papers, but they are so important as they are
the basis for the future intervention and services. I would actively encourage people to
attend this session.
Bereavement Seminar
In Conjunction with
CONSOLE
MY STORY
NUALA WHELAN
Bereaved by Suicide
Abstract
Nuala lost her husband to suicide in July 1999, she was left with eight
children ranging in age 6 – 18. Her mission now is to tell the story of how
she coped and to give anybody themselves going through this horrific ordeal
hope for the future.
I actually found recounting my story quite a harrowing experience. However, if telling
my story helps another through a similar tragedy, then surely, it will have been
worthwhile.
My name is Nuala Whelan. When I was 38 years old my husband John committed
suicide. Today, I am a widow with eight lovely children, and as proud as punch of every
one of them. They are Emma 25, Derek, 24, Anne Marie 23, Siobhan 21, Brendan 20,
Eoin 17, Edwin 15 and Conor 13.
It was the 19th of July 1999, the day before my eldest daughter Emma’s 18th birthday.
My eldest son Derek was 17 just the day before. My husband John decided that he was
going to take the day off work in order to talk to a family member. John kissed me
goodbye and told me he loved me and the kids, like he always did. He left home with
Emma, as he was dropping her off at work on his way.
I did my usual mundane things about the house, went to work and came home at 3pm.
Naturally, I began to wonder where John was, as It wasn’t like him to be out of touch
with me for so long. I carried on getting dinner ready for the kids, but worrying in the
back of my mind as to where on earth he could be. We had two Chernobyl boys staying
with us at the time. So, when night-time came and all the children had gone to bed, I
waited up for John. I was angry at first, as he must have known that I would worry. It was
about 3am that morning when I started to cry and wonder - Had he been involved in an
accident? Was he in the hospital? All manner of strange and weird scenarios went
through my head.
As morning broke, I had to pull myself together as today was Emma’s 18th birthday. I
went through the day in two minds – Part of me was sick with worry on the inside and on
the outside, mammy was joining in with Emma’s birthday celebrations. The children
didn’t question where John was, as they were used to him working shifts. That evening,
Emma took my three small children, plus both the Russian boy to her boyfriend’s house.
Once they had left, I rang John’s sister to see if she had seen John and explained that he
had been missing now for 36 hours. We decided to check out John’s old home, which had
been lying idle for two years since being sold. John would check the house regularly.
Helen and her husband Michael picked me up from home. When we arrived at the house
I saw John’s car. I went from relief to annoyed in a matter of seconds. Strange to say it
now, but I was going to kill him for the worry he had caused me. I passed the shed and
saw an old bucket wedged in the door. Anxious and curious, I went with Helen to push
open the door. A man shouted at us and in shock, I grabbed Helen thinking we had been
caught trespassing or something. Sadly, that wasn’t it at all. John had been found by his
brother in law Bobby, just minutes earlier and before he ran to get help, he had sent a
neighbor to look out for me. It was the neighbor that shouted at me. That was the moment
my world just fell apart! John had hung himself inside the shed! I stood outside and
cried openly. Then it dawned on me - The Children!!!! I started to panic……. “Get me
home to the children”. My head was spinning and my thoughts went into overdrive.
How on earth do I tell them? What do I say? How the hell, do I break something like
this to them? I rang my sister Susan, telling her what had happened and asked her to tell
the five older children. We agreed that I would tell the three younger ones when I got
home. That I did. I told them that Daddy had chosen to go to heaven.
After consoling the children and finally getting them off to bed, my whole family; i.e.
mother, father, sisters, brothers, partners, nieces and nephews arrived. The house was
bursting at the seams with people. In the middle of all of this, I looked at the dresser and
saw Emma and Derek’s birthday cards and could not believe that John had done this on
such a happy time in his children’s lives. I felt as though I was living in some awful
nightmare. A nightmare from which I could not wake!
My sister Susan, my brother Ciaran and five of Susan’s children stayed to support the
children and myself. At around 4am I broke down, questioning everything about John…..
my life, our lives, the lives that we had built around the children - I questioned
everything. I just could not understand why? I still can’t. It was shortly afterwards that I
decided within myself that I had to be strong, whether I liked it or not. I kept reminding
myself, that these good children had lost their daddy, (whom they idolised). I was
damned sure that they were not going to lose their mother to insanity as well! This was
not such an easy step to take so soon after something so harsh has been forced upon you.
I had to face some more facts though….. Now that John was gone, I was no longer a
wife. I was no longer my partners best friend, or part of a unit in what I thought was a
marriage with sound foundations. Moreover, I had to quickly accept that I was now a
widow and the only person the children could realistically look to for reassurance at this
time. I never touched a drink or took a tablet during this time, as I was afraid I would
become dependant on them or they would cloud my judgement. I had to be fully aware of
everything around me if we were to pull through this tragedy. And I was determined that
we would do just that!
No matter how difficult the subject matter, we always held family meetings with the
children. We still do now, but not as often. However, the meeting we held the day after
John was found, had to be the hardest family meeting we had ever held. It was here that I
handed the funeral arrangements over to the children and asked them to “just do it with
dignity and respect”. I can proudly say, that that is exactly what they did. They all had
their parts to play in the funeral. The children were fantastic. To this day though, I can’t
help but wonder why John couldn’t also see, how great our children were. It is something
that will always baffle me!
The amount of neighbors, family and friends that called to offer condolences was huge.
Day and night, night and day they came. Finally though, on Thursday night, Susan
persuaded me to go to bed, as I hadn’t slept since the Sunday. I had put off going to bed,
as I knew that when I woke up, I really would have to face the fact that John was dead. I
was too exhausted to object now though.
Ironically, the funeral was held in the same church that we were so happily married in
some nineteen years earlier. All our babies were christened in the same church. Joyous
occasions all of them. The church held over a thousand people and was packed inside and
out, far into the car park. I looked at all those people and wondered if John really knew
just how much he was loved. Normally, one can take stock of their life once the funeral is
over. When the death has been one of suicide though, it is completely different. An
inquest has to be held and of course, your life is on hold until that happens. One can only
wait.
Three months later, I decided to seek emotional help for the children. This is when I
found out about Sr. Sheila and her suicide support in Bray. The three girls and myself
went to the first meeting. I told them I didn’t know what to expect but we had to give it a
try. Emma and Siobhain never went back but Anne-Marie found comfort there. Derek
joined us later. The three younger children went to Rainbows, which was great for them.
I had told them at the time, that Daddy had killed himself. I hadn’t told them that he had
hung himself. Edwin asked how his daddy had died but I hadn’t the strength to tell him
then. I told him that the inquest hadn’t been held but once that was over, I would be in a
position to tell him. It also gave me time to put that uncomfortable matter on hold until he
was at least a little older.
The first Christmas came without John, but we still celebrated and for the sake of the
three little ones and as they still believed in Santa. We still had our Christmas dinner.
January arrived, and a brand new millennium followed, it was to be the start of a whole
new way of life for me. It was also the advent of the inquest into John’s death. The
inquest was hugely important to me, as the bank was looking for several mortgage
payments, and the insurance company wouldn’t pay out until I had an official death
certificate. The inquest was held on the 23rd January - the day before my wedding
anniversary. It was a horrible experience, but it had to be done in order for me to at least
start to get my life back on track.
With the inquest finally out of the way, I embarked upon a mission of teaching my
children how to laugh again. I started with a family meeting and I asked them all to give
me a bucket of laughter for every tear they had shed. Eventually, we planned John’s 1st
anniversary. Most people thought I was mad as I took the kids to Butlin’s for the day and
then visited John’s grave the same evening. All in all, the day was one of good heart. It
was a good day, on a bad date.
As a family unit, we had to cope without John at the head of our huge and happy family.
We had to cope with the fact that he had killed himself and left us to fend for ourselves.
Bringing up eight children on my own really was an uphill struggle, and at times I was
fraught with despair, but we all soldiered on and battled through those hard times.
Seven years on and I can honestly say that my children have done both themselves and
me proud. Sure, we had our bad times, but they were over-shadowed by the good times
that we carved out for ourselves.
Emma has a diploma in interior design and has a lovely home with her fiancée Dale. She
is planning on getting married on her daddy‘s birthday. Derek has a first-class honors
degree in computers science, is working in the financial centre in Canary Wharf and has
just bought his first home in London. Anne-Marie achieved a first class honors degree in
Law and is now a barrister. Siobhain is a qualified nurse and works in St Vincent’s
hospital in Dublin. Brendan has recently qualified as an architect and works for the
National Building Agency. Eoin has just passed his leaving certificate and is doing a
course in interior design. Edwin is got his stupid junior certificate results as that’s what
we listened to from him doing the exams and Conor is doing his junior cert even though
he is 13 , as he is a sponge for knowledge. And me? Well, what mother wouldn’t be
happy to see her whole family pull through hell on earth, with such flying colours?
As you can see it has been a long road for us but we struggled through. That’s why I want
people in the same circumstances to understand that you can live again after suicide. It is
the learning that is the hard bit. Talking is important, as it helps to get out all the whys
and learn to leave that big “why did he or she do it” with the person who died.
Thank you for listening and I would wish that if even one person could find hope in my
story then that’s my job done
Ms. Nuala Whelan, 1, Farrenboley Cottages, Windy Arbour, Dublin 14
GOOD PRACTICE IN THE CORONERS COURT
JOHN O’DWYER
Coroner for South Mayo
Abstract
In this talk the role of the coroner in Ireland will be discussed. It will outline
the importance and indeed the necessity of investigating deaths due to
external causes such as accidents, suicides and homicides. The public interest
is best served by public and open inquiry to establish the facts, to establish
the truth and thereby to allay rumour and misrepresentation which can be so
hurtful particularly to those bereaved through suicide. Aware that practices
differ from coroner to coroner the personal approach to inquests is outlined.
The importance of explaining to the relatives of the bereaved what the
proceedings are and what to expect on the day is expressed. The importance
of care not to add to the grief and pain of the family and the need for proper
support services are available to the bereaved is also stressed.
1.
The Coroner is the Legal Officer charged with responsibility for investigating
sudden, unexplained or unnatural deaths.
2.
A Coroner may be a Solicitor, Barrister or General Practitioner. At the present
time there are 40 Coroners in the Republic of Ireland and the numbers are almost
equal between Lawyers and Medical Practitioners.
3.
A Coroner is subject to the general supervision of the Minister for Justice.
He/She enjoys operational independence similar to that of a High Court Judge.
The Coroner is solely responsible under law for the discharge of his/her duties in
any decisions made by him/her in the course of his/her duties.
4.
The accurate certification of the Cause of Death is the most important function of
the Coroner. I suggest it reflects the recognition of civilised communities of the
need for an independent and open investigation of unexplained and unnatural
deaths, free from political interference or control from any outside body.
5.
The Supreme Court has previously decided the number of public interest duties of
a Coroner in holding Inquests and they are as follows:a)
b)
c)
d)
e)
6.
To determine the medical cause of death
To allay rumours or suspicions
To draw attention to the existence of circumstances of which if
unremedied might lead to further deaths
To advance medical knowledge
To preserve the legal interests of a deceased family, heirs, or other
interested parties.
The Coroner system puts its emphasis on investigating the relatively wide range
of unexplained deaths and reflects the essential value placed on life itself. No
death should be left uninvestigated unless there is a clear and certifyable reason
for that death. The Coroner honours the dignity of human life by the proper
investigation of the cause of the ending of life. The Coroner Service is
independent of the medical profession, the Garda Siochana and all other State
Agencies or any parties who may have an interest in the outcome of the death
investigation. The Coroners’ Service assures society that there is an independent
process of a public hearing which can establish that nothing unlawful has taken
place. At the present time the Coroners’ Service operates under the Coroners’
Act, 1962. This is subject to review and Coroners are awaiting new legislation
which has been promised for many years. There have been some interim changes
made dealing primarily with the question of compellability of witnesses to attend
an Inquest. Witnesses who are in a position to give evidence which might assist
the Coroner in establishing the facts surrounding a death can now be compelled to
attend an Inquest. There is also a proposal by the Department of Justice to abolish
Coroners in each County and replace them with fewer regional ones. This is the
position in Northern Ireland where there are 3 Coroners covering the entire North
of Ireland. This is unlikely to happen in the near future unless the Department of
Finance decide to buy out the Contracts of Coroners who are entitled to remain in
their appointments until the age of 70. At the present time no new Coroners are
being appointed and of the total number of Coroners operating at the present time,
about half of these are in an acting capacity having been a Deputy Coroner to a
Coroner who either retired on age grounds or who died.
7.
The purpose of an Inquest is to establish the identity of a deceased person and
how, when and where the death occurred.
8.
All sudden, unexplained, violent or unnatural deaths must, by law, be reported to
a Coroner. Examples of these include:Where a Medical Practitioner cannot sign a Medical Certificate as to the cause of
death;
Where the deceased had not been attended by a Registered Medical Practitioner
for a documented illness,
sudden infant death,
road traffic accidents;
accidents in the home, workplace or elsewhere;
any physical injuries;
falls and fractures, fractures in the elderly;
drug overdose or drug abuse;
neglect including self-neglect;
burns or carbon monoxide poisoning;
poisoning from any cause either occupational or therapeutic or accidental;
drowning;
hanging;
firearms injuries;
deaths resulting from industrial disease or accident;
deaths which are directly or indirectly the result of any surgical and/or medical
treatment or procedure;
where there is an allegation of medical negligence;
misconduct or malpractice on the part of a registered Medical Practitioner or
Nurse;
septicaemia which may have been caused by injury;
death occurring during a surgical operation or anaesthesia;
acute alcohol poisoning;
deaths connected with crime or suspected crime;
deaths due to homicide or occurring under suspicious circumstances;
deaths of prisoners or those in legal custody in a Garda Station;
death of a patient in a Mental Hospital;
death of a child in care;
death due to CJD;
where a person is found dead or where human remains are found;
death occurring in an Accident or Emergency Department of a Hospital;
deaths occurring within 24 hours of admission to hospital;
deaths associated with childbirth;
where a patient dies in hospital having been recently discharged from hospital or
discharged from a Nursing Home or other Residential Institution including a
Mental Hospital or a Prison or in any other case where there is any doubt as to the
cause of death.
You will see that there is a wide range of deaths which are reportable to a
Coroner. No Doctor may certify a cause of death which is due directly or
indirectly to any unnatural cause. The Coroner’s enquiry is concerned with
establishing whether or not the death was due to natural or unnatural causes.
9.
A death involving self-destruction or suicide is automatically reportable to the
Coroner. A Medical Practitioner cannot certify the cause of death in such a case.
The legal requirements make it quite clear that where a Medical Certificate as to
the Cause of Death is not available, the Coroner must cause inquiry to be made to
establish the cause of death by directing a Post-Mortem examination to establish
the definitive cause of death. A Pathologist’s Report following the Autopsy on a
deceased person will disclose the cause of death which will clearly establish
whether or not the death was due to violence or occurred in a natural manner and
if it is the finding of the Pathologist that death was due to unnatural or violent
means, then the Coroner is legally obliged to hold an Inquest in to such death.
10.
The Coroner then directs that the Garda Siochana who act as Coroners’ Officers
to take appropriate statements from all the relevant witnesses and furnish a file to
the Coroner who then decides within the limitations of the Coroner’s Act, what
witnesses are required and fix a date for the holding of a formal Inquest in to the
death of a deceased person.
11.
The Coroners’ Act is limited to establishing the identity of the deceased person
and as to how, when and where the death occurred. An Inquest cannot deal with
issues of civil or criminal responsibility. In fact there is a specific prohibition in
the 1962 Coroner’s Act to prevent this occurring.
12.
The arrival of the Gardai at a home can and does cause a lot of anxiety to a family
at a time of tragedy especially in the case of suicide. However in almost 30 years
as a Coroner I have found that members of the Garda Siochana have shown
themselves at their professional best in such circumstances. The gardai use tact
and discretion in dealing with such matters and in many cases they have asked me
to post pone Inquests in suicide cases where they have brought to my attention
that members of the family are not able to cope with an Inquest at a particular
time. If the family contact me I will also facilitate them.
13.
The social stigma of suicide has diminished but still exists. This is not necessarily
an unhealthy thing for Society. Society must retain some of its taboos to survive.
Suicide is a taboo subject in western cultures especially within the Christian way
of life and this is still quite real. There was a time when the Church would refuse
to allow persons whose deaths resulted from suicide to be buried in consecrated
grounds. That unilateral policy by Catholic clergy in particular caused untold
grief to the bereaved.
14.
All of those who deal with Suicide including the Coroner should fully and
fearlessly enquire in to the cause of death to establish the truth. If the truth is that
it was a death by suicide then this should be reflected in bringing in a suicide
verdict. I suggest that the bereaved cannot begin to grieve properly until they face
the truth and it is only then that they begin a process of acceptance and healing.
15.
Whilst dealing with suicide is emotionally difficult for the family, it is also
difficult for the Gardai who have to deal with it as well as the Coroner and others
who have to interact with the bereaved.
16.
I believe that there is a social value of an Inquest. Some family members go into
denial and these cases are sometimes the most difficult for a Coroner to deal with.
A person in denial may tend to latch on to every rumour or suspicion that flies
around the District pending the completion of an Inquest in to the death. Human
nature being what it is, sometimes the family members may be the object of
malicious gossip which generally is unfounded.
17.
The Inquest which is held in public provides society with a forum to raise
questions concerning the death.
18.
At an Inquest there is a right of an aggrieved relative to voice a complaint
publicly which I believe is valuable. It might be described as a safety valve
because some grievances once expressed publicly do not survive examination in
an open forum like an Inquest when faced with the facts.
19.
It is important to realise that an Inquest is unlike a civil or criminal trial. People
will have seen and heard reports of court cases but they have no idea of what
happens at an Inquest. It is a policy of mine to outline to people at the
commencement of the Inquest why they are there, inform them of what is going to
happen and what the Inquest will hope to achieve. It can be a great comfort for
people to be present at deaths but in the case of suicides in particular, there is no
opportunity to say goodbye and in many instances family members may be totally
unaware that a loved one is so troubled as to take their own life. Many relatives
come to an Inquest with expectations at finding answers which regretfully they
will not because of the limited powers of an Inquest in death investigation.
20.
An Inquest is a fact finding exercise and it is not a method of apportioning guilt.
The procedure and rules of evidence as applied in Civil or Criminal Courts are
unsuitable at an Inquest. In an Inquest it should never be forgotten that there are
no parties, there is no indictment, there is no prosecution, no Defence and there is
nobody on trial. It is simply an attempt to establish the facts and the truth about a
death of a loved one.
21.
Suicide inquests are held without a Jury. It is my policy to leave self-inflicted
deaths to the end of the List of Inquests and to try and deal with them in a
sensitive way. I usually hold such Inquests around a table where everybody sits at
the same level as opposed to the more formal Court setting. I have to say that I
did not always deal with Inquests in this way but as a Coroner now for almost 30
years I have to acknowledge that I have changed in the way that I deal with
Inquests, particularly when I see, in many cases, the agony in front of me. It is
impossible not to be affected by the grief that one sees. The following people are
present at an Inquest:- the Superintendent of the Garda Siochana who presents the
evidence, the Gardai who conducted the Investigation, members of the family or
non-family members who have made Statements and the Pathologist.
22.
Each person giving evidence is sworn. The Statements are read out to an Inquest
by the Superintendent. Each Witness is then asked to confirm the contents of the
Statement as being true and accurate and they are invited to sign the Statement.
This Statement becomes their Deposition to the Inquest. There will be a Witness,
possibly a family member who gives evidence of identification. The final witness
is the Pathologist who gives evidence of the cause of death. If there is alcohol
involved, he is in a position to confirm what the alcohol level is. I should say to
you in general terms that in many cases of suicide there is a high level of alcohol
in the blood when analysed post-mortem. Anybody with an alcohol reading of
over 80mgs% is over the legal alcohol driving limit in Ireland. It is not unusual
to have results of between 300mgs % and 450mgs% in Post Mortems. Many
people who take their own lives consume large volumes of alcohol prior to doing
so.
23.
When all the evidence is completed I then have a discussion with the next-of-kin
as to what type of verdicts they believe I should record. I have found it valuable
to the next-of-kin to be involved in this process. I outline to them what I see from
the facts as contained in the Statements which have just been read to the Inquest
which lead me to form a certain view that this may well be a suicide death. I
invite them to tell me why I should not hold this view and I give them an
opportunity of trying to defend the deceased. This exchange of views takes place
for a little while and very often the family themselves will come round to accept
that what actually happened to the deceased was in fact suicide. I believe that this
exchange with the next-of-kin is helpful to the family to acknowledge in effect the
type of death of the deceased.
24.
I should say that the degree of proof required to reach a suicide verdict is the
criminal degree of proof, that is beyond all reasonable doubt. It is not the civil
degree of proof which is on the balance of probabilities. If, for instance, there is
a suicide note or previous threats from the deceased or in the case of drowning if
the deceased had removed their clothes before entering the water, folding them
neatly, this could be regarded as evidence of an intention to commit suicide.
Psychiatrists take the view that behaving in this fashion is indicative of an
intention to take one’s life. On the other hand if somebody is found drowned and
there is no contemporaneous evidence that there was an intention to take a life
then in fairness to the deceased, I would record an open verdict because I would
not have sufficient evidence to establish a verdict one way or the other. An open
verdict is generally recorded where there is not a chain of evidence up to the time
that a body has been found. Dr. John Connolly, Consultant Psychiatrist when
employed by the Western Health Board undertook a review of all of the Coroners
files in County Mayo to see whether or not there were cases which might not on
paper be seen to be on the face of it suicide but on further examination would be
sufficient to allow the medical people to reach a conclusion that the death was by
suicide. For example there have been a number of road traffic accident cases in
my area when the question of a suicide clearly has been on my mind but there is
insufficient evidence to reach that conclusion. In one case that comes to mind, a
man had a row with his wife. He left the house telling her he intended to kill
himself. He drove his car and met an oncoming truck and for no apparent reason
the car simply swerved in to the path of the truck and as a result he died. When
the driver of the truck went to the car immediately after the impact he found that
the deceased had pulled his t-shirt over his head before he swerved in to the path
of the truck. Some people might conclude that this was an intention to commit
suicide but from using the yardstick of beyond all reasonable doubt, I could not
and did not reach a verdict of suicide in that particular case.
25.
After engaging with a deceased’s family in coming to a conclusion as to what the
appropriate Verdict is, bearing in mind that I would err on the side of caution for
the sake of the family, I then suggest to the family that I believe that they should
not assume a cloak of guilt for what has occurred. Many people say that if they
had known that the deceased was unwell or unhappy they might have kept a better
eye on them or gone to visit them more often or be more attentive to the deceased
during their lifetime. This I believe is unfair to the relatives themselves and I do
not believe that they are responsible for the life of another adult.
I know many people who are watching a relative all the time. They are on edge
knowing that a person has threatened to take their own life or that there is a
suspicion or anxiety that such an incident could take place. This can and does
cause great stress to a family who are living with a potential nightmare that may
become a reality at any time and over which they have no control.
26.
If somebody is determined enough to take their life then they will do it at a time
when nobody is around.
27.
Having spoken to bereaved families they feel that an Inquest brings closure after
the death of a loved one. They can get a Death Certificate and deal with the
affairs of the deceased and try and move on.
28.
The title of this paper is “Good Practice at the Coroner’s Court”.
29.
Coroners as a group are effectively independent republics. There are no set
guidelines laid down as to how to conduct an Inquest. It may well be suggested
that some Coroners are cold or clinical but I would have to say that the more I do
this work the more I see the need for a caring role for the sake of the family to
help them come through it. I speak to family members on the telephone on a
regular basis. Sometimes they are afraid of certain matters about the deceased
coming out in public. If there are notes left then these are read by me and handed
to the investigating guard. A note of intention to take one’s life generally
contains matters of a personal nature for the family or seeking forgiveness for
what they are about to do or in some cases giving reasons why they are doing it
and blaming somebody. In a recent case I had there was a very detailed letter
written by a man clearly in great distress where he blamed his father for having
mistreated him all of his life to such an extent that he felt like a leper within the
family. He was not allowed to live in the family home. He was made live in a
mobile home. I made the deceased’s brothers and sisters aware of this fact in
advance of the Inquest and left it to their own discretion whether or not they
would inform their father who was in his 80’s. The father was the one who was
being blamed and there was a general acceptance by the family members that
what was contained in the note was true and accurate.
Some families wish to obtain possession of such a note. Generally I request the
Gardai to supply me with a copy only. The attitude of the Garda Siochana is that
they retain the original note as they believe they should. There have been
occasions where people have suggested that a suicide was not in fact a suicide but
rather a murder and there is always the possibility that the Gardai might find
further evidence at some state to re-open a case, hence the reason for retaining the
original note. Certain difficulties have also arisen recently in relation to getting
copies of notes particularly where spouses may have been estranged and suddenly
the estranged spouse comes back and wants to reclaim the deceased. This can and
does cause difficulties. In one situation a man was asked by his wife to leave
home. She wanted a separation from him. He left, went out to a tree in the
garden and hanged himself. He left a note and his wife who had an exceptional
sense of guilt for what occurred wanted the note. The Gardai did not make this
available to her. She was however supplied with a copy of the note.
30.
Unfortunately modern technology has now delivered a new way of sending a
chilling message and that is either by text message or by voicemail. This is
becoming a common way of advising family or friends of an intention to take
one’s life.
31.
The public nature of an Inquest also serves the public well by highlighting the
increase in suicides or self-destruction cases in recent years. A substantial
minority of deaths reported to Coroners may be ascribed to social breakdown in
one form or another. Inquests and the accurate certification of a cause of death
are an important social function which show social trends such as an increase in
suicides which challenges the State and State bodies to investigate the underlying
causes and to establish a social programme designed to reduce its incidence.
There was a family where 3 sons have committed suicide. Such families feel very
isolated even within their own community. Many people shun them because they
seem to be “different”. They approached a local GP for help. To date the HSE
have not given any assistance. The question I ask in these situations is can or
should society intervene or offer support to these people or are we too busy in our
own lives to think of our neighbour ?
32.
The question of why people kill themselves is a matter for Society to deal with. I
believe that we may have become too affluent, too busy and have less time for
human contact resulting in vulnerable people feeling isolated.
33.
As to the media and publication of Inquests, I have spoken from time to time to
the Reporters who cover my Inquests. I have asked them what their views are.
There are some of these who take the view that having them reported is an
intrusion in to people’s lives. Listening to the death notices in the local radio
station, the word “tragically” is commonly used. Anybody listening to this clearly
knows that somebody has taken their life so the cause of death becomes generally
known to the listener. One of the arguments used for not reporting suicides is the
risk of copy-cat deaths occurring. Having examined the suicides that I have dealt
with over past years, no where can it be suggested that there has been any copycat
death. There are those who suggest that people who are considering taking their
lives take courage when they hear that somebody has successfully done so. The
data of suicides I have does not support this argument.
34.
The other commonly held belief is that suicide is generally of young people. In
the total number of suicide cases I have had over the past 2 years only in 2 cases
out of 29 was a person below the age of 30. Of the 29 persons 7 were female and
22 male. The average age of the 29 persons was 47 years with the youngest 25
and the oldest 73 years. Certainly there is a common feature of the single male,
generally living alone, sad, with no one to talk to, feeling isolated from friends
and relatives and feeling that life has neglected them. Of more recent times I have
had a number of suicides of married women in their 50’s.
35.
I would ask this question as to whether or not we are grown up enough in society
to deal with unpalatable matters in our lives. We have had full disclosure of sex
abuse cases, paedophilia and other high profile matters which the public appear to
have been able to take in their stride so why not the reporting of suicides in a
plain factual non-judgemental manner ?
36.
Having read the final Report of the National Task Force in January, 1998 on
suicides there was a recommendation that the Media in general and journalists in
particular would establish a code of good practice applicable to reporting matters
relating to suicide and that the headline writers, editors, sub-editors and
newspaper photographers follow the same stringent code as journalists writing
particular articles.
37.
It suggested that “the reporting of individual suicides be limited to particular cases
where it is thought to be in the public interests to do so, so a Coroner may decide
to address the press in this regard but the report should not include specific details
as to the mode of death and nothing should be written or said that might
encourage others to end their lives.”
38.
I do not, as a Coroner, comment on any death before me. I am conscious that the
family are already grieving enough and it is not for me to judge a person who has
died or the circumstances in which they have died, whether it is a suicide or some
other violent or unnatural death. I do not believe it is a task of a Coroner to add to
the grief of the family by commenting.
39. I believe that following an Inquest that adequate support services should be
available to those who wish to avail of them, be there but not be intrusive.
Many people who have gone to support groups or have listened to other
persons who have been through the same experience find comfort and support
in dealing with their loss of a loved one. It has been my experience that
nothing can prepare a family for the loss of a loved one in such a manner, no
matter whether expected or not.
John T. O’Dwyer, Coroner, Mayo South, Ballyhaunis, County Mayo .
Chairperson: Joan Freeman – Comments
This session involved two speakers who witnessed the impact and trauma of suicide form
two different perspectives.
Firstly we heard from Nuala Whelan a mother of eight children who was devastated by
the suicide of her husband, John. What was most obvious listening to Nuala was her
innate wisdom and her selfless concern for her children. She handled that awful question
“why” by barring it from the house for six months. This gave her children and herself the
space to allow the acceptance of the loss to sink in. Nuala also supplied us with a
strategy of coping with and managing those first milestones. The first anniversary was
spent as a family going to Butlin’s. This was a true celebration of life and by spending a
fun day on their father’s anniversary also included him on the family outing.
The second perspective of suicide was a talk given by John O’Dwyer. He spoke about
how an inquest is a “fact finding exercise” which of course makes it cold clinical and
very public. John O’Dwyer recognised the level of upset and distress experienced by
people who are bereaved by suicide and how he created a system that involved the family
in a more private and compassionate setting.
Both of these speakers, through personal wisdom and experience provided us with
personal strategies and structures that could be implemented on a professional level
without losing any compassion for the people involved
‘WELCOME TO MY WORLD’
CAROLINE MCGUIGAN
Founder, Suicide or Survive
Abstract
Caroline invites the audience into her world. A world which moves in and
out of the complexity of being “human”, of being “real” and the struggle and
hardship this can have on an individual. So much so, she herself attempted
suicide. She shares what brought her to this point and how after her
attempted suicide, she worked on rebuilding her life. She shares what her
world is like today and how she now lives on a daily basis being “human”
and “real”. Caroline also shares with the audience the “Eden Programme”.
How the project was identified, its aims and activities and when it will
commence. Caroline shares her overall experience of suffering with panic
attacks, being a user of the psychiatric services, attempting suicide, training to
be a therapist and being the founder of Suicide or Survive.
Talk, talk, talk, that’s what I remember. Constant talking, constant chattering. Non stop,
day in, day out. Wakening in the morning thinking, thinking, thinking. So tired, so
weary. Who will I meet today? What will I say? How will I get the hell away from
them? Oh God what excuses can I come up with today. I fell the pain coming on, I fell
the lump in my throat, the tears in my eyes and the pit in my stomach. Take a pill, that
will help for an hour or two. Take two pills, sure that will give me the morning. Take
them all – NO NEVER – or maybe – NO- maybe – NO – June the 13th 1995.
Hello, I would like to introduce myself, my name is Caroline McGuigan. I am married
and have two great children. On a daily basis I question my abilities as a parent, I worry
about how I am bringing my children up and yet, this is the only way I know. In my life
today I am comfortable to share the many parts of myself. The kindness, the
genuineness, the passion, the experiences, the expertise, the humour but also the
hardness, the anger, the dismissive parts of myself.
At a time in my life I was ashamed, embarrassed and uncomfortable to be “me”, as I
feared what other people may think of me. My greatest fear was “if they really knew
me”. So I became Caroline, who truly worked hard at being liked, entertaining others,
believing that “these people knew what they were talking about” and I started to become
a shell. Why did I feel this way? Why did I believe this? LIFE. My life experiences
had allowed “my story” to unfold.
I now realise every individual’s life is complex and it will be a combination of life
experiences, the impact they may have on the individual and their copying mechanisms
which will have a huge part to play in how life effects them.
How and what brought me to be here today, sharing my experience of attempted suicide.
Determination, passion, anger, frustration, a drive that I wonder where it came from,
people I have met along the way and situations I have experience and at times something
that is more than all of this – what that is I am not sure, but I know I sense it.
I was diagnosed with an anxiety disorder or “panic attacks”. What was actually
happening was I felt I was going crazy? I believed something awful was going to happen
in front of everyone and I would have not control. I started to avoid people and places
and loss my belief in myself, my self-esteem was slowly falling and my anxiety was
quickly rising.
At the time I did not know what panic attacks were and thought this was something
happening outside of me.
I was introduced to medication, again I did not know anything about medication, the
effect it would have on me and the road of addiction that lay ahead.
The supports that were offered to me were psychiatric. I resisted at first because I
believed that only “crazy” people went there. By the time I got there “I” believed I was
crazy. I was on 16 tablets a day, full of anxiety and terrified.
So now I carried the “stigma” of being in a psychiatric ward so my self-esteem was rock
bottom. I did not know what was happening to me. I knew if I took tablets I could
function, so I did – 16 a day, every day.
I met a lot of wonderful, kind and scared people, this describes both the staff and the
clients (I use the word client, in the services you are a patient). I still believed that “panic
attacks” were something going on outside of me so I was waiting to be fixed. In the
hospital we had a community room which we sat in for most of the day. My smoking
trebled.
There was a number of very helpful people who truly cared but time was not on their
side. There was also a number of very controlling, unfriendly people who believed they
were the expert and knew what was best for me. I now realise it was not about me, it was
their own insecurities they were fighting with.
I started to become a part of this world, which kept me safe from outside and gave me my
medication. I also became dependent on this world. I fitted in, I did not feel excluded,
different or “crazy”. But outside of the hospital, the staff, the clients, I could barely
function. Outside of this world I lied, I avoided people and situations. My world was
becoming smaller and smaller. Over time I lost my job, friendships, my self-worth.
I remember once a person saying to a friend of mine, “do you feel safe letting Caroline
mind your baby, after all she has those Panic Attacks”.
I cried and cried and cried.
I started to realise people genuinely did not understand when someone was mentally
unwell and for a lot of people it frightened the living day lights out of them. But this
made it worse for me.
So my journey continued – panic attacks, medication, psychiatric services, avoidance, not
belonging.
Over time I started to see the world I was in (psychiatric) and did not want it yet did not
know how to get out of it. At the time I was able to get to the hospital and back, go
certain places if I had someone with me. If I drank I could stay out longer but a couple of
times I mixed the booze with the drugs, which was a disaster. But I started to become
dependant on booze. I was crumbling. WHY, because I was starting to loose hope. The
services I was attached to had nothing else to offer, I did not know where to turn. I did
know I didn’t fit in anymore. I know I felt great sadness, extreme pain and aloneness.
Even though I had people supporting me I felt so alone. Through everything I looked the
same on the outside but inside my heart was breaking.
At no time was I offered counselling or invited to explore the idea of counselling.
The thoughts started. At first I was shocked and quickly started to think about something
else. But the thoughts came back. I was exhausted, I felt permanently guilty of the
“burden” I had become to others. All I wanted was a minute, an hour, a day where my
head would switch off, where I got a break, where my day did not start with……
“God here we go again. Get through this day without having a panic attack, within
feeling scared all day long, without making excuses, without lying, without depending on
others”.
The thoughts, the thoughts……
Take a pill, take two, take them all.
Quietness, just a little bit of quietness.
The night I attempted suicide I had had a great time. I had enjoyed a bbq with friends
and had smiled. I had had drink, which made it easier. So why that night? I just did not
want to wake up to those thoughts again. I was so so tired, so weary and just did not
know what to do – I felt a failure.
After that it become a haze – hospital/blackness/bringing me back/not
breathing/gone/back
I remember when I woke up and I was surrounded by elderly people who were unwell. A
nurse came up to my bed, not much older than I was and said “that was a really silly thing
to do, look around you at all these people fighting for life and there is you trying to end
yours. I lied in the bed curled up like a foetus. I looked at the locker, all my medication
had been left there. I cried and cried and cried. People came, people went. The shock on
their face the uncomfortableness of what I had done and the avoidance of talking about
my attempted suicide. I was thinking, “I couldn’t even get that right”
Over the days that followed the impact of what I had done started to hit me. My world
was still a mess but I felt different. I had survived a suicide attempt and was alive. I
started to think, “well why am alive, do I want to be alive, yes I do but how the hell do I
rebuild my life”? So without me knowing the part of me that was a survivor, that strove
to live and change, was coming alive.
At the time I was given an option of being signed in, which I refused or going back to the
hospital I attended as a day patient 5 days a week. Also, lucky for me, a Therapist was
made available for me to work with. I spent 3 days a week for the next year to year and a
half talking. Talking, talking talking. It was hard, it was painful. I thought this is a load
of crap, all this is doing is going around in circles but I kept going. I cried, I laughed, I
became angry, I STARTED TO UNDERSTAND. My anxiety was still in full swing. I
joined a support group to help me with the day to day practical issues of living with an
anxiety disorder. All of this was so so hard and I wanted to on numerous of occasion’s
walk away. Why didn’t I – I was started to change. I was started to feel there was hope,
small as it was, it was there. I was still pumping the medication into me but decided with
the support of the hospital over a long period of time to come off it but only because I
now had access to therapy and a support group to help me with my panic attacks.
My recovery is a whole story in itself. It had its good times and it had its bad times. The
biggest question and the scariest question throughout was WHO AM I. You see in my
“madness” I had a sense of security, I knew I was all over the place and I had somewhere
to go. Now I had to figure out who I was, what had brought me to the different
experiences in my life and the big one I had to take responsibility for my own recovery
and my own quality of life.
So what and who was I. What I started to notice was how I was treated in the services
and how others were treated. I started to listen to myself and to others. I started to hear
what people were craving for – warmth, understanding, kindness and empathy, not
sympathy. The services provided some of this but in general they did not have the time
and also did not believe a person, given the right environment, could explore what their
needs were. It was very much “we know what is best for you”.
Through my recovery I realised that to share my experience and for people to listen, I
would need to become a “professional” myself. So I started the journey of becoming a
therapist. This took me six years. Throughout these years I continued to work on my
own development and started to see/understand why and how my medication and
treatment had been decided. I wasn’t always happy when I realised some of the reasons
for my treatment/medication. But the big thing that stuck out for me was that throughout
my journey, it wasn’t the theory/treatment it was some of the people whom I met that
made a difference. Qualified and insightful people, who could see that I was more than a
label from the DSM book and allowed me to participate in my own recovery. What these
people had in common was that I experienced warmth, genuineness, honesty and
compassion from them and towards me.
So SOS started to form in my head. What would it be like to offer an individual a group
where they would experience warmth, genuineness, respect and structure. What would it
be like if people were educated on depression, anxiety, the psychiatric services,
medication etc. What would it be like if people were given the opportunity to work on
their life skills, What would it be like if people were allowed to explore and reflect on
the impact life was having on them, particularly when their thoughts were moving
towards suicide. What would it be like if all of this was offered to an individual in a
group setting? Not for 15 minutes a week, not for a couple of weeks but for a period of
time that would allow them to pause and reflect and see if they were ready to start to take
responsibility in their own recovery.
I spoke to a lot of friends and colleagues. Everyone believing this environment was
essential for an individuals development, some wanting to be involved. So Suicide or
Survive was established.
Suicide or Survive will be running its first programme, the “Eden Programme” within the
next couple of months. We as an organisation fund raise on an ongoing basis. We learn
through our individual experiences and as a group. We are open and transparent. We do
not believe our way is the one and only way but we do believe that it is an option for a
person.
A tremendous amount of work goes on behind the scenes all being carried out by very
passionate, strong and determined people.
What have I learned. You need to be ballsey, persistent, determined, passionate and have
a tough skin. Why? Because our Country is only starting to recognise that the revolving
psychiatric door is not always the way for everyone but is still cautious/fearful of the
other options available.
Fear was what brought me down. Now I realise if I stop, listen, be compassionate to
myself and others, I can respond rather than always reacting.
I remember once saying to a very wise lady “I met some really special people along the
way who truly made a difference”. She replied “I am sure you did but Caroline we are all
special”.
I have learned I am made up of many parts and my biggest gift to myself is to try
somehow to allow compassion into my life so I don’t continuously judge myself. If I can
do this for myself I can then do this for others.
I would like to read a piece by a very beautiful young woman who is 17 years of age and
is called Hannah Tatschl.
PIECE
I would like to offer a gift to everyone here today. It’s a piece that stays with me every
day.
PIECE
Thank you for listening to my story.
E-mail: carolinemcguigan@eircom.net
Chairperson: Josephine Quinlan - Comments
Caroline McGuigan, a qualified therapist and tutor shared her personal story of struggling
with mental ill health and went on to describe her subsequent suicide attempt. Caroline’s
story began when she experienced difficulties coping with everyday life, followed by
being diagnosed with an anxiety disorder, entering a psychiatric hospital, returning to her
original life, attempting suicide, and again picking up the pieces of her life following her
attempted suicide and finally the crossroads! If you feel exhausted just reading the
previous sentence, imagine what it is like for thousands of Irish people who go through
similar experiences on a daily basis. Why? Caroline stated that our country is only
starting to recognise that the revolving psychiatric door is not always the best way for
everyone, and that Ireland is still fearful and cautious of the other options available.
What stood out in Caroline’s story? The loneliness that accompanied her inner struggle
and her need to pretend that everything was ‘okay’, no doubt in an effort to avoid the
shame and stigma that our society continues to associate with mental ill health.
Thankfully, at the crossroads of her life, following her suicide attempt Caroline chose to
travel down the road of personal care and self development, eventually becoming a
qualified therapist. Caroline’s personal experience and professional training gave her the
determination and insight to create options for people that are struggling with an anxiety
disorder or those that have attempted suicide and are trying desperately to rebuild their
lives. Caroline founded an organisation called Suicide or Survive that will launch its first
major project called the ‘Eden Programme’ over the coming months. The Eden
Programme, is one of a number of new innovative programmes initiated by such creative
and courageous thinkers as Caroline McGuigan.
Finally, delegates were invited to discuss issues surrounding bereavement before the
seminar concluded. Not surprisingly, the discussion swayed through many topics such as
mental ill health, the predominance of the psychiatric system in mental health care and
the scarcity of suicide bereavement services. The two themes that emerged were firstly
that it takes hard work, commitment and determination to launch new projects or services
in the present Irish health system. Secondly, everyone both personally and professionally
must play a vital role in an effort to reduce the stigma and shame associated with mental
ill health. Stigma and shame are barriers that we as a society have created preventing us
from seriously tackling the issues surrounding mental ill health.
THE SPEAKERS
ANNETTE BEAUTRAIS
Associate Professor Annette Beautrais is Principal Investigator with the Canterbury
Suicide Project at the Christchurch School of Medicine & Health Sciences in New
Zealand. She has conducted research and published on various aspects of suicidal
behaviour since 1991. She is a current executive member of the International Association
for Suicide Prevention and Co-Editor-In-Chief of CRISIS, the journal of the International
Association for Suicide Prevention.
VERONICA O’KEANE
Veronica is Head of Section of Perinatal Psychiatry at the Institute of Psychiatry, London
and honorary consultant at the Mother and Baby Unit, Bethlem Royal Hospital: where
she is lead clinician in a specialist national-referral centre for perinatal psychiatry. She
has also worked as a consultant in General Hospital Psychiatry in Cambridge and Dublin
and established the psychiatric service in Beaumont Hospital from 1998-2002.
Her research interests are hormonal abnormalities in psychiatric disorders and the effects
of stress hormones on behaviour and brain function. Her current research programme
examines the mechanisms and the effects of depression during pregnancy on women,
pregnancy and their babies. She lives in Howth with her two children.
ANNIE DILLON
Annie works with the National Women’s Council of Ireland (NWCI) as Policy Outreach
Facilitator. She has an MA in Women’s Studies and MSc in Education & Training
Management and is a qualified Psychiatric & General Nurse and Midwife Annie has
worked in the area of women’s health in Australia, England and Ireland.
ANGELA MOHAN
Angela is Consultant Psychiatrist in Rehabilitation at St. Vincent’s Hospital Dublin.
Former Clinical Director St. Brendan’s Hospital Dublin. Practioner in Cognitive
Analytic Therapy and currently in advanced Psychotherapy training.
MICHAEL FITZGERALD
Michael qualified in medicine in University College Galway in 1979. He did his training
in Psychiatry in the Maudsley Hospital and in Kings College Hospital London. He
obtained an M.D. from Trinity College Dublin in 1996. He is a consultant psychiatrist
for the National Children’s Hospital Dublin, Our Lady’s hospital for Sick children Dublin
and the Southern Area Health Board. In 1996 he became Henry Marsh Professor of Child
Psychiatry at Trinity College Dublin. Michael is a Fellow of the Royal College of
Psychiatrists and plays an active part on the specialist sections of that organisation. He
has a special interest in Autism and Asperger’s syndrome and is research consultant for
the Irish Association for Autism. He is the first and only Psychoanalyst practicing in the
Republic of Ireland recognised by the international Psychoanalytic Association. He is an
accomplished teacher in all aspects of his chosen speciality. Michael has set up numerous
training courses in psychoanalysis and psychotherapy. He has founded two journals and
has published over 300 scientific articles and letters and edited a number of books. He is
on the editorial board of several international journals. Michael became chairman of the
Irish Association of Suicidology in 2002.
PAT LITTLE
Pat was appointed Scottish Development Manager for Penumbra’s young people’s
services in 1999. He previously developed and managed Penumbra’s young people’s
community mental health project in the Scottish Borders. He has over 25 years
experience working with young people most of which was specifically with 16-25 year
olds. He now has responsibility for networking with young people’s agencies in Scotland
to form strategic alliances in order to raise awareness of young people’s mental health
issues. He also has responsibility for promoting research and developing training on these
issues as well as identifying gaps in current provision of services across the country. This
involves contact with the Scottish Executive, Local Authorities, Health Boards and the
Voluntary Sector across Scotland. Pat has contributed to several National and
International conferences and provides training and consultancy on young people’s
mental health issues (particularly on self harm) both in Scotland and abroad. He was
responsible for the development of Penumbra’s six dedicated Self Harm projects and
currently chairs the Scottish Self Harm Forum. He was a member of the Scottish
Executive’s Planning Group on the National Framework for the Prevention of Suicide
and Self-Harm (Choose Life) and the planning group which produced Scottish Needs
Assessment Programme (SNAP) Report on Child and Adolescent Mental Health in
Scotland.
CAOIMHE GLEESON
Caoimhe is Equality Officer with the Health Service Executive (H.S.E.). The H.S.E. is
the biggest public sector employer and service provider in the Republic of Ireland
employing over 100,000 employees from diverse backgrounds.
Since 2001 she has established an equality and diversity programme within the North
West and is currently working through the reform process to ensure this work can be
replicated across all regions within the HSE. This work includes policy development,
equality information dissemination and training, and the development of new and
innovative practices and supports in employment and health service delivery to diverse
groups. She formerly worked with NUI, Galway in partnership with a wide variety of
agencies and organisations in the North West region of the Republic of Ireland and in
Northern Ireland. She has a particular interest in equality, human rights and gender
issues and continues to work in a voluntary capacity with a number of organisations. She
has also worked on projects relating to gender equality, youth work, intercultural
education, development of civil society and citizenship rights in El Salvador, Ghana,
United States, Croatia and Bosnia-Herzegovina.
HELEN MACWHITE
Helen Mac white is the Communications Officer with Bodywhys – The Eating Disorders
Association of Ireland. Much of Helen’s work focuses on awareness raising and
increasing understanding of the experience of people affected by eating disorders. This
includes looking at the language that is used to communicate distress and to respond to
distress as well as gaining an understanding of how to promote supportive healing
relationships. Before working in the area of mental health, Helen was a lecturer in the
School of Applied Language and Intercultural Studies in Dublin City University. She has
also undertaken studies in Counselling and Psychotherapy and hopes to complete a BSc
in Psychotherapy in the near future.
NUALA WHELAN
Nuala a mother-of-eight devastated by the suicide of her husband is now a beacon of
hope for those bereaved through suicide. Nuala's life was changed forever when her
normally happy husband John left the house one morning never to return. Nuala was left
to bring up eight children on a small pension and little money from part time work. When
her husband died, the family had only £4.50 in the bank. But Nuala did a remarkable job
rearing her family. Daughter Ann-Marie is now a qualified Barrister; Brendan has just
graduated as an Architect and Siobhan as a Nurse; Derek is working in London's Carary
Wharf after getting a first- class Honours Degree in Computer Science from UCD where
he was top of his class two years running and Emma has a Diploma in Interior Design.
Nuala's is a compelling story that offers hope and inspiration to those bereaved through
Suicide.
JOHN O’DWYER
John O’ Dwyer is Coroner for Mayo South based in Ballyhaunis, County Mayo.
John is a Coroner for over 30 years and has a wide experience in dealing with Inquests
which may be suicides. Because of the exceptional level of upset experienced by family
and friends he has evolved a system of involving family and next-of-kin in the Inquest
process particularly in attempting to reach what is a fair Verdict to the deceased.
CAROLINE MCGUIGAN
Caroline Mc Guigan is a qualified Therapist/Tutor. Her work involves one-to-one
therapy and group work. She presently works as a Tutor for Maynooth College
delivering the “Foundation in Counselling Skills Course”, a one-year course that covers
Theory, Skills and Self-Awareness. Caroline is the Founder and Co-ordinator of Suicide
or Survive, a registered Charity. Suicide or Survive aims to support people who have
attempted suicide or have suicide ideation, through a group setting over a 6-month
period. The group will allow a person to explore their own experiences, develop their
skills and source avenues of support and assistance. Caroline is also the Irish Co-
ordinator for a Charity called “No Panic”, which has been in existence for 15 years in
England and is in Ireland the past 2 years. No Panic aims to aid the relief and
rehabilitation of people who suffer with anxiety disorders through a Helpline, Telephone
Recovery Groups, Literature and Written Recovery Programmes. Caroline personally
believes that a person needs to experience an environment that is genuine, understanding
and non-judgemental before they consider trusting and working with another individual.
For Caroline to be in a place to provide this environment to another person she used her
own personal experiences, went the long road of training and took her “dreams” and
made them a “reality”.
PAPER PRESENTERS
DEREK CHAMBERS
Derek is a Research and Resource Officer of the National Office for Suicide Prevention
(NOSP) and recently acted as Project Manager for the development of the National
Strategy for Action on Suicide Prevention which was published September last under the
title ‘Reach Out’. He has an MA in Sociology from UCC and is interested in social
change models of suicide and in general population approaches to suicide prevention.
IAIN MCGOWAN
Iain McGowan is a mental health nurse employed as a lecturer at the University of Ulster.
He has authored numerous articles and conference presentations and compiled one book
on the philosophical aspects of suicide. He is currently studying for his PhD at the
University of Ulster investigating the non-linear dynamics and applying the principles of
chaos theory to suicide. Mr McGowan is editor of Mental Health Nursing On-Line.
MARTINA O’RIORDAN
Martina is a Research Officer with the National Suicide Research Foundation. She has
previously undertaken research roles in the Department of Applied Psychology,
University College Cork in studies commissioned by the Health Services Executive and
the Mental Health Commission. She also worked as a Researcher on the COPINE
(Combating Paedophile Information Networks in Europe) Project at UCC. She has a BA
in Applied Psychology from University College Cork and a MSc in Forensic Psychology
from Glasgow Caledonian University.
CARMEL MCAULIFFE
Carmel began working as a research psychologist with the National Suicide Research
Foundation in 1996, following graduation with a B.A. and Higher Diploma in Applied
Psychology at University College Cork. During her appointment she worked on the
Repetition-Prediction part of the WHO/EURO Multicentre Study on Suicidal Behaviour.
She also completed an MPhil examining suicidal ideation in university students, and an
MA in Behavioural and Cognitive Psychotherapy, at University College Cork. She
currently works for the HSE Southern Area co-ordinating a randomised controlled trial of
group problem-solving skills training for deliberate self-harm patients. She recently
submitted her PhD thesis investigating problem-solving characteristics of deliberate selfharm patients.
CHAIRPERSONS
MICHAEL FITZGERALD
Michael qualified in medicine in University College Galway in 1979. He did his training
in Psychiatry in the Maudsley Hospital and in Kings College Hospital London. He
obtained an M.D. from Trinity College Dublin in 1996. He is a consultant psychiatrist
for the National Children’s Hospital Dublin, Our Lady’s hospital for Sick children Dublin
and the Southern Area Health Board. In 1996 he became Henry Marsh Professor of Child
Psychiatry at Trinity College Dublin. Michael is a Fellow of the Royal College of
Psychiatrists and plays an active part on the specialist sections of that organisation. He
has a special interest in Autism and Asperger’s syndrome and is research consultant for
the Irish Association for Autism. He is the first and only Psychoanalyst practicing in the
Republic of Ire land recognised by the international Psychoanalytic Association. He is an
accomplished teacher in all aspects of his chosen speciality. Michael has set up numerous
training courses in psychoanalysis and psychotherapy. He has founded two journals and
has published over 300 scientific articles and letters and edited a number of books. He is
on the editorial board of several international journals. Michael became chairman of the
Irish Association of Suicidology in 2002.
ANNE CLEARY
Anne is a sociologist and lecturer in the Department of Sociology, University College
Dublin. Her research interests include health and illness – particularly the gender
patterning of health and illness, childhood and adolescence. She is the author of several
books and reports on these topics most recently ‘From Child to Adult: A longitudinal
study of Irish children (2004) and ‘Young Men on the Margins’ (2004). Her current
research project (funded by the Irish Research Council for the Humanities and the Social
Sciences) involves a qualitative study of suicidal behaviour amongst young Irish men.
BRIAN HOWARD
Brian is Chief Executive Officer of Mental Health Ireland. Mental Health Ireland is the
largest voluntary body representing the interests of people with a mental illness in Ireland
and is actively engaged in the promotion of positive mental health. He was elected to the
Board of Mental Health Europe in 2001 and to the Board of the World Federation for
Mental Health in 2003. Prior to joining Mental Health Ireland, Brian worked with the
Department of Health and Children and was assigned to the Mental Health Services
Division of that Department. His main responsibilities were preparing, drafting and
finalising the content of the Mental Health Act 2001 and the development of psychiatric
services in accordance with Government policy. He chaired the National Task Force on
Suicide which published its Report in 1998 and is currently a member of the National
Advisory Group on Suicide Prevention.
SEÁN MCCARTHY
Seán is the Regional Suicide Resource Officer for the south eastern region of the Health
Services Executive – South. He has worked in the area of suicidology since 1999. He
is a member of the Irish Association of Suicidology and of the International Association
for Suicide Prevention. Seán is a founder member of “Talk it Over’’, a suicide
bereavement support group based in County Waterford and south Kilkenny. He was a
member of the steering group for the development of Reach Out, National Strategy for
Action on Suicide Prevention 2005-2014 and was also a member of the advisory subgroup on suicide prevention for a Vision for Change, the Report of the Expert Group on
Mental Health Policy. Sean’s particular interests lie in the development of bereavement
support services and in the development of services to respond and support persons who
self-harm. Prior to taking up his current position, Seán worked with the Waterford
Mental Health Services as a Clinical Nurse manager. He has also previously worked in
Forensic Psychiatry Special Assessment and Supervisory Services in Maidstone, Kent.
SHEILA DALTON
Kilkenny born Sheila has been a volunteer and support group facilitator with Aware for
16 years. She is also a member of Kilkenny Bereavement Support Group and is involved
with their on-going training. She has a special interest in and works with people who
have been bereaved by suicide. A qualified Psychiatric Nurse, she worked with CarlowKilkenny Mental Health Services in many capacities for 36 years until her retirement in
2003, she is also a director of Kilkenny Health Association.
JOAN FREEMAN
Joan had a private counselling practice for 16 years. In January of this year, she opened
the first centre for the Prevention of Self-harm or Suicide. Pieta House is based in Lucan
where Joan and her team of qualified psychotherapists provide a groundbreaking service
to people who have suicidal ideation, people who have attempted suicide and a service
for people who self-harm. It is hoped that this service will be nationwide over the next
two years. Joan is at present creating a workshop for people who have family members in
crisis and workshops for professionals who deal with people who self-harm.
JOSEPHINE QUINLAN
Josephine is Service Manager of Console in Limerick; an organisation that works with
people Bereaved through Suicide. She is a member of Irish Association for Counselling
and Psychotherapy (MIACP) and the Irish Association of Alcohol and Addiction
Counsellors (MIAAAC). Prior to this, she worked as a Registered Nurse (R.N) in Ireland
and Australia.