9th Annual Conference
Suicide Prevention: What You Can Do
29th September – 1st October, 2004
Talbot Hotel
Wexford
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Welcome Note
Irish Association of Suicidology
Dear Delegates,
The ninth annual meeting of the Irish Association of Suicidology has at its theme
“Suicide Prevention – What you can do”. This challenges society to acknowledge its
responsibility for recognising and responding to this serious public health issue. Hiding
behind the stigma that is still attached to suicide must end. There is need to substantially
invest in research into why the level of completed suicides is averaging 450 per annum.
Why this has risen from an average of 64 per annum in the nineteen sixties. There is a
need to invest substantially in carefully researched suicide prevention programmes.
While recognising the success of other countries in this area and drawing from their
experiences, programmes in Ireland must be based on careful research of the special
societal issues present in modern Ireland.
There is urgency in recognising the need to invest in the psychiatric Services.
International research demonstrates that in excess of 80% of people who complete suicide
are suffering from a psychiatric condition. Since 1997 state contribution to the
psychiatric services has dropped from 11% to 6.7% of the national health budget.
Substantial investment in the services will have a pronounced effect on the level of
suicides. There is a need for appropriate specialisms, user and carer involvement,
management efficiency and community mental health teams with true multidisciplinary
capacities. In particular there is a need for adequate service for a range of specific
groups; the homeless, children and adolescents, those with eating disorders, and those
requiring forensic psychiatric services, including prisoners. The concern regarding the
psychiatry of learning disability must be addressed.
Stigma remains an enduring problem, with widespread negative consequences. It has
negative impact on the willingness of people to acknowledge mental health problems
with subsequent difficulties for early diagnosis and treatment.
The 2004 conference is especially recognising the trauma of the bereaved of suicide.
This has been addressed over the years in our conferences. A dedicated section at this
year’s conference is a most welcome development and will add to our knowledge of the
deep human tragedy of suicide and how those bereaved and service providers can obtain
a better understanding of the area.
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Mr. Dan Neville TD
President
Irish Association of Suicidology
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Bereavement Seminar
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A GRIEF CONCEALED
Mr. Christy Kenneally
Author of ‘Life after Loss’
You should never say to a Cork man can you hear me at the back.
One of the advantages about being occasionally on television is that total strangers come
up to you in Talbot Hotel in Wexford and say we love your programme on the television
Duncan. His hair is naturally that colour, ok so behave yourselves. There are
advantages, last Christmas my wife and I were coming home in Dublin and we were
driving out the road and there was a Garda check point, and you know the way you pull
up and you put down the window and you inhale as you say goodnight Garda, he came
over to the window he looked in and said I know your face yes he said your Bob the
builder drive on. Do you know in the civilised parts of the world at this time of the day
people go to bed, it’s typical of Irish people of course that they come to a course or a
series of lectures or whatever. It’s that great masochistic thing in Ireland, you know, I
enjoyed myself yesterday I have to punish myself today and this is the pure kind of ritual
punishment that Irish people have to come to the after lunch, a spot like this. They traced
it back to the Jansenists, now in case there is anybody here, who is not from Mayo, does
not know very well what Jansenism is, well the Jansenists basically believed that human
nature was evil, you know, but joy was suspect laughter was not on the menu. It was
very popular in Switzerland, for some reason, where they have a sense of humour but
they take it very seriously. I think to understand the Swiss you have to realise that the
Italians had 150 years or murder and mayhem out of which they gave to the renaissance
the Swiss had 800 years of uninterrupted peace of which they gave us the cuckoo clock
and Toblerone chocolates.
Toblerone chocolate is the perfect symbol for what we are doing this afternoon because
as you know as you are biting off the first piece the second piece is sticking strategically
and painfully up your nose; now that is Jansenism, and it certainly explains the after
dinner speaker as well. The job of the introducer is usually, in Ireland anyway, to use
what is called a collective epidural for the audience which in Ireland is called the
euphemism. So now we say, now we will have a few words ‘from’ and of course that in
Irish means a minor thesis because no Irish person is cultural capable of saying a few
words. If Noah of the Old Testament had been Irish about the second day of the flood he
would have said ‘ah tis too heavy to last’. There was an exception to the rule, there was a
clergy man in Cork who was a man of few words in fact he had used all of them. It was
said that if there was a lull in the conversation he was sure to be in the thick of it. Once
he got started he couldn’t stop and at weddings it was his chance to glow for fifteen
uninterrupted minutes and at this particular wedding one of the uncles of the bride had
drunk not wisely but too well and eventually called the waiter and said I will give you
fifty Euro if you go up and clock him and the waiter said I’ll do it for nothing and he took
a bottle slipped up behind him took a lash at him, missed him, connected with the father
of the bride who collapsed under the table. The priest kept on talking until the voice from
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under the table said hit me again I can still hear it. If it’s any consolation to you, as a
married man, I’m quite accustomed to talking in somebody else’s sleep. Or as Henry the
eight said to each of his wives I will not keep you long. Its nice to hear you laugh and I
understand of course, grave people here, we are all grave people here and I think we
know that laughter and tears come from the one place and its an important part of our
grieving that we are able to see other sides and other dimensions as well. So it is nice to
hear you laugh. My title today is rather ironic really when you consider the vast crowd’s
that have turned up. My title is “A Grief Concealed”, but we done very bad job of
concealment if we could devote the next couple of days to the subject. But it is a real
question isn’t it surely? We have to have days like this and the other days is that there
are certain areas of grief that gets swept into the shadows and that of course ferment in
the shadow and ferment to demons and can devour peoples lives. This was a very tragic
part of our culture I think that many areas of grief and not only the grief of suicide were
kept under wraps. “Uisce fe talaimh” was the Irish expression water that runs beneath the
ground.
To start off I have to say that nobody lives in the abstract and nobody dies in the abstract.
Wasn’t it John Donne, the poet, who said no man is an island? I will take from that even
if we are islands in a very real sense we are part of the archipelago of peoples that we are
bound together by that interlocking network of umbilical cords that keeps us in
communication with each other. At best that is the safety net of community, family and
culture that sustains us in times of CRISIS. At worst it is something that pulls us apart
something that imposes ways of behaving and feeling or not feeling that are acceptable to
this society. The real question is what kind of society we live in. Should I have a band
around it saying this country is dangerous to your health if you happen to be bereaved,
particularly if you happen to be bereaved through suicide? The Chinese as you know
have a curse and the curse is ‘may you live in interesting times’; it’s typical and
enigmatic isn’t it. But we live in interesting times. Elizabeth the second of England said
change is a constant which an Irish fellow translates into ‘constant change is here to stay’.
But we are tremendously fast moving society now. We know that you are evolving or
devolving, that you can’t stop. As a fellow said, onetime, there is no handbrake in a
marriage, you’re either driving happily up hill or you’re reversing furiously down hill.
You try to pull into a lay-by and say ‘we are grand here now Mary’ that would be the end
of the relationship. This is a country that is hugely on the move now, you know, and of
course the human mind resists change with the same ferocity with which the human body
resists an invading organism. If you think of the scientific advances even in our day, in
our age, it is incredible to think that the fiction of our past is a fact of our present. To
think that our grandparents stood on the earth and marvelled at the stars and the
likelihood is that our grandchildren will stand out there and looked back on this little
green and blue orb called the earth. When we think of the technology of communication,
I should say communications now to make the distinction because the technology of
communications is all about when your daughter comes outside and says I have an essay
to do on the Romans during the republican period you say ah that’s a good idea go to the
library and she looks knowingly at you and goes into the room next door and taps in on
the internet to the library of congress in Washington. That is their norm. We have the
highest percentage of mobile phone owners in Europe; to think that you can pick up your
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phone anywhere in Ireland today and you can, you know, phone a total stranger in
Borneo or even though you phoned your brother in Ballina. But I think that’s ESAT lads,
but don’t quote me on that. Yet in the middle of all that we have what the poet said, ‘the
centre cannot hold’. I think we have a tremendous loss of meaningful connection
between people. We end up like the molecular structure of loneliness, the coral reef of
individual selves we walk into multinationals where people are separated by simple
partitions and we are there emailing each other and the other person is two feet away and
we can see that permeating out into the society around us as well. I was reading about
ancient Rome last night as Cork people often do you know. When you run out of the
Examiner you have to read something. The temples in ancient Rome were five and six
stories high and they were remarkable things honey combed with rooms of course
because the landlord wanted to have money. But you couldn’t have a fire in your room
for danger that the house would burn down and because you couldn’t have a fire you
couldn’t cook. In fact you had to have all your meals outside. So on the bottom floor
were the shops and the Taverna and places where you could go and have something to
eat. You know things don’t change an awful lot do they and interestingly they were
called insulae which actually means islands in Latin. So we have lots meaningful
connection this is island now of the septic kitten where the emigrant ship has sailed into
dry dock, where unemployment has become a thing of the past. Of course in that society
when the rich get richer and the poor get poorer and the gap between the two grows more
enormous and more contrasting because think of it if you fail in a time of failure what’s
the big deal but if you fail in a time of great success then what does that say about
yourself. There is a distinction and we have never made the distinction in Ireland
between failing and being a failure which I think is very important in the subject which
we are addressing over the next couple of days. We couldn’t wait of course for the Celtic
tiger to disappear. Why? Because it worried us because we are not used to success in
this country. Eight hundred years of tender loving care from a near neighbour or one of
our off shore relatives from the UK does not encourage people who have a strong self
image. Wasn’t it Nelson Mandela who said the only thing we have to fear is our
giftedness and that certainly will be part of the Irish mentality as well. The greater thing
that could be ever be proud of an Ireland of course was humility it was our proudest
boast. If it was in the Olympics every four years we would definitely get gold. But of
course we would be much too modest to go up for the medal. After that in our life time
we have witnessed I believe the loss of the church as we knew it. I refer to the roman
catholic church which is my own, but the loss of the church as we knew it, the church that
has been shadowed by the shame of a minority and this is a time when clergy are cowed,
I believe, or shadowed by all that’s going on around them they are tempted very much to
withdraw from the market place in that sense and particularly in the area of suicide and
the clergy who are very often so afraid to say anything less they say the wrong thing, who
are so afraid sometimes to celebrate the life of the person who has taken their live in case
they would seem to be celebrating the manner of their death or encouraging other people
to emulate the manner of their deaths.
I think we are lost for community. We see in this country the gradual erosion of the links
that were all over rural Ireland there was a time when people went to the mart, there was
a time when people went to the creamery, there was a time when people went to the
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meitheal and you know saved each other’s hay did those sort of things. These things are
largely becoming a thing of the past and we are ending up with islands of loneliness in
the rural community. I mentioned already about the city ones and the pressures on
people. I see in young couples today, you know pressure to make a small farm pay
particularly for young men in our rural society the pressures to have you know to make a
farm pay probably at the cost of not having a few bob in your pocket to socialise or to
create the kind of life that you could invite a man or woman to share with you and again
we know the disenfranchisement of people like that from the norm and have the
responsibility of continuing the land in a time when perhaps its no longer viable or
feasible and you are fifth of the generations of that family to hold that land in your care.
Pressure on the ordinary couple to work all the hours that God help or gave for what? To
pay a mortgage yes, but sometimes to give our children all we never had and in doing so
of course to risk depriving them of the values that we developed in our first suit of hard
work. The tectonic plates of change have moved under our feet and the danger is that
people are falling through the cracks and the first deduction in time of change is go back
to nostalgia, is to go back to what we have and the second is to throw ourselves
emotionally and whole heartily into the new without ever sifting or willowing what was
there in the past for its value and incorporating it into the now. As a nation I think this is
a tremendous time for us to take time to think about the basics who are we, what kind of
people are we, what do we value, what kind of country do we wish to have, do we wish
as others have said, do we wish to have an economy or to have a society what value do
we put on people in our society, how do we express their value in our ordinary everyday
communication and relations with them. All changes, all changes bring loss very simply
the grieving process is how we cope with that reality and of course we must do it to be
real and the goods news from what we read in here is that we are instinctive grievers that
we do it from our bellybuttons rather than from our brains. The fact there is research to
say that the less educated can’t agree better than the better educated because the better
educated are trying to figure it out from the neck up the other crowd are actually feeling it
and going through the process at a much deeper and visceral level down here. It is
important to say that there are a lot of false ideas going around about bereavement one is
that you will recover the other is that you will get over. This is not an illness that you
will recover from this is not an obstacle that you get over from this is something that you
learn to live well with for the rest of your life, for the rest of your life. That is why the
word closure always worries me in this context because I think to a lot of people it
suggests well now you’re grand, that over, on we go good luck. Where as I believe
anybody who has lost someone, a father or mother or loved one, they carry that person
within them. How they carry them is the quality of their living and the quality of their
grieving for the rest of their lives. So it is something that we must face for better or for
worse. Is suicide a worse grief than any other grief? We are a great nation for
comparing things, we have great ways of shutting out anybodies pain from our lives and
talking about our own. You know when you caught your finger in the door, Mr. Murphy
had his leg off last week you know we are classic in the ways we put you down. What
we do is we reduce your pain to a size that we can handle thanks very much and
eventually what we learn is keep stump about and go off into a corner. You remember
you were a child and you cut your leg and they said you’ll be better before you get
married you know that sort of thing. I don’t know what that said about marriage but
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eventually learned to go into the corner and have a happy quite gangrene but there are
special features and I think special problems that we need to find out. A couple of
interesting quotes a man called Edmund Shneidman he is regarded as the father of
suicide prevention in the United States said I believe the person who commits suicide
puts his psychological skeletons in the survivors emotional closet it can be a heavy load.
I’m not sure we should say anybody puts anything on anybody else; people do what they
do its up to other people to cope with it. I think you very easy work yourself into
blaming there. A Richard Mee who runs a suicide prevention programme in Florida said
suicide is the most difficult bereavement crisis for any family to face and resolve in an
effective manner. I hope these don’t sound negative. No I tossed the book just to
underline the acuity of some of the areas here. What I like about the language I hear in
lots of the stuff is that word survival is used, survival rather than victim is used because a
survivor is somebody who is some way has incorporated the darkness into themselves
and transformed it perhaps into something life giving but is dealing well within
parameters of whatever evil or whatever pain happens to be in their lives. To get back to
Ireland, there is a stigma in Ireland and stigma means to shame. I know you could say if
you went out this minute and stopped people on the street outside the Talbot Hotel and
asked them do you believe a person who is a suicide should be buried in the church yard I
think nine out of ten people would look at you if you had two heads and say well these
days are gone you see. These days may be gone from the neck up but I wonder if there is
not a deeper shadow that is cultural and that we have taken down into us otherwise I find
it very hard to explain how so many people turn up for bereavements in Ireland. It is one
of our national hobbies but how you can have a depleted group at the funeral of
somebody who is deemed to have taken their own lives, I wonder about that. I wonder
how people find it so hard to talk to the relatives of people in circumstances like this, why
they see people crossing the road, the street when they come why they see changing lanes
in the supermarket when they come. I had a letter from a priest not so very long ago who
said a boy had taken his own life in his parish a rural Irish parish. He said you know I did
my best with the prayers and the mass and I tried to be sensitive and so on. I went down
after it all, I went down to the house to show cause to find the father and mother sitting
on their own on either side of the fire. I was the only member of the community there, he
said now what does that say, what does the absence of your neighbours say to the abscess
in your heart in circumstances like that and about the perception of your loved one. So
there is that stigma a tendency perhaps to pull out a tendency perhaps for avoidance. I
would say it’s no love it’s based on the fear of saying the wrong thing; who ever said
there was a right thing, who ever said there was a right thing in any bereavement to say. I
have often advocated that people who go and visit the bereaved should take with them a
packet of fig roll biscuits, I’m on a commission from Jacobs as well, and they should
open it as soon as they go into the house and begin to eat the packet top to bottom every
single biscuit because there is eating and drinking in fig rolls and its very hard to talk
when your mouth is full of fig roll biscuits so your total contribution philosophical and
theoretical to the conversation for the next hour will be ‘hum’ and ‘ah’. I think there is a
great benefit in that, because the reason we go to the bereaved at all is not to step into
their world but allow them to step out, it is not to speak to their reality but to allow them
to articulate their perception of their reality and in doing so get a grip on their reality see
a clear picture of it. The word companion is a beautiful word it comes from the word
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‘companio’ literally the one who has bread with me and if you’re eating bread you can
never say the wrong thing. But it is to be there it is the solidarity of one human being
who comes and sits in the silence of another human being literally to keep them
company. There is also the stigma of a person who attempts and fails, and I think this is
exacerbated by the fact that they may come back into a community that passes very
negative reactions on them because of their attempt and that in a sense it becomes a
cyclic thing and they in fact become more encouraged to move and to make sure the next
time around. I think in all bereavement and in the bereavement of suicide of course there
is guilt. People say, should I have said something, should I have heard something, should
I have seen something, should I have been something else to this person and would it
have made a difference and of course particularly if there has been a falling out or
anything in the immediate past before the death that is exacerbated by the death you
know whatever is closest to an explosion is most deeply embedded in the background
even the tiniest, tiniest element can be most deeply embedded in the memory and the
spirit afterwards can be incredibly painful and the way the old people treated that was
that they would let you tell your story of the silo of omission or commission, they would
let you tell it five hundred times knowing that there is sandpaper in the tongue and what
one has talked about will find its level and find its context if it is articulated. Nowadays
we tell people don’t be talking about that at all .you’ll only upset yourself. What they
mean is you’re only upsetting me would you please stop I can’t take it, here’s two tablets
you’ll be fine. It means I’ll be fine, you’ll be in a happy coma and ill be able to slosh you
around sit you down and stand you up and I wont have to deal with you tearing the wall
paper off the wall. Sorry I got carried away there lets get back to the point but anyway so
its that idea about allowing people outing their guilt particularly, and is there a single one
of us here today who did not say if I had my life over again, when somebody died, if I
had my life over again. We are very conscious that we have shadowed lives, ordinarily
we’re not the full bob in our relationship as well as everything else. We are people who,
if our loved one was taken from us in the morning, there would be huge things perhaps
that we would be sorry we didn’t do or didn’t say, things left unarticulated and lost in
silence and these are things that need to be dealt with and faced, because what’s faced
need not be fear it is what is put into it, what is put into it, its what’s put into the
wardrobe of mind and is put under lock and key. They are things that grow into demons
and dragons and devours the life of a human being, become so enormous and powerful
that they crush them or that they spend so much of their life energies keeping that shadow
at bay that they have nothing left to give to life and so you have to help people and give
people professional help to have that guilt that anger at themselves is tremendously
important and of course added to that is perhaps taking responsibility was it my fault, was
it my fault you know was it my fault and these questions are normal and natural. Arising
from that people feel that they should behave in a way now that punishes themselves I
mean the survivors how can I live fully now that X or Y is dead how can I have joy in my
life. As a bereaved man said to me one day we were chatting he said did you hear me
laughing there imagine me laughing. You know its indicative of people saying you know
I cant enjoy myself anymore because that would be a slur on the person who is dead or
worse again I feel guilty for what went on here and I have to punish myself or maybe I
will behave in a way so that society will punish afterwards or I will punish myself with
drugs or with drink and so on like that. I think what we have to look at as well, and may
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do so in a very kind of brief way, is Irish anger because of course there isn’t any as you
know. This American psychiatrist god love him came to Ireland to do a study on Irish
anger. He had a questioner and everything he was well equipped and he went around and
he asked all the men do you get angry and they said no I might get a bit put out and he
asked the women and they said god no I never get angry I might get a bit upset. He said
the Eskimo have five hundred words for snow the Irish have one thousand for Ireland
anyone except anger will do because it was a gorgeous promotion we were all born with
and had great out of it at the earliest possible opportunity. Do you remember when you
were a child you were angry what did they call you so that you could tell a kind of a
mixed audience. But wasn’t bold a great word wasn’t pup a might word to. Do you
remember what was the worst punishment for anger, apart from a skin graft bed, do you
remember? How any of us ever grew up to be mature sexual adult I will never know and
do you remember they said get up them stairs you pup and come down here with a civil
tongue in your head? And you went upstairs and there was a I better go down and they
say you’re the brave boy saying your sorry oh, I’m sorry, I cant hear you oh. I’m sorry,
get up that stairs you pup and you’re off around again. Anger equals ex-communication
and you would wonder is it important, how important it is that we bring our children
particularly to be assertive instead of the usual sure I don’t mind, like no chance of a half
day, no thank god. A terrible non-assertiveness or a terrible aggressive that builds up and
builds up and boom a terrible nuclear holocaust whole house inhabitable for three million
years, generations in the family dying from radioactivity boys and teach our children to
be self respecting we are a country we taught them to respect everybody else except
themselves anybody bigger than yourselves for self preservation but never yourself who
do you think you are, who do you think you was the great question. You could never
have anything of yourself you passed an exam your mother said you have my brains your
father said who question………………if there is anybody here form Kilkenny I sincerely
congratulate you on two in a row and I hope ye have two in a row again the next time.
What happens when you come up against the anger of bereavement? You are inarticulate
in it unless you have been reared to it and unless there are people who can draw it out of
you, people who are poultices to the soul people who draw up the venom of the spirit
otherwise we self combust otherwise we punish ourselves with bad behaviour we are so
busy swallowing our anger that we cant save our life people who smell of gun powder or
children tip toe around us all the time and there’s a huge level of fear as well I think in
those who survive a suicide and the primary fear I suppose is am I next, is this how I will
die, is this genetic, you hear people say ah it was in the family. Now this is what experts
need to address publicly and get it out whether it is or is not something you can inherit
because these are fears that seem to crush people and crush their spirits down. Could I
sum up perhaps just to say its terribly important as well to use our anger to winnow, to
establish the reality of the person who has died because ordinarily there is nothing you
could ever do for your reputation in Ireland that is as good as dying you are guaranteed
posthumous honour you could be the greatest roaring ‘lo la’ and once die up there well
say he had his little ways, he could have drunk us out of farms and we will say musha he
was fond to the drop you know, we will play you smooth in respect if only you have the
good manners to die and then impossible burdens are put on the living to carry the
pastoral statue of this demi-god who was their father while in fact he was a real person
like all of us are real and the burden and pressure of carrying the myth for years can be
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life sapping for them. I know a story of a woman in Dublin she married a fellow who
managed to stay a bachelor for the thirty five years of their married life she had seven
children with which he was biologically involved that was it, she reared them on her own
then he had the good manners to die she took him to the church the priest came out and
said this man was a pillar of the Christian community a paragon of all Christian virtue she
gave the elbow to the eldest fellow she said go out there and see is that your father in the
coffin. I think very important that we bury the real person or otherwise the real person
will haunt us. It is it a normal thing grief it is a normal thing and in the area of suicide it
is a normal thing in the area of what you might call extraordinary circumstances it affects
everybody around it, ripples out through family, through community the dead belong to
god the living belong to us I say that because I think we can ask forever about the
theological niceties we can dance on the head of pins with Aquinas and the rest of them.
Frankly, we shouldn’t be wasting our breath or our time we need our energies for the
ones who mean to make a meaning of it here and now they are the survivors who are
among us. I think as a country we need to get over our fear of psychology and of going
for help and that emotions and such like are not signs of weakness in human being and
we need to challenge our whole idea of what it is to be a healthy community today.
Bring up our children into self respecting, gifted children who are prepared rather than
protected for life and children who would look on failure especially as part of the rising
graph of developing their knowledge rather than something that is a cul-de-sac in their
lives and the fundamental question we must ask is what is this about the quality of our
lives I mean our lives in Ireland today that so many precious so precious men and women
decide not to buy into it.
Granite Lodge, Vale of Clara, Rosdrum, Wicklow Telephone: 0404 - 46561
NO TIME TO SAY GOODBYE: SURVIVING THE SUICIDE OF A LOVED ONE
Ms. Carla Fine
Author of ‘No Time to Say Goodbye
Abstract
Carla Fine’s physician husband killed himself in 1989 at the age of 43. Carla
draws from her own experience as well as those of many other survivors and
professionals to provide information and guidance to help deal with the grief
and despair that follow in the wake of suicide. Carla speaks about the
overwhelming feelings of confusion, guilt, blame, anger, and loneliness that are
shared by all survivors, including the intense isolation that surrounds mourning
the loss of a loved one to suicide. Carla discusses how the bereavement process
of suicide survivors is shrouded in stigma and silenced by shame. She offers
practical steps and suggestions for healing and easing the burden of pain so that
survivors can begin to remember their loved one’s life, not just their death.
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Carla shows how by talking about suicide openly and reaching out to others
who are also alone in their grief and suffering, survivors can turn their loved
one’s legacy into one of hope instead of despair.
It is such an honor being here today. I am a native New Yorker and therefore consider
myself partly Irish. I grew up with the St. Patrick’s Day parade and green bagels to
celebrate! I have always wanted to visit your beautiful country and truly appreciate your
inviting me here. I would like to thank Dr. John Connolly and the Irish Association of
Suicidology for this wonderful and important conference, and for their work in reaching
out to so many people about this important subject. I would also like to thank Josephine
Scott for her graciousness in helping arrange my trip and the details of my stay here. I
hope Josephine plans to come to New York soon, so I can extend the same courtesy to
her.
The topic of suicide has always been defined by its silence--we hide it, we deny it, we're
ashamed to discuss it. To be able to talk about how it feels to lose a loved one to suicide
in a public forum such as this fills me with courage and hope. I would be happy to
answer any questions you might have at the end of my talk.
Every person in this room has experienced the suicide of a family member or a colleague
or a friend. It is a frightening and threatening ordeal. Someone we know and care for has
chosen to die by his or her own will. Those of us left behind find ourselves mourning the
very person who has taken our loved one's life. Fifteen years ago, my husband, Harry
Reiss, a successful New York physician, killed himself at the age of 43. At that moment,
I was thrust into a world I knew nothing about, dealing with a reality that seemed more
like a dream. The man I thought I knew better than anyone else in my life, my husband
of 21 years, the man I thought I would grow old with chose to die without telling me of
his decision. He didn't give me the chance to help him, to save him, to extend to him my
hand. He left me without a word and no time to say goodbye. I felt alone. I felt
betrayed. I felt crazy. I felt isolated. I felt scared. This was on top of feeling guilty and
ashamed and angry, and of course, terribly sad. Because, as I was to learn over my long
and winding road to acceptance--and eventually uneasy forgiveness-I could no longer
believe in that human conceit that if you love or care for someone, you can be their life
support system, you can keep them going, you can will your life spirit over to them. It is
almost easier to blame yourself than to admit that you have been rejected and deliberately
abandoned.
I live only 20 blocks from what used to be the World Trade Center. Death and loss has
become part of our city’s fabric, along with its wonderful intensity, resiliency, diversity,
and, as always, sense of humor. A good friend of mine lost her husband on September
11. She was eight and one-half months pregnant--her beautiful son is now almost three
years old--and her 32-year-old husband was at his only second day of work at his new job
when he died. They found his body and the autopsy report showed that he had jumped
from the 105th floor. My friend and I have had many long discussions about losing our
husbands at a young age to a violent and unimaginable death. We speak to each other as
girlfriends, but also as poets and philosophers. Could her husband's death be construed
13
as a suicide? After all, he had to know that he couldn't survive such a free fall. On the
other hand, he was an experienced sky diver. Maybe he thought he could catch on to
some falling beam or some other type of miracle that would save his life. My friend will
never know what her husband was thinking before he died. But she is certain of one
thing--it was not his choice to die. Her situation, then, is quite different from the young
woman I interviewed for my book whose husband walked into a lake and drowned
himself two weeks before she was to give birth. Her husband did have a choice, and
chose not to be around for his family's future. She and her daughter are forced to live
with that knowledge every day.
I wrote my book No Time to Say Goodbye: Surviving the Suicide of a Loved One
because I want the voices of those of us whose loved ones have killed themselves to be
heard. We who have experienced the suicide of our mothers and fathers, sisters and
brothers, husbands and wives, sons and daughters, relatives and friends, feel separate and
apart. Our grieving process is often shrouded by stigma and silenced by shame. Only by
letting go of the silence, can we start to remember our loved one's life, not just their
death.
MY STORY
I would like to tell you my story. When suicide survivors meet each other, we always
begin with the how, relating the details of the actual act with an openness that is based on
the reality that other survivors will never judge us, no matter how grisly the details. We
know the questions we ask each other are not based on prurient interest or are fuel for
future gossip. We engage in a safe exchange of information, always followed by a
variation of "I'm sorry for your loss." When we describe the indescribable out loud, it
makes it seem more real, less like a dream that we have somehow found ourselves in.
Harry and I had married in college. He was originally from Cali, Colombia, South
America, born to Jewish refugees from the Holocaust who had fled Vienna in 1938.
After much struggle, Harry was just beginning to achieve success in his medical career.
He was a board-certified urologist with a private practice that was starting to take off, he
had recently been promoted to assistant professor at New York University Medical
School, and had already published 12 research papers in leading medical journals. Then
his mother had a stroke, followed by a long and painful decline. Within a year of her
death, Harry’s father died from colon cancer that had been in remission but recurred after
the death of his wife. Four months after his father's funeral, Harry injected himself with a
lethal dose of the anesthetic Thiopental. I found him lying in his darkened medical office
on his examining table, the intravenous needle still attached to the crook of his arm.
Harry's dedication to his work had seduced me from recognizing the truly despondent
state of his mind. I still can't believe that he was able to treat patients up to two hours
before executing his own death. Like most other survivors, the option of suicide seemed
inconceivable to me at the time. Sure, Harry was sad. Of course I could understand his
devastation about his parents' death. Yes, I could see that he was becoming withdrawn
from me and our marriage was suffering. But whenever I said something or suggested
that he get help, he blew me off. "I'll get over this," he would say. When someone you
love and trust kills himself, your whole world shakes and changes. Nothing feels steady,
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everything is upside down. The world becomes divided into before and after; there is no
turning back. You think you will never recover. I felt so alone after Harry died. I
thought I was the only person in the world who had gone through such an experience,
that no one could possibly understand what had happened to me. The man I trusted and
loved did not give me the chance to help him, to save him, to extend to him my hand.
There was no time to say goodbye.
When people ask me to describe what it's like to lose a spouse to suicide, I tell them to
picture having a really bad fight with their husband or wife. You yell, they yell, you cry,
they go into the bedroom and slam shut the door. You pound on the door, "Let me in. I
just want to say one more thing." Eventually the other person opens the door and the
fight is somehow resolved. But let's say you keep knocking on that door and they never
answer. And they never will. When people kill themselves, they win the argument, so to
speak. They get the last word. But what is winning and what is losing? Those of us who
are left facing the blackness of permanent silence will never have the chance at
resolution, at understanding, at forgiveness, at peace. Because the husband or wife we
have loved--or son or mother or brother-- has taken the answers with them. We can only
guess, reconstruct, look for reason, point the blame, pass the guilt, accept the
responsibility--and we usually doing everything at once in the jumble and confusion that
suicide leaves in its wake. Dr. Edward Dunne describes how the act of suicide hits like a
meteorite--it crashes into a family and each person is left to circuit in his or her own
individual orbit of grief. The people closest to us, those who have experienced the same
loss, often experience the death in different ways. This, too, can intensify our feelings of
loneliness and alienation, and make us feel even more confused.
As survivors, we live and relieve the suicide of our loved ones. We turn every detail in
every way possible, always looking for the time when we could have stepped in and
stopped what was happening. We torture ourselves with the if-onlys: if only I had
entered Harry's office earlier; if only I had checked his computer before he died and not
afterwards and could have discovered the extensive research he had conducted on the
best kind of drug to use to bring on the fastest and least painful death. (The medical
examiner told me that Harry took ten times the needed dosage for Thiopental and was
asleep in seconds, dead in minutes). If only I had been more forceful about Harry's
getting help and not allowed myself to believe his medical man's stance that his was "a
normal reaction to the double loss of his parents" and that even Freud said that mourning
could not be helped by therapy.
Like all survivors, I was seized by ravaging guilt at Harry's suicide. It defined me, it
shaped my days and woke me from sleep with nightmares. There was no question in my
mind--I could have stopped Harry, I should have stopped him, I was guilty for his death,
and most important, I was responsible for not keeping him alive. My initial reaction
was to cover up Harry's suicide. I told everyone except for a few close friends and my
immediate family that Harry had a heart attack. It takes a lot of work to keep up a lie;
avoiding the truth is draining and exhausting. I convinced myself that I had no other
recourse but to deny the true circumstances of his death: if I had failed to keep my
husband alive, the least I could do was to protect his name and reputation by lying about
15
his decision to kill himself. I remember when I decided to stop lying. Several months
after Harry killed himself, I took a part-time job to help ease my disastrous financial
situation. The first week I was there, a group of women who worked at the organization
invited me out to lunch. "So tell us all about yourself," one of them began. "Are you
married? Single?" I froze, totally unprepared for how to answer her question.
"I was married," I stammered my reply.
"Oh?" she continued. "How long has it been since your divorce?"
"No, it's not that,” I was finally able to collect myself. "My husband died."
There was a long silence at the table. Then, the same woman said to me in a sympathetic
hush, "I'm sorry. I thought you were one of us." Her words cut through me like a knife.
If these women considered me an outsider because I was a young widow, what would
they think if they knew that my husband had killed himself? Panic swept over me; I
wanted to run out of the restaurant.
"How old was your husband?" another woman asked.
"Forty-three." I could hear myself talking from a distance, as if I were dead
myself.
"Do you mind if I ask how he died?" the interrogation continued.
"Of course not," I replied, hoping that they would mistake my almost paralyzing distress
for conventional grief. I launched into a detailed story, describing how Harry had
suffered a heart attack from working too hard. How he had exhausted himself from
taking care of his dying parents. How he was slightly overweight. I even added the facts
that heart disease ran in his family, that his cholesterol was high. I recounted entering
into his office to find him slumped over his desk. Calling 911 emergency. Watching the
police and paramedics trying to save him. The medical examiner pronouncing him dead.
Although the framework of the narrative remained intact, the facts were reshaped for my
comfort. The women listened supportively, yet with intense curiosity. This was my
standard version for how I explained Harry's premature and sudden death. I told
variations of this story to his patients, our neighbors, my relatives, the doctors with whom
he worked, his secretary, our casual friends. I was convinced that I had no other recourse
but to deny the true circumstances of his death: if I had failed to keep my husband alive,
the least I could do was to protect his name and reputation by lying about his decision to
kill himself.
A few days after this calamitous lunch, I found myself on the elevator with the woman
who had asked me about my marital status. She started telling me about the unexpected
death of a board member which had occurred the day before. It was a massive heart
attack, she confided. All of a sudden, she gasped. "I'm so sorry," she apologized. "How
insensitive of me. Please forgive me." For the life of me, I could not understand what
she was talking about. Why should I be upset that this person had died? Awkward
silence filled the elevator as the woman looked away in embarrassment. I racked my
brains as to what could possibly be wrong. Then, I remembered. "That's right," I blurted
out. "My husband died of a heart attack." I felt humiliated by my inappropriate response.
At that moment, I realized how dramatically my life had become transformed by the
stigma that surrounds suicide. Why should I have to cover up what had happened? Yet,
I also knew that if I decided to be honest with my colleague in the elevator, the real
reason for my husband's death would be broadcast throughout the office by the end of the
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day. Even though part of me wanted to tell her the truth, I was convinced that it was
none of her business. The boundary between my right to privacy and the shame I felt at
hiding my secret had totally blurred.
The taboo against suicide can often condemn us to a life sentence of silence. Some
religious beliefs still consider suicide a sin, and there is often a fear among survivors that
their loved ones may be condemned to everlasting damnation. Fortunately, most
religions now consider suicide the result of a illness and not as a sin. Many clergy now
council that a person's decision to die should not be allowed to invalidate the positive and
wonderful things he or she did in life, or affect the mourning process of the loved ones
they leave behind.
SURVIVOR'S GROUPS
After Harry killed himself, I became convinced that there was no one in the world who
could possibly understand what I was feeling, what I was going through. I felt alienated
from my family and closest friends--all their sympathetic words and compassionate offers
for help could not address or penetrate the aloneness and helplessness that defined my
waking days and sleepless nights. I knew I had to reach out to others who had
experienced what I was now feeling. One month after Harry's suicide, I forced myself to
go to a survivor support group in the basement of a church on the Upper West Side of
Manhattan. I walked around the block a couple of times before I was able to enter the
room, even though there was a sign on the door that read, "Safe Place." I walked into a
space filled with men and women who looked so normal. There was no way these people
could have possibly lost a husband or daughter or mother to suicide. Some were actually
laughing, others were eating cookies, others were sitting quietly in a rapidly filling circle.
The group leader came up to me and introduced himself. "I'm Jean Claude," he said.
"Welcome to Safe Place." I sat down next to him as if in a daze. The meeting slowly
came to order. One by one, we went around the circle saying who we had lost, how they
had died, and when it occurred. In that instant, I knew I wasn't crazy. What had
happened was crazy but I wasn't. Because all these people were describing unbelievable
events yet I knew that what happened to them was not their fault. They were the ones
who were painstakingly putting the pieces of their lives back together again, who were
doing everything in their power to survive and not be consumed by the chaos that defines
the aftermath of a suicide.
Suicide survivors do not judge each other--just the opposite. We tell each other: "You
did the best you could." "How could you have known in advance?" "All of us fight with
our children." "People leave their girlfriends all the time." "I'm sure your brother didn't
kill himself because you didn't go to his basketball game." And gradually we begin to
see that if others are not to blame for their loved one's suicide, maybe it wasn't our fault
either. That if other people do not have the power of life and death in their hands, maybe
we don't either. And by feeling genuine compassion and empathy for others, we
gradually start to become less judgmental and kinder to ourselves. The suicide support
groups I attended literally made me feel sane and offered a safe place and calm refuge as
my world shook and trembled. I went monthly for the first two years and now I
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occasionally return for holidays or the anniversary of Harry's death or to accompany a
recent survivor who is afraid of attending his or her first meeting alone.
The defining part of losing a loved one to suicide is the isolation and alienation you feel
from all that was once familiar. To sit in a room filled with people who know exactly
what you have been through, who feel crazy and suicidal and homicidal and confused just
like you do, gives you the lifeline of connection. Every one of the people I have met in
those groups has become a part of me. If there is only one piece of advice that I could
give to suicide survivors, it would be to find some kind of support network where they
can meet other people who have also “been there.” Survivors
are
brave
and
compassionate people. We drag ourselves to meetings or therapy or conferences to try to
make sense of our unthinkable tragedies. We are survivors of a shipwreck, left
rudderless, not knowing what hit us. We are consumed by guilt for having failed to save
the dearest people in our lives yet ashamed at still being alive. Yet, somehow, despite all
this, gradually, we survivors start healing, we begin moving on. We realize that we are
still alive, that our lives did not end with the suicide. Although for a while we are
consumed about what happened 24 hours a day, we discover there are minutes, then
hours, then chunks of time, when we are able to think of other things than the intricate
details of our loved one's death. We begin to remember the wonder of their lives, not just
the circumstances of how they died.
REACHING OUT AND GETTING HELP
Those of us who lose a loved one to suicide are thrust into a world that is unfamiliar and
frightening. In the United States, we learn in an instant that in addition to everything
else, suicide is a crime, and most of us have had little exposure to this world.
Survivors are people who need help--who desperately want help--yet many of us are
often discouraged by a system that places more emphasis on the whys and motives of our
loved one's suicide than the pain and confusion that we are feeling. Suicide is a complex
and fascinating subject. A person crosses a forbidden boundary and creates a mystery
that can never be solved. We are left behind as witnesses and as such, our emotional
response is usually defined in the context and circumstances of our loved one's death.
As a result, many survivors start off as skeptics regarding getting help for ourselves and
our families, especially if our loved one had been in any kind of analysis, therapy or
counseling at their time of their death. We angrily reason that the mental health
professional--whether he or she is a counselor, social worker, psychiatrist, psychologist,
or whomever, should have seen the impending signs of anguish and despair and either
tried to intervene more actively or told us what was going on or both.
Survivors talk about going for counseling after the suicide and having most of the session
centered on the person who has died. "Was your mother depressed?" we are asked.
"Was your daughter involved in drugs?" "Were there any indications that your partner
was thinking about taking his life?" "Did you notice anything abnormal about your
husband's behavior?" These questions just reinforce the guilt we are already feeling
about our failure as a wife, a father, a son. We interpret the therapist's questions as
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implying we should have seen something happening but were either too self-involved to
notice or blinded by our own denial.
We try to answer, we speculate, we turn the
clues and signs over and over again, looking for an answer, a clear and simple sound-bite:
"My husband killed himself because both his parents died in one year." "My brother shot
himself because he was diagnosed with HIV." "My mother didn't want to be a burden to
us any more." "My sister's boyfriend broke up with her." Who knows? Who will even
know? The only thing we will know is what we feel about what happened. We are
embarrassed and ashamed. We feel alone and isolated in our grief. That's why we look
for help to sort out our complicated emotions and responses. If we go to a mental health
professional who is uncomfortable with the subject of death or suicide or both, we know
it right away. Our radar is finely tuned. A therapist's uneasiness with our grief only
serves to confirm our own conviction that we are to blame for our loved one's death; it is
indeed our fault.
On the other hand, there are many of us who have made it through because we have had
the good fortune to be helped by sensitive and sympathetic counselors and therapists. I
was lucky. My therapist was not afraid of the subject of death nor death by suicide, and
her insights and wisdom helped me through the darkest of times. For me, therapy was an
essential part of my healing process. And one I still call on from time to time!
CONCLUSION
I didn't believe it would ever be possible to recover from the impact of my husband's
decision to die. I thought I would feel that incredible raw pain forever, that I would never
be able to put the pieces of my shattered life back together ever again.
I was afraid I would never write again and certainly never marry again. I was terrified of
dating--after all, it's not exactly a turn-on--or so I quickly discovered--to tell a man that
your husband killed himself. But the road to recovery is filled with unexpected twists
and turns. Eight years ago I met a kind and compassionate man who respected my love
for Harry and cherished me as a caring woman who had experienced and survived both
the joys and sorrows of what life brings. There was no one more amazed than I to
discover that my ability--or capacity--to love had not been extinguished by Harry's death.
Two years later, Allen and I decided to get married. We both agreed that we wanted to
have a big wedding, filled with music and dancing and laughing and eating and lots of
fun. We wanted our union to be joyous and we wanted to share it with others.
I was ready for happiness, believe me. But what I was not prepared for was the guilt that
flooded through me as I approached the day of the wedding. I couldn't get beyond the
idea that I was forsaking Harry--or at the very least his memory. I was not prepared for
the shame of, in my mind, abandoning my husband and the blame that flooded through
me of knowing that I had survived and was moving on, while Harry was lying in the cold
ground. I remember going with Allen to meet the rabbi to ask him if he would marry us.
I worried through all the possibilities, and was nervous the rabbi might turn us down if he
found out that Harry killed himself. This had nothing to do with Jewish law, mind you,
but with my own guilt. In the bottom reaches of my mind, I still believe that I could have
saved Harry and therefore had contributed to his death. I was unworthy, undeserving.
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All those thoughts I believed that I had put to rest came out of the darkness to haunt me,
yet once again. When the rabbi asked if either one of us had been married before, I
mumbled yes. Then I was silent. "He died," I finally blurted out. "Your husband must
have been young," the rabbi said. "Was it an illness?" I took a deep breath. "No, he
killed himself." The rabbi reached across his desk and took my hand. "I am so sorry," he
said. "Would you like to talk about it?" I told the rabbi that Harry's parents had died
within a short time of each other, and how he had never seemed to recover from their
deaths. I told him how Harry had killed himself only four months after his father's
funeral. The rabbi listened carefully. "My parents also died within one year of each
other," he said. "I have never known such sorrow. I was 36 years old, I was married to a
wife I loved more than the world, and had two wonderful children who were the light of
my life. Yet, it didn't seem to matter. All I could feel was the terrible loss of my parents.
Even the love of my wife and children couldn't reach me. Slowly, I emerged from my
pain and came to cherish the love of my family once again. "I understood what the rabbi
was trying to tell me. That I hadn't been a "bad" wife, that Harry's journey was his alone,
that despair and grief is private, and that we cannot will another person to live or give
him our life force.
Our wedding was joyous, filled with friends and relatives, laughter and song. During the
ceremony, the rabbi said: "Everyone here wishes you great happiness. Because you
deserve it." We all deserve happiness. I have accepted that I can go on living and still
remember Harry and honor his memory. Embracing life is truly is a tribute to our loved
one's legacy and our need and desire not only to survive but also to thrive. Even though
each of us has been transformed by suicide, our scars are reminders of the person whom
we lost. They are part of us, as are the wonderful memories and beautiful times.
Imre Kertez, the Hungarian writer who won the Nobel Prize for Literature, wrote a book
called "Fateless" about his experiences as a 15-year-old boy in the Auschwitz
concentration camp during World War II. Although he loses his entire family, he
survives the brutality and returns to Hungary after the war. When asked to recount the
horrors of the death camp, he finds that he would rather remember the small graces and
people who helped him along the way instead. The book ends: "There is no
impossibility that cannot be overcome and survived. Further down the road, I now know,
happiness lies in wait for me like an inevitable trap. Even back there, in the shadow of
the chimneys, in the breaks between the pain, there was something resembling happiness.
Everybody will ask me about the deprivations, the 'terror of the camps,' but for me, the
happiness there will always be the most memorable experience, perhaps. Yes, that's what
I'll tell them the next time they ask me: about the happiness in the camps.
"If they ever do ask.
"And if I don't forget."
I remember attending a support group where a woman in her late seventies spoke about
her 14-year-old son who had killed himself more than 35 years before. In those days,
electric shock treatment was recommended for survivors to try to erase some of the
trauma and treat any ensuing depression. This woman had undergone the prescribed
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treatment and was left with only the blurry impression of the events surrounding her son's
death. Then, around two years before I saw her at the meeting, she began to be flooded
with specific recollections of coming home one day to find her son hanging from the light
fixture in his bedroom. She began having nightmares and started obsessing, reliving the
incident over and over again in her mind. Finally, she went for help--for individual
counseling and to support groups for suicide survivors. "You cannot escape what
happened," she told our group that night. "You cannot hide. You have to go through it to
get through it."
Each one of us must go through our individual voyage, to confront the truth, to tell our
children, to learn to not be ashamed, to stop whispering. Only as more of us begin
talking about suicide openly, will the secrecy of mourning our loved one's death begin to
diminish and allow us to heal. In letting go of the silence, we also let the many others out
there know they are not alone in their grief and pain.
Survivors soon begin to discover inner resources that we never knew existed. Although
we didn't ask for this test of our endurance--and would reverse the circumstances if given
the choice--we discover that we are more resilient, less afraid, more empathetic and
understanding as a result of what has happened to us.
Survivors do not waver from one unassailable certainty--we dearly miss our mothers and
fathers, our sisters and brothers, our sons and daughters, our husbands and wives, our
relatives and friends. Harry was a gifted healer. It is my hope that in telling his story and
mine, I can provide some kind of insight for those who have been left behind as well as
those who help us with our pain, and ensure that Harry’s death--and the deaths of all our
loved ones—will not have been in vain.
Ms. Carla Fine, 477 West 22nd Street, New York, N.Y. 10011. E-mail: carlafine@earthlink.net
Chairperson: Ms. Mary Hutchinson – Comments
It was a pleasure and privilege to chair the first section of the seminar on bereavement by
suicide, in which we heard papers from Christy Kenneally and Carla Fine. While the
content of the two papers was very different, both speakers’ delivery was comprehensive
and eloquent, setting the scene for what was a very stimulating and important seminar.
Christy’s presentation was entertaining and thought provoking. He drew our attention to
changes in methods of communication and highlighted how people conceal, and are at
times ‘expected’ to conceal grief, especially grief surrounding suicide. The listener was
both challenged and informed in a most interesting way.
Carla shared the story of her husband’s death by suicide with us and told us of her
journey through grief, her difficulty in telling people that her husband died by his own
hand and her struggle to acceptance. Her testimony was compelling and effective and
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many in the audience seemed to nod in agreement with the sentiments expressed, and
reacted with understanding and compassion as she relived her ordeal.
As a person, also bereaved by suicide, I felt that both presentations complemented each
other very well, and I could tell that the audience received them with enthusiasm. The
session was also enhanced by comments and questions from the floor. It seemed that
quite a number of people wished to participate during this period and it was a matter of
regret that we ran out of time.
THE EMPIRICAL APPROACH TO BEREAVEMENT SUPPORTS
Dr. Tony Byrne - Sr. Kathleen Maguire
Community Educator and Director of programmes on Facing up to Suicide, Confronting
Bullying, Harmony in the Home and Facing up to Alcohol Misuse
Abstract

Empirical versus normative approach to bereavement support

Compassion: the key to bereavement support

Levels of bereavement: shock, unnecessary blame and shame, loneliness and loss,
certificate, inquest, beginnings of recovery, transcendent level

The fear factor and bereavement

“I cannot be responsible for my dear one’s death by suicide, but I should feel
responsible for trying to heal because I owe it to myself, my family and my
friends”

Collaborative/gender balance approach to bereavement support

Suicide and the Moral issue
1. Language and Bereavement Support:“Language is the house of our being. It names the world in which we reside and
establishes its limits and horizons” (Heidegger, Martin, Being and Time)
Language is always inadequate and can be improved. Our experience makes us
convinced that language has little or no value at the initial stage of grief, except the words
“I am sorry for what has happened and I don’t know what to say.” At this stage, the
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language of the heart – real, genuine compassion – is absolutely essential for effective
bereavement support.
2. Do we need to critique our bereavement support language?
“Gobbledygook/waffle” language is useless. Words like “clients”, “survivors”, and
making nameless reference to the deceased can be inappropriate and unhelpful.
3. Normative Approach:This approach downplays the importance of the local culture, traditions, customs,
experience and the background of the bereaved. It emphasis global research findings,
principles of counselling and ignores the local culture, beliefs and customs. This type of
bereavement support needs to be critiqued.
The empirical approach respects the culture, sub-culture, traditions, customs, mentalities
and attitudes, while not ignoring the accepted principles of bereavement support and
research findings. Culture in this context is understood as a set of beliefs, feelings,
attitudes and behaviour patterns that shape and form a local community / society. Culture
is never static, it is always changing.
4. Need for inculturation:Imported ways of bereavement support that are transplanted from another culture, society
or historical times are usually not very effective or helpful. We need to place our
bereavement support in the context of our Irish Culture. We need to think globally but
act in a local way according to our culture.
5. Gender balance / Collaborative Bereavement Support:Gender balance improves the quality of bereavement support because it lessens the risk
of litigation and false accusations; it avoids creating a dependence relationship on one
individual person. Male and female bereavement support provides a more integrated
support service for the bereaved. It can be one way of encouraging more males to be
involved in this service.
6. Fear and Bereavement:Families who lose their dear ones by suicide often fear that another member of the family
will kill himself or herself. Suicide per se is not hereditary but negative emotions and
other factors in a family can trigger suicide. From our experience we have found that it
can be helpful for family members to reach an agreement that they will not kill
themselves without first talking about their problem in the family.
7. The Dimensions of Bereavement Support:-
23
1. The intellectual dimension: That is the cognitive dimension of
bereavement support, i.e., knowledge of the principles of bereavement and
knowledge of the local culture, customs, etc.
2. The affective dimension: It is related to feelings, sympathy, genuine
loving compassion and real concern for the bereaved.
3. The behavioural dimension: This is about reaching out, being available,
visiting and revisiting homes, remembering anniversaries or birthdays.
These three dimensions are symbiotically related and are mutually advantageous. They
are essential components for effective bereavement support.
8. Sin and Suicide:- The majority of responsible researchers, suicidologists and moral
theologians would believe that 90% of those who die by suicide have diminished
responsibility. Moral theology claims that to commit sin one must have full knowledge
and full consent. The majority of those who die by suicide lack full consent. However,
the question of sin and suicide was discussed down the years of history. The Ancient
Egyptians, Stoics and Epicureans denied that suicide is sinful. Plato, Socrates, St.
Augustine, St. Thomas Aquinas, Immanuel, Kant and Flavious Josephus claimed that
suicide is sinful. For many years, the Catholic Church, together with the Protestant,
Jewish and Islamic faiths, denied religious burials for those who died by suicide. Now
the Catholic, Protestant and Jewish faiths do not deny religious burial for those who take
their own lives. It is interesting to note that the Bible records many suicides without
condemning those who kill themselves.
Dr. Tony Byrne, Sr. Kathleen Maguire, Community Education Office, 3 Cabra Grove, Dublin 7.
Telephone: 01 8388888. E-mail: awarenesseducation@eircom.net
MENS’ EXPERIENCE OF GRIEF FOLLOWING DEATH BY SUICIDE
Dr. Adrian Hill
Executive Director of the Legal Profession Assistance Conference and Treasurer of the
Canadian Association for Suicide Prevention.
Abstract
Adrian will address the issue of men’s’ grief and bereavement. By sharing our
experience, strength and hope, He will confront the confusion, anger, denial
and the erosion of the value of living, while identifying what has worked to
bring forth healing, renewed optimism and purpose. We will invite men to
explore their grief following a death by suicide and to identify what worked in
moving past the pain and anguish and re-establishing acceptance, equilibrium
and serenity. Men can fall into an emotional wasteland following a death by
suicide.
24
In 1994 I attended my first suicide prevention conference with my wife, a noted
psychologist with considerable expertise in suicide prevention and bereavement
programs. Travelling to Canada’s artic. We visited Iqaluit in Nunavut, a community of
3,000 people, the only city in a vast region.
Organized by the Canadian Association for Suicide Prevention, there were keynote
addresses, workshops, seminars and meetings with speakers from around the world. I
immersed myself in the conference and experienced first-hand the anguish and grief of
the local community which has been ravaged by suicide deaths for the past twenty years.
Knowing next to nothing about suicide, prevention and bereavement, there was much to
learn, absorb and take to heart.
This first conference experience for me started an educational process that quickly
accelerated in 1996 when I became Executive Director of a national Lawyers’ Assistance
Program in Canada. While I had helped found the program in 1990, I was now
responsible for developing Health, Wellness and Recovery materials for 70,000 lawyers
and judges across Canada. To me, it had become natural to include suicide prevention in
the new materials I was creating.
Our interest in suicide prevention and bereavement services accelerated when LPAC
received an urgent call for help from the Province of Nova Scotia after a series of lawyer
suicides in the city of Halifax. The Barristers’ Society, the Nova Scotia Branch of the
Canadian Bar Association, and the entire legal community were in distress.
LPAC initiated a comprehensive response, which included an attempt to research and to
understand the scope of the problem. The LPAC 1997 Lawyer Suicide Study identified
suicide as the third leading cause of death and established an approximate suicide rate of
69.3 suicide deaths per 100,000 population, nearly six times the general population.
The original LPAC 1997 Lawyer Suicide Study was the first reported investigation of
lawyer suicide in Canada and the data has been widely reported and quoted in research
papers and in professional articles around the world. It appears to be the first time
anywhere that lawyer suicide had been studied.
THE LPAC SUICIDE PREVENTION PROGRAM
In response to the situation in Nova Scotia, LPAC began a nation-wide suicide prevention
and bereavement support training program for lawyers and judges and for Lawyer
Assistance Programs in 1997. LPAC consulted with Dr. Brian Taney and Dr. Roger
Tierney of the Canadian Association for Suicide Prevention (CASP) and with Dr. Lanny
Berman and Dr. Morton Silverman of the American Association of Suicidology (AAS)
for ideas and direction. We accessed information, data and materials from the Suicide
Information and Education Centre in Calgary, the leading suicide library facility in the
world. We enlisted the support and expertise of Dr. Heather Fiske, a clinical
psychologist with expertise in hospital and community-based suicide prevention
25
programs and strategies whose innovations have enjoyed strong peer support and
approval within both CASP and AAS.
LPAC presented a half-day suicide prevention program at the 1997 National Workshop
for the American Bar Association Commission on Lawyer Assistance Programs (CoLAP)
in Washington, D.C. featuring Dr. Fiske and Dr. Berman, Executive Director of AAS.
This was the first time that suicide prevention was addressed at any CoLAP Workshop
and it appears to have been the first such program in the world. This was a remarkable
accomplishment for the Canadian Bar Association. LPAC presented a second suicide
prevention program the following year at the joint LPAC/CoLAP 1998 International
Workshop in Montreal. This program featuring Dr. Taney and Dr. Fiske focused on
suicide bereavement and support training.
LPAC and Dr. Fiske created the Suicide Prevention Education Manual with teacher and
student materials for LPAC’s Health, Wellness and Recovery Education Series in 1999,
the most comprehensive lawyer wellness materials available anywhere. Awareness of
suicide risk in the legal profession has been greatly improved by the CBA and its LPAC
programs. Suicide prevention is now an accepted part of the mandates of assistance
programs for law students and lawyers and judges. A cluster of lawyer suicides has not
occurred again in Canada.
In every year since 1999, LPAC has provided suicide prevention programs for the
Canadian Bar Association, and for many provincial and state Lawyer Assistance
Programs and Bar Associations in Canada and the United States. In 2001, LPAC
presented its course materials for peer review at a major medical conference for addiction
physicians.
In 2002, LPAC’s website was expanded to include all of the 25 courses in the Health,
Wellness and Recovery Education Series, with funding from the CBA’s Law for the
Future Fund. Our courses can now be read, downloaded and printed without charge by
anyone in the world. LPAC’s suicide prevention course has been translated into four
languages for use by Bar Associations in Canada, the United States, Europe, New
Zealand and Australia.
To visit the website: Go to www.LPAC.ca... English…Education Programs…
On-Line Courses…Suicide Prevention and Awareness.
MENS’ EXPERIENCE OF GRIEF
In 2003, my wife and I again travelled to Iqaluit, Nunavut for the annual CASP suicide
prevention conference. She was to Chair a panel of men speaking on our experience of
grief and the panellists included me and two of our friends, Hugh and David. The panel
presentation was dramatic, emotional, and very revealing.
Heather addressed 7 questions to each of us:
1. How has your grief been expressed?
26
2. What steps or stages can you see in your healing?
3. What has helped your healing? Specifically, what have other people done or said that
made a difference?
4. What has hindered it? And what do you think can or could have made a difference
with the hindrances?
5. How do you think that your experience as a survivor has been the same as or different
from that of women survivors in your life? What has been more or less challenging?
6. What have you learned in your journey so far that you want to tell others?
7. What gives you hope?
We learned that both Hugh and David had been stuck in their grief and confusion for
nearly ten years. Each had lost a son in his twenties and the loss had been devastating.
Hugh told us that he had been angry, frustrated, confused and bewildered. While his wife
had gone to survivor groups and then busied herself in starting bereavement support
groups and teaching at conferences, Hugh had been on the side lines. His pain was so
deep and so repressed that he had no means of understanding or accepting his loss, much
less letting go or moving on. In addition to anger, Hugh left overwhelming guilt and
remorse, even though he fully understood that there was nothing further he could have
done to prevent his son’s death by suicide. Slowly, over a period of more than ten years,
cracks began to appear in Hugh’s impervious shell so that little by little the light began to
get in. Hugh met other men and this allowed for quiet and private sharing so that little by
little, Hugh began to experience progress.
The culmination of Hugh’s growing understanding and acceptance was his participation
on the panel in Iqaluit. For the first time in his life, he shared openly and publicly in a
room full of suicide survivors. Tears flowed, anguish was evident and they were joined
by love, support and acceptance. At the end of the session, every man and woman in the
room lined up to hug Hugh.
For Hugh, his healing was finally well under way.
David’s story was remarkably similar but his approach had been very different. Rather
than accompany his wife to suicide prevention and bereavement events and stand in the
background as Hugh had done, David had stayed away all together. On his own, he had
searched and researched with an engineer’s zeal to find out and to understand why his
son had died by suicide. He believed that if he could understand the reasons, he could
come to understand and accept his son’s death. While telling no one about his search and
his research, he studied the investigative file respecting his son’s death, including the
autopsy report and the coroner’s report, difficult, even dreadful reading for anyone.
David maintained a dispassionate and professional approach as a coping mechanism. His
research led him to studies and reports which added to his general knowledge but gave
him little insight into his son’s death.
Like Hugh, cracks slowly began to appear in David’s thick skin and slowly and gradually
the light filtered through. It now appears likely, these many years later, that both of these
27
young men had died by suicide as a result as an undiagnosed and untreated bi-polar
disorder. While both had been treated for clinical depression, the medications they were
prescribed would be useless or even harmful to someone who’s true or correct diagnosis
is bipolar disorder. This appears to be plainly established by research done in Canada by
leading psychiatrists and psychologists and it is confirmed by similar research done
elsewhere.
So, Hugh and David teach us that men can find the pain of a death by suicide, especially
the loss of a child, overwhelmingly painful. It may be that our skills as men are limited
in this area and that our ability to seek help is limited as well, perhaps by custom, training
or habit. While Hugh and David’s respective wives had turned their bereavement and
suffering into a loving involvement in suicide prevention and bereavement support, Hugh
and David’s inability to step outside their intolerable pain left them locked in isolation.
For those of us who work in suicide prevention and bereavement support, the experience
of Hugh and David is not unusual. For many men, the stereotype appears to fit.
Now, some of you may have noticed that I have neatly avoided my own participation in
the panel. It’s time to fill in my story. As you now know, I became seriously involved in
suicide prevention work in the mid 90s and by 1999 I was the author of a major study, the
creator of a national program and I was someone who came to suicide prevention and
bereavement support conferences. I helped set up chairs, take registrations, moderate
educational programs and I attended the bereavement services with my friends. Every
now and then, a stranger would cry on my shoulder and I would provide the natural
support we learn in our role as parents.
I thought I understood.
My story continues in 1999. In addition to running my federal Lawyer Assistance
Program, I was still practicing law and everything was going very well. In fact, I was
having a great year professionally and personally. My law practice was going very, very
well and I felt honoured to be chosen to represent a very large police service at a Public
Inquiry. My wife Heather and my two children were doing well in their chosen fields.
As an alcoholic in recovery, I had been sober more than 10 years and I felt great.
Nonetheless, as the year developed, events began to overtake me. In September, a very
close family friend died in my arms and taught me, for the first time in my life, to truly
grieve. As it turned out, this was a new skill I would soon need a little closer to home.
The Public Inquiry turned ugly and threats by terrorists meant I was going to work in
body armour, protected by a fully armed tactical police team. As an aside, I must tell you
that it is difficult to express the shame a man feels at bringing the risk of terrorism into
his home and to his wife and children. As you can sense, things were beginning to get
more than a little difficult.
In my recovery program, we have a tradition of mentoring called a sponsor, and my
sponsor was an elderly man who I love dearly. A survivor of lung cancer some 15 years
earlier, he learned that fall that his remaining lung was cancerous and he quickly became
seriously ill. So in this setting and at this time, in late October I received a telephone call
telling me that my mother had died by suicide in her retirement home in the South of
28
England. My parents, immigrants to Canada in 1948, had retired to England in 1988.
Using a combination of pills and alcohol, my mother had suffocated herself with a plastic
bag after carefully researching the most lethal and reliable methods. She had sent my
father out of town so that he could not be implicated in her death.
My mother, Francis, had been unable to walk, using a wheelchair for more than a dozen
years. A fiercely independent woman, she had died by suicide rather than face the fear of
being institutionalized with the loss of autonomy and dignity she believed that would
bring. She had planned her death very carefully and packages were sent by courier with
her suicide note by one of my brothers. I had no idea how to feel. I carried on with my
work feeling numb and little else. I spoke with my father by overseas telephone, and he
appeared to be frightened, confused and uncertain. As is often the case in families when
there is a death by suicide, people can act poorly. In our case, my father avoided telling
me and another of my brothers about the arrangements for our mother’s funeral, with the
result that we could not attend. With us in Canada, and my dad in the South of England,
this was easily achieved by him. The funeral was delayed for a time as the police made
their inquiries and a full investigative autopsy was conducted by the county coroner. The
funeral was about two weeks after her death and we were not notified until just hours
before the event.
Many of our friends asked me why my father would do such a thing. I have no idea but I
now suspect that fear and anger were the cause. In truth, I cannot explain further.
I was deeply hurt, confused and even shocked. I felt stuck. When I confronted my father
about his conduct, he blamed the situation on me. He soon became ill and he too died not
long after. This is often the case when a couple has been married more than 50 years.
When one spouse dies, the other often follows not long after.
With both my parents dead, I was even more confused and stuck. But I was lucky.
Things happened that brought me progress and peace. First, I attended a suicide
prevention conference in Los Angeles. While I had planned to go to the conference
anyway, what I discovered when I arrived was a revelation. For me, everything was
different. Every poster, every bulletin and book, every presentation, speech and seminar,
every face-to-face contact. I was pretty well known at the event and had dozens of
friends and several hundred acquaintances in attendance. I had a good reputation as a
hard worker, a friendly individual and a kindly man. Word spread quickly and I was to
receive hundreds of pats and hugs and words of comfort. During the survivors’ portion
of the conference, we had the usual candle light ceremony. The organizers asked me to
light the candle during the service as a survivor who lost a parent. As a trial lawyer, I had
30 years experience in performing in public, even when I felt poorly. I walked to the
front with my candle, lit it and confidently placed it in the holder. My task complete, I
turned to walk the twenty paces back to my seat in front of the crowded auditorium. It
was the longest walk of my life. Safely seated, I cried on the shoulder of a stranger.
That stranger is now a good friend and colleague and earlier this year, he and I were on a
new panel, describing the experience of men’s grief.
29
So, I should now fill in the answers to the questions that were posed to me in these
panels.
1. How has your grief been expressed?
I was bewildered, sad, confused and angry. At the same time, I felt peacefulness in
my relationship with my mother who is no longer in pain and distress. This leads me
to an observation I feel compelled to make. While the experts will tell us that we
should not compare our losses, I am most firmly of the view that there is a huge
difference between the loss of an aged parent, disabled or otherwise, and the loss of a
spouse or the unspeakable suffering of the loss of a child. While my mother’s death
by suicide opened my mind, my heart and my eyes in a way I had never anticipated or
expected, I have been spared the profound and complex grief that you and many of
my friends have experienced. Quite frankly, your loss and pain to me appears
intolerable.
2. What steps or stages can you see in your healing?
From numbness, to hurt and loss, to anger and to peaceful resolution. I remember
each of these stages with clarity.
3. What has helped your healing? Specifically, what have other people done or said
that made a difference?
I was so lucky in three different ways. Firstly, my wife and two children held me,
comforted me and loved me. This made all the difference. Secondly, I put the word
out to my friends, colleagues and associates and the results were truly astonishing. I
received notes, cards, e-mails, flowers and phone calls from over 200 people and I
was completely overwhelmed with this support. From the janitor and the security
guard in my office building, to friends and professional colleagues, to a former
president of the United States. They all took time to get in touch. This outpouring of
support was as humbling as it was healing. Finally, I had your help. I was already a
part of the suicide prevention and bereavement support world and you all came to my
rescue. At conferences and at meetings; from that day until this day, you have all had
your hand in keeping me safe.
4. What has hindered it? What do you think can or could have made a difference
with the hindrances?
Clearly, my family and our dysfunctional history. I needed a chance to grieve at my
mother’s funeral and I needed an opportunity to comfort my father and be comforted
by him. None of this was possible.
30
5. How do you think that your experience as a survivor has been the same as or
different from that of women survivors in your life? What has been more or less
challenging?
Strangely, the stereotypes all apply. As a man, I was quick to shut down and shut off.
On the other hand, I had the support of my family and my friends and I took their
advice to reach out for help. They were smarter than I could be at that time and I
was lucky to have their advice and even luckier to be able to take it. As I have told
you, the support I received was truly astonishing.
6. What have you learned in your journey so far that you want to tell others?
7. What gives you hope?
I’ll answer these two questions together in a minute, but first I have to give you the
final chapter of my story.
After my father died, I felt trapped in an issue I could never resolve. With my sister and
brothers, I did attend his funeral and for me it was a ceremony for both of my parents. I
taped letters from me and from my children to my dad’s coffin with the goal of burying
my hurt and anger with him. It only helped a little. One last event came to pass that
made me whole again.
You remember my sponsor Clive and the reoccurrence of his cancer. As time went by,
he grew more and more ill. He was in and out of hospital and I visited him often,
sometimes with my security detail in tow. One Sunday morning in February I realized
that it had been several weeks since I had called Clive and when I did telephone I learned
that he was back in hospital and very, very ill. I drove to the hospital that day and
learned that it was his 75th birthday. He wanted pizza for lunch and this became my
birthday gift to him. He entertained his family, including his grandchild and had a
wonderful day. Yet, it was clear to me that his hours were numbered. With his family’s
permission, I let a number of our joint friends know and quite a few of them dropped by
to see him the next morning. That evening I went back to the hospital to attend a meeting
of Alcoholics Anonymous with my three closest friends and our plan was to drop by and
see Clive, go to the AA meeting, then say goodnight to Clive. If he was well enough,
we’d take him to the meeting as well.
When we arrived at the hospital, Clive’s daughters were in great distress. Clearly, he was
dying and he was very, very uncomfortable. We stayed for a few minutes and then went
to the meeting as planned. We left the meting early, going back to his room before
visiting hours closed. The scene in Clive’s room was awful. He was semi-conscious and
in great agitation and picking at his skin. His daughters were very upset. I looked at
Clive closely and realized that his oxygen tube was behind his head and I replaced it in its
proper place, with the cannula into his nose. This is rather a personal thing to do for
another man but as soon as I did it, Clive calmed right down and became relaxed. I
31
realized that he had been suffocating without the oxygen, causing the behaviour and
symptoms we had seen.
With their father relaxed and comfortable, his daughters calmed down and together we
watched Clive slip off into death. For me, this experience with Clive healed the loss I
had felt from my absence at the deaths of my own parents. While I truly regret that my
mother died alone and at her own hand, I am now at peace with it. While I still regret my
father’s conduct at the time of her death and after, I am at peace with it. By being able to
care for Clive and to comfort his widow and his daughters and to stand as his pallbearer, I
found peace and serenity. In dieing, Clive gave me what I needed to move on. There is a
saying in AA, Doing for us what we cannot do for ourselves.
To answer question 6 and 7, let me say this.
If there was one thing by way of experience or advice I would want to pass on to
you all here today, it is this: Men need your support, love and experience every
bit as much as women and children. For many of us, we also need your guidance
and your ability to reach out even when we as men do not have the common sense
to reach back and take your hand. We are teachable, if a little slow. Have
patience. We too have much to offer.
Dr. Adrian Hill, Legal Profession Assistance, Conference of Canadian Bar Assoication, National
Administrative Office, 35, Scarborough Rd, Toronto, Ontario, M43 3M4, Canada. 001 4169648438
adrian@LPAC.ca
Chairperson – Ms. Margaret Hayes - Comments
Fr. Tony Byrne, community educator and Director of programmes on Facing up to
Suicide, focused on the different approaches to bereavement support. He said that the
key to support is compassion. Concentrating on the fear factor and bereavement he
outlined the different levels of bereavement; shock, unnecessary blame, shame, loneliness
and loss.
Sr. Kathleen Maguire, who initiated bereavement support training and facilitated
community and pastoral programmes in Mullingar parish, spoke about her personal
experience of suicide with the death of her nephew and how it affected her own life. She
focused on the coping mechanisms in dealing with suicide and the need for
understanding.
Dr. Adrian Hill, Advisory Board Member to the Ontario Suicide Prevention Network,
spoke about men’s experience of grief. He outlined his early introduction to conferences
on dealing with suicide prevention. He shared with us his personal experience of suicide
32
on the death of his mother and the deep hurt, confusion and shock he felt about the way
his mother’s death was handled.
In sharing with us his response to seven key questions about bereavement and grief he
left us with this piece of advice “men need your support, love and experience every bit as
much as women and children, they also need your guidance and your ability to reach out
even when they do not have the common sense to reach back and take your hand”
OPENING ADDRESS
Mr. Tom Byrne
Regional Manager, Mental Health and Older People Services. South-Eastern Health
Board
I am delighted to have been invited here to deliver the opening address for the 9th Annual
Conference of the Irish Association of Suicidology. I am particularly delighted to
welcome you to the South East, my adopted part of the country. For those of us who
were privileged to be here yesterday for the bereavement part of the conference we heard
the very moving accounts of the speakers who had themselves had experienced the very
depths of despair involving the death of a close family member/ partner through suicide
and yet were able to leave us with a very positive message of hope.
Since its foundation the Association has been to the forefront in ensuring that the issue of
suicide prevention kept in the public domain. It is worth recalling it's aims and objectives
which are:
1.To facilitate communication between clinicians, volunteers, survivors and researchers
in all matters relating to suicide and suicidal behaviour.
2.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 material
through the media.
3.To ensure that the public is better informed about suicide prevention.
4.To support and encourage relevant research
5.To encourage and support the formation of groups to help those bereaved by suicide
Together these represent a noble and yet attainable set aims and objectives. Today's
conference will focus on the third objective, it's theme being "Suicide Prevention: What
you can do" The Association has assembled an impressive panel of national and
international speakers and presenters to share their wisdom and the results of their
research with us. While the optimist in me would love to see this conference develop the
33
universal theorem of suicide prevention, the formula which we could apply in any
circumstances and which would always guide us to the most appropriate approach; the
realist in me suspects that this may prove elusive. However a knowledge of the
approaches which have been shown to work, or perhaps more importantly known to have
failed elsewhere is an essential ingredient in the formulation of our own plans.
In this regard it is also worth noting that the Health Boards Executive (HeBe) in
partnership with the National Suicide Review Group and the Department of Health and
Children is currently preparing a National Strategy on Suicide Prevention and it is hoped
that this will be published in the coming year.
Epidemiological studies from around the world have identified suicide as a major public
health issue. Here in Ireland in 1976 there were 5.7 deaths reported for every 100,000
population. This has increased steadily over the years to a rate of 11.1 per 100,000 in
2003, 444 deaths in all. Here in the South Eastern Region, which has a population of just
under 425,000 people, there were 60 deaths by suicide registered by the CSO in 2003 and
in the same year 975 people attended at our A&E Departments having deliberately
harmed themselves. In the latter case those most at risk were young women in the age
range 15 - 19 and young men in the age range 20 - 24. These statistics spur us on to
increase our effort in the whole area of suicide prevention and guide us on where specific
interventions need to be targeted.
I would like to thank the Association for putting this conference together and to
commend it for the tenacious manner in which it has promoted it's message and
attempted to fulfil it's aims and objectives since it's foundation.
In particular I would like to pay tribute to: President: Mr Dan Neville TD, Chairperson:
Professor Michael Fitzgerald, Secretary: Dr. John Connolly
I would also like to acknowledge the dedication and professionalism of the organizing
team of Josephine Scott, Angela Coleman and Niamh Connolly.
Finally may I wish you all a very pleasant stay in Wexford and I hope that you find the
papers to come both interesting and thought provoking.
Mr. Tom Byrne, Regional Manager, South Eastern Health Board, Lacken, Dublin Road, Kilkenny
The Michael Kelleher Memorial Lecture
GLOBAL PERSPECTIVES OF SUICIDE PREVENTION STRATEGIES
Dr. Annette Beautrais
Principal Investigator, Canterbury Suicide Project, New Zealand
34
Abstract
This talk will provide an overview of national suicide prevention strategies.
This issue will be examined from several perspectives: a. international
recommendations for suicide prevention strategies; b. common and unique
elements of national suicide prevention strategies; c. current evidence for the
effectiveness of elements of different national plans; d. approaches to
determining appropriate indicators for national progress in suicide prevention; e.
research needs to promote evaluation of existing plans and development of
national plans in countries which have not yet developed strategies.
INTRODUCTION
During the last two decades suicide rates have risen in many countries 1. This trend has
led to increased public awareness of suicide as a problem and to demands that countries
develop national strategies to reduce and prevent suicide.
The development of national suicide prevention strategies has a very recent history,
beginning with Finland which developed a national strategy in 1992. More recently, a
number of countries (including the United States, England, Australia and Sweden) have
developed national plans. Other countries (including Ireland, New Zealand, Canada,
China, Germany and Estonia) are currently developing strategies.
In the main, national suicide prevention strategies have developed without clear
guidelines and without strong evidence about the effectiveness of either national
strategies or of various components of these plans.
In the absence of strong evidence-based guidelines the development of national plans is
vulnerable to influence by such factors as the personal experiences of political leaders
and policy makers, political ideology, advocacy and special interest groups, and by
political pressure to allay public concern that "something must be done".
While these difficulties of strategy and programmatic development apply in varying
degrees to the development of national plans for a range of health related issues, they are
exacerbated for suicide prevention by the highly emotive nature of the issue, by limited
public knowledge and understanding, and by a reluctance to debate suicide or promote
knowledge about it because of concerns that public health messages about suicide may
have undesirable consequences.
During the last 15 years a substantial body of research about risk and protective factors
for suicidal behaviour and research methods has been generated and this provides a basis
upon which to develop prevention programmes. Review of this body of evidence
suggests that there is a remarkable consistency, across countries, cultures and research
35
approaches, about the risk factors and causal pathways for suicidal behaviour (for a
review, see, 2).
While all national suicide prevention strategies acknowledge a similar broad aetiology of
suicidal behaviour, individual national strategies tend to reflect prevailing models of
suicidal behaviour and political, policy and public influences. For example, New
Zealand adopted a community-based model for youth suicide prevention, with a strong
emphasis on educating community gatekeepers 3, Finland focussed strongly on
addressing mental health issues 4, and the United States has endorsed a public health
model 5.
The United Nations and the World Health Organisation promulgated recommendations
for national suicide prevention plans in 1996 6, advocating six major approaches: gun
control; detoxification of domestic gas; detoxification of car emissions; control of toxic
substances; media reporting guidelines; treatment of mental illness. The relative
importance of any one of these approaches depends on the profile of suicide in a
particular country. In China, for example, the high rate of suicide by pesticides suggests
a focus on control of toxic substances, while in the United States the predominant suicide
method (firearms) dictates a focus on gun control.
This paper will examine current knowledge about programmes and strategies that show
effectiveness, or promise of effectiveness, in reducing suicide, and which merit inclusion
in national suicide prevention strategies.
Research evidence clearly suggests that suicide is multifactorial and complex. Thus,
multiple interventions targeting a range of different populations and sites are needed to
reduce suicide. To synthesise various potential interventions into an orderly conceptual
framework, this paper examines these strategies using the Institute of Medicine's (1994)
model of Universal, Selective and Indicated (USI) interventions 7.
Universal
programmes are those targeted at the general population, regardless of risk status.
Selective programmes address high-risk sub-groups within the total population, and
indicated programmes address high risk individuals.
UNIVERSAL PROGRAMMES
There is sufficient research evidence to support a range of programmes targeted at the
general population. These programmes include:
MEANS RESTRICTION
Reducing access to particular means of suicide has been shown to reduce suicides by that
specific method, and sometimes, to reduce total suicide rates. These findings span a
range of means including: detoxification of domestic gas; various levels of restriction of
access to guns; imposing controls on emissions of carbon monoxide in vehicle exhaust
gas; reduction in the pack size of analgesics, and installing barriers at jumping sites 8-16.
MACROSOCIAL INTERVENTIONS
36
Research findings suggest consistent linkages between family, social and economic
disadvantage and suicide risk 17-21. While we lack evidence which clearly demonstrates
that achieving social equity in targeted areas (including, for example, poverty,
employment and racism), reduces suicide, nevertheless it seems sensible to advocate for
macro-social changes in such areas in order to provide the optimal environment for more
targeted prevention programmes for high risk groups or individuals to have the best
chance of success. In addition to social equity issues, there are general population
strategies in other social policy areas which may minimise suicidal behaviour. These
areas include social welfare, strengthening families, reducing family violence and child
abuse, and providing adequate welfare and mental health care for at risk children and
adolescents.
PUBLIC EDUCATION AND MENTAL HEALTH LITERACY
Improving public mental health literacy is regarded as an important public health goal,
and one which may make a contribution to suicide prevention by changing public
recognition and attitudes towards mental illnesses, particularly depression 22-29. In New
Zealand, evaluation of a national mental illness de-stigmatisation programme found
improved knowledge and attitudes about mental illness in the general population 30.
However, changes in outcome measures such as treatment seeking were not assessed.
Programmes focussing specifically on increasing awareness about depression have been
conducted in both Britain and Germany 27 31. Evaluations in both countries found
improvements in attitudes and knowledge about depression. However, this knowledge
failed to translate into improved attitudes about the use of antidepressant medication.
More research is needed to determine how public education approaches might be able to
change entrenched attitudes against the use of medication to treat depression.
MEDIA COVERAGE OF SUICIDE
Certain ways of presenting and portraying suicide in the media appear to provoke suicidal
behaviour in vulnerable individuals 32-37. This evidence has led a number of countries to
develop guidelines for media reporting and coverage of suicide. However, there have
been few evaluations of the impact of such guidelines. To date reports have suggested
mixed results. The introduction of media guidelines reportedly resulted in fewer
sensationalised stories about suicide in Switzerland 38, for example, while Lithuania
found no change 39. Further research is needed in this area.
IMPROVING CONTROL OF ALCOHOL
National strategies which seek to improve control of alcohol may reduce suicidal
behaviour by decreasing:
i.
risk of acute alcohol intoxication,
ii.
ii. the fraction of the population with alcohol use disorders.
A USA study of state minimum drinking age policies found that higher legal drinking
ages were associated with lower suicide rates in young people 40. The pronounced
decline in suicide rates during perestroika in the former USSR has been attributed to the
strong anti-alcohol policy introduced during that period, from 1985 to 1989 41 42.
37
PROMOTING MENTAL HEALTH/RESILIENCY
The World Health Organisation, the United Nations, and many national suicide
prevention strategies regard mental health promotion as an activity which contributes to
suicide prevention 3 5 43 44. These promotion activities include programmes to enhance
factors which might protect against suicide or mitigate the effects of risk factors. Such
approaches can be applied nationally or within communities or workplaces. The National
Suicide Prevention Programme in Finland, for example, includes public education
campaigns to enhance personal resources and coping abilities, to promote good parenting
styles, and to prepare people for retirement 4.
ORGANISATIONAL AND COMMUNITY LEVEL SUICIDE PREVENTION
PROGRAMMES
Recently the United States Air Force (USAF) Suicide Prevention programme has
received considerable publicity as an example of a population-based suicide prevention
programme 45. In this programme a united effort by community agencies within the
USAF was followed by a significant reduction in suicides among USAF personnel.
While it is likely that various advantageous features of the USAF institution (for
example, pre-screening for mental disorders) enhanced the implementation and
penetration of the programme, nevertheless, the programme has broad principles which
make it potentially transferable to civilian communities, including, for example,
universities, colleges, and work place organisations.
School-based suicide awareness and peer support programmes A range of school-based
informational and peer support suicide awareness programmes has been developed
based upon the premise that young people are more likely to divulge suicidal ideation to
peers than adults 46 47. However, these programmes have been controversial with some
evaluations showing improvements in knowledge, attitudes and help seeking and others
finding no gains or undesirable effects 47-54. Further evaluations of these programmes
are needed. In the meantime some countries (for example, New Zealand) have developed
criteria for schools to consider in deciding whether or not to implement specific schoolbased programmes 55.
SCHOOL BASED COMPETENCY AND SKILL PROMOTING PROGREMMES
Based on the assumption that promoting competency in a range of social skills will
mitigate risk of suicidal behaviour, some programmes have been designed to instil such
skills in young children in the hope that the acquisition of these skills will enable children
to cope with problems throughout childhood and adolescence. There are, for example,
positive reports for a programme which teaches social coping skills to six and seven year
olds, with children receiving the programme coping better with the transition from
kindergarten to school, than those not receiving it, and with the acquired skills
maintained at one year follow-up 56.
SELECTIVE PROGRAMMES
A body of research evidence supports a range of prevention approaches which focus on
high risk groups within the general population. These approaches include:
38
IMPROVING ACCESS TO MENTAL HEALTH PROGRAMMES AND ENHANCING
TREATMENT AND SUPPORT
A strong evidence base suggests that most of those who die by suicide have mental
disorders at the time of their death, which are, however, often unrecognised or
undertreated 57-59. These findings imply, firstly, that improving access to mental health
care, and enhancing treatment and management of mental illnesses, will reduce suicide
risk in those with such illnesses. In the well-reported Gotland study, for example, lower
suicide rates in females, as well as improvements in a range of measures of mental illhealth were reported after a programme to train general practitioners to better recognise
and treat depression 60 61.
Secondly, these findings imply that enhanced treatment and support for people who are
depressed and/or suicidal will reduce suicide risk. Support programmes may incorporate
elements of both mental health and community care 62-68. In one such programme,
General Practitioners and mental health professionals collaborated to manage patients
with depression. Findings suggested increased patient satisfaction with care, improved
compliance with medication and reduction in depressive symptomatology 62 63.
INFORMATIONAL AND EDUCATIONAL PROGRAMMES AND COMMUNITY
GATEKEEPERS
A range of programmes has been designed to enhance the ability of various gatekeeper
groups ( eg, military, school staff, social workers) to better identify and refer for
treatment individuals with depression and suicidal behaviour. In general, however,
guidelines and information programmes for a range of professional groups and
community gatekeepers have not been well evaluated. Evaluations have tended to focus
on process rather than outcome measures and there is a need for further large scale
evaluations of such programmes using a range of outcome measures.
CRISIS CENTRES AND TELEPHONE HOTLINES
Since there is substantial evidence that many suicide attempts are precipitated by stressful
life events, crisis centres and telephone hotlines have been developed to provide support
in times of crisis. While it may seem intuitively appealing to develop such centres,
several evaluations of crisis hotlines have failed to find clear evidence of their efficacy in
reducing suicidal behaviour and there is a need for further research 69-72.
SCHOOL BASED SKILLS PROMOTING PROGRAMMES
Skill-enhancing and competency-promoting programmes have been introduced as an
alternative to didactic suicide awareness programmes in schools and are based on the
premise that enhancing self-esteem, and coping and problem solving skills, may protect
vulnerable young people against a range of adverse outcomes including suicidal
behaviour, depression and substance abuse. Positive findings have been reported for such
programmes targeted to high risk high school students 73-76.
INDICATED PROGRAMMES
There is research evidence to support various prevention approaches targeted at high risk
individuals. These approaches include:
39
PHARMACOLOGICAL APPROACHES
A number of psychopharmacological treatments for specific mental illnesses have been
shown to reduce suicidal behaviour in patients with these illnesses. These treatments
include: long term maintenance therapy with lithium for patients with recurrent bipolar
disorder and major depressive disorder 77-82; the use of the antipsychotics clozapine, and
perhaps olanzapine, in patients with schizophrenia 83 84; and the use of Electroconvulsive
Therapy (ECT) with selected patients who are acutely suicidal 85-87.
Notably, there is no evidence from randomised controlled trials (RCTs) that
antidepressant therapy or treatment with mood-stabilising anticonvulsant drugs reduces
suicidal behaviour in patients with mood disorders, and no evidence that treatment with
anti-anxiety agents reduces suicide or suicide attempts in patients with depression and
anxiety 81 88-92. However, the failure of RCTs to show significant reductions in suicidal
behaviour for antidepressant therapy may reflect the methodological difficulties of
research in this area.
Controlled trials of antidepressant therapy versus placebo have shown significant
reductions in suicidal ideation 93-96. There is also growing evidence from population
based studies to suggest that the recent widespread introduction and use of the class of
antidepressants known as selective serotonin reuptake inhibitors (SSRIs) has been
associated with decreased suicide rates 95 96.
However, recent controversy regarding reported adverse events that occurred in clinical
trials of SSRIs for children and adolescents 97 has led to re-evaluation of the research
evidence. Recently the US Food and Drug Administration has recommended that a
“black box” warning be added to the health professional labelling of all antidepressant
medications to describe an increased risk of suicidal thoughts and behavior in children
and adolescents being treated with antidepressant medications 98. There are concerns that
this warning may result in the decreased use of medication in depressed children and
adolescents 99.
BEHAVIOURAL THERAPIES
A range of behavioural therapies and approaches have shown effectiveness, or promise of
effectiveness, in reducing suicidal behaviour. These approaches include Cognitive
Behavioural Therapy (CBT), Interpersonal Psychotherapy (IPT), Dialectical Behavioural
Therapy (DBT), provision of an emergency 'ready access' card to patients who have
attempted suicide, maintaining postcard or letter contact after a suicide attempt, and being
referred for active follow-up after a suicide attempt 100-106.
CONCLUSION
Suicide is a complex behaviour with multiple causes, which nevertheless seems to have a
single common pathway via mental disorder. This evidence suggests that no single
programme will achieve a significant reduction in suicide rates. Rather, it seems likely
that a multi-compartmental approach is needed in which multiple prevention programmes
are developed in a number of different areas which contribute to suicide risk, with,
40
perhaps, small gains in each of these areas aggregating to make a substantial overall
impact on suicide rates.
While a number of areas appear to show promise for suicide prevention, rigorous and
compelling evaluations of the efficacy, effectiveness and cost effectiveness of suicide
prevention programmes are still lacking. One way of assigning priority to the wide range
of prevention options is to consider the relative contributions of specific risk factors to
suicidal behaviour. One way of estimating the relative contribution of a given risk factor
to risk of serious suicidal behaviour is to compute the Population Attributable Risk
(PAR) 107. The PAR describes the percentage reduction in the outcome of interest, (here,
suicide or suicide attempt), which might be possible if a. the risk factor were causally
related to suicide, and b. if it were possible to eliminate that risk factor. PAR estimates
consistently suggest that mood disorders (approximately 70%) and substance use
disorders (approximately 30%) make the largest contributions to suicide risk 108-110.
These estimates imply that, to be successful, any suicide prevention policy needs to
include programmes that address these two issues. In particular, given the overwhelming
role of major depressive illness, a fundamental approach for any national suicide
prevention plan would appear to be programmes to improve mental health literacy, and
particularly to increase awareness about depression and substance abuse.
THE INTERFACE BETWEEN RESEARH AND POLICY
The evidence outlined above can be used as a basis to develop national suicide prevention
strategies. However, while research suggests a clear policy agenda for suicide
prevention, in practice, policy directions have tended to be shaped by other agenda and
themes. In New Zealand for example, the implementation of the National Youth Suicide
Prevention Strategy has been influenced by a strong focus on 'positive youth
development', on community based initiatives, and on overcoming socio-economic
disadvantage. While all approaches have strengths and weaknesses, at times there have
been difficulties in reconciling these themes with research evidence 111.
This observation suggests that one of the foremost tasks for suicide prevention is to
develop a body of scientific knowledge about programme effectiveness. There is a need
for suicide researchers to identify clearly: i. programmes that are effective; ii.
programmes that are not effective; iii. programmes that appear promising; and, iv. what
is not yet known. This resource base would, in turn, provide policymakers with
information that would allow them to fund programmes that are effective, not to fund
programmes for which there is not evidence of efficacy, and to fund programmes that
appear promising with the provision that adequate evaluations are included.
EVALUATION
One reason we lack information about effective programmes is that suicide prevention
programmes have often been conducted without adequate evaluation. In part, this line of
evidence stems from the fact that evaluation of suicide prevention programmes is
undeniably problematic. Firstly, the framework of suicide prevention has been conducted
in a multi-sectoral, multiple-programme approach in which it is difficult to separate out
the individual contributions of specific programmes. Secondly, programmes are not
41
conducted within a vacuum, and the effectiveness of some approaches may depend on
their institutional contexts. Thirdly, suicide is a rare outcome, and evaluations which
focus on this outcome alone require trials of large numbers of subjects followed over
many years. While the primary factor for evaluating programmes is evidence of their
impact on suicidal behaviour, there is a need to develop outcome measures other than
suicide, including for example, suicide attempts, and measures of treatment seeking and
compliance, so that the impact of prevention programmes can more comprehensively be
assessed.
Notwithstanding these difficulties, evaluations of programme effectiveness need to be
based on rigorous scientific analyses, rather than on (often ideologically driven)
assumptions about programme content or intent. Currently, most evaluations tend to be
process evaluations which describe what was done, rather than impact evaluations which
assess the effect of the programme on suicidal behaviour and other measures of
programme effectiveness. Evaluations that include both process and outcome measures
will provide the most information about programme effectiveness.
NATIONAL SUICIDE PREVENTION STRATEGIES
While a number of countries now have national suicide prevention plans, in most cases
their development has been very recent and their impact has not been assessed.
Nevertheless, the experiences of these countries suggest some guidelines for countries
involved in developing such plans. These recommendations include:
 using a research, evidence-based, best practice approach to policy development
and programme selection;
 putting in place, at the inauguration of the national strategy, mechanisms, and
adequate funding, for evaluation of both the strategy itself and individual
programmes;
 giving a strong focus to effective implementation and prevention (in addition
to development) of policy;
 harnessing effective political leadership or championship to stimulate and
sustain programme development and ensure priority for funding;
 maintaining surveillance to identify ways of improving national plans;
 ensuring national plans have the capacity for flexibility, so they can be adapted
to address changing trends and incorporate new programmes;
 ensuring adequate funding for long-term sustainability of the national strategy
and component programme;
Finally, the major, global tasks for suicide prevention in the 21st century appear to be
better development of current promising lines of suicide prevention; greater investment in
evaluating the efficacy and effectiveness of these programmes, and, the development of
innovative programmes at population levels, and for both high-risk groups and high-risk
individuals.
42
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Prevalence and comorbidity of mental disorders in persons making serious suicide
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109. Beautrais AL. Risk factors for suicide and attempted suicide amongst young
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110. Brent DA. Some strategies to prevent youth suicide. In: Romer D, editor.
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111. Stanton T. Phase One Evaluation of the New Zealand Youth Suicide Prevention
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Dr. Annette Beautrais Ph.D., Principal Investigator, Centerbury Suicide Project, PO Box 4345,
Christchurch, New Zealand. E-mail:annette.beautrais@chmeds.ac.nz
49
Chairperson: Prof. Michael Fitzgerald – Comments
Annette Beautrais points out that there is research evidence to support various prevention
approaches targeted at high risk individuals’ e.g. lithium with bipolar patients, Clozapine
and possibly Olanzapine with schizophrenia and ECT with selected suicidal patients.
Controlled trials of antidepressant therapy versus placebo have shown significant
reductions in suicidal ideation. Cognitive behaviour therapy, interpersonal
psychotherapy, dialectical behaviour therapy, and provision of ‘ready access’ card to
patients have shown effectiveness or promise of effective. No single programme will
achieve a significant reduction in suicide rates rather a multi-compartmental approach is
needed in which multiple prevention programmes are developed are likely to be more
effective.
STRATEGIES OF SUICIDE PREVENTION
Dr. Maila Upanne
Development Manager, National Research and Development Centre for Welfare and Health, Helsinki,
Finland
Abstract
Finland was the first country to prepare a national strategy for suicide
prevention in 1992. Today at least ten countries, including Ireland, have
prepared strategies of their own. Suicide prevention can, indeed, be considered
a comprehensive international movement for developing activities and
encouraging research all over the world. New international guidelines have
been published, as well, to reinforce those countries without the strategy to start
developing activities (Mental Health Europe, Belgian Federal Ministry of
Health and WHO European Network on Suicide Prevention and Research,
2004).This means that commonly accepted understanding and strategic
principles concerning suicide prevention really are available. The core of this
understanding is, first, a conception of suicide as a multi-factorial and processtype phenomenon and, accordingly, a broad conception of activities needed.
Due to many factors on many levels - various kinds of life events in various
kinds of conditions in various phases of life - , several kinds of interventions,
several groups of actors and several levels of authorities, as well, are needed.
Voluntary work as a visible and invisible authority is a most relevant power in
of suicide prevention. When developing suicide prevention in practice two
main challenges remains. First, what we know about suicide and how we
understand or conceptualise it (i.e. "content") and secondly, how to create a
strategy, how to implement it and finally, how to evaluate its effects (i.e.
50
"strategy and methods"). How clear and comprehensive general guidelines may
be, conceptions in practice may follow quite different lines. Different priorities
referring to e.g. where to focus and when (in what phase of the process) to
intervene occur. E.g. my study-results (Upanne, 2001) showed that preventionapproach and care-approach meaning "late intervention" can be competitors in
practice. What seems to be essential for success of practical programmes will
be characterised using experiences from Finland as an example.
In this presentation four approaches will be used for discussing challenges of suicide
prevention: 1) paradigms as a basis for strategy: conceptual windows, 2) empirical
findings: conceptions and practices, 3) experience from Finland and 4) questions and
contributions for practical planning.
PARADIGMS AND CONCEPTIONS AS A BASIS
Strategies and practices of suicide prevention are based on conceptions of suicide and
paradigms of prevention adopted by professionals. Different choices can be made. The
paradigm applied will inevitably be manifested in the strategy and practical activities,
even if the choice would remain implicit in nature. Awareness of theoretical choices
would, instead, provide a considered basis for a strategy.
Conceptions of suicide can differ among professionals and actors even if a certain line of
thinking and definitions frequently occur in the literature and, consequently, could be
defined as a common paradigm. Based on literature review (Upanne, 2001b), the
definition of suicide applied in the Finnish programme for the most part followed the
common paradigm.
Also conceptions of suicide prevention vary. Paradigms adopted - concept of man,
explanation for the emergence of problems in life etc. - really matter when planning
strategies of suicide prevention. These conceptions refer to the basic idea of suicide
prevention: what factors to include in the strategy as targets or foci of interventions. And
further, what are the contexts of these factors: intra-individual, inter-individual, social,
life circumstances, phase of life etc. The factors and their contexts (location) in particular
provide a guide for creating a strategy and methods for interventions (Upanne 2001a).
There are two main challenges in developing suicide prevention: firstly, to clear the
content, i.e. what we know about suicide, how we understand or conceptualise it and,
secondly, strategy and methods, i.e. how to create a strategy, how to implement it and
how to evaluate possible effects and impact. Creating a strategy will be discussed in later
in this paper.
Keywords referring to "content" of suicide-conception are multi-factorial and process.
They can be differentiated as follows.
"Multi-factorial" means
51





many factors: many features, behaviours, experiences, feelings, thoughts etc. in
people
many contexts, circumstances where factors appear
many occasions to discover and recognise
many possible actors
many sectors those responsible
"Process-type" phenomenon means



several phases or steps for intervention
different foci for each phase
different aims for each phase
 protective factors < promotive aims
 precipitating factors < preventive aims
 predisposing factors < preventive / curative aims
Pathway to suicide is often presented in the form of a process-model or antecedent
conditions model. The pathway is conceived a process with many phases combining life
circumstances, life events and individual characteristics and behaviour. In unlucky
circumstances suicidal behaviour can be kindled as a contribution of many factors.
Unfavourable development can cumulate and further increase risk for suicidal behaviour.
In the process, individual vulnerability plays an essential role. However, even that is
regarded as a combination of individual prerequisites and experiences in unfavourable
circumstances. (Felner, Farber & Primavera 1983; Bloom 1986; Schneidman 1989; APA
1990; O’Carroll 1993, Lönnqvist et al.1993; Coie et al. 1993; Silverman and Felner
1995; Antonovski 1996; Maris 1981). The process is usually divided in three phases of
development with three types of factors present: factors that promote well-being and
protect from suicidal development, factors that predispose the individual to that
development and factors that precipitate committing suicide.
Protective factors in individuals and in circumstances or as life events promote
preconditions of resilience and coping and, in the same time, decrease the probability of
development of problems and the risk of suicidal behaviour as well. Protective factors
are targets for promotive interventions.
Non-specific predisposing factors refer to experiences or circumstances which decrease
options for healthy psycho-social development and create psychologically demanding
experiences and coping problems. Examples of these are socially and psychologically
deprived living conditions and traumatic experiences.
Precipitating factors refer to conditions or experiences which can act as triggers for
suicidal acts, like serious traumatic life events, mental disorders or substance abuse.
Suicide attempt is considered a most serious antecedent condition. Precipitating and
predisposing factors are targets for preventive interventions. The model makes
discernible ”complex developmental pathways”; a gradual cumulative, multi-factorial
trend of development of suicidal process.
52
Different conceptions of the problem and of prevention can be characterised using the
paradigms of medical model and interactional model (Upanne; Hakanen & Rautava,
1999) or disease model and health model by Tudor (1996). Most of the literature of
today seems to prefer the process-model and interactional intervention paradigm.
Nevertheless, many scholars consider activities following the medical model the most
effective method to make an impact (Gunnel and Frankel 1992; Wilkinson 1994; Maris
and Silverman 1995; Isaksson 2000). Differences in views culminate in the concept of
primary prevention (Albee 1980; Kessler & Goldston 1986; Breton 1999).
The conclusion of this section would be that theoretical discussion on suicide prevention
has a practical meaning. Conceptions work like a map. With certain cognitive maps in
mind things can be recognised and choices can be made on a more considered basis.
PROFESSIONAL PARADIGMS OF SUICIDE PREVENTION: EXAMPLES
In this section I will present a few examples of conceptions professionals have in mind
when thinking and planning suicide prevention. I refer to my recent study, which was a
part of the evaluation of the Finnish project (Upanne, 2001b). The empirical data were
conceptions of suicide prevention expressed in three studies during nine years
(psychologists, n=138 definitions) and practical action plans prepared in five sectors
(n=207).
The key of the analysis and description was a coding frame including the most essential
viewpoints of suicide prevention according to theoretical analysis and professional
experience. In the model, two kinds of criteria were included: descriptive criteria and
conceptual criteria.
The key categories of the descriptive codes were
- focus (what?), the subject matter of prevention efforts,
- strategy (how?), how to intervene or what to do, and
- sector (who?), those who were regarded as responsible.
The conceptual codes for interpretation were timing, aim and location.
- timing (when?) refers to the phase of the process considered adequate to interfere,
- aim of an intervention (for what purpose?) to the intended effect on the target, for
example to reduce suicide risk or to increase protective factors, and
- location of a focus (where?) to the”level” on which the foci are ”situated”, such as
whether the matters in question are connected with the individual or with
circumstances.
The analysis provided a nice description of the paradigms people had in mind. A few
examples:

In the beginning of the project the status of promotive aim among psychologists
was firm. During years conceptions changed. The share of promotive aims
decreased significantly and, instead, the aim of taking care of suicidal risk
53
increased. Promotive practices are seemingly not possible as a part of clinical
practice and so you lose your belief!

Also non-clinical sectors (e.g. social sector, church..) tend to concentrate on the
aim of decreasing suicidal risk, not more preventive or promotive aims. As far as
process and timing is concerned, interventions come too late. As far as problems
are concerned, people think according to medical model.

analysis using the code location showed the same: main topics concern mostly
individual problems, not e.g. experiences, inter-individual relationships or life
circumstances. The problem is located and limited to a person.

approaches applied in different sectors are very similar, not different and typical
to the special sector, as might be expected, expressing general loyalty to medical
model.
The idea of suicide prevention adopted in Finland as the basis for national strategy
Although suicide as a phenomenon is much the same all over the world, there are reasons
to discuss the topic in every country to recognise what is essential. There might be
differences in risk factors and in protective factors, something special in every country
that might stress a need for certain activities. An example is the meaning of alcohol as a
risk factor in Finland. Although the measures would be the same everywhere, ideas must
be adapted and interventions performed according to the specific culture and resources in
good and bad: how services are organised, what kind of professional practices are
common, how much energy professionals and others involved can engage with the topic
etc.
When starting the programme in Finland, an extensive procedure was carried out to
understand suicide in the Finnish culture. The idea of suicide and suicide prevention
strategy were grounded on empirical knowledge on risk factors and recommendations for
prevention provided originally by field professionals. In addition, a theoretical model of
prevention applicable to the context was developed.
A country-wide investigation of all suicides committed during one year using
psychological autopsy-method (Suicides in Finland -87) produced a comprehensive
information of risk factors of suicide in the country. In addition, over a thousand
recommendations for suicide prevention were provided by local expert groups involved
with the study all over the country. Based on findings (Lönnqvist, Aro, Marttunen &
Palonen 1997) and recommendations a national strategy was formulated (Suicide can be
prevented, 1993). The strategy included a model for suicide prevention, detailed descriptions of practical challenges, and recommendations for developing practices in various
fields (Upanne, Arinperä, & Lönnqvist, 1990). In the same time, the procedure in itself
gave a good start for national prevention activities. Implementing the investigation phase
as a locally driven collaborative process delivered information and created motivation
and commitment to participate later in the implementation of the strategy. The bottom-up
–type collaborative method was developed further during the implementation.
54
In the strategy the conception of suicidal development and suicide was made explicit and
visible:
Process-theory and multi-factorial, multi-sectoral and multi-professional views were
applied. Essential from theoretical and strategic point of view was understanding suicide
as a result or an aggregation of many harmful experiences and contextual factors during
life process. In the strategy the main clusters of factors and connected interventions were



specific factors (eliminate or reduce the effect of factors which directly
increase the risk of suicide, e.g. suicide attempts and suicidal ideas),
non-specific factors (eliminate or reduce the effect of factors which can lead
into a dead end in life, e.g. alcohol, problems, mental health problems, life
crisis) and
constructive/promotive factors and interventions (create circumstances and
experience which improve an individual’s chances to master his life and
increase capacity to cope). Consequently, protective, predisposing and
precipitating factors were involved in a differentiated way.
The strategy followed the structure where key topics (foci), goals of intervention,
measures of intervention and sectors involved were differentiated and named. (Upanne et
al. 1999).The strategy was published as a booklet (Suicide can be prevented 1993) and
delivered widely in the country.
The main topics and aims were formulated as follows:
We can reverse the rising suicide rate if:

everyone who has attempted suicide receives as effective help as possible

depression is recognised and the person offered al the support he/she needs.
Everyone suffering serious depression should get appropriate and effective
treatment

we can prevent alcohol being used as the universal solution to problems, and find
better means of supporting efforts to cope

mental and social support are enhanced within the treatment of somatic illness

a person in a life crisis receives appropriate support from relatives and friends,
and from professionals when necessary

the risk of youngsters becoming alienated from life can be avoided, and
individuals running a risk of suicide are guaranteed the possibility of coping and
improving their self-esteem

cultural climate in Finland, education system included, becomes more relaxed and
permissive, and less guilt-promoting, stigmatising and punitive than it tends to be
55
at present. It needs to promote belief in life, resourcefulness, self-esteem,
initiative and mutual support.
MAIN LINES AND PRACTICES OF IMPLEMENTATION
The approach adopted in the Finnish programme was the aim of developing practices in
collaboration with sectors in response. The main strategic principles were

nation-wide implementation. All regions of the country were participating

key sectors approach for maximal number of contacts the main route for
interventions being on the professional level. Nevertheless, all sectors or "levels"
of life were included (every day level e.g. mutual support, cultural level e.g.
public information).

real context approach. Activities were carried out in real-life circumstances,
integrated in everyday work, in collaboration with natural professional groups.

goal of developing practical models instead of or in addition to mere training.

goal of developing aim-oriented, systematic way of proceeding

activities via horizontal collaborative processes. A method (co-operative process
model) was developed. The model has proved to be the most efficient and
feasible method in developing practices in social- and health-care.
EVALUATION OF THE PROGRAMME
The Finnish project was evaluated from three viewpoints: internal evaluation based on
the field survey (Hakanen & Upanne, 1999), internal description and process evaluation
by the team (Upanne et al.1999, and external evaluation concerning the entire project the
research-phase included by an international peer group (STM 1999). In addition, a few
other evaluative papers have been published (e.g. Taylor, Kingdom & Jenkins 1997;
Singh 2000). The latest study (Upanne 2001b) concerned more theoretical aspects on
suicide prevention and the programme. A second follow-up of continuity of suicide
prevention activities, included in the national field survey of preventive mental health
work, will be published in 2004.
Altogether, the implementation incorporated over 40 sub-programmes and spontaneous
development work in several fields. In addition to comprehensive field activities several
specific subprojects were kindled for example in collaboration with health centres
(practices of care of suicide attempters), school, the army and the church (practices for
crisis situations among young people), media (good practices in suicide information).
Practical models were evolved usually by
collaborating with a pilot group in a pilot area, preparing a report or a guide-book and
delivering it in a country-wide scale. Unfortunately, due to time-tables, only in a few
occasions a feed-back study could be accomplished (Upanne et al. 1999).
56
The field survey showed that some 2000 professionals participated the investigation and
preparing the strategy. This way of starting had both practical and psychological effects.
Preventive practices, especially local training started right away. During implementation
phase some 2000 working units: 43% of all “human service units” in the country reported
development activities and some 100 000 professionals were estimated to have
participated in interventions according to the evaluation survey in 1996.
CONCLUSIONS
In addition to the conceptual frame, certain administrative preconditions are needed as a
basis for organising the programme. The programme needs a decision to begin, a
structure, institutions and persons in response, a plan for the aims and actions and finally,
some money. The fact that the project in Finland was set by the ministry (the
government) had many important social, functional and cultural consequences. It gave an
official permission and delegation to start the project: something must be done. It
included a message to people: the government and administration is concerned about
people and their problems. This is why the project ought to be widely discussed in the
media. In Finland the attitude of the media was positive and fact-oriented. The
administrative context gave informally prestige to the programme and strength to people
involved: our work is supported by the state.
The strategy of running the programme in the way described here was based on certain
conditions present at that time. Centralised health and social administration (National
Board of Health and Social Affairs) gave the authority to run the programme. Today,
after changes in the national administration the programme could not be run in the same
way. This fact indicates the meaning of cultural preconditions and the need for tailormade solutions and strategies adapted to prerequisites available.
During the programme we learned that
 it is possible to prepare and implement programmes in country-wide scale
 a comprehensive suicide prevention approach is a feasible approach
 it is possible to introduce the issue of suicide prevention in social institutions
 even in authoritarian, masculine organisations (the army) it's possible to
enhance coping and support
 crisis -approach is felt to serve as a good starting point.
According to external evaluation good points of the project were
 covering broad public sectors all over the country
 putting the suicide problem on the social agenda
 developing interactive models for health promotion
 publishing many guidebooks
 influencing organisations and professionals in the service sector.
Further, important prerequisites proved to be for example
 commitment of the national administrative and supervising level
57






co-operation with all key professionals, not only mental health professionals
adapting to real life situations
co-operative work, not ready-made models
speaking the same language
respecting the culture and practices of the field in question
aiming at practical models of action.
Running the programme from the very beginning as a common enterprise was decisive
for the good progress of suicide prevention in Finland. Professionals were invited as
experts of their own fields and felt their role and know-how respected. My experience is
that factors connected with atmosphere and psychological effects can be decisive for the
practical progress. The field gave good feedback for the collaborative approach and good
atmosphere. Resistance was almost non-existent.
The suicide rate in Finland had a declining trend from 1990 (30.3/100 000) to 2000
(22.5). In 2002 the rate was 21.1/100 000. There is no exhaustive analysis available to
explain the decrease. As factors which may be connected with it has been mentioned
several facts: economic recession and connected factors in nineties, decrease of alcohol
consumption as a part of it, increase of the consumption of antidepressants etc.
Interventions organised by the national project are a part of the explanation.
CREATING A STRATEGY
So, the idea of best ways to intervene and can vary. Approaches in suicide prevention
can be universal interventions targeted at communities, selective interventions targeted at
high-risk groups or indicative interventions involving identification, treatment and skill
building among individuals and families. So far most interest in suicidology has been
directed to individual level analysis and individual suicide risk assessment (Potter 2000).
Practical approaches most widely used are education of professionals, public information,
developing practices and research or studies. Choices here refer to our conceptions of
how to make an impact. Education of professionals is related to the idea of them as key
persons with plenty of individual contacts with the population. The challenge is
empowering professionals and elaborate more sensitive practices. Public information
also follows the idea of empowerment aims being to inform of warning signs, options of
self care, the meaning of social support etc. These approaches usually imply so called
top-down approach. Study-approach usually has more academic than practical purposes.
In a descriptive study the point is to gather data, to describe certain, e.g. epidemiological
phenomena. Using experimental design effects and impact of methods can be
investigated. Is the programme supposed to be focused (concentrating maybe only in one
specified focus, e.g. care of suicide attempters) or comprehensive (including several foci
on several levels) is an example of the strategic choices related to the idea of impact.
Nevertheless, a study can provide applicable information and act as an intervention. The
aim of evaluation studies is, instead, connected with practical developing of methods or
activities. Developing practices based on empirical study was the approach adopted in
Finland. In many strategies approaches are combined.
58
The logic and structure of the strategy can be well-thought or haphazard and sporadic.
The study on practical action plans (Upanne, 2001a) showed that in practice whatever
aspect can serve as a starting point for an action plan: administration (organising
services), a method of intervention, target (risk) group or target phenomenon or focus.
So a strategy and a practical plan as well can be a mixture of many kinds of starting
points, topics and details without a considered logic. Further, the study showed that the
most important thing: the aim of the intervention is often missing. The poor defining of
the key phenomenon (focus) and the aim (the intended change) is decisive as far as
evaluation of efficacy and efficiency of practices is concerned. If you don’t know what
your aim was you are not able to assess if you have reached it.
To conclude, principles discussed in this paper can be concentrated as a list of key
questions to serve as a practical guideline for planning.
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Psychiatry, 147(12), 1701-1704.
Albee, G. W. (1980). Competency model must replace the defect model. In L. A.
Bond & J. C. Rosen (Eds.), Competence and coping during adulthood (pp. 75-104).
London: University Press of New England.
Antonovsky, A. (1996). The salutogenic model as a theory to guide health promotion.
Health promotion international, 11(1), 11-18.
Bloom, B. L. (1986). Primary Prevention: an overview. In J. T. Barter & K. Talbott
(Eds.), Primary prevention in Psychiatry: state on the art (pp. 3-12). Washington:
American Psychiatric Press.
Coie, J. D., Watt, N. F., West, S. G., Hawkins, J. D., Asarnow, J. R., Markman, H. J.,
Ramey, S. L.,
Felner, R. T., Farber, S. S., & Primavera, J. (1983). Transitions and stressful life
events: a model for primary prevention. In R. D. Felner , L. A. Jason, J. Morizugu, &
F. S. Farber (Eds.), Preventive psychology: theory, research, and practice (pp. 199215). New York: Pergamon press.
Gunnel, D., & Frankel, S. (1994). Prevention of Suicide: aspirations and evidence.
British Medical Journal, 1227-1233. Universities press, Inc.
Hakanen, J., & Upanne, M. (1999). Itsemurhien ehkäisyn käytännöt Suomessa.
Itsemurhien ehkäisyprojektin seuranta ja arviointi (228). Helsinki: Stakes.
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Scandinavica, 102, 113-117.
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Kessler, M., & Goldston, S. E. E. (1986). A Decade of Progress in Primary
Prevention. London: University press of New England.
Lönnqvist, J., Marttunen, M., Aro, H., Henriksson, M., Isometsä, E., Heikkinen, M., &
Palonen, K. (1997). Suicide in Finland -research project . Helsinki: National Public
Health Institute.
Maris, R. W. (1981). Pathways to suicide: a survey of self-destructive behaviours.
Baltimore: Johns Hopkins University Press.
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and Life-Threatening Behavior, 25(1), 205-209.
O'Carroll, P. (1993). Suicide causation: pies, paths, and pointless polemics. Suicide and
Life-Threatening Behavior, 23(1), 27-36.
Shneidman, E. S. (1989). Overview: A multidimensional approach to suicide. In D.
Jacobs & H. N. Brown (Eds.), Suicide; Understanding and responding (pp. 1-30).
Madison, Connecticut: International Universities Press.
Silverman, M. M., & Felner, R. D. (1995). Suicide prevention programs: Issues of
design, implementation, feasibility, and developmental appropriateness. Suicide and lifethreatening behavior, 25(1), 92-104.
Singh, B. (2000). Suicide prevention strategies - an international perspective.
International Review of Psychiatry, 12(1), 1-17.
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Helsinki: National Research and Development Centre for Welfare and Health.
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international peer
group. Helsinki: Ministry of Social Affairs and Health, Copies 1999:2.
Taylor, S. J., Kingdom, D., & Jenkis, R. (1997). How are nations trying to prevent
suicide? An analysis of national suicide prevention strategies. Acta Psychiatrica
Scandinavica, 95, 457-463.
Tudor, K. (1996). Mental health promotion. Paradigms and practise. London:
Routledge.
Upanne, M., Arinperä, H., & Lönnqvist, J. (1990). Developing strategy for suicide
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973-978). Bologna: Monduzzi Editore.
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Upanne Maila, Hakanen Jari and Rautava Marie (1999) Can Suicide be Prevented?
Suicide Prevention Project in Finland 1986-1996: Goals, implementation and evaluation.
Helsinki: National Research and Development Centre for Welfare and Health.
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Dr. Maila Upanne, Development Manager, Stakes, Mental Health Unit, PO Box 220, 00531 Helsinki
maila.upanne@stakes.fi Tel:+358 9 3967 2121
SUICIDE PREVENTION IN IRELAND
Dr. John F. Connolly
Hon. Secretary, Irish Association of Suicidology
Abstract
In this talk we look at the history of suicide in Ireland, the legal frame work within which
we work, the changing trends in suicide rates over the past 30 years, the steps that have
been taken in suicide prevention in recent times and make some suggestions for the
future.
SUICIDE IN ANCIENT IRELAND
Among the Ancient Celts suicide was not uncommon. It was a matter of honour
following defeat in battle and similar circumstances that might bring shame or dishonour
on the individual or clan. The Celts did not have a written tradition and therefore our
knowledge of these matters comes to us from the writings of other peoples such as the
Romans and from what was subsequently written down from the oral traditions of the
Celts by the monks in early Christian timesiii. No doubt the latter was distorted in the
telling sanitised and romanticised in many instances. Much of what is written about the
Celts and their wisdom in Ireland omits the darker side of their culture as for instance
human sacrifice. Little is known about the common people of the time either in life or
death. Life was short and brutish and only the stories and deeds of the ruling classes are
recorded.
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There are many stories about suicide in ancient Ireland. It was prophesised that Deirdre
of the sorrows would be the cause of slaughter among the men of Ulster. And for this
reason she was reared in isolation. Conor Mac Neasa declared his intention to marry her
but Deirdre was in love with Naoise one of the three sons of Usna. She eloped with him
and his brothers and eventually sought refuge in Scotland. They were persuaded
eventually by Fergus Mac Roich and other renowned Ulster warriors to return to Ireland
on the understanding that Conor had promised forgiveness. However Conor arranged for
the sons of Usna to be killed. Enraged by this treachery Fergus and his warrior declared
war on Ulster causing great bloodshed. Deirdre spent a year in the company of Conor
without smiling. Fearful that Conor would force her to marry Eoghan Mac Durthacht
who had murdered her lover. One day she was in a chariot between the two men when
Conor suggested that she was that ‘she was making the eye of a sheep between two
rams’. At that she leapt from the chariot and killed herself by dashing her head on a
stone, a method of suicide known as the warrior’s salmon leap.
In the story of Cano Meic Gartnain (Scela Cano Meic Gartnainiii), Cred the daughter of
Guaire who was in love with Cano, after a battle in which he had been severely injured,
saw his face. Thinking him dead she dashed her head against a stone. At that time she
had in her possession a stone containing his life principle, his stone of life, which she
broke. He died nine days later.
The tragic Death of Curoi Mac Dariiv illustrates another example of suicide in ancient
Ireland. Curoi was killed through the treachery of a woman Bathmat and in vengeance
the poet Ferchertne takes her and throws the two of them over a cliff in revenge.
There are many other examples in the literature and the legends of Cuchulainn are very
interesting reading. Interestingly then as now problems in and break down of
relationships were factors in suicide.
In ancient Irish it was the custom of fasting to death or near death on the doorstep of
someone who had wronged you to shame them until the matter was set right or until
death occurred. To allow a person to die of hunger on one’s doorstep contravened the
laws and customs of hospitality which were so much a part of life in ancient Ireland. The
person against whom the deceased had taken this drastic action was shamed and held
responsible for the death. This custom continued until some time in the 15th century.
The custom was also common in India and some say that it is still practiced there.
There are parallels between this ancient custom and the political hunger strikes in modern
times. However many would regard the latter as altruistic suicides as defined by
Durkheim.
In ancient Irish law suicide (fein-mharu) was regarded as kin slaying (fingal)v, which
undermined the kin based structure of Irish society. It could not be accommodated in to
the early Irish system of compensation to the kin of the deceased nor could it be avenged
without the avengers themselves becoming kin slayers. A king who was guilty of fingal
looses his honour-price and fingal was one of three crimes which cause the overthrow of
a king.
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LEGAL ASPECTS OF SUICIDE
Ireland was the last western European country to decriminalise suicide. Thanks to the
efforts of Dan Neville TD and others this occurred with the passing of the Criminal Law
(Suicide) Act, 1993. section 2 of that Act states that:
(1) Suicide shall cease to be crime
(2) A person who aids, abets, counsels or procures the suicide another, or an attempt of
another to commit suicide, shall be guilty of an offence and shall be liable on conviction
or indictment to imprisonment for a term not exceeding fourteen years
Perhaps this Act went some way towards helping to remove the stigma of suicide and the
debate on the issues involved certainly brought the topic of suicide, so long ignored, into
the public demesne. Officially suicide remains a sin according to the Catholic Church.
However pastoral care has changed enormously and it is many years now since a person
who died by suicide was refused burial in consecrated ground
Until recently suicide was dealt with under the Coroners Act 1962vi. Sect. 30 of that Act
stated that “questions of civil or criminal liability shall not be considered or investigated
at an inquest and accordingly every inquest shall be confined to ascertaining the identity
of the person in relation to whose death the inquest is being held and how, when and
where the death occurred”. Verdicts of suicide were seldom passed. In a number of cases
where verdicts of suicide were delivered the matter was appealed to the high court and
the verdicts overturned in the light of section 2 of the Act as quoted above. Following
those judgements coroners were precluded from passing a verdict of suicide and were
restricted to passing a verdict only on the basis of the medical cause of death. A verdict
of suicide would be seen as censuring the deceased and implying guilt of s criminal act.
Quote from the latest report on the coroner system
TOWARDS SUICIDE PREVENTION
Following the decriminalisation of suicide in Ireland in 1993 in the campaign for which
our President Dan Neville was a central figure the next important event was the
establishment of the National task force on suicide in 1995. the task force had the
following objectives
1. To define numerically and qualitatively, the nature of the suicide problem in
Ireland.
2. To define and quantify the problems of attempted suicide and parasuicide in
Ireland including the associated costs involved.
3. To make recommendations on how service providers can most cost effectively
address the problems of attempted suicide and parasuicide.
4. To identify the various authorities with jurisdiction in suicide prevention
strategies and their respective responsibilities and
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5. To formulate, following consultation with all interested parties, a National
Suicide Prevention / Reduction Strategy.
The task force issued an interim report in 1996 dealing with the first two issues. The
final report was published in January 1998 and contained eighty recommendations
dealing with all aspects of suicide.
On foot of the publication of the report the National Suicide Review Group (NSRG) was
established and Suicide prevention Resource Officers were appointed by the health
boards. The NSRG has the following Brief



To Review on-going trends in suicide and parasuicide.
To co-ordinate research into suicide
To make appropriate recommendations to the Chief Executive Officers of the
Health Boards
The board members represent a wide range of statutory and voluntary bodies involved in
dealing with all the different facets of suicide and suicidal behaviour. It has a limited
budget to cover the year to year expenses of running the organisation. It is also
responsible for distributing a small budget to support research and local suicide
prevention projects. The NSRG annual reports contain an outline of all the work carried
out.
National Suicide Research Foundation
The National Suicide Research Foundation (NSRF) was founded in January 1995 by the
late Dr Michael J Kelleher. Dr Michael J Kelleher, being aware of the multi-factorial
nature of the problem of suicide, formed a research team drawn from a broad range of
disciplines. The Unit continues to consist of the Director, a Project Coordinator,
Research Psychiatrist, Statistician, Research Psychologist, Research Sociologist and Data
Administrator. The foundation is funded by the Department of Health, the Southern
Health Board and the Mid-Western Health Board. It became a Unit of the Health
Research Board in 1997. Professor Ivan Perry, Department of Epidemiology and Public
Health, University College Cork is now Director of the National Parasuicide Registry
Unique of its kind) and Dr. Ella Arensman is Director of Research NSRF.
National Suicide Bereavement Support Network
The N.S.B.S.N is a voluntary organisation set up in 1998 to support and comfort those
bereaved by suicide. The short term aims are to unite groups and individuals through out
the whole of Ireland with the intention in the long term to unite with organizations
throughout the United Kingdom and eventually with groups around Europe creating a
European Network
Irish Association of Suicidology
On the basis that as no group professional or voluntary has a monopoly of wisdom or
knowledge about suicide and recognising that suicide prevention is everybodies business
the Irish Association of Suicidology was established in 1996 with the aims
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

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
to ensure that the general 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 by
suicide

In conferences such as this the Association has become a forum for all persons and
organisations interested in any aspect of suicide and suicidal behaviour to meet and share
ideas and experiences. In addition to conferences the Association has produced ‘Suicide
Prevention in Schools: Best Practice Guidelines’ which was launched by our Patron Mrs
Mary McAlesse President of Ireland. A copy of this book was sent to each second level
school in the country and a number of workshops on its implementation and use have
taken place. In partnership with Samaritans we produced ‘Guidelines for the Portrayal of
Suicide in the Media’ and most recently published a pamphlet on Coping with Grief and
Loss.
The three Ts Turning the Tide of Suicide is a charitable organisation, founded to raise
awareness and funding to lower the suicide rates in Ireland through dedicated research,
educational support and intervention in the problem of suicide in Ireland. Over 500
people in Ireland died through suicide last year (2002). Suicide is the number one killer
of Ireland's young men. To achieve this goal, the 3T's embarked on a fund-raising
campaign which to date has included:

- Women (and men!) from all over Ireland participated in the Flora Women’s
Mini Marathon in Dublin aid of the 3Ts. nearly €4,000 was raised. Many thanks
to all who took part.

The 3T's All-Ireland Golf Tournament - launched in 2003 by Irish golf superstar,
Padraig Harrington, this annual competition is held over 4 years with over 400
golf clubs eligible for participation. Over 10,000 golfers entered in 2004.

Jimmy Magee Video: Greatest Sporting Moments - Jimmy Magee celebrated 50
years in broadcasting by compiling his greatest sporting memories, partially
underwritten by the 3T's, with part proceeds from the sale kindly donated to the
3T's.
Its beneficiaries are Mater Hospital Foundation, St Vincent's University Hospital,
The INSURE Project, National Suicide Research Foundation, AWARE, AFSP
Ireland, Irish Association of Suicidology, Samaritans, Schizophrenia Ireland and
the National Suicide Bereavement Support Network.
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It is supported by The Louis & Zelie Martin Foundation | The Professional Golfers’
Association | The Ireland Funds | The K Club, Co. Kildare
DATA ON SUICIDE PREVENTION IN IRELAND
In order to develop a suicide prevention strategy it is important to have adequate and
accurate data on suicide trends. The following is a brief overview of suicide trends in
Ireland from 1890 to date which illustrates the size of the problem. In Ireland suicide
accounts for a little under 1.4% of all deaths. However suicide is the leading cause of
death in the age group 14 to 25 years of age, exceeding the number of deaths resulting
from road traffic accidents.
Graph 1 shows suicide rates in Ireland 1890 to 2002. It can be clearly seen that Irish
suicide rates were stable, at 2-4 per 100,000, until about 1970 when they began to
increase. In those early years there was a great deal of shame and stigma attached to
suicide and for this reason there was very much underreported. Research suggests that
the real rate of suicide in the fifties and early sixties was probably twice the officially
reported rate. Even allowing for this, suicide Irish rates were genuinely low by
international standards. From 1970 onwards suicide rates continued to rise a trend that
continued and reached a peak in 1998 when there were 514 deaths by suicide, a rate of 13
per 10 0,000. Since then rates have fallen to 10.2 per 100,000 in 2002 (get the rates and
numbers for 2004). Under reporting of suicide is not as big a problem as it has been in
the past. According to the Central Statistic Office (CSO) the figures are accurate to
within about 5%vii.
Irish Suicide Rates 1890-2002
16
14
12
10
8
6
4
2
0
90 897 904 911 918 950 957 964 971 978 985 992 999
1
1
1
1
1
1
1
1
1
1
1
1
18
Graph 2 shows rates of suicide for the total populations of the 25 EU partners and it can
be seen that at 10.2 per 100,000 Irish suicide rates are below averageviii
66
Lithuania
Latvia
Hungary
Slovenia
Estonia
Finland
Belgium
Austria
France
Czech Republic
Poland
Denmark
Luxembourg
Sweden
Slovakia
Germany
Ireland
Netherlands
UK
Spain
Malta
Italy
Portugal
Greece
39.6
28.8
27.7
25.7
24.5
8.6
21.2
17.4
16.6
15.1
14.1
13.8
EU Total Population
12.5
12.3
Suicide
Rates per 100,000
12.3
Age-Standardised
11.9
11.5
Source: WHO site, May 10th.
10.2
2004
7
6.8
6.5
5.9
3.9
3.1
0
5
10
15
20
25
30
35
40
Graph 3 is however, a great cause for concern and shows that in this country we have the
fifth highest suicide rate of all our partners for the age group15-24ix. Youth suicide
peaked in Ireland in 1997 when there were 127 such deaths in that age group. The figure
for 2003 was xxx or yyy per 100,000. According to an OECD report of 2000 Ireland had
the second highest rate of youth suicide in the world, second only to New Zealand. The
situation has improved some what as, according to a World Health Organisation report
for 2002 Ireland has the 24th highest rate of youth suicide in the world.
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Lithuania
Finland
Estonia
Latvia
Ireland
Slovenia
Austria
Belgium
Poland
Hungary
Sweden
Czech
Luxembo
Slovakia
Germany
France
UK
Denmark
Netherla
Spain
Italy
Malta
Greece
Portugal
18.1
17.9
29.5
19.9
15.7
15.5
13.9
13.8
11.4
10.9
10.7
10.5
6.7
6.7
6.5
EU Youth Suicide Rates
per 100,000 population
8.2
8.2
8
7.9
Source: WHO site, May 10th.
2004
4.8
4.3
3.4
2.4
2.4
0
5
10
15
20
25
30
Graph 4 shows male and female suicide rates for the age group 15 -24 years of age. It
can be readily seen that suicide is very much a male phenomena with at on stage a ratio
of male to female of 4.7M: 1F in 2002. Although the numbers are small it can also be
seen that the rates of suicides for young women in this age group doubled between 1993
and 2002
Irish Male and Female Suicide Rate
aged 15-23, 1980 - 2001
35
Rate per 100,000
30
Male
Female
25
20
15
10
5
3-year moving averages
0
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000
National Suicide Research Foundation
68
The reason for the increase in Irish suicide rates must be seen in the dramatic changes
that have taken place in our society in the past thirty years cultural, spiritual, social and
economic. In that time the country has undergone more rapid change that most of our EU
partners. All of these factors must be addressed in a suicide prevention strategy.
AN IRISH SUICIDE PREVENTION STRATEGY
The Health Boards Executive, the Department of Health & Children and the National
Suicide Review Group are currently developing a strategy for action in the area of suicide
prevention. This Strategy will build on the work of the National Task Force on Suicide,
which reported in 1998. Already the group has consulted widely with all the stake
holders in the field and held a number of workshops with interested groups. A review of
the task force recommendations has been carried out. Themes that emerged from the
workshops were the role of education, community responses to suicide, problems in
health service delivery, alcohol and drugs misuse, support for parents and public
awareness.
The strategy framework will include a general population approach, focus on the needs of
high risk groups, research and information and of course monitoring and evaluation. The
outcome will be improved understanding, knowledge and attitudes, standardised
protocols of response, bereavement support, reduced rates of suicide and self harm. It is
expected that the report will be published in 2005 and implemented over the following
ten years.
In approaching the issue of suicide prevention we must be conscious of the lack of robust
research in this area. Diego De Leo in a presentation at a recent conference in Slovenia
in which he analysed the impact of suicide prevention strategies around the world arrived
at the following conclusions. Declines in suicide following the introduction of national
suicide prevention strategies cannot be validly attributed to the introduction of these
strategies. Even if national plans are partly responsible for recent reductions, the
component of those plans which have contributed to the reduction cannot currently be
identified.
What appears to work or at least have some impact on suicide rates are treatment of
mental disorders; training of primary health care personnel; help-lines and crisis centres;
school-based programs; restriction of access to means and improving media portrayal of
suicidex.
Developing suicide prevention strategy is a very complex piece of work. It is essential
that all the stake holders, interested parties, relevant government departments and local
authorities are involved. Everybody must be able to claim ownership of the strategy as
otherwise implementation will be impossible. It is also clear from international research
that unless there is the political will and commitment to see the strategy through it will
not succeed. We will learn a lot about the pitfalls in suicide prevention strategies and
what works from our distinguished speakers at this conference. However on going home
based multidisciplinary research is essential as what applies in other countries and
cultures may not always be appropriate or translate to an Irish context. Suicide is a
69
multifaceted problem and therefore needs a multidimensional response. Simplistic knee
jerk reactions to a crisis are ultimately of little value and may in fact make matters worse.
In an effort to prevent suicide the following issues must be addressed
•Deal with the social causes of suicide
•Combat stigma related to mental illness
•Ensure equal access to quality health services
•Create equitable access to education
•Deal with the problem of violence in society
•Ensure that in every sense our schools are health promoting schools
•Combat poverty - ensure the disadvantaged a proper standard of living
•Implement the national policy on alcohol
•Create a just society
Many of these points may seem asperational, they are important in their own right and
must be addressed if Ireland is to become a safer place in which to grow up and live.
I wish to thank Mr Derek Chambers, Chief Executive of the NSRG for his help in
preparing this paper.
Dr. John F. Connolly, Secretary, Irish Association of Suicidology, 16, New Antrim St, Castlebar, Co.
Mayo. Tel: 00353 (0)94 9250858, E-Mail: drjfc@iol.ie
Chairperson: Mr. Geoff Day – Comments
Dr. Maila Upanne presented on the development of the national strategy on suicide
prevention in Finland. In setting out to create a strategy, Dr. Upanne stressed the key
factors as preventative, curative and prescriptive. The model developed was multifactored with emphasis on vulnerability indicators such as deliberate self harm,
depression, alcohol, young men, life crises and culture. Professional skills were used
collaboratively, dependant on the different sectors involved.
In concluding, the success of the Finnish strategy which since 1982 had seen a reduction
in suicide rates, Dr. Upanne stressed the importance of a theoretical framework
providing the map for future direction and the cooperation between professionals,
individuals, agencies and government. This is an important experience which we can
learn from.
Dr. John Connolly outlined ‘Suicide Prevention in Ireland’ by charting the history of
suicide to modern times, the importance of decriminalisation in 1994 and the
developments since then. In setting out the current data, Dr. Connolly stressed that while
Irish suicide rates are not high by European standards, the youth suicide rate in Ireland is
70
the fifth highest in Europe. Actions taken to address areas of concern were highlighted.
The need for improvement in services relating to mental disorders, primary care training,
access to means and media coverage were seen by Dr. Connolly as the areas to focus on
in the future.
The history of suicide prevention in Ireland is relatively short and therefore as we
develop our responses we can learn from the best of the international evidence, as well as
contributing our own experience.
WHAT CAN RECENT DEVELOPMENTS IN PSYCHOTHERAPY TEACH US
ABOUT WORKING WITH PEOPLE WHO ARE PRONE TO SUICIDAL
BEHAVIOUR?
Dr Tony Bates
Dept of Psychiatry, Trinity College Dublin
Abstract
Psychological theory and research have evolved some valuable insights into key
processes in the mind that precede suicidal behaviour. What happens for some
individuals such that their experience of loss, depression or rejection, leads to a
suicidal crisis whereas for many others this is not the case? This talk will review
two recent ‘mindfulness-based’ psychotherapeutic approaches that appear to
directly address these processes and expand our repertoire of helpful
interventions for this population. They have been developed through working
with people with severe personality difficulties (Dialectical Behaviour Therapy)
and with those who suffer from severe recurrent episodes of depression
(Mindfulness-Based Cognitive Therapy). Both of these groups contain a high
proportion of people who are highly at risk for suicide. These newer
approaches incorporate many of the useful strategies in earlier forms of
behavioural and cognitive therapies but they also recognise specific limits in
these earlier approaches. Their relevance for suicidal patients in particular will
be explored. An overview of these newer interventions will be presented, with
sample exercises, case examples and critical discussion about the appropriate
timing and integration of these interventions within an overall treatment
strategy.
There are many factors that can lead someone to choose to commit suicide. No matter
what the particular route to suicide it is without doubt one of the saddest events in human
experience. It leaves devastation in its wake as relatives, friends and loved ones struggle
with the trauma of inexplicable loss and shock. When my cousin took his life at 24 years,
I watched his parents slowly retreat into an unspeakable pain that broke their hearts, until
71
death released them both, prematurely, from their unanswered questions, a short time
after this event.
Worldwide, the figures for death by suicide are startling. Every 17 minutes, someone in
the United States commits suicide. Suicide ranks number three among causes of death
for Americans under age 21, and is number two for college students. In 1995, more
young people died of suicide than of AIDS, cancer, stroke, pneumonia, influenza, birth
defects, and heart disease combined. According to the WHO suicide is responsible for
2% of deaths worldwide in 1998, which puts it way ahead of war and homicide. The rate
of suicide is climbing and each attempt at suicide significantly raises the likelihood that it
will be tried again and ultimately be successful.
In this talk I would like to review briefly some of the psychological processes known to
precede suicidal behaviour. I would also like to present a brief introduction to the newer
mindfulness-based approaches in psychotherapy and consider how they might address
and possibly counter these factors and prevent a crisis becoming a suicidal crisis. I am
especially indebted to the ‘Cry of Pain’ model of Mark Williams (1997) and to some of
his very recent writings on the relevance of mindfulness to suicide prevention (Williams
and Swales, 2004)
SUICIDAL BEHAVIOUR AS A CRY OF PAIN
Williams (1997) proposed a model of understanding suicide as a “cry of pain”. It this
model he views suicide as a reaction to finding oneself in a trap from which there is no
escape (what sociologists have termed “arrested flight”), where one feels both defeated
and “locked in” with no possibility of rescue.
This feeling of being defeated can arise from external circumstances such as conflicted
interpersonal relationships or the absence of social support, economic stresses or
unemployment, or from protracted inner turmoil, e.g. recurrent depression. The critical
factor is that the individual interprets the presence of psychological pain as evidence that
they are defeated in some aspect of their life that is deeply important to them.
Furthermore, they perceive that there is nothing they can do that to resolve this
predicament (“no escape”) and no possibility that other people or changing circumstances
are likely to alleviate their suffering (“no rescue”).
People do not immediately succumb to this very despondent style of thinking. In the
early stages of their struggles, they may be angry, protest and resort to multiple and often
frenzied efforts to change their predicament. Eventually, repeated failure to alter their
plight gives way to despair and helplessness. Williams has noted the similarity between
this pattern of response to chronic stress in adults and the behaviour of infants and
animals faced with separation from secure attachments, who universally exhibit
responses that proceed from anxiety, to protest to despair.
The cry of pain model describes the subjective experience of someone who feels trapped,
defeated and beyond rescue. Suicidal attempts in this model are seen as an expression of
attempts to re-establish some escape from pain, a reaction to a grim combination of
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circumstances. The “cry of pain” model differs from the popular conception of suicide as
a “cry for help”, which views suicide as an attempt to purposefully communicate distress.
According to this model, there is a sequence of processes that can develop over time and
increase one’s vulnerability to suicidal behaviour. These are considered below:
PRESENCE OF INTENSE PSYCHOLOGICAL PAIN
Most models of suicide behaviour agree that a central experience for the individual
concerned is intense psychological pain. This may be provoked by loss, failure, rejection
or any combination of these. But it isn’t true to say that there is always an identifiable
major upsetting life event prior to a crisis in the life of someone prone to depression or
suicidal behaviour. John Teasdale (1999) has shown how small changes in mood can
activate large and potentially devastating changes in thought patterns in people who have
been previously depressed. This phenomenon, which he called the ‘differential activation
hypothesis”,
“Whereas most people might be able to ignore the occasional sad mood, in previously
depressed persons a slight lowering of mood might bring about a large and potentially
devastating change in thought patterns.” (Teasdale, 1999).
BIASED ATTENTION TO NEGATIVE INFORMATION
Attentional processes are high jacked as the individual becomes distressed and their
perceptions become biased to only pick up cues in the environment that correspond with
their sense of pain. Their mind increasingly focuses on elements in their world that are
negative which, in turn, intensifies their sense of anguish and despair.
RUMINATION
Another aspect of mind that enters this unfolding drama is what has been called a
“discrepancy monitor” (Segal et al, 2002). Evolution has hard wired this capacity within
us to monitor where we are in respect to achieving goals we have set for ourselves. It
comes into its own, for example, when we attempting to play a musical instrument and
sound each note with the correct intonation. We know what we’re trying to achieve as a
desirable sound, and we monitor our playing until we have reached an acceptable sound.
When this capacity of the mind perceives a serious mismatch between our current mood
state and what we have always considered a desirable mood state, it is alerted to our
growing dilemma and seeks to rectify it in some way. Unfortunately our discrepancy
monitor is poorly equipped to deal with negative mood states. It seeks to avoid or
distance us from our negative mood state by a process of rumination. We begin to try to
think our way out of our negative mood by “pushing it away”, lamenting how “awful” it
is to feel this way, and catastrophizing all the negative consequences that will ensue if we
don’t “get a grip”.
However well intentioned this cognitive process may be, it is singularly unhelpful in
depression. Instead of generating helping strategies to free us from the nightmare that is
unfolding, rumination digs an even deeper hole than the one from which we are trying to
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escape. Rumination is relevant in a suicidal crisis because it has also been shown to
impair our memory in ways that make us lose touch with positive memories that may
guide us through a crisis. Also, rumination reduces our capacity for problem solving, so
that we find it increasingly difficult to see a way forward when we are in distress. There
is some evidence that rumination may be a more critical factor in suicidal behaviour than
external stressors. Joiner and Rudd (2000) observed that external stresses are much less
evident in repeated suicide attempters than in first time attempters. Rumination
intensifies the feeling that there is no escape from these recurrent lapses in mood and
brings the individual one step closer to considering suicide as their only option.
HOPELESSNESS
Hopelessness has been consistently identified as a strong predictor of suicide. Though
suicide assuages present suffering, in most instances it is undertaken to avoid future
suffering. If rumination reduces our capacity to access specific positive memories that
gave meaning and direction to our lives, hopelessness refers to the inability to believe
that the goals we aspire to in the future can ever be achieved.
MacLeod (2004) has recently refined our understanding of the role that hopelessness
plays in suicidal behaviour. For a long time, we believed that people who were hopeless
were people who had nothing to look forward to. Clinicians viewed them as people who
had become separated from whatever dream they had for what might give their lives
meaning and value. They saw the problem as one of depressed people becoming
“disengaged” from their future. But recent research has challenged this and offered a
much more precise insight into the nature of hopelessness.
Two groups of people were asked to participate in a study of what the future held for
them. People who were depressed and who had attempted suicide, and people with no
such history, were each asked to identify what they felt would make their lives worth
living. Surprisingly, both groups came up with virtually identical sets of “hopes” for the
future. This was quite contrary to what had been predicted. However, serious
differences emerged between the groups when they were asked to rate how likely they
felt they could bring about their hopes and how important they thought it was to have
specific hopes for the future.
Those who had a history of suicidal behaviour had virtually no confidence in being able
to bring about good events in their lives. They also differed from the non-depressed
group in believing that it didn’t help to have hopes because you would only end up being
disappointed. Contrary to the researcher’s predictions that “hopeless people” are people
who are disengaged from their future, they found that people who were vulnerable to
suicide were those who were “painfully engaged” with their futures. Those who had
resorted to suicide had the same dreams as those who did not, but they had very little idea
about how to make them happen. They were conscious of exactly what it would take to
make them happy, but they felt very unsafe in believing that good things could happen.
This research lends support to the recent emphasis of improving problem-solving skills in
those with a history of recurrent suicide attempts.
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CRY OF PAIN
SUMMARY
The processes described above are all closely inter-related. Each of these components,
intense affect, attention biases, rumination, and hopelessness can rapidly coalesce and
create a state of mind which eclipses all sense of joy, value, meaning and attachment to
others. Futile attempts to avoid these states or to “think” their way out of them can
understandably leave them with the idea of suicide as the only means of escape. A
tendency towards impulsivity and ready access to lethal options greatly increase the
possibility of suicidal behaviour. People who carry within them a vulnerability to
depression are easily primed to experience this kind of negative mental state that throws
them into despair. It is unrealistic to think we can remove their vulnerability to lapses in
mood, but it is likely we can teach people ways to prevent the avalanche of negative
psychological, emotional and physical forces which can take hold in such moments.
Mindfulness as been recently employed as a different strategy from conventional
psychotherapy approaches that may offer individuals different options for responding to
their emotional storms.
MINDFULNESS APPROACHES IN PSYCHOTHERAPY
In the past 50-year there have been 3 distinct phases in the development of structured
psychotherapies. The first phase started in the late 1940s with the application of learning
theory to the amelioration of emotional disorders. Behaviour therapy, as it became
known, focused on changing external behaviours by modifying the consequences of these
behaviours in the immediate environment. The second phase began with the birth of
cognitive therapy in the 1970’s, which focused on the role of key attitudes and beliefs on
shaping our experience of the world. Incorporating many of the traditional behavioural
techniques that had been found to be useful in treating phobias and other behavioural
disorders it shifted the focus of therapy to examining and modifying negative thought
patterns which gave rise to recurrent emotional distress. Originally developed as a
therapy for depression, it has been elaborated considerably in the past 30 years,
producing customised treatment approaches for disorders that include social anxiety,
PTSD, psychosis, eating disorders generalised anxiety and panic, to name but a few. The
third phase, which has referred to as the “third wave” is still in its early stages of its
development. It retains many of the features of the earlier cognitive and behavioural
approaches, emphasising structure, personal formulation of individual difficulties, and
treatment efficacy, but it has broadened out to include elements that emphasise
acceptance, relationship, mindfulness and body-focused interventions. These newer
elements are given central importance in therapeutic approaches such as Acceptance and
Commitment Therapy (ACT; Stephen Hayes, 2002), Dialectical Behaviour Therapy
(DBT; Marsha Linehan, 1993) and Mindfulness-Based Cognitive Therapy (MBCT;
Segal, Williams and Teasdale 2002). The aim of this paper is to describe mindfulness
meditation as it is taught in two of these ‘third wave’ therapies (DBT and MBCT) and
used with groups of people that are vulnerable to suicidal behaviour.
What these approaches have in common is a focus on changing our relationship with
experiences of emotional distress like anxiety and depression, rather than on changing the
content of these disorders. The common goal of these approaches is to help clients accept
and relate to what is happening to them in the here and now, and to realise that whatever
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is happening is neither a statement of who they are nor a statement of reality. Thoughts
are thoughts, feelings are feelings, they arise, they pass and they are only powerful to the
extent that we believe them to be real and true.
This shift in emphasis has many echoes with spiritual traditions in the East and West, and
it incorporates practices such as mindfulness, which has been developed within these
traditions for many thousands of years. Mindfulness is one aspect of this third wave and
its elaboration into a structured programme for people prone to severe recurrent
depression has been shown in repeated RCTs to be an effective intervention for reducing
relapse (Teasdale, Segal, Williams, and Ridgeway, Lau, and Soulsby, 2000; Ma and
Teasdale, 2003).
WHAT IS MINDFULNESS?
Mindfulness refers to a particular way of paying attention to our experience in any given
moment. It is a capacity within each of us for moment-to-moment, non-judgemental
awareness that can be very liberating. It does not so much seek to change what we are
feeling and thinking as much as to become curious about it, to be gentle with it and to
hold it in awareness rather than running from it, or acting on it.
Paul McGrath was someone who could be described as mindful on the pitch. His gift
was the ability to hold in his awareness a sense of where the game was at in any moment.
Knowing how the game was unfolding, he could place himself with an incredible
economy of movement right in the path of the ball. Mindfulness practice is about
developing this quality of attentiveness to what is happening around us and in our inner
lives. We can be mindful of a piece of music and all it evokes, or the sensation of wind
touching our skin as we walk. It’s harder to bring our attention to what is troubling and
painful. We are afraid. There is a lot of internal suffering and conflict that we would
prefer to avoid. We run away from ourselves and don’t attend to our bodies, feelings, or
thought processes. The pain and conflict we ignore in our inner lives often become
expressed in conflicts in our relationships with family, friends and work colleagues.
Mindfulness cultivates in an individual the capacity to become aware of automatic
patterns which thinking and feeling which are triggered in everyday life, to disengage
from these automatic patterns and switch into states of mind that can give us a freedom
from being pulled into reflexive and self-defeating patterns of reacting. For example, the
depressive/suicidal mode of thinking is characterised by a strong desire to push away, to
avoid, negative affect; focusing on discrepancies, a view of thoughts as reflecting reality,
the experience of being pulled back into past negative memories and of being drawn into
futuristic scenarios that are hopeless, and automatic physical and behavioural reactions.
In contrast to this mode of thinking, a mindfulness mode encourages approach rather than
avoidance, an attitude of acceptance and allowing of whatever feelings are present, a
recognition of thoughts as mental events rather than as accurate reflections of reality, and
a focus on present moment experience as it unfolds, rather than allowing the mind to be
pushed and pulled into the past and future. By changing how we attend to our
experience, mindfulness changes how we process that experience and connects us with
our deeper capacity for discerning what is really happening and how we might best act to
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address our needs. Mindfulness intentionally disengages our autopilot, focuses us on our
direct experience rather than what we think is happening and moves us into a gentler and
non-avoidant relationship with our actual experience. It does not seek so much to remove
our unwanted symptoms but to place us in a different relationship with them, one where
we become calm enough to observe what is happening and bring compassion rather than
self-condemnation to our inner lives.
THE RELEVANCE OF MINDFULNESS-BASED APPROACHES FOR SUICIDAL
BEHAVIOUR
Traditional CBT approaches have generally focused on changing behaviour and
cognition, with the unfortunate consequence of sometimes invalidating the client’s
experience and thereby increasing their distress rather than alleviating it. This
observation led Martha Linehan to develop DBT which is an approach to helping people
with enduring personality difficulties. She observed that when people feel invalidated
they react by becoming more out of control, failing to process new information and
reacting instinctively or automatically rather than skilfully. Her therapy incorporates a
delicate balance of acceptance and challenge. She introduced mindfulness as a means of
helping clients to internalise this attitude of acceptance, teaching them to observe their
experience, describe it as it was unfolding and participate with it on a moment by
moment basis. She communicated her success with this intervention to John Teasdale
and mark Williams when she was on sabbatical in Cambridge in the mid 90’s and she
encouraged them to explore its relevance in their research on interventions which might
reduce relapse in depression. They, in turn, developed Mindfulness-Based Cognitive
Therapy (Segal, Williams and Teasdale, 2002) and demonstrated its effectiveness in
reducing relapse by a factor of 40% in clients who had a history of three or more episodes
of depression (Teasdale et al., 2000). Both of these populations – people with borderline
personality disorders and recurrent major depression – are characterised by a high
incidence of self-harm and suicidal behaviour. Major depression is a highly significant
determining factor for 80% of suicides (Beautrais, Joyce, Mulder, Fergusson et al., 1996).
A therapeutic approach which helps to reduce relapse in depression may be highly
relevant in managing and reducing suicidal risk.
MBCT assumes that “much of the unendurable ‘psychic pain’ experienced by suicidal
people arises from their attempts to reduce, change, or fix their pain and from the
thoughts that arise when such attempts fail” (Williams and Swales, 2004). The cry of
pain model details a number of processes that are automatically activated when people
are thrown into a suicide crisis. Mindfulness may be useful in helping people to monitor
the automaticity of these processes and to disengage from them. Cultivating a capacity
for mindfulness may give people a means to stabilise themselves in the face of emotional
storms rather than be carried away by them. Early training in mindfulness sessions
teaches an increased awareness of the tendency for the mind to ruminate as an avoidance
mechanism in the face of upset. Mindfulness enables clients to disengage from this
process before it leads to an escalation of negative thinking and hopelessness.
Mindfulness training also deepens people ‘s awareness of the mind’s tendency to wander.
It encourages them to notice the pattern of their thinking and to become aware of what
issues it keeps coming back to. By learning to simply observe rather than act on these
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thoughts, clients can be empowered to make choices concerning whether they want to
indulge in well-worn pathways of thoughts or to disengage from them by acknowledging
their presence and bringing their attention back to the present moment by focusing on the
breath.
In addition, mindfulness teaches clients to treat thoughts as thoughts rather than as
reflections of reality. As one client described it, mindfulness gave him a viewing tower
from which to observe his thoughts and see them for what they were, rather than an
accurate verdict on his life, which he had always believed them to be.
Mindfulness does not merely focus on the problem of eliminating psychopathology but of
nourishing and strengthening the self. The practise of mindfulness connects people with
their deepest strengths and resources and encourages a philosophy of self-care, which
extends into every aspect of their life. Ma and Teasdale (2003) reported that MBCT
reduced relapse among recurrent depressives by a factor of 42%. Success was correlated
with a decentred relationship with symptoms that liberated people from automatic
patterns of thought and behaviour that they provoked. For many participants, the benefits
of the 8-week programme extended beyond this to include positive changes in their
eating patterns, a greater sense of trust in self, and an increase in spontaneity.
CONCLUSION
Mindfulness is not a stand-alone approach and its application should be informed by the
needs of the client and their current mental state. Studies have demonstrated its
usefulness with those who are currently in remission rather than those who are in the grip
of a major depressive episode. Before considering mindfulness approaches with this
latter group, a more conventional range of interventions should be considered including
medication. Secondly, mindfulness approaches may initially increase self-focus and
rumination. This may well result form clients becoming caught up in using this
technique as an extension of their desire to fix/put right the negative feelings and
thoughts which form part of their mental state. Re-orienting them to the function of
mindfulness can generally reduce this problem. With people who are vulnerable to
intrusive traumatic memories, mindfulness approaches should be preceded or
complimented by more traditional interventions aimed at processing traumatic memory
so they are not overwhelmed by it.
The challenge in working with people accustomed to bouts of suicidal despair is to
position ourselves in such a way that we can affirm and validate their experience of
intense pain, while also bringing to them a perspective on what is happening that can
liberate them from the sense of entrapment they may feel. Mindfulness fosters such a
stance both on the part of the therapist and the client. It offers skills that can help clients
to notice their biased attentional processes, steady themselves in the heat of emotional
storms, and disengage from the avalanche of negative thinking that often accompanies
these storms and triggers impulsive behaviour. It offers them relief from having to
constantly fight their negative thinking, and the freedom that comes from realising having
these thoughts does not mean they are weak or pitiful human beings. They discover that
if it in their nature to be vulnerable to depression that this will happen, that they should
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not be surprised but that, and that is may be though acceptance and self-compassion that
they discover what these attacks are really about, and how best to care for themselves as
these episodes unfold. Above all mindfulness offers a means for people to come home to
themselves and accept the full scope of their life experience, with appreciation and with
respect for what it has to teach them.
I would like to end with a poem by Derek Walcott, which I think captures something of
the yearning each person who has struggled with their inner life to feel at ease with
themselves.
LOVE AFTER LOVE
The time will come
When, with elation, you will greet yourself arriving
At your own door. in your own mirror,
And each will smile at the other’s welcome,
And say, sit here. Eat.
You will love again the stranger who was yourself.
Give wine. Give bread. Give back your heart
To itself, to the stranger who has loved you
All your life,
Whom you ignored for another,
Who knows you by heart.
Take down the love letters from the bookshelf,
The photographs, the desperate notes,
Peel your own image from the mirror.
Sit. Feast on your life.
REFERENCES
Beautrais, A.L., Joyce, P.R., Mulder, R.T., Fergusson, D.M., et al. (1996) Prevalence and
co-morbidity of mental orders in persons making serious suicide attempts: a case
control study. American Journal of Psychiatry, 153, 1009-1014
Hayes, S. (2002) Acceptance, mindfulness, and science. Clinical Psychology Science
and Practice, 9, 101-106
Joiner, T.E. & Rudd, M.D. (2000) Intensity and duration of suicidal crises vary as a
function of previous attempts and negative life events. Journal of Consulting and
Clinical Psychology, 68, 909-916
Linehan, M.M. (1993) Cognitive-behavioral treatment of borderline personality disorder.
New York: Guildford Press
Ma, S.H., & Teasdale, J.D. (in press, 2003) Mindfulness-Based Cognitive Therapy for
depression: Replication and exploration of differential relapse prevention effects.
Journal of Consulting and Clinical Psychology
MacLeod (2004) Presentation at the European Association of behavioural and Cognitive
Therapies
Segal, Z.V., Williams, J.M., and Teasdale, J.D. (2002) Minfulness-Based Cognitive
Therapy for Depression: A new approach for preventing relapse New York: Guilford.
Teasdale, J.D. (1999) Emotional processing, three modes of mind and the prevention of
relapse in depression. Behaviour Research and Therapy, 37, S53-S78
79
Teasdale, J.D., Segal, Z.V., Williams, J.M.G., Ridgeway, V., Lau, M., & Soulsby, J
(2000) Reducing risk of recurrence of major depression using Mindfulness-Based
Cognitive Therapy. Journal of Consulting and Clinical Psychology, 68, 615-23
Williams J.M.G. and Swales Michaela (In press) The Use of Mindfulness-Based
Approaches for Suicidal Patients
Williams, J.M.G. (1997) Cry of Pain: Understanding Suicide and Self-Harm.
Harmondsworth: Penguin
Dr. Tony Bates, Principal Clinical Psychologist, St. James Hospital, Donnybrook, Dublin 4
mabates@eircom.net
Chairperson: Dr. Patricia Noone - Comments
In his talk Dr. Bates stressed the valuable insights into key processes of the mind that
precede suicidal behaviour. He emphasised in particular the important role played by
“Mindfulness-based Psychotherapy”. He referred to 2 types of therapy – one dialectic
behaviour therapy and mindfulness based cognitive therapy. Both these techniques
incorporate many useful strategies from earlier approaches but are especially designed for
suicidal patients.
Dr. Bates outlined the combination of psychological pain, negative perception,
rumination and feelings of hopelessness can coalesce and eclipse any feeling of joy
leading to the belief that suicide is the only escape from the pain. Mindfulness teaches
clients to concentrate on their own thoughts and feelings, to accept them and strive to
strengthen the feeling of self. Mindfulness teaches people to connect with their deepest
thoughts and strengths and encourages a philosophy of acceptance and self care. It
“offers a means for people to come home to themselves and accept the full scope of their
life experience” accepting both their negative and positive thoughts and feelings.
WORK OF THE IRISH ADVOCACY NETWORK
Ms. Noreen Fitzgibbon
Irish Advocacy Network
I was asked to speak to you about what the Irish Advocacy Network does to prevent
suicide and how it supports people who are suicidal. The very nature of our work
provides such support.
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It is my belief that many people who presently use, or have used the psychiatric services
take their own lives, or attempt to take their own lives because of being disempowered,
stigmatised and lack the hope of recovery. People in care become unable to trust their
own judgement, become indecisive, submissive to authority and frightened of the outside
world. I will briefly address these issues in my talk.
The Irish Advocacy Network is an island wide organisation run wholly by and for people
who use or have used the mental health services. We provide information and support for
mental health service users and survivors. Our aim is to facilitate user empowerment by
supporting people to speak up and speak out and take back control of their own lives
again. Empowerment is one of the buzzwords at the moment. By empowerment I mean
enabling a person to speak up and take control of their own life, having a say and making
decisions in their own life, realising their own self worth and value, having the ability to
self advocate and being accountable for their own decisions. In order to achieve this aim
we are engaged in a variety of activities that include the provision of a range of services,
contributing to Mental Health Reviews North and South, influencing policy, legislation
and service provision and liaising with statutory bodies and mental health professionals.
People particularly need peer advocacy when they are disbelieved, discounted, devalued
and discriminated against, as people who have been diagnosed with serious mental health
problems often are, within the services and in the wider community. We in the Irish
Advocacy Network play a vital role in supporting people who use the mental health
services. I believe the most powerful supporting tool we have is our own personal
experience of being service users ourselves, our ability to empathise with the people we
meet and to be able to say, “I know exactly what that feels like.”
When we meet people we meet them as equals, there is no power imbalance between us.
People yearn to and can connect emotionally with others especially when they are
experiencing severe emotional distress.
I believe that one of the ways forward in suicide prevention is to reduce the stigma of
mental illness. By each of us in the Irish Advocacy Network openly and unashamedly
declaring that we have experienced mental health problems, we help to destigmatise
mental illness.
People who use the mental health services frequently complain about staffs’ inability to
listen without either analysing or diagnosing what they say and as a result they are often
not open and honest when speaking to staff. We see the people we work with as
independent people in need of temporary support. We actively listen to the person and
are non-judgemental. Also we provide a confidential service to the client so the person
has the freedom to be open and honest with us. The client knows that the only time that
confidentiality is broken is if the person tells us that they are going to harm themselves or
others. We in the Irish Advocacy Network are committed to hearing the voices,
respecting the views and defending the interests of the people we serve. By openly
valuing and validating the expressed thoughts, beliefs and feelings of the person rather
than dismissing their significance we increase the persons self esteem and lead to
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empowerment. Often all clients’ want from us is for us to listen to what they say and
validate how they feel.
In order to feel empowered the person needs to have a clear sense of control over the
proceedings of the interaction. In our work relationships with clients the person is in
control at all times and can terminate the relationship at any time.
We are all familiar with the language used in psychiatric diagnosis and being labelled and
how disempowering it can be. This was certainly true for me. I lost my identity and I
became the label. It took over my whole being to such an extent that I gave up living and
was actively suicidal for 17 years. When service users come together and talk, they don’t
use medical language, we use words that best describe how we are and feel and this can
be very empowering. By sharing information and learning from each other we learn that
having a mental illness does not mean that we have to give up on our dreams and goals.
Recovery is not a concept that I, or most people, encounter within the system. Nothing
about recovery is mentioned. Perhaps this is because recovery is usually taken as broadly
equivalent to a ‘cure’ or ‘getting back to normal’, and by these standards few people
recover from severe mental illness. However, many service users view recovery as,
despite often living with enduring symptoms, being in control and living the lives we
want to live and achieving our goals. Recovery viewed in this way is personally
empowering and raises a realistic hope for a better life. When recovery and hope for the
future are not mentioned, is it any wonder so many people feel suicidal? People can and
do recover from even the most severe forms of mental illness. Understanding that mental
illness is a label for severe emotional distress, which interrupts a person’s role in society,
helps in a person’s recovery. Because every one working with the Irish Advocacy
Network has reached a level of recovery, we are living proof to people that recovery is
not only possible but is within each person we meet. We believe that the person is an
expert on his/her life, its problems and potential resolutions. The person knows what is
helpful or right for his/her own life. We believe in every person we meet and when
someone believes in you they assist in the recovery process. We never give advice to
clients. People have to be able to follow their own dreams to recover.
In order to improve the skills, knowledge and self-esteem of our people, in conjunction
with Mind Yourself we designed a peer advocacy training course. The course is the first
of its kind in Europe and it is accredited with the Northern Ireland Open Colleges
Network. It consists of ten modules that cover a range of topics pertinent to mental
health.
The feedback I get from clients every day leaves me in no doubt of the support and hope I
give to clients. Comments such as “If you can recover, then there is hope for me”, and
“It’s great to be able to talk to someone who really understands what it’s really like”.
Ms. Noreen Fitzbibbon, Irish Advocacy Network, Old Rooskey House, Rooskey, Monaghan
Tel: 047 38918
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SUICIDE PREVENTION: A CHANGE OF ATTITUDE
Ms. Sheila Dalton
AWARE
Abstract
In 1998, the Department of Health and Children published the report of the National Task
Force on Suicide. That same year, after extensive research and consultation, Aware
published “Suicide in Ireland - A Global Perspective and A National Strategy”. Prof.
Patrick McKeon, in his foreword, stated that “Reducing the suicide rate cannot be
achieved without a change of awareness, attitude, and commitment to the care of people
with depression, alcohol, drug dependence and schizophrenia”. These conditions,
however, do not seem to receive similar or equally effective life-saving attention as do
other areas of medicine. The question is asked, ‘Why? ’However, responsibility for the
prevention of suicide does not lie with the Statutory and Health Care Agencies alone.
Attitudes must change throughout society. In this context, a further question is asked:
‘Have we moved forward as individuals, as communities and as a political system in
changing our attitudes to suicide and its prevention’?
In 2003, 444 people died by suicide. On reflecting on these numbers one questions the
increase in these figures over the past years despite all the educational programmes aimed
at preventing suicide. Has there been a change of attitude?
I’m asking three questions on this:
1. What is my personal attitude in the area of suicide prevention?
2. What is society’s attitude and responsibility?
3. What is the government’s attitude?
Looking at the first question it is important to focus on how I react and feel on hearing of
a death by suicide. Do I say “Just another statistic”? “God help the family” or does it go
over my head. If I know the person or the family my response is different: disbelief,
anger etc. Wondering what to do or say. It can take some time before I ask, “what was
happening in this person’s life?” Very often I can be more interested in the “HOW”
rather than the “WHY”. It happened out of the blue. I’m puzzled. NO WARNING
SUICIDES ARE VERY RARE. The realisation that I should be making a deeper
response by asking “WHY”? This is where I believe that I have a personal and justifiable
responsibility in the area of suicide prevention.
At least I might place myself in the shoes of someone who experiences
the deep sense of hopelessness, despair, the unending dark tunnel, the physical pain, the
feeling of being locked inside oneself. The real desire to finish with life. Life-events and
their traumas can often shatter the core of my existence. So what can I do? Most of us
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are very good at taking care of our physical health. We have regular check –ups and so
on. Maybe we can begin to think more on how we can improve our emotional and
mental health. So how do I do that?
 Recognising my weaknesses, taking steps to strengthen them.
 Being aware of my limitations and working within them.
 Improving my self- esteem and confidence.
 Accessing practical and emotional supports from family. Keeping contact.
 Ensuring that I have an interactive relationship with a circle of friends and
maintaining that above all.
Other People
In winter, during a cold snap, we are reminded to look-out for elderly neighbours. We
respond to this and do our bit.
There isn’t a suicide snap. Unfortunately we have suicide every day. So, maybe we
should be alert to the needs of other people in this area.
Their needs and problems are often hidden and unexpressed.
 The neighbour who has suddenly become reclusive, - gently asking if they need
shopping or just a chat.
 The family member who seems withdrawn and always the quiet one in
conversations.
 The unusually moody teenager.
There are many other examples.
These are some of the things I can do: Reach out the hand of friendship and care. Allow
the time, allow the long silences but be there with a listening ear. Maybe I can offer
some advice, if not; maybe I can suggest a visit to the family doctor, - attendance at an
AWARE meeting. At an AWARE meeting, they will be given the space, the security, the
time, to express themselves in a supportive environment and to be listened to with
respect.
At some time each of us need to be listened to: I have my story to tell, my joys, my
sorrows, my pain my guilt. I will always know when someone hears me. So, I too must
return that to those I meet in their pain. It’s not always easy. There can be rebuffs but in
the rebuff the connection is made and it is the first step of many steps. So I look into my
own heart and ask the question am I making a conscious effort to be alert and take the
steps in my responsibility towards an ongoing change in attitude in the prevention of
suicide
Over the past two decades there has been a noticeable change in society’s attitude to
suicide. Apart from decriminalisation, there is no longer the dark secret and mystery that
surrounded it. Families had a “black mark” which they carried down through the years.
They were spoken about in whispers.
84
It was a bar against marriage. Suicide has had the longest of consequences and a subculture all of its own.
Thankfully those dark days are dwindling. There is an uphill battle in society’s
responsibility in suicide prevention. Many people feel that the Ireland of this 21st
Century is suffering from a breakdown in family and community structures. People are
left isolated, disconnected and in despair not really knowing where to turn to. There is a
real challenge in this for us.
We must bridge the gap from our own self-absorbing concerns to a real and visible
commitment to our community.
It’s easier to walk by and not get involved. We live in a world dominated by economics,
when almost everything is measured or valued in monetary terms: - the size of the house;
the make of the car; the number of foreign holidays in the year. The AD’S on T.V.
assure us of 100% success if we buy a particular product. It goes on.
So there is not very much room in our present-day society for those whom we think don’t
measure up. They are seen as liabilities. Do we hear their plea for help? Or do we really
care anymore? A lot of people support AWARE DAISY DAYS or other such
organisations, and this is good. These monies are vital to the life-blood of these
organisations. But does this salve our conscience? Is this commitment enough?
All of us who are here in Wexford these days are here because we care and are
concerned. How do we get Society to change and care? Society needs to re-educate
itself. Can we recognise the symptoms of depression? What can we do about it?
FESTIVAL is Award’s acronym for depression – its signs and symptoms. One in four of
us will have a significant depressive illness during our lifetime. Will it be a closed
subject for us? Will we say it to our friends over a cup of coffee or to lads in the local
over a “Pint?”Being a Volunteer with AWARE I’ve heard people talk in our Groups of
being misunderstood, alienated and discriminated against. Can society afford to be
indifferent to that?
Drugs, and particularly alcohol, play a big role in suicide related deaths in young people,
so there is an ever increasing need to be alert, aware to the signs, risk factors and how to
respond to them. In past decades young people were not as affluent. The rapid change in
society has exposed young people to problems which are hard to keep track of. Problems
that we adults might only see on the big screen. We need to keep ourselves informed to
help them cope with them when these problems arise. Parents must get involved in their
children’s moral and personal development. It’s often easy to take the easy option and
expect Schools and other Agencies to provide information and answers. Parents will get
more respect if they set boundaries. Young people quickly react to this. There may be an
initial dust-up about it. They do appreciate it in the end.
85
AWARE has a programme called BEAT THE BLUES. This is aimed at second level
students. This has proved to be of great value in getting students to recognise,
understand, and discuss depressive illness with its many aspects.
Despite the busyness of life many people feel isolated. Isolation separates people from
society even further when they are depressed. In the past we all seemed to have time to
keep contact and visit. We must be alert to these fragile people. At the risk of repeating
myself, a listening ear, an outstretched hand, a pointer in the right direction for help can
be a major influence on someone in need.
We need to have a long hard look at ourselves as a society and see have we honestly
changed our attitudes, and if not: “what are we going to do”?
Are we going to become the caring society that our Irish-ness was once noted for?
My third and final question is of a political nature. Over the past few years, we have seen
the appointment of Suicide Prevention Resource Officers to our Health Boards. The
services are being expanded gradually. But do our Politicians fully understand our
problems? During our recent European and local elections we were inundated with visits
from candidates. One called on me recently. Earlier in the day I’d met a the family of a
person actively suicidal. I asked the candidate what was his party’s response to the need
for suicide prevention. “Sure Mrs. that’s a medical problem”. You may smile but it
made me quite mad. In 2003 as I said earlier, 444 people died by suicide. That does not
include the many single vehicle road traffic accidents that there may be a question mark
over. And then the candidate says “it’s a medical problem” 83% of Psychiatrists have no
access to a Psychologist’s service. By our very nature, we are fully human; it is our right,
so we deserve to be treated accordingly.
Our Taoiseach in the last election used the phrase:- “A lot done but more to do” I don’t
wish to offend anyone but I think for our services “there is a lot more to do” This will
only be done when the Government seriously looks and thinks about investing money
wisely and constructively in co-operation with all the Vol. Organisations in the mental
health of Ireland’s future generation. This year 7% of the Budget for the Health Services
went to Mental Health. – if you like to think of it in real terms its €1.40 out of every
€20.00. Much less than we were getting in 1990. As The Celtic Tiger reasserts itself
what are we to do? Our voices must be heard. Our voices must be heard for the most
vulnerable people in our society.
We need to get together as individuals, as organisations and write to and lobby
Politicians. We need to get them to prioritise. One in five people will have a psychiatric
condition. Will we have to wait for an epidemic before the Government sees that we
need serious funding? Will they help to prevent and ease the pain and heart break that the
families of the 1.5 people to-day Thursday who will die by suicide in this country.
Ms. Sheila Dalton, Aware, 23, Father Murphy Square, Kilkenny. Telephone: 056 7762054
86
SCHIZOPHRENIA IRELAND’S LIFE HOPE PROJECT
Ms. Kahlil Thompson
Projects Officer for Schizophrenia Ireland and Project Manager of The Life Hope
Project
Abstract
Suicide is the single largest cause of premature death among people with schizophrenia.
Against this backdrop, Schizophrenia Ireland (SI) considers that suicide prevention is an
integral part of addressing the needs of people with schizophrenia. The purpose of the
“Life Hope” project is to increase awareness about suicide and its prevention, offer
enhanced counselling services and to empower people with mental illness and their
relatives with the tools to aid suicide prevention. It is SI’s view that the best prevention
of suicide is the social and emotional support given to people with schizophrenia,
offering them hope that life will improve.
Ms. Kahlil Thompson, Project Officer, Schizophrenia Ireland, 38, Blessington St, Dublin 7.
Tel: 01 8601620
LEARNING AFTER DESPAIR
Mr. Mike Watts
National Programme co-ordinator, GROW
Abstract
As young people both myself and my wife Fran experienced long periods of
despair, with a growing desire for the pain of that despair to end. Suicide
became a definition option for us both, for very different reasons, in different
ways and at very different stages in our lives. Through our involvement in
GROW, with its emphasis on finding and nurturing healing relationships we
now look back on those times from positions of personal fulfilment and a
gratefulness for the gift of life. This presentation looks at some of the
relationships that helped us and some that hindered. It looks at the effects of
labelling people, either as people with illness or people with qualifications.
Finally it suggests how any individual that is experiencing despair can be
reached and helped to find a way towards hope and healing.
87
My name is Mike Watts and I am very pleased to have this opportunity of sharing some
of my experience and ideas with you at this forum. It is particularly good to be part of
this panel of speakers, all with different insights into the problem of suicide. I remember
John Connolly once describing mental health as being like a huge jigsaw puzzle and
saying that each of us holds a piece of that puzzle. The problem is finding a way to fit
those pieces together so that we get the best possible picture. Maybe by fitting those
pieces in different ways we might see different realities.
What I want to do in the next few minutes is first tell you a little about my own
experiences as a young man and also of the circumstances around a time when Fran, my
wife was extremely despairing and suicidal. I want to try and give some idea of how we
moved from this position to our lives today, which are relatively normal and satisfying.
As part of this I want to use a concept that I call a recovery map. A recovery map is a
map of resources that exist in every community, and which can be used at very specific
and very personal levels to help people to recognise and access those resources as and
when they need them.
I then want to talk a little about labels and about their ability to block the chance of real
relationship whether they are labels of illness or of profession.
Lastly I want to draw on material from Recovery research, which would suggest that
there are definite right ways to help someone overcome despair. I want to tell you a little
about the leadership course we have pioneered in GROW and which is proving very
helpful to those undertaking it and which has huge relevance in training people to learn
how to care for each other especially people who have thought of themselves as useless.
The Beckoning Place
By the lake without love
I look to the depths
Of the dark inexorable pool
Thoughts of death in
The beckoning place
And murmurs, soft of fool
And all around the twittering birds
Are singing with the trees
Look at you young man
You’re quite absurd
You and all your dreams
That poem really illustrates how I felt for many years as a young man. I felt I was
someone shut off from and unworthy of love. Suicide and death was something that
called to me like the sirens that called seductively to the sailors of mythology, along with
a growing and disturbing number of mocking thoughts which ebbed and flowed in the
tides within my mind. Once these appeared as a menacing voice threatening to “get me”.
Like many young men I sought comfort and courage in drink, which probably made me
88
more vulnerable. The most probable way I would have sought death would have been to
drive into something. I didn’t, and I think I didn’t because I had been brought up to
believe that suicide was wrong. At home I had heard this message over and over again.
A temporary turning point came when I met my wife Fran. My life became meaningful.
I was in love. We started a family. Fran broke down very dramatically and her life
became increasingly unbearable. Diagnosed with schizoaffective disorder, schizophrenia
and manic depression, she was on a massive cocktail of drugs that more or less totally
immobilised her. In and out of hospital, hope rushed and then continued to trickle out of
the door. Fran used to go to bed praying that she would get cancer and die in the night.
She told our neighbours she was thinking of killing herself. Our neighbours were really
wonderful, warm Clare people whom she respected enormously and they reacted angrily
telling her that would be a sin. This in turn made Fran extremely angry. She learned,
over the years to channel that anger into getting better, which she has done. Today we
both have pretty fulfilling lives and get increasing glimpses of the deep spiritual and
sacred beauty there is in just being alive.
I have stressed in both our stories that the idea that suicide is wrong, had a direct impact
on both our thinking and acting. I do this because I believe that this needs to be said to
counteract the culture that says that suicide is somehow noble and inevitable. We have to
get across the message that it is better to live than to die. I think the best argument for
this is for people who were in despair to show that they are glad they didn’t take that
final, sad, but very understandable step.
How did we get better, or move from despair and reliance on medication and hospitals to
independence. Firstly GROW helped. GROW provides people with a week by week
personal development or recovery plan. It also gives you a practical psychology of
mental health that enables you to tackle your symptoms and a group of people who will
cheer you on for even the most hesitant of efforts. Most importantly it directs you to love
in the community. We have recently developed the idea of a recovery map. I will share a
page of my own.
A PAGE FROM A RECOVERY MAP
Where was I? I was in despair. Fran was sick and threatening to leave or kill herself. We
had 3 small kids. I was still very much a social outcast. Extremely shy and still plagued
with destructive thoughts. Where did I want and need to go? I needed human warmth,
hope, belief in myself, fun and security. The map helped me realise that all around me
there were resources that really could give me all of these things and more. Neighbours
who had warmth, fun and easily believed in me. The charismatic renewal which offered
warmth and music, hope and the promise of healing. It also offered mystery which was
vastly preferable to the cold certainty of how we were feeling and the labels we had been
given. A local committee I joined that helped me develop skills and endurance. A
factory where the craic was mighty and I learned to loosen up a little. Also on the map
was Our Lady’s Hospital in Ennis. Our Lady’s definitely saved our lives but at this point
the help it could offer was very much in the background. It was a place of refuge if
things got too bad. Without actively working on recovery on being discharged we
89
wouldn’t have moved forward and many of the people who were then in our Lady’s are
still either in or attached to it. We needed relationships that fed us and helped us believe
in ourselves. We needed friends. And we found them in abundance.
THE NEGATIVE EFFECT OF LABLES
One of the big difficulties of reaching young people at risk is labels. It’s not only the
effect of giving a psychiatric label which can be totally devastating but also the effect of
professional labels. As part of my recovery I went to UCG. The Chaplin there was a
very gifted man named Ned Crosby. He spoke about the potential barriers of being a
priest. He used a chair as an illustration. Before becoming a priest he needed a degree in
philosophy. (He put a chair on his back) Then he needed another one in theology. (He
put a chair on his front) Then he had to speak the gospel (he held a book in front of him)
Then he had to meet people as a humble, vulnerable equal. (He walked towards someone
bristling with chair legs and holding a heavy book) The same is true with professional
labels. They should be seen as a huge challenge to be human while involved in
relationships with those seeking help. Professionals must realise that they are primarily
human beings just as are those whom they meet and that the quality of the relationship
they form is more important than any skills they may or may not have. The most
important ingredients in that relationship are belief in the other, compassion, warmth and
dignity as a fellow human being.
THE RECOVERY MODEL
Much work has been done on the conditions that are not only necessary but essential for
recovery. Glen Roberts a psychiatrist working in the UK, uses a table that illustrates the
difference between a treatment and a recovery model of health. If we are to catch people
who are in despair we definitely need to be learning the language of recovery
Recovery Model
Distressing experience
Biography
Interest centred on person
Pro health
Strengths based
Experts by experience
Personal meaning
Understanding
Value centred
Humanistic
Growth and discovery
Choice
Modelled on heroes
Guiding narratives
Transformation
Self management
Self control
Personal responsibility
Medical Model
Psychopathology
Pathography
Interest centred on disorder
Anti disease
Treatment based
Doctors and patients
Diagnosis
Recognition
(Apparently) value free
Scientific
Treatment
Compliance
Under pinned by meta analysis
Randomised controlled trials
Return to normal
Expert care coordinates
Bringing under control
Professional accountability
90
Within a social context
Decontextualised
THE LEADERSHIP POTENTIAL OF BROKENNESS
Over the past few years we in GROW have been pioneering a distance learning course
entitled Personal Growth and Community Building through Leadership. Almost 100
Grow members have undertaken this course which was evaluated by UCC through a
grant from HRB and the Gulbenkian Foundation. What we have discovered is that
broken people have enormous leadership to give. That through being trained to see their
experience of brokenness and of healing as a resource for others, they can become whole
and create community and that through this process others become whole and are healed
as well.
I believe that young people at risk also have a huge leadership role to reach out to each
other. I believe that the teenage years are particularly difficult for most young people. I
believe that maybe the jigsaw puzzle pieces we most need are those pieces involving
experience of suffering, of being helped or not helped and of healing. I believe that we
need to be talking to young people as was done in the wonderful research from Mary
Begley in Limerick. There are many wonderful things happening such as a peer
counselling program being coordinated by Diarmuid Ring in UCC. The idea of advocacy
as being promoted by the Irish Advocacy Network also has huge relevance to the young.
I think that the focus needs to shift from words like treatment and psychiatric illness to
words like love and human distress, and while treatment has a part, relationships are the
key.
Mr. Mike Watts, Grow Centre, Ormond Home, Barrack St, Kilkenny. Telephone: 056 7761624
WORK OF THE RESOURCE OFFICERS IN SUICIDE PREVENTION
Teresa Mason
Resource Officer for Suicide Prevention, Northern Area Health Board.
Abstract
The position of Resource Officer for suicide prevention is a relatively new one in the
health boards in Ireland. The first officer was appointed following the publication of the
Report of the National Task Force on Suicide in 1998. An outline for the role was
presented in the Task Force Report and this has been developed since that time. This
presentation will explain the role and responsibilities of the Resource Officer for suicide
prevention. It will discuss how the Officers link with others working in suicide
prevention and outline a number of suicide prevention projects involving Resource
Officers that are underway in the country.
91
Ms. Theresa Mason, Health Promotion, Northern Area Health Board, 3 rd Floor Parkview, North Circular
Road, Dublin 7. teresamason@erha.ie
Poster Session
92
SUICIDE RESOURCE OFFICE – SOUTH EASTERN HEALTH BOARD
RESOURCES AND PUBLICATIONS
Mr. John Kennedy/ Ms. Agatha Lawless
Training & Development Officers, Suicide Resource Office, SEHB
Abstract
This display will highlight the Training Programmes being delivered by the Suicide
Resource Office and the Resources and Publications that have been developed there.
As well as delivering general awareness training around suicide, the Suicide Resource
Office delivers the following programmes:

1 Day Suicide Awareness Training

Older Adults: Depression and Suicide

ASIST - 2 day workshop – Applied Suicide Intervention Skills Training

Suicide Awareness in Schools – A 15 hour training programme for teachers

Community Education Programme - 20 hour training
Resources & Publications include ‘Help and Health for you’ information cards that
contain information relating to Health Board services and local support groups along with
regional and national support numbers. ‘Concerned About Suicide’ leaflet - provides
general information about risk factors, warning signs, key facts about self-harm and
suicide. ‘Suicide Information Handbook’ provides detailed information on suicide in
Ireland. ‘Suicide Awareness - an Information Pack for Post-Primary Schools’, provides
guidance to school staff so they are best able to respond to suicide/suicidal behaviour.
‘Bereavement Information Handbook’- an information support resource for people
bereaved through suicide or sudden death.
The role of the Training/Development Officers is to develop and deliver training
programmes relating to suicide and suicidal behaviours to both voluntary and statutory
services in the region.
As well as delivering general awareness training around suicide, the Suicide Resource
Office delivers the following programmes:

1 Day Suicide Awareness Training
Aim: To increase participant awareness of suicide and to explore interventions and
support structures.
Objectives: At the end participants will be able to:
 Discuss the incidence of suicide nationally and in the S.E.H.B.
 Discuss the risk factors of suicide
93


List the signs of suicidal behaviour
Identify support groups/resources for people in distress

Older Adults: Depression and Suicide
Aim: To increase participants knowledge and skills in supporting older adults who may
be depressed and/or at risk of suicide.
Objectives: Upon completion of this training participants will be able to:
 Discuss the incidence of suicide nationally and in the S.E.H.B.
 List the signs and symptoms of depression in older adults
 Indicate situations that increase risk of suicide in older adults
 Identify support groups/resources for the bereaved

1.
2.
3.
4.
5.

ASIST 2 day workshop – Applied Suicide Intervention Skills Training
ASIST has five learning sections:
Preparing - sets the tone, norms, and expectations of the learning experience.
Connecting - sensitizes participants to their own attitudes towards suicide.
Creates an understanding of the impact which attitudes have on the intervention
process.
Understanding - overviews the intervention needs of a person at risk. It focuses
on providing participants with the knowledge and skills to recognize risk and
develop safeplans to reduce the risk of suicide.
Assisting - presents a model for effective suicide intervention. Participants
develop their skills through observation and supervised simulation experiences in
large and small groups.
Networking - generates information about resources in the local community.
Promotes a commitment by participants to transform local resources into helping
networks.
Suicide Awareness in Schools – A 15 hour training programme for teachers
Aim: To improve the knowledge and competency of designated school staff in the
recognition and management of potentially suicidal young people. It also aims to
develop staff members ability to access support for staff and students in the event of a
death by suicide or sudden death.
Objectives: Upon completion of this training participants will be able to:
 Gain insight into their own attitudes and beliefs about suicide
 Recognise the risk factors and warning signs of suicide
 Have improved competency in identifying students in distress and encourage
them to seek help
 Outline the resources available to support young people at risk

Community Education Programme - 20 hour training
94
Aim: To enable participants to acquire the knowledge, attitudes and skills to identify
people at risk of suicide and to refer them to appropriate sources of help.
Objectives: Upon completion of this training participants will be able to:
 Describe the risk factors and warning signs of suicide
 Identify people at risk and be competent in supporting them in their distress
 Outline the resources available to support people at risk in the community
 Demonstrate a knowledge of the needs of families/friends bereaved by suicide
Resources & Publications
These include ‘Help and Health for you’ information cards that contain information
relating to Health Board services and local support groups along with regional and
national support numbers.
‘Concerned About Suicide’ leaflet - provides general information about risk factors,
warning signs, key facts about self-harm and suicide.
‘Suicide Information Handbook ’ provides detailed information on suicide in Ireland.
‘Suicide Awareness - An Information Pack for Post-Primary Schools’, provides guidance
to school staff so they are best able to respond to suicide/suicidal behaviour.
‘Bereavement Information Handbook’- an information support resource for people
bereaved through suicide or sudden death.
Contact Details: Mr. John Kennedy/Ms. Agatha Lawless, Suicide Resource Office, Front Block, St.
Patrick’s Hospital, John’s Hill, Waterford. Tel. 051-874013 E-Mail: kennedyjohn@sehb.ie
lawlessa@sehb.ie
A HEALTH SERVICE RESPONSE TO SUICIDE BEREAVEMENT: DONEGAL
MODEL AND FINDINGS
Ms. Carol Phelan
Bereavement Counsellor, North Western Health Board
Abstract
The North Western Health Board Bereavement Counselling Service has
operated for almost five years in County Donegal, providing a model of
response to suicide bereavement within an integrated bereavement service.
Traumatic deaths and complicated grief reactions were prioritised, without the
service being dedicated to suicide bereavement per se. Suicide bereavement has
steadily risen in the four full years of service, representing 22% of all referrals
in 2003 and 43% of open cases at year-end. In total 78 referrals have been
received relating to suicide bereavement in four years, and this paper will
present statistical findings relating to same. This will include referral patterns
and pathways, timing post bereavement, length of engagement, age range and
95
relationship with person who died by suicide, method of suicide, and whether
witnessed by person referred. Discussion will be made of the above and their
implications in terms of both service and therapeutic responses to suicide. A
case study will be briefly presented, mapping the different phases of therapeutic
engagement, including individual therapy and therapeutic group work.
The NWHB Bereavement Counselling Service was initiated in December 1999, with the
appointment of a dedicated counselling post in Bereavement. By the end of 2004 it is
expected that this will be doubled with the appointment of a second post in bereavement.
Having operated for almost five years in County Donegal, it has provided a model of
response to suicide bereavement within an integrated bereavement service.
The NWHB Bereavement Counselling Service has and is responding to demand from
those affected by suicide. The service has built up a professional track record, evidenced
by strong referral rate by GP’s and increasing self-referral rates. It is a vital and
significant part of the NWHB’s response to suicide in County Donegal.
Traumatic deaths and complicated grief reactions are prioritised
While suicide represents 22% of referrals in Donegal in 2003, it compromised 43% of
cases held open at end of 2003. This represents a clinical situation of complex
presentations, with additional traumas as well as bereavement reaction. There is evidence
to suggest a process more complex and prolonged than other types of bereavement,
confirmed by the literature as being longer, more intense and difficult to resolve. In total
78 referrals have been received relating to suicide bereavement in the initial four years.
An average 10.34 suicides per annum are recorded for Donegal between 1997 and 2001.
Many more happen to families living within the county where the deceased person
resided outside the county (emigration/mobility etc) and thus are not registered for this
county.
The NWHB Bereavement Counselling Service, while not directly initiated as a response
to suicide, is a vital part of current response to suicide in Donegal.
The degree of uptake reflects both the need post suicide and the acceptability of this
model of service provision.
The NWHB Bereavement Counselling Service offers an integrated, neutral and nonstigmatised response to bereavement, with a high standard of privacy and physical
environment.
The model outlined here and the evidence arising from its first four years of service
provision might usefully be considered by other Health Boards or Regional Service
Providers in the area of responding to suicide
96
Referral policy and criteria
The service aims to provide the following services:
 Information and consultation services in bereavement and the grief process
to NWHB staff, GP’s, community groups, and the public
 Training on bereavement issues and in bereavement support to staff and
community groups
 Counselling/therapy to individuals and families in cases of difficult or
traumatic grief, such as bereavement by suicide, bereavement of a child,
and accidental or traumatic deaths
 A counselling/therapy input to palliative care and hospice services; that is
to those who are terminally ill and/or their families
 Individual counselling to NWHB staff who experience stress arising from
bereavement issues
How referrals are made:
How the service operates
 Referrals can be made by GP’s, staff, etc… and self referrals are acceptable
The service has evolved in adapting its response to referrals post suicide.
 A written referral is desirable where possible
There are a number of levels at which intervention takes place:
 1.There Individual
should be at least two months since the bereavement
2.
Family
3.
Group
 4.The person
being referred
must themselves
want a counselling input
Parental/Individual
consultation
model
5.
Community
6.
In service/staff
 The counselling
service is not intended in situations of “normal” grieving;
but useful written information on bereavement is available by post in such
cases
Most frequently the service is sought in relation to an individual.
However, suicide does not just affect the person presenting, and often the service needs to
 Referrers
canmembers
discussofand
any case
byiscontacting
service
respond
to several
the consult
family oron
network.
This
done either the
directly,
where
this service or another counsellor/psychotherapist will be accessed for other members
wishing to avail a therapeutic service, as appropriate. Or indirectly; i.e. by providing
information (including written information), consultation, and reflection space to the
97
member attending.
When a family/couple presents together, current practice is for an initial family meeting,
followed by individual sessions with members if required and with family group
meetings at intervals.
This allows opportunity for individual as well as group processing.
Community and in service interventions take place at the level of training and in terms of
group facilitation response
Statistical findings from 2000 to 2003
Suicide referral pattern:
78 referrals post suicide to the NWHB Bereavement Counselling Service in Donegal in 4
calendar years to end 2003
Referral for Counselling Post-Suicide
30
No. Referrals
25
20
15
10
5
0
Year 1
2000
7
Year 2
2001
21
Year 3
Year 4
2002
2003
24 (3*) 26 (5*)
*family groups
More than a three fold (350%) increase in referrals between 2000 and 2001, an increase
of 14% in
2002, and a further increase of 9% in 2003.
Referrals to the service have been from one week to 16 years post bereavement, the
majority who successfully access and engage are between 6-24 months post loss.
98
2000 (n=7)
2001 (n=21)
2002 (n=24)
2003 (n-27)
Totals
4.
Length of time since death
Less 6wks 6w-6mts
6mts-2yrs
1
2
2
4
7
3
4
5
13
3
7
7
12
21
25
2-10 yr. 10 yrs+
2
3
4
1
1
3
6
9
11
There is a non-attendance rate associated with the service as is associated with
most psychological interventions and with bereavement responses.
Reasons for non-attendance and refusal include:



Inadequate consultation and agreement on the referral between referrer
and client/patient
Timing of referral
Personal fears/acceptability of counselling/services to the bereaved person
Those who decline a service have been given telephone support and written
material, as appropriate. They are made aware that they can avail of the service at
any stage in the future, should they so wish, and when they feel ready.
GP’s are the single largest referrer, with a significantly increasing pattern in relation to
self-referrals. This is observed to reflect increased literature containing service
contact numbers for the North West, e.g. “You Are Not Alone” booklet published
by NWHB; as well as information passed informally/by word of mouth and
between family members.
2000 (n=7)
2001 (n=21)
2002 (n=24)
2003 (n=26)
Totals
GP’S
2
13
16
14
45
Referral pathways – Suicide
PHN Psych Misc Gardai Self
1
1
1
1
1
1
1
4
1
1
1
9
2
2
3
1
15
Suicide Presentation:
The following tables give details relating to presentation:
By whom bereaved
99
OHB Hosp
1
5
2
7
1
21
Son
Husb/pa Father Mother Brothe Sister Frnd/r Son/bro Hus/fat
rt
r
el
*
h
3
1
2
4
1
5
3
2000 (n=6)
2
2001
6
(n=21)
2002
1
3
(n=24)
2003
4
2
(n=26)
Totals
9
8
 Family group referrals
1
2
3
5
4
8
1
5
7
1
7(1*)
13
1
8
3*
2*
3
Age Range of the person who committed suicide
U 20 20-30 30-45 45+
2000 (n=6)
1
1
3
1
2001 (n=21)
8
4
8
1
2002 (n=24)
7
7
9
1
2003 (n=26)
3
11
7
5
Totals
19
23
27
8
Method of suicide
Hangin Drownin Shooting Overdos Gas Other Unknow
g
g
e
n
2000 (n=6) 3
1
1
1
2001
8
6
2
4
1
(n=21)
2002
14
3
1
1
1
4
(n=24)
2003
13
4
2
1
3
(n=26)
Totals
38
14
6
6
1
1
8
7.
22 clients had found/witnessed the body immediately post suicide
A look at one year: Referrals in 2003
26 new referrals in 2003, representing 22% of total referrals
Of these 26 new referrals:

21 had stated reason for referral as suicide, 1 was ambiguous but suspected
100


4 arose from reclassification, where suicide was not the given referral reason
but emerged during therapy
5 cases involved family group referrals*
A total of 25 suicide-bereavement cases open at year-end, that is 43% of active case-load.
This represented an increase from 16 cases at end 2002, i.e. 32%
Suicide as % of case load at end of 2003
100
90
80
70
60
50
40
30
20
10
0
2002
2003
43 individuals attended for counselling post suicide in 2003. 6 were children. 5 were
originally met with in family groups, which in several cases became individual
clients.
In addition to individual therapeutic interventions, in 2003 formal focused groupwork
was provided for women who had been bereaved by the suicide of their husband. All had
engaged in individual therapeutic work with the service prior to this. It ran for 6 sessions
and was most effective.
Ms. Carol Phelan, MWHB, Millennium Court, Letterkenny, Co. Donegal. Telephone: 074 9123670
carol.phelan@nwhb.ie
101
WE CAN ALL BE SAMARITANS
Mr. Paul O’Hare
Public Relations Officer, Samaritans, Ireland
Abstract
The most recent stage in Samaritans' emotional health positioning, the 'We can
all be Samaritans' posters shown demonstrate the relevance and importance of
attitudes towards emotional health issues. Developed by Advertising agency
'Social Republic' using a brief centring on 'Human Connections', each poster is a
colour photographic image reflecting different everyday scenarios which
suggest two people making this connection. The use of photography enhances
the reality of the situations and evidence of the connection - such as two empty
glasses and two sets of footprints - is shown. This campaign reinforces
Samaritans' relevance in emotional health promotion and delivers a message
about how everyone can be of assistance to those who may need of support.
The postering is accompanied by press creatives, television, radio and on-line
banner advertising. This has appeared in Ireland since March 2004 courtesy of
Samaritans’ Irish media agency, Initiative.
Human connections theme by Samaritans encourages people to talk – and listen – more
Park benches and paths were the unlikely focus of a Samaritans brand awareness
campaign which appeared during 2004 and which was displayed at the Irish Association
of Suicidology conference poster session. This campaign theme has the direct aim to
tackle the stigma of talking about issues that can lead to major health problems such as
stress and depression.
Covering the entire Samaritans Ireland and UK-wide organisation, this campaign was
announced in November 2003 and drew to an end at the start of November 2004 although Samaritans branches which have a use for the postering and advertisements are
free to use them if they wish. Samaritans is the emotional support charity, and to reflect
this, it was decided to feature a number of everyday scenes that highlight a moment of
human connection between two people in a normal setting. The ads suggest that although
there are no easy answers to problems, by being there for others, we can make a
difference to each other's emotional health. Each advertisement features the strapline,
'We can all be Samaritans'.
While this campaign appears similar to a volunteer recruitment campaign, it is intended
to convey a message that in everyone's daily life, it is possible for anyone to provide a
supportive response to someone who displays a sign of an emotional health issue.
Samaritans believes that emotional health issues such as self-harm and suicide are
everyone's business and that there can be a community wide response on all levels. The
102
campaign comprised advertisements for radio, print, television and web content. The
creatives were devised by Samaritans' lead marketing agency, Social Republic, London.
The ads lead people to a Samaritans' microsite where they can choose to contact
Samaritans for emotional support, to find out about volunteering. This site will remain
available for a period following the end of this particular campaign and can be visited at
www.samaritans.org/wecan.
The campaign appeared in national newspapers, on outdoor poster sites, on-line, on the
radio and on television, made possible by the generous donations of unsold advertising
space from media-owners in support of its work. Its media agency, Initiative works to
secure these offers of free space on a retained basis. This campaign was superseded
in November 2004 by a sponsored promotion of Samaritans email support service aimed
at younger people. In Northern Ireland and the UK, this campaign is supported by the
Vodafone UK foundation and in the Republic of Ireland, it is supported by the Irish
Youth Foundation. Postering used differ according to the sponsor but are aimed at
younger people and encourage contact to the email service by stressing the positivity
of expressing difficult and/or painful emotions.
Mr. Paul O’Hare, Public Relations Manager, Samaritans, The Irish Regional Office, Room 35,
112 Marlborough St.,Dublin 1. Telephone: 01 8781822
WEXFORD SELF HARM INTERVENTION PROJECT
Mr Athol Henwick
Counsellor Therapist, Wexford Self Harm Intervention Programme
Abstract
The aim of the project is to evaluate the effectiveness of a counseling /
psychotherapy service offering short-term contracts as a strategy to reduce the
incidence of suicide and parasuicide.
The objectives of the project are:
1) To enable individuals who are at risk to have a choice in terms of the available
interventions
2) To provide a non-judgmental, client-centered service where potential clients can
begin to explore and understand the nature of their emotional distress
3) To empower individuals to explore alternative coping strategies
4) To assist individuals take control of their lives by providing a service which
promotes the personal autonomy of the individual
BACKGROUND
103
The project draws on the learning gained from developing counseling/psychotherapy
within the National Counseling Service but is being adapted to the needs of this particular
project and client group. The project is intended to operate as a pilot project within the
Wexford Community Care Area which has a population base of 108,000. The suicide
rate within the South Eastern Health Board 2001 was 14.72 per 100,000 which was above
the national average. During this period there were 15 suicides in the Wexford area made
up of 13 men and 2 women. The number of episodes of parasuicide within the Board
area during the same period was 1049 undertaken by 817 individuals. When analysed by
place of residence there were 233 episodes in the Wexford area undertaken by 194
individuals made up of 71 men and 123 women. Thus there were 6 male repeaters and 17
female repeaters. (1)
PREVIOUS WORK UNDERTAKEN
A range of initiatives have been undertaken in the area of suicide and parasuicide in both
prevention and postvention under the auspices of the Regional Suicide Resource Office
including the establishment of bereavement support groups and educational and training
initiatives to raise awareness within the Health Board and with other organizations.
Within the Wexford Mental Health Services the establishment of a liaison psychiatric
nursing post to Wexford General Hospital is seen as an important development. (2) The
current proposed project is seen as complementary to existing service provision and
intended to increase the choice of intervention available to individuals at risk of suicide
and parasuicide. The liaison psychiatric nurse is seen as the initial source of referral to
the counseling/psychotherapy service and this protocol can be reviewed in the light of
clinical experience.
IMPLEMENTATION
If the proposal is successful in obtaining funding a counselor/therapist would need to be
recruited. It is intended that the eligibility criteria used for applying for posts in the
National Counseling Service (NCS) will apply in this case but a new job description and
person specification will need to be revised. The project will need to be overseen by a
small working group consisting of representation from the managerial and clinical areas
and also service user representation. The working group will need to meet three to four
times to monitor implementation, review progress and contribute to the final evaluation
of the service. The working group will also need to produce a final report with regard
identifying the learning gained from the project and make recommendations in relation to
future service provision.
PROJECT EVALUATION
Service user views will form the core part of the evaluation of the service. Recent
evidence has confirmed the efficacy of psychotherapy and more importantly the quality
of the working alliance as the key factor in predicting successful outcomes. (4) It is
therefore intended to obtain feedback on how service users experienced the service
directly. This can be achieved by means of a specially designed questionnaire and clients
will be informed about the evaluation as part of the standardized information giving
process. The client will then be in a position to give informed consent to participate or
decline depending on their preference.
104
In addition it is planned to undertake a statistical comparison with statistics for the area
for previous years or a similar area with similar socio-economic and demographic
features. It is intended therefore to get both qualitative and quantitative data to inform
the evaluation of the project. Furthermore the data can make a contribution to the
question of the wider applicability of the project in other geographical areas.
CURRENT SITUATION
The project was implemented on 10 May 2004 and will run until 10 May 2005. During
this time the project has been marketed to role-players in the field, notably, Psychiatric
services, GPs, Youth Services, Family Life Service and others. The response, although
initially slow, has increased dramatically to the extent where clients availing of the
service as at 10 September 2004 now total 19. This represents a nearly full case load as
there is only one counselor therapist at present.
Mr. Athol Henwick, Consultant Public Health, NHS Highland, Inverness, Scotland, IV2 3HG
105
Paper Presentations
106
SUPPORTING ONE ANOTHER: RESPONDING TO A COMMUNITY IN CRISIS.
Sean McCarthy/Derek Chambers.
Resource Officer for Suicide Prevention SEHB. Research & Resource Officer NSRG
Abstract
The aim of this paper is to highlight the challenges faced within County
Wexford by the health services in responding to a suspected cluster of suicides.
Within a six-week period during November/December 2002 there were 11
suspected deaths by suicide in the area of Enniscorthy and its hinterland. This
attracted considerable media attention, some of which might be considered
insensitive, further increasing public concern and trauma for the community.
This paper shall discuss the actions undertaken by the health services to respond
to these deaths. Such actions were taken in the immediate, medium and long
term. It shall highlight the uptake of services that were provided along with the
resource implications of providing such services in the immediate to medium
term. The long-term response in County Wexford shall be discussed. This
response is a true interdisciplinary multi-agency response and is in line with The
United Nations Guidelines for the formulation and implementation of National
Strategies, which recommend that we should aim ‘to promote, co-ordinate and
support intersectoral programmes for the prevention of suicidal behaviour at
national, regional and local levels’. The action plan dovetails with the National
Task Force Report 1998 and The South Eastern Health Boards suicide
prevention strategy 1999 thus providing a national, regional and local response.
The action plan is led by the Wexford County Development Board this is
unique as it is the first attempt in the Country by a County Development Board
to address the issue. There are 31 action points in the plan under the headings
of reducing risk factors and enhancing protective factors. Recent figures
released by the Central Statistics office indicate that there were 23 deaths
registered as suicides in the Wexford area for 2003. A number of these could be
attributed to the deaths in the latter part of 2002.
In November 2002 the County of Wexford experienced a number of sudden
traumatic deaths all of which had a profound effect on both individuals within
the community and the community itself. Between 20 October and 28
November 2002 the Central Statistics Office registered a total of 7 deaths as
suicides and 4 as a result of undetermined causes, of these 9 were male and 2
female. These numbers far exceed what would normally be expected for this
area over this time span. Most of these deaths occurred in a small geographic
area and may be considered to be a cluster. ‘Suicide clusters refer to a group of
suicides or suicide attempts, or both, that occur closer together in time and
space than would normally be expected in a given community’ (Carroll 1990).
107
In 2003 the rate of suicide per 100,000 for males in County Wexford was 34, this
compares to a rate of 26 per 100,000 in 2002 and 24 per 100,000 in 2001. Most of the
deaths that occurred in the latter part of 2002 would have been registered in 2003, as the
inquests into these deaths would not have been held until the early months of 2003.
40
35
30
25
Male
Female
National m
National f
20
15
10
5
0
1999
2000
2001
2002
2003 x
During this time the South Eastern Health Board implemented a strategic plan targeted at
supporting both individuals directly affected by the deaths and supporting the community
at large. The plan was implemented and delivered by local service providers from both
mental health services and community care services with the support of the regional
suicide resource office whose stated objective is ‘to support local services throughout the
South Eastern Health Board region through close collaboration with the local area teams
in relation to issues pertaining to parasuicide and suicide’. Services were faced with the
simultaneous tasks of trying to prevent further deaths and trying to manage the crisis that
existed at that time.
The Centre of Disease Control in America has made a number of recommendations for
the development of a community plan for the prevention and containment of suicide
clusters. These include the following:
1. The response to the crisis should involve all sectors of the community and this
response needs to be co-ordinated.
2. Relevant community resources need to be identified.
3. The response plan should be implemented under either of the following two
conditions; (a) when a suicide cluster occurs in the community; that is, when
suicides or attempted suicides occur closer together in space and time than is
considered by members of the co-ordinating committee to be unusual for the
108
4.
5.
6.
7.
8.
9.
community; or (b) When one or more deaths from trauma occur in a community
which the members of the co-ordinating committee think may potentially
influence others to attempt or complete suicide.
If the response plan is to be implemented, the first step should be to contact and
prepare the various groups identified as part of the response team.
The crisis response should be conducted in a manner that avoids glorifying the
suicide victims and minimises sensationalism.
Persons who may be at risk should be identified and have at least one screening
interview with a trained counsellor, these persons should be referred for further
counselling or other services as needed.
A timely flow of accurate, appropriate information should be provided to the
media.
Elements in the environment that might increase the likelihood of further suicide
or suicide attempts should be identified and changed.
Long term issues suggested by the nature of the suicide cluster should be
addressed.
Within the Wexford area a response plan was put in place so as to support individuals
affected either directly or indirectly by the deaths as they had occurred in the region. It
was also necessary to support the community at large. One of the immediate initiatives
undertaken by the response team was to put in place a free phone help line. This was put
in place on 18 November 2002 and continued for six week. It was in place between the
hours of 10am and 3pm and between 7pm and midnight and was staffed by mental health
community nurses. For the period that the help line was in place it was open for 173
hours. The help line dealt with a total of 53 calls over this period 23 of which related
directly to the recent deaths and the difficulties people were experiencing as a result of
them. The remaining 30 calls were made by people seeking advice and support for a
wide range of health related difficulties, which could be considered as inappropriate as
they were not specifically related to the issues for which the help line was put in place.
Alongside the help line a drop in counselling facility was put in place and this was
available from 19 November until 1 December 2002. This was open during the hours of
3pm and 7pm. During the hours of opening there were 2 counsellors available at all
times along with community mental health nurses. The counsellors were private
contracted counsellors who were not health service employees. These were contracted by
the health service to provide a specific service to a specific client group. In total 14
people availed of the drop in counselling service over the period it was available. It was
discontinued as a drop in service when the uptake declined. An assertive outreach to
those families who were bereaved was instigated; this meant that health service
practitioners contacted all families that we were aware of, that had suffered bereavement.
They were then able to avail of advice and support in relation to available services and
support agencies in the area. The counselling service for people bereaved as a result of a
suicide death continues to be provided by contracted counsellors. This is a free and
confidential service to those referred to it through the referring mechanisms in place.
In an effort to inform the community as to the available services at this time, an extensive
media campaign was undertaken in the local and national media. This was to highlight
109
the free phone help line and the counselling service alongside the available mainstream
services. The events as they occurred also attracted a considerable amount of media
attention at the time some of which could be described as somewhat insensitive
particularly in relation to some of the headlines and photos that were in the national
media. There was a greater effort to inform people of supports in the local media.
Some of the headlines in the local and national media.
110
Picture of grappling hooks that appeared in national Sunday newspaper
111
Some of these headlines and photos caused considerable distress and upset to people in
the community at time.
Alongside the media campaign to inform people of the supports that were available a
number of community meetings were undertaken where local community leaders
facilitated community information meetings whereby local service providers were
available to meet and support people. There were also 4,000 help and health information
leaflets distributed through the various churches at that time. These cards provided
information about local, regional and national support organisations and health services.
It is important to remember that these actions were undertaken in partnership with the
local health service providers, primarily the mental health services in the area. It is
crucial that this type of response is provided by and facilitated by the local service as this
is where the long term supports for the individuals and subsequently the community shall
come from.
The cluster that occurred in the County of Wexford has resulted in the Wexford County
Development Board developing a long term response to the problem of suicide in their
County. It is the first such action plan undertaken by either a County or City
112
Development Board in the Country. It involves all the relevant partners in an action plan
which is titled ‘Supporting one Another an action plan aimed at assisting in the
prevention of suicide’. It outlines 32 actions that need to undertaken in the area, there are
16 actions under two groupings; enhancing protective factors and reducing risk factors.
The development of this plan which includes all the statutory, voluntary and community
groups in the County provides a long term approach to tackling the problem of suicide in
the area.
Mr. Sean McCarthy, South Eastern Health Board, Suicide Prevention Strategy, St. Patrick’s Hospital,
John’s Hill, Co. Waterford mccarthys@sehb.ie Telephone: 051 874013
Mr. Derek Chambers, National suicide Review Group, C/o National Suicide Research Foundation, 1,
Perrott Avenue, College Rd, Cork
Presentation by
Caroline Farquhar MBA MBE
Head of Implementation for Choose Life
Choose Life is the Scottish Executive‘s national strategy to reduce and prevent suicides in Scotland. The
strategy was launched in December 2002 after a 3 year consultation period with carers, professionals,
academics and communities.
Choose Life is an integral element of the Scottish Executive National Programme to improve mental health
and well being for the people of Scotland. The National Programme has 4 key aims :



To raise awareness of and promote positive mental health and well being
Eliminate stigma and discrimination
Prevent suicide
Promote and support recovery
Information on The National Action Plan which underpins the programme can be obtained from
www.wellontheweb.net. The National Action plan has financial support from the government of £24
million for 2003 – 2006.
The Choose Life strategy is underpinned by a strong vision
“In addressing suicide we must continue our efforts to eliminate poverty; achieve greater social justice and
inclusion for those who are vulnerable in our society; address inequalities where these exist ; improve and
expand educational opportunities ; improve self esteem and confidence, especially amongst our young
people ; improve health both our physical and mental health and well being ; and address the needs of our
children and young people who are our vital and precious resource for the future.
If we tackle suicide as a one issue policy we will fail. Our collective attempts to prevent suicide and
reduce the rate of suicide are directed at the heart of our Scottish Executive policies – be they economic
regeneration, social justice, inequality, education, health local government, communities, policies for
children, for better public services or for improved health care”.
Then Minister for Health & Community Care, Malcolm Chisholm, December 2002 (Choose Life strategy
and action plan.)
As well as strong political leadership for the strategy, there are financial resources. £12 million for the first
3 years of implementation, which comes form the National Programme
113
There is a clear overarching target to reduce suicides in Scotland by 20% by 2013. The strategy and action
plan has clear objectives and targets priority groups. The objectives include:






Early prevention and intervention
Improving crisis response
Providing hope for support and recovery
Improving resilience and coping skills
Increasing awareness of suicide and encouraging people to seek help early
Supporting the media
Finding out what works
Priority groups are not exclusive and often overlap but in summary those being targeted are :






Children, especially looked after children
Young people, especially young men
People with mental health problems ( those in contact with MH services )
People who attempt suicide
People affected by the aftermath of suicide
People who abuse substances
People in prison
Other groups where partnership working is critical include, the elderly, ethnic minorities, lesbian, gay, bi
sexual and transgender support groups, isolated individuals or those living in rural communities,
unemployed and homeless people.
Implementation of the plan is based on a public health approach.
Scotland’s’ suicide rate is the highest in the UK.
Funding for Choose life is allocated for both national and local work, the split being £3 million and £9,
million respectively.
National activity is focussed on developing national partnership work with organisations who have a key
role to play in suicide prevention, for example in the voluntary sector, Samaritans and Childline. In the
public sector, Scottish Prison Service, Accident & Emergency services, police, GP’s and other
“gatekeeper” agencies.
Nationally a suicide prevention and intervention training strategy is being develop and a Guide for
journalists on the reporting of suicide and mental health – “The Reporting of Mental Health and Suicide by
the Media” - was created in partnership with the National Union of Journalists.
114
Choose Life is in it’s infancy in terms of delivery but one of the first national actions was to improve the
quality, collection availability and dissemination of information relating to suicide and suicidal behaviour
and on relevant effective interventions. To meet this objective the Scottish Executive embarked on an
extensive research process which was intended to ensure that practice is supported by a reliable up to date
evidence base.
The project consisted of two stages 1) to conduct a survey of national and international researchers who
specialise in suicide or suicidal behaviour about their views of the existing base 2) to review the findings in
consultation with a group of Scottish and UK suicide and suicidal behavioural experts.
The resultant conclusion was that further review will be commissioned. There will be five reviews in total,
three on determinants and two on interventions. For details see www.scotland.gov.uk/socialresearch
Critically however the National Implementation Support Team provide guidance for and co – ordination of
activity at local level. The national team comprises a Head of Implementation, a National Information
Manager, a National Operations Manager and a Business Support Officer.
A practical example of co – ordination would be; many local plans identified the need for information to
support families bereaved by suicide. There was no logic in having multiple versions of the same thing.
SAMH Scottish Association for Mental Health were already in the process of developing a booklet which
included practical information on, benefits, funeral arrangement, dealing with the police, other statutory
agencies and most importantly your own and others emotions. Funding to support the national roll out of
this came from central resources. The booklet can be downloaded free from www.samh.org.uk Similarly a
video supported by training was developed by CRUSE.
Work in local areas lead by a local Choose Life coordinator. There is one coordinator for every local
authority areas in Scotland. ( 32 ).
The local Choose Life action plans are an integral part of the Community Planning Partnership process and
as such are approved by local people representing a wide variety of stakeholders, including education,
social work, health, voluntary sector, users and carers.
Early indications are that this was an extremely practical approach to take, as there is multi disciplinary
ownership of the plan and a great deal of local “buy in “.
Local plans although very diverse, comply with the national objectives previously outlined.
Some local coordinators are funded by Choose Life. Others are performing the role as part wider
responsibility, for example Director of Social Work, Consultant for Public Health GP.
Local plans will be evaluated at local level. A national evaluation has also been commissioned. This is to
ensure that we identify as early as possible exactly where, with whom, for whom and how Choose Life is
adding value to existing support services and or creating new integrated approaches.
The aim at local level is to ensure a sustainable structure for the delivery of Choose Life beyond the
duration of the ten year strategy.
In short making us all responsible for the prevention and reduction.
Caroline Farquhar MBA MBE, Head of Implementation for Choose Life , NHS Highland, Inverness,
Scotland, IV2 3HG
115
STAFF NURSES PERCEPTIONS OF THEIR ROLE IN CARING FOR SUICIDAL
CLIENTS IN A PSYCHIATRIC HEALTHCARE SETTING IN THE REPUBLIC OF
IRELAND
Catherine Delaney
St. Patrick’s Hospital, Dublin
Abstract
To date there has been little research conducted in the Republic of Ireland about
the role of psychiatric nurses in caring for people considered to be at risk of
ending their lives. International nursing literature has revealed that nursing staff
working in acute in-patient psychiatric hospitals are involved in caring for
people admitted following attempted and high risk behaviour (Long & Reid,
1996; Midence et al, 1996; Cleary et al, 1999). This research paper focused on
the role of psychiatric nurses employed in a psychiatric hospital in the North
Dublin area. The aim of this study was to gain an understanding of the nurses
role in caring for people who have been admitted to hospital following an
attempt to end their lives. Ethical approval was sought and granted prior to the
study. Individual tape-recorded interviews were conducted with eight registered
psychiatric nurses. A phenomenological approach was utilised during data
collection to obtain a meaningful understanding of the nurses experiences when
caring for a suicidal person. During the interviews a number of issues were
discussed, these included nurses knowledge and awareness of suicide and
further education in suicide awareness, and their perception of suicide. Other
issues discussed during the interviews included the length of time nurses spend
on special observation of a suicidal person, the legal implications on the nurse
when caring for a suicidal patient and nurses suggestions and recommendations
regarding the care of suicidal people. A number of themes emerged following
analysis of the findings from the interviews. Some recommendations for
nursing practice and for further research were presented in the final report of
this paper.
BACKGROUND
Nurses working in psychiatric hospitals are involved in caring for people admitted to
hospital following an attempted suicide and high-risk behaviour. This is the first study
undertaken in the Republic of Ireland that explored nurse’s perceptions of their role in
caring for suicidal clients in a psychiatric hospital setting. A review of the literature
revealed that nursing staff in Northern Ireland and other countries felt they were
completely responsible for the persons’ safety while in their care. While nursing staff are
usually assigned to provide special observation for the persons’ own safety, it can evoke
within the nurse a sense of confusion about his/her role.
AIM
The researcher conducted this study to obtain an understanding of the nurse’s role in
caring for a suicidal person. During the study the participants were invited to discuss
their perceptions about their role when caring for a suicidal client. At the close of each
116
interview the participants were encouraged to discuss any issues that they felt were
relevant to the nature of the study, and had not elaborated on during the course of their
interviews.
METHOD
This research study focused on psychiatric nurses employed in a psychiatric hospital in
the Northern Area Health Board. Ethical approval was obtained from the Ethics
committee of the hospital prior to the study. The Medical Director and Director of
Nursing in the Hospital granted their permission prior to the study. The researcher
conducted semi-structured tape-recorded interviews with eight purposefully selected
registered psychiatric nurses. The interview schedule was tested in a pilot study with two
registered psychiatric nurses prior to the main study. A phenomenological approach was
adopted for the purpose of data collection. Phenomenology has its roots in philosophy
and psychology. This is an approach used by social scientists that aim for a meaningful
understanding of people’s experiences. The data obtained from the interviews was
analysed by following Colaizzi’s framework of phenomenological data analysis.
FINDINGS
A number of themes emerged from the study. These included the care and support
provided by the nursing staff, and their role in the safety of the client. Another theme
included the liaison role of the nurse between the client, their relatives and the doctors
while the person is in hospital.
CARE AND SUPPORT
Nurses are conscious of their role in providing support to a person following admission to
hospital. They enjoy caring for people and felt a sense of reward when they see someone
they had cared for, recovered to good health and discharged from hospital.
Some of the words used to describe nurses perceptions of their role included being gentle
with and encouraging the person at a vulnerable stage of their lives. Demonstrating an
empathic understanding to the person was another word used by the participants during
their interviews. It was felt that nurse’s acceptance of the persons concerns and issues
that contributed to his/her distress was important; particularly as the persons self-esteem
could be low. This would help to reassure the person, and could assist in their recovery.
One participant stated that it was important to be gentle with, and encourage people to get
well and regain their lives. The participants felt that they must provide full nursing care,
and also ensure that all available resources were provided for the person while in
hospital. Some of these resources would include access to a social worker. These
findings reflected Virginia Henderson’s (1996) philosophy that the prime role of the
nurse is to assist the person regain their independence swiftly.
NURSES PERCEPTION OF SUICIDE
Some of the participants expressed a feeling of sadness that a person could be in such a
state of despair, that suicide was felt to be the only option available to them. This was
similar to the literature where Long & Reid (1996) reported that some nurses might
experience conflict with their emotions when dealing with people whose sole wish is to
end their lives. The researcher found that some participants suggested that for a person to
117
die by suicide, their mind must be in a state of turmoil at the time of the act. This reflects
Kelleher (1996) that suicide was “a permanent solution to a temporary problem”, and
Long & Reid (1996) that the killing of oneself is to obliterate a painful period of time. It
was felt that some nurses regard a suicide attempt by a person in their care as a failure of
their role. Midence et al (1996) found that nurses questioned if they could have done
more to help the person.
CARING FOR A SUICIDAL PERSON
The nurses in this study stated that they have a duty of care to keep the person safe when
providing special observation of a suicidal person. Their main role is to prevent the
person from engaging in acts of deliberate self harm and to be totally alert and aware of
the person. Cowman et al (2001) stated that the central factor of psychiatric nursing
involves caring for, and the assessment and maintenance of a person’s safety. The nurse
is responsible for the possessions that the person is allowed to keep, however potentially
harmful items such as matches or a razor are not allowed while the person is considered
at risk of ending their lives. This is similar to Bowers & Gournay (2000) who stated that
nursing staff are required to audit the ward regularly, and to identify any opportunities for
the person to engage in discreet acts of self-harm.
It was felt that each nurse should spend a maximum of two hours at a time when engaged
in special observation or one-to-one care of a person. Some participants stated that two
hours was sufficient as it was found to be a very tiring part of their practice. Nurses
found special observation to be a stressful part of their role because they are constantly
alert to any changes in the person’s mood. These findings are similar to Cleary et al
(1999) who stated that participants in their study found special observation mentally
draining.
In this study the participants agreed that they could never underestimate the person at risk
of suicide.
FURTHER EDUCATION IN SUICIDE AWARENESS
It was suggested that training and education into suicide risk assessment would enhance
their skills of caring for a suicidal person. In addition training in counselling skills were
suggested, because the participants stated that they often felt unsure how to speak to a
suicidal person, and were concerned that they would say something that could exacerbate
the person’s problems.
RECOMMENDATIONS
(1) Some recommendations that emerged included the standardisation of pre-discharge
protocols in psychiatric settings. Another recommendation included that the approaches
to the care of suicidal clients across different settings should be monitored and compared.
(2) That the length of time that nurses spend on special observation duty should be
reviewed and standardised.
(3) While the participants felt that their training and education has provided them with
the skills to keep a suicidal person safe, they would like further education into suicide
awareness and the best way to communicate with suicidal people. These opinions
118
support the recommendations contained in section 2.5 from the Report of the National
Task Force on Suicide (1998).
(4) Development of formal policies on the care of the suicidal person.
CONCLUSION
This study found that psychiatric nurses have a positive regard for suicidal people in their
care. It was agreed that on occasion special observation was the only way to keep a
suicidal person safe. While the participants did not regard it as a therapeutic practice they
did not regard it as a custodial act.
Ms. Catherine Delaney, Research Nurse, St. Patrick’s Hospital, James’ St, Dublin 8. Tel: 01 2493200
PARACETAMOL RESTRICTION – AN EFFECTIVE PUBLIC HEALTH
INTERVENTION?
Mr Paddy Hopkins – Head of Health Intelligence, NHS Highland, Scotland.
Dr Cameron Stark – Consultant in Public Health, NHS Highland, Scotland.
Abstract
To evaluate the effectiveness of the legislation, introduced in 1998, restricting
pack sizes of paracetamol and aspirin in reducing suicide and non-fatal
deliberate overdoses in Scotland. A before-and-after study, testing for statistical
significance using the comparisons of proportions of two independent samples,
by age group and gender. The data covered all hospital admissions following a
non-fatal overdoses, and suicides from deliberate overdoses in Scotland
between 1994-2002. Previous work on the impact of the restrictions was
conducted soon after the introduction of the legislation, and data was limited to
specific geographical areas. This work provides a longer-term follow-up with
complete coverage of Scotland. We found initial reductions in the numbers of
paracetamol suicides and non-fatal overdose admissions, but this has not been
sustained. Of equal importance are the differences between age groups and
gender, contributing to existing evaluations by highlighting target groups for the
future.
INTRODUCTION
In September 1998 legislation came into effect to restrict the availability of paracetamol
and aspirin. Previously sales of these analgesics from pharmacies were unlimited and
from other retail outlets were restricted to 24 tables. The legislation introduced limits for
pharmacies of 32 tablets per sale, and 16 tablets from other outlets. The justification for
the legislation was that such analgesics were commonly used in impulsive overdoses
(both fatal and non-fatal) associated with low suicide intent1,2.
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In Scotland, deliberate self poisoning (overdoses) accounts for 32% of all suicides and
91% of all deliberate self harm3. During the 1980s and 1990s it was widely
recognised4,5,6,7,8 that paracetamol was a common drug used in overdoses, both fatal and
non-fatal. Hawton8 et al proposed that restricting the availability of this common nonopioid analgesic would have an impact on the numbers of overdoses and the numbers of
those requiring liver operations and transplants as a result of paracetamol overdose.
Hawton9 et al undertook an evaluation of the legislation in England between September
1996 and September 1999. Their findings showed significant reductions in the numbers
of suicides and non-fatal overdoses using paracetamol or aspirin, and significant
reductions in the numbers of liver transplantations following paracetamol overdose.
They concluded that the legislation had ‘substantial beneficial effects’ in reducing the
numbers of overdoses using paracetamol and aspirin in the United Kingdom.
Other studies in Ireland10,11, Wales12 and Scotland13 found no such effect. However,
these studies concentrated on hospital catchment areas or smaller geographical areas
within those countries. This study will evaluate the effect of the legislation restricting
pack sizes of paracetamol and aspirin on self-poisoning throughout Scotland using three
years data since the legislation was introduced.
OBJECTIVE
To evaluate the effectiveness of the legislation in Scotland by examining the trend in the
use of paracetamol and aspirin in fatal and non-fatal overdoses by age group and gender.
A statistical test will compare the proportions before and after the legislation for
significant reductions in the use of paracetamol or aspirin.
METHOD
Using hospital patient data collected by hospitals in Scotland using the Scottish
Morbidity Recording dataset (SMR01 – general and acute), all non-fatal overdoses from
1995 to 2002 were obtained from the Information & Statistics Division (ISD) in
Edinburgh. Suicide data was obtained from the General Register Office for Scotland
(GROS) from 1995 to 2001. Accidental overdoses and adverse reactions to therapeutic
use were excluded, but undetermined deaths were included.
The data contained up to six substance codes (e.g. T34.1) which were converted into
substance names (e.g. paracetamol). Each substance was then attributed to a hospital
admission or death. Records that contained multiple substances had each substance
recorded separately against the admission or death, e.g. a single admission or death with
multiple substances was analysed for each substance.
Using the comparison of two proportions for unpaired samples, tests for significant
differences between individual substance use before and after the legislation were
undertaken using Confidence Interval Analysis v2.0.014.
RESULTS
From 1995 to 2002, there were 130,000 admissions to hospitals in Scotland following an
overdose. From 1995 to 2001 there were 2,074 suicides as a result of an overdose. Of
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the 2,074 fatal overdoses just under 80% used analgesics, sedatives, antidepressants or
opiates singularly or in combination. Analgesics included both non-opioid and opioid;
sedatives included hypnotics, anxiolytics, drugs used in psychoses, anti-epileptics;
opiates included heroin, opium, and morphine. Analysis of overdose data is made
complex by combinations of substances taken, without knowing which substance or
combination was the most toxic.
Figure 1 shows the trend in use of analgesics in fatal self poisoning, highlighting
paracetamol and co-proxamol as well as aspirin. The use of all three substances
decreased between 1997 and 1998 but the use of paracetamol increased between 1998
and 2000. The use of co-proxamol increased from 1999.
Fig 1. Trends in fatal deliberate self poisoning in Scotland, 1994-2001 (analgesics and
aspirin).
90
80
70
Suicides
60
50
40
30
20
10
0
1994
1995
Aspirin
1996
Coproxamol
1997
1998
Non opioid
1999
Opioid
2000
2001
Paracetamol
Figure 2 shows the trend in use of analgesics in non-fatal self poisoning, highlighting
paracetamol and aspirin. The use of co-proxamol is not highlighted because ICD9 and
ICD10 do not specifically identify co-proxamol as a substance but do identify the
constituents. Its use is added to ‘opiates’. The use of paracetamol and aspirin both
decreased after the legislation, although an increase in paracetamol use was experienced
in 2001/02. The use of ‘opiates’, which contains co-proxamol also increased from
1998/99.
Fig 2. Trends in non-fatal deliberate self poisoning in Scotland, 1994-2002 (analgesics
and aspirin).
121
6000
5000
4000
3000
2000
1000
0
1994/95
1995/96
Aspirin
1996/97
1997/98
Opiates
1998/99
1999/00
Other analgesic
2000/01
2001/02
Paracetamol
Figure 3 shows the impact of the legislation on fatal deliberate self poisoning (suicide) by
substance with 95% confidence intervals. Whilst reductions in the proportions using both
paracetamol and aspirin were experienced, the reduction in paracetamol use was not
statistically significant. There were, however, increases in the proportions using coproxamol and opiates that were both statistically significant.
Fig 3. - Fatal deliberate self poisoning, all ages, both sexes, in Scotland. Comparison of
proportions by substance before and after the legislation, with 95%CI.
Change Lower
Upper Signif
Paracetamol
-2.01% -4.99% 0.97%
Aspirin
-0.94% -1.69% -0.20%
x
Co-proxamol
4.29% 0.57% 8.00%
x
Opiates
4.53% 2.40% 6.65%
x
Sedatives
-2.51% -4.62% 0.41%
Antidepressants
1.28% -2.22% 4.77%
Opioid analgesic -0.54% -2.37% 1.30%
Non opioid analg 0.32% -0.62% 1.27%
Figure 4 shows the impact of the legislation on non-fatal deliberate self poisoning
(overdoses) with 95% confidence intervals. The reductions in the proportions of those
using paracetamol, aspirin, and other non-opioid analgesics were both statistically
significant. However, there were increases in the proportions using opiates (including coproxamol) and sedatives that were also statistically significant.
Fig 4. Non-fatal deliberate self poisoning, all ages, both sexes, in Scotland. Comparison
of proportions by substance before and after the legislation, with 95%CI.
122
Paracetamol
Aspirin
Other analgesics
Opiates
Sedatives
Antidepressants
Change
-4.12%
-0.82%
-1.88%
5.18%
5.39%
0.35%
Lower Upper Signif
-3.60% -4.64%
x
-0.63% -1.01%
x
-1.57% -2.18%
x
4.87% 5.49%
x
4.99% 5.79%
x
-0.13% 0.83%
Analysing the impact of the legislation on the fatal use of paracetamol by age group and
gender generated too many numbers between 0 and 5 for statistical analysis to be
meaningful. However, for non-fatal use the volume of patients was substantial. Figure 5
shows, using the same statistical test, the impact on non-fatal use of paracetamol by age
group and gender, with 95% confidence intervals. Statistically significant reductions in
the proportions using paracetamol were experienced in young (under 24 years) males and
females. However, statistically significant increases in the proportions using paracetamol
were found in older (40-59 years) males and females.
Fig 5. Non fatal deliberate self poisoning in Scotland 1994-2001 using paracetamol.
Analysed by age group and sex, before and after the legislation.
0-14
15-24
25-39
40-59
60-69
70+
Male
Change Lower Upper
Female
Change Lower Upper
-0.59% -0.94% -0.23%
-3.65% -5.17% -2.14%
-0.51% -2.18% 1.15%
3.91% 2.47% 5.36%
0.63% 0.09% 1.17%
0.21% -0.19% 0.61%
-1.24% -1.90% -0.59%
-1.39% -2.74% -0.04%
-0.83% -2.16% 0.50%
2.65% 1.56% 3.75%
0.35% -0.03% 0.73%
0.46% 0.11% 0.81%
DISCUSSION AND CONCLUSION
These results show reductions in the proportions of both fatal and non-fatal deliberate self
poisoning using paracetamol, with statistical significance in non-fatal use. Statistically
significant reductions in the proportions of fatal and non-fatal self poisoning using aspirin
have been found. Such results would suggest that the legislation has therefore been
effective. However, given that the reductions were experienced only in younger people
(under 24 years), and that increases were apparent in older (40-59 years) males and
females, it would seem that the results are inconclusive.
It may also be prudent to ask were reductions of 2% and 4% in fatal and non-fatal self
poisoning using paracetamol worthwhile? This question may be answered in two ways.
Firstly, that reductions in the all-age, both sexes, proportions using paracetamol has been
achieved by a relatively inexpensive public health intervention suggests that the
legislation has been worthwhile. Secondly, the increases in the proportions using coproxamol and opiates, coupled with increases in the proportions using paracetamol in
123
older (40-59) age groups, would suggest that the legislation has had a limited or shortterm impact in Scotland.
It will be necessary to monitor the longer-term impact before drawing any conclusions on
the effectiveness of this legislation, and certainly before contemplating other drug
restricting legislation.
REFERENCES
1. Hawton K, Ware C, Mistry H, Hewitt J, Kingsbury S, Roberts D, et al.
Paracetamol self poisoning. Characteristics, prevention and harm reduction.
British Journal of Psychiatry, 1996; 168: 43-48.
2. Hawton K, Ware C, Mistry H, Hewitt J, Kingsbury S, Roberts D, et al. Why
patients choose paracetamol for self poisoning and their knowledge of its dangers.
British Medical Journal, 1995; 310: 164.
3. Stark C, Hopkins P, Gibbs D, Rapson T, Belbin A, Hay A. Trends in Suicide in
Scotland 1981-1999: Age, Method, and Geography. BioMedCentral Public
Health, 2004.
4. Gunnell D, and Frankel S. Prevention of Suicide: aspirations and evidence.
British Medical Journal 1994; 308: 1227-1233.
5. McLoone P, and Crombie I. Hospitalisation for Deliberate Self Poisoning in
Scotland from 1981 to 1993: Trends in rates and Types of Drugs Used. British
Journal of Psychiatry 1996; 169: 81-85.
6. Hagen S, Hall D, Stark C, Smith H. Admissions due to overdoses of aromatic
analgesics have increased in Scotland. British Medical Journal 1996; 312: 1538.
7. Simkin S, Hawton K, Fagg J, Whitehead L, Eagle M. Media Influence on
Parasuicide: A Study of the Effects of a Television Drama Portrayal of
Paracetamol Self Poisoning. British Journal of Psychiatry 1995; 167: 754-759.
8. Hawton K, Arensman E, Townsend E, Bremner S, Feldman E, et al. Deliberate
self-harm: Systematic review of efficacy of psychosocial and pharmacological
treatments in preventing repetition. British Medical Journal 1998; 317: 441.
9. Hawton K, Townsend E, Deeks J, Appleby L, Gunnell D, Bennewith O, Cooper J.
Effects of legislation restricting pack sizes of paracetamol and salicylate on self
poisoning in the UK: before and after study. British Medical Journal 2001; 322:
1203.
10. Donogue E, Tracey J. Restrictions on sale of paracetamol in Ireland had no
impact on the number of tablets ingested in acute deliberate overdose. Journal of
Toxicology - Clinical Toxicology 2000; 38: 251.
11. Robinson D, Smith A, Johnston D. Severity of overdose after restriction of
paracetamol availability: retrospective study. British Medical Journal 2000; 321:
926-927.
12. Thomas M, Jowett N. Severity of overdose after restriction of paracetamol
availability: Restriction has not reduced admissions with self-poisoning. Letter
in British Medical Journal 2001; 322: 554.
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13. Sheen C, MacDonald T. Severity of overdose after restriction of paracetamol
availability: Study’s results conflict with those of other papers. Letter in British
Medical Journal 2001; 322: 553.
14. Altman D, Machin D, Bryant T, Gardner M. Statistics with confidence. 2000,
BMJ.
Mr. Paddy Hopkins, Head of Intelligence & Knowledge, NHS Highland, Inverness,Scotland,
IV2 3HG. E-mail: Paddy.Hopkins@hhb.scot.nhs.uk
Ms. Cameron Stark, Consultant Public Health, NHS Highland, Inverness, Scotland, IV2 3HG
SOCIOCULTURAL FACTORS IN IRISH ADOLESCENT SUICIDE
Dr. Caroline Smyth & Mr. Mark Logan
Rehab Care, Galway
Abstract
Ireland currently ranks 24th internationally in terms of its youth suicide rate
(World Health Organisation, 2002) and 25th highest of 35 countries across
Europe (Lyddy, 2004). More dramatic than the overall rate of suicide, is
Ireland’s top ranking in terms of the gender ratio of completed suicides where,
for 2002, 4.7 male suicides were seen for every 1 female suicide. This increase
in suicide has been seen at a time of extensive socio-cultural change. Despite
the general suggestion that this socio-cultural redesign may be linked to the
increase in suicide, both research and clinical investigations have, in the main,
failed to include social and cultural factors resulting in a dearth of information.
This research specifically took a contextualised, culturally embedded approach
to youth suicide. Each of psychological, situational, and cultural factors were
considered in combination with regard to their impact on youth suicide.
Working with a total of 673 participants aged between 15 and 19 years the
aforementioned issues relating to psychological experience, culture and
situational life stressors were examined. Thus, contextual factors were
considered at two levels – the level of acculturation experience and at the level
of situational precursors to suicidal behaviour. Significant, gendered pathways
were observed. There was no over-lap between the male and the female
trajectory to suicide, thus providing some insight into the differential experience
of adolescent males and females, possibly linked to the previously mentioned
gender disparity in suicide rate. The implications of these findings for the
prevention of suicide and the promotion of emotional health in the Irish context
will be discussed.
Working with 673 adolescents between the ages of 15 and 19 years, the interaction
between situational precursors to suicide (i.e. life stressors), culture change and mental
125
health were investigated. The results clearly demonstrate significant, gendered,
“pathways” to suicidal behaviour. There was little over-lap between the male and female
trajectory to suicide, thus providing some insight into the differential experience of
adolescent males and females, possibly linked to the previously mentioned gender
disparity in suicide rate.
“Role Status” was a particular issue for Irish youth. For example; being unable to get a
girlfriend/boyfriend, becoming unemployed, and having no money were significantly
seen (in some cases) as “understandable” or “acceptable” reasons to consider taking one’s
life by suicide.
For males, the experience of hopelessness, alongside strong personal identification with
elements of modern Ireland significantly predicted the endorsement of “Role Status”
issues as acceptable antecedents to suicidal behaviour. This pattern presents a picture of
young males who do not derive identity or meaning within the more traditional elements
of Irish culture, but who are wholly embedded in Celtic Tiger existence. Importantly
however; this cultural setting appears not to be related to a sense of personal meaning, as
hopelessness at high levels is also seen.
Thus, for these males, it is the experience of Role Status difficulties (such as the absence
of a romantic, interpersonal relationship; change in status as a result of job loss; and the
inability to obtain material goals as a result of lack of money) which may act as “triggers”
to suicidal behaviour. This is very much in keeping with the stereotyped view of male
adolescents, for whom identity is inextricably linked with each of the aforementioned
“status” issues (Clare, 2000).
In the case of females, it is the experience of hopelessness, depression and low selfesteem in combination, and within the context of cultural isolation which significantly
predicted “Role-Status” risk.
These findings present a more complex picture than the male case. Thus, it is suggested
that in today’s cultural setting, adolescent female identity has moved into previously
“male” domains. However; “triggers” to suicide become relevant only for those females
who are on the fringes of society and feel themselves to be marginalized.
These gendered pathways effectively illustrate much of what has been said about the
nature of Irish culture change. That Ireland is now a consumer-driven society where
perceived “status” is all-important, and lack of this status a significant factor related to
the experience of psychological distress. Furthermore, the theoretical underpinnings of
the relative misery hypothesis (Barber, 2001) as it relates to youth suicide, can clearly be
seen.
In order to approach the issue of suicide prevention, suicide must first be seen as
preventable, and suicide prevention as both acceptable and desirable. This specific point
is addressed in a comprehensive review of the area of suicide prevention by Miller & Du
Paul (1996). These authors argue that suicide intervention/prevention has to be seen as
126
an extension of existing healthcare provisions and systems for the youth population. This
is in keeping with recommendations from others in the area, such as Dryfoos (1994) and
Gutkin (1995) where suicide prevention is not considered to be specialist-oriented, or an
isolated aspect of healthcare systems. This perspective marks an important move away
from seeing suicide as a problem for psychiatric or mental health settings alone, and
recognizes the important role schools and communities have to play.
In contrast to this approach, and in recognition of the “image” problems inherent in
health promotion efforts in the area of mental health, Samaritans (following a process of
re-branding and service review) have developed an emotional health promotion campaign
which will be put into place in schools, workplaces and prisons in the UK and Ireland
over the next five years. In a similar vein, RehabCare is in the process of developing an
evidence-based, assertive outreach model of suicide prevention which challenges the
standard model of service provision in the area, and seeks to effectively engage with the
at-risk youth population. Inherent to both these programmes is the perspective that of
fundamental importance in the promotion of mental health and wellbeing, are the various
skills (such as coping, help-seeking, problem-solving, self-esteem & stress management)
which can be taught rather than the title under which such skills fall, that is of primary
importance. Thus, rather than present a “mental health” campaign, in an area so stifled
by stigma, it is to be “sold” as “emotional health promotion” and “personal
development”. While this may appear, to some, to be an issue of semantics, the research
undertaken thus far indicates that even a re-wording such as this, leads to a greater
acceptability, openness and tolerance of mental-health issues than is otherwise
experienced.
This marks a significant departure and clearly recognizes the relevance of issues such as
branding and image and interestingly, utilizes the aforementioned developments in our
society in an advantageous manner. If we are now a consumer-driven society, so
concerned with status, image and appearance, then perhaps it is time that mental health
and general wellbeing are marketed with the same gusto as computers, mobile phones
and alcohol. This image-savvy, consumer-aware approach may well be the way forward.
At the level of professional involvement in suicide prevention, while it remains more
acceptable, and in many ways, more “comfortable” to leave responsibility for suicidal
behaviour at the feet of individual people, it is certainly not the most accurate or indeed
constructive way to approach the issue. Suicide is an issue for everyone. A home must
be found in our families, our schools and our communities for mental health promotion
and suicide prevention. We must go beyond the common, yet unfounded fear that the
very mention of the word can increase the likelihood of its occurrence. We must move
past what is perhaps, this last remaining taboo.
Dr. Caroline Smyth, Mr Mark Logan, Rehab Care, 24, Heather Grove, Ballybane, Galway
127
AN INVESTIGATION INTO ATTITUDES TOWARDS SUICIDE AMONG
CORONERS FROM THE REPUBLIC OF IRELAND AND NORTHERN IRELAND.
Farrow, R.1, Corcoran, P.1, Arensman, E1, Perry, IJ2
1
National Suicide Research Foundation
2
Department of Epidemiology and Public Health, University College Cork
Internationally, various groups of professionals and students have been studied regarding
attitudes towards suicidal behaviour. These include politicians, medical doctors, nurses,
medical students, nursing students, psychology students, people who engage in suicidal
behaviour and the families of those who engage in suicidal behaviour. Coroners
represent a professional group that is frequently confronted with completed suicide.
However they have rarely been studied in relation to their attitudes towards suicide and
its prevention. In most European countries coroners are not involved in the decision
process of how a person died. However, in Ireland and the U.K. coroners play an
important role in this decision making process. Coroners are either medically trained or
legally trained.
Historically, coroners have always played an important role in the verdict of suicide,
which started in England in 1194. Coroners were appointed to bring more money into the
Crown’s treasury. If a person died by suicide their possessions were automatically forfeit
to the Crown. If a person who died by suicide was found to be mentally ill at the time of
death their possessions remained with their family or next of kin. Henry VII put pressure
on the coroners to give verdicts of felo de se (self-murder) even when it was clear the
death was not suicide. As a consequence many families were left homeless and unable to
provide for themselves. Sympathetic coroners and juries began to give more verdicts of
‘non compos mentis’ that is mentally ill in order for families to survive. This could be a
historical explanation as to why suicide and mental illness are so intertwined.
The questionnaire used was the Attitudes Towards Suicide Survey developed by Salander
Renberg (Salander Renberg, 2001). Using factor analysis, Salander Renberg identified
10 factors. However, due to the small number in this survey, we were not able to carry
out a factor analysis on the survey data. The questionnaire contains 37 statements
including a rating scale (Likert scale), ranging from “strongly agree” to “strongly
disagree” as well as. The qualitative questions were analyzed using thematic analysis
with the aid of an independent researcher.
Ethical approval was obtained and included all professional groups to allow for further
studies. Ninety-seven coroners and deputy coroners in the Republic of Ireland and
Northern Ireland took part in the postal survey. Each coroner received a follow-up
reminder letter two weeks after the questionnaire had been sent. One week later each
coroner was phoned to remind him or her to return the questionnaires and also to thank
them for their time. Gender was not asked for due to the very low number of female
coroners (11%).
Sixty coroners returned a completed questionnaire, giving a 62% response rate. The
majority of participants were aged 45-59 years. Having carried out comparisons,
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coroners’ attitudes did not differ significantly by age, training (medical / legal) or
location (Republic of Ireland / Northern Ireland). Frequencies were generated for all
questions yielding the following results. Sixty-three percent of the coroners agreed that
most people avoid talking about suicide. Encouragingly, only 5% of coroners agreed that
people should not talk about suicide. Seventy-eight percent of the coroners understood
why people suffering from an incurable disease die by suicide. However, 20% agreed
that this is an acceptable action and 17% agreed that a person suffering from an incurable
disease should get help to die. On a personal level, 24% would consider the possibility of
suicide if they suffered from an incurable disease. Seven percent indicated that they
would like to get help to die by suicide if they suffered from an incurable disease. The
question ‘What do you think are the reasons why people commit suicide?’ was asked of
coroners. Nine themes were identified. Forty-two percent of the respondents who
answered this question believed mental health difficulties to be reasons for suicide. This
seems to contradict the quantitative finding of 23% of coroners agreeing that those who
die by suicide are usually mentally ill. Mental illness is/was only one facet of the overall
theme ‘mental health difficulties’, with hopelessness, loneliness and sexuality also being
included. Fifty-nine percent of coroners believe it is always possible to help a person
with suicidal thoughts.
The question ‘What do you think should be done to prevent suicide?’ was asked. Six
themes were identified. Raising awareness was the most prominent theme, including
education and awareness of the signs of suicide to enable people to help where possible.
Multiple possibilities revealed that coroners have thought about suicide prevention and
realise that more than one specific area needs to be addressed. This theme encompassed
issues such as mental awareness, treatment of mental illness, public awareness of suicide,
less pressure at school and more openness about sexuality. Help and support highlighted
that more counselling should be made available along with better mental health facilities
and also that relatives and friends should be proactive in offering support. Risk
management was described as “attempt to identify inadequate vulnerable personality
types and strengthen their confidence so that they can deal more appropriately with the
ups and downs of day to day living.” Irish coroners are aware of the multidetermined
nature of suicide. Coroners also have very varied ideas in how to prevent suicide and
realise that there is a need to develop more initiatives in the area of suicide prevention.
Ms. Rachel Farrow, Mr. Paul Corcoran, National Suicide Research Foundation, 1, Perrott Avenue,
College Rd, Cork.
Prof. Ivan Perry, Dept of Epidemiology & Public Health, University College, cork
Chairperson: Dr. John Connolly - Comments
This was a very refreshing part of the conference designed to be a window on some on
going original research carried out in these islands. The papers were of great interest and
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covered a wide range of topics that are very pertinent and relevant to our day to day
work.
Sean McCarthy’s paper highlighted the challenges faced in County Wexford, by the
health services, in responding to a suspected cluster of suicides occurring in a six week
period. The trauma suffered by individuals and the community was added to by
insensitive reporting of the situation in the media. The paper has lessons for every county
in Ireland in the need to be prepared with a multidisciplinary response to such crises.
I am so choked with envy hearing about the suicide prevention strategy for Scotland that
I can hardly comment on the presentation of xxx. It shows what can be done when the
political will is there and adequate finance is made available and ring-fenced for the
purpose for which it was intended.
Catherine Delaney stressed the importance of the role of the psychiatric nurse in caring
for the suicidal patient and in suicidal risk assessment. Her experiences in this study will
be of benefit to those health boards placing nurses skilled in suicide risk assessment in
casualty departments.
Mr Hopkins in his paper showed that the impact of the restrictions on the sale of
paracetamol is variable. In the area covered by his study, which is very similar in many
respects to the west of Ireland, the introduction of restrictions showed immediate
reduction in the number of paracetamol deaths and deliberate self poisoning admissions.
The fact that this has not been sustained is very worrying.
Caroline Smith and Mark Logan in their paper told us that Ireland currently ranks 24th
internationally in terms of its youth suicide rate (World Health Organisation, 2002) and
25th highest of 35 countries across Europe. This would seem to be an improvement on
the report of the OECD in the year 2000 which said that Ireland had the highest rate of
youth suicide in the world second only two New Zealand. They highlighted the lack
adequate research into social and cultural factors in the origin of suicide and suicidal
behaviour.
In a postal survey of 97 coroners Rachel Farrow and Her colleagues found a diversity of
attitude but showed that Irish coroners display understanding towards those who die by
suicide and have strong opinions and ideas on suicide prevention which we all need to
take on board.
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WORKSHOPS
131
LIVING WITH A SUICIDAL PERSON: WHAT FAMILIES CAN DO
Heather Fiske
Clinical Psychologist, Therapist, Supervisor, Consultant, Educator and Trainer, Ontario.
Abstract
Any individual who is living with a suicidal family member is both a person facing
enormous pain and stress, and a potential resource in the successful treatment of the
person at risk. Providing helpful information, support, guidance, and validation for
family members’ efforts can facilitate better outcomes for both the suicidal person and
for family members who want to help. This workshop focuses on what family members
can do to make a difference and on how volunteer and professional helpers can assist.
This article is intended as a handout for anyone living with or caring for a suicidal
person.
Suicidal thinking or behaviour in a family member is one of the most difficult realities
that any individual can face. It is hard to see a loved one in pain under any
circumstances. It can be intolerable to see that person in such pain and distress that
suicide seems like an option. It takes love and courage for people in this painful situation
to seek help for their family member and themselves, to learn what to look for and how to
intervene—or just to read an article like this one.
Family members in this situation sometimes feel so overwhelmed, and so afraid of doing
or saying the wrong thing, that they are paralyzed. They may feel that if their
relationships with the person at risk and their efforts to have a good family life haven’t
prevented things from getting this bad, then there is nothing they can do. These reactions
are common and understandable, but misinformed. More importantly, such views may
interfere with the many important things that caring relatives can do to help, protect and
support the suicidal person. Further, the understanding provided by family members can
be a key factor in making professional interventions effective. The most helpful
situations are those where families and helping professionals work in partnership.
So, what can family members do?
THREE BASIC GUIDELINES
ASK. Ask the person about suicidal thoughts and plans. Contrary to popular myth,
asking will not “get them thinking about it”. In fact, everything we know from research
and practice suggests that asking will slightly reduce the risk—and it is an essential first
step toward getting necessary help. Ask for information, as well, wherever you can:
information about risk factors, about available helping resources, and about how people
recover.
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GET HELP. Often, especially after a crisis has passed, the first inclination is to “put it
all behind us and move on”. This is a healthy and positive impulse. However, steps must
be taken to make “moving on” both possible and safe. Most people who die by suicide
suffer from mental illnesses such as depression, which can be effectively treated. Family
members can play a crucial role in getting their loved ones the help that they need. And
family members should get help for themselves also: the stress of caring for a suicidal
person takes a serious toll.
DO WHAT YOU CAN DO. This apparently simple principle goes to the core of the
dilemma inherent in preventing suicide. On one hand, we must understand and accept
that suicide happens, sometimes despite our very good efforts; and on the other hand, we
must remember that most suicide can be prevented, and intervene with energy and
optimism. Helping a suicidal person does not mean doing everything, or doing the
perfect thing: it means doing what we can. This may mean staying with the person 24
hours a day; it may mean sending a postcard once a week; it may mean working overtime
to pay for treatment; it may mean brewing a cup of tea.
HELPFUL PRACTICES
When you are concerned
Use the word “suicide”. Using the word, and trying to be matter-of-fact about it, conveys
the message that we are willing to listen and help even if things are that bad.
Don’t be afraid to ask “Has it been so bad you have thought about suicide?”
Respect their pain. Acknowledging how much the person is hurting is a first step
toward communication. Trying to minimize (“It’s not that bad”) or to argue them out of
their pain (“You don’t really mean that. Look how much you have to live for”) may
alienate and convince the person that you cannot understand.
Offer comfort. It is easy to feel that simple comforts—a touch, a kind word, home
cooked food, favourite photographs or blankets—might be helpful in a less serious
situation but are inadequate in the face of a suicidal crisis. In fact, anything that makes
even a small difference can help. Because suicidal people are often not thinking very
clearly and may be very negatively focused, concrete reminders of positive connections
and experiences are strongly recommended. When we ask individuals who have been
acutely suicidal what helped them to carry on, their most common answers are small,
apparently “trivial” words or gestures of warmth and connection from other people—or
even from pets.
Just be there. “They were there for me” is the tribute we make to those who have
helped us to get through the dark times in our lives. It does not take a professional to
provide this kind of loyal support.
To understand and support
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Identify risk factors and warning signs. In the vast majority of cases, diagnosable and
treatable mental illnesses such as depression contribute to suicidal thoughts and
behaviours. Depression is very common but often unrecognized, especially when the
most noticeable symptoms are irritation and hostility (especially common among young
males) or increased complaints about physical aches and pains (especially common in the
elderly), rather than the sadness and crying we more typically expect. Both counseling
and medication are effective treatments for depression.
Depression has been shown to have a basis in brain chemistry, which is one of the
reasons that medication is often recommended as part of treatment. Fears and
misunderstandings about antidepressant medication are widespread, and so it is especially
helpful if family members are able to:
(1) get good information about the medication and its effects;
(2) work closely with both their at-risk family member and the prescribing doctor;
(3) help to ensure that medication is taken as prescribed; and
(4) if the medication is not helpful, check with the physician to see, first, whether a
change in dosage, timing or drug choice might work better; and second, if
stopping the medication, how to do it safely.
Regular exercise has also been shown to be an effective treatment for depression and
other mental illnesses. Family members can play an important role in helping a
depressed person to “get moving”.
Other illnesses and conditions that can contribute to suicide risk include bipolar disorder
(manic-depressive illness), conduct disorder, borderline personality disorder, severe
anxiety, learning disabilities and of course substance abuse (including problem
gambling). “Dual diagnosis” (more than one illness) creates greatly increased risk. In
particular, the combination of substance abuse with any other condition is a very highrisk situation.
The risk category of “stressful or painful life events” includes a long list of experiences
that contribute to suicide risk, including: relationship loss, adjustment factors (e.g. to
physical illness or disability, or sexual/gender identity issues), performance failure; and
family factors (such as stress, illness, conflict, abuse or violence, or substance use
problems within the family).
It is useful to remember that almost always there has been an accumulation of stressors,
usually in the context of depression or other illness, rather than a single “event” which
causes a suicide plan or attempt. While there may be no single “solution”, intervening
with any of the difficulties that have contributed to the person’s pain and distress can help
to reduce the risk of suicide.
For example, school failure associated with learning problems or depression may be a
factor for one suicidal teenager. If so, working with the school to get appropriate extra
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help or tutoring, or educating teachers about what the child is going through, may make a
difference.
As noted above, some of the risk factors involve family issues. The “good news” about
recognizing that family factors may be involved is this: If family members are able to
take steps to deal with any of their own problems, their actions can make a difference in
the suicidal individual’s level of risk. And of course, seeing a family member getting
help is an excellent example for a troubled person.
A last major category, environmental risk factors, primarily concerns the availability of
the means or methods of suicide in the person’s surroundings. Block the exit! Remove
guns, pills and other poisons, ropes, knives, car keys—anything that you know or suspect
could be used for self-harm.
Warning signs of imminent danger for suicidal behaviour may be direct and obvious,
like saying “I am going to kill myself today”, or more subtle and hidden. Once the
suicide issue is out in the open, often as the result of a crisis, families have the
opportunity to consider the person’s recent behaviour in a new light and to understand
individual warning signs.
Common signs include:
 preoccupation with death
 self-destructive behaviour of any kind
 signs of depression (see attached list)
 changes (including increases, decreases, and differences) in :
--behaviour
--motivation
--appearance
--mood
--emotions
--physical state
(Because the changes vary so much among individuals, family members’ knowledge of
what is typical for the person is important).
 hopelessness is very strongly associated with suicidal thinking and behaviour,
even in people who are not clinically depressed.
 making final arrangements
 lack of interest in future plans
 substance abuse (in a vulnerable person, can increase the likelihood of impulsive
self-harm and remove inhibitions on suicidal behaviour).
Support suicide prevention groups and networks. Local suicide prevention groups
and regional/national groups like the Irish Association of Suicidology and its Canadian or
American counterparts can provide useful information, a sense of connection with a
community working to reduce suicide, and, when they are ready, opportunities for people
who have “been there” to make valuable contributions in volunteer work or advocacy.
To keep them safe
135
Learn the basic “do’s and don’ts” of crisis intervention.
Do’s:







Do ask about suicide
Do know the warning signs.
Do act calm. Soothing tones of voice can make a difference.
Do try to be accepting and honest.
Do give them a sense of control. To the extent that they are capable, suicidal
people should be offered choices. For example, if they are able to participate in
the decision to get help, this is ideal.
Do restrict access to their intended means of suicide (“block the exit”). In
particular, remove firearms and poisons.
Do GET HELP. There is a range of options for getting help in a crisis, from
contacting a family doctor or school counselor through various crisis-specific
services (hospital emergency room, mobile crisis unit, distress line, etc.). In
extreme cases where the person is unable or unwilling to cooperate, an ambulance
or police can be called.
DON’Ts
 Don’t panic
 Don’t ignore the signals
 Don’t promise secrecy
 Don’t leave the person alone
 Don’t debate the morality of suicide
 Don’t tell the person to be grateful for what they have
 Don’t say that everything will be all right
 Don’t challenge the person to go ahead
 Don’t do nothing.
The essentials in a suicidal crisis are to keep the person safe, to respond (do something!)
and to get help. Remember: often a crisis is the beginning of helpful intervention and
change.
Connect with local resources and advocate for treatment. Helpful treatment is widely
available but not always readily accessible. Any of the following resources may be able
to provide (a) direct help or (b) referrals to appropriate agencies and professionals:
 Physicians
 Hospitals
 Crisis or distress centers
 Mental health clinics
 Mental health professionals, e.g. psychiatrists, psychologists, social workers,
psychotherapists (employed persons and their immediate family members may
have coverage for these services through insurance or employee assistance plans).
 Family and friends
136



Clergy: many have training in counseling and most will be able to make
suggestions about other resources as well as offering support
Self-help programs
For young people, school- or college/university-based helpers (psychologists,
social workers, counselors, etc.)
Suicidal people may be easily discouraged in help-seeking, especially if there are delays
or complications. Family members can be of great assistance in actively pursuing
treatment. One of the most common difficulties is waiting lists. I recommend that
families (a) get on the list!—the appointment can be cancelled if something turns up
earlier; (b) continue to look for alternatives in the meantime; and (c) call regularly to
inquire where they are on the list and to remind the service provider that they are eager to
be seen and (if possible) willing to come on short notice if an opening occurs. There are
no guarantees, but “squeaky wheels get grease”.
To make a healing difference
Support people’s reasons for living. Anything one person does to recognize, reinforce,
or support another person’s reasons for living is suicide prevention. Family members are
often uniquely qualified to understand what may be most important, salient, and relevant
for the suicidal person, and may be most likely to divert attention or interest away from
death as a solution.
Communicate a sense of belonging. Psychologist Thomas Joiner has identified
“thwarted belonging”—the belief that they do not and cannot fit in anywhere--as one of
the key perceptions held by individuals who are in imminent danger of suicide. Family
members can say and do many things to counter this view and to communicate a sense of
inclusion.
Communicate that the person is valued and valuable. A second view identified by
Joiner is “perceived burdensomeness”—the idea that “they’ll be better off without me”
which is a common theme of suicide notes. Family members can contradict this belief
both directly (in words) and indirectly (by showing and telling the person how they are
valued).
For your well-being and theirs
Maintain healthy routines. In order to be able to help and support a loved one who is at
risk for suicide, it is essential that family members get regular rest, exercise, healthy
nutrition, and positive social activity. Maintaining these routines also means that they are
available for the person at risk to participate in when he or she is ready.
Look for signs of progress, change, and hope. Just as it is important to be aware of
warning signs and be prepared to act, it is important that family members be oriented to
positive change and be prepared to reinforce and celebrate such changes. Like warning
signs, signs of progress are highly individual. Some examples include:
137

Crying or saying “I feel sad”, especially in an individual who has kept pain
hidden in the past
 Being obnoxious, in the case of a depressed teen who has been withdrawn and
listless
 Asking for help
 Making future plans
 Showing pleasure or enjoyment
 Recovery in sleep, eating, or energy
 Development of new pain management or stress coping skills (a positive
alternative to “SOS”—“suicide as the only solution”)
Often, family members notice the first small signs of progress before the individual is
aware of the changes.
MODEL SELF-CARE
Even when there is conflict in families, close relatives are a primary source of
information about how to deal with life and problems. (One everyday demonstration of
this is the kind of advice that young people give their friends—often modeled on what
their parents say to them). Much more effective than telling our family members what
they should do to be healthier and happier is showing them healthy ways of living and
coping through their own actions..
An important first step is to acknowledge one’s own emotional responses. Normal
reactions family members may have to suicidal behaviour in a loved one include guilt,
fear, resentment, anger, denial, panic, relief, sympathy, grief, frustration, confusion,
disbelief, impatience, shame, hopelessness…..and the list goes on.
A second step is to model appropriate help-seeking: by having people we confide in, by
relying on supportive relationships, and by using professional help when it can make a
difference. Positive attitudes about getting help are instructive, especially for those who
fear that going for help means that they are weak, bad, or hopelessly sick. Family
members can present a constructive alternative to these fears by saying and
demonstrating that getting help when it is needed is positive, strong, responsible
behaviour, and that treatment can help people feel and function better and give them new
skills for coping well.
Other aspects of modeling self-care may include lifestyle changes to reduce stress and
improve general health; learning to live “one day at a time”; relying on strengths; and
developing one’s capacity to notice and celebrate small improvements.
CONCLUSION
Anything we can do that relieves pain or supports reasons for living is helpful in reducing
the risk of suicide. Both the sources of pain and the reasons people find to continue
living in spite of it are highly individual. Those who know and love troubled people best,
their families, are in an excellent position to assist with these efforts.
138
SIGNS AND SYMPTOMS OF DEPRESSION
Heather Fiske
Physical
Emotional
Sleep Disturbance
Change in Appetite, Eating
Lack of Energy, Fatigue
Loss of Sexual Desire
Digestive Problem
Pain
Sadness
Shame, Worthlessness
Irrational Guilt
*Irritability, Resentment
Anhedonia (Lack of Pleasure/interest)
Helplessness/hopelessness
Cognitive
(often lead to
school or work
problems)
Concentration difficulties
Memory problems
Indecisiveness
Suicidal ideation
Lack of interest
Pessimism, negativity
Behavioural
Withdrawal
Crying spells -or- “flat” response
Slowing -or- restlessness
Neglect of responsibilities
Neglect of personal care
Reduced coping
Complaints
Substance abuse
THE DISPOSAL OF UNUSED MEDICATION PROPERLY (DUMP) PROJECT. AN
INITIATIVE TO REDUCE ACCESS TO MEANS
Denis O’Driscoll, Catherine Brogan
Addiction Services, SWAHB, Dublin, Resource Officer for Suicide and Mental Health
Promotion, SWAHB.
Abstract
Parasuicide and suicide represents a significant cost on health and resources in Ireland as
well as the threat to human life. The Disposal of Unused Medication Properly (DUMP)
139
project was piloted as a potential for reducing access to means for suicide and
parasuicide. Added benefit would be to include reducing accidental poisoning in
children, and environmental pollution from pharmaceutically active compounds (PhACs).
The pilot was run over 6 weeks in Oct-Nov 2002 in 6 community pharmacies. Each
pharmacy was provided with waste disposal containers, paper carrier bags printed with
the project logo containing an information leaflet detailing the project aims, and a poster
advertising the project. Each pharmacist was required to record all medicines returned,
approximate quantity, the date and reason for return. Waste disposal containers were
collected three times during the pilot and disposed of in line with E.U and Irish
legislation. The results demonstrated: significant quantities of unused/ unwanted
medications were returned, 108 kg of pharmaceuticals primarily due to not finishing or
not starting. A correlation was noted between the medication of choice as a method of
overdose and medication type being returned (National Parasuicide Registry Annual
2002). Results demonstrated using the WHO ICD-10 classification that in the X60, X61
and X62, 59, 55 and 19 items out of a total of 421 returned. DUMP has subsequently
been implemented in all pharmacies registered within SWAHB.
INTRODUCTION
In order to address the recommendations of the National Task Force on Suicide (1998),
relating to Para suicide with medicines, an interagency group consisting of SWAHB,
EHSS, Clinical Collections, Sterile Technologies Ltd, Sharpes Containers Ltd, and IPU
was set up. The main aim of the group was to organize, the proper disposal and
destruction of unused medicines from the community in order to reduce potential suicides
and para-suicides, prevent accidental overdose in children and protect the environment
from pollution.
The DUMP project aspired to ensure the safe disposal and destruction of unused
medicines in the South Western Area Health Board, by guaranteeing a safe method of
disposal by returning unused medicines to a local pharmacy, rather than disposing of
them with the household waste or flushing them down the toilet.
The terms of reference include:
 Examine the quantity of medicines returned and destroyed
 Conduct BNF and ICD 10 drug classification on medicines returned
 Examine the reasons for return of medicines
 Consider the Cost to the SWAHB.
The main benefits to public health underpinning the campaign were:
 Prevention of Suicide / Para suicide
 Accidental poisoning
 Environmental Protection.
Each year, in Ireland, there is an estimated 10,000 attendances at A& E departments
following attempted suicide. In the annual report published by the National Suicide
Research Foundation on Para suicide (2002), the methods most frequently employed was
overdose (65% men and 77% women), followed by Cutting, Hanging, Drowning and
Alcohol poisoning. The most common choices of drugs used are Minor tranquillisers
46.4%, Analgesic 40.8%, and Major Tranquillisers 10.8%. Paracetamol is the most
140
common analgesic seen in 27.6% of overdoses, Antidepressant SSRI’s are found in
18.8% of overdoses and other prescribed medical drugs found in 21.4% of cases. In
February 2000, the Department of Public Health and the Health Promotion Department of
the former Eastern Health Board developed a preventative strategy for specific types of
injury; poison prevention in children was one of the main priorities. One of the main
points of the plan was to implement an imaginative poison awareness campaign targeted
at parents. This report also recommended a reduction of hospital admissions and A&E
attendance’s by 50% (over a 10-year period from 1997) among children under 5 years of
age. This had been previously investigated in a scheme which had been launched in the
ECAHB in cooperation with the Dun Laoighaire -Rathdown county council in 2001.
Further to this it has demonstrated up to 80 pharmaceutically active compounds (Pac)
have been found to microgram level per litre in treated effluent and surface water
downstream from these plants. Further to this polar compounds especially clofibric acid,
carbamazapine and contrast media have been know to leach into subsoil and ground level
aquifers However in drinking water levels of PhACs were below the levels of detection,
however it has been suggested from some research that levels of for example EE at levels
of o.1ng/l may cause feminisation in some wild fish species. This in turn may lead to
extinction of species or even the possibility of build-up within the food chain of these
PhACs.
METHODOLOGY
In the pilot it was decided that a rural urban cross would be targeted, initially 6
pharmacies were chosen as the project team had little or no idea of what the results would
be and the resources that would be required. The costing for this project were kept to a
minimum and the companies involved in the disposal and removal of the waste offered
their services free of charge. The pilot phase lasted for 6 weeks, and included three pick
ups of medication, the first allowing the pharmacy to rid themselves of any previously
returned medication/ out of date stock. The participating Pharmacist were asked to keep
a record of medicines that were returned and reason for the returns, this was the data
which was analysed
To further encourage patients to return medications, bags were prepared with an
identifying logo; the contents of this bag also contained a leaflet (contained relevant
telephone numbers of agencies that provide information and advice on medication and
support) and the booklet' Knowledge is the Best Medicine' (IPHA). Due to the local
nature of the initial pilot advertisement was kept to a minimum, a poster for display in the
pharmacy and both statutory and voluntary local agencies informed.
RESULTS
On analysis of the data 32 BNF classification of drugs were returned, some are obviously
not as suitable for means in suicide and para-suicide as others i.e. Topical corticosteroids
versus cardiovascular compounds.
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Items returned
Drug Classes in which 9 or more items were
returned
80
70
60
50
40
30
20
10
0
Pharmacy F
Pharmacy E
Pharmacy D
Pharmacy C
Pharmacy B
Pharmacy A
1
3
4
5
6
7
8
10 11 12 17 18
Drug Classification
This shows the classifications of medicines of which 9 or more of the same class were
returned. That is not individual quantities but rather total monthly prescribed aliquots.
It is clear that Class 1 cardiovascular (16.2%), Class 6 (Non-opioid analgesics, 11.2%),
Class 11 (OTC supplements, 12.6%) and Class 17 (Antibacterial agents, 13.3%) are the
items that are of the highest returns accounting for a total of 53.3% of all returns. In this
it is apparent that there was a high rate of returns of benzodiazepines (5.2%), atypical
anti-psychotics (2.9%), which are number 7 and 18 respectively. Quantitatively there
appeared to be a greater return of medication from pharmacies in a rural setting than
those in an urban/suburban setting, with the former accounting for approx 2/3 of the total
amount (108kg) of medication returned. This may be attributed to a number of factors,
the lack of other community pharmacies in the rural vicinity and also the closeness of the
community i.e. in one location there was an announcement at the church of the scheme at
all masses.
142
Drugs which were returned and are grouped according to the
WHO ICD-10 Classification of Mental and Behavioural
Disorders
Quantity returned
30
25
X60
X61
X62
20
15
10
5
F
Ph
ar
m
ac
y
E
ac
y
D
Ph
ar
m
ac
y
Ph
ar
m
ac
y
C
B
Ph
ar
m
ac
y
Ph
ar
m
Ph
ar
m
ac
y
A
0
X60 – Intentional self-poisoning by and exposure to non-opioid analgesics, antipyretics
and antirheumatics.
X61 – Intentional self-poisoning by and exposure to antiepileptic, sedative, hypnotic,
antiparkinsonian, and psychotropic drugs, not elsewhere classified includes,
antidepressants, barbiturates, neuroleptics, psychostimulants.
X62 - Intentional self-poisoning by and exposure to narcotics and psychodysleptics
includes cannabis, cocaine, codeine, heroin, LSD, mescaline, methadone, morphine,
opium
On analysis of the data using WHO ICD 10 classification of drugs that are used in parasuicide and suicide, X60, X61 and X62 accounting for 14%, !3% and 4% of returns
respectively. This appears to follow the drug category of choice for attempted suicide in
five Health Boards in Ireland according to the NPSR 2001, with X62 being the least used
drug as seen in this data. Although the trend has no statistically provability it is hoped
that with the analysis of returns from Sept 03 to Sept 04 that a greater correlation is seen,
which in turn may further demonstrate a reduction in the numbers attending A&E owing
to these drugs
Qualitatively on analysis of the reasons for returns of the medication, over 70 % of
returns were ‘Not required or unwanted’, this was seen to included some of the following
reasons, prescription change and allergy type response. The remainder was due to the
medication going out of date (22.5%) and due to the death of the patient (6.7%). It would
be anticipated that in the future the recordings for this would be more streamlined in the
sense that the pharmacist recording would be given options rather than interpreting
reasons themselves.
A further aspect of the results was analyzing the cost of these returns of medication, at
cost price it was estimated that it was €6886.25 over the six week pilot phase. However
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it should be noted that this does not include the cost of the fees to the health professionals
or any other hidden costs e.g. hospital time, patient time, A &E visits.
RECOMMENDATIONS
 Extension of the service to all community pharmacies in the HSE (SWA)
 Increase communication and links within the Primary care structure
 Patient empowerment by provision of more information on medicines
 Improve the pharmaceutical care of patients, by promoting and discussing
medicine management
Reference:
National Para suicide Registry Ireland, Annual report, 2001. National Suicide Research
Foundation
Report of the National Task Force on Suicide, 1998. Department of Health and Children.
Suicide in Ireland . A National Study, 2001. Department of Public Health on Behalf of
the Chief Executive Officers of the Health Boards
Schiliro T, Pignata C, Fea E, Gilli G, Toxicity and Estrogenic Activity of a wastewater
treatment plant in Northern Italy, Archives of Environmental Contamination and
Toxicology, 2004; 47: 456-462
O’Driscoll D, Brogan, Presentation to the ‘10th European Symposium on Suicidal
Behaviour- Research, Prevention, Treatment and Hope’, Copenhagen 25-28 August 2004
Ms. Catherine Brogan, Suicide resource office, 3rd Floor, Health Promotion Department, 52 Broomhill
Road, Tallagh, Dublin 24. catherine.brogan@swahb.ie
Mr. Denis O’ Driscoll, Bridge House, Cherry Orchard Hospital, Dublin 10. Telephone: 01 6206437
THE SPEAKERS.
CHRISTY KENNEALLY
Christy was born in Cork and has worked in the area of communications for nearly 30
years. He has lectured throughout the world for many organisations including the
American Cancer Foundation. Christy was the presenter of ‘No Frontiers’. He has
recently filmed a series of documentaries for TG4 which took him to thirteen different
countries. He starts filming again around the world in October. Christy is author of ten
books including Life after Loss.
CARLA FINE
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Carla is the author of No Time to Say Goodbye: Surviving the Suicide of a Loved One
(Broadway Books/Doubleday). This widely acclaimed book is a personal story—Carla’s
husband, a prominent New York physician, killed himself in 1989 at the age of 43. Carla
also interviewed more than 60 other people who lost sons and daughters, wives and
husbands, fathers and mothers, sisters and brothers, friends and relatives to suicide. The
book describes the different stages of bereavement surrounding the suicide of a loved
one, and helps survivors see that they are not alone in their confusion and grief. Carla
is the author or coauthor of seven other books. She also lectures extensively to suicide
survivors' groups and professional organizations throughout North America, and has
appeared on numerous television and radio programs. Carla received her Masters of
Science degree with honors from the Columbia University Graduate School of
Journalism. Carla lives in New York City with her husband, Allen Oster, and their two
Labrador Retrievers, Sancho and Rosie. Her website is www.carlafine.com
TONY BYRNE
Tony is a Spiritan (Holy Ghost) Priest who worked in Africa, West Indies and Asia on
community awareness programmes for 35 years. Since his return to Ireland he has
organised courses and seminars on Facing up to Suicide, Confronting Bullying, Harmony
in the Home, and Facing up to Alcohol Misuse. He has studied social policy, industrial
relations, and community education at Swansea University, Boston College, and St.
Mary’s University in Baltimore, USA. Tony has written several books, on bullying,
justice/peace, development, structural evaluations, and the Airlift to Biafra. He has
written extensively on suicide in Irish newspapers and has appeared on TV and radio
programmes dealing with suicide and bullying. He is currently the Director of the
Awareness Education Office.
KATHLEEN MAGUIRE
Kathleen is a Presentation Sister. She directed education, pastoral and social programmes
in Pakistan and India for twenty years. On her return to Ireland taught in Mullingar
Community College and was Home/College Liaison. Kathleen initiated bereavement
support training and facilitated community and pastoral programmes in Mullingar parish.
She is currently facilitator of awareness education programmes on Facing up to Suicide,
Harmony in the home, Confronting Bullying and Facing up to Alcohol Misuse. Kathleen
co-authored, with Rev Dr. Tony Byrne, a book on Bullying in the Workplace, Home and
School: Questions and Answers
ADRIAN HILL
Adrian is Executive Director of the Legal Profession Assistance Conference of the
Canadian Bar Association. Adrian is a Peer Volunteer and Clinical Supervisor of the
Ontario Bar Assistance Program, Treasurer of the Canadian Association for Suicide
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Prevention, a member of the American Association of Suicidology, and an Advisory
Board Member to the Ontario Suicide Prevention Network. Adrian has been the recipient
of the American Bar Association Service Award and the Law Society Medal in Ontario.
He practiced law for over thirty years as senior counsel and managing partner of a
Toronto law firm. Adrian is a Certified Drug and Alcohol Addiction Counsellor in
Canada, a Certified Gambling Counsellor in the United States and a Professor of
Addiction Medicine.
TOM BYRNE
Tom has responsibility at Regional Manager level for services for Mental Health and
Older people including the Regional Suicide Prevention Programme, Physical Sensory
and Intellectual Disabilities and Regional Developments.
ANNETTE BEAUTRAIS
Annette is the Principal Investigator with the Canterbury Suicide Project at the
Christchurch School of Medicine in Christchurch, New Zealand. The Canterbury Suicide
Project consists of a series of studies of suicidal behaviour. Major research studies
include a case control study of suicide and serious attempted suicide; a five -year followup study of people who have made serious suicide attempts; a study of the impact of
suicide on close family members. Annette has written a number of research articles,
reviews and reports about various aspects of suicidal behaviour, and has contributed to
the development of a series of guidelines for professional groups regarding suicide
recognition , treatment and management. She was involved in the development of New
Zealand’s National Youth Suicide Prevention Strategy, and is an advisor to several
international suicide research and prevention centres.
MAILA UPANNE
Maila is Development Manager with the National Research and Development Centre for
Welfare and Health in Helsinki; she was leader of the Finnish Suicide Prevention Project
1992 -1996. Maila is responsible for the development and implementation of the Suicide
Prevention Strategy in Finland.
JOHN CONNOLLY
John is a co-founder and secretary of the Irish Association of Suicidology. He is
currently working as a Consultant Psychiatrist/Clinical Director of the Mayo Psychiatric
Services. He qualified in Cork and worked for a time in Bantry. He trained as a
psychiatrist in England and worked there as a consultant before returning to Mayo in
1979 to take up his present post. John is a fellow of the Royal College of Psychiatrists.
His main research interest is in suicide and he has published a number of articles on
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trends in suicide rates, underreporting of suicide and media reporting of suicide. He is
Chairman of the Mayo Mental Health Association Ltd., a Director of Mental Health
Ireland and a member of the National Suicide Review Group. John is Co-editor in Chief
of CRISIS the international journal of Suicide Prevention and Crisis intervention. He is
also Proprietor and Managing Director of the Connaught Telegraph Newspaper
TONY BATES
Tony is a principal clinical psychologist at St James’s Hospital Dublin and
Lecturer/Course Director (M.Sc. Cognitive Psychotherapy) in the Department of
Psychiatry TCD. He received his PhD from University College Dublin and did further
post qualification training at the University of Pennsylvania and the University of
Oxford. He is author of Depression: A Common Sense Approach (Newleaf) and is a
columnist with the Irish Times. Tony has been committed to disseminating psychology
to the general public and working towards the provision of a more holistic and
therapeutic approach in mental health. He is a member of the Mental Health Expert
Group and involved in the preparation of a broad policy framework intended to advice
the minister in respect to developing mental health services in this country
SHEILA DALTON
Kilkenny-born Sheila has been a volunteer a nd support group facilitator with Aware
for14 years. A qualified psychiatric nurse, she worked with Carlow-Kilkenny Mental
Health Services in many capacities for 36 years until her retirement in 2003. a director of
Kilkenny Mental Health Association, she is also a member of Kilkenny Bereavement
Support Group and is involved with their on-going training.
KAHLIL THOMPSON
Kahlil Thompson is the Projects Officer for Schizophrenia Ireland and project manager
for the “Life Hope: Suicide Prevention through Information and Counselling” project.
The Life Hope project aims to discuss the problem of suicide, particularly for people with
schizophrenia and related illnesses, and how to become proactive about suicide
prevention. Prior to joining Schizophrenia Ireland, Kahlil worked with the United
Nations in Vienna, Austria, where she held the posts of analyst, specialist, and Junior
Political Officer.
MIKE WATTS
As a young man I experienced many years of despair. Over the years that despair has
been replaced by a growing belief in the value of life and of people. Much of that change
has come about through my 25 year involvement in GROW, but also included studying
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for a BA in psychology and Masters in family therapy. I am married with four children
and three grandchildren.
TERESA MASON
Teresa works as Resource Officer for suicide prevention in North Dublin for the Northern
Area Health Board. She has worked with the issue of suicide for five years. Prior to this
she was employed as a Senior Occupational Therapist in the adult mental health services
in Dublin. Teresa is a trainee Group Analyst.
CHAIRPERSONS
MARY HUTCHINSON
Mary has been a Director on the Board of the Irish Association of Suicidology since
2001. Born in Coleraine, Co. Londonderry, Mary holds a BSC (Hons) degree in Social
Policy and Administration from the University of Ulster. Mary is currently completing
her doctoral thesis on the contribution of the voluntary sector in Northern Ireland to the
promotion of children’s rights, particularly within the field of youth justice. Having lost
her eldest son to suicide in 1996, Mary has a special interest in the needs and experiences
of the bereaved by suicide and the support systems available to them.
MARGARET HAYES
Margaret who comes from Tara, Co. Meath married the late Jim in 1957. They had five
children, three girls and two boys. Their eldest child, Gerard, took his life in 1983, aged
24 years. Since his death Margaret helps, on a voluntary basis, those who have been
bereaved by suicide. She has taken part in many T.V. and Radio programmes dealing
with the topic of suicide and is delighted to participate in today’s events.
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
148
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.
GEOFF DAY
Geoff is Assistant Chief Executive of the North Eastern Health Board in the Republic of
Ireland. He is responsible for the management of community care, primary care, mental
health, the ambulance service and health promotion. Prior to 1997, Geoff worked in the
National Health Service in England, where he was firstly a service planner for elderly
services and then performance manager in the NHS Reforms programme of the early
1990’s. A social working by training, Geoff moved into health management in the mid
1980’s. He is currently chair of the National Suicide Review Group in Ireland, the
national body which oversees the implementation of the recommendations set out in the
Task Force Report on Suicide, published in 1998.
PATRICIA NOONE
A graduate of N.U.I. Galway, Patricia’s Graduate Training in Psychiatry was at the
University of Toronto and The Clarke Institute where she was Chief Resident to
Professor Robin Hunter and subsequently became a Consultant Psychiatrist on the staff of
the Institute where she undertook further studies in Psychodynamic Psychotherapy.
Patricia’s research into Death, Dying and its effect on Nursing Staff was at Toronto’s
Princess Margaret Hospital. She returned to Ireland and has been a Consultant
Psychiatrist in the Mayo, Psychiatric Services for several years.
FRANK MURPHY
Frank is Regio Alcoholics Anonymous nal Manager with Mental Health & Older People
Services, Western Health Board.
149
SUPPORT AGENCIES
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Aware
AWARE is a voluntary organisation formed in 1985 by a
group of interested patients, relatives and mental health
professionals. To provide support group meetings for
sufferers of depression and manic depression and their
families.
AWARE
72 Lower Leeson St., Dublin 2
Tel: +353 1 6617211. Fax: +353 1 6617217
Callsave: 1890303302. E-mail: info@aware.ie
www.aware.ie
Alcoholics Anonymous
AA is a self-help programme for people who may have a
problem with alcohol. Group meetings are held in most
towns throughout the country.
Tel: 048 90 774879 N.I.
Tel: +353 1 4538998 E-mail: ala@indigo.ie
www.alcoholicsanonymous.ie
Al Anon
A fellowship of young people whose lives have been or are being
affected by parent’s compulsive drinking
Al Anon Information Centre, Room 5, 5 Chapel
St., Dublin 1.
Tel: +353 1 8732699. Helpline +353 1 8732699
Association for Psychiatric Study of Adolescents
Brings together those concerned with the psychiatric care of
adolescents.
Evelyn Gordan, c/o St. Joseph’s Adolescent
Unit,
Richmond Rd., Fairview, Dublin 3.
Tel:+353 1 8370802
Bodywhys -
Bodywhys is a charity which offers help, support, understanding
and information to people with anorexia or bulimia nervosa to
families and friends and to professionals involved in the treatment
of eating disorders
Bodywhys Central Office, PO Box 105
151
Blackrock, Co Dublin.
Tel: +353 1 2834963. info@bodywhys.ie
Bullying
A.B.C. Anti Bullying Research and Resource Unit.
Advice, guidance and counselling for all who need help and
support in relation to bullying.
Room 3125, Arts Building, Trinity College, Dublin 2.
Tel: +353 1 6082573 Fax:+353 1 6082573/6777238
e-mail: imcguire@tcd.ie
Campaign Against Bullying.
Aims to reduce the incidence of, and minimise the ill-effects
of bullying
72 Lakelands Avenue, Stillorgan, Co. Dublin
Tel:+353 1 2887976
E-mail: odonnllb@indigo.ie
Child Bereavement (Ni)
Tel: 048 90 403000
Cruse Bereavement Care (Ni)
(Regional Headquarters)
Tel: 048 90 792419
Cumas - Supporting families around drugs
The Old Supermarket,
Neilstown Shopping Centre,
Clondalkin, Dublin 22
Tel: 01 4573515. Fax: 01 4573122
e-mail: cumas@indigo.ie
Drug Treatment Centre Board
Provides services for drug misusers. Treatment is free of
.
charge. Offers advisory service to medical profession,
parents, young people and teachers.
Trinity Court, 30-31 Pearse Street, Dublin 2.
Tel: +353 1 6771122
Foyle Search &
Foyle Search & Rescues main aim is the preservation of life
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Rescue
in and around the river Foyle. It is made up of volunteers
that patrol the banks of the river
Tel: 01 504 313800
foylesearch@foylesearch.demon.co.uk
Gamblers Anonymous
Gamblers Anonymous is self-help for people who may have
a problem with gambling.
Tel: 048 71 351329 N.I.
Tel: 048 90 249185 N.I.
Tel: +353 1 8721133
www.gamblersanonymous.ie
Grow
GROW aims to help the individual grow towards personal
maturity by use of their own personal resources, through
mutual help groups in a caring and sharing community. The
programme is based on providing a supportive environment
for its group members.
GROW
National Office, Grow Centre,
11 Liberty Street, Cork
Tel: +353 21 277520
Irish Association For Counselling And Therapy
Offers courses in personal development and self-esteem.
Provides counselling services for alcohol and drug abuse,
and bereavement.
8 cumberland Street, Dun Laoghaire, co.
Dublin.
Tel: +353 1 8370802
Irish Stammering Association
Aims: to improve service provision for children and adults;
set up local self-help groups throughout the country; arrange
intensive stammer courses for adults; research the causes of
stammering.
Carmichael House, North Brunswick St.,
Dublin 7.
Tel: +353 1 8724405. Fax: +353 1 8735737
153
Helpline +353 1 8735702
Legal Aid Board
The Legal Aid Board provides legal aid and advice in civil
cases to persons who satisfy the requirements of the Civil
Legal Aid Act. 1995. The Board makes the services of
Solicitors and if necessary Barristers available to people of
moderate means at little cost. The service includes anything
from writing a solicitors letter on your behalf to representing
you in court. In practice the Board deals mainly with family
law.
Legal Aid Department
Tel: 048 90 246441 N.I.
Tel: +353 669471000
Mental Health Ireland
The Mental Health Ireland is a national voluntary
organisation with over 99 local association and branches
throughout the country. Its aim is twofold - to help those
who are mentally ill and to promote positive mental health.
Tel: 01 2841166
www.mentalhealthireland.ie
e-mail info@menalhealthireland.ie
Nar-Anon
Nar-Anon is a self-help group for relatives and friends of
people who may have a problem with drugs.
Tel: +353 1 8748431
Narcotics Anonymous
NA is a self-help group for people who feel they may have a
problem with drugs.
4-5 Eustace St., Dublin 2
Tel: +353 1 8300944 ext. 486
National Youth Council of Ireland
The NYCI is the representative body for voluntary youth
organisations.
3, Montague St., Dublin 2.
Tel: +353 1 4784122
Fax: +353 1 4783974
E-mail: info@nyci.ie
154
National Youth Federation
The National Youth Federation (NYF) is Ireland’s largest
youthwork organisation. The NYF has published research
on young people and suicide, produced guidelines for youth
workers on prevention and postvention work and provides
workshops on the use of the guidelines.
Tel: +353 1 8729933
e-mail fbissett@nyf.ie
Northern Ireland Mental Health Association
Tel: 028 90 328474
Overeaters Anonymous
The only requirement for overeaters anonymous membership
is a desire to stop eating compulsively
Tel: (01) 2788106
Prism – Bereaved And Separated Parents.
A programme specially designed for bereaved and separated
parents. It helps them to become attuned to their own and
their child’s grief process and to learn single parenting skills
so they can recreate family life again.
Oanda, The Association for Phobias in Ireland
OANDA was set in 1974 as the National Organisation for
sufferers of Agoraphobia.
OANDA,
140 St. Lawrence’s Road, Clontarf,
Dublin 3.
Tel: +353 1 8338252/3
Psychological Services, Department of Education and Science
Psychological support service for Post Primary Schools &
Colleges
Marlborough St., Dublin 1.
Tel: +353 1 8892700
Rainbows Ireland
155
Rainbows is a support group programme for children and
young adults who have suffered a significant loss through
death or separation or any painful transition.
Tel: 01 4734175
Recovery Incorporated
Offers self-help mental health programme for people
suffering form anxiety, phobias, depression and nervous
symptoms.
Tel: +353 1 6260775
E-mail: recovirl@indigo.ie
Samaritans
The Samaritans vision is that fewer people will take their
own lives. Samaritans befriending is available at any hour
of the day or night for everyone passing through personal
crisis and at risk of dying by suicide. Samaritans provide
society with a better understanding of suicide, suicidal
behaviour and the value of expressing feelings that may lead
to suicide.
Linkline
Tel: 0345 909090 N.I.
Tel: 1 850 60 90 90 `
Schizophrenia Ireland
Schizophrenia Ireland is the national organisation dedicated
to advocating the rights and needs of those affected by
schizophrenia and related illnesses, and to promoting and
providing best quality services for the people it serves
Schizophrenia Ireland
38 Blessington St, Dublin 7.
Tel: +353 1 860 1602. Fax; +353 1 8601602
Helpline: 1890 621 631
http://www.iol.ie/lucia
Email: schizi@iol.ie
156
SUICIDE BEREAVEMENT
SUPPORT GROUPS
157
CARLOW:
CARLOW SUICIDE BEREAVEMENT SUPPORT GROUP
Dr. O’Brien Centre, Dublin Rd, Co. Carlow. Tel: 059 9151277
CORK/KERRY:
HEALTH SEVICE EXECUTIVE
SUICIDE BEREAVEMENT SUPPORT SERVICE 087 7986944
CORK:
COMMUNITY CENTRE
Fermoy, Co. Cork, Co-ordinator , Sr. Una Boland
YOUGHAL SUICIDE BEREAVEMENT SUPPOR GROUP
League of the Cross Hall, Grattan Street, Youghal, Co Cork
Tel: 024 95561, E-Mail:nsbsn@eircom.net
DUBLIN:
THE BEREAVEMENT COUNSELLING SERVICE
Dublin St., Baldoyle, Dublin 13, Tel: 01 8391766
St. Annes Church, Dawson St, Tel: 01 6767727
bereavement@eircom.net, www.bereavementireland.org
NORTHSIDE COUNSELLING CENTRE
Coolock Development Centre,, Bunratty Drive , Bonnybrook, Dublin 17
Tel: 01 8484789, ncsl@eircom.net
SUICIDE BEREAVEMENT SUPPORT GROUP
Blessed Sacrament Chapel, 20, Bachelors Walk, Dublin 1. Tel: 01
8724597
TALLAGH SUICIDE BEREAVEMENT SUPPORT GROUP
Tallagh Hospital, Dublin 24. Tel: 01 4142482,
kathleen.oconnor@amnch.ie
CONSOLE
Bereaved by Suicide Foundation
All Hallows College, Grave Park Rd, Drumcondra, Dublin 9
Help Line, Free Phone:1800 201 890
Tel: 01 8574300, Fax: 01 8574310
e-mail: info@console.ie
www.suicidebereaved.com, www.console.ie
DÓCHAS
The Oratory, Blanchardstown Centre, (Yellow Entrance)
Blanchardstown, Dublin 15. Tel: 01 8200915, 086 8090633,
www.dochas.info
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DÓCHAS
Ballymun Health Centre, Dublin 11. Tel: 086 8569283
DÓCHAS
Balydoyle Family Resource Service. Tel: 086 1714839
SÓLÁS:
BEREAVMENT COUNSELLING FOR CHILDREN
Barnardos, Christchurch Square, Dublin 8
Helpline: 4732110, Callsave: 1850 22 23 00
Tel: 01 453 0355, Fax: 01 453 0300, E-Mail: solas@barnardos.ie
KILDARE NORTH
TURAS LE CHILE:
Carmel, Tel: 01 6287640, 01 6287602
KILKENNY:
BEREAVEMENT SUPPORT GROUP
27, Riverview, Kilkenny., Mr. Padraig Morrow, Tel: 056 626421
KERRY:
KENMARE BEREAVEMENT SUPPORT GROUP
C/O The Presbytery, Kenmare, Co. Kerry. Tel: 064 41222, 086 814
5856
KILDARE SUICIDE BEREAVEMENT SUPPORT GROUP
Parish Centre, Church of Irish Martyrs, Ballycain, Naas, Co. Kildare.
Tel: 045 895629
LAOISE:
COMMUNITY MENTAL HEALTH CENTRE
Bridge St., Portlaoise, Co. Laoise
Co-ordinator – Ann Cass, Tel: 086 8157320
Fax: 0506 46747, E-Mail: william.bland@mhb.ie
LONGFORD:
COMMUNITY MENTAL HEALTH CENTRE
Dublin Road, Co. Longford, Co-ordinator – Ann Howard.
OFFALY:
COMMUNITY MENTAL HEALTH CENTRE
Wilmer Rd., Birr, Co. Offaly. Co-ordinator -Claire Hernon
CLOGHAN HOUSE
Arden Rd., Tullamore, Co. Offaly.
Co-ordinator – Sr. Gerard McCarthy
ROSCOMMON:
BOYLE SUICIDE BEREAVEMENT SUPPORT GROUP
Family Life Centre, Boyle, Co. Roscommon
Mr. Brian Conlon, Tel: 071 9663000, info@familylifecentre.ie
159
Suicide Bereavement Healing Programme
GALWAY.
TUAM DAY HOSPITAL
Venue: Tuam Day Hospital, Hermitage Court, Dublin Rd, Tuam, Co.
Galway.
Contact: Ms. Marie MulryanTel: 093 25052/24695
Venue: Arus de Bruin, Newtownsmith, Galway
Contact: Christine 091 565066 (office hours)
Sr. Marguerite Buckley, Tel: 087 6405239
EAST
GALWAY/ROSCOMMON
Venue: Health Centre, Ballinasloe, Co. Galway
Contact: Social Work Department, Portiuncula Hospital.
Tel: 090 96 48306
BOYLE
Venue: Family life Centre, Boyle, Co. Roscommon
Contact: Brian Conlon, Tel: 071 96 63000
CASTLEBAR
Venue: Family Centre, Castlebar, Co. Mayo
Contact: Peter 094 90 25900
FAMILY CENTRE
Vita House Family Centre, Abbey St.,
Roscommon
Sr. Mary Lee
Tel: 0903 25898
vitahouse@eircom.net
www.vitahouse.org
TYRONE:
PATHS, POSTGRADUATE CENTRE
Postgraduate Centre, Tyrone County Hospital, Omagh, Co. Tyrone.
Tel: (028)82833100
WESTMEATH
COMMUNITY MENTAL HEALTH CENTRE
Grace Road, Mullingar, Co. Westmeath. Co-ordinator – Bernadette
Burke
HEALTH CENTRE
District Hospital, Athlone, Co. Westmeath,
Co-ordinator – Bernadette Sheriff.
WEXFORD:
H.O.P.E. SUICIDE BEREAVEMENT SUPPORT GROUP
Community Health Centre, Summerhill, Co. Wexford. Tel: 053 23899
160
WATERFORD:
CAIRDEAS
Tel:1 850 201249
WICKLOW:
SUICIDE BEREAVEMENT SUPPORT
Holy Redeemer Parish Centre, Bray, Co. Wicklow.
Sr. Sheila O’Kelly, Tel: 01 2868413
Meetings held 1st Monday of every month, Royal Hotel, Main St, Bray
8.00pm -10.00pm
161
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
Dr. Justin Brophy
Consultant Psychiatrist
Dr. Anne Cleary
Sociologist
Mr. Michael Fahy
‘Solace’ Suicide Support Group
Dr. Tom Foster
Consultant Psychiatrist
Mrs. Mary Hutchinson
Student N.I.
Ms. Eileen Jones
The Samaritans
Prof. Kevin Malone
Consultant Psychiatrist
Prof. R.J. McClelland
162
Consultant Psychiatrist
Mr Barry McGale
Suicide Awareness Co-ordinator
Mr. Jack McLachlan
Samaritans N.I.
Mr. Dan Thompson CBE
Coroner for South Down
Ms. Eileen Williamson
National Suicide Research Foundation
Executive Officer – Ms. Josephine Scott
Clerical Assistant – Ms. Angela Coleman
Conference Objectives.
This conference will illustrate

That suicide is a complex multifaceted problem.

Suicide prevention needs a multidimensional response.

Suicide prevention is everybody’s business and each of us has a part to play in
translating a Suicide Prevention Strategy into action.
This conference has CME and CPD approval.
Sponsors
This conference is part sponsored by Wyeth Pharmaceuticals
163
i
Van Hoof
Annals of the four masters
iii
Ed D A Binchy, Dublin Institute of Advanced Studies 1963. Page 19 line 509
ii
iv
Journal Erin eriv. Vol. 2 1905 page 24-25 30
A Guide to Early Irish Law
Fergus Kelly
vi
Coroners Act 1962. Government Publications Office
vii
Is there a reference for this see report of the task force
viii
can we get the year for these stats
ix
check that the age group is correct
x
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v
164