Monthly Archives: July 2012

Dr Amy Chandler ~ The social contexts of suicide: sociological contributions to understanding suicide

Suicide is a complex issue that touches many lives, and is the concern of a range of social and health-care professionals. It is also an important public health problem, being the “tenth leading cause of death worldwide” (Windfuhr & Kapur 2011: 28). While suicide is strongly related to poor mental health; it is widely understood that suicide often occurs in the absence of a psychiatric diagnosis. Although psychiatry and related mental health professionals have an important role to play in suicide prevention, the complexity of suicide necessitates the involvement of multi-disciplinary researchers and practitioners.

Published last year, Understanding Suicide: A Sociological Autopsy (Fincham, Langer, Scourfield & Shiner 2011) presents research from a broadly sociological (though incorporating other social scientific approaches) investigation of 100 suicide case files from a coroner’s office. The study incorporated both qualitative and quantitative analysis of the files, in an adaption of the more well established psychological autopsy approach to studying suicide. The research findings illuminate important, but often overlooked, social factors relating to suicide:

1. That the group of people most at risk of suicide are men in mid-life.

Fincham et al combine a quantitative analysis of the 100 case files they studied, with official statistics on suicide rates. Through this, they highlight that suicide rates for men peak between the ages of 35 and 45, with suicide being a relatively rare occurrence among young men. However, many suicide prevention programmes have focused on reducing suicide among young men. This reflects an increase in the suicide rate among young men; but obscures the fact that the men in mid-life complete suicide in greater numbers. Fincham et al’s analysis examines the ways that age and stage of life might be implicated in suicides. In particular, they highlight the varying strength and importance of social relationships and social bonds in youth, mid-life and old-age.

2. The importance social relationships in understanding suicide.

A commonly held understanding of suicide is that it is related to social isolation – leading from Emile Durkheim’s pioneering work on the sociology of suicide, which argued that social isolation increased the chances of suicide. However, Fincham et al argue that social relationships – or more accurately, unravelling social relationships – might be a more appropriate way of explaining suicide. Their research found that the deceased in the case files had often recently experienced a break-up in a relationship or had lost contact with their children. This approach to understanding suicide provides one way of explaining the connection between suicide and unemployment, with work being an important source of social relationships – particularly for men, particularly men in mid-life. A related finding was that suicide can be seen as a way of trying to work on social relationships. Analysis of the suicide notes included in just under half of the case files studied suggested that the notes were often used to attempt to heal, create, or sever social ties. Fincham et al suggest that “[r]ather than seeing death as the end … suicide notes can be a means to continue or even to initiate relationships through which agency can be exerted” (p. 89)

3. The role of gender in understanding suicide.

In an earlier paper, Jonathan Scourfield (2005) highlighted the importance of gender in seeking to better understand suicide. Scourfield’s approach emphasised the problematic way in which much previous research on suicide had addressed gender: that is in a rather straightforward way, looking at ‘males’ and ‘females’ as two separate, largely similar groups. In Understanding Suicide, a more nuanced gendered analysis is presented. This takes account of the importance of differences within men and women, rather than focusing on the differences between men and women. Thus, in Understanding Suicide, greater attention is paid to the complex interactions between gender, life stage, and employment, family-life, and intimate relationships.

Each of the above points serves to improve our understandings of why people die by suicide. By examining the role of life-stage, social relationships and gender on individual suicides, Fincham et al propose novel ways of explaining why certain groups of people are more vulnerable to suicide. Additionally, their approach further confirms the usefulness of qualitative approaches to researching suicide. Perhaps most importantly, Understanding Suicide demonstrates the need for wide-ranging approaches to suicide prevention, which incorporate social interventions alongside medical and psychological treatment (p. 185).

This blog draws on an earlier review, published in Network, the magazine of the British Sociological Association (Chandler, 2012).

Posted by:
Dr Amy Chandler
Research Fellow
Centre for Research on Families and Relationships University of Edinburgh

Chandler, A. (2012), ‘Understanding Suicide: A Sociological Autopsy, by Ben Fincham, Susanne Langer, Jonathan Scourfield and Michael Shiner, Book Review’, Network, 111, 37.

Fincham, B., Langer, S., Scourfield, J. and Shiner, M. (2011), Understanding Suicide: A Sociological Autopsy, London, Palgrave Macmillan.

Scourfield, J. (2005), ‘Suicidal Masculinities’, Sociological Research Online, 10, 2.

Windfuhr, K. and Kapur, N. (2011), ‘International Perspectives on the Epidemiology and Aetiology of Suicide and Self-Harm’, in O’Connor, R.C., Platt, S. and Gordon, J. (eds.), International Handbook of Suicide Prevention: Research, Policy and Practice, Chichester, Wiley-Blackwell.

 

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Dr Victoria Tischler ~ The IMH’s Sculpture

An update on the IMH’s sculpture from Victoria Tischler the Institute’s arts co-ordinator :

We’ve now commissioned Ekkehard Altenburger to create a sculpture for the building. See an image of his initial design and concept here http://www.institutemh.org.uk/-about-us-/art-at-the-institute and examples of his work here http://www.altenburger.co.uk/

Ekkehard will be sourcing marble in the North of Italy next week and he will be working there over the summer to create the piece which will weigh over 6 tonnes when completed. It will be transported directly to the IMH via road and sea in late October ready for its unveiling in November. He will hold a number of sculpting workshops with service users in the Autumn, using pieces of marble cut from the block he creates the main sculpture from.

Ekkehard visited the site recently and he and I were joined by Richard Wigginton (University Estates) and Tim Harris (project manager) to discuss logistics. Part of this meeting involved half an hour standing in the rain getting very soggy feet whilst deliberating exactly where the sculpture will be sited, X marks the spot! The Estates office will soon begin to prepare the site by pouring the concrete foundation which will be allowed time to ‘settle’ before the giant marble piece comes to stay – all the way from Italy to Nottingham.

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Dr Hanna Pickard (All Souls College, Oxford) ~ Responsibility without Blame

Do mental disorders excuse people from responsibility when they harm others? It’s easy to feel trapped between two extremes. Either people with mental disorders aren’t responsible because they lack control, in which case we need to help them, not blame them. Or they are responsible because they do have control, in which case we should blame them, not help them. I think we need to escape this trap and that philosophical reflection on real clinical practice with patients with personality disorder can help us do so.

I began life as an analytic philosopher at the University of Oxford but for the last five years I’ve worked at the Oxfordshire Complex Needs Service, a Therapeutic Community (TC) for people with personality disorder. When I first started working clinically, I was struck by the stance adopted towards TC members who hurt others. I call this stance, ‘Responsibility without Blame’. Both in theory and in practice, this stance requires separating our concepts of responsibility and blame much more sharply than as a society we typically do.

As a philosopher, my research aims to do just this. My view is that responsibility is fundamentally about a person’s own capacity for agency. To be responsible is to have control over your behaviour, in which case you can be held accountable, as well as supported to do things differently.  Blame, in contrast, is about how we respond when a person is responsible for harm. We blame someone when, in addition to asking someone to answer for their behaviour and to change, we also do things like retaliate and reject them, judge them or write them off, and feel all sorts of hostile emotions, like hate, anger, disgust, scorn, and contempt. Blame gets in the way of people’s motivation to change. Responsibility and accountability, in contrast, are central to it.

As a society, we should learn from clinical practice. Control comes in degrees, and no doubt all of us, not just people with mental disorders, sometimes don’t have enough control to be responsible for what we do. But when someone is responsible, we can’t help them if we deny their agency. For people can only work to change what they can control. We need to be real about when people have control and so are responsible and accountable for harm. But we can do this with concern and compassion, not with blame. 

I’m currently trying to take the clinical stance of Responsibility without Blame into the criminal law. One of my projects is the development of a Responsibility without Blame training for prison officers, in conjunction with the KUF programme at the Institute of Mental Health, as part of a joint Department of Health and Ministry of Justice initiative to increase awareness of personality disorder and create a more psychologically informed environment within prisons. If you want to read more about this and other aspects of my research, you can access information and articles on my webpage http://www.philosophy.ox.ac.uk/members/research_staff/hanna_pickard as well as listening to the podcast above.

To hear a Philosophy Bites [http://www.philosophybites.com/] podcast with Hanna on this topic, click here [http://llnw.libsyn.com/p/9/1/1/9117f1dac5d99c98/Hanna_Pickard_on_Responsibility_and_Personality_Disorder.mp3?s=1342277553&e=1342279353&c_id=4681789&h=4fda6a9e4646a75c85d044dfaa967ddd].

All comments very welcome!

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Dr Pritpal S. Tamber ~ Evidence and the real world

Dr Pritpal S. Tamber ~ Evidence and the real world

Re-posted from: http://www.optimisingclinicalknowledge.com/evidence-and-the-real-world/

There is a lot of angst around why research evidence takes so long to penetrate routine clinical practice. My view is that it’s a miracle that any of it makes it into practice at all because research-derived information is very much the square peg to clinical practice’s round hole.

The gold standard of experimental clinical research is the randomised, controlled trial (RCT), a study design created to make the research environment look nothing like the real world of the non-compliant, socially-complicated and co-morbid. You likely know all this otherwise you wouldn’t be reading a blog (first) posted on bmj.com but in my experience few do. My favourite example of this blissful ignorance was in a meeting with someone from the Department of Health of England who insisted that the company I was representing had to do what they asked “because it was based on a randomised trial”. That was the full extent of her rationale. I couldn’t help thinking about where my taxes were going.

The limitations of trials are brilliantly laid out in a 2009 article by Shaun Treweek and Merrick Zwarenstein entitled, Making trials matter. They discuss the tension between ensuring the trial is methodologically robust (internally valid) and of value in the real world (applicability). “An internally valid trial,” they believe, “that has poor applicability… is a lost opportunity to influence clinical practice and healthcare delivery”.

Despite all this, being able to cite published research has a significant influence on clinicians. A friend of mine performs market research for pharmaceutical companies. He’s stood on the anonymous side of a double-sided mirror and watched doctors leaf through marketing material. He says that without fail the presence of a citation to an RCT gets their attention and approval, and is the most likely thing to influence their behaviour.

There’s something crazy about a world in which we know research-derived information bears little resemblance to the real world and yet we continue to generate and cite it to influence behaviour.

There are some big hitters out there trying to get people to see the world as it is, including none other than the Chair of NICE, Michael Rawlins. In his Harveian Oration of 2008 he said: “Randomised controlled trials, long regarded as the ‘gold standard’ of evidence, have been put on an undeserved pedestal… Observational studies are also useful and, with care in the interpretation of the results, can provide an important source of evidence”. I understand he reiterated that point in a lecture to the Office of Health Economics.

The pharmaceutical industry has tried to show leadership in this arena by generating information more closely associated with real-life practice. They call it real world data. Although they still have to generate the usual kind of evidence to illustrate efficacy and safety they’ve recognised that real world data “increasingly plays an important role in ensuring that medicines are accepted by national policy makers and are adopted into practice”.

We often need small children (or Hans Christian Anderson) to point out what’s crazy in this world but luckily for the egos in healthcare we have Richard Bohmer. In his succinct Perspective in the New England Journal of Medicine he describes the four habits of high-value healthcare organisations. The third and fourth are measurement and self-study. In essence, they collect and analyse real world data – round pegs for round holes.

I was lucky enough to hear Bohmer give a presentation and when asked what one thing all organisations need to start doing tomorrow to improve care he said they should start collecting local performance data that local clinicians could identify with and believe in. His view was that research evidence, although important, emerges too slowly and is too abstract to keep up with the demands of real-life practice. Rather than evidence-based medicine, he said, we need to embrace evidence-capturing medicine.

I’m with Treweek, Zwarenstein, Rawlins and Bohmer; how about you?

Competing interests: I helped launch the journal in which Shaun Treweek and Merrick Zwarenstein’s article was published, although I had nothing to do with its peer review, acceptance and publication.

This blog has been co-posted on bmj.com/blogs.

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Dr Pritpal S. Tamber ~ Doctors only trust doctors

Dr Pritpal S. Tamber ~ Doctors only trust doctors

Re-posted from: http://www.optimisingclinicalknowledge.com/doctors-only-trust-doctors/#more-175

I’m petrified.

I’ve been invited to participate in the Institute of Medicine‘s Roundtable on value- and science-driven health care. The focus of the all-day meeting is “continuous learning and the digital infrastructure for informed clinical decisions“, and the bit that I’m expected to speak about are the “functional needs for digital information at the point of care”.

What’s scaring me is that I want to tell them that “functional” needs are not what health leaders should be focussing on. I want to tell them that what really matters is getting doctors to trust information, and, although how the information functions is part of it, it’s only a small part of it.

In my experience, doctors only trust doctors when it comes to clinical matters. That’s the first and most important rule. It’s so important, in fact, that I am going to ask you to read it again: doctors only trust doctors.

I’ve met many non-doctors that hate that rule. They hate it so much they pretend it’s not there. I’ve watched health managers, IT experts and policy-makers all fool themselves into thinking they can influence what doctors do. They rarely – if ever – can.

Anyway, based on that rule, there are a bunch of sub-rules.

When I was a medical house officer it was clear that the gastroenterology registrar trusted other physicians before he trusted surgeons. This made all the sense in the world when you consider how many patients with “negative laparotomies” he was asked to see. When I was a surgical house officer, the nephrologists trusted the vascular surgeons because they worked closely to create anastomoses in patients in need of dialysis. They probably also trusted the transplant surgeons for much the same reason.

So the first sub-rule is that different specialists have different levels of trust for other specialists.

There are now about 180 guidance producers in the world. In my experience, Americans like to think that non-Americans want to practice like them but they’re wrong – although not always. For instance, in England I’ve come across respiratory physicians who will only follow guidance produced by the British Thoracic Society, as opposed to guidance from the American Thoracic Society; meanwhile cardiologists have tended to be more welcoming of guidance produced by the American Heart Association.

So the second sub-rule is that you have to understand what sources of information different specialists trust.

I’ve been involved in trying to convert content created for English clinical practice to Danish clinical practice. The English content was based on the regional biases of English doctors. I spent three days in Copenhagen meeting with a variety of doctors to understand their preferences and was quite surprised by how different they were to those of doctors in England. For instance, some American guidance producers were barely recognised by the Danes, while they put great stock in European guidance producers that were never mentioned by doctors in England.

So the third sub-rule is that clinicians in different countries display different levels of trust for the same sources of information.

One thing I did not test when I was in Copenhagen is whether the same specialty biases exist in Denmark as they do in England. I hypothesise that they do, but my experience has told me time again not to presume. For instance, a friend of mine is a “physical medicine” doctor in Belgrade. From what I understand she is a cross between a senior physiotherapist and a sports medicine physician but, unless the specialty has been introduced in the last few years, I don’t believe we have such specialists in England. The existence of this “new” specialty likely influences the complex dynamic of trust between specialties.

Doctors – like all people – are also more trusting of people facing the same issues as them. For instance, general practitioners in tough, urban environments more keenly seek out the views of other general practitioners working in the same kind of environment. There is an instinctive logic to this.

So the fourth sub-rule is that doctors trust other doctors dealing with similar issues.

All of these sub-rules matter because knowledge nerds like me have learnt that creating standard forms of information rarely influences doctors’ behaviour. You have to tailor the information to the biases of the specialist. The point is made rather spectacularly by England’s National Institute of Health and Clinical Excellence (NICE); despite creating globally-revered, high-quality guidance, very little of it penetrates clinical practice. The problem is so glaring that the recent government strategy for health innovation seemed more about getting NICE guidance actually used than catalysing and distributing great new ideas.

Information needs to be endorsed by doctors – or clinical bodies – that doctors trust. Achieving this requires understanding the complex interplay of the sub-rules above. It’s only if you get this right does it matter how the information “functions” at the point of care. Indeed, if you get the trust right, the function needn’t be perfect; but well-functioning content that’s not trusted is a waste of everyone’s time and energy.

I’m going to tell the IOM all this. What are the odds they’ll ever invite me back?

This blog was first posted on bmj.com.

This blog has been co-posted on bmj.com/blogs.

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Peter Bates ~ Dirt, Disgust, and Denial

Bates, P. (2012)”Wash and brush up?”, Mental Health and Social Inclusion, Vol. 16, Iss. 2, pp. 97-102. http://dx.doi.org/10.1108/20428301211232522

Peter Bates ~ Dirt, Disgust, and Denial

In opening a conversation about how to work with people who are dirty and unwashed, it is unsettling to raise the subject of the human disgust response. All our liberal inclinations are alerted to a possible violation of the principle of non-judgemental respect and we are ready to defend smelly people we have known from insult and misunderstanding. Perhaps, in raising the topic, I will become disgusting.

At some point, I guess we have all been troubled by the sights, sounds and smells we encounter on rare occasions in working with people who are losing the battle for daily survival. Whether it is unpleasant body odour, verminous hair or seeping wounds, a glimpse into someone’s mouthful of half-chewed food, a spillage of bodily waste or an admission of repugnant behaviour towards others – we all have found a trigger that fires up the human disgust response. It shapes our interactions and so we should understand it and ourselves if we are to work successfully with others. Denial is no solution.

Research as shown that three threats  – pathogen, sexual  and moral – universally trigger a characteristic facial expression as well as withdrawal, shuddering,  immune strength and nausea. These responses protect us from disease, reproductive risk and collapse into anarchy and the death of the tribe that would inevitably follow.  By the same logic, strangers evoke disgust, as they may bring unfamiliar diseases, while women respond more strongly than men, as they have to be disgusted enough for both themselves and their children.

The disgust response starts early – giving a 14 month old child a new toy, along with a 15 second ‘disgust message’ leads to the toy being avoided for an hour or more. It also generalises beyond the stimulus itself. Disabled individuals activate similar responses to those with contagious diseases, even when the observer is explicitly aware that they are neither sick nor contagious. The presence of a disgusting smell in the interview room results in people making more severe moral judgements, reduces the amount of money that they will pay for certain things, and strengthens their resolve to use a condom in future sexual activities.

So how do mental health workers deal with all their reactions when faced with a smelly, dirty or disgusting person? Disgust is plastic, as shown by the upscaling of negative responses to obesity in recent years and also by the positive learning shown by children who discover that vegetables, olives and wine are delightful. Of course, it may be that all mental health workers have already eliminated this unbecoming disgust response from their repertoire – but I fear not. Meanwhile, the primitive blend of fear and fascination that forms human disgust is itself deeply moral, as, like the birds, we set aside our own need for survival in order to give a warning cry and save the flock. Thus there is a way to take care of our own needs whilst prioritising those of others and reaching for the goal of respecting, understanding and supporting the person who troubles us.

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