Monthly Archives: January 2016

Emma Nielsen – Mind your ‘C’s and ‘S’s: The Language of Self-harm and Suicide (and why it matters)

We all say things that we don’t mean sometimes. Perhaps the time that you snapped at the end of a long day or said that deliberately hurtful comment in the heat of an argument. Sometimes these instances are easily recognisable (perhaps easily apologised for). However, often our language conveys more subtle messages as well. Even everyday expressions may carry connotations we have not considered and speak to ideas we don’t condone. The words we use when we talk about self-harm and suicide show just that; while our language can convey compassion, provide hope, empowerment and optimism, we can also unwittingly express messages that divide and stigmatise.

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I’m definitely guilty of this – while I may not like to admit it, my undergraduate notes are littered with phrases that now make me uneasy. Far from meaning to be impertinent, I was passionate about battling the silence and taboo surrounding mental health and in particular getting people talking about suicide. But, to be honest, at that point I don’t think I’d ever thought carefully about the language used when doing the talking. Then I had a conversation with a lady whose son died by suicide and realised that phrases like ‘committed suicide’ weren’t simply a case of well, it’s just what you say. For the first time I felt some of the impact of our everyday language and understood why accurate, non-stigmatised terms really matter. I’m grateful that she took the time to explain to me how challenging she found some words. That conversation prompted me to mind my ‘commits’ (‘C’s) and ‘suicides’ (‘S’s), as well as reflect further on the potential inadvertent messages conveyed by the language we choose.

The term ‘committed suicide’ has perhaps prompted the most publicised opposition. Although commit can mean a number of things, if we think about other times we use the word, it tends to be associated with negativity and wrong-doing. People commit crimes. People commit moral atrocities. People die by suicide. While opinions about suicide vary, we don’t usually associate the term commit with a public health concern, or mental health tragedy and the phrase goes no way to acknowledging the turmoil faced by someone prior to taking their life. Historically, suicide was deemed a crime. Not anymore (not since the 1961 Suicide Act in the UK). While we’ve updated our legislation appropriately, we haven’t updated our language; suicide is a cause of death and our language should reflect this. In no other situation would we say that someone committed their death, regardless of any personal or lifestyle factors which may have contributed to the outcome.

People commit crimes.

People commit moral atrocities.

People die by suicide.

The word committed in relation to suicide is not only unnecessary, inaccurate and outdated, but for many it can be insensitive language which amplifies the distress of an already difficult situation. Those affected by suicide, whether through having experienced suicidality personally or via the experiences or loss of a loved one, are vulnerable and often stigmatised [1]. Stigmatising language with its residual connotations of illegality, shamefulness and sin only exacerbates this [2, 3].

Stigma can be life-changing and life-limiting. It reduces both the propensity to help-seek and the provision of help-giving behaviour [4]. Stigma is also faced by those who have experiences around self-harm. For some, phrases like ‘self-harmers’, ‘cutters’ and ‘ideators’ (describing people who have thought about harming themselves/taking their lives, but have not acted on these ideas) are also loaded with difficulty. Language here could be seen as dismissive and pejorative. Some feel such terms take away from individual identity; typically, self-harm affords people a means of dealing with intolerable (and often deeply distressing) emotions. It may be someone’s coping response. It is not who they are. We all hold multiple identities which intersect with each other and it is imperative that our language reflects this. Being respected and valued first and foremost as an individual is important to wellbeing and this may be especially pronounced in situations where people have traditionally been labelled, perhaps diagnosed, by others. Adopting such shorthands may be unintentionally offensive, but damaging nevertheless.

Because of this, many advocate for the use of ‘people first language’ [e.g., 5]. That is to say, to make references to ‘people who self-harm’, rather than ‘self-harmers’. Such an approach can also increase the accuracy with which we use words; unlike phrases like ‘self-harmer’, person first phrasing can easily accommodate further information regarding recency (e.g., people who have self-harmed in the last 6 months) and frequency (e.g., more than 5 times) etc. Here, language matters as it helps to shape our attitudes and ideas. Phrases that can accommodate temporal dynamics encompass notions of change and recovery. These things are really important as the possibility of change is laced with hope. And hope is vital. Hope keeps people alive.

Phrases that focus on a single behaviour, such as ‘cutter’, also present challenges to accuracy. Such terms may be seen to imply that individuals only engage in one form of self-harm. This over-simplified account might lead us to miss important details and obscure the scope of behaviours. Indeed, research shows that a change in behaviour, or engaging in multiple behaviours, is common [6]. Additionally, phrases commonly employed in medical settings, such as the term ‘deliberate’ in relation to self-harm, arguably cannot reflect the ambivalence often reported and convey unhelpful and naïve messages regarding the controllability of self-harm. This perception may lead to negative emotional responses, as well discriminatory behaviours [7].

Other common phrases that also have negative connotations include referring to non-fatal outcomes as ‘failed’ attempts and any potentially dismissive comment regarding the ‘superficial’ nature of injuries. Medical severity doesn’t tell us about the magnitude of distress [8] and crucially it is paramount that we don’t inadvertently suggest that the behaviour and associated suffering isn’t as valid. Similarly, by the logic of this language practice, to have ‘failed’ is to be alive. This is not a failure, this is an opportunity. It is important that we take any attempt seriously, that we recognise the distress and provide appropriate and timely, compassionate support. Any notions of ‘failure’ don’t contribute to that.

Of course everyone is different. People may be comfortable with different words and phrases and it’s important that individuals are free to tell their story in their own words. We can’t always anticipate what language people will be most comfortable with, but we can ensure that our words are considered and sensitive. And if we are unsure, we can ask the people we are talking to if they have preferences. We need more people discussing suicide in an informed, compassionate and open way, and we need to be clear that talking about these issues is OK and unlikely to lead to someone harming themselves [9]. By creating healthy, hopeful environments where people acknowledge emotional distress and relate sensitively about all aspects of suicide we will help to support survivors of suicide loss and help to save lives. By having an awareness of the historical context of terms, and listening to people’s feedback on language commonly employed, we can make sure our words don’t build unintentional barriers that exclude those who most need to be heard.

We have an opportunity to lead by example, to consider the choices we make and to politely and helpfully challenge those around us. We can all be part of a cultural shift. Starting with such a small and simple change, that’s quite something…

Emma Nielsen (@EmmaLNielsen) is an Associate Fellow of the Institute of Mental Health and PhD student in the School of Psychology (Lpxen@nottingham.ac.uk)

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Further information and great advice for media reporting of suicide is available from the Samaritans and Mindframe

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If you need someone to talk to, Samaritans are available round-the-clock (and free to contact) on 116 123 (UK & ROI)

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[1] Cvinar, J. G. (2005). Do suicide survivors suffer social stigma: A review of the literature. Perspectives in psychiatric care, 41(1), 14-21.

[2] Maple, M., Edwards, H., Plummer, D. & Minichiello, V. (2010). Silenced Voices: Hearing the stories of parents bereaved through the suicide death of a young adult child. Health and Social Care in the Community, 18(3), 241-248

[3] Sommer-Rotenberg, D. (1998). Suicide and language. CMAJ: Canadian Medical Association Journal, 159(3), 239.

[4] Reynders, A., Kerkhof, A. J. F. M., Molenberghs, G., & Van Audenhove, C. (2014). Attitudes and stigma in relation to help-seeking intentions for psychological problems in low and high suicide rate regions. Social psychiatry and psychiatric epidemiology, 49(2), 231-239.

[5] Guidelines on language in relation to functional psychiatric diagnosis (2015). The British Psychological Society, Division of Clinical Psychology, accessed 08-01-2016

[6] Owens, D, Kelley, R., Munyombwe, T., Bergen, H., Hawton, K., Cooper, J., Ness, J., Waters, K., West, R. & Kapur N. (2015). Switching methods of self-harm at repeat episodes: Findings from a multicentre cohort study. Journal of Affective Disorders, 180, 44-51.

[7] Corrigan, P., Markowitz, F. E., Watson, A., Rowan, D., & Kubiak, M. A. (2003). An attribution model of public discrimination towards persons with mental illness. Journal of health and Social Behavior, 44(2),162-179.

[8] Haw, C., Hawton, K., Houston, K., & Townsend, E. (2003). Correlates of relative lethality and suicidal intent among deliberate self‐harm patients. Suicide and Life-Threatening Behavior, 33(4), 353-364.

[9] Zortea , T. (2016) Is it dangerous to ask or talk about suicide? IHAWKES (Institute of Health and Wellbeing Knowledge Exchange Students) blog, accessed 14-01-2016.

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Andrew Grundy – Thoughts on Patient and Public Involvement (PPI): Involvement in research has changed my life!

A few years ago, if you had said to me that I would be celebrating the publication of an academic research paper, I would have laughed. In 2007, attempting my MPhil nearly broke me, and this, amongst other life pressures, caused me to have a psychotic breakdown. I was in and out of hospital that year, and was eventually given a diagnosis of paranoid schizophrenia. That diagnosis felt like a death-sentence, and I felt hopeless about the future. My wife and kids and my faith kept me going, but my life was very different now – unpredictable psychotic episodes, plus medications that clouded my thoughts, made me feel emotionally numb and sedated.

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It was in December 2010 that a key-worker in a mental health day-centre I was attending approached me with a leaflet looking for service users and carers to be trained in research methods and design. The course was designed by researchers at the University of Manchester and the University of Nottingham. I wasn’t sure it was for me and whether it would lead to anything fruitful, but I decided to go for it. After an interview process, I was invited to attend the training – one day a month in Manchester for six months from January to June 2011. We looked at general study skills, the research process, literature searching, how to read a paper, qualitative and quantitative methods and ethics. I found it hard to concentrate at times, but I learned so much and really enjoyed the course. The course was actually cited as an example of good practice by NICE [1].

Following the training, in 2012 the research team invited me to be a co-applicant on a programme of research which would become known as ‘EQUIP: Enhancing the quality of user involved care planning in mental health services’ [2]. I then became a Research Associate in the School of Health Sciences, University of Nottingham in February 2013. I realised that the researchers wanted service users and carers to collaborate as part of the research team – that they actually placed a great deal of value on my own lived experience, and that this could be used to help shape the research programme. This for me is where my life really turned around!

As part of EQUIP, I’ve been involved in conducting focus groups and interviews with different stakeholders, assisting with the development of a new Patient Reported Outcome Measure (PROM) in user/carer involved care planning, in co-delivering a training intervention for mental health professionals, and am now involved in doing some follow-up questionnaires. It’s been so varied and I’ve developed so many different skills – it’s been wonderful. Outside of my part-time hours on EQUIP I’ve also taken on other projects, some of which are based at the Institute of Mental Health [3]. I’ve had some really great mentors: Prof Patrick Callaghan and Dr Oonagh Meade have been so very understanding and have really helped me develop and flourish. But it’s the ethos of the School of Health Sciences and the Institute here at the University that makes the difference – really valuing Patient and Public Involvement (PPI) in research.

I’m so excited that my very first academic paper, bringing meaning to user involvement in mental health care planning: a qualitative exploration of service user perspectives, has now been published [4]. It’s a topic that I have had a lot of personal experience of, and one that I’m particularly passionate about. But if it wasn’t for the PPI ethos of the University here and at Manchester, I would never have had this opportunity to do this work. I’m so thankful and can’t wait to see what happens for me next…

Andrew Grundy

Research Associate, School of Health Sciences

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* Puss in Boots Google doodle by Sophie Diao.

References

[1] https://www.nice.org.uk/sharedlearning/enhancing-the-quality-of-service-user-involved-care-planning-in-mental-health-services-equip

[2] The EQUIP project website can be found here: http://sites.nursing.manchester.ac.uk/equip/

[3] For example, http://www.institutemh.org.uk/x-research-/managed-innovation-networks/youth-mental-health-and-wellbeing-min

[4] Grundy et al., ‘Bringing meaning to user involvement in mental health care planning: a qualitative exploration of service user perspectives’ Journal of Psychiatric & Mental Health Nursing (Dec 2015) http://onlinelibrary.wiley.com/doi/10.1111/jpm.12275/abstract

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This blog-post summarizes independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (grant reference number RP-PG-1210-12007). The views expressed are those of the author and not necessarily those of the NHS, the NIHR or the Department of Health.

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