Christabel Owens

Tales of biographical disintegration: how parents make sense of their sons' suicides

Suicide research relies heavily on accounts provided by bereaved relatives, using a method known as the psychological autopsy. Psychological autopsy studies are invariably quantitative in design and their findings reinforce the medical model of suicide, emphasising the role of mental illness. They largely ignore the meanings that narrators attach to events, the nature of the sense-making task and the influences bearing upon it. This study drew on psychological autopsy data but used qualitative analytic methods. Fourteen semi-structured interviews with the parents of young men aged 18-30 who had taken their own lives form the basis for this paper. Some parents represent their sons as victims who were cruelly destroyed by external forces, while others portray them as agents of their own destruction. Either way, their narratives are dominated by moral rather than medical categories and by questions of personal accountability. We show how the parents use the interview to perform a complex reconstructive task, striving to piece together both their sons and their own shattered biographies and repair damage to their moral identities. We argue that their stories represent survival tools, enabling them not only to make sense of the past but also to face their own future.

Suicide outside the care of mental health services: a case-controlled psychological autopsy study

BACKGROUND Three-quarters of people who commit suicide are not in contact with mental health services at the time of death. No previous UK study has focused specifically on this group of suicides. AIMS To identify the characteristics of people who commit suicide while outside the care of mental health services. METHOD A case-control study was conducted in SW England involving 100 individuals who committed suicide while not in contact with mental health services and 100 age-sex matched controls drawn from the living population. Data were collected by means of semistructured interviews with key informants and from medical records. RESULTS Key predictors of suicide were previous attempted suicide, social and interpersonal problems, current mental illness, past mental illness, and previous contact with specialist services. However, nearly a third of cases (32%) appeared to have no current mental disorder. CONCLUSION This group is distinguished by a markedly lower rate of mental illness than has previously been recorded. The findings highlight the difficulty of identifying individuals outside specialist mental health care who are at risk of suicide and therefore support the continued development of broad population-based measures rather than the targeting of high-risk groups.

Problem presentation and responses on an online forum for young people who self-harm

In this article we investigate the nature of problem presentation and responses on an online forum for young people who self-harm. Previous studies have raised concerns about the peer encouragement of self-harming behaviours in online forums, and this analysis considers the nature of peer interaction on a specific forum, ‘ SharpTalk’. This was a research forum which explored the potential of online communities to foster engagement and shared learning between NHS professionals and young people who self-harm. This analysis draws on conversation analysis methods to study problem presentation and responses, and nature of advice given. Analysis highlighted both the tendency to offer advice where it was not asked for, and the mundane ‘safe’ nature of advice. This awareness of how young people interact and provide support online is important for those setting up online interventions to support young people who self-harm.

Interventions to reduce suicides at suicide hotspots: a systematic review

Background‘Suicide hotspots’ include tall structures (for example, bridges and cliffs), railway tracks, and isolated locations (for example, rural car parks) which offer direct means for suicide or seclusion that prevents intervention.MethodsWe searched Medline for studies that could inform the following question: ‘What interventions are available to reduce suicides at hotspots, and are they effective?’ResultsThere are four main approaches: (a) restricting access to means (through installation of physical barriers); (b) encouraging help-seeking (by placement of signs and telephones); (c) increasing the likelihood of intervention by a third party (through surveillance and staff training); and (d) encouraging responsible media reporting of suicide (through guidelines for journalists). There is relatively strong evidence that reducing access to means can avert suicides at hotspots without substitution effects. The evidence is weaker for the other approaches, although they show promise.ConclusionsMore well-designed intervention studies are needed to strengthen this evidence base.

Involving service users in intervention design: a participatory approach to developing a text-messaging intervention to reduce repetition of self-harm.

Objective  To engage a group of people with relevant lived experience in the development of a text‐messaging intervention to reduce repetition of self‐harm.

Do different stakeholder groups share mental health research priorities? A four-arm Delphi study.

Background  Despite considerable investment in research priority setting within diverse fields of healthcare, little is known about the extent to which different stakeholder groups share research priorities. Conflicting priorities may jeopardize stakeholder engagement in research.

Ethical practice in internet research involving vulnerable people: lessons from a self-harm discussion forum study (SharpTalk)

The internet is widely used for health information and support, often by vulnerable people. Internet-based research raises both familiar and new ethical problems for researchers and ethics committees. While guidelines for internet-based research are available, it is unclear to what extent ethics committees use these. Experience of gaining research ethics approval for a UK study (SharpTalk), involving internet-based discussion groups with young people who self-harm and health professionals is described. During ethical review, unsurprisingly, concerns were raised about the vulnerability of potential participants. These were dominated by the issue of anonymity, which also affected participant safety and consent. These ethical problems are discussed, and our solutions, which included: participant usernames specific to the study, a closed website, private messaging facilities, a direct contact email to researchers, information about forum rules displayed on the website, a ‘report’ button for participants, links to online support, and a discussion room for forum moderators. This experience with SharpTalk suggests that an approach to ethics, which recognises the relational aspects of research with vulnerable people, is particularly useful for internet-based health research. The solutions presented here can act as guidance for researchers developing proposals and for ethics committees reviewing them.

Recognising and responding to suicidal crisis within family and social networks: qualitative study

Objective To shed light on the difficulties faced by relatives, friends, and colleagues in interpreting signs of suicidality and deciding whether and how to intervene. Design Qualitative study of completed suicides, based on in-depth interviews with multiple informants. Setting London, southwest England, and south Wales. Participants 31 lay informants (one to five for each case), including parents, partners, siblings, friends, and colleagues of 14 cases of suicide in which the deceased was aged 18-34 and was not in contact with secondary mental health services. Results Informants described both intellectual and emotional barriers to awareness and intervention within the family and social network. They reported that signs and communications of distress were often oblique and difficult to interpret, that they may have disregarded warning signals and focused instead on positive signs, and that, even when they were aware that something was seriously wrong, taking any action at all involved considerable personal risks. Conclusions As the suicidal process unfolds, significant others are faced with a highly complex task. Their proximity to the suicidal person and their emotional investment in the relationship make it difficult for them to see what is happening, to say anything to the person or to other members of the network, or to seek help outside the network. Efforts to strengthen the capacity of lay people to play a role in preventing suicide are urgently needed and should be informed by a thorough understanding of these difficulties. They should highlight the ambiguous nature of warning signs and should focus on helping people to acknowledge and overcome their fears about intervening.

Using Metrics to Describe the Participative Stances of Members Within Discussion Forums

Background Researchers using forums and online focus groups need to ensure they are safe and need tools to make best use of the data. We explored the use of metrics that would allow better forum management and more effective analysis of participant contributions. Objective To report retrospectively calculated metrics from self-harm discussion forums and to assess whether metrics add to other methods such as discourse analysis. We asked (1) which metrics are most useful to compare and manage forums, and (2) how metrics can be used to identify the participative stances of members to help manage discussion forums. Methods We studied the use of metrics in discussion forums on self-harm. SharpTalk comprised five discussion forums, all using the same software but with different forum compositions. SharpTalk forums were similar to most moderated forums but combined support and general social chat with online focus groups discussing issues on self-harm. Routinely recorded time-stamp data were used to derive metrics of episodes, time online, pages read, and postings. We compared metrics from the forums with views from discussion threads and from moderators. We identified patterns of participants’ online behavior by plotting scattergrams and identifying outliers and clusters within different metrics. Results In comparing forums, important metrics seem to be number of participants, number of active participants, total time of all participants logged on in each 24 hours, and total number of postings by all participants in 24 hours. In examining participative stances, the important metrics were individuals’ time logged per 24 hours, number of episodes, mean length of episodes, number of postings per 24 hours, and location within the forum of those postings. Metric scattergrams identified several participative stances: (1) the “caretaker,” who was “always around,” logged on for a much greater time than most other participants, posting but mainly in response to others and rarely initiating threads, (2) the “butterfly,” who “flitted in and out,” had a large number of short episodes, (3) two “discussants,” who initiated many more discussion threads than anybody else and posted proportionately less in the support room, (4) “here for you,” who posted frequently in the support room in response to other participants’ threads, and (5) seven “people in distress,” who posted many comments in the support room in comparison with their total postings and tended to post on their own threads. Conclusions Real-time metrics may be useful: (1) by offering additional ways of comparing different discussion forums helping with their management, and (2) by identifying participative stances of individuals so allowing better moderation and support of forums, and more effective use of the data collected. For this to happen, researchers need to publish metrics for their discussion forums and software developers need to offer more real-time metrics facilities.

Suicide communication events: Lay interpretation of the communication of suicidal ideation and intent

Previous research has shown that a majority of people communicate their suicidal ideas and intent prior to the act of suicide, but very little is known about the way in which these suicide communication events are interpreted by relatives, friends and significant others. A suicide communication event (SCE) is defined as a set of circumstances in which a person expresses suicidal feelings, thoughts, intentions or plans, either directly or indirectly, in interaction with other people in their social environment. In a qualitative study conducted in 2008-9 we collected narratives from people bereaved by suicide. Here we examine these narratives using an analytic framework derived from communication pragmatics and face-work theory. We analysed 14 cases of completed suicide drawn from coroners case files in London, Southwest England and South Wales. We found that the SCEs described were potentially face-threatening situations requiring face-saving strategies, which often resulted in off-record, indirect, ambiguous, humorous and euphemistic communications. Listeners frequently found it difficult to judge the meaning and intention of utterances referring to suicide. The outcome was often misunderstanding and closure of the communication, limiting the possibility of further support and referral for professional help. SCEs are important elements of the suicide process and we conclude that better understanding of how they occur and the challenges they pose for significant others may provide a basis for strengthening public involvement in suicide prevention. We draw our findings together in a model that could inform public awareness campaigns designed to improve the way people communicate with each other about suicide and distress.