Research from the University of Washington Medical School suggests how to improve treatments for college students struggling with non-suicidal self-injury (NSSI). Treatments which develop people’s practical skill in managing emotions may be more effective than the current therapies that increase people’s confidence in their ability to cope with events.
The study involved 187 students with a history of self-injury. The students provided information about their experiences with NSSI, including the age at which they first self-injured and the reasons behind their self-injury.
(This is the third post in this series; my first post discusses the most popular current theory of suicide as well as some statistics on it, while my second post talks about what suicide prevention means in practice.)
In the previous posts about World Suicide Prevention Day, I looked at what research currently says about suicide, and at what ways organisations and societies try to prevent suicide. In this post, I’m going to look more closely at what these methods assume about suicide prevention, and if those assumptions make sense.
1) There is a good reason to exclude workplaces and jobs from this conversation.
When first searching generally online, links to suicide “post-vention” appear more readily than for prevention. However, there are some useful resources online, mostly created by Australian mental health organisations.
(This is the second post in this series; my first post discusses the most popular current theory of suicide as well as some statistics on it.)
In the lead-up to this years WSPD I’ve seen many videos aimed at individuals who currently feel suicidal, encouraging them not to act on that feeling. But that can’t be the full story for such a large goal as preventing suicide. So, my question for today is- what does “suicide prevention” actually mean? What areas does it cover, and how does it work?
According to Wikipedia, suicide prevention is “the collective efforts of citizen organisations, health professionals and related professionals to reduce the incidence of suicide”. This is centred on direct intervention accompanied by four supporting parts: treating depression, improving people’s coping strategies, reducing risk factors for suicide, and giving people hope.
(This is the first post in this series; later posts will discuss suicide prevention strategies and the evidence supporting them.)
September 10th is World Suicide Prevention Day, a day of awareness held by the International Association of Suicide Prevention (IASP) alongside the World Federation for Mental Health and the World Health Organisation.
After reading about the day and the organisations involved, I was curious about how suicide is understood from a research perspective, and what explanations or theories about suicide are used to talk about suicide prevention. This post covers a widely-used theoretical approach – the Interpersonal-Psychological theory of suicide. The interpersonal-psychological theory (IPT for short) was first created by Joiner (2005), and is the theory used to guide the IASP.
Theresa May’s mental health reform speech on Monday was the first time I’ve heard her say more than a soundbite, and also the first time I’ve heard her talk about anything other than Brexit, so I wasn’t sure what to expect.
At the opening of her speech, I wanted to support her. I wanted to believe she would say something genuinely meaningful and compassionate. I also hoped (perhaps naively) that she would make reference to the effect of austerity upon mental health. May is in a good place to acknowledge the negative impact of previous political choices, after all. While she is maintaining many of those choices, she didn’t instigate them. She has mostly inherited the bad decisions made by others, most obviously David Cameron, becoming essentially the country’s largest-scale supply teacher.
Initially, her opening discussion of the overt and covert injustices present today were impactful, leaving her actual reform strategies as arguably the weakest element of her speech. Similarly, while her view on reducing stigma (below) says all the “right” things, it does so without providing anything tangible or practical, or any awareness of where the Government themselves have been guilty of removing that attention and treatment.
If you have a smartphone, then right now you could be taking part in the world’s largest mental health study. Sounds interesting? Then head over to http://howistheworldfeeling.spurprojects.org/ to join in.
If you need a bit more convincing, then read on.
The survey is called How Is The World Feeling?, and it’s aiming to get a snapshot of how everyday people around the world are feeling during this week (October 10th- October 16th). The target is to have 7 million people taking part, and 70 million emotions logged.
Everyone has a level of physical health which changes over time and as a result of circumstances.
A minority of people are at their peak of physical health, the healthiest they could possibly be.
The majority of people are generally healthy: they don’t have to worry about their physical health as everything is working well enough to live their life.
Minor physical health issues such as colds or aches and pains, are common. They temporarily make life doable but more difficult. People with longer-term minor issues learn to adapt and accommodate around what is tougher for them- perhaps they can usually function at 95% of the generally healthy level .
Major physical health issues can make normal life very difficult, requiring someone to change how they live for a bit and often need a recovery time/ gradual return afterwards.
Then a small percentage of people have chronic, severe physical health issues that mean they either cannot function in a typical life at all, or they need to adapt almost everything about their life to live and function.
Why did I just write that? Everything I’ve just said is common sense. It doesn’t need saying.
But try it again, swapping physical for mental…
In 1994, Dr Phillip Long founded www.mentalhealth.com aiming to create a cross-cultural encyclopaedia of mental health conditions. The site is looking a little archaic now, using older DSM categories not commonly used now, and containing diagnostic ideas that didn’t really catch on, such as analysing all mental health symptoms through Greek personality dimensions.
While the site may not be entirely relevant these days, it’s a fascinating and detailed read. Moreover, it’s attached forum has been consistently running since 2005. In internet terms, this is an incredibly long time. Imagining friendships possibly extending for 10 years, its easy to see the best part of forums; their ability to connect people with others across time and space, providing friendships built on common experience and support.
Of all the major social networks, Tumblr is the one I wanted to write about the most, because its a dramatic difference from the stoicism of Twitter and the envy-inducing highlight reel of Facebook. Just like most of its users, its young, bold, and easily misunderstood.
For the uninitiated, Tumblr is a microblogging site with a very “anything goes” attitude towards content: drawings, videos, music, gifs, longform text, links and pretty much anything else you can think of are all found there. Its major feature is reblogging, which is reposting someone else’s content onto your own feed and adding commentary, opinions, or a visual response- a cross between a Twitter retweet and a standard blog’s comment chain. Content is organised and collected using hashtags, which are essential for posts being discovered and read.
Part of Tumblr’s appeal is how it conveys the impression of a private, almost clandestine association. Continue reading
Compared to Facebook, I didn’t think of Twitter as a useful place for discussing mental health issues. This was partly due to the 140 character limit; I couldn’t see the use of tweets for in-depth discussion compared to something like a blog post or video.
However, when I looked through my twitter feed more closely, there was a lot of talk about mental health. Most of the people talking were advocates; either they wanted to start conversations, to support mental health organisations, or start their own campaigns. And most of these advocates were survivors, using their experiences with mental health to show others why researching mental health matters.
Twitter doesn’t have the same kind of scare-headline news stories as Facebook, and there isn’t any research saying it affects people negatively. However, there is some research on responses to individual hashtags. Shepherd et al studied the #DearMentalHealthProfessionals thread, a conversation set up by Amanda O’Connell in August 2013, and found there were four main types of discussion:
Everyone, their mum, and their cat has Facebook, or so it can often seem. As one of the most subscribed-to places online, and perhaps some people’s only online connection, looking at what Facebook has to do with mental health could be important on a large scale.
Simply searching for “Facebook” flags up a New Yorker headline- “How Facebook Makes Us Unhappy”. Narrowing it down to “facebook and mental health” adds BrainBlogger’s “Facebook is no friend to mental health”, and “7 Ways Facebook is Bad For Your Mental Health, from Psychology Today.
The BrainBlogger and Psychology Today articles were almost uniformly negative, showing research that connects Facebook use to envious friendships, jealous relationships and decreased life satisfaction.
The New Yorker article included its fair share of research on the unhappy consequences of Facebook usage, but also included some optimistic findings. Their best answer was: it depends what people are actually doing on Facebook. People actively using Facebook to keep in contact and engage with loved ones benefit from the social connection. People passively browsing their timelines, however, are often left feeling worse after using Facebook.
Facebook as a mental health resource
If actively participating on Facebook is generally beneficial, does that make Facebook a good resource for people with mental health issues?
On February 25th, Facebook’s safety division announced an extension of their suicide prevention initiative. They describe the initiative as being based on work with suicide prevention organisations, clinical research, and lived experiences from mental health survivors.
From what I’ve seen so far, parts of this initiative seem beneficial, and useful for helping people through a bad night or self-destructive impulse. However, there are still some concerning areas, and there has already been at least one example of just how this initiative can be dealt with wrongly.
Firstly I’ll go through its helpful aspects. The idea of pointing out that the post suggests someone is upset or distressed could be effective. Receiving this message might be the shock that lets someone realise they are having difficulties beyond typical ups and downs, and so might encourage them to see what the offered help is.
From the other side, allowing people to send an anonymous “someone thinks you might be in trouble” message reduces one of the barriers people often have in talking about mental health issues. It starts the conversation in a low-risk way, without requiring the face-to-face questions that many people just don’t know how to carry out.
Facebook’s post showed some pictures of the support options. The support page offers the following message:
When talking about treating mental health issues, it’s important to look at what medical staff, researchers, and people with mental health issues consider to be successful treatment. As its a lot harder to measure and accurately define mental health symptoms than physical ones, it is harder to accurately judge treating them. To show what kind of terms are used when treating mental health conditions, I’m using some hypothetical case studies. Imagine that each of these patients has just been diagnosed as being in their first Major Depressive Episode, and this is their first mental health issue. Each patient starts with a score of 18 on the PHQ-9, representing moderately severe depression using that system, is treated with an antidepressant, and is followed up six months later.
After a six-week course of medication, Patient A retakes the PHQ-9 and scores 14. Six months later, their score is 15. Because their score has stayed lower, Patient A has had a treatment response. Their diagnosis would not change. In a purely medical sense, this is progress. An academic study testing the effectiveness of patient A’s antidepressant would be happy with a 3-point response, and would consider this a successful response. However, the patient themselves won’t see it that way.
There is currently more published information about mental health than ever before, and it has never been so easy to connect with experts, health workers and charities supporting mental health issues. Yet misinformation, stereotypes and stigma still exist, and often people still don’t know where to turn. The problem isn’t a lack of information, but in communicating what information we currently have, and what we need to have. One of the most basic pieces of information would be a clear description of exactly what people mean when they talk about mental health and mental health issues. Definitions are often expressed differently depending on who the target audience is; articles written for a general audience will often focus on a single problem or dysfunction, while medical articles get more of the complexity across. Here are some examples of different online resources, and their definitions.
Mind: “problems that affect they way you think, feel, or behave”.
Wikipedia: a mental or behavioural pattern or anomaly that causes either suffering or an impaired ability to function in ordinary life (disability), and which is not a developmental or social norm.
BBC Science: symptoms that go beyond typical responses, and are severe enough to interfere with a person’s ability to function.
Now for the big one, the DSM- IV. As you might expect, this is a comprehensive and rigid explanation:
- A clinically significant behavioural or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.
- [This] must not be merely an expectable and culturally sanctioned response to a particular event.
- A manifestation of a behavioural, psychological, or biological dysfunction in the individual.
- Neither deviant behaviour (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above.”
Breaking this down, the DSM requires a mental health condition to be a pattern of symptoms that cause suffering to the person, go beyond culturally normal experiences, and are caused by a biological or psychological difference in that person. The ICD- 10 definition is a common research basis, striking a good balance between comprehension and simplicity. They define a mental illness as “a clinically recognizable set of symptoms or behaviours associated in most cases with distress and with interference with personal functions.”
From Illness to Wellness
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the official instruction book for diagnosing and treating mental health conditions in the US. It is used by psychiatrists, medical staff and academic researchers.
The DSM works based on the principle that psychological symptoms can be objectively classified and observed in the same way as physical symptoms, so psychiatric illness can be diagnosed and studied as medical illnesses. Emil Kraepelin, one of the first psychiatrists, pioneered this idea, which is why systems like the DSM are sometimes described as neo-Kraepelinian methods.
In Kraepelin’s time (1883), people were diagnosed haphazardly, based on their most obvious symptoms. Most doctors also believed in Unitary Psychosis, the idea that all symptoms of mental illness were variants of one overall illness. Kraepelin instead looked for syndromes – patterns and trajectories of symptoms. He wrote an encyclopaedia of psychiatry which contained case histories and trajectories of specific syndromes and also promoted his diagnostic system.