Carl O’Brien’s series, “After the Asylum”, raises important questions about how best to support individuals who have mental health difficulties, but it also highlights how much stigma still exists.
That stigma is in no small part responsible for the underfunding of mental health services even during our so-called Celtic Tiger era, and now they are in an even worse state.
During the week, consultant psychiatrist and clinical director of Cluain Mhuire Community services Dr Siobhán Barry likened our community mental health services to Jenga – the game where players pull blocks from a wooden tower. She said that so many blocks had been pulled from community mental health that it seemed likely the next one would cause the system to collapse completely.
It is likely that suicide-prevention services will be one of the casualties of cutbacks, at a time when people are experiencing significant new stresses that contribute to the complex factors that sometimes trigger suicide.
Naive notion of openness
However, seeking to remove stigma must be carefully handled. For example, we have the naive idea that by talking about suicide we have somehow reduced the stigma surrounding mental illness. If only.
It seems to me that instead of normalising help-seeking behaviour, suicide has become part of a repertoire of possible responses in a way that would have been unthinkable even 20 years ago.
Furthermore, See Change, a partnership of 74 Irish organisations working to change attitudes to mental health problems, published research that indicates Irish people are becoming more fearful, not less, about revealing a mental health difficulty.
In 2010, half of those surveyed by See Change would not want others to know about their mental health problem, but in 2012, it had risen to 56 per cent.
Similarly, the figures for those who would delay seeking treatment for fear of someone else knowing, rose from 18 per cent to 28 per cent, while those who would hide a mental health issue from friends rose from 32 per cent to 41 per cent.
Erving Goffman wrote a classic work in 1963, Stigma: Notes on Management of Spoiled Identity. It talks about stigma in terms of a "discredited person facing an unaccepting world".
Sadly, despite more enlightened times, it is still too often true today. For example, take medication. It is only a part, yet for some people a vital part, of the treatment of mental illness.
However, needing to take medication to control a condition is perfectly acceptable if you have diabetes or asthma, but often stigmatised if you “only” suffer from mental health difficulties .
Similarly, a chronic condition like a bad back is likely to receive support and interest, whereas admitting to depression often provokes embarrassment and avoidance.
While seeking help for depression and other mental illnesses remains stigmatised, or leads to worry about employment prospects, we will never be able to reduce these rates. But we also need a functioning health service available to respond. Services other than health have also been hit. For example, guidance counselling in schools has been radically undermined by cutbacks.
In May, innovative research conducted by Prof Kevin Malone and his team at UCD was published by the 3 Ts charity (Turning the Tide of Suicide).
Suicide in Ireland 2003-2008 has several strands, including research involving 104 families bereaved by suicide. The team interviewed over 250 relatives in 23 counties about more than 100 young lives lost to suicide.
One of the findings is that young men between 16 and 20 are particularly vulnerable to death by suicide.
This highlights a significant problem with the way that our services for young people are organised. For example, providing psychiatric care for young people in adult psychiatric units is clearly wrong, but while there have been marked improvements, there were still 106 admissions of young people under 18 into adult units last year.
There have been tragic cases where young people have died by suicide, citing the prospect of returning to an adult unit as a contributory factor.
Prof Malone points out that adult units are hardly suitable for 18-22 year olds either and that, in other jurisdictions such as Australia, there are both community teams and units geared towards young adults that do not use the arbitrary cut-off point of 18.
One heartbreaking finding is that while few of the young people who died by suicide had alcohol in their system, many had made disclosures of suicidal intent when under the influence. They laughed them off as “the drink talking” when asked about them later.
Danger of normalising references
Because references to suicide have become normalised, often peers did not realise the significance of these disclosures, or how to deal with them.
Multilayered interventions can help bring down suicide rates, as an initiative by the US air force shows.
Vigorous leadership from the command structure was vital, as was rewarding admission of problems and ensuring that such admissions were “career-enhancing” rather than “career-crushing”.
We need similar sustained political leadership here, including robust legislation to protect people who disclose problems to employers.
Instead, we have a pretence of supporting mental health, while at the same time massaging figures to conceal gaping gaps in services.