Cover Up: Understanding Self-Harm is a guide for parents, teachers, therapists or anyone who lives with, supports or provides therapy for people who self-harm. This book blows away the stigma and myths that are attached to this distressing behaviour. It explains fully and comprehensively what self-harm is really about and includes a step-by-step section on how people who self-harm should and can be supported and helped.
Joan Freeman received a People of the Year Award for her commitment and dedication to the prevention of suicide and self-harm. Having seen a gap in services, Joan was inspired to close her own counselling business and put her home on the line to create the first Pieta House in Lucan in 2006. The only service of its kind in Ireland, it provides counselling, support and advice for those who are actively suicidal, who may be contemplating suicide, or who self-harm.
A psychologist by profession, and author of Cover Up: Understanding Self-Harm, Joan wanted a service that embraces the broken lives of people in our community and that would be strong enough to help the most vulnerable. From humble beginnings, today Pieta House boasts five centres in Dublin and Limerick with over 60 staff, and is a real source of hope for those who pass through its doors. The Award was presented by An Taoiseach, Enda Kenny TD.
- CHAPTER ONE: UNDERSTANDING SELF-HARM BY UNDERSTANDING SUICIDE
This chapter will deal specifically with suicide. It will discuss why there is such a stigma attached to it, and will identify and dispel the many falsehoods that surround suicide by looking at the facts.
It will then go on to deal with the reasons why someone would choose to die by suicide, focusing on the issues and problems that concern specific ages, from the child right through to the older person.
The overall purpose of this chapter is to inform and educate about the warning signs of suicide and what to do if you discover that someone you know or love is suicidal.
Although I have kept suicide specifically to this one chapter, the subject will be referred to throughout the book, regarding in particular how it might be, in certain situations, linked to self-harm.
SUICIDE THROUGHOUT HISTORY
Suicide has been around for a very long time. It was written about in the Bible, when Judas Iscariot hanged him?¡self after he betrayed Jesus, his friend and master, to the Roman soldiers. Samson pulled down the pillars of the temple with the words, Let me die with the Philistines, thus killing himself and many others. In early Christianity, suicide was strongly appealing. This was probably because the act was often seen to be one of martyrdom. The most notable group who were enthusiastic in their promotion and encouragement of suicide was the Donatists, who believed that by killing themselves they would have a direct path to heaven. This was not only tolerated by the Church, but was actively condoned.
In the sixth century, the Church changed tack and decided to promote teachings of the immorality of suicide. Those who had taken their own lives were denied a Christian burial. If someone even attempted suicide they were regarded as having committed an ecclesiastical crime; this person would then be excom?¡municated.
It was not just the Church who tried to prevent further deaths by suicide. In later centuries, civil and criminal laws were imposed to discourage suicide. This resulted in the person not only being denied a proper burial, but also the confiscation of the possessions of the deceased and their family.
Today, suicide is viewed differently, though there is still much shame and taboo attached to the act. In 1993, suicide was decriminalised by the State, while the Church also changed its attitude, with burial being permitted in sacred grounds and the acknowledgement that the person who died by suicide did so with a mind that was distraught and unable to make rational decisions.
THE MYTHS OF SUICIDE
There are many untruths surrounding suicide. Many people believe that if a person talks about suicide they wont take their lives, or that most suicides occur with no warning. The complete opposite is true.
People who talk about suicide are obviously feeling suicidal. They may make clear statements such as, I dont want to live anymore, I see no future, I want to die, or, I dont see the point of my life anymore. Or they may ask questions like, Would you miss me/be alright/be better off without me?
Certain behaviours can also provide signs. For example, a person might begin to give away their possessions, or they might make a will. One of the most obvious signs , but one that is sadly often missed , is when a person purchases a rope or other paraphernalia that could aid in bringing about their death.
Many people at some stage in their life think about suicide. At Pieta House, we have discovered that it is not necessarily those who are seriously depressed or who suffer psychiatric disorders that end up attempting suicide or having suicidal ideation: it can be anyone , it could be you or me. We have discovered that suicide can follow a serious life event that leaves the person reeling. Take, for example, the couple who have been together for a few years and have two children. Suddenly, they end their relationship. The woman remains in the family home with the children. The man leaves and, within a few weeks, is either contemplating suicide or attempting suicide. Why is this? I believe the reasons are loss and isolation. This man has not only lost a romantic relationship but also his home, more than likely a shared circle of friends and, in many cases, spontaneous access to his children. In other words, overnight this person has lost everything, and this loss is so huge that he cannot see his way through the pain or come up with a solution that will ease his problem. The only alternative this person sees is to take his life.
Take, for example, a woman in her fifties (suicide in women in their fifties is the highest rate amongst women in Ireland (National Suicide Research Foundation, 2009)). Look at what could be happening in her life. Chances are that her children are now grown up and have left home, so her identity as a mother has suddenly gone. Maybe her relationship has suffered because she has devoted her life to her children. Many women of this age feel invisible. On top of all that, they are more than likely going through the menopause, which signifies an end to their fertility and their femininity as they know it. So many pieces of identity have been chipped away.
Media in the past have highlighted the rate of suicides amongst young males between the ages of seventeen and twenty-four, which may lead people to believe that we should only concentrate on young men. Studies do tell us that the number of young men who take their lives in Ireland is higher than in any other country in the European Union. In Ireland, our research shows that the second highest risk group, after young men, is men aged between forty and forty-four, followed closely by men aged forty-five to fifty-four. However, it is important to remember that these studies only tell part of the story. Suicide affects every age and gender. If we stay focused on one group, we will miss the opportunity to recognise problems in another. We are all vulnerable at different stages in our lives , all age groups and both genders are at risk. The youngest person we encountered in Pieta House was seven; the oldest was seventy-five. Suicide knows no boundaries; it does not discriminate based on age, gender or class.
Another myth about suicide is that the lethality of the attempt indicates the seriousness of the intent. This myth peddles the notion that if, for example, someone uses a gun or rope, they are more serious about suicide than those who overdose. This is simply not true: people will use methods that they are more comfortable with or have to hand. The person who takes an overdose may have the same intention to die as the person who uses a rope; the only difference is that a rope is, more often than not, lethal, while with an overdose there is a chance of survival.
Finally, one myth that should be blown out of the water is that suicidal people want to die. The truth is that people who are suicidal are quite ambivalent about life and death. Most people do not want to die , they just want to end their suffering, and while sleep may give them some relief from their despairing thoughts, the irrational belief is that only death will end their pain for good; they see no alternative. Someone once described to me what it was like to be suicidal: Imagine you are all alone at the top of a very tall building, and its engulfed in flames , the only escape is to jump!
FACTS ABOUT SUICIDE
- Although there is an impulsive element to many suicides, it is mainly seen as the only option when there are no other alternatives.
- Suicide is not a cry for help, it is an act to end unendurable pain.
- Only about one-third of people leave notes; more often nowadays these are in the form of text messages or emails.
- If someone dies by suicide on a significant day (Christmas or someones birthday) or in a sig?¡nificant place, it is not out of malice that the person has chosen that day or that place, but because they want to be remembered or included on that significant day or in that significant place.
- It is thought that if a person returns to a significant place in their past, such as the house they grew up in or a place where they spent holidays, they are hoping that the people who are left behind will remember them when they were happy and when life was good.
THE SEVEN VULNERABLE STAGES OF BEING HUMAN
We need to be aware who is at risk, and we need to know what warning signs to look for. Always listen to someone when they express suicidal thoughts, and believe that if someone expresses that they are feeling suicidal, it is better to err on the side of caution than to blithely disregard the threat.
Who is at risk? As mentioned before, everyone is at risk: everyone who has ever experienced a serious life event, who has little or no support, or who is unable to look for help and support. There are also certain times in our lives when, due to age or circumstances, we are more vulnerable. I call these the Seven Vulnerable Stages of Being Human.
ELEVEN YEARS AND UNDER
Thankfully, there are very few children in Ireland who die by suicide. The children who have come to us and have disclosed that they feel suicidal are usually intelligent, articulate children who use the word in the appropriate context. This could mean one of two things: that they are so intelligent, they understand and can visualise suicide; or they have heard of suicide (a neighbour, family friend or relative may have died by suicide) and use the concept of suicide as a way to express or communicate their distress over some event , they may not mean it the first time, but it could become a viable option for them.
What would cause a child to feel so distressed that they would rather be dead? At this stage of a childs life, their self-esteem, confidence and belief in them?¡selves is based on the opinion of the adults in their lives. Although they get distressed if they are ignored or bullied in school, what happens after school, in their home life or in extracurricular activities can com?¡pen?¡sate for what is missing in their school life. In particular, their parents and teachers opinions matter. These are the people who will tell them they are loveable, clever, kind and so on, but they may also tell them they are bold, selfish and lazy. Almost all children can survive and thrive on this type of parenting, but there are some children who are so sensitive to any criticism, so easily bruised psychologically, that they are damaged by it. Suicide in this situation can be an impulsive or knee-jerk reaction to remarks that might not even register with other children. This knee-jerk reaction can take place if the child has recently been made aware of the circumstances of another suicide, especially if it is someone they know and can identify with.
TWELVE, SIXTEEN YEARS
These are such delicate, vulnerable years for the developing teenager. There are so many changes in their life , the commencement of secondary school, physical and emotional development, heightened emphasis in the expectations of teachers and parents, peer scrutiny.
At this stage of a childs development, they need recognition and approval from those their own age for their well-being and self-esteem. Previously, it only mattered how their parents thought or felt about them; now the young persons confidence or lack thereof is dependent on the opinions and attitudes of their peers. The popular nursery rhyme, Sticks and stones may break my bones but names will never hurt me, is unfortunately not applicable to children this age. A young person who is searching for their identity relies heavily on the labels their peers place on them. There?¡fore, whatever name or label is attached to a person now will influence how they see themselves.
Bullying and social exclusion are rampant during this stage of development. The experience of bullying is most traumatic and damaging. Whatever you have experienced at this stage in your life, whatever your opinion of yourself, tends to stay with you for many years, sometimes always. When young people of this age come to us at Pieta House after a suicide attempt, they usually disclose that this is not their first attempt. What is worrying is that if they are not helped at this time, it could be the start of a pattern of suicidal beha?¡viours that could last for many years or until suicide is completed. Young people really believe they are invincible, and so a suicide attempt is often a reaction to a given moment or distressing situation. The fear is that our young people do not fully comprehend the finality or the fatality of suicide.
SIXTEEN, TWENTY-FOUR YEARS
This age group is the most cited by researchers and the media because more young men in this age bracket in Ireland die by suicide (with our country having the fifth highest rate of suicide in Europe) than in any other age bracket. The reasons behind this are many and varied and, in most situations, complicated. We need to consider the kinds of situation people of this age may be facing.
At this age, young men can experience conflict in relationships, and often the ending of relationships; they may abuse alcohol or drugs; for some young men, a lack of focus or structure in their lives, often a result of unemployment, little or no interaction with other male friends, or being in a high-risk environment where suicide is a regular occurrence, can contribute to the development of suicidal thoughts.
For young women in this age group, issues such as poor body image, poor self-esteem, conflict in or ending of relationships and isolation due to early motherhood can lead to thoughts of suicide.
Sexual orientation and isolation or discrimination arising from it in both this and the previous age group can also be distressing and a causal factor of suicide.
TWENTY-FOUR, FORTY YEARS
Studies indicate that suicidal ideation levels off during this time in a persons life. People have stronger reasons for living, for staying alive: the arrival of children, supportive and loving relationships, gratifying and satisfying employment, a healthy and supportive network of friends and family.
However, if this stabilising and life-enhancing dynamic begins to unravel or disappear, then suicide can become a consideration for some. As mentioned previously, when a relationship ends, men in particular find the sense of loss enormous, simply because all those life-sustaining factors vanish almost overnight.
In contrast, for women it is being single , not due to separation or divorce but rather because of lack of or missed opportunities, causing them to feel unloved, isolated and lonely. The possibility of not having children could also cause women to feel great despair.
It would appear that the fundamental cause of suicidal ideation in both men and women of this age group is a sense of failure , a failure at life, or at the common understanding of what constitutes a success?¡ful, fully-rounded life.
FORTY, FIFTY-FIVE YEARS
Men and women in this age group can experience an overwhelming sense of loss at this stage of their life. For women, there is the aforementioned loss of their femininity, fertility and identity as a mother. They also often find themselves caring for their elderly parents. Men of this age can feel a sense of loss, especially those who have never married. They may look back and wonder what they have to show for their life. There is also a great sense of loneliness, particularly amongst men in rural areas and those who are living alone after separation or divorce.
FIFTY-FIVE, SEVENTY YEARS
People in this age group may experience a sense of loss and loneliness with children moving away; they may have lost their youthful mobility and might now be experiencing a marked reduction in energy. Retirement might be enforced, either due to statutory age regulations or because of physical ability. They may encounter ageism and notice a loss of respect towards them, when wisdom and experience is seen as neither an attribute nor a resource.
This is a period of great physical and mental change. Facing mortality , that of oneself and of others , is probably the main concern of this age group. It is the time of losing partners, family and friends, as well as the ability to do even the simplest things, such as drive a car or go up the stairs unaided. It is a time of increased dependency and of giving up ones dignity in circum?¡stances where physical help is needed. It can also be a time for regrets and for ruminating on what could have or should have been.
Most of us pass through these seven stages with little difficulty. We can cope with whatever life throws at us, and while certain stages can be difficult, we are usually fortunate enough to have people in our lives that support and encourage us through distressing or traumatic events. The people who do not get through these difficult times often have nobody in their lives, or believe they have nobody in their lives to whom they can turn.
Now I will look at some of the warning signs that indicate when someone is at risk:
- Changes in the usual pattern of living. For example, the person who stops performing well in school, begins to miss days at work, doesnt keep the house clean or stops paying attention to their personal hygiene.
- Changes in normal physical patterns. For example, someone who usually sleeps well begins to have trouble sleeping and is now awake for several hours during the night; or perhaps they are sleeping more than usual but still wake up feeling exhausted.
- Someones eating patterns might change. For example, they may either comfort eat or skip meals because of lack of appetite.
- Activity levels drop. For example, someone who is normally very active now spends hours doing little or nothing. Perhaps an everyday activity (such as collecting the children from school or going to work) now seems to demand huge amounts of energy. Likewise, activities that someone used to consider enjoyable, such as walking, gardening or playing football, are now considered a chore, requiring energy that they dont have.
- Self-enforced isolation. For example, a person who is normally sociable, talkative and involved is now withdrawn and has ceased normal social activities. They might also go to bed too early, retreating to their bedroom. They might not answer the phone or the door or they might turn their mobile phone off.
- Religious despair. Expressing the feeling that they have been abandoned by God or that there is no God.
- Other warning signs include an interest in morbid music or poetry; looking up internet sites that contain morbid or dark information on death or suicide; talking about death or how pointless life is; writing funeral plans; making out a will; or, in what has become a worrying trend, posting or sending messages revealing a distressed state to friends and acquaintances on social networking sites.
USING FAMILY, FRIENDS AND THE COMMUNITY AS A RESOURCE IN THE FIGHT AGAINST SUICIDE
As mentioned earlier, many therapists are afraid of having a client who may be suicidal, so imagine how a family member feels if they are confronted by someone in crisis. If they take the person seriously, and believe that they are thinking of ending their lives, the fear can be unbearable. However, if they dont take the threat seriously, the situation might not be given its due consideration. Those well-meaning statements such as pull yourself together, snap out of it, or, its just a phase are made, I believe, not as reassuring words for the person who is in crisis, but as reassurance for those dealing with the suicidal person.
It is family, friends, colleagues or neighbours who may be able to identify if someone is at risk. No matter how many Pieta Houses are set up around the country, someone has to first identify the person who is at risk, and that someone could be you.
I firmly believe that suicide is a problem that affects the whole community; we need to remove the stigma surrounding suicide, suicidal behaviour and mental illness so that if someone is in trouble, friends, family and neighbours will feel able to rally around to help.
I often tell the story about how my grandparents had an arranged marriage. The day my grandfather took his new bride to his home, she must have thought she had done very well for herself. The kitchen fire was blazing while a pot of stew was gently cooking over it. The chairs had plump cushions resting on them, the dishes on the dresser shone in the bright firelight, and in the bedroom the double bed had crisp white sheets turned down. The newness of her situation must have been softened for my grandmother when she saw all these lovely things in her new home. Can you imagine then how she felt when, first thing the next morning, all the neighbours arrived, one taking away the cushions, the other taking away the dishes and, most humiliating of all, another neighbour whipping the sheets off the bed? The items had been lent out for my grandmothers first day in her marital home.
While this must have been quite embarrassing for her, it also showed the kindness and compassion of her neighbours. They tried not only to make her feel welcome, but also to make this new life a bit easier for the young bride. I think for many of us, its hard to imagine having supportive neighbours and friends like that, but for us to tackle suicide seriously, we need to come back to that supportive, caring com?¡munity we used to be. We are very quick to blame the government when the numbers of people who die by suicide increase. But think for a moment: if your loved one was in crisis, who would you ring, a gov?¡ern?¡ment minister or your neighbour?
However, for you to be able to recognise signs of suicide, you need to educate yourself about the subject. So lets get this straight once and for all: the reason behind the act of suicide is to end negative and painful thoughts that seem to the person unendurable and unending, without any possible solution. The act is self-inflicted and is not the result of another persons action or behaviour. A person does not commit suicide, because suicide is neither a criminal act nor a sin. It is without a doubt an unnecessary end to a very necessary life , a death that could be prevented, a life that could be prolonged if only we knew how.
WHAT TO DO IF SOMEONE IS SUICIDAL
There are signs that clearly indicate when someone is distressed. If there is a combination of these signs, then this person is in crisis. The secret is to be aware, be alert and be not afraid to ask.
Now that you know who is potentially at risk and what signs to look out for, what do you do with all this information and, more importantly, what do you do if you discover someone is suicidal? The answer is APR: Ask Persuade Refer , the emotional resuscitation of someone who is in emotional crisis.
Ask. If you are concerned about someones emotional well-being or if you feel that you recognise the signs of someone in crisis, dont be afraid to ask, Are you suicidal? If they are suicidal, they will answer you truthfully , that is, if they feel safe with you, if they trust that they wont be stigmatised or hospitalised. They will be relieved that someone notices and is not afraid to ask the question that has been filling them with such fear. If they are not suicidal, they will simply say No and may perhaps ask you why you felt it necessary to ask that question. This gives you a wonderful opportunity to make them aware that you care about them and that their behaviour has seemed different lately. Do not under?¡estimate the power of such a simple question. As stated before, it is far better to query and risk seeming overly cautious about the perceived mood and intentions of someone else than to ignore them entirely.
Persuade. If the person has said that they are suicidal, what do you do? First, try to persuade this person to allow you to get help for them. It is no good trying to convince them to go and get help , they werent able to do that before, so why would they find it easier now? Tell them that you are going to be involved and that you and other people will help them through this. Persuade them to give this a try, to trust you; tell them they have nothing to lose.
Second, make plans. Start by gathering an army of people who will support and help you with this situation. Inform family, friends, relatives , anyone who can help you make sure that this person stays safe. It is very important that someone who is suicidal is not left alone, as this gives them the opportunity to brood and ruminate. It is also important that you have other people involved because the responsibility of this persons life could overwhelm you. You need to share this; you need your own self-care. Further, having more people on board will reinforce to the person in crisis how important and loved they are and how concerned everyone is for their welfare. I have seen cases where families and friends flock around a person who is in crisis to the point that they even sleep with them at night time to ensure that they are not left alone.
Refer. The emotional energy and loving support of family and friends is incredibly powerful , but it has a life span. During this time of cocooning it would be very easy to allow the urgency of the situation to dissipate, so it is at this time that you need to get professional help.
Whether it is somewhere like Pieta House or another organisation that offers crisis intervention, make sure that the person attends and that it is the right sort of intervention. Do not be afraid to ask for second opinions; gather as much information as possible.
It is essential that the person in crisis is not forced to face the failings or negative events in their life (whether real or imaginary). What is required is a practical, solution-focused approach to the problems facing them at present and gentle reminders of what has worked and is good in their life. It is also essential that this professional help is not once a week or fortnightly, but rather every couple of days, or in some cases daily, so that the momentum is not lost and the despair not allowed to creep back in. However, remember that professional help usually lasts just one hour, so, even if it takes place daily, what happens during the other twenty-three hours? This is why you must have an army of people ready to help the distressed person. Crisis has a short life span. With the right support , personal and professional , not only will a person be able to get through this, but they will also learn new skills that will help them cope with future difficulties.
I have focused on suicide in this chapter so that the differences between it and self-harm will become clear. Getting it right could save a person from ending their life or help a person cope with their life. However, it is important to note that self-harm usually starts in childhood, while suicidal ideation at this age is unlikely.
However, if self-harm is allowed to continue and goes unnoticed or unchecked, over a period of years the person can move from using self-harming as a way of coping to considering suicide as the only way out of despair. A history of self-harming often prefigures a suicide attempt. We must also acknowledge that strong emotions do not always follow the usual solutions for people who self-harm. Sometimes a person can be so distressed that the thought of self-harm is not enough at that moment, that to end it all is considered the only solution. In a recent survey in Northern Ireland, adolescents were questioned about their self-harming behaviours and when asked what their reasons for self-harming were, in both girls and boys the second most common answer was: to die (with the most common being to communicate).
Although in Pieta House we stand by our con?¡viction that suicide and self-harm are two very different beha?¡viours that have very different functions, we are aware that once a person is on a path of dangerous behaviours, it might only be a matter of time before someone reaches the end of the line.
The next chapter will look at what self-harm really is and consider it from the perspective of parents or carers.