It is a well known and much discussed fact that more young Irish people die by suicide than by any other means and that includes road traffic accidents. The male/female ratio of completed suicides is 4:1 and statistics show that the incidence in the Kerry region is slightly higher than in other regions. Young Kerry people are not seeking help for emotional problems, not in adequate numbers anyway, and there is evidence to show that there is little awareness of the existing support systems.
This qualitative study investigated the reasons that prevent young people seeking help. Information was obtained through focus groups and individual interviews of young people and professionals within the health and education sector. The following is a synopsis of the barriers identified.
1) Fear of Breach of Confidentiality emerged as a problem. Within the school system, for example, young people are concerned that information given to the guidance counsellor might be discussed with other members of staff.
2) Locus of Control - People with an internal locus of control tend to see themselves as agents of change, responsible for their own choices. A number of studies have demonstrated that suicidal individuals are characterised by an external locus of control with lethality of attempt associated with a greater external locus of control (Begley et al 2003:8). This researcher found that women evidenced strong internal loci of control (‘It has to start from within yourself because if you don't have the courage to go and get help, you never will.....who else's fault is it?), whereas the men were more inclined to see themselves influenced by external circumstances ( ‘He might try and ask us to start drinking as well and then we'd turn into alcoholics and then our other friends, we'd ask them to start drinking and if it was like that then we could'nt win at all ‘cause all our friends would be alcos.)
3) Self Development and Coping Skills: There is evidence to show that poor communication and self expression skills are barriers to good mental health and help-seeking and that boys in particular are poor performers in this area. Coping with loss has been identified as particularly difficult for young men. As school is an opportune place to teach coping strategies to young people, then early school leaving must also be seen as a barrier to help-seeking. Part of Finland's recent successful suicide prevention strategy involved ‘creating circumstances and experiences which improves an individual's chances to cope' (Upanne 2005:5). It is vital, however, that any strategies are taken seriously by the schools and organisations responsible and that they are evaluated properly. The programme ‘Expressing Masculinity' designed by the Department of Education and Science to address these issues, is apparently not being implemented adequately by the majority of schools. An investigation by Smyth et al (2003:99) showed that only a small minority of schools have implemented the programme and those who have implemented it report that they omit the sections on ‘Men and Power', ‘Relationships, Health and Sexuality' and ‘Violence against women, men and children'. This highlights the need for structures to monitor the work already being done ‘and to establish leadership for these efforts' as suggested in the Forum Report (2005:2).
4) Trust emerged as an important issue. Men appeared to be very resistant to talking to a stranger - women less so. However, it emerged that the men were willing and eager to discuss problems with a ‘stranger' who is a friend of a trusted person i.e. a counsellor who attends a local youth club and is perceived to be a friend of the youth leader, as opposed to visiting a counsellor in his/her formal consulting room. The implication here appears to be that if young people are to access professional support, this support should be brought to them in an environment that is familiar to them and in a way that feels comfortable to them.
5) Social Class emerged as a barrier between young people and their supports. There were suggestions that young people are ‘insular' and unfamiliar with professional terminology. The women evidenced more familiarity than the men. Schaffer et al (1998:257) claim there is a reluctance of many young people to seek help ‘outside their immediate social circle'. This perhaps indicates a benefit in training community leaders and peer support groups.
6) Peer Group Support: Literature shows that the majority of young people would seek help from peers whereas only a small minority would seek help from professionals (Russell et al 2002:24). There are mixed views about the concept of peer group support. However, it appears to this researcher that proper peer training in closed co-operation with professionals would be of great benefit.
7) Family, Community and Cultural Change: Although family dysfunction and discord appear to be risks to healthy psychological development, there is also evidence that even in close, functional families, young people will not necessarily disclose their distress to their parents.
Community centres and activities can help young people avoid isolation, particularly in rural areas and also provide access to alternative role models - in the absence of sound parental role models in the home. A directory of support organisations and resources is currently being made by Kerry Mental Health Services.
Changes in culture or ‘Acculturation' is a concept related to escalating suicide rates (Smyth et al (2003:48) describe acculturation as:
...the way in which individuals relate to, in terms of their attitudes and behaviours, and come to exist within, a cultural context that may not be the same as the socio-cultural context into which they were socialised.
Cultural evolution involves a change in values, attitudes and custom changes within our social system. Ireland has certainly undergone many recent social and economic changes with increases in immigration, economic globalisation, fallen icons in family, church and political life. It is as if the goalposts are moving and young people have difficulty knowing what it expected of them. Suicide rates tend to be highest in societies that are undergoing greatest cultural change.
8) Health Cafes and Walk-in Centres.
Health cafes were suggested as a useful resource in the community where young people could have a chat and a cup of coffee. Information and support could be available here in a user-friendly way, avoiding the bureaucracy that proves to be a barrier to help seeking.
Walk-in centres might also be a useful resource. Even if appointments still have to be made to see a professional, this facility might act as a stop-gap in a worsening situation. The women interviewed approved strongly of this type of facility, the men tended not to, re-iterating their reluctance to talk to strangers. One health professional interviewed felt that young people would not use this facility as they would not ‘want to be seen' looking for support. He would prefer to see the expertise coming out to the youth centres and ‘places of activities' to educate and equip the individuals to deal with their problems. However, one professional stated that no supports are available at the weekend so these walk-in centres might be useful to have available at these times.
9) Help-Lines: The women interviewed were aware of some telephone help lines and were very much in favour of this facility and some felt it should be available twenty four hours a day. The men interviewed were unaware of The Samaritans and Aware but were familiar with a drug abuse help-line. Two of the men had phoned this line but encountered an answering machine, did not leave a message and did not ring again. None of the women or the men interviewed were aware of the Kerry Suicide Help-Line. Texting help-lines at time of writing were being planned by Kerry Mental Health Services.
10) Pride and Stigma: There were strong opinions from all concerned that pride and stigma were significant barriers to seeking help. This view is well supported in literature. One health professional expressed a view that mental and physical aspects of health need to be integrated into an inclusive concept of general health. He feels that this ‘normalising ‘ of mental health issues would help break down the stigmas and taboos. There is also evidence that stigma around mental health issues exists within the medical profession itself. Also, the poor conditions and low priority given to the provision of psychiatric hospital and treatment facilities speaks volumes about the government's attitude to this sector.
11 ) Role Models: When asked to identify a role model in their life, all of the women in the study chose a woman as a role model and half of the men also chose a woman. One of the men described how influential a male sporting role model had been in his life and how his involvement in sport had kept him out of trouble, unlike his friends who are not involved in sport. The value of ‘marketing' integrated (mental and physical) health information through sport icons was highlighted by one health professional. This researcher felt that the findings might indicate a lack of positive male role models for the men and would stress the importance of providing opportunity for male identification in schools, community centres etc. Mary Hanafin, minister for Education recently stated that she is considering positive discrimination towards men in competition for places in teacher training to address this issue. This initiative is being considered to address the fact that many schools now have no male teacher and the remaining schools often have only one male teacher. Another factor is that in the case of marital breakdown, often the mother remains the main care giver. Also,literature shows that the image of ‘maleness' has become increasingly negative (Smyth et al 2003:88). Smyth goes on to claim that ‘self continuity has a protective role against suicide' and this researcher feels that if young men do not have suitable male role models, this may inhibit their projection of self-continuity, thereby rendering them more vulnerable to depression and suicide.
12) Attitude to Professionals: One educational professional working with early school leavers stated ‘To most kids I work with, GPs are official and they are trouble. You go to them to get a medical cert. or something'. The attitude of the young men to professionals was very negative - ‘I'd never go to a doctor with a problem, never'. The women's attitude was more positive. The men believed that the likely treatment from a doctor would be medication and one of the men associated this with drug problems, a problem he had recently overcome, stating that he believed that if a person was prescribed medication and the medication did not work, ‘he might think he'd get a bigger buzz from ecstasy and then go on to say, cocaine'.
There is much evidence to show that public waiting lists for counsellors and psychologists are long (a year and a half at least) and that GPs therefore are the only professionals available on demand. Also, because of the prohibitive costs of counsellors and psychologists, the only treatment that many people can afford is medication. People with medical cards do not have to pay for visits to the doctor or for medication and so this route is the only one open to them. Doctors themselves are frustrated at this shortcoming. Also, it was felt that even if finance is not a factor, it may still prove difficult to find an appropriate, well qualified counsellor and that ‘counsellors who are not accredited can do more harm than good'. This researcher feels that there is poor awareness of accreditation in the public domain and suggests that this need for democratisation of information is an area for further research.
13) Substance Abuse: Kelliher et al (1996:35) suggested that the health services in this country have a ‘marketing problem'. However, it is obvious that the alcohol industry have no such problem. Dr John Connolly (IAS 1:2:2004) warns us that alcohol is the ‘commonest and most dangerous drug on sale in Ireland'. He goes on to tell us that doctors in the sexual assault unit in the Rotunda Hospital, Dublin have said that they now encounter blood alcohol levels in teenagers that they ‘had only previously seen in the post- mortem room.' Young people are using alcohol as a coping mechanism and according to Smyth et al (2003:33), this phenomenon becomes more common in a changing culture. Smyth et al go on to tell us that alcohol ‘does not cause people to have suicidal thoughts or behave in a suicidal manner, but for those who already hold such thoughts, the consumption of alcohol may make them more likely to act'. Previous studies by Wasserman and Varnick have found strong links between suicide and alcohol consumption. They found that the anti-alcohol policy of Mikhail Gorbachev resulted in significantly reduced suicide mortality rates. This study tells us that when the anti-alcohol restrictions were later relaxed, the suicide rate increased again. The drinks industry in Ireland is a lucrative business and any efforts to curtail drinking levels requires putting serious pressure on powerful forces. However, it is only in providing other more creative ways of allowing young people to gather and socialise that we can attempt to offer an alternative to this destructive path.
14) Mental Health Budget: Poor financial backing for mental health resources is a major barrier to help-seeking. Although mental health problems constitute 25% of total health problems, they only receive 6.6% of the health budget. For the age group up to sixteen years, ‘there are only sixteen beds nationwide' (MacNamara cited Kenny Live 2005). According to Professor MacNamara, the Irish College of Psychiatrists have proposed to the government that six hundred and fifty six beds should be provided. Dan Neville, President of the Irish Association of Suicidology (IAS 1:2:2004) accused the Minister of Health of putting lives at risk by not providing adequate psychiatric services, ‘Patients of this age require a developmental perspective and appropriate multidisciplinary input, which would centre around family, school and social interventions'. Statistics show that every year ‘six hundred girls and three hundred boys per one hundred thousand population between the ages of fifteen and nineteen deliberately harm themselves, with one per cent dying by suicide within a year (IAS 1:2:2004).
15) The Media and Contagion: The media can play a positive and a negative role as an influence in mental health issues. It emerged that it is important to get the media ‘on board' as the health service is dependent on the media to publicise initiatives. However, reporting of mental health issues and suicide must be done responsibly and without sensationalism if contagion is to be avoided. Literature supports the belief that reporting of the means of suicide increases the incidents of suicides by that particular means.
This study identified feelings of loyalty as a possible cause of contagion. Boys appeared to experience strong feelings of loyalty to one particular friend. The girls appeared to respond differently, being more connected to a larger group. This researcher believes that this sense of loyalty, coupled with a difficulty in dealing with loss (discussed earlier) might leave young men particularly vulnerable to the effect of suicide contagion.
16) Spirituality and the Church: The church was mentioned by some of the young men as a possible source of help. One teacher/coordinator stated that he did not feel that unemployment is an issue for young people but ‘...I hesitate to call it spiritual stuff but actually, what is it all for is a question.....I have a sense of a lot of kids working hard at being distracted from some consciousness of self or of reality and that sometimes when that breaks through, it's a kind of eruption'. In the Finnish study, Upanne et al (1999:120) recognise the role of the church as a means of support, ‘Church based functions can touch a chord in people at a turning point in their life' and they also acknowledge that of all sectors involved in their research, the church was the most actively cooperative.
17) Homosexuality: Homosexuality did not emerge, in the primary research for this study as a particularly separate problem related to mental health. However, this is not the view evidenced in a wide sample of literature that holds that ‘the exacerbated problems of being gay are not getting appropriate attention'. Evidence shows that self harm and suicide is significantly higher among the gay communities ‘thirty two percent of those who took part in the study had attempted suicide' (www.youth-suicide.com/gay-bisexual/news/england-scotland-ireland.htm) .
The fear of homophobic bullying was raised by one health professional who claimed that negative attitudes to homosexuality are affecting young men's ability to confide in each other. This researcher believes that there is sufficient evidence to warrant this subject be given more attention and would also draw attention to the reluctance among educators to deal with issues of sexuality in schools mentioned earlier in this paper.
Conclusion: Cultivating positive mental health attitudes is a multi-faceted issue and requires recognition of the many influences that operate along the journey, through many sectors, past many gatekeepers. A growing awareness of the need for suicide prevention has resulted in at least ten countries, including Ireland, preparing suicide prevention and intervention strategies of their own. Changes can be achieved - Finland was the first country to undertake this and as a result has lowered it's suicide rate by 17% over a six year period. This success is not attributed to any one intervention but is claimed to be:
Due to many factors on many levels - various kinds of life events in various kinds of
conditions in various phases of life, several kinds of interventions, several groups
of actors and several levels of authorities. (Upanne 2004:52)
Ronnie Moore B.A., H.Dip. in Ed., D.G.C.