Editorial

On suicide and subcultures

Graham Martin OAM
Professor of Child and Adolescent Psychiatry, Discipline of Psychiatry, University of Queensland, St Lucia QLD

PP: 166 - 170

Article Text

A recent group of suicides in young people has caused grief in a number of specific schools, a fear of further suicides in the local school community in general, concern in the community as a whole, and questions and some soul searching in the media.

The story thus far is that one young person died about a year ago. Some connections can be traced to a second person who killed themself more recently, and a further suicide from the same school occurred shortly after this. Within two weeks a young person from another school died and a very short time after this, a second young person from the same school completed suicide. All of the suicides are said to have chosen hanging as the method of suicide. All of the suicides were high school age, and the two most recent schools are geographically close.

The suicides have caused considerable grief for each of the families, as well as the immediate friends and classmates. Questions have been raised about whether other students at the same school should be publicly informed (they should in the simplest manner possible, to provide a basis of fact and to avoid confusion); whether the funeral should be public (while the needs and wishes of the family must be met, in most cases it allows the expression of appropriate public grief, the offering of tributes from family and friends, as well as providing some sense of closure for all of those involved) and, whether there should be some public memorial on school grounds (in most cases this is not done, unless it is the practice of the school to create memorials for all students who die during their time at school). Professionals from local mental health services have been called in to provide appropriate advice, and have turned to a readily available booklet called euphemistically 'Education for Life' which is part of the Mind Matters suite of resources available in all schools (Howard & Taylor, 1996). There have been meetings with student groups (to provide a safe context for discussion and grief), with teachers (also to provide some grief work, but in addition to allow some planning for the return to normal teaching), with school authorities (to plan the whole school approach to bereavement), and with parent groups (to allay some fears, and to answer a vast number of appropriate questions). Questions have been raised about whether the events can be called 'contagion' (possibly), 'copycat suicide' (possibly), or a 'cluster' (this term is usually reserved for when all suicides occur in the same school or other 'closed' institution, as a group and/or within a short time frame).

Of course there has been much speculation and rumour. It is said that all of the young people had had some contact between themselves prior to death, possibly through SMS. Much has been read into the fact that all of the suicides used hanging, even though this is the most common method used nationally. There is some evidence that all of the students identified themselves as being 'Emo' - that is that they thought of themselves as emotional or depressed, preferred mixing with their own group, and had particular preferences in music (post-punk, 'emotive hardcore', or heavy metal styles) and clothes (tartans, black, tight jeans, and the use of scarves), used eyeliner to darken the eye sockets, and combed their (sometimes greasy) hair in a particular fashion (usually down over one eye). Some in the community and in the media, on the basis of these connections and similarities, have raised the possibility of an agreement or a pact to die. There have also been suggestions that influences may not have been just personal, but rather that identifying with Emo culture may in itself influence toward suicidal behaviours.

We should really begin by examining whether any subculture increases the risk for suicide. Although there is a paucity of research looking at this aspect of subcultural groups, recent work suggests that compared with other subcultures, identification with being a Goth may be problematic. Robert Young and his colleagues (2006) from Glasgow in a longitudinal study found that the lifetime risk for self-harm and for suicide attempts was significantly increased, with close to 50% of the young people giving a positive history. This of course does not mean that any particular Goth will ultimately suicide, but self-harm and suicide attempts are known to be factors along pathways to suicide, and are often used as proxy measures for suicide in program outcome research.

It may be problematic to compare Goths and Emos, given that Emos become enraged with people who suggest they are similar to Goths. In fact one website exploring and explaining Emo culture has suggested a critical difference between the two groups - Emos hate themselves, while Goths hate everyone. If this hating the self is true, then it might be argued that Emos are at more risk of hurting the self than their Goth counterparts, so there could be some risk in identifying with Emo culture. Certainly (and while there is no formal research on this) the reported incidence of cutting behaviours is said to be high in the group, and a key feature of Emo culture.

Of course, such associations with suicidality are not just found in youth subculture. Stephen Stack has suggested that opera buffs as a group, because of their group experience with suicide in Grand Opera, are more than twice as likely to believe that suicide as an outcome is acceptable where honour has been lost (Stack, 2002b). Again this does not necessarily mean that any particular fan of opera will actually have a higher likelihood of suicide, despite the fact that suicide acceptability has been associated generally with suicidality. We would certainly not jump to such conclusions simply based on identification with a group of fans of opera.

Some people have suggested the possibility that the music to which Emos listen may be the crucial part of the influence - either because of its dark, driving style, or because of the words which often discuss death and pain and sometimes suicide. This kind of argument was used some years ago to suggest that certain rock or heavy metal groups were in some way increasing the risks for suicide, but little of this was ultimately substantiated either in formal research or in the courts. Our own work certainly found associations between heavy metal music and depression and suicide attempts (Martin, Clarke & Pearce, 1993). However, our best understanding of this was that young people seek out the music which best resonates with their own feelings. For most, this was a validating experience - 'What a relief, others have felt like I do' - and led to improvement. Only a tiny proportion were made to feel worse, and they had a range of other contributing factors as well. Again, Stephen Stack (2002a) has shown an association between liking blues music and suicide acceptability, his suggestion being that the liking for blues music with its themes of death, depression and pain led to lowered religiosity levels, the most important predictor of suicide acceptability. Once again we would have to say, that this association at the group level would not necessarily lead us to believe that a particular fan of blues music was more likely to suicide simply because they preferred that kind of music, and Stack supported our reasoning about seeking out the music because it echoed something inside, rather than the music per se directly causing any suicidal feelings.

One other piece of this jigsaw is worth brief discussion. Part of the National Suicide Prevention Strategy is based in the fact that connectedness to another human being or to a group or to an institution may be protective. So, Resnick and colleagues (1997) found that connectedness to school reduced suicidal thinking significantly. Other research has supported the fact that belonging provides protection. The key question for us is then does belonging to a group which identifies as Emo provide some protection? I know of no research to support this, but general principles would suggest that it may.

The next question is: 'Should parents, schools and professionals be concerned about self harm when they discover that a young person identifies with Emo culture?' From what has been said above I would recommend that parents should be pleased that the young person is connected to some sort of group. However, clearly they then need to acknowledge that the young person may have joined the group because the emotion in the others in the group resonates with their own thinking. That is they may be struggling or frankly depressed. This may need exploration, and/or referral for professional assessment, on the grounds that any opportunity to reach out and assist a troubled young person should be grasped.

In this issue of AeJAMH, Craig Murray and Jezz Fox from the United Kingdom struggle with similar problems in their paper on self-harm and whether contact with an internet group can help or hinder. Internet groups centred around particular issues have appeared rapidly over the last few years, and our knowledge about their role is still somewhat spartan. The current paper appears to conclude that in general participants gain support, and there are overall reductions in self harm. For some, though, the risks may be heightened, and our problem as professionals may be how to intervene with this particular group. Considerable more work is needed here.

Erminia Colucci addresses related issues to do with culture more broadly and its influence in suicide. She reviews what is known about the impact of culture, explores in depth some of the meaning and interpretation of suicide in cross-cultural research, and makes the case that these issues are complex and in need of further work to understand the prevailing culture-specific norms, meanings, social representations and attitudes regarding suicide in the various cultural (and sub-cultural) communities of the world.

Alan Headey and Jane Pirkis from the University of Melbourne, along with other colleagues, present an overview of the 156 local projects funded under the National Suicide Prevention Strategy, and report on lessons learned. They note the need to 'maximise gains in Australian suicide prevention activities by highlighting promising processes and impacts and minimise repetition of less successful elements'. Overall, they conclude that the projects 'achieved improvements in knowledge about risk and protective factors for suicide, social connectedness and mental health literacy, and reductions in depressive symptomatology', but were somewhat constrained by their short-term funding.

But this issue is not all about suicidal behaviours and, in fact, covers a wide range of current issues in mental health. Desley Casey in her guest editorial thoroughly explores the current status of consumers who contribute to mental health systems, noting that we still lack clear frameworks for engagement, clear expectations, position descriptions, and a set of ethical guidelines on both sides. In making the case that the expectations, roles and responsibilities must be clear so that the very important contributions which can be made by our consumers do not leave them feeling used and abused, she makes a strong argument for ongoing and wider debate.

Brenda Happell and Cath Roper explore some of these issues further in their paper focused on what they call the 'myth of representation', that is the key question as to whether one consumer can represent the wider range of consumer needs. They argue that such an expectation is actually discriminatory, something that would not be expected of professionals sitting on committees in other services, and that in any case there is no way of testing whether an individual has canvassed wider opinion. They conclude that a shift in models may be necessary, perhaps toward what is termed consumer leadership in services, a concept explored further in the paper.

Chris Lloyd, Samson Tse and Frank Deane explore how the concept of social inclusion can be applied in the everyday practice of health professionals working with people with psychiatric disabilities. They describe practical strategies in a range of areas: addressing attitudes and beliefs, promoting employment opportunities, supporting families, and addressing issues around housing, finances, transport, access and information. They conclude that there are many opportunities for practitioners to facilitate social inclusion, but it may require a willingness to shift to a more recovery-oriented approach.

Later in this issue, Sujata Satapathy and Ajinder Walia take us to the heart of clinical work with a child who was burned in a school fire. An in-depth case study, this paper provides us with a fascinating insight into mental health services in India which are still to be incorporated into the main primary health care system. The disaster specific piece of work both reminds us that clinical intervention works, but also points to the immense need for counselling services in India.

Another international paper from Canada examines cross cultural work which has implications for our own indigenous peoples. William Thomas and Gerard Bellefeuille report on a qualitative study of the healing circle, which incorporates elements of experience, relationships, spirituality and connectedness, empowerment, and self-awareness. A key issue explored is the need for researchers to respectfully incorporate Aboriginal needs into the research plan, and Aboriginal knowledge into the research process, and for Aboriginal communities be given the opportunity to decide what the research priorities should be for their communities.

Mike Cunningham, Ron Rapee and Heidi Lyneham from Macquarie University report on a novel computer-based therapy to help reach the many adolescents who have an anxiety disorder but who do not access traditional psychological services. While the reported pilot study has small numbers, overall the results are promising, suggesting that further exploration using a larger sample is warranted.

Sue Outram and her colleagues from the University of Newcastle explore a very large sample of women where they used logistic regression to examine factors associated with medicine use for psychological problems. A high proportion of the women were taking medications related to both mental health issues and recent life events, and this was despite their concerns about dependency and the possibility that medication does not solve the actual life problem. One major conclusion explored in the paper is that many women would prefer to have had their problems discussed, rather than medicated.

Larne Wellington and colleagues from Brisbane explore the beliefs underlying intention to take part in parenting groups. Their research demonstrates a number of key factors (perceived costs and benefits, as well as the views of key others) which may inhibit participation. They conclude that both attendance at groups, and successful resolution of the issues in parenting may depend on working with these control beliefs, and finding clear strategies to overcome them.

Susan Fealy and Ian Story report on RAMP (a comprehensive Risk Assessment and Management Process), a systematic set of processes for schools that promote early identification and intervention for children and adolescents at risk of mental health problems. The authors describe the three domain risk and protective factor framework, a team-based approach to pastoral care, structured team processes, protocols and solution focused strategies tailored to the school setting, and the provision of professional development in mental health for school staff. The authors note that such an approach can help to begin to address the unmet needs of at-risk young people using current resources.

In the final paper in this, the largest AeJAMH issue to date, Susan Fealy then joins her colleagues Alison Shortt and John Toumbourou in a second paper which reports on the evaluation of the program. The paper describes the process of implementing RAMP in nine schools, where it assisted in identification of students not previously known to be at risk, improved staff knowledge of risk and protective factors, and continues to be used.

As this issue goes to press in December, we at AeJAMH offer our very best wishes for the season. We hope you have a good rest, safe travel, and a return to work that is fully refreshed, and committed to producing more papers for this now important, abstracted and widely distributed online mental health journal.

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