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'Face of Evil' - The Stigma Associated with Mental Illness
'Gen Y gets lost in the realms of cyber space
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'Nothing Fits, I Have Nothing' - Social Support in Mental Illness
'Ooh La La, Did you see that'- How equitable is the playing field when it comes to women's sport
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Mental Illness, Suicidal Tendencies and Ecological Systems
Name: David Rodwell
Student Number: n7463936
Tutor: Colleen Niland
“In short, all suicides of the insane are either devoid of any motive or determined by purely imaginary motives. Now, many voluntary deaths fall into neither category; the majority have motives, and motives not unfounded in reality. Not every suicide can therefore be considered insane, without doing violence to language”
Emile Durkheim, Suicide, 1897
Institutionalized is a song by influential United States hardcore punk band Suicidal Tendencies. Co-written by vocalist Mike Muir and bassist Louiche Mayorga, Institutionalized became one of the first hardcore punk videos to receive substantial airplay on American MTV. Lyrics are not sung but spoken from the first person point of view of “Mike” and accompanied by heavy guitar-based music. The song structure incorporates repeated sudden tempo changes that mirror the intensity of lyrical delivery (Suicidal Tendencies, 2010; Trouser Press, 2011).
Public Health Issue
The human and economic costs of suicide are disproportionately large relative to its incidence in the Australian population (Australian Bureau of Statistics [ABS], 2011). Because of this, suicide has been identified as a major public health challenge (Department of Health and Ageing [DOHA], 2007; Community Affairs Reference Committee [CARC], 2010). Although, research has indicated that individual mental illness is a major risk factor (CARC, 2007), suicide is intimately connected to the socio-cultural environment of the sufferer (Wray, Colen & Pescosolido, 2011). Thus, suicide must be broadly understood as involving the complex interplay of biological, cultural, economic, social and psychological risk and protective factors (Martin & Page, 2009), only one of which may be an individual mental disorder (DOHA, 2007).
Australian coronial services classify a death as a suicide if there “is evidence that a person has died as a result of a deliberate act to cause his or her own death” (DOHA, 2007 p. 10). Suicide accounted for 1.5 percent of all deaths and was the fourteenth leading cause of death in Australia in 2009 (ABS, 2011). The recognition that different groups commit suicide at different rates has a long history in sociology (Wray et al., 2011).This is reflected in Australia where there is some clear stratification between at risk and not at risk groups (CARC, 2010). Identified at risk groups include males aged 20 to 40 years, indigenous Australian males aged 17 to 23 years, men over 75 years old, men living in rural areas, male prisoners, men undergoing traumatic life experiences such as divorce, and refugees (DOHA, 2007). In 2009 around seventy seven percent of completed suicides were male (ABS, 2011). Additionally, it is estimated that over 60 000 people, predominately women, make an uncompleted suicide attempt per year (CARC, 2010).
The prevalence of suicide and suicide attempts is most likely underreported (CARC, 2010). This occurs for a number of reasons. Firstly, the establishment of intent is often problematic for the coroner due to the circumstances in which suicide is carried out (CARC, 2010). Secondly, Australian coroners code a death as a suicide in the National Coronial Information System using definitional parameters mandated by the International Classification of Diseases-10 (ICD-10) (World Health Organisation, 1992). The ABS (2011) uses this data to establish Suicide rates. Definitional requirements for suicide, undetermined intent, and accidental death changed when ICD-9 was replaced by ICD-10.These changes lead to a significant increase in the use of the latter two codes. However, it is expected that a decrease will be seen in the undetermined intent code due to data revision currently being undertaken by the ABS (2011). This may increase numbers coded as suicide.
A related controversy in Australian suicide research is seen in statistical analysis of mortality data. Basic mortality statistics, such as death counts, are recorded as equal (Australian Institute of Health and Welfare [AIHW], 2010) providing a summary measure of Australia’s mortality experience (Pan American Health Organisation [PAHO], 2003). This type of measure tends to be negatively skewed towards older age brackets (AIHW, 2010). It has been argued that a more socially relevant statistical measure of suicide prevalence is Potential Years of Life Lost (PYLL) (CARC, 2010). PYLL provides an estimated number of premature or untimely deaths by combining age of death with the total number of deaths for a specific cause and comparing this against a predetermined life expectancy. As such, deaths that occur at a younger age are assigned more weight (PAHO, 2003). Premature deaths are assumed to be a greater loss of life because of the disproportionate effect they may have on families, society and the economy. Using a life expectancy of 75 years the AIHW (2010) estimated that in 2007, suicide accounted for the second largest percentage of PYLL for Australian males.
This controversy notwithstanding, the personal, social and economic cost of suicide is enormous (CARC, 2010). Suicide affects families, workplaces, and communities in both the short-and-long term (Suicide Is Preventable, [SIP], 2009). Intrapersonal costs reported to CARC (2010) involved intense and long lasting feelings of grief, anger, guilt, and personal blame. Somewhat counter-intuitively, DOHA (2007) includes suicide bereavement as a possible “tipping point” (p. 22) that leads an individual to themselves make a suicide attempt. Compounding these beliefs is the stigma associated with suicide (SIP, 2009). Underreporting of suicides, especially in small rural and regional communities, may also be a product of the stigma associated with mental illness and suicide (De Leo, Dudley, Aebersold, Mendoza, Barnes, Harrison, & Ranson, 2010).
In an American study, Corso, Mercy, Finkelstein and Miller (2007) estimated that a suicide directly affects at least six individuals. Personal consequences experienced by those affected include unemployment, use of counselling services, use of antidepressant medication, drug and alcohol dependence, and relationship breakdown (CARC, 2010). Thus, suicide has flow on effects for communities resulting, for example, from economic hardship experienced by suicide bereaved or the social costs of increased alcohol and illicit substance abuse (SIP, 2009).
Not discounting the individual and social costs involved, suicide impacts the economy at a macro level. However, there are no completely reliable estimates for the economic impact of suicide in Australia (CARC, 2010). Organisations that have researched this issue have provided varied figures. For example, SIP (2009) estimated a financial burden of $17.5 billion dollars in 2007-2008 as a result of suicide. Alternatively, suicide can be costed at $12 billion dollars per year, using a different methodology involving comparison with research regarding the cost of road accident deaths in Australia (Lifeline Australia 2009 cited in CARC, 2010). Impacting calculations is the complexity and controversy of calculating the Value of a Statistical Life (Lifeline, 2009).
Suicide may result from reckless behaviour (Martin & Page, 2009), may be an attempt to escape unmanageable physical or psychological pain, or be an expression of an individual’s ultimate right to choose the manner of their death (DOHA, 2007). It may also be a combination of these things (CARC, 2010). Suicide may be carefully planned, or the result of irrational impulsivity (Martin & Page, 2009). DOHA (2007) emphasises the importance of specific trigger events for those at risk.
Mental illness, most prominently depression, is a major risk factor for suicidal behaviour (DOHA, 2007). However, not all mentally ill people commit suicide (CARC, 2010) and mentally healthy people may commit suicide, for example as an altruistic act (DOHA, 2007). Conceptually, individualistic Western cultures, such as Australia, locate an individual at the centre of a “system of values, behavioural choices, and convictions” (Halpern, 1995 cited in Eckersley & Dear, 2002). Personal autonomy, self-actualisation and independence are emphasised and valued (Burton,Westen & Kowalski, 2009). Flowing from this perspective, individualistic cultures also tend to view psychopathology egocentrically. Psychological normality and abnormality are personally and internally derived while, at the same time, the social roots of psychiatric disease are largely ignored (Lewis-Fernandez & Kleinman, 1994). Despite this, the importance of socio-cultural factors relating to mental illness is recognised by the peak American Psychiatric Association (APA). Axis IV and V of the Diagnostic and Statistical Manual of Mental Disorders IV-TR (APA, 2000) explicitly incorporate an assessment of psychosocial problems experienced by a person, and the global level of functioning of an individual, in a multi-axial approach to the clinical diagnosis of any mental disorder. An individual exists within a culture and both individual characteristics and cultural norms contribute to suicidal behaviour (Portes, Sandhu, & Longwell-Grice, 2002).
Ecological Systems and Suicide
Human ecology, as a theoretical orientation, focuses on human populations and the interactions between the biological, social, and technological characteristics of the environments they inhabit (Eisenberg & Sartorius, 1990). Ecological models can be used to study complex public health issues and provide insight about health disparities in communities (Reifsnider, Gallagher, & Forgione, 2005). Ecological systems theory (EST) asserts that individuals develop within, and as a consequence of, a number of interrelated systems and contexts (Bronfennbrenner, 1992). EST is often visually represented as a series of nested concentric circles (Reifsnider et al., 2005) with the individual placed in the middle (Darling, 2007). Each circle represents a linked open-system that has varying levels of proximate or distal influence on the other systems and the individual at the centre (Darling, 2007).
Bronfennbrenner's Ecological Systems Theory
This model is non-deterministic in that the individual both actively shapes their environment and is shaped by it. Additionally, the phenomenological experience of a person is paramount. The combination of these factors has the effect that a person is both an individual identity as well as part of a particular overarching “ecological niche” (Darling, 2007 p. 204). Wray et al. (2011) argue that suicide should be understood as the interaction of multiple influencing factors at both macro and micro levels. Thus, it is possible to examine Australian suicide from a human ecological perspective. Supporting this assertion is the fact that EST has been used to focus research into suicide in other cultures, such as Lee, Hong, and Espelage’s (2010) examination of youth suicide in South Korea.
An individual’s Microsystem is comprised of social structures that the person has direct interaction with, such as their family (Hoffnung, Hoffnung, Seifert, Smith, Hine, Ward, & Quinn, 2010). It is apparent that these interactions impact on suicidal behaviour. DOHA (2007) cites family relationship breakdown, for example, as a major risk factor for suicide in males. Additionally, interconnections between Microsystems, known as Mesosystems (Reifsnider et al., 2005), may also impact suicidal behaviour (Lee et al., 2010). For example, work stress affecting one parent may impact family relationships leading to increased levels of depression, and thus suicide risk, for vulnerable family members.
Microsystems are embedded within the Exosystem (Bronfenbrenner, 1992). The Exosystem is made up of settings and contexts which impact the individual but in which the individual does not directly participate (Hoffnung et al., 2010). For example, government regulation may be part of the Exosystem. A specific example relating to suicide is the coincidental occurrence of gun law reform and advent of the national youth suicide prevention policy implemented by the Howard government in the 1990s. Although unintended by the legislation, reducing access to lethal means of suicide (i.e. firearms) coincided with a reduction in both completed suicides using guns and the overall suicide rate (DOHA, 2007).
The Macrosystem encircles each other system and is made up of the cultural environment the individual exists within (Hoffnung et al., 2010). The attitudes and ideologies of a culture impact individuals in conscious and unconscious ways (Burton et al., 2009). Despite a current emphasis on multiculturalism and an increase in attention and value afforded to indigenous Australian cultures, Australia remains primarily a Western centric individualistic culture (Andrews, 1995). As noted before individualism places emphasis on the self rather than the group and research has demonstrated that this has impacts regarding social relationships, behaviour, mental health (Burton et al., 2009) and, therefore, suicidal actions. As an example, Eckersley and Dear (2001) found a significant positive correlation between male youth suicide and several aspects of individualism, such as unrealistic beliefs regarding personal autonomy and freedom.
Analysis and reflection
Institutionalized is a first person commentary on the connection between social structure and mental illness. The lyrics describe a circular relationship between a youthful protagonist “Mike”, and the social and cultural institutions in his ecological system. Society, personified by his parents, judges Mike as being crazy despite the fact that he attended “your schools...your churches... your institutional learning facilities”. Compounding this fact is that the solution for Mike’s mental illness is to return him to the same institutions that have contributed to his problems. It is clear that social structures contribute to the fact that Mike is “having a lot of problems” and needs to be “protected from the enemy, myself”. Contradictorily, without the protection of these institutions it is feared he may “hurt somebody” or “hurt yourself”. Thus, the song clearly enunciates a connection between social institutions, mental illness and suicidal behaviour.
Upon reflection, this assessment has enabled me to see the connections between the socio-cultural environment and the behaviour of an individual. It has also highlighted the importance of the relational effects of distal social structures and cultural ideologies to behaviour at the individual level. Suicide is costly in human, social and economic terms and is preventable. It is also not solely contained within the individual but the result of many levels of risk and protective factors which must be examined when attempting to tackle suicide on both personal and national public health levels.
Living Is For Everyone
Lifeline Crisis Support
Australian Institute for Suicide Research and Prevention
Australian Institute of Health and Welfare - Mental Health Data
Society for Human Ecology
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Comments on other Wikis
comment on ‘Face of Evil’ – the stigma associated with mental illness
I was highly interested in your examination of the stigma surrounding Mental Illness using Attribution theory. My understanding of attribution theory is that it is a model of how an individual assigns reasons for the behaviour of others. I previously had not thought about the impact that macro-cultural processes have on the way we explain another person’s behaviour. It makes great sense that in individualistic Western nations, such as Australia, responsibility for actions is more often located as part of the internal workings of a person – a personality trait or chemical imbalance – rather than the result of many situational and societal factors. It is easy to see how internal attributions combined with societal group inclusion pressures results in generalised stereotypes of the Mentally Ill and stigmatisation and leads to a self-fulfilling spiral for both the mentally ill person and the perpetrators of the prejudice.
Comment on what John Stuart Mill has to teach Doctor Cox from Scrubs
The question of personal agency is very relevant to the doctor-patient relationship especially in Australia, which is very heavily invested in the western biomedical model of health. Power tends to be very unevenly distributed in this relationship based as it were on the assumption of greater knowledge and experience. I found your discussion of John Stuart Mill’s view of Agency to health – that an individual is responsible for and has the power to make their own health decisions even if they may not be ‘right’, and the doctor’s (as a representation of society) responsibility to accept (or not accept) this decision – highly interesting. I was also intrigued by your examination of the implications for doctors of online health information in increasing personal agency and reducing or levelling the power distribution in the doctor-patient relationship.
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