MIND MOVES: Today is the birthday of Lucia, James Joyce's only daughter. Her experience of schizophrenia was a tremendous source of distress for Joyce, who felt utter despair and helplessness over her symptoms and fell out with Carl Jung over her treatment, which he regarded as a "calamitous failure".
Lucia's memory is marked today by Schizophrenia Ireland (SI), which has designated this week 'Lucia Week' with events nationwide highlighting the needs of schizophrenia sufferers and their families.
The theme of this year's awareness campaign is suicide prevention. People who experience schizophrenia - which is characterised by acute episodes of hallucinations, delusions and frightening mental turmoil interspersed with periods of emotional withdrawal and isolation - are 40 times more vulnerable to taking their own lives than people who do not experience this particular form of human suffering.
Disturbing statistics and numerous reports have recently made suicide a major public health concern. Whereas the majority of people who die by suicide are not within the mental healthcare net, a fact we may deeply regret afterwards, the majority of people with schizophrenia are already in the care of services. Yet 10 per cent of them die by suicide.
These statistics understandably cause concern among service users and their families. SI's publication, launched today, Supporting Life: Suicide prevention for mental health care service users, explores the circumstances and the reasons why someone with schizophrenia might choose suicide, and identifies what the services can do to offer them more meaningful options.
We already know that people who take their lives by suicide often do so because they reach a point where they feel trapped by their particular suffering, and see no possibility of being able to escape their predicament.
The intense psychological distress we call schizophrenia can leave people feeling trapped and stigmatised. Some sufferers cope with these feelings and overcome them, but some do not. Identifying those most at risk should direct us to talk to them about their real difficulties and prevent problems escalating to a point where they view self-harm as their only means of ending the pain.
Research has identified the mental health service users who are most at risk - young, male, with an illness characterised by repeated lapses and short hospitalisations, and a high IQ are features that typify those who take their lives. In addition, there are certain times when these people are more at risk than at other times, notably during their hospital admissions or in the weeks directly following discharge.
For some service users, their sense of mistrust becomes so intense that they feel painfully isolated. During the brief periods when their paranoia takes a commanding hold over them, medication may be the most critical intervention. But there is also a need to engage with them when the crisis has passed and help them make sense of their thoughts and feelings. Cognitive therapy has proven itself to be one therapeutic approach that can empower a service user to manage some of the more disturbing experiences of schizophrenia and recover their sense of self.
Repeated hospitalisations often reflect non-compliance with medication resulting from the service user's difficulty in accepting they have a problem or from seeing any possibility of recovery from it. Those with high intelligence and insight may see a future unfolding before them where their lives are limited in painful ways by the experience of schizophrenia. They may require an opportunity to grieve the life they may have wanted for themselves, their crushed dreams, and to build a different vision of what is still possible.
Adopting this 'recovery' approach means being realistic about what has been lost, but also conveying a strong message that the experience of schizophrenia is never the whole story for any person. There is still a life to be lived.
Finally, research has shown that the time of greatest risk for suicidal behaviour is during, or immediately after, hospital admission. This finding highlights the need to engage sufferers in realistic care planning as soon as possible following their admission. Having a plan, particularly one that you personally have helped construct, gives a person a feeling of hope that something good can happen, even when things feel chaotic. This plan needs to take into account what the service user wants to achieve and to address the practical problems that are making it hard for them to find their place in the world. In the immediate aftermath of discharge, intensive community support may be critical to ease their transition back 'home' and to strengthen protective relationships in their lives that will carry them through inevitable setbacks.
SI is committed to ensuring the best quality services for its members. It is to be commended for bringing the issue of suicide prevention in this very vulnerable group to our attention. Let's hope one outcome of Lucia Week will be that service providers will think more sensitively about the real needs of service users, and ensure that the issue of suicide risk is considered and addressed across all services.
Tony Bates is principal psychologist at St James's Hospital, Dublin. He has written the introduction to Schizophrenia Ireland's suicide prevention pamphlet, Supporting Life.
