JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Tuesday, 7 Sep 2010

Suicide in Ireland: Discussion

Chairman

I welcome Professor Kevin Malone, professor of psychiatry and mental health research, St. Vincent's University Hospital and Mr. Séamus McGuinness, artist. Before proceedings commence, I advise that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of the evidence they give to the joint committee. If they are directed by the committee to cease giving evidence on a particular matter and continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against a person or persons or entity by name or in such a way as to make him, her or it identifiable.

Members look forward to the presentation about which we have heard positive comment. I understand Professor Malone and Mr. McGuinness will speak for approximately 20 minutes, after which we will have a series of questions from members. Questions will be grouped to ensure we proceed in the most efficient manner possible in the time available to us. Members appreciate the serious nature of the issues under discussion.

Professor Kevin Malone

I thank the Chairman and joint committee for inviting us to make a presentation today. I understand the invitation was made following a public presentation Mr. McGuinness and I gave on our work on suicide in Ireland to the College of Physicians just down the street in May last. Rather than present old or, if one likes, rehashed data, we wanted to present data that was live, new and compelling and which had come about through engagement, consultation and permission — informed consent — with families who had been bereaved by suicide in Ireland in recent years. The presentation represented a journey from a private story in people's kitchens into the public space of the College of Physicians. We are grateful for the invitation to do so again before the Houses of the Oireachtas.

Suicide is a traumatic loss which results, through our learning, in the deceased and the bereaved, the lived life and the lost life. Throughout our research we are acutely aware that we are not dealing with stocks and shares or commodities but with lived lives which have been lost to suicide. What can Irish research do in this field? Mr. McGuinness and I have recently returned from a major international suicide conference that is convened in Europe once every two years. We made five presentations at the conference but we do not propose to present our recent genetic findings, suicide modelling work, the paracetamol story or the waterways and railways studies in which we have been involved. Instead, we will present the family stories of the lived life and lost life, which were created through a unique collaborative science-arts project with bereaved families in the past 12 months, which I predict will have an international impact and implications.

At the conference, which was attended by representatives from Europe and all over the world, there was nothing remotely like the presentation, of which the joint committee will be given a brief excerpt today. This is a project about bringing the private, traumatic loss of suicide from the kitchen tables around Ireland into the public domain through informed consent, collaboration, dialogue and conversations. The point is to create a meaningful platform to discuss and articulate this loss in a place beyond stigma. Two short five-minute movies in the presentation present the voice of the families, which must be heard.

To put the issue in context, suicide is a global public health issue. Globally, someone dies from suicide every 40 seconds. The image on the bottom left of the slide represents suicide rates in Ireland for all ages in 2006, the most recent year for which official statistics are available Europe wide. Although Ireland is ranked 18th out of 25 countries in suicide incidence, unfortunately it is fourth in the area of youth suicide rates — the 15 to 24 year old age group — behind Lithuania, Finland and Estonia. Ten years ago, the Finnish youth suicide rate was ten points higher than in the most recent figure, which shows Finland has tackled the problem. Much can be learned from the manner in which it did so.

Moving on to the project we decided to undertake, internationally one way of understanding more about suicide is to conduct psychological autopsies, that is, talking to next-of-kin. We decided we did not want to approach this issue in a "me too" fashion, in other words, by simply doing what had been done in other countries. It was clear from the international conference that factors in suicide and suicide risk groups vary from country to country and community to community. We, in Ireland, have a large knowledge gap because very little research has been done either nationally or at a community level to understand more about suicide. Prior to our study, no systematic type of study had been done in which one spoke to relatives and consulted families and friends of suicide deceased to gain new knowledge and understanding via clinical science. Internationally, a study integrating science and arts had not yet been done. For this reason, such a study seemed the obvious thing to do.

Much has been made of the increase in suicide rates in recent years. Sometimes one is criticised for presenting raw numbers as opposed to rates per 100,000. However, the raw numbers are somewhat more compelling in that Ireland is not getting any larger but more suicide deaths are taking place in the same area of land. Therefore, the reverberations and fallout from an increase in suicide deaths will be felt more acutely in small communities such as those that we have in Ireland.

I draw attention to two lines on the slide, the top red line which is the combination of suicide and undetermined deaths in Ireland, and the bottom orange line which is the undetermined deaths as reported in Ireland over the past 30 years. These show that on average ten undetermined deaths were reported per annum in the 1990s. In 2009, more than 160 undetermined suicide deaths were reported. We have done a coroners' study of 400 coroners' cases of suicide and open verdict. Despite a suicide note featuring in at least 20% of the open verdict or undetermined deaths, the coroner in the case returned an open verdict, in other words, in his or her estimation, it could not be determined beyond reasonable doubt that the death was a suicide. The top line adds the suicide rate with the undetermined rate. One can see the blue line represents what has been referred to recently, namely, the 527 suicide deaths in 2009. If the suicide and undetermined deaths are added it comes to 709 suicide and open verdicts in 2009. Can we sit idly by while this is happening?

This is a study that I referred to. We started out with great assistance from a couple of coroners, from whom we got 400 suicide and open verdicts. We decided to interview a sub-group of those, 104, and talked to the relatives of the suicide bereaved, focusing in particular on young suicide death where the problem has been identified. That was the plan we started out with, until I met Mr. Seamus McGuinness, who is an artist in Galway Institute of Technology. He created this piece of work in 2003 and I had the privilege of seeing it when it was installed in his home in Ballyvaughan. He explained it to me just like he is going to explain it to the committee now and it made complete sense for us to join forces, as it did for him.

Mr. Séamus McGuinness

Good afternoon. I should like to extend a special word of thanks to Ms Liz McCormack in the Public Gallery. Without families such as hers the research would not have happened. It was really through speaking to people in their homes that we have got this much material. The piece members will see in front of them is called "21 Grams". It was a piece of work I made in 2003 and it consisted of in excess — and I use the word carefully — of 92 short fragments that weighed 21 grams, which is the mythical weight of the soul. This was very important to me, as an artist, because it gave me a tangible form through which to describe something very intangible, namely, suicide. I was working independently at the time and I met Professor Malone at a conference in 2004. I am still unsure whether that was a good thing. We discovered we were researching the same things, one through the language of science and one through the language of art. We continued our conversation over the next year and the upshot was that I completed a PhD in the school of medicine where I was working on this project.

Professor Kevin Malone

Yes. It took four years and this is one of the first outings of this data. The final model was like this, where a sub-group of the psychobiographical autopsy study also agreed to take part in the visual arts autopsy study. In other words 62 families agreed to take part out of the 104.

People still wonder how we did it, but one can see that there are similarities with regard to our methodology. The science approach was conversation and semi-structured interviews which allowed a certain amount of analysis. We adopted a model where we invited people to come forward with their stories if they had lost anyone to suicide between 2003-08, under the age of 35. Therefore it was a naturalistic type model. Of course one had to go before an ethics committee to obtain permission to do this type of study, and to get formal consent. As regards the approach I was taking, there was confidentiality and anonymity and therefore no names could be disclosed at any point in the publication etc. In the art world——

Mr. Séamus McGuinness

In the art world we encountered many institutional hurdles in this process. A family would give me a photograph of the child when I first visited the home, and that meant the identity of the family was compromised. That is a central plank of this research. It was not about cold anonymous statistics but rather about the individual life that was lost and the aftermath of trying to deal with that. The process of negotiation with the ethics committee was very helpful and eventually we got permission to proceed on the basis that we could use identity in the research. It is the first time in the history of St. Vincent's Hospital that a medical ethics committee has given such permission.

Professor Kevin Malone

This came about through a member of the public who had been bereaved by suicide addressing the ethics committee and informing it what it was like to be so bereaved and not permitting the identity to be part of the research.

Mr. Séamus McGuinness

Essentially, our question to the committee was: "What is your right to tell me what I can or cannot put into the public domain?" It was quite an interesting conversation.

Professor Kevin Malone

It was also deemed to be of great interest at the international conference we attended recently. We interview most of these families in their homes. Obviously I was collecting data, so there was a clipboard component. The first period of time with all the families comprised an open-ended conversation which ended up in very rich narrative. With regard to all the families, bereavement counselling was made available, or they were pointed in the direction of bereavement counselling. Obviously we are now engaged in quantitative and qualitative analysis, and there will be impacts as we go forward. I believe it is similar in the world of art.

We examined 400 coroners' cases and interviewed 220 relatives, mostly in their homes, about the lived lives of 104 suicide victims from 23 counties in Ireland. I also interviewed 104 suicide attempters as part of a different study. The methodology again took about four hours per case. We never interviewed more than one family in a day, because when we went to the homes we left when they kicked us out. It was not a case of saying in effect: "We are off to the next one now. I am sorry, but we have got to go." That approach was important for the families and it was probably important for avoiding burn-out, on our part as well.

Then, the visual art autopsy approach comprised an open invitation to families to donate images, belongings and writings, anything associated with the lived life. In other words, it was not prescriptive. Would Mr. McGuinness agree?

Mr. Séamus McGuinness

Yes, I would.

Professor Kevin Malone

We will not have time to show the committee the couple of movies that are part of this, so I am not going to dwell on the statistics. However, two-thirds of our sample were under the age of 30 and 36 of them were under 21. Again, in international terms as regards doing this in-depth type of review, that is a large population to study in detail. As one might expect, there was an excess of males, about five to one and the majority of these were single, half of them with no leaving certificate. In terms of their suicidal features, half of them had made no previous suicide attempt. Interestingly some 59 had been exposed to some type of suicide in the three months prior to their deaths, and 70% had communicated their suicidal ideas in the month prior to their deaths. Therefore these deaths did not really come out of the blue. Most of them died by hanging and half died in their homes, particularly the younger people, which is not typical in the international literature.

Some 12 of the cases we interviewed involved people that were part of larger clusters which we will refer to in subsequent studies. On the right hand side one can see, in terms of their recent suicidality, that in one third of cases none was detected, whereas two-thirds or 68 out of 98 either had mild, moderate or severe suicidal ideation.

Very briefly, before we move on to the visual arts data, emerging themes that we now have to drill into, such as humiliation by bullying, assault or mugging, occurred in almost a quarter of the youth suicide deaths. Again, I mentioned the clusters. Half of them involved a relationship break-up within a month of death, 16 out of 36 involved substantial alcohol use — which means that alcohol was a factor in some deaths, but not in others — and five had severe mental illness.

As regards the stigma of mental health services, I am not going there. I shall kill myself before going there, but this has come out in several of the narratives.

Mr. Séamus McGuinness

One of my aims when I was working with the official art autopsy, the name I coined, was to try to find out what could be learned from lay knowledge, once the data that could be gleaned from medical and clinical knowledge had been gleaned. What could we learn from the people who knew the victims? This took two forms. I asked the families if they could donate anything belonging to their deceased children in terms of writings, images or clothing. The deal was that I should make art works with these and then we would have a private exhibition for the families only, when they could decide whether these could go into the public domain. It was a question of meeting people half way because they were putting an enormous amount of trust in me, and I wanted them to be able to decide whether this exhibition work could go forward. Following that, when we got family approval we started to enter into the public domain.

This is one of the first pieces. If one looks inside this building one sees that this a round portrait gallery. As regards the images in the background, I made a jacquard portrait from any images given by the families and these were installed in this room in life-size. We started with the youngest member, Rebecca, at 14 and went around. Each jacquard, as the committee can see, was installed at the height of the deceased. The images were generally installed in terms of age, but sometimes that was interrupted. For example, James and Harry were interrupted because they were brothers and the mother asked us to install them together.

I shall play a little movie now.

The joint committee viewed an audio-visual presentation

I am an artist, and I am trying to articulate a language that gets around the stigma of talking about suicide because in Ireland we cannot yet articulate that language. This extract from the movie shows family members coming to view the tapestries for the first time.

All the families had an opportunity to come together in Galway to view the works over a four day period last year and to decided whether they wanted them to be released into the wider public domain. At that stage I was quite prepared to scrap all these works if the families decided not to release them, because as members will have seen, the works are intimate and emotive and address the question of what it is like to be present to the pain of others.

Professor Kevin Malone

We invited all of the families who had engaged privately with the work to write to us in due course and let us know how they felt about them. The final lady in the last movie clip in the course of her reply to us wrote:

The most profound part of this Visual Arts Autopsy for me was when I went into the circular white room.... I stood in front of her and I put my hands either side of her face. There was nobody in the world but us... I kissed her and walked out of the circular room and stood outside looking in at her for what seemed like an age . Three days later, I still feel healing and warmth. I felt the best I have felt in 5 years, since my beloved 1st born child Fiona handed her life back to God. My block of ice in my chest is thawing.

One of the other ladies, the mother of John aged 24 years, wrote:

I will never forget being in Galway and being able to touch the tapestry. I could feel John ...- at last and touch his precious face. The textures of his hair, the shape of his nose... the light stubble on his chin and ears (that always needed a touch of sunblock in the sunshine to stop them getting burnt).

Mr. Séamus McGuinness

Further on, Rosemary, John's mother says: "I couldn't touch John's body when he died.... I just couldn't. Being able to touch the tapestry of John allowed me to say goodbye to my beautiful boy."

In many ways, these works had a cathartic effect on the families, although that was not the prime focus of the study. The main focus of the study was to bring the culture of awareness that we read about in the newspapers and transform awareness into action. We are trying to challenge society on the way it views those who die by suicide, as we can no longer view them as cold statistics. That model is not working. After all the families viewed the work, and we had their permission to bring this work into the public domain, we then asked ourselves what we should do next. This is a democratic process in every way and we always revert to the families and act on their wishes. This next clip, No. 2, shows the conversation that came up in the discussion with families.

Once we had the family's permission to take it into the public domain, we received an invitation from the Royal College of Physicians down the road to present at one of their series of public meetings, and this happened at the beginning of May, where we met Senator White. We agreed to do the presentation if we could bring the artwork into the building, so we constructed the round portrait room in one of the rooms and installed all the works there.

The works create a platform that crosses a chasm and allows people to imagine those who die by suicide as people. It might be their son or brother, so a direct link is made and this is no longer an anonymous statistic, but a life.

Professor Kevin Malone

There was a roof in the movie of the Lost Portrait Gallery in Galway, but Mr. McGuinness decided to leave the roof off in the installation at the Royal College of Physicians in Ireland, so members can see from the presentation some of the greats of Irish medicine from the past looking in at a modern tragedy. It would be great if we had their wisdom when tackling this problem.

Mr. Séamus McGuinness

We have these sites of mourning. My background is in cloth, and we all have a particular relationship with cloth. These are paintings and sculptures in the traditional form, and there is a barrier because we have been taught from an early age not to touch art. I believe that art is not about what it is, but what it can do. There was much touching of the fabric and saying "goodbye" and so on. This is known as new public art practice, and it is not about art that can be traded as a commodity in the market, but about what art can contribute to society.

Professor Kevin Malone

When President McAleese stepped inside this space, she went to touch the tapestries and said it was a strong metaphor when compared with the "do not touch" stigma that we associate with suicide. That was very eloquently put.

Mr. Séamus McGuinness

Caroline's mother and her friend came back three or four times.

We always invite feedback from every presentation we do. When we go to art galleries to see an exhibition, someone might hand us a glass of champagne, everything is lovely, we walk around and we talk to our friends. In this process, everybody is asked to contribute through the feedback forms and are questions such as whether the exhibition should be seen by under 16s, under 14s and so on. We placed a ballot box at the exit and we received enormous feedback. We wanted to hear what the public thought about it and we got some powerful comments. One person said that she found it very cathartic, as somebody who has had suicidal thoughts.

Professor Kevin Malone

Five hundred people came to the public lecture, and almost 200 of them made comments. We thought there would be just box ticking and a couple of comments, but there was frantic scribbling all over the place as people were writing down what they thought. The following are some of the comments. "Am I dreaming — such beautiful faces, such humanity I have never experienced". Another person said "...I feel empty but not lacking". A Cork woman said "Rendering a Cork woman speechless by the powerful but cathartic evening is a rare event. But it will push me to have many conversations henceforth with families, friends and patients". It was also described as "a powerful and visceral articulation of the unspeakable". Another stated: "Merging science and the arts is a wonderful concept...Can be seen by the impact it had on participants" and another referred to a "very honest means of engagement... real discourse and dialogue". That is what we are trying to generate. Other comments were: "For me it was heartaching, seeing free-flowing emotion, I cannot help but fall into that space", "The silent connection was powerful. To be vulnerable and safe in that vulnerability is the beginning of healing and bringing it to the world" and:

This shows something often overlooked. The loss and sorrow of families left behind. It was a wonderful feeling to stand side by side with people in this room. It needs to be felt, thought about, and of course discussed. It may really cause a person thinking about suicide to see the whole picture and prevent another suicide death.

This work cannot be done without a whole team. Mr. McGuinness and I are the front men but we have many people who are generous with their time and energy. I draw the attention of the committee to Console, which provided bereavement support throughout the project and at the public engagement. I refer to the 104 Lived Lives families, without whom we would not be here today. This work is expensive though not inordinately so when one considers the cost of every lost life. Funding has come for the most part from Turning the tide of Suicide, the national lottery, the National Office for Suicide Prevention, the Ireland Fund and Mr. Denis Kelleher, the Be Not Afraid campaign, ESB Electric Aid, the Pádraig Harrington Foundation, the Community Foundation for Ireland and Culture Ireland. I thank the Chairman and members for their attention and I look forward to the members' questions.

Mr. Séamus McGuinness

I thank the committee.

Chairman

It will be hard to follow that. I thank the delegates. I propose breaking with protocol because Deputy O'Hanlon must leave us. If Deputy Neville accepts, I will call him first.

Deputy Rory O’Hanlon

I will be staying.

Deputy Dan Neville

I thank the delegates for their presentation. I want to recognise the research and work and the exposé of this issue by Professor Kevin Malone over a number of years. Once we start speaking about this topic we become emotional so it is difficult to remain objective. I told Senator White that I received a phone call last Friday from a young person starting a job as a teacher. She wanted the Garda vetting office in Thurles to clear her application. I telephoned the Garda vetting office and it returned my call on Monday, saying there was no problem but it wanted her date of birth. As we were about to contact her for her date of birth, we saw her death notice. We rang the undertaker and he said she went to Ballybunion and took her life by jumping off a cliff.

Six weeks ago, in Newcastle West, a young man of 32 years of age, with four children, found his wife hanging. She had some problems. He returned to his home in Sixmilebridge with his four children and hanged himself. That is the extent of the issue we are dealing with. It is an emotive issue and I find it hard to respond to the emotive aspects presented other than to understand it from my work and to say we want more of it. How do we address this with the broader public? The State invests more than €4 million in suicide prevention and €40 million on road deaths prevention. That sum is not enough for road death prevention and this is not a criticism of that funding. How do we move this topic forward and how do we get the political process to recognise that this is a serious issue that must be funded and resourced other than through voluntary bodies? That question is directed to Professor Malone.

I spoke recently at the conference referred to by Professor Malone. How do we challenge the State, which took care of TB and cancer, to take care of mental illness and suicide prevention in the same way? That is the challenge that faces us. It can be done but I do not know when. Does Professor Malone have views on how to challenge the State to recognise this is a serious social issue and people are suffering in the way illustrated by the presentation? Every week I see people suffering from this. They contact me from around the country. It is most upsetting that people anticipating death by suicide want help but do not get it. How do we challenge that situation and move it forward as fast as we can? It can be done within 30 or 40 years but how can we do it in ten years?

Chairman

We will take a number of speakers together.

Senator Phil Prendergast

I thank the delegates for their presentation. Like Deputy Neville, I attended a conference with world experts on suicide. The range of stories we heard was astounding. The aspect of today's presentation that I find different is showing the art and how real it is. We tend to deal in statistics and this does not involve numbers but people and families. It is made extraordinarily clear how it could be cathartic for people in healing process. The major question raised by Deputy Neville is that we need to change numbers and make something available to people that will prevent this.

I also attended the 12th symposium in Glasgow. There was a postcard and text system, which is not costly. We could join a few models together so that we do something to increase awareness. We know so many families that have been bereaved because of the recession. It has caused undue heartache and it will be a long time before people get over it. This was an emotive presentation and brilliantly done. I hope we can work to prevent suicide. South Tipperary has the highest rural suicide rate in the country. This is not a statistic I am delighted to tell the committee about. It is a real subject.

Senator Mary M. White

Along with Senator Prendergast and Deputy Neville, I attended a conference in Rome last week. World experts attended and I am very proud of Professor Malone and Mr. McGuinness for their participation. How does one experience the agony of feeling so hopeless? How does a person feel? How does one get into the hearts and minds of people who feel so hopeless that they want to take their own lives? It is very difficult if one has not experienced it. How do we feel for the families' anguish when we have not felt it? That point was made last week, when a top psychiatrist, having never experienced schizophrenia, asked how to help a schizophrenic person. As was stated by one of the ladies, we have to get beyond cold statistics and there is no doubt this presentation of human emotion could be a catalyst if it were shown to more people throughout the country. The families clearly stated that they were helped by the ability to caress the faces of their loved ones who died.

We have health campaigns for issues and every day we hear on the radio about reducing the number of heart attacks and road deaths, and reducing these is a priority for the Government. However, despite the fact that more people die by suicide than by road accidents every year and that an increasing number of people are dying from suicide and self-harm it still has not hit the political radar that this must be prioritised and that the families whose loved ones die from suicide need urgent help. This is an opportunity for every member of the committee to support Professor Malone and Mr. McGuinness. I also thank Ms Liz McCormack for inviting me to the exhibition in the Royal College of Physicians in Ireland; it would be good to share it with committee members.

Friday is national suicide prevention day and we can all spread the word that each one of us can help people who are suffering. One can look for signs. Not everybody shows pain on his or her face but in many cases it can be seen and that pain can be shared. I want the issues of suicide and self-harm to have the same level of energy from the Government as other major health issues. People are dying unnecessarily. Last week, it was stressed that many deaths by suicide can be prevented.

When we returned from Rome on Saturday night I watched Charlie Rose on Bloomberg, who was speaking to a Nobel laureate in physiology, Professor Kandel. Also on the programme were two top female psychiatrists in the United States, one of whom is bipolar and the other of whom is schizophrenic. They have reached the highest levels in their profession and are able to do their jobs because they received help, counselling, psychotherapy and medication. The number of people suffering from depression or mental illness here who cannot get help because they do not have the money to do so kills me. There is a very long waiting list for those who are poor. I do not want to go on and on but the committee needs to put this issue on the radar. I very much appreciate the presentation by Mr. McGuinness and Professor Malone; it was very moving.

No matter what group of three or four people I sit with socially, the chances are that one of them has a family member who died by suicide. It is very common. The point was also made last week that the figure of 1 million a year dying by suicide is an under estimation.

Deputy Kathleen Lynch

I thank both delegates. At the best of times I find these issues difficult to take. To a great extent, the reason we do not speak about suicide is that it is every parent's nightmare and if we do not speak about it perhaps it will not touch us, but of course this is not true. Finland's experience should give us all hope and that is where the committee has a part to play; the numbers can be reduced and people can be talked over the hurdle of that hopelessness which brings people to suicide. It is about encouraging people to come forward to speak to someone. It does not have to be someone as qualified as Professor Malone, it is just to speak to someone and say how hopeless one feels and that one feels it is pointless to go on.

Several years ago I was involved with a friend whose son had very bad epilepsy. I always remember the first time we went collecting funds; she asked where we would go. I suggested that we stand outside the bank and that we would tell anyone who asked us what we were collecting for. At that time one did not speak about epilepsy; one spoke about people having a fit or a little episode. We should speak about issues and explain them to people, particularly young people with whom we must start. We talk to them about the devastation that something like this causes, not only in the family but in the community, and we have all been there. We all know of young lads and young girls who caused this type of devastation in communities.

When it comes to early childhood development, the guru in the United States says that the greatest gift one can give one's child is an optimistic outlook on life. We should start there, and speak to our very young about optimism, and tell them no matter how bad things seem there is always hope. We should examine the Finnish experience and seriously consider how they did it and what we need to do to get the same results. The exhibition probably started the process of realisation that we need to talk about this issue. It can no longer be hidden away as it is having too big an effect on communities. We need to talk loudly about it and explode the myth. We should argue that it should not happen, and that in itself will probably start the process of reducing the numbers.

Deputy Rory O’Hanlon

I thank the delegates for a very good presentation. I appreciate very much the good work they do. The slides show that we are at the bottom of the European league for the general population but we are fourth from the top for 15 to 24 year olds. Do the delegates have any views on why this should be? One of the slides mentions 40% at the first attempt and the number of those who communicate and who are exposed to suicide.

I have several questions on prevention. What do the delegates see as the priority needs? What further measures would they like the Government and State agencies to take? If the organisation of which they are a part had more funding, what priority measures would they take?

Deputy Jan O’Sullivan

I thank both delegates for their presentation. As Senator Mary M. White said, this committee must move this process forward in whatever way it can. We have to raise the issue and try to take away the stigma.

The tactile element of the exhibition was extraordinary and it was remarkable to see how many people touched the exhibits and the faces of their loved ones. I had not realised the exhibition was material in this way and the amount of touching was extraordinary. One lady put her two hands on either side. Can Mr. McGuinness explain what we can learn from that? Can he explain the healing power of being able to touch?

As Deputy O'Hanlon said, in Ireland the statistics are heavily weighted towards younger people, in contrast to other countries. I was struck by one of the mothers in the film, who said her child had gone to a hospital twice but had been turned away without receiving help. I recently visited the Jigsaw project in Galway, which was excellent. It was held on the street in the middle of the city and one could walk in and self-refer. It was linked into schools and doctors in the area, as well as the general health services. One did not have to wait long for somebody to listen and counsellors were available as well as doctors. Do the delegates feel the Jigsaw project is a good example of appropriate intervention? Are there other projects where young people feel they can go if they are under stress, as a result of bullying or other things which contribute to their contemplating suicide? What should we do, in practical terms, to provide a place where young people can go? A public response to their cries for help should be a priority. When a young person takes his or her life, he or she is gone forever. It is important to get the message across to such people that there is somewhere they can go. They need to understand that there are alternatives, even if they are in terrible despair.

Deputy Beverley Flynn

I welcome the delegates and thank them for a powerful and emotive presentation. I come from County Mayo where there have been incidents of cluster suicides, especially involving young boys. These suicides have upset everyone in the county and caused a huge amount of concern about how we might deal with it. Some schools have put in place chaplaincy services so that young people can talk to someone and the HSE monitors Bebo sites. We are trying to prevent suicide and to bring the numbers down because the figures are startling. As Deputy O'Hanlon mentioned, we are the fourth lowest in the table for older suicides but the story is very different for youth suicides. Other countries at the bottom of the ladder for older suicides are also at the bottom for youth suicides but such a trend does not seem to be followed in Ireland. What is the reason for that?

I know a family who recently lost their 15-year-old son to suicide. The delegates interviewed 36 bereaved families and there always seemed to be a reason, such as bullying or assault. In contrast, when I meet the families of young people who have committed suicide there seems to have been no indication of what was to come. Perhaps this is typical of the immediate reaction to a suicide but it appears to come out of the blue and nobody seems to know why it happened. The young person is described as having been happy only hours previously. If suicide comes as a bolt from the blue in this way, how can we ever prevent it? Are there early signals which we can look out for? How can we train medical staff and teachers to be alert to those signals? It is a complex area and most people know nothing about it.

People are a bit frightened by suicide and even I am afraid to talk about it openly. I do not want to upset a family which has lost somebody through suicide by saying the wrong thing. When one goes to a family to sympathise after somebody has committed suicide, what is the appropriate thing to say? It is very difficult to know when one does not understand it.

I did not know what today's presentation would involve and it was certainly not what I had expected. I had expected a clinical analysis and some practical solutions but the art in the presentation opened my mind. Is there a plan to bring the exhibition to schools, particularly those where there has been an incidence of cluster suicides? I compliment the families who participated. They are extremely brave to open their emotions to public view and I have total admiration for them.

Deputy Margaret Conlon

I welcome Professor Malone and Mr. McGuinness. I found the presentation very moving and was struck by the tactile element. When a family loses a member to suicide the days that follow are so busy that they pass in a haze. For many people the grieving does not start until later and the ability to touch and feel helps them in that process.

There is still a stigma around mental illness. The Minister of State at the Department of Health and Children, Deputy John Moloney, is doing great work to bring about a sea change in this area so that mental illness is treated like any other illness. A person who suffers should receive treatment and recover in exactly the same way as those with other illnesses so that, as Senator Mary White said, he or she can go on to do wonderful things.

This weekend I spoke to a girl who is in the depths of despair. She told me she self-harmed, not because she wanted to kill herself but to release the pain she felt inside. She said she hated herself and her life and felt that self-harming gave her an outlet. I asked what would happen to her if it went wrong and she only said "It won't". Some people do this because they believe they are not doing any real harm to themselves, but they are afraid to talk to people about it or otherwise look for help. I hope she will now receive help.

Many years ago, when I started in Fianna Fáil by attending Ógra Fianna Fáil meetings, Deputy O'Hanlon said that one thing which had to be on the agenda of every meeting was the promotion of positive mental health. It should be something people talked about openly and people should know there was a place where positive mental health was promoted. The schools play a role and much more can be done. In the school where I taught, we introduced the "Know Yourself" programme, which was hugely important in promoting positive mental health and helping young people. There is a tendency, particularly among young boys, to hold everything in; it is not considered macho to talk about feelings and sharing emotions, it is just not the done thing. Girls find it easier to do. We must break down that barrier.

Sometimes young people issue veiled threats that they may not necessarily carry out, but there is a chance they may. It is difficult because families are walking a fine line and find it hard to cope with a young person who might say he will not be seen again if he cannot go to the disco on Friday. It happens and it is upsetting for families while they must try to maintain a balance. The lines of communication are important. Parents do not have the skills needed to deal with teenagers as they grow up. A parent is given the baby, goes home and learns as she goes along. There is no programme to show people how to do the right thing. It is something we need.

The "See Change" programme, when it is fully rolled out, will help to remove some of the stigma surrounding mental health because there is nothing better for young people than role models, people they admire in sport or music. They often listen to them far more than they listen to parents or politicians. Someone told me Jedward were on "The Late Late Show" on Friday night and they said they were positive and wanted to send a positive message out to young people; that is what we need, more positivity in mental health.

Deputy Caoimhghín Ó Caoláin

I could not follow Jedward. I thank the delegates for the presentation. It was thought provoking — the whole presentation and role of the bereaved in finding strength in the art work developed by Mr. McGuinness was touching to see. What we have been exposed to this afternoon has an important and direct role in helping people come to terms with their loss, and certainly a role in coping with bereavement through suicide.

I wonder about the impact on younger, non-suicide experienced family members. Would this have a role in terms of prevention, which is the bigger challenge? Helping people to deal with loss is a hugely important part of all of the areas that must be addressed but it is impossible to know where prevention really has occurred; statistics may be the only indicator. Could Professor Malone or Mr. McGuinness offer their view of the expectation and evaluation of the project in terms of its role as part and parcel of the wider address of suicide prevention?

There are no simple answers and we have all been exposed as elected representatives to suicide as a result of crises of confidence, despair and loss of self-esteem. As Deputy Neville said, there can be a snap and, without any advance signal, an immediate reaction. One can never be prepared for that, it is so very difficult.

We all have a role to play in this. Being a friend is a good place to start, but has the National Suicide Prevention Office or any of the other working groups analysed the statistics? Ireland is placed fourth from the top of the table in 15 to 24 year olds. What are the triggers? Has there been any analysis of any of the cohorts of suicides over a period of time that would indicate a common denominator in some proportion of cases that would help in the direction of Government and social thinking on how to best direct support and assistance?

Chairman

I join members in thanking Professor Malone and Mr. McGuinness for the presentation. We hear many presentations here but we have never heard or seen one quite like this. It has evoked enormous interest from members. Watching the presentation was very moving and I can only imagine what it would have been like to have been in that circular room and to experience what was being conveyed. The work is powerful.

What I saw on the screen was the frightful waste of the potential of those wonderful lives and the unremitting grief and pain of those left behind. Following Deputy Ó Caoláin's remarks, is there anything in the studies, including the interviews with the 104 who had unsuccessfully attempted suicide, that indicates that if we could communicate to these people the awfulness of the aftermath of this decision in terms of the waste of potential and the unremitting tragedy for families, this could be a preventative initiative? That is something to which I would like the representatives to refer if they can.

We hear much general discourse now about the impact of the economic position on suicide, and obviously it has an impact, but when we look back to the days of the Celtic tiger and the time of plenty, we still had a frightful plague here. There is a multiplicity of factors at play, therefore. I ask the representatives to comment on the ready availability now on every street in every village and community of all sorts of hallucinogenic substances that young people can readily access. They show clearly in their report that alcohol is a major contributory factor to the problem but to what extent is that exacerbated by other substances that are so readily available? Young people appear to be oblivious of their impact despite the publicity and media campaigns on the consequences of taking them. I have asked many questions but the representatives might synopsise responses to them as best they can.

Professor Kevin Malone

Neither of us will start because there is a person who was in the Lost Portraits gallery who experienced it at a personal level. She is in the audience and if she is willing to speak——

Chairman

Is she willing to come forward and talk to us? We do not want to put her on the spot.

Mr. Seamus McGuinness

This is undermining the whole principle that this is not about academics or politicians. It is about people.

Chairman

Can you identify yourself?

Ms Liz McCormack

Thank you, Chairman. My name is Liz McCormack.

Chairman

Thank you for coming forward.

Ms Liz McCormack

I first met Professor Malone and Mr. McGuinness next door in the Royal College of Physicians of Ireland. I am not sure of the year.

Professor Kevin Malone

It was about three years ago.

Ms Liz McCormack

About three years ago I had read an article on a conference that was taking place on a Sunday. I travelled up for the conference. At the time Professor Malone was encouraging people to come forward to take part in the survey and the art work and because I had lost my son to suicide in 2006 — he was 26 — and my mother to suicide in 1983 I felt that perhaps some of my story would help in the survey. Much of the emphasis is on the young people who die from suicide, and prior to Robbie passing away I would have felt that, but older people and women die from suicide also, and I felt very strongly about that. They were very good. They came to our house on the anniversary of Robbie's death. It was quite a painful day for us all and we gave some small pieces. My son had died in America. There was no ambiguity in that respect. Suicide was recorded on his death certificate. I travelled to America about six months after his passing and met the emergency services personnel who had dealt with him. It was dealt with as a crime scene. I met the detective and the undertaker who looked after him so well and took him home to us.

When I went to Galway I travelled alone. Looking back on that it was not a good idea. I was not in any way prepared for how powerful the whole event was and the effect it would have on me. As a result I am not in any of the group sessions. I travelled home after speaking with the counsellor. I found the art gallery very moving but there were other parts to the exhibition. There was a library where there was a number of folders. I do not know what one would call them.

Mr. Seamus McGuinness

Was it slide shows?

Ms Liz McCormack

It was like a library. There were folders with the young person's image on it. If one took up the earphones one would hear the voice of the family.

Mr. Seamus McGuinness

The data boxes.

Ms Liz McCormack

The data boxes.

Also, in the preparation of the portrait for the gallery the room we were taken into was like a mini cinema in that when one went in it was in total darkness. One was surrounded by noise first and gradually the image appeared in front of one, and that was the most effective and emotional part of the journey for me. My younger son found the 21 Grams piece to be very emotional when he saw it as Robbie had died by hanging and because of the collars and the suspension from the ceiling.

I believe this should be brought into the public domain. Obviously, one would need a very large venue to accommodate it and to do justice to the work Mr. McGuinness and Professor Malone have put into it. I also believe that the statistics Professor Malone has put into the public domain can be stood over. As he said at that time, and the landscape moves so much, many young men of 20 said goodbye because that was the peak age but now, as the economic climate has changed, we wonder what will be the age of people who chose to say goodbye when the next set of figures come out.

Chairman

Thank you, Ms McCormack for sharing that with us.

Mr. Seamus McGuinness

The piece of work we looked at today is only one of nine works. There are other works which describe it very well.

Chairman

We appreciate that.

Professor Kevin Malone

I thank Ms McCormack. We had no idea that she would be here. She met us on the way in here and said "Hi" and therefore I figured she wanted to be here. While we can talk to the experience, it was important to hear from someone who has been there and experienced it. Another point is that we could have excluded Ms McCormack from the survey because her son did not die in Ireland. There is a host of repatriated young men buried in cemeteries throughout Ireland who do not feature in the Irish statistics but their deaths have a huge impact on Irish society and for that reason I felt they were almost like undocumented Irish that have reverberations in the Irish community without actually featuring in the statistics.

I am not sure if I will be able to answer all the Chairman's questions unless he will be here for the next——

Chairman

We would be happy if Professor Malone made some general comments and if he wishes to correspond with us on matters on which he would like to expand he may do so. In particular we want to know from him what we can do as a committee to be of practical assistance.

Mr. Seamus McGuinness

In terms of what we have to do, everybody here talked eloquently but we are not very good at listening. As part of this project we went out to people's homes, sat down for four hours and we listened. To have a conversation one must listen. We are great talkers but we are not great listeners. The first thing we have to do is to listen to people who have experience of suicide.

The reason we do not talk about the fact that the same number of people die by suicide as by car accidents is a good question. Why do we not talk about the 700 who committed suicide? If every life is deemed to be equal, why can we not have active, meaningful and productive conversations about people who die by road crashes or by suicide? The answer to that question is very clear. We are in a dangerous position. We think we have removed the stigma from suicide but we have not——

Senator Mary M. White

Hear, hear.

Mr. Seamus McGuinness

——and that is much more dangerous. The stain of suicide is seeping into this country. We think we have dealt with the stigma but we have gone backwards in that respect. Many of the comments and questions around this table have been stained by that stigma and we must articulate that.

Another point is that families who lose people by suicide are ordinary people. They are not fetishised people or victims but ordinary people who have gone through this most horrendous event. We have been fortunate and privileged to hear 104 of the most horrific stories that any parent would want to tell. That is the type of thing we have to do.

Professor Kevin Malone

To answer the Chairman's question and the main question as to what we can do, we have done six years of longitudinal collaboration. While we welcome the opportunity to present our work cross-sectionally today, if we really want to get results, we have to keep at it. Even if one has a heart attack halfway through it, as happened to me, one has to get up after it and continue and finish the job because it has to be done. This is a collective responsibility.

Today, this presentation, whether members liked it or not, has been an intervention. Their eyes have been opened, they are talking about this issue in a different way from how they previously talked about it and I do not believe they will revert to talking about it in the way they previously talked about it. That is how interpersonal relationships work. That is the impact of being moved about an issue and changing one's position on it. Although the Deputies talked a good deal, while they were watching the presentation, they were listening. I believe they were listening and listening is definitely a message in moving forward in this respect. Therefore, longitudinal collaboration is required, as Mr. McGuinness and I have done.

The question of why and what triggers people to do this was asked. The truth of the matter is that we have done practically zero research. I know this sounds like an academic rabbiting on about research, but Deputy Ó Caoláin asked do we know this and do we know that and Deputy O'Hanlon also asked a similar question. This is the only project that has systematically and methodically plodded its way around Ireland into people's kitchens. We sat down and talked to people at length and now we are at the point of beginning to drill down into that analysis. That has been done through painstaking research.

A Deputy asked how Finland dealt with this issue. They carried out research on it. Not only did the Finns interview 104 families, they interviewed every family in Finland that had been bereaved by suicide in 1988 — some 1,798 cases. They put a team together and interviewed all those people and they then had data from which to work for the next ten years. They asked themselves what would they do and how they would deal with this group and that group, as they are not all the same. Different interventions are required for different groups across the life cycle, whether the issue is related to mental illness or alcoholism. The Finns put together a dedicated youth depression programme and early intervention alcohol schemes. The reason they did all that was because they put suicide at the tip top of their list of priorities. Dealing with suicide is ranked at the bottom or is scratching its way along the bottom of our list of priorities. There is an energy in terms of perception that suicide, like the poor, has always been with us, and the number of incidents are up one year and down another year and that is really all people want to know about it. There is no dedicated research programme on suicide in this country. Obviously I am doing research. A National Suicide Research Foundation in Cork is examining parasuicide or attempted suicide or deliberate self-harm. Those members who were in Rome recently will know that there is an area of research called non-suicidal self-injury, NSSI, which is another different component.

We are very far behind other countries in terms of our knowledge. We are working in a complete knowledge vacuum. How can an action plan be put together when there is a knowledge vacuum? In terms of other difficulties in the State, we would not say we will put together an action plan when we do not know the problems involved only the numbers. We have to rededicate ourselves to research.

Deputy O'Hanlon asked what we would do if we have extra money available. A dedicated research programme could be put in place across the life cycle. There are many issues to which we do not know the answers. I would also carry out an audit of who is doing what with regard to suicidal depression and suicide intervention and prevention in this country. Surely that is the first thing one would do — audit who is doing what. We should examine who is doing what, how much it costs and if it is working. We should examine if the pattern is the same across the country, how we deal with black spots and with evolving clusters. Deputy Flynn mentioned a cluster. We should have an early warning system. All young people attend school. Every month there is an incident reporting system to the national education system. We should be able to detect vulnerable people early. There is evidence from international studies that it is possible to close down clusters but we must be able to identify them. There is no point in saying that it is terrible that have been six incidents in Mayo, 14 in Cork and another number in Meath — that is a comment after the fact. We are reactive as opposed to proactive and that does not help our case. I will finish on that note and pass over to Mr. McGuinness who will talk about the touch of cloth.

Mr. Seamus McGuinness

To respond to Deputy O'Sullivan's question, my background is in cloth. I am an artist and I trained in cloth. When I started this project I thought about what language I could use to articulate this subject matter that cannot be articulated in words because sometimes we do not have the words to do so. Cloth was the first thing to be made in the world. When humankind began, cloth was made for shelter and it was made before people developed speech. Therefore, we have this innate relationship with cloth. This is evident in terms of a child's "blankie" or people's favourite clothes. It is a way to immediately interact with people. People have a relationship with cloth and the shared materiality of cloth. One can cut cloth or cut the body or one can stitch cloth. Therefore, cloth is deeply ingrained in our lives in many ways of which we do not know. It is a language that readily exists. That was the language I decided to use — the ability to touch. My idea in terms of the Lost Portraits galleries is that eventually they will all fade away by touch, as the memory will fade too. As in the case of ourselves, we will all fade away. It is like a metaphor for the human condition.

Professor Kevin Malone has reminded me of Lithuania. We had some cross-cultural exhibitions there. We brought the Lost Portraits exhibition to Lithuania. I got the exhibits made in Lithuania. What point did Professor Malone want to make in that respect?

Professor Kevin Malone

The point is that of universality. From a language point of view cloth transcends different cultures.

Mr. Seamus McGuinness

We got the same response.

Professor Kevin Malone

That was the feedback from people in Lithuania. They did not understand what we were saying but they still got the same feeling from the exhibition.

Mr. Seamus McGuinness

That is one thing art can do. Art is a universal language. It does not need words, people can get the impact of it. That is what I am trying to get across. I heard the phrase that members were moved today, that this has been an emotional experience. When one looks at these works, what happens is an aesthetic experience. Aesthetics comes from a Greek word which means a bodily experience. It is only in the 19th and 20th centuries in the era of Modernism that aesthetics became associated with the eye. An aesthetic experience is a bodily experience that moves a person. When one looks at these works, one has to enter them. It is an emotional experience. One is moved to another position. One's brain might tell one to stay away but one goes there.

Professor Kevin Malone

A Deputy asked whether this project can be an intervention in terms of having an effect on young people and whether what we are doing can be an intervention. One of the findings that has emerged from the study is that bereavement in the event of a young suicide death in particular causes the community to be at increased risk. The idea that one is immune from risk in the event of a youth suicide in a community is far from the truth; the opposite is the case. In rural Ireland that community can be geographically in a small location but even in urban Ireland if a young suicide death occurs, the little urban community on which it impacts would be at risk for a period of time afterwards, not days or weeks but months, and communities do not like to know that.

In terms of the Chairman's question as to how the committee can help, there is a question as to whether this exhibition should be exhibited in communities. We consulted all the families and the members of the public who saw it and the response was that it could be and should be brought to people. Second, there should be a mediation involved, in that it is not enough to put up the exhibits, walk away and let people wander in and out of the exhibition. Third, bereavement counselling should be available, which is what we did at the public exhibition. Two bereavement counsellors from Console were present for the duration and unofficial or official bereavement counselling was provided. The exhibition was a demonstration of a responsible and meaningful discussion about a subject that is very tragic.

Mr. Seamus McGuinness

One of the interesting things is that generally when one goes to large exhibitions that are in any way controversial, such as in the Tate Modern, there are curators and others deciding how they should be seen, but in this case it was the families who discussed that. Members will recall they discussed 16 year olds, under 16 year olds and whether there should be information. As a way of modelling painful experiences in the public domain, it is quite unique because it was not experts who decided but the people whose experience we were trying to articulate. However, we are talking about something that is more than an exhibition, it is almost like a roadshow. It is a big thing which will ultimately work out to be expensive. If we have spoken with 104 people in a room and asked them to share their experiences, we cannot let them down. There is that ethical responsibility in research where one must bring it to the conclusion.

Professor Kevin Malone

I will make a couple of points. I agree with Deputy Flynn that it is every parent's nightmare. The families have said to us: "We did not want this but this is what we got." It is how they deal with that loss. The Deputy mentioned her reluctance to speak about it, which is a courageous acknowledgement, but the alternative of silence on this issue has not served us very well. Certainly, this type of meaningful discussion must be a platform to be welcomed.

In response to Deputy O'Hanlon's question about what one would do, I do not see many signposts to care, or even signposts that society cares, in young people's lives. In fact, when we talk to families we more often hear about obstacles to care. We need a simple graph which on one side outlines signposts to care and points out what one must do and on the other side shows the obstacles to care with which we must deal. Unfortunately, the obstacles to care list would be five times as long as the signposts to care list. Again, that speaks volumes. We really must let young people know that society cares. It is not enough to tell them to go to this or that person; there must be visible signs that we care. It is not enough to tell them to look after their mental health because people do not know how to do that. There are so many levels on which we must do this.

Deputy Ó Fearghaíl made the point, which is correct, that there were 444 suicides a year before the recession. Are we just to forget about those and focus on the 70 extra that have occurred since the recession? I understand that there were a number of 12-year-olds in the latest statistics. Are we happy with that? I do not believe so. We have a job of work to do. If we really have the health of the nation at the top of our list, this issue is up there in terms of young people.

Chairman

I thank the delegates. It is a subject to which we will return on a regular basis. You certainly have challenged us.

As there is no further business, the meeting is adjourned until 3 p.m. on Thursday, 16 September 2010, when we will meet with the Minister of State with responsibility for children and youth affairs.

The joint committee adjourned at 5.15 p.m. until 3 p.m. on Thursday, 16 September 2010.