Suicide and self-harm: new research directions podcast

Transcript

Suicide and self-harm: new research directions

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Thomas Creighton (TC): Hello, my name is Thomas and welcome to the Emerald Podcast Series. Today I'm joined by three special guests to discuss the topic of suicide and self-harm. Sarah Waters is Professor of French Studies with the School of Languages, Culture and Societies at the University of Leeds. Dr. Cathy Brennan is an Associate Professor in Psychological and Social Medicine, with the School of Medicine also at the University of Leeds, and Dr. Hazel Marzetti who is a Research Associate with the School of Health and Social Science at the University of Edinburgh. All three have contributed to a special edition in the Journal of Public Mental Health entitled 'Suicide and self-harm: new research directions.

I would just like to say thank you very, very much for joining me. And I've been looking forward to this topic quite a bit, actually. You've all been involved with the Emerald journal, in the Journal of Public Mental Health. Can I first of all ask you how did you get involved with that? Could I start with Professor Sarah Waters?

Sarah Waters (SW) Yes, absolutely. So, I was approached by one of the editors by Julian Ashton to ask whether I'd be interested in putting together a volume on suicide and self-harm, and we had this idea to bring together research developments in the field and also to try to bring together very different disciplinary perspectives. And so that was the sort of rationale behind the volume trying to bring together new research developments in the field and a range of different researchers to sort of try to give a sense of what's going on in suicide research and in research on self-harm.

(TC) It is a very unusual topic; can you tell us a little bit about why you are approached to head this?

(SW) Well, I have published previously in the Journal of Public Mental Health, so I knew Julian and my own research is very much focused on suicide and more particularly work-related suicide. And so, Julian and I put our heads together about who we might invite, and who was doing interesting work at the moment in this field.

(TC) Sounds like a very collaborative addition. Can I pull in one of your collaborators, Dr. Hazel Marzetti to explain some of your involvement with this.

Hazel Marzetti (HM) So, I'm working at the University of Edinburgh on a project funded by the Leverhulme Trust called 'suicide in as politics. And as part of that we're kind of using a critical policy analysis technique called 'what's the problem represented to be'. And the idea of that technique is that we look at the kinds of interventions that are suggested within policies and work backwards from there to see what the problem is representative be - what the problem of suicide in this instance - is represented to be. And that's what the paper was on.

(TC) Thank you. And when you're looking at these factors, are you looking at factors that lead to suicide?

(HM) We're not particularly looking at risk factors. We don't do risk factor research. We're looking specifically at the suicide prevention policies of the four UK nations in the time period 2009 to 2019. And in a critical policy analysis of those suicide prevention policies, looking at kind of what is in those suicide prevention policies, what kind of interventions are suggested within those suicide prevention policies, and then working backwards from there to see what the problem of suicide is represented to be.

(TC) Thank you very, very much. And finally, can I introduce Dr. Cathy Branham, would you like to explain some of your involvement with this issue?

Cathy Brennan (CB) Yeah, so I work at the University of Leeds, same institution as Sarah and we've been collaborating on an interdisciplinary project that was funded through an award from the University that was looking at bringing diverse perspectives together to explore the interplay between person and place and how that might impact on risk of suicide. So, we ran a few seminars and we organised a workshop where we were we had quite a few people and a lot of practitioners and researchers brought together to discuss the issue of environment and how place impacts on suicide risk. So, Sarah approached me and asked me if I had something to contribute. And luckily for me, I was just coming to the end of a project that was funded from by the Samaritans and that was looking at social media and the impact of social media, particularly the content on social media and how that might relate to risk of self-harm and suicide. So, it was a well-timed approach.

(TC) And to all three of you and anyone who wants to answer I must ask the standard research question: what is the importance of this topic area?

(SW) For me, I very much take a sociological approach to suicide, and I see it as a problem of society, rather than a problem of, of the individual. And my work would be very much influenced by the French sociological tradition going back to Emile Durkheim who wrote about suicide in the end, at the end of the 19th century, and very much founded a sociological tradition of suicide. And for Durkheim, suicide is like a mirror held up to society. It tells us what's going on in society, or at any one time, it tells us about the problems and dysfunctions in society at a given historical period. So, to understand society, we need to, to understand suicide and understand the complex relationship and dynamics between the individual and broader society. And by society, I mean, economic problem, the impact of institutions, the immediate social, cultural, and economic environment of the person. And then because I'm a sort of French Studies scholar, there's also Albert Camus, who said that suicide was the most important question to ask; asking why someone would take their own life. There is no more important question than that and it is the central philosophical question. Suicide is at the center of everything.

(TC) And you get right into the sociological drivers of this. And we can see that reflected when I was reading through the paper. It's really interesting that there's very different approaches in different countries and very different outcomes. And as you mentioned earlier, very different policies even within the four kingdoms of the UK. So, Dr. Hazel, can I go straight to you and ask you, what are some of those big differences? How does it manifest?

(HM) I think actually there's some real kind of core commonalities; you can see some real differences in terms of the lengths of those documents. If you're looking at Northern Ireland, you're looking at over 100 pages. It's really kind of a meaty document. But what I think is really interesting is those kind of commonalities and convergence is in the UK suicide prevention policies, which tend to be around kind of mental health support for individuals who are deemed at risk. And I put that in kind of air quotes, particularly surveillance to identify individuals, again, at risk. And then the kind of the restriction of lethal means for anybody who is deemed to be at risk of suicide. So, there's those kind of key convergences around means restriction, mental health support and identifying people at risk.

(TC) Can I ask, you put at risk those in air commas. Can you go a bit more into that please?

(HM) Yeah, absolutely. So, I think very, very often kind of within our discipline risk factors are seen as kind of quite kind of discrete, quantifiable, able to be isolated from one another. And actually, I think one of the core things that that the project that I'm working on 'suicide in as politics is' trying to unpick is actually well, how do these kind of risk factors which are often conceptualised as extremely individual, often kind of pathological risks are actually part of this broader kind of narrative that Sarah was talking about, about the kind of socio economic and political conditions in which people live, and therefore in which a life becomes or does not become unlivable?

(TC) Can I ask you, again, a bit further about, like, it's a really interesting paper…what were the socio-economic factors?

(HM) Yeah. So again, like our work does not particularly concentrate on the identification of those factors, it isn't much more about thinking about how these kinds of policy interventions are constructed. And in thinking about how these policy interventions are constructed, and working backwards to see how the problem of suicide is constructed. Of course, there are those kinds of massive, massive rafts of groups within the prevention policies that are identified as being at risk. And honestly, there's probably over 40 groups that are considered at risk within these policies that are named, particularly thinking about, you know, homeless people, people in such as criminal justice system, LGBT + people. There's like a real range of different kinds of factors that are identified within these policies. But actually, I think rather than identifying these kind of risk factors in these groups at risk, what's quite interesting is to think about is how those kinds of social relations contribute to that and how those conditions for living have become unlivable within that. So, kind of rather than thinking about the kind of those individual risks as being like unemployment or homelessness, or LGBT, + people being at risk. Actually, when we think about what are these social conditions that make people at risk, rather than thinking about the risk themselves being within the individual?

(CB) So I think it's a really important discussion. And I think and it's one of the things that's that I think about when I think about suicide research and self-harm research is that actually, if you look at risk factors, they don't really tell you that much because, you know, why is there an increase or an increased likelihood that somebody who has these characteristics dies by suicide? But actually, if you look at the data, there's a lot of people who have the same characteristics who don't die by suicide. And actually it's some picking what it is about that particular person with those circumstances at the particular time. And I think we haven't, that that's where the interest in really getting to grips with how, how do we prevent suicide. And I think one of the reasons I'm interested in suicide research is that, ultimately, this is something that should be preventable in the grand scheme of things. You know, yes, there's structural determinants but those are all something that is within our grasp, to be able to do something about. So, you know, it's a tragedy of our times that people die by suicide when it's something we can do something abou. Lots of people have different reasons as to why they come into suicide research. Mine was very, very circular. But I've had experience of friends who've died by suicide. And I think that was one of the drivers to think that was the something that we this is quite often what people ask themselves when they notice someone's died by suicide - was something I could have done, should I have known? How should we've done something differently? That sort of drives a lot of those questions. And ultimately, the driver of that question is that there should have been something that we can do not as an individual to stop that individual dying by suicide, but as a society to create a place where people don't die by suicide.

(TC) In any academic discussion, we very quickly get to the question of defining terms. So, this podcast is about suicide and self-harm, perhaps we can start with self-harm and ask what constitutes self-harm?

(CB) Every time I write a paper about self-harm, we have there's a discourse that goes depending on where the paper goes and who the peer reviewers are. There's quite a discourse on how you define self-harm in the UK. Well, the World Health Organization has got a very long definition of self-harm that basically is any, any intentional act against your body whether it's wishing to die or not, whether there's any intent intent to die or not. And probably the National Institute of Health and Care Excellence say it a bit more simplistically than it's, it's any act of harm, regardless of intent to die. So attempted suicides would come under the umbrella, a general umbrella of self-harm. There's lots of terms in the literature and professional discourse and people talk about non suicidal self-injury. So quite often the definitions there sometimes they related to the nature of the method of harm, and or whether there's any intent to die associated with that. I always prefer the more general term self-harm for a number of a number of reasons. Because I think, basically, all of them are a manifestation of some sort of underlying distress. And that in some ways, the self-harm itself is an is an act, regardless of any intent to die associated with an act. There's something about distress that's being enacted even if there's not suicidal thinking with that. And I think that the suicide and self-harm are linked. I know that we've talked a little bit about risk factors. But if you look at the risk factor research the underlying psychological and social risk factor for self-harm and suicide are very, very similar, a lot driven by inequality of opportunities, or inequality and power imbalances about deprivation. Those things that are linked in terms of risk factors, and self-harm, even without suicidal intent in the act itself is associated with subsequent death by suicide. You're much more likely to die by suicide if you've had a previous episode of self-harm even if that episode of self-harm wasn't associated with suicidal thinking. So, all those are really important. And I always think that actually what we're talking about here is we're talking about people and not necessarily an act. So yes, we're talking about an act of self-harm or attempted suicide or a suicide, but there's a person behind that. And one of the other things we also know is that you can have suicidal thinking, and you can be thinking about suicide and wanting to end your life and you can engage in an act of self-harm that has nothing to do with those suicidal thinking. And sometimes some people describe it as it's a way to resist thoughts of suicide. So, I think the concept of self-harm suicide is intrinsically linked and complicated.

(HM) I actually really resonate is kind of where you ended up there. And I don't know if I'm allowed to talk about this, but my previous research was on LGBT plus youth suicide. And when we were kind of talking about suicidal feelings, suicidal thoughts, suicide attempts, and with the young people who participate in in my doctoral study one of the things that really, really came up with this idea of kind of that self-harm had multiple different meanings. One of which was exactly what you were just talking about Cathy. So, this idea that actually self-harm was engaged with as a practice to try and self soothe to deescalate suicidal distress and for some young people that actually couldn't be kind of disentangled. It was really difficult because sometimes if self-harm didn't work to reduce kind of those feelings of suicide or distress, that then that could become part of the suicide attempt. But that that initial kind of practice and initial engagement with self-harm was actually to try and soothe oneself. So, I think it's really interesting those kinds of relationships.

(CB) Yeah, and I think the other interesting thing about because we make definitions as professionals as, as researchers, because they are important because you need to tell people what you're talking about. But interestingly in self harm, so even the UK definition of by the National Institute of Clinical Excellence excludes things like disordered eating, for example, or substance abuse or excessive risk, taking a role are all excluded from the definition of self-harm. But interestingly if you look at the work that we're doing on social media, particularly if you if you look at how what, what people tag as self-harm on social media, then those distinctions that we have in professional discourse just don't apply. We did a study a couple of years ago now where we looked at images that people tagged on social media as self-harm, and user generated content or the links that they chosen, and when you looked at the nature of those images, much of those were actually documenting things like extreme fineness. There was lots of posts about recovery that mirrored the language of sort of alcohol and substance addiction, you know, I'm six months clean this week. So actually, in when you're talking about the person those definitional things aren't as clear cut. And we also know in the back to risk factors that there's a link between things like eating disorders and self-harm in terms of you know, there's an overlap in the people who might engage in one or one or the other, or both. So, I think they are linked, although definitionally, we tend to exclude them. So yeah, I think it's always thinking about you go back to the there's always a person behind these definitions. And people aren't… people aren't so neatly put into boxes, you're this or you're that person, you know, we're complex, complex beings with complex lives.

(SW) Definitions is one of the issues that I come up against. I work with the trade union campaign led by hazards where we're trying precisely to have work related suicides recognised and defined. At the present moment in the UK, they are not defined and are not recognised or acknowledged in terms of legislation or policy. And for instance, according to the current legislation, if in the workplace someone has asthma or a rash, or a broken limb that is linked to working conditions, then that has to be reported to the authorities, it has to be investigated. Suicide doesn't need to be reported, because it's presumed to be non work related, because work related suicide isn't defined and doesn't exist. And we're precisely calling for that definition. And the idea that if a suicide takes place in the workplace, or if there is material evidence of a link to work, then it should be reported, it should be investigated, it should be acted on. And the idea that numbers and justice are linked, that if you don't count something you can't account for it, you can't make others accountable. So, definitions are very important. And as far as the Health and Safety Executive is concerned, work related, suicide doesn't exist. And suicide is voluntary, is individual is complex and is disconnected from the workplace. So, we're actually pushing for a clearer definition in order to recognise, acknowledge and respond to what is a social reality, which has been documented, but that there is a reluctance to recognise and act on.

(TC) I understand that workplace suicide is recognising other countries. Is that right?

(SW) Yes, absolutely. So, for example, in in the United States, the United States has centrally collected numbers of workplace and work-related suicides since 1992. They've been collected centrally by the Bureau of Labor Statistics in France. Work related suicides are documented in Australia, in Victoria, they're, they're recorded and registered. In Japan work related suicide is considered to be a major public health phenomenon. And that's precisely the sort of argument we put to the HSE when they say, ''Oh, this is too complex and individual to document'. We say, well, in France and in Japan and in Australia and in Belgium and in Germany it isn't considered to be too complex, too subjective, or too difficult to record and to be taken seriously. Why is that the case only in the UK?

(CB) That's an example of where definitions become really important, aren't they? Because it's actually about it's about naming something and saying what it is. I think when we're talking about the definitions of self-harm some of it's about saying what it isn't or disputing over minor details where we're going actually, what we're talking about here is all acts of harm, and that have an underlying issue about distress.

(TC) Because I understand that in Japanese there is a single word for this phenomenon of workplace related suicide. Is that right?

(SW) In fact, there's two words: Karo-jisatsu which means suicide by overwork. But there's also karoshi, which is death by overwork. So, it's a recognised term. And it's, it's very much treated as a public health phenomenon on which the government and employers need to act. And in 2014 there was a new law put in place, which requires government and employers to put in place preventative measures to prevent suicides and work-related deaths taking place. So, I think there are there are models out there that the UK could look towards. But as a basic minimum these deaths should be counted, you know, and they should be taken seriously. And suicide that is work related, or that occurs in the workplace should be treated as a health and safety issue and treated with the same rigor as any other work-related accident or work-related deaths. And at the moment it isn't and that creates huge difficulties for bereaved family members. Because that, you know, in a recent project that we did on - it was a small-scale project on 12 recent cases of suicide - where work-related causes had been identified by an official source. We interviewed bereaved family members. And there really was a deep-seated sense of injustice that this had happened that there was sort of documented material evidence of links to work and yet it wasn't acknowledged, and nobody was taking responsibility for what had happened. And still that no changes had taken place in the workplace after the suicides. So, there's a sense that it's, it's a sense of injustice about the person who has died, but also a sense that their death hasn't led to any important changes for others. And we have to remember that when someone dies by suicide, that person's spouse, that person's children not only lose a salary, which is important, but they also are left with no recourse in terms of having a legal claim in relation to the employer for recompense in the same way that they would have in many other European countries and internationally.

(TC) We're talking about government's policies and how we can kind of shape narratives to help prevent suicides. If you'd like to go into some detail about how has there been effective action from governments on this issue…has there been a good case or a a good example of what governments or societies can do?

(CB) The evidence isn't there yet to say how effective it's been, but Hazel when you were talking about that Northern Ireland had, like 100 Page suicide prevention document. It's enormous!  And one of the places that seemed to be a bit more on the ball with actually thinking about wider things that they can do. And I remember, I was at a conference once and I was hearing a project that was looking at this particular place I think it's in Belfast… might be in Belfast, they looked at that, and it was a place where people would it was like a destination that people would go to take their life. And they were thinking well actually, how can we in the UK what tends to happen is that you know, you maybe build a put a fence up and put a sign saying call the Samaritans, but they decided to do something a bit different and they looked at thinking about the wider determinants of what might be leading people to think about suicide why this place and actually could they make the place a place where people didn't want to go to take their own life so it they actually did a lot of work to re imagine the place. Yes, they put up a barrier. It wasn't just a metal barrier. I think they made it and it will look like it was like metal flowers that that blew in the wind so it stopped you being able to use that as a place to take your life but actually it was made it look like a nice place. And they also thought that actually these people then they turn away from now and they'll go somewhere else. Let's make the environment where they're walking through somewhere that promotes positive thinking rather than. So they created pods that you could go and sit down and there was people around to talk to. So, I think they were in the start of the evaluation, so it'd be interesting to see whether that shows to be any effective. But I just like the idea that there are places that are innovative.

(HM) I went to the IS conference that was in Derry a few years ago. And I think they've done a similar kind of thing around, maybe around the Foyle Bridge, but I'm not sure.

(CB) Yes, you're right it was Derry not Belfast.

(HM) I think the Foyle Bridge is sometimes called the Peace Bridge; I think. Yeah, yeah. Yeah. I think on this kind of policy, that the idea of policy, I think one of the things that I'm really intrigued by and it's not necessarily thing that is working well, I'm afraid. But I think one of the things I'm intrigued by this kind of difference as I was doing the kind of the analysis of these eight suicide prevention policies from across the four nations of the UK, I was really interested in how we do the kind of balancing act, or the kind of death prevention methods that we talked about in the paper. So, things like restriction of lethal means identifying populations at risk, and, and doing mental health support for those who have been identified. And the kind of policy interventions that could happen, that are around promoting the conditions for the living. So, when we're talking about these kinds of, you know, 40 plus groups at risk, well, what can we do to actually look at those conditions for living and transform them in different ways. So, one of the examples that we talked about in the papers is idea of the Jobcenter as being a really good place to identify people at risk of suicide, which undoubtedly, there are, you know, is potentially a good site to identify people who are at risk of suicide. But there was no kind of conversation that seemed to be given any prominence around what can we do to tackle those kinds of real structural issues that are happening that mean that people are in the Jobcenter and feeling suicidal? And I think that that that for me, is one of the kind of key areas that I'm really interested in, in policy innovation? Is this kind of balancing? Of course, we need crisis intervention, of course, we need to help people who are feeling suicidal, in that immediate moment of crisis. But what can we do that is a bit bigger than that? What can we do that's a bit more ambitious, and that that actually means that people want to continue living not just that they are stopped from dying? And I think that's, that's a really interesting kind of future avenue for policy.

(CB) And that was that it was interesting that the journal was public mental health was because actually the public health bit the understanding that there's structural drivers of inequalities in health in a lot of physical and mental health. You know we have been talking about this for decades. But actually, most of most of resources goes towards sorting out immediate problems as they arise without thinking about, well, how can we stop them arising in the first place? And actually, one of the things is that when you're thinking about suicide, and the structural determinants is that these same structural determinants are responsible for lots and lots of poor health outcomes. So actually, having a way to think about making a better world for everybody works, but works on a number of health outcomes, not just mental health and suicide and self-harm. But we yeah, we haven't quite got there yet to think about how we join up those, those things.

(SW) So in my own area, one of the problems is that suicide prevention is very much volunteeristic. It depends on getting employers on board and getting them to put in place wellbeing strategies and other techniques that will stop suicides taking place. It's not to undermine those initiatives, but to say that we do need a minimum framework in place. What we find is that some employers are very good and where a suicide takes place they investigate it. They're interested in getting to the bottom of what happened and making sure that other employees aren't at risk, but it very much depends on the personality and the goodwill of that individual employer. It will happen in some workplaces, but not in others. So, it's completely fragmented and it depends on the individual of decision of an employer as to whether anything takes place or not. So, what we're asking for is sort of a very minimum framework where if a suicide takes place, could it please be investigated as being potentially work-related. Investigations are really important in the in the study that we did. Wwhere an employer had made a decision to investigate the suicide, it did produce very important results. And prevention methods were put in place as a result of the investigation. But again it was I think about a quarter of the of the cases an investigation followed the suicide. And so there is a tendency for it to be left to the goodwill of the individual employer. Also, a frustration around well-being strategies. I remember one case we looked at where there was a suicide by a university lecturer and we interviewed quite a few of his colleagues afterwards, and there was a real sense of anger against the way the response of the university to the suicide because they precisely had put the emphasis on, on wellbeing strategies. They organise wellness walks, yoga, therapeutic initiatives whilst doing nothing to address what was very obviously the underlying causes which were on manageable workload. So well-being strategies were really a way of deflecting attention. And the colleagues that we spoke to felt, you know, quite angry and bitter about how the death was responded to by the university and the fact that the university wasn't obliged to do anything, which wasn't, you're not, you don't have to do anything, you don't have to make any changes. In another case, just to mention that we looked at which went back to 2019, there were four suicides in the same organisation in the space of two months in one-year 2019. And, you know, we did ask, ''well, if the response had been different after the first suicide, could the others have been prevented?'' You know, and the tragedy that further suicides took place after the first one because of the lack of the lack of investigation, the lack of rigorous response, the lack of adequate preventative measures after the first suicide. So let's get let's get a framework in place, let's have guidelines that were a suicide play takes place, the employer has to do a certain number of things and not just brush it off as something subjective as a mental health problem or as a personal issue that doesn't concern. And we're talking often here about large organisations that employ hundreds and thousands of individuals. And you can, you can just you don't need much imagination to understand what happens when a suicide isn't taken seriously. It should be considered as the tip of an iceberg of something more, more of something more of complex that needs to be addressed and taken seriously and responded to.

(TC) It sounds like we need more data on this subject. It sounds like we need perhaps more research… where would you see your own research heading in this area? Perhaps I can ask this to each of you in turn.

(SW) My work because I I'm a professor of French Studies my interest has always been on the French workplace, on French labor studies. And in fact, my interest in suicide emerged from my interest in the French workplace and labor studies. And we then went on to undertake a study in the UK. So what I'm trying to do now is to do a comparative, a large comparative UK- French study that looks at suicide cases and that tries to draw lessons from the different policy responses and the different Institutional responses to work related suicides in these two settings. Also, what lessons can we learn nationally, at European level and internationally. By studying what happens in individual cases across two countries.

(TC) Professor Sarah Waters, thank you very, very much. And can I ask the same question to Dr. Hazel Marzetti? Where do you see your research going? Again, in this area.

(HM) Okay, so we're at a really exciting point, I think is exciting. I would say that because I work on it. But in our project - so we were in the first phase of the project - we did this kind of critical policy analysis of the eight suicide prevention policies on every mention of suicide in the UK for Parliament's in the same time period 2009 to 2019 and on nine charity campaigns. And at the moment, next month, starting first of August, we are taking those findings out to the public and running a series of Artspace workshops with the public to see how the public thinks about this kind of political representations of suicide and suicide prevention. So that is our next step, which I'm super excited about.

(TC) But it's something to be excited about. That sounds really, really interesting. Thank you very much. And Dr. Cathy Brennan, I think you can guess the question, where do you see your research going in this area?

(CB) Well, so the paper that was in the special edition was a review looking at the evidence on content found online and its relationship to self-harm and suicide. And one of the things that came out is actually we need a way to start to engage with the complexity of the issue. And I think that's where that's our next steps is putting together something where we can think about drawing together, understandings of the person, the situation, they're in the context in which they're on social media, what they're doing on social media, and linking those all together to get a fuller picture of what's happening. It's important at the moment because there's a bit of a push to regulate social media, particularly to regulate content on social media. And it's being pushed without really much thought about what regulating content actually might mean. We'd like to do something that contributes to that, that debate a little bit. So, for example, one of the things that we do know is that social media is sometimes the first port of call for somebody to talk about the fact that they're thinking about self-harm on that, or they're having suicidal thoughts. It's the first time they've disclosed to somebody in air quotes because it might be just in a in a forum. And one of the things that we haven't really started to think about in regulation is that there's people behind posts, so if we start regulating what people can post then what happens to those people who were using social media, to seek support to find people who understand what that what they might be going through. So we'd like to do something, something that's looking at that I'm also really interested in imagery. I'm quite excited about Hazel's project actually. One of the things that got me into research and self-harm and suicide, was actually using creative methods with people who self-harm to help to see if that was the way to explore understandings about self-harm. So, I've always been interested in the use of imagery, and what we mean by images of self-harm. So, I think that's, that's the next port of call is to really understand how people use representations of self-harm through imagery on social media.

(TC) I must ask, and I mean this question hasn't actually been sent to you, but often with the serious topics they do get represented in fiction in media, is there a case of a fiction or play a book or novel, anything like that, which you feel does deal with the issue sensitively and well?

(SW) It's actually interesting because in in France, there's been a huge body of fiction, linked to the phenomenon of work-related suicide for lots of different reasons. And one of the reasons which is, I think, interesting is that some of the key novels that were written, and then went on to be turned into films were written by people in those companies. So, there are at least two were very well known novelists who used to work at France Telecom, France Telecom was the main French company where a wave of employee suicides took place. And so their novels are very much grounded in their experiences of being employees over 20 years in those companies. So, these are really, you know, work. They're novelists but they're also former employees. One of the key novelists who's whose book was turned into a film and had a nervous breakdown. As a result of his experiences working at France Telecom, he wrote a novel it was turned into a film with a very famous French actress. So, some of these novels and films are really brilliant. And some of them are based very, very closely on real events. There's a film called Corporate that that came out a few years ago that was based very, very closely on what happened in France Telecom. And it's, it's a story of other work-related suicide, but the methods that are, it's a brilliant film, but the methods that are conveyed and represented in films are based on the actual methods that were used by managers in the company. So, this is for whatever reason it is a major is a source of great interest for filmmakers, for documentary makers, for novelists, for writers of all sorts. So there's a really interesting body of work and I've always believed that fiction is important. That fiction gives us a very important perspective on, on, the human condition that it shouldn't just be dismissed as not being factual and not important. Fiction is really important and gives us an incredibly rich insight into mental health in the workplace and suicides in the workplace in France.

(CB) For me, I think that's really important, isn't it Sarah? That actually thinking about empathy and understanding that's where literature and film and all those things and other cultural things can come into it. Something I always recommend and it's not because I think it's a really good representation. But actually, something about helping people understand the complexity is a book A Little Life by Ileana Hara. It is basically a novel about following the lives of four people in America. One of them struggles with mental health difficulties and self-harms. It is actually a really long book. And it sounds like it's deep material, but it's one of those books that you can't put down. It's a great book to represent the complexity of characters and the different reasons behind why people go down certain paths and also the power of systems around them and the people around you to create a positive environment and to help in recovery. So yeah, I would always recommend anything I have, it's not something I have any monetary value in. It's in and of itself.

(TC) So I'LL take the recommendation. Genuinely, thank you very, very much. I really enjoyed the conversation. Thank you.

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