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A Social Semiotic Interpretation of Suicidal Behaviour in Young People

Martin Anderson, P. J. Standen and Joe P. Noon J Health Psychol 2005 10: 317 DOI: 10.1177/1359105305051418 The online version of this article can be found at: http://hpq.sagepub.com/content/10/3/317

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A Social Semiotic Interpretation of Suicidal Behaviour in Young People

Journal of Health Psychology Copyright 2005 SAGE Publications London, Thousand Oaks and New Delhi, www.sagepublications.com Vol 10(3) 317331 DOI: 10.1177/1359105305051418

Abstract
This article presents a study of nurses and doctors perceptions of young people who engage in suicidal behaviour. A contemporary view of grounded theory is used to guide the collection and analysis of qualitative data from nurses and doctors working with young people in an accident and emergency department, paediatric medicine and child and adolescent mental health services (adolescent inpatient unit). The analysis of 45 semi-structured interviews generated the category: Processes of communication and associated meanings: Another voice, Complex messages and Seeing and using the social environment. A social semiotic framework is used to explore the way in which nurses and doctors perceive young people who engage in suicidal behaviour. The article concludes by considering the implications for policy and practice.

MARTIN ANDERSON, P. J. STANDEN, & JOE P. NOON

University of Nottingham, UK

M A RT I N A N D E R S O N , BA(Hons), MSc, PhD, RN (Mental Health), Dip HE is Senior Lecturer in Mental Health, University of Nottingham, and Regional Fellow in Suicide Prevention at the National Institute of Mental Health (East Midlands). P. J . S TA N D E N ,

BSc, PhD, C.Psychol is Professor in Health Psychology and Learning Disabilities, University of Nottingham, with special interests in research models, the social context of health behaviours and therapeutic effects of interactive software.

J O E P. N O O N ,

BSc (Hons), PhD, RN, RM, FRSM, is Associate Professor in Nursing, Faculty of Nursing, University of Alberta.

AC K N OW L E D G E M E N T S .

Acknowledgement text. None declared.

COMPETING INTERESTS: ADDRESS.

M A RT I N A N D E R S O N ,

Correspondence should be directed to: School of Nursing and School of Community Health Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, Room B50, Medical School, Queens Medical Centre, Nottingham, NG7 2UH, UK. [email: martin.anderson@nottingham.ac.uk]

Keywords
perceptions, semiotics, suicidal behaviour, young people
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Introduction
T H E W E A LT H

of literature relating to suicidal behaviour in young people over the past 20 years illustrates the concern health practitioners, policy makers and the public have with regard to the phenomenon (DoH, 1999, 2002; Hawton, Rodham, Evans, & Weatherall, 2002; Hawton & van Heeringen, 2000; Jenkins & Kovess, 2002; Pritchard, 1995; WHO, 2000). Suicidal behaviour has become evermore visible today in the press and in story lines for television soap operas such as Channel 4s Hollyoaks and BBC 1s Casualty (Gerrard, 2002; Simkin, Hawton, Whitehead, Fagg, & Eagle, 1995). There has been considerable debate over the past 30 years surrounding the relationship between self-harm and suicide. Hill (1995) refers to a suicide spectrum, and argues that the motives behind young people who overdose or injure themselves are wide-ranging. The suicide spectrum is composed of the range of actions that carry connotations of suicide. At one end of this spectrum is self-harm, at the other end is suicidal behaviour: a clear desire to end ones life. In between, active within this spectrum, are the behaviours fed by increasing ambivalence, confusion and volatile incentives of many young people who take overdoses or self-harm in other ways. The young persons intent to die increases across this spectrum. The notion of the suicide spectrum is a valid concept to use when considering the complex terminology used in suicidology. This article endorses the work of Hill (1995) and uses the terms self-harm and suicidal behaviour. Such behaviour includes taking an overdose (tablets), ingestion of other substances (bleach, fuel, etc.), self-suffocation, self-strangulation, drowning, etc. (Rioch, 1995). In carrying out these behaviours, the individual may have complex, ambivalent and confused views of their intent, quite clearly falling within the contexts of the suicide spectrum. The immense scale of suicidal behaviour in young people, and the public and political response to the issue, means that new ways of working are a central concern for healthcare providers, researchers, families and young people themselves. Nurses and doctors practising in accident and emergency (A&E) departments, paediatric medicine and child and

adolescent psychiatry are likely to hold a range of attitudes, beliefs and understandings towards a young person who has been admitted following an episode of self-harm. These factors will have an impact upon the relationship with the young person. Establishing effective communication with people who self-harm is recognized as an essential part of preventing further self-harm and suicide (Talseth, Lindseth, Jacobsson, & Norberg, 1999). Indeed, for the young person who has felt isolated and unable to communicate for some time, the opportunity to talk is a great relief (Aguilera, 1994; Bonnivier, 1996; Burgess, Hawton, & Loveday, 1998; Hill, 1995). Research evidence suggests that in practice areas such as medical units, young people (or adolescents) are seen as being difficult (Boyes, 1994; Burr, 1993; Foote, 1997). However, the World Health Organization included suicide in target 12 of Health for all by the year 2000 and in more recent documented guidance on suicide prevention for physicians and teachers, offers the following advice: During the development of the suicidal process, mutual communication between suicidal young people and those around them is crucially important (WHO, 2000: 14). Communication difculties and the interplay of previously held perceptions can reinforce the stigma associated with suicidal behaviour and therefore jeopardize the effectiveness of professional interventions (McGaughey, 1995). Often such perceptions are grounded in everyday inaccuracies and myths about suicide in young people. Lowering suicidal behaviour to unhelpful representations encourages inappropriate responses to the young person, distancing them further from obtaining adequate help and support. Myths among adults can range from believing that young people do not think or contemplate suicide, to the misconception that talking will actually make things worse (Hill, 1995). Ultimately, healthcare professionals, such as nurses and doctors, can become conned to their own set of meanings using language to describe symptoms employed to conceptualize suicidal behaviour. Barriers are erected between the professional and the patient because understandings are so far removed from each other, and shared meanings are never developed (Aldridge, 1998).

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ANDERSON ET AL.: SUICIDAL BEHAVIOUR IN YOUNG PEOPLE

The World Health Organization has recommended that educational programmes need to train practitioners in the diagnosis and treatment of depression (WHO, 2001). School-based interventions involving crisis management, problem solving and training in coping skills are also suggested as ways forward in solving the problem of suicidal behaviour in young people. Deglamorizing media representations of selfharm and suicide may also reduce the chances of wider imitation or contagion effects. There is no doubt that these interventions may help reduce levels of suicidal behaviour. Yet if such interventions are to work, much more needs to be done in terms of developing peoples views and understanding of this group of young people. Nurses and doctors are often the rst point of contact for young people coming into a hospital setting after engaging in an act of suicidal behaviour. They are therefore expected to develop their ability in working with the young person and their family. Current policy guidance also specically targets health professionals providing care within accident and emergency departments, medical inpatient services and child and adolescent psychiatry (DoH, 2002; Paykel, 1994; Royal College of Psychiatrists, 1998). It is accepted that the attitudes of professionals towards people who engage in suicidal behaviour will impact on the effectiveness of the care and treatment provided (Hawton, Marsack, & Fagg, 1981). However, there is still very little evidence on how such health practitioners construe this patient group (Anderson, 1997). One approach is to focus on the cultural and symbolic ways in which these nurses and doctors choose to describe young people. Given that nurses and doctors work in the front-line of services for suicidal young people, they will inevitably have access to and make use of a range of culturally mediated social meanings about why young people engage in such behaviour and make value judgements about it. Before these nurses and doctors can be adequately trained to improve their practice in working with such young people, we need to gain a better understanding of the meanings that they attribute to their behaviour. This involves looking at what a young persons suicidal behaviour might symbolize for the

nurse or doctorthe signication systems through which they make sense of what is going on. Understanding the signs nurses and doctors use in relation to these young people may be integral to the further development of practice in this area. This is new ground and a pathological causeeffect model is not appropriate for such material. Instead, social semiotic theory offers one way of exploring the signs used in social life and different cultures. This approach is a move forward in understanding the signs health professionals use in relation to this group of people. For the purposes of this article the next section outlines some of the main characteristics of social semiotic theory.

Social semiotics
Social semiotics provides an established theoretical framework for an interpretation of the social meanings or signs. Semiotics itself is dened by the work of Swiss linguist, Ferdinand de Saussure. Historically, semiotics is based on language, yet language is only one of many sign systems within our culture, others being etiquette, music, fashion, etc. Saussure argued that semiotics was the science that studies the life of signs within society (Guiraud, 1975; Saussure, 1974). The French structuralist Roland Barthes took this notion forward during the 1960s with his interest in the way structural relations go to make up any sign system. At the centre of this view is the social production of meaning. Semiotics seeks to relate this production of meanings to other kinds of social production and social relations. This provides a way of systematically analysing symbolic systems based on a set of assumptions and concepts (Olds, 1995; OSullivan, Hartley, Saunders, & Fiske, 1983). Semiotics (as linguistic theory) has also been applied in the eld of sociology. In Presentation of self in everyday life (1959) Goffman was interested in observing the way in which people communicate something about themselves by using signs to be interpreted by others. It is the contribution of popular culture in understanding young people in social life that draws together many of these original theoretical aspects. Popular culture has been particularly useful when considering what inuences young people, their interests and fashions (Chambers, 1986). However, the sociological concepts of moral panic and folk
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devils developed by Cohen (1980) are perhaps the most helpful way of exploring how society develops meanings around youth and youth behaviour. The aim of this article is to explore nurses and doctors perceptions of young people who engage in suicidal behaviour. The collection of data and their analysis was guided by a contemporary grounded theory approach. The data generated are presented and then explored by using the principles of social semiotic theory (highlighted earlier). The purpose of this approach is to build an interpretation of the meanings nurses and doctors have in relation to this group of young people. The researchers (authors) own views, conceptualizations and assumptions (including the social semiotic approach) are a central part of this process. Finally, the implications of this study for practice, research and policy are discussed.

Method
Semi-structured interviews were conducted with 45 nurses and doctors practising in accident and emergency, paediatric medicine and child and adolescent mental health services (adolescent inpatient unit). A range of qualied nurses and doctors, working in the relevant specialty areas, were invited for interview. The clinical areas in which these professionals worked are presented in Table 1.

Grounded theory approach

Since its inception in the 1960s, there have been a number of changes to the original grounded
Table 1. Nurses and doctors by clinical area Speciality Accident and emergency A&E nurse Paediatric A&E nurse Doctor in A&E Paediatric medicine Paediatric medicine nurse Doctor in paediatric medicine Psychiatry Mental health nurse Doctor in psychiatry Total 320 Number of participants 10 5 14 6 2 7 1 45

theory approach. Strauss and Corbins (1990) development of the original method includes four main alterations. First, the researchers experiences connected to the phenomenon are considered to be legitimate empirical data. Second, a hypothesis can be applied to the process of constant comparison. Third, that consideration of the conditions inuencing the phenomenon should not be limited to those indicated by the data themselves. This means that the understanding of a given category should be broadened by taking into consideration all of the conditions that might impact on the meaning represented by the category. Fourth, a schema that consists of conditions, context, interactions, consequences is applied in the process of generating the meaning of a category (Rennie, 1998). This is particularly evident in the process of coding in grounded theory analysis. Here, one of the most signicant points of debate is the interaction between the researchers experiences and his/her data (Chamberlain, 1999). An advocate for a more contemporary view of grounded theory is Kathy Charmaz. Charmaz (1995) agrees that the researcher denes the data by relying, in part, upon the perspectives that they bring to it. In many ways, collection and analysis of data are about using our assumptions, experience and knowledgethese will become essential in developing theoretical sensitivity. Nevertheless, Strauss and Corbin (1990) argue that the researcher must challenge their assumptions, move deeper than their experience, to transcend the literature, if phenomena are to be discovered and new theoretical perspectives developed. With this debate in mind, a logical approach is to view any emerging theoretical account as the result of a continued interaction between data and conceptualizationa ip-op between ideas and research experience. Contemporary grounded theorists argue that grounded theory can go further to bridge the gap between positivist and interpretative methods. It is maintained that grounded theory methods are able to do this because they are utilized in identifying research participants meaning, consider the research to be empirical and offer a set of guidelines to be followed (Chamberlain, 1999; Charmaz, 1995; Henwood & Pidgeon, 1992; Rennie, 1998). Proponents of the interpretative

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ANDERSON ET AL.: SUICIDAL BEHAVIOUR IN YOUNG PEOPLE

view share the objective of understanding the world of lived experience from the point of view of those who live it. The approach is, therefore, concerned with understanding meaning, and reaching the actors denition of the situation. The actors in specic places, at specic times fashion meaning out of events and phenomena through processes of social interaction (Denzin & Lincoln, 1998). The rationale for using the principles of grounded theory in this study is based on this contemporary view as it offers a set of recognized and established procedures to guide data collection and analysis. With these methods it would be possible to build on existing knowledge (generating the interview guide) and analyse data from those living the experience of working with young people who engage in suicidal behaviour.

This helped enhance, rather than limit, ideas and as the interviews progressed at specic stages, the interview guide was revised to accommodate the participants direction (Patton, 1990).

Analysis of the semi-structured interviews

The interviews lasted for approximately 45 minutes and were conducted in a quiet room in the respective clinical areas (accident and emergency, paediatric medicine and adolescent inpatient unit). The interviews were audiotaped with the nurse or doctors permission and all the interview tapes were transcribed by the rst author. The development of the interview guide over specic stages (based on the principles described earlier) highlights the inductive approach used in analysing the interview data. The research team remained exible and open to the data arising from the transcripts until saturation; in other words until no new data were apparent. The process of analysis was based on a rened version of specic stages suggested by Burnard (1991). These stages are presented in Fig. 1.

Generating the interview guide

The semi-structured interview guide was based around eight clinical scales identied in the Suicide Opinion Questionnaire (SOQ)a structured attitudinal instrument developed by Domino (1996). While initial interviews began with a set of simple prompts, the interview guide went through a series of changes at specic points during data collection and analysis. This process originates from an important characteristic of qualitative research in that the questions focus on particular issues but there would be a constant interplay of theoretical formulations, literature, interviewees feedback and what made sense (Denzin & Lincoln, 1998; Henwood & Pigeon[RJS6], 1992; Mathieson, 1999). Glaser and Strauss (1967) and Strauss (1987) suggest in these early works that categories exist and leap out of the data themselves. This is central to an inductive methodology that pulls together theory and data. Charmaz disagrees with this, stating that: the categories reect the interaction between the observer and the observed. Certainly, any observers worldview, disciplinary assumptions, theoretical proclivities and research interests will inuence his or her observations and emerging categories (1995, p. 32). Charmazs view of grounded theory is that it implies a delicate balance between possessing grounding in the discipline and pushing it further. In the development of the interview guide, the SOQ was used as a point of departure (Charmaz, 1995), to observe the data, to listen to interviewees and to think analytically about the data.

Findings
The analysis of interviews illustrated how nurses and doctors perceived suicidal behaviour as a communicative act. For some nurses and doctors the term cry for help was useful, and described the meaning of suicidal behaviour as a form of communication. However, for these professionals there was an ambiguity in this suicidal behaviour is not a straightforward form of communication. Therefore, particularly in the case of young people, there are Processes of communication. This formed the main category. Working through the various explanations of communication among nurses and doctors, three key meanings were identied under the main category. These were as follows: Another voice, Complex messages and Seeing and using the social environment.

Another voice
Clearly, for nurses and doctors the act of suicidal behaviour is a way of saying something, and by the very nature of the act it was a powerful form of communication. Young people who feel hopeless, who struggle in developing their
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Stage One Transcription of interviews (first phase 10 interviews). Writing up of notes of meetings and discussions carried out in the field. Stage Two Re-reading of transcripts. Identification of key words and possible category titles noted. Coding of data. Stage Three After coding approximately 10 first phase transcripts, the relevant concepts were collapsed into 12 general categories. Stage Four Further analysis of incoming transcripts. Alterations of semi-structured interview guide in accordance with the emerging concepts and questions. New emerging issues were integrated into the interview guide to be focused on in subsequent interviews. Stage Five First set of categories was generated. Further interviews conducted and transcribed. Alterations were made to the interview guide as necessary. Stage Six New incoming interview data were typed up and included in the analysis. Transcripts had been read and re-read, and no new information appeared to be arising out of the interviews. The central theme, categories and sub-categories had been generated. Stage Seven The research team continued to work on each category. Reading through original transcripts and checking original meanings. Saturation of categories. Reflection on the methodological concepts underlying the research methods and revisit the aim and objectives of the study.
Figure 1. Stages of analysis.

identity were those who might engage in suicidal behaviour. In this experience, the young person is unable to communicate using conventional channels. This view can be identied in the words of the following nurse working in paediatric medicine in a discussion of young people and the struggle to make a point or communicate their feelings: I think young people nd it difcult to express their feelingsif they are being abused or if they are being bullied at school, young people just dont seem to like to express those sort of feelings, so they will draw attention to themselves in other ways. Similarly for a doctor practising in A&E: I suppose a lot of young people are trying to discover who they are and nd it difcult to communicate their feelings and emotions.
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For the nurse, taking an overdose appeared to be a way of conveying the feelings they have been unable to express in any interpersonal encounter. Some nurses indicated that when a young person had reached the end of their tether the reaction was often to aim the behaviour (expressing the feeling) at an individualusually another family member. The following nurse working in A&E describes this situation: I think some of them are pushed to the limit and it is the only way that they can get the person that they are having a problem with to pay them some attention . . . usually a relative. There appeared to be a straightforward perception that suicidal behaviour was an expression of emotion and reaction to not being heard. A nurse placed in A&E explores this:

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Because some people see it as attention seeking behaviour and stuffI would be disinclined to believe that, in some ways, I thinkand I know it has been said here, they did that for attention seeking. And like I have said before, I think some people would use it because they are letting us know . . . look. But I dont think it is about attentionI think it is about letting us know how they feel. I think for someone to actually do thatthis is how I feel. On the other hand, a doctor in paediatric medicine extended this view and described the fact that such an act could be an interpersonal response to a number of different events: There is a range isnt there. I think you will see the spectrum. And you will see the impulsive schoolgirl or schoolboy who is trying to make a point or take a stance on something and this is the only way that they know. I think you can see that calculated individual who is trying to manipulate other people, or get their own back, or something like that, so I think you can see the spectrum of responses there. This describes the perception of suicidal behaviour as a form of communication to others around the young person. This forms part of a young persons social context. The extracts also reiterate that the communication is not just about a sender of and a receiver of a particular message. The action of suicidal behaviour might be used to inuence the status of the whole family or direct a punitive gesture at one particular member. Whichever way those involved are active in the process. In this context, suicidal behaviour became a forceful voice for the young person. This interpersonal encounter would often involve a relationship in the family. The perception that young people who decide to engage in suicidal behaviour are trying to communicate something to signicant others (family, friends and professionals) had the characteristics of an interaction. More importantly, nurses and doctors perceived this as another way of communicatingin many ways another voice for the young person.

the message in this communication is often very complex. Working out what these young people are saying about the situation or themselves can be very difcult. One doctor pointed out that for many young people who have taken an overdose this is the rst and only time they may be admitted to a paediatric unit. The overdose was the rst instance of the behaviour. There may be repetition of self-harm through to more serious acts of attempted suicide. All such behaviour raised the questions: what would the young person be trying to say? How are they presenting themselves? What were they attempting to elicit in the signicant other? The following quote represents the importance of these questions. The mental health nurses comments illustrate the complexity of this aspect of suicidal behaviour as a form of communication and, in their view, the need to listen to and hear what young people are not saying: If they are expressing suicidal thoughts, to me as far as I am concerned, there is no textbook answer whatsoever. You have got to be able to decipher what they are sayingthat they want to kill themselvesor are they saying that they dont want to be around anymore? Its making that interpretation between . . . do they really want to die or am I to take it at face value? Am I using the feedback they are giving me, to put the right questions, to really look for what they are really feeling, is it really suicidal? Is the fact that they dont want to be around anymore or the situation has changed? Thats why I keep on about listening. You have got to listen to them . . . it is hard to categorize it . . . its like a poem by Stevie Smith Not waving but drowning are you listening to that?or are you saying that because that person mentions suicide you think yeah they are denitely going to be a suicide . . . are you listening to them or not? Other nurses practising in mental health expressed a similar challenge when working with young people. While it can be seen that suicidal behaviour is a communicative event, the meaning in the message was not always clear. The following two quotations emphasize this view: I think they are trying to say something and I think sometimes they are not sure themselves
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Complex messages
While nurses and doctors recognized suicidal behaviour as another voice for young people

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what they are trying to sayand thats where I think the difculty is in trying to make a connection with teenagers. Its a powerful form of communication and the trick is what they are trying to communicate to us. The complexity of suicidal behaviour as a form of communication also became evident among nurses and doctors working in paediatric medicine and A&E. These professionals often talked about young people who engage in suicidal behaviour as individuals who are living in a family where incongruent situations occur. The term incongruent situations is used to refer to instances where family communication itself is poor, discordant and problematic. The young person faced so many issues, traumas and unhappy circumstances that the message in the act of suicidal behaviour itself becomes complicated. The following nurse, practising in paediatric medicine, spoke about the complexity of understanding what was being communicated by an act of suicidal behaviour: I think for the children that repeatedly come inI think they are hurting so much that you dont even know why sometimes, and they do self-harm and they are not sure why. But it is still a form of communication even though they dont connect, it is very complicated that is just my opinion. For this nurse the young person is hurting because they are faced with signicant communication problems in the family. Nurses and doctors perceive young people as presenting a range of complex issues and therefore the act of suicidal behaviour as form of communication is itself complex.

seen as having experienced a situation whereby a family member has carried out a similar kind of act. One doctor placed in A&E recalls seeing two members of the same family attending the department for treatment: It does seem to be a repeated pattern. And quite often they have seen their parent do it. We have one father and son who often present together. One takes an overdose, they have an argument, so the other one goes off and takes an overdoseits almost becoming learned behaviour for them, that is, it is normal if their parent does that . . . theres nothing abnormal about it. This perception described by nurses and doctors seemed to place an emphasis on the young person being caught up in family communication, and this would include other relatives, as well as the persons immediate family. The following quotation from a doctor working in A&E illustrates this: Parents have done it or cousins have done it or someone in the family and they live in an environment where someone has been doing it. And they think, maybe this is the answer. This last quotation highlights the idea that suicidal behaviour has to have come from somewhere, and that often the development of such acts is attributable to the young persons participation in a matrix of interpersonal encounters i.e. parentyoung person; siblingyoung person; outside family members young person; peersyoung person and so on. In this paediatric nurses discourse, the inuence is seen as coming from the individuals peer group or friends or even less directly just by identifying the behaviour within their immediate social context: Or they have heard of peopleif we see one teenager a week and usually around 13, 14 years oldthey are bound to have known somebody from school where they have tried it. Nurses and doctors working in paediatric medicine and A&E observed the possibility that young people adopted the behaviour from the family and other social networks. Those working in mental health expressed that in the adolescent unit environment, collusion and contagion was the best way to give meaning to this process. Collusion happened sporadicallythat is

Seeing and using the social environment

Nurses and doctors perception of young peoples suicidal behaviour as a communicative process between the individual and others had a further meaning. Nurses and doctors talked about the fact that in the lives of young people, they are exposed to acts of suicidal behaviour. Young people were seen as being directly or indirectly inuenced by events/objects/people external to them. For example, many young people who engage in suicidal behaviour were
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seeing/being shown an act of self-harm in others and then engaging in the behaviour themselves. This had a signicant effect on the individuals involved, as a mental health nurse describes: I found it difcult in the past when one resident cut another resident . . . and the person they cut had never self-harmed in the past. It is something that they didnt really want to do . . . and that made me angry. The collusion is difcult. I understand that more, because that is to do with belonging and being part of a group. But when somebody goes to the shops to buy paracetemol for somebody else . . . and doesnt tell staff. Then six hours later it comes to light . . . that somebody else has got the paracetemol knowing they were going to take them . . . that is so dangerous . . . I can understand it in a way . . . but . . . thats a difcult one . . . it happens a lot. A doctor attached to the unit explained that this behaviour can grow and become contagious. Contagion had a competitive characteristic and could be used to create a response in clinical staff. In this sense, the behaviour has to be observed as an individual issue, and a group issue. This would correspond to the points made earlier indicating that suicidal behaviour in the social context of the family is used to inuence another person. The following mental health nurses comments illustrate the nature of contagion, when it occurs: I think they try and emulate each other. Its odd to sort of thinkIll try and be the worst self-harmer on the unit, but I think that is part of adolescence and they compete in some ways with each other. I mean we have not had so much now, but we have had times where they have colluded together to cut. The contagious nature of suicidal behaviour had a further meaning when nurses and doctors began to refer to wider aspects of a young persons social world. The media, in particular television, were seen as a powerful means of seeing images of suicidal behaviour. Nurses and doctors talked about soap operas running at the time that the interviews were being conducted and a number of interviewees referred to BBC 1s medical soap opera Casualty. In an episode of the programme, a patient was shown having taken 50 paracetemol and

was subsequently diagnosed as having severe liver damage. A nurse practising in paediatric medicine perceived the possible inuence of this programme on young people: There was also something on Casualty . . . I think Doctor XXXX actually wrote to Casualty and the people that make it saying what are you doing, this is like you have taught somebody how to do this properly. So he was quite angry with themunderstandably. The meaning associated with the how young people see suicidal behaviour is reiterated again by a doctor working in paediatric A&E: They have done it to themselves, but they have done it in an very naive state of mind not knowing much and I think they have done it fromwell you see things like this on TV a great deal, in soap operas and stuff and thats what they watch. But, for nurses and doctors, the impact of such images of suicidal behaviour had to be considered in the context of the overall inuence of what was seen on television, as a form of media. Another doctor in A&E describes the perception that media images of suicidal behaviour may inuence young people: I didnt watch Casualty I heard about itI dont knowI am sure that watching things like the overdoses, killing, murder, etc. on telly makes people more hardened to it and inuences them perhaps to do it. I certainly think it does inuence people, I certainly think it doeshardens them to itdoes anything shock people any more? Nothing does, does it? You see things on TVI think if it is the right sort of personlike Casualtyfor examplemedical drama shocksthey will inuence peoplebut then are you going to say are you going to take all these things off telly? Therefore, nurses and doctors talked about processes such as seeing a family member or friends engage in suicidal behaviour, or in an indirect way, seeing the behaviour on television. These inuences could have an impact together. Not necessarily at the same time, but exposure to such an environment or culture would engender such behaviour. By this, nurses and doctors expressed the view that young people develop
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their decisions on whether to engage in suicidal behaviour by being informed in a number of different ways. The following doctor practising in paediatric A&E illustrates this perception by referring to the media in a more general sense (the rst, by including lm): I think a lot of their ideas can come from friends or peer or family background. Depending on what sort of a family background they have, their social circumstances. If mums done it or they have got an auntie that frequently does this, and TV. I think a lot of its media and televisionand seeing it in lmsI think they are the two main sources. In the news, its not portrayed as anything glamorous or . . . I know the lm stars and stuff go through it and do it, and that might be another idea why, or another reason why, but that comes under the media option. So those are the two main sources. A lot of it has to do with family background and what they have been used to. What they have seen as they are growing up and what is normal for thembecause mum might have a sister who has done this or been depressive all her life and it may be something they have grown up with. So it might be that and I think a lot of it is media. This meaning is illustrated and summed up by the following comments from a doctor working in psychiatry: There is the common, or more common relationship problems, both in terms of social peer group type relations or family relations that can lead to self-harm. Sometimes inuenced by peer experiences or indeed media experiences . . . I think to add an intensity to it that gets played out every night two or three times a night in the different soap operas that are on TV. Most of which nowadays seem to be geared around young people in one form or another. I think it has been written up and well documented, a well publicized soap . . . suicide on some soaps you will then get an increase in similar sort of incidence. And indeed some individuals do present when they have had a peer experience of someone near them when they have done a similar thing. Nurses and doctors in this study have described the way in which they perceive the possible
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inuences media representations of suicidal behaviour have on young people. However, they do not see such a process as occurring in isolationother interpersonal encounters will impact on the young person at the same time. Therefore, the view that the media have an inuence on a young persons decision to engage in a certain kind of behaviour would imply that this is not a simple one-way process of communication. The professionals in this study describe their view that young people encounter others engaging suicidal behaviour parents, relatives, friends, other patientsand this is seen to occur alongside phenomena such as the media (TV programmes, etc.). The young person is seen as experiencing a range of situations where acts of suicidal behaviour have been carried out. Nurses and doctors in this study perceive such individuals as seeing and using such encounters arising from their social environment.

Discussion
Contemporary research focusing on young people who engage in suicidal behaviour continues to connect mental disorder and incongruent family situations with increased risk of suicidal episodes in teenagers (Apter et al., 1995; Hawton, Fagg, Simkin, Bale, & Bond, 2000; Pfeffer, Normandin, & Kakuma, 1998). This is the accepted basis of current clinical interventions and treatment used to reduce suicidal behaviour in this group of people (Harrington et al., 2000). This article has focused on meanings nurses and doctors associate with suicidal behaviour in young people. The ndings show how nurses and doctors construe young people who engage in suicidal behaviour. They illustrate the symbolic system and the culturally mediated social meanings these professionals have in relation to young people who engage in such behaviour. It is evident that suicidal behaviour is seen as a communicative act. This link between suicidal behaviour and communication is not a new observation. Much of the literature providing evidence for this link still relies on a causeeffect model (Babiker & Arnold, 1997; Eldrid, 1988; Fairbairn, 1995; Hill, 1995). This article has not been concerned with providing an account of why young people engage in

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suicidal behaviour, but it has focused on nurses and doctors use of a range of signs to describe this phenomenon. What arises from the ndings in this study is that they see young people who engage in suicidal behaviour using many aspects of their social life. Thus, instead of taking a pathological approach to explain these ndings a social semiotic analysis provides an understanding of the social meanings discovered. In doing this, the author(s) highlight the fact that they are taking these data and applying a selected theoretical perspective.

A social semiotic interpretation

Social semioticians maintain that social life, group structure, beliefs, practices and the content of social relations resemble, functionally, the units that structure language. This argument, within the eld of social semiotics, leads to the view that all human communication is a display of signs, in many ways, a text to be read. Roland Barthes observes: A garment, an automobile, a dish of cooked food, a gesture, a lm, a piece of music, an advertising image, a piece of furniture, a newspaper headline these indeed appear to be heterogeneous objects . . . What might they have in common? This at least: all are signs. (Barthes, 1988, p. 157) Even when we walk down a street or as we go through life and come into contact with these objects, we are presented with an array of signs (Barthes, 1988). People spend their time reading these messages, signs and signals (whether they know they are doing it or not). We read above all images, gestures, behaviours. We are given messages to read: the car someone drives, the clothes they wear, the way someone shakes your hand. These readings Barthes argues are central in our life, they imply many social, moral and ideological values. The world is full of many signs, yet these signs do not all have the rudimentary nature of the alphabet, of highway signs or football team coloursthey are much more complex. From this, it is important to express that semiotics is above all, an intellectual interest in the ways we represent our world to ourselves and each other (Barthes, 1988; OSullivan et al., 1983; Sless, 1986). In this study, while nurses and doctors perceived suicidal behaviour in young people as

Processes of communication the associated meanings Another voice and Complex messages might at one level be seen as another way of saying something to another person. Yet this simply echoes the previous rather mundane observations that suicidal behaviour is a form of communication (Eldrid, 1988). Another voice represents nurses and doctors perception that a young persons suicidal behaviour is a sign used in their social life (Barthes, 1988). Complex messages highlighted the difculty in ascertaining what is being said by the young person. From the social semiotic point of view, this involves not only suicidal behaviour as a way of overtly saying somethingbut also a range of signs presented by the young person. The health professionals in this study recognized this and talked about it. Therefore both Another voice and Complex messages illustrate an essential part of the symbolic system nurses and doctors use in relation to a young person who displays suicidal behaviour. This can be taken further by looking at the concept of meaning in social interaction. In Presentation of self in everyday life, Erving Goffman focused on forms of communication (Goffman, 1959; Heiskala, 1999). Goffman indicated that the expressiveness of the individual appears to involve two radically different forms of sign activity: expression that the person gives, and the expression that the person gives off. The rst involves verbal symbols that they use to communicate information that they and others accept as being related to these symbols. The second relates to a wide range of action that others can treat as being specic to the actor, the expectation being that the action was engaged in for reasons other than the information conveyed in this way (Goffman, 1959). This may be purposefully engineered and other times not. The information the individual gives off in such a communication may be non-verbal and perhaps unintentional. Therefore, the way in which an individual appears before others and the motives for attempting to control the characteristics of the situation is of primary importance to Goffman (Heiskala, 1999). Theoretically, this is very useful when looking at young peoples acts of suicidal behaviour. These young people are seen as expressing themselves in an otherwise conicting interpersonal relationship. The associated meanings of
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Another voice and Complex messages may support this assumption. But the act of suicidal behaviour can also be seen as an act of communication in which the young person is saying something else: the information the young person gives off. Heiskala (1999) maintains that Goffman restricts his argument by the focus in his study on face-to-face encounters. Signs are part of many areas of culture, they take place between a newspaper or book and a reader, lm and viewer, just as much as between two people engaged in conversation. As Pierce (1985 [1897]) pointed out we live in a sea of signs. The individual exists in a social, family and historical context (Olds, 1995). From a systemic point of view, Aldridge (1998) posed two pivotal questions: what does the behaviour mean? and more importantly, what does the behaviour mean in a particular context? There may not be straightforward answers to these questions. Fundamentally, they describe suicidal behaviour as part of the signs young people use and ultimately these occur in all aspects of the young persons culture.

Representations of young people in social life

Social semiotics extends into the study of popular culture that has in the past offered important interpretations of youth within society. Contemporary popular culture has highlighted the fundamental changes of the way in which young people represent themselves in society and how others construe them (Hall & Jefferson, 1976). The way in which society makes sense of what young people are and what they do continues to be an important area in which knowledge needs to be developed. Shucksmith and Hendry (1998) suggest young people are perceived in society as a strange tribe. It is normal to regard young peoples perceptions, attitudes and patterns of reasoning as very often being distinct and different. Identifying the very different ways in which young people construe and make sense of their lives has meant that adults view young people as a race apart; creatures from a parallel planet. Shucksmith and Hendry state: The cultural images which we use to describe children and childhood are important, as they give direction and shape to the attempts which we make to understand
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childrens and young peoples worlds (1998, p. 136). This underpins the need to understand the signs nurses and doctors use to make sense of young people who engage in suicidal behaviour. Yet young people and their cultural world has been the focus of previous research. Chambers (1986) main interest was in the signs of social life and, in particular, changes in youth culture. At the forefront, is the example of male subculture where a foreign most often transatlantic inuence has always been present. The Teddy boys and their devotion to the Hollywood gangster, the Mods who were as equally inuenced by Black American soul music and Continental fashion (Cohen, 1980). These are private obsessions of the male youth subculture. But they are imposed on the public arena, in societyyoung people wishing to be seen as the wild ones, the cool ones (Danesi, 1994; Lesko, 1996). They are a young persons temporary escape from time, circumstances, history. They translate an imaged state into the fashion, music and style of a carefully studied live performance (Chambers, 1986). Here it can be argued that young people who engage in suicidal behaviour have become equals to the youth groups identied in popular culture research. The inuences shaping the behaviour, style and identity of the these well-established youth subcultures are based on what they saw and the way they use(d) their social environment (Seeing and using the social environment). Nurses and doctors who work with this group talked about aspects of the young persons cultural experiences (with peers, family, friends, media, etc.). This demonstrates understanding of this groups world and cultural experiences. Again, Chambers (1986) theoretical view contributes to some further exploration of a young persons social world. In particular, the ambiguity of fashion is linked to the advertising and marketing techniques employed, but also to the construction of our public selves. The consumption of everyday products is also about the consumption of social signs: these we use to construct our identities. This world of goods (commodities we buy: clothes, music, lm) can turn over previous identities and place threats on power, values and British institutions. A signicant example would be the Spice Girls (and girl power) impacting on millions of

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young girls fashion, interests and behaviour. Equally, this concern for the body (female and male)in fashion, music, TV, etc., can draw us further into ambiguity, an escape from previous identities and the identication of new ones (Chambers, 1986; Collins & Kearns, 2001). To some this is disturbing. Members of a society become morally sensitized to threats of accepted values by deviant groups (OSullivan et al., 1983). Cohen (1980) used a case study of Mods and Rockers in the 1960s, to illustrate the way in which moral panics can be developed within society. One of the central features of Cohens account of moral panic is the concept of deviance (Downes & Rock, 1998). The examination of deviance and moral panic in specic aspects of social life is not a new eld of research. A number of studies have been conducted, including moral panics and youth subcultures (Hall & Jefferson, 1976; McRobbie, 1994) and moral panics and welfare scroungers (Golding & Middleton, 1982). Like Cohen, the interest here has been the interplay between the forces of social reaction, social control, the mass media and certain forms of deviant activity (OSullivan et al., 1983). Cotterell (1996) takes Cohens point that antisocial types (toughs, skinheads) are constructed by the popular media from an inventory of deviant features of young peoples clothing, appearance and behaviour. Cohen argues that a result of this process is that young people become folk devils, illustrating the role they ll in modern society. They become visible reminders of what we should not be. An expectation is created that the emergence of youth harbouring these features symbolizes the decline of community and the outbreak of destructive behaviour (Cotterell, 1996).

on the dance oor or a young black youth ring a gun in North London (Chambers, 1986). In a similar way, one view might be that the media today contribute to creating a moral panic around suicidal behaviour in young people by reconstructing it as deviant behaviour. The associated meaning Seeing and using the social environment presents the multifaceted world the young person is exposed to (family, relatives, peers, friends, soap operas, music, lms, etc.) and how this is made available to the young person as a way of expressing oneself. For nurses and doctors, seeing a family member, relative, friend or peer engaging in suicidal behaviour may often occur in juxtaposition with seeing the deviant act on TV played out by a favourite soap actor or pop star, or in other media (newspapers, teen magazines, inside covers of CDs, etc.). An important theoretical interpretation arises from applying a social semiotic approach to the meaning of Seeing and using the social environment. If we take Cohens work it can be argued that nurses and doctors perceptions form part of the deviant meaning associated with young people who engage in suicidal behaviour. Indeed, future research needs to take account of the cultural images we use to describe this group of young people, as they may have already become a modern day folk devil.

Implications for policy and practice

This article presents a group of nurses and doctors perceptions of young people who engage in suicidal behaviour. Taking a broad view, these young people have been depicted as being caught in a personal, public, practical and political debate (Cohen, 1980; DoH, 2002; Harrington et al., 2000). Suicide prevention policies acknowledge the importance of health professionals opinions, but are often based mainly on causeeffecttreatment models of suicidal behaviour (Harrington et al., 2000). These perceptions may be crucial for ongoing establishment of any national strategy for suicide prevention. Such professionals are a vital part of many general population approaches to reducing suicide. Indeed, such strategies encompass action in terms of media guidance, public education, school-based work and most often professional training (Jenkins &
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Todays folk devils?

Aldridge (1998) takes the view that when individuals demonstrate suicidal behaviour, observers articulate the reasons for those actions. People who become patients (together with their families) present as deviants challenging the accepted normality of society. Youth engaging in suicidal behaviour is disturbing to society. It challenges what is seen as normal in society just as Mods and Rockers ghting on Brighton Beach, skinheads and punks spitting

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Kovess, 2002). From a practical point of view the ndings highlight how these professionals make sense of suicidal behaviour in young people. The ndings reveal the staffs perceptions and describe the symbolic system being used in relation to this group. An understanding of how such factors function should be integrated into all levels of training for professionals involved in the care of these young people. One argument is that all training sessions should have some exploration of how the professional (being trained) views suicidal behaviour. Moreover, one of the key aspects of helping young people who have or do engage in suicidal behaviour must be to get closer to factors that mean something to that individual. This study has revealed that nurses and doctors perceive suicidal behaviour in young people as being associated with processes of communication. Perhaps a starting point is to address these healthcare professionals perceptions if new ways of working are to be developed and explored for future practice. Further qualitative research would help in this process, which also represents a key message in the current national suicide prevention strategy for England (DoH, 2002).

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