Culture and Self-Harm

Attempted Suicide in South Asians in London

Dinesh Bhugra

• Publisher: Psychology Press
• Year: 2020
• ISBN:
  9781000144437
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Attempted suicide is a matter of serious public health concern. Culture and Self-Harm considers the factors that may contribute to this increased rate of self-harm and suicide among south Asians in London, which cannot be blamed on migration alone. Cultural pressures that dictate the way stress is dealt with are examined and the effects of cultural conflict and changes in an individual's cultural identity are considered. Culture and Self-Harm offers a new preventative strategy that will be of theoretical and clinical interest to all mental health professionals, social workers, voluntary and primary care workers. It will help them understand significant factors that play a key role in the lives of south Asians who attempt suicide and what lessons can be learnt for dealing with other ethnic groups with the same problems.

CHAPTER ONE

Suicidal behaviour

INTRODUCTION

Suicide and attempted suicide have often been described as the two ends of the same spectrum. However, not all attempted suicides will lead to suicide and not all suicides will have a history of attempted suicide. Suicidal behaviour has been well described in human history in a number of settings and across different cultures.

Suicide has been seen as one kind of death where psychological motivation may well be present, i.e. the death results from a conscious initiation of activity by the deceased that was intended to bring about his/her own demise (Farberow, 1975). The motivation becomes an important factor in that intention plays a valuable role, consciously or unconsciously. Farberow (1975) gives examples of a diabetic who chooses to disregard his/her diet or antidiabetic medication, or a cardiac patient who chooses to carry on with heavy physical exertion such as shovelling snow — deaths in either case may well be termed as natural. On the other hand, a car driver who drives at high speeds may well be putting his/her life at risk and were death to occur under these circumstances the attributed cause may well be accidental. The equivocal motivation in these cases, as well as in cases of suicide, is difficult to judge. Their definitions are discussed further in chapter 3.

There is considerable evidence in the literature that rates of suicidal behaviours vary across cultures. Some of this variation is genuine, whereas some is attributable to the actual process of reporting and identification of cases. There are several countries around the world, including some in the Indian subcontinent, where the act of suicide remains illegal. Thus acts of both suicide and attempted suicide will often be subsumed under other causes.

Suicide as a word is of recent origin in the English language. Derived from the modern Latin suiciduim, which in turn stems from the Latin pronoun for ‘self’ and verb ‘to kill’, suicide inherently indicates a thread of self-destruction, but the definitions of self vary according to cultures. This is discussed further later in this monograph (see chapter 2).

Suicide is seen as a multi-axial behaviour rather then a category of mental illness and its treatment becomes complex too. The types of therapy available include psychological, pharmacological, sociotherapies, and other different kinds of intervention, which must deal with factors like age, gender, place where behaviour takes place (e.g. prisons), and cultural and social factors. Self-harming behaviours too are many, and apart from ingestion of prescribed or over-the-counter medication well above the therapeutic dose, cutting, ingestion of herbicides and pesticides, and more violent means such as hanging, drowning, gunshot, and other actions such as jumping from heights can be seen as means to commit suicide. The spectrum between attempted suicide and complete suicide is sometimes very wide and sometimes very narrow.

Nonfatal suicide attempters (Maris et al., 2000a) are individuals who have survived the attempt and are available for treatment or intervention, though not necessarily willing to undertake this. Maris et al. (2000b) suggest that different types of suicidal behaviour are interrelated but the exact degree of such a relationship is not very clear. The attitudes towards the act and the repetitive nature of the act do have implications for the development and acceptance of intervention strategies. Although the discipline of suicidology cannot just study suicide attempts because the individuals are alive and available and sometimes willing to undergo batteries of tests (Maris et al., 2000a), it is worth bearing in mind that not all successful suicides would have previously attempted suicide prior to the successful act. They may not have sought help or been identified as having any needs on the basis of assessment.

FACTORS IN SUICIDE ATTEMPTS

Suicidal behaviour may be preplanned or impulsive or related to psychiatric disorders. The gender differences in different kinds of suicidal behaviour are worth bearing in mind. Various social and cultural factors contribute to suicidal behaviour. These are not the same as the Durkheimian sociological perspective, which is discussed in chapter 4, but it is only relatively recently that other cultural factors like religion, caste, culture conflict, and alienation have been discussed and studied. It is not always possible to be absolutely certain about the causes of completed suicide or even attempted suicide and only educated guesses are possible at times. Factors like unemployment, alcoholism, and domestic violence need to be studied. These contribute to frustration and self-directed aggression, which may lead to suicidal behaviour. At the same time, factors such as family organisation, kinship systems, and access to organisations that may provide short-term, dedicated support, may interact with stresses to provide an element of protection. Suicidal behaviours may well be a response to a chain of events that may not be easily separable from each other or identifiable even for purposes of intervention.

Another key factor that is becoming an increasingly important focus for study is the act of migration and associated migratory status. This reflects the increased mobility of populations across a range of settings, be it internal — rural to urban — or external — from one country or culture to another. These migratory processes are the result of a number of factors, which either push or pull the individual towards migration. The reasons for migration can be economic, political, or academic. The patterns of migration may be voluntary or involuntary, singly or in groups. Each of these patterns has a different yet definite set of responses, which contribute to stress the individual experiences. At the same time, the welcome (or a lack thereof) by the host culture may introduce a further element, which pushes the individual to self-injurious behaviour. The roles of alienation, acculturation, and deculturation are worth bearing in mind. These are further discussed later in this volume (see chapter 5).

In addition to the patterns of migration and interactions with the host community, individuals also interact with members of the same ethnic and cultural group, which produces its own set of problems and difficulties. The concept of culture conflict emerges from such an interaction. An individual, by virtue of a number of factors (such as age at the time of migration and economic and educational status) may well hold less traditional attitudes and beliefs, which may then be at odds with those of his/her parents, extended family or community elders, thereby producing a sense of alienation within his/her own community.

In addition, this may also produce alienation from the host community, which might find it difficult to deal with these emotions and feelings. The role of protective factors and an understanding of these are essential in understanding the causes of suicidal behaviour and how to plan and evaluate interventions.

The factors that push the individual towards suicidal behaviour are also linked with factors of the culture or the personality of the culture. Hendin (1964a) suggests that the national character contributes to the actions of its subjects and that the social values of the national character allow the clinician to understand these acts and also help to develop preventive strategies.

What people think they should feel is indicative of certain social values present in the culture (Hendin, 1964a, p. 2). Hendin argues that if the same question — whether the subject was a good nurse — is asked of Norwegian and American nurses, the responses are remarkably different, indicating that social and cultural identities vary within the same profession. He urges the use of the term ‘psychosocial character’ rather than ‘national character’ because psychological, psychoanalytic, and cultural attitudes will contribute to the behaviours and moral values of individuals.

An individual’s race and ethnicity also contribute to his/her beliefs and responses to suicidal behaviour. Sex, age groups, and social economic status all interact with race and ethnicity and allow clinicians and researchers to develop strategies for assessment and intervention. The definitions of race and ethnicity emphasise not only biological factors but also social and cultural factors. The interactions between individuals and their social and cultural backgrounds become extremely complex. In primary care settings a lack of prevention strategies that are culturally appropriate and culturally sensitive, and insufficient understanding of cultural factors, mean that not only are the rates of suicidal behaviour much greater in some settings and ethnic groups, but also that these are influential in help seeking and pathways into psychiatric care.

Historical accounts of how a community migrates, its aspirations for the future in the new country and how these are met can be seen as contributing to the national character of the country. In societies where feudal systems have lasted for a long time, e.g. the Indian subcontinent, politicians sometimes continue to behave as if they are still feudal lords, despite the introduction of democracy. As Benedict (1934) explained in her accounts, cultures too have personalities and, like that of the individual, lead individuals to behave in specific ways. In societies such as the Indian (which is a large heterogeneous group with several languages and religions) the response to acts of attempted suicide remains a patriarchal-controlled, feudal response where the elders know best and the younger members have to behave in a particular way to ‘survive’.

Any conflict therefore becomes important within the individual psyche as well as within the larger kinship and society. Cultures based on the establishment of society by violent methods will encourage violent means for suicidal and homicidal acts. A major problem in understanding and studying suicidal behaviours is the individuality of the act, which is deeply embedded in the cultural context. Therein lies a paradox with which researchers and epidemiologists have to struggle in order to make sense of the behaviour.

The spread of suicidal behaviour across the life span and the life cycle is well known. It appears that in many cultures and societies the rates have been high among the youth or the elderly, both in ancient and modern times. It is likely that the frequency of suicidal behaviour not only fluctuates over the life cycle of an individual, depending upon his/her psychological, social, and cultural settings, but is also embedded within the national or psychosocial characteristics of the society or culture itself, as highlighted by Durkheim (see chapter 4).

Cultures or societies at the zenith of their power of development, or just beyond it, may well show permissive attitudes towards suicide, as well as an increase in the frequency of suicidal behaviour (Bayet, 1922). Conversely, Diekstra (1992) argues that cultures in early states of growth and development have more restrictive attitudes towards suicide, with a concomitant lower frequency of the phenomenon. The underlying argument is that the varying rates of suicidal behaviour across different cultures and societies may well be associated with the growth and development of the societies. However, this does not explain the high rates reported in some ethnic and racial groups compared with their host societies.

Social factors like isolation, alienation, poor support, estrangement, unemployment, and alcohol have been associated with rates of suicidal behaviour. Suicide rates are highest in the upper and lowest social classes. The role of imitation and societal and religious attitudes to suicidal behaviour are worth studying too. As a result of failure to respond to help in an appropriate and sensitive way, repetition of the suicidal act may also lead to further alienation and distancing from those around the individual, especially during the period immediately before his/her death. This malignant alienation remains understudied. Recurrent depression may contribute to the withdrawal of individuals from the society and culture.

In this volume, the main emphasis of study is on South Asian individuals who have migrated from South Asia, especially to the UK. Their rates and sociocultural factors are compared with those in South Asian countries and the Indian diaspora and placed in historical and religious contexts; preventive strategies that may be helpful are described.

CHAPTER TWO

South Asia and concepts of self

INTRODUCTION

South Asian countries, for the purposes of this monograph, constitute the Indian subcontinent. India forms the largest component, with its eastern neighbours Nepal and Bangladesh (which until 1975 was a part of Pakistan), and to the west Pakistan, with Sri Lanka to the South. The geographical area of the subcontinent is larger than the geographical area of Europe and extends from the Arabian Sea to the Himalayas. Its population exceeds 1.5 billion and the religions within the subcontinent are Hinduism, Islam, Buddhism, Sikhism, Christianity, and other minority religions like Judaism and various subsets. In India itself, more than 20 languages have been recognised in the country’s constitution as key languages spoken within the country, thus establishing a heterogeneous group. Such broad heterogeneity needs to be borne in mind when attempting to understand any patterns of behaviour. The similarities and differences interact to make studies more complex in their interpretation.

This chapter aims to cover basic events of different religions and their attitudes towards suicidal behaviours. This is followed by historical aspects of suicidal behaviours across different religious groups and nations. Until 1947, India included not only Pakistan and Bangladesh but also Burma (now Myanmar) within its borders, so wherever possible historical descriptions will include these nation states as well.

BASIC TENETS OF HINDUISM AND SELF

Very comprehensive accounts of these religions are beyond the scope of this chapter and interested readers are directed to Brockington (1996), Wilkins (1882), and Kalupahana (1987). For both Hinduism and Buddhism, most of these volumes barely scratch the surface in terms of philosophy, morals, rituals, and other tenets.

Hinduism is said to be a way of life and is neither a monolithic religion nor a unitary concept. This is exactly what makes it not only interesting, but also difficult to understand at times. Brockington (1996) argues that Hinduism has an incredible variety of expressions. Hinduism has no doctrine universal to the whole of Hinduism, but most people will accept Hinduism as a definite and reliable entity. With hundreds of thousands of gods and goddesses that people choose to worship (according to their spiritual need and personality trait), Hinduism cannot be deemed to have an exhaustive description of the religion. Brockington (1996) recommends using internal and external criteria for Hinduism. The external criteria can be a test of orthodoxy and the internal criteria used for definition. The stereotype of Hinduism is its rigidity as regards its caste system. For most Hindus, religion is all-pervading, but the individual in general is not obsessively concerned with it. However, the practice of religion is internalised and it is neither extraneous nor imposed from outside. The flexibility of...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• List of figures
• List of tables
• Acknowledgements
• 1. Suicidal behaviour
• 2. South Asia and concepts of self
• 3. Definitions of suicidal behaviour
• 4. The Sociology of self-harm: Contributions of Durkheim
• 5. Social and personal factors and suicidal behaviour in adolescents
• 6. Women and suicidal behaviour
• 7. Sati and jauhar
• 8. Attempted suicide in the Indian subcontinent
• 9. Attempted suicide and the Indian diaspora
• 10. Rates of attempted suicide and social cultural factors in West London
• 11. Rates of attempted suicide in adolescents in West London
• 12. Cultural identity and deliberate self-harm
• 13. Prevention strategies and community involvement
• 14. Conclusions and the way forward
• Appendix I: The Asian Cultural Identity Schedule (ACIS)
• Appendix II: Educational pamphlet
• Appendix IIIA: DHS Assessment by Clinicians (DACS) Adolescent version
• Appendix IIIB: DHA Assessment by Clinicians (DACS) Adult version
• References
• Author index
• Subject index