One of my favourite "cocktail party" conversations involves discussion of mental health issues with those who deny them, and the efficacy of treatment, then ask for advice and recommendations in diverse covert ways. I am not being facetious in this. These conversations have made me realize that I can be helpful, in a semi-professional manner, to people reluctant to seek professional care--at least for the time being. They have also enlightened and modified my professional understanding of mental health and mental health care delivery.
These conversations most often occur in settings where I am doing my best imitation of a corporate wife, or being the token Canadian-born Canadian in a room of one minority culture or another, or being the only non-Arab in the room, or some combination of these. They sometimes start with a loud public derision (in polite form, of course) of psychiatric illness as being fake, psychiatrists as being useless and too stupid to get into a real medical specialty, and the psychiatrically ill as being weak personalities or malingerers.
Sometimes there is an acknowledgement that such problems occur in Western societies, but not in "my culture/country" because "we have family and faith". I usually agree with the protective role of strong, extended family ties, and faith-based coping strategies as important preventives and supports for the mentally or emotionally challenged. I do so in all honesty, because research bolsters common experience to show that this is true. However, if possible in the context, I do introduce the idea that professional care doesn't replace the importance of these supports, but adds to them, and offers help in a way non-professionals cannot, particularly as much mental illness is biologically induced, mediated, or exacerbated, no matter the other psychological and social factors involved.
This public conversation is often then followed by a private one--either quietly spoken seatmate to seatmate, sometimes by the loudest of the public disclaimers; or later, in a one to one conversation off to the side of the group, by the disclaimer or someone else, sometimes even the spouse of the disclaimer. That conversation usually starts with "You're a psychiatrist, right?". I have come to recognize that this seemingly unnecessary question has important functions. It helps the person introduce the topic, reassures them that they are speaking to a professional, gives them time to calm their anxiety about doing so, even in a friendly, "this is not really a consultation" setting, and allows them to have a reassuring affirmation verbally and non-verbally (nod, smile, open posture) that yes I am, with the unspoken subtext, "...go on...". They then introduce a concern about a family member, a friend, a neighbour, sometimes themselves, but most often themselves in a helping capacity. I take this at face value, since it might be true, and whether or not it is the precise truth, it is a useful way to discuss the topic while letting them save face, and maintain their self-identity.
As a result of both types of conversation I have had the opportunity to learn more of how different cultures (including corporate cultures, a study unto themselves) frame and present mental health issues, seek to resolve them, and interact with the majority culture when they are an ethnic or other social minority. While I have always appreciated that good quality self-help or psychiatric/psychological books written for the general public have an important role in mental health self care, and as an adjunct to professional care, these conversations have made me more aware that for some people they are the only acceptable way to access much needed information and guidance.
Particularly in the private conversations, people will share the titles of books they have bought or borrowed and read, and ask my opinion of them, or ask for recommendations. I am particularly impressed with the wives and mothers, who may or may not have much formal education, especially beyond high school, who have made the effort to seek out and read these books, including from public libraries. I am impressed because, although I have every confidence in the intelligence and capacity for life long learning of those with even no or little education (television and videos are another resource), these women have crossed a cultural line to obtain openly mental illness related books. In more traditional settings, and in their home countries, they may have gone only so far as to seek religiously-themed psychological works. Some of the latter are very good too, and combine excellent contemporary understanding of mental illness with a religious framing that is helpful for believers.
Once I picked up one such religiously framed book lying on a living room couch in Morocco during the summer academic vacation. It was well-written and the faith base was broad. The reader was a family member who was a medical student in France, despite herself, and in compliance with her mother's wishes, also the quiet and somewhat overlooked middle child in a family of strong personalities, going through a parental divorce. We had a brief discussion of the book's quality without engaging in the whys and wherefores. She is now a general practitioner with a specialization within that broader practice.
I am also impressed with all those from any culture who have the courage to seek professional mental health care where there is a need, or they are wondering if there is a need. Some, like recent immigrants, immigrants who have held more closely to their culture, the children of immigrants, and international students have done so against ethnic stigma and rejection of psychiatric solutions in favour of family and religious ones. Again, family and faith are helpful--until they prove insufficient.
Sometimes the family is the problem, and particularly in an immigrant context there are few extended family members to confide in or have mediate among the problematic members. The solution to find an excuse to live in another city with a different family member may be less available or involve changing countries, and may only be a short-term, partial solution anyway. Sometimes the particular interpretations of a faith are the problem, or the counselling available from religious leaders is unskilled or inappropriate.
Within MENA countries there is generally greater stigma against mental illness as found in many traditional cultures compared with less traditional ones. Mental illness or emotional distress may be perceived as a failure of the individual's faith or family. The evil eye may be seen as causative and various measures may be taken to reverse it, or counteract a hex. Some can be quite extreme, as are the exorcism techniques at Bouy Omar, the famous mental health marabout in Morocco. Others are as simple as wearing verses of the Qur'an as amulets.
I once saw a young Muslim man who had been brought back to the psychiatric hospital after a previous admission because of a relapse. After the initial discharge, the patient took his antipsychotic medication with his family's encouragement. They also took him to London England to visit a particular religious figure who blessed him and gave him amulets of Qur'anic verses to wear. He did so.
Eventually, like all psychotics commonly do, he stopped taking his prescribed medication. After a time, he relapsed. His family brought him back for assessment and to receive further medication. In discussion, they believed he had relapsed because the amulets had broken and fallen off. No matter. They did come to the psychiatric hospital, and for medication specifically. I encouraged them and him to use both the medication and the amulets. Unlike some others, I don't see these as mutually exclusive or even conflictual.
Islam in particular encourages the faithful to seek help from science for their afflictions. Hopefully, as MENA countries move from more pressing needs in often third world economies, or still limited infrastructures in rapidly evolving wealthy economies, and away from dictatorships that have other priorities, there will be greater investment in mental health care initiatives beyond psychiatric hospitalization and treatment for only the most disturbed and most difficult to control. Public education about mental illness, or emotional distress in its broader and milder forms, can help reduce stigma, and foster the acceptability of professional help seeking. Most importantly, an ounce of prevention is worth a pound of cure.
World Suicide Prevention Day is one ounce of prevention. The 2008, 2009, 2010, and 2011 have taken a deliberately cross cultural approach to the topic after a number of years of broader perspectives. The 2011 focus is on multicultural communities within majority cultures. There are always such minorities, even in seemingly homogenous majority culture countries. The smaller, the more recent, and the more disenfranchised the minority group, the fewer professional resources tailored to their needs.
MENA countries have minority groups of longstanding ethnic communities who have migrated there over time, or became minorities after national boundaries were drawn, and of expatriates, both guest workers and guest professionals, and their families. Some MENA countries are, from their national creation, composites of different faith and ethnic groups who form more of a plurality than a true minority. Depending on the affiliations of the ruling power and international pressures they may be more or less well served in all aspects of their social lives, including culturally sensitive, accessible mental health care.
The events of the Arab Spring have brought new meaningfulness, purpose, and hope to many, but also new sources of frustration, trauma, grief, and loss. Suicidal thoughts or gestures may be a part of any of these. Individuals, families, and friends struggle with the consequences of imprisonment, torture, injury, killing, and a general atmosphere of insecurity, even where there is not outright war or military repression, which also have specific challenges. Some places like Gaza are in a chronic state of traumatization by undeclared war.
The events of the Arab Spring and more particularly of the Arab Summer have also brought new minority groups within majority cultures, as families, towns, and ethnic groups flee or are forced to new locations with a country, across borders into neighbouring countries, or overseas. Family and group cohesion at these times are particularly important. Those dealing with refugee communities have learned that it is best for mental health outcomes to keep families intact, and to provide community groupings drawing on the resources of the displaced group to help each other, and have a sense of purpose and social structure themselves, as well as drawing on necessary broader supports.
Below is information from the website for this year's World Suicide Prevention Day, with ideas on actions to be taken in follow up.
WORLD SUICIDE PREVENTION DAY 2011
World Suicide Prevention Day is held on September 10th each year. The purpose of this day is to raise awareness around the globe that suicide can be prevented. Disseminating information, improving education and training, and decreasing stigmatization are important tasks in such an endeavour. The theme in 2011 is "Preventing Suicide in Multicultural Societies".
The themes of the last two years of the World Suicide Prevention Day have focussed on suicide prevention in different cultures across the world. This year's theme aims at raising awareness of the fact that all countries in the world are multicultural. Many countries harbour different minority groups, in the form of various indigenous and/or immigrant groups, refugees and/or asylum seekers. Some countries comprise many different ethnic groups due to artificial borders having been drawn by former colonial powers. This means that in all countries there are a variety of ethnic and religious groups living in the same society.
Multicultural societies require cultural sensitivity in all suicide prevention efforts. However, a common mistake is to treat culture as something objective that explains differences. When we find differences between cultural groups in a society, e.g. suicide rates and risk factors, we tend to explain these in terms of cultural differences. This can, however, conceal the real reasons for differences that may or may not have something to do with culture at all. Examples of other factors that may be important are unemployment, poverty, oppression, marginalisation, stigmatisation, or racism. Moreover, culture is not a static or measurable variable; rather culture describes the dynamics evolving in an interaction between individuals and their surroundings. So, at the same time as we need to be culturally sensitive and aware of potential cultural differences, we must not let "culture" overshadow other important factors that might be at play. Neither must we overlook similarities in our vigilance to find differences.
The WHO estimates that about one million people around the world die by suicide every year. However, many countries still lack reliable suicide statistics, and even countries with reliable statistics may lack knowledge about the magnitude of the problem in (some of) their minority populations. This knowledge might also be challenging to acquire due to stigma having a larger impact in various minority groups compared to the majority. Nevertheless, such information is needed. Some studies have shown that suicide rates among immigrants are more similar to the suicide rates of those in their original country compared to the new country in which they have settled. Other studies, however, show that this varies across country and subgroup. Therefore, we need to be careful about drawing universal conclusions.
Risk factors for suicide vary across cultural groups. Knowledge about common risk factors in a society often stems from research in majority populations. However, in a multicultural context we need to be aware that some risk factors may play different roles in the suicidal process as well as in suicide prevention for some minority groups compared to the majority population. For instance, risk factors for elderly men in the majority population may have little relevance for young immigrant girls. In addition, other factors that might have a different impact on minorities compared to the majority population are attitudes towards suicidal behaviour and suicidal people (e.g. taboo, stigma), religion and spirituality, and family dynamics (gender roles and responsibilities).
Studies have shown that stereotyping might be common in the health and social care system in dealing with minority groups. Therefore, we need to be careful to distinguish between how the rules and traditions of a cultural group define how members of that group may or should behave and how individuals from a cultural group actually do behave. We must not let stereotypes rule what we perceive or do. Some of the previous research reporting average values for immigrant groups or comparing heterogeneous groups of immigrants with the majority population in the country may contribute to such stereotyping in suicide prevention. However, it gives little meaning to compare the relatively homogeneous majority population in a small country such as, for instance, Norway, with Asian immigrants to this country since the latter group can comprise people from a vast number of very different countries, cultures and religions, as Asia stretches out from the Middle East to Siberia. In the health and social care system the individual must not be met as a representative of a cultural group, but be allowed to be themselves with their own beliefs, attitudes, understandings, thoughts, and knowledge.
Gender issues and racism in therapeutic settings are important to be aware of in multicultural societies. Use of interpreters in the health and social care system also requires special attention when a sensitive issue such as suicide is on the agenda. Often, minority populations in a community are small and interpreters are recruited from the same social circle as the client. If suicidality is particularly taboo or stigmatised in the minority group, it may be necessary to check the interpreters' attitudes towards suicidal behaviour and suicidal people because these might affect both what is being said by the client as well as what is translated and how by the interpreter.
National suicide prevention strategies have now been implemented in several countries, but not all of them reflect the fact that the country is comprised of various minority groups. The strategy/program is often aimed at the majority population and a specific cultural perspective or focus is missing. Strategies therefore may need revision with this in mind and countries still not having initiated suicide prevention efforts should integrate a cultural perspective from the start.
Even though suicide is a complex and multifactorial phenomenon with cultural differences, there are still some suicide prevention efforts that might have "universal" effect.
- Experiences of connectedness are important in the mental health and wellbeing of all people. Thus, communities that are well integrated and cohesive may be suicide preventive.
- Educating professionals of health and social services as well as communities in general about how to identify people at risk for suicide, encouraging those who need it to seek help, and providing them with needed and adequate help can reduce rates of suicide. These efforts require both cultural sensitivity and cultural competence.
- Methods of suicide vary across cultural contexts, but restricting access to whatever means are commonly employed has been found to be effective in reducing the number of suicides (e.g. safe storage of firearms, pesticides and medicines; restricting access to bridges and high rise buildings commonly used as jumping sites).
- Educating the media on how to report on suicide responsibly, and
- Providing adequate support for people who are bereaved by suicide.
Suicide prevention in multicultural societies needs to be targeted as a multidisciplinary effort. Effective suicide prevention involves a multifaceted and intersectoral approach to address the multiple pathways to suicidal behaviour in a socio-cultural context. People who can contribute to suicide prevention include, for instance, health and social care professionals, researchers, teachers, police, journalists, religious leaders, cultural leaders, politicians and community leaders, volunteers, and relatives and friends affected by suicidal behaviour. People also tend to open up to bartenders, hairdressers, and taxi drivers, among others. In short, suicide prevention is everybody's business, and thus everyone can contribute.
WHAT YOU CAN DO TO SUPPORT WORLD SUICIDE PREVENTION DAY
WORLD SUICIDE PREVENTION DAY, September 10th, is an opportunity for all sectors of the community - the public, charitable organizations, communities, researchers, clinicians, practitioners, politicians and policy makers, volunteers, those bereaved by suicide, other interested groups and individuals - to join with the International Association for Suicide Prevention and the WHO to focus public attention on the unacceptable burden and costs of suicidal behaviours with diverse activities to promote understanding about suicide and highlight effective prevention activities.
Those activities may call attention to the global burden of suicidal behaviour, and discuss local, regional and national strategies for suicide prevention, highlighting cultural initiatives and emphasising how specific prevention initiatives are shaped to address local cultural conditions. Initiatives which actively educate and involve people are likely to be most effective in helping people learn new information about suicide and suicide prevention. Examples of activities which can support World Suicide Prevention Day include:
- Launching new initiatives, policies and strategies on World Suicide Prevention Day
- Holding conferences, open days, educational seminars or public lectures and panels
- Writing articles for national, regional and community newspapers and magazines
- Holding press conferences
- Placing information on your website and using the IASP World Suicide Prevention Day banner, promoting suicide prevention in one's native tongue (www.iasp.info/wspd/2011_wspd_banner.php)
- Securing interviews and speaking spots on radio and television
- Organizing memorial services, events, candlelight ceremonies or walks to remember those who have died by suicide
- Asking national politicians with responsibility for health, public health, mental health or suicide prevention to make relevant announcements, release policies or make supportive statements or press releases on WSPD
- Holding depression awareness events in public places and offering screening for depression
- Organizing cultural or spiritual events, fairs or exhibitions
- Organizing walks to political or public places to highlight suicide prevention
- Holding book launches, or launches for new booklets, guides or pamphlets
- Distributing leaflets, posters and other written information
- Organizing concerts, BBQs, breakfasts, luncheons, contests, fairs in public places
- Writing editorials for scientific, medical, education, nursing, law and other relevant journals
- Disseminating research findings
- Producing press releases for new research papers
- Holding training courses in suicide and depression awareness
- Becoming a Facebook Fan of the IASP (www.facebook.com/IASPinfo)
- Following the IASP on Twitter (www.twitter.com/IASPinfo), tweeting #WSPD or #suicide or #suicideprevention
- Creating a video about suicide prevention (/www.youtube.com/IASPinfo)
- Lighting a candle, near a window, at 8 PM in support of: World Suicide Prevention Day, suicide prevention awareness, survivors of suicide and for the memory of loved lost ones.
Consider the candles sincerely, though belatedly, lit.
Your comments, thoughts, impressions, experiences?
ArabPsyNet (In Arabic, English, and French) a resource for Arab psychiatrists and psychologists with relevance to non-professionals.
World Psychiatric Association (Advancing Psychiatry and Mental Health Across the World); including academic journal issues in Arabic; a section on Public Education addressing major mental illnesses including suicidality.
Gaza Community Mental Health Group with resources on setting up support and training programs for those traumatized by torture, war, deprivation, and the resulting challenges to the family constellation and the individuals within it men, women, and children.