It is afternoon, and we are sitting in the peaceful setting of the courtyard of the Green Hotel, Mysuru, south India, drinking cappuccino and eating date and walnut cake. All of the ambiguities of the British relationship with India are here. The Green Hotel is run by a UK charity as a model of sustainable tourism. It was formerly the Chittaranjan Palace, home of the Mysore princesses. There is an unmistakable echo of the British Raj in this shady idyll, but the organisation has laudable aims and it has saved a charming historic building from redevelopment.
In the background, there is the ominous drumbeat of Trump week zero. It is not attenuated by distance. The papers and the news broadcasts here are as disturbed and disturbing as the US and UK media. I feel real shame that Theresa May, holding hands with Trump and dreaming of a trade deal, seems to have concluded that what he is doing in US right now is a quarrel in a far away country between people of whom we know nothing. It is truly a strange Tory Prime Minister who takes Neville Chamberlain as her role model rather than Winston Churchill. Twitter is one of the things that has facilitated this dreadful global crisis, but Twitter is keeping me in touch with friends and colleagues as we try to decide the most appropriate response to the Alt Right threat. UKIP’s saloon bar bores may look less sinister than their American allies, but they are not. Trump is not some remote clownish bully. He and his allies threaten us all.
I have blogged about the Bangor-Mysore collaboration for suicide prevention in India before. I set out the rationale for developing international links of this sort here and I described our last visit in 2015 in a series of blogs commencing here. I think that, for anyone working in mental health services in the UK, there are real lessons to be taken from this utterly different setting.
South Asia has a huge problem with suicide and self-harm. According to the WHO, south India has the highest suicide rate in the world. Preventing suicide and self-harm is difficult, because large-scale cultural, social and economic forces have a big impact. It is not, however, impossible. Structural social measures, community intervention and services for individuals all have a role to play.
Obtaining evidence relevant to the setting is crucial, as well intended but evidence free interventions can be harmful. Psychological debriefing after psychological trauma is a prominent example of the latter. It was deployed in Liverpool after the Hillsborough disaster, where I saw first hand the effects of a sometimes disastrous though well-intentioned intervention. Psychological debriefing was later convincingly shown to cause more harm than good.
In the UK, the social and demographic risk factors for suicide are quite well understood. They have been much less studied in India. We have published findings from two studies, and they show both similarities and differences with European findings. Financial stress and debt appear to be important in both settings. Family and relationship problems, whilst common in both populations, have a different complexion here. People live in extended family households, and young couples usually live with one set of parents. This creates pressures of a different sort to those experienced in the dyadic couple relationships of the West.
One of the things that we really do not understand, but plan to study, is a very strong theme in family and media accounts of suicide suggesting that inconsequential motivation for violent self-harm is common. This mainly involves the young urban population. The story tends to be that a minor dispute within the family or an insignificant setback has been followed by self-immolation (usually dowsing oneself with kerosene and igniting it) or consumption of organophosphate pesticides. This is hard to understand, and causes puzzlement. The issue is ideal for exploration using qualitative research methods. We have piloted these, and they are not difficult to use here. It seems to me likely that either the stated inconsequential motivation is a cover for a more troubling problem or what appears inconsequential is much more serious to the person concerned if you understand the full context. A comprehensive suicide prevention strategy will require a proper understanding of this phenomenon.
Confidentiality is tricky everywhere when it comes to self-harm. Trying to prevent someone from taking their own life routinely creates a dilemma whereby action compromises confidences. Despite the huge difference in lifestyle between India and the UK, privacy seems to work in much the same way. For example, in our research, very few people decline to participate, but a significant proportion decline follow up interviews. We are uncertain about the stigma of deliberate self-harm here. Some accounts suggest that the social standing consequences for survivors can be catastrophic, others that it is much as it is in the UK, in other words there is stigma but it is not disastrous. These conflicting accounts may relate to different impacts according to economic and social circumstances.
We are often asked if the high rate of self-immolation here is due to sati. The simple answer is no. Sati was the practice in some parts of India of widows throwing themselves onto their husband’s funeral pyre. It is essentially a historical phenomenon that still causes concern, but more or less ended a long time ago. Although Hindus have a somewhat higher rate of suicide than Muslims and Christians in India, the difference is not huge. Self-immolation is common in Muslim Pakistan and, for that matter, Kurdistan, which is a very long way away. I think a link between the suicide rate here and sati is fanciful.
Our big finding was that 16% of self-harm survivors here have a depressive illness, and that the patients who were depressed had the highest level of suicide intent. For most of them, their depression would be unrecognised but for participation in our research. Decent psychiatric services at low or no cost are in place, but there are major problems in accessing them. Some obstructions are cultural and others geographical. Our current focus is to improve assessment and to develop care pathways acceptable to the population.
This work is slow and long-term. We have sustained it through many grant applications, most of them involving small amounts of money. At each stage we find that there is more that we need to know. We do not have grandiose intentions. Our aim is to help our colleagues in Mysuru to develop sustainable improvements, not to somehow fly in from the UK as experts and solve India’s self harm problem. Instead, we facilitate, and this seems to work.
What we have learned and have taken back home is the danger of making assumptions. One of our colleagues here has completed a large epidemiological study that has startling and unexpected findings. I cannot write about these until they are published, but they undermine many assumptions about the mechanisms mediating between social class and physical disease. It required a study in Asia to challenge assumptions from European studies that were, on the face of it, perfectly reasonable but which, in the light of this new evidence, appear to be incorrect.
In the UK, the increased political profile of mental health has been associated with a large number of suggestions and initiatives based upon good intentions rather than evidence. For example: mindfulness training in education as a preventative measure; the suggestion that displays of compassion can prevent suicide and that compassion is a quality that can be promoted; the assumption that, on balance, social media do more to promote suicide than prevent it. I would not wish to undermine people who want to make a difference in mental health, but evidence does matter. It is not a case that the intention is more important than the effect.
As I write, a group of Buddhists are chanting and meditating a few yards away. Mediation is a common practice here, but that does not prevent a high rate of suicide. We should not assume that meditation-based practices could act as a kind of prophylactic measure in the young until this has been demonstrated to be so.
So amongst the important lessons for the UK here is one that we seem to have to learn over and again. Evidence matters, and context matters to evidence.