On surviving suicide in south India – Exploring support mechanisms from the perspectives of survivors and service providers

Abstract

The suicide rate in India (15.84) currently exceeds the global average (11.23) making suicide a significant public health concern. Although suicides in India are debated on medico-legal, socio-cultural, economic and political fronts, the help that is offered to people during times of crisis, before and after the attempt is very minimal. The paper aims to explore support mechanisms from the perspectives of 15 survivors, eight mental health professionals and seven traditional healers in south India. The data were analysed thematically and explored further using Bourdieu’s theoretical concepts. Data indicated medical intervention as a prominent method with reservations towards psychological therapies. Reliance upon religious and traditional healing systems was a dominant source of support and culturally accepted means. A key finding is the importance of recognising social and cultural power experienced both by service users and service providers. These potentially inform behaviours, attitudes, influences upon decision-making, changing dispositions, approaches to services and strategies for support. A firmer approach to integration of services within the healthcare and a fusion of both biomedicine and traditional practice could be a future direction for suicide prevention.

Introduction

The World Health Organisation (WHO) recognises suicide/self-harm as one of 20 leading causes of death worldwide. A report by WHO on suicide and suicide prevention in Asia, identifies that the problem is not being addressed adequately, lacking research and policy attention (Hendin et al., 2008). The rate of suicide in India (15.84) currently exceeds the global average (11.23) and recorded high rates (13-16 deaths per 100,000 population) for the past decade (Institute for Health Metrics and Evaluation, 2016). The Indian government’s policy and preventative approach to suicide is characterised by a generic rather than individualised focus (Murthy, 2011p.232) with an underlying assumption of attempted suicide being synonymous with mental illness.

The National Mental Health Programme of 1982 integrated mental health care services into the primary health care system. This integration aimed to deliver better mental health care services to the communities, however lack of mental health professionals left most primary health care centres operate without mental health professionals (Gururaj & Isaac, 2003; Mayer, 2011). With an aim to reduce the gap in mental health treatment, the government of India allocated more spending into training of ‘non physician mental health professionals’ and into community-based mental health programmes in the current (and 12 th) five year plan (2012-2017) (Planning Commission, 2011p. 7). The spending was increased by threefold in comparison that of the previous plan (2007-2012) but represented less than one per cent of the total health budget on mental health (Mayer, 2011; Staff Reporter, 2012). Although suicide prevention was not on the national agenda in previous mental health policies, the Mental Health Bill, 2016 decriminalises suicide, treats mentally ill people with dignity, gives people the power to make choice in their treatment and assigns central and state authorities the power to regulate mental health sector and register institutions.

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An evaluation conducted by an independent body in the year 2008, presented to the government the need for suicide prevention not only from a mental health perspective but also acknowledged socio-cultural, economic and religious aspects (Government of India, 2011; Hendin et al., 2008). Despite this proposition very little has been done to address the social, cultural and economic challenges and reduce gaps in mental health care delivery. To plan effective intervention and prevention strategies, there is a greater need to explore and understand the socio-cultural process. Furthermore, identify its influences upon suicidal behaviour while recognising individuals within their social setting, their interactions, the meanings they derive, their responses and the impact of such interactions. Another article (Lasrado et al., 2016) deals in detail how certain cultural mechanisms can be distressing and present a risk for suicidal behaviours for men and women in South India based on the accounts of survivors of suicide, mental health professionals and traditional healers.

Besides the government’s attempts at providing mental health care, culture has vastly shaped perceptions towards mental health, mental illness and has even negatively influenced help seeking behaviours. People hesitate to approach counselling and psychological services for fear of stigma and being called ‘mad’ or classified as mentally ill (V. Patel, 2007; V. Patel, Saraceno, & Kleinman, 2006; Vikram Patel, Simon, Chowdhary, Kaaya, & Araya, 2009). This classification adversely affects family life, career, education, marriage opportunities and other aspects of the social life. Stigma associated with suicide, is common in almost all parts of the world and is reflected through the cultural forces of society (Mayer, 2011). In India, members of victims’ families are sometimes under the impression that a suicide attempt was a result of a black magic, evil eye and possession (Jayaram, Goud, & Srinivasan, 2011; Staples, 2012). Whilst on the other hand the cost involved in accessing services, consulting health professionals and obtaining medication could create a barrier in approaching medical and psychological support (Raguram, Venkateswaran, Ramakrishna, & Weiss, 2002). Due to these difficulties and the religious contexts, people often turn to traditional healing methods. They tend to approach faith healers, herbalists and Ayurveda practitioners regardless of medical support (Parkar, Nagarsekar, & Weiss, 2009; Sebastia, 2009).

The social and cultural contexts are central to understanding the support mechanisms and approaches towards help at times of distress and on surviving suicide. Although the wider literature discusses the mental health provisions within biomedicine and affiliations towards traditional practices, there is a gap in explaining how individuals’ belief systems interact with these systems and shape the choices and potentially treatment outcomes. The narratives around how survivors and service providers interact with these systems and insights into process of making choices are discussed in this paper.

Methods

This study adopted a qualitative approach drawing on constant comparison method and thematic analysis (Bryman, 2004; Corbin & Strauss, 1942). This approach facilitates in depth exploration of social and cultural phenomena through the experiences and accounts of participants which could hardly be achieved otherwise through quantitative or statistical models (Lindlof, 1995).

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Setting & Participants

The study was situated in a range of urban, semi urban and rural locations such as the Bangalore/Bengaluru, Mysore/Mysuru and Coorg/Kodagu districts of Karnataka, South India. Three groups of participants were recruited, survivors of attempted suicide (S), mental health professionals (MH) and traditional healers (TH) over a period of six months (January 2012 – July 2012). The survivors of suicide (n=15) were sampled purposively and accessed via gatekeepers (mental health professionals) in hospitals and private clinics. Among them were both men (n=6) and women (n=9), belonging to religions - Hindu (n=10), Muslim (n= 1) and Christian (n=4). The participants were within the age range of 18-44yrs with various qualifications, professions and socio-economic background. There was one participant who was illiterate. Mental health professionals (n=8) were sampled purposively and consisted psychiatrists (n=2), general practitioners (n=1), psychologists (n=2) and social workers (n=3) with an experience of more than a year in practice. General practitioners formed a part of this sample group as most of the survivors do not seek mental health treatment and present to general physicians. There were two female and six male professionals. This group was recruited through general hospitals and private clinics. The traditional healers (n=15) were snowballed with the help of service users and believers. There were religious ministers (n=6) and lay people (n=2) from the three dominant religions namely Hindu (n=3), Muslim (n=3) and Christian (n=2). Hindu healers conducted their services mostly within the temple. On the other hand, Muslim healers used clinics and offices specifically for the purpose of consultation and treatment. Whereas Christian healers practiced either in church or offices attached to churches. Muslim and Hindu healers practiced alternative medicine such as Ayurveda, Rekhi and Hamdard (naturopathy) alongside religious healing.

Data collection & analysisThe participants were interviewed in-depth either in their homes, hospitals, offices or places of worship. The researcher (first author) conducted the interviews in their preferred languages, Kannada or English. The researcher being multilingual and an insider to the cultural context, was able to gather the subtleties of cultural expressions and factors. The participants used multiple languages to express certain phrases, which they could best do in the language that they were most comfortable. The interviews were transcribed into source primary languages (kannada or English) and analysed using NVivo 10. The Initial process of analysis used principles of thematic analysis, by grouping the data into themes and categories. These findings were further compared and contrasted within and across three participant groups for similarities, differences and subtleties. The analysis was underpinned by Bourdieu’s theory of habitus, doxa, cultural capital, symbolic power and violence (Bourdieu, 1983, 1986, 1999). These theories debated the data on several fronts while exploring the various support mechanisms and approaches towards these.

Limitations The sample size was influenced by data saturation (Strauss & Corbin, 1994) however there are limitations in arguing that the size was solely determined by theoretical saturation. The limited availability of time, access difficulties and diverse cultural and religious practices across wider geographical areas limited the sample size and challenged if data saturation was achieved. As a qualitative study the most important aspect was to facilitate in depth exploration of participants’ experiences in relation to suicide prevention. Therefore it should be noted that the findings may not be generalizable but may be transferable in parts

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among similar cultures. The extracts presented here are examples of individual’s experiences, perceptions and in places their opinions. These may be open to further interpretations.

EthicsThe University of Manchester research ethics committee approved this study and it adhered to the Indian ethical guidelines for social science research in health.

Findings

The findings presented here provide a detailed view of survivors, mental health professionals and healers experiences and perceptions of current interventions. The survivors’ accounts will feature their encounters with health and mental health services on surviving suicide and approach to traditional healing. The mental health professionals and traditional healers accounts will discuss their approach to treating and helping survivors.

Themes

The findings will be presented under the following three main themes: 1) medical management and psychiatric referrals 2) treating stress and suicidal behaviour through religious and alternative means and 3) Need for collaboration

Medical management and psychiatric referrals

Many survivors sought hospital intervention merely during apparent physical illness. They were brought into the hospital in a critical physical state on attempting suicide. As suicide was illegal in India at the time, there was an understandable fear of legal implications and social stigma that limited willingness to approach help. It is interesting to note, only one survivor of the total 15 participants had previously sought psychological help. All of them had a good recollection of being referred to psychiatric assessment during the period of their hospital stay in order to qualify for a discharge. The mental health professionals, while explaining the care delivery system in the hospitals, commented that it is mandatory for every patient admitted to a hospital for reasons of attempted suicide to be referred to a psychiatric unit prior to their discharge. However as pointed by few mental health professionals, “not all the cases go through psychiatric consultations due to lack of beds, time and limited availability of mental health professionals” (MH 1).

Survivors explicitly linked medical interventions to extreme conditions of physical ill-health and did not seek help for mental health problems. It became quite evident when two female survivors (S2, S3) discussed their recent diagnosis of depression, anxiety and panic attacks on hospitalisation, regardless of experiencing these symptoms much prior to the attempt. Most survivors perceived family, friends and religious healers as their source of counselling and support. An in-depth analysis of survivors’ accounts clarifies, members of family and friends failed to recognise the need for mental health support in time. This has led to widening of gap between identification and treatment, limiting timely intervention and increasing the risk of suicide. Some of the other reasons cited by all three groups of participants for not approaching timely support were not just the fear of stigma but the

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anxiety of facing the outcomes. For example some survivors feared the adverse impact upon their job and prospects for marriage. Cultural power demonstrates a significant influence and dictates help seeking behaviours.

There was insufficient evidence to establish a direct correlation between survivors’ education, profession, economic background and approach to mental health services. Survivors’ awareness of mental health problems, recognition of need for help, finding appropriate time and prioritising mental health needs over other needs were some of the factors that influenced survivors approaches for help. During this process survivors were often guided by the social norms and accessed locally available services.

From survivors’ accounts, it was evident that they shared a belief in a combination of approaches including medical, religious and alternative methods (meditation, counselling, Ayurveda etc). It became apparent they approached counselling services in the hospital as a matter of procedure. For example most of the survivors considered counselling as a one off visit. Although they were advised to return for a follow up very few returned. When asked, the survivors responded by saying that they didn’t feel the need to seek professional support. They sought advice and support within the family, community and through religious services. “I have never approached any counselling services or mental health professionals after I was discharged from the hospital” (S 5)

One of the mental health professionals explained that people approach general physicians in the first instance whether it is for physical ailments or mental health concerns. Physicians thus refer cases to psychiatrists. And the participant went onto say that “referrals established in this way do not always comply with follow up as the clients do not feel comfortable to speak openly about their life events to a counsellor or a mental health practitioner” (MH5). While another participant (MH 6) explained that people approaching psychiatric services or attending counselling sessions feel rejected by the family and society. However this notion of stigma varies across urban, semi urban and rural population as evidenced in the participants’ accounts. “They are worried about the status, if I go to the psychiatrist or to counselling I am rejected by the society, not only my family but also people around me. With all these problems why I want to tell the society I have a problem. That is preventing… definitely the problem increases” (MH 6)

The most common treatment method discussed by MH professionals is medical management. One professional reported that the lack of mental health practitioners limited their ability to function effectively and psychiatrists relied on prescribing medicines, as the quickest way of attending to service users. However making reference to a particular hospital in the city of Bangalore, the practitioner explained the involvement of the entire mental health team in providing individualised and person centred care. It was explicit from other participants’ accounts (MH 1, MH 5, MH 6), not all the hospitals were equipped with a mental health team and varied in treatment approaches and care. “Once the medical condition is stable, the patient is referred to us. Later on we evaluate, if they require any medication …we start on SSRI to prevent any further attempt. If I identify any particular issue, we do address those, try to solve the differences. We do give couple therapy. It is not done extensively as in other institutes. Because we have only one psychiatrist and we don’t have psychologist or psychiatric social workers posted here” (MH 2)

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Some mental health professionals used psychological therapies alongside medical management in an attempt to deliver holistic care. For participant MH 5 the success of therapies depended on the service user’s belief system and level of follow up. He stated, “people believe more in medication rather than therapies. Even vitamin pills produce therapeutic impact” (MH 5). Another mental health professional stressed the importance of addressing emotional, financial and family issues alongside psychological therapies. The participant discussed it as an important strategy to assist survivors relocate into mainstream society. Other participants found dearth of government support and initiatives into community-based interventions.

Some participants’ accounts indicated a gap in mental health knowledge among professionals and general public. A participating psychiatrist perceived poor knowledge among medical professionals as one of the potential causes for delays in identification of depression or other mental health concerns. “… we need to create awareness in our fraternity, then we can identify and treat at early stage” (MH 1). Another professional (MH2) while reflecting on practice expressed physical ailments and complaints take precedence during a treatment regime. Resource and time constraints limit their ability to explore underlying mental health issues or even early symptoms of depression.

Treating stress and suicidal behaviour through religious and alternative means This theme summarises the various methods used by traditional healers in treating stress and suicidal behaviour. There are a few commonalities and differences in practices across three religions (Hindu, Muslim and Christian). The perspectives of survivors, healers and MH practitioners on religious and alternative healing are discussed under this theme.

Most survivor participants and their families practiced religions and sought remedies for their problems through religious measures. Many survivors expressed, their faith in god and the support of religious groups helped them cope and overcome hopelessness and despair. A survivor who identified as a transgender felt an outcast within the community and wider society. The only place that he felt welcomed and accepted was the church. “I became a Christian without the knowledge of my parents. I go to church…I feel peaceful and comforted…there they understand me….” (S 12).

A wider discourse on religion, God and faith during crisis accounted in survivors’ narratives identified God as a powerful symbol. The religious and traditional rituals were perceived to be sources that offered strength in encountering hardships. However a few survivors expressed no reliance on God in terms of attributing their difficulties to God’s wrath or to find comfort and support. For instance, a survivor with a postgraduate qualification in business administration, who previously held a job in the IT industry and led a comfortable, independent life said, “God and religion make no sense” (S7). He held himself responsible for his troubles and the family for forcing him to quit his job and move back home after the attempt at suicide. Although he expressed that family meant him good and thought of the approach as a support but it was more distressing and triggered another attempt.

A relevant finding in survivors’ accounts is, participants who did not share faith in God and religion, rediscovered meaning in ‘fate’. For instance, a woman survivor associated all her hardships to fate and did not think any rituals would resolve the situation for her. She recalled how her husband and his family harassed her and spoke rudely of her mother who

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was a single parent and accused her mother of being characterless. She expressed that her background and upbringing was questioned and blamed for all the unfortunate events that took place in her marital home. “If anything goes wrong at home they blame it on me. I don’t think it is anything to do with magic but it is my fate” (S 9).

Another male survivor (S1) explained that religion was central to his family and although he shared no faith in religion but felt obliged to participate in religious rituals. This survivor was an undergraduate student and depended on his family for his living. Being a younger member of the family he felt his role required him to respect his parents’ wishes. When he was brought into the hospital in a critical condition on attempting suicide, his mother prayed and pledged to God to offer his (survivor) hair if he would be made well. “My mother had vowed to swami (god), that she would give my hair. So I thought I must go and do it but I don’t believe in all this’” (S 1)

The narratives of healer participants identified exploring individuals’ process of conceptualising god, religion and problems informed healers’ approaches towards each service user. Most healers recognised rapport building and understanding service users mental state as an initial and crucial stage. This was often facilitated by means of religious rituals and counselling. Some healers described the importance of creating an environment where service users felt comfortable to discuss the most personal issues. Few others explained, patiently listening to what is being shared meant allowing them to “release tension and think clearly” (TH 5).

Discourse around God and faith differed across three religions. The Christian healers began their healing sessions with a prayer that related God as merciful, forgiving and loving. While Muslim healers emphasised on continuing faith in god and used scripture to help people open up. And Hindu healers were often guided by religious ritualistic performances and offerings. All the healer participants valued facilitating a discussion of problems as a crucial step in healing process. A few healers believed, unless the service users were honest and truthful, they could not help. These healers used varying methods to motivate service users to open up and be honest. When the healers were questioned about being coercive, they responded these means were essential to help service users. For example a Hindu healer explained, “people don’t always tell us the truth, so I tell them; you are in a holy place and if you are not truthful it will affect your children or parents or others in the family. If you tell the truth we can find a solution. Then they tell us what really happened” (TH 1). The dominant discourse in religious healing processes identified in the data is that of TH participants instilling various emotions in service users and attaching them to god and supreme power. For a Hindu healer (TH 7), presenting “god as love, a symbol of hope and power” meant urging people to continue their faith, belief and asking them to patiently wait for god’s mercy while they offer worship. And as reported by the healer this resulted in boosting service users’ self-image, building confidence and recouping courage to live life.

“People can witness the true value of worship (poojas) only when it is performed with complete faith. The more faith they exercise and wait patiently the more benefits they will reap” (TH 7)

Healers from all three religions predominantly used verses from Holy Scriptures, water and oil in the healing ceremony. The data revealed a significant association between healers’

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choice of objects and methods to service users mental dispositions and problem situations. For example a survivor participant expressed that she believed someone was trying to hurt her by casting spells and black magic and a religious healer further confirmed this. “…he said that someone had tried several times (to harm by casting magic spells) but I am very strong. He told me that my time isn’t right until the 15th of May, so I am waiting…” (S6). From the above excerpt, it may be drawn that traditional healers make use of psychological theories alongside religious measures. In this instance, using positive reinforcement technique convinced the survivor that she is strong enough to face problems and calling upon her religious faith, she was led to believe that the difficult time was momentary.

Similar findings were evident in some Hindu healers (TH 6, TH 7 and TH 8) accounts as well. They used horoscope and the analogy of ‘time and constellation of stars’ to interpret problems and suggest solutions. This process meant convincing service users, that they were soon to approach better times where good things would happen and meanwhile they have to perform some rituals to reduce the bad effects. Healers explained the approach as an effective method as it gave service users hope and helped them reorient their thoughts by engaging in different activities. “It is not possible to reduce the problem and bad effects all of a sudden, asking them to visit a temple everyday creates a change in environment, which might be therapeutic. I also look into their horoscope (jataka) and advise them when they would be relieved of their problem” (TH 7)

Four healers from Hindu and Muslim religions explained some service users were under the effects of evil spirits that led them to self-harm and attempt suicide. The participants claimed that they delivered the possessed from evil spirits and ‘gyn’ through the utterance of verses from Holy Scriptures and giving them holy (blessed) water to drink. However, the method of casting off spirits varied across religions. For a Muslim healer (TH 1) exorcism ceremony involved beating and whipping the possessed person. Another method was fumigating fragrant herbs to create smoke. When the researcher questioned about the health and safety of a service user undergoing such procedures the healer explained that these methods were used symbolically to drive spirits away and that the service users were not physically hurt. A Hindu healer discussed another stream of practice within Hindu religion known as ‘Tantric practice’ that dealt with casting off spirits by means of religious ceremonies and worship. The healers explained that the entire process could be very exhausting both financially and emotionally for the service user and the family. It also involved making certain changes in the house and life style in order to gain control of the possessed spirit. “This person was possessed by a wandering spirit of a girl who died by suicide. That spirit refused to leave that house so I placed a big picture of goddess (Amma) in the house and every day we offered worship (pooja). I told that spirit you can stay in this house but do not trouble us and we will not trouble you; I will take care of you just like my daughter. In this way I exercised power and took control of the spirit” (TH 6)

Participants (survivors and healers) from a Christian background revealed that the ‘sacrament of confession’ helped in establishing trust. They explained that the identity of both the healer and the service user were concealed within a confessional. However for participant TH2, bringing service users out of the confessional for continued support and counselling was a perceived need. The healer (TH2) acknowledged that many people with suicidal behaviour and severe financial, family and health problems responded to this suggestion. “Few voluntarily speak of the attempt (at suicide) in confession so I ask them if

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you need counselling they need to see me outside the confessional. So they come for counselling as they believe in me but I tell them believe in yourself” (TH 2)

Collaboration across medical and traditional systemsParticipants from all three groups (survivors, mental health professionals and Traditional healers) shared similarities and differences in their belief systems and approaches in dealing with stress. Healers and MH professionals respected service users’ choices for treatment and support and were empathetic towards their circumstances. For some survivors seeking support through religious and spiritual means was primary while for few others it was only a means to fulfil family’s wishes. All the participants respected various methods people employed in dealing with challenges of life whether in relationships, family or concerning health and welfare. Healers and mental health professionals indicated that service users expressed a readiness to try any method that would prove beneficial. This meant people approached temples, prayed to gods, offered sacrifices and worship, followed rituals, carried out the instructions given by healers and simultaneously approached medical services.

“They go to a doctor, temple and perform some kind of rituals too so they get washed away from those kind of problems which they have. This is usually performed by a faith healer or a priest” (MH 2)

A MH professional recollected various cases referred to hospitals by healers. These included those of attempted suicide and spirit possessions. Another professional testifies that most of his patients approached religious healing as a first resort because they shared greater faith in religious methods. Some mental health professionals perceived religious and traditional healing practices as therapeutic while, the analysis revealed that their own beliefs and religious backgrounds influenced this perception. Participant MH 3 stated “faith healing works for cases of possession” (MH 3). Two other MH practitioners perceived religious methods as an essential part of holistic intervention in addressing mental health concerns. In analysing mental health professionals’ accounts it became apparent that although they supported alternative healing practice but expressed disagreement with certain ritualistic practices. For example, MH 8 condemned rituals such as plucking blocks of hair, exorcism and any forms of physical assault or those procedures that violate human rights. According to MH 8, there is a need to guide people out of their current unhealthy belief system that impacts their safety and worsens health conditions especially of those vulnerable and lack capacity. Thus for this participant reducing a gap between awareness raising and help-seeking was a current and identified need.

“We are flexible if these kind of things can solve the problem of the client why not accept it. But not in all circumstances” (MH 6)

“….. they find it soothing and other practices should not be coming in the way; except we should not allow practices such as exorcism…because that threatens the basic rights of a particular person who is having distress. Beating, whipping, cutting of the hair, pulling hair and nailing it to a tree these are few practices that we need to be against. These are the sorts of belief systems we need to work a lot with, instead of asking them to be away from it” (MH 8)

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The interviews with traditional healers revealed some service users were referred internally to other practitioners within their (healer) religion and externally to health care practitioners. Internal referral is illustrated in the following instance. A hindu healer (TH 7) directed service users with complaints of spirit possession and evil effects to ‘Tantric’ (magic) healers for a deliverance ‘pooja’ ceremony/worship. However the data pointed out that no healers referred service users to practices outside their religion. A Christian healer expressed that the objects and procedures used in healing process were not always very helpful. This discourse located a sense of doubt among healer participants about healing practices across other religions.

“…they use lemons and tayta (metal piece) but they do no good…its only symbolic” (TH 2)

External referrals meant healers referred service users to health care professionals (psychiatrists, general practitioners) and to hospitals for further investigation and medical treatment. They provided various reasons for establishing such referrals and most of them thought biological conditions and mental illness required medical attention. For a Muslim healer (TH 3) psychiatric support alongside religious healing was crucial. However, healer reported that some of his service users disregarded the psychiatric treatment due to the extensive nature of enquiry. Data made implicit reference to approaching religious healers being acceptable and prevented service users from being subjected to judgemental opinions.

“Need psychiatry support as well as these spiritual chantings. Then only they can benefit” (TH 3) “We need to have both the approaches – God and medicine, the grace (krupe) of God and medical consultation. So people do approach both…. ‘vaidyo narayana bhavo’ (physician is as is God) therefore traditional methods and medical approach both are needed” (TH 7)

A Muslim healer TH 4 saw spiritual healing as the answer to the problems to which medical science had none. Other participants related instances of people who have had no results from medical treatment and thus turned to religious/Ayurveda healing practices. Some healers described such cases as being possessed and thus referred to them by medical practitioners. Most healers, except for Christian healers, used Ayurveda or Hamdard (naturopathy) medicines in their healing process. ‘The surgeons and doctors from well-known hospitals refer us cases who suffer from devilish effects’ (TH 4)

A Christian healer (TH 2) reported one of the limitations of traditional healing system were that the ‘results depended on the faith of people and their patient endurance’. On similar lines a woman Hindu fortune-teller and a healer (TH 8) cited “if people believe, they will be cured. Otherwise they won’t”. Most healers used a mechanism of invisible power accompanied with the concept of god to gain people’s trust in their healing practice. A Muslim healer (TH 3) perceived traditional healing systems is instrumental in preparing individuals mentally well for a medical treatment. A dominant discourse across all participant groups present neither traditional healing system nor the medical systems was effective on their own. From the perspectives of service providers, service users who approached both systems coped better with life situations. The data did not indicate a slightest feeling of threat among the participants regarding the co-existing healing practices or conventional medical practice. The data did strongly emphasise the need for

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collaborating with traditional support systems in the context of raising mental health awareness and acknowledging identifiable psychiatric conditions and interventions.

Discussion

The rationale presenting individual’s choices for help is incoherent unless it is understood within the bounds of socio-cultural contexts. These contexts may be interpreted as spaces, where social and cultural capitals dictate a way of life. Bourdieu’s idea of capital extends beyond Marx’s economic capital. He describes cultural capital as the power relations that are inherent in a wide variety of resources such as ‘verbal language, cultural awareness and educational credentials’ (Swartz, 1997). Cultural capital can be embodied in abilities, skills and internalised dispositions through a process of socialisation (Bourdieu, 1986). For example, the association between medical intervention and apparent physical ailments (not mental health conditions) evidenced in the data can be explained by the power exercised by cultural capital to influence behaviours. The survivors and their family’s choices hugely depended on how they perceived and identified themselves with a medical system. Their choices for help were guided by widely accepted social norms that held symbolic power and a motivation to avoid stigma. Medical interventions held power only in relation to physical illness.

The experience of Social and cultural capital varied for participants across three groups. Health professionals owing to their affiliation to biomedical practice derived higher degree of social capital. The professionals who shared faith in religious practices simultaneously experienced symbolic and cultural capital. However for survivors although they attributed higher degree of cultural capital to biomedical practice, their opinion altered when they referred to psychiatric practice and more so in the absence of drugs. As identified by mental health practitioners, people shared better dispositions towards consuming medicines rather than being responsive to psychological therapies. This identifies the power of cultural capital that has naturalised certain forms of beliefs in survivors. It reveals a particular form of doxa 1 as experienced by users of medical services.

The interrelatedness of socio-cultural capital, power and approach for support is to be understood beyond the discourse of health and illness. For example, the cultural capital experienced by some survivors and service providers led them to attribute challenging life situations to inauspicious time or negative manifestations of curse or witchcraft. The findings interpreted survivors’ judgments of situations were derived from their doxaic belief system and influenced their choices for support. It is important to recognise that these dynamics took place within the setting of family, community and society. There was power associated with both medical and traditional healing systems. But the legitimisation of power (Swartz, 1997) happened only when participants actively involved with these systems. The findings revealed that the individuals’ (survivors’, service users of healing and medical practice) dependence on medical and healing practices was determined by their perception of benefits and experiences of recovery. For example, whenever survivors did not experience immediate effects or healing from medical services, they switched to traditional methods and in a few cases, survivors approached both practices simultaneously.

1 Doxa refers to a deep system of beliefs that are naturalised through the process of unconscious mechanism where individuals accept and practice many things without even knowing them as though they were legitimate. (Bourdieu (2000); Bourdieu & Eagleton, 1994)

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The field of medical practice is identified with a higher-degree of social capital in the data. However the users of medical services do not always experience the same level of social capital. This is particularly true of mental health service users as recognised by the participants (TH and MH) in this study. The stigmatising nature of cultural and social capital made psychiatric services impermeable and inappropriate to be acknowledged as a service user within the community. Healers and MH professionals appreciated the transforming social structures and technological advances in the society. They suggested that these advances have opened up new avenues and phases for approaching psychiatric services in forms of therapies and wellbeing centres (counselling, psychotherapies) located outside the institutions of psychiatric hospitals. They further acknowledged that the response rate to counselling is minimal in semi-urban locations, whereas gradually increasing in urban areas. As evidenced from survivors’ accounts, they derived benefits of therapeutic services from religious and traditional practices both in rural and urban locations. The cultural capital sanctions healers and service users’ power and authority to use healing services as a means of support in times of distress. Thus, traditional healing services combined with medical practice performed positive effects in reconstructing individuals’ dispositions (thoughts, actions and behavioural responses) to difficult situations.

The analysis highlights contemporary medicine and traditional practices as systems with specific boundaries. It revealed both practices acknowledged the need for mutual collaboration in order to address the problem of attempted suicide and mental health concerns. The fields of contemporary medicine and traditional healing both advocated their own theory of practice. The primacy of each practice depended upon the perceived benefits, faith and power experienced by individuals who approached these practices. The social and cultural power experienced by survivors and their family was crucial in considering any approaches, beyond their interest for complete recovery. The analysis reveals the importance of bearing in view, service users’ experiences and affiliation to various forms of capital while planning an intervention for suicide prevention.

Conclusion

To prevent suicides and increase access to interventions and make interventions socially acceptable there is a need for a fusion of both biomedicine and traditional healing practices. This may offer mental health service users a safe and culturally accepted medium of intervention. The collaboration has a potential to educate healers, practitioners of alternative medicine about mental health and enforce ethical standards and safety regulations. The power dynamics and the forms of capital inherent in alternative and biomedical practices are posed with a challenge of power share and willingness for integrative practice. This might be a future direction for mental health intervention and suicide prevention.

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