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Appendix A
Answering Two Serious Charges on Suicide
Prevention*
Ajai R. Singh
There are two serious, though well intentioned,
charges on suicide prevention which deserve our equally serious consideration:
1) Whatever we do, the rate of suicide in a particular
society will remain fairly constant (Durkheim, 1952).
2) Suicide is disturbingly ubiquitous and universal across
cultures and ages. Psychiatry does not seem (yet) to fare better than the more traditional, menacing attempts of moralists,
theologians and legislators at stopping people from killing themselves (Heyd and Bloch, 1984).**
The First Question
When Durkheim makes the first statement, it is improper to read it as a resignation to the inevitable. It should
spur us on to find out why this is so, if indeed it is. The attack on suicide cannot be only at the personal level, although
that is very important. It must as well, and moreso, be at the social level, to identify and tackle those sociological processes
that predispose individuals to such action. In this we must identify atleast two factors: social isolation of the individual
and social disintegration of the society. Preventing social isolation will involve Befriending and Samaritan like programmes
allright. But equally important would be strengthening of the social networks: the family, religious and community welfare
activities, avenues for involvement with people and programmes, identifying at risk population and absorbing them in the mainstream
etc. etc.. First and foremost, it must involve a change of perception among the members of society, wherein a suicidal thought
or attempt is acceptable as a cry for help. An occasion to mobilise all resources to help rather than stigmatize or ostracize.
To rally around the individual rather than leave him to fend for himself. When we talk of preventing social disintegration,
we are talking of social processes that will integrate rather than divide members of society from each other. Religion has
proved to be a preventive factor, for example; for in general Catholics show lower suicide rates than Protestants, and there
is much less suicide amongst Muslims in the month of Ramzan. What is that hold of religion which prevents, or postpones, suicide
is worth further exploration. Rapid social change brings about alienation and anomie. Greater deviance and suicide are the
price we pay for such destabilizing progress. What the social engineers should therefore attempt at is such social change
as grows on its members, that integrates rather than dismembers. Which is conscious of the fact that maladjustment is the
fallout of all progress, no doubt, and the greater the rate of progress, the greater the maladjustment. This realisation is
not only to accept it as inevitable, but to make active attempts to stem deviance. Where one can identify the at risk population,
find out those who are maladjusted, and intervene on the side of integration, to absorb them as productive members of
society. Ofcourse, it goes without saying that members of society must actively resist any attempts by its leaders, or social
pundits, to force rapid change on its members. Messiahs in a hurry to do good can be very hard to sustain. Changeovers, whether
they involve change from tradition to modernity, from a command economy to a liberal one , from spiritualism to materialism,
from Indian to Western values, must indeed be allowed to seep in rather than be forced on by subtle, and not
so subtle, means.
In other words, concrete steps to reduce social isolation
and prevent social disintegration are a must. It is these two which are the wellsprings of psychopathology in general and
suicidal attempts in particular, and need to be actively combated. Psychiatric care is often only a damage control exercise.
The lesson, therefore, is : if you plug the source , the need for damage control will reduce greatly, if not disappear completely.
Ofcourse this realisation does not absolve mental health workers of their responsibilities. In fact, it makes them more aware
of the problem, of the wider perspective, and also make efforts to find better ways of tackling it. Pointing to the social
psychopathological processes should not become a convenient means of passing the buck. Which means, mental health workers
cannot blame society for generating suicides, and society cannot blame the former for not doing their job well. That is an
immature debate, and a poor way of solving the problem. The solution lies in a two pronged attack. Society takes up the responsibility
of reducing social isolation and preventing social disintegration. Mental health workers take up the responsibility of handling
psychiatric disorders, and finding new and more efficient means of treating them. Psychopathological entities like suicide
can then be drastically minimised, and finally eradicated.
The Second Question
The second question of proof whether psychiatry has succeeded where the rest have failed, should now be answered.
Psychiatrists play a limited, though significant, role in reducing social morbidity. They are essentially specialists in treating
psychiatric diseases. This also undoubtedly reduces the social burden by reducing the overall psychological distress of members
of society. There is no doubt on that score. Moreover, realising that the problem is too complex to yield to a piecemeal approach,
they are ready to coordinate with other social scientists in an attempt to reduce this manifestation of social morbidity.
Without giving up on their core activity, they will, and must, cooperate with all those processes that generate social health
rather than promote social psychopathology. Hence the shift of emphasis from psychiatric diseases to mental health.
But we need remember that essentially they are mental diseases’ specialists. While they can treat, rehabilitate, and
even help prevent mental diseases, they may not have that great a say in those social processes that generate social isolation,
and cause social disintegration.
Hence to reduce suicide rates, positive attempts by society to reduce social isolation and prevent social disintegration
are a must. Otherwise psychopathology and consequent morbidity and mortality will continuously result. The third sphere of
influence is of the mental health workers. Let us take up their role now.
Suicide and Depression
The greatest threat of suicide comes from patients of Major Depression. This is a condition eminently suitable
to treatment, as every psychiatrist knows only too well. Suicidal thoughts remit as the depression is controlled, and the
gratitude of patients and relatives is there for all to see. But the fact of the matter is that even today, and even in an
advanced society like the USA, only one third cases of depression take treatment, not only because of under recognition by
health care providers but also because individuals often conceive of their depression as a type of moral deficiency, which
is shameful and must be hidden (Stahl,2003).* Which means two-thirds cases of depression do not even take treatment. Who is
to ensure that these people are brought for treatment? These two-thirds run a big risk of suicide. Society may just label
them as failures, cry over them for a while, and carry on. But precious lives are lost because other members of society, the
family, close friends, employees, welfare bodies are unaware of the needs of such depressed patients, and make no attempts
to get them into treatment. This is one area where positive action is most urgently needed. The other area of concern is the
fact that 15% severely depressed patients eventually commit suicide inspite of treatment (Stahl,2003).* It means two things:
one, 85% do not, and they have been helped by psychiatric treatment, which is not a bad success rate by any standards. (Although
15% failure rate is not something to be happy about, it is acceptable in any treatment setting in any branch
of medicine). But to accept this failure rate is not enough. We need to work towards better and more efficient psychiatric
care, with that becoming a major thrust area in research, coupled with a greater sensitization of society and relatives to
the needs of the severely depressed so that they are not cast aside, or given up. It may help to think of the severely depressed
as emotionally handicapped, atleast temporarily. They need the crutches of social and family support to help them tide over
their difficulties, like an accident victim or a physically handicapped may need crutches or callipers to tide over his physical handicap.
Therefore, better psychiatric care, newer and more effective treatments, greater research and funding, and greater
social support are the need of the hour, not meek acceptance of ideas that whatever we do, death rates will not drop, for
death will find newer avenues to manifest. If infections are controlled, life-style diseases come up to claim victims. If
they are controlled, some other diseases will come up to lead to the inevitable. So why have medicine at all? This nihilistic
position is erroneous because even if death eventually has to occur, it has to occur eventually, it is not to be desired or welcomed prematurely. We got to ensure a
better quality of life by removing distress and disability, which is what the whole science of medicine is all about. One
expression of this distress and disability is suicide. And the role of the psychiatrist in preventing it in his
patients and thus reducing psychopathology in society at large cannot be underestimated. Hence, we may reiterate that psychiatry
plays a limited but significant role in reducing social morbidity, and that is something to be proud of, not apologetic about
at all.
Report statistics of prevented suicides
We must also remember, further, that whilst suicide that takes place becomes a statistic , one that is prevented
does not. The clinician who knows and treats his suicidal patients, who then get rid of their suicidal ideas and become productive
members of society, has no figures to claim that he has indeed saved a life. Maybe he should present these figures to society
as well. That will probably be an eye opener. One suspects that suicide rates do not come down inspite of psychiatrists’
attempts is not because they are useless but inspite
of them. This just goes to show how menacing
are those social processes which do generate such psychopathology. Most probably, with mental health workers not being around,
the rate of suicides would have been much higher. Psychiatrists need not feel disheartened that suicide rates have not dropped.
If indeed they haven’t. They only need to work harder on research and treatment of their suicidal patients. But they
must also help make society aware that it must tackle those processes in its functioning that generate social isolation and
disintegration, of which suicide is one malignant fallout. To that extent, Durkheim was right when he refused to blame either
the suicidal patients, or praise or condemn the different forms of suicide that he described. He never meant to praise altruistic
compared to egoistic, or anomic, suicide. He merely mentioned them as different types. But he definitely meant to raise a
finger at those social processes that generate and force individuals to commit such acts, and then get reduced to mere numbers
in such categories.
If a suicide free society is the goal, then suicide prevention
must become public health policy. And the three fundamental parameters must be:
i) Reduce social isolation, ii) Prevent social disintegration,
iii) Treat psychiatric disorders.
The wider implications of this realisation, and the microprocesses
to bring this about must be the plan on which suicidologists, policy planners and governments all over must unite and act.
This is the agenda to set. This is the blueprint to plan for.
This is the frontier to be crossed.
*First Published as Mens Sana Monographs I: 3, Sept.-Oct., 2003. Revised
Version.
** MSM would be interested in carrying forward this
debate by suicidologists and other thinkers too. The two charges
are disturbing enough for you to put pen on paper. -eds.
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Mens Sana Monographs [MSM]: A Mens Sana Research Foundation Publication
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