PSYCHOLOGICAL AND SOCIAL ASPECTS OF DELIBERATE SELF-HARM IN SOUTHERN SRI LANKA

Abstract

Sri Lanka reported the highest suicide rate in the world in 1995. Although there is evidence that the national suicide rate has dropped considerably since then, little is known about changes in nonfatal self-harm. In Sri Lankan culture, deliberate self-harm (DSH) is understood as an impulsive response to difficult interpersonal situations. A significant amount of literature on medical and epidemiological aspects of deliberate selfpoisoning in Sri Lanka is available. However, the psychosocial aspect of DSH has not been adequately studied. This thesis presents four studies aimed at learning about the psychological and social circumstances preceding self-harm and about the responses it triggers in family members and others. As self-harm is common among youth, special attention was given to suicide and DSH in adolescents. To achieve the objectives, semi-structured interviews were conducted with a group of patients admitted for DSH to the Teaching Hospital, Karapitiya in southern Sri Lanka. Parents of adolescent patients were also interviewed. Some patients were re-interviewed 1-2 months after their hospital discharge. The findings indicated that the self-harm is a relational practice, which serves to communicate negative emotions to the individual’s family or close associates. Sometimes it is a conscious means to influence behaviour of one’s family or close associates; for example, youth turn to DSH during disputes with their parents. Following discharge, families continued to care for self-harming individuals. In the few instances of negative responses from family and other associates, the patient’s psychosocial recovery was impeded. In addition to examine changes in adolescent suicide and DSH overtime, hospital records of children and adolescents hospitalized for DSH were studied for four years between 2001 and 2007. Between 2001 and 2007, hospital admissions of adolescents and children for DSH increased by 91%, although the case fatality rate did not increase. Girls were overrepresented in this group; overall, for each boy, three girls engaged in self-harm. Paracetamol overdoses increased during this period. Episodes of DSH are often labeled as acts committed without thought. On the one hand this draws attention from the conflictual relationships prompting DSH, most of which lie within the family. On the other hand it facilitates the individual’s co-existence in the family following DSH. Moreover, this could lead to the normalization of self-harming behaviour in the Sri Lankan culture. Based on these observations, following areas were identified for further research: understanding ‘cultural narratives’ of DSH in Sri Lanka, parental discipline of adolescents, development of appropriate and acceptable interventions for the families of individuals who are not successfully re-integrated into their families after DSH. The studies also indicate the need for establishing a national database on nonfatal DSH. To improve psychosocial aspects of the hospital management of DSH patients, training for doctors and nurses should include skills in communicating with such patients and their families. The studies on adolescent DSH indicate a need to help children to re-evaluate costs and benefits of self-harm. In relation to research methodology, the studies point to the importance of using open ended questions.