In 1980, Arthur Kleinman, a psychiatrist who also trained in anthropology, published a book titled *Patients and Healers in the Context of Culture: An Exploration of the Borderland between Anthropology, Medicine, and Psychiatry* (Kleinman, 1980). Kleinman argued in favour of an interdisciplinary approach to psychiatry, including ideas, methodologies, problem-frames, and solutionframes from both social science and clinical science. He argued that this was the best way to proceed in cross-cultural studies of health care. In this especially compelling volume, Kleinman recommended *mixing* disciplines alongside sharing ideas and approaches. In the book's epilogue, he noted the limited progress of medical anthropology in coming to terms with clinical reality and its different constructions in varied social structural and cultural settings.

Kleinman's observations were powerful and long overdue. Eight years later, in *Rethinking Psychiatry: From Cultural Category to Personal Experience*, he added that interdisciplinary relationships require work to flow in both directions (Kleinman, 1988), which is a point that is often missed in discussions of this topic: conversations work both ways. Kleinman further argued that psychiatry is a surprisingly good subject to re-examine from a cultural standpoint and offers particular opportunities to link anthropological theory to a much broader set of issues. This remains true today: bio-psycho-social psychiatry holds a very particular, multi-faceted mirror to society, exploring and illuminating areas of human culture and activity that other fields rarely approach. Often, mental health professionals work at the very edges of human experience.

The case of Miguel at the start of this chapter illustrates many of these points. Miguel's first framework for interpreting his experiences was a religious one, so he went to see a priest. The priest offered advice that was useful, sensible, and meaningful to Miguel and his family. In many cases, such advice might be all that is needed, not least because it accords with a pre-existing belief system (rather than introducing a new one) and fits into a familiar cultural framework (rather than imposing or constructing a different one). In Miguel's case, unfortunately, the advice from the priest did not prove sufficient over time, because the voices of the gods became more negative, persistent, and commanding. Even so, the initial impulse was clearly appropriate and wise: interpreting and responding to an unusual experience by using familiar concepts and coping strategies. That is how most people cope with most things, most of the time.

But the case of Miguel also illustrates the value of individual stories as a way of understanding the strengths *and* limitations of cultural interpretations of phenomena such as auditory hallucinations or paranoid delusions, which many cultures and societies ultimately associate with mental illness in one form or other. As a result, there is a specific role for ethnography within anthropology, and within the anthropologies of mental illness and psychiatry in particular, when individual case histories move beyond the bounds of the familiar and into the relative unknown, tugging at the edges of the knowable.

Ethnography, in this context, is the systematic description of peoples and cultures with their customs, habits, and differences. Ethnography forms a key part of social and cultural anthropology. Carefully conducted, this approach can not only deepen knowledge, but also advance engagement and understanding, with many consequent benefits. In fact, Lemelson and Tucker, in a detailed consideration of psychopathology and recovery in cultural context, argue that the issues, categories, factors, and domains which are identified in detailed, personcentred ethnography are directly related to *better health outcomes* (Lemelson and Tucker, 2015). This observation both reflects the value of experience-near ethnography and develops the idea that the understanding which results from it has identifiable therapeutic benefit.

This makes sense. As discussed in Chapter 3 ('Diagnosing Mental Illness'), most diagnoses in psychiatry are based on history, symptoms, and mental state examination, rather than biological tests.  As a result, it is virtually inevitable that cultural factors will play a role in expressions of distress, diagnostic practices, and provision of care. Bhugra and Gupta note a range of factors which are relevant, to varying degrees, in the relationship between culture and diagnosis and management in psychiatry, including ethnicity, race, racism, migration, life events, acculturation, and cultural identity (Bhugra & Gupta, 2010a). The culture of the individual is central, but also the cultures of organisations and clinicians, alongside cultural influences on treatments, ranging from psychotherapy to pharmacotherapy to social care. Understanding how these factors play out in practice requires near-person ethnography that illuminates lived experience rather than just theory.

In 1988, in *Rethinking Psychiatry: From Cultural Category to Personal Experience,* Kleinman argued that the decades at the end of the twentieth century and start of the twenty-first century would likely see the orientation of psychiatry swing from a western focus to encompass the broader world, including developing countries (Kleinman, 1988). This has occurred to a certain degree, as 'globalisation' (conceived as an intensifying of global interconnections) continues to change both perceptions of mental disorders and, possibly, some of their causes (Bhattacharya et al., 2010). Bhattacharya and colleagues point, in particular, to the potential effects of technology (such as television) on mental health, the cultural appropriateness of diagnostic practices, the consequences of economic disadvantage, risks of social fragmentation, and various other concerns and potential impacts of globalisation. Of course, these eventualities will not necessarily come to pass in all locations, and globalisation has many benefits, but these issues are worth considering from the perspective of cultural and social assimilation, and from the perspective of the evolving anthropology of psychiatry. The world changes, and how we suffer changes with it.

Integrating these perspectives into thought and practice is not always simple, especially in a rapidly shifting world. Writing in the context of anxiety disorders, Hinton and Simon propose a 'multiplex model' to describe the ways in which the biological mechanisms of anxiety and their psychological correlates are embedded in, shape, and are shaped by specific cultural contexts (Hinton & Simon, 2015). Composite, multi-level models are likely the best way to integrate these considerations in the future, and move towards a culturally informed neuroscience that truly mixes and assimilates knowledge from different sources, rather than maintaining contrasting kinds of knowing in separate conceptual boxes.

Incorporating culture into such models is important not only for improving understanding and treatment at the individual level, but also for shaping perceptions of psychiatry and mental health care at the level of societies and in the public arena. This topic is considered next.

#### **Public Expectations of Psychiatry**

Psychiatry has always been a social endeavour, as well as a medical one. From earliest times, societies routinely ostracised people with what would now be termed 'mental illness', treating them as different, dangerous, and 'other' (see Chapter 2: 'The History of Psychiatry'). While there were a small number of exceptions to this general rule, most societies expected that people with mental illness or other forms of unusual thought or behaviour would be either institutionalised or 'managed' in some way, often by psychiatry. Many times, the emergent profession of psychiatry colluded, implicitly or explicitly, in this task in an excessive or inappropriate way. This makes the relationship between psychiatry and society complicated, conflicted, and essential for understanding the history, present, and future of this discipline.

In 1977, Kathleen Jones, Professor of Social Administration at the University of York, delivered the 51st Maudsley Lecture before the Royal College of Psychiatrists, titled 'Society Looks at the Psychiatrist' (Jones, 1978). Jones proposed that, up until the early 1960s, psychiatrists had a key role as administrators, initially in asylum administration and then in the relatively more sophisticated administration of therapeutic communities and community psychiatry services, following the establishment of the National Health Service (NHS) in 1948. Since then, Jones argued, there was a growing tendency for psychiatrists to see themselves, and be seen, as doctors more than administrators, the emphasis shifting from their administrative roles to their medical ones.

Jones recommended that a balanced view should be taken of the anti-psychiatry movement of the 1960s and 1970s, which viewed psychiatrists as agents of social control. This critique was often taken to extremes but contained important lessons nonetheless, pointing to the potential for psychiatry to let itself become the vehicle for social vested interests or to serve the profession's own interests to an excessive degree. The history of psychiatry supports this concern (as outlined in Chapter 2).

Finally, Jones wrote that there was, in 1977, a new role for psychiatrists as innovators in an unstable situation of professional interaction, arguing that psychiatrists should always have one foot in medicine (which is psychiatrists' basic skill) and the other foot in the social sciences (because the practice of psychiatry moves well beyond medicine). There are philosophical issues, sociological factors, and inter-professional matters that inevitably shape psychiatry and its practices. Jones concluded that psychiatry had 'produced some great innovators in the past':

We need them now […] if you take your professional title seriously, if you are prepared to work at the point where the *psyche* meets the *soma* and to accept the multiple roles which society thrusts upon you, you have a unique task.

(Jones, 1978; p. 332)

Jones's points remain fiercely relevant today, almost half a century later. Psychiatry should be cautious about accepting the roles that society seeks to assign it, and psychiatry should explicitly acknowledge the degree to which it is shaped by culture and society – and the ways in which a thoughtful psychiatry can interact with both, for the benefit of all. Two particular demands made of psychiatry require focused thought and attention today: society's demand that psychiatry become a repository of 'risk' (even when such risk is not linked with mental illness) and the demand for psychiatric medication even when it is not indicated ('a pill for every ill'). Both issues merit attention.

In many people's minds, mental illness is associated with a risk of harm to self or others. While there is a relationship between mental illness and various kinds of risk, there are significant limits to assessing the risk of violence at the individual level, even with the best tools available (Connors & Large, 2023). Notwithstanding clear evidence that such risk cannot be accurately assessed, society's demand for psychiatry to be a repository of risk of all descriptions is strong. In 1999, Holmes and Warelow argued that psychiatry had now become a system of risk management and that diagnostic classification facilitated and colluded in this process (Holmes and Warelow, 1999).

In 2019, Nikolas Rose, in *Our Psychiatric Future: The Politics of Mental Health*, wrote about this 'police' function of psychiatry and how it rests uneasily with efforts to destigmatise mental illness (Rose, 2019). This remains true today and is deeply regrettable. Mental health legislation in many jurisdictions has perpetuated the problem by incorporating 'risk' requirements into criteria for psychiatric admission and treatment without consent. For example, as discussed in Chapter 5 ('Treatment Without Consent'), Ireland's Mental Health Act, 2001 permits admission without consent if a person has 'mental disorder', which is defined as follows:

In this Act 'mental disorder' means mental illness, severe dementia or significant intellectual disability where –

	- (ii) the reception, detention and treatment of the person concerned in an approved centre would be likely to benefit or alleviate the condition of that person to a material extent.

(Section 3(1))

This emphasis on risk (especially in Section 3(1)(a)) is deeply regrettable and is not justified by the scientific evidence about risk assessment tools. Nobody can predict the future, so it is essential that psychiatry renegotiates its contract with society, so that deeply flawed risk assessments do not inadvertently lead to unjustified involuntary admissions (Gulati et al., 2020). This requires both legislative reform and addressing a culture of risk 'assessment' and risk aversion that is emerging in psychiatry and across society more broadly. This heavy emphasis on risk places psychiatry in a false position, likely results in significant injustice, and further stigmatises mental illness, psychiatry, and mental health care. It needs to stop.

The other key, disturbing societal demand of psychiatry, along with pressure for psychiatry to become a repository of ill-defined 'risk', is the demand for medication to treat both mental illness *and* the problems of day-to-day life: 'a pill for every ill'. This is considered next.

#### **'A Pill for Every Ill'?**

There is strong evidence to support the use of various medications for the treatment of mental illnesses such as depression, bipolar affective disorder, schizophrenia, and various other conditions (see Chapter 4: 'Treating Symptoms and Disorders'). This evidence, however, relates to diagnosed conditions only. Despite the many limitations of symptom-based diagnoses in psychiatry, they assist with identifying treatments that tend to help for specific sets of symptoms – but only for those particular conditions (see Chapter 3: 'Diagnosing Mental Illness'). That does not mean that such medications are necessarily useful for other conditions, for symptoms of lesser severity, or for general problems of living. These medications can, in fact, be actively unhelpful in such situations.

Despite these facts, there is a growing demand to medicalise many parts of everyday life, as diagnostic thresholds fall across all of medicine, including psychiatry (Burns, 2013). One of the consequences of this development is increased demand for diagnosis, treatment, and, in particular, psychiatric medication for reasons that are not necessarily related to diagnosed mental illness. This is a real concern which has grown in recent years and shows little sign of slowing down in the future.

In 2021, the Organisation for Economic Co-operation and Development (OECD), an intergovernmental organisation with 38 member countries, noted that consumption of pharmaceuticals has been rising for several decades, owing to increased need for medications to treat age-related and chronic diseases, and changes in clinical practice (Organisation for Economic Co-operation and Development, 2021). Use of antidepressant medications more than doubled in OECD member countries between 2000 and 2019. Why? What is driving this trend? What does it reflect?

In 2017, one study of rising rates of antidepressant use in the UK found that increased prescriptions between 1995 and 2011 appeared 'to be driven by an increase in long-term use of these medications' (Mars et al., 2017; p. 193), rather than new prescriptions:

The prevalence of [antidepressant] prescribing doubled between 1995 and 2011, although levels remained relatively stable between 2002 and 2005, when there was a notable reduction in prescribing to those under 30 years. The overall rise in prescribing was largely driven by an increase in [selective serotonin reuptake inhibitors] and other [antidepressants]. Our findings suggest the observed rise in prescribing is not due to an increased number of people starting [medication], but rather appears to be explained by an increase in the duration of treatment.

(Mars et al., 2017; pp. 197–8)

These authors recommended that, 'in the future, research, guidelines, and performance indicators should focus more on the appropriateness of long-term prescribing, and ensure regular review of patients who become established on long-term treatments' (Mars et al., 2017; p. 199). In addition to longer prescriptions, the overall increase in rates might also reflect better recognition of depression, expanded availability of treatment, evolving medical guidelines, or changes in the attitudes of patients and providers towards use of psychiatric medications in general. In other words, the trend is likely to be multi-factorial, with myriad different forces driving up prescription rates.

The role of non-medical factors in this phenomenon is suggested by the fact that there is significant variation in antidepressant use between countries (Organisation for Economic Co-operation and Development, 2023). Iceland, for example, reported the highest level of antidepressant consumption in the OECD in 2021, at a rate that was over seven times that of Latvia, which was the OECD's lowest. It is enormously unlikely that epidemiological differences in the occurrence of mental illness explain these variations fully, so social and cultural factors are undoubtedly relevant, including public and professional attitudes towards treatment and the structures of health and social care systems in different countries.

Overall, the general trend in psychiatric medication usage is upwards, and this shift appears primarily rooted in social factors rather than epidemiological ones. More broadly, the social contract between medicine and society is changing rapidly both in this way and in other ways, and merits close consideration and conscious renegotiation, rather than haphazard change that is poorly understood (Cruess & Cruess, 2011a). Ethics, too, are evolving in parallel with this in our increasingly globalised world, especially in the context of more informed service-users and stakeholders with expertise from both systematic study (across diverse fields) and personal experience (of illness and caring).

In relation to the ethics of psychiatry, Robertson and Walter argue that medical ethics have developed over recent decades in response to the scale of contemporary health care, the growth of interdisciplinary care and the biopsycho-social approach, technical advancements, improved health care literacy, public policy, and the expectations of third parties (Robertson & Walter, 2011). Psychiatry has negotiated this change, they write, by adopting an ethical approach which can be seen as a social contract based on a three-way relationship with patients and other stakeholders in health care. Inevitably, ethical dilemmas emerge from tensions between responsibilities towards patients and responsibilities towards third parties.

These ethical tensions can be navigated in a number of ways, and Robertson and Walter suggest that social contract theory can help with deliberation on such matters. Consciously describing the social contract between psychiatry and society is an important first step, followed by examining psychiatry's relationship with society, and renegotiating this as needed. This process can usefully include honest acknowledgement of, and continued reflection on, the pressure for psychiatry to become a repository of ill-defined social 'risk' and the increased demand for psychiatric medications and other treatments to manage both diagnosed conditions *and* problems of everyday life which were not previously deemed to require interventions. These developments lie at the heart of key ethical tensions in psychiatry today. Articulating them clearly is an important first step towards understanding, learning, and resolution, including acknowledging psychiatry's own role in generating these trends.

Another area of concern regarding the contract between psychiatry and society is the continued risk of psychiatry being misused in ways that (explicitly or implicitly) seek to re-shape psychiatric thought, diagnoses, practices, or institutions in inappropriate ways or for inappropriate reasons. This is a long-standing issue in the history of psychiatry which persists today. It is considered next.

#### **Misuse of Psychiatric Practices, Institutions, and Diagnoses**

So far in this chapter, we have discussed the importance of culture in psychiatry (especially the work of Arthur Kleinman) and society's expectations of psychiatry, particularly its tendency to press certain roles upon psychiatry (and psychiatry's willingness to accept them), such as managing ill-defined 'risk' and providing medication for problems of living (in addition to evidence-based treatment of mental illness). Over-medicalisation is a broad problem across all areas of medicine, not just psychiatry, but it is especially concerning in psychiatry, not least because of the broader misuse of psychiatric diagnoses, practices, treatments, and institutions in the past and today.

This is a long-standing problem, dating from the earliest origins of the discipline of psychiatry. Chapter 2 examined 'The History of Psychiatry' in some detail and noted not only accounts of apparent mental illness in religious texts and ancient literature, and the emergence of psychiatry as a medical discipline, but also the history of psychiatric institutionalisation, deeply questionable treatments in the past (e.g., experimental surgical bacteriology, malaria therapy, insulin treatment, and lobotomy), and the many historical critics of psychiatry (especially, but not exclusively, during the 1960s and 1970s). Case histories from Richmond District Lunatic Asylum at Grangegorman in Dublin, Ireland were interspersed throughout that chapter to illustrate relevant points (Kelly, 2023), showing that, while the history of psychiatry certainly presents evidence of caring and progress, there was also excessive institutionalisation, harmful treatments, disproportionate deprivation of liberty, neglect of basic care, and violations of human rights.

Over the past century, the misuse of psychiatry for political reasons has been especially apparent and has proven difficult to eliminate completely. The most egregious example of this was the persecution of people with mental illness and intellectual disability in Nazi Germany where, in 1939, Adolf Hitler authorised a programme of systematic killing of people 'deemed incurably sick, after most critical medical examination' (Kelly, 2022). At least 275,000 people, generally with disability, mental disorder, or neurological illness, or elderly people, were killed at extermination centres located at psychiatric hospitals in Germany, Austria, occupied Poland, and what is now the Czech Republic. This killing programme ran from 1939 to 1945 and was known as 'Aktion T4', after Tiergartenstraße 4, the street address of the department set up in Berlin to administer the programme. Regrettably and shamefully, psychiatrists and other health professionals collaborated with this process in various ways.

While Aktion T4 was, perhaps, the most extreme persecution ever experienced by the mentally ill, there is also more recent evidence of the misuse of psychiatric diagnoses, treatments, and institutions in other countries. Robert van Voren notes that this matter gained attention during the 1970s and 1980s owing to evidence of systematic political abuse of psychiatry in the Soviet Union during this period, when around one third of political prisoners were incarcerated in psychiatric hospitals (Van Voren, 2010). Van Voren notes that this triggered a major division in the World Psychiatric Association, from which the Soviets were compelled to withdraw in 1983, although they returned conditionally in 1989. There is also evidence that political abuse of psychiatry occurred in other socialist countries, and on a systematic scale in Romania. In addition, van Voren points out, it became apparent during the first ten years of the current century that systematic political abuse of psychiatry was taking place in the People's Republic of China.

These misuses and abuses of psychiatry require investigation, remediation, and prevention for the future, wherever they are found. In addition, however, psychiatry can be misused or re-shaped in more subtle ways in many countries with apparently better records on human rights. In the UK, for example, Ikkos and colleagues write about the impact of sensational tabloid publicity on mental health policy, service provision, and even diagnosis:

To stem tabloid headlines, Tony Blair's Labour government practically invented a mental disorder which had no basis in science and the aim of which was not the treatment of mental ill health but the imagined protection of the public. Despite the opposition of all mental health professions, government, led by the Home Office rather than the Department of Health, spent £480 million on a 'treatment programme' for people with the invented disorder of 'DSPD' (dangerous and severe personality disorder). Results were predictably negative. (Ikkos et al., 2023; p. 154)

This episode demonstrates what is, perhaps, psychiatry's most concerning Achilles heel: the diagnostic process. In the absence of definitive biological tests to positively diagnose mental illness, diagnosis can be subject to myriad influences, ranging from legitimate medical findings and genuine public interest to sensational media coverage and unhelpful political pressures. The potentially distorting role of powerful pharmaceutical corporations also merits attention, given that current medications are often effective but not curative and are therefore commonly prescribed for long periods.

Balancing these kinds of pressures and concerns with the social distribution of mental illness and the need for bio-psycho-social care is a challenging task. Poole and Robinson explore related themes in a 2023 paper in *BJPsych Bulletin*, titled 'Breaking out of the citadel: social theory and psychiatry':

Looking back at the impact of the 'Decade of the Brain' in the 1990s through the lens of what is now known about Big Pharma on the one hand and the role of urban deprivation in psychosis on the other, open-minded empiricists must acknowledge that some postmodern critiques have some scientific validity. An overemphasis on biological causes and treatments does tend to serve the interests of large corporations and tends to be associated with neglect of service users' social needs, irrespective of the effectiveness of biological treatment in relieving their symptoms. This acknowledgement does not imply acceptance that mental illness is a myth or that empirical psychiatry should be abolished. If we enter into a dialogue with those social theorists who respect empiricism, it is possible to see that psychiatrists relieve the suffering of many service users while also being part of a discourse that has some adverse sociocultural effects. To take an example, we should be able to acknowledge that while we fight stigma, psychiatry is part of the larger system that generates it.

(Poole and Robinson, 2023; p. 147)

#### **Professionalism in Psychiatry**

Psychiatry is a complicated endeavour, to state the matter at its mildest. In addition to its empirical basis in medicine and science, psychiatry is subject to myriad other influences including cultural factors (which can shape everything from expressions of distress to the acceptability of particular forms of treatment), social expectations (especially in terms of risk management and treating problems of everyday life), political pressures (from governments and others, sometimes leading to abuses of psychiatry), and the positives and negatives of big pharmaceutical corporations (which have both treatments that work and shareholders to satisfy, thus creating complex incentives). In short, the practice of psychiatry is convoluted, knotty, and possibly impossible to get fully right. Even so, we try.

Against this background, it is clear that a strong sense of professionalism is especially important if the discipline of psychiatry is to maintain its focus on treating mental illness, protecting rights, and continuing to develop as a part of medicine that is firmly rooted in evidence. The fact that most jurisdictions have mental health legislation which permits admission and treatment without consent in certain circumstances adds to the need for strong professionalism in this field, underpinned by clear responsibility, continual accountability, and transparent decision-making. These are challenging tasks, but essential ones for psychiatry.

In 2010, Bhugra and Gupta explored the issue of medical professionalism in psychiatry in particular depth in the journal *Advances in Psychiatric Treatment*  (Bhugra & Gupta, 2010b). They wrote that the key principles of the primacy of patient welfare, patient autonomy, and social justice lie at the heart of medical and psychiatric professionalism, which also embraces the idea of fostering and celebrating good practice. They argued that the unwritten contract between psychiatry and society should be renegotiated regularly, as both a set of values and behaviours on the one hand, and relationships with patients, carers, and other stakeholders on the other. They identified various threats to medical professionalism over previous decades, linked with demoralisation among professionals. A perceived loss of autonomy and even learned helplessness appear to be significant factors in the 'loss' of professionalism, and they argued that part of the solution lies in psychiatry identifying its core attributes as a profession, as well as its competencies and skills.

These tasks are not easy but they are progressive, iterative, and essential. The core skills of a psychiatrist today are both similar to and different from those of a psychiatrist 50 or a 100 years ago. Key values persist, including, most notably, the centrality of patient care, supporting autonomy, maintaining compassion, adhering to evidence-based treatments, and certain other tenets of good practice which endure over time. But some essential skills change, such as learning how to practise new psychotherapies (e.g., mindfulness-based interventions) or staying abreast of advances in epidemiology or (to a lesser extent) neuroscience (see Chapter 6: 'Neuroscience and Psychiatry'). In addition, the balance between values shifts as society changes, with, for example, a more explicit emphasis on individual autonomy today, compared to a century ago. Many of these developments are deeply positive and long overdue, but all require recognition, attention, reflection, and, if needed, renegotiation.

George Ikkos, in a valuable contribution to a 2011 book, *Psychiatry's Contract with Society: Concepts, Controversies, and Consequences*, titled 'Psychiatry, professionalism, and society: a note on past and present', argues that the history of psychiatry suggests that psychiatrists should devote increasing attention to understanding values, working as part of teams, and managing systems, in addition to being proficient in both the art and the science of direct clinical assessment and treatment (Ikkos, 2011). Ikkos points to the 'integrative' nature of psychiatry, noting the role of 'culture' in the mix:

Narrative, values, culture as well as science (social, psychological, and biological), and clinical skills are crucial to the practice of the speciality. It is a broadly integrative discipline.

(Ikkos, 2011; p. 19)

In the same volume, Bhugra and colleagues explore 'Stakeholders' expectations of psychiatric professionalism' and note that diagnosis and managing medication are just one part of the professional role of psychiatrists (Bhugra et al., 2011). It is also necessary for psychiatry to speak to broader society and deliver services that are holistic, appropriate, and inspire confidence. They conclude that there is 'little doubt that professionalism in psychiatry is extremely important and it is up to the profession to explore this with stakeholders' (Bhugra et al., 2011; p. 69). Indeed it is.

Again, the 'integrative' nature of the psychiatric enterprise is evident here, necessitating a combination of medical practice and social engagement. In the end, all psychiatry is social, all psychiatry is personal, and all psychiatry should be evidence-based and accountable. It is a complex mix in practice and even more so in training, as the next generations of psychiatrists inculcate the knowledge, attitudes, and values that will shape their practice and careers.

Teaching professionalism is challenging and important, but modelling professionalism is even more impactful. Often, the structure of mental health services and the myriad pressures placed on psychiatry do not assist in either teaching or modelling professionalism to younger doctors. Impractical cost-saving in services and a growing culture of risk management can subtly undermine the education and training of a new generation of psychiatrists (Lydall & Malik, 2011). These factors can also imperil doctor wellbeing and even lead some trainees to leave psychiatry, given the impossible and often contradictory demands placed upon the discipline. Psychiatrists are routinely criticised for both admission and treatment without consent on the one hand, and adverse events such as patient suicide when admission does not occur on the other hand. The correct balance is difficult or even impossible to achieve. Either way, psychiatrists are blamed, mostly unjustly, for adverse outcomes that are largely beyond our control.

#### 164 *Psychiatry, Culture, and Society*

Teaching professionalism is a key part of addressing this issue, recognising the reasonable extent and limits of responsibility at the level of the individual psychiatrist in clinical practice. More broadly, teaching and modelling professionalism need to address issues such as leadership, allocation of responsibility, institutional culture, and experiential learning and reflection, among other matters (Cruess & Cruess, 2011b). Understanding the extent and limits of professional responsibility is central, along with developing a practice of personal reflection, providing collegial support, and actively cultivating compassion for all stakeholders in this complex arena: patients, families, colleagues, and ourselves.

#### **Cultural Psychiatry**

This chapter in the book focusses on 'Psychiatry, Culture and Society', looking at the socially and culturally embedded nature of mental illness (in the case history of Miguel at the start), the relationship between psychiatry and society (including public expectations of psychiatry, especially in terms of risk management), misuse of psychiatric diagnoses, practices, and institutions (in history and today), and the importance of professionalism in psychiatric training and practice. To complete the chapter's focus on culture, this section looks at the relevance of culture in clinical practice in relation to diagnosis and treatment. The final section explores issues related to discrimination in psychiatry, including sexism, racism, and LGBTQIA+ issues, as well as ways to improve matters in the future.

Practising psychiatry with an awareness of culture is a complex but essential task. It is helpful to consider this issue in relation to both the diagnosis of mental illness and its treatment. It makes sense to start with diagnosis.

In Chapter 3 of this book ('Diagnosing Mental Illness'), we noted increasing rates of diagnosis of various conditions, including rising rates of diagnosis of juvenile bipolar disorder and, perhaps most commonly, increased diagnosis of autism spectrum disorder (ASD) in recent times. While these rising rates might reflect a correction of previous under-diagnosis, it is also likely that culture plays a number of roles, ranging from shaping expressions of distress to influencing thresholds for help-seeking, and determining the acceptability of specific diagnoses and treatments.

The role of culture was apparent in the case history at the start of this chapter. Miguel heard the voices of two gods which were not immediately troublesome or disturbing, chiefly because they fitted with Miguel's religious beliefs and cultural background. He shared these experiences with his family and his priest, all of whom, like Miguel, interpreted them within a spiritual framework, rather than a medical or psychiatric one. This makes perfect sense and is sometimes all that is needed (although not in Miguel's case).

The role of culture in shaping expressions of mental distress and how such distress is understood has been explored in particular detail in the context of depression. Thinking in this area expanded notably in the 1980s and, in 1985, Marsella and colleagues contributed a compelling overview of 'cross-cultural studies of depressive disorders' to a book titled *Culture and Depression: Studies in the Anthropology and Cross-Cultural Psychiatry of Affect and Disorder*, edited by Arthur Kleinman and Byron Good (Marsella et al., 1985). Marsella and colleagues wrote that concepts equivalent to 'depression', as it is defined in North American and European contexts, were not found among certain non-European groups:

That no conceptually equivalent terms for depression exist in many non-European cultures does not mean depressive disorders do not exist. Rather, it is possible that the subjective experience of depression, its behavioral manifestations, and the social responses to it may vary across cultures.

(Marsella et al., 1985; p. 301)

They argued that, in order to understand depression, we needed to acknowledge the 'interdependency of culture, psychology, and biology' (p. 314). In the four decades since these comments, anthropological research and cross-cultural studies of depression and other conditions have confirmed this position: psychology, biology, and sociocultural factors strongly influence how we interpret psychological distress in ourselves, how we respond to it in others, the thresholds for help-seeking, and the kind of help we seek. Humans are social creatures, living in families, communities, and societies, so our sociocultural environment shapes a great deal of what we feel, think, and do. We influence each other.

Against this background, changes in the sociocultural environment will inevitably result in changes in diagnostic practices and treatment. Other factors are also relevant, including scientific advances and medical discoveries, but it seems that, in psychiatry at least, sociocultural factors are closely linked with shifts in terminology and understanding. Edward Shorter, in *How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown,* explores how the terminology for 'depression' changed over time and will likely change again, based on a broad range of influences (Shorter, 2013).

Culture is also relevant to treatment, as well as diagnosis, although the precise effects of culture on treatment are likely to vary between cultures, across conditions, and over time. Given the sheer breadth of this field, the number of treatments involved, and the diversity of cultures around the world, recent years have seen research start to look at specific treatments in particular sociocultural settings, so as to bring focus and therapeutic pragmatism to this vast thematic area.

A good example of this kind of work is provided by Li and colleagues, who conducted 'a systematic review and meta-analysis' of the 'efficacy of culturally adapted interventions for common mental disorders in people of Chinese descent', which was published in *Lancet Psychiatry* in 2023 (Li et al., 2023). These authors noted that 'evidence suggests that culturally adapted psychological interventions have some benefits in treating diverse ethnic groups', so, they 'aimed to systematically assess the evidence for the efficacy of different cultural adaptations in treating common mental disorders in people of Chinese descent (i.e., ethnic Chinese populations)' (Li et al., 2023; p. 426). Following an extensive literature search, they included 67 records in their meta-analysis, encompassing 6,199 participants. They concluded that:

Psychological interventions can be transported across cultures with appropriate modifications. Adaptations to interventions can be made by modifying evidence-based interventions, or in culturally specific ways that are rooted in the sociocultural context. However, findings are limited by the insufficient reporting of interventions and cultural adaptations.

(Li et al., 2023; p. 426)

While further work is needed, these results suggest that, once psychological interventions are modified appropriately to a given culture, they can prove helpful even in different sociocultural contexts. This finding is important because over-attributing to culture might be just as harmful as under-attributing. Often, we have more in common than we think, even across cultures, provided we take the time to explore each other's perspectives. In psychiatry, pragmatic studies and reviews such as this are required to ensure that psychiatric treatments are culturally appropriate (with modifications, if needed), and then see if they retain effectiveness in diverse sociocultural settings. There is much to gain in this process. Sometimes, factors which are linked with culture, such as religion, can form part of important cross-cultural dialogues with psychiatry, and can be mediating factors in culture change (Bhugra, 1996). We ignore culture at our peril, and we explore it to the benefit of all.

#### **Discrimination and Psychiatry**

Finally, in any consideration of culture, it is necessary to consider the culture of psychiatry itself and, in particular, issues of sexism, racism, and discrimination. As a counterpoint, it is useful to articulate psychiatry's potential to overcome these issues and act as a vehicle for empowerment, especially for people who experience several kinds of discrimination and marginalisation at the same time.

In 1989, Joan Busfield, a senior lecturer in sociology, explored 'sexism and psychiatry' in the journal *Sociology* and concluded that psychiatry supported sexism by both 'contributing to the processes whereby social conformity is achieved' and helping with the construction and popularisation of 'conceptions of psychological normality which are gender-based' (Busfield, 1989; p. 360). Busfield argued that this conclusion did not mean that 'psychiatry is necessarily oppressive', but rather it necessitated examining 'the complex ways in which sexism may affect constructs and judgements', and 'the complex ways in which social relations generate mental sickness'. The former task lies firmly within psychiatry's remit, while the second lies not only within the ambit of psychiatry but also in the realms of social studies, politics, and economics.

The issue of sexism was evident in psychiatry not only at these conceptual levels, but also in the details of day-to-day clinical practice. In 1995, Hall and Deahl published a paper in the *Psychiatric Bulletin*, asking: 'Are psychiatrists sexist? A study of bias in the assessment of psychiatric emergencies' (Hall & Deahl, 1995). These authors examined 227 consecutive new patient assessments by psychiatry trainees and found that 'trainees were more likely to take alcohol, substance use and forensic histories from men, and more likely to take substance use histories from younger patients' (Hall and Deahl, 1995; p. 538). They 'concluded that trainees make sexist and ageist assumptions when they assess patients'. As a result:

Sustained educational efforts are still required to increase the awareness of medical staff to the importance of substance use and alcohol histories in all patient groups, in order to overcome sexist and ageist clinical assumptions as demonstrated in our study.

(Hall and Deahl, 1995; p. 540)

Psychiatric practice has changed in many ways in the three decades since Hall and Deahl's study, but addressing issues such as sexism, ageism, and racism is a continuous, iterative process. In 2021, for example, Joseph and Bhui noted that one 'concern for Black youth is that they are pathologised' through psychiatric diagnosis and 'sectioned' (under mental health legislation), and that some of this is linked with 'unconscious biases' or 'institutional racism' (Joseph and Bhui, 2021; p. 353). This is most apparent 'in detentions under the powers of the mental health act and in the forensic and criminal justice systems' (p. 358). How can this be addressed?

Appropriate use of diagnostic systems, maintenance of professional standards, and other quality assurance mechanisms can help identify and reduce such problems, but structural discrimination often requires structural solutions. These approaches must be rooted in psychiatric training, continuing professional development, and openness to cross-disciplinary work that identifies and addresses issues which might not be apparent to psychiatrists working within mental health systems, but might be readily identified from other perspectives. We need to be open and to learn.

Another area of concern for psychiatry is the position and treatment of members of LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, questioning, intersex, and asexual) communities by and in psychiatry. Homosexuality was classified as a mental illness by the American Psychiatric Association until 1973 and by the World Health Organisation until 1990 (Kelly, 2017). Bartlett notes that the 'sickness model of LGBT people was dominant' in UK psychiatry (as it was elsewhere) for many years, and while more gay-affirming and positive therapies have been developed, 'many LGBT people report concerns' regarding their mental health care (Bartlett, 2021; pp. 343–4).

These issues require urgent, ongoing attention in the delivery of mental health care, but also in psychiatry more broadly, given the contingent nature of current conceptions of 'mental illness'. In other words, for as long as psychiatry relies on symptom-based diagnoses rather than diagnoses based on biological tests, psychiatry will remain uniquely susceptible to unconscious bias, discrimination, and the influence of various other inappropriate factors on diagnosis and treatment. These factors must be identified in the history of psychiatry (and apologies made), addressed today (in partnership with patients and families), and avoided in the future (through continued awareness, training, and education).

There is still much work to be done on these issues, but awareness is growing in psychiatry, as it is across broader society, especially during the last ten years. Poole and Robinson point out that 'organised psychiatry has become substantially more reflective over the past decade or so':

The Royal College of Psychiatrists has apologised for previous abusive practices, such as aversion therapy to change sexual orientation.  It has been respectful of sincere but flawed attempts to reinvent psychiatry.

(Poole and Robinson, 2023; p. 148)

Today, the Royal College of Psychiatrists 'recognises and values the diversity amongst its members, associates, affiliates and staff', and 'is committed to eliminating discrimination on the grounds of gender, race, ethnic origin, sexual orientation, religion, belief, disabled status or any other unjustified condition' (Royal College of Psychiatrists, 2023). This value system is important, not least because psychiatry often has contact with people who already experience multiple kinds of discrimination in their lives and in the lives of their families. Psychiatry is, therefore, in a unique position to address, rather than amplify, disadvantage, and should make sure it does so.

This is a key mission for psychiatry today: eliminating the injustices experienced by people with mental illness and their families. Joseph and Bhui point out that mental health services are well positioned to act in response 'to societal harms to the marginalised' (Joseph & Bhui, 2021; p. 358). For the future, this will likely involve psychiatrists developing a new kind of professionalism that shifts further towards a partnership with patients and their families, rather than the models of medical professionalism that prevailed in the past (Borman, 2011). The need for this shift has never been greater. Some of these themes are revisited in Chapters 9 ('Global Injustice in Mental Health Care') and 10 ('The Future of Psychiatry: Person-Centred Care and System-Level Change') in this book, but they infiltrate most of the other chapters too: justice can only be achieved together.

*Miguel, the 25-year-old man whom we met at the start of this chapter, heard the voices of 2 gods who told him to leave his home and spread a message of love in the world. Miguel duly departed in the middle of the night and got a train to a nearby city. There, he found a large monastery and spoke with a monk. Miguel told the monk that he wanted to spread a message of love. The monk sat down with Miguel, gave him some food, and asked where he was from. Miguel told the monk that he had two children at home, but the voices of two gods had told him to leave them behind and spread love in the world.*

*After listening to Miguel's story, the monk said that Miguel could stay the night at the monastery on one condition: Miguel had to telephone home to tell his family that he was safe. Miguel agreed to this and phoned his wife, who was very worried about him. She was relieved to hear that he was safe and offered to come to the city to collect him, but Miguel said he wanted to stay at the monastery for the night. Later, however, the voices told Miguel to leave the monastery. He slipped out the back door and walked along the motorway out of the city.*

*Some days later, Miguel's wife received a phone call from another monastery, telling her that Miguel was there, and appeared to be mentally ill. She collected him, but Miguel was not very happy to go home. As soon as they arrived back, Miguel walked away again, this time to the bus station. Miguel's wife collected him there and they spoke to their family doctor who arranged psychiatric assessment for Miguel in the local hospital. Miguel agreed to this only because his wife asked him to do it. The psychiatrist felt that Miguel was mentally ill, but his condition was not severe enough to meet the strict legal criteria for treatment against his wishes. Miguel refused voluntary treatment, declined all forms of support, went to the bus station, and travelled to another monastery in a distant city. His wife was distraught.*

*At that monastery, Miguel was given a room to sleep in, even though he was not a monk. He stayed for almost two months, before the monks asked him to move to a smaller room at the side of the nearby church. There, Miguel worked as a cleaner and caretaker in the church. He continued to hear the voices of the two gods, but they settled into a steady pattern. They were persistent but quieter. The priest was happy to let Miguel stay at the church in return for cleaning and minding the building. Over the following years, regular churchgoers became familiar with Miguel, as he swept and tidied the church, and opened and closed the building. All the time, Miguel muttered quietly to himself and to the gods, although nobody understood what he said.*

*Eventually, Miguel lost touch with his family, because he did not return their phone calls or talk to them when they tried to visit. Miguel lived the rest of his life as a church caretaker. When he died, some decades later, the new priest had*  *no contact details for his family and he could not trace them, because he did not know Miguel's surname. Miguel was buried beside the church. His gravestone simply reads: 'Miguel'.*

## **Key Messages**

## **References**

Bartlett A. Sexual diversity and UK psychiatry and mental health. In: Ikkos G, Bouras N (eds), *Mind, State and Society: Social History of Psychiatry and Mental Health in Britain 1960–2010* (pp. 336–47). Cambridge: Cambridge University Press, 2021 (https://doi.org/10.1017/9781911623793.036).

#### **8 Self-Harm and Suicide**

10.4324/9781003378495-9

**8**

#### **Chapter Content Advisory**

This chapter discusses issues such as self-harm, suicide, depression, mental illness, and related matters in direct terms, in order to demystify, delineate, and understand them better. For this reason, certain readers might find certain sections distressing. If you are concerned about any of these matters from a personal perspective or in relation to family, friends, or colleagues, please contact a registered health care provider immediately, and follow their advice.

*Brad was 15 years old when he started to harm himself. An intelligent highachieving boy, Brad had always done well in school and had many friends until the age of 14. He enjoyed sport and was especially good at football. For many years, Brad played on the school football team and always looked forward to training on Friday evenings. Brad would spend time at his friend Liam's house before training and after matches. Brad and Liam were inseparable: they went to school together, played together, and their families went on vacation together.*

*When Brad became 14, things began to change. Over time, Brad became reluctant to attend football training and sometimes skipped matches. The team coach noticed this and mentioned it to Brad's parents. They agreed that this was likely just a phase and would pass. But Brad also spent less time with Liam and started avoiding the 'pizza parties' he used to enjoy with his friends at the weekends. At home, Brad was silent and withdrawn. He scarcely spoke a word to his older brother, and spent all his time in his room on his phone.*

*Brad's parents were worried, but they assumed that this was a teenage phase. Many teenagers become more solitary, appear preoccupied, and communicate less with their families for periods of time. Liam, too, was concerned about his friend Brad, but soon began to spend time with other friends and other teammates at the football club.*

*Soon, Brad rarely went out, except to school, and, even then, he attended reluctantly. His grades deteriorated rapidly, even in history, which had been his favourite subject. Brad stopped going to football and spent most of his time alone.*

*One day, when Brad's mother was tidying Brad's room, she found two boxes of matches at the bottom of a drawer. Brad's mother thought this was strange:*

#### DOI: 10.4324/9781003378495-9

This chapter has been made available under a CC-BY - Attribution license

*why did Brad have matches in his room? He did not smoke cigarettes or light candles. Brad's mother took the matches away and said nothing to Brad that day. She did not want to upset or embarrass Brad. Besides, Brad was very moody and would probably fly into a rage if his mother mentioned the matches.*

*But Brad's mother was worried and discussed it with Brad's father. They spoke about it together, and the next day they asked Brad about the matches. Brad became angry. He said that he was 15 years old and could live his own life. He said that his mother was not allowed into his bedroom ever again. Brad stormed upstairs and slammed his bedroom door. Brad's parents were disappointed, but not surprised: this was the response they expected.*

*Several hours later, Brad came back downstairs. He was very upset, sobbing uncontrollably. Brad told his mother that he used the matches to burn himself. Brad rolled up his sleeves and showed his mother multiple small burns on his upper arms. Some of the burns were old and some were quite new. Brad said he burnt himself where nobody could see the burns. He said he could not go to football training anymore because his friends would see the burns on his arms in the changing rooms. Brad was very upset.*

*Brad's parents were shocked and distressed. 'Why do you do this?', his mother asked. Brad replied: 'I don't know. I just feel tense. I wish I could stop, but I don't think I can.  'Why do you do this?', she kept asking. 'I just feel tense', Brad kept replying. Soon, they were both in tears, both deeply upset, and both with no idea what to do next.*

#### **Introduction**

*Self-Harm and Suicide*

Deliberate self-harm is common. Suicide is less common, but is also a constant feature of all societies for which there is recorded history. Both non-fatal deliberate self-harm and suicide are public health problems of great magnitude and both merit close attention. Both deliberate self-harm and suicide involve deep suffering at the level of the individual, their family, the community, and society as a whole.

Brad's experience of deliberate self-harm is not uncommon, and neither are the experiences and responses of his parents. Brad feels upset, tense, and alone. He lacks the emotional and psychological skills to manage his feelings, which seem overwhelming to him. He is surprised and confused by his own behaviour and feels ashamed when his parents find out. If he cannot explain this behaviour to himself, how can he explain it to them? Is he mentally ill?

Brad's parents are also in a difficult, distressing position. They are baffled by Brad's behaviour and struggle to understand why he burns himself. They want to help, but their initial reactions are confusion and helplessness. This experience is entirely new to them, so they struggle to react in the level-headed, supportive way that they might wish to. They do not know what to do next, or where to turn. Who can help? And how?

Against this background, this chapter examines issues relating to 'Self-Harm and Suicide'. It starts by exploring definitions of self-harm and suicide, and then looks at suicide in the history of psychiatry, with particular reference to the views and writings of leading asylum doctors of the nineteenth century. Global rates of suicide are discussed, along with consideration of trends over recent decades, including the impact of the Covid-19 pandemic on rates of suicide.

This chapter pays particular attention to the (very limited) value of 'risk assessment' in individual cases of mental illness or psychological distress, and the use of evidence-based approaches to suicide prevention, focussing especially on public health measures and the broader social context in which self-harm and suicide occur and are managed. Issues relating to suicide and the law are explored, including the decriminalisation of suicide and attempted suicide in various jurisdictions (e.g., in India's Mental Healthcare Act, 2017), the use of 'risk' of suicide in mental health legislation (commonly as part of criteria for admission or treatment without consent), and some of the issues surrounding physician-assisted suicide (PAS), which is a topic that commands increasing attention around the world. The chapter concludes with a consideration of useful directions for future research and service developments in this area.

But, first, how are deliberate self-harm and suicide defined?

#### **Definitions of Self-Harm and Suicide**

Suicide is intentional self-killing, while deliberate self-harm is the intentional infliction of non-fatal harm on oneself. The latter includes a wide variety of methods such as self-cutting and self-burning (Kelly, 2017).

The definitions of deliberate self-harm and suicide are the subjects of ongoing debate. Many people would agree that intentionally cutting one's wrists constitutes deliberate self-harm, but what about other, less clear forms of selfharm, such as smoking cigarettes? There is widespread awareness that smoking reduces life expectancy owing to smoking related diseases such as cancer and heart disease. But does this mean that smoking can be accurately or usefully regarded as a form of deliberate self-harm? Or is it better seen as an addictive or medical condition, like a physical illness, over which the person has some, but limited, control?

There are also questions about the definition of suicide. For example, if a person routinely uses illegal drugs and is aware that their level of drug use is such that they could easily die of an 'accidental' overdose, does that mean that if they are found dead following drug use, the death is a form of suicide? Or is their death an accident? Or is it the result of an illness, such as dependence on alcohol or other substances, and thus similar to a death from pneumonia? Or is it a combination of all of these?

In this scenario, it is useful to consider the concept of a 'sub-intended' death. This might occur when a person might not identify a single moment when they decide to end their life, but rather make a series of choices which indicate, at the very least, significant ambivalence about living and dying; e.g., routine excessive use of alcohol or drugs, despite knowing the risks of self-harm or death. This can be compounded by a diagnosed condition (such as a dependence disorder) and a degree of accidental or excessive use of substances on any given occasion.

In this way, a death that results from a person knowingly taking risks that might result in death can be considered a 'sub-intended' death; i.e. a death which is attributable to a combination of personal behaviour, an addictive condition, or other diagnosis, and additional circumstances, as indicated in each case.

Regardless of precise definitions, self-harm and suicide are major public health issues and merit attention at all levels: individual, family, community, and society (Knipe et al., 2022). In the United States, the National Institute of Mental Health (NIMH), in common with similar organisations across other jurisdictions, provides clear information to the public about risk factors for suicide:

People of all genders, ages, and ethnicities can be at risk. Suicidal behavior is complex, and there is no single cause. The main risk factors for suicide are:

(National Institute of Mental Health, 2023)

Looking at the scientific literature more broadly, general risk factors for nonfatal deliberate self-harm include female gender, younger age, poor social support, major life events, poverty, being divorced, being unemployed, mental illness, and a history of previous deliberate self-harm (Kelly, 2017). Risk factors for suicide include male gender, poor social support, major life events, family history of suicide, chronic painful illness, mental illness, and a history of previous deliberate self-harm. Availability of means is also significant for both deliberate self-harm and suicide (see below).

### 178 *Self-Harm and Suicide*

In terms of mental illness, suicide is associated with major depressive disorder (long-term risk of suicide: 10%–15%), bipolar affective disorder (10%–20%), schizophrenia (10%), and alcohol dependence syndrome (15%) (Williams, 1997). In addition, individuals who engage in deliberate self-harm have a 30-fold increased risk of completed suicide over the following four years (Cooper et al., 2005). Other contextual factors also matter, as the NIMH points out:

For people with suicidal thoughts, exposure, either directly or indirectly, to others' suicidal behavior, such as that of family members, peers, or celebrities can also be a risk factor […] Stressful life events (such as the loss of a loved one, legal troubles, or financial difficulties) and interpersonal stressors (such as shame, harassment, bullying, discrimination, or relationship troubles) may contribute to suicide risk, especially when they occur along with suicide risk factors.

(National Institute of Mental Health, 2023)

Overall, then, there are risk factors for deliberate self-harm and suicide at the level of the individual, in the context of their family and social circle, and against the backdrop of their socio-economic situation, as well as the events of dayto-day life. This makes it even more important that we look after each other in the changing, challenging, and often overwhelming circumstances in which so many people find themselves. As the NIMH points out, 'family and friends are often the first to recognise the warning signs of suicide, and they can take the first step toward helping a loved one find mental health treatment' (National Institute of Mental Health, 2023).

### **Self-Harm and Suicide in the History of Psychiatry**

Self-harm and suicide have featured in ancient societies, traditional literatures, and religious texts since the beginning of recorded history (Williams, 1997). Social and religious responses shifted considerably over time, resulting in increased medicalisation of self-harm and suicide, especially in the twentieth century (Alvarez, 1974). The emergence of the discipline of psychiatry within the profession of medicine during the nineteenth century laid the groundwork for this shift, as is reflected in the writings of various prominent asylum doctors on the subject of suicide.

In 1853, James Foulis Duncan (1812–1895), a leading Irish asylum doctor and (later) president of the Medico-Psychological Association (1875), wrote extensively about suicide in his book, *Popular Errors on the Subject of Insanity Examined and Exposed* (Duncan, 1853). Using the language of the times, Duncan argued that suicide could be the result of a 'delusion', such 'as when the individual fancies that he has received a divine commission to offer himself up as a voluntary sacrifice for the benefit of others':

It may in other instances proceed from the derangement of natural conscience, leading the individual to look upon that with satisfaction, or at least without remorse, which in health he would be ready to denounce […] It may still further emanate from a depressed condition of the moral feelings, rendering the individual to a great degree unconscious of what he is doing; and lastly, it may be the result of a perverted condition of the instinctive principle of self-preservation, and then it is perpetrated suddenly under the influence of a momentary impulse, and without apparent premeditation.

(Duncan, 1853; p. 86)

Duncan located the impulse to self-harm very much within the individual, consistent with increased medicalisation of suicide at this time. He drew particular attention to

persons whose consciences have been awakened to a sense of guilt arising from irregularities in their past life, and who think that they have committed the unpardonable sin, or that they are delivered over to a condition of hopeless despair.

(p. 87)

He urged caution, however, at presuming that everyone who died by suicide was necessarily mentally ill: 'Is the mere act of self-destruction of itself a proof that the person who committed it was insane at the time? Medical authorities are divided on this point' (p. 93). They remain so divided today.

Five years after Duncan's book, in 1858, two leading English asylum doctors, John Charles Bucknill and Daniel H. Tuke, elaborated on the types of 'conditions of the mind' that were linked with suicide, in their classic *Manual of Psychological Medicine: Containing the History, Nosology, Description, Statistics, Diagnosis, Pathology, and Treatment of Insanity, With an Appendix of Cases* (Bucknill & Tuke, 1858; p. 202). For Bucknill and Tuke, again in the language of the times, psychological or psychiatric conditions affected different people in different ways:

of two patients, equally a prey to melancholia, the one will attempt to terminate his existence, while the other, so far from contemplating, will recoil with horror from, the act. By the latter, the natural desire to retain life may be possessed in much greater force than by the former; or there may survive, in one, religious convictions antagonistic to the execution of the act of suicide, which may either never have been present in the other, or have been paralyzed by disease. Other motives than those now referred to, may prompt self-destruction. Thus, the act may be intimately associated with delusional forms of insanity; or again, it may be instantly committed, in consequence of any one of the feelings receiving a shock.

(Bucknill and Tuke, 1858; p. 202)

Given this variability in risk and behaviour across patients who were 'equally a prey to melancholia', it was clear that constant vigilance was needed. Thomas Clouston, another well-known asylum doctor, addressed this matter in his 1883 book, *Clinical Lectures on Mental Diseases*:

The question of the patient being suicidal should never in any case of melancholia be left unconsidered, and the risk of his becoming suicidal should never in any case be left unprovided for […] When a man takes away his own life, or even when a serious attempt is made, it is so distressing to everyone connected with the patient, so hurtful to his prospects, and so damaging to the reputation and foresight of the doctor in charge, and so in the teeth of the radical medical principle to obviate the tendency to death, that no pains should be spared to guard against its occurrence.

(Clouston, 1883; p. 112)

As psychiatry developed during the remainder of the nineteenth century and the long twentieth century, responses to deliberate self-harm and suicide shifted to reflect both the evolving discipline of psychiatry and broader social changes, which have always influenced psychiatry profoundly (Kelly, 2022). The role of social risk factors became especially apparent: poor social support, major life events, poverty, getting divorced, and being unemployed. The availability of means (e.g., tablets to take overdoses) was also found to be significant, along with sociocultural interpretations of deliberate self-harm and suicide, and the behaviour of others.

There was also, from the outset, clear recognition of the phenomenon of 'copycat' suicides. As long ago as 1853, Duncan referred to 'those cases of suicide that seem to have their origin in the principle of imitation':

It is a well-ascertained fact that when one case of self-destruction happens, especially when it takes place in a large town, and excites an unusual degree of attention, several others are sure to follow, presenting precisely similar circumstances.

(Duncan, 1853; p. 89)

This matter remains relevant today, as one element within the complex set of risk factors for deliberate self-harm and suicide that have evolved and become apparent over the past two centuries.

#### **Global Rates of Suicide**

Given the diversity of personal, medical, social, and other risk factors associated with self-harm and suicide, it is not surprising that rates change over time. What is interesting, however, is the magnitude of the shift over recent decades (which is substantial), the direction of the change (which is positive), and its distribution around the world (which is uneven). This merits close attention if we are to understand the challenges presented by suicide today and the best ways to address them.

In 2019, Naghavi on behalf of the Global Burden of Disease Self-Harm Collaborators used 'estimates from the Global Burden of Disease Study 2016 to describe patterns of suicide mortality globally, regionally, and for 195 countries and territories by age, sex, and socio-demographic index, and to describe temporal trends between 1990 and 2016' (Naghavi on behalf of the Global Burden of Disease Self-Harm Collaborators, 2019; p. 1). This group found that there were an estimated 817,000 deaths from suicide globally in 2016, accounting for approximately 1.49% of total deaths that year. This is an enormous number of deaths which confirms suicide as a public health problem of the greatest magnitude.

Looking at trends over time, however, data showed that 'the age standardised mortality rate for suicide decreased by 32.7% (27.2% to 36.6%) worldwide between 1990 and 2016' (p. 1). This is an extraordinarily important statistic and one which offers real hope for the future. While a one-third decline in the suicide rate is not nearly enough, it shows that positive change is possible. If the rate can decline by one third, surely it can decline by another third? Or more? Nobody is born wanting to die by suicide, and even one suicide is one too many.

Notwithstanding the positive trend and progress to date, then, there is clearly still more work to be done. Naghavi on behalf of the Global Burden of Disease Self-Harm Collaborators is clear on this point:

When ranking leading causes by age standardised mortality rate, this study found that suicide deaths were in the leading 10 causes of death across eastern Europe, central Europe, high income Asia Pacific, Australasia, and high income North America.

> (Naghavi on behalf of the Global Burden of Disease Self-Harm Collaborators, 2019; p. 11)

They also note that the decline in the suicide mortality rate is not universal: men still have higher rates of suicide than women at all time-points (except among those aged 15 to 19 years), and the greatest decline in rates is seen in women, rather than men, thus potentially widening the gender gap. In addition, much of the global decline to date is attributable to falls in suicide mortality in China and India, rather than certain other countries:

Taken as a whole, these patterns reflect a complex interplay of factors, specific to regions and nations, including sociodemographic, sociocultural, and religious factors; levels of economic development, unemployment and economic events; distribution of risk factors, such as exposure to violence or use of alcohol and drugs; choices of and access to means of suicide; and patterns of mental illness […] as well as culturally specific relations with suicide. Moreover, although the decrease in suicide mortality has been substantial during the period 1990 to 2016, if current trends continue, only 3% of 118 countries will attain the Sustainable Development Goals target to reduce suicide mortality by one third between 2015 and 2030.

> (Naghavi on behalf of the Global Burden of Disease Self-Harm Collaborators, 2019; p. 11; citations omitted)

These international variations highlight regions and issues that need particular attention, but the global decline in the suicide mortality rate is still an enormously positive development overall. It provides clear evidence of progress rather than deterioration in at least one important indicator of mental health. The declining trend does not support the idea of an overall 'crisis' in mental health (Council of Economic Advisors, 2022; see also Chapter 1 of this book: 'Why Does Psychiatry Exist?'). There is, of course, still substantial work to be done, and global statistics mean little to those who are suicidal or bereaved by suicide, but there are reasons for optimism (Kelly, 2023a).

Since these data were published in 2019, the world experienced one of the largest public health emergencies of recent decades: the Covid-19 pandemic. Covid-19 brought enormous physical and mental suffering, and the loss of millions of lives, but there was also more resilience than many people might have anticipated in such difficult circumstances. There were certainly mental health problems during the pandemic, and some people suffered ongoing symptoms from Covid-19, but there was no surge of serious mental illness after the outbreak (Kelly, 2023b). So, how did the pandemic affect suicide rates?

In 2023, one 'systematic review with meta-analysis' examined 'suicide before and during the Covid-19 pandemic', and 'identified 51, 55, and 25 samples for suicidal ideation, attempt, and death by suicide' (Yan et al., 2023; p. 1). This group found that 'the prevalence of suicidal ideation increased significantly' and 'suicide attempts were more prevalent during the pandemic', but there was no significant change in rates of death owing to suicide. In other words, there was increased distress among some people, but this did not translate into increased rates of suicide during Covid-19.

This is broadly consistent with another systematic review and meta-analysis of 137 studies of mental health symptoms before and during the pandemic, which reported no overall negative change in terms of general mental health and anxiety symptoms, although there was a slight worsening of depressive symptoms, and women were more affected than men (Sun et al., 2023). Writing about this study in the *Guardian*, Hall noted the consistency in overall findings about suicide, and also the fact that some subgroups of the population were more affected than others:

The researchers at McGill said their findings were consistent with the largest study on suicide during the pandemic – which found no increase – and applied to most groups, including different ages, sexes, genders and whether people had pre-existing conditions. Three-quarters of the research focused on adults, mostly from middle- and high-income countries.

However, they acknowledged that women had experienced worsening anxiety, depression or general mental health symptoms during the pandemic, possibly due to juggling more family responsibilities, or because more work in health or social care, or, in some cases, due to domestic abuse.

(Hall, 2023)

In 2023, the Organisation for Economic Co-operation and Development (OECD) provided a similarly nuanced account of the mental health effects of the pandemic:

OECD analysis has shown that population mental health went up and down over the course of the pandemic – typically worsening during periods when infection and death rates were high, or when stringent containment measures were in place. Available data point to some recovery in population mental health as the pandemic situation improved, but also suggest that mental ill-health remains elevated […] Persistently high levels of mental distress 'beyond' the pandemic could reflect the confluence of multiple crises: the cost-of-living crisis, climate crisis and geopolitical tensions.

Shocks such as pandemics, severe weather events and financial crises can also heighten the risk of suicidal behaviour. While complex social and cultural factors affect suicidal behaviour, mental ill-health increases the risk of dying by suicide. Rates of death by suicide currently vary almost sixfold across OECD countries, and are over three times higher for men than women.

> (Organisation for Economic Co-operation and Development, 2023; p. 80)

Overall, evidence to date indicates that the Covid-19 pandemic increased rates of distress and suicidal ideation, but not rates of completed suicide. As the OECD points out, other factors inevitably influence suicide rates: gender, social circumstances, cultural factors, environmental concerns, and various other matters. But, as best as can be established, Covid-19 did not increase rates of suicide.

#### **Assessing Risk of Self-Harm and Suicide**

Notwithstanding the declining rate of suicide over recent decades, self-harm and suicide remain public health challenges of the greatest magnitude. They are also acute challenges at the level of individual patient care, so a great deal of effort has been devoted to identifying risk factors for self-harm and suicide (as outlined above). Similar attention has been devoted to trying to predict the risk of given individuals engaging in deliberate self-harm or dying by suicide, especially if they have signs of mental illness or have expressed suicidal ideation in the past.

Overall, however, research in this field indicates that it is not possible to predict suicide at the level of the individual, at least not in an actuarial or statistical way (Kelly, 2017; Hawton et al., 2022). While certain people can be regarded as low-risk or high-risk at certain times, based on general risk factors, it is still not possible to predict who will die by suicide and who will not. Assessing and understanding risk factors can help to inform care and shape therapeutic relationships, but it does not provide a mathematical evaluation of risk. Suicide cannot be predicted, even in apparently high-risk circumstances.

Recent research strongly supports this position. In 2019, one systematic review and simulation of prediction models for suicide attempts and deaths found that the accuracy of suicide prediction models for 'predicting a future event is near 0' (Belsher et al., 2019; p. 642). There are many reasons for this. In statistical terms, suicide is a rare event, which means that risk assessment methods inevitably have low positive predictive values (Knipe et al., 2022). This is true even in apparently high-risk groups: one follow-up survey found that fewer than 1 in 200 people who experience suicidal thoughts go on to complete suicide (Gunnell et al., 2004).

In addition, risk factors for self-harm and suicide are widely distributed across populations, so the vast majority of people with such risk factors will not die by suicide. As a result, the 'population paradox' means that the absolute number of people who die by suicide is greater in the 'low-risk' group, because a greater proportion of the population are classified as 'low risk'. In short, prediction is impossible, even in apparently high-risk groups and even using risk assessment tools.

There are also potential harms from inaccurate or inappropriate risk assessment, including possible alienation of patients, restriction of care based on apparent low-risk status, and impairment of therapeutic relationships. It is conceivable that some of these factors could increase distress and maybe even increase the risk of suicide in the long term, rather than help reduce it. So-called 'risk assessment' might itself present a risk.

Given that deliberate self-harm is more common than suicide, it is statistically possible that prediction models will perform better for self-harm than for suicide. One 2022 study examined the use of clinician assessment, patient selfreport, and electronic health records (EHRs) 'to predict suicide attempts within 1 and 6 months of presentation at an emergency department (ED) for psychiatric problems' (Nock et al., 2022; p. 1). Findings suggested 'that the ability to identify patients at high risk of suicide attempt after an ED visit for psychiatric problems improved using a combination of patient self-reports and EHR data' (p. 2). More specifically:

In the best 1-month model, 30.7% (positive predicted value) of the patients classified as having highest risk (top 25% of the sample) made a suicide attempt within 1 month of their ED visit, accounting for 64.8% (sensitivity) of all 1-month attempts. In the best 6-month model, 46.0% (positive predicted value) of the patients classified at highest risk made a suicide attempt within 6 months of their ED visit, accounting for 50.2% (sensitivity) of all 6-month attempts.

(Nock et al., 2022; p. 1)

Research is ongoing in this area, with interesting work on the topics of machine learning to identify suicide risk among text-based crisis counselling encounters (Broadbent et al., 2023) and the development of a clinical prediction rule for suicide in severe mental illness (Senior et al., 2020) and a clinical prediction score to evaluate the risk of death by suicide following self-harm presentations to health care (Fazel et al., 2023), among other initiatives.

At the present time, however, it remains the case that it is not possible to predict self-harm or suicide at the level of the individual. Moreover, risk can change rapidly in response to myriad factors that are unpredictable, unknown, and possibly unknowable. The element of impulsivity in much suicidal behaviour adds further to the difficulty with prediction.

This is not a new conclusion. In 1883, Thomas Clouston made similar points in his book, *Clinical Lectures on Mental Diseases*:

No tendency to suicide exists at all in many melancholics from beginning to end of their disease, but it does exist in some form or other, in wish, intention, or act in four out of every five of all the cases, and we can never tell when it is to develop in any patient. The intention and the act may come on suddenly, by suggestion from without or within, or by the sight of opportunity or means of self-destruction.

(Clouston, 1883; p. 112)

One hundred and forty years later, the NIMH emphasised the difficulty with prediction in a similar fashion, along with the need for a flexible response as circumstances evolve and presentations change:

Most people who have risk factors will not attempt suicide, and it is difficult to tell who will act on suicidal thoughts. Although risk factors for suicide are important to keep in mind, someone who is actively showing warning signs of suicide may be at higher risk for danger and in need [of] immediate attention.

(National Institute of Mental Health, 2023)

Overall, it is impossible to predict which patients will die by suicide and which will not. Even following meticulous psychiatric evaluation, 'risk assessment', treatment, effective communication with family, and close follow-up, it is still entirely possible that any given person will engage in deliberate self-harm or suicide (Kelly, 2017). All of these assessments and services should be provided, and they might both alleviate distress and reduce the risk of self-harm and suicide. But it remains the case that the outcome cannot be predicted for any given person: even with the highest standard of assessment, treatment, and care on any given day, deliberate self-harm or suicide can still occur on that same day, and cannot be predicted.

#### **Evidence-Based Approaches to Suicide Prevention**

So, if suicide cannot be predicted in individual cases, can it be prevented? A great deal of time and effort have been rightly devoted to preventing suicide, given that it remains an intensely individual tragedy as well as a substantial public health problem. The fact that rates are declining globally indicates that positive change is possible.

Against this background, the issue of preventing self-harm and suicide can be considered at three levels: the political level (e.g., re-shaping the landscape of risk for psychological distress, mental illness, and suicide), the population level (e.g., restricting access to means of deliberate self-harm and suicide for the entire population), and the individual level (e.g., seeking to alleviate distress, treat mental illness, and reduce the likelihood or severity of self-harm). While there are connections across the three levels, it is useful to consider each in turn.

First, at the broadest political level, it is necessary to address the root causes of much (but not all) psychological distress, mental illness, deliberate selfharm, and suicide. These root causes include poverty, inequality, injustice, prejudice, and all forms of social exclusion (Kelly, 2022). These problems must be addressed at the political level, locally, nationally, and internationally. Advocating on these themes requires that health care professionals move beyond the world of individual patient care, step outside the clinic, and enter the realms of public advocacy, social activism, and political involvement. Some of the relevant issues are explored in Chapters 9 ('Global Injustice in Mental Health Care') and 10 ('The Future of Psychiatry: Person-Centred Care and System-Level Change') of this book.

Second, restricting access to means of deliberate self-harm and suicide across the entire population can help reduce rates of deliberate self-harm and suicide. Given that it is not possible to predict suicide in individual cases, the strongest evidence to date supports suicide prevention measures that avoid prediction altogether and simply apply to the entire population, regardless of apparent risk. On this basis, restricting access to means of self-harm can prove effective. This might include national bans on the most toxic forms of pesticide in countries where pesticides are commonly used for suicide, or restricting access to firearms, in order to reduce risks associated with impulsivity (Knipe et al., 2022).

The effectiveness of population-level interventions stems from the fact that they do not rely on risk assessments at the level of individuals, but apply to everyone in the population. It is important that such measures are tailored to the environments in which they are applied, so as to optimise both acceptability and benefit. The necessity for flexibility in implementation was emphasised in one 'scoping review' of 'facilitators and barriers to implementation of suicide prevention interventions':

Our results indicate that interventions based on restricting access to the means can benefit from adaptability of the intervention. This means that intervention should in the best-case scenario provide few guiding principles, which can be tailored to the needs of the target environment no matter if it tries to restrict access to certain places, availability of firearms or pesticides. On the other hand, not reflecting the needs and resources of the target group in the intervention can lead to implementation failure.

(Kasal et al., 2023; p. 10)

At the level of the individual, it is important to remain aware of the possibility of self-harm and suicide, to provide open, honest assessments, and deliver care that is responsive, flexible, person-centred, and evidence-based. The NIMH provides a useful list of 'warning signs that someone may be at immediate risk for attempting suicide', including:

The NIMH adds that 'other serious warning signs that someone may be at risk for attempting suicide include':

#### 188 *Self-Harm and Suicide*

It is important to use these features as reasons to enquire further into a person's symptoms, rather than using them as a statistical or actuarial method to assess risk, which cannot be reliably assessed at the level of the individual.

In terms of specific interventions, it is vital to establish a strong therapeutic relationship that facilitates disclosure, to suggest involving family or friends in care (as appropriate), and to have clear arrangements for follow-up care and emergency access. Specific therapeutic interventions for self-harm will depend on the individual case and the presence or absence of mental illness. In broad terms, there is evidence to support psychological interventions in certain situations such as dialectical behaviour therapy (DBT) in some people with personality disorders, or brief interventions, although the evidence base is limited (Knipe et al., 2022).

Certain medications for the treatment of particular conditions might also reduce risk in some people, although it is difficult to assemble a complete evidence base because people at apparently high risk of self-harm or suicide are often excluded from clinical trials (Knipe et al., 2022). This is a regrettable problem with the evidence base in psychiatry, which is generally as strong as, or stronger than, the evidence base for treatments in other areas of clinical care, such as cardiovascular medicine (see Chapter 4: 'Treating Symptoms and Disorders').

Despite this methodological issue, there is evidence of potential benefit in terms of reduced suicidal behaviour with certain medications, including, most notably, lithium, which appears to be associated with reduced risk of suicide in people with bipolar disorder and depression. This effect seems to be specific to lithium. As Malhi and colleagues point out, bipolar disorder is a 'serious mental illness that is widely acknowledged as one of the most debilitating and the most likely to result in suicide', and while 'competition has grown within the pharmacological armamentarium for bipolar disorder with newer treatments promoting an image of being safer and easier to prescribe […] none of these mimics have the additional benefits of preventing suicide' (Malhi et al., 2023; p. 1).

As a result, lithium is, perhaps, the psychiatric medication with the most convincing evidence base for reducing the risk of suicidal behaviour, and this should be considered in prescribing decisions in bipolar disorder. More broadly, individual care should include careful therapeutic risk assessment, formulation, therapeutic risk management, and safety planning, as appropriate to each individual case (Hawton et al., 2022).

#### **Suicide and the Law**

This chapter started with the case of Brad, a 15-year-old boy who had been burning his arms with matches for almost a year. When Brad's parents discovered this, it was not clear to them or to Brad what to do. Was he mentally ill? To whom should they turn? Could anything be done? Why was Brad doing this?

We will return to Brad's case at the end of this chapter, which has, so far, considered clinical and therapeutic dimensions of self-harm and suicide; i.e., definitions of deliberate self-harm and suicide, suicide in the history of psychiatry, global rates of suicide over recent decades, the limited value of 'risk assessment', and the use of evidence-based approaches for suicide prevention. But, for Brad and others, are there also legal consequences to their actions, as well as personal and clinical consequences? This is an important issue in many parts of the world and merits close attention.

Three main legal issues arise in relation to deliberate self-harm and suicide: the decriminalisation of suicide and attempted suicide in various countries; the use of 'risk' of self-harm or suicide in mental health legislation as a ground for admission or treatment without consent; and evolving laws governing physicianassisted suicide (PAS) in various jurisdictions, especially in the context of mental illness.

To begin, there is a long history of criminalising attempted suicide in many countries around the world, but developments in science and medicine over the nineteenth and twentieth centuries led to significant changes in attitudes in certain jurisdictions:

During this period, cognitive and emotional distress were presented as complex phenomena that could also be caused by natural biological factors. Consequently, several countries repealed laws criminalizing suicide, predominantly in Europe and North America.

Advances in attitudes toward human rights, including the Convention on the Rights of Persons with Disabilities, have prompted many other countries to abolish laws that criminalize suicide. Furthermore, the World Health Organization *Mental Health Action Plan 2020-2030*, which calls for human rights oriented policy to tackle suicide, has impelled many countries to commit to decriminalizing suicide.

Despite such breakthroughs, suicide remains criminalized in many countries around the world, particularly in [low- and middle-income countries] in Africa and Southeast Asia which bear the biggest burden of suicide mortality.

(Ochuku et al., 2022; p. 2; citations omitted)

Despite the uneven pace of change, decriminalisation of suicide is progressing. In India, for example, the Mental Healthcare Act, 2017 states that, 'notwithstanding anything contained in section 309 of the Indian Penal Code any person who attempts to commit suicide shall be presumed, unless proved otherwise, to have severe stress and shall not be tried and punished under the said Code' (Section 115(1)). This is a positive development, which will hopefully emphasise health care responses to attempted suicide, rather than criminal proceedings.

The second key legal issue concerns the use of 'risk' of self-harm or suicide in mental health legislation as a ground for admission or treatment without consent. The broader issue of mental health legislation was considered in Chapter 5: 'Treatment Without Consent'. That chapter noted the continued role of 'risk' in criteria for admission and treatment without consent in many jurisdictions, despite our very limited ability to assess risk of harm to self (see above) or others (Large et al., 2024). Future revision of legislation should de-emphasise risk as a criterion for admission and treatment without consent, focussing instead on demonstrated needs and potential benefits of treatment.

The third legal issue concerns laws governing PAS in various jurisdictions, especially in the context of mental illness. A full consideration of this topic is beyond the scope of the present chapter, but it is important to note growing concerns about PAS for mental illness alone, not least because suicidality is a feature of many mental illnesses, and socio-environmental circumstances can be major factors in the onset and progression of such conditions (Gergel, 2024). PAS for mental illness alone also rests uneasily with psychiatry's overall efforts to decrease rates of deliberate self-harm and suicide (Kelly and McLoughlin, 2002).

These concerns, combined with uncertainty about the biological basis and prognosis of many mental illnesses, mean that PAS on the basis of suffering from mental illness is qualitatively different to PAS on the basis of suffering from 'physical' illnesses which have a clearer biological basis and a clearer prognosis. And if PAS is to be provided on the basis of 'unbearable suffering' alone, without requiring any diagnosis, it is unclear why physicians would be involved to begin with. As a result, the provision of PAS for mental illness alone is not advised.

#### **Future Directions for Research and Service Development**

This chapter has examined various definitional, clinical, and preventive matters relating to deliberate self-harm and suicide. Throughout all such discussions, it is important to bear in mind the NIMH's reminder that 'suicide is not a normal response to stress':

**Suicidal thoughts or actions are a sign of extreme distress and should not be ignored.** If these warning signs apply to you or someone you know, get help as soon as possible, particularly if the behavior is new or has increased recently (National Institute of Mental Health, 2023).

(emphasis in the original)

In terms of useful directions for future research and service development, it is helpful to start from a broad, societal perspective. Psychiatry is a social endeavour as well as a medical one, so a wide-angle lens is optimal. From this position, there is a clear need for continued study of the political, social, and economic contexts in which thoughts of self-harm and suicide develop, are interpreted, and are managed. Mental illness is often a factor in these situations, but mental illness does not occur in a vacuum, so it is neither accurate nor helpful to view self-harm and suicide as entirely personal matters (Bharati et al., 2021). Research and interventions need to acknowledge this broader perspective, as well as providing supports at the levels of individuals, families, and communities.

In terms of population measures, Beattie and Devitt note that restricting access to means (as discussed above) and reducing overall alcohol consumption are both likely to help reduce rates of suicide (Beattie and Devitt, 2015). In terms of individual-level care, they note the potential of DBT and lithium for certain patients, as well as the possible roles of follow-up contacts and safety planning interventions. Ochuku and colleagues point to similar 'evidence-based strategies for suicide prevention such as means restriction, improved mental health literacy and access to psychosocial support, and responsible media coverage of suicides' (Ochuku et al., 2022; p. 1). The importance of positive therapeutic relationships cannot be overstated, and the provision of support to families.

Future research could usefully focus on more fine-grained analysis of the underpinnings of the recent decline in suicide rates, the impact of the Covid-19 pandemic (on both mental health and rates of self-harm and suicide), and the precise ways in which evidence-based approaches to prevention are best devised. For example, which are the most impactful models of means restriction, and in what ways should these vary from country to country? At the level of the individual, to what extent do follow-up contacts and safety planning interventions help, and do particular models work better than others? What are the roles for technology? And what is the role of artificial intelligence (AI), if it is judiciously deployed?

In terms of legislative change, future research might usefully interrogate legal and regulatory responses to suicide and self-harm across jurisdictions, with comparative legal analysis of both national legislation and international standardsetting. Can one set of standards be recommended for every legal system around the world, regardless of historical, cultural, and legal backgrounds? Legislative change is often slow, and sometimes wisely so.

The use of 'risk' of self-harm or suicide in mental health legislation as part of criteria for admission or treatment without consent is a particular cause for concern, as is the provision of PAS for mental illness alone. Regarding the latter, further research might conceivably help establish how to systematically and reliably differentiate a desire to die that stems from mental illness from a desire to die that does not. For now, however, such a distinction can be essentially impossible to make, and legal provisions often fail to reflect the complexity, ambiguity, and changeability of clinical assessments in these situations.

*Brad, the 15-year-old boy whom we met at the start of this chapter, had been burning his arms with matches for almost a year. When his parents found out, they were deeply upset. They spoke to Brad about it, but none of them knew what to do next. Brad's mother phoned her sister, who suggested that Brad should see his general practitioner (family doctor). The doctor spoke with Brad and his mother, and listened when Brad tried to explain why he burnt himself. 'Does it relieve the tension?', the doctor asked. Brad was honest: 'Burning my arms takes away some of the tension for a few minutes, but then it comes back. I know that it makes me feel worse in the end. I am so ashamed.'*

*The doctor referred Brad to see a child and adolescent psychiatrist, who discussed the situation in detail with Brad and his parents. Brad was quite embarrassed and asked to see the psychiatrist on his own, without his parents, even though he was not yet 16. Brad's parents agreed to this, and Brad discussed his problems privately with the psychiatrist. Brad was worried about schoolwork and about his friends. 'My friends all seem so confident', he said. 'Am I the only one who is anxious, tense, and burning their arms? Have you ever seen anything like this before? Am I out of control? What should I do now?'*

*The psychiatrist listened to Brad's concerns and reassured Brad that he was not alone. The psychiatrist told Brad that other people experience similar problems, but people often do not talk about it. Brad understood this: he didn't really want to talk about it either, so why would anyone else? That made sense.*

*The psychiatrist recommended that Brad attend a series of appointments with a qualified psychotherapist, focussing on dealing with difficult emotions, tolerating distress, and developing better coping mechanisms. Brad asked: 'Am I mentally ill?' The psychiatrist told Brad that he was not mentally ill, but needed support, treatment, and follow-up. Brad's parents asked: 'Will Brad continue to self-harm?' They really wanted to ask: 'Is it likely that Brad will die by suicide?' They were terrified.*

*The psychiatrist reassured both Brad and his parents. Brad showed good insight into his problems and was willing to reach out for help. This was very positive, as was the fact that Brad had a supportive family – even if Brad still slammed his bedroom door sometimes. While Brad's self-harm placed him at higher risk of suicide compared to someone who did not self-harm, the most likely outcome was that Brad would improve over time. Psychotherapy would hopefully help Brad to understand his problems, manage his emotions better, develop other coping mechanisms, and stop burning himself. The psychiatrist was steady, pragmatic, and optimistic.*

*Brad duly attended the psychotherapist for therapy and the psychiatrist for follow-up appointments. Over the following months, Brad stopped burning himself. He still felt the urge to self-harm from time to time, especially when he was*  *under stress. But, with the psychotherapist, Brad identified other, better coping strategies for these situations. Some of these 'coping steps' (as Brad called them) were very simple: standing up, going into another room, or phoning someone. On other occasions, Brad needed to use other coping skills that he learnt for dealing with bigger stresses that might arise. It all took time and effort, but the situation improved substantially, thanks to Brad's hard work, his openness to help, the availability of care, and his family's support.*

*Brad reached out to his friends again, who were very happy to have him back. He rejoined the football team, and soon looked forward to training. Talking to the psychiatrist six months later, Brad was very critical of himself in the past. He said: 'I don't know what I was thinking when I burnt my arms. Was I thinking at all?' The psychiatrist suggested that Brad should not be so hard on himself. Life is not always easy, the psychiatrist said, and everyone does the best they can. 'It is better to focus on now', she added. 'Now is all we have'. Brad was happy to take this advice.*

### **Key Messages**

#### 194 *Self-Harm and Suicide*

#### **References**

clinical prediction rule (OxSATS). *BMJ Mental Health* 2023; 26: e300673 (https://doi .org/10.1136/bmjment-2023-300673). (Link to licence: https://creativecommons.org/ licenses/by/4.0/) (accessed 7 November 2023).

## **9 Global Injustice in Mental Health Care**

**9**

10.4324/9781003378495-10

*Carl was 16 years of age when he first showed signs of serious mental illness. Carl's father had a diagnosis of schizophrenia, but died by suicide before Carl was born. Carl's mother was addicted to drugs, so Carl was brought up in a series of foster homes. Carl was physically abused as a child in two of these placements. As a result, Carl did not do well at school. He was suspended on several occasions. He left school permanently at the age of 16.*

*Carl was first arrested for possession of cannabis when he was 16. He was released without charge, but was arrested numerous times over the following years for similar offences. Carl was twice convicted of possessing drugs. He was also convicted of robbery, but not sent to prison. He was fined and assigned a probation officer, with whom he did not cooperate.*

*Carl tried to find work, but his lack of education and criminal record made that impossible. Carl signed up for social welfare payments, but found that this was not enough for his growing drug habit. Carl now used cannabis daily and took cocaine at weekends. Finding it difficult to rent an apartment or a room anywhere, Carl moved in with a group of other people who smoked cannabis. They lived together in a squat – an abandoned house that they broke into and simply stayed in.*

*Around two months after Carl moved into this arrangement, he began to feel paranoid. He felt that the people with whom he lived were talking about him behind his back, stealing his money, and planning to harm him. He was not clear why this was happening, but he was certain that he was in danger. One night, after everyone went to sleep, Carl set the house on fire.*

*The fire went out quickly and nobody was hurt, but a passer-by who saw the flames called the fire brigade.  The paramedics from the ambulance spoke with Carl and saw that he was not burnt. When they asked how the fire began, Carl was honest: 'I started it because these people are planning to harm me. They might kill me. I don't know them. They are dangerous to me'.*

*The paramedics asked Carl if he took drugs and Carl said he smoked cannabis, but insisted that cannabis had nothing to do with it. 'There's a plot', he said. 'I don't know who is behind it, but my life is in danger'. Carl added that he*

DOI: 10.4324/9781003378495-10

*sometimes heard 'the man' talking to him, even when there was nobody there. 'The man' told Carl to 'watch his back'.*

*After some discussion, the paramedics persuaded Carl to come to the Emergency Department at the hospital for assessment. Carl got into the ambulance, but did not stay in the Emergency Department to be assessed. He left the hospital before being seen and went to the city centre where he bought cocaine.  Eventually, the police arrested him and placed him in a cell in the police station while they tried to figure out what to do next.*

*The next morning, Carl appeared in Court, charged with disturbing the peace and attempted arson. The judge recognised Carl because he had appeared in her courtroom many times previously. While she had never sent Carl to prison before, she was concerned that his offending behaviour was escalating. He had placed lives at risk. Also, Carl had never paid his fines in the past and had not engaged with the probation officer. With great reluctance, the judge sent Carl to a remand prison to await a full Court hearing. She instructed that he be provided with a free solicitor and medical care as needed, including psychiatric assessment.*

#### **Introduction**

Carl's case is a common one: a mixture of social disadvantage, childhood trauma, substance misuse, symptoms of mental illness, and offending behaviour. His story can be told in very different ways, depending on the background of the person telling it. There is a clear social dimension: poverty, social exclusion, and imprisonment. The story can also be told using the terminology of psychology: adverse childhood circumstances, experiences of trauma, and limited opportunity to develop adaptive coping skills. Carl's trajectory also has a psychiatric dimension, with symptoms of paranoia and thought disorder following substance misuse.

Too often, these approaches – sociological, psychological, and medical – are seen as different aspects or separate components of a person's story. This is misleading. They are better seen as different languages which can be used to describe the same thing: one human being's experience of themselves and the world. For some people, the language of sociology makes most sense, prioritising social, economic, and political interpretations of circumstances and events. For others, the language of psychology is most attractive, constructing meaning and creating a valuable feeling of understanding. And, for other people, the language of medicine proves the most useful: symptoms, illnesses, disorders, conditions, evidence, and treatments.

Against this background, this chapter seeks to blend these approaches, foregrounding social considerations in its examination of 'Global Injustice in Mental Health Care'. The chapter starts by using evidence from the World Health Organization (WHO) and other sources to demonstrate and describe global inequity in mental health care. Particular attention is given to the relationships between mental illness and poverty, unemployment, homelessness, imprisonment, reduced rates of marriage, and issues relating to migration. The concept of 'structural violence' is used to explore the political, economic, and social circumstances that shape the landscape of risk for mental illness, the likelihood of receiving care, and contrasting outcomes for people with mental illness around the world. The chapter starts with evidence on this topic, summarises responses at international level, emphasises the centrality of dignity, and concludes with an outspoken manifesto for culturally informed change.

#### **Global Inequity in Mental Health Care**

Levels of self-reported well-being vary greatly around the globe. The *World Happiness Report 2023*, published by the Sustainable Development Solutions Network, reported average levels of happiness in 137 countries around the world over a three-year period from 2020 to 2022 (Helliwell et al., 2023). Happiness was rated from zero to ten, with a higher score indicating greater happiness. The happiest country in the world was Finland (with a score of 7.8 out of 10), followed by Denmark (7.6), Iceland (7.5), Israel (7.5), and the Netherlands (7.4). The least happy country surveyed was Afghanistan (1.9 out of 10), followed by Lebanon (2.4), Sierra Leone (3.1), Zimbabwe (3.2), and the Democratic Republic of Congo (3.2). Ireland was in 14th place (6.9 out of 10), the United States in 15th place (6.9), and the United Kingdom in 19th place (6.8).

Happiness surveys have many methodological limitations including differing understandings of happiness between individuals, contrasting cultural contexts in different countries, and the fleeting nature of happiness and life satisfaction in many people's lives. Despite these limitations, the headline findings from most studies of happiness and well-being are remarkably consistent over time: happiness tends to be higher in countries that are wealthy, stable, and peaceful, and lower in countries that are poor, unstable, and troubled by conflict and socioeconomic challenges. This is especially true in countries that do not enjoy the opportunity to re-build their social infrastructure between periods of challenge, instability, and war. These circumstances erode happiness and well-being.

In terms of the provision of mental health care, similar differences between countries are apparent around the globe. In low- and middle-income countries, up to 85% of people with severe mental illness receive no treatment whatsoever (Insel et al., 2015). This is directly attributable to a lack of resources for the relevant services and the low political priority accorded to mental health in many regions. The WHO points out that mental health conditions 'cause 1 in 5 years lived with disability':

Two of the most common mental health conditions, depression and anxiety, cost the global economy US\$ 1 trillion each year. Despite these figures, the global median of government health expenditure that goes to mental health is less than 2%.

(World Health Organization, 2023)

These figures vary around the world but remain generally insufficient. Moitra and colleagues, in 'a systematic review and Bayesian meta-regression analysis' of 'the global gap in treatment coverage for major depressive disorder in 84 countries from 2000–2019', highlight these differences in no uncertain terms, although coverage is remarkably patchy even in high-income settings:

Treatment coverage for health service use ranged from 51% [95% UI (uncertainty intervals) 20%, 82%] in high-income locations to 20% [95% UI 1%, 53%] in low- and lower middle-income locations. Treatment coverage for mental health service use ranged from 33% [95% UI 8%, 66%] in high-income locations to 8% [95% UI <1%, 36%] in low- and lower middle-income countries. Minimally adequate treatment (MAT) rates ranged from 23% [95% UI 2%, 55%] in high-income countries to 3% [95% UI <1%, 25%]) in low- and lower middle-income countries.

(Moitra et al., 2022; p. 2)

Elsewhere, Moitra and colleagues point out that, 'despite the high prevalence of mental health conditions worldwide, treatment coverage remains low and varies by setting and population':

Furthermore, data on treatment coverage is not routinely collected despite it being part of international priorities such as the targets set by the World Health Organization Mental Health Action plan [World Health Organization, 2021]. There are sparse data on treatment coverage from many parts of Sub-Saharan Africa and Asia that comprise nearly three quarters of the world's population [Moitra et al., 2022]. This continues to hold true particularly for major depressive disorder [MDD]. Analyses of treatment coverage data from 84 countries estimated mental health treatment coverage for MDD to be 33% in high-income countries and only 8% in [low- and middle-income countries] [Moitra et al., 2022]. There has been little literature in recent years on treatment coverage for severe mental disorders (SMDs) such as schizophrenia. Recent analyses estimate treatment coverage for schizophrenia to be 9.4% in Ukraine, 19% in the Philippines, and 10% in Ethiopia [Kemp et al., 2022; Alem et al., 2009].

(Moitra et al., 2023; p. 304)

Even in high-income countries, there are demonstrable variations in the provision of different types and levels of care for mental illness. In 2020, Eurostat reported dramatic variations in hospital bed numbers for psychiatric care across European Union (EU) member states (Eurostat, 2020). This survey found that Belgium had the most psychiatric beds per capita, at 135 psychiatric beds per 100,000 inhabitants, followed by Germany (128) and Latvia (122). Italy had the lowest (9 psychiatric beds per 100,000 inhabitants), followed by Cyprus (18) and Ireland (34). The EU average was 73 psychiatric beds per 100,000 population, but the differences between countries were substantial.

International comparisons of bed numbers are always challenging because different countries count psychiatric beds differently and have contrasting histories in the development of models of care. It is even more challenging to compare community-based services across borders, because outpatient care takes different forms and is accessed in different ways in various countries. In addition, most cross-national comparisons of mental health services to date tend to look at features of psychiatric care that are prioritised in high-income countries, such as inpatient beds, admissions, and outpatient clinics. These comparisons do not capture other forms of care that might be more culturally or locally appropriate than the specific parameters of multi-disciplinary care that are currently privileged in high-income countries. For these and other reasons, cross-national comparisons of levels of mental healthcare are both complex and contested (Applbaum, 2015).

Even with these caveats, however, the variations described across all of these studies are considerable. These differences are unlikely to be entirely attributable to differing service models or challenges with cross-national comparisons. Overall, findings indicate that the nature and levels of care provided for mental illness vary dramatically around the world. More care is generally provided in high-income countries (albeit with considerable variations between countries), but levels of care are generally inadequate in all regions of the world.

#### **Social Exclusion and Mental Illness**

There are many definitions of the term 'social exclusion' (Boardman et al., 2023). For the purpose of the present discussion, social exclusion is regarded as including (but not limited to) the processes whereby many people with mental illness and their families are partially or fully excluded from full and equal participation in the societies in which they live. Particular attention is given to the relationships between mental illness and poverty, unemployment, homelessness, imprisonment, reduced rates of marriage, and certain issues relating to migration, especially refugee status.

The association between mental illness and poverty is a long-standing one. Psychiatric epidemiologists were among the first to describe this link and it has been a strong feature of the literature since then (Muntaner et al., 2008). This relationship is bi-directional: people who are poor are more likely to suffer from serious mental illness, and serious mental illness impairs future income and prospects for financial well-being. These associations are often related to other indicators of social exclusion which are discussed here, including unemployment, homelessness, and imprisonment, which often co-occur in different combinations for different people at various points in their lives.

People with mental illness are at increased risk of unemployment compared to people without mental illness (Boardman & Rinaldi, 2021). Again, there are bi-directional aspects to this relationship: while conditions such as schizophrenia impair employment prospects for the future, unemployment itself is associated with higher rates of anxiety, depression, and alcohol and substance misuse. Bio-psycho-social approaches to treatment could usefully focus more on supporting a return to training and employment, especially for people with enduring mental health problems. Traditionally, mental health services have not accorded sufficient weight to this goal as part of overall treatment plans.

In addition to poverty and unemployment (and often as a result of them), people with mental illness have increased rates of homelessness, with resultant high levels of psychiatric morbidity among homeless populations (Timms, 2021). While there have been some responses to this situation in certain areas, the factors driving homelessness remain largely unaddressed. These include a lack of accommodation options for many people with serious mental illness when they are discharged from acute psychiatric inpatient care. In that circumstance, patients are sometimes discharged to the streets once their episode of illness is partially resolved, owing to the pressure for inpatient psychiatric care for people in more acute stages of illness and the absence of appropriate hostel beds in the community for those discharged.

This, in turn, can increase the risk of imprisonment of people with mental illness, often for minor offences which would not lead to the imprisonment of someone who is mentally well and has a fixed address (Kelly, 2005). While many people with mental illness are fully responsible for their actions, mental illness can and should be considered in certain cases. Long-standing challenges in this area are centred on difficult interactions between criminal law and psychiatry, which Peay describes as 'problematic bedfellows' (Peay, 2024; p. 268). At the system level, it is well established that there is an inverse relationship between psychiatric hospital beds and prison places, with reciprocal time trends demonstrated in many countries (O'Neill et al., 2021). Torrey notes that, as mentally ill homeless persons became a subject of increasing national concern in the US during the 1980s, the number of mentally ill persons in prisons rose (Torrey, 2014). This remains a problem in many countries today as people with serious mental illness end up in prison even when psychiatric inpatient care would be more appropriate (e.g., Carey, 2023).

These problems stem not only from decisions to reduce bed numbers in psychiatric units and hospitals, but also from a general lack of preventive interventions, broader psychological programmes in primary care, expanded community services, and joined-up social support for people with mental illness and their families (Kelly, 2023). Many countries have seen an increased focus on lifestyle measures to support mental well-being over recent decades, but there is also a need to acknowledge the lived realities of severe mental illness. There are effective treatments for conditions such as schizophrenia, provided multidisciplinary services are available and accessible to those who need them (see Chapter 4: 'Treating Symptoms and Disorders'). If these services and supports are not available, problems such as unemployment, homelessness, and imprisonment intensify and can lead to downward social spirals among many people with mental illness.

Other factors can also contribute to this situation, including, on occasion, legislation that fails to protect the rights of people with mental illness and can even discriminate against them.  This is especially the case among people with certain conditions such as major depression and alcohol abuse. The reasons for this are likely complex, but it is noteworthy that, in 2016, one study of domestic laws in 193 countries found that 37% of countries explicitly prohibited marriage by persons with mental health problems (Bhugra et al., 2016). In 21 countries (11% of those surveyed), the presence of mental health problems could render a marriage void or could be considered as grounds for nullity of marriage. Such laws are inconsistent with human rights and further diminish social inclusion among many people with mental illness.

Finally, there are various links between mental illness and migration. While this is a very broad topic that is beyond the scope of the present chapter, it merits mention in the context of social exclusion. The first point to note is that many people who migrate or become refugees show extraordinary resilience in the face of deeply challenging circumstances (Hughes & Katona, 2021). There are, however, also associations between refugee status and increased risk of mental illness, including (but not limited to) post-traumatic stress disorder. For refugees, basic needs must be met, in addition to addressing mental health issues. This involves providing psychosocial support that is culturally appropriate, as well as tailored mental health care for the full diversity of psychological and psychiatric problems that can develop. Social inclusion is a key part of this process and merits greater consideration at the levels of both policy and individual care.

Overall, there are significant relationships between mental illness and poverty, unemployment, homelessness, imprisonment, reduced rates of marriage, and issues relating to migration, especially the experiences of refugees. Taken together, these factors increase the risk of social exclusion and incremental distancing of people with mental illness and their families from full and equal participation in the societies in which they live.

#### **Structural Violence and Mental Illness**

Carl, the young man whom we met at the start of this chapter, experienced substance misuse problems, mental illness, social challenges (including homelessness), and eventual imprisonment. All of these experiences contributed to social exclusion and added further to the difficulties in Carl's life. This common combination of experiences reflects a set of arrangements and processes in society that routinely fail to meet the needs of people with mental illness and various other problems. In fact, a great many of these societal arrangements and structures seem to actively work *against* people with conditions such as schizophrenia and other enduring mental illnesses, leading to negative social outcomes for all concerned: the person, their family, their community, and society in general.

These matters have come to the fore over recent decades owing to the emergence of empirical evidence about the social determinants of mental health, along with the limited progress of biomedical technology in delivering new treatments for many common mental illnesses (Poole & Robinson, 2021). Psychiatry has always had a strong social dimension, but this aspect of the discipline is, perhaps, more engaged today than it has ever been in the past.