By Piumee Bandara
Earlier this year, I found myself deep in Sri Lanka’s lush, leafy suburbs, knocking on doors for an interview. I was there with a team of local researchers to gather information from people primarily about adverse experiences in childhood and current experiences of domestic violence. My aim, to gain a better understanding of the risk factors for suicidal behaviour in Sri Lanka.
While suicide and self-harm is a global issue, 79% of all suicides occur in low- and middle-income countries. Despite carrying the bulk of the suicide burden, much of the research around suicide and suicide and self-harm is skewed towards high income countries. In Sri Lanka, like elsewhere, suicidal behaviour is influenced by a range of social, cultural, and economic factors. While mental disorders have been significantly associated with suicide in high-income countries, the strength of this association is less clear in Sri Lanka and neighbouring Asian countries. A 2019 systematic review found that the prevalence of psychiatric morbidities may be lower among individuals who have self-harmed or died by suicide in LMIC compared to HIC. This raises the question of whether interventions designed for populations in high-income countries are suitable in low-resource settings.
Marital disputes and domestic violence have been consistently identified in Sri Lankan qualitative and case-series studies as a key trigger for suicidal behaviour. Increased rates of medicinal self-poisoning among young women, coupled with the high burden of domestic violence in the country highlights the importance of further research. Furthermore, evidence examining the relationship between domestic violence and suicidal behaviour in low and middle-income countries is scarce. I spent almost a year in Sri Lanka’s central province, investigating to what extent domestic violence plays a role in self-harm.
Confronting the stark reality and distress of individuals suffering from abuse and self-harm was a deeply emotional experience. While I thought I was hardened to suffering, at least a little, hearing stories of abuse from childhood and into adulthood was overwhelming. The sensitive topics we explored as part of the research, namely childhood neglect, abuse, and the current experience of physical, emotional and sexual abuse are generally not openly discussed in any context, and almost certainly not in a conservative, patriarchal society like Sri Lanka. I was surprised by how willing men and women were to participate in the research. Many people were open and frank in sharing their story and appreciated the opportunity to be heard. For some, I believe, it was a welcome conversation and potentially therapeutic. Others explained that they appreciated participating in something that would help others or even simply to support the research team with their ‘studies’.
While this was encouraging, it also meant that as researchers we were regularly exposed to accounts of trauma. Although it’s crucially important to protect our participants, it’s also essential to protect ourselves, as researchers, not just from the physical risk but the emotional risk too. Self-care is easier to say than to practice, and requires active engagement and effort. One of the strategies I found helpful was having daily, informal debriefing sessions with the data collection team. In these sessions we discussed a range of things, from the physical struggle of trekking through hilly terrain in suffocating heat, to dealing with disclosures of abuse and depression. We discussed, the difference between sympathy, experiencing the participants’ emotions – the fear, the grief, the hopelessness, and empathy, understanding the emotions but not incorporating them into our own person or inserting them into our relationships with the people around us. We discussed feeling a sense of helplessness yet finding comfort in allowing participants to share their story, and in providing pathways for support through a referral to a psychiatrist and/or women’s shelter where required, as per our safety protocol.
In addition to peer debrief sessions, regular meetings with our Principal Supervisor were immensely valuable. We were very fortunate that our Principal Supervisor was also a psychiatrist. Having access to this professional supervision, provided the team with guidance when sensitive, complex cases arose and reassurance that appropriate actions were taken. It also provided an outlet to talk through issues, outside of the more informal debrief sessions.
The research was an important reminder to look after ourselves and fellow researchers as much as the people we are researching. While domestic violence and self-harm are not easy topics, I continue to find solace in the hope that the research will inform the development of context-specific service and policy responses to ultimately reduce the number of people suffering from these complex issues. It may take some time, but with this research, the work has already begun.
Piumee Bandara (@piumee_b) is a PhD student at the Translational Health Research Institute, Western Sydney University. She is currently undertaking suicide and self-harm research in Sri Lanka. She has previously worked on the evaluation of national and community-based health promotion programs for Indigenous and culturally and linguistically diverse communities in Australia.