Understanding the cultural meanings and context of suicide attempts : a qualitative study from Karachi (Pakistan)

Abstract

Background: An understanding of the decision of ending one’s life by people across the globe has to be interpreted within the respective culture. The microscopic processes of the suicidal minds and the cultural influences on them are still unclear. Limited number of qualitative studies have illuminated several areas for exploration; one area being that of ‘meanings’ attached to suicidal behaviors. Methods: This study addresses theoretic and methodological gaps by using a “cultural experience” model to guide a qualitative exploration of suicide attempts in Karachi, Pakistan. Pakistan is a rich multi-ethnic predominantly Muslim, South-Asian country that has low reported suicide rates and strong religious and legal sanctions against suicide. To examine the unique suicide situation in Pakistan, this study had two stages; first stage focused on individual meanings attributed to suicidal behavior by adult suicide attempters attending hospitals in Karachi (Pakistan). Qualitative in-depth interviews addressed the purpose, nature and meanings of the suicide, influence of meanings on decision-making and shaping of meanings within cultural context. The second stage focused on cultural meanings attributed by individuals from society (i.e., immediate family members, health care providers and members of corrective institutions that is medico-legal officers, police, lawyers). Data Analysis and Results: All interviews were transcribed verbatim. Grounded theory analysis was performed using NVIVO Version 11. The core category identified was an ‘Expectation-Reality Conflict’ that arose primarily in context of family and marital problems. Action-Interaction strategies adopted were that of ‘Upholding izzat/honor’, failure of which resulted in suicide threats, feelings of betrayal, anger, despair and hopelessness leading to a state of ‘ambivalence to life’. Suicide attempts occurred in a continued state of ambivalence. Religious prohibitions did not deter the suicidal process but attempters engaged in religious internal dialogue that involved rationalizations and distortions. Medico-legal investigation were negatively perceived as ‘interrogative’ and family made efforts to by-pass or avoid them in fear of shame. Interviewees in the second stage of the study believed that (1) suicidal acts are forbidden, shameful, selfish and done by a ‘weak personality’; (2) life stresses become unbearable because of mental illness for the suicidal individual; (3) suicidal attempts are ‘fake’ attempts with hidden agendas of gaining attention and sympathy or influencing family upon one’s decision, (4) marital problems especially domestic violence, impotency and divorce were special situations that ‘caused’ the suicide act; (5) health care providers, police and lawyers believed suicide prevention required family-based approaches. Medico-legal investigations were suggested as necessary for the deterrent effect although challenges of corruption and exploitation were recognized. Promotion of religious values was seen as the ‘ultimate’ suicide prevention strategy. Conclusion: An integrated model of the suicidal process involving culturally relevant variables is proposed based on the findings of this study. The context of family/marriage appears to be more prominent than religious and legal sanctions for the suicide attempters in Pakistan. Culturally-specific suicide prevention recommendations are suggested.