Science and self-harm

Published January 2, 2022
The writer is a consultant psychiatrist and national technical adviser, Ministry of Planning, Development & Special Initiatives.
The writer is a consultant psychiatrist and national technical adviser, Ministry of Planning, Development & Special Initiatives.

THIS week the Senate of Pakistan debated and deferred a proposed bill seeking to decriminalise suicide attempts. The bill recommended that Section 325 in the Pakistan Penal Code, 1860, and the Code of Criminal Procedure, 1898, be omitted. This section reads: “Whoever attempts to commit suicide and does any act towards the commission of such offence, shall be punished with simple imprisonment for a term which may extend to one year, or with fine, or with both.”

In contrast, the proposed bill stipulates: “Despite the crucial nature of the act of suicide and reasons behind it, Section 325 incriminates the person committing it and prescribes the sentence ... The issue of suicide ought to be dealt as a disease and should be treated as one… The object of this amendment is to decriminalise the suicide attempt by any person as it is always done with some depression or mental illness or disorder.”

Although the bill received some support from Senate members, there were concerns that medicalising and therein legitimising suicide was inappropriate, given the clear religious sanctions prohibiting it.

Read: Decriminalisation will lead to suicide prevention

Regrettably, the bill’s wording and the arguments that were made in the Senate reflect a lack of scientific understanding around decriminalising self-harm and the larger challenge of suicide prevention. Crucially, it must be noted that all instances of self-harm are not attempts to end one’s life. The intent to die is difficult to operationalise, even after a careful psychiatric assessment. In fact, a majority of episodes of self-harm are triggered by intolerable feelings, bleak situations, or are a cry for help.

There is no evidence that laws criminalising suicide attempts have lowered suicide rates.

For this reason, the nomenclature of “attempted suicide” has long been displaced by the more scientific “self-harm” which may or may not entail suicidal intent. The former is predominantly caused by serious mental disorders, for example severe forms of depressive or psychotic illnesses, which distort emotional and cognitive abilities but which can be completely treated if detected well in time. The latter case is usually the result of severe emotional pain where hurting oneself may help numb tormenting experiences and bring about temporary relief. Such cases, too, need medical help where a therapeutic alliance, empathic understanding, a strengthening of existing support and guidance to navigate forward can reverse situations of hopelessness and despair. In other instances, social adversity, severe conflict, violence or loss may also be associated with suicidal behaviour.

Irrespective of the nature of the malady, those who are at risk of taking their own lives must be helped. Furthermore, it should be noted that even from a religious point of view, the reason Islam condemns chosen death is because it upholds the sanctity of life. It is a strong doctrine which equates saving a life to saving humanity.

There are other problems at hand too. There is no evidence that legislations that have criminalised suicide attempts, often originally introduced by colonial powers, have led to any reduction in suicide rates. In the absence of any legal persecution in Pakistan, this legislation serves to socially persecute and shame those already suffering. As a result of deeply ingrained stigma, citizens resist seeking help, medicolegal services act as a threat and health professionals remain ignorant of their medical duty to offer effective interventions. For these reasons, many countries have removed such legislations altogether and are instead working to strengthen suicide prevention programmes that are centred on population-based, education-based and healthcare-based interventions.

According to the World Health Organisation, nearly 20,000 people die by suicide every year in Pakistan. The estimated number of Pakistanis who try to harm themselves each year is about 10 to 20 times higher. It is also well established that the strongest risk factor for suicide is a previous attempt. Any person who ends up attempting self-harm needs medical attention and regular follow-up. In many cases, the tendency for suicidal ideation fluctuates over time and can be detected in medical reviews.

As Pakistan prioritises its 2030 SDG agenda, it is worth noting that addressing suicide mortality rates is one way to reduce premature mortality from non-communicable diseases through the extension of mental healthcare. So far Pakistan lacks official suicide mortality statistics, which are much needed to monitor suicide indicators. In an encouraging development this year, mental health has been identified as a priority for public health planning and coordination by the Ministry of Planning, Development & Special Initiatives as part of the country’s national priorities. Under these efforts, a national suicide database has been initiated in the Civil Registration and Vital Statistics database.

Pakistan has also committed to the WHO Mental Health Action Plan 2013–2030 to scale up mental health services for priority conditions including prevention of suicides. In this respect, another recent development is that Pakistan has adapted an evidence-based technical guidance by the WHO for the Mental Health Gap Action Programme (mhGAP) and developed it into a mobile application. This technical guidance can help build the capacity of primary care staff to manage all cases which present with self-harm or related disorders. Furthermore, the country’s first ever National Security Policy mentions mental health as a component of health security, and emotional well-being as a component of gender security.

In light of these efforts to promote mental health and develop related services, it is critical to review existing legislation which only sets us back by stigmatising self-harm, and forbidding those in need of help. It is also worth remembering that a similar bill was passed by the Senate of Pakistan in February 2018 following approval by the Council of Islamic Ideology and sent to the National Assembly before unfortunately lapsing when the last parliamentary tenure ended. Following what was essentially a procedural glitch, it has taken three years to present a fresh bill. In the last three years, an estimated 60,000 Pakistanis may have ended their own lives. Science tells us that all people who are at risk can be helped, and therefore all suicides are preventable. It is therefore imperative we act to prevent such tragedies from taking place.

The writer is a consultant psychiatrist and national technical adviser, Ministry of Planning, Development & Special Initiatives.

Twitter @AsmaHumayun

Published in Dawn, January 2nd, 2022

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