Findings and Recommendations

This section presents and discusses the findings and recommendations of my Churchill Fellowship research. My aim was to gain an insight into suicide interventions that could be beneficial to the UK in supporting Punjabi Sikh women like myself. Punjab is immensely diverse culturally, regionally and religiously hence, non-Sikhs are likely to resonate with the themes and may find this research useful. Past research shows that Punjabi Sikh women are highly at risk of suicide and self-harm within the UK (Husain et al, 2011). My objective therefore, was to investigate for alternative suicide interventions ideally sourcing information from my ancestral homeland in India which presently continues to be recognised for some of the highest rates of suicide and attempted suicide in the world. 

Having experienced suicide bereavement myself as have some of the interviewees that I met, I can empathise with how problematic suicide is. I reflect on my experiences of observing a perpetual disengagement of the issue within my own community and how it impacts on all generations. Overall, both the familiarity and enlightenment of suicidology as a social practice has added value to my study. Wall (2006) on discussing postmodern research explains of using the freedom of the researcher to speak as a 'player' in the research project. To mingle experience in with those who are being studied as it is what is needed to move inquiry further along. She quotes Ellis (1991 cited in Wall, 2006) who advocates for social scientists to use their lived experience, unanswered questions and introspection within their study. 

Ideation

Theme 1. Self-harm and Stages of Suicide Ideation 

contributions from Dr Amandeep Singh, Dr Sarabjeet Singh, Nelson Vinod Moses

Suicide ideation is the intermittent disturbance of thoughts and emotions that may lead to ending one's life. I learn that suicide does not occur overnight but that it develops over time in stages. It is explained to me that social inter-personal and etiological factors such as substance abuse, financial debt, emotional/physical abuse, poor health or grief from bereavement are triggers which initiate emotional responses. 

There are similarities conveyed in terms of explaining the stages of ideation, followed up with recommended interventions and reference to policy from the World Health Organization (WHO). I am informed by both Nelson and Dr Amandeep in separate interviews that it is at the very early ideation stage (preliminary or formative), that a person suffering from emotional imbalance may themselves be unaware of declining mental health. I learn that this preliminary ideation stage preceding actualised ideation, is the most important stage in which to intervene.

Actualised ideation is the main stage where recognition and more seriously, verbalisation occurs often leading to threats to attempt self-harm. It is hoped at this stage that self-acknowledgment of feelings and actions leads to a request for help. It is revealed that self-inflicting injuries at this stage are particularly problematic in younger women and girls and often continues even after help is sought from by health professionals. The next stage includes the planning or preparation of an attempt. The final stage is attempting with or without finalisation of death.

Selfcare plans

Theme 2a. Psychological First Aid and Selfcare Plans 

contributions from Dr Sarabjeet Singh, Dr Amandeep Singh

Dr Sarabjeet shares his recommendations with me by reflecting on a former research project in collaboration with Dr Amandeep, called ‘Utshah’ ('to endure'). His research investigates farmer suicides and implements desensitisation interventions, addressing the stigmatisation of suicide in regions of India. He finds that psychological, cultural and behavioural perspectives are being overlooked in research policy. He believes that depression, stress and anxiety particularly in the farming sector, are major factors in instigating instability and self-destruction within family units. He tells me of cases of entire family suicide attempts and deaths and of a ‘no other way out’ mindset. For those left behind, the fear of ostracization from community and lack of support from government is a major issue and does nothing for postvention support. The worrying trend to conspire or acquiesce with suicide planning seems to be emerging. I am told that the effects of capitalism, extreme debt and the disbanding of families has significantly changed the social fabric of Punjab. 

On the topic of responsible reporting of suicide deaths by Indian journalists, it was important for Dr Sarabjeet to clarify that he recommends following the World Health Organisation (WHO) guidelines. The do’s and don’ts of reporting suicide is imperative to disclose factual data and discourage reliance on hearsay. In the UK journalists follow the Editors Code of Practice and rules and regulations of the Independent Press Standards Organisation (IPSO) and must follow these Codes carefully when reporting on an inquest.

It is suggested for talking therapies to be conducted in Gurdwaras or in local social settings, helping to re-engage individuals who feel isolated or unheard. Dr Amandeep explains that reflecting on the core principles of Sikhi in a group setting often helps in times of distress and provides a re-grounding experience. The undertaking of daily volunteering activities distracts from rumination and encourages altruism (although one should not neglect their own needs). On questioning the difficulties of implementing interventions, Dr Amandeep advises that it is important to "recognise your own boundaries" and to not to be forceful with advice if people are unwilling to receive help at that particular time. Dr Sarabjeet's main recommendations and advice is to practice resilience building and accept that trials and tribulations arise and dissipate within all family and community structures. He finds engaging in Sikhi to be a useful, grounding practice particularly in times of despair.

Dr Sarabjeet recommends applying his model of the 7 D’s counter-acted with the 7 R’s and implementing the 7 C’s  Psychological First Aid - a free toolkit which he proudly shares with all his university students. The key area that will reduce the exacerbation of the 7D's will be to tackle depression as it is his theory that all the other D's stem from a depressive mental state. The 7R's are advised as a lifestyle management tool to address the challenges within Punjabi communities and 7C's for selfcare and in helping others to manage stress.

Training

Theme 2b. Psychological First Aid and Selfcare Plans: Gatekeeper Training

contributions from Nelson Vinod Moses, Sanjana Jain

Nelson is the CEO of Suicide Prevention India Foundation (SPIF) which bases its training on the QPR Institute method of Gatekeeper and Pathfinder Training Q - Questioning, P - Persuading and R - Referring suicidal individuals to a mental health professional. The concept applies the framework of recognizing warning signs (soft signs) of suicide ideation very early on, and acting on it similarly to CPR training. Nelson's recommendation is for British Punjabi Sikh women to devise a safety plan to be followed up with self-care interventions as an immediate and on-going lifestyle practice. His advice is to normalise spiritual practice in daily healthcare routines in addition to physical exercise as it imparts grounding, refocus and an awareness of fluctuating emotions and cognition. Alternatively, he recommends making use of local resources that offer support for example the Centre for Wellbeing in Bengaluru at the NIMHAMS institute offers support to anyone who feels they need to speak to a professional. They state that "there is not much awareness about minor mental disturbances that could be a part of anybody’s daily life." (NIMHANS Centre for Well Being – NIMHANS)

Sanjana Jain is Project Co-ordinator at Outlive, a four year suicide prevention programme focusing on youth advocacy, peer support and public engagement. Outlive is youth-led by 18-24 year olds and their initiatives are implemented in colleges, universities, online and via a select Fellowship Programme. Suicide is recognised as the number one cause of death in this age group and is a public health issue in India (Senapati et al, 2024). Sanjana explains the importance of suicide prevention awareness generation, of policy advocation and of provision of Gatekeeping resources in the form of training. Outlive youth consultations reveal that young people in India are more likely to approach their peers than adults when feeling anxious, ideating self-harm or suicide. This division between social groups is of concern. Applying focused interventions for young people in educational spaces is advised as an effective approach. 

Students at Outlive share their experiences through public story-telling and on private online forums under the supervision of professional mental health practitioners. It was explained to me that young people initially did not know how to approach suicide prevention and that a number of consultations were required to devise information friendly resources. Sanjana states that from the Covid-19 lockdown era until today, the real time web-chat resource that is peer-run, continues to work well with young people and advises me of its replication for British Punjabi students who may prefer to receive support online in anonymity. We discuss why young people ideate suicide, and she reveals that caste-based discrimination, relationship issues, academic stress followed by parental expectations are some of the most common reasons.

Challenges and Solutions

Childhood

  Theme 3. The Importance of a Holistic Childhood

contributions from Vikram Singh, Dr Jahnvi Sharma

Vikram Singh is Founder and Head Coach of EqO Sports FA in Bengaluru. He supports young people delivering football coaching, fitness training and entry into football leagues competitions. I learn from our conversations about mental health and parental support, that he would have benefitted from the coaching practices that he instils in young people during his childhood. He advocates variating communication styles, recognising alternative learning approaches in players and being mindful of young people in their capacity as children. He expresses that parental expectations of education being placed above all else is existent in Indian culture, and explains that his interactive style of coaching addresses conditioned thinking that he believes stagnates personal development and suppresses creativity in young players.

EqO coaching plans are designed to improve motivation, develop cognitive skills and support physical strength. The plans provide structure for players to follow, enables the formation of relationships and improves clarity in communication. Vikram recommends holding regular brainstorming sessions with parents and players to encourage inclusive dialogue, to troubleshoot issues and to set future targets. These are all factors which help young people foster trust in others and develop faith in themselves. We reflect on his UK coaching experiences with the girls teams and of the cultural comparison between the 'parental investment' appointed to daughters as football players and agreed that more needs to be done for Punjabi girls to benefit from what football offers and that depends on societal attitudes to gender equality.

Mental health challenges v Sports-related peer support 

 Dr Jahnvi Sharma is a homeopathic practitioner, consulting with patients locally in clinic and globally online. Homeopathy use is increasing in the UK although, India still holds the highest figures of use in the world (HRI, 2023). We discuss her expertise in homeopathy and of her methods of prescribing according to the homeopathic medical repertory. Her primary interest is in the function of the endocrine system and how it affects hormonal production, regulation and dysfunction. She mentions that the majority of her clients are women, displaying symptomatic ailments often linked to hormonal imbalance. She applies homeopathy to remedy "how a client is thinking, and to find the cause". We discuss how she spends more than an hour in consultation in order to gain the trust of her clients and for them to feel safe to disclose, when counselled, of their personal issues. The benefits of unrestricted time, enables clients to gradually disclose any traumatic experiences that may be asymptomatic or psychosomatic and require resolve. 

Dr Sharma reveals that untreated childhood trauma is very common in clients, and she is aware of socio-cultural issues affecting Punjabi women that induce externalised symptoms. She presents an example of ideation where a client visualises drowning. Dr Sharma will investigate the cause of where the thoughts of drowning transpire from (using counselling methods) to determine why ideation arises. She reveals that internalisation of ideation is often formed from language and ideologies reflected in society. It is common for women to verbalise "killing themselves" as a way of coping with unmanageable situations and indicates helplessness. We discuss examples of the impact of disfavour by close family. It is common for elders to collectively express their disappointment at how young people have accultured to becoming 'like foreigners'. Often finding empty nesting syndrome difficult to accept with complaints of isolation and loneliness. 

On treating a younger client living within a wider family unit, Dr Sharma includes and lectures the household to avoid further aggravation of the client's symptoms. She will instruct them to not over-express care and to maintain positive parenting so the process of recovery remains consistent. Issues arise when individuals in wider families express conflicting or dismissive actions which undermines the position of the person suffering. She advises that a client set clear boundaries with the family unit and to continue with regular counselling and self-care planning.

 In a case of extreme anxiety in a client, Dr Sharma tells me that the nervous system is targeted with 'rescue remedies' bringing an internal calmness and  equilibrium in the immediate term. A diagnosis will be followed up with counselling therapy or further homeopathic remedies depending on the severity of the issue. She explains the importance of increasing serotonin levels as the brain gets used to reduced levels. Depression caused by low serotonin levels is a major factor in the treatment of managing suicide ideation. She highlights negative effects of pollution, lifestyle changes, food intolerance, exposure to different environments (common in migrants due to weather changeability). Dr Sharma reveals that she consults with diaspora clients from abroad in places like Canada as homeopathy is expensive under healthcare insurance. I am told that the remedies are cost-friendly and quick to send by courier from Punjab to other parts of the world. 

Mental health challenges in childhood

Immigration

 Theme 4. Post-Immigration Care

contributions from Kulpreet Singh

 Kulpreet Singh is Founder of South Asian Mental Health Alliance (SAMHAA) in British Colombia (BC) area of Canada. He highlights some of the extensive damage that is done to Punjabi Sikh communities, impacting on Punjabi Sikh women. These include but are not limited to immigration, exploitation and drug and alcohol misuse. He explains of trends in issues relating to loneliness and isolation. A feeling of being 'stuck' from one's current position and of experiencing parental or partner separation anxiety. In exampling cases of international students in BC, he states that exposure to poor living conditions impacts on their mental state and jeopardises educational chances. His organisation offers pre-arrival orientation interventions which is stepped in its approach. Support is offered during the study inquiry stage, visa approval stage and on arrival. The additional services that students are signposted to by SAMHAA can be seen below, providing restorative justice outcomes and solutions to exploitative behaviour and dealing with issues with administration and legal services.

Mental health challenges and interventions linked to matters of immigration 

Connection

Theme 5. Connecting Globally: A Gender Issue 

contributions from Case Studies