Yousuf Raza – Suicide Prevalence and Prevention
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Assalamu alaikum everybody, this is Yusuf Reza and
Azam, Assalamu alaikum, how are you?
Walaikum Assalam Yusuf, how are you?
Alhamdulillah So Azam, what are we doing today?
So Yusuf, I was in my house job
in New York Hospital and I was doing
a house job in psychiatry.
I was doing a house job in New
York Hospital.
It was my last house job.
I saw in our department a small workshop,
I cannot remember it but we had a
guest from Karachi.
and he was he was he was the
professor of there at that time and.
and my friend who who was in he
texted me.
or he's this this this and that.
but.
but.
you.
you.
you.
you.
you.
and he or his team, they went to
those, to those homes and a psychiatric autopsy.
Okay.
Okay.
Okay.
Okay.
There was something, there was an effort that
someone is going out and doing these interviews.
And other than that, we just say, generally,
even in Even if I look at myself
now, what we would say about someone who
had done a suicide, that there must be
some psychological or psychiatric issue, but what stood
apart was that we should get into the
nitty-gritty because this issue is so important
and because a person died in it.
So it is not only for that person,
but for the family as well.
This issue is so important that in order
to understand this phenomenon better and subsequently to
avoid it, we have to go into details
and do an analysis.
So what happened, I think about a week
back, we lost a colleague and we would
opt not to take any name and we
lost a colleague and I got literally, I
got a message that the psychiatrist himself is
not safe anymore.
So we thought, why not we invite Dr.
Murad Musa so that we can, so that
we don't do the usual gibberish and we
have an expert with us.
So that's what I said.
Dr. Murad Musa, he is head of department
at Aadhaar Khan University and he is a
psychiatrist, he has a PhD and he has
a lot of work in this specific field.
We can say that he has spent his
entire career in this field, especially in our
country.
What are the factors?
What are the correlations?
And how can we avoid this phenomenon, which
we call suicide?
So, Dr. Murad Musa Khan.
Assalamu Alaikum, sir.
I'm sorry.
Assalamu Alaikum, sir.
Sir, how are you doing, sir?
Okay.
Thank you so much for agreeing to be
a part of our show.
A lot of us, a lot of our
team members, our viewers, when they were asking,
we should say something on whatever had happened
and we felt really inadequate, to be honest,
to share anything.
So, you're honoring us with your presence here.
Thank you so much.
Thank you for inviting me.
And sir, I hope that I didn't describe
your work in a wrong way.
I've described it as I understood it.
No, you did it right.
I'm no longer the head of the department.
I ended my term in 2013.
Okay.
Right, right, right, right.
Sir, when we look at something as like
suicide, as serious and as prevalent as it
is becoming, the work that you've done, what
you've been able to decipher, what you've been
able to uncover, specifically with respect to Pakistan,
I think we can say, thanks to you,
there's no copy-pasting of prevalence or epidemiological
factors from abroad.
There's a lot of indigenous work that has
been done in this area.
So, when we do look at that from
our perspective, from the Pakistani perspective, what is
it that stands out with respect to suicide?
Well, there are many commonalities across the globe
of the 800,000, 8 lakh to 1
million suicide that happened globally.
There are many commonalities between what happened in
Pakistan and in the other places.
Two or three things that really stand out
for Pakistan.
One is the social factors.
They feature very prominently in our suicides.
Now, suicide is a pathway.
So, there is no direct jump from someone
who is poor and someone going and killing
themselves.
But as distal factors or upstream factors, social
factors really are very, very prominent in Pakistan,
suicides in Pakistan.
So, that's one thing.
The final common pathway, of course, is always,
in most suicides, a mental health issue.
But the upstream factors, what are called the
distal factors, certainly are different in different settings.
And in Pakistan, social factors, unemployment, poverty, violence,
these really feature very heavily.
The second thing that really stands out is
the gender difference between Pakistan and other places,
particularly the West.
In Pakistan, the proportion of young married females
attempting suicide and dying by suicide is proportionately
much higher than you see in the West,
where marriage is protective in the West, generally.
So, that was the second thing.
The third thing that I think is very
prominent is, like everywhere else, the most common
method is hanging in Pakistan also.
But the second and third method are the
use of poisons or use of substances, of
which two-thirds use substances that can contain
organophosphates.
So, that's the other important point.
And this is same as in many other
South Asian countries like Sri Lanka, India, China,
South Korea, and so on.
And the third most important factor is use
of firearms, which in the recent years, the
recent couple of decades or so in Pakistan,
because of the proliferation and the easy accessibility
of firearms in Pakistan, that has now become
the number three.
So, these are two or three very important
factors that really stand out from studying suicide
in Pakistan as compared to the rest of
the world, particularly the West, because I say
the West because most studies have been conducted
in the West.
So, that is where we compare our own
studies with.
But if you look at the region, we
have much more commonalities within the region.
And sir, you mentioned that unlike what happens
in the West, that in our textbooks,
we have been reading that marriage is a
protective factor.
So, yeah.
So, you know, I think you should have
another session on this marriage and mental illness.
And I'm serious about this because this is
a very important topic.
There are cultural, religious, social factors behind this.
The way the two genders are brought up
in Pakistani society, which is again informed by
a lot of sociocultural and religious factors, and
the differential treatment in the upbringing of men
and women or girls and boys in Pakistan
contributes hugely to this.
Women generally, the way they are brought up
in Pakistan is they are given second preference
over boys.
So, if there's a family which has both
got sons and daughters, the son is given
preferential treatment in everything, right from the time
of conception to birth, to education, to leisure
activities, to food, access to health, education, and
so on.
So, the girl in Pakistan kind of grows
up with the thought that she has to
grow up, get married, go to the in
-laws, and somehow has to put up with
whatever treatment is meted out to her.
And I'm talking very generally.
If you go into obviously different social classes,
it will be different, but I'm talking as
a general society.
So, the girls grow up, and many times,
because the average age of marriage of Pakistani
girl is much lower, they have to interrupt
their education.
They don't have economic independence, so they're totally
dependent on the husband.
Joint family system is very prevalent in Pakistan,
as you know, and that has its challenges
of living with the in-laws.
The son then becomes in a very difficult
position, because on the one hand, he has
his mother and his sisters and so on,
and he also has responsibility towards his wife.
So, the wife is many times seen as
an intruder in this very strong relationship between
the boy, the mother, and other females in
the family.
That leads to a series of issues, which
then over a period of time, in many
cases, compromises the mental health of the female.
And this is what we are seeing, not
just in suicidal behavior, but if you look
at psychological morbidity, depression, anxiety, health-seeking behavior,
women who seek help for the psychological problem.
In every way, women outnumber men.
And then if you look at the marital
status of women, you will find married females
outnumbering single females in the majority of the
studies.
So, this whole concept of arranged marriages and
some of the other factors that we talked
about, then gets translated into compromised mental health.
And the compromised mental health, a part of
that then goes on to develop serious mental
issues, and then some of them go on
to the suicidal pathway.
And this is what is reflected in the
studies that we are witnessing.
So, that's in a nutshell.
Obviously, each of them needs to be unpacked
in more detail in a different session, perhaps.
So, just briefly, we're going to come back
to suicide.
Obviously, this is originating from there.
When we talk about our society and the
values with which we grow up, we hear
a lot about the responsibilities of the wife,
of the woman, as she's going to go
into the new household, how much she's supposed
to do, what she's supposed to take care
of.
And it's very detailed, and the burden is
pretty well established.
As far as the men are concerned, typically,
other than the financial responsibility, the idea that
the emotional needs have to be met, or
that there are emotional needs, or that there's
other responsibilities that need to be taken care
of, that side never seems to, or hardly
ever seems to be highlighted or stressed.
So, the kind of protective factor that we
see in other countries, perhaps the Western countries,
the emotional support that can come from an
intimate relationship, do you think that has an
important role to play with respect to why
we have this discrepancy?
Yes, I think you're absolutely right.
And that is why studying these factors in
the local context becomes very important.
So, what you mentioned earlier, Dr. Azim, about
the psychological autopsy study, the purpose really was
to look at social, local factors, because the
problem is global, but the solution always has
to be local.
And for the solution, you need really good
evidence at the local level.
So, what you're saying, Yusuf, you're absolutely right.
Men and women are influenced differently.
They face different kinds of stresses.
Suicide rates in men are two to three
times higher than women, and we see that
in Pakistan as well.
In some countries like India, China, Bangladesh, the
ratio is much, much closer.
It's almost one-to-one.
But they both face different problems.
And in Pakistan, it's a unique issue that
men have a different kind of stress, the
responsibility of the family, being the bread earner,
issues about the self-esteem and self-confidence
and come from a job and then being
unemployed and not being able to provide for
the family.
That has a different effect on men, which
is again translated into psychological morbidity and suicide
as well.
And women are affected very differently.
But overall, the stakes against women are very
high of not being affected by men.
So, the kind of stresses women face are
far, far more than what men face.
But of course, both face different issues.
Men have a different kind of and different
kind of stresses.
Women have different kind.
But if you look at overall, women are
under far more stress than men are.
Sir, you talked about some factors in the
beginning and then we move to the factors
related to the marriage.
Sir, thinking about Pakistan, can you talk about
something?
What are the factors that are protective, rooted
in our culture and society?
And what are the factors that are not
protective?
They contribute towards this, the suicide.
If you talk specifically about suicide, then one
of the most important factors is religion.
In Islamic religion, the suicide is considered as
gunal kabir, one of the major sins.
And if you look at the statistics, epidemiology
of suicide in Islamic and non-Islamic countries,
then rates in Islamic countries generally, compared to
non-Islamic countries are much, much lower.
So religion does provide a very strong protective
factor through deterrence because of what is said
in the Holy Quran, what is said in
the Hadith.
And that I think has an important bearing.
We all know when we are growing up,
two or three things are really ingrained in
us.
We don't want to eat pork, we don't
want to eat pig, we don't want to
drink alcohol, we don't want to commit suicide.
So this is what we kind of grew
up with.
So it's got a very strong deterrent value,
deterrent effect, and it is across the Islamic
world.
However, what we are seeing now, particularly from
countries like Pakistan, Iran, Indonesia, Turkey, some of
these are very traditional conservative Muslim societies, like
Iran, for example, some perhaps not so much,
like Turkey, Malaysia.
But overall, suicide rates have been climbing up.
And therefore, one has to ask the question,
has Islam lost its deterrent value?
And the answer really is, yes, it may
not have lost it completely, but it has
certainly loosened its deterrence value.
And the reason is because there is a
very tenuous balance between these protective religious factors
and some of the social factors and the
economic factors, like poverty, unemployment, and so on.
So it is a balance.
So I think as long as these factors
are taken care of, people are looked after,
they have employment and so on, religion really
plays a very important protective factor.
But when this starts to really cut in,
as it is in Pakistan, then the protective
effect of religion starts to lower down.
So one or two factors are religion, which
is a very important factor.
Secondly, I think what is very good is
the family system.
Now the family system can both be a
stressor, like it is for many females, but
it is also protective because people don't live
on their own.
In the West, social isolation is a big
factor.
And in the West, there are two peaks
in suicide, one is in the young, and
then in the elderly.
And in the elderly, the two things that
are important are social isolation and medical comorbidities,
because they live into a very old age,
80s, 90s and so on.
So of course, medical problems also increase.
So there is isolation, there is a medical
problem, so they either end up in a
nursing home or they live on their own,
so that's a major problem.
Pakistan doesn't have this.
Very few elderly people live on their own,
there are virtually no old people's homes except
in a few communities, so people are looked
after either by the immediate family or by
extended family.
So that's another very positive factor in Pakistan.
The third thing, which I think is a
weak factor, is that suicide is still criminalized
in Pakistan.
So if you were to make an attempt
and you survive, then you can be charged
under the Pakistan Penal Code 329 for committing
a crime, so you can be prosecuted, you
can either be sent to jail for one
year, rigorous imprisonment, or you can be fined
10,000 rupees.
So that may also be a factor in
making people not go this way.
So these are two or three things that
may be protecting us as a society from
indulging in this act.
And sir, a supplementary question, because you mentioned
religion as a protective factor, and we see
that a lot in our practice, that this
data is also interpreted as if religion, then
no suicide, that it is only a correlation
or it is a causal factor.
If there is religion, then will there be
a surety that there will be no suicide?
Because then some people tend to interpret it
backwards, that he committed suicide because he had
nothing to do with Islam.
That is a very important question, Azam, and
I think this is the value of research,
that you don't make generalizations like that.
So you're absolutely right.
So the study that I did, the psychological
autopsy study, in which I studied 100 cases
of suicide and matched them with 100 living
controls, I found that almost two-thirds of
the people had moderate to high religiosity.
97 of these 100 were Muslims.
So religiosity is the practice of the religion.
It is not simply what religion you are,
but the practice of it.
So two-thirds had either moderate degree of
religiosity or high degree of religiosity, in which
the things that we measured, things like hajj,
umrah, fast, pray, and so on and so
forth.
So religion as a whole might be protective,
but then individual factors start to come in.
For example, if someone is clinically depressed, is
a very good Muslim, but is clinically depressed,
and that depression may be driven by biological
factors.
There's a very strong family history, for example,
which means there is genetic overloading for depression.
But this person is a very good Muslim,
has done everything that one would require, and
as part of depression, they went towards suicide.
So you can't say that in this particular
case, this man was not a strong Muslim.
He failed as a Muslim, and that's why
he died by suicide.
No, you've really got to take into account
all of these different contributory factors also.
And you also need to really see at
what level is that factor working.
For example, job, we know, is a very
important protective factor.
We know children are protective factors.
We know that having a good support system
is a protective factor, and we know religion
is a protective factor also.
But these protective factors may work at different
levels in different people.
So for example, in a woman, the religion
may be working at a lower level, but
children might be the highest level, the last
threshold for them to cross before they will
say, I can't live anymore.
So we really got to look at all
the factors, and you really look, you need
to look at what level is a certain
factor working for which person.
So it's very complex.
Suicide itself is very complex.
Studying suicide is very complex also, but we
have to do it to really understand what
is happening.
And then we, from the generalizations, we need
to go into the individuals.
The example you gave about the case of
the doctor who committed suicide, and he apparently
also killed the daughter, I only know from
what I read in the news.
Obviously, this must have been going on for
a long time.
It is not something that happens in a
vacuum or happens suddenly.
These factors have been playing for a very,
very long time, and it may have come
to a point then when the situation become
untenable, whether it was due to the COVID
restriction, whether it was due to whatever, I
don't know.
I mean, that is, it requires a psychological
autopsy to really understand what was happening.
And then you have a unique issue here,
which is called homicide-suicide, in which the
person who dies by suicide then kills their
loved ones before, and sometimes the children, sometimes
the spouse, and then dies by suicide themselves.
So this was a homicide-suicide, and it
really would be very important to not only
do a forensic autopsy, we just really see
the method they used and so on but
also to look at the psychological aspects of
this act to really understand what was happening.
And sir, all the factors that you have
told us so far are protective, it seems
that they are protective over the long term.
But sir, in your research, did you find
any impulsive acts too?
I'm asking from the standpoint that the general
perception is that females are more impulsive or
they tend to go for self-harm and
suicide.
So yes, impulsivity is an important factor.
But in my research, as well as research
that has been conducted elsewhere also, it is
in the minority, very few people actually die
by suicide impulsively.
And in majority of these cases, it is
really the method that determines the outcome.
So if you were to take, say impulsively,
five tablets of diazepam, benzodiazepines, knowing that benzodiazepines
really on their own without any alcohol or
anything else are relatively safe in overdose, very
few people actually die by just ingesting benzodiazepine
unless it's mixed with alcohol or with other
medications.
So if one was to take five tablets
of diazepam impulsively, they will probably survive.
But if this person impulsively was to drink
this insecticide, Mortaine or Typhoon or something like
that, and then they vomit and they ingest
the vomit or they can't reach a medical
facility in time, the case fatality ratio in
this case is very high.
Okay, so impulsively the people who die are
usually those who may have taken a substance
of which survival is much, much less.
So the method is determined by that.
But impulsivity is a factor.
No history, no psychiatric problem, nothing.
Something small happened and the person then goes
and does something.
But in that case, one has to look
very carefully of the method that was accessible
to the person and what happened soon afterwards.
But that's a very, very small number of
cases.
In the vast majority, there are factors that
have been going on that may not be
so apparent.
People may not have looked at them.
When we read about it, there was a
very famous case of Umar Azhar Khan some
years ago.
Umar Azhar Khan was a developmental consultant.
We have an external life, which other people
know about us, but we also have an
internal life.
And very few people have access to that
internal life, what is going on, the conflicts,
the difficulties we have in ourselves, the problems
that we are facing.
And we don't always talk about those things.
So that thing is going on.
We are struggling with these things.
And some people are struggling really badly and
they can't find a way out.
And particularly people who are not those who
can express themselves or they have access to
professional help or they're open to discuss the
problems, and it kind of germinates within themselves,
they reach a breaking point.
And then it may require a very small
trigger then to push them over the edge.
So in many of these cases where you
find, they say, well, they have this internal
life that has been going on.
They've been struggling for that for a long
time.
And then suddenly something may have happened that
pushes them over the edge.
And that is why the value of really
reconstructing the pathway that led to the person
taking such an extreme act is very important,
but it's not done.
So we end up by making these very
kind of superficial connections.
No, it is not like that.
There are very important individual factors that we
need to be aware of or to study.
And only then we can understand what happened
in a particular case.
So, to what you just said, this internal
life that's been going on.
Like the more distant factors that we spoke
about earlier, there seems to be an interface
or an overlap here that those distant social
factors, when they are of the nature, the
idea of mental illness is so stigmatized.
And that is reflected in the backward causation.
That contributes to that stigmatization of the whole
mental illness and the legal aspects as well.
And the person who has that internal life
going on and there's mental health challenges there
will not end up seeking help or getting
the appropriate help.
And then the culmination is, unfortunately, in that
suicide attempt.
So, in a sense, all of what we're,
the way we're contributing to the stigmatization of
mental illness is contributing to the increased prevalence
of suicide.
Yes, I would agree with you.
Absolutely.
So, most suicide prevention programs will emphasize affordable,
accessible and culturally relevant mental health services.
So, the mental health services could be psychiatric
services, it could be helplines, it could be
drop-in centers, it could be counseling services,
any type of that where the person can,
once they get into a crisis, either a
suicidal crisis or a mental health crisis or
any type of crisis that will impact his
mental health, can seek help from there.
So, all suicide prevention programs will emphasize on
all of these.
So, the more we can talk about these
things in a healthy manner, that it is
not wrong to harbor such ideas or get
these ideas or under stress, under conflicts or
problems, people can feel like that it is
okay and you can seek help, the more
the stigma will decrease and the more people
will be able to seek help before they
get onto the suicidal pathway or if they
are on the suicidal pathway, they can get
off before they reach the, you know, the
critical points.
So, that is why it's extremely important that
at an individual level, the more support system
a person has, friends, family, people who he
or she can confide in, it's very important,
but also at a societal level, if we
are able to provide services, confidential services that
are affordable and accessible, then people can seek
help if they run into problems.
And so, when you say raise awareness, which
is a big thing, raise awareness, media has
a big role, definitely raise awareness, it's a
very good thing, but along with that, give
people a weapon, where will they go when
they realize that they have depression?
Privately, a psychiatrist who charges 2000 to 5000
rupees in Pakistan for a session, how many
people can afford it?
If you go to a public sector hospital,
a civil hospital, any city, you can see
the rush over there and that is why
it's only accessed by the very poor.
So, along with raising awareness, it is also
our responsibility to develop quality services at the
same time.
We are not doing that.
There are 450 psychiatrists, there are so many
psychologists in Pakistan, all of them are in
big cities and our population is suffering like
anything.
So, it's a big problem, but stigma will
decrease when you have all aspects of the
program being developed or in place.
So, if we take it a little further,
when we say that there are 450 psychiatrists,
a lot of people will say that I
had problems, I went to a psychiatrist, but
then they didn't even listen to me.
It took me 10-15 minutes at most,
they gave me 3-4 medicines and told
me to come back after 2 weeks.
And then when such practices and such stories
become more popularized, then people who are already
having a difficult time thinking about making themselves
vulnerable in front of a stranger are going
to think even harder or the deterrence of
going to seek professional help becomes all the
more for them.
So, Yusuf, there are lots of unwritten things
that we'd never talk about in public.
Anyone working in a public sector hospital, please
ask yourselves, why do they have to do
private practice?
If your salary is Rs.
1 lakh or Rs.
80,000 or Rs.
1.5 lakh and your expenses are Rs.
10 lakh, because your two children are studying
in an American university and three children are
going to a private school, how are you
going to make the ends meet?
So, as a doctor, you have to do
private practice.
Now, in private practice, volumes will bring you
more cash.
The more patients you're able to see, the
more money you'll make that month.
So, it's a purely economic issue.
So, people are forced to go into private
practice.
And in private practice, you're only there because
you have to earn money.
If you see 10 patients, you'll only earn
Rs.
30,000.
If you see 20 patients, you'll take Rs.
60,000 from a clinic.
So, how do you do that?
You either cut down the duration of your
contact with the patient or you increase your
fees.
If you take Rs.
10,000 from a patient that you can't
afford, you'll kind of go out of the
market.
So, if you're taking Rs.
3,000 and you want to fit in
20 patients, and my colleagues see about 40,
50, 60 patients, 100 patients in a clinic
in an evening, this is not a hidden
secret.
So, this is pure economics.
So, what you have to do then if
you want to get away from this practice
is you've got to provide a proper career
pathway and you've got to then pay them
properly so that they don't have to cut
corners and see the patients.
You're talking about 10 minutes.
I know that the patients who come to
me and tell me, they don't even talk
to them for 3 minutes.
They don't even look at them.
They give them 6 medicines.
So, this is economics.
Second is your training supervision.
The programs in Pakistan, generally speaking, I'm not
talking about any special program.
They're very poorly organized.
There's no depth in their psychiatric program.
And there's an emphasis on the FCPS exam
that they just need to pass the exam
somehow.
You can see the quality of the dissertation.
So, all these things then come up on
them.
What role models do they have?
What kind of model are they following?
Biomedical model.
We read in books that it's a biopsychosocial
model.
In practice, it's purely a pharmacological model.
A patient comes to you, you listen to
him.
From the DSM checklist, you say, this is
depression.
And you prescribe him 2-3 medicines.
So, that becomes a big problem.
Training, education, supervision.
There's no accountability then.
Absolutely none.
The kind of patients that I see in
my clinic, the kind of...
No one carries medical summaries.
But the ones who do, they carry prescriptions
of doctors.
So, what I see there, you've got a
very good idea what this person must have
been put through.
And then, the pharmaceutical industry has a big
role in influencing our practices and promoting medicines.
So, it's a huge problem.
And to address that, you really have to
look at everything.
Workforce, career planning, financial reimbursement of a specialist
and development of the services.
So, it is a big problem.
But the only way you can address that
is to be transparent and open and really
put these things on the table.
If you don't do that...
And the patient is suffering in Pakistan.
There's no doubt.
And the psychiatric patient is suffering very badly.
So, I totally agree with you on what
you said.
When they go and they get this kind
of treatment, whether it's 4,500 or 4
,500 psychiatrists or 4,000.
And if they practice this, then the patient
won't benefit.
So, I agree with you.
Sir, because...
that might have been obvious to you.
Sir, every now and then...
Sir, what do you think?
Because we generally think...
that they don't have any responsibility and they
don't have drugs in common.
They don't have access to firearms, drugs and
other things.
But, sir, we still see that there are
suicides in them as well.
So, what are the causes in them?
And how can we prevent them, of course?
Look, fortunately, suicide in young people, children, under
the age of 12 or 10 is very
rare.
But it's not that it doesn't happen at
all.
It's very rare.
But that's a good thing.
Because children, because of their age, are protected
against certain things.
Some naturally, some because of the way societies
are organized.
However, because nowadays of access to the media,
through cell phones, through internet and the TV
channels, they have much more access to these
things.
And a lot of them are unsupervised.
And we know now that, you know, six
years, eight years, 10-year-old child also
now has a cell phone.
So, they have access to all of these
things.
And they can go to sites and all
kinds of things are there.
So, one thing is that if people are
writing their problems, their issues with their parents
at school, they can associate themselves, relate to
those issues also.
That's one thing.
The second thing is that there is absolutely
no doubt because the way the society are
now functioning and competition has increased both for
admission, for tuitions, for results, exams, and so
on.
Children are under much more stress.
There's absolutely no doubt about that.
So, that again causes problems.
But I don't think it's new.
In every generation, there have been problems.
The issue is that, I mean, the second
part of the question is what can parents
do if such things are happening?
The most important thing for parents is communication
with the children.
How do you maintain communication?
So, there is a term called emotional literacy.
And emotional literacy means that you are able
to not only express yourself freely, talk about
your feelings and emotions, but also be aware
of the other's feelings and emotions.
So, it's very important for parents to work
on that communication channel, good communication with the
children, and invest time in that.
And if you are able to have good
communication, that will lead to a good, healthy
relationship, a warm relationship, a constructive relationship, so
that when the child gets into a problem
and all children and adolescents as they grow
up, run into problems.
Well, it's part of growing up.
You will experiment certain things that you shouldn't
do.
You will get involved in certain activities that
you shouldn't do, but that's part of growing
up.
But if you have a good relationship with
your children and they run into problems, they
will come to you and discuss that.
But if you have a weak relationship, it's
punitive, it's offhand, it's temperamental, it's one based
on power dynamics.
So parents must try and develop as good
a relationship as they can with the children.
Or basis of good relationship is always communication.
How can you communicate?
Our communication, as you know, is a two
-way street.
So both parties have to know that, children
as well as adults.
This can obviously be supplemented by what are
good child-rearing practices, what is respect of
the elders, both in the school and as
well as home.
What does our religion say?
All these things become supplementary.
But the basic thing is that parents are
older, so they have more responsibility.
It's how you can develop a good relationship,
a good healthy relationship.
And the basis of that is communication.
It's very important to emphasize this.
Yusuf, should we take some questions?
Because there are 2-3 questions in the
chat, and then we should not keep...
Absolutely right.
Sir, just one question, which came up quite
a while ago, even in the chat, I
think it wasn't from Ecosra, but it's been
going on in people's minds for a while
now.
The recent event that happened, mental health professionals
are being affected.
We talk about mental health awareness, we talk
about protective factors.
They say, Physicians heal themselves.
If this is something that our own community
is, you know, so that's a question that
people generally get.
What is it that you have to offer
as psychiatrists?
It's very important that individual cases are not
generalized.
Because these cases will always happen.
That's number one.
Number two is that doctors, any specialist, psychiatrist
or psychologist, they're also human beings.
So they are faced with the same kind
of issues and problems.
And therefore, it's extremely important that individual level,
all of mental health professionals, develop their own
good systems of coping with stress.
Whether it's, you know, religion, or whether it's
hobbies, interests.
Individual level, professional level, it's extremely important that
you must have a good support system.
One of the really good things about working
at AHA and Department of Psychiatry is, we
have a weekly peer review group.
So every Friday, 8.30 to 10 o
'clock, we have a peer review.
It's a support group.
So all the people in the department, they
come, we don't discuss clinical cases.
If it is a clinical case, we'll discuss
the effect it is having on us, the
stress that it is causing.
And so people can, you know, give their
views and support each other.
But the most important thing is that you
feel supported.
You're not alone dealing with that issue.
In the field of mental health in Pakistan,
the issues that we face are huge.
Enormous.
Child being sexually abused by the father, but
the mother says, what do you do with
the child?
You have a woman who's being abused by
the husband, and she tells you not to
bring it up with anyone else.
You're carrying that information with you.
And then so many other things that we
carry.
Secrets, intimate information, and so on.
And what do you do?
Where do you park these things?
So you need a good support system.
At the individual level, you must have healthy
activities, exercise, diet, sleep, the three pillars of
stress management.
And to have the most important thing about
stress management is balance.
A balance between your professional life, your personal
life, your spiritual life, your family life.
And where you ignore one and focus more
on the other, and you become a god
of balance, it will affect you somehow or
the other.
It will affect you in the physical, medical
illness type of thing, stress-related illness, hypertension,
IBS, and so on and so forth.
Or it can affect you psychologically.
And the psychological effect is what we saw
in this unfortunate incident.
But even that's an extreme incident.
Before that, let me tell you about burnout.
Burnout when you become totally, totally kind of
dissociated from the patient's plight and his pain.
And that is why a lot of us
who just write prescription and want to get
the patient out, have actually are burning out.
They don't want to listen to any other
patient with their problems.
They just want to write a prescription and
get the patient out.
So these are all signs of burnout.
Recognizing these signs are very important.
And then taking care.
And you have colleagues, you can talk to
them, people within your department, or other people
you can talk to.
But if you feel, first, recognize the symptoms.
And secondly, if you do feel you are
in that area, then seek help.
Right.
So thank you so much.
But before we move on to the other
questions, you talked about the support group in
the beginning.
So there was an incumbent in that, that
if you're going to perform a psychoanalysis, you
should be analyzed yourself.
But for some reason, as we are progressing
and becoming more biomedical and pharmacological, that practice,
or any psychotherapeutic practice for that matter, seems
to be very distant from psychiatrists themselves.
And all the more reason we are, we
become vulnerable.
Yeah.
I mean, you know the famous saying, know
thyself.
The more you're able to know yourself, the
better you'll be able to understand other people.
So if you can know yourself, psychoanalysis is
one method of knowing yourself, but there are
other methods also.
If you're able to do that, you can
understand yourself.
You'll be able to understand other people also.
So spend time, invest in yourself.
Any questions?
There was one question about, does the number
of children has any protective factor in suicide?
I don't know about the number of children,
but children definitely are protective factors.
Too many children can actually work the other
way, because obviously too many children mean that
the women may have undergone a lot of
pregnancies, and therefore she may have undergone a
lot of physical stresses, particularly if there's not
much spacing between the children.
Too many children also means economically, the family
has to be much more hardworking.
So it is not the number of children,
but I really feel children, as having children
are protective factors, but too many children can,
you know, a number of children can work
either positively, or it can work negatively.
On the other side, infertility is a major
risk factor for women in Pakistan.
It's a major, major risk factor for psychological
morbidity and suicidal behavior.
So another question is, are there any particular
identifiers for an, of an individual who wants
to commit suicide?
So the word you used, commit, you don't
use the word commit, because commit means it's
a crime, and suicide is not a crime,
although Pakistani law says it's a crime, but
from the medical point of view, it's, you
die by suicide, you don't commit suicide.
So, sorry, what was your question?
Sir, any particular identifiers?
Identifier.
Sorry, there are a lot of identifiers, but
the general thing is that a person whom
you know, you should
become worried.
So for example, if there is someone who
is always very happy, always laughing, always making
you laugh, and suddenly he's become, he or
she has become really quiet, then you really
have to just sit back and say, what
is happening with this person?
And if you get other clues also, then
your red flag should be raised.
Similarly, if the person normally is a very
quiet person, and suddenly you find this person
to be really talkative, and very friendly, then
you need to be concerned about.
Other things like people who are missing out
on the work, not calling you, and not
replying to your messages and so on, then
you know that something might be happening.
So reach out to this person.
So number one, suicide prevention, suicide prevention strategy
at the individual level, it is connectedness.
Anyone who dies by suicide, dies in isolation.
Except for those very few suicides, who do
it publicly because of some issue, majority of
the suicide people who die by suicide, do
it in isolation.
And they feel totally alone.
They feel no one can understand their problem.
There is no way out of the problem.
All doors are closed.
So connectedness is number one suicide prevention strategy.
Reach out if someone, you've not heard from
somebody, reach out to them.
Message them, call them, haven't heard from you
for a long time.
Is everything okay?
So that's number one.
And the number one suicide prevention area, that
is family and friends.
If you're able to reach out, you will
decrease the tendency for this person, to feel
isolated.
And family friends are the people, who can
recognize the change in the person most.
Because you see them every day, or you
see them regularly.
So you see the change.
So reach out to people who you find.
And these are the pointers for the others.
So another question is asking, what is the
solution for people who are suffering, but can't
afford to go for therapy, since the charges
are so unaffordable?
So we manage up with either.
It is a major problem.
There's absolutely no doubt.
In every city, I think there are organizations,
that run on charitable basis.
I know in Karachi, there are several such
organizations.
Maybe the quality may not be that good,
but at least we'll get help.
There are a few helplines, that at least
offer some assessment.
So a lot
of
practitioners, who are in private practice, if you
request them, that you can't afford it, and
could you please give a concession in the
fees?
Majority will do it.
It's a good thing in Pakistan, that there
are volumes and revenues, but most people will
also give a concession, in the fees, if
you're not affording.
So it's not a hopeless situation, but there
are people, and you can do it, and
request them.
So you will definitely get it.
Great, sir.
Thank you so much, for your time, for
sharing your valuable experience, and guidance with us.
We hope for this connection to continue, for
you to, if you can spare time, join
us on Saik Patek again.
In the future, we would be honored to
have you again.
Sir, thank you very much.
Sir, you should also give a concession.
Oh, sure.
So, this is the end of our live
broadcast.
Thank you so much, everybody, for being a
part of this.
We will be back with you, for future
sessions of Saik Patek Weekly.
Inshallah.
As sir said, at Delhi Psychiatry Pakistan, we
are creating such a service, in which those
who cannot afford, will be accommodated for as
much quality, as we can possibly offer.
Inshallah.
So, thank you very much.