Self-Harm in South Asian Women: A Literature Review Informed Approach to Assessment and Formulation
Ahmed, Kamran, Mohan, Rajesh A., Bhugra, Dinesh, American Journal of Psychotherapy
The rates of self-harm among South Asian women in the United Kingdom are much higher than among their White counterparts. However, the explanation for this is far from clear, and there is a need for more culturally informed assessments for this group. Using literature review we identified cultural factors associated with self-harm in South Asian women. These findings were used to guide the clinical assessment of an Asian woman who had self-harmed using a personal narrative approach. Three independent clinicians analysed the narrative and identified important themes that gave an insight into the problems associated with the incident, arriving at a cultural formulation. Our interview showed that specific cultural factors, such as level of acculturation, cultural conflicts, stigma and interpersonal relationships, were important factors associated with distress and resilience. Literature reviews can help in conducting culturally competent assessments and enable better interventions for this group of patients. The key cultural areas identified are discussed in detail.
Women of South Asian origin (including those of Indian, Pakistani, Bangladeshi and Sri Lankan ethnicity) in the United Kingdom, have higher rates of attempted suicide compared to other ethnic groups (Merill & Owens 1986, Glover 1989, Raleigh et al 1990). The attempted suicide rates among younger Asian women are 2.5 times those of White women and seven times those of South Asian men (Bhugra et al, 1999a). High rates of self- harm in this group of women are worrying as self- harm or attempted suicide are strong predictors of completed suicide (Hawton et al, 2003, Zahl & Hawton 2004). This is reflected in the National Suicide Prevention Strategy for England, which identified populations at highest risk, including ethnic minorities and younger age groups (Department of Health, 2002).
There is evidence that socio- cultural factors may contribute more than psychiatric factors to self- harm among South Asian women (Bhugra et al, 1999b), which highlights the need for assessing these factors to better understand patient distress. However, routine assessments of self-harm have been criticised for inadequately identifying cultural and social factors in ethnic minority patients (Hunt et al, 2003). There are also wide variations in the assessment and management of self- harm among care centres, including a two-fold difference in the rate of psychosocial assessment offered after presentation of self- harm (Kapur et al, 2003). Patients from ethnic minority groups may not seek help for their problems due to socio- cultural factors, including stigma of mental health contacts, and hence, may be less likely to receive appropriate and culturally sensitive interventions (Chew-Graham et al, 2002, Bhui et al, 2001).
The Diagnostic and Statistical Manual of Mental Disorder IV ( [DSM IV] APA, 1994) offers a framework for cultural formulation.which can help inform culturally sensitive assessment, diagnosis and treatment. It includes:
(1) identifying cultural identity,
(2) explanatory models,
(3) cultural factors in the psychosocial environment,
(4) cultural elements of the clinician-patient interaction, and
(5) the role of culture in diagnosis and management.
These. are ideal components, but their exploration in clinical settings is problematic. In this paper we report on the use of a literature review to guide culturally competent assessments for South Asian women who have self- harmed. We aimed to use available evidence from the literature for guiding assessment and enabling us to provide culturally appropriate interventions.
We conducted a literature review, using MEDLINE®, Ovid, and EMBASE to identify articles on factors associated with self- harm in South Asian women. Using the search terms self-harm, attempted suicide, South Asian, women, and female, we identified articles including published case reports that highlighted cultural and psychosocial factors associated with self-harm in South Asian women. …