Suicide ideation - experiences of adversely racialised people: research

4 Findings

4.1 Introduction

The following sections report from the focus groups and individual interviews which were undertaken to explore how individual racialised people and community organisations understood experiences related to suicide ideation and completion within the broader context of mental health.

4.1.1 A brief overview of the conversations

Similar to the general population, people spoke about the comorbidity of health illnesses as a factor contributing to poor mental health and suicide ideation. A few organisations supported clients who are living with a combination of HIV, Hepatitis, Diabetes and high blood pressure. The combination of medication that clients are on was reported to lead to the onset of their poor mental health. Some clients experienced a double burden, stigma in their communities for being HIV positive and having poor mental health, which may increase their propensity to suicide. There was discussion about mental health issues in conjunction with organisations who are providing support for key social issues related to employment, housing, education and poverty, disability, and adverse childhood experiences.

The increase in prevalence of drug and alcohol addiction during the COVID-19 pandemic was identified by some support organisations as a key factor to the worsening of mental ill health conditions and severity of suicide ideation in clients. And gender-based violence was discussed as a contributing factor for poor mental health and suicide ideation in some female clients who sought support. Some suggested that women's experiences were further compounded by the stigma against reporting cases of gender- based violence because this was frowned upon in some racialised communities. As a result, some female clients sought support when their mental health had worsened or after the onset of suicide ideation. These issues seem to reflect more general understanding of mental health.

However, beyond the areas outlined above there were four key themes, found through analysis of the data and discussed below.

Four key themes

1. Racism

2. Immigration

3. Mistrust of services

4. Stigma and lack of knowledge within racialised communities.

Each thematic area is discussed using direct quotes from the transcriptions to help us understand how each issue was expressed by those who spoke about them.

4.2 Racism a trigger and a constant presence

Racism is trauma and is the lived reality for racialised people and their communities in Scotland. There is interpersonal, institutional and systemic racism and each can impact in different ways at different times throughout people's lives (Stephanie, et al., 2016; Royal College of Psychiatrists, 2018; Nazroo, et al., 2020). It has taken generations of grassroots activism, research, scholarship and now a pandemic or as many understand it a syndemic for the local, national and global conversation to finally name and openly discuss racism and its impact on people's lives (Horton, 2020).

There is a growing body of evidence that demonstrates how racism leads to mental ill health, depression, prolonged grief and periods of adjustment, and difficulty processing traumatic events. Research highlights a strong association between racism and suicide ideation and attempts in racialised groups.

Engagement through the focus groups and individual interviews found that significant emphasis was placed by the participants who took part, on the effect of the racism they or their clients experienced and how it exacerbates their mental health illnesses that increased propensity towards suicide.

"And, it's just everything, like I think, it's just everything that triggers, me mentally. Like I get affected by, you know, racism, I get affected by... the justice system, the government, Africa, my family. You know, so it's like a whole build-up...." (participant 2)

The organisational focus group (OFG) reported how experiencing racism was very frequently mentioned as a key factor that perpetuated poor mental health and suicide ideation in client's from racialised communities. In particular experiencing racism at their workplace. Racism made their working environment hostile and toxic. Their client's reported feeling overwhelmed by trying to endure racist treatment alongside high workloads. As result, this leads to the onset of the poor mental health they experienced and often suicide ideation.

"I was not even outside of work, not even, they couldn't even wait for me to get to the car park or wherever but they actually did it in work, on-site. So, I'm like, yeah, those type of things just like bewildered me. It just- when you combine all of that like, you know, like yeah. It kind of leads you to know not wanting to live anymore, you know, because it wasn't just one incident. It's like a combination of so many things so many things. And then yeah, just boom. Then when that happened I just didn't want to live anymore. But [sigh] yeah, to be honest that's that." (1 to 1 participant 3)

The constant threat of racism and biological weathering it causes is openly discussed in the interviews and focus groups.

At a recent Glasgow Centre for Population Health (GCPH) seminar, Global scholar Professor David Williams presented to the Scottish Public Health landscape his 20 years of evidence about "How Racism Shapes Our Health". 1-1 participant 3 continues…

"And this starts to make me paranoid ... I had to leave that place. because that place wasn't, wasn't affecting me in the right way at all. It was just- was messing my head, you know, I started questioning, umm, my my non-black friends. You know, I start I start looking at them some type of way like differently like…. I'm like, are all white people like this"

Similarly, to the OFG racism was identified as a trigger of mental health distress and suicide ideation in the elders focus group (EFG). For instance, EFG participants who have supported their teenage nieces and nephews who have experienced suicidation or attempted suicide completion. Reported that one of the key factors influencing suicide ideation in this age group is peer pressure and racist bullying, especially at school.

4.2.1 Sense of belonging disrupted by racism

Racism played a key role in participants' feeling a lack of a sense of belonging coupled with what they felt was their inability to easily feel part of Scotland and Scottish culture.

"...When I was here, when I was in Scotland and went to school, I was the only black person so already like I was really suffering with identity. Because everybody around me didn't look like me, and didn't share experiences like me." ...I like the idea of being mixed race. It was two cultures and stuff. But I remember my mother warning me very early.... they're just going to see you as black and you're probably going to be treated as black so you have to be strong" (1-1 participant 5)

It is recognised that the social capital that normally accompanies an individual's sense of belonging, serves as protective factors that help individuals to manage stressful and traumatic events in their lives (Garner, 2012). Kwansah-Aidoo and Mapedzahama (2018) suggest that when individuals feel supported, they often cope more effectively with traumatic experiences. Furthermore, that one factor that influences an individual's sense of belonging is how similar or different they feel to others in their community.

Some spoke of how racism is the trigger to serious challenges to their sense of self and sense of belonging not only within their relationship to Scotland but with the disconnect living in Scotland created about their heritage.

"You know like, the problem is, I'm mixed so, even in Africa, I was discriminated against. I came here, I was a discriminate against, so that was also another factor is just like everywhere you go you're getting a beating. You're not allowed to be in this group, you know allowed to be in that group" (1-1 participant 5)

The lack of feeling a sense of belonging in Scotland, based on their race, family environment and social class was recognised by the participants as a factor that contributed to their mental health distress. Participants expressed being shamed and feeling embarrassed because they did not grow up in a traditional family structure with a mother and father in comparison to some of their peers. This, perpetuated feelings of anger, depression and not belonging.

The issue of loss of a family members and premature deaths is increasingly documented as a key issue in racialised people's lives (Umberson, 2017). For some participants, this compounded their depression and anxiety and resulted in them feeling lost and unsupported which led them to believe that suicide was their only option. For instance,

"as a child I was going through so much like I was going through immigration, I was going through racism, I was going through body image, I was going through daddy issues, everything like being even in a different environment because I left Africa where I had all my cousins around me for support, I had so many people around me, and I came here, and it's just me and my mom. And on top of that, my mom's not even available for me...I felt I didn't belong…". (1-1 participant 4)

4.3 Immigration – a destabilising experience in family life

Participants felt there is a lack of understanding or acknowledgement on the effect of racism in the immigration processes in the UK on the mental health of racialised groups. Participants mentioned experiencing the effects of racism through the experiences of their parents as they went through the immigration process as it was felt to affect their whole families' mental health. The immigration process can be stressful, financially exorbitant and complicated but it was more than that. Participants felt that seeing the racism their parents experienced going through this added to a sense of family vulnerability. The tense home environment affected the ability of their parents to be supportive when they were going through traumatic experiences. Thereby, leaving them to process their emotions and these events in a more harmful manner, through suicide completion or self-harm. It was a sense of lack of control and injustice and a feeling that these processes are not even scrutinised as a potential mental health stressor for their communities. A sense that there were no safeguards for racialised groups when going through immigration to prevent them from being victims of racism and discrimination.

"Like I'll put it in this way. immigration immigration immigration is a big issue. I found myself in a situation where anything I could have done for myself to live a good life. Has been taken away from me. From my coffee shop. How am I supposed to eat if I don't work? The system has deprived me, taken away my power to work. Taken away my power to study, took away everything from me. So, every effort I make to get better, there are barriers everywhere. No matter how hard we try…back in my country where I'm from... it wasn't good. I left that country for a purpose. And then I came here, I find myself in a very worst situation" (EFG participant)

Several participants within the EFG reported these feelings of hopelessness, powerlessness and defeat after engaging with immigration services.

The uncertainty of the immigration process and at times enforced economic inactivity has led to an onset in poor mental health that worsened and increased the elderly's propensity to suicide ideation and attempts at completion. There was no direct mention of the hostile environment evidenced through the Windrush scandal (Wardle & Obermuller, 2019; Gentleman, 2020; Hewitt, 2020) but it may be of relevance to the broader feelings of immigration uncertainty expressed by those in the EFG, despite having lived full lives in Scotland.

Most of the organisations in the OFG identified negative social factors influenced by immigration processes and status, as the primary factor that perpetuates poor mental health in racialised communities. As a result, participants in the OFG suggest that it is difficult to expect racialised communities to prioritise their mental health when there are key areas of day to day life that may require more urgent attention and this puts them at greater risk.

Participant 4 who had lost her son through completion of suicide said

"Especially for us, as people who've come here, your new you don't know your way around. You're still trying to find yourself, you're still trying and all- in all this you're trying to make sure that your family is fine. That they've settled okay, that they are, you know, independent responsible citizens. Yet, if this is what's coming up because you've trusted the system."

4.4 Mistrust of services

"You know, usually what happens, especially in the black community is that when somebody gets to crisis point, then they'll end up in an inpatient ward. And then it means that their only experience of services is being dragged into an inpatient ward, probably under some sort of order, they've been sectioned, you know. And then they don't have a great experience because they're still going into an area that they're underrepresented in, there's a lack- there's complete inequality in it, there's a lack of cultural understanding, religious understanding." (1-1 participant 5)

The first point of support when individuals makes suicide completion attempts are normally the NHS through the hospitals. As a result, people generally look to healthcare providers to provide them with guidance on pathways to care and support after their admission in hospital. However, most of the participants in the focus groups and interviews felt that they did not receive adequate support from healthcare providers. Especially once they were discharged from healthcare facilities.

"The first time I tried to commit suicide I just took pills and alcohol and ended up in hospital...I never received support from services...I just got one phone call from the hospital after and that was it…" (YPFG participant)

And another YPFG participant explained…

"All three times I have tried to take my own life, I did not get any support from health services…" (YPFG participant)

Similarly, participants who had been in the social care system from a young age stated receiving satisfactory mental health support from their carers who facilitated for them to get therapeutic support. However, once they were out of the social care system and living on their own all support stopped.

"...at 17 actually they gave me the flat I'm in now. And I feel like from then, soon as they gave me this flat, everything just kind of went, well, you're on your own. you need to deal. you're an adult now. your mental health is yours. You need to deal with your depression and suicidal thoughts. You need to find a way…". (1-to-1 participant)

The lack of mental health support or guidance on how to access support from services was consistently mentioned by all participants. For people who did not have any support from personal social structures, they suggested this increased their propensity to suicide ideation and led to them having multiple attempts at suicide completion.

Participants who sought and gained support from therapists felt that these sessions were not always helpful and they were not provided with tools to overcome their challenges. Participants felt there was a lack of understanding of what they were going through or their varying backgrounds. The lack of cultural competence and understanding of the experiences of racialised groups posed an additional barrier to the mental health support participants received from counsellors/therapists. Furthermore, participants expressed the frustration of having to constantly explain their experiences as racialised people to their service providers, and felt that they were participating in research rather than being patients, and getting the help they desperately need.

"with the health professionals as well, they have to be sensitive to our culture, and not look at us as an experiment because the first time that I ever went for counselling, my counsellor was just like I'm going to use you for research. I was like wow, I was stunned…" (YPFG participant)

For participants who have experienced traumatic events, these encounters they suggested can result in them feeling re-victimised and vulnerable.

They also felt that individuals attempting suicide completion because their feelings of being unsupported are compounded by the notion that even mental health professionals would not understand their experiences. When accessing services, most participants wanted to see a counsellor, therapist, mental health expert who looked like them and who would be able to understand their culture, recognise and sympathise with their experiences.

"I do have Suicidal thoughts hundred percent. I'm not saying they've gone, they probably got worse since Covid, but I'm finding my own ways to, to deal with it because the route that I found to get support was medication…. having to talk to a therapist who, at a times like this …I think that therapist needs a therapist themselves." (1-1 participant 2)

Another concern emphasised by participants is the lack of alternative options of therapy offered to them besides medication. Participants mention often not receiving any other options besides medication that left them feeling worse off due to the negative side effects. They felt there was a need for mental health professionals to be educated on the pathways of mental health care for racialised patients and alternative therapies for patients in need and more diverse mental health work forces and cultural competency training (Memon, et al., 2016; Rethink Mental Illness, 2020).

Distrust of mental health as a system was frequently identified within the OFG as a factor that negatively affected client's help seeking behaviour.

"It comes from a history of not being able to, you know, trust the system, and rightfully so, because you know, there were experiments that were done, and they did focus on us people as black. You know, they were done with ill intention and all these things." (OFG participant)

This stance is well documented and increasingly recognised as a significant factor in health behaviours of racialised people (Anstiss & Ziaian, 2010; Robinson, et al., 2011; McConnell, 2017; Batelaan & Krystal, 2021)

The OFG also mentioned that the root cause of client's feelings of distrust towards mental health practitioners is due to the high number of mental health sectioning of racialised people and the over prescription of medication offered to this group. To avoid falling into either category clients often allow their mental ill health conditions to worsen which has they felt increased their propensity to suicide ideation.

This was felt to be compounded by a sense of a lack of cultural competence of mental health practitioners and GP's that may contribute to a reluctance in clients to seek support because of the lack of understanding of their cultural experiences, which is reflected in their inability to sympathise with the diverse realities of racialised groups. A few clients reported positive experiences with GP's and psychologists they were signposted to by organisations. Their positive experiences highlighted by clients was the ability of some GP's to take the time to get to the root cause of the mental health distress and suicide ideation they experienced. This allowed for clients to explore alternative treatment options besides medication, and fast tracked their waiting time to receive psychiatric support.

4.5 Lack of awareness of services for and by racialised communities

There was a general sense of a lack of awareness in racialised communities of mental health services and how to access them (BBC Scotland, 2018; Barnett et al, 2019). Participants suggest that this is one of the key factors that perpetuates the worsening of mental health conditions in racialised communities. As people feel helpless because they don't know where to get help. Resulting in them not acknowledging their mental health illnesses at all. Participants who did seek guidance on how to access mental health support from their GP, felt that even GP's are not aware of minority ethnic community organisations that patients can be referred to. This was an additional source of frustration for some participants that exacerbated their feelings of helplessness.

Some participants felt strongly that key mental health organisations do not make enough effort to engage with racialised communities to conduct mental health awareness campaigns or promote awareness/access to services because of communities' lack of knowledge.

"You know, and it's always like the mental health posters it's quite stereotypical and it's always someone with their head in their hands and they're like that, you know, "Are you struggling? Call this number", but it's always a white person that's in it. So, people always look at that and go on "Oh well, I'm not welcome there. I don't feel part of", and that was one of my biggest barriers of to getting into recovery" (1-1 participant 5)

This disconnect from the need to address service change because Scotland's demographics have changed is well documented in other sectors (Young, 2016; Arshad, 2016; Mohammed, 2020). Similarly, growing community mental health organisations reported a lack of support and willingness to collaborate on mental health initiatives by key mental health organisations when community organisations are still at a grassroots level.

"It's like they only want you when you're up there when you're known as an organisation but when you're still growing nobody really wants to know you." (OFG participant)

Participants from grassroots organisations felt that this lack of support and engagement by key third sector and public health sector organisations is a major contributor to the rising mental ill health and suicide rates in racialised communities. They suggested that collaboration with key organisations would increase the resources to ensure mental health initiatives in these communities have more reach and make a greater impact as a way of reducing negative mental health outcomes in racialised groups. This disconnect or lack of engagement with the reality of Scotland's changed demography was recognised as existing across the whole landscape of key statutory agencies (Hopkins, 2016; Lyle, 2016).

Well documented barriers to communication (Cleland, et al., 2012; Crowther & Lau, 2017; Martzoukou & Burnett, 2018) were identified as a factor that negatively affected client's help seeking behaviour. As many clients from racialised communities are from countries where English is not their primary language. The inability to communicate comfortably with mental health practitioners results in clients choosing to endure worsening mental health conditions that may increase their propensity to suicide ideation.

4.5.1 Adverse experiences accessing mental health support

In the OFG it was explained that experiences of institutional racism in mental health services were consistently reported by clients. Clients reported feeling unwelcome and having rushed consultations at mental health facilities, a generalised approach and being prescribed high doses of medication irrespective of clients' attempts to express their reluctance of taking medication to treat their symptoms. Furthermore, clients reported to them that the severity of their mental health distress is not treated with a sense of urgency due to the stereotypes that racialised groups have high pain or distress tolerance. As a result, specialised treatment for clients from racialised communities is not felt or seen as prioritised and clients feel they are put on longer waiting lists in comparison to their white counterparts. One organisation reported that this is reflected in partner services that clients are referred for mental health and suicide support to. This organisation stated:

"Services are still kind of advising things like, black people have a higher threshold for pain than white people. That's still something that's being taught in the medical community, which is complete nonsense, you know and then they wonder why black women are having more complications and death through childbirth, it's because of pains not being taken seriously. So how do we expect our mental health to be taken seriously when we access these Services. When I look at addictions there's one Community Addiction Team that deals with BME. I've not seen one referral from them. Not once. In the two years I've been there, I have not seen one black person come in for a detox. When we looked at their 2019 number, it was 11,500 white people who were admitted for a detox, White Scottish people. But when it came down to BME people they say their services are targeted at, it was 36 people from the Asian Community, 9 from the Caribbean community, and 6 from the African Community…"

Similarly, an elder who sought support from a GP on behalf of her granddaughter at the initial stages of her mental health decline, before her first attempt at suicide completion reported receiving support that was dismissive and lacked a sense of urgency.

"So, I went with my granddaughter to the GP and she was more or less dismissed, you know, and told that there wasn't very much wrong with her and she was just maybe missing her friends. It took another three to four months before she was seen again…" (EFG participant)

A lack of support and follow up after suicide completion attempts was frequently reported amongst elders in the study. Most reported that their family members or themselves were discharged the next day and prescribed a lot of medication to deal with their conditions. This was concerning for elders whose family members attempted suicide completion by taking pills. Elders reported expressing an interest in alternative options out of fear that the large supply of pills would encourage more attempts. However, they were not provided any other options.

The elders shared concerns that the lack of support and care shown to individuals who already made attempts at suicide completion increased their propensity to more severe attempts. Due to the fact that in some cases individuals with severe mental health distress are desperate for support outside of their families. As a result, when they feel unsupported and not understood by experts who are supposed to be better positioned to support them. They feel hopeless and attempt suicide completion again, in more severe manners.

Another elder echoed the same concern as discussed in the OFG and stated that some GP's and mental health service providers promote an unfounded stereotype that racialised individuals have higher pain thresholds. This perpetuates a sense of a lack of urgency provided to racialised individuals even after they have made attempts at suicide completion.

"Well for me, all my attempts before, I spoke to a doctor, and it was just falling on deaf ears, you know. It is almost like I felt like I needed to convince the doctor, and then I began to doubt myself, like, maybe I am exaggerating. I was made to feel like I was attention-seeking, you know, even up until the third attempt. The doctor just says, it's okay, it's okay. We are taking care of it and nothing is done…" (EFG participant)

An elder suggested that the more general lack of concern by mental health services for racialised people with mental health conditions is demonstrated through patients who have committed suicide completion while in mental health support facilities.

"this is a 23 year- old boy or man who committed suicide in hospital. What concerns me is that those who are in charge of the hospital and where he was actually...The nurses, doctors who were supposed to be taking care of this boy. I mean letting him go that far to just kill himself... So, I'm just concerned. I don't know whether most of the people there have experience with somebody with that mental state... individuals not being cared for... " (EFG participant)

4.6 Stigma

In addition to the systemic barriers to accessing mental health support that racialised groups face, the lack of knowledge and ease to be open about mental health illnesses and channels of accessing support within communities was seen as a significant problem. Researchers suggest this has resulted in the worsening of mental health conditions and an increased rate of suicide completion cases within racialised communities (Hamilton & Rolf, 2010; Adedoyin & Salter, 2013; Armstrong, 2019; Gunson, et al., 2019; Bowden, et al., 2020)

Some participants suggested that the lack of knowledge of mental health illnesses in racialised communities results in an inability in individuals to recognise symptoms of poor mental health.

"...first of all, I just didn't even have any education about mental health, you know, I just felt like, you know, this is life. It's hard but you push through because like that's what we're taught from a young age…" (1-1 participant 2)

Participants felt that this may lead to worsening mental health conditions and increases their propensity to suicide ideation and completion.

"...I just never took a moment to stop and actually observe what was even happening with me, what was going on with me...I didn't even know what mental health was until I went through my own mental health breakdown. (YPFG participant)

Another participant echoed the same feelings stating

"...racialised people often have no clue what is happening until they go through a mental health breakdown...". (YPFG participant)

Participants also suggested that in racialised groups where there is more awareness of mental health illnesses some community members are not aware of mental health conditions like anxiety, depression, post traumatic disorder etc.

"some black communities only understand mental health to be schizophrenia and extreme cases of bipolar, many are not aware that there are many other mental health illnesses.". (EFG participant)

This lack of community knowledge of mental health illnesses was frequently mentioned within the OFG as a key barrier to reducing the burden of mental health illnesses in racialised communities. Stigma towards mental health illnesses was viewed as a persistent barrier to their clients' poor help seeking behaviour.

"… those are the challenges we have as a community to make sure that, you know, people understand that there's mental health issues mental health issues like any other illness. And, yes with our communities [it will be] hard work, it would take a while to make sure, I mean to, to make people realise that actually, it's an illness that can be treated like any other like a physical illness" (1-1 participant 4)

It was frequently reported in the OFG that clients typically sought mental health support when their conditions were more severe, which often increased their propensity to suicide ideation. They also mentioned that the age range of clients typically accessing services from organisations are 16 - 35. They suggested that this may be due to the mental health stigma in the older generation in racialised communities.

We tend to keep, we tend not to want to know, anything outside our surroundings, our cultures. And that affects, the way we are going to definitely erm access Services. Because if we don't if we don't openly, say issues, then who's going to know that you have issues? So, we, we can't, we need to be em, self-aware. We need to, you know, to make our community, em, aware, of issues for instance (1-1participant 4)

Among the OFG, it was suggested that clients from racialised communities seldom report that they are experiencing suicide ideation during their initial visit. Clients who have expressed experiencing suicide ideation are often reluctant to expand on their experiences or simply tell key personnel that they don't want to talk about it.

They agreed that most clients reported their experiences of suicide ideation to their GP's and that clients are mainly referred on for suicide prevention through their GP. However, in some cases clients are prescribed medication to cope with these experiences. According to the organisations, some racialised communities were more likely to engage in discussions if mental health was not the sole focus, due to stigma against mental health issues (Plaistow, et al., 2014) (Gary, 2005; Knifton, et al., 2010; Memon, et al., 2016; Linney, et al., 2020). Although it is not usual practice to include YouTube chat references in a research report, Trevor Noah,^[2] the popular US TV host of the Daily Show, recently released a piece discussing the issue of mental health, space and place for racialised people.

There was sense from some that the act of seeking help is in itself a racialised experience. That their own communities along with society's racial ideas of them may increase stigma.

"It is a stereotype that you must be a strong black woman. And it's not just them seeing you are a strong black woman, it's almost like behind it is that you must be, or you're less than. So, for that it was just, for me all that did was create walls, you know, and that stopped me from accessing help. Going and getting treatment things like that." (1-1 participant 5)

"You know, I feel like my white friends are more... errr, more open, to listen to it- to talk about it compared to my black friend. You know, once a once I try to open up to some of my friends, and they start making fun of me. "Aw you really. You are acting white''', and what they heck what does it mean? You know, I mean like yeah, this type of things. This type of stigma, those type of nonsense statements" (1-1 participant 3)