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  Number 463 | Febrero 2020
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Nicaragua

“The public health system is incapable of responding to our mental health crisis”

Carlos Manuel Fernández This specialist in mental health and crisis shares experiences, reflections and information to better understand aspects of the mental health problems caused by the human rights crisis Nicaragua is experiencing. These problems are made worse by the serious shortages In the health system’s ability to respond to them.

Carlos Manuel Fernández

The crisis in Nicaragua these past two years has affected the life and mental health of many people. It began brewing as the public institutions, including those of health, quit responding to the purposes for which they were created. The overall questioning of the institutions increased as their existence made less and less sense. This crisis ended up defining itself in a violent manner. People were killed and imprisoned for reasons that were difficult to understand. If one tries to find a rational explanation for what is continuing to happen, none is found because we are surrounded by irrational, impulsive, aggressive acts.

This is a social crisis, a crisis of the whole of society, which affects individuals, marriages, families, neighbors, and communities.

Social crises are not
new to Nicaragua


Without going too far back in time, Nicaragua has experienced several social crises of great magnitude within half a century, one after another. In 1972 an earthquake flattened Managua, killing an estimated 10,000 people. Seven years later a social revolution was brought into being through an armed insurrection that toppled a family dictatorship but cost the lives of tens of thousands of people. Like all real revolutions, it changed “the rules of the political game,” and was immediately followed by a war that went on for a decade, killing tens of thousands more. In 1990 there was another change in the game’s rules, although this time through peaceful elections. But again the change was wrenching for many. Then In 1998 Hurricane Mitch caused huge disasters. It was followed by several other hurricanes, which caused lesser but still serious damage. And now this serious political crisis, in which the breakdown has been tremendous, causing so many people to have to adapt: she who lost him, he who found himself imprisoned, he who is now without a job, so many who were persecuted and had to leave the country, all things they never thought would happen. All of these extreme situations forced people to seek resources they don’t have to face what has happened to them.

I’ve accumulated experience seeing patients for over 40 years, researching mental health and teaching in the university. I have studied the repercussions different critical situations have on people, including situations like we are experiencing in the country today.

They always stir up
memories of past crises


After Mitch I cared for people from communities affected by the hurricane in several different parts of the country. A team of several of us spent many months listening to a lot of people. We would meet and do group exercises to help them be able to talk about their trauma. And when we would ask them how they felt about what happened to them, with the hurricane destroying their homes and crops, the river dragging away their cows, family members who died… Very frequently people would start talking about that but would quickly say they wanted to talk about other things. A 40-year old woman talked about when she was raped at age 15; a man talked about how he and his entire family were kidnapped by the Contra during the war… They were taking advantage of the only moment in which they had ever been given a chance to talk about their problems, their traumas, to express their feelings: 35 years for her, 10 for him! So much of what came out had nothing to do with Mitch, but with older, unresolved crises. I said to my workmates: “We’ve opened Pandora’s box and when we leave here in two months, who’s going to do follow-up with these people?”

Yes, the critical personal, family and social situations experienced in Nicaragua due to all kinds of problems, including natural happenings such as hurricanes, earthquakes, tsunamis have been traumatic, and many people affected have never been treated. As a result, each new crisis weighs even heavier on the mental state of people forced to deal with it without any support.

Crisis Theory


There are important moments in the history of psychiatry and psychology. One such moment was during World War II, when there was a search for more holistic explanations to what people were experiencing as a reaction to the crisis they were living through. During those years the word “life experience” acquired a new, more important meaning. Other theories appeared to explain human experiences.

What is called Crisis Theory analyzed the crises people experienced throughout their life or the one being experienced and the symptoms they caused. The action-reaction relationship began to be understood, in which it was seen that every conflict every problem can explain the psychic situation of the person experiencing it.


Gerald Caplan, theorist of this trend, said that when people were facing a problem, a conflict of any nature, they experience a crisis and react with the resources they have. In most cases, the conflict is resolved and the crisis ends. But when the problem is very large, when it lasts longer than the person expected and his/her resources run out, the crisis explodes in the form of symptoms, even when people have had no previous psychiatric pathology. And if they have, naturally the case becomes more complex.

This humanist, existential trend approaches these people holistically, as biopsychosocial-spiritual beings. In other words, all the aspects that make us what we are as humans will react and experience symptoms when facing a crisis. Headaches, high blood pressure, loss of appetite, nausea, vomiting, diarrhea, shortness of breath, muscular pains and other such varied symptoms of the biological systems will appear, all related to acute stress.

Crisis Theory became so important in the early 1950s and on into the 1960s that it led to changes in psychiatric care, prevention and patient management that had an impact worldwide. Today it’s such a common, everyday practice in many countries around the world that all their second-tier hospitals—general hospitals—have psychiatric services attached to emergency services in a section called “Crisis Intervention Unit.” A team of psychologists works with patients who come to the hospital with depression or suicidal thoughts to avoid having to send them to a psychiatric hospital. This practice has had excellent results worldwide.

Protocols for patient care have been created for patients with several characteristics and disorders, and especially for those with suicidal thoughts or who have attempted suicide. These indicate the duty to do follow-ups and states that the health system cannot disengage from the patient at any point while there is still a risk of relapsing. These once-novel changes are working better and better in many countries. But in Nicaragua they don’t work. Here, sadly, we haven’t developed this culture.

The psychological system’s most common symptoms are anxiety, sadness, anger and in some cases hopelessness. Sometimes anger can bring about aggressiveness and add on to stories of childhood cases of domestic violence or sexual abuse. Aggressiveness can frequently revert back on the person experiencing it as self-harming acts. Sometimes anxiety is covered up by overworking. On occasions sadness and hopelessness can lead to suicidal thoughts.

Social communication is key


In the social aspect, crisis tends to cause people to either join some sort of group or become isolated. Any crisis is easier to face if the person has a solid support network beforehand. If they don’t have one or don’t find one, the feeling of loneliness with nobody to talk to about what’s happening makes the crisis worse. People who isolate themselves in their room increase the physical and psychological symptoms of the crisis because in isolation they aren’t thinking positively, but instead are having negative thoughts: that life isn’t worth anything, that they have bad luck, that everything goes wrong for them. In any crisis the best psychologist is a close friend, a relative, someone trustworthy to talk to.

It’s been seen in studies and confirmed in practice that almost 80% of the people who face a crisis haven’t had to go to a psychiatrist or psychologist if that exists, because they’ve had someone to talk to about what they’re going through. It has made them capable of overcoming the crisis, not without suffering of course. But suffering and risks decrease if the person finds a space understanding and empathy where they can talk, find support and feel listened to. Such a space is scarce these days. The other 20% should find professional help in the health system because they’ll always need it.

Lack of communication is a problem with mental health consequences in Japan and Northern Europe, countries where people are reserved, live in buildings without knowing their neighbors and don’t relate to each other to share what’s going on. Latinos are frequently criticized for being so talkative that we can tell our most intimate problems to strangers on a bus. Even though this venting can be superficial, not analyzing the reasons of the problem, not getting to the roots, there’s no doubt that talking helps us live the difficult life we have to live in our countries. Those emotional releases are resources we’ve been creating to keep going. The problem may be so serious it might be better to see a psychologist or psychiatrist, but there’s never enough money to do so.

Crises have multiple causes


When we speak about reactions to crisis we’re not talking about pathologies. We’re talking about “normal” responses to a crisis. A problem, a conflict, a social reality that places us in crisis can make a person sad, but if the person lets it follow its course and finds support, the sadness will go away in a few days and won’t turn into depression. It turns into depression when the sadness gets deeper, lasts almost all day and extends into two weeks or more, developing other physical, psychological and social symptoms.

Just as there are numerous reactions to a crisis, there are also numerous causes. Crises can be generated by personal, partner, family or other problems.

Dysfunctional families. Domestic violence and violence in general, albeit covered up at times, places people and families in crisis. Statistics show that half of Nicaragua’s families have no father figure, which is indispensable for children. Fathers are often absent and if they are present they are often irresponsible, alcoholic or violent, which only makes the situation worse.

Employment problems. Crises can also be related to work, either because people are unemployed—one of the most massive consequences of the current crisis—or because they work in a place they don’t like. We spend about 50% of our waking hours at work. The best job is one that gives us pleasure. And, if we do something that doesn’t fulfill or reward us, it doesn’t give us pleasure. Or if our salary doesn’t cover our basic needs and we have to be there because there’s no other alternative, it could be a problem to spend 8-10 hours a day doing it.

Mobbing, which is harassment at work similar to bullying can also cause a crisis. Several studies about mobbing in different companies explain that it happens when a subordinate is deliberately overworked, threatened, tangled in problems not of his/her making, not given enough information to do the job right, spoken ill of or isolated from the other co-workers. Sometimes the harassment comes from a boss, other times from a group. It frequently can be sexual. The person harassed experiences a crisis and has to give in, adapt or resign. We have done research in several companies and institutions, including state ones, during the last 20 years and Nicaragua is not exempt from this.

Problems with neighbors. Crises can also occur in communities, in the neighborhood, with neighbors. And such a crisis can be of an even greater magnitude. These are social crises that affect the whole society. Nicaragua has experienced many…

Psychiatric advances
come to Latin America


With psychiatry’s worldwide advances, not seen enough in Latin America, the American Psychological Association (APA) held a meeting in Caracas in 1990 attended by experts from all over the continent. The objective was for the States to commit themselves to what was called “Restructuring of Psychiatric Care in Latin America.” All countries signed the agreements. In Nicaragua’s case, they were signed by the then-vice minister of health. The first agreement was to create mental health units—a room with about 10 beds for psychiatric patients in crisis—in all general hospitals in each country. A general hospital is one with services in pediatrics, obstetrics/gynecology, internal medicine and surgery.

The state institutions in some countries were rigidly against towards accepting changes. To get them to move, laws were first created so the institutions would comply with the agreement. Costa Rica is an example. There, psychiatry is now, by law, the fifth basic medical specialty in general hospitals. And when a new hospital is built, it must have psychiatry, in addition to the four other services mentioned above.

What came to Nicaragua?


We, unfortunately, have no plans for any of this nor have we complied in any way with the signed agreements. In Nicaragua this unit should be in at least three hospitals in Managua and in all departmental hospitals. Was this done? Never. The country has only one crisis intervention unit, located next to the emergency services in Managua’s Psychosocial Hospital, the same one we had back in 1972, when we were only 3 million people and the capital’s population suffered an earthquake that killed so many and left many more with acute trauma. Today the population has doubled and almost 50 years have passed and all we have is that same one hospital for psychological treatment we had back them… still on the fringes of technical development, security and comfort.

The States also agreed in Caracas to have complete mental health teams in their countries. Again, Nicaragua signed, but did not complete those teams in its health centers, even though they are indispensable in each of the 153 municipal health centers around the country. Mental health care should always be done as a team. A psychologist or psychiatrist alone cannot solve the problem. Psychiatric social workers and nurses specialized in psychiatry are also needed. The work should be done as a team because in many cases, the social worker may be more important than the psychologist to see what’s happening to the person we are caring for. The work the psychiatric social worker does is also very important. Field visits for on-site observation is where the truth of what’s going on is proven. The nurse’s work is also important because of the enormous importance of a holistic understanding of the problem. And the kindness with which a person who comes for mental health care is treated is just as important. What can we expect if we go to a health center for a mental health problem and are treated badly?

No Nicaraguan government has done any of what the State of Nicaragua signed in 1990. In fact, the opposite has been done. Back in the 1980s, we created the psychiatric specialty and were forming specialists in psychiatry in the Psychosocial Hospital, the Military Hospital and the Interior Ministry Hospital. With the abrupt change in the 1990s there was a halt. The psychiatric guild fought hard during those years, but given other health demands due to the end of the war, it was a difficult period for the Ministry of Health; other priorities prevailed. I worked with the Ministry of Health for many years and remember that when a psychologist would retire or resign we had to fight tooth and hail not to lose the post.

No awareness of the
need for mental health


I feel like the awareness of the need for mental health care has never existed in Nicaragua, except when a member of a powerful family is sick. To make things worse, the Ministry of Health made the decision in 2007 to eliminate health programs, including the mental health program. Our guild protested, but we weren’t able to do anything to avoid it. This Sandinista government thus eliminated the first national mental health program it had created in 1979. I was among those who turned in documents for this program to two people we didn’t even know and were given no logical explanation for ending it. They didn’t even present statistics or a logical explanation to justify the decision that there was no need for psychiatrists. It was sad and to date we don’t know the reason. There are still psychiatrists and psychologists in some health centers, but without infrastructure to work as a counterpart with organizations and colleagues from other countries regarding mental health.

At some point the psychiatry specialty was suspended at the National Autonomous University (UNAN) in Managua. Now when a psychologist leaves a position, nobody replaces the person, and there are no new positions. There are some psychologists and psychiatrists, mostly in departmental capitals, but none in the municipalities in rural areas. There is currently one psychiatrist in Granada and one in Rivas, but they work as private doctors and not everyone has the money to go to them.

Article 59 of the Constitution says Nicaraguans have equal rights to health care. This right should be to holistic health, to all areas of health including mental health. The State should not decide which one stays and which one doesn’t. This is so serious that mental problems aren’t even included in the Nicaraguan Social Security Institute’s basic care program. In the middle of the 21st century this shows utter ignorance.

How is Nicaragua’s
mental health care today?


A key factor in protocols for mental health crisis intervention is that care should be expeditious. But what happens in Nicaragua? A person who has attempted suicide by taking pills arrives at the emergency unit of the Roberto Calderón general hospital. Once there they pump the person’s stomach and the family is given a note that says: “Ask for a mental health appointment in your health center.” This type of action is not allowed in the mental health protocol. This person is at serious risk and the doctor caring for him/her shouldn’t disengage. What the doctor should do, according to the protocol, is take the person in the hospital’s ambulance the Psychosocial Hospital and deliver him/her to a psychiatrist or psychologist. Those are the norms established by the World Health Organization (WHO). This obviously doesn’t happen in Nicaragua.

The first three months after a person’s attempted suicide are fundamental and there needs to be follow-up because of the risk of relapsing. The risk is greater the closer to the day of the first attempt. It’s very likely the person will try again the next day. During the first week it is still likely the person will try again. Statistics show that as time passes the possibility of another attempt decreases. This is the reason for follow-up. Are there conditions in Nicaragua to do this? Do we have the capacity to do it? In 1990 the State of Nicaragua, in the APA meeting, committed itself to do it. It did not comply.

There’s not only a lack of care but also a lack of prevention. In this sense, I should point out another serious shortfall. A prevention model is basic for all health issues, including, naturally, mental health. If there’s no education for prevention, there will be no health. That’s why most countries have within their health ministries a vice ministry of hygiene and epidemiology, which intervenes in everything having to do with prevention in primary health care, again including mental health. However, the Nicaraguan Ministry of Health never created that vice ministry. Never. The only vice ministry our Ministry of Health has is of medical care. The Ministry of Health should actually be called the Ministry of Sickness.

Suicide


Let’s discuss the most serious responses some people have to a crisis: suicide. When discussing suicide we must be careful with opinions and prescriptions. It’s a multi-causal phenomenon found worldwide. Each cause and each case demands a detailed evaluation.

The main book by Émile Durkheim, considered the “father of sociology,” was titled Suicide: A Study in Sociology, written in 1897. In it he tried to explain the phenomenon from his perspective as a fervent Catholic. He considered the increase in suicides happening in Europe at the time a consequence of the rise in Protestantism, which distanced people from Catholic values. Despite this very personal starting point, Durkheim reached some interesting conclusions that still carry some weight when doing research on suicide.

He identified three types of suicides. “Egoistic suicide” is when the I predominates, not relationships with others or with society, in the decision to take one’s life. It’s the one we see most frequently in mental health care practice. Someone who is in crisis or in a depressive state for any reason (separation from partner, economic crisis, lack of meaning in life, or an illness such as bipolar disorder) quits thinking about family or children and is absorbed in his/her problem, sadness and hopelessness, and takes his/her life.

Durkheim also mentions “altruistic suicide.” That the action of those who do risky, reckless, suicidal—also considered heroic—acts for the homeland or to save someone. It’s the firefighter who knows that what he’s going to do will cost him his life, but does it anyway. It’s the one who jumps into the ocean to save someone drowning knowing he too could drown. It’s the Japanese kamikazes who during World War II piloted planes loaded with bombs to crash them against US aircraft carriers, in a journey of no return preceded by a ritual in which they would drink their last tea before climbing into their suicide planes. It’s the suicide—which already existed in Japan by then—of those who did hara-kiri to take their lives for honor or for having failed in their moral duties.

The third type of suicide Durkheim identified is the “anomic suicide.” It’s when one takes his/her life during a social situation of anomie, which Durkheim defined as a moment in which there is a serious social breakdown in which rules change abruptly and the usual relationship of people with society is shattered.

Nicaragua has experienced
many moments of social anomie


The 1972 earthquake, the 1979 revolution, the war during the 1980s, the end of the revolution in 1990, Hurricane Mitch in 1998, and the current crisis are all moments of anomie. Many things break down all of the sudden and a large number of people don’t feel they have the needed resources to react in a healthy way to this breakdown. A biopsychosocial-spiritual crisis explodes within such people. It’s very serious is that Nicaragua has set up no mental health policy to deal with all the situations of social anomie the country and its general population have experienced so recently and frequently, and all the many other critical personal and family situations.

1990 was a year of a very serious social anomie. Patterns were broken, even organizations and ideology were questioned. It was a huge leap that meant a huge breakdown in patterns and concepts. Then and during the first half of that decade, many people were left without work, without their routines, without their structure. How to survive? In those years alcoholism increased to an extraordinary degree, as did drug consumption.

Subintentional suicides


In crises, be they social, family or any other kind, people obviously don’t always respond by committing suicide. Instead we often see what are called “subintentional suicides”: you don’t intentionally take your life, but everything you do is aimed at losing it because it doesn’t matter to you. If a man drives a motorcycle drunk at 65 miles per hour every day, one of these days he’ll kill himself. Legal Medicine will call it a traffic accident, traumatic brain injury, cardiorespiratory arrest or alcoholism-related. But the fact is he comiitted suicide. We don’t know why, but everything indicates he didn’t want to continue living. A lot of behavior classified as negligent is a subintentional suicide.

Thoughts of suicide or suicidal acts are psychological responses to a crisis. And one doesn’t need to be depressed to opt for that response. It’s now clear, through research, that many attempted suicides didn’t respond to a plan, but to an impulse. It depends on the moment the person is experiencing; such that if five hours go by after the impulse, it’s possible he/she won’t do it.

That’s not to say there aren’t people who plan their suicide for months or weeks. There are certainly planned suicides, but most suicides seem to have a much larger component of impulsiveness than we once thought. Therefore, it’s important to pay attention to messages someone may be sending, slight changes in behavior those who know the person can detect. Those are signs that need to be taken into account. Say someone who never gets up early is up at two in the morning writing a letter. This should call the attention of those who live with the person. Or someone who suddenly says he’s tired of living, bored of living…this is another sign. We shouldn’t ignore message like these.

Have in Nicaragua…


Any crisis, if it’s had an early diagnosis and a good approach, should be resolved in four to six weeks, but there are crises that go on longer, especially those caused by social anomie. The WHO speaks of two years for people who have gone through an important crisis to return to being what they previously were personally, in the family, at work and socially.

Does this happen in Nicaragua? No, because in Nicaragua crises are extended and overlap and there’s no culture of mental health in the country. There are no options as to where to go. In addition, there are paralyzing cultural prejudices that keep a person from being aware of the need to talk, to ask for help: “You’re crazy, be strong, one has to be strong”;, “You aren’t crazy, don’t go to a psychologist!”; “The best psychologist is oneself”; “Going to a psychologist or a psychiatrist is for the crazy and the weak”… And if someone talks about a family problem: “Dirty clothes get washed at home!” We all know that in almost all families there are dark areas and in those shadowy places there are realities everyone knows exists but nobody dares talk about So the crisis remains.

Have suicides gone up?


Have suicides increased during this current crisis? Since we can only scientifically respond based on statistics, we can’t answer that question, because there have been no public statistics on suicide in Nicaragua since 2008. The last known figure from that year was 13 suicides for every 100,000 inhabitants. The rate was the second highest in Latin America after Cuba with 16.7 per 100,000 inhabitants. After 2008, it became state policy in Nicaragua not to publish suicide figures. It’s not known who made the decision or why it was made. Cuba continued reducing its rates.

So, we can’t say we know if there are more suicides now due to the current crisis. We surely can suspect that the crises people are facing with this social anomie we’re experiencing are influencing an increase in suicides. But without statistics we can’t compare, and science requires proof, not just good will or inferences. Any affirmation remains a hypothesis or personal criteria.

Nor can we affirm that femicide or other criminal acts have increased with the current crisis. It’s logical to think that a new critical situation could increase abnormal behavior which already existed, but precise facts and many factors related to what happened and what caused it are missing. For example, we don’t know whether alcohol intake or drug addiction rates have increased in Nicaragua in this last year, but we all could accept they are a scourge and destroy people and families every day.

The importance of statistics


It’s important to know statistics in each country, because it allows us to know risk levels and which measures are working and which aren’t. They allow us to also compare. But in some countries statistics are state secrets, among them suicide rates, because it would indicate there are people who aren’t “happy” in those countries.

We know the suicide rate had increased since the 1970s and up until after the 1990s, not only here but in the rest of the world as well. In countries where we think people live well and have everything, like Japan, Denmark, Norway, Switzerland, Sweden and Finland, suicide rates are very high, much higher than in Latin America. They’re also very high in Russia.

Another problem is that the figures in Latin American countries, where they exist, aren’t very trustworthy. At one point in Nicaragua, the Police had one set of figures for suicides and the Ministry of Health had another. What’s the truth?

The increased suicides in
the world are to be expected


In 1990, the WHO warned that “the 21st century… will be the century of the depression epidemic.” This warning was a unique opportunity to improve the mental health systems and psychological and psychiatric care, to make care more accessible and to create better venues—a psychiatric clinic shouldn’t look like a hospital; it should look like a hotel.

WHO was warning us that crises, which are always multi-causal, were going to increase. By then it was also known that environmental problems affecting the bio¬diversity were causing crises in many parts of the world, and climatic crises also cause suicides. Two years ago, the population in the dry zone of León and Chinandega had gone three years without rain. Hundreds of people lost their farms because they had no harvest and couldn’t pay the banks. Many had to sell their homes to pay, and some committed suicide when their farms were taken away. So, the ecological crisis, the climate crisis, which is only getting worse, will affect mental health more. In fact, it already is.

Nonetheless, WHO’s warning and the resulting opportunity were wasted in Nicaragua. Nobody took the warning into account and everything went on as usual.

Suicide is a worldwide problem today


There’s no profile for suicide, but there are enough statistics to indicate that the number of suicides has increased significantly in the world. And that most people who commit suicide are young. Also many people who are particularly valuable such as intellectuals and renowned artists commit suicide. There are no differences: millionaires who have everything they need take their lives as do very poor people. All we know is that a large variety of problems can make any person decide to take his/her own life.

Suicide is a worldwide problem today. And it’s one that should interest us all.. The WHO lists suicide among the five most frequent causes of death in the world. It’s the second cause in many developed countries, including the United States, above all among youth between the ages of 15 and 24. The amount of drugs being used currently has an influence in the increase of suicides. Deaths from heroin overdose or caused by so many other opiates are also considered suicides. Using drugs and alcohol are aggravating and underlying factors for suicide.

There are striking differences in the WHO statistics about suicides and attempted suicide. They show more attempted suicides than suicides. There used to 10 attempts for every successful suicide; now they talk about 30 to 40 attempts for every suicide. And both rates are on the rise.

Statistics show that more women attempt suicide than men, but men successfully commit suicide more than women. They show youth have more attempted suicides, while more successful suicides are in those over 60. During the recent years the number of suicides of young people has increased.

The methods used to take one’s life could vary these findings. People used to shoot themselves with guns or hang themselves. Later came pills. In Nicaragua, people would attempt suicide taking excess Valiums but a stomach pumping would save them. Then ng the 1990s, a very lethal method appeared: the pill to cure beans. With just one of these pills, nobody is saved and what could have been an attempted suicide becomes a committed one. The deadliness of this method becomes easy due to its accessibility.

The role of religiosity and genetics


How does spirituality, religion influence or not the decision to commit suicide?

There are typically two extremes in regard to our beliefs or faith when faced with crisis. One is to become excessively attached to religion, praying all day, going to church, frequently generating magical compensatory thoughts; asking for supernatural strength to overcome the crisis in short, intensifying all behavior related to religion.

The alternative is the total opposite, abandoning all activity that has to do with religion, getting angry with God, demanding explanations, like Job in the book named after him in the Bible.

From my experience, I believe there are three levels of religiosity in a person, and I will focus on them even though spirituality is much broader than religiosity. The first level is their beliefs: they believe in God without asking too many questions. The second level is faith in God, i.e. in in God’s actions in their lives. Then there’s a third level which I find exemplified in the story of Christ on the boat in the middle of the storm. He was asleep and his disciples wake him to do something about the crisis and he says: “Men of little faith. Why have you doubted?” And he stands in the middle of the boat and the storm stops. When someone places God in the center of their life, they can hang on to that. Depending on each person’s levels of religiosity, I believe suicidal thoughts can be controlled. If there are only beliefs, it’s easier for these thoughts to advance. It they have God in the center of their life it’s possible to stop.

Genetic factors can also influence suicides, suicidal thoughts and attempted suicides. Some psychiatric illnesses in which the genetic component is determinant, like schizophrenia, bipolar disorders and depression, can explain suicides. There are psychiatric problems that are mental disorders so not all psychiatric or psychological problems can be defined as responses to a crisis. It’s important to consider Leavell and Clark’s mental health model which states that whenever the diagnosis is early and treatment timely and adequate, any patient’s prognosis can be defined.

Psychological autopsies
of suicide survivors


The most serious research on suicide has been done with people determined to kill themselves but just as they were about to achieve it, something unexpected and casual frustrated their determination. For example, someone picks a tree on a hill where nobody has passed for a long time to hang himself and just as he is hanging, by chance a peasant hunting for iguanas comes by, sees him hanging, and cuts the rope.

They are suicide survivors and their cases allow for “psychological autopsies,” research to understand what goes inside the head of a suicide victim. It’s impossible to do such an autopsy on someone who died by suicide, but we can learn something about the minds of frustrated suicides.

Studies of cases like this have shown that impulsiveness is a determinant element, in which the suicidal person experiences a very strong, perhaps only momentary, but very strong impulse. In Cuba suicide by fire is frequent among women, who pour alcohol over themselves and set themselves on fire. When they run down the street neighbors sometimes manage to put out the fire and get them to a hospital, but with such serious burns they often end up dying anyway. I personally remember from several such cases that when they were about to die that they would grab my hand tightly and say “Save me!” That coincides with research showing that suicide responds to momentary impulses in a person’s life.

Nobody is ever in a “suicidal state,” which is why it’s so important to give whatever support we can to a person who has that impulse, to listen to someone who’s saying to us, “Life is no good.” With the little culture we have of talking about serious issues, when we hear someone say that, we often shy away from listening: “Forget that, let’s talk about something else!”

The perverseness of today’s
crisis makes things harder…


Today, with so many people in exile living in difficult situations with so much social pressure, the social networks can help us listen and support each other. Support and therapy can be given through a computer and WhatsApp. The networks are making crisis intervention easier and there have been some very interesting experiences.

In any case, care for those who can’t find the resources to face the current crisis has become hard due to the perverseness of what has happened, with the breakdown of the rules of the game so deep and lasting so long. Staying in power at all costs means precisely that, breaking all the rules of the game to follow Machiavelli: “the end justifies the means.” If the end is power, institutions quit functioning, reason quits functioning, emotions quit functioning, humanity quits functioning, kindness quits functioning. .. There are people whose main personal objective is the search for power, to have power over everyone else. Adler, with outstanding capacity, studied the cases of people with this power-seeking behavior, describing their inferiority complex and their struggle to overcome it.

…but there are reasons for hope


There are also those who seek power to do good. We must have hope and believe those kind of people exist. I think, for example, of Nelson Mandela, a man whose example hasn’t been studied in sociology or psychology. Cases like his should be studied, as someone who was imprisoned for 27 years, with everything that happened there, with all he must have suffered, with everything they must have done to him. Yet he left prison without hate and became President of the country that had imprisoned him all those years. When he was in power and the members of his political movement urged him to get rid of the white people, he was capable of saying to them: Haven’t we been saying for 30 years that we are better than them? Are we going to do the same…? This example gives us hope that we can be better; it tells us there’s hope.

It’s difficult to face any mental health crisis with this inefficient health system we have. But to give you hope I want to remind you that all crises also mean moments, stages, in which reality is telling us that we’re doing something wrong and there’s something we must change. There’s information in every crisis; something is obsolete, something isn’t working, there’s something we must do. A child who doesn’t yet walk but wants something on top of the table he can’t reach, tries and tries then finally grabs the table and pulls himself up! He learns to stand up. The cognitive crisis, as Piaget called it, appears in the child when he couldn’t grab what was on the table, but that crisis made him learn; made him change and grow. One always learns from crises.

Many classical psychology authors have talked about crisis in a positive sense. Critical moments speak to us: when the old isn’t working we need to learn something new about ourselves, about life, about errors and feelings. If the crisis is social, it tells us something isn’t working in society and the crisis appears because there are no results, no happiness and the emotional cost of not having any of this is very high. If we’re lacking resources to face the crisis, we have to learn new resources. Crises teach us about new resources. They are moments for growing. In Chinese the Word crisis has two “parts”. It can be read as “imminent danger” or as “unique opportunity.” Crises, even this terrible one we’re experiencing, bring this message to us: it’s a unique opportunity for learning, so let’s take advantage of it.


Carlos Manuel Fernández is a medical doctor, a psychiatrist and a university professor.

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