Most participants associated the act of non-fatal self-poisoning with a recent interpersonal conflict. This is no surprise – previous studies from Sri Lanka [7, 13] and South Asia [9] have linked self-poisoning behavior to interpersonal conflicts. Interpersonal conflict could be described as a proximal trigger, closely linked to the act of non-fatal self-poisoning and the motivations associated with it. Similarly, interpersonal conflict has been commonly associated with attempted suicide in other parts of Asia, as well as in the West [14–17]. While interpersonal conflict was the most commonly reported trigger, a smaller proportion of participants also described the act of self-poisoning being associated with other triggers, such as severe financial stressors, and unbearable pain symptoms. Interestingly, severe pain symptoms were also significantly associated with a self-reported intent to die. One possible explanation is that the reported somatic pain symptoms may reflect an underlying ‘hidden’ depression, which contributed towards the suicidal intent [18].
Despite differences in culture and background, the motives or intentions for non-fatal self-poisoning, described by the participants in these two studies are strikingly similar to motives described in the Western literature - namely a desire to escape or a wish to die [19, 20].
The findings of this research provide additional insight into the processes involved. In particular, a difficulty tolerating distress associated with interpersonal conflict emerged as a key factor driving people towards self-poisoning behaviour. For instance, participants of Study 1 described in detail the difficulty in tolerating emotional pain following interpersonal conflict, for example - “I felt very hurt” (after conflict with daughter); and “I felt very alone” (after conflict with mother-in-law and perceived lack of support from husband). A theme of acute distress, and inability to cope with this emotional state emerged clearly – one young female articulated this as, “I couldn’t bear it. There was nothing else I could think of to do (other than taking poison)” (after conflict with mother). In Study 2, about one-third of participants described ‘inability to control himself/herself’ at times of emotional distress as contributing towards this act.
Among the semi-structured interviews (Study 1), a 24-year old male participant who drank poison said he had done so because he felt angry and distressed after his mother objected to his choice of girlfriend, but denied having had overt confrontation with his mother about the issue. Self-harm as a means of communicating or enacting anger has been reported by previous Sri Lankan studies [21]. The hierarchical nature of Sri Lankan society where deference to elders is encouraged, may contribute to such situations [22]. Some participants, particularly those who were older, also reported feelings of shame after interpersonal disputes, e.g., - a middle aged male participant stated: “I felt very ashamed” (after a dispute with his son about alcohol misuse). The overall emerging feature in the study was emotional distress associated with an interpersonal conflict, and reported inability to deal with that distress.
The majority of participants of the in both Study 1 and Study 2 reported an intention to die at the time of attempting self-poisoning. This finding is consistent with that of a previous Sri Lankan study reported by Hettiarachchi et al. [7]. Males and older participants were significantly more likely to report an intention to die – this is in keeping with international findings that increasing suicidal intention is associated with older age and male gender [23, 24].
In most instances, the desire to die was expressed in the context of acute distress associated with interpersonal conflict. In keeping with this, by time of interview (within one week of the act of non-fatal self-poisoning), the majority of participants of the semi-structured interviews reported no current suicidal ideation, and was glad to have survived. Likewise, the duration of premeditation associated with the act of non-fatal self-poisoning was short. Most of the acts of non-fatal self-poisoning occurred within 24 h of the interpersonal conflict, similar to previous Sri Lankan studies [25, 26].
While the desire to escape, or to die, emerge as key themes, overall motivations often appeared mixed and complex. Although not the most commonly reported motivations, many participants in the cross-sectional survey subscribed to motives such as to change someone's mind, to make someone sorry, to show how much I care, to show helplessness – which appear to be acts of communication with a significant other. Further, the distressing emotions described by the participants, such as sadness, anger, or shame are all likely to have contributed towards self-poisoning behaviour.
Notably, none of the participants in either study identified depression as being associated with the non-fatal self-poisoning act. This was despite the fact that about one third of the interview participants (Study 1) were clinically depressed at interview. This is in contrast to findings from the West [27], where survivors have described their self-harm attempts as being associated with depression. This difference in the way persons interpret their experiences may be partly due to the fact that in Sri Lanka, as in other South Asian cultures, the symptoms of depression are often not conceptualized as a disorder [28], and indeed there is no colloquial term for depression in the Sinhala language.
Limitations
The semi-structured interviews were limited by the small sample size, but a strength of the study was the structured, detailed nature of the interviews, and that relevant information was extracted systematically by use of audio-taping, transcribing, data extraction sheets and dual coding of the intervention strategies. Although the data was assessed by two raters, inter-rater reliability was not formally assessed which is a limitation. The assessors discussed and agreed upon the method of assessment prior to analysis, but there was no formal training prior to the analysis, which also may have been a limitation. However, the qualitative nature of this study added depth and detail to the information gathered through the quantitative survey. The retrospective recall of events by participants in both the interviews and cross-sectional survey is also a limitation, since this method may have led to a recall bias, although efforts were made to minimize this by conducting the interviews within one week of the non-fatal self-poisoning act. Further, due to restriction of numbers, it was not possible to undertake further analysis of possible associations between different types of triggers and motivations, and this is a further limitation of the study.