“I think I am worth it. I can give up committing suicide”: Pathways to recovery for Chinese-Canadian women with a history of suicidal behaviour

Abstract

This qualitative study explored the experiences and patterns of recovery of Chinese-born women living in Canada with a history of suicidal behaviour. It explores a number of dimensions of recovery including clinical, existential, functional, physical, and social. The women described engaging in “survival” recovery in the short term and “thriving” recovery in the long term, with survival strategies extending into the thriving phase of recovery during their complex path to it. The survival recovery phase included accessing culturally sensitive mental health care and obtaining social and instrumental support to help ensure safety, manage stress, and treat psychiatric symptoms. The thriving phase of recovery was described as involving six components: developing an explanatory model with their health care provider; undertaking a process of narrative reflection and prioritizing self-care; engaging in interdisciplinary care team support; engaging the support of family and friends; exploring spiritual and existential supports; and creating goals for the future and a sense of mastery. Through these six avenues, the women began to experience a sense of self-efficacy and agency that improved their ability to cope with stress and pressure, leading to building a life with meaning. The interviews provided insights into how clinical care can be improved and how practitioners can implement a more recovery-oriented approach to practice.

Keywords

Canadian Chinese qualitative recovery suicide thriving

Introduction

The clinical model of recovery from serious mental illness and suicidal behaviour, focused on a reduction in suicidal ideation, symptom remission, and functional improvement, is only one method of conceptualizing the recovery process (Trainor, Pomeroy, & Pape, 2004; Whitley & Drake, 2010). A review of policy documents from several countries reveals variation in approaches to recovery beyond the clinical model (Adams, Daniels, & Compagni, 2009; Le Boutillier et al., 2011). These approaches to recovery can be viewed along a continuum of empowerment where one end consists of recovery language (patient-centered care) being grafted onto the predominant medical model and the other end a user-driven perspective that sees recovery as a personal journey that is unique to each individual (Bellack, 2006). Between these poles we see models of collaborative practice and community capacity building to enhance supports for those with mental illness on their recovery journey (Casey, 2008). In 2012, for example, the Substance Abuse and Mental Health Services Administration (SAMHSA) defined recovery as a “process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential” (del Vecchio, 2012, para. 5); thereby integrating clinical and nonclinical models of recovery.

On this continuum of empowerment, a more holistic conception of recovery has emerged as a key concept in mental health policies and programs in many countries (Le Boutillier et al., 2011; Ramon, Healy, & Renouf, 2007). Several long-term outcome studies have highlighted much higher recovery rates than previously assumed for persons with long-term mental illness (Bellack, 2006), suggesting that a more holistic model of recovery facilitates improved recovery rates beyond what is possible when focused solely on clinical recovery. Service users and professionals are now promoting the approach of holistic recovery (called the “recovery model” or the “recovery approach”); which for services users incorporates the idea of recovery as taking control over their own lives and introducing improvements that may or may not be related to clinical indicators of recovery (Tew et al., 2012). This approach also requires that professionals work with clients in a much more collaborative fashion than in the past. Many high-income countries formally accepted this approach to recovery as the cornerstone of their mental health policies and are currently in various phases of implementing it (Shera & Ramon, 2013).

In suicide research, this holistic approach to recovery is important because several studies have suggested that recovery from experiences of suicidal ideation and behaviour involve more than remission of symptoms; rather, they have stressed improved quality of life, greater self-esteem, connection with supportive people, self-reflection, and agency (Chi et al., 2014; Kasckow, Liu, & Phillips, 2012; Lakeman & FitzGerald, 2008; Sun & Long, 2013). However, relatively few studies emphasize the subjective experience of those who have lived through suicidal behaviour, and their reflections on the key factors in their recovery from these episodes are therefore scarce (Chi et al., 2014; Lakeman & FitzGerald, 2008) and lacking to inform suicide prevention practices. Further, as described by Nina Heller (2015), current evidence-based suicide prevention strategies reflect a “risk-dominated” paradigm, where clinicians are trained to identify warning signs of suicidal behaviour, aiming for an absence of suicidal behaviour, while the recovery model encourages a move towards client-focused and less restrictive interventions. This juxtaposition can create tension and challenges.

One model of recovery from suicidal behaviour that has the potential to bridge these competing perspectives on recovery is the dimensional approach. Whitley and Drake (2010) propose five superordinate dimensions of recovery: clinical recovery (experiencing improvements in symptoms and monitoring and reducing suicidal ideation and behaviour); existential recovery (having a sense of hope, empowerment, agency, and spiritual well-being); functional recovery (obtaining and maintaining valued societal roles and responsibilities, including employment, education, and stable housing); physical recovery (pursuing better health and a healthy lifestyle); and social recovery (experiencing enhanced and meaningful relationships and integration with family, friends, and the wider community). This multimodal approach to recovery attempts to integrate clinical and nonclinical approaches to recovery and may offer a more comprehensive framework with which to analyze and learn from journeys of recovery after suicidal behaviour and inform suicide prevention strategies.

Introduction to the current study

The current paper emerged from analysis of the data collected for a study (Zaheer et al., 2016) designed to examine the experiences, stressors, and beliefs of a sample of Chinese-born women living in Canada with a history of suicidal behaviour. In most countries in the world, including Canada, women die by suicide at much lower rates than men do (Canetto & Sakinofsky, 1998). However, until recently, the rate of female suicide in China has been higher than the rate of male suicide, and almost twice the rate of female suicide seen in North America (Wang, Chan, & Yip, 2014). Women of Asian descent in the United States, including women of Chinese background, have the highest rate of suicidal ideation and the second highest rate of suicide for women of any ethnic group (Duldulao, Takeuchi, & Hong, 2010; Jacobs, Brewer, & Klein-Benheim, 1999). Cultural factors have been identified as a partial explanation for the differences in these rates, including the Chinese cultural construction of suicide as a feminine “act of the powerless” rather than a consequence of mental illness, restricted opportunities and lower social status for women, and access to pesticides and poisons (Canetto, 2008, p. 259; see also Aubert, Daigle, & Daigle, 2004; He & Lester, 1998; Meng, 2002). In North America, qualitative studies have linked internalized emotional distress resulting from the sublimation of one’s own desires in order to fulfill family obligations with suicidal ideation in Chinese and Asian American women (Chung, 2004). Further, experiences of racial or sexual oppression by the dominant culture have been linked with distress leading to suicidal behaviour (Noh, 2007).

In this study, we interviewed 10 Chinese-Canadian women about their experiences of suicidal behaviour (Zaheer et al., 2016). The respondents described restricted patterns of emotional communication, feelings of lack of agency, experiences of victimization and oppression, and stress related to traditional gender expectations and those related to social change. Expectations of immigration are often unmet and stress results from financial, educational, and family pressures. Many of the women described struggling to endure this stress and experiencing a negative view of self, worsening depressive symptoms and hopelessness. Many spoke of reaching a “breaking point” leading to suicidal behaviour that can be understood as an escape from pain, a strategy to communicate distress, and a consequence of pervasive hopelessness.

During the data analysis, a secondary and somewhat unexpected outcome of the study was a better understanding of how the health system responded to these individuals, but also the diversity and complexity of the pathways that individuals experienced in their journey of recovery. No qualitative studies exist to our knowledge that describe the recovery from suicidal behaviour in women living in China or women of Chinese descent who have immigrated to other countries. These journeys of recovery are the focus of this current article. We hope to give voice to the resilience of the women we have interviewed.

Methods

The main research question guiding this study asked: How do Chinese-born women living in Canada understand and experience suicidal behaviour, and how are these conceptions and experiences influenced by cultural and social constructions of gender? More specific questions examined the perceived culturally informed expectations for women, the perceived consequences for not meeting culturally bound expectations of gender, and perceived options available to cope with these stressors. The qualitative interviews and analysis employed in this study were informed by constructivist grounded theory (Charmaz, 2006; Glaser & Strauss, 1967). The methodology allows for the exploration of cultural and social determinants that may influence behaviour, and the ways that gender as a social construction influences the perception of available options and the communication of distress (Charmaz, 2003; Chung, 2004). A secondary research question in this study, which is the focus of this paper, asked: How do Chinese-born women living in Canada recover from experiences of suicidal behaviour?

Chinese-born women with a lifetime history of suicide-related behaviour receiving psychiatric assessment or ongoing psychiatric care at four study sites in the Greater Toronto Area were invited to participate in this research study. Inclusion criteria consisted of being born or raised in Mainland China, Hong Kong, Macau, or Taiwan; being fluent in English, Mandarin, or Cantonese; and being 18 years of age or older. Suicide-related behaviour was defined as a self-inflicted, potentially injurious behaviour for which there is evidence that the person wished to use the appearance of intending to kill herself to obtain some end or intended at some undetermined or some known degree to kill herself (Silverman, Berman, Sanddal, O’Carroll, & Joiner, 2007). Individuals who were currently experiencing manic or psychotic symptoms or active substance intoxication or withdrawal were excluded. Diagnostic data was obtained by using the most recent clinical diagnosis given by the treating psychiatrist and recorded in the patient chart, and each participant completed a semistructured qualitative interview and a brief structured demographic interview.

A semistructured qualitative interviewing format allowed the interviewer and respondent to engage in a one-on-one, informal interview. Interviews (N = 10) were taped and transcribed verbatim. If a participant identified a greater comfort level in Mandarin or Cantonese, a Mandarin- and Cantonese-speaking member of the research team and qualified graduate student conducted the semistructured interview. The interview was transcribed in Mandarin or Cantonese and translated into English by a paid professional translator. Given the importance of culture, language, and expression, the translations were reviewed by three Mandarin- and Cantonese-speaking research team members to ensure proper interpretation of the concepts described in the Mandarin-language and Cantonese-language semistructured interviews. In the case of uncertainty, the section of the transcript was reviewed by the research team and discussed until consensus was reached.

The transcripts were open coded from both a procedural and a substantive perspective. Memos were written immediately after open coding was completed and the coding and memos were reviewed and discussed by the research team. Memos were prepared that detailed the discussions of the research team meetings. Coding was an ongoing process conducted during the data collection period, and analysis conducted during the data collection procedure informed the list of “sensitizing concepts” in later interviews. Analytic memos were written iteratively to capture the major issues relevant to each code. Each transcript was read, coded, reread, and recoded as necessary. Each transcript was coded at least three times during the data analysis process to ensure that earlier transcripts were examined for themes that developed through the process of serial memo-writing. The team met every 2 months to work on data analyses and to ensure consistency in coding, compare analytic memos, explore emergent themes, and finally to construct larger theories. Data collection ended when new codes were not generated in the analysis of the data. Further, the identified themes categorized the phenomena and explained relationships between concepts, and were complex enough to capture the participants’ experiences.

Results

A total of 10 women who have immigrated to the Greater Toronto Area from Mainland China or Hong Kong and experienced suicidal behaviour, with self-reported intent to die, within the previous 12 months were recruited for participation in this study. These women were receiving psychiatric care at one of four mental health services providers in the Greater Toronto Area. They ranged in age from 19 to 51 (average 39.6; SD = 10.9). Half the sample were married while the other half were single or divorced. Eight participants were from Mainland China while two were from Hong Kong. All 10 women were diagnosed with either major depressive disorder (n = 8) or were in the depressed phase of bipolar disorder (n = 2). Every woman had at least one episode of suicide-related behaviour with intent to die over the last 12 months, ranging in frequency from one episode (three women) to over 10 episodes (one woman). No major differences were seen in the description of recovery based on number of episodes of suicide-related behaviour.

Recovery: Surviving vs. thriving

Recovery can be conceptualized through a multimodal approach. The first focus that the women described is on “surviving,” which includes accessing mental health care and obtaining social and instrumental support to help ensure safety, manage stress, and treat psychiatric symptoms. The second focus is on “thriving,” or building a life with meaning. Strategies for surviving versus thriving, as described by the respondents in this study, are summarized in Table 1.

Table 1.

Summary of the strategies for surviving versus thriving as part of recovery after suicidal behaviour, as described by the Chinese-Canadian respondents in this study

Area of recovery	Strategies for surviving	Strategies for thriving
Mental health care	Hospitalization for acute safety crisis, connection to outpatient services after hospital discharge, medication management, ensuring instrumental support	Helping patients develop an explanatory model, fostering narrative reflection and self-care
Mental health care team	Physician only (often psychiatrist) in charge of hospitalization and providing regular follow-up after discharge, mainly to provide medication management and ensure instrumental support	Interdisciplinary team, including social workers offering social support and engaging with patients outside of the hospital setting
Family involvement	Practical strategies to keep patient safe after discharge	Engaging emotional support and improving communication within the family; helping family understand her distress, validate her emotions, and communicate her value within the family
Cultural and spiritual factors	Being aware of language barriers, providing psychoeducation for family, being aware of potential cultural differences in care including the potential need for greater family involvement	Exploring spiritual and existential supports
Focus of recovery	Accessing mental health care and obtaining social and instrumental support to help ensure safety	Building a life with meaning, creating goals for the future and a sense of mastery

Surviving suicidal behaviour

Accessing mental health care through the emergency department

Nine of 10 women were hospitalized for risk of suicide or postsuicidal behaviour during their lives, and seven were connected with specialized mental health care services for the first time following an episode of suicidal behaviour that resulted in hospitalization. None had presented to the emergency department for mental health support prior to engaging in suicidal behaviour in their initial presentation. However, four of six women with more than one hospitalization brought themselves to the emergency department prior to engaging in suicidal behaviour following the index presentation.

Stabilization in hospital

Six women described hospitalization as a stressful experience with little benefit outside of preventing imminent suicide risk, while five women described how hospitalization can be a deliberate way to keep oneself safe from self-harm when in crisis. It appears that hospitalization was conceptualized as a strategy to prevent suicide in the short term, but was not seen as a beneficial strategy to reduce symptoms or facilitate recovery.

Several women described feeling that prevention of suicide was paramount for those treating them. Several women described feeling like “nothing happened” during their admissions, and once the team felt they would not harm themselves, they were discharged. No woman described a demonstrable benefit to her mood following her first discharge.

Five women described returning to hospital as a strategy for safety when feeling distressed or unsafe in the moment. As one woman described,

The first two times needed emergency. The third was that I felt that I might be in danger, and I went to hospital in a normal and healthy state. Just, just I thought I might have the kind of impulse to, and I got moody, became very angry easily, very likely to be angry, and then sad, and in rotation, so I went there by myself.¹

Stabilizing in the community with mental health support

All 10 women were or had been engaged in long-term mental health care with a psychiatrist in the community. Six had interdisciplinary support, while four were seen only by a psychiatrist. Their experiences highlighted four key aspects to quality mental health care that allowed them to survive and recover from the immediate aftermath of distress and suicidal behaviour.

1. Medication treatment as an evolving process:

All 10 women were currently taking or had taken psychiatric medication. Seven women indicated that medications were eventually helpful in improving symptoms, but medications alone were insufficient to manage their distress completely or return them to their previous level of functioning. Rather than a fast-acting cure for distress, medication management was seen as an ongoing process between the woman and her physician to balance improvement of symptoms with emergence of side effects.

Medication treatment can be difficult to initiate for several identified reasons, including feelings that medication would not be helpful, negative family attitudes toward medication, previous negative experiences with medication, and hopelessness. A supportive, longitudinal therapeutic relationship between physician and patient was described as helpful in managing these issues.

The second important step in medication management involves frequent reassessment of symptoms to optimize benefits and minimize side effects. While seven women identified a benefit to taking medication, five described that this benefit took time and required adjustment. As one woman related,

Then after taking the medicines for several months, gradually I felt like I was … more peaceful … My thoughts were less messy. My conditions of not willing to do anything and of not willing to listen to anyone were relieved. So I took [the medicines] for a number of months … [Dr. Y] let me try the medicines, and then he modified the prescriptions according to my conditions … until they fit. I started to feel more peaceful.

Six women described difficulties in finding a balance between insomnia and oversedation. Sleep difficulties were seen as a major contributor to distress, and the management of insomnia was linked with overall symptom improvement. However, oversedation and overreliance on sedative medication were also identified by four women as a major difficulty. One woman described how her mood remained low as she traded insomnia for oversedation. Oversedation was identified as a factor that created difficulties in achieving goals associated with recovery. As one woman described, “So I think later when I can sleep less I can take some classes, I can learn something or I can go to the community … but lately I have been sleeping too much so I can’t do that.”

For another woman, the initial benefit of the sleeping pill wore off, leading to medication overuse and feeling that there is nothing else she can do to alleviate these symptoms. During the initial management of insomnia, the experience of sedative medication “not working” or having “stopped working” was identified by six women as a precipitant of suicidal behaviour.

Only one woman identified medication side effects other than oversedation (“trembling hands”). Eight women described that while medication was helpful, it was only one piece of their recovery.

2. Family promoting safety through practical strategies:

Family support helped the women survive during periods of high distress and worsening suicidal ideation. Nine women identified ways in which family and friends promoted safety, including calling 911 or taking her to hospital prior to and after suicidal behaviour, and providing intensive supervision in high-risk periods. As one woman describes, a cousin stayed with her 24 hours a day when she was having intense suicidal ideation, helping her stay safe. A second woman went to work with her husband every day to keep herself from engaging in suicidal behaviour. Another woman reported that at the peak of her hopelessness and distress, her husband stopped working and kept her safe at home, “I didn’t want to go to the doctor. I thought that nobody could save me, nobody could cure me. My thoughts at that time were like that. Uh … so later my husband just looked after me constantly, constantly.”

Providing support in arranging and attending mental health care appointments was seen as valuable in the recovery process by six women.

3. Instrumental support:

Four women in this sample required support from their mental health care team to gain access to the Ontario Disability Support Program (ODSP), a governmental financial support program advocated by physicians for patients in early recovery phases. All four women indicated that help in obtaining financial support in this way had a tangible effect on improving their health. One woman specifically identified the important role her psychiatrist played, not only by completing the necessary forms, but by providing validation that she was entitled to the benefits:

I said I felt very guilty now, because I stayed here … and fed on other people, it’s like I am doing nothing. My body is doing okay but the government gives me money each month, he said that you needed to get rid of this idea, the government … Dr X said … I think I should get government’s subsidy and government agrees to subsidize so I shouldn’t worry to receive those money.

4. Awareness and sensitivity to cultural issues and support in the navigation of family relationships:

Clinician awareness and sensitivity to cultural issues can be beneficial to women engaged in treatment in several ways. For example, certain modalities of care may create difficulties for women that may not be seen for other patients. One woman described her experience of day hospital as being unhelpful for her because it was an English language program; it was difficult for her to communicate with the staff and other clients.

Another woman described difficulties with the group therapy, as she felt uncomfortable expressing herself emotionally in this setting: “I’m not very good … in the group sessions … these groups are very big.” She was able to discuss this issue with her care team who were able to understand her concerns and modify the treatment approach.

Mental health professionals can also provide support to women to improve family relationships. One woman identified her counsellor’s work with her husband helped to improve his anxiety as well as her own.

Thriving after suicidal behaviour

The components of “thriving” described by the women in the sample include: (a) developing an explanatory model with their mental health care provider; (b) undertaking a process of narrative reflection and prioritizing self-care; (c) engaging in interdisciplinary care team support; (d) engaging support of family and friends; (e) exploring spiritual and existential supports; and (f) creating goals for the future and a sense of mastery. Through these six avenues, the women began to experience a sense of self-efficacy and agency that improved their ability to cope with stress and pressure.

Development of an explanatory model that validates emotional experience and instils hope

The development of an explanatory model with their mental health care providers in order to understand their experiences was described as a benefit of engaging in mental health care and an important factor in recovery. The development of the explanatory model happens in two ways: (a) by providing education about mental health diagnoses and how it applies to the patient’s life based on the patient’s own understanding and reflections, and (b) by validating the patient’s emotions over their life history to help them understand how their experiences contributed to their current distress. This process was an implicit, organic, evolving process that occurred over several meetings with the members of the care team through the validation of distress, psychoeducation, and provision of context for the symptoms by situating the distress in the patients’ life history. The women described a collaborative, informal process rather than a structured, top-down approach.

Mental health care providers charged with making diagnoses validated distress by acknowledging the severity of symptoms and the patient’s own understanding of their experiences, and used diagnosis to create a model from which the women could better understand their experiences. One woman described how her doctor was able to reframe the last 10 years of her life as having been suffering from daily depressive symptoms since adolescence.

Mental health care providers also supported women in constructing an explanatory model that allowed them to understand their distress by reflecting on their life histories. This can be understood as co-constructing a new narrative that shifts the woman from the role of victim to the role of a strong person who has agency in her life. A “life history” approach broadens the focus from current symptoms and stressors to the woman’s experiences over the course of her life. Exploration of childhood, family, and romantic relationships; education; and work history over the course of several sessions allows women to reflect on their journeys and resilience. One woman described her psychiatrist’s reflection on the difficulties she has faced, which led her to feel that she could try to change her own status:

Dr. X said, wow, “I have seen so many cases, but I have never heard such a tragic story. How could everything [have] happened to you?” I said I did not know. I now wonder, I just think, I also try to change my own status; I also try to think that I should have a better life; I tried not to commit suicide.

Another woman described how she was able to understand her symptoms in the context of her past experiences through reflection with a counsellor. She also described a meeting with a physician who helped frame her physical symptoms in the context of psychological distress and life stressors.

Through the encouragement of self-reflection and the validation of suffering, mental health care supported the women to change their way of thinking about themselves and to consider other options, thus encouraging a sense of agency.

Narrative reflection and prioritizing self-care

While the development of an explanatory model required collaboration with their care providers, fostering of narrative reflection and prioritization of self-care are strategies for thriving that the women established themselves during their recovery process. Every woman described a new ability to see themselves in the context of their family, relationship, and immigration histories, to better understand the pressures that led to their distress. By framing their distress in a life history model, the women are better able to understand the antecedents of their suicidal behaviour and reframe themselves from being weak women who cannot endure difficulties to women who have endured a great number of things in their lives. This reframing can result in a view of the self as stronger and better able to cope, and provide a rationale to ensure proper self-care in the recovery process.

Eight women described their recovery using a now-versus-then approach. Self-reflection as part of recovery was evident as women found ways to reflect on their journeys, specifically how far they had come. Rather than feeling overwhelmed and unable to communicate, they described gaining a capacity to reflect on and manage their emotions. One woman described her experience:

You didn’t know my state of mind at the beginning. I was in tears all the time in front of my doctor. I simply could not control myself … Now I think if I did not spend this period of time to adjust, I would not be able to talk to you like this. I might cry, badly, and might not be able to talk in a clear way. Clueless. Now, more clearly. Maybe not in the exact sequence. But at least I can talk to you clearly. At that time, it was a state of unclear mind.

One woman compared her previous and current emotional states by focusing on function. Everyday activities were seen as an indication that she was “mentally … normal,” and provided touchstones for her to understand the difference between now and then, as she was now able to “go to work, every day, doing chores every day at home.” Another woman described a recovery process where she felt more capable and introduced a daily schedule, contrasted with her experience of depression, which she described as lying in bed all day feeling unsure of what to do.

By reflecting on how distressed they were at the worst stages of their illness, the women were able to identify self-care as a priority to improve their abilities to cope.

Social support and interdisciplinary care team engagement

Six women described a benefit from the social aspect provided by their care team. Having social workers engage in home visits or meeting in the community was identified as a way to stay integrated and feel less isolated. As one woman described,

Although I don’t have a husband now, I have social workers who often come to see me. Like B … from [the mental health care team] … she has a great impact on me, I really like her, it’s not like you have to … comfort me or something, sometimes you just need to listen to me, listen to what I want to say, or you can say a few words, I don’t need you to teach me a lesson or whatever, you only have to listen to what I have to say. B sometimes comes over and we go out for coffee, so things get better and I’m able to get over it now.

Another woman described how the long-term interactions with her social workers helped her “calm down and live a normal life.”

Engaging support of family and friends

The women described their family as being very helpful in surviving in the short term and thriving in the long term whenever they had thoughts of suicide. In addition to promoting safety through practical strategies, as described in the section on survival recovery, this familial support could also come through emotional support. Importantly, a focus on intergenerational achievement can provide a sense of meaning during recovery for these women; all seven women with children identified hope for the future of their children.

Seven of the women described how communicating interpersonal distress provided one explanatory model for suicidal behaviour. Many of the women described how their illness and suicidal behaviour allowed their families to better understand their distress, validate her emotions, and communicate her value within the family. Improved communication within family relationships was identified as extraordinarily helpful. One woman described her son’s response to her suicidal ideation and behaviour. By understanding the value she held in his life, she felt that she was able to “survive”:

My son said, “Mom, you should not leave me alone. If anything happens to you, I cannot live anymore. Do you care about me?” I said I cared about you. My son’s words actually worked. I just cried. [My son] told me “if you felt uncomfortable, just call me anytime. I don’t want to go to school, I’ll take several days off. I’ll catch up with my study. I assure you. Just talk to me. Or I fly over to here.” I said no, no. I survived in such a mental state.

Five women described improved emotional communication with family members as a key part of their recovery. One woman described how the process of “venting” her emotions with her mother was helpful, contrasted with a lack of emotional communication in the past. “Venting” and “chatting” can be contrasted with the experience of enduring difficulties on one’s own and holding emotions in.

Four women with difficulty communicating with their husbands prior to the period of distress identified clear improvements, which aided in recovery. One woman poignantly described how she and her husband became closer during her year-long recovery process, and how their improved communication and closeness were valuable in her recovery, contrasting with enduring her distress alone:

I feel that he has done a lot for me this time. Now I have recovered … Now when he looked back to the past, he noticed that he had changed. He started … to get along better with me. I feel that we are better now. At least he would … er … would chat with me … He tries not to lose his temper over me. He has changed those things. He goes out with me more often … on a walk with me, or to do some shopping, or to have a meal or have a drink.

Friends were also described as important for support during the recovery process.

Exploring spiritual and existential supports

Three women described finding religion as a key component of their recovery, providing a sense of community and meaning. Two women identified the church as the primary factor in their recoveries; as one woman stated, “If there is no God I think my life is over a long time ago.” The church provides a sense of identity, family, and community to her, including people who validate her emotions and suffering. The church provided a framework for a journey into recovery: a way of achieving peace and mental health, and providing hope for the future. She described her experience of the church as accepting, open, and de-stigmatizing.

A second woman described feeling emotionally validated by the Bible:

I was so so upset … I suddenly saw a sentence, in the Bible, it said, could exactly describe my state. It said singing to a broken soul, just like add the frost on snow … Ah so right. How could it be so right? I also showed it to my pastor … She said oh “Do you think that the person was singing to you?” I said “Exactly.” It’s like, perhaps, patients with depression firstly, need reorganization. To be recognized; if you accept her, then I think it maybe, it would be helpful to her.

She also described receiving instrumental and financial support from the church community.

However, in some cases, some interpretations of the church’s teachings can also encourage the value of endurance and restricted agency for women. One woman described that she did not choose to divorce her husband because “God said one couldn’t leave a marriage.” It appears that for this woman, the church’s teachings created a way to reconcile the double bind of traditional gender roles and increasing academic expectations for modern Chinese women by endorsing a view that women should submit to men within a marriage, and that this will “change things”:

The Bible said … men are the heads of women, we are all educated under modern Chinese education system, it’s very hard for men to be our head, so that’s why I said the position was not put right, it’s very difficult. Now I’m trying to learn this lesson, I need to put men first, I have to look up to him and that will change things.

For one woman, reading works of fiction provided her with a new philosophical view of herself and the world, which led to an increased sense of agency and self-efficacy. She described changing her view on restrictive standards of beauty, previously a source of tremendous distress, by referencing a popular modern Chinese author named Sanmao:

I read all novels written by Sanmao. After that I realized … my attention gradually shifted away from women’s appearance, look, height, and beauty … which means I have gradually developed a more mature ideology, and gradually I walked out [of the past]. I walked out of it by myself … I like [Sanmao’s] care-free personality, then I slowly walked out … it’s a real maturity … I realize that a woman’s attractiveness entails many different dimensions, and the maturity … mental and psychological maturity will continue to develop, so after I realize this I feel better.

Creating goals for the future and a sense of mastery

Six women described a process of gaining a sense of mastery or self-efficacy during their recovery, increasing hope for the future. One woman focused on how a mastery of cooking and caring for her home led to positive emotions and self-image:

I think it’s really nice to cultivate some interests, and to make my home clean, comfy and cozy, I think it’s to make life … I’m already a good cook, but there are so many recipes in this world … Now I want to learn how to make buns and bread … finding something that I enjoy doing to reduce my negative emotions I think this is really nice and I think this is a good strategy, and I think this strategy is working for me.

Pursuing work and educational opportunities can build mastery and increase a sense of agency, but while it was seen as protective for six women, two women described returning to work or school as a source of stress. The type of work is clearly important; women who work in higher status or higher paying professions tended to see return to work as more beneficial than those working in positions with less power (i.e., in a factory, in sales, or in childcare). It appeared to be key that the women see work or school opportunities as positive and feel that they can incorporate them into their lives without compromising self-care or putting themselves back in a position to endure stress or pressure without feeling well enough or having the strategies to do so.

For one woman, working led to a sense of purpose that helped her feel less “useless” and allowed her to put less pressure on herself to do household work:

I felt I was happier when I started working. I thought that at least I had a job … I felt that even if I came home and didn’t cook or whatnot, I felt that er … I wasn’t that bad, I wasn’t that useless. At least I went to work … I could help our family financially and whatnot. So I felt a little better, a little better.

Discussion

The data in this study support the growing view that we must employ a much more holistic approach to care that goes well beyond the provision of clinically focused mental health services. This approach, derived from an understanding of the social determinants of mental health (Allen, Balfour, Bell, & Marmot, 2014), embodies a biopsychosociopolitical frame (Williams, Almeida, & Knyahnytska, 2015), which asserts the importance of the social context of recovery and the need to support those with mental illness to find meaningful social roles and become more engaged as citizens in their communities.

Leamy, Bird, Le Boutillier, Williams, and Slade (2011) developed a conceptual framework of recovery that highlighted the most important aspects of the recovery process: connectedness, hope and optimism about the future, identity, meaning in life, and empowerment—themes of recovery strongly resonating with those identified by the women in this study.

Current clinical approaches to treatment and rehabilitation put priority on medication adherence, maintaining activities of daily living, and participating in rehabilitation programs; the person’s own role in this process remains ambiguous and is often driven by the implicit expectations of health care providers for passivity and compliance (Davidson, Shahar, Lawless, Sells, & Tondora, 2006). Davidson et al. (2006) argue that recovery requires reconstructing an effective sense of social agency from which pleasure and success can be derived, and then incorporating “these experiences of pleasure and success, and what they convey about one’s abilities and efficacy, back into an expanded sense of self” (Davidson et al., 2006, p. 158). They developed a guide to recovery-oriented practice as an alternative to clinical case management (Davidson, Tondora, Lawless, O’Connell, & Rowe, 2009).

Two critical dimensions that have emerged from some of the recent literature are the role of spirituality and the importance of culture-specific factors, which are also prominent in this current study. Sullivan (2009) argues that religious and spiritual issues matter for many who seek mental health services. Several of the women in our study found religious/spiritual support to be pivotal in their recovery. Religious and spiritual beliefs and other aspects of cultural context require attention in initial assessments and are important factors in the care planning process (Sullivan, 2009). Cross-cultural studies of recovery frameworks developed in the West have suggested that nondominant ethnic group members may place greater importance on the spirituality component of recovery (Leamy et al., 2011).

The recovery process described is not always a linear one; only one woman described a straight path from suicidal behaviour to recovery. For the other nine women, their recovery journey involved setbacks, recurrence of symptoms, and sometimes recurrent suicidal behaviour and/or hospitalization. Recovery from depression may differ from recovery from suicidal behaviour in that those with a history of suicidal behaviour may need to engage in “survival” recovery during their “thriving” recovery phase, as suicidal behaviour can return during any phase of recovery. One example of how survival recovery can extend into thriving is how spousal support was described as being very helpful in surviving in the short term and thriving in the long term. “Survival” recovery included increased support socially and through promoting safety via practical strategies. Meanwhile, “thriving” recovery required improvement in interpersonal communication with their partner, as described by four women, and feeling valued and understood. Suicidal behaviour may return at any phase of recovery from depression, and the women in this study described using survival recovery techniques to promote safety even during their thriving recovery.

Recommendations for mental health care practitioners

The women in this study described what they have found useful and important in their recovery process following suicidal behaviour, which we summarize here. They described how the emergency department and hospitalization were the first stages in surviving suicidal behaviour. Clinically, validation of emotional experience by health care providers was identified as a key strategy. The women also described their health care providers working with them to develop an explanatory model that places their symptoms in the context of their life histories and within a medical framework as extremely helpful. Meanwhile, medication management should be seen as a process rather than as a one-time event. Important pieces for clinicians include assessment of patient and family attitudes, psycho-education and support, managing side effects, and regular follow-up.

Awareness of culturally significant issues can help the clinician better identify and understand stressors in the patient’s life, and many women described a benefit from discussing these issues with their care team. Clinicians can help by liaising with family members to provide psycho-education and support. Many women found family inclusion to be very helpful in the recovery process. Although the women stressed the importance of the clinical model of recovery, all agreed that symptom improvement through medication management was only one piece of the recovery process.

The women in this study provided strong evidence for the importance of a dimensional approach to recovery, which encompasses not only clinical recovery but functional, existential, physical, and social recovery (Whitley & Drake, 2010). They described each of these pathways in their personal recovery stories, highlighting the need for health care practitioners to be aware of and be able to help foster recovery beyond clinical recovery. Existential recovery—encompassing religion and spirituality, agency and self-efficacy, and personal empowerment—was a key factor in the recovery narratives of all 10 women. They focused particularly on building a stronger sense of identity and agency as they moved through their recovery. Functional recovery, focusing on employment, education, and housing, was also discussed at length by all 10 women. In this population, functional recovery is tied closely with resources available to women postimmigration, and they described the difficulties they had navigating this new system. Physical recovery, including improved diet and exercise and other lifestyle factors, maps on nicely to the theme of improved self-care that the women described. Culturally, the women described being focused on enduring or “pushing forward” rather than stopping to take time to care for themselves, and several described the importance of self-care in their healing process. These elements of recovery urge the health care provider to shift the focus of support beyond clinical recovery, or merely surviving after their suicidal behaviour, towards supporting their patients in other dimensions of recovery that help individuals thrive.

Finally, social recovery encompasses engagement with family, friends, peers, community, and social activities. These factors, specifically the importance of engaging family support, were noted by almost every woman as being key for recovery. This ties with the importance for clinicians to engage social support during the recovery process, specifically engaging emotional support and improving communication within the family, including helping the family understand the patient’s distress, validate her emotions, and communicate her value to them.

Conclusion

The Chinese-Canadian women in this study described their recovery process in terms of strategies for surviving and strategies for thriving. The strategies for surviving largely correlated with a focus on clinical recovery, which ensured safety in the short term, but were described as insufficient in the recovery process in the long term. Moving towards thriving after suicidal behaviour required a dimensional approach to recovery, which included existential, social, physical, and functional recovery. These strategies for thriving shift the focus beyond merely the absence of active symptoms to building a life with meaning.

The interviews provided useful insights into both how clinical care can be improved and how practitioners can implement a more recovery-oriented approach to practice. While the strategies for surviving may not all be applicable to those without active suicidal ideation or self-harm, some of the strategies (like medication management and family psycho-education) are likely still important in the short term to engage in treatment Chinese-Canadian women with depressive symptoms but no suicidality. Meanwhile, the strategies for thriving are likely relevant in supporting recovery of Chinese-Canadian women with a mood disorder but not suicidality, since all 10 women in the study had a diagnosed mood disorder.

While there are some limits to generalizing these findings to other conditions, a dimensional approach to recovery is also being used to treat conditions like early psychosis (Kane et al., 2016). What this current study adds is evidence for the need of a more holistic approach to recovery directly supported by the patient perspective. This study also highlights the importance of considering the cultural context in treatment interventions, specifically engaging family emotional support and increasing emotional communication in the family as a prime example described by the Chinese-Canadian women in this study. The cultural importance of family engagement has already influenced the design of some interventions, such as the provision of a multifamily psycho-education group for Chinese families of assertive community treatment patients (Chow et al., 2010). This psycho-education group was also open for Tamil patients and family members, suggesting that a set of similar cultural factors can resonate with other immigrant and nonimmigrant populations, but would need to be confirmed with further research. Studies have suggested that the acculturation process significantly changes the cultural influence on subsequent generations of immigrant Chinese families, but the subsequent generations are still distinct from host cultures (Rosenthal & Feldman, 1990). We wonder whether and how much the findings with Chinese-Canadian women with a history of suicidal behaviour in this study would apply to second-generation Chinese-Canadian women or Chinese women who did not immigrate. The latter population is the focus of another study that is currently in progress.

Footnotes

Acknowledgements

The authors would like to acknowledge Catherine Cheng, who conducted the interviews in Cantonese and Mandarin and assisted in data analysis. Most importantly, we would like to thank the 10 women who selflessly shared their time, experience, and insight. Their bravery and strength in the face of adversity is profoundly moving.

Note

Juveria Zaheer, MD, FRCPC, MSc, is a clinician investigator at the Centre for Addiction and Mental Health and an Assistant Professor in the Department of Psychiatry at the University of Toronto. Dr. Zaheer’s research interests include gender, culture and suicide, qualitative program evaluation, and medical education.

Wes Shera, MA, PhD, is Professor and Dean Emeritus at the Factor-Inwentash Faculty of Social Work at the University of Toronto. He is also cross-appointed to the Department of Psychiatry at the University of Toronto. His areas of teaching include community organization, social policy, group work, management, and practice and policy in the field of mental health. Dr. Shera’s research, primarily in the field of mental health, focuses on operationalizing and testing concepts of empowerment in working with clients, organizations, and communities. He has also been engaged in comparative policy analysis of recovery-oriented mental health reform in Canada, the UK, Australia, Israel, China, and Brazil.

June Sing Hong Lam, MDCM, is a resident physician in the Department of Psychiatry and in the Clinician Scientist Program at the University of Toronto. His current research interests include cultural psychiatry, medical education, health systems, and understanding complexity in mental health care.

Wai Lun Alan Fung, MD, MPhil, ScD, FRCPC, is an attending physician and the Medical Director of Research at the North York General Hospital (NYGH) Department of Psychiatry, and has chaired the NYGH Research Ethics Board since 2014. He is also a Research Professor at the Tyndale University College, as well as a faculty member of the Department of Psychiatry and the Neuroscience Program at the University of Toronto. His key clinical and academic interests are in the cultural and spiritual dimensions of mental health care; neuropsychiatry and genetics; sleep medicine; intellectual and developmental disabilities; mental health promotion; collaborative care; and health professional education.

Samuel Law, MDCM, MPH, FRCPC, is an Associate Professor and actively involved in the Equity, Gender, and Population Division at the Department of Psychiatry, University of Toronto. His research interests are in cross-cultural issues in psychiatry, including cross-cultural health systems studies, health economics, and knowledge translation in service delivery models. As the lead of the Department’s China Initiative, he is also involved in liaising and developing research and educational exchanges with Chinese counterparts. His clinical work is mainly in community-based care, with emphases on assertive community treatment and clinical consultations to ethnic minority populations.

Paul Links, MD, FRCPC, MSc, joined the Department of Psychiatry at McMaster University in 2017. From 2012 until 2016, Dr. Links served as Professor and Chair in the Department of Psychiatry, Schulich School of Medicine & Dentistry, The University of Western Ontario, and Chief of Psychiatry in the London Health Sciences Centre and St. Joseph’s Health Care, London, Ontario. Prior to coming to Western University, Dr. Links was holder of the Arthur Sommer Rotenberg Chair in Suicide Studies, University of Toronto for three terms. This Chair was the first in North America dedicated to suicide research. Dr. Links is former President for the Canadian Association for Suicide Prevention (CASP) and former President of the Association for Research on Personality Disorders. Dr. Links served as the Editor of the Journal of Personality Disorders from 2009 to 2011. He was previously on the Editorial Board of the Canadian Journal of Psychiatry.

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