Treating anorexia by nourishing the heart

Warren Ward's patients are often critically ill with diseases like anorexia.
Warren says asking someone with anorexia to eat is like asking an arachnophobe to put their hand in a jar full of spiders.
As a psychiatrist, Warren uses psychotherapy to help his patients.
He encourages those with an eating disorder to approach their mental illness as one part of their whole self.
His interest in the mystery of human nature informed his study of philosophy, and led him to examine the love lives of philosophers.
Further information
Originally broadcast in February 2022.
Lovers of Philosophy is published by Ockham Publishing.

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Chronically stressed? These small changes can help

Sana Qadar: I thought I knew what it meant to feel stressed, or overworked, or underslept, or close to burnout. I mean, I feel versions of these often enough. But then Dr Rangan Chatterjee told me a story that's almost unbelievable. It's the story of his father. Dr Rangan Chatterjee: So my dad grew up in India. He came to the UK in 1962. And dad basically worked to give his family in the UK, so my mum, me and my brother, and his family back home, a better life. But the way dad worked, looking back now was mind-blowing, honestly. Like, because for 30 years, my dad only slept three nights a week. Sana Qadar: Did you catch that? Three nights a week. Dr Rangan Chatterjee: So he was a consultant physician at Manchester Royal Infirmary. And I can remember this so clearly. Dad would do his day job in the middle of Manchester. So we lived in a suburb of Manchester. So he'd drive home, maybe take him 40 minutes or so. And he'd come in about 6, 6.15pm. Mum would have dinner ready for him. He'd go to the kitchen, he'd have dinner. He'd go upstairs and shave. And then at 7pm, he'd leave the house to do GP house calls all night. And he'd arrive back again at 7am. When he got in at 7am, he'd have breakfast in the kitchen. He'd go upstairs and shave again. And then he'd drive 45 minutes in traffic back to Manchester to do his day job. So for 30 years, dad was doing both of these jobs, and he only slept three nights a week. And I didn't know this at the time. And there was a lot of stress at home. And of course, there's, you know, he was exhausted all the time. Sana Qadar: At the age of 58, all of that chronic stress and sleep deprivation finally caught up with Rangan's father. First, he was diagnosed with lupus, which is an autoimmune disease where the immune system starts attacking healthy tissues and organs. Dr Rangan Chatterjee: And basically he had to medically retire. His kidneys completely failed. He lost the sight in one of his eyes. And then he was literally chained to a dialysis machine three times a week for 15 years. And so what's really interesting for me is, you know, reflecting back now, although my dad's case might seem quite extreme, I have seen many iterations of that in my practice for years. People think they can keep pushing, pushing for more, better job, a bit more money, another promotion, a nicer holiday, whatever it might be. But yeah, the thing is, that quest for more is driving so many people to stress themselves out in the belief that at some point in the future, everything's going to be okay and I can chill and relax. But I've seen time and time again, people come in wishing they'd stopped earlier. Sana Qadar: Dr Rangan Chatterjee is a GP with more than 20 years experience. And his focus and his passion has long been lifestyle medicine. Dr Rangan Chatterjee: In fact, 80 to 90% of what we see as medical doctors today is in some way related to our collective modern lifestyles. Sana Qadar: But you might recognize him from his mega popular podcast, Feel Better, Live More, where he delves into the science of lifestyle medicine and wellbeing. And in his experience, one of the biggest lifestyle factors impacting people's health is chronic stress. Dr Rangan Chatterjee: The 53 year old executive who kept pushing and working every weekend and coming back late until he gets the heart attack. The 46 year old mother who never does anything for herself, everything is for her partner, her children, her elderly parents. I've seen this so many times. And for me, it's always trying to get to the root cause. And I would say for so many people, chronic stress is at the root of many of their short term symptoms and their long term health problems. Sana Qadar: So today on All In The Mind, we are focusing on chronic stress, what it's doing to our brains and bodies, everything from our decision making abilities to our libidos. And we're also finding out the signs and red flags to look out for that tell you your stress levels are unhealthily high. We'll also find out what you can do about it. This is All In The Mind. I'm Sana Qadar. Sana Qadar: Just going back to when you were first talking about your dad's story and how he was working for 30 years while you were growing up. I just wondered, like, whether you or your family did anyone think that his pace of work was nuts? Or was it kind of just normalized, the fact that he was only sleeping three days a week? Dr Rangan Chatterjee: I think as a kid, that's just your normal. You're just like, you're used to dad not being around. Oh, dad's working tonight. Dad's working this Sunday, or whatever it might be. So on a personal level, me and my brother, I'm not sure we were aware. I think it was normalized for us. I do remember mum often saying, why are you doing this? You don't need to work on Christmas Day. You don't need to work on Boxing Day to gain even more money to send home. Why don't you just stay? So I don't want to speak about my parents' marriage in the sense that I don't know what went on. But I certainly think as kids, we didn't really see the full impacts of it. I think for us, it was normalized. Sana Qadar: It's such an immigrant thing for especially that generation to want to work so hard and send quite a lot back home to help sisters and brothers. It's a familiar story in a way. Not that anyone in my family was only sleeping three nights a week, but the other details of it are similar. Dr Rangan Chatterjee: Yeah, but that's why I feel as I've got older, I've just become, I'm pretty non-judgmental these days. I think I used to be. I just think more and more, none of us know what's going on in someone else's life. I think once you really get that, you just become a lot less judgmental and more compassionate to the world around you. Sana Qadar: Now, you would think watching his father's punishing schedule, the chronic stress, the lack of sleep would put Rangan off a career in medicine. But like I said, he followed in his footsteps and also became a doctor. But early on in his medical training, Rangan started to feel like something pretty important was missing from the medical system. Dr Rangan Chatterjee: Yeah, I think when I qualified from Edinburgh Medical School back in 2001, I thought that I'd been taught all the tools that I needed to go out there into the world and help my patients. So when you qualify, you start off in hospitals and I did that for quite a few years. And I think there was a frustration early on in my career that what I'd been taught to do was suppress symptoms often with medications. And that was really front of mind for me when I did move into general practice because I thought a lot of these patients who are coming in, we're not really getting to the root cause of their problems. In fact, 80 to 90% of what we see as medical doctors today is in some way related to our collective modern lifestyles. Yet not only do we not get trained in how our lifestyle specifically affects different aspects of our health, we're not really taught how we actually put that into practice. So our default as medical doctors often ends up being prescribing pharmaceutical medications for symptoms that are driven by our lifestyle. And for me, that was very unsatisfactory. And I tell you, Sana, one really seminal day for me was when I finished a long day in NHS general practice where I'd probably seen about 50 patients. And I was tired. It was the end of the day. And I looked at my patient list on my computer screen and I asked myself, Rangan, how many patients have you really helped today? Like honestly. And hand on heart, I thought, well, I think I probably helped about 20% of people. The other 80%, sure, I was professional. I listened to them. I might have sent them for a test or given them a medication to help hide a symptom. But I thought, they're going to be back. I didn't really help them get to the root cause of their problem. So that day, I realized that actually I can't do this for the next 40 years of my career. There must be another way. And for me, that way is what we call lifestyle medicine. Sana Qadar: Lifestyle medicine is a relatively new field. It's a branch of evidence-based health care that focuses on trying to prevent diseases before they start, rather than just treating them once they set in. Chronic diseases like Alzheimer's, heart disease, type 2 diabetes, cancer, and stroke. It's a response to the fact that in the modern post-industrial era, there's been a shift in the kinds of diseases that most affect people in high-income countries. That's a shift from mostly infectious diseases to mostly chronic diseases, which often have lifestyle or environmental drivers. Dr Rangan Chatterjee: I want to be really clear, Sanaa. I'm not blaming people here. I understand that modern life is challenging, and a lot of people are not able to eat as well as they want to. Their jobs mean that they're sedentary for a lot more time than they might choose to be. They're chronically stressed, chronically sleep deprived. I'm not saying that people are doing this to themselves. I'm saying I don't think there's enough awareness that our lifestyle, and if you can personalize and change specific parts, what I call the four key pillars of health, food, movement, sleep, and relaxation, you can have profound impact on all aspects of our health, short-term and long-term. Sana Qadar: And so that brings us back to chronic stress, one of the main lifestyle factors wrecking havoc on people's health. Because stress sets off a whole bunch of responses in the body. It makes your blood pressure rise Dr Rangan Chatterjee: so that more oxygen can be delivered around your body. Sana Qadar: It makes your blood sugar levels rise Dr Rangan Chatterjee: so more glucose can get to your brain. Sana Qadar: It also throws your amygdala, Dr Rangan Chatterjee: which is the emotional reactive part of your brain, into high alert so you're hyper-vigilant. Sana Qadar: And while we evolved this stress response to keep us safe, the problem is our brains can't fully tell the difference between the threat posed by a lion or tiger who wants to eat us versus our email inbox. Dr Rangan Chatterjee: Yeah, you know, the email inbox, the children we have to rush to pick up after work, the elderly parents we're having to look after when we don't even have our tribe community around us anymore, the three social media channels we're trying to keep up to date with, the constant bombardment of negativity on the news, whatever it might be, our bodies are responding in very similar ways, whether it is a real physical threat or the emotional, psychological stresses that are coming at us in the 21st century. So just to tie the loop up, blood pressure going up in the short term when you're running away from a tiger or a lion, great. Blood pressure going up temporarily while you're doing a 30-minute spinning workout at the gym, great, no problem. But blood pressure going up day in, day out to the state of your life, well, that's what's going to increase your risk of a heart attack or stroke. And you talk about the brain, the amygdala, the emotional part of our brain. If you think there's a wild predator there, the emotional part of your brain becomes hyper-vigilant. Why is that important? So you can hear everything, a pinprick, or there's a rustling in the bush. If that's happening to the state of your daily life, well, that's what we call anxiety. So once you understand the stress response, you actually understand stress is there for a reason, but we're not designed to be stressed all the time. Sana Qadar: I want to dive deeper into how chronic stress affects our brains, specifically our mood and cognition, because you might have noticed, I definitely have, that when you're super stressed, you are probably more moody and snappy and you struggle to make decisions. Dr Rangan Chatterjee: Chronic stress has a huge impact on the way we make decisions. Okay, so think about your brain in two parts. It's a slight oversimplification, but I think it really helps us understand this concept. One part is the front of your brain, the prefrontal cortex at the front of your brain, where you make your logical and rational decisions. And then further back, the emotional part of your brain, where the stress response comes from when you think you're in danger. Ideally, you want both of those parts online and in balance. But when you're chronically stressed, you switch off the prefrontal cortex, that part of your brain that makes logical and rational decisions, it goes offline. So you're left with the emotional brain ruling the roost, which is one of the reasons why we struggle when we're chronically stressed to make good decisions. In fact, many of us know that feeling at the end of the day when we've not taken a lunch break, we're a bit frazzled, and an email comes in and we need to make a decision, and we can't. We don't have the clarity. And that's because our logical brain has gone offline. And that's why stress reduction practices, you know, a bit of breath work, a 10-minute walk at lunchtime, one minute of jumping jacks or moving your body, whatever it might be, just helps to break the cycle, lower the stress response, and then that front part of your brain where you make those logical decisions from starts to come back online. Sana Qadar: And this also explains why when you're stressed, you can be more emotionally dysregulated. And this is a real problem long term, because chronic stress doesn't just change the functioning of the brain, it can change the structure. For example, there is a well-established link between chronic stress and depression, and we also know that chronic stress can shrink the hippocampus, a part of the brain that's critical for learning and memory. I could go on, but I'll stop there because I think you get the point. Chronic stress is bad for many different reasons. But just two other points I do want to briefly make is that, one, there is plenty of research finding that people from poorer backgrounds often experience higher levels of chronic stress because of the precariousness of their lives. That puts them at a higher risk of being impacted by these kinds of changes in the brain. Second, there's also growing research in Australia, the UK, and the US suggesting Gen Z are the most stressed generation, thanks to a combination of factors, including the COVID pandemic, financial insecurity, and the rising cost of living, and the impact of social media and technology. Sana Qadar: Okay, so I want to ask, when should a person start to be worried about the amount of stress they're feeling? Like, when can you know, what are the signs to look out for that you've been chronically stressed for too long? Dr Rangan Chatterjee: I mean, it's highly individual for all of us. And the problem is that the more you get used to chronic stress, the harder it is to tune into your own body and figure out that, oh my God, I need a break. You know, this is going on for too long. One of the big factors is also that these boundaries between work and home have been decimated with technology. Right? So 25 years ago, there were natural endpoints to the working week. You know, when you left the office, you were kind of done. So, you know, how can people know? Well, one good sign is when their mind is racing at night and they can't switch off to fall asleep. That's a good sign that your mind has been overactive and you've not given yourself a chance to sort of wind down. Sana Qadar: Another sign, Rangan says, is stomach problems. Dr Rangan Chatterjee: We know from a bit of research done a few years ago that in the UK at least, and I've no reason to believe that it will be different in Australia, 84% of UK adults have some form of gastrointestinal symptom each year, which is incredible. The number one cause is not, in my view, diet, it's stress. Sana Qadar: The connection between our stress levels and gut health has been well studied and the relationship seems to go both ways. Our gut can influence our mood and stress levels, as well as our stress levels influencing our gut. It's an idea that was popularized in a big way in a book called Gut by Julia Enders back in 2014. Dr Rangan Chatterjee: Think about it. If you think there's a predator about to attack and you have to keep yourself safe, your body will switch off functions that are not essential to your survival. You do not need to be able to digest food efficiently if your body thinks it's in danger, which is also why some of the time we're trying to eat our healthy whole food meal, but we're also doing it whilst answering work emails. The reality is you're not going to absorb that food properly. Now, I'm not judging. I will also do this despite knowing it, but the truth is sometimes, and I've had patients who think they're intolerant to certain foods, but once I taught them a simple breathing technique called the 3-4-5 breathing technique to help them downregulate their stress response before they eat, they find, oh man, I'm not getting symptoms anymore. Sana Qadar: If you're wondering how that breathing technique works, keep listening. We'll explain that in a moment. Dr Rangan Chatterjee: Now, of course, there are true food allergies. I'm not talking about that, but for some intolerances, you're not actually reacting to the food, you're reacting to the fact that you're eating that food in a stressed out state. So, if you're getting a lot of indigestion, a lot of bloating, constipation, or whatever it might be, that might indicate that you're chronically stressed, right? Sana Qadar: And then just one other sign we'll mention that can tell you you might be chronically stressed is if you find your libido is starting to suffer. Dr Rangan Chatterjee: We, as doctors, are seeing more low libido in younger and younger and age groups than we've ever seen before. Number one factor is chronic stress. Again, think about it through that evolutionary lens. If you think your body's in danger, your body doesn't think, oh, I need to now be able to chill out and procreate with my partner. So, it switches off libido, and this is a massive issue because it affects relationships, it affects how men and women feel about themselves and their vitality. And again, I've treated lots of cases of low libido by helping people lower their stress levels. Sana Qadar: I want to know more about, you mentioned the breathing exercises, I want to know more about tools and tips for de-stressing. What do you advise people do? Because, you know, work is still stressful, the news is stressful, like modern life doesn't fully change, we have to change how we relate to it. What do you suggest people do? Dr Rangan Chatterjee: Yeah, so the first thing I want to say here is that one thing that 23 years of medicine has taught me is there's very rarely one thing that works for everybody. We've all got different gut microbiomes, we've all got different emotional histories, and so we respond to different things. Let me give you a selection of things that I recommend to people and then people can sort of play around and see what works for them. I believe the way you start your day has a huge impact on the rest of your day. So, I think a useful way to look at the way we start the day is through the lens of what I call micro stress doses. Okay, so what's a micro stress dose? It's a little dose of stress that in isolation we can handle just fine, but when those micro stress doses accumulate, they get you closer and closer to what I call your personal stress threshold. And at your personal stress threshold is when things start to go wrong. So, let's say you went to bed late because you were watching Netflix and your alarm goes off on your phone at 6am. That is what I call micro stress dose number one or MSD number one. Okay, because it jolted you out of a deep sleep. You look at it, you go, I'm still tired, you put snooze on. Six minutes later, the alarm goes on again. Micro stress dose number two. Then whilst you're in bed, you open up your email app. Oh man, there's three work emails I didn't do from yesterday. I need to get onto that today. You're nodding your head a lot here at the moment. Sana Qadar: (Laughs) you're describing my mornings pretty much. Dr Rangan Chatterjee: MSD number three. Okay, then you go to the news app and see about some gas explosion that has happened that's killed people, whatever it might be. Okay, and I don't mean that to sound negative. Obviously, if people are dying with something, I'm deeply compassionate about that. The point I'm trying to make is that many people I've seen in practice over the years, in the first hour of the day, they've accumulated 10 to 15 micro stress doses. It means you are very near your personal stress threshold, which means you have less capacity in the day to deal with it. So it won't take much to tip you over. So going back to your question, some of us have got more agency to make decisions and change things than others. I'm saying that for some of us, we don't need to start our day with 10 to 15 micro stress doses. If you had an alarm clock instead of your phone, for example, that can be game changing. Sana Qadar: Simple, but effective. Rangan also recommends a morning routine that he recognizes people can sometimes balk at the idea. Dr Rangan Chatterjee: They're like, oh man, I don't have time for a morning routine. The thing is, everyone already has a morning routine. The question is, are you conscious of that morning routine? Right? You've got a routine, that routine I just mentioned. That's a morning routine (both laughing). Sana Qadar: That's my routine, the emails and the social media. Dr Rangan Chatterjee: You're repeating that routine every day. Fine, but that's going to have an impact on you. So I believe a nice framework to think about a morning routine is what I call the three M's, mindfulness, movement, and mindset. You don't have to do all three, but I think if you have the time, all three can be done quite beautifully in quite a short period of time. So mindfulness could be anything like a bit of meditation, breath work, whatever, drinking a coffee in silence, right? Just paying attention to the coffee and not actually scrolling your emails or Instagram at the same time. Movement can be some stretches, a few weights, whatever it might be. And mindset is something to put you in the positive frame of mind. So it could be reading a little bit or journaling. Now I get it. A lot of people will be going, I don't have time for any of that in the morning. Okay. Let me give you an example of one of my patients who said that to me. She was a single mother. I think she was about early forties from recollection. She had really bad skin that was flaring up lots and it was making her life miserable. And I got a strong sense that chronic stress was driving her skin flare ups. So what I suggested about a little morning routine, she said, I don't have time for any of this stuff. Right. I said, okay, do you have 15 minutes? No. Do you have 10 minutes? No. Do you have five minutes? Well, yeah, I've got five minutes. I said, okay, great. So M number one mindfulness, she did what I call the three, four, five breaths. Let me just explain what that is because I mentioned it before as well. Anytime your out breath is longer than your in breath, you help to switch off the stress part of your nervous system and activate the relaxation part of your nervous system. Okay. So three, four, five breath is simply you breathe in for three, you hold for four and you breathe out for five. One of those breaths takes 12 seconds. Five of them takes simply one minute and it will literally change your physiology in just that one minute. Sana Qadar: And this is something you can do obviously at any time, not just as part of a morning routine before a big meeting, before an exam. But the question I have is, is the breathing exercise or even the routine enough on its own to actually have a long lasting impact? Dr Rangan Chatterjee: Well, it is because I'll tell you why. So let's go back to that patient then. So she did one minute of three, four, five breathing, two minutes of movements, and she used to love yoga, but since she became a mother, she never had time. So she did three or four of her favorite yoga moves and then she did two minutes of mindset. And for her, it was just affirmations. Now, there is quite a bit of research on affirmations and what they can do for our wellbeing and our stress levels. They're a little bit controversial. Not everyone buys into the research, but nonetheless, I think it's a very positive, empowering thing for someone to do. So she would say for two minutes, I'm happy, I'm calm, I'm stress-free. I'm happy, I'm calm, I'm stress-free. Remember, this took her five minutes. Sana Qadar: Rangan says that over the next 10 days, this patient's skin flare-ups reduced significantly. Dr Rangan Chatterjee: Because it's not just about those five minutes. What do those five minutes do? They remind you of what it feels like to be calm and relaxed. Once you started doing that, she was much more likely to stop at lunch and go for a 10 minute walk around her office block. She was much more likely to pay a bit more attention to her evening meal and make it a bit healthier. Sana Qadar: Basically, that small change had a ripple effect. Now, despite his own busy schedule, there's a lot that Rangan does in his own life as well to keep stress at bay. Things like having a hobby, he plays guitar, journaling daily, making time for some form of physical activity every day. Dr Rangan Chatterjee: I now, at this stage in my career, have quite a bit of autonomy. And I recognize that, okay? Not everyone does. I'm able to structure things so that I can. Sana Qadar: And one of the ways he's restructured his life recently is he quit his medical practice. He did that to free up time to focus on his podcast and his books and his public speaking and his role as a visiting professor of health education and communication at Chester Medical School. It's a very different life to his 30s when he was working full-time, taking care of his young family, and helping to care for his ailing father. Sana Qadar: I'm curious to know, what do you think your father would think about the life you've carved out for yourself and the work life you've carved out for yourself? Dr Rangan Chatterjee: Yeah, that's a great question. I actually think about this quite a lot. You know, dad died, I think, yeah, 12 years ago, just over 12 years ago. One of the things on a personal level that used to make me sad was that all the things that my dad would have been proudest about, you know, as an Indian immigrant to the UK in the 1960s, the fact that, you know, I had my own primetime BBC One TV show. I've had six Sunday Times bestselling books. I have the largest health podcast in Europe, whatever it might be. My dad got to see none of those things. And it used to really upset me. But at the same time, now I realize that if my dad was still alive, I wouldn't be doing any of these things. Because, well, there's two reasons for that. One is, and if there's anyone listening who's a carer, you know, they'll know how stressful life is when you're a carer. You know, I came back to the northwest of England to help my mum and my brother look after my dad. I didn't have time for anything else. You know, it was hard enough just to look after dad, just about keep my job going and see my wife. Right? It was very, very stressful. So number one, if dad was still alive, I don't think I'd have time to do the things that I've done. But secondly, the most important things I've learned have come from my dad's death. And now I've reframed my dad's death to believe that dad actually gave me a gift through him dying. Because the man I am today, the questions I started to ask myself after my dad died, I'm not sure any of those things would have happened until dad had died. So actually, again, I understand the death of a parent is a really challenging time for most people. I'm not expecting or asking anyone else to reframe their own parents' death in this way. But I do believe that life is simply a set of experiences and it's the story we put onto those experiences that ultimately determine the quality of our life. And I'm able to 12 years on now, reframe my dad's death as being, that was a gift to me. Because all this wisdom, I hope that I can share with people that really helps them. A huge part of that has been through my dad's death. Sana Qadar: And you mentioned other patients you've worked with who had also kind of worked themselves to the bone, regretted not stopping earlier. I'm wondering, do you know if your father wished he hadn't worked quite so hard by the time he got sick? Did he wish he had stopped earlier? Dr Rangan Chatterjee: You know, there's only one question I would love to ask my dad if I was still alive. And I don't know the answer. One of the questions, the only question is, dad, was it worth it? Because being truthful, although dad worked himself to ill health, I've changed my view on this over the past years. I now think, Rangan, you have no right to think that your dad made a mistake. You don't know that. Dad may say, if he was alive, he may go, I'd do that all over again. Because my only purpose in life was to look after my family back home and to give you and your brother the very best start in life that I could. Now, if that is true, which I believe it to be true, my dad may say, well, I kind of did that, right? I looked after everyone at home and look at what you're now doing, son. Look at how many people you're helping all over the world with what you do. I would do that all over again. So I'm hypothesizing here. I honestly don't know. Do I believe my dad could have done those things and not got ill at the same time? Yeah, I do believe that was possible. But how can I possibly know? But he never said to me, to be clear, I wish I'd stopped earlier. So I'm speculating. Sana Qadar: Rangan, it's been so lovely chatting to you. Thank you for sharing your family story and the story of your patients and everything you've learned over the course of your career. We really appreciate it. Dr Rangan Chatterjee: Yeah, thanks so much for having me on. Sana Qadar: That is Dr. Rangan Chatterjee, until recently a practicing GP, and he's also the host of the Feel Better Live More podcast. Rangan is going to be touring Australia in mid-July with live events in Melbourne, Sydney and Brisbane. If you want to find out more, just search An Evening with Dr. Rangan Chatterjee. He'll be at Melbourne Town Hall, the State Theatre in Sydney and Brisbane City Hall. That is it for All in the Mind this week. Thanks to producer Rose Kerr, senior producer James Bullen, and sound engineer Tegan Nicholls. I'm Sana Qadar. Thank you for listening. I'll catch you next week.

SBS Australia

2 days ago

• SBS Australia

Suicide prevention workshops in language try to help refugees, asylum seekers find mental wellness

Listen to Australian and world news, and follow trending topics with SBS News Podcasts. Nuha Abdul Razaq arrived in Australia from Iraq as a refugee in 2005. She says the topic of suicide is something many from the Arabic-speaking community find especially difficult to talk about. "It's a topic which they never talk about it in our country. When I was in Iraq or many people, I have clients from Syria, from different countries, from Lebanon or from Jordan, maybe we didn't talk it, we didn't talk about suicide in our countries. It's like, some people they feel it's shameful." She now delivers suicide prevention workshops in Arabic for refugees and asylum seekers. The workshops are part of a program launched by Wesley LifeForce which provides training in suicide prevention in six languages: Arabic, Dari, Farsi, Karen, Khmer and Tamil. It's co-designed with survivors of torture, trauma and forced displacement, paired up with the program by an organisation called Service for the Treatment and Rehabilitation of Torture and Trauma Survivors - STARTTS. Ms Abdul Razaq says the success of the training is in large part because it's delivered by people like herself who understand the challenges and stresses of displacement and resettlement. "To move to another country, it's not easy. Some people, they stay in camps for 10 years, 12 years, moving to other country, which is different languages, financial, most of them, they don't have any money to spend, even if they move to other country, if they want to find a job, it's struggling to get a job. And when you get settlement to Australia, another one, you have all (the) stress comes with you." Recent research shows refugees and asylum seekers in Australia experience disproportionately high rates of suicide. Data from the Australian Institute of Health and Welfare shows between 2007–2020, humanitarian entrants to Australia were 1.7 times more likely to die by suicide compared to other permanent migrants. Bethany Farley, the National Training Manager at Wesley Lifeforce, says the broader figures around mental wellbeing for refugees and asylum seekers are also deeply concerning. "There's reports that show that over 50% do actually report that they have poor mental health with more than 25% experiencing PTSD. There are some other reports around thoughts of suicide, which for men can be as high as 10% and for women can be as high as 17%." Deputy CEO of STARTTS Lachlan Murdoch says the trauma of war and displacement presents complex psychological challenges for refugees and asylum seekers. "So being pushed out of your country in traumatic circumstances, exposure to conflict and war, being subjected to things like shelling and bombardment, in some cases being imprisoned and being held in circumstances of great deprivation. Experiences of torture. So all those things impact people in ways that affect their psyche. So refugees experience much higher levels of anxiety and depression and post-traumatic stress disorder and suicidal ideation." He says for asylums seekers, these experiences of trauma can be further complicated by fear of being returned to the country they have fled. "Asylum seekers are in a situation where they're living in protracted uncertainty. And so there's not clarity for them about whether the person will remain in a situation of relative safety or could be returned to circumstances of danger. So that experience of uncertainty also compounds the traumatic effects of exposure to violence and to conflict." Ms Farley says these challenges are exacerbated by a lack of access to culturally appropriate care for refugees and asylum seekers arriving in Australia. "Then you add the other challenges of a language barrier, not understanding how the processes work. And finding services that have translators or people that can actually understand the nuances of how their community and culture responds to different situations, to different processes. The mental health models themselves can be alienating in that they do not meet the needs of a multicultural community." The suicide prevention training delivered by community members like Ms Abdul Razaq aims to address some of these issues by facilitating workshops where participants can share experiences in their own language and learn from each other about the supports available. Ms Abdul Razaq says the stigma attached to speaking about suicide was initially a barrier for her. "And at the beginning I was stressed when I was trained for the first time and I hearing something, some information, but later I accepted that if that's happening in the community, we need all the community to know about it." After delivering the first training session, she says she was inspired by the openness of the participants, and their ability to move past any shame they might associate with talking about suicide. "Nine women attended and it was very good and I liked the way they talk about it. They open their mouth and talk about their stories as well. And it's to build comfortable space between us and to build the trust between us. When they want to talk, they will talk in a normal way." If you or someone you know needs crisis support, contact Lifeline on 13 11 14, the Suicide Call Back Service on 1300 659 467 and Kids Helpline on 1800 55 1800. More information and support with mental health is available at and on 1300 22 4636. Embrace Multicultural Mental Health supports people from culturally and linguistically diverse backgrounds.