Trigger Warnings : Mentions suicide. If you have suicidal feelings, please consider seeking help through the helplines and resources listed here.
Suicide in India cannot be separated from the family context. The National Crime Records Bureau’s 2022 data reports family problems (34%) as the leading reason for suicide, followed by illness (18%), marital conflict (5%), and what the report refers to as love affairs (4%).
Marital conflicts and love affairs overlap with family problems. If you combine these three, family-related problems contribute to nearly half of suicide deaths in our country. The Indian context makes this especially salient.
Our average family size is four to five people, compared to two to three people in the United Kingdom (UK) or the United States (US). The average size of the house these five people share in India is around 500 square feet, compared to 800 to 1000 square feet spaces shared by two to three members in the UK or the US. Which is to say: those of us living with mental health issues are often crying in the face of our families, whether they are the cause of it, they see it clearly, or only sense it.
Consistent with this, a real-world study from India reported that 64% of suicide survivors perceived their family members could have helped in preventing their attempt. Nevertheless, family-based interventions for suicide prevention remain largely untested in our settings and figure mostly in post-bereavement support in our national suicide prevention strategy.
But should we even consider families as sites of interventions? As Ocean Vuong, a Vietnamese American poet, put it, how can one be expected to heal in an environment that is inflicting wounds in the first place?
The Cost of Lacking Skills to Heal Together
It’s important to unpack the family environment of suicide survivors to be able to answer this critical question. There are very few qualitative studies that unpack our context. That leaves personal anecdotes to fill in the gaps.
I lost my elder sister to suicide in 2014. At least a year before her death, I could hear her self-harming from across the closed door. She was 22, I was 20. Both of us were medical students. She needed help. I wanted to help. But that exchange of support never happened. A lot of it had to do with a lack of capability on either of our ends to start and sustain a conversation full of overwhelming emotions.
Suicidal intent comes shrouded in a range of unpleasant feelings and behaviours alongside concern and care. I was shocked, concerned, angry, and helpless at the same time. I did not even begin to imagine how she felt until I found myself in her place years later. Borrowing from Kafka, I could have built the Pyramids with the effort it took me to cling to life and reason.
Dealing with these emotions is not a one-time event. They wax and wane. They require understanding, patience, and skills to be dealt with appropriately. And emotions are not the only element. Even within our singular family, the family problems that led up to us losing her ranged from our mother’s terminal illness, our dysfunctional bond as siblings, financial difficulties, strained relations with other family members, and topped by our lack of knowledge and skills in communicating the urgent yet uncomfortable.
We as a family were a “risk factor”. Our interactions inflicted damage. Irreversible damage. Could we have also been a site of healing? As counterintuitive as it sounds, the answer is an emphatic yes. Some support, some guidance, some training, some experience sharing, and we could have seen things in perspective. That could have spelled the difference between life and death for her. There is research to back up this claim.
Methods That Work
In many countries, different types of family-focused therapies have been tried to prevent suicide. These include approaches that help families talk better, manage emotions, solve problems together, and support each other during crises. Some examples are family counselling, home-based support, and therapies that teach coping and communication skills. These methods haven’t been widely tested in India yet. A type of counselling called Cognitive Behavioural Therapy has also been tested to help people who struggle with both substance use and suicidal thoughts at the same time. These interventions have shown mixed results. But will these interventions work in our setting?
It is important to note that whether an intervention works or not is shaped by the context in which it is implemented and the reasoning and beliefs it changes in the target population. So, a program can work in one setting, may fail in another, and may need reiterations in some other setting. The important thing is to test these in our settings.
Indian mental health researchers and practitioners do some excellent work with community-based interventions for severe and common mental health conditions. I spent a month with Ekjut, a grassroots organization that partners with tribal communities in Jharkhand to improve mental health and well-being through a community-led approach.
What struck me the most were the peer support groups. These groups were a mix of family carers and people living with severe mental health conditions. Everyone was at a different point in their mental health journey.
The meeting I attended was facilitated by a community member with such empathy and psychosocial competence that I left wanting the same program back in my hometown. These were safe spaces where people could share, heal, receive support, and feel less alone. Burans’s work in Uttarakhand supports family carers using similar ground-up approaches.
Can these be extended to suicide prevention? Can families find a place in, say, the brilliant workplace mental health model developed by our own mental health researchers? The beauty of this model is in its focus on the cause of stress. Rather than seeing stress simply as “the problem,” it asks what sets stress in motion, and then offers solutions at both the personal and workplace levels. Families, too, can be looked at through a similar lens when we think about suicide.
Family as a Unit of Intervention
There is undoubtedly the risk of conflict escalation within families that may make things worse. In no way am I belittling the harm families can cause. The complexity of family dynamics is not lost on me. As complex as these are, there is also heterogeneity, the presence of multiple actors. In my own experience, I had to completely cut off from some family members and some are the reason I am still alive.
A recent study posits that 135 people are exposed when one person dies of suicide. It shows there is a potential network of people who can be moved to the solution side of suicide prevention. For example, in an intervention to prevent suicides in teenagers, each teenager was invited to name the adults they trusted most, the ones who felt safe to lean on. Usually, this turned out to be three or four people.
These nominated adults were then gently guided with practical information on how to be supportive and encouraged to stay closely connected with the teen for the next three months. It was a way of wrapping young people in a circle of care, built from relationships they already valued, towards preventing suicide. Approaches like these may be a safer way to start testing family-based suicide prevention in our settings.
Within our current national suicide prevention strategy, we can invite families into gatekeeper trainings and build skills for psychological first aid to spot warning signs, to listen without judgment, and to connect someone to care. A worried parent may pick up the phone before a crisis escalates. A sibling may notice a subtle withdrawal.
Recognising suicide triggers, learning how to talk about the messy and uncomfortable feelings around suicide, finding ways to grieve and to live with a loss to suicide - these are not skills most of our families have. And these are not skills we’ll gain without concerted external support.
A life may be saved when such tools are within reach. Think about the people closest to you. Ask yourself if you ever find yourself at the deep end of mental health, are they capable of steering you towards life? Are you capable of doing the same for them? And, most importantly, are you willing to gain the capability for the same? If it’s two nos followed by one yes, it’s time to advocate for inclusion of families in suicide prevention. Now.
Edited by Parth Sharma
Image by Gayatri
