Keywords

1 Introduction

The rapid growth of suicidal death has been identified suicide as a public health problem worldwide that implies taking urgent actions to reduce the suicide rates (Mueller et al., 2021). Recent estimates (2021) of suicide found that 703,000 people die by suicide every year worldwide, which represents on average more than 1 death in every 100 deaths occurred by suicide (World Health Organization [WHO], 2021). Globally, suicide is one of the fourth leading causes of death among the young people aged 15–29 years for both male and female (World Health Organization, 2021). It has been estimated that approximately three fourths of suicide deaths occur in lower and middle-income countries (LMICs) due to the greater size of their populations and lack of resources for interventions for preventing suicide (Edwards et al., 2021; World Health Organization, 2021). Currently, suicide is the 4th leading injury-related deaths in Bangladesh (Khan et al., 2021). Despite a growing number of studies on suicidal behaviors in Bangladesh, there is no longitudinal, nationwide, interventional, and epidemiological study on suicide especially on suicide prevention (Arafat, Hussain et al., 2021). Majority of the previous studies explore the individual risk factors of suicide such as depression, substance use, prior suicide attempt, financial crisis, and so on (Frey and Cerel, 2015; Urme et al., 2022). But there is a need to assess the attribution of family in suicide and develop prevention measures to reduce suicidal behavior based on family dynamics (Arafat, Saleem et al., 2022; Edwards et al., 2021; Frey and Cerel, 2015).

Worldwide, the common age range of suicide is 15 to 44 years old, where suicide is rare before the age of 15 (Edwards et al., 2021; Urme et al., 2022). Bangladesh has the highest adolescent fertility rate among the South Asian countries and adolescent pregnancy impacts psychological health which increases the risk of suicide (Li et al., 2021). Family dysfunction, family conflicts, family socio-economic condition, family violence, and family stress are frequently associated with suicide risk behaviors for adolescents (Khan et al., 2020; Randell et al., 2006). A number of studies revealed that more than half of the suicides occurred due to emotional reasons within family (Reza et al., 2014; Shahnaz et al., 2017). Marital disharmony, family stress, extra and pre-marital issues, relationship strife, and poverty were found as most common risk factors within the family environment (Arafat, Hussain et al., 2021; Arafat, Saleem et al., 2022). Although there is a paucity of research on suicide prevention in Bangladesh, supportive and healthy family environment, raising awareness, gatekeeper involvement, identification of protective factors, continuity of care, and increase access to marital therapy were assessed as prevention methods by engaging family members (Arafat, Saleem et al., 2022). Parental homework check would also be a prevention strategy for suicide among the school-going adolescents in Bangladesh (Khan et al., 2020). As there are no national surveillance system or suicidal database, criminal legal status, and social stigma, most of the suicide cases are underreported (Arafat, 2019; Arafat, Hussain et al., 2021).

Nevertheless, suicide prevention is often a less prioritized issue by governments and policymakers (World Health Organization, 2018). To promote mental health and well-being, suicide is an indicator of Sustainable Development Goals (SDGs) 3.4.2 which targets to reduce suicide by 33% in 2030 through enhanced prevention and treatment strategies (Khan et al., 2021). According to the World Health Organization (WHO), the role of family can positively contribute to mental health policies and practices (World Health Organization, 2018), which is especially significant for LMICs including Bangladesh that has a fragile mental health system (Arafat, Saleem et al., 2022; Edwards et al., 2021). Against this backdrop, this chapter will interpret the relationship between suicidal behaviors, within the family context that can be helpful in developing effective suicide prevention programs.

2 Family Structure in Bangladesh

Family is a culturally constructed unit which is a building block of social structure for all societies. Family is defined as a group of people who have interacted and communicated with each other by marriage, blood, or adoption, constructing a single unit and also shared common culture or common beliefs (Arafat, Saleem et al., 2022; Uddin, 2009). In Bangladesh, most of the families are governed by patriarchal lineage and males have the decision-making power where women are dominated by their husbands and as well as their in-law’s family members. But through modernization and urbanization, there has been a change as women are involved in employment and playing a more active role in decision-making of families and societies (Arafat, Saleem et al., 2022; Bhandari and Titzmann, 2017; Samad, 2015; Zahangir, 2011).

The family structure and size are also changing in Bangladesh, from extended family to nuclear family because of the participation of women in economic activity which was rare before (Samad, 2015). Another study focused on the changing family patterns in Bangladesh demonstrates that fertility rate is declining by the role of family planning methods in both rural and urban areas. Furthermore, age of marriage is rising by reducing child marriage, increasing awareness about reproductive health, implementation of marriage-related laws, enhancing the education rate, and reducing existing social taboos on early marriage (Samad, 2015). With changing the rate of divorce in Bangladesh, a new family pattern single parenthood has been trending (Afroz, 2019).

The household size has decreased from 5.7 in 1981 to 4.2 in 2019 (Arafat, Saleem et al., 2022). About 35% of women in Bangladesh have experienced domestic violence at home where their marital age, number of children, decision-making role in family, lack of support from family members, and household food insecurity are associated with this violence (Arafat, Saleem et al., 2022; Haque et al., 2020). Intimate partner violence is associated with such as sexually transmitted infections, long-term pain, perinatal mental health problems, substance abuse, stress, depression, anxiety, and suicide (Haque et al., 2020).

Bangladeshi families have a higher level of solidarity, interconnectedness, and amalgamation between the household members. Parents must look after their children before their marriage and sometimes even after marriage when the children are in an economic crisis in their in-law’s household. The children, especially the male children, also take the responsibility of their parents after getting job. Bangladeshi parents decide what their children will do in future and the children follow their instructions without raising any complaints (Arafat, Saleem et al., 2022).

3 Risk Factors for Suicide in Bangladesh Related to Family

We discussed the risk factors for suicide in Bangladesh in the first chapter of this book (Kabir et al., 2023). Here risk factors related to family have been emphasized. The French sociologist Emile Durkheim explains that suicide is a social fact which occurs due to less social integration with family, friends and so on, and also lack of social norms and regulations on behavior would force to take lives by suicide (Mueller et al., 2021). Risk factors of suicide related to different aspects of family have not been extensively studied yet by the previously in Bangladesh (Arafat, Hussain et al., 2021). The previously noted common risk factors of suicide are previous suicide attempt, physical and sexual violence, psychiatric disorders (such as depression, anxiety and stress, personality disorders, substance abuse), hopelessness, loneliness, familial psychiatric history, familial suicide predisposition (such as not reared by biological parents, marital discord and family disharmony), relationship problems (like loss of loved one or loss of family relationship), financial hardship, and unemployment (Arafat, Mohit et al., 2021; Shahnaz et al., 2017; Feroz et al., 2012; Reza et al., 2014). Many of the risk factors of suicide are related to familial issues (Arafat, 2019). One study identified that approximately 93% of the participants took their own lives due to familial and marital disputes which were sorted by assessing newspaper contents (Shah et al., 2017). A community-based survey in selected rural areas of Bangladesh showed that 63% of suicide cases occurred due to family issues, among them 57% had a family conflict (Feroz et al., 2012). A case–control study found that 65.5% of suicides occurred due to family events including romantic relationship problem, death of a near kin, academic persecution, financial hardship, marital disharmony, family quarrels, and not reared by biological parents found by a case–control study in rural area of South-West Bangladesh (Reza et al., 2014). An extreme case of family involvement was noted in 2007 where nine members of a family took their own lives together due to their delusion regarding religion (Selim, 2010). A narrative review study demonstrated that conflict between husband and wife, family discords, widowhood, broken family, and relationship break-ups were the leading causes of suicide (Arafat, 2017). Another study showed that exam failure, suicidal death of close kin, marital dispute, not raised by biological parents were frequently reported as the risk factors for suicidal behavior (Shahnaz et al., 2017). A recent psychological autopsy study found several life events related to family events such as extramarital affair, family conflict, marital discord, broken engagement (Arafat, Mohit et al., 2021). About 40% of the life events were closely related to marital and sexual affairs including conjugal strife, pre-marital romantic relationship, illicit love relationship, forcible wedlock, and contention with kins contribute suicidal ideation (Arafat, Mohit et al., 2021; Arafat, Saleem et al., 2022). In addition, there are also perceived a few risk factors of suicide relevant to parent-children subsystem such as early marriage, academic failure, death of children, romantic relationships, negative parenting, domestic abuse by the parents; and experiencing psychosocial, physical and sexual abuse by teachers or peers in schools (Arafat, Saleem et al., 2022). Another risk factor is sibling subsystems which may be affected by intrafamilial abuse such as sibling conflicts, financial issues, and family business failures (Arafat, Saleem et al., 2022).

4 Role of Family in Suicide Prevention in Bangladesh

Every suicide has impact on a family’s well-being in various ways (Shahnaz et al., 2017). In other ways, engaging and involving the family members is vital to develop an effective suicide prevention program. Reducing suicidal tendency family members and care givers may play an important role by creating a supportive family environment, good communications between family members and strong relationships between them (Arafat, Saleem et al., 2022; Edwards et al., 2021). If the deceased person had a friendly environment in his/her family, that individual could share about his/her discomfort which can keep him/her far away from suicide (Edwards et al., 2021; Shahnaz et al., 2017).

A recent qualitative study which focuses on public university students of Bangladesh reported some suicide prevention strategies those are also related to family. For example, parenting skills training and workshops can be arranged at community level, ensuring follow-up care for the suicide attempt survivors by the support of family, raising awareness among all the general people through advertising and representing a drama are urgently needed for diminishing suicidal death (Urme et al., 2022). Stigma and taboo attached to mental health disorder patients and suicide survivors negatively play a role in both post-trauma counseling and suicide prevention (Arafat, Saleem et al., 2022; Shahnaz et al., 2017; Urme et al., 2022). The family-oriented prevention strategies would be raising awareness, gatekeeper training, identification of protective factors, access to psychiatric services, treatment facilities for suicide patients, continuity of care, access to marital therapy, supportive family environment, and promotion of family interactions (Edwards et al., 2021; Zalsman et al., 2016; Arafat and Kabir, 2017; Arafat, Saleem et al., 2022).

4.1 Raising Awareness

There is a need to organize awareness raising programs regarding suicide and suicide prevention for educating the general population including parents and family members through mass media (Zalsman et al., 2016). Efforts could be aimed to increase suicide literacy, decrease suicide stigma, identification of risky individuals, and available nearby health services. The parents will be more interested to seek mental health treatment for their children when the existing myths are allayed from society (Arafat, Saleem et al., 2022; Edwards et al., 2021). Bangladeshi family prefer to hide the suicidal thought or death due to ignoring the social stigma and legal harassments, so arranging awareness-raising programs at community level would be beneficial (Arafat, Saleem et al., 2022; Arafat, Hussain et al., 2022; Urme et al., 2022).

4.2 Gatekeeper Interventions

Family members can play a role as a gatekeeper as they have a connection with their kin who have suicidal tendency. It is a potential preventive strategy by which the vulnerable populations can be identified (Zalsman et al., 2016). Additionally, family interventions help to identify the warning signs of suicide among the adolescents (Zalsman et al., 2016). So, a formal training for the gatekeepers must be arranged to execute a problem-solving discussion on how to reduce suicidal ideation, attempt, and death.

4.3 Enhancing Healthy Communication in Family

Everyone must have good communication and engagements with the family members by which parent–child conflict and sibling dispute can be reduced in the family environment (Arafat, Saleem et al., 2022; Edwards et al., 2021). An effective and supportive communication between the family members can support them to combat depression, anxiety, hopelessness, and suicidal behavior (Arafat, Saleem et al., 2022).

4.4 Life-Event Focused Couple Counseling

Marital conflict and familial discord are potential life events for the suicide exposures (Arafat, Khan et al., 2021). In addition, the spousal subsystem affects the parent–child or sibling subsystem, so organizing a program for the couple's need which can be played a prominent role to keep a healthy relationship between family members. From this program, they can be benefitted knowing how to manage marital discords (Arafat, Saleem et al., 2022).

4.5 Follow-Up Care

Hospitalization or follow-up care is urgently needed for the suicide survivors who had prior suicide attempts. In this respect, information from the patients itself and also from close kin members is important to assess the risk factors of suicide (Edwards et al., 2021). Additionally, the time after the discharge from the hospital has been identified as a vulnerable period. Therefore, family members could be careful about the suicidal behavior during this period and should ensure the regular follow-ups.

4.6 Postvention

Suicide survivors are more stigmatized and ostracized by the community people rather than survivors of other types of death that is also true for the deceased persons’ parents who lose their child to suicide. After being negatively judged by the society people, the survivors sometimes keep them isolated from any social networks, a process called self-stigmatization, though this situation has been changed over time (Cerel et al., 2008). The family members need care after any suicide attempt (fatal or non-fatal) in the family. Care for the vulnerable family members for keeping them outside of mental health crisis helps to reduce the further risk of suicidal behavior recommended by the WHO (Arafat, 2021; WHO, 2018). But the family members always try to keep secret about their close kin’s mental health sickness because they think that the community can stigmatize them for this (Arafat, 2021). Sometimes suicide is contagious, one person can influence by another person’s death especially if the deceased person was his/her closed one (Urme et al., 2022). In this regard, postvention is urgently required which can be worked as an effective prevention method.

5 Conclusions

This chapter examines the relationship between the risk factors of suicide that are relevant to family, which can be helpful for developing and implementing effective suicide prevention strategies in Bangladesh. The common reasons behind self-destruction related to family such as marital discord, familial disharmony, extramarital affair, pre-marital love relationship, conflicts with family members, or weak interrelation with them should be taken into account for developing suicide prevention programs where family members have roles and responsibilities. This chapter discusses the potential areas of involvement of family members while considering the suicide prevention.