The role of the family and the environment of people at risk of suicide

The environment that lives with a person at risk of suicide is key in preventing suicidal behavior. The link with the clinical environment is essential in order to increase protection in people who may be at risk of suicide, but the immediate environment is the group that must deal with informal care and that, according to different studies, is most impacted by the psychological burden of this experience.

We also know that suicidal behavior is more common among single, divorced, living alone, or lacking social support. In this sense, the number and quality of people's social relationships has suffered a great impoverishment , due to the individualism established in our consumer society, which evidences the loss of interpersonal bonds and the decrease in spaces for community relationships, which lead us to situations of greater vulnerability and social isolation.

Within the framework of the Suicide Prevention Plan in Catalonia , the community environment is identified as a main element in the prevention of suicidal behavior and different actions are defined to accompany and involve families, friends and colleagues, who become the protective environment of a person at risk of suicide .

Some of these proposals are:

• Generate specific guides.
• Offer advisory services on preventive strategies and warning signs.
• Incorporate the family into the process of caring for people at risk of suicide with a previous history of suicidal behavior.
• Involve the environment in the person's safety plan or individualized plan.
• Supporting the family after a suicide attempt.

Therefore, there is a broad consensus that prevention measures must go beyond strictly health policies . We know that it is necessary to strengthen the value system of our society, cultivating from childhood skills and competencies such as communication and problem-solving and coping skills, which can help us enhance this protection towards people in our environment who may be suffering emotionally. In short, being able to increase interpersonal cohesion and enhance the empathy of each of us in relation to the suffering of others. As an environment, it is a priority to influence those protective factors in the context of people at possible risk of suicide, in order to link them to life, knowing that this vital purpose correlates negatively with hopelessness and, therefore, with the risk of suicide.

But how do we do it? What do families, friends and colleagues need to know in order to be able to support, reduce the suffering of others and at the same time protect ourselves from the impact that this situation has on our quality of life?

How the stigma of suicidal behavior affects the family and the environment

There are many limiting beliefs, the result of the stigma associated with suicide , that do not allow us to carry out our role effectively. Often, the family becomes the guardian-responsible and this increases their anxiety and contributes to the perception that the person at risk is a burden to their family or environment. If we accompany a person who has already carried out suicidal behavior, the fear of repetition will lead to a situation of sustained stress in the environment, and the symptoms related to the so-called caregiver stress will appear:

• Feeling of constant worry.
• Frequent feeling of fatigue.
• Poor ability to concentrate to carry out usual tasks.
• Loss of interest in activities that were once enjoyed.
• Increased irritability.
• Social isolation often caused by the stigma of the family member's suicidal behavior.
• Lack of control over the situation, due to the lack of resources to deal with the situation.

The environment of a person at risk of suicide experiences so-called caregiver stress, which must be recognized in order to seek help.

We know that suicide itself is associated with negative stereotypes, and survivors of suicide attempts experience both the stigma of mental illness and suicide, which can contribute to an increased risk of completed suicide. This stigma is also reflected among family members, through language that avoids the use of the term suicide itself, which is replaced by “the accident” or “when that happened”, among other expressions. The family and the environment generate a myth about what happened , and often limit the involvement of other people in the environment, which makes it difficult to expand the protection network.

One of the most difficult times for this environment is after an attempt, when community monitoring and support are crucial to avoid recurrences and to ensure a sustained recovery process. People discharged often lack social support and can feel isolated once they leave care, and their families can also feel helpless and have limited resources to provide appropriate support. Community monitoring and support have been shown to be effective in reducing deaths and suicide attempts among people who have recently been discharged.

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The risk after a suicide attempt

Having made a suicide attempt is one of the strongest predictors of future suicidal behavior . For this reason, it is essential to adequately support the person at risk during the months following an attempt.

In the event of an attempt, the most common thing is to go to the emergency services of a hospital so that the person can receive multidisciplinary care, from both physical and mental points of view. This may be the first contact with mental health services and should be used to rethink everything that has happened and see how it can be addressed from now on. We could say that a moment of crisis like this can be an opportunity to do a "reset" and be able to look at the future differently.

Some of the people who go to the emergency room will require hospital admission, while others will be preferentially linked to outpatient mental health services. In both situations, once the person is discharged, it is advisable to offer some strategies to the family or close environment so that they can detect and prevent potential risk situations in their daily lives.

The most important recommendation for the family is to actively listen to the person at risk and not avoid the difficult conversations that this listening may generate. Talking about suicidal behavior does not increase the risk, but rather reduces it.

It is also important to inform about those warning signs that one should be attentive to and seek a protection network so that one is not alone in accompanying the person at risk. Finally, it is essential to convey that if risk situations are identified, they should be communicated to the relevant professional and avoid establishing pacts of silence with the person at risk that may be counterproductive.

Tips for providing good accompaniment

The family, therefore, and especially in adolescence, is the main protective factor against the poor development of suicidal behavior. So, beyond the resources that families have at their disposal, the role they assume is also important in achieving four aspects that are basic in suicide prevention: reducing discomfort, increasing hope, increasing the sense of belonging and reducing the capacity for suicide. Some tips on how to provide this close and protective support are:

• Eliminate or guard access to lethal methods that may exist in the family environment.
• Ensure that the person at risk complies with specialized outpatient monitoring, even at times when it makes no sense to do so.
• Convey hope: "We will get through this together, patiently and without haste, but we will get through it."
• Encourage social and family participation, encouraging the person at risk to see their friendships and be told that they are important to everyone.
• Convey to him the idea that we feel good being able to help him, that we can all go through a bad time like his, and that, sometimes, helping others gives meaning to our lives.

Healthcare system resources

Emergency services and Primary Care are usually the most frequent gateways to the healthcare system after a suicide attempt. In both cases, urgent psychiatric assessment is requested after physical stabilization of the potential damage resulting from the attempt. The person will be assessed for mental status and suicide risk to determine the best approach to follow to ensure a successful outcome of the process.

Normally, the decision is made to hospitalize after an attempt those people who:

• They present serious symptoms of a mental disorder.
• They have carried out an autolytic attempt with high lethality.
• They have a high and sustained suicide risk.
• They have difficulties in autonomous functioning and high social vulnerability.
• They do not have a containment environment that can constitute an adequate protection network.

When these situations do not occur, a preferential referral is usually made to a mental health center (for adults or children and adolescents, depending on age) or, if there is a concomitant addiction problem, to an outpatient drug addiction care and monitoring center. In these centers, multidisciplinary teams made up basically of professionals from Psychiatry, Psychology, Social Work and Nursing provide specialized care on an outpatient basis.

Making an attempt is an opportunity to link or reconnect with the healthcare system.

In all these devices, the interaction of professionals with the family and the close environment of the person who has made the suicide attempt is essential. The family constitutes a basic element to reconstruct the situation of the person at risk and to guarantee a protection network in day-to-day life . Furthermore, the healthcare system is aware of the suffering that a family experiences when one of its members is at risk of suicide.

If the person at risk authorizes it, an attempt is always made to contact the family to accompany them during the process, in addition to establishing a reciprocal flow of information and deciding on an action plan. It is important to mention that, in general, if the person at risk does not accept it, the healthcare staff will not be able to inform their family.

Suicide prevention programs and resources in Catalonia

In the last ten years, different programs and resources focused on suicide prevention have been developed within the Catalan healthcare system. Among them, we highlight the Suicide Risk Code, the Catalan Suicide Prevention Plan 2021-25 (PLAPRESC) and the direct helplines that have been created in the last year.

The Suicide Risk Code (SRCC)

The Suicide Risk Code (CRS) is a protocol for care and preventive actions for suicidal behavior that the Department of Health of the Generalitat of Catalonia launched in 2014 and that has provided full coverage to all of Catalonia since 2016. The main objective of the CRS program is to detect early people who have attempted suicide or who are at high risk of suicide and provide them with urgent care and continuous preventive monitoring, according to the level of risk. The CRS is activated by mental health teams throughout Catalonia and, above all, by Emergency teams. The most innovative part of the CRS program is that it ensures a rapid specialized care visit after hospital or emergency discharge, within a maximum period of 10 days for adults and 72 hours for minors under 18, and a follow-up telephone call within 30 days.

Suicide Prevention Plan of Catalonia 2021-2025 (PLAPRESC)

The Department of Health of the Generalitat de Catalunya has been operating the Catalan Suicide Prevention Plan 2021-2025 (PLAPRESC) since 2021 , a prevention tool coordinated by Dr. Diego Palao, which has been worked on jointly with mental health associations and with family and survivor organizations. The PLAPRESC aims to reduce the rate of suicide attempts and death and reduce social stigma through community-based actions.

Direct service telephones

Among some of the PLAPRESC's actions, the creation of the 061 Salut Respon professional mental health coordination center to address and prevent suicide, which has been operating since June 2022, stands out . This is a specialized telephone assistance and care health team with mental health specialists –Nursing, Psychology and Psychiatry– that offers service 24 hours a day, 365 days a year to people with suicidal behavior or ideation , but also to family members and loved ones. This team also has the capacity to activate the CRS to ensure a rapid link with the health system.

Along the same lines, at the state level, the Ministry of Health created the 024 Suicidal Behavior Helpline in May 2022.

It is important to mention that the pioneering telephone line for suicide prevention in Catalonia was created in November 2020 by the Barcelona City Council. The free hotline 900 925 555 was enabled, operating 24 hours a day with the guidance of the Ajuda i Esperança Foundation . The service is offered by volunteers who have been selected and trained to answer this type of call, and is coordinated and supervised by a psychology team and an expert committee. This initiative was developed within a mental health emergency plan that also included the activation of a point of care located in the Barcelona Cuida space, designed to serve family, friends and people in the work environment of people at risk of suicide, managed by the Catalan Association for Suicide Prevention (ACPS ) and by the association After Suicide – Association of Survivors (DSAS) .

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Community resources to support families and people at risk

The need to link the medical, family and community spheres is fundamental in suicide prevention, and in this sense it is important that families and those around them can seek support in:

• Reference professionals who give them advice and help them understand suicidal behavior.
• Social Work Professionals, who will offer you appropriate resources for your family member's situation.
• Entities specialized in the disorder that the family member has, in case there is a diagnosis.
• Family associations specializing in suicidal behavior.
• Psychoeducational groups for family members, offered in primary care centers, mental health centers and associations specializing in suicidal behavior.
• Professionals who can help them cope with the situation. If necessary, additional psychological support can be sought.

Ultimately, the involvement of family, friends, colleagues and mental health professionals is necessary to strengthen the protective network of the person who may be at risk of suicide, and it is necessary to-it together, breaking with the stigma associated with this behavior. We need to establish an active dialogue with ourselves, with the person who suffers and with the professional environment in order to increase the protection, not only of the person at risk, but of the environment that is involved in the recovery process.