Addressing Suicide Risk Among Immigrant Women Survivors of Intimate Partner Violence

Abstract

Intimate partner violence (IPV) is a significant public health problem contributing to multiple morbidities. Immigrant women who experience IPV may be disproportionately vulnerable to poor mental health outcomes, including self-harm and suicidal ideation, due to cultural experiences and contextual factors that prevent them from accessing services. While existing studies identify the risks for suicidal ideation amongst survivors of IPV, there is limited knowledge on how to tailor strategies to support immigrant women survivors of IPV who experience suicidal ideation. This study was conducted as part of the formative phase of a longitudinal research project designed to develop and evaluate a safety planning intervention for immigrant women survivors of IPV. Using qualitative in-depth interviews, we explored the perspectives of immigrant women survivors of IPV (n=46) from various countries of origin, ages, and educational backgrounds on effective strategies for supporting immigrant women who disclose suicidal ideation. Study participants discussed various strategies for supporting survivors including building trust, providing encouragement, strengthening social support networks, and reminding survivors of parental responsibilities. Participants also pointed to the importance of the following services: domestic violence support, faith-based health resources, supportive immigration programs, mental health support, and emergency and medical treatment. These findings are informative for researchers and practitioners who work with immigrant women survivors of IPV, and they can be used to develop appropriate safety protocols and support strategies for survivors who are experiencing or have previously experienced suicidal ideation to mitigate the risk of self-harm.

Intimate partner violence (IPV) is a national concern with about 26% of ever married or partnered women aged 15–49 in the USA reporting experiencing IPV at least once in their lifetime (World Health Organization [WHO], 2018). Immigrant women survivors of IPV have diverse cultural experiences and contexts that contribute to higher risk of IPV and subsequent distress. For example, Mexican and Latina immigrant women survivors of IPV reported an increase in IPV after immigrating to the U.S. due to challenges such as language barriers, difficulty with adapting to new social and cultural structures, social isolation, economic disparities between themselves and their partners (Dutton et al., 2000). Rates of IPV are around 40% in South Asian communities in the USA, which is twice as high as the lifetime prevalence rate in the country (Mahapatra, 2012). South Asian immigrant women from countries such as India, Pakistan, Bangladesh, Nepal, and Sri Lanka often deal with a patriarchal cultural system that pressures them to depend on their partner and stay in abusive marriages to “uphold family values and honor” (Kallivayalil, 2010; Sabri et al., 2018). Furthermore, religion can act as both a protective and risk factor for immigrant women (Sabri et al., 2018). Religious beliefs and community can be a resource to assist women who are trying to address or cope with abuse, while also maintaining their relationships (Ghafournia, 2017). Moreover, African survivors of IPV have been found to face responsibilities to stay in their marriage and keep their families together and their abusers are likely to use cultural beliefs for harmful tactics (Sabri et al., 2018). Immigrant women survivors of IPV face even more significant health challenges than their U.S.-born counterparts (Stockman et al., 2015). At the most extreme, immigrant survivors are at greater risk of becoming victims of homicide secondary to IPV (Sabri et al., 2021) and suicide-related mortalities (Forte et al., 2018).

Immigrant survivors are less likely to have knowledge of and access to resources and support for their safety, health, and empowerment (Ayub et al., 2020; Sabri et al., 2018). This can be understood as related to immigrant women’s greater reluctance to disclose their experiences of IPV due to societal attitudes, lack of awareness of their rights, and fear of repercussions related to immigration status (Park et al., 2021). For example, African immigrant women experience IPV at high rates and are often unaware of social and legal services available to them, and they are unlikely to either report abuse or accept help from outside their family or community (Ting & Panchanadeswaran, 2009). Immigrant survivors are also less likely to seek formal support for mental health (Alvarez & Fedock, 2018; Vroegindewey & Sabri, 2022).

IPV is a known risk factor for adverse mental health outcomes, particularly suicidal ideation. Suicidal ideation is defined as thinking about, considering, or planning suicide (National Institute of Mental Health [NIMH], 2023). Experiences with IPV are associated with symptoms of depression and subsequent suicide attempts in women (Devries et al., 2013). Suicide attempts and depressive symptoms—such as crying easily, inability to enjoy life, and fatigue can also significantly exacerbate IPV experiences (Devries et al., 2013; WHO et al., 2013). Studies suggest an increased risk for suicidal distress among immigrant populations, potentially related to various population-specific risk factors such as immigration trauma, language barriers, separation from family, inaccessible culturally competent resources, and acculturative stress, among others (Amiri, 2022; Fortuna et al., 2016).

Though understudied, the potentially heightened risk of suicide among immigrant populations is of particular concern for immigrant IPV survivors. During the COVID-19 pandemic, immigrant women who experience IPV have been further marginalized by unprecedented barriers to mental health care as the pandemic has also affected symptoms of distress (Sabri et al., 2020). Distress and mental health crises among this population are further intensified by limited access to support resources, financial strain, social isolation, decreased ability to report abuse, and increased abuse, among other stressors (Sabri et al., 2020). Due to the increased risk for suicide this population faces, it is imperative to gain a better understanding of best ways to support immigrant women survivors of IPV who indicate self-harm and suicide ideation.

There is, however, a lack of knowledge about how researchers conducting studies on intervention development and evaluation and practitioners such as nurses, social workers, and mental health providers who frequently work with immigrant women survivors of IPV can best support immigrant women who disclose suicidal ideation in the process of research as well as when accessing services in the community. It is particularly valuable to obtain input on strategies of support from survivors themselves who experience IPV given the heterogeneity of cultural and contextual factors that shape diverse immigrant women’s needs. Accordingly, the aim of this study was to explore support strategies to respond to suicidal ideation when conducting research or intervening with immigrant women survivors of IPV.

Conceptual framework

The Socio-Ecological Model outlined by the Centers for Disease Control and Prevention (CDC) has been used with multiple populations across IPV and trauma research (Centers for Disease Control and Prevention [CDC], 2022). Cramer & Kapusta have articulated a Social-Ecological Suicide Prevention Model adapted from the CDC socio-ecological model that delineates protective and risk factors specific to suicidal behavior (Cramer & Kapusta, 2017). The Social-Ecological Suicide Prevention Model consists of four eco-social levels: individual, relationship, community, and societal (CDC, 2022; Cramer & Kapusta, 2017). The first level is the individual level, which includes biological and personal history factors that may influence suicidal behavior such as age, education, income, substance abuse, history of abuse, mental health diagnoses, prior suicide attempts, and presence of suicidal intent. The relational level encompasses close relationships such as peers, partners, and family members that influence the risk of suicide. The community level comprises of schools, workplaces, neighborhoods, and other settings where social relationships occur. The last level, the societal level, consists of health, economic, educational, and social policies that govern economic or social inequalities within different people groups; it also considers social and cultural norms in support of violent behavior (Cramer & Kapusta, 2017). The Social-Ecological Suicide Prevention Model was used to contextualize the findings from this study.

Methods

This study was part of the formative phase of a sequential mixed methods (Creswell, 2009) and longitudinal research project that was designed to develop and evaluate a digital safety planning intervention for immigrant women. This study utilized individual in-depth interview data collected from 46 immigrant women survivors of IPV in the formative phase of the parent study (DiCicco-Bloom & Crabtree, 2006). The approval was obtained from the Institutional Review Board at the university the study took place. Data collection ended once saturation had been reached, meaning that novel findings and key themes no longer emerged.

Following obtainment of oral consent from participants, one on one interviews were conducted over the phone or via Zoom video conference by three trained interviewers. The interviews were conducted virtually due to the ongoing COVID-19 pandemic at the time of the study. Each interview lasted 60–90 min. The interview guide included questions to elicit feedback on components of the digital intervention, as well as suggestions for improvement. In addition, the questions focused on the impact of COVID-19 (Sabri et al., 2020), strategies for recruiting and retaining immigrant survivors of IPV in intervention research, methodological, safety and ethical considerations and strategies to respond to distress and suicide ideation (Sabri et al., 2023). Three questions were asked to understand strategies to support immigrant women survivors of IPV experiencing suicidal ideation. The questions were: (1) If an immigrant woman says that she feels sad or very down, what do you think would be the best way for us to help her? (2) If an immigrant woman says that she wants to hurt herself, what do you think is the best way for us to help her? (3) If an immigrant woman said that she has thought about hurting herself in the past, what do you think is the best way for us to help her? The responses from these questions were used to explore support strategies to use in response to suicidal ideation among immigrant women survivors of IPV.

Sample description

Eligible survivors of IPV were foreign-born immigrant women residing in the USA who were English-speaking and over the age of 18. All participants had to report recent experiences of IPV (i.e. physical, sexual, or psychological abuse within the past year). The participants were recruited through purposive and snowball sampling methods from multiple states, including New Jersey, Illinois, Texas, Massachusetts, Virginia, Maryland, and Washington, D.C. through flyers and verbal invitations to participate by staff from partner organizations serving immigrant women survivors of IPV. Survivors interested in participating in the interview consented to be directly contacted by members of the research team. Sample descriptions are detailed in Table 1.

Table 1.

Participant demographics.

IPV survivors
	n (n = 46)	%
Age
20–29	9	19.6%
30–39	20	43.5%
40–49	15	32.6%
50–59	2	4.3%
Length of time residing in USa
1–9 years	22	48.9%
10–19 years	15	33.3%
20–29 years	7	15.6%
30–39 years	0	0%
40–49 years	0	0%
50–59 years	1	2.2%
Education
High school or less	5	10.8%
Some college	9	19.6%
Undergraduate degree	9	19.6%
Post graduate degree	23	50.0%
Region of origin
Africa	12	26.1%
Asia	22	47.8%
Caribbean	5	10.9
Latin America	7	15.2%

^aLength of time residing in US of one survivor was not provided.

Data analysis

Thematic analysis (Braun et al., 2019) was conducted to understand participant-recommended strategies to support immigrant women survivors of IPV with thoughts of suicidal ideation. The interview transcripts were thoroughly reviewed by two members of the research team, which consisted of graduate students enrolled in public health and nursing schools. The team members coded transcripts independently and consulted the Principal Investigator (PI), who has background in conducting intervention research with immigrant survivors of IPV, to ensure connection between the data and the main study themes and to assess for conformability, or congruence between data accuracy, relevance, and meaning (Lincoln & Guba, 1986). The team members and Principal Investigator engaged in reflexivity by ensuring the data collection and analysis reflected the thoughts of participants by utilizing thick description. Credibility, dependability, and confirmability were accounted for by creating an audit trail of procedures and written notes during both the individual coding processes as well as following meetings with both coders. When there were coding disagreements, the PI was consulted to reach consensus. Codes were created based on reported individual experiences of immigrant women survivors and then grouped into broader conceptual themes (Braun et al., 2019). The Social-Ecological Suicide Prevention Model served as a guide for separating the themes and identifying support strategies at the relational and community levels of the participants’ lives based on the model. Data collection stopped when no new novel findings on key themes related to the study aims emerged. Data analysis was conducted using the latest version (v.8.3.35) of Dedoose qualitative analysis software (SocioCultural Research Consultants LLC, 2019).

Results

The study participants recommended several different strategies to support immigrants experiencing thoughts of self-harm and suicide. Strategies were identified at the relational and community levels of the socio-ecological model (CDC, 2022) and are detailed in Table 2.

Table 2.

Summary of themes.

Strategies to respond to suicidal ideation
	n (n = 46)
Relational level
Build Trust	12
Encouragement	14
Social Support Networks	11
Children as Motivation	5
Community level
Domestic Violence Services	3
Faith-based Resources	4
Resources for Immigrants	9
Mental Health Services	24
Emergency and Medical Services	5

Relational level

Study participants recommended ways to support and build personal connections with immigrant women with thoughts of suicide. Participants specifically emphasized the importance of providing emotional support by building trust, giving encouragement, and maintaining confidentiality. Study participants also shared that relationships with close peers, partners, and family members can alleviate burdens and challenges that cause feelings of isolation and subsequent suicidal thoughts.

Build trust (n = 12)

Three participants discussed the need to build rapport with women and safeguard privacy. According to study participants, establishing trust is important to ensure survivors feel comfortable with talking to another person on the phone and sharing thoughts of suicide. One participant described that women in abusive relationships may not be comfortable with openly sharing their experiences and that building trust takes time. The participant shared how one could communicate to build trust and rapport:

You have to tell her… “I totally understand [you], and if you feel comfortable you can share, what’s making you sad or depressed? But if you’re not, I will give you time, and you can just speak about another topic,” … It’s little bit of a process. And next time she will open more. Through this way, you are building trust, and you will start helping her, and she will feel less depressed. (Survivor, Age 28, Tajikistan)

Maintaining confidentiality was also shared as essential component about building trust with immigrant women survivors of IPV. A participant stated, “If the person is willing to take help, then they will take help. If they’re becoming upset, the common reason might be thinking, ‘whatever I share, it might not be private. It might be shared with my partner.’ So, we have to reassure them that everything will be confidential” (Survivor, Age 28, India).

Participants also mentioned that they would feel more comfortable speaking about health concerns with providers that shared their cultural and ethnic backgrounds. Three participants said they would prefer that their providers were directly from their community or culture and spoke their language. “When I was speaking to my counselor who had a similar background or spoke the same language as me, it helps because they have a similar mindset…and they could connect with the individual on a personal level” (Survivor, Age 32, Pakistan).

Additionally, some participants preferred to receive care from providers who lived in their community because provider residency in the community alluded to providers being knowledgeable about community resources:

The key for immigrant women is to be closer to the cultural framework. Talking about what she’s living, because once you are there, and you feel that, okay, I understand you, and I’m talking in your language, or I’m talking from your community. Not someone who is out there, but someone who is in the community, in the local community. So, then it’s easier. It would be ideal if there were people from the same community—who are more in touch with the agencies or the groups. (Survivor, Age 43, Peru)

Provide encouragement (n = 14)

Participants shared that instilling hope is another beneficial strategy for helping survivors feel resilient and optimistic about their future. Several participants explained that survivors often feel hopeless about having to support themselves and overcome challenging past experiences, which is why hope is especially needed:

You have to encourage her…They hurt themselves because they feel they’re alone, and they cannot do without him…They feel very unsafe or insecure…Whatever is happening, that is not her fault. That is the other person’s fault. And she should not think about that. She’s brave. She’s fighting against those things. (Survivor, Age 39, India)

Another participant shared an example of how to remind women of their strength:

‘Your pain is real. But there is a way out. You can turn this pain into joy. Just like the boat that is sailing on the sea. It doesn’t sink. But once water gets in the boat, it sinks. So don’t let this get into you. You are stronger than you think you are.’ It’s just to bring out the power in her, which is dormant, and she doesn’t even know that she possesses it. (Survivor, Age 40, Cameroon)

Nine participants discussed the importance of providing reassurance and validation to promote feelings of self-worth to immigrants with thoughts of suicide. One participant shared the need to foster confidence: “Reassure her that…she’s important. Just because someone may think she’s unimportant doesn’t mean she isn’t important. Build up her confidence” (Survivor, Age 44, Bermuda). In validating women, participants also noted the importance of providing empathy and provided specific examples of empowering statements:

‘You are important to people here. You are important in this world’…There has to be something that makes them feel positive, that ‘What if my husband is not nice, but there are other people. The world is so beautiful. I can do that’ … Somebody should be there to assure them that life is beautiful. (Survivor, Age 46, Pakistan)

Enhance social support networks (n = 11)

Participants commented that they faced thoughts of suicide due to challenges associated with residing in a foreign country and living far away from their families. “Immigrant women [are] more stressed because we grew up in a different country…Going through here without a family is a big thing and then family doesn’t support that is a big thing again” (Survivor, Age 37, India). Participants described difficulties with adapting to a new culture and feeling isolated due to lack of community and friends. Participants shared the need to identify local support systems for emotional support, yet al.so expressed hesitation approaching community members due to fears of judgment:

You can’t go back to your family when they thought you would have a better life. You chose to move so far away from them. And so, you’re kind of on your own. And then if there’s a language barrier, where do I go? I don’t want to talk to anyone about this. And your own community might be like, ‘That’s shameful.’ They don’t want to talk about that. Like, ‘Just put up with it. That’s private stuff’ So, there’s really no one to go to. (Survivor, Age 31, South Korea)

Five participants discussed the importance of reaching out and providing opportunities for survivors to talk and share their experiences. One participant stated, “In such situations, the best thing to do is to talk to the person so that the person can vent out…Be a friend with good listening ears and just hear out the person” (Survivor, Age 47, India). Showing genuine interest by asking about their needs was also described as an effective way to connect with survivors with suicidal ideation. “If she needs help in getting out or getting groceries or any help with her kids, those kinds of questions might help her. Like, what kind of help she’s looking for” (Survivor, Age 28, India).

Many participants discussed that women with suicidal ideation should be surrounded by friends or trusted group of people from her country, culture, or her community. “Making sure that she has someone to talk to safely…Either a group of friends or someone from their own culture, or even just the fact of knowing or sharing that you can go to this place and talk to other people that speak your own language” (Survivor, Age 34, Mexico). One participant shared that it may be helpful for a survivor to join a cultural activity that connects her to her community. “Find a way to get her connected with her people and try to get her out there in the community. For instance, I love dancing, and a lotta Brazilian women love dancing. So maybe find a salsa dance, and provide that” (Survivor, Age 34, Brazil).

However, while support from friends was seen as being able to provide reprieve from daily stresses, some participants stated that those interactions were not enough to stop them from having negative thoughts altogether. “It’s hard to help a battered woman emotionally while she’s still in that relationship…I have a friend that will come and pick me up every so often, but after that hour or two of laughter and enjoyment, I’m still going back there” (Survivor, Age 43, Guyana).

Thus, three participants discussed connecting women to other survivors of IPV to reassure women that they are not alone. One participant shared that hearing success stories was a motivating factor and gave her hope that her circumstances would improve:

My biggest motivational factor was my sister-in-law who’d been through the exact same situation. And at that point in time, she was happy. She was free. She had a family. She had a career. It gives you motivation that, “Okay, I’m not the only one who is going through this. There are other people who went through it. Now, look at her. She’s happy. She’s fine. That could be me too. (Survivor, Age 32, Pakistan)

Remind them of children as motivation (n = 4)

Responsibility toward children also prevented women from harming themselves. Reminding survivors with children that they have responsibilities to raise and protect those children was described as helping to decrease the risk of suicidal behavior. Participants shared their personal experience with depression and suicidal ideation and how their children were their motivation to live and not act on their suicidal thoughts. Participants shared feelings of a need to ensure that their children were protected from their abusive partners. One participant discussed how she experienced suicidal ideation several times. When her therapist asked why she did not act on them, she said “It was my son because—if I leave him, my ex-husband is going to move onto his next sexual pleasure. And my son is very small, and who’s going to take care of him?” (Survivor, Age 37, India). The participant further described how she responded when her therapist asked if the situation has changed in the present:

I said, ‘No, he has gotten bigger. He’s six now, but he’s still small, and he can’t take care of himself,’ So then she brought me back to the realities. “What worked for you last time, it’s still the same, and you still have to take care of your child … That means you can’t do the deed.’ (Survivor, Age 37, India)

Another participant disclosed that having children can have a two-fold effect. Either the mother would not act on suicidal thoughts in consideration of her children or could hurt both herself and her kids. Children are a protective factor for survivors because it reminds survivors that they need to care for their children. The participant shared her personal experience about how she decided not to entertain thoughts of suicidal ideation because she did not want her child to navigate life without a mother. A survivor’s suicide ideation can also place her kids at risk of harm:

It’s important you ask about the kids because those who feel like they are not worth living and they don’t want to leave the kids suffering, they will also kill the kids. If she takes poison, she will poison the kids first, and then she takes the poison last… So that’s what they’ll do. So, it’s always good to explore what led you to feel that you could harm yourself? (Survivor, Age 44, Kenya)

Participants also shared that in addition to the sense of duty to care for children, a deterrent to suicidal behavior was the desire to be a good role model to not only children, but other women as well, “You need to be a role model to your kids. You need to be strong and empower other women who are less privileged.” (Survivor, Age 40, Cameroon).” Another participant shared the importance of highlighting how essential they are to their families:

Try to make her realize about the people who are there for her and love her and how much they’ll be hurt if something happens to her. Make her feel important, that she’s worthy. Because I know women [who] see themselves through their intimate partner’s eyes because that’s what I used to do.… She needs to know that she was a whole person herself before she got into this relationship. (Survivor, Age 43, Peru)

Several participants described that family is a big motivator to live for many immigrants and that focusing conversation on loved ones and family members is important when speaking with women with thoughts of suicide and self-harm:

Immigrants are very connected to family and community. Reminding them of the importance of the people they’ll leave behind, the kids, or the family members: the mother, the father, the cousins, the people that will hurt if they hurt themselves. It also helps, maybe getting their family involved. (Survivor, Age 39, Nigeria)

Community level

At the community level, community resources such as domestic violence organizations, faith communities, and health services were highlighted by the study participants as crucial modes of support. Participants highlighted that these resources were essential to prevent exacerbation of suicidal thoughts.

Connect to domestic violence services (n = 3)

Three participants emphasized the importance of connecting immigrant women survivors of IPV with domestic violence organizations to minimize feelings of distress that could lead to suicidal thoughts. One participant who had experienced suicidal ideation in the past described her experience with a domestic violence organization that made her feel supported and not alone:

What helps me is, ‘You are not alone. And we are going to be there every step of the way. Even if it’s in the middle of the night, you can call us.’ I never called [local organization for help] because my own inhibitions stopped me. But they always said that they are available even in the middle of the night. (Survivor, Age 37, India)

Participants also shared that participating in events organized by domestic violence organizations brought women out of isolating environments and allowed them to form new connections to social networks and resources. “Take them to your organization if they have activities or anything to keep their minds busy, keep them more positive… They’ll be scared to come out. But they can’t stay in the house. They’ve got to get out and be helped” (Survivor, Age 53, Ecuador).

One participant shared that she was able to overcome feelings of suicide and hopelessness though group therapy and classes offered at a local domestic violence organization:

All the women were like me, so I was not an outsider… We used to talk about our stuff and shared our stories…Then I used to feel ‘Okay, that’s good. I’m not the only one. So, I’m not garbage,’…That’s what made me feel really comfortable. Group therapies are important, making yourself busy is very important and you can give us some classes. We cannot do anything right now. We cannot go out in the world and do something, but meanwhile, there is this class for two hours, and then this class for three hours. So, half the day is gone, and I feel good. (Survivor, Age 46, Pakistan)

She went further to discuss how the organization provided group therapy and classes for learning skills to help women find a job and learn English. She also described the importance of offering classes for Microsoft Office applications such as Word and Excel and secretarial courses so that women could find employment.

Another participant shared that she overcame thoughts of self-harm brought about by familial pressures to stay in an abusive relationship by seeking refuge at an emergency shelter. “The shelter location really helped me. Imagine if I didn’t even have that option or if I had little hope. There were no options for me. I would just end everything or maybe just go crazy. So, it’s good to help people get on their feet” (Survivor, Age 35, Mali).

The participant shared that instilling hope and encouraging women were effective communication strategies to provide women with a sense of purpose and confidence to achieve their life goals.

Connect to faith-based resources (n = 4)

Religion was identified as a factor that discourages self-harm and suicidal ideation. Two participants discussed how religion prevented them from hurting themselves because they believed suicide was a sin. For instance, one Muslim participant shared her personal experience and why religion served as a motivation to live for her and others:

All of the women that I know who have been through this situation and were Muslims… the only thing that stopped them, including myself, was that it’s a big sin, and your life after death is then over. If you commit suicide, you’re ruined for eternity. So, I feel religious beliefs play a humongous role in this…Especially in the case of suicide or women who want to hurt themselves…the fear of God or their religious beliefs is what kept them alive. (Survivor, Age 32, Pakistan)

As noted in this quote, survivors who believed suicide was a sin feared that it would have eternal negative consequences. Another Muslim participant shared similar beliefs: I used to say to myself, “Life over here with him is hell. Why would I want to make my life after death hell, too? … I don’t want to suffer there as well… I don’t want to die with a sin. I just want to be happy there when I die” (Survivor, Age 28, Pakistan).

Participants shared that assessing a survivor’s religious affiliation is important to connect them to organizations or religious leaders who can provide support. One Muslim participant shared that many immigrant women have ties to religion, and it would be important to “Find out what religion she’s affiliated with and come from a religious angle… Find out what that [tie] is and be able to tap into that as a resource” (Survivor, Age 39, Nigeria). Another participant shared that if a woman says she is going to hurt herself, it would be important to find a priest, community, or church group that would help provide an immediate intervention and talk to her and give her religious and culturally sensitive support:

Reach out to them to talk because sometimes cultures might interfere with people getting help…A lot of immigrant communities, we are from cultures that don’t allow you speaking against your husband or going against him. So sometimes it’s hard for us to go—especially the ones that are not really educated, it’s hard for them to let go of their traditions to seek help. (Survivor, Age 46, Sierra Leone)

Connect to resources for immigrants (n = 9)

Immigration status is a main barrier to accessing services for mental health. Nine participants discussed the importance of providing support resources that are safe for undocumented women. Immigrant women are often afraid to seek help because they are undocumented and unsure of whether they can receive any help or services. “If you’re an immigrant, and you don’t have all your documents then that might be a concern, that do I need to show ID? Do I need to show an American identification?” (Survivor, Age 48, Trinidad & Tobago).

In addition to resources that address thoughts of suicide, participants identified the need for other forms of support such as legal assistance and immigration resources for breaking free from an abusive situation. A participant shared, “I am sad because my marriage is not working out, and I am in a shelter home. I’m insecure. My biggest thing is just that I get a legal thing here in this country so I can work here and live on my own instead of in an abusive relationship” (Survivor, Age 46, Pakistan). Participants also shared that valid legal status in the U.S. may be a sole reason for women to stay in abusive relationships:

Many women want to take divorce, but… when they file divorce, they won’t be on a status. They will be out of status and may have to go back to their home country, leaving the kids here. Why? Because abuser may not give the passports. (Survivor, Age 41, India)

Furthermore, participants described that fear of legal status and deportation are used by abusive partners as control tactics to keep them in abusive relationships which may have added to their distress. Therefore, it is important to consider suicide ideation in the context of other challenges faced by women. One woman shared, “A lot of abusers blackmail women, and then force them to stay in the abusive relationship because of their immigration status…they are in that situation where they’re being constantly threatened to be deported…So, putting her in touch with resources that can help her out of that—I think that is huge” (Survivor, Unknown age, Pakistan). She emphasized that providing immigrant women survivors of IPV with resources is essential as they may face controlling behavior from partners that hinder them from seeking help.

Four participants also highlighted language barriers and the need for resources tailored to non-English speakers because they may not understand the information being provided to them or feel overwhelmed:

There’s a lot of fear of calling numbers where you’re just going to be blasted with English… It’s filling out tax forms and other forms that I’ve been helping her fill out her whole life… They’re like, ‘Oh…I’m not going to be able to do this without my kids or someone to help me translate this stuff.’ That’s scary. (Survivor, Age 31, South Korea)

A participant also shared the importance of having someone who shared her same language by saying: “I can still speak English, and I work in a hospital setting so I have different exposures, but a lot of women don’t. so, if you can get somebody who can speak their language, that would be the best” (Survivor, Age 37, India).

Connect to mental health services (n = 24)

Twenty-four participants highlighted the importance of connecting women with thoughts of suicide to counseling or mental health services. Mental health resources can help women figure out the cause of their distress and find ways to manage their mental and emotional health. “Connect her with a counselor to help her figure out how to take control of her own happiness and identify what exactly is making her sad and depressed and how those things can be changed for the better” (Survivor, Age 27, Kenya). Many participants shared personal experiences with therapy and how therapy helped create a safe space for them to share their experiences.

“I’ve never felt desperate in my life since I’ve started doing counseling…You’re in a nonjudgmental room…You can share your feelings. I can cry as I like…I pour it out, and with no judgment, or nobody’s telling me, ‘Shut up. What are you crying for?” (Survivor, Age 43, Guyana)

Participants also went into detail about the importance of counseling services being free and affordable.

Therapy can be expensive. Even if she does have a situation where she can get out of the house, if she cannot afford [therapy], then she pretty much will be sulking on her own. So, enabling the person to get access to good therapy…maybe a program or something which she can do free of cost. Or subsidized if the person can afford it…That’s really, really important. (Survivor, Age 33, India)

However, participants also stated that despite the importance of seeking mental health services, there may be cultural deterrents to effectively seeking those services. These barriers included perceptions of abuse being a family matter where women are not supposed to disclose abuse to anyone outside the home, including health care providers. One African participant mentioned “Women don’t talk and are not supposed to talk” (Survivor, Age 37, India). Another participant mentioned how it would be difficult to offer counseling as a resource to sub-Saharan African women because they may not be comfortable with seeking help for mental health. “When you tell someone to go to counseling who’s never done that before and who doesn’t want their business to be out there if they don’t know the person, it’s kind of hard to offer them that as a resource” (Survivor, Age 39, Nigeria). Some participants described survivors not going to mental health counseling for suicidal thoughts or other issues due to mental health stigma in their communities. For example, a South Asian participant shared how she was afraid to seek counseling because of how her community would react:

People will judge me…It’s my society. It’s my community…There are many people who are educated and know counseling is normal, and everybody goes through stuff, and it’s okay. But there are majority of them who think that the person is crazy, and they have a lot of baggage, and if you talk about this…you’re too broad-minded. (Survivor, Age 28, Pakistan)

Connect to emergency and medical services (n = 5)

Five participants suggested that a woman at high risk for hurting herself should be connected to emergency and medical services. “That’s a very dangerous situation. And I think that warrants the person to actually go and see a psychiatrist or something because they definitely need anti-depressants” (Survivor, Age 29, Pakistan). Three participants mentioned that calling 911 and having someone check-in would be necessary if the women is actively planning to hurt themselves and required immediate attention. “If somebody said they’re going to hurt themselves, it either happened the same time or 24-h later. So, I say the best thing is to call them—911” (Survivor, Age 34, Jamaica).

Discussion

In this study, we explored strategies to support immigrant women survivors of IPV experiencing suicidal ideation. The results of this study were aligned with the relational and community levels of the socio-ecological model (CDC, 2022) and illustrate the importance of having positive, close relationships and safe settings for immigrant women survivors of IPV to seek help from when they are experiencing suicidal ideation. Regarding appropriate and supportive support strategies for when immigrant women experience suicidal ideation, direct forms of contact to build personalized connections with others was mentioned by multiple study participants as an essential component of providing support. Study participants also emphasized that they preferred receiving phone calls rather than online resources because they wanted active conversations with someone who was empathetic and listening intently. Previous studies have shown that phone calls that provide support, empathy, and reassurance prevent suicidal ideation and behavior and also improve depressed mood, anxiety, hopelessness, and negative thoughts (Kreuze et al., 2017). Therefore, building trust and personal connections by strategically contacting study participants to provide direct, genuine, and personal support must be prioritized by research teams that interact with study participants who may experience suicidal ideation. A study with a nationally representative sample reported that social support reduces rates of suicide attempts (Kleiman & Liu, 2013). Study participants also shared that it is important to provide interventions that prevent isolation, and connect them to domestic violence services and organizations that offer group therapy where women can meet others with shared experiences. In addition to domestic violence organizations, faith-based resources such as community organizations and religious leaders may play a critical role in providing needed support to immigrant women who may not feel comfortable seeking care elsewhere. Existing literature is supportive of providing faith-based resources because religious attendance is associated with decreased odds of suicide attempts (Rasic et al., 2009). Additionally, Muslim participants in this study also explained that religion was a protective factor against suicide because they feared that due to their beliefs that suicide is sinful. They believed that acting on thoughts of suicide could have negative eternal consequences, which is supported by existing literature that discusses how Islamic faith deters followers from suicide due to beliefs in the sanctity of life and that the perpetrator of suicide would face eternal retribution (Shah & Chandia, 2010).

Many participants emphasized the importance of connecting survivors to therapy and counseling services. Connection to community resources have shown to decrease risk for suicidal ideation in both the U.S. and international contexts (Borum, 2012). While therapy may not be the solution for all immigrant women survivors, those who are open and willing to use mental health resources must have access to accessible and affordable forms of therapy and counseling services that are culturally and trauma-informed and address their complex care needs. Study participants specifically mentioned that they value rapport-building and ensuring privacy, as many are often weary of sharing their experiences with a stranger. As such, trauma-informed therapeutic strategies, as well as measures to build trust and confidentiality must be practiced and made transparent to this population (Ahmad et al., 2013). Connecting survivors with providers with similar cultural backgrounds is also key to encourage clear communication and establish provider understanding of the cultural and societal norms of survivors. These sentiments align with existing study findings that describe higher satisfaction rates from patients with providers with concordant ethnicities and genders (Takeshita et al., 2020).

While the focus of the in-depth interviews with study participants was to examine immigrant survivors’ perceived strategies to address suicidal ideation, several study participants also shared factors that increased their risk for suicidal ideation. An obvious risk factor was social isolation from family and community. The negative impact of social isolation was further compounded by the challenges of adapting to life in a foreign country away from close family. Factors related to increased thoughts of suicide consisted of religious beliefs and having children. These findings about factors that increase risk for suicidal behavior are consistent with existing literature on contributing factors to suicidal ideation (Forte et al., 2018; Stack & Kposowa, 2011). Social support from friends and family was also reported to discourage study participants from thoughts of suicidal ideation. This has also been found to be true for Asian immigrants residing in the U.S (Kim, 2021). Prior literature has also demonstrated that family dynamics such as high parental attachment to children protect against suicidal behaviors, while higher parent-child conflicts and lower engagement and affection can be risk factors for suicidal ideation (Lai et al., 2017). Our study participants also described children as their motivation to live, especially so that they could work toward a safer future for their children. However, our study findings also revealed that while support from others was helpful, they only provided temporary relief to certain participants. Thus, professional resources and aid must be supplied in tandem with building up social systems to support this population.

Study strengths and limitations

In terms of limitations, study participants only included immigrants residing in the U.S., which means that our findings may only be applicable for immigrant women survivors of IPV who live in the US. Moreover, the sample consisted primarily of survivors that were recruited through organizations serving immigrant women survivors of IPV. As such, it is highly likely that they are already connected to mental health services and personalized interaction with providers, which may explain why most participants promoted connecting women to health services and resources without discussing extensive barriers or skepticism with accessing mental health services. Additionally, half of our study sample also holds post-graduate degrees, which may impact their perspective on building social networks and developing resilience, and as a result, may not reflect the perspectives of immigrant women from other educational levels (Njie-Carr et al., 2021). However, our study adds to existing literature by exploring ways to assist immigrant women survivors of IPV with suicidal ideation from the perspective of the immigrant survivors. Using the findings from our study, future studies with this population may use community-based participatory research approaches to apply these strategies into suicide protocols. This study highlights necessary considerations for creating culturally appropriate and effective ways to reach immigrant women survivors of IPV who experience suicidal ideation.

Study implications

To provide the best possible care to immigrant survivor women experiencing suicide ideation and thoughts of self-harm, researchers conducting intervention research and practitioners must provide access to resources that address immigration-related barriers and work in collaboration with survivors to develop suicide-specific safety plans to prevent self-harm and remove them from unsafe situations. This is important because the research process may cause mental and emotional distress to research participants, and researchers are ethically obligated to address potential threats to participants’ safety, minimize their distress, and provide referrals for support (Ellsberg & Heise, 2005; Kyriakakis et al. 2015). Survivors must have access to physical and mental health resources and legal services regardless of their legal status. It is also critical to enhance the cultural understanding of research team members and practitioners to ensure that survivors of IPV who experience suicidal ideation receive the best care possible without being negatively affected by cultural stereotyping and miscommunication. There is a need for researchers and advocates from diverse cultural backgrounds so that survivors feel more comfortable seeking help. Researchers and practitioners should support survivors in their first language to ensure that survivors can navigate seeking support and resources without facing language barriers. Cultural sensitivity training must be offered in tandem with internal bias training to provide respectful care to people from all cultural and ethnic backgrounds.

In studies with immigrant survivors, researchers should also refer participants to care providers if deemed necessary so that the participant can work in active partnership with a provider to develop safety plans. This is critical because safety plans have been shown to improve levels of suicidal ideation, behavior, reduce number of deaths, and improve mental health symptoms such as depression and hopelessness (Ferguson et al., 2022). Moreover, safety plans need to account for the risk factors immigrants experience and provides resources that allows them to maintain personal safety. These safety plans might be tailored to the unique needs of immigrant women by addressing their personal strengths, as acknowledging these strengths are related to improvements in adult mental health (Xie, 2013). Adopting a strengths-based approach to safety planning focuses on identifying an individual’s strengths as protective factors to include in a traditional safety plan. This is done with the aim of cultivating hope by providing patient-centered intervention.

Some study participants also noted that distractions are a way for survivors to divert their attention from distressful situations, but distractions are not supported by literature as a strategy to address suicidal ideation. While coping mechanisms such as finding a distraction are important and nurture resilience (Al-Naser & Sandman, 2000), there is a pressing need for education on how distractions are not solutions to suicidal ideation. Many study participants commented on how concrete resources, mental health resources, and professional services should be made more accessible to ensure that the mental health needs of this population are adequately addressed. Recommended community level interventions to support this population include engaging with religious communities, supporting family interactions, and improving access to community and mental health resources. This will enable communities and help providers to understand how to address barriers to seeking help and make sure interventions are sufficiently culturally tailored and trauma informed.

Conclusion

Immigrant women with IPV experiences recommended doing the following to provide support to immigrant survivors with thoughts of self-harm or suicidal ideation: building trust and providing encouragement; strengthening women’s social support networks and emphasizing the importance of family; and, connecting women to community, religious, and health services that meet multiple needs including but not limited to mental health (e.g. immigration). The findings will inform researchers and practitioners serving immigrant women survivors of IPV who are experiencing or have previously experienced suicidal ideation by highlighting the need for culturally informed care provision, availability of services in multiple languages, and developing tailored strengths-based safety plans that honor the goals of the survivor to cultivate hope. Moreover, the results of this study may be used to inform the design of prevention and intervention strategies for immigrant survivor populations that experience suicidal ideation. This study serves as a significant contribution to researchers and practitioners who work with immigrant women with experiences of IPV by providing a detailed overview of best practices as recommended directly from immigrant women survivors of IPV.