April 2021, Volume 71, Issue 4

Research Article

Impact of perceived social support and parental bonding in predicting suicidal intent among self-harm patients

Naila Yaqoob  ( Department of Psychology, foundation university Islamabad, Pakistan. )
Sadaf Ahsan  ( Department of Psychology, foundation university Islamabad, Pakistan. )


Objective: To investigate the impact of perceived social-support and parental bonding in predicting suicidal intent among self-harm patients.

Methods: The cross-sectional study was conducted at Foundation University, Rawalpindi, Pakistan, from February to September 2019, and comprised self-harm patients from mental health department of different hospitals in Rawalpindi, Jhelum and Peshawar. Data was collected using multidimensional scale of perceived social support, parental-bonding instrument and the Beck suicide intention scale. Data was analysed using SPSS 23.

Results: There were 50 patients aged 18-35 years. Social support and parental bonding factor 'care' had significant negative correlation with suicide intent (p<0.05).  Parental bonding factor 'overprotectiveness' had significant positive correlation with suicide intent (p<0.05).

Conclusion: Social support and parental bonding can both play substantial role in saving lives.

Keywords: Perceived social support, Parental bonding, Suicide intent, Self-harm. (JPMA 71: 1148; 2021)

DOI: https://doi.org/10.47391/JPMA.1299




Self-harm (SH) is one of the most important concerns in public health domain, and one of the most distressing events in a parent's life is the loss of a child. It becomes more heart-breaking if a child deliberately chooses to end or harm his or her own life to get escape from agonizing sufferings. Studies suggest the occurrence of SH incidents are on the rise.1 SH is regarded as the sixth major cause of ill-being around the globe, and its incidence is 10-20% higher than suicide. SH behaviour in young females is >75% which is high compared to young males.2 According to a World Health Organisation, 2014 report,3 annually around 800,000 people die from suicide, demonstrating a yearly international suicide ratio of 11.4 per 100,000. According to an estimate, nearly 100,000 acts of SH take place in Pakistan alone.4 SH typically refers to an array of behaviours involving an individual purposely perpetrating harm to his own body regardless of suicidal intent, and these behaviours are not socially sanctioned.5 A suicide attempt is self-inflicted, possibly harmful act, with consequence for which there is manifestation of a purpose to pass away.6 SH is quite difficult to predict because of varying intents, both suicidal and non-suicidal, making it a challenging job to manage thoughtfully.7 It is estimated that suicide attempts occur 10-20 times more often than completed suicides.8

Social support (SS) is assumed as the quality of apparent support from social relations, and it provides a shield through help-seeking esclation.9 Suicide tells how an individual related to society, as suicidal thoughts are in a way formulated by social patterns.10 The Interpersonal Theory of suicide speculates that professed burdensomeness and dissatisfied relations can lead to suicidal ideation as a first step, while individual's prerequisite is to acquire the ability to inflict SH to follow the suicidal thoughts.11 Similarly, high-risk suicidal individuals feel like they are a burden to their relations, they feel isolated, and have the knowledge about ways to hurt themselves. SS is suggested as a rescue factor which regulates stress and suicidal behaviour.12 Similarly, parental bonding (PB) has also been known to be associated with suicidal behaviour.13

The relationship among SS and PB and suicidal intent has gained less attention compared to other aetiological aspects in relation to suicide intent among self-harm patients. Social relationships have been proposed as a significant factor for illuminating SS role in the multifaceted SH phenomenon.14 Further, SH may get worse and this may be an indicator for subsequent suicide and this threat among clinical population is significantly higher than in the general population.15 There is limited knowledge regarding SH in the clinical population. The current study was planned to investigate the impact of perceived SS and PB in predicting suicidal intent among SH patients. It was hypothesised that less SS, less parental care and high parental over-protectiveness would be predictors of suicide intent among SH patients.


Patients and Methods


The prospective cross-sectional study was conducted at Foundation University, Rawalpindi, Pakistan, from February to September 2019. Data was gathered of SH patients from mental health department of three hospitals in Rawalpindi, Jhelum and Peshawar after obtaining approval from ethical review committee. The sample size was estimated using EpiTools epidemiological calculator16 while keeping level of significance 5%, confidence level 95%, and absolute precision 5% and estimated true proportion 73%.17 The sample was raised using purposive sampling technique from among SH in-patients at the three hospitals. Two trained clinical psychologists were approached at Rawalpindi and Peshawar hospitals for data-collection, while data from the hospital in Jhelum was gathered by the researchers. Those included were SH inpatients of either gender aged 18-35 years. Those with SH in form of tattoo and/or culturally-sanctioned behaviours, current active risk of SH behaviour and identified as having active psychosis or intellectually disabled were excluded.

After written informed consent, personal and demographic data was collected using a predesigned proforma, while self-reporting psychometric scales were administered by a trained clinical psychologist to gather clinical data.

To determine suicide intent, Beck Suicide Intention Scale (BSIS) was administered. It comprises 15 items denoting to the patient's protections and views of the act. Each response is documented on a scale from 0 to 2, with a total score of 30 and a cut-off score of 15; 15-19 = low intent; 20-28 = medium intent, 29 and above = high intent of suicide.18 In the current study, subjects were divided into two groups; BSIS score <15 indicating no suicide intent, and BSIS score >15 indicating SH with suicide intent.

Parental Bonding Instrument (PBI) comprises 25 items scored on a 0-3 four-point Likert scale from "very unlike" to "very like". It assesses individual's recollected memory of PB during the first 16 years of life in the two factors of care and protection. Higher scores depict their perceived parental caring and/or protectiveness. The scale has internal consistency Cronbach's alpha of 0.65-0.73, and reliability 0.66-0.88.19

Multi-dimensional Scale of Perceived Social Support (MSPSS) has 12 items concerning friends, family and significant other supports, which has 8 statements scored using a 7-point scale, ranging from 1 = very strongly disagree to 7 = very strongly agree. The scale showed good internal reliability with a = 0.93. The subscales, including significant other a = 0.90, family a = 0.89) and friends a = 0.89, showed good internal reliability as well.20

Data was analysed using SPSS 23. Descriptive analysis and item total correlations were computed to check internal consistency of the scales. Bivariate correlation analysis was used to find relationship between the variables. To gather causal relationships between the variables, linear regression analysis was used. Independent sample t-test was used to find out mean differences across demographic variables. P<0.05 was taken as level of significance.




Of the 50 patients aged 18-35 years, 35(70%) were in the non-suicidal SH group and 15(30%) were in the suicidal SH group. PB factor 'over-protectiveness" had significant positive correlation with suicidal intent (p<0.05). PB factor care had significant negative correlation with suicidal intent (p<0.05). SS had significant negative correlation with suicidal intent (Table-1).

Mother's care bonding predicted suicide intent in negative direction, and accounted for 15% variance in suicide intent (p<0.05). Mother's over-protective bonding positively predicted suicide intent, and accounted for 22% variance in suicide intent (p<0.05). Father's care bonding predicted suicide intent in the negative direction, indicating that if father's care was high, there was low prediction of suicide intent, and it accounted for 12% variance in suicide intent (p<0.05). Father's over-protective bonding positively predicted suicide intent, and accounted for 17% variance in suicide intent (p<0.05). SS negatively predicted suicide intent and accounted for 31% variance in suicide intent (p<0.05) (Table-2).

Suicide intent had significant difference on PB and SS subscales (p<0.05). There was a significant difference on mother's and father's care bonding in which patients with non-suicidal intent had more parental care than patients with suicidal intent (p<0.05). There was a significant difference on parental over-protectiveness (p<0.05), revealing that patients with more suicide intent had more parental over-protectiveness than patients with non-suicidal intent. There was a significant difference with respect to SS (p<0.05), revealing that patients with non-suicidal intent had more SS than patients with suicide intent (Table-3).




The findings of the current study are consistent with previous finding and are generalisable as it is anticipated that youths with healthy SS are cherished, esteemed and, by means of parents, are part of a social structure that is available in times of need.21

Studies have found that the family environment, specifically the nature of PB, can be a predictor of suicidal behaviour.22 Results of the present study are similar with Attachment Theory which suggests that parents are receptive to the youth's needs and to provide emotional support.23 Such connections, in return, yield a feeling of being socially connected and a sense of contentment, lowering the hazard of suicidal intent. Studies have revealed that the supposed SS is an important threatening or defensive factor of suicide in clinical and normal population.24,25 The current findings are also supported by a study which established that the family factor, especially supposed negative relationship with parents, is associated with suicidal behaviour.26 Besides, a study found the causes of suicidal attempts amongst youth to be negative-bonding and communication with parents.27 At certain point, youth desires a healthy closeness, particularly with family, to enhance self-esteem and wellbeing.28 The current study's findings are consistent with a study which found that the nature of PB is a strong predictor of suicide attempt;29 more precisely, lesser parental care and higher parental over-protectiveness were found to be associated with suicidal ideation and suicide attempts.22

The current study has limitations, like a small sample size and the study's inability evaluate the possible interaction of study variables. Further large-scale studies are recommended in order to have high external validity, to take account of numerous precipitating, protective factors to assess aetiology of suicidal intent, and to examine mediating or moderating roles of study variables among SH patients.




Less social support, less parental care and high parental over-protectiveness were strong predictors of suicide intent in self-harm patients.


Disclaimer: None.

Conflict of Interest: None.

Source of Funding: None.




1.      Nock MK, Borges G, Bromet EJ, Alonso J, Angermeyer M, Beautrais A, et al. Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. Br J Psychiatry. 2008; 192:98-105.

2.      Perry IJ, Corcoran P, Fitzgerald AP, Keeley HS, Reulbach U, Arensman E, et al. The Incidence and Repetition of Hospital-Treated Deliberate Self Harm: Findings from the World’s First National Registry. PLoS One. 2012; 7:e31663.

3.      World Health Organization. Health systems: Improving performance. Pan American Health Organization. Essential public health functions. Geneva: World Health Organization; 2014.

4.      Shahid M. Deliberate Self Harm Prevention in Pakistan. J Coll Physicians Surg Pak. 2013; 23:101-2.

5.      Whitlock J. What is self-injury? Cornell Research Program on Self-Injurious Behaviour in Adolescents and Young Adults. [Online] 2010 [Cited 2019 June 10]. Available from: URL: http://crpsib.com/factsheet_aboutsi.asp

6.      Silverman M, Berman A, Sandal N, Carroll PW, Joiner T. Rebuilding the Tower of Babel: A revised nomenclature for the study of suicide and suicidal behaviours Part I: Background, rationale. Suicide Life Threat Behav. 2007; 37:248-63.

7.      Kidger J, Heron J, Lewis G, Evans J, Gunnell D. Adolescent self-harm and suicidal thoughts in the ALSPAC cohort: a self-report survey in England. BMC Psychiatr. 2012; 12:69.

8.      American Foundation for Suicide Prevention. [Online] [2019 May 28]. Available from: URL: https://afsp.org/aboutsuicide/suicide-statistics/.

9.      Wu CY, Stewart R, Huang HC, Prince M, Liu SI. The impact of quality and quantity of social support on help-seeking behaviour prior to deliberate self-harm. Gen Hosp Psychiat. 2011; 33:37-44.

10.    Denney JT, Rogers RG, Krueger PM, Wadsworth T. Adult suicide mortality in the United States: marital status, family size, socioeconomic status, and differences by sex. Soc Sci Q. 2009; 90:1167.

11.    Van Orden KA, Witte TK, Cukrowicz KC, Braithwaite SR, Selby EA, Joiner TEJ. The interpersonal theory of suicide. Psychol Rev. 2013; 117:575-600.

12.    Willoughby T, Heffer T, Hamza CA. The link between non-suicidal self-injury and acquired capability for suicide: A longitudinal study. J Abnorm Psychol. 2015; 124:1110-5.

13.    Dale R, Power K, Kane S, Steward AM, Murray L. The role of parental bonding and early maladaptive schemas in the risk of suicidal behaviour repetition. Arch Suicid Res. 2010; 14:311-328.

14.    Rasmussen S. Predicting depression, anxiety and self-harm in adolescents: The role of perfectionism and acute life stress. Behav Res Ther. 2010; 48:52-9.

15.    Owens D, Horrocks J, House A. Fatal and non-fatal repetition of self-harm: systematic review. Br J Psychiatr. 2002; 181:193-9.

16.    EpiTools Epidemiological Calculators. AusVet. [Online] [Cited 2018 December 29]. Available from: URL: http://epitools.ausvet.com.au/content.php?page=1Proportion.

17.    Mbugua MN, Kuria MW, Ndetei DM. The Prevalence of Depression among Family Caregivers of Children with Intellectual Disability in a Rural Setting in Kenya. Int J Family Med. 2011; 2011:534513.

18.    Beck AT.Beck scale for suicidal ideation (BSIS). USA: The Psychological Corporation, 1991.

19.    Parker G, Tupling H, Brown L. A parental bonding instrument. Br J Med Psych. 1979; 52:1-10.

20.    Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensional scale of perceived social support. J Personal Ass. 1988; 52: 30-41.

21.    Grav S, Hellzèn O, Romild U, Stordal E. Association between social support and depression in the general population: the HUNT study, a cross-sectional survey. J Clin Nurs. 2012; 21:111-20.

22.    Amitai M, Apter A. Social aspects of suicidal behavior and prevention in early life: a review. Int J Environ Res Public Health. 2015; 9:985-94.

23.    Dubois-Comtois K, Cyr C, Pascuzzo K, Lessard M, Poulin C: Attachment theory in clinical work with adolescents. J Child Adolesc Behav. 2013; 1:1-8.

24.    Wilkinson P, Kelvin R, Roberts C, Dubicka B, Goodyer I. Clinical and psychosocial predictors of suicide attempts and non-suicidal self-injury in the adolescent depression antidepressant and psychotherapy trial (ADAPT). Am J Psychiatry. 2011; 168:5.

25.    Zalsman G, Levy T, Shoval G. Interaction of child and family psychopathology leading to suicidal behaviour. Psychiatr Clin North Am. 2008; 31:237-46.

26.    Consoli A, Peyre H, Speranza M, Hassler C, Falissard B, Touchette E, et al. Suicidal behaviors in depressed adoloscents: role of perceived relationship in the family. Child Adolesc Psychiatr Ment Health. 2013; 7:8.

27.    Hong YS, Jeon SY. The effect of life stress and depression for adolescent suicidal ideation. Ment Health Soc Work. 2005; 19:125-49.

28.    Larson RW, Wilson S, Mortimer JT. Conclusions: adolescents’ preparation for the future. J Res Adolesc. 2002; 12:159-66.

29.    Amit N, Ibrahim N, Mohd Jaladin RA, Che DN. The predicting roles of reasons for living and social support on depression, anxiety and stress among young people in Malaysia. Med J Malaysia. 2017; 72:291-7.


Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: