What Does it Take to Create Religiously and Culturally Congruent Suicide Interventions?

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The U.S. average for lifetime suicide attempt is nearly 1%. Said another way, nearly 1% of all Americans will attempt, or die by, suicide in their lifetime. A recent study found that sobering number, which is cause for concern at any size, jump to an alarming 8% among a sample of American Muslims.

Dr. Rania Awaad, the director of Stanford’s Muslim Mental Health & Islamic Psychology (MMHIP) Lab and coauthor of the study that revealed this statistic, was shocked and dismayed by the disparity. Awaad was compelled to begin her research into this topic after engaging with various communities coping with the aftermath of suicide deaths. Throughout the 2010s, the lab fielded a growing number of calls from Muslim communities in the San Francisco Bay area and beyond looking for guidance. 

When Awaad and team were approached following the death by suicide of a local Muslim high school student, she realized, “I am a Stanford-trained, board-certified psychiatrist, and I’m certified in Islamic law, and I don't know where to start to help these communities heal from a suicide loss.” 

Looking for answers

Moved and humbled, Awaad began to look more closely at the problem and found a notable lack of data about Muslims and suicide. In 2019, she was part of a team of Muslim mental health professionals who were able to urge the inclusion of mental health questions on the Institute for Social Policy and Understanding’s annual American Muslim poll. The results of the survey, published by JAMA Psychiatry in 2021, changed the conversation in the Muslim community. “If Muslims are attempting suicide at such high rates, we can no longer say that faith alone will prevent mental health conditions or suicidality,” said Awaad, who is keenly aware that her dual expertise in psychiatry and Islamic law uniquely positions her to design ways to support the Muslim community while exploring why the rates of attempted suicide are so high.

Awaad then convened a global gathering of suicide experts to help her and her colleagues better understand which methods work for suicide prevention and postvention and explore how they might apply those approaches to the Muslim community. A paper from their collaboration will be published in 2023. In addition, her lab recently published a case study in the Journal of Muslim Mental Health on two suicides in neighboring Muslim communities in the U.S.

This recent work identified spiritual support as a key factor for Muslims, both with prevention and for helping communities after a death by suicide has occurred. In this, Awaad recognized both a challenge and an opportunity. “In Islam, choosing to die by suicide with full rational faculties is a grave and mortal sin. Someone considering it is not likely to go speak to their imam about it or seek help from their family or friends. In addition, most imams don’t tend to talk openly about mental health or suicide.” As a scholar of Islamic law herself, Awaad realized if she could persuade enough imams of the importance of talking about and providing support for these issues, she could help shift the taboos around suicide and mental health in Muslim communities.

Mental health resources for faith leaders

With the support of Stanford Impact Labs funding granted to all SIL Design Fellows (of which Awaad is one), she refined and scaled the 100-page Muslim suicide response manual and its accompanying 8-hour training for imams created by her lab. Because of skyrocketing mental health concerns–many caused by the pandemic–most imams she approached welcomed the support and training. Others remained skeptical but participated nonetheless, giving Awaad the opportunity to propose a different way of addressing suicide in the Muslim community.

“We find that when discussing suicide prevention, the theological ruling that suicide is a mortal sin is protective. But with postvention, the message needs to be different,” said Awaad. “In postvention, we explain that in Islamic law, if someone does not have full, rational mental capacity, then they are not held accountable for their actions. The research on suicide estimates that in about 95% of suicides, there were underlying mental health issues. And while we can’t say for certain what may happen to those who take their own life, we know that God is the only judge and in His infinite mercy is forgiving. This window of possibility for forgiveness can provide hope for those who are grieving. The imams we’ve worked with have appreciated the nuance of this distinction.”

The lab’s goal was to offer the training to 500 imams by the end of 2022. They reached 487. Because of the success of the training, the curriculum is being modified and offered to youth leaders, community leaders, Sunday school teachers, and others in leadership positions. Awaad’s hope is to train at least one or two people from 80% of the 3000 mosques in the U.S. over the next five years - an ambition made possible by alliances with key partners. 

Awaad’s partners include Maristan, a holistic Muslim mental health organization and the nonprofit arm of the lab, which coordinates the training and trains the trainers. Other partnerships have included the Islamic Circle of North America, who funded two of the trainings for imams in 2022, Rabata, a Muslim women’s organization, and 200 Muslim Women Who Care, a Tampa-based Muslim women’s collective .

As the program scales and her research continues to expand, Awaad hopes to bring several more partners to the table, including those with lived experience and parents who have been asking for their own training. In addition, she is exploring how to forge partnerships with the U.S. government. “It is hard for the government to support a faith community, as opposed to a racially, ethnically, or socio-economically identified community, but the Muslim community is diverse and can’t be parsed along those lines. I’m hoping we can find a way they can support these programs in the future.”

While the work around prevention and postvention has been a success, the initial findings left a big, unanswered question: Why are so many American Muslims attempting suicide? A study is ongoing, but initial findings indicate two primary risk factors—feeling a lack of belonging (especially prevalent during the “Muslim ban,” from 2017-2021) and an increased sense of burdensomeness, the feeling that one is a burden to others and that perhaps others would be better off if one were gone. Awaad hopes the results of this study will lead to refined pre- and postvention approaches to make them more holistic and—by taking spirituality into consideration—particularly tailored to Muslim communities.

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