Family Relations from the Perspectives of Female Youths with Suicidal Behavior: A Qualitative Study

Research on youth's suicidal behavior often focuses on individuals rather than families. This exploratory research is related to family relations in female youths with suicidal behavior. This study's respondents were ten suicidal female youths (aged 15 to 24) divided into two groups: ' attempt' and 'no-attempt'. The FACES IV, family communication scale, and family satisfaction scale were given at the beginning of the study, which was continued with indepth interviews to explore the flexibility, cohesion, and communication of their family relations. In the attempt group, FACES IV resulted in low balanced cohesion (35.8 respectively), low balanced flexibility (41.2 respectively), and low family communication (15.4 respectively). Surprisingly, all participants of both groups rated their family satisfaction levels low, meaning that all participants were dissatisfied with the family functioning. The interview resulted in eight main themes: lack of emotional closeness, family conflict, sibling relationship, leadership in the family, obedience, autonomy, and control, and mendhem rasa (buried emotion, in Javanese culture), and weak communication skills. In conclusion, the family's hierarchical relationships, family conflict, and emotional distance become the risk factors for adolescent suicidal behavior. The perspectives found in this study with suicidal female youths suggest that family-based prevention and intervention of suicidal behavior in youths need to understand family cultural values while encouraging to build emotional closeness and communication skills in the family.

Psychological Thought 2021, Vol. 14(1),  South-West University "Neofit Rilski" https://doi.org/10.37708/psyct.v14i1.506 risk to a suicide attempt (Klonsky et al., 2013). Previous findings confirm that female adolescents with a history of NSSI and suicide ideation tend to conduct lifetime suicide attempts (Scott et al., 2015). The findings suggest that studies on suicidal behavior in adolescents cannot overlook adolescents with self-harm behaviors.
Adolescence is the period of dramatic biological changes, new experiences and duties, and changes in their relationship with parents (Santrock, 2011). Adolescence is regarded as a period of transformation (Adams, 2005). When a family comes to the phase when the child grows to adolescence, one of the most significant changes in parent-adolescent relationships is the increased flexibility of family rules in allowing adolescents to be more independent (Goldenberg & Goldenberg, 2013). The family's responsibility in this phase is to change the approach of parent-adolescent relationships and allow adolescents to move in and out of the system (Goldenberg & Goldenberg, 2013). Parent-adolescent relationships play an essential role in the process of identity development and self-regulation of adolescents (Berzonsky et al., 2007). A well-functioning family can encourage the fulfillment of individual potency in its every member by giving them the freedom to explore and discover themselves as there is protection and security (Goldenberg & Goldenberg, 2013). Family relationship is often described from the perspective of System Theory (Olson, 2000(Olson, , 2011Olson et al., 2019), which originates from General System Theory's concept suggested by Ludwig von Bertalanffy (Bertalanffy, 1968). A system can be defined as a set of elements that interact with one another and with their environment (Bertalanffy, 1972). It means that the best way to understand a system is by knowing every element of the system and its simultaneous interactions (Gavazzi, 2011). Therefore, each family member must be understood in the whole family's context to describe their functioning (Santrock, 2011).
Family System has three characteristics, namely cohesion, flexibility, and communication (Olson, 2011). Family cohesion describes emotional closeness in the family (Olson, 2000;Olson et al., 2019). Family flexibility shows the quality and expression of leadership and management, role relationship, and rules of relationship and negotiation (Olson, 2011).
Family communication is needed to facilitate the movement of both cohesion and flexibility. It focuses on the skills of listening and delivering opinion, openness, attention to the topic, and respecting others (Olson et al., 2019).
There are limited qualitative studies regarding the family relationship as reflected on the parental relationship and relationships between parent and youths with a history of suicidal behavior. Quantitative studies explain that adolescents with severe depression, who have Psychological Thought 2021, Vol. 14(1),  South-West University "Neofit Rilski" https://doi.org/10.37708/psyct.v14i1.506 ideation and plan of committing suicide, and even have attempted to suicide, come from 'problematic' families as marked with conflicts, low cohesion, and flexibility (Gouveia-Pereira et al., 2014;Miller et al., 2012). The cultural values that avoid conflict passed down in families in Indonesia, especially Javanese families, can affect family relationships (Geertz, 1960). Efforts to avoid conflict in the family are thought to hinder openness in family interactions. A qualitative study is the best way to investigate family dynamics (Ganong & Coleman, 2014). Therefore, this qualitative research is expected to discover the dynamics of family relations in Javanese families from the perspective of Family System Theory proposed by Olson (2011) according to suicidal female youths from Javanese families. Hence, this study can contribute to family-based adolescent suicide prevention.

Participants
The participants of this study were ten female youths who had history of suicidal behavior within the last two years. Their aged ranged from 15 to 24 years, and are not married town. The other 80% came from middle SES groups and lived in big cities with one or both parents who had a fixed income that was enough to meet their education and daily needs.
The participants, who were still attending high school and university, were fully financed by their parents. The participants who had finished university did not live with their parents because they continued their education or looked for jobs in other cities, but they at least returned to their parents' homes once or twice a month. The participants were purposively selected from the psychiatry/psychology department of Gadjah Mada University's Academic Hospital, which provides outpatient services for youths with suicidal behavior, and from community health centers referred by the schools attended by the participants who engaged in self-harming behavior.
The participants were divided into two groups, namely 'attempt group' and 'no-attempt group' ( Table 2). The participants of the attempt group were those having attempted to commit suicide once or more. The no-attempt group participants never attempted to commit suicide but had thoughts of doing so and conducted self-harm behavior. Eight participants were outpatients of hospitals' psychiatry departments. The two other participants were selected from a junior high school that showed multiple self-harm behaviors but never received psychiatric treatment.

Characteristics of suicidal behavior and psychiatric disorders of the participants.
Characteristics of suicidal behavior and psychiatric disorders N (%) Written consents were given to every participant. Participants above 17 years old can give their own consent, but for the participants of 15-17 years old, ascent forms were added to get approval from their parents and teachers.

Stages of Study
This study used two stages to explain and explore family relationships from the perspective of female youths who conduct suicidal behavior. In the initial stage, Indonesian version of Family Adaptability and Cohesion Evaluation Scale IV (FACES IV) was given to each participant. The Indonesian version of FACES IV has been used extensively in research on Indonesia's family systems (Wiguna et al., 2015). The interview data were explored with multiple case study methods, choosing several cases that described the studied issue in order to show the difference of perspectives on the cases (Creswell, 2007). The cases addressed by this study were those showing suicidal behaviors that altogether occur as a continuum, namely suicidal thought, self-harm, and suicide attempt.

Data Analysis
The data obtained from FACES IV were analyzed by calculating the scores on each dimension of cohesion and flexibility. The higher the balanced cohesion and balanced flexibility scores, the healthier the family system (Olson, 2011). The higher scores on all four unbalanced scales (disengaged, enmeshed, rigid, and chaotic) indicate the more unhealthy family system (Olson, 2011). The higher the score for the family communication scale and the family satisfaction scale, the more positive feelings of the adolescents about communication and family satisfaction (Olson, 2011).
Psychological Thought 2021, Vol. 14(1), 9-34 South-West University "Neofit Rilski" https://doi.org/10.37708/psyct.v14i1.506 For the interview data, the researcher listened to the interview tape and then transcribed it into verbatim form. To maintain the confidentiality of the identity as well as information about the participants that made them identifiable, all identity data were deleted. Two transcripts contained several statements in Javanese because the participants considered Javanese better describing how they felt. The sentence or statement had been translated into Indonesian by a native Javanese, who understands Javanese culture so that all transcripts were in Indonesian.
The data analysis in case studies consisted of detailed descriptions of the cases (Creswell, 2007). In analyzing data, researchers observe every case acquired data and carry out categorization (Yin, 2014). One of the steps taken is member checking (Harper & Cole, 2012). Member checking allows researchers to interact with participants and get feedback from them on the initial information given by participants to researchers (Arora, 2017). Surprisingly, the youths of both groups rated low family satisfaction (10.6 and 15.2), meaning that all of them were dissatisfied with family functioning. Table 3 is a sample of descriptive statistics. Table 3.

Variables
Attempt ( Table 4 represents eight categories and 17 subcategories from the interviews that explored the dimensions of cohesion, flexibility, and communication. The main categories on the dimension of cohesion are (1) lack of emotional closeness, (2) family conflict, and (3)   Female youths who feel less emotional closeness in their family relationship, feel alienated at home. They opt to leave parents' houses and live in other cities. Although they occasionally come back home, they still feel and experience reduced interaction at home. They feel negative emotions like sadness and anger due to cold family relations. Such emotional distance was reflected in the relationship between these youths and their fathers. Female youths regarded their father as a stranger and merely a source of financial needs.

Family Conflict
This category consists of 2 sub-categories, (1) psychological and physical violence in the family, and (2) conflict with the mother and loss of the father as triggers to suicidal behavior.
• Psychological and physical violence in the family Psychological Thought 2021, Vol. 14(1), 9-34 South-West University "Neofit Rilski" https://doi.org/10.37708/psyct.v14i1.506 Parental conflict and parent-youth conflicts often occur in the family. One cause of family conflicts was the affair of one parent. The conflicts were followed by divorce despite the likelihood of the parents getting together again. In addition, psychological and physical violence also occurred in families, from father to mother and from parents to the children. • Conflict with the mother and loss of the father as triggers to suicidal behavior A female's relationship with her mother and with her father can be different. Females in late adolescence who are not used to openly communicating with their mothers tend to have conflict with mothers, leading to self-harm behavior. Female youth who closes to father, the death of father triggers to a suicide attempt.

Sibling Relationship
This category has 2 sub-categories, namely (1) closeness to versus distance from siblings and (2) Parents comparing children.
• Closeness to versus distance from siblings There were participants who considered themselves unable to have an open discussion with their mothers but showed closeness to their siblings and openly communicated with them.
"It is not usual for me to discuss with my mother. • Parents comparing children The participants considered that their parents treated their children differently, that their siblings were treated better than them. These female youths did not like being compared with their siblings and other children.

"I'm not close to my big sister, because we are different. She is the queen of the family, and I am the black sheep. She is an introvert, never sharing stories. So, I feel it is not comfortable for me to share with her." (Participant 3)
"I don't like the way my parents treat their children. They said my sister is more diligent than me, and her academic achievement is better too. I am also compared with their friends' children whom they think are better than me." (Participant 6) 2. Flexibility

Leadership in the Family
In this category, there are 2 sub-categories, (1) Sharing roles, and (2) father as the decisionmaker • Sharing roles The participants admit that their parents were responsible for fulfilling family needs. In twoparent families, the mothers played the roles of managing family finance and instilling values into the children. Maternal figures becoming the backbones of the family occurred in singleparent families.

"I know my parents work so hard, looking for extra incomes, because they want their children to get the best education. My father wants his children to pursue a Master degree. My
parents always try to make sure their children not run out of money. My mother manages all family finance." (Participant 6) "My mother cares more about values like attitudes and characters" (Participant 4) "The great thing is that she is a single parent. She is able to support her child's education up to Master degree. That's what makes me so proud. My mother has many debts, but she is still able to finance her child's education. I am so amazed with that." (Participant 2).
• Father as the decision-maker Not all families discuss daily problems. When a situation demands a decision, the father often becomes the decision-maker. There were families that discussed family problems, but the participants regarded no behavior change in the family members for a long time. The absence of consistent behavioral changes in the family relationship made the family discussion useless.

Obedience
In this category, there are 2 sub-categories, (1) Obedience to an authority figure and (2) Parents feeling to have the right to control children.
• Obedience to an authority figure The theme of obedience became an interesting finding regarding the family relationship. It reflects on the wife's obedience to husband and children to parents. The obedience of mother to father, according to the participants, indicates the mother's weakness. On the other Psychological Thought 2021, Vol. 14(1), 9-34 South-West University "Neofit Rilski" https://doi.org/10.37708/psyct.v14i1.506 side, parents demand obedience from their children. Children's disobedience is regarded as a behavior of opposing the parents.

"My mother always loses from my father. My mother is not brave to oppose my father. He's
too stubborn, uncompromising. If he has a desire or an opinion, everyone must follow him." (Participant 6).
"Now, everything is ruled by my parents, even a trivial thing. If everything is not as they wish, they will be angry. "Why are you against your parents?" There's no time for me to decide thing on my own. Everything is controlled by my parents." (Participant 3) • Parents feeling to have the rights to control children Although the participants had stated their aspiration to decide by themselves, their parents responded that it is parents' right to determine their children's future. Youths eventually will obey their parents in order to avoid conflict and please them. "Obey… Although I get upset, everything my mother tells, I always obey. If I just decide something by myself, I am afraid it will not suit my mother's wish. She will surely get angry.
Not to make her angry, I ask her first, can I do this, Mom?" (Participant 2)

Autonomy and Control
In this category, there are 2 sub-categories, (1) self-determined to choose education, (2) parental control hampering autonomy, and (3) rigid rules about school and religious activities.
• Self-determined to choose education Parents give their children autonomy to choose a college major and university they desire.
Most of the college students had left their parents' house and live in other cities for studying. • Parental control hampering autonomy There were playtime restrictions. It is considered as an obstruction to autonomy according to middle adolescents and as a restraint on building relationships with peers. Parents control the behavior and decisions made by youths. Parents control youths' activities because they keep a value that a child is the parents' responsibility until the child gets married. Strong control from parents over children occurs until late adolescence, which encourages female youths to get married in order to determine her own life. • Rigid rules about school and religious activities Parents impose strict rules toward early and middle youths regarding their school activities.
In contrast, these youths accept the demands of carrying out religious activities and assume that these demands are the way parents instill spiritual values.
"I was asked to join acceleration class, but I rejected. They said, "You are against your parents." Every little thing that I want and does not suit their wish, they judge me as going against them. Anyway, children have their own will, don't they? (Participant 3) "My mother always reminds me to do the prayer, study, recite Al-Qur'an. My mother is so fussy about doing the prayer. Such is the value she implants. (Participant 2)

• Mendhem
Mendhem rasa or mendhem is a term that the participants use to explain the tendency not to express and communicate what they thought and felt when facing a problem. Mendhem means buried their emotions or feelings, usually negative emotions such Psychological Thought 2021, Vol. 14(1), 9-34 South-West University "Neofit Rilski" https://doi.org/10.37708/psyct.v14i1.506 as disappointment, sadness, and anger. They choose mendhem rasa because they did not want to intensify problems and did not find anyone with whom they could share stories. One female from a single mother family did not want to share with her mother because she did not want to burden her.
"When my mother and father had a fight, mother kicked father out of home, so they lived separately for some time before they got together again. It was always like that. I was tired of witnessing them fighting. My mother maddened me, but I could not say anything to her. It was mendhem here (touching her chest), so upset, but I could hardly say it." (Participant 2) "When I have a problem, I more often mendhem. There is no one with whom I can share. If I share with my mother, I am afraid it would be a burden for her." (Participant 5) • Less open communication The participants felt there was emotional distance in the relationship with their parents that hampered communication. Most of them felt uncomfortable sharing things openly with their parents. The feeling of distance had grown for a long time so that they found it weird when their parents asked them to share their stories or problems. Even when the parents knew their children's suicidal behavior, they did not respond with attention as the female expected.
One participant could share with her mother but felt distant in the relationship with her father.

Weak communication skills
This category consists of 2 sub-categories, (1) mother less-understanding children, and (2) criticizing and blaming children • Mother less-understanding children Psychological Thought 2021, Vol. 14(1), 9-34 South-West University "Neofit Rilski" https://doi.org/10.37708/psyct.v14i1.506 The participants thought their mothers were not good listeners. Mothers could not understand their youth's opinions and tended to be reactive or angry towards their opinions.
The way the mothers responded in communication triggered mother-youth conflicts and selfharm behavior among youths.

Discussion
To intensify the family-based prevention of suicidal behavior in female youths, it is important to understand the family relation from these youths' perspectives. This qualitative study aimed to describe family cohesion, flexibility, and communication from suicidal female youths' perspectives (Olson, 2011;Olson et al., 2019). As described in Circumplex Model, Psychological Thought 2021, Vol. 14(1), 9-34 South-West University "Neofit Rilski" https://doi.org/10.37708/psyct.v14i1.506 communication helps the family to change its cohesion and flexibility when facing a problem (Olson, 2011). Communication in parent-youth relations reveals closeness that can maintain the connectivity among the family members (Laursen & Collins, 2004) The ambivalence in the relationship of female youths and especially with their mothers, was identified in this study. These youths want to develop openness in communication with mothers and share their problems, but their different opinions became sources of conflicts between mothers and females. This study indicates that conflict with the mother was one of the factors triggering self-harm behavior. Contrast with previous studies that revealed the level of emotional closeness between female youths and their parents, especially mothers, builds the females' preparedness to share everything that is either important or frightening for them (Karabanova & Poskrebysheva, 2013), and reduces the likelihood of attempting to suicide (Zayas et al., 2011). The daughters need their mothers as a source of emotional support to deal with life's stresses. Unfortunately, these needs are often not fulfilled.
The cultural aspect of Indonesia family relationship also reflects on the hierarchical relationships, which demand obedience to an authority figure, such as from wife towards husband and from children towards parents. Authority figures hold control over the family members, as seen in the father's role as the family's decision-maker. These fathers often do not involve other family members to discuss family problems. This condition occurred in the families of both attempt and no-attempt groups. The youths tended to mendhem rasa or bury their emotions and not share what they felt to show their obedience to their parents and avoid conflict with them. It is not surprising that Indonesian culture holds a hierarchical relationship and avoids conflict (Moffatt, 2012). Cultural values that avoid conflict and Psychological Thought 2021, Vol. 14(1), 9-34 South-West University "Neofit Rilski" https://doi.org/10.37708/psyct.v14i1.506 hierarchical family structures have an unfavorable impact on parent-youth relationships.
Female youths can only give opinions about what they want, but the decision about whether these youths' expectations can be realized depends on their parents' consent. The hierarchical relationship builds conformity in family communication, which tends to be onedirection communication from superiors to subordinates.
The tug of war between the opportunity to be autonomous and parents' desire to control their adolescents to ensure conformity to parental authority occurs from childhood to late adolescence. As understood, early adolescence is the period of negotiation for autonomy within the parent-youth relationships (Steinberg, 2001). The results of this study showed that female youths have limited opportunities to be independent in making their own decision.
Although youths want to choose and determine their own future, parents think that they are the ones who have the right to decide their children's future. The culture held by Indonesian society considers that a child is the responsibility of the parents until the child is married. Parents will fulfill the child's needs before working to meet their own needs. Parents also have the right to make decisions about their children's future.
On the other hand, this situation hinders the autonomy of youths. For early and middle female youths, their parents limit their activities outside the home and make sure that they are at home before dark. In particular, for female youths, there are gender-based norms that make their mobility more restricted than that of male ones, so that they must always be protected and not allowed to be outside the family home (Blum et al., 2017). Female youths consider restrictions on activities outside the home as limiting opportunities for personal development. Middle and late adolescents who are going to college are given the opportunity to choose their intended tertiary education, but parental control is still felt to be strong enough in relation to the non-academic activities and with whom they are friends. Female youths respond to parental control by choosing to undergo education outside the city so that they can 'get out of the house' and avoid confrontation with parents. Separation from parents becomes an opportunity for youths to break away from parental control and develop autonomy.

Limitation of the study
Although it was attempted to carry out the study following the planned design, this qualitative study conducted on suicidal youths had several limitations: Psychological Thought 2021, Vol. 14(1), 9-34 South-West University "Neofit Rilski" https://doi.org/10.37708/psyct.v14i1.506 1. This study involved suicidal youths from Javanese families who live in cities and villages. This study's findings cannot capture the differences between youths who live in cities and villages on how cultural values internalized in the family that affect relationships within the family.
2. Female youths involved in this study were selected purposively based on their type of suicidal behavior. This study did not analyze the possibility of participants' psychiatric disorders that contribute to youth suicidal behavior.
3. This study's findings cannot be generalized to youths from other different cultures, and the results can also be different if the same study was conducted on Indonesia male youths.

Conclusion
Overall, this qualitative study with ten suicidal female youths has shown that poor family relations and the impact of rigid cultural traditions become the risk factors of suicidal behavior. Family dysfunction are reflected in family conflicts that are not resolved with solutions accepted by all family members. Physical and verbal abuse from parents against youths and the hierarchical family relationships widen emotional distance among family members. This study's implication indicates the importance of involving family cultural values and family relationship patterns in preventing family-based adolescent suicidal behavior.

Funding/Financial Support
This research was funded by Indonesia Endowment Fund for Education (LPDP), Indonesia.

Other Support/Acknowledgement
I would like to say thank you to all the participants of this research. I also thank to my supervisors for an encouraging discussion: Prof. Noor helped the first author to build the concept of adolescent suicidal behavior. Prof. Tina helped the first author to build a strong basic theory for this article. Prof. Byron gave his argument to include the family culture value in collecting data and analyzing.

Competing Interests
The authors have declared that no competing interests exist.