1. Background
Suicide is one of the biggest concerns of the World Health Organization. Every year, around 703,000 people end their lives (1). A suicide attempt is a conscious attempt to take one's life which can be studied as a multi-dimensional illness and a solution chosen for a specific problem (2). One of the common mental disorders often accompanied by suicide is substance use (3). The global prevalence of substance use in individuals aged 15 to 64 has risen from 0.7% (around 35 million people) in 2015 to 1.2% (around 58 million people) in 2018, and the deaths caused by suicide saw an increasing rate in 2019 (4, 5). The rising number of people dealing with substance use and its resulting death rates has become a serious issue in developed and developing countries (6).
Substance use is considered a male problem that is more prevalent in men (7). Furthermore, men commit more suicide attempts and die as a result than women (8). People who are dealing with substance use commit suicide six times more than the normal population, and men who deal with substance use are three times more prone to commit suicide than the rest of the male population (9). Therefore, considering the importance of suicide attempts in men who are dealing with substance use and studying the circumstances that lead to these attempts, this study was performed within a qualitative platform.
A qualitative study provides a general insight into an issue that allows the researchers to discover the depth and complexity of the phenomena relating to human experience. Therefore, a qualitative study helps the researchers understand an issue that supports the creation of hypotheses and theories. One of the approaches within qualitative studies is the descriptive phenomenological approach or hermeneutics, which studies people's experiences while dealing with a particular phenomenon (10). Therefore, the descriptive phenomenological or hermeneutics approach can provide an in-depth insight into the experiences of men dealing with substance use who have attempted suicide. So far, no qualitative studies have been carried out on the issue of suicide in men who deal with substance use, which adds to the significance of this research even more (11).
2. Objectives
Based on the significance of the study, the purpose of this research work was to provide a phenomenological study of suicide attempts in men dealing with substance use.
3. Methods
This qualitative study was performed by the hermeneutic method. This study allows us to become aware of the views of others. Heidegger believes that phenomenological research provides insight into the true meaning of life in the process of everyday life without any disturbance in the methods expressed by the meaning of this real life (12). Hermetic phenomenology also helps to understand the worldview of the phenomenon of suicide attempts in men with substance use.
3.1. Sample and Setting
This study was performed in the psychiatric ward of Ilam, Iran. After the initial interview, we selected participants who met the inclusion criteria, including a history of drug use, suicide attempt, no psychotic disorders, expressing suicide attempt experience and willingness to participate in the study, using a purposive sampling method with maximum variety in age, year of drug use, marital status, educational status, and several suicide attempts.
3.2. Data Collection and Analysis
Data collection was performed simultaneously with data analysis. A semi-structured individual interview was conducted from 2020 to 2021 in the psychiatric ward of Mostafa Ilam Hospital. The interviews were in Persian and Kurdish and lasted between 25 and 50 minutes. A distinguished researcher with a Ph.D. interviewed all participants. The main questions asked to the participants in the rehabilitation counseling are as follows: (1) what is your experience with suicide attempts?; (2) what are your thoughts and feelings about the suicide attempt?; (3) what does suicide mean to you? Exploratory questions were also asked in the interview for more information on the phenomenon's occurrence. The interviews ended after saturation. Twelve interviews were conducted, and data analysis was performed using the method of Diekelmann et al. (13). It is a seven-step process with a team approach, as follows: Step 1: Each interview text was read in its entirety to gain a broad understanding. Steps 2 and 3: Possible common meaning units were identified using abstracts to support interpretation. The authors listened to the tapes over and over again to extract the true meanings of the data. Step 4: The research team evaluated the similarities and differences in its interpretations and first reviewed them. The manuscript was prepared for further insight and agreement. Step 5: All texts were revised to confirm emerging themes and sub-themes. The research team categorized these topics and sub-topics. Step 6: A constructive pattern was identified to visualize the relationship between these themes and sub-themes in all texts. Step 7: The research team prepared a final report, including quotes presented to each participant for discussion (13).
To ensure the data accuracy, effectiveness, and reliability, we followed the Lincoln and Guba approach, and to determine the transferability of the findings, the results were shared with two clients who attempted suicide but were not present in the study (14).
4. Results
The findings of this study are categorized into two main themes: "Inefficient personality traits" and "the stigma associated with addiction." Two sub-themes were also defined for these themes: "Impulsive behavior" and "emotional instability."
4.1. Inefficient Personality Traits
Within the context of inefficient personality traits, two sub-contexts were defined, including impulsive behavior and emotional instability. The participants who exhibited both of these patterns had attempted suicide.
4.1.1. Impulsive Behavior
The participants, who exhibited a certain level of impulsiveness as a personality trait, attempted suicide as a response to an impulse, without thinking about the outcome of their decision; so reported a participant of the conditions relating to his suicide attempt: "Out of nowhere, I started smoking; I thought it might help me forget, but there was no use! I became more and more agitated and isolated each day. I couldn't stand hearing what others had to say to me. I barely ate anything. I sat somewhere and stared at a spot or wandered the streets for hours. After getting hooked on the cigar, I went to cafés and started using a hookah. I just started doing drugs very recently as a result of an impulse. I even attempted suicide just like that, decided in the matter of a moment, and regretted it instantly" (P4).
Another participant describes reaching the end of the line and attempting suicide: "It was as if whatever I said, my father wouldn't listen. I even yelled at him, but he couldn't care any less. He saw I was drowning but did not give a damn. I couldn't figure him out. But I had reached the end of the line, and I had to set the record straight that day. I told my dad that if he did not give me my inheritance, I would kill myself, and I do not remember what happened next. I was very angry. I headed towards the kitchen and hit my chest and abdomen with the big long-handled kitchen knife that was in the sink" (Ps).
4.1.2. Emotional Instability
In the following, emotional instability is detailed as an inefficient personality trait that entails a lack of normal sustainability and uniformity in one's temperament and emotions, followed by sudden changes in one's mood. In this account, a participant details his experience: "I was very angry back then, and I wanted to show my anger by a suicide attempt. I want to let everyone know how angry I was with myself and others. After taking up all those pills, I felt a sense of relief and light because I thought it would be over soon. But I was interrupted by the thought that 'you are crazy! You killed yourself, and you are going to die, just like that!' That was when I got scared and realized what a big mistake I had made. The thought of dying got me scared" (P2).
Another participant detailed: "I always suffered from mood swings; one day, I was high, and the next day I was down. A few days after my first suicide attempt, I felt much better, but soon I was thinking about the suicide attempt again. I headed to the medicine cabinet this time and took out all the pills. I don't remember how many I took, but shortly after taking them, and since it was so long from my last fix, I collapsed" (P9).
4.2. The Stigma Associated with Addiction
Regarding the stigma associated with addiction, the participants referred to the labels, blames, and insults directed towards them, making them feel worthless, useless, judged, and like they were a burden to others. Also, they uniformly claimed that they attempted suicide in response to the stigma associated with their addiction: "When you have graduated from a state university and become addicted, you feel like an outcast in society. No one will hire you, and all doors are knocked in your face wherever you go. Everyone looks at you as a burden, worthless, and no one respects you. This will crush you from the inside. One of my fellow villagers told me when he saw me one day: 'Check you out! High to your nose!' I got so angry when I heard it and realized that now the entire village would learn about my substance use problem, and no one would respect me again. The sun was setting when one of my relatives with a drug problem approached me, and I told him what had happened. He said, 'don't worry! Let them all talk! It's not like you're an actual addict, right?' I knew he was messing with me, which got me even angrier. I often blamed myself for what I had done to myself and felt remorse for my condition. In my mind, there was a constant record playing, 'by now, your family must've learned about your addiction, and they are probably unfortunate. An entire village is judging you right now, just like this bastard making fun of you.' I was under much pressure. I couldn't think straight, I really couldn't, and all I was thinking was one thing which was to set myself free. That is why I went out and bought an aluminum phosphide pill, dropped it in a glass of water, and started stirring. As I was stirring it, I would repeat these sentences to me 'damn this life! damn it! You saw how they were talking behind your back. Death is much better than a scandalous life, and I drank the entire glass afterward" (P2).
Another participant details: "I begged everyone I knew for a job, but as soon as they saw my messed up face, they would refuse to hire me. My friend was a taxi driver, and I begged him to let me drive his taxi when he was not working and making more money, but he disagreed. I went to the city hall and said I would do anything, even be a night guard, but they did not give me a job either. After being repeatedly disappointed, I was fed up and did not know what else to do" (P5).
4.3. Constitutive Pattern of Being Crippled with Remorse and Judgment of Others
Based on the participants' reported experiences in this study, the inefficient personality traits and the stigma associated with addiction were the two main concepts constructing the constitutive pattern of this research. Two inefficient personality traits predominantly observed in men dealing with substance use who had attempted suicide were impulsivity of behavior and emotional instability in dealing with life challenges and issues. Having inefficient personality traits, including emotional instability and impulsiveness of behavior, creates a sense of remorse in one, which is even amplified by the judgment, blame, and rejection of others. Together they create a constitutive pattern that leads them to suicide attempts and the risks of another try.
5. Discussion
One of the sub-contexts that reinforce the inefficient personality traits in a phenomenological study of suicide attempts in men who suffer from substance use addiction is the impulsiveness of their behavior. Being repulsive suggests that while being motivated to act in this regard, one has no control over one's behavior, feelings, and impulses. A highly impulsive person will set aside no time to think and consider the possible outcomes of his behavior; therefore, he cannot make a proper decision (15). Hofmann and Friese (16), Stahl et al. (17), and Marashi and Mehrabian (18) describe impulsivity as the central core of many social and psychological problems, including substance use, compulsive gambling, personality disorders, sexual, criminal conduct, and suicide. The participants, in many stances, have suggested that their impulsive behavior has resulted in their addiction and subsequent suicide attempts. The participant's inability to control and manage their feelings, emotions, and behaviors and to make the right decisions validates this assessment. Trezise and Reeve states that, when pressured to start using drugs by their peers and friends, men cannot prevent themselves from reusing, and it is this lack of control over their emotions that intensifies their risks of reusing drugs and becoming a drug addict (19). On the other hand, this impulsivity that led them to the drugs in the first place leads them to a suicide attempt. An addict has no appropriate control over his emotions and cannot make the right decisions for solving his problems; that is why he is under constant pressure to exhibit the right emotions and behaviors. This constant pressure sometimes leads him to hasty and unsound decisions without considering the outcomes of his decisions, which would inevitably bring him remorse in the future. The same process is observed in those who have attempted suicide. The participants who had attempted suicide stated that they suffered from impulsivity in their behavior and reactions. The findings of this study are confirmed by Berg et al. (20), Millner et al. (21), Anestis et al. (22), and King et al. (23), who have discovered that suicide attempts, antisocial behavior, substance use, and reckless sexual behavior all account for a trait of impulsiveness in one's personality.
The sub-context of emotional instability as a constituting agent of personality issues indicates that emotional instability results in inappropriate displays of anger, chronic feelings of worthlessness, and swift mood swings. Emotional instability accounts for high emotional variability and the intensity of affection in the people who suffer from this condition compared to those who do not. People who suffer from emotional instability are far more sensitive to emotional stimuli. Malesza and Kaczmarek claims that people who suffer from emotional instability are often involved in dangerous behaviors, including intentional self-harm and suicide, alcohol and substance use, unprotected sexual intercourse, and drug use (24). The fact that all participants suffered from emotional instability poses the risk of committing suicide attempts. These individuals, therefore, require a great deal of attention and support; otherwise, this existing personality trait can easily lead them to death. Grilo and Udo (25), and Park and Kim (26) conducted various studies and concluded that emotional instability plays a significant role in attempting suicide, which concords with the findings of this study. Rockstroh et al. discovered that emotional instability, as one of the main components of borderline personality disorder, plays a vital role in driving one to suicide attempts (27). Based on what has been discussed to this point, the participants displayed a constant trait of emotional instability in making their decisions and, at times, regretted their suicide attempts afterward and called it an immature and impulsive decision that did not take into account the possible outcomes. The participants constantly complained about their emotional instability, and some even voiced their concerns about committing suicide again because of their emotional instability.
Another concept the participants reported about their suicide attempts was the stigma associated with addiction. Schnyder et al. believes that stigma is developed in social interactions, and the stigmatized person usually holds the same unflattering beliefs about himself that society holds against him (28). Park and Park believes that stigma can lead to many adverse emotional outcomes, including a sense of lacked self-respect and negligence (29). To combat the stigma, the stigmatized individuals usually withdraw from society, isolate themselves, and decide not to disclose their problems to others. These individuals do not seek help from others in time because they believe that if they hide their problem, it will just go away (30).
Gonzalez-Torres et al. (31) and Topkaya et al. (32) believe that the social stigma associated with addiction forms the most critical obstacle in the path of those who need to seek psychological help, continue their treatment, or get into a rehabilitation center. The most damaging impact of social stigma is observed when the individual accepts and internalizes the stigma and negative outlook cast on him by society; in this situation, the person is said to have had a personal or emotional stigma. This process changes one's view of oneself, losing identity and choosing to believe the stigmatized picture as one's view of "oneself" (33). Furthermore, social stigma causes an array of other adverse outcomes for the individual, including lack of self-esteem, depression, guilt, self-reproach, internal restlessness, and distress, decreasing one's quality of life and feeling of self-worth, addiction, and suicide, and physical disturbances such as sleep problems and a feeling of chronic exhaustion (33). Due to the negative and damaging impacts of social stigma on the mental health of people dealing with substance use, it should be considered an important issue to be advocated for in the realm of mental health (34).
On the other hand, cultural institutions contribute significantly to the emergence of mental disorders in society, including addiction. Papadopoulos et al. reports that in the countries that favor individualism, including the United States, Germany, and Australia, compared to countries that favor pluralism, including Asian, African, and Arab countries, less social stigma is associated with mental health disorders (35). Stigmas are primarily created due to a lack of understanding and fear, both at the personal and social level, associated with mental health disorders (36). Whether or not the stigmatized individuals seek help depends on their personality traits.
Based on the findings of this study, the stigmatized individuals believe they are worthless and feel rejected by their families, friends, and even society, and that is why they do not ask for psychological help or treatment. The findings of this study fall in line with the findings of Gronholm et al. (33), van Boekel et al. (37), and Smith et al. (38) about the impact of stigma, which causes psychological problems, including lack of self-confidence, depression, conduct disorder, anxiety, suicide, and physical issues. The fact that the participants, when judged and rejected by their families, friends, and society, feel worthless and empty on the inside and choose to attempt suicide as a way to relieve themselves from this social pressure supports this argument. The study participants uniformly reported that while interacting with others, they felt rejected, useless, worthless, and like a burden to the people around them. The increasing negative social pressure caused by these interactions causes individuals to think of attempting suicide as a way to relieve themselves from this heavy burden of having no self-esteem and this feeling of worthlessness.
5.1. Conclusions
The findings of this study provided an in-depth insight into suicide attempts by men dealing with substance use. The participants' experiences were mainly impacted by their inefficient personality traits and the stigma associated with addiction. Having inefficient personality traits and the stigma associated with addiction were two personal and interpersonal components contributing to suicide attempts by men who suffered from substance use. Men who are dealing with substance use since they suffer from inefficient personality traits, including impulsivity of behavior and instability of emotion, once being stigmatized, judged, blamed, neglected, and rejected by their loved ones and society because of their addiction, seek to find a solution to their ordeal through a suicide attempt. Since these inefficient personality traits and social stigmas pose this special-needs population the risk of suicide, mental health consultants and psychiatrists should diligently consider them to reduce and prevent suicide attempts in society.
5.2. Limitations of the Study
This study faces the challenges of generalizability and the small sample size, which is typical of all qualitative studies. In future studies, these limitations should be addressed for studying this topic on female participants.
