What Protects Adolescents from Suicidal Attempt: A Qualitative Study

Suicidal attempt refers to involvement in potentially self-injurious behavior with a non-fatal outcome and an evidence of the persons’ tendency to die (1). Suicide theories cover various viewpoints such as biological, psychodynamic, cognitive-behavioral, and developmental/systems. Among these theories, developmental/systems theories play a key role in upset social forces (2). Many of Durkheim’s assumptions, one of the most well-known theorists of suicide in the late 19th century, were based on developmental/systems model (2, 3). The important role of social factors in the etiology of suicidal attempt was highlighted by Durkheim (2, 4, 5). According to Durkheim’s theory (1897), disorganization of social forces leads to suicidal attempt. He suggested that the lack of social integration besides moral integration leads to a rise in suicide attempts (2, 4, 6). He argued that social ties can protect the individuals against suicidal behavior by social integrations and moral regulations (5). Due to the importance of the suicide attempt issues, rates of suicidal attempts are among important indicators of a community’s mental health (7, 8). According to estimates by the world health organization, in the year 2020, approximately 1.53 million people will die from suicide and at least 10 times more people will attempt suicide worldwide. This is on average 1 death every 20 seconds and 1suicidal attempt every 1 - 2 seconds (9, 10). In Iran, suicide attempts have become increasingly important. The suicide attempt rate in our country is higher than the majority of Muslim countries (11). Recently, the rate of suicide attempts in Southern Iran has increased and the age of people who attempt suicide has declined (12-14). A review of previous studies suggests that adolescence is a critical period for initiating self-injurious behavior (15). Suicidal attempts in adolescents are accompanied by different results, such as disability and increased costs of treatment in this population (16, 17). In addition, the suicide attempt in adolescents is a dramatic event, but it is avoidable (18). Unfortunately, few studies have been carried out in Iran for a comprehensive understanding of suicide attempts and suicide prevention with regard to the Iranian culture (19). Furthermore, few qualitative studies have been carried out in the socio-cultural context of our country regarding protective factors against suicidal attempts among adolescents; there may be issues less addressed by available literature. Therefore, it is necessary to investigate protective factors against suicidal attempts among adolescents with regard to socio-cultural characteristics and conditions in our country.

Our study was carried out to investigate the protective factors against suicidal attempts among adolescents who recently attempted suicide. The results of this study can help the related authorities coordinate their activities in order to meet the needs of this age group.

Qualitative content analysis was used in this study to investigate protective factors against suicidal attempts among adolescents. One of 3 approaches for the qualitative content analysis method is a conventional qualitative content analysis. In this approach, coding categories are derived from the raw data directly and inductively without imposing predetermined categories or theoretical perspectives on them (20).

Eighteen adolescents (6 males and 12 females) aged 16 to 19 years, who were referred to 2 hospitals in Shiraz, from September 2013 to June 2014, after attempting suicide with drugs, agreed to participate in this study.

In the first step, the adolescents visited hospitals for establishing a close rapport with them and determining an appropriate time for an interview. In the second step, interviews were conducted 48 to 120 hours after the participants were discharged from the hospital. Based on their medical condition, ability, and interest, the time for interviews was determined.

The participants who had one of the inclusion criterias, such as inability to participate in the study for any reason expressed by them like lack of interest or diagnosis with severe depression and acute psychosis. Convenient sampling method was carried out and continued until data saturation was reached.

Each interview was started by introducing the interviewer and explaining the purpose and method of the study. Data were collected using semi-structured in-depth interviews. A general question (How do you describe a day in your life?) was the first question and then the interview continued with follow-up questions. Finally, the interviewer asked the participants to discuss other important issues that were not mentioned during the interview. A calm and quiet place was chosen for convenience of the participants during interviews. Each participant was interviewed during 1 session. The mean duration of the interview was almost 54 minutes.

Collecting and analyzing data were done simultaneously. For the analysis, first, each interview was recorded. After listening to it several times, the interview was typed verbatim and then entered into MAXQDA 10. In the software, every interview was read word by word and each text was broken into meaning units. Then, similar meaning units were grouped in 1 category. Finally, based on the content and similarities, the main categories were formed by using subcategories. After each interview and throughout the data analysis, the researchers wrote theoretical memos that were then coded. This contributed to the richness of the data. The main categories were summarized in 3 themes.

To improve the accuracy and rigor of the findings, Lincoln and Guba’s (1985) criteria were used (21). To increase the credibility of data, a prolonged engagement with the data collection process and analysis was kept.

The data were collected from 2 major referral hospitals where the participants had been admitted. The memos were written by the interviewer and the accuracy of the data analysis was confirmed by 3 specialists in the field of qualitative research. Finally, original codes were checked by some participants to compare the findings with the participants’ experiences.

To increase the dependability and conformability of data, maximum variation was observed in the sampling. Finally, to increase the power of data transferability, adequate description of data was provided in the study for critical review of the findings by other researchers.

All participants and their parents signed the informed consent prepared in accordance with the Helsinki Declaration.

The mean age of the adolescents in this study was 17.44 ± 1.15, all being single. Three main categories and 10 sub-categories of data were obtained (Table 1).

In this study, protective factors against suicidal attempt among adolescents were studied. Suicidal attempt is a cry for help. Therefore, this has a positive potential towards treatment and re-adjustment (31, 32). This movement should certainly start with the person himself/herself. The methods these people used to keep away from suicidal ideation included self-control of suicidal thoughts and self-actualizations via working, exercise, and study. In this way, the person tries to ward off negative thoughts to put off the decision to attempt suicide (19, 23). Research stresses the effects of patient-centered measures such as encouraging them to get busy by doing things of personal interests such as working, exercise, and watching TV. Families who take such measures to care for people who attempted suicide will have a better chance of recovery than those who do not for various reasons such as lack of information on taking care of these patients (33).

The role of religion in prevention of suicide has been mentioned in numerous studies. Lack of religious beliefs can diminish the hope of improving conditions (19, 31, 33-36). It is, therefore, essential that counselors consider psychological as well as spiritual dimensions.

Research suggests an inverse relationship between fear of death and suicidal attempt so that people who are afraid of death are less likely to report suicidal ideation (37, 38).

Family problems such as conflict with parents and other family members are the most important causes of suicidal attempts among adolescents (39-41). On the contrary, sense of family cohesion, emotional support from the family, and a warm relationship between family members are among the most important protective factors against suicidal attempt by adolescents (19, 31, 42). Emile Durkheim demonstrated that suicide attempt rates were higher in populations that were less cohesive in family. For Durkheim, social cohesion, especially traditional life, provided the best protection against self-destructive behavior (43). Therefore, when adolescents think about their families and how they will be affected by their attempted suicide, they are likely to abandon such ideation.

When adolescents are faced with problems in their lives, they show some emotional reactions, the most common form of which is a sense of hopelessness (41). Research suggests that psychological characteristics such as hopelessness increase the risk of suicidal ideation (38, 40). On the other hand, valuing life and having hope for the future can be protective factors against suicide attempts (19).

Community members such as friends play an important role in the prevention of suicidal attempts among adolescents. Adolescents are at a period of life in which they are affected by their peers significantly. Therefore, friends can have a role in changing the adolescents’ attitudes and prevent their suicidal attempts (19, 31). Negative attitudes towards suicide attempts in the society and a person's consideration of what will be said about him/her after suicide attempt can prevent him/her from doing so (37, 38).

Durkheim’s adherence to a theoretical framework that considered social relationships as a protective factor against suicide attempt (5). A common theme from sociological theories regarding suicide attempts is the fact that positive social connections may be protective against suicide attempts, whereas negative social connections may enhance the risk of attempt suicide (4, 5). According to Durkheim’s theory (1897), the outcome of disorganization of social forces is attempting suicide. He suggests that too little social integration as well as too little moral integration leads to a rise in suicide attempt (2, 4, 6). He argued that social ties can protect the individuals against suicidal behaviors by integrating them into society and providing them with moral regulation (5).

There is some evidence that indicates that receiving professional support plays a significant role in preventing suicidal attempts (27-29). Yet, most people, who have committed suicide, had not received the special psychological care before death (44). In the same line with other studies, the present study showed that some individual characteristics are the reasons why individuals and families do not seek professional help at times of trouble. These include help-resisters by nature, attempt to solve the problem without the help of others, fear of medication, lack of recognition of the problem by family, lack of awareness, and social stigma of mental illness (28, 45).

Suicidal behavior is generally not accepted, especially in societies like Iran, where people have strong religious beliefs. Many people who are seeking help in various areas seek help from the clergymen. One of the areas where people do so is suicidal behaviors. Therefore, clergymen can be the first ones to help these distressed individuals. These people, along with health professionals play a critical role in preventing suicide attempts (46, 47).