The way you ask dictates the answer you receive?
If following a suicide the bereaved are interviewed based on a diagnostic questionnaire, as in traditional PA studies, there is a relatively strong possibility of ending up with a diagnosis for the deceased. This emerges clearly from the review study by Cavanagh et al. (3). However, such diagnoses are based on the subjective perceptions, emotions and experiences of the bereaved, or on speculations about questions which, in many cases, they cannot possibly answer with certainty on behalf of the deceased (5). On the other hand, if the bereaved are allowed to speak freely about what they think was central to the suicide, the picture is entirely different.
A clear example of this is a PA study from England (7, 8). In the first part of this study the informants answered diagnostic questions. 68 % of the deceased were then found to qualify for a psychiatric diagnosis (7). When the narrative part of the interviews with the same informants was analysed qualitatively, however, it transpired that very few spoke of psychiatric disorders as being central to the suicide (8).
Two qualitative PA studies have now been conducted in Norway, in which several bereaved persons associated with each suicide have been able to tell their story of what led to the suicide. In her study of suicide among the elderly (65 – 90 years) Kjølseth found that suicide had to do with who the deceased had been, how they had lived their lives given their circumstances and what their experiences meant when confronted with old age (9). Many had lived in very difficult circumstances, both when growing up (for example, with the loss of important carers, illness and poverty) and later in life (serious losses and challenges). The informants described the deceased as conscientious, action-oriented and skilled in their work (10). They were also described as emotionally distant, obstinate and with a need for control, which had contributed to creating conflicts in close relationships. It had been difficult for them to accept help. This would entail relinquishing control, which was contrary to their self-image/identity (10). It might thereby appear that their strength and ability to deal with difficulties throughout their lives were what made them vulnerable to suicide in old age, because they would not or could not adapt to age-related loss by developing new coping strategies or accepting necessary assistance (9, 10). Age-related loss of function resulted in a feeling of having lost themselves, since they could no longer do what they wanted. Life was thus perceived as a burden. They had a realistic view of the future, a future they did not want, and therefore made an existential choice to take their own lives. In this way they regained control. The title of Kjølseth’s PhD thesis is hence also «Control in life – and in death: an understanding of suicide among the elderly» (9).
In Rasmussen’s study of suicide among young men (18 – 30 years) (11) only men who had not been in contact with mental health care, and who had made no previous suicide attempts were included. In-depth interviews with mothers, fathers, siblings, girlfriends and friends, as well as the deceased’s suicide notes made it possible to analyse data from both a developmental and a relational perspective. As in Kjølseth’s study, the young men were also described as diligent and achievement-oriented at their work and studies. Several were described as perfectionists. Despite the fact that they appeared successful, however, the analysis showed that early in life they had developed a fragile, performance-based self-esteem that made them vulnerable even when encountering small setbacks. The study reveals a particular vulnerability to experiencing themselves as unsuccessful and rejected when they failed to live up to their ideal of performance and how they had envisioned that life should be. Instead of lowering their performance expectations in such situations, they were overwhelmed by strong emotions, particularly shame and anger, which they were unable to either regulate or deal with. Their previous strategy of compensating by continuously improving their performance no longer worked, and suicide became the way out of a state of intolerable mental pain (12).
An interesting finding of both these studies is that the informants placed little emphasis on mental disorders in their narratives about what was central to the deceased’s suicide. Few informants had seen signs of serious mental illness (11), and many explicitly stated that the deceased had not been depressed (11, 13). This is in strong contrast to the conclusion drawn in most quantitative PA studies, namely that almost everyone who has taken his/her own life was found to have one or more mental disorders (3), with accompanying causal implications. The findings therefore challenge the established notion that suicide is mainly a symptom of a mental disorder.