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The importance of the 'little' things

Lisbet Borge About the author

It is not always easy to see the warning signs of suicide in young men.

Experiences of the bereaved in connection with the suicide of young men is a qualitative study of the perceptions of 61 close relatives and friends following the suicides of ten young men (1). The article discusses whether future action plans for suicide prevention should have a broader perspective than the current disease model.

The bereaved in the study often assessed the danger of suicide among these men as being negligible because of their apparently high degree of self-efficacy, and the absence of signs of serious mental disorder. Several of the deceased had relational conflicts prior to the suicide, but the bereaved had believed that the person concerned was able to cope. These findings are important, because mental disorder is often claimed to be a contributory cause in almost 90 % of suicides (2). The bereaved were of the opinion that this prevailing notion, combined with the deceased’s facade of being able to cope, was instrumental in their overlooking other signs of suicide risk (1).

In recent years, the prevention of suicide has been an important priority area for the authorities (3). But despite wide-ranging measures, there has been little change in the number of those who take their own lives (1). Handlingsplan for forebygging av selvmord og selvskading 2014–2017 (Action plan for the prevention of suicide and self-harm 2014−2017) (3) stresses an objective, evidence-based approach and recommends that standardised assessments of suicide risk be made. The question is whether the quantitative research tradition has dominated suicide research to such an extent that it has been at the expense of understanding the meaning of suicidal behaviour for the individual (4). Subject-oriented research whose focus includes existential, relational and sociocultural factors among other things may provide us with new knowledge of possible risk factors (5). However, the action plan also points out the importance of emphasising more contextual factors, and not explaining suicide by mental illness alone (3).

The biomedical model of illness has traditionally enjoyed great prestige and is frequently linked to evidence-based quantitative research. The objective is to acquire precise, robust treatment models. Even though quantitative research has provided us with considerable knowledge of the risk factors influencing suicidal behaviour, we still have insufficient knowledge of the prior process and what leads to a suicidal act (6).

One way to make progress is to apply knowledge from qualitative research traditions and ʻgo to the heart of the matter’ by collecting data about the experiences of people exhibiting suicidal behaviour or their relatives.

Historically, the role of the bereaved has received little attention in research and literature on the subject (7). Obtaining knowledge from the bereaved helps to incorporate user and experience competence in the knowledge base, in line with measure 27 in the action plan (3, p. 40). This measure makes it clear that user experience and experience-based competence should be included in research on the prevention of suicide. The subjective narratives of the bereaved can contribute to a contextual and relational understanding of suicidal behaviour.

In Rasmussen & Dieserud’s study, the bereaved pointed out that ʻirregularities, little things’ can give young men a mistaken feeling of defeat despite apparently being high achievers, and that this knowledge is vital for healthcare professionals and relatives. Another important finding was that none of the young men had tried to get help prior to the suicide (1). Studies in which people have been interviewed after suicide attempts show corresponding findings. The decision had been made alone, and was not communicated to anyone – neither relatives, friends nor healthcare personnel (8). These findings provide useful knowledge that promotes understanding of how difficult it can be for those involved to interpret and understand the development of possible suicidal behaviour. This may be particularly challenging in cases where relational conflicts trigger such behaviour (1, 8). Mental health professionals, public health nurses and psychologists can be important collaboration partners for GPs in preventive psychosocial work. Nevertheless, the bereaved and relatives with their varied user experiences can also contribute, and the action plan highlights the usefulness of this (3).

Qualitative research methods can supplement quantitative suicide research (9). The qualitative approach has advantages in respect of understanding people’s perceptions, experiences, opinions, motives, attitudes and social interactions in a given context. Exploring meaning in those involved can help us to comprehend suicidal behaviour better, how suicidal behaviour is interpreted and understood, and what attitudes those affected are confronted with.

1

Rasmussen ML, Dieserud G. Etterlattes erfaringer ved selvmord hos unge menn. Tidsskr Nor Legeforen 2018; 138.

2

Hawton K, Saunders K, Topiwala A et al. Psychiatric disorders in patients presenting to hospital following self-harm: a systematic review. J Affect Disord 2013; 151: 821 - 30. [PubMed][CrossRef]

3

Handlingsplan for forebygging av selvmord og selvskading 2014–2017. Oslo: Helsedirektoratet, 2014.

4

Hagen J, Hjelmeland H, Knizek BL. Selvmordsforebygging i psykisk helsevern – på tide å tenke nytt? Tidsskr Nor Legeforen 2014; 134: 1222. [PubMed][CrossRef]

5

Hammerlin Y. Et kritisk blikk på forebyggingsarbeidet i fortid, nåtid eller framtid. Suicidologi 2016; 21: 34 - 42. [CrossRef]

6

Ekeberg Ø, Hem E. Praktisk selvmordsforebygging. Oslo: Gyldendal Akademisk, 2017.

7

Thorvik A. De usynliggjorte. Etterlatte gjennom historien. Suicidologi 2014; 19: 3 - 9.

8

Ghio L, Zanelli E, Gotelli S et al. Involving patients who attempt suicide in suicide prevention: a focus groups study. J Psychiatr Ment Health Nurs 2011; 18: 510 - 8. [PubMed][CrossRef]

9

Hjelmeland H, Knizek BL. Why we need qualitative research in suicidology. Suicide Life Threat Behav 2010; 40: 74 - 80. [PubMed][CrossRef]

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