A Narrative Web-Based Study of Reasons To Go On Living after a Suicide Attempt: Positive Impacts of the Mental Health System

Abstract

Background and Objective:  Suicide attempts are 10-20X more common than completed suicide and an important risk factor for death by suicide, yet most people who attempt suicide do not die by suicide.  The process of recovering after a suicide attempt has not been well studied.  The Reasons to go on Living (RTGOL) Project, a narrative web-based study, focuses on experiences of people who have attempted suicide and made the decision to go on living, a process not well studied.  Narrative research is ideally suited to understanding personal experiences critical to recovery following a suicide attempt, including the transition to a state of hopefulness. Voices from people with lived experience can help us plan and conceptualize this work.  This paper reports on a secondary research question of the larger study: what stories do participants tell of the positive role/impact of the mental health system. Material and Methods: A website created for The RTGOL Project (www.thereasons.ca) enabled participants to anonymously submit a story about their suicide attempt and recovery, a process which enabled participation from a large and diverse group of participants.  The only direction given was “if you have made a suicide attempt or seriously considered suicide and now want to go on living, we want to hear from you.”  The unstructured narrative format allowed participants to describe their experiences in their own words, to include and emphasize what they considered important. Over 5 years, data analysis occurred in several phases over the course of the study, resulting in the identification of data that were inputted into an Excel file.  This analysis used stories where participants described positive involvement with the mental health system (50 stories).  Results: Several participants reflected on experiences many years previous, providing the privilege of learning how their life unfolded, what made a difference.    Over a five-year period, 50 of 226 stories identified positive experiences with mental health care with sufficient details to allow analysis, and are the focus of this paper. There were a range of suicidal behaviours in these 50 stories, from suicidal ideation only to medically severe suicide attempts.  Most described one or more suicide attempts.  Three themes identified included: 1) trust and relationship with a health care professional, 2) the role of friends and family and friends, and 3) a wide range of services. Conclusion: Stories open a window into the experiences of the period after a suicide attempt.  This study allowed for an understanding of how mental health professionals might help individuals who have attempted suicide write a different story, a life-affirming story.   The stories that participants shared offer some understanding of “how” to provide support at a most-needed critical juncture for people as they interact with health care providers, including immediately after a suicide attempt.  Results of this study reinforce that just one caring professional can make a tremendous difference to a person who has survived a suicide attempt. Key Words: web-based; suicide; suicide attempt; mental health system; narrative research Word Count: 478 Introduction My Third (or fourth) Suicide AttemptI laid in the back of the ambulance, the snow of too many doses of ativan dissolving on my tongue.They hadn't even cared enough about meto put someone in the back with me,and so, frustrated,I'd swallowed all the pills I had with me— not enough to do what I wanted it to right then,but more than enough to knock me out for a good 14 hours.I remember very little after that;benzodiazepines like ativan commonly cause pre- and post-amnesia, says Google helpfullyI wake up in a locked rooma woman manically drawing on the windows with crayonsthe colors of light through the glassdiffused into rainbows of joy scattered about the roomas if she were coloring on us all,all of the tattered remnants of humanity in a psych wardmade into a brittle mosaic, a quilt of many hues, a Technicolor dreamcoatand I thoughtI am so glad to be able to see this. (Story 187)The nurse opening that door will have a lasting impact on how this story unfolds and on this person’s life. Each year, almost one million people die from suicide, approximately one death every 40 seconds. Suicide attempts are much more frequent, with up to an estimated 20 attempts for every death by suicide.1 Suicide-related behaviours range from suicidal ideation and self-injury to death by suicide. We are unable to directly study those who die by suicide, but effective intervention after a suicide attempt could reduce the risk of subsequent death by suicide. Near-fatal suicide attempts have been used to explore the boundary with completed suicides. Findings indicated that violent suicide attempters and serious attempters (seriousness of the medical consequences to define near-fatal attempts) were more likely to make repeated, and higher lethality suicide attempts.2 In a case-control study, the medically severe suicide attempts group (78 participants), epidemiologically very similar to those who complete suicide, had significantly higher communication difficulties; the risk for death by suicide multiplied if accompanied by feelings of isolation and alienation.3 Most research in suicidology has been quantitative, focusing almost exclusively on identifying factors that may be predictive of suicidal behaviours, and on explanation rather than understanding.4 Qualitative research, focusing on the lived experiences of individuals who have attempted suicide, may provide a better understanding of how to respond in empathic and helpful ways to prevent future attempts and death by suicide.4,5 Fitzpatrick6 advocates for narrative research as a valuable qualitative method in suicide research, enabling people to construct and make sense of the experiences and their world, and imbue it with meaning. A review of qualitative studies examining the experiences of recovering from or living with suicidal ideation identified 5 interconnected themes: suffering, struggle, connection, turning points, and coping.7 Several additional qualitative studies about attempted suicide have been reported in the literature. Participants have included patients hospitalized for attempting suicide8, and/or suicidal ideation,9 out-patients following a suicide attempt and their caregivers,10 veterans with serious mental illness and at least one hospitalization for a suicide attempt or imminent suicide plan.11 Relationships were a consistent theme in these studies. Interpersonal relationships and an empathic environment were perceived as therapeutic and protective, enabling the expression of thoughts and self-understanding.8 Given the connection to relationship issues, the authors suggested it may be helpful to provide support for the relatives of patients who have attempted suicide. A sheltered, friendly environment and support systems, which included caring by family and friends, and treatment by mental health professionals, helped the suicidal healing process.10 Receiving empathic care led to positive changes and an increased level of insight; just one caring professional could make a tremendous difference.11 Kraft and colleagues9 concluded with the importance of hearing directly from those who are suicidal in order to help them, that only when we understand, “why suicide”, can we help with an alternative, “why life?” In a grounded theory study about help-seeking for self-injury, Long and colleagues12 identified that self-injury was not the problem for their participants, but a panacea, even if temporary, to painful life experiences. Participant narratives reflected a complex journey for those who self-injured: their wish when help-seeking was identified by the theme “to be treated like a person”. There has also been a focus on the role and potential impact of psychiatric/mental health nursing. Through interviews with experienced in-patient nurses, Carlen and Bengtsson13 identified the need to see suicidal patients as subjective human beings with unique experiences. This mirrors research with patients, which concluded that the interaction with personnel who are devoted, hope-mediating and committed may be crucial to a patient’s desire to continue living.14 Interviews with individuals who received mental health care for a suicidal crisis following a serious attempt led to the development of a theory for psychiatric nurses with the central variable, reconnecting the person with humanity across 3 phases: reflecting an image of humanity, guiding the individual back to humanity, and learning to live.15 Other research has identified important roles for nurses working with patients who have attempted suicide by enabling the expression of thoughts and developing self-understanding8, helping to see things differently and reconnecting with others,10 assisting the person in finding meaning from their experience to turn their lives around, and maintain/and develop positive connections with others.16 However, one literature review identified that negative attitudes toward self-harm were common among nurses, with more positive attitudes among mental health nurses than general nurses. The authors concluded that education, both reflective and interactive, could have a positive impact.17 This paper is one part of a larger web-based narrative study, the Reasons to go on Living Project (RTGOL), that seeks to understand the transition from making a suicide attempt to choosing life. When invited to tell their stories anonymously online, what information would people share about their suicide attempts? This paper reports on a secondary research question of the larger study: what stories do participants tell of the positive role/impact of the mental health system. The focus on the positive impact reflects an appreciative inquiry appr