Suicide is a leading cause of death worldwide in young people, whilst in Scotland it makes up about one-quarter of deaths in this age group (WHO, 2021; Public Health Scotland, 2022). However, how young people experience “suicidal distress” – which the authors defined as the “feelings and emotions underpinning suicidal thoughts and attempts” – is poorly understood.

Prior literature has focused on examining self-harm, suicidal thoughts or actions, and risk and protective factors in a quantifiable format (Hawton et al., 2012; Paul et al., 2015). Diversity in language and conceptualisations used by young people to describe their experiences can also contribute to difficulties for clinicians in the identification of suicidal distress (Silverman, 2006). Concerns around iatrogenic effects (e.g., that talking about suicide will put the idea in a young person’s head) can also prevent in-depth discussion about suicide, and contribute further to stigmatisation (Frey et al., 2016).

Therefore, Marzetti and colleagues (2023) wanted to understand how young people make sense of their own experiences of suicidal distress, whilst acknowledging and centring the inherent “messiness” in these types of experiences. The study aimed to also identify opportunities for early intervention for youth suicide and self-harm.

Methods

This qualitative study used in-depth semi-structured interviews, conducted with 24 young people aged between 16-24 years (mean age = 19.6 years) in Scotland. Participants represented a range of social classes and geographical locations, genders, sexual orientations, and ethnicities.

Participants chose the location of the interviews, and interviews were centred around a main question:

• “How has suicide affected your life?”.

The authors used visual tools to facilitate further prompts, and several safety practices were employed, including researcher and participant debriefing, direction to resources and support services, and offering the opportunity for breaks throughout.

To analyse the data, the authors used a reflexive thematic analysis approach (Braun & Clarke, 2006; 2021), which included reflexive journaling throughout data collection and analysis, and developing a preliminary report of themes which was discussed and refined by the research team. They noted that these practices helped to develop more theoretical themes and contributed to the central organising structure of the findings.

Results

The authors positioned young people’s experiences of suicidal distress, self-harm, and suicide attempts as often blurred and overlapping, paying particular attention to the boundaries and distinctions between these that participants made, how these changed throughout their narratives, and scrutinised the potential causes. Three main themes were discussed: (un)/intentionality, (ir)/rationality, and (in)/authenticity.

1. (Un)/Intentionality

The authors found that young people tended to categorise their suicidal thoughts in a binary way, according to their intention to act upon them. However, throughout their narratives, an overlap was revealed – participants tended to consider early suicidal thoughts with an absence of intention to act as not “that big of a deal”, although they described their frequency and intention changing as time went on. The authors noted that this was consistent with existing research outlining an “escalating trajectory” of suicidal thoughts (O’Connor & Kirtley, 2018).

Differences in language and concepts used by young people were also identified; some categorised aborted suicide attempts as just “suicide plans”, whilst others categorised aborted attempts as actual attempts, even if abandoned. Similarly, some characterised self-harm as distinct from suicide attempts, yet others described how self-harm could become part of a suicide attempt or escalate to an attempt, with overlapping suicidal feelings.

Blurred boundaries regarding intentionality to live or die were present, where young people reported being unclear about their intentions before, during, and after the incident. The authors noted this contrasts with existing literature proposing a “suicidal mode” where intentionality is clear and consistent (Brüdern et al., 2018), and instead supports the presence of intention ambiguity throughout self-harm and/or suicide attempts.

2. (Ir)/Rationality

The authors highlighted further blurriness in young people’s descriptions of the rationality of their experiences of suicide. Often participants described their suicidal thoughts as due to a “causal chain” of difficulties, in which suicide was positioned as a rational option. However, they described their suicide attempts as representing an irrational, impulsive act, or a loss of control, in contrast to the “rationality” of suicidal thoughts. One participant described:

Once I step over the threshold, it’s very hard to then stop myself… it’s like you don’t have control of your own body after that.

To scrutinise such accounts, the authors drew similarities to “mind-body dualism” (Chandler, 2016), where the “unruly body” overrode control of the “rational mind”. The authors speculated whether this change in narratives could be a dissociative or unconscious response to overwhelming emotional distress or to avoid the shame and stigma of a suicide attempt.

3. (In)/Authenticity

Young people relayed poor experiences of help-seeking and concerns about not being considered “bad enough” to warrant professional support. Their narratives made distinctions of themselves as someone who was “authentically” self-harming, rather than for “attention-seeking”. They also discussed the pressure to disclose more than they wanted to help professionals to demonstrate their need for help. One participant said:

I had to talk about like self-harm and things like that I didn’t really want to talk about with her [the GP], because she had already been dismissive, but I felt this is the only way.

The authors questioned whether young people felt pressure to “authenticate” their self-harm and suicidal distress due to these poor help-seeking experiences. They discussed a “perverse paradox” in which the anticipation of stigma and internalisation of negative attitudes resulted in young people both downplaying their feelings to avoid stigma, yet also feeling obligated to demonstrate their “authenticity” to be granted professional support.

Conclusions

This study highlighted the nuanced relationship between self-harm and suicide for young people. The findings also reinforced previous research on how dismissive responses to help-seeking and negative social attitudes could impact young people’s future help-seeking (Byrne et al., 2021). Overall, this in-depth exploration adds further to the current literature, has important clinical applications, and supports the need for positive help-seeking experiences.

Strengths and limitations

The authors included a good range of participants from various locations in Scotland, representing differing gender identities, sexual orientations, and social demographics. The agency to choose interview locations may have helped to enhance comfort among the participants. However, they noted it was likely that participants who took part were more comfortable discussing their experiences of suicide and self-harm, which many other young people may not. Thus, the authors acknowledged that future research could use additional or alternative methods to capture young people’s views who may not feel comfortable with a face-to-face qualitative methodology.

It would have also been useful to include some critical reflection on the authors’ positionality, roles, biases, and influences as part of the analysis and data interpretation process, possibly as a supplementary piece. The main author noted they engaged in reflexive journaling practices throughout the analysis and writing, and it would have been beneficial to see some examples of how this worked in action, or to share some reflections they had.

Lastly, although not part of the qualitative framework the study used, it would have been an interesting and useful addition to measure participants’ pre- and post-interview mood, levels of distress, and particularly suicidal feelings. This information may have been able to contribute further literature on the safety of in-depth interview methods with young people on the topics of suicide and self-harm. It could also provide evidence that research methods on sensitive topics, when conducted ethically and safely, do not necessarily contribute to increased suicidal distress or generate harm, which has been previously raised as concerns in the literature, despite evidence showing otherwise (Biddle et al., 2013; Blades et al., 2018; Muehlenkamp et al., 2015).

Implications for practice

The authors identified several important clinical practice implications and opportunities for youth suicide prevention:

1. Clinicians and other helping professionals should prioritise the importance of positive disclosure and help-seeking experiences. They also need to recognise the potential for lasting impacts of negative experiences on young people’s future help-seeking, internalised stigma and shame, and suicide prevention. Any formal help-seeking contact represents an important opportunity to prevent escalation of suicidal distress.
2. Clinicians should be mindful that early suicidal thoughts, even without an intention to act, can progress over time and be an important early intervention opportunity.
3. Clinicians should not assume shared meanings of language used by young people to describe their suicide and self-harm experiences. Instead, they should critically examine the language used by young people and aim to find shared meaning together.
4. Clinicians should explore young people’s experiences of suicidal distress, clarify intent, and the variety of roles of self-harm can play for a young person, being mindful of overlap and blurriness. The authors recommended that self-harm should be understood as neither “necessarily contributing to, nor protecting, young people from suicide.” Overall, clinicians should take an individualised, person-centred approach to work with young people with suicidal distress.

Statement of interests

None.

Links

Primary paper

Marzetti H, McDaid L, O’Connor R. (2023) A qualitative study of young people’s lived experiences of suicide and self-harm: intention, rationality and authenticity. Child and Adolescent Mental Health 2023.

Other references

Biddle L, Cooper J, Owen-Smith A. et al (2013) Qualitative interviewing with vulnerable populations: individuals’ experiences of participating in suicide and self-harm based research. Journal of Affective Disorders 2013 145(3) 356–362. [PubMed abstract]

Blades CA, Stritzke WGK, Page AC. et al (2018) The benefits and risks of asking research participants about suicide: a meta-analysis of the impact of exposure to suicide-related content. Clinical Psychology Review 2018 64 1–12. [PubMed abstract]

Braun V & Clarke V. (2006) Using thematic analysis in psychology. Qualitative Research in Psychology 2006 3 77–101.

Braun V & Clarke V. (2021) Thematic analysis: a practical guide. Los Angeles: Sage Publications.

Brüdern J, Stähli A, Gysin-Maillart A. et al (2018) Reasons for living and dying in suicide attempters: a two-year prospective study. BMC Psychiatry 2018 18(234) 1–9.

Byrne SJ, Bellairs-Walsh I, Rice SM. et al (2021) A qualitative account of young people’s experiences seeking care from emergency departments for self-harm. International Journal of Environmental Research and Public Health 2021 18(6) 2892.

Chandler A. (2016) Self-injury, medicine and society: authentic bodies. London: Palgrave Macmillan.

Frey LM, Hans JD, Cerel J. (2016) Perceptions of suicide stigma. Crisis 2016 37(2), 95-103. [PubMed abstract]

Hawton K, Saunders KEA, O’Connor RC. (2012) Self-harm and suicide in adolescents. The Lancet 2012 379(9834) 2373-82. [PubMed abstract]

Muehlenkamp JJ, Swenson LP, Batejan KL. et al (2015) Emotional and behavioral effects of participating in an online study of nonsuicidal self-injury: an experimental analysis. Clinical Psychological Science 2015 3(1) 26-37. [PubMed abstract]

O’Connor RC & Kirtley OJ. (2018) The integrated motivational-volitional model of suicidal behaviour. Philosophical Transactions of the Royal Society B: Biological Sciences 2018 373(1754) 20170268.

Paul E, Tsypes A, Eidlitz L. et al (2015) Frequency and functions of non-suicidal self-injury: associations with suicidal thoughts and behaviors. Psychiatry Research 2015 225(3) 276–282. [PubMed abstract]

Public Health Scotland. (2022) Scottish suicide information database: Suicide among young people in Scotland.

Silverman MM. (2006) The language of suicidology. Suicide and Life-Threatening Behavior 2006 36(5) 519–532. [PubMed abstract]

World Health Organization. (2021) Suicide.

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