ORIGINAL ARTICLE
Healing and recovering after a suicide attempt: a grounded theory study Mei-Ting Chi, Ann Long, Shiow-Rong Jeang, Yan-Chiou Ku, Ti Lu and Fan-Ko Sun
Aims and objectives. To explore the healing and recovery process following a suicide attempt over 12 months ago. Background. Literature has explored the process leading up to attempted suicide. However, there is a lack of information exploring the healing and recovery process after a suicide attempt. Design. Qualitative research using the grounded theory approach. Methods. Data were collected during 2010–2011 from the psychiatric outpatient’s centre in Taiwan. Interviews were conducted with people who had attempted suicide more than 12 months prior to data collection and had not reattempted since that time (n = 14). Constant comparison analysis was used to scrutinise the data. Results. Findings demonstrated that healing and recovering evolved in five phases: (1) self-awareness: gained self-awareness of their responsibilities in life and their fear of death; (2) the inter-relatedness of life: awareness of the need to seek help from professionals, friends and family for support; (3) the cyclical nature of human emotions: reappearance of stressors and activators causing psyche disharmony; (4) adjustment: changes in adjustment patterns of behaviour, discovering and owning one’s own unique emotions, deflecting attention from stressors and facing reality and (5) acceptance: accepting the reality of life and investing in life. Conclusion. The healing and recovery process symbolises an emotional navigation wheel. While each phase might follow the preceding phase, it is not a linear process, and patients might move backwards and forwards through the phases depending on the nursing interventions they receive coupled with their motivation to heal. It is important for nurses to use advanced communication skills to enable them to co-travel therapeutically with patients. Relevance to clinical practice. Listening to patients’ voices and analysing their healing and recovery process could serve as a reference for psychiatric nurses to use to inform therapeutic interventions. Key words: attempted suicide, grounded theory, healing and recovery process, suicidal behaviour Accepted for publication: 13 February 2013
Introduction Suicide has become a global issue; on average about one million people die from suicide around the world per year (World Health Organization 2012). The suicide rate has Authors: Mei-Ting Chi, MSN, RN, Associate Head Nurse, Department of Nursing, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Ann Long, RGN, RMN, D.Phil, Honorary Fellow Senior Lecturer, School of Nursing, University of Ulster, Belfast, UK; Shiow-Rong Jeang, MSN, RN, Supervisor, Department of Nursing, Kaohsiung Veterans General Hospital, Kaohsiung; Yan-Chiou Ku, PhD, RN, Director, Department of Nursing, Kaohsiung Veterans General Hospital, Kaohsiung; Ti Lu, MD, MS, Chief, Department of Psychiatry, Kaohsiung Veterans
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1751–1759, doi: 10.1111/jocn.12328
increased in some countries including Korea (247/100,000 in 2005, 310/100,000 in 2009), Japan (242/100,000 in 2005, 244/100,000 in 2009) and Singapore (101/100,000 in 2005, 103/100,000 in 2006) (World Health Organization 2012). Department of Health, Executive Yuan, Taiwan, General Hospital, Kaohsiung; Fan-Ko Sun, PhD, RN, Associate Professor, Department of Nursing, I-Shou University, Kaohsiung, Taiwan Correspondence: Fan-Ko Sun, Associate Professor, Department of Nursing, I-Shou University, No.8, Yida Road, Jiaosu Village, Yanchao District, Kaohsiung 82445, Taiwan. Telephone: +886 7 6151100 ext. 7731. E-mail: [email protected]
1751
M-T Chi et al.
R.O.C. (2012) statistics show that since 1997, suicide is one of the top 10 causes of death. The Taiwanese government designed a national network for suicide in 2006 (Suicide Prevention Centre 2007) aiming to reduce the rising rate of suicide (Lee 2009). Subsequently, the suicide rate fell from 193 per 100,000 in 2006 to 151 per 100,000 in 2011 (Department of Health, Executive Yuan, Taiwan, R.O.C. 2012). Bergmans (2008) conducted a grounded theory study to explore the meaning of recovery from recurrent suicide attempts, and 16 participants, aged 18–25 years, were interviewed. In Taiwan, Ke (2008) completed a phenomenological study (n = 6) exploring resilience of the survivors, aged 31–52 years. Findings from both studies demonstrated that self-awareness is a key in the process of moving from ‘living to die’ to ‘dying to live’. In Taiwan, the highest rate of suicide occurred in young people between the ages of 25 –44 years and the age group with second highest rate being between 45–64 years old. This study used grounded theory to explore the healing and recovery process of a wide age range of individuals, 15–64 years old, who had recently attempted suicide.
Background A suicide attempt is a predictor of death by suicide (Hawton et al. 2003, Wilcox & Anthony 2004, Capron et al. 2012). Chiu et al. (2006) pointed out that as many as 40% of people who died from suicide had made a previous suicide attempt. Consequently, suicidal risk is extremely high after a previous suicide attempt especially in the first year. Further, the first method of attempted suicide influences the suicidal behaviour trajectory in the future (Hulten et al. 2001, Runeson et al. 2010). Moreover, the 35- to 54-year-old age group had the highest suicide rate than the other age group (Chen et al. 2010). Suicide is a tragedy, not only because of the loss of an individual, but also because it impacts on families and society in general. Everybody has a collective responsibility to humanity. At a closer level, death by suicide impacts on the internal system of the family unit and consequently threatens the stability of the family (Patterson 2002, Xing et al. 2010). Moreover, Sun and Long (2008) reported that family members who provided holistic care for their suicidal relatives also thought about suicide because of the physical and emotional pressure sustained when caring for their suicidal relatives. It is fundamental therefore for healthcare professionals to provide care both to people who attempt suicide and to families (Lee & Liao 2006).
1752
At society level, repetition of attempts not only includes a sense of failure to humankind but also increases medical costs (Lee 2010). Consequently, the prevention of suicide requires a network of agencies working together, and in partnership, to help make a difference in terms of providing holistic care to the community we serve. Greve and Staudinger (2006) argued that social participation and social support can promote the development of resilience, which enables people to face adversity at times of crisis as suffering is inescapable in life. With this raised awareness, it is fundamental to provide holistic health care on prevention as well on the aftermath of the first attempt as well as relapse-prevention. A literature search demonstrates that this is the first study in Taiwan to use grounded theory to explore the healing and recovery process of individuals who attempted suicide.
Methods Aim To explore the healing and recovery process of patients with a history of suicidal attempts but who have had no further attempts in the past year.
Design Denzin and Lincoln (2000) contended that grounded theory is the most appropriate research method to use if the research questions focus on the process and experience. This study explored the process and experiences of people who had attempted suicide with no further attempts or suicidal ideations in the past year. In addition, Glaser (1992) claims that grounded theory is particularly useful for health professionals as it is a systematic, detailed and rigorous method more structured than other forms of qualitative research. Consequently, Strauss and Corbin’s method of grounded theory was considered to be the most appropriate method to use (Strauss & Corbin 1998).
Sample This study used theoretical sampling to collect data (Strauss & Corbin 1998). This means that each interview guideline was modified before the next interview in accordance with the new emerging findings, which emerged from the previous interview. Participants were accessed from the outpatient’s department of a medical centre in Southern Taiwan. The inclusion criteria were that participants: (1) had attempted suicide and had not re-attempted nor had © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1751–1759
Original article
suicidal ideations for one year; (2) were assessed by a psychiatric consultant who regarded them to be medically fit to participate in the study; (3) were diagnosed with depression; (4) were over 20 years of age; and (5) agreed to share their healing and recovery process. The exclusion criterion was severe personality disorder. The demographic details of the total sample group (n = 14) comprised women (n = 12) and men (n = 2); aged between 35–57 years; religious belief (n = 10) and nonbeliever (n = 4); university education (n = 5), senior high (n = 5), elementary (n = 3) and junior high (n = 1); married (n = 8), divorced (n = 2), widowed (n = 2) and separated (n = 1) single (n = 1); employed (n = 11) and unemployed (n = 3); major caregivers were relatives (n = 11), friends (n = 1) and themselves (n = 2). Further, regarding the suicide attempt, the methods of attempted suicide were drug overdoses (n = 9), jumping from a high place (n = 2), gunshots (n = 1), poison fumes (burning charcoal) (n = 1) and wrist-cutting (n = 1). Number of previous suicide attempts was between one to three times (n = 10), four to six times (n = 2), seven to nine times (n = 1) and over 10 times (n = 1).
Recovering after a suicide attempt
comment on how the emergent findings represented their disclosure about their lived experiences.
Ethical considerations This study was approved by the medical centre’s hospital review board (VGHKS 100-111). The consent form was designed and included information such as the aim of the study, the participants’ rights and the confidentiality involved in the data collection process. Further, the ethical principle nonmaleficence was adhered to meaning that some ways were adopted to prevent participants from enduring any harm by inviting them to (1) consent to the use of a tape-recorder during interviews; (2) state when they would like to end the interview or refrain from continuing with the interview at any time and without remonstration; (3) request for data to be deleted or erased when they did not wish it shared with others. Moreover, the lead researcher has worked in psychiatry for 13 years and is competent to deal with participants’ painful emotions and, with their permission, refer them to the psychiatrist if required.
Data collection
Data analysis
Semi-structured interviews were used to collect data during 2010–2011. Interviews lasted between 45–80 minutes in a private hospital room after participants had been reviewed at the outpatient clinic. Interview guidelines contained five themes: (1) healing and recovering from an attempted suicide, (2) internal and external motivators for change in suicidal behaviours, (3) reasons for not re-attempting in the past year, (4) internal and external difficulties or discontent encountered during the past year and (5) suggestions for other individuals who might attempt suicide.
Grounded theory emphasises using coding to conceptualise the data. The main purpose of coding is to condense the data line-by-line to uncover what is important, repeated and highlighted as the researchers become immersed in the data, which are later coded as concepts (Chen 2000). Each interview transcript was typed within three days. Subsequently, each typed transcript was read and important concepts coded within three days. Next, similar concepts were classed as subcategories using the constant comparative method. Subsequently, similar subcategories were classified as categories using the constant comparative method (Strauss & Corbin 1998, Chen 2000). Findings demonstrated that five categories emerged from the data to develop the five-phase emotional healing and recovery process after a suicide attempt.
Rigorousness Four methods were used to promote the credibility of this qualitative research: (1) prolonged involvement: a healthy therapeutic relationship was initiated, maintained and closed with all participants; (2) continuous observation: participants’ verbal and nonverbal communications were observed closely during the total interview acknowledging that the participants’ clinical needs took precedence over the research process at all times; (3) expert review: two suitably academically qualified professionals scrutinised the total process of the data analysis and ensured findings were consistent with the participants’ descriptions; and (4) member checks: two participants were invited to review the concepts, subcategories and categories that emerged from the data analysis and © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1751–1759
Results Findings revealed that the healing and recovery process for the participants happened in five phases: (1) self-awareness: gained insight and self-awareness of their responsibilities in life and their fear of death; (2) the inter-relatedness of life: aware of the need to seek help from professionals, friends and family for support; (3) the cyclical nature of human emotions: reappearance of stressors and activators causing psyche disharmony; (4) adjustment: changes in adjustment patterns of behaviour, discovering and owning one’s own
1753
M-T Chi et al.
unique emotions, deflecting attention from stressors and facing reality; and (5) acceptance: accepting the reality of self, others and life, and investing in life. Each of the five phases interact with each other and are represented in Fig. 1 as an ‘Emotional healing and recovering navigation wheel’. They are now explored.
job or their future. So, now it’s as if I have woken up to my needs and the needs of my children for the first time in my sorry life. (P3) When I think of my overdose I remind myself that I might have left a trail of destruction behind me…and my children would be afflicted with this scar. I tried to kill myself quite a few times but in reality I don’t want to die. I want to live…but I just didn’t know
Phase 1: Self-awareness
how to…I felt so lost…now I’m learning. (P10)
In the first phase, participants awoke to the reality that they are responsible for their life and also to the realisation that they were afraid of death. Consequently, this category was reduced to two subcategories. Awakening responsibility Many participants expressed they needed to take responsibility for self and their children, and this awakening helped reduce their suicidal ideations. After they attempted suicide, they realised the painful impact their attempt had on their children. Observing their anguish helped participants realise that they were important and that their life was precious. This was ‘the first time’ they had acknowledged that: ‘I’m important and my life’s important too’ (P2). Two examples depict this:
Awakening of the fear of death Many participants mentioned that they realised they were ‘afraid of death’ and terrified in case they had been left physically or mentally disabled. Nine of the 14 participants attempted suicide by taking drug overdoses because they ‘did not have the courage to use lethal methods’ to end their life. They were also afraid that the lethal methods would not work and they would again be disabled for the rest of their lives. Two examples illustrate these findings: When I woke up, I realised that this suicide is a very painful thing…I had attempted once before. A light went on in my head and I then understood that…I don’t want to die…in fact, I’m really afraid of death. (P6) I didn’t have the courage to commit suicide by jumping from a
…I lacked responsibility for my actions and my children. Before
high place. I thought it would work by taking an overdose of
the attempt I never thought about all this…I was too wrapped up
drugs. If truth be told, I’m afraid of death and more afraid of the
in myself…I didn’t care if my suicidal behaviour would affect their
aftermath of another attempt on me, if it didn’t work. (P8)
Phase 2: The inter-relatedness of life Self-awareness stage
Investing in life
Seeking help from the social support systems
Figure 1 Emotional navigation wheel for healing and recovering following a suicide attempt.
1754
The participants stated that running parallel with their realisation that they did not want to re-attempt suicide, they surrendered to the feelings that would seek help in the future, if anything untoward happened in their lives. They acknowledged that seeking help at times of distress could alleviate their concerns and help cope with distress. This category was divided into two subcategories. Seeking help from healthcare professionals Participants found that seeking help was a positive experience as we all need each other. They perceived that healthcare professionals helped them to cope with their negative thinking patterns when they were at risk of suicide. They benefited greatly from their experiences at the outpatient department when they felt listened to when they were doubtful about themselves or feeling low. If they presented as ‘serious’, the doctor re-admitted some of them for further interventions. Two examples depict these findings: © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1751–1759
Original article
Recovering after a suicide attempt
When I’m in a bad mood, I pick up the phone and go and see a
Now, my son has been diagnosed with depression too and I’m wor-
doctor or nurse. They always give me time and listen carefully to
ried because he doesn’t go to school…on top of that my mother has
me. They understand my worries. (P1)
cancer and goes for dialysis every week. She has suffered for years
I felt safe in the hospital because I knew doctors and nurses were there to look after me and protect me…the ward environment is
with Parkinson’s and heart disease. I’m always afraid she will leave me soon. So, my emotions are all over the place. (P4)
different from the outside world because I feel I can focus on my problems there. (P10)
Seeking help from social support systems Participants perceived that it was very important to access help from social support systems in the community when they were at risk of suicide. Family members, friends, religion and pets were included in these systems. They believed this type of help and care was invaluable and gave life some meaning. Two narratives illustrate these findings: When I’m helpless and hopeless, my friends stay beside me to keep me company on this lonely journey. They’re kind to me and listen
Symptom interference Some participants who had been diagnosed with depression said it was difficult to control their illness and remain stable (n = 6). They had lost interest in ‘the joys of life’ and some felt ‘sad’ and all suffered from insomnia leaving them ‘emotionally tired’. Some had stopped taking their medicine and this led to them ‘feeling worse’ causing some symptoms to reoccur again. Two participants said: Not being able to sleep is the hardest thing to bear. Old memories haunt me like fighting with my wife in the past. Then, I get upset for a long time and I can’t control my emotions…they close in on me and overwhelm me. (P3)
to me. They don’t judge me when I tell them about unhappy things
Sometimes I take my medication and sometimes I don’t. It’s not
that have happened to me. I always feel better after talking to
that I forget…I just think that I’m feeling better. When I don’t take
them. (P3)
my tablets my mood lowers and I become very unstable. I’ve made
The support I get from my family helps me realize I’m not alone anymore. I used to think I was a burden to them. Now, when I feel
a decision that I need my medicine and now take it every day to feel better. (P7)
down, I also feel lonely and I need the company of my family to support me. Even though they just sit there sometimes and don’t talk, I still feel safe. (P4)
Phase 3: The cyclical nature of human emotions Participants considered that they might have suicidal ideations again if and when they suffered from painful life experiences, or when their mental disorder became unstable. This category was divided into two subcategories. Reappearance of stressors During the healing and recovery process after an attempted suicide, individuals have a long way to travel. They perceived that they would experience many stressors and life events that might reawaken their suicidal ideations. Many of the participants disclosed that they did not like suffering and were unable to distinguish between ‘normal human suffering’ such as sadness, following a life event for example, and a mental disorder. Two examples follow: The doctor said I’ve improved a lot. However, when my mother died, I was so sad. I went to her grave every day for three and a
Phase 4: Adjustment The participants perceived that all human beings encounter ‘difficulties in their life’. They knew that it is important to ‘face personal problems’ and life events but previously did not know how to ‘cope with these difficulties’. During the healing and recovery process, they learned healthy coping strategies for coping with the stresses of life. They perceived that they might re-attempt suicide if they were not given the ‘emotional first-aid tools’. They believed they would keep repeating their ‘self-destructive’ behaviours had they not had this information. This category was condensed into four subcategories.
Adjusting to health-nurturing patterns of behaviour Participants said it was very important to adjust ‘their thoughts’, ‘mindset’ and ‘behaviours’ in the face of pain and adversity. Further, they perceived that they needed to learn how to ‘interact with others in a healthy way’. Some said this would involve ‘changing myself first’. Two examples illustrate these findings:
half hours for six dark months…I wanted to die too so that I could
After this suicide attempt, my view on life changed completely. I
be with her. (P6)
think I’ve been given a lot so now it’s my turn to give back to soci-
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1751–1759
1755
M-T Chi et al. ety. If I’ve the ability I’ll do something for someone. I thought life
My job puts a lot of pressure on me. I decided to face up to the
was just about me… now I know it’s about giving and receiving.
facts and told my company about my problem…they helped me
(P12)
change to a more flexible work schedule. This made sense to me
I’ve discovered that many bad things happen to me because I bring some of them on myself…I’m not a good communicator. I had to
where before I was afraid to ask. I haven’t thought of suicide since. (P3)
discover that I need to communicate to sort problems out…and not run away from them. (P7)
Discovering one’s own way of releasing emotions Participants expressed when they encountered problems or difficulties, they would exercise, go shopping, talk with others or cry to release their emotions. Many had kept their emotions ‘bottled up’ and come to realise that they needed to express them in their own unique way. Gaining this insight helped them cope with unstable emotions. Two examples follow:
Phase 5: Acceptance Participants moved backwards and forwards naturally through the first four phases of the emotional navigation wheel and eventually reached the phase of acceptance. This category comprised two subcategories.
to vent my emotions. (P10)
Accepting the reality of self, others and life Participants said that as they moved through the phases, they began to accept and embrace self, others and their current life situation. Those who had been diagnosed with depression learned to ‘befriend their illness and not fight it. It was their ‘reality’. Two examples of acceptance follow:
When I’m in a bad mood, I cry very loud and I cry for a long time.
Now, I’ve very good insight into my illness. I know I’ve an illness
When I stop crying, I feel relaxed. I feel lighter within myself…as if
and I never wanted to have it…but I know to care for me at times
I’m not carrying the weight of the world on my shoulders. (P3)
of sadness or distress. If life gets too rough I go to see my doctor
I energise myself by taking a walk for an hour every day… I’ve come to enjoy it…and when I’m in a bad mood I walk even faster
to review my medication. (P7)
Deflecting attention from stressors Participants expressed they would do something that they were interested in to deflect attention from their stressors. For example, reading books, listening to music and playing computer games. These findings are illustrated below: I’ve discovered a way to deflect my stress. I used to yell at my family before. Now, I walk away when something annoys me and play computer games and listen quietly to music. This helps. (P12) When I’m in a bad mood and feeling down, I read inspirational books to feed my spirit. When I can concentrate on a book, I feel calmer and more relaxed. (P4)
Facing the reality of life Participants said that they ‘did not know how to live normally’ and they did not know how to ‘cope with life’s problems’. Hence, many changes occurred to enable them to ‘face the reality of life’. When they realised that ‘life’s full of ups and downs’ (P13), many made the decision to learn how to cope with the uncertainties of life. Two examples follow: My daughter sold my house and I couldn’t face the problem at that
I’m not cranky and my emotions are stable when I take medicine on time. It was very important for me to accept the illness and ask the doctor for treatment. (P3)
Investing in life Many participants expressed that they had begun to do something they derived benefit from to support their reasons for living and hence ‘reduce the risk of suicide’. They tried to do anything that might ‘reduce pain’ such as developing relationships with people they ‘could confide in’. During the healing and recovery process, they became aware that ‘recovering does not mean forever’. Recovering is an ongoing process that has to be worked at by self-care and finding ‘new ways of coping with feelings and emotions’ and ‘re-building my confidence’. Two examples follow: I want to work in a nursing home as a volunteer. I’m not interested in money because money can’t make me happy. I want to do something meaningful to make me contented and improve the lives of others. (P1)
time. I know I lost my house and my money but it did not kill me.
Before, I had no goals in life. Now, I’m learning calligraphy and I
I’m still alive and I know my life’s important now. (P12)
feel I’ve recaptured a goal in life. (P12)
1756
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1751–1759
Original article
Discussion Findings from this study demonstrate that the participants worked through the five phases of the ‘emotional navigation wheel’ during the healing and recovery process after an attempted suicide. The first phase was self-awareness wherein participants took ownership of their role in being responsible for their life and indeed realised they did not want to die, but had a healthy fear of death. These findings concur with those two other researchers. Ke (2008) ascertained that the recognition of responsibility helped suicidal individuals change their behaviours and attitudes towards life and enabled them to become more positive. Participants in her study perceived they would not attempt suicide again because they needed to care for their loved ones and hence not want to cause them any pain or distress by their selfdestructive actions. Later, Sun (2011) found that participants who had attempted suicide (n = 15) wanted to survive because they realised that they had a responsibility to: their families, especially their children; to those they loved and they also feared dying. The findings from these two studies coupled with those of the current study indicate the importance of gaining insight into the reality that all human beings have some responsibility for our own lives and also for not causing distress and hurt to others by taking our own lives. Becoming responsible has a role to play in the actions we take and the values we hold in the future. The second phase of the healing and recovery process was the inter-relatedness of life. These findings demonstrate that we all need each other and that it is essential to reach out for help especially at times of emotional discontent or distress. Lee et al. (2010) argued that around 148% of the populace in Taiwan had suicidal ideations at sometime in their lives, but these experiences did not lead them to attempting suicide. They found that some individual sought help from counselling or other sources of talking therapies and others accessed support from the healthcare professions when they had suicidal ideations. Su et al. (2005) reported that the healthcare professionals not only provided treatment and care in the acute phase but also offered comparative treatment and care during the whole suicide care trajectory in the hope of preventing repeated suicide attempts. Findings from the study by Huang and Lee (2003) pointed out that depressed patients who were at risk of suicide considered they needed support from family and friends as well as medicine and psychotherapy. These findings together with those from the current study reveal that suicidal individuals require support and help from many sources, verifying the notion that the bio-psycho-social-spiritual model of care is paramount for their holistic health. © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1751–1759
Recovering after a suicide attempt
Phase three of the findings from the current study, the cyclical nature of human emotions, indicated that the participants realised that in the past they used self-destructive and avoidance behaviours to cope with either the stressors of life or mental disorders, sometimes ending up with repeated hospital admissions. These findings support those of Lee (2006) and Sun et al. (2007). Moreover, Sun et al. (2007) found that some of the reasons why people might attempt suicide were the patients’ stress history and past traumatic life experiences, illness, and feelings of abandonment, which led to inability to cope with life. All of the previous findings together with those from phase four of the emotional healing and recovery process ‘adjustment’ signify that healthcare professionals could design and implement psycho-education programmes to educate suicidal patients and their families about the nature of stress, its impact, healthy and unhealthy coping strategies, so that individuals could learn to survive the trials and tribulations of life without succumbing to suicide. It would be important to include how professionals could use the skill of discernment to identify the difference between ordinary human experiences, within the context of the felt emotions, such as loneliness and sadness following the death of a loved one, and those experienced in circumstances of mental disorders (Davies 2012). With the latter, the importance of complying with prescribed medication is paramount. Further, findings revealed the value of suicidal patients having access to follow-up of their treatment in order to prevent further attempts supporting those of Lin (2009). Moreover, the findings from the current study alongside those of Wong and Wong (2007) demonstrate the importance of suicidal individuals learning how best to change their negative attitudes about life and how to discover their own unique ways of releasing painful and distressing emotions such as anger and rage. The final phase of acceptance was reached when participants came to believe in and accept self, others and the reality of life. With the aid of nonjudgmental others, participants regained the desire to be alive and began investing in life.
Limitations of research There are two major limitations in this study. First, the difficulty in accessing individuals postsuicide attempt in the community. Hence, this study was conducted with patients in a psychiatric setting. It would be interesting to investigate those who had attempted suicide and had never been admitted to hospital. Second, this study only accessed those who had been diagnosed with depression. It would be appealing to include the full gambit of psychiatric disorders in future studies of suicide.
1757
M-T Chi et al.
Conclusion Findings from this study demonstrated that participants traversed a five phases of ‘emotional navigation wheel’ during the healing and recovery process after a suicide attempt. During phase one, participants gained ‘self-awareness’ and awakened to the reality that they held some responsibility for their own self, life and the lives of others around them. They also awakened to the realisation that they had a healthy fear of death. Subsequently, they gained insight into the ‘interrelatedness of life’ where they realised that there are times in all of our lives when need to reach out for help especially when stressors reappear and there is symptom interference, which could lead to a relapse of their illnesses. Subsequently, they learned about the ‘cyclical nature of human emotions’ and how to cope in a healthy manner with the stresses in life and to the realisation that living is an emotional journey therefore they needed to ‘adjust to this reality’. Finally, they came to a phase of ‘acceptance of self, others and of life itself’. Many of the participants then aspired to the role of investing in life by caring for self and others. This study could provide healthcare professionals with an understanding of the five phases of the healing and recovery process after a suicide attempt. More research is required into the nurses’ role in facilitating individuals to negotiate these five phases.
Relevance to clinical practice As soon as nursing care begins and during the healing process following a suicide attempt, nurses could facilitate people to gain insight into the reality that they have some
responsibility for their own life. Nurses could also enable individuals to acknowledge that all human beings need help at times and that it is acceptable to ask for help, especially at times of emotional distress. Corresponding with this care, nurses could facilitate patients to accept and own these truisms as well as provide therapeutic care to enable them to learn healthy coping skills to access during times of stress. Following discharge from hospital, community healthcare nurses could continue this therapeutic work until individuals learn to adjust to the realities of life and accept self, others and their life with unconditional positive regard and investing in life. It is paramount for healthcare professionals to realise that although healing and recovering can occur after a suicide attempt, the vulnerable part in all of us remains, sometimes dormant, within us. This vulnerable part requires continuing self-nurturing to prevent further attempts.
Acknowledgements We would like to thank the participants of this study.
Contributions Study design: MTC, FKS; data collection and analysis: MTC, FKS, SRJ, YCK, TL and manuscript preparation: MTC, FKS, AL.
Conflict of interest None.
References Bergmans Y (2008) Exploring the Meaning of Recovery from Recurrent Suicide Attempts. Available at: http://wellesleyinstitute.com/files/recoverysuicide.pdf (accessed 9 April 2012). Capron DW, Cougle JR, Ribeiro JD, Joiner TE & Schmidt NB (2012) An interactive model of anxiety sensitivity relevant to suicide attempt history and future suicidal ideation. Journal of Psychiatric Research 46, 174–180. Chen YJ (2000) Introduction. In Qualitative Nursing Research Methods (Chen YJ ed.). The Fellowship of Hope, Taipei, pp. 1–20. Chen CC, Yeh JY, Li CY, Chen CY & Hung HW (2010) A study of Taiwan’s suicide mortality rate and related
1758
factors: 1973–2003. Taiwan Journal of Public Health 29, 201–215. Chiu CH, Kuo CJ, Chen YY, Chen CC, Lee MB, Lin CH, Lin CC, Dy H & Lin CC (2006) Comparison of epidemiological characteristics between first-ever and repeated suicide attempters. Taipei City Medical Journal 3, 1000–1007. Davies J (2012) The Importance of Suffering. Routledge, New York, NY. Denzin NK & Lincoln YS (2000) Handbook of Qualitative Research, 2nd edn. Sage, London. Department of Health, Executive Yuan, Taiwan, R.O.C. (2012) Health and Vital Statistics. Department of Health, Taipei. Glaser BG (1992) Basics of Grounded Theory Analysis. Sociology, Mill Valley, CA.
Greve W & Staudinger UM (2006) Resilience in later adulthood and old age: resources and potentials for successful aging. In Developmental Psychopathology (Cicchetti D & Cohen A eds). Wiley, Hoboken, NY, pp. 796–840. Hawton K, Harris L, Hall S, Bale E & Bond A (2003) Deliberate self-harm in oxford, 1990–2000: a time of change in patient characteristics. Psychological Medicine 33, 987–995. Huang LC & Lee MB (2003) Depressive disorder and suicide. Formosan Journal of Medicine 7, 929–934. Hulten A, Jiang GX, Wasserman D, Hawton K, Hjelmeland H, De Leo D, Ostamo A, Salander Renberg E & Schmidtke A (2001) Repetition of
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1751–1759
Original article attempted suicide among teenagers in Europe: frequency, timing and risk factor. European Child & Adolescent Psychiatry 10, 161–169. Ke YJ (2008) Suicide Attempts by the Resilience of Explanatory Style and the Course of the Study. Unpublished MSc Dissertation, National Changhua University of Education, Changhua City. Lee MB (2006) New knowledge on suicide prevention. Newsletter for Suicide Prevention Network 1, 12–15. Lee MB (2009) New knowledge on suicide prevention. Newsletter for Suicide Prevention Network 4, 3–8. Lee MB (2010) Cherishing life and restoring hope. Newsletter for Suicide Prevention Network 5, 5–6. Lee MB & Liao SC (2006) Risk factors and strategies for the prevention of suicide. Formosan Journal of Medicine 10, 367–374. Lee MB, Liao SC & Lai SW (2010) Investigating cognitive strategies for the prevention of suicide in Taiwan. Newsletter for Suicide Prevention Network 5, 11–13. Lin CY (2009) Suicide assessment and communication skills: the suicide
Recovering after a suicide attempt prevention gatekeepers. Counseling & Guidance 284, 48–55. Patterson JM (2002) Integrating family resilience and family stress theory. Journal of Marriage and the Family 64, 349–360. Runeson B, Tidemalm D, Dahlin M, Lichtenstein P & Langstrom N (2010) Method of attempted suicide as predictor of subsequent successful suicide: national long term cohort study. British Medical Journal 341, c3222. Strauss A & Corbin J (1998) Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory, 2nd edn. Sage, Thousand Oaks, CA. Su TW, Chiu CH, Kuo CJ, Chen CC & Lee MB (2005) Epidemiology of suicide. Taipei City Medical Journal 2, 6–15. Suicide Prevention Centre (2007) Objectives. Available at: http://www.tspc. doh.gov.tw/tspc/portal/center/index.jsp (accessed 6 July 2012). Sun FK (2011) Mind Helper – How to Assist Family Members Dealing with Suicide. I-Shou University, Kaohsiung.
Sun FK & Long A (2008) A theory to guide families and carers of people who are at risk of suicide. Journal of Clinical Nursing 17, 1939–1948. Sun FK, Long A & Tsao LI (2007) Patients’ and nurses’ perceptions of reasons why people attempt suicide in Taiwan. New Taipei Journal of Nursing 9, 39–56. Wilcox HC & Anthony JC (2004) The development of suicide ideation and attempts: an epidemiologic study of first graders followed into young adulthood. Drug and Alcohol Dependence 76, S53–S67. Wong MS & Wong SR (2007) Suicide awareness and prevention. Counseling and Guidance 260, 20–22. World Health Organization (2012) Suicide Prevention (SUPRE). Available at: http:// www.who.int/mental_health/prevention/ suicide/suicideprevent/en/ (accessed 9 April 2012). Xing XY, Tao FB, Wan YH, Xing C, Qi XY, Hao JH, Su PY, Pan HF & Huang L (2010) Family factors associated with suicide attempts among Chinese adolescent students: a national crosssectional survey. Journal of Adolescent Health 46, 592–599.
The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of clinically related scholarship which supports the practice and discipline of nursing. For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http:// wileyonlinelibrary.com/journal/jocn
Reasons to submit your paper to JCN: High-impact forum: one of the world’s most cited nursing journals, with an impact factor of 1316 – ranked 21/101 (Nursing (Social Science)) and 25/103 Nursing (Science) in the 2012 Journal Citation Reportsâ (Thomson Reuters, 2012). One of the most read nursing journals in the world: over 19 million full text accesses in 2011 and accessible in over 8000 libraries worldwide (including over 3500 in developing countries with free or low cost access). Early View: fully citable online publication ahead of inclusion in an issue. Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur. Positive publishing experience: rapid double-blind peer review with constructive feedback. Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley Online Library, as well as the option to deposit the article in your preferred archive.
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1751–1759
1759
Healing and recovering after a suicide attempt: a grounded theory study Mei-Ting Chi, Ann Long, Shiow-Rong Jeang, Yan-Chiou Ku, Ti Lu and Fan-Ko Sun
Aims and objectives. To explore the healing and recovery process following a suicide attempt over 12 months ago. Background. Literature has explored the process leading up to attempted suicide. However, there is a lack of information exploring the healing and recovery process after a suicide attempt. Design. Qualitative research using the grounded theory approach. Methods. Data were collected during 2010–2011 from the psychiatric outpatient’s centre in Taiwan. Interviews were conducted with people who had attempted suicide more than 12 months prior to data collection and had not reattempted since that time (n = 14). Constant comparison analysis was used to scrutinise the data. Results. Findings demonstrated that healing and recovering evolved in five phases: (1) self-awareness: gained self-awareness of their responsibilities in life and their fear of death; (2) the inter-relatedness of life: awareness of the need to seek help from professionals, friends and family for support; (3) the cyclical nature of human emotions: reappearance of stressors and activators causing psyche disharmony; (4) adjustment: changes in adjustment patterns of behaviour, discovering and owning one’s own unique emotions, deflecting attention from stressors and facing reality and (5) acceptance: accepting the reality of life and investing in life. Conclusion. The healing and recovery process symbolises an emotional navigation wheel. While each phase might follow the preceding phase, it is not a linear process, and patients might move backwards and forwards through the phases depending on the nursing interventions they receive coupled with their motivation to heal. It is important for nurses to use advanced communication skills to enable them to co-travel therapeutically with patients. Relevance to clinical practice. Listening to patients’ voices and analysing their healing and recovery process could serve as a reference for psychiatric nurses to use to inform therapeutic interventions. Key words: attempted suicide, grounded theory, healing and recovery process, suicidal behaviour Accepted for publication: 13 February 2013
Introduction Suicide has become a global issue; on average about one million people die from suicide around the world per year (World Health Organization 2012). The suicide rate has Authors: Mei-Ting Chi, MSN, RN, Associate Head Nurse, Department of Nursing, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Ann Long, RGN, RMN, D.Phil, Honorary Fellow Senior Lecturer, School of Nursing, University of Ulster, Belfast, UK; Shiow-Rong Jeang, MSN, RN, Supervisor, Department of Nursing, Kaohsiung Veterans General Hospital, Kaohsiung; Yan-Chiou Ku, PhD, RN, Director, Department of Nursing, Kaohsiung Veterans General Hospital, Kaohsiung; Ti Lu, MD, MS, Chief, Department of Psychiatry, Kaohsiung Veterans
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1751–1759, doi: 10.1111/jocn.12328
increased in some countries including Korea (247/100,000 in 2005, 310/100,000 in 2009), Japan (242/100,000 in 2005, 244/100,000 in 2009) and Singapore (101/100,000 in 2005, 103/100,000 in 2006) (World Health Organization 2012). Department of Health, Executive Yuan, Taiwan, General Hospital, Kaohsiung; Fan-Ko Sun, PhD, RN, Associate Professor, Department of Nursing, I-Shou University, Kaohsiung, Taiwan Correspondence: Fan-Ko Sun, Associate Professor, Department of Nursing, I-Shou University, No.8, Yida Road, Jiaosu Village, Yanchao District, Kaohsiung 82445, Taiwan. Telephone: +886 7 6151100 ext. 7731. E-mail: [email protected]
1751
M-T Chi et al.
R.O.C. (2012) statistics show that since 1997, suicide is one of the top 10 causes of death. The Taiwanese government designed a national network for suicide in 2006 (Suicide Prevention Centre 2007) aiming to reduce the rising rate of suicide (Lee 2009). Subsequently, the suicide rate fell from 193 per 100,000 in 2006 to 151 per 100,000 in 2011 (Department of Health, Executive Yuan, Taiwan, R.O.C. 2012). Bergmans (2008) conducted a grounded theory study to explore the meaning of recovery from recurrent suicide attempts, and 16 participants, aged 18–25 years, were interviewed. In Taiwan, Ke (2008) completed a phenomenological study (n = 6) exploring resilience of the survivors, aged 31–52 years. Findings from both studies demonstrated that self-awareness is a key in the process of moving from ‘living to die’ to ‘dying to live’. In Taiwan, the highest rate of suicide occurred in young people between the ages of 25 –44 years and the age group with second highest rate being between 45–64 years old. This study used grounded theory to explore the healing and recovery process of a wide age range of individuals, 15–64 years old, who had recently attempted suicide.
Background A suicide attempt is a predictor of death by suicide (Hawton et al. 2003, Wilcox & Anthony 2004, Capron et al. 2012). Chiu et al. (2006) pointed out that as many as 40% of people who died from suicide had made a previous suicide attempt. Consequently, suicidal risk is extremely high after a previous suicide attempt especially in the first year. Further, the first method of attempted suicide influences the suicidal behaviour trajectory in the future (Hulten et al. 2001, Runeson et al. 2010). Moreover, the 35- to 54-year-old age group had the highest suicide rate than the other age group (Chen et al. 2010). Suicide is a tragedy, not only because of the loss of an individual, but also because it impacts on families and society in general. Everybody has a collective responsibility to humanity. At a closer level, death by suicide impacts on the internal system of the family unit and consequently threatens the stability of the family (Patterson 2002, Xing et al. 2010). Moreover, Sun and Long (2008) reported that family members who provided holistic care for their suicidal relatives also thought about suicide because of the physical and emotional pressure sustained when caring for their suicidal relatives. It is fundamental therefore for healthcare professionals to provide care both to people who attempt suicide and to families (Lee & Liao 2006).
1752
At society level, repetition of attempts not only includes a sense of failure to humankind but also increases medical costs (Lee 2010). Consequently, the prevention of suicide requires a network of agencies working together, and in partnership, to help make a difference in terms of providing holistic care to the community we serve. Greve and Staudinger (2006) argued that social participation and social support can promote the development of resilience, which enables people to face adversity at times of crisis as suffering is inescapable in life. With this raised awareness, it is fundamental to provide holistic health care on prevention as well on the aftermath of the first attempt as well as relapse-prevention. A literature search demonstrates that this is the first study in Taiwan to use grounded theory to explore the healing and recovery process of individuals who attempted suicide.
Methods Aim To explore the healing and recovery process of patients with a history of suicidal attempts but who have had no further attempts in the past year.
Design Denzin and Lincoln (2000) contended that grounded theory is the most appropriate research method to use if the research questions focus on the process and experience. This study explored the process and experiences of people who had attempted suicide with no further attempts or suicidal ideations in the past year. In addition, Glaser (1992) claims that grounded theory is particularly useful for health professionals as it is a systematic, detailed and rigorous method more structured than other forms of qualitative research. Consequently, Strauss and Corbin’s method of grounded theory was considered to be the most appropriate method to use (Strauss & Corbin 1998).
Sample This study used theoretical sampling to collect data (Strauss & Corbin 1998). This means that each interview guideline was modified before the next interview in accordance with the new emerging findings, which emerged from the previous interview. Participants were accessed from the outpatient’s department of a medical centre in Southern Taiwan. The inclusion criteria were that participants: (1) had attempted suicide and had not re-attempted nor had © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1751–1759
Original article
suicidal ideations for one year; (2) were assessed by a psychiatric consultant who regarded them to be medically fit to participate in the study; (3) were diagnosed with depression; (4) were over 20 years of age; and (5) agreed to share their healing and recovery process. The exclusion criterion was severe personality disorder. The demographic details of the total sample group (n = 14) comprised women (n = 12) and men (n = 2); aged between 35–57 years; religious belief (n = 10) and nonbeliever (n = 4); university education (n = 5), senior high (n = 5), elementary (n = 3) and junior high (n = 1); married (n = 8), divorced (n = 2), widowed (n = 2) and separated (n = 1) single (n = 1); employed (n = 11) and unemployed (n = 3); major caregivers were relatives (n = 11), friends (n = 1) and themselves (n = 2). Further, regarding the suicide attempt, the methods of attempted suicide were drug overdoses (n = 9), jumping from a high place (n = 2), gunshots (n = 1), poison fumes (burning charcoal) (n = 1) and wrist-cutting (n = 1). Number of previous suicide attempts was between one to three times (n = 10), four to six times (n = 2), seven to nine times (n = 1) and over 10 times (n = 1).
Recovering after a suicide attempt
comment on how the emergent findings represented their disclosure about their lived experiences.
Ethical considerations This study was approved by the medical centre’s hospital review board (VGHKS 100-111). The consent form was designed and included information such as the aim of the study, the participants’ rights and the confidentiality involved in the data collection process. Further, the ethical principle nonmaleficence was adhered to meaning that some ways were adopted to prevent participants from enduring any harm by inviting them to (1) consent to the use of a tape-recorder during interviews; (2) state when they would like to end the interview or refrain from continuing with the interview at any time and without remonstration; (3) request for data to be deleted or erased when they did not wish it shared with others. Moreover, the lead researcher has worked in psychiatry for 13 years and is competent to deal with participants’ painful emotions and, with their permission, refer them to the psychiatrist if required.
Data collection
Data analysis
Semi-structured interviews were used to collect data during 2010–2011. Interviews lasted between 45–80 minutes in a private hospital room after participants had been reviewed at the outpatient clinic. Interview guidelines contained five themes: (1) healing and recovering from an attempted suicide, (2) internal and external motivators for change in suicidal behaviours, (3) reasons for not re-attempting in the past year, (4) internal and external difficulties or discontent encountered during the past year and (5) suggestions for other individuals who might attempt suicide.
Grounded theory emphasises using coding to conceptualise the data. The main purpose of coding is to condense the data line-by-line to uncover what is important, repeated and highlighted as the researchers become immersed in the data, which are later coded as concepts (Chen 2000). Each interview transcript was typed within three days. Subsequently, each typed transcript was read and important concepts coded within three days. Next, similar concepts were classed as subcategories using the constant comparative method. Subsequently, similar subcategories were classified as categories using the constant comparative method (Strauss & Corbin 1998, Chen 2000). Findings demonstrated that five categories emerged from the data to develop the five-phase emotional healing and recovery process after a suicide attempt.
Rigorousness Four methods were used to promote the credibility of this qualitative research: (1) prolonged involvement: a healthy therapeutic relationship was initiated, maintained and closed with all participants; (2) continuous observation: participants’ verbal and nonverbal communications were observed closely during the total interview acknowledging that the participants’ clinical needs took precedence over the research process at all times; (3) expert review: two suitably academically qualified professionals scrutinised the total process of the data analysis and ensured findings were consistent with the participants’ descriptions; and (4) member checks: two participants were invited to review the concepts, subcategories and categories that emerged from the data analysis and © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1751–1759
Results Findings revealed that the healing and recovery process for the participants happened in five phases: (1) self-awareness: gained insight and self-awareness of their responsibilities in life and their fear of death; (2) the inter-relatedness of life: aware of the need to seek help from professionals, friends and family for support; (3) the cyclical nature of human emotions: reappearance of stressors and activators causing psyche disharmony; (4) adjustment: changes in adjustment patterns of behaviour, discovering and owning one’s own
1753
M-T Chi et al.
unique emotions, deflecting attention from stressors and facing reality; and (5) acceptance: accepting the reality of self, others and life, and investing in life. Each of the five phases interact with each other and are represented in Fig. 1 as an ‘Emotional healing and recovering navigation wheel’. They are now explored.
job or their future. So, now it’s as if I have woken up to my needs and the needs of my children for the first time in my sorry life. (P3) When I think of my overdose I remind myself that I might have left a trail of destruction behind me…and my children would be afflicted with this scar. I tried to kill myself quite a few times but in reality I don’t want to die. I want to live…but I just didn’t know
Phase 1: Self-awareness
how to…I felt so lost…now I’m learning. (P10)
In the first phase, participants awoke to the reality that they are responsible for their life and also to the realisation that they were afraid of death. Consequently, this category was reduced to two subcategories. Awakening responsibility Many participants expressed they needed to take responsibility for self and their children, and this awakening helped reduce their suicidal ideations. After they attempted suicide, they realised the painful impact their attempt had on their children. Observing their anguish helped participants realise that they were important and that their life was precious. This was ‘the first time’ they had acknowledged that: ‘I’m important and my life’s important too’ (P2). Two examples depict this:
Awakening of the fear of death Many participants mentioned that they realised they were ‘afraid of death’ and terrified in case they had been left physically or mentally disabled. Nine of the 14 participants attempted suicide by taking drug overdoses because they ‘did not have the courage to use lethal methods’ to end their life. They were also afraid that the lethal methods would not work and they would again be disabled for the rest of their lives. Two examples illustrate these findings: When I woke up, I realised that this suicide is a very painful thing…I had attempted once before. A light went on in my head and I then understood that…I don’t want to die…in fact, I’m really afraid of death. (P6) I didn’t have the courage to commit suicide by jumping from a
…I lacked responsibility for my actions and my children. Before
high place. I thought it would work by taking an overdose of
the attempt I never thought about all this…I was too wrapped up
drugs. If truth be told, I’m afraid of death and more afraid of the
in myself…I didn’t care if my suicidal behaviour would affect their
aftermath of another attempt on me, if it didn’t work. (P8)
Phase 2: The inter-relatedness of life Self-awareness stage
Investing in life
Seeking help from the social support systems
Figure 1 Emotional navigation wheel for healing and recovering following a suicide attempt.
1754
The participants stated that running parallel with their realisation that they did not want to re-attempt suicide, they surrendered to the feelings that would seek help in the future, if anything untoward happened in their lives. They acknowledged that seeking help at times of distress could alleviate their concerns and help cope with distress. This category was divided into two subcategories. Seeking help from healthcare professionals Participants found that seeking help was a positive experience as we all need each other. They perceived that healthcare professionals helped them to cope with their negative thinking patterns when they were at risk of suicide. They benefited greatly from their experiences at the outpatient department when they felt listened to when they were doubtful about themselves or feeling low. If they presented as ‘serious’, the doctor re-admitted some of them for further interventions. Two examples depict these findings: © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1751–1759
Original article
Recovering after a suicide attempt
When I’m in a bad mood, I pick up the phone and go and see a
Now, my son has been diagnosed with depression too and I’m wor-
doctor or nurse. They always give me time and listen carefully to
ried because he doesn’t go to school…on top of that my mother has
me. They understand my worries. (P1)
cancer and goes for dialysis every week. She has suffered for years
I felt safe in the hospital because I knew doctors and nurses were there to look after me and protect me…the ward environment is
with Parkinson’s and heart disease. I’m always afraid she will leave me soon. So, my emotions are all over the place. (P4)
different from the outside world because I feel I can focus on my problems there. (P10)
Seeking help from social support systems Participants perceived that it was very important to access help from social support systems in the community when they were at risk of suicide. Family members, friends, religion and pets were included in these systems. They believed this type of help and care was invaluable and gave life some meaning. Two narratives illustrate these findings: When I’m helpless and hopeless, my friends stay beside me to keep me company on this lonely journey. They’re kind to me and listen
Symptom interference Some participants who had been diagnosed with depression said it was difficult to control their illness and remain stable (n = 6). They had lost interest in ‘the joys of life’ and some felt ‘sad’ and all suffered from insomnia leaving them ‘emotionally tired’. Some had stopped taking their medicine and this led to them ‘feeling worse’ causing some symptoms to reoccur again. Two participants said: Not being able to sleep is the hardest thing to bear. Old memories haunt me like fighting with my wife in the past. Then, I get upset for a long time and I can’t control my emotions…they close in on me and overwhelm me. (P3)
to me. They don’t judge me when I tell them about unhappy things
Sometimes I take my medication and sometimes I don’t. It’s not
that have happened to me. I always feel better after talking to
that I forget…I just think that I’m feeling better. When I don’t take
them. (P3)
my tablets my mood lowers and I become very unstable. I’ve made
The support I get from my family helps me realize I’m not alone anymore. I used to think I was a burden to them. Now, when I feel
a decision that I need my medicine and now take it every day to feel better. (P7)
down, I also feel lonely and I need the company of my family to support me. Even though they just sit there sometimes and don’t talk, I still feel safe. (P4)
Phase 3: The cyclical nature of human emotions Participants considered that they might have suicidal ideations again if and when they suffered from painful life experiences, or when their mental disorder became unstable. This category was divided into two subcategories. Reappearance of stressors During the healing and recovery process after an attempted suicide, individuals have a long way to travel. They perceived that they would experience many stressors and life events that might reawaken their suicidal ideations. Many of the participants disclosed that they did not like suffering and were unable to distinguish between ‘normal human suffering’ such as sadness, following a life event for example, and a mental disorder. Two examples follow: The doctor said I’ve improved a lot. However, when my mother died, I was so sad. I went to her grave every day for three and a
Phase 4: Adjustment The participants perceived that all human beings encounter ‘difficulties in their life’. They knew that it is important to ‘face personal problems’ and life events but previously did not know how to ‘cope with these difficulties’. During the healing and recovery process, they learned healthy coping strategies for coping with the stresses of life. They perceived that they might re-attempt suicide if they were not given the ‘emotional first-aid tools’. They believed they would keep repeating their ‘self-destructive’ behaviours had they not had this information. This category was condensed into four subcategories.
Adjusting to health-nurturing patterns of behaviour Participants said it was very important to adjust ‘their thoughts’, ‘mindset’ and ‘behaviours’ in the face of pain and adversity. Further, they perceived that they needed to learn how to ‘interact with others in a healthy way’. Some said this would involve ‘changing myself first’. Two examples illustrate these findings:
half hours for six dark months…I wanted to die too so that I could
After this suicide attempt, my view on life changed completely. I
be with her. (P6)
think I’ve been given a lot so now it’s my turn to give back to soci-
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1751–1759
1755
M-T Chi et al. ety. If I’ve the ability I’ll do something for someone. I thought life
My job puts a lot of pressure on me. I decided to face up to the
was just about me… now I know it’s about giving and receiving.
facts and told my company about my problem…they helped me
(P12)
change to a more flexible work schedule. This made sense to me
I’ve discovered that many bad things happen to me because I bring some of them on myself…I’m not a good communicator. I had to
where before I was afraid to ask. I haven’t thought of suicide since. (P3)
discover that I need to communicate to sort problems out…and not run away from them. (P7)
Discovering one’s own way of releasing emotions Participants expressed when they encountered problems or difficulties, they would exercise, go shopping, talk with others or cry to release their emotions. Many had kept their emotions ‘bottled up’ and come to realise that they needed to express them in their own unique way. Gaining this insight helped them cope with unstable emotions. Two examples follow:
Phase 5: Acceptance Participants moved backwards and forwards naturally through the first four phases of the emotional navigation wheel and eventually reached the phase of acceptance. This category comprised two subcategories.
to vent my emotions. (P10)
Accepting the reality of self, others and life Participants said that as they moved through the phases, they began to accept and embrace self, others and their current life situation. Those who had been diagnosed with depression learned to ‘befriend their illness and not fight it. It was their ‘reality’. Two examples of acceptance follow:
When I’m in a bad mood, I cry very loud and I cry for a long time.
Now, I’ve very good insight into my illness. I know I’ve an illness
When I stop crying, I feel relaxed. I feel lighter within myself…as if
and I never wanted to have it…but I know to care for me at times
I’m not carrying the weight of the world on my shoulders. (P3)
of sadness or distress. If life gets too rough I go to see my doctor
I energise myself by taking a walk for an hour every day… I’ve come to enjoy it…and when I’m in a bad mood I walk even faster
to review my medication. (P7)
Deflecting attention from stressors Participants expressed they would do something that they were interested in to deflect attention from their stressors. For example, reading books, listening to music and playing computer games. These findings are illustrated below: I’ve discovered a way to deflect my stress. I used to yell at my family before. Now, I walk away when something annoys me and play computer games and listen quietly to music. This helps. (P12) When I’m in a bad mood and feeling down, I read inspirational books to feed my spirit. When I can concentrate on a book, I feel calmer and more relaxed. (P4)
Facing the reality of life Participants said that they ‘did not know how to live normally’ and they did not know how to ‘cope with life’s problems’. Hence, many changes occurred to enable them to ‘face the reality of life’. When they realised that ‘life’s full of ups and downs’ (P13), many made the decision to learn how to cope with the uncertainties of life. Two examples follow: My daughter sold my house and I couldn’t face the problem at that
I’m not cranky and my emotions are stable when I take medicine on time. It was very important for me to accept the illness and ask the doctor for treatment. (P3)
Investing in life Many participants expressed that they had begun to do something they derived benefit from to support their reasons for living and hence ‘reduce the risk of suicide’. They tried to do anything that might ‘reduce pain’ such as developing relationships with people they ‘could confide in’. During the healing and recovery process, they became aware that ‘recovering does not mean forever’. Recovering is an ongoing process that has to be worked at by self-care and finding ‘new ways of coping with feelings and emotions’ and ‘re-building my confidence’. Two examples follow: I want to work in a nursing home as a volunteer. I’m not interested in money because money can’t make me happy. I want to do something meaningful to make me contented and improve the lives of others. (P1)
time. I know I lost my house and my money but it did not kill me.
Before, I had no goals in life. Now, I’m learning calligraphy and I
I’m still alive and I know my life’s important now. (P12)
feel I’ve recaptured a goal in life. (P12)
1756
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1751–1759
Original article
Discussion Findings from this study demonstrate that the participants worked through the five phases of the ‘emotional navigation wheel’ during the healing and recovery process after an attempted suicide. The first phase was self-awareness wherein participants took ownership of their role in being responsible for their life and indeed realised they did not want to die, but had a healthy fear of death. These findings concur with those two other researchers. Ke (2008) ascertained that the recognition of responsibility helped suicidal individuals change their behaviours and attitudes towards life and enabled them to become more positive. Participants in her study perceived they would not attempt suicide again because they needed to care for their loved ones and hence not want to cause them any pain or distress by their selfdestructive actions. Later, Sun (2011) found that participants who had attempted suicide (n = 15) wanted to survive because they realised that they had a responsibility to: their families, especially their children; to those they loved and they also feared dying. The findings from these two studies coupled with those of the current study indicate the importance of gaining insight into the reality that all human beings have some responsibility for our own lives and also for not causing distress and hurt to others by taking our own lives. Becoming responsible has a role to play in the actions we take and the values we hold in the future. The second phase of the healing and recovery process was the inter-relatedness of life. These findings demonstrate that we all need each other and that it is essential to reach out for help especially at times of emotional discontent or distress. Lee et al. (2010) argued that around 148% of the populace in Taiwan had suicidal ideations at sometime in their lives, but these experiences did not lead them to attempting suicide. They found that some individual sought help from counselling or other sources of talking therapies and others accessed support from the healthcare professions when they had suicidal ideations. Su et al. (2005) reported that the healthcare professionals not only provided treatment and care in the acute phase but also offered comparative treatment and care during the whole suicide care trajectory in the hope of preventing repeated suicide attempts. Findings from the study by Huang and Lee (2003) pointed out that depressed patients who were at risk of suicide considered they needed support from family and friends as well as medicine and psychotherapy. These findings together with those from the current study reveal that suicidal individuals require support and help from many sources, verifying the notion that the bio-psycho-social-spiritual model of care is paramount for their holistic health. © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1751–1759
Recovering after a suicide attempt
Phase three of the findings from the current study, the cyclical nature of human emotions, indicated that the participants realised that in the past they used self-destructive and avoidance behaviours to cope with either the stressors of life or mental disorders, sometimes ending up with repeated hospital admissions. These findings support those of Lee (2006) and Sun et al. (2007). Moreover, Sun et al. (2007) found that some of the reasons why people might attempt suicide were the patients’ stress history and past traumatic life experiences, illness, and feelings of abandonment, which led to inability to cope with life. All of the previous findings together with those from phase four of the emotional healing and recovery process ‘adjustment’ signify that healthcare professionals could design and implement psycho-education programmes to educate suicidal patients and their families about the nature of stress, its impact, healthy and unhealthy coping strategies, so that individuals could learn to survive the trials and tribulations of life without succumbing to suicide. It would be important to include how professionals could use the skill of discernment to identify the difference between ordinary human experiences, within the context of the felt emotions, such as loneliness and sadness following the death of a loved one, and those experienced in circumstances of mental disorders (Davies 2012). With the latter, the importance of complying with prescribed medication is paramount. Further, findings revealed the value of suicidal patients having access to follow-up of their treatment in order to prevent further attempts supporting those of Lin (2009). Moreover, the findings from the current study alongside those of Wong and Wong (2007) demonstrate the importance of suicidal individuals learning how best to change their negative attitudes about life and how to discover their own unique ways of releasing painful and distressing emotions such as anger and rage. The final phase of acceptance was reached when participants came to believe in and accept self, others and the reality of life. With the aid of nonjudgmental others, participants regained the desire to be alive and began investing in life.
Limitations of research There are two major limitations in this study. First, the difficulty in accessing individuals postsuicide attempt in the community. Hence, this study was conducted with patients in a psychiatric setting. It would be interesting to investigate those who had attempted suicide and had never been admitted to hospital. Second, this study only accessed those who had been diagnosed with depression. It would be appealing to include the full gambit of psychiatric disorders in future studies of suicide.
1757
M-T Chi et al.
Conclusion Findings from this study demonstrated that participants traversed a five phases of ‘emotional navigation wheel’ during the healing and recovery process after a suicide attempt. During phase one, participants gained ‘self-awareness’ and awakened to the reality that they held some responsibility for their own self, life and the lives of others around them. They also awakened to the realisation that they had a healthy fear of death. Subsequently, they gained insight into the ‘interrelatedness of life’ where they realised that there are times in all of our lives when need to reach out for help especially when stressors reappear and there is symptom interference, which could lead to a relapse of their illnesses. Subsequently, they learned about the ‘cyclical nature of human emotions’ and how to cope in a healthy manner with the stresses in life and to the realisation that living is an emotional journey therefore they needed to ‘adjust to this reality’. Finally, they came to a phase of ‘acceptance of self, others and of life itself’. Many of the participants then aspired to the role of investing in life by caring for self and others. This study could provide healthcare professionals with an understanding of the five phases of the healing and recovery process after a suicide attempt. More research is required into the nurses’ role in facilitating individuals to negotiate these five phases.
Relevance to clinical practice As soon as nursing care begins and during the healing process following a suicide attempt, nurses could facilitate people to gain insight into the reality that they have some
responsibility for their own life. Nurses could also enable individuals to acknowledge that all human beings need help at times and that it is acceptable to ask for help, especially at times of emotional distress. Corresponding with this care, nurses could facilitate patients to accept and own these truisms as well as provide therapeutic care to enable them to learn healthy coping skills to access during times of stress. Following discharge from hospital, community healthcare nurses could continue this therapeutic work until individuals learn to adjust to the realities of life and accept self, others and their life with unconditional positive regard and investing in life. It is paramount for healthcare professionals to realise that although healing and recovering can occur after a suicide attempt, the vulnerable part in all of us remains, sometimes dormant, within us. This vulnerable part requires continuing self-nurturing to prevent further attempts.
Acknowledgements We would like to thank the participants of this study.
Contributions Study design: MTC, FKS; data collection and analysis: MTC, FKS, SRJ, YCK, TL and manuscript preparation: MTC, FKS, AL.
Conflict of interest None.
References Bergmans Y (2008) Exploring the Meaning of Recovery from Recurrent Suicide Attempts. Available at: http://wellesleyinstitute.com/files/recoverysuicide.pdf (accessed 9 April 2012). Capron DW, Cougle JR, Ribeiro JD, Joiner TE & Schmidt NB (2012) An interactive model of anxiety sensitivity relevant to suicide attempt history and future suicidal ideation. Journal of Psychiatric Research 46, 174–180. Chen YJ (2000) Introduction. In Qualitative Nursing Research Methods (Chen YJ ed.). The Fellowship of Hope, Taipei, pp. 1–20. Chen CC, Yeh JY, Li CY, Chen CY & Hung HW (2010) A study of Taiwan’s suicide mortality rate and related
1758
factors: 1973–2003. Taiwan Journal of Public Health 29, 201–215. Chiu CH, Kuo CJ, Chen YY, Chen CC, Lee MB, Lin CH, Lin CC, Dy H & Lin CC (2006) Comparison of epidemiological characteristics between first-ever and repeated suicide attempters. Taipei City Medical Journal 3, 1000–1007. Davies J (2012) The Importance of Suffering. Routledge, New York, NY. Denzin NK & Lincoln YS (2000) Handbook of Qualitative Research, 2nd edn. Sage, London. Department of Health, Executive Yuan, Taiwan, R.O.C. (2012) Health and Vital Statistics. Department of Health, Taipei. Glaser BG (1992) Basics of Grounded Theory Analysis. Sociology, Mill Valley, CA.
Greve W & Staudinger UM (2006) Resilience in later adulthood and old age: resources and potentials for successful aging. In Developmental Psychopathology (Cicchetti D & Cohen A eds). Wiley, Hoboken, NY, pp. 796–840. Hawton K, Harris L, Hall S, Bale E & Bond A (2003) Deliberate self-harm in oxford, 1990–2000: a time of change in patient characteristics. Psychological Medicine 33, 987–995. Huang LC & Lee MB (2003) Depressive disorder and suicide. Formosan Journal of Medicine 7, 929–934. Hulten A, Jiang GX, Wasserman D, Hawton K, Hjelmeland H, De Leo D, Ostamo A, Salander Renberg E & Schmidtke A (2001) Repetition of
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1751–1759
Original article attempted suicide among teenagers in Europe: frequency, timing and risk factor. European Child & Adolescent Psychiatry 10, 161–169. Ke YJ (2008) Suicide Attempts by the Resilience of Explanatory Style and the Course of the Study. Unpublished MSc Dissertation, National Changhua University of Education, Changhua City. Lee MB (2006) New knowledge on suicide prevention. Newsletter for Suicide Prevention Network 1, 12–15. Lee MB (2009) New knowledge on suicide prevention. Newsletter for Suicide Prevention Network 4, 3–8. Lee MB (2010) Cherishing life and restoring hope. Newsletter for Suicide Prevention Network 5, 5–6. Lee MB & Liao SC (2006) Risk factors and strategies for the prevention of suicide. Formosan Journal of Medicine 10, 367–374. Lee MB, Liao SC & Lai SW (2010) Investigating cognitive strategies for the prevention of suicide in Taiwan. Newsletter for Suicide Prevention Network 5, 11–13. Lin CY (2009) Suicide assessment and communication skills: the suicide
Recovering after a suicide attempt prevention gatekeepers. Counseling & Guidance 284, 48–55. Patterson JM (2002) Integrating family resilience and family stress theory. Journal of Marriage and the Family 64, 349–360. Runeson B, Tidemalm D, Dahlin M, Lichtenstein P & Langstrom N (2010) Method of attempted suicide as predictor of subsequent successful suicide: national long term cohort study. British Medical Journal 341, c3222. Strauss A & Corbin J (1998) Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory, 2nd edn. Sage, Thousand Oaks, CA. Su TW, Chiu CH, Kuo CJ, Chen CC & Lee MB (2005) Epidemiology of suicide. Taipei City Medical Journal 2, 6–15. Suicide Prevention Centre (2007) Objectives. Available at: http://www.tspc. doh.gov.tw/tspc/portal/center/index.jsp (accessed 6 July 2012). Sun FK (2011) Mind Helper – How to Assist Family Members Dealing with Suicide. I-Shou University, Kaohsiung.
Sun FK & Long A (2008) A theory to guide families and carers of people who are at risk of suicide. Journal of Clinical Nursing 17, 1939–1948. Sun FK, Long A & Tsao LI (2007) Patients’ and nurses’ perceptions of reasons why people attempt suicide in Taiwan. New Taipei Journal of Nursing 9, 39–56. Wilcox HC & Anthony JC (2004) The development of suicide ideation and attempts: an epidemiologic study of first graders followed into young adulthood. Drug and Alcohol Dependence 76, S53–S67. Wong MS & Wong SR (2007) Suicide awareness and prevention. Counseling and Guidance 260, 20–22. World Health Organization (2012) Suicide Prevention (SUPRE). Available at: http:// www.who.int/mental_health/prevention/ suicide/suicideprevent/en/ (accessed 9 April 2012). Xing XY, Tao FB, Wan YH, Xing C, Qi XY, Hao JH, Su PY, Pan HF & Huang L (2010) Family factors associated with suicide attempts among Chinese adolescent students: a national crosssectional survey. Journal of Adolescent Health 46, 592–599.
The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of clinically related scholarship which supports the practice and discipline of nursing. For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http:// wileyonlinelibrary.com/journal/jocn
Reasons to submit your paper to JCN: High-impact forum: one of the world’s most cited nursing journals, with an impact factor of 1316 – ranked 21/101 (Nursing (Social Science)) and 25/103 Nursing (Science) in the 2012 Journal Citation Reportsâ (Thomson Reuters, 2012). One of the most read nursing journals in the world: over 19 million full text accesses in 2011 and accessible in over 8000 libraries worldwide (including over 3500 in developing countries with free or low cost access). Early View: fully citable online publication ahead of inclusion in an issue. Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur. Positive publishing experience: rapid double-blind peer review with constructive feedback. Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley Online Library, as well as the option to deposit the article in your preferred archive.
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1751–1759
1759
