578402
research-article2015
QHRXXX10.1177/1049732315578402Qualitative Health ResearchWerbart Törnblom et al.
Grounded Theories: Article
Shame and Gender Differences in Paths to Youth Suicide: Parents’ Perspective
Qualitative Health Research 2015, Vol. 25(8) 1099–1116 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732315578402 qhr.sagepub.com
Annelie Werbart Törnblom1, Andrzej Werbart2, and Per-Anders Rydelius1
Abstract Risk factors, suicidal behavior, and help-seeking patterns differ between young women and men. We constructed a generic conceptual model of the processes underlying youth suicide, grounded in 78 interviews with parents in 52 consecutive cases of suicide (19 women, 33 men) identified at forensic medical autopsy and compared by sex. We found different forms of shame hidden behind gender-specific masks, as well as gender differences in their paths to suicide. Several interacting factors formed negative feedback loops. Finding no way out, the young persons looked for an “emergency exit.” Signs and preparations could be observed at different times but recognized only in retrospect. Typically, the young persons and their parents asked for professional help but did not receive the help they needed. We discuss parents’ experiences from the theoretical perspective on gender identity and developmental breakdown. Giving voice to the parents’ tacit knowledge can contribute to better prevention and treatment. Keywords suicide; adolescents / youth, at-risk; gender; grounded theory; families; depression; eating disorders; abuse, sexual; health care; interviews In the last 45 years, suicide rates have increased by 60% worldwide (World Health Organization [WHO], 2015). Since 1990, suicide rates in Sweden have increased in 15to 24-year-olds, with current suicide rates of 6.0 per 100,000 for girls and 13.8 per 100,000 for boys (Socialstyrelsen, 2013). Suicide is now the leading cause of death for both sexes in this age group in Sweden and many other Western countries. Simultaneously, the volume and number of studies of suicidality have grown extensively. We have today a solid body of knowledge about risk factors and prevention. However, each act of suicide leaves close survivors with a feeling of powerlessness and raises the question of what could have been done to prevent this lethal outcome. Known risk factors for suicidality among children, adolescents, and young adults include early neuroticism related to later depression, anxiety, substance abuse and conduct disorder, family problems, loss, and disturbed or insecure attachments in childhood, lack of parental care and maternal overprotection, stressful life events and risk behaviors (Fergusson, Woodward, & Horwood, 2000; Goschin, Briggs, Blanco-Lutzen, Cohen, & Galynker, 2013; King et al., 2001; Shiner, Scourfield, Fincham, & Langer, 2009). In the ages 6 to 13, suicide-related behaviors were associated with depressive symptoms and low
perceived quality of life (Bourdet-Loubére & Raynaud, 2013). There are well-documented gender differences in suicide rates, both completed and attempted (Payne, Svami, & Stanistreet, 2008). In most Western countries, women have higher rates of suicidal ideation and behavior, but lower rates of suicide mortality than men. Despite possible cultural biases in reporting and classifying death by gender, a consistent research finding is difference in youth psychopathology. Women completing suicide suffer more often than men from diagnosed mental illness, particularly depressive disorders (Beautrais, 2002; Hawton, 2000). In a prospective study of North American adolescents and young adults, the suicide attempt hazard rate was significantly higher for women than for men, but this gender difference disappeared by age 19, despite the gender difference for major depression (Lewinsohn, 1
Karolinska Institutet, Stockholm, Sweden Stockholm University, Stockholm, Sweden
2
Corresponding Author: Annelie Werbart Törnblom, Child and Adolescent Psychiatric Unit, Department of Women’s and Children’s Health, Karolinska Institutet, SE-171 76 Stockholm, Sweden. Email: [email protected]
Downloaded from qhr.sagepub.com at UNIV OF PENNSYLVANIA on October 4, 2015
1100
Qualitative Health Research 25(8)
Rohde, Seeley, & Baldwin, 2001). In a cross-sectional study of a representative sample of Norwegian students (ages 12–20) with 2-year questionnaire follow-ups, more girls than boys reported a previous suicide attempt. This gender difference was significantly reduced when applying a stepwise logistic regression analysis that controlled for depressed mood and eating disorders (Wichstrøm & Rossow, 2002). In a German community panel of adolescents and young adults, girls attempting suicide in the youngest age category (14–17 years) had significantly more suicidal thoughts and attempted suicide significantly more often than did boys. Furthermore, women experienced much more frequent sexual abuse, as well as significantly more post-traumatic stress disorder (PTSD) and anxiety disorders, probably as a consequence of traumas, whereas young men attempting suicide showed higher rates of alcohol disorders and financial problems (Wunderlich, Bronisch, Wittchen, & Carter, 2001). An extensive body of research (summarized above) has demonstrated that the effect of most risk factors differs significantly by gender. Boys are more prone to externalize problems, resulting in conduct problems and substance abuse, whereas girls are more prone to internalize problems, resulting in anxiety and depressive symptoms. This is often linked to sex differences in expressions of anger, aggression, self-assertion, relational needs, and is related to differences in masculine and feminine gender-role socialization (Rosenfield, 2000). Whereas effective depression care can bring a dramatic drop in the suicide rate, current diagnostic criteria are more likely to identify women’s depression (Oliffe & Phillips, 2008). Men’s expressions of depression (anger, impulse control difficulties, irritability, aggression, substance abuse, risktaking, escaping behaviors, inability or unwillingness to express emotion, and impoverished relationships) are strongly influenced by dominant ideals of masculinity (Oliffe & Phillips, 2008). Developmental research has shown that, whereas boys tend to show more overt, physical, or verbal aggression than girls, girls tend to show more relational aggression than boys (e.g., damaging peer relationships via manipulation, social exclusion, and vicious rumor; Crick & Zahn-Waxler, 2003). Gender-specific, help-seeking patterns are well documented. Women are more likely to seek help for mental problems (Addis & Mahalik, 2003; Beautrais, 2002; Hawton, 2000). Adolescent men have a lower propensity to seek help for depression than women; however, the majority of adolescents with depressed mood or at risk of self-injury never seek help (Sen, 2004). In a Swedish longitudinal study of former Child and Adolescent Psychiatry patients, only few of them who later committed suicide were initially admitted to psychiatric care for attempted suicide (Engqvist & Rydelius, 2006). Of those young people with suicidal thoughts or self-harming behavior
who do seek help, the majority turned to their social network and not professionals (Michelmore & Hindley, 2012). Furthermore, women were significantly more likely to seek help from peers, and men from emergency services (Michelmore & Hindley, 2012). Taken together, decades of research indicate that risk factors, suicidal behavior, and help-seeking patterns differ between young women and men. In a previous study (Werbart Törnblom, Werbart, & Rydelius, 2013), we analyzed parents’ perspective on their sons’ suicide using grounded theory. In the present study, we widen the perspective and include the parents’ attempts to understand and explain to themselves why their daughter committed suicide. Our aim is to build a generic conceptual model of the processes underlying youth suicide, grounded in the parents’ perspective, and to compare girls’ and boys’ suicidal processes. Thus, we include all consecutive cases of boys’ and girls’ suicide where there are parental interviews available, drawn from a larger case-control study (see below). Our starting point is that complementing a theory-neutral and empirically driven, inductive approach with a theory-driven, deductive approach might enhance our knowledge of paths to youth suicide. An inductive qualitative methodology can be particularly fruitful in exploring and systematizing the parents’ tacit knowledge, to make it more explicit and to provide grounded hypotheses for further research. In the next step, we discuss the parents’ understanding of their child’s suicide from the theoretical perspective on gender identity and disrupted personality development in adolescence and emerging adulthood.
Method The present investigation is a part of a larger, case-control study of suicide and sudden violent death up to age 25 years in Stockholm County, Sweden. The project has been approved by the Regional Research Ethics Committee at the Karolinska Institutet, and all participants have given their informed consent. We identified consecutive cases of suicide among those referred to forensic medical autopsy from 2000 through 2004. About 3 months postmortem, Annelie Werbart Törnblom contacted family members by letter and then by telephone to request interviews. In 62 cases of suicide, the informants wanted to participate in the study, whereas in 9 cases the relatives declined, and no further information was collected. Of the 22 suicides by girls, 19 cases included at least one parental interview (16 maternal and 11 paternal interviews). The comparison includes 33 cases of suicide by boys, drawn from the same case-control study (28 maternal and 23 paternal interviews, previously analyzed in Werbart Törnblom et al., 2013). Thus, the total material
Downloaded from qhr.sagepub.com at UNIV OF PENNSYLVANIA on October 4, 2015
1101
Werbart Törnblom et al.
Table 1. Sociodemographic Data (19 Girls and 33 Boys). Girls
Figure 1. Flowchart of data collection.
consists of 78 interviews. The study flowchart is presented in Figure 1. For sociodemographic characteristics of girls, boys, and their families, see Table 1. The interview protocol followed basic psychological autopsy procedures for examining the relationship between particular antecedents and suicide by reconstructing the person’s state of mind, mental and physical health, personality, experience of social adversity and social integration (Cavanagh, Carson, Sharpe, & Lawrie, 2003). The questions covered the following areas: the informant’s contacts with the child prior to suicide, family relationships, the deceased’s stressful life events and coping strategies, psychiatric contacts, previous suicide attempts and suicidal communication. Open-ended questions allowed the participants to develop their own story: “How have you tried to understand and explain to yourself why this death happened?” “Please give a description of your spouse and of your relationship.” “Please give a description of the deceased and of your relationship, as compared to the siblings.” Annelie Werbart Törnblom tape recorded interviews lasting 3 to 4 hours per participant at their home. In the cases of girls’ suicide, the 16 maternal interviews were conducted 3 to 13 months (M = 6.13; SD = 2.39) postmortem and the 11 paternal interviews 3 to 11 months (M = 5.64; SD = 2.34). In the cases of boys’ suicide, the 28 maternal interviews were conducted 3 to 15 months (M = 5.75; SD = 2.38) postmortem and the 23 paternal interviews 3 to 8 months (M = 5.13; SD = 1.49).
Data Analysis The interview transcripts were analyzed using basic grounded-theory methodology (Strauss & Corbin, 1998). In grounded theory, theoretical concepts are generated from the data and related to each other as a theoretical
M (Range)
Boys SD
M (Range)
Age at suicide 19.6 (14–24) Mother’s age at 29.9 (20–42) the child’s birth Father’s age at the 32.3 (21–45) child’s birth
3.5 5.6
21.2 (12–25) 28.7 (20–37)
2.7 4.9
5.6
32.1 (23–49)
5.7
%
n
%
57.9
19
57.6
21.1
13
39.4
5.3 15.8
1
3.0
42.1 5.3 15.8 26.3 10.5
19 2 2 9 1
57.6 6.1 6.1 27.3 3.0
36.8 63.2
13 20
39.4 60.6
10.5 15.8 26.3 47.4
2 10 11 10
6.1 30.3 33.3 30.3
31.6 68.4
14 19
42.4 57.6
78.9 5.3
32
97.0
n
Parents’ marital status at suicide Separated or 11 divorced Married or 4 cohabitant Dead mother 1 Dead father 3 Habitation at suicide With parent(s) 8 With partner 1 With friends 3 Alone 5 Psychiatric 2 ward Stepparents Yes 7 No 12 Birth order Only child 2 First born 3 Middle child 5 Youngest 9 Half-siblings Yes 6 No 13 Country of birth Sweden 15 Other 1 European country Asia 3 Africa Mother born in 14 Sweden Father born in 13 Sweden Education Compulsory 7 school or less High school 9 Post-secondary 3 or university University degree
Downloaded from qhr.sagepub.com at UNIV OF PENNSYLVANIA on October 4, 2015
SD
73.7
1 28
3.0 84.8
68.4
25
75.8
36.8
8
24.2
47.4 15.8
20 3
60.6 9.1
2
6.1
15.8
(continued)
1102
Qualitative Health Research 25(8)
Table 1. (continued)
Mother’s education Public school or less High school Post-secondary or university University degree Father’s education Public school or less High school Post-secondary or university University degree Occupation Work Student Work and student Sick-listed Unemployed Mother’s occupation Work Student Sick-listed Father’s occupation Work Sick-listed Unemployed Criminality None Yes Sentenced or investigated Addiction Alcohol Substance Anabolic steroids Medication None Mother’s addiction Alcohol Medication None Father’s addiction Alcohol Substance None Psychiatric care Outpatient 18 9 years None 5 Mother’s psychiatric care Outpatient >18 4 years Inpatient >18 1 years None 14 Father’s psychiatric care Outpatient >18 4 years Inpatient >18 1 years 15 None
%
n
%
21.1
2
6.1
47.4
18
54.5
47.4
13
39.4
26.3
12
36.4
21.1
3
9.1
5.3
1
3.0
73.7
29
87.9
21.1
6
18.2
5.3
2
6.1
78.9
25
75.8
explanation of the main concern of the participants in focus for investigation. For data analysis, we used ATLAS.ti (2000). This software retains links between transcripts, codes, categories, and memos, permitting movement back and forth between coding, category elaboration, and conceptual model building. All utterances relating to parents’ attempts to understand and explain the suicide were assigned open codes summarizing the content. The networking function of ATLAS.ti was used to group closely related codes into categories. As distinct categories emerged, the relationships among categories were re-examined, and latent patterns could be identified in several interviews. In this procedure of constant, comparative analysis, new data were compared with the existing data until saturation was reached (no new categories emerged). During selective coding, the previously constructed tentative model of processes underlying boys’ suicide (Werbart Törnblom et al., 2013) was tested, refined, and integrated to elucidate the processes underlying girls’ suicide and capture gender differences in this respect. The categories were graphically connected into tentative diagrams to visually depict and examine their relationships. This step of the qualitative analysis allowed a core category to emerge and capture, on a meta-level, the essence of the suicidal process in youth, as viewed from the parents’ perspective, while retaining a relationship to all other categories. Finally, we assembled the generic conceptual model of the suicidal process. The first author carried out the main coding. During selective coding, the second author reviewed all codes and theoretical memos and collaborated in refining the model. Differences in opinions were discussed in relation
Downloaded from qhr.sagepub.com at UNIV OF PENNSYLVANIA on October 4, 2015
1103
Werbart Törnblom et al.
Figure 2. The generic conceptual model of processes behind youth suicide from the parents’ perspective.
to the original transcripts until agreement was reached. On the basis of these audits, the model was deemed grounded. We report category frequencies separately for mothers and fathers of girls and boys using the nomenclature from Hill et al.’s (2005) study, following criteria for larger samples (Knox, Schlosser, Pruitt, & Hill, 2006): General: ≥90% of the cases; Typical: ≥50% to
research-article2015
QHRXXX10.1177/1049732315578402Qualitative Health ResearchWerbart Törnblom et al.
Grounded Theories: Article
Shame and Gender Differences in Paths to Youth Suicide: Parents’ Perspective
Qualitative Health Research 2015, Vol. 25(8) 1099–1116 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732315578402 qhr.sagepub.com
Annelie Werbart Törnblom1, Andrzej Werbart2, and Per-Anders Rydelius1
Abstract Risk factors, suicidal behavior, and help-seeking patterns differ between young women and men. We constructed a generic conceptual model of the processes underlying youth suicide, grounded in 78 interviews with parents in 52 consecutive cases of suicide (19 women, 33 men) identified at forensic medical autopsy and compared by sex. We found different forms of shame hidden behind gender-specific masks, as well as gender differences in their paths to suicide. Several interacting factors formed negative feedback loops. Finding no way out, the young persons looked for an “emergency exit.” Signs and preparations could be observed at different times but recognized only in retrospect. Typically, the young persons and their parents asked for professional help but did not receive the help they needed. We discuss parents’ experiences from the theoretical perspective on gender identity and developmental breakdown. Giving voice to the parents’ tacit knowledge can contribute to better prevention and treatment. Keywords suicide; adolescents / youth, at-risk; gender; grounded theory; families; depression; eating disorders; abuse, sexual; health care; interviews In the last 45 years, suicide rates have increased by 60% worldwide (World Health Organization [WHO], 2015). Since 1990, suicide rates in Sweden have increased in 15to 24-year-olds, with current suicide rates of 6.0 per 100,000 for girls and 13.8 per 100,000 for boys (Socialstyrelsen, 2013). Suicide is now the leading cause of death for both sexes in this age group in Sweden and many other Western countries. Simultaneously, the volume and number of studies of suicidality have grown extensively. We have today a solid body of knowledge about risk factors and prevention. However, each act of suicide leaves close survivors with a feeling of powerlessness and raises the question of what could have been done to prevent this lethal outcome. Known risk factors for suicidality among children, adolescents, and young adults include early neuroticism related to later depression, anxiety, substance abuse and conduct disorder, family problems, loss, and disturbed or insecure attachments in childhood, lack of parental care and maternal overprotection, stressful life events and risk behaviors (Fergusson, Woodward, & Horwood, 2000; Goschin, Briggs, Blanco-Lutzen, Cohen, & Galynker, 2013; King et al., 2001; Shiner, Scourfield, Fincham, & Langer, 2009). In the ages 6 to 13, suicide-related behaviors were associated with depressive symptoms and low
perceived quality of life (Bourdet-Loubére & Raynaud, 2013). There are well-documented gender differences in suicide rates, both completed and attempted (Payne, Svami, & Stanistreet, 2008). In most Western countries, women have higher rates of suicidal ideation and behavior, but lower rates of suicide mortality than men. Despite possible cultural biases in reporting and classifying death by gender, a consistent research finding is difference in youth psychopathology. Women completing suicide suffer more often than men from diagnosed mental illness, particularly depressive disorders (Beautrais, 2002; Hawton, 2000). In a prospective study of North American adolescents and young adults, the suicide attempt hazard rate was significantly higher for women than for men, but this gender difference disappeared by age 19, despite the gender difference for major depression (Lewinsohn, 1
Karolinska Institutet, Stockholm, Sweden Stockholm University, Stockholm, Sweden
2
Corresponding Author: Annelie Werbart Törnblom, Child and Adolescent Psychiatric Unit, Department of Women’s and Children’s Health, Karolinska Institutet, SE-171 76 Stockholm, Sweden. Email: [email protected]
Downloaded from qhr.sagepub.com at UNIV OF PENNSYLVANIA on October 4, 2015
1100
Qualitative Health Research 25(8)
Rohde, Seeley, & Baldwin, 2001). In a cross-sectional study of a representative sample of Norwegian students (ages 12–20) with 2-year questionnaire follow-ups, more girls than boys reported a previous suicide attempt. This gender difference was significantly reduced when applying a stepwise logistic regression analysis that controlled for depressed mood and eating disorders (Wichstrøm & Rossow, 2002). In a German community panel of adolescents and young adults, girls attempting suicide in the youngest age category (14–17 years) had significantly more suicidal thoughts and attempted suicide significantly more often than did boys. Furthermore, women experienced much more frequent sexual abuse, as well as significantly more post-traumatic stress disorder (PTSD) and anxiety disorders, probably as a consequence of traumas, whereas young men attempting suicide showed higher rates of alcohol disorders and financial problems (Wunderlich, Bronisch, Wittchen, & Carter, 2001). An extensive body of research (summarized above) has demonstrated that the effect of most risk factors differs significantly by gender. Boys are more prone to externalize problems, resulting in conduct problems and substance abuse, whereas girls are more prone to internalize problems, resulting in anxiety and depressive symptoms. This is often linked to sex differences in expressions of anger, aggression, self-assertion, relational needs, and is related to differences in masculine and feminine gender-role socialization (Rosenfield, 2000). Whereas effective depression care can bring a dramatic drop in the suicide rate, current diagnostic criteria are more likely to identify women’s depression (Oliffe & Phillips, 2008). Men’s expressions of depression (anger, impulse control difficulties, irritability, aggression, substance abuse, risktaking, escaping behaviors, inability or unwillingness to express emotion, and impoverished relationships) are strongly influenced by dominant ideals of masculinity (Oliffe & Phillips, 2008). Developmental research has shown that, whereas boys tend to show more overt, physical, or verbal aggression than girls, girls tend to show more relational aggression than boys (e.g., damaging peer relationships via manipulation, social exclusion, and vicious rumor; Crick & Zahn-Waxler, 2003). Gender-specific, help-seeking patterns are well documented. Women are more likely to seek help for mental problems (Addis & Mahalik, 2003; Beautrais, 2002; Hawton, 2000). Adolescent men have a lower propensity to seek help for depression than women; however, the majority of adolescents with depressed mood or at risk of self-injury never seek help (Sen, 2004). In a Swedish longitudinal study of former Child and Adolescent Psychiatry patients, only few of them who later committed suicide were initially admitted to psychiatric care for attempted suicide (Engqvist & Rydelius, 2006). Of those young people with suicidal thoughts or self-harming behavior
who do seek help, the majority turned to their social network and not professionals (Michelmore & Hindley, 2012). Furthermore, women were significantly more likely to seek help from peers, and men from emergency services (Michelmore & Hindley, 2012). Taken together, decades of research indicate that risk factors, suicidal behavior, and help-seeking patterns differ between young women and men. In a previous study (Werbart Törnblom, Werbart, & Rydelius, 2013), we analyzed parents’ perspective on their sons’ suicide using grounded theory. In the present study, we widen the perspective and include the parents’ attempts to understand and explain to themselves why their daughter committed suicide. Our aim is to build a generic conceptual model of the processes underlying youth suicide, grounded in the parents’ perspective, and to compare girls’ and boys’ suicidal processes. Thus, we include all consecutive cases of boys’ and girls’ suicide where there are parental interviews available, drawn from a larger case-control study (see below). Our starting point is that complementing a theory-neutral and empirically driven, inductive approach with a theory-driven, deductive approach might enhance our knowledge of paths to youth suicide. An inductive qualitative methodology can be particularly fruitful in exploring and systematizing the parents’ tacit knowledge, to make it more explicit and to provide grounded hypotheses for further research. In the next step, we discuss the parents’ understanding of their child’s suicide from the theoretical perspective on gender identity and disrupted personality development in adolescence and emerging adulthood.
Method The present investigation is a part of a larger, case-control study of suicide and sudden violent death up to age 25 years in Stockholm County, Sweden. The project has been approved by the Regional Research Ethics Committee at the Karolinska Institutet, and all participants have given their informed consent. We identified consecutive cases of suicide among those referred to forensic medical autopsy from 2000 through 2004. About 3 months postmortem, Annelie Werbart Törnblom contacted family members by letter and then by telephone to request interviews. In 62 cases of suicide, the informants wanted to participate in the study, whereas in 9 cases the relatives declined, and no further information was collected. Of the 22 suicides by girls, 19 cases included at least one parental interview (16 maternal and 11 paternal interviews). The comparison includes 33 cases of suicide by boys, drawn from the same case-control study (28 maternal and 23 paternal interviews, previously analyzed in Werbart Törnblom et al., 2013). Thus, the total material
Downloaded from qhr.sagepub.com at UNIV OF PENNSYLVANIA on October 4, 2015
1101
Werbart Törnblom et al.
Table 1. Sociodemographic Data (19 Girls and 33 Boys). Girls
Figure 1. Flowchart of data collection.
consists of 78 interviews. The study flowchart is presented in Figure 1. For sociodemographic characteristics of girls, boys, and their families, see Table 1. The interview protocol followed basic psychological autopsy procedures for examining the relationship between particular antecedents and suicide by reconstructing the person’s state of mind, mental and physical health, personality, experience of social adversity and social integration (Cavanagh, Carson, Sharpe, & Lawrie, 2003). The questions covered the following areas: the informant’s contacts with the child prior to suicide, family relationships, the deceased’s stressful life events and coping strategies, psychiatric contacts, previous suicide attempts and suicidal communication. Open-ended questions allowed the participants to develop their own story: “How have you tried to understand and explain to yourself why this death happened?” “Please give a description of your spouse and of your relationship.” “Please give a description of the deceased and of your relationship, as compared to the siblings.” Annelie Werbart Törnblom tape recorded interviews lasting 3 to 4 hours per participant at their home. In the cases of girls’ suicide, the 16 maternal interviews were conducted 3 to 13 months (M = 6.13; SD = 2.39) postmortem and the 11 paternal interviews 3 to 11 months (M = 5.64; SD = 2.34). In the cases of boys’ suicide, the 28 maternal interviews were conducted 3 to 15 months (M = 5.75; SD = 2.38) postmortem and the 23 paternal interviews 3 to 8 months (M = 5.13; SD = 1.49).
Data Analysis The interview transcripts were analyzed using basic grounded-theory methodology (Strauss & Corbin, 1998). In grounded theory, theoretical concepts are generated from the data and related to each other as a theoretical
M (Range)
Boys SD
M (Range)
Age at suicide 19.6 (14–24) Mother’s age at 29.9 (20–42) the child’s birth Father’s age at the 32.3 (21–45) child’s birth
3.5 5.6
21.2 (12–25) 28.7 (20–37)
2.7 4.9
5.6
32.1 (23–49)
5.7
%
n
%
57.9
19
57.6
21.1
13
39.4
5.3 15.8
1
3.0
42.1 5.3 15.8 26.3 10.5
19 2 2 9 1
57.6 6.1 6.1 27.3 3.0
36.8 63.2
13 20
39.4 60.6
10.5 15.8 26.3 47.4
2 10 11 10
6.1 30.3 33.3 30.3
31.6 68.4
14 19
42.4 57.6
78.9 5.3
32
97.0
n
Parents’ marital status at suicide Separated or 11 divorced Married or 4 cohabitant Dead mother 1 Dead father 3 Habitation at suicide With parent(s) 8 With partner 1 With friends 3 Alone 5 Psychiatric 2 ward Stepparents Yes 7 No 12 Birth order Only child 2 First born 3 Middle child 5 Youngest 9 Half-siblings Yes 6 No 13 Country of birth Sweden 15 Other 1 European country Asia 3 Africa Mother born in 14 Sweden Father born in 13 Sweden Education Compulsory 7 school or less High school 9 Post-secondary 3 or university University degree
Downloaded from qhr.sagepub.com at UNIV OF PENNSYLVANIA on October 4, 2015
SD
73.7
1 28
3.0 84.8
68.4
25
75.8
36.8
8
24.2
47.4 15.8
20 3
60.6 9.1
2
6.1
15.8
(continued)
1102
Qualitative Health Research 25(8)
Table 1. (continued)
Mother’s education Public school or less High school Post-secondary or university University degree Father’s education Public school or less High school Post-secondary or university University degree Occupation Work Student Work and student Sick-listed Unemployed Mother’s occupation Work Student Sick-listed Father’s occupation Work Sick-listed Unemployed Criminality None Yes Sentenced or investigated Addiction Alcohol Substance Anabolic steroids Medication None Mother’s addiction Alcohol Medication None Father’s addiction Alcohol Substance None Psychiatric care Outpatient 18 9 years None 5 Mother’s psychiatric care Outpatient >18 4 years Inpatient >18 1 years None 14 Father’s psychiatric care Outpatient >18 4 years Inpatient >18 1 years 15 None
%
n
%
21.1
2
6.1
47.4
18
54.5
47.4
13
39.4
26.3
12
36.4
21.1
3
9.1
5.3
1
3.0
73.7
29
87.9
21.1
6
18.2
5.3
2
6.1
78.9
25
75.8
explanation of the main concern of the participants in focus for investigation. For data analysis, we used ATLAS.ti (2000). This software retains links between transcripts, codes, categories, and memos, permitting movement back and forth between coding, category elaboration, and conceptual model building. All utterances relating to parents’ attempts to understand and explain the suicide were assigned open codes summarizing the content. The networking function of ATLAS.ti was used to group closely related codes into categories. As distinct categories emerged, the relationships among categories were re-examined, and latent patterns could be identified in several interviews. In this procedure of constant, comparative analysis, new data were compared with the existing data until saturation was reached (no new categories emerged). During selective coding, the previously constructed tentative model of processes underlying boys’ suicide (Werbart Törnblom et al., 2013) was tested, refined, and integrated to elucidate the processes underlying girls’ suicide and capture gender differences in this respect. The categories were graphically connected into tentative diagrams to visually depict and examine their relationships. This step of the qualitative analysis allowed a core category to emerge and capture, on a meta-level, the essence of the suicidal process in youth, as viewed from the parents’ perspective, while retaining a relationship to all other categories. Finally, we assembled the generic conceptual model of the suicidal process. The first author carried out the main coding. During selective coding, the second author reviewed all codes and theoretical memos and collaborated in refining the model. Differences in opinions were discussed in relation
Downloaded from qhr.sagepub.com at UNIV OF PENNSYLVANIA on October 4, 2015
1103
Werbart Törnblom et al.
Figure 2. The generic conceptual model of processes behind youth suicide from the parents’ perspective.
to the original transcripts until agreement was reached. On the basis of these audits, the model was deemed grounded. We report category frequencies separately for mothers and fathers of girls and boys using the nomenclature from Hill et al.’s (2005) study, following criteria for larger samples (Knox, Schlosser, Pruitt, & Hill, 2006): General: ≥90% of the cases; Typical: ≥50% to
