Suicidal N o Longer
M . A. Hoover
B. L. Paulson
University of AlbertaAbstract
In this phenomenological study, participants who had been suicidal were interviewed and asked, "What was helpful in suicidal healing?" Participants' stories of healing were analysed themati-cally. The metaphor of "A Journey Away From the Self describes the participants' suicidal processes as disconnection from others and from the self: their feelings, their self-worth, and their ability to negotiate their lives. The "Return to the Self describes their healing as reconnection with others and with the self, developing new perspectives of the self and living, becoming self-accepting, self-advancing, and self-enduring. This investigation of the suicidal person's perspective contributes the voice of those "Suicidal No Longer." The the-matic structure identifies processes that have implications for conceptualizing and directing treatment.
Résumé
Dans cette é t u d e p h é n o m é n o l o g i q u e , des participants, autrefois suicidaires, ont r é p o n d u à la question suivante : "Qu'est-ce qui vous a é t é utile pendant le processus de votre guérison?" Une analyse thématique de leurs histoires a ensuite été faite. La métaphore "Un voyage loin du soi" décrit les processus qui ont a m e n é les participants à se sentir suicidaires comme une séparation des autres, du soi, de leurs sentiments, de la perception de leur propre valeur et de leurs capacités à gérer leur vie. L'autre métaphore, "Le retour vers le soi," décrit le processus de guérison comme étant le rétablissement de liens significatifs de l'individu avec les autres et avec son soi intérieur. Sa perception, à ce stage, de son soi et de la vie en général change. L'individu s'accepte plus facilement et acquiert la confiance dans ses habiletés à s'affirmer et à gérer les défis quotidiens. Cette recherche sur les perspectives de la personne suicidaire nous permet d'entendre la voix de ceux et de celles qui peuvent être d é n o m m é s "suicidaires, plus maintenant." La structure thématique identifie des processsus qui ont des implications quant à la conceptualisation et à la direction des traitements.
W h a t is known about suicidal behaviour a n d suicide treatment has come from traditional approaches o n understanding suicide, suicide treatment, a n d the efficacy o f treatment. T r a d i t i o n a l approaches have identified factors associated with suicide, integrated these factors into assessment a n d treatment models, a n d evaluated treatment based o n these models (Brent, Kupfer, Bromet, & Dew, 1988; Jacobs & B r o w n , 1989; L i t m a n , 1995; Maris, B e r m a n , Maltsberger, & Yufit, 1992). T h e majority o f sui-cide literature r e p o r t i n g these developments has emphasized assessment a n d management rather than treatment. T h e assessment o f suicide risk has h a d a clear goal, a n d that is, p r e d i c t i o n . T o predict who is likely to suicide, from the vulnerability o f groups to those who are i m m i n e n t l y at risk, is to be able to intervene a n d save lives. Management o f those w h o are suicidal, once identified, has focused o n ensuring survival a n d pro-v i d i n g the optimal e n pro-v i r o n m e n t for treatment. T h e assumption o f man-agement has b e e n that o n c e the p r e c i p i t a t i n g crisis has passed a n d
individuals are n o longer highly suicidal, traditional treatments w o u l d follow (Fremouw, de Perczel, & Ellis, 1990). T r a d i t i o n a l treatments have been i m p l e m e n t e d with factors identified as most likely to result i n cide based o n the rationale that i f those factors were ameliorated, sui-cide a n d suicidal behaviour w o u l d be prevented.
Disciplines have organized the factors identified with suicide into treat-ment models a c c o r d i n g to their different philosophies ( B l u m e n t h a l & Kupfer, 1990; Fawcett, 1988; L i n e h a n , 1987; Maris et al., 1992; M o t t o , 1989; S h n e i d m a n , 1985,1987; Weishaar & Beck, 1990). G e n e r a l models ( B l u m e n t h a l , 1990; Maris et al., 1992) have integrated the myriad o f fac-tors into the generic domains o f biology, psychiatric disorders, personal-ity traits, family h ß t o r y , a n d psychosocial stressors a n d events. T h e challenge to treatment has been to address the assessment domains, management, a n d factors that apply across assessment categories.
T h e p r e d o m i n a n t treatment strategies that have been utilized are so-matic interventions, p r i m a r i l y p h a r m a c o l o g i c a l but also E C T , a n d psy-chosocial interventions w h i c h i n c l u d e psychodynamic therapies a n d psychological therapies that address behavioural, cognitive, affective a n d interpersonal factors ( L i t m a n , 1995; B r e n t et al., 1988). T h e most com-prehensive m o d e l reviewed i n the literature is L i n e h a n ' s (1987) approach w h i c h utilizes a variety o f treatment modalities to address biological and social domains.
Somatic treatments have targeted the assessment domains o f biology and psychiatric disorders. Pharmacotherapy has been shown to be effec-tive, a n d important to suicide prevention by studies that support the se-r o t o n i n hypothesis o f suicide se-risk ( N o se-r d s t se-r o m & Asbese-rg, 1992), a n d by the fact that most suicides have o c c u r r e d d u r i n g a psychiatric episode, most c o m m o n l y depression (Brent et al., 1988).
Cognitive, behavioural, a n d interpersonal therapies, evolved from Beck's (1974) early work o n the cognitive aspects o f depression i n sui-cide, have focused o n how individuals perceive, interpret, a n d respond affectively a n d behaviourally to their environments. Based o n these pro-cesses, treatments have been directed to suicidal individuals identified as having skill deficits a n d vulnerable cognitive characteristics (Freeman & Reinecke, 1993; Weishaar & Beck, 1990), p r i m a r i l y addressing the as-sessment domains o f family history, personality traits, a n d psychosocial stressors a n d events.
T h e significance o f e m o t i o n i n assessment a n d i n treatment varies according to the philosophy o f treatment. Behavioural a n d interpersonal therapies have intervened direcdy with affect to teach skills to manage e m o t i o n a l expression a n d regulation ( L i n e h a n , 1987) a n d to develop strategies for self-soothing (Buie & Maltsberger, 1989). Few psychosocial therapies have attended to affect directly even though psychological p a i n has been identified as central to suicide (Fawcett, 1988; M o t t o , 1991;
S h n e i d m a n , 1987) a n d empathy, the key element i n therapy successfully dealing with despair (Havens, 1989).
W h i l e outcome studies have shown treatment efficacy for pharmaco-logical a n d psychosocial therapies, alone a n d i n c o m b i n a t i o n (Brent et al., 1988; F r e m o u w et al., 1990), the confidence r e q u i r e d to guide the selection o f treatment interventions has been u n d e r m i n e d by the singu-larity o f factors treated a n d evaluated, a n d by m e t h o d o l o g i c a l problems. Few studies were prospective, c o m p a r e d treatments, h a d r a n d o m design, or used c o n t r o l groups. W i t h the lack o f m e t h o d o l o g i c a l rigour a n d in-consistent results, uncertainty remains about the efficacy o f treatments. T h e question o f a particular treatment's efficacy is further c o m p o u n d e d by treatment errors that have c o n t r i b u t e d to suicidal acts. T h e absence of adequate risk assessment has been identified as an e r r o r o f omission, the failure to prevent suicide w h e n events c o u l d have been foreseen. Errors o f commission have been d e t e r m i n e d to result from direct h a r m or inappropriate therapy (Bongar, 1991). These errors cut across assess-ment domains a n d treatassess-ment modalities. I m b e d d e d i n the query o f a specific treatment's efficacy is the challenge to evaluation o f truncated treatment. Treatment has frequently e n d e d with crisis intervention a n d the management o f suicidal behaviour a n d has not progressed t h r o u g h the stages o f resolving the issues s u r r o u n d i n g the precipitating event or the u n d e r l y i n g suicidal process. Repetitive crises (Fremouw et al., 1990) a n d suicidal c h r o n i c i t y have followed w h e n the o r i g i n a t i n g issues have not been resolved (Roth,1989).
T h e c o m m o n factors o f suicide, the models o f suicide treatment, a n d the errors o f treatment have c o n t r i b u t e d to the accumulated knowledge of the elements involved for the effective treatment of suicidal behaviours. Despite the knowledge o f the preponderance, complexity, a n d interac-tion o f factors involved with suicide risk, reported treatments have re-m a i n e d f r a g re-m e n t e d a n d the r e s e a r c h u n i d i re-m e n s i o n a l , w i t h b o t h c o n t r i b u t i n g to the paucity i n the research o f w h i c h treatments really work. Overall, the research findings indicate, o n the one h a n d , the effi-cacy o f interventions, a n d o n the other, that suicide treatments have not consistently or significantly r e d u c e d suicidal behaviour or suicide mor-tality rates (Dorwart 8c C h a r t o c k , 1989). Ultimately, research has shown that suicide i n t e r v e n t i o n a n d treatment has failed many: those who have c o m m u n i c a t e d their intent (Fawcett, 1988), those who have sought help, a n d those who have received treatment a n d then d i e d by suicide (Coombs, M i l l e r , A l a r c o n , H e r l i h y , L e e , & M o r r i s o n , 1992; Fawcett, C l a r k , & Sheftner, 1991; Isometsa, H e n r i k s s o n , & A r o , 1994).
T h e knowledge that traditional approaches to suicide treatment have failed many a n d have not significantly r e d u c e d suicidal behaviours raises the question o f what m o r e d o we n e e d to know a n d to understand to increase treatment effectiveness a n d p r o m o t e h e a l i n g . B e y o n d the
per-spectives o f theorist, therapist, a n d observer, another perspective o n what is helpful i n resolving suicidal behaviour is available from those who have been suicidal a n d are n o longer. A l t h o u g h a body o f literature exists o n being suicidal from the suicidal person's perspective, consisting o f clini-cal interviews (Havens, 1989), biographies (Lester, 1991), a n d suicide notes (Leenaars, 1991), there is virtually n o t h i n g written o n what sui-cidal individuals have experienced as helpful i n their healing. T h e i r voices are absent. Individuals' descriptions o f their h e a l i n g experiences can illuminate the process o f healing. T h e i r experience o f what made a dif-ference to their h e a l i n g w o u l d contribute a hitherto u n h e a r d view to existing perspectives o n suicidal healing.
M E T H O D
T h e purpose o f this research r e q u i r e d a m e t h o d focused o n discovery a n d understanding rather than the natural science pursuit o f cause a n d effect relationships (Dilthey, 1977). P h e n o m e n o l o g y explores individu-als' experience i n consciousness. It considers p h e n o m e n a , such as sui-cidal healing, as being available to discovery through dialogue, a discourse that is believed to reflect a person's experience as a synthesis o f their i n t e r n a l a n d external worlds (Colaizzi, 1978). T h e premise o f p h e n o m -enology and this study is that individuals can faithfully describe what was helpful i n their healing, a n d that a systematic thematic analysis o f par-ticipant dialogues can illuminate the p h e n o m e n o n o f suicidal healing.
Participants
T h e full i l l u m i n a t i o n o f a p h e n o m e n o n ' s structure flows from the range of factual variation p r o v i d e d by diverse subjects (Wertz, 1984). T h e goal was to draw o n a variety o f experience a n d n o t circumscribe respondents in any way, either by their specific suicidal behaviour, o r by their particu-lar h e a l i n g experience o r h e a l i n g setting. T o this e n d participants were solicited t h r o u g h a newspaper advertisement inviting them to tell their stories of healing. Those who participated constitute a purposive sample, not a r a n d o m sample, o f individuals who were once, but were n o longer suicidal, a n d w h o wished to share their stories. Self-report o f suicidal intent a n d behaviour, a l o n g with the requirement that n o attempt(s) had o c c u r r e d i n the last two years, served as screening criteria. T w o were screened o u t due to recent attempts. N o r e m u n e r a t i o n was offered.
T h e r e were n i n e C a n a d i a n a n d E u r o p e a n participants, seven w o m e n a n d two m e n , ranging i n age from 27 to 57. A t the time o f the study, five participants were single a n d four were m a r r i e d , three h a d divorced, a n d one was r e m a r r i e d . Five h a d c h i l d r e n . F o u r were C a t h o l i c a n d five Prot-estant. Participants' education a n d / o r occupation i n c l u d e d clerical, tech-nical, a n d university educated professionals. Most o f the individuals who
participated h a d e x p e r i e n c e d m o r e than one suicidal crisis, a n d their healing h a d o c c u r r e d over many years with many changes. Six h a d expe-r i e n c e d expe-repeated suicidal behaviouexpe-r staexpe-rting i n c h i l d h o o d . T h expe-r e e h a d e x p e r i e n c e d suicidal crises only as adults. T h e participants i n c l u d e d i n -dividuals who d i d not receive treatment i n a f o r m a l sense or setting as well as those who d i d . T h e interview dialogue was the opportunity for the p h e n o m e n o n o f h e a l i n g to show itself.
Procedure
Preparation for the study i n c l u d e d a n u m b e r o f tasks: to prepare materi-als to solicit a n d to screen respondents, to obtain i n f o r m e d consent for participation a n d for the release o f i n f o r m a t i o n , to guide interviews, a n d to satisfy ethical concerns. T h e study came alive w h e n individuals re-s p o n d e d to the newre-spaper advertire-sement. Rere-spondentre-s were re-screened, the purpose a n d nature o f the study was o u t l i n e d , a n d a date was set for the personal interview. T h e interview began with an o p e n inquiry, "What was helpful i n your healing?" Care was taken to establish rapport a n d to follow, not lead, the participants' stories. T h e format i m p o s e d m i n i m a l structure, allowing the participants' experience to present itself as spon-taneously as possible. Prompts were initiated when participants came to closure o n their story. E a c h interview took approximately two hours, a n d was audiotaped a n d transcribed.
Data Analysis
Each participant's written transcript, or p r o t o c o l , was read a n d reread i n order to acquire a feeling for the data a n d to become i m m e r s e d i n the description o f the participant's life w o r l d . E a c h p r o t o c o l was considered statement by statement with respect to its significance to suicidal a n d healing processes. Significant phrases, sentences, o r paragraphs were extracted a n d recorded i n a table format. T h e n , c o r r e s p o n d i n g to each significant statement i n the table, a paraphrase was made for each state-ment i n an attempt to elicit the m e a n i n g o f the statestate-ment.
G o i n g b e y o n d what was i n the statement, to what was given with it allowed for the emergence o f themes, w h i c h were n a m e d a n d r e c o r d e d beside the paraphrase a n d the significant statement i n the table. These themes were the first level o f abstraction. T h i s process, illustrated with the following example, was repeated for each o f the protocols, a n d rep-resents a within-persons analysis.
Significant Statement Psychological Theme Paraphrase
I never d i d that action. I've h e l d Was p o i s e d w i t h C o l l e c t e d s u i c i d e knives in my hand ready to cut my knives to cut a n d i n options. Rehearsed wrists. We had a big pine tree, o n the tree r e a d y to suicidal behaviour, our land and I'd been in that tree j u m p at age 11.
T h e themes from a l l the protocols were p o o l e d a n d g r o u p e d . T h e groupings were n a m e d , a second level o f abstraction, f o r m i n g first o r d e r themes w h i c h were then g r o u p e d a n d n a m e d , f o r m i n g second order themes. T h i s process, illustrated i n table 1, o f g r o u p i n g a n d n a m i n g the p o o l e d themes represents a between-persons analysis.
T h e movement from descriptive instances o f surface meanings to the second-order themes o f i m m a n e n t meanings is a movement t h r o u g h successive levels o f abstraction. It is a process that unites factual ity t h r o u g h abstract themes with c o m m o n m e a n i n g . T h e factual variabil-ity a n d frequency o f themes were all accounted for i n this process. T h e closing phases o f analysis c o m p a r e d the second-order themes with the interview transcripts a n d with the extracted significant statements. A l o n g with this comparative review, the participants a n d invited others were asked to review the levels o f themes to validate the n a m i n g , g r o u p i n g , a n d m e a n i n g o f the themes. T h e thematic structure was present i n all protocols for a l l participants a n d for other reviewers. T h e c u l m i n a t i n g structure o f second-order themes is considered to be internally cohe-sive, fully i l l u m i n a t i n g the p h e n o m e n o n o f h e a l i n g as expressed explic-itly o r implicexplic-itly i n the participants' descriptions.
T h e validity o f the m e t h o d resides i n the premise that p h e n o m e n a may be described a n d may be u n d e r s t o o d t h r o u g h a thematic structure. T h e validity o f the data analysis rests o n faithfully following p r o c e d u r a l steps o f h a n d l i n g the data throughout the analysis process, from data collection to the final thematic structure. In this study this i n c l u d e d ar-ticulating the procedure a n d validating the c u l m i n a t i n g thematic struc-ture with the o r i g i n a l protocols, with participants, a n d with u n i q u e experiences (Shapiro, 1986; Wertz, 1984). T h i s process, m o d e l l e d o n the work o f Colaizzi (1978) a n d O s b o r n e (1990), followed a systematic step-by-step analysis, from extracting significant statements o f descrip-tive instances t h r o u g h successive levels o f abstraction to the final struc-ture. W h e n the thematic structural understanding is present a n d resonant i n the experience o f others, empathie generalization occurs. T h i s vali-dates the structure a n d provides the basis o f reliability a n d credibility. Reliability exists i n the sameness o f m e a n i n g across individuals a n d across factual variability (Shapiro, 1986; Wertz, 1984).
R E S U L T S
T h e final thematic structure provides a n understanding o f b e c o m i n g s u i c i d a l a n d s u i c i d a l h e a l i n g as processes o f d i s c o n n e c t i o n a n d r e c o n n e c t i o n . T h e metaphor o f " A J o u r n e y Away F r o m the S e l f reso-nates with the process o f d i s c o n n e c t i n g from feelings, self-worth, experi-ence, a n d the ability to negotiate life. T h e metaphor o f " A R e t u r n to S e l f describes the processes o f h e a l i n g as a r e c o n n e c t i o n , with the
de-velopment o f a new relationship to the self and new perspectives o n liv-i n g . T h e thematliv-ic structure liv-is presented lliv-inearly liv-i n Table 1, descrliv-ibed with participant quotations, a n d then summarized i n a synthesis.
T A B L E 1.
Suicidal No Longer Phenomenological Thematic Structure
Second Order Themes
The Journey Away From the Self
I. Context: Learning What is Lived
II. Coping: Living What is Learned
III. Worthlessness
IV. Awareness of Suicidality V. Deterrents to Suicidality VI. Suicidal Behaviour
The Return to the Self
VII. Crisis
VIII. Reaching Out:
Connecting With Others I X . Reaching In:
Connecting With Self
X . Breaking Patterns
X I . Evaluating XII. New Patterns:
Trusting and H o n o u r i n g Self
First Order Themes
Disconnection 1. Loss 2. Negative Interaction 3. Invalidation 1. Silencing 2. Withdrawal 3. Constriction 4. Accepting Responsibility 5. Acting Out Self-Judgements 1. Function 2. Recognition Types Types Reconnection Crisis 1. Connecting 2. Misconnecting 1. O p e n i n g to Feelings 2. Connecting Feelings 3. Connecting Suicidality 4. Identifying Patterns 1. Awareness vs. Denial 2. Listening to Self 3. Maintaining Connections 4. Determining Needs, Limits 1. Confronting Experience 2. Identifying Goals, Boundaries 1. Self-Accepting
2. Self-Advancing 3. Self-Enduring
The Journey Away From the Self: Disconnection
Context. Participants' "Journeys Away F r o m the S e l f were set i n the
con-text o f their l e a r n i n g environments. Participants experienced loss a n d disrupted attachments t h r o u g h death a n d t h r o u g h e m o t i o n a l a n d / o r physical separation i n relation to others, goals, or health. T h e i r particu-lar loss contributed to their isolation a n d to their lack o f structure a n d d i r e c t i o n . Participants' interpersonal interactions were negative a n d stressful. T h e y experienced physical abuse, sexual abuse, o r e m o t i o n a l abuse i n the f o r m o f criticism, b l a m i n g , or discounting. Forms o f emo-tional abuse were experienced with helpers. Invalidation was experienced blatantly a n d overdy, a n d m o r e subtly t h r o u g h c o l l u d i n g alliances, i n families, with friends, a n d i n treatment. T h e context o f loss, negative interaction, and invalidation i n which participants lived and learned about life a n d themselves was described by one participant this way:
I saw a lot of abuse, I saw a lot of people yelling at each other . . . my brothers p u n c h i n g each other until the b l o o d come out of their lips and their eyes would be black and I would get picked on because of my size . . . parents fighting . . . the yelling stuff and withdrawing from each other, walking away in a rage. A n d , I remember that I always wanted out. I d i d not want to be in that environment. I hated who I was, I hated what I d i d , I hated the fact that I violated another h u m a n being the same way I was violated, and the thing that I was, I wanted to kill h i m . . .just end it.
Coping. Participants described u t i l i z i n g m u l t i p l e strategies o f
discon-nection to cope with situations, events, a n d feelings. T h e y disconnected from others a n d from activities through a lack of contact, a n d from them-selves through a lack of awareness a n d / o r deliberate actions. They learned ways to live a n d survive physically a n d emotionally. A c c e p t i n g responsi-bility and accepting blame were vehicles for accepting invalidation w h i c h was frequently accompanied by self-injury behaviour, as described by this participant.
I started to become very self-abusive. . . . Bit myself, p u n c h e d myself, hit myself, stood in front of the mirror, slapped my face, and then I'd go, "You stupid puke o f G o d . " A n d I reasoned I was puke of G o d because if I was diarrhoea of G o d at least I would have gone through the system, but puke wouldn't even go through the system.. . . G o d wouldn't want me in the system.
Instead of accepting responsibility o r blame, others acted out. Respon-sibility was redirected a n d misdirected t h r o u g h anger with violence to-wards others, animals, o r the self, a n d with addictions to activity, a l c o h o l , drugs, eating, or sex. A c t i n g out was described by one participant this way:
W h e n I was younger, for acceptance, I j o i n e d a gang. I was a bad k i d . . . . I beat up kids, slashed tires, stole cars, but it's for acceptance again, looking for support, looking for s e c u r i t y . . . . I'd do anything to get acceptance so I had to, and after a while I got so hard I just didn't think about it.
A n d by another participant, this way:
I got very promiscuous, really promiscuous, because I just felt so bad about my-self, so I thought well, this is all I'm going to get, so I'll just sleep with him. It was never for the sex. I never really enjoyed it or anything but. . . to be loved. Participants were silenced i n body a n d voice as they accepted invalida-tion, d e n y i n g their feelings a n d reactions a n d b e c o m i n g unable to speak for themselves. They e x p e r i e n c e d a n u m b i n g a n d a sense o f unreality. As they disconnected they began to lose a sense o f their self as described by this participant.
It felt like I was having all these masks that I wore, and I didn't have one for me. It was just masks, and I felt like a shadow and I was fading away, and fading away, and fading away more, and if you put your hand on me you'd go through me. I didn't feel real, I didn't feel like a person.
Worthlessness. Participants drew conclusions about themselves a n d their
lives. T h e y described conflicts between their inside a n d outside selves. T h e perception o f l o o k i n g g o o d a n d d o i n g it right o n the outside a n d feeling bad o n the inside meant they were wrong. T h e y described them-selves as "feeling bad a n d b e i n g bad, no good, dirty, a n d ugly." They b l a m e d a n d rejected the self for b e i n g a n d for h u r t i n g . They believed they were helpless a n d worthless, deserving n o t h i n g . In the moments when they believed they deserved better, they d i d not believe anything c o u l d change or be different.
Awareness of Suicide. Participants moved between times o f wanting to
die a n d not wanting to die. T h o u g h t s o f death a n d suicidal behaviours were precipitated by distressing situations, demands, a n d memories. T h e c o n n e c t i o n between these triggers a n d b e c o m i n g suicidal was clear for some a n d not recognized by others. Some participants recognized their behaviour as suicidal, a n d attributed their impulses to forces beyond their control. Others recognized they were e x p e r i e n c i n g a crisis while remain-i n g unaware that they were suremain-icremain-idal. Several were shocked to dremain-iscover they were "suicidal."
In the dark of one night, in the ruminations about what I could do . . . it was actually what I could not do . . . there was no way out, things could not change, there was nothing to change. . . . I gave up trying. It was somewhere in the midst of how I could hook up the exhaust that I realized what I was doing. The realiza-tion I had was that I was in the midst of killing myself . . . that I was doing this because he didn't approve of me, that his opinion and right to life were more valid than my own, that he had a right to live and that I didn't because he was right and I was wrong. Wrong according to whom? It seems incredible in this moment of telling, the thinking I had, and the power of the realization in the darkness of that moment.
Deterrents to Suicide. A variety of beliefs, behaviours, a n d events deterred
suicide.Descriptions i n c l u d e d participants' religious beliefs, their need to care for c h i l d r e n , not k n o w i n g how to complete suicide, searching for
the perfect p l a n , interruptions, altered perspectives, shifts from help-lessness to anger, bereavement, dissociation, a n d the d e t e r m i n a t i o n to resist powerful impulses. Dissociation, w h i c h deterred suicide, was con-fusing for one participant. H e said,
I don't know. I don't know. I just came to the edge and then, I don't know. It was the same way with the tree, it's like, the time on the bridge seemed to pass and I end up not there.
Suicidal Behaviour. M e t h o d s o f suicide a n d lethality were not a focus o f
the interviews, but, rather, that participants h a d acted with intent a n d h a d engaged i n suicidal behaviour. These behaviours i n c l u d e d ideation, expression, a n d action. Participants had thought about dying; they wished to die a n d they p r a y e â to die. They persevered with their suicidal thoughts, threatened suicide, engaged i n h i g h risk behaviour, a n d wagered with G o d . T h e y collected plans for k i l l i n g themselves, rehearsed their plans, attempted suicide, a n d repeated their attempts.
The Return to Self: Reconnection
Crisis. Crisis p r o v i d e d the o p p o r t u n i t y for change a n d with it came the
potential to reconnect. F o r some participants, a singular crisis was a piv-otal t u r n i n g point, for others there were many crises o n their journeys. F o r all participants, a crisis began the r e c o n n e c t i n g process to the self t h r o u g h i n t e r n a l shifts a n d altered perspectives, a n d / o r through their contact a n d involvement with others.
Reaching Out: Connecting With Others. Contact with others d u r i n g crisis
frequently m a r k e d the b e g i n n i n g o f supportive e m o t i o n a l connections. Participants e x p e r i e n c e d support w h e n others respected their experi-ence: listened, dialogued, a n d encouraged self-understanding a n d help seeking. Participants also recognized support when others set limits, h e l d t h e m accountable, a n d w o u l d n ' t let them withdraw. O n e participant's initial supportive c o n n e c t i o n o c c u r r e d this way.
What started me in therapy, I was really angry at (partner) for something. I had gone to the dentist in the morning and I had a chiropractor's appointment in the afternoon, and I walked out of the dentist's and he was supposed to be there to drive me back and he wasn't there, and it was like I couldn't count on him for anything and it was, if I can't count on him there's no sense having him around, so by the time I took a bus . . . to my chiropractic appointment, I was so upset and so tense and so everything that when he walked in and said "Hi, how are you today?" I just burst. . . everything just burst, so he talked to me, I was a mess for about an hour. And he said, "Look, I know this person. Would you go and see her?"
A l t e r n a t e l y , c o n t a c t t h a t was n o t s u p p o r t i v e r e p r e s e n t e d a m i s c o n n e c t i o n . T h e lack o f support resonated with the participants' experiences o f feeling bad, w h i c h they interpreted as b e i n g b a d them-selves, w h i c h , i n t u r n , validated t h e i r e x p e r i e n c e o f b e i n g helpless
a n d worthless. T h e p o t e n t i a l f o r c o n t a c t to b e g i n the process o f reconnection was lost t h r o u g h m i s c o n n e c t i o n . Participants c o n t i n u e d to cope with their strategies of disconnection. O n e participant described it this way:
I went there and he said, "Describe your life." Then he said, "Well, you're coping really well considering all you've got on your plate. I don't see a problem here." And he sent me home. He said, "I have patients with problems." Because I felt so bad I thought I didn't do it right, there was something wrong with me, that I was bad. . . . I was scared, I was angry at myself for feeling like this, I was self-abusive. Another, this way:
One Dr. I talked to about my unhappiness and not liking sex. He instructed me to draw up a scale to measure my anxiety in relation to a male body, clothed, naked, at a distance, closer and certain body parts. I understand this as desensitizing to a phobia. This encounter fills me with anger as I look back . . . I could not have labelled it then, I had no idea, but I can say now that this Dr. had no idea of what was going on with me, and no idea of women, nor did he make any effort to find out.
Reaching In: Connecting with Self. W i t h supportive connections a n d
sufficient safety, participants allowed themselves to risk, to explore, and to confront differences, anger, o l d wounds, and unfinished business. They opened to their ability to feel, experienced their feelings, connected their feelings to events with meaning, and developed an understanding o f their experience. T h e y began to identify their life patterns, and, i n particular, the triggering events w h i c h precipitated suicidal behaviour. O n e par-ticipant described b e c o m i n g aware o f his patterns when his attention was drawn to his bodily feelings a n d their historical associations and meanings.
I had my stomach massaged and had a memory come up about, great hate, the bully who used to punch me in the stomach when I'd come out of the bathroom. He used to get a big laugh out of it because I wouldn't flinch. It didn't hurt. I'd go out into a corner and gasp for air, but it didn't hurt, I was tough. And when she massaged my stomach, it was like these cloud bursts of feeling came. And I didn't know where it come from and I said to the masseuse, "Go back and hit that again." I told her what was happening. The muscles, the memories. The feelings that I wanted to kill myself.
Breaking Patterns. Participants struggled with awareness and denial.
T h e i r struggle was between m a i n t a i n i n g their new connections, with awareness, a n d retreating into their o l d patterns o f disconnection. They moved back a n d forth between a new pattern o f believing that they h a d the worth, the right, and the ability to negotiate their lives a n d the o l d pattern o f believing they were helpless a n d worthless, b e c o m i n g suicidal. B r e a k i n g their o l d patterns involved l e a r n i n g to listen to the self a n d their feelings, a n d to determine their needs a n d limits rather than auto-matically p l u m m e t i n g into feeling bad, powerless and helpless, a n d want-i n g to dwant-ie when they experwant-ienced dwant-istress. Movement want-into the new pattern
o c c u r r e d t h r o u g h sudden acceptance i n crisis o r gradual acceptance t h r o u g h e x p a n d i n g awareness. O n e said,
I learned what was important to me, a little at a time by noticing what was impor-tant in the moment. I learned to listen and trust myself. And as imporimpor-tant, I learned to say that out loud. It was learning emotional honesty. . . . I guess one thing I've learned over the years is the part that I played in making my own pain. I had waited for my husband to make it right for me, rather than learning to do it for myself. . . . And we couldn't, didn't know how or what was going on to do it differently. Evaluating. T h r o u g h their willingness to explore a n d to confront their
feelings a n d life experience, participants became able to evaluate their own experience a n d patterns i n comparison to others' patterns and, more importandy, i n comparison to their own patterns. This was often expressed with h u m o u r .
There's two people on the street, we both walk out at seven in the morning, both got flat tires, and we look at each other and go back into the house. My neighbour goes in, gets on the phone, calls AMA, "I've got a flat tire, please come down and fix it." I just call suicide prevention. You know, I'm just going to die. I've got a flat tire. Something happens and my life is screwed. You know, and that's the thought process: it just kicks in, bang, negative, negative, and I'm just going to die.
NewPatterns: Trusting and Honouring the Self. T h r o u g h the trials o f
break-i n g t h r o u g h the barrbreak-iers o f dbreak-isconnectbreak-ion partbreak-icbreak-ipants came to belbreak-ieve i n a n d to trust the self, discarding o l d patterns a n d developing new ones. O n e participant described r e a c h i n g back to infancy a n d reconnecting with that early experience i n o r d e r to make sense o f her adult life. T h i s reconnection allowed a new perspective to evolve. She described the process o f reconnecting with her experience this way:
I could see myself as being a little baby in a crib and afraid to cry or do anything because I would be hurt, you know, you'd be . . . and my thing was that I was going to protect this baby so it didn't get killed and then it started, you know all my life I'd been doing that, trying to protect myself, and then the next minute I'd want to kill myself and like I couldn't understand i t . . . . I started crying, and crying and crying and thinking you know, like I won't, at times I thought they would kill me and then, you know, I'd fight, I didn't want to die. But then when things would happen to me, then I'd want to die and so I had to just go back in my mind and think, you know, they can't hurt me any more. Like, there's nothing they can do to hurt m e . . . . My parents. There's nothing they can do. I'm grown up, you know. They can't hurt me any more and I don't need to kill myself. It was like I needed to kill myself to get out of these situations or to get out of something that was hurting me.
O l d patterns were dissolved a n d new patterns evolved t h r o u g h the process o f c o n n e c t i n g with their own lives, managing their fears a n d feel-ings without b e c o m i n g suicidal. R e c o n n e c t i n g l e d the "Return to the S e l f a n d to the development o f new perspectives o n the self a n d living. Participants became self-accepting, self-advancing, a n d self-enduring, the antitheses o f worthlessness, helplessness, a n d hopelessness. T h e y chose to trust the self, to act for the self, a n d to live.
Summary and Synthesis of "The Journey Away and The Return to the Self
Participants' disconnections a n d their 'Journeys Away F r o m the S e l f began i n the context o f what they lived a n d the c o p i n g responses they learned i n order to survive. W h e n their strategies, evolved for protec-tion, functioned to disconnect t h e m from the self, from their experi-ence, a n d from others, they e x p e r i e n c e d despair. W h e n they were not delivered from their difficult situations o r from their despair, partici-pants became suicidal a n d e x p e r i e n c e d crises.
T h e 'Journey Back to the S e l f began with a crisis p r o v i d i n g the op-portunity for r e c o n n e c t i o n to the self through internal shifts, a n d / o r through contact with others. A s they reached out to others a n d shared themselves, they experienced support a n d the validation o f the self, their experiences, a n d their painful feelings. N o t every crisis or contact brought supportive connections. W i t h c o n n e c t i o n , they experienced permission to be with the self, to feel, a n d to understand their experience a n d them-selves.
As they e x p e r i e n c e d their feelings a n d connected their feelings to the events, interactions, a n d patterns they h a d learned as a response to liv-i n g , they broke o l d patterns o f dliv-isconnectliv-ion. Sliv-ignliv-ifliv-icant connectliv-ions were discovering their patterns o f coping and becoming suicidal. T h r o u g h o p e n i n g to feeling, participants processed their experience, identified their fears, clarified unfinished business, a n d articulated their anger. They struggled with d e n i a l a n d awareness, staying with the p a i n o f feeling, o w n i n g a n d accepting what they felt, a n d dealing with what it meant. T h e i r awareness developed as they r e m a i n e d connected with others ,as they listened to the self, stayed present a n d connected to their own feel-ings. In t u r n , they d e t e r m i n e d a n d c o m m u n i c a t e d their feelings, needs, a n d boundaries, a n d received validating feedback.
W h e n participants were believed a n d valued, they began to believe i n themselves a n d their own experience. T h e y began to act o n their own needs a n d to believe i n their right a n d their ability to d o so, discarding their o l d patterns o f despair a n d helplessness along the way. T h r o u g h -out this process o f reconnecting, participants developed new patterns a n d perspectives o n the self a n d o n living w h i c h became their healing. T h e y o p e n e d to k n o w i n g themselves, b e c o m i n g k n o w n , a n d k n o w i n g others. T h e y l e a r n e d self-trust, self-agency, a n d they o p e n e d to life, ac-cepting the j o u r n e y o f the self.
DISCUSSION
D r i v e n by the gap between suicide treatments a n d the efficacy o f those treatments, this study sought new perspectives o n suicidal healing. T h e study accessed the experience o f those who h a d healed to explore a n d to understand their process of healing. Participant's stories began with when
they were suicidal, first identifying their disconnections. O n l y then were they able to describe their h e a l i n g a n d their processes to r e c o n n e c t i o n . Participants described a 'Journey Away F r o m the Self a n d the R e t u r n to the S e l f . T h i s metaphor emerged from their descriptions a n d their con-veyed sense o f movement t h r o u g h a process. T h e i r experiences were analyzed p h e n o m e n o l o g i c a l l y y i e l d i n g a thematic structure illuminat-i n g the p h e n o m e n a o f suilluminat-icilluminat-idal behavilluminat-iour a n d suilluminat-icilluminat-idal healilluminat-ing.
Participants' disconnections evolved t h r o u g h living and r e s p o n d i n g to life. T h e i r life contexts (Maris, et al., 1992), c o p i n g strategies (Brent etal., 1988), and despair (Beck, Steer, Beck, & Newman, 1993; Dahlsgaard, Beck, & B r o w n , 1998; F ä r b e r , 1977) c o n c u r with previous findings. Par-ticipants learned what they lived a n d lived what they learned, the de-spair o f worthlessness, helplessness, a n d hopelessness. T h e importance of despair for participants is consistent with the view that to understand despair is to understand the psychology o f suicide (Maltsberger, 1986; M o t t o , 1991; S h n e i d m a n , 1987).
T h e thematic structure describes the processes l e a d i n g to despair as disconnection, with the self b e c o m i n g disenfranchised. T h e loss of a sense o f self has been identified by a n u m b e r o f researchers (Maltsberger, 1997; Rudestam, 1986; W e i n e r & W h i t e , 1982). Suicide models identify sui-cidal despair as resulting from the inability to negotiate life a n d to real-ize satisfactory life goals due to the influence o f cognitive distortions, errors of processing (Freeman & Reinecke, 1993; Weishaar & Beck, 1990), a n d the inability to utilize one's processing, specifically the inability to feel o r to follow one's feelings to anything other than despair (Shapiro, 1985). T h e thematic structure concurs with this understanding a n d i l l u -minates the process l e a d i n g to despair.
Participants despair a n d d i s c o n n e c t i o n emerged from their cognitive a n d e m o t i o n a l processing a n d the conclusions they drew about them-selves. T h e y attributed worthlessness a n d hopelessness to the self, rather than to the situation o r to the way they were treated, a n d without relief, they believed they were helpless. These conclusions, i n the initial early construction o f m e a n i n g , were experientially a n d developmentally ap-propriate a c c o r d i n g to the stages o f Piaget's cognitive development a n d K o h l b e r g ' s m o r a l development ( C r a i n , 1980). W i t h c o n t i n u e d exposure to invalidation a n d negative interactions their developmental l e a r n i n g was m a i n t a i n e d . They c o n t i n u e d to believe as i f they were trapped chil-d r e n a n chil-d c o u l chil-d not, as achil-dults, act o n their own behalf. These initial con-s t r u c t i o n con-s o f m e a n i n g are dicon-scucon-scon-sed i n the l i t e r a t u r e acon-s c o g n i t i v e distortions and errors of processing. T h e processing error is h o l d i n g these conclusions, valid developmentally when drawn i n one's past, t h r o u g h time into the present.
Participants' descriptions o f self-injury provide a deeper understand-i n g o f thunderstand-is c o p understand-i n g strategy a n d affunderstand-irm thunderstand-is behavunderstand-iour as a defence agaunderstand-inst
dissonance, anxiety, a n d d i s s o c i a t i o n a n d as a d e t e r r e n t to suicide ( G r u n e b a u m & K l e r m a n , 1967; H i m m e l h o c h , 1988). F o r participants, self-injury transferred their e m o t i o n a l p a i n into physical p a i n , function-i n g as a valfunction-idatfunction-ion o f 'thefunction-ir sense o f self function-i n the w o r l d ' creatfunction-ing a sense o f stability a n d an e q u i l i b r i u m between their i n n e r a n d outer experience.
T h e themes o f the ' J o u r n e y Away F r o m the S e l f describe the process of disconnection to the self, to e m o t i o n a l and cognitive processing, to experience, to others, and ultimately to despair a n d the loss o f a sense o f self. A paradox o f this process is that disconnection evolved through cop-i n g strategcop-ies to provcop-ide safety, survcop-ival, and an e q u cop-i l cop-i b r cop-i u m w h cop-i c h func-tioned to sever connections to the self, to the ability to process, a n d to experience.
Crisis brought d i s e q u i l i b r i u m to the processes o f disconnection, al-lowing for the possibility o f change a n d r e c o n n e c t i o n . T h r o u g h crisis and supportive validating contact, participants began breaking the bar-riers o f d i s c o n n e c t i o n . Supportive connections were not always estab-l i s h e d t h r o u g h crisis a n d contact. T h e "miss" t h r o u g h contact, o r misconnections, concurs with r e p o r t e d errors o f treatment (Bongar, 1991). A zeal to instil hope, to increase options, to p r o b l e m solve, or to medicate misses validating the individual's experience. T h i s automati-cally invalidates participants' feelings, constructions o f meaning, and efforts at c o p i n g with participants r e t u r n i n g to their patterns o f discon-nection.
W h e n supportive connections were established, participants o p e n e d to themselves, to their processing, a n d to their experience. They began r e c o n n e c t i n g to themselves. Repeatedly, participants described the revi-sion o f their patterns c o m i n g about when their feelings, precipitated i n experience, were understood a n d validated, thereby allowing them to shift their attributions o f "wrongness" a n d "badness" out o f themselves and attribute them to situational, contextual, and c o p i n g dimensions. T h i s changed the automatic relationship between feeling bad a n d being suicidal, a n d altered their sense o f helplessness as well. T h e focus o n accepting the self, one's feelings, a n d one's developmental processing allowed for the emergence o f self-trust. T h i s resulted i n a reorganization o f the self, processing, and experience. T h e power o f experiential valida-tion a n d a relavalida-tionship to provide the context a n d catalyst for change clearly concurs with empathie methods o f treatment (Havens, 1989; Rogers, 1959) and with descriptions o f self-validation f o r m i n g a sense o f self a n d identity through relational a n d validating contexts (Ishiyama, 1995). T h e significance o f e m o t i o n a l k n o w i n g as a path to change and integral to one's beliefs about the self has been articulated by M a h o n e y (1991):
A developmental or constructivist perspective considers emotions to be primi-tively powerful knowing processes that are integral to the lifespan organisation of
the individual. From this view, emotions are still associated with episodes of dis-comfort and disorganisation, but the latter are seen as ( 1 ) natural expressions of an individual's current realities, and (2) necessary (and often facilitating) ele-ments in the reorganisation of that person's tacit assumptions about self and the world, (p. 208)
A c c o r d i n g to the thematic structure, the pathways to r e c o n n e c t i o n were experiential validation and e m o t i o n a l k n o w i n g . W h e n participants were believed a n d valued, they began to believe i n themselves and to believe i n their own experience allowing them to become o p e n to the process o f reconnecting.
Implications for Suicide,Prevention and Treatment
Conceptualizing Treatment. T h e major i m p l i c a t i o n o f the thematic
struc-ture is its conceptualization o f suicidal behaviour a n d suicidal h e a l i n g as p r o c e s s e s o f d i s c o n n e c t i o n a n d r e c o n n e c t i o n , a n d h o w t h a t conceptualization directs treatment. Conceptually, the process o f treat-ment w o u l d explore the patterns o f disconnection, the precipitating and predisposing vulnerabilities, a n d the individual's resources. Interwoven with this exploration, and guided by the relevant themes, treatment w o u l d facilitate reconnecting individuals with others, with their experience, and with the self. Strategies w o u l d be directed towards individuals cognitive and affective processing of experience, past and present, i n order to iden-tify, confront, a n d modify the patterns o f disconnection and the suicidal path. T h i s is an implicitly recursive process that weaves its way through breaking o l d patterns to the development o f new perspectives.
Facilitating Treatment. T h e structural understanding implies that
treat-ment facilitates healing when the treattreat-ment p h i l o s o p h y recognizes the impact o f context, c o p i n g styles, and despair to the disconnecting pro-cess. F u r t h e r m o r e , it utilizes the pathways o f experiential validation and e m o t i o n a l k n o w i n g to initiate the dissolve o f o l d patterns and stimulate reconnecting. Participants' descriptions articulated three aspects inte-gral to the reconnecting process.
First, the presence o f a validating relationship forms an external an-c h o r and an-catalyst for rean-connean-ction with others, with experienan-ce, and with the self, p r o v i d i n g the f o u n d a t i o n for d e v e l o p i n g trust a n d self-acceptance. A n d alternately, contact characterised by a lack o f validating support reinforces despair a n d d i s c o n n e c t i o n . T h i s type o f contact, or m i s c o n n e c t i o n , occurs when others lack acceptance for the integrity o f persons a n d their experience and are unable or u n w i l l i n g to identify suicidal behaviour.
Second, how others handle the cognitions and feelings of despair shift the movement one way or the other between suicidal a n d healing pro-cesses. Distinguishing between e m o t i o n a l experience a n d the
attribu-tions a n d conclusions flowing from e m o t i o n a l a n d cognidve processing encourages individuals to label a n d to trust their emotions as reflecting interpretations o f events, distinct from evaluations o f the self.
T h i r d , the breaking o f suicidal patterns requires dealing with discon-nections related to u n d e r l y i n g issues. D i s c r i m i n a t i n g between precipi-tating a n d u n d e r l y i n g factors is p a r t o f the process o f d e v e l o p i n g awareness, m a k i n g connections, a n d identifying patterns. Participants described the necessity o f recognizing, accepting, a n d understanding the past experiences that h a d brought about their disconnection i n or-der for healing to occur, allowing for a process o f reconnection a n d the "Return to the Self."
Multidimensional Treatment. Participants described disconnection a n d
r e c o n n e c t i o n i n relation to their external worlds a n d to their m u c h d e e p e r a n d c o m p l e x i n t e r n a l w o r l d s . T h e i r d i s c o n n e c t i o n a n d reconnection involved their thoughts, feelings, physiologies, behaviours, a n d life situations. T h i s u n d e r s t a n d i n g o f suicidal a n d healing processes directs a shift away from disciplinary r e d u c t i o n , a n d places the focus o n discrete factors a n d treatments o f c h a n g e that d e c o n t e x t u a l i z e affect, cognitions, a n d behaviour, i n time, from each other a n d from experience.
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About the Authors
M. A. Hoover is a Chartered Psychologist formerly of Student Counselling Services, University of Alberta, Edmonton, Alberta, and now in private practice in Edmonton, Alberta.
B. L. Paulson is an Associate Professor in the Department of Educational Psychology, Univer-sity of Alberta, Edmonton, Alberta.
Correspondence concerning this article should be addressed to M . A. Hoover, 361 Hedley Way, Edmonton, AB T6R 1T8. Fax: 780-988-6804.
This manuscript is based on a doctoral dissertation study and a paper presentation at the 27th Annual Conference of the American Association of Suicidology.
