Re-Vitalizing Worthiness: A theory of overcoming suicidality

Evelyn Gordon, RPN, Reg. Fam. Ther. & Sup. (FTAI), MSc, Ph.D.; John R. Cutcliffe, RMN, RGN, BSc (Hon), Ph.D.; and,
Chris Stevenson, RMN, CPsyc., BA (Hons), MSc, Ph.D.

Abstract

Rates of suicide and suicidality have risen in many countries in recent years and in Ireland this trend has been particularly evident among young men (NOSP, 2005), focusing attention on how best to respond to this group. Although mental health professionals have been identified as a key group to respond to the suicidal person, it has been suggested that they are ill-prepared for working in this area (Maltsberger & Goldblatt, 1996; Ting et al., 2006; Cutcliffe & Stevenson, 2007). This study aimed to address these issues by developing a theoretical understanding of suicidality among young men to inform professional practice. Using Classic Grounded Theory (Glaser & Strauss, 1967), in-depth one-to-one interviews were conducted with 17 young men who had been suicidal and had been in contact with the mental health services. The substantive theory that emerged, re-vitalizing worthiness in overcoming suicidality, describes the psychosocial process that young men go through to resolve their main concern, which centres on their painful pull between life and death. Overcoming suicidality involves moving from a death orientation to a life orientation while incorporating the inevitability of death into their new sense of being. This transition entails identity re-configuration whereby young men emerge as individuals of value who are deserving of life. The process is influenced significantly by personal insights and interpersonal interactions that influence their suicide trajectories and life pathways. The theory contributes to the fields of suicidology and mental health by providing a theoretical understanding of overcoming suicidality and identifying professional and social practices that facilitate and impede this process.

Key Words: suicidality, young men, recovery, suicide prevention, suicide intervention.

Introduction

There has been a notable increase in suicide and suicidality rates in many countries, including Ireland, in recent years. This trend has been particularly evident among young people and, in Ireland young men between the ages of 16-34 years are a specific group identified as being at higher risk. This group of young men accounted for almost 40% of deaths by suicide in Ireland in 2003 (NOSP, 2005), focusing attention on how best to respond. Although in Western societies mental health professionals have a prominent role in responding to the suicidal person, it has been argued that their lack of training in the specific area of suicide renders them ill-prepared for this work (Maltsberger & Goldblatt, 1996; Ting et al., 2006; Cutcliffe & Stevenson, 2007). This study aimed to address these issues by developing a theoretical understanding of suicidality among young men to inform professional practice.

Using Classic Grounded Theory (CGT) (Glaser & Strauss, 1967), in-depth one-to-one interviews were conducted with 17 young men who had been suicidal and who had been involved with mental health services. Participants were, to varying extents, transitioning away from suicidality, hence the substantive theory that emerged, re-vitalizing worthiness in overcoming suicidality, refers specifically to this process. It captures how these young men resolve their main concern, which centres on their torturous pull between life and death. This conflict is conceptualized as negotiating a dialectic of destiny and is resolved by undergoing a complex non-linear psychosocial process. This process involves confronting ambivalence about living and dying and re-establishing oneself anew in the world, thereby re-configuring one.s identity. For young men moving from a death orientation to a life orientation, this also means incorporating an awareness of the inevitability and unpredictability of death into one.s new being. This transition is facilitated by profound intrapersonal insights and interpersonal encounters that influence the suicide trajectory and life path. Re-vitalizing worthiness, which refers to regaining a sense of value as an individual who is deserving of life, is central to this process.

The substantive theory contributes to the fields of suicidology and mental health by providing a theoretical understanding of how young men overcome suicidality and identifies how others, including health professionals, influence this process. Validation by self and others is deemed helpful, for example acknowledgement of the person.s struggles with life and a demonstrated desire to work alongside them to resolve their fears and concerns. Responses that minimize the person.s subjective experience, or objectify the young men and exclude them from their own care and treatment are viewed as invalidating and unhelpful, and serve to reinforce their sense of unworthiness.

Methodology

CGT evolved from the collaborative work of sociologists Glaser and Strauss (1967) and provides the researcher with an orientation to and systematic method for theory generation. This methodology was chosen as there are identified knowledge gaps in the field of suicidology. For example, there is limited understanding of the suicidal process and suicidal person (Aldridge, 1998).

CGT incorporates a number of interlinked processes, such as: analyst theoretical sensitivity that guides his / her engagement with the study process as this unfolds; the Constant Comparative Analytic Method that allows all data to be systematically analysed; sampling procedures that guide movement from selective to theoretical sampling, in order to enrich emergent categories; and theoretical memoing that facilitates integration of theory. These activities combine in an iterative process throughout data gathering and analysis.

A CGT study identifies the main/core concern of participants, or the issue that preoccupies those involved in the substantive area. The analyst then identifies how this concern is resolved, which is captured in the core category/variable and accounts for most of the activity in the substantive area. Hence, the theory is grounded firmly in the data, as opposed to being pre-determined by existing theory. At the latter stage of theory-building a thorough literature review is conducted which serves as further data (Glaser, 1998; Glaser, 2001). In this study, this process was concerned with how participants resolved their torturous pull between life and death in order to overcome suicidality.

Data analysis

Key elements of the Constant Comparison Analytic Method in CGT include building categories, or describing key incidents in the data; outlining their properties, or the characteristics of these categories; and formulating hypotheses that explain the relationship between categories until a core category emerges. In this method, data collection and data analysis do not occur in a linear sequence, they are cyclic in nature. However, for the purposes of reporting the research, the process of analysis is described in stages. The first stage involved open coding whereby the researcher listened to the recorded interviews and identified incidents in the data. Each of these identified incidents or processes was then labelled, termed substantive coding as the labels codify the substance of the data. Each label was then compared with every other label and these were assigned to categories according to obvious fit, allowing a tentative heading for each category.

The next stage of the analysis saw the development of the tentative framework. This was achieved through selective sampling of the data to expand and densify the emerging theory. The tentative categories and perceived links were examined to discover umbrella terms under which several categories fit, as a result of comparing each category with other categories to see how they connected. The umbrella term therefore encompassed several initial tentative categories, while further comparison with more data helped the refinement of these concepts and variables and the development of hypotheses and the main category. The final stage was dominated by theoretical coding where concepts are compared with more highly developed concepts, and these are compared with more data.

Rigor

In CGT interrelated criteria for rigor are provided (Glaser & Strauss, 1967; Glaser, 1998) against which the study can be evaluated by the researcher and others, as follows:

. Relevant theory provides explanations that make sense of what is going on in the substantive area.

. Fit of theory describes theory that is substantively congruent, or fitting the study phenomenon.

. Workability means that the theory informs the everyday practice of those involved in the substantive area.

. Modifiability refers to the unfinalized nature of the theory, which can be expanded with new information.

. Parsimony suggests that the theory should identify and succinctly describe central processes that address the core concern of participants in the substantive area.

. Scope in applicability refers to how useful the theory is to those in the substantive area and beyond.

. Grab means that the theory should be attractive to and memorable for those who hear about it.

Thus far, the theory has been discussed with some of the participants, other non-participant suicidal individuals and professionals working in the mental health field who have confirmed its relevance, workability and grab.

Participants

Inclusion criteria for participants were males, aged between 16-34 years, who were suicidal and were involved with mental health services. Participants were recruited through a number of mental health facilities where poster invitations were displayed. Local health professionals also brought the study to the attention of those fitting the inclusion criteria. In-depth one-to-one interviews were conducted with 17 young men, with an average age of 25 years, who came from diverse socio-economic and educational backgrounds, had experienced different levels of suicidality, from suicidal ideation to multiple suicide attempts, and who had varied experiences of the mental health services. Ethical approval for the study was granted by the Research Ethics Committee at Dublin City University.

A Theory of Re-vitalising Worthiness in Overcoming Suicidality

The main concern, negotiating a dialectic of destiny, describes two opposing pulls the young men experience, one that yearns death and the other that yearns life. In attempting to protect themselves and others from this deep inner conflict they cut themselves off from the world, becoming increasingly isolated. Profound ambivalence shows itself in a belief that they have nothing to offer the world and that they do not deserve to live, while simultaneously they yearn for a different life. Hence, they are caught between their desire for life and their drive toward death, while unable to communicate this openly and clearly for fear of recrimination. This concern occupies their being as they work out if and how they should be in the world while moving along their unique suicide trajectory and life path. The psychosocial process the young men undergo to resolve their conflict about living and dying is conceptualized as re-vitalizing worthiness, thereby overcoming suicidality. This is a complex interconnected and non-linear process that is unique to each individual, however, for the purposes of describing the process it is presented in stages.

The theory, re-vitalising worthiness in overcoming suicidality, captures the psychosocial process whereby young men transform their identities and their lives as they re-negotiate the nature and meaning of their relationship with living and dying. This process involves bringing life to an aspect of their being that has been dormant, that is, their sense of worthiness as individuals of value who are deserving of life. They face and challenge their suicidal existence, shed their suicidal selves and move forward to enact new lives. This major shift involves making choices about how they position themselves in relation to their suicidality, their selves, their relationships and their worlds. Rather than concealing their suicidal selves, they begin to accept this as part of who they are and to do so in a way that allows them to occupy themselves with living rather than dying. Hence, they move from a death orientation or a position of living to die when suicidal, to a life orientation or a position of living to live with an awareness of dying when beyond suicidality. This transitional process is represented in the concepts, confronting a crisis of destiny and earning a life, each of which incorporates a number of categories.

Confronting a crisis of destiny

Confronting a crisis of destiny, describes how the young men pause, take note of their life situations and decide that things have to change, so that they are no longer pulled between life and death. This awareness is frequently initiated when they reach a point of immense crisis and find that they can no longer continue in their suicidal existence. They discover that they can make a choice about whether they live or die and they make a clear decision to live and to change their lives. This stage of the process is conceptualised in two categories, living the crisis and reaching a point of no return.

Living the crisis

Finding themselves devoid of value as human beings, the young men gradually withdraw from the world and disassociate from the parts of themselves for which they feel guilt and shame, thereby becoming unreachable and losing personage. This isolation also serves to protect others from their dark worlds and the inevitability and close proximity of death. They assess their worthiness by comparing themselves with other people and measuring their life performances against perceived social norms and personal goals. Failure to fit with such norms or achieve these goals confirms to them that they have little to offer the world and it had little to offer them, resulting in a strong negative self-conception and increased suicidal ideation and behaviours, which frequently culminates in a suicide attempt.

…like you don’t know who you are and it’s horrible to feel like that…and a lot of people don’t understand when you say that…

The young men view themselves as different and adopt personas that reflect their personal designation such as the “black sheep,” “failure”or “freak.” The powerlessness associated with failure perpetuates a sense of victimhood, blame, shame and being voiceless. They feel lost and occupy an in-between world. Consequently, they are consumed with self-loathing, which is frequently coupled with despise for others. This results in self-directed and other-directed violence, consistent with the idea that “…homicide and suicide are two channels of a stream of destructiveness” (Aldridge, 1998, p.27).

…I was so pissed off with people around me and so pissed off with myself because there was nothing I could do to change it [life]…

The young men live out their destiny crises by testing life and death while remaining ambivalent about both. Ambivalence is recognised as a central component in suicidality, which ironically facilitates the person to stay alive as it keeps open the possibility of death (Caruso, 2009). In the aftermath of an unsuccessful attempt they remain ambivalent about survival, at times simultaneously glad and sad to be alive.

I don’t know if I was more sad or pissed off because I didn’t do the job [kill self], or more pissed off because I was in hospital…

The young men experiment with risky behaviours that challenge death such as dangerous driving, and with behaviours that makes them feel alive such as self-mutilation. Such activities serve to numb their pain, providing temporary relief and enabling them to engage superficially with life. Many of their suicidal acts are associated with excessive alcohol and drug consumption, a common feature in suicidality (Hawton, 2005), although the young men view substance misuse as a soothing strategy rather than a causal factor in their suicidality.

…that’s why I started taking drugs, to blank it out…It helps when you are out of your head because you forget everything…

Some try to resolve their destiny crisis by attempting suicide. The suicidal acts are complex as they avoid death by alerting another to the event, or are rescued unexpectedly, thereby getting another opportunity to live. These acts are impulsive, confirming the view that there is frequently a short time-frame between trigger events and a suicidal act (O.Connor & Sheehy, 2001). However, despite the impulsive nature of the act, many of the young men harbour suicidal thoughts for many years before taking action, hence, their impulsivity could be seen as reflecting and perpetuating their long-standing strong sense of loss of control over themselves and their lives.

Reaching a point of no return

Living with their torturous crises of destiny the young men eventually reach a point where living in their in-between worlds is no longer tolerable, signalling to them that life must change.

You can’t stay in that crisis state. You have to move forward or back. If you decide to go back, you can.t expect help anymore…

Various events provide them with the impetus they need to review their relationship with living and dying and to make a choice about their fate, a process that is paced differently for each person. These pivotal moments that challenge their negative self-conception initiate a change from looking externally to looking internally for a solution, and begin to shift their perceived locus of control form external to internal (Esposito-Smythers et al., 2004). This facilitates them to take charge of their destiny, and to make some sense of their suicidality and their lives, and thus has a significant impact on them in terms of their sense of personal agency and self-determination. Such events include being unburdened from enacting a life that does not seem to be of their own choosing, allowing their uniqueness to be celebrated. In addition, realizing that nobody else can change their lives encourages them to take responsibility for themselves, influencing how they manage their lives and distress.

If I wanted to stay alive I had to change my life, I knew I had to change the situation…

The young men frequently signal their distress and desire for change to others. Some of these signals are responded to in a helpful manner, enhancing the transitioning process. Responses that minimize their pain or convey a lack of interest or understanding are unhelpful and impede the transitioning process temporarily. Nevertheless, in making a decision about their destiny, they begin to move towards life rather than death and face the challenge about how to live in ways that are meaningful and worthwhile, beginning the process of re-shaping themselves and their lives.

…I don’t know if I realised I had to change myself or I don’t know how it happened, or I just changed who I was because I didn’t like the person I was at the time and so I just changed me altogether…

Earning a life

Earning a life describes how the young men reach a point that forces them to decide on the course of their destiny and to choose to live. They begin to build and enact their new sense of self. The construction of a new sense of identity has been recognized as key to recovery from a range of life adversities (Clarke, 2001). This confirms to them and others that they have earned a place in the world. It involves integrating different perspectives and experiences in their journeys toward consolidating a new identity. They also need to decide with whom they will engage and whose version of reality they will accept. This requires making decisions about how they present themselves in the world and how they relate to others. This stage is conceptualised in two categories, real-izing worthiness and enacting a new worthy identity.

Real-izing worthiness

In shifting their focus from a life that is dominated by a desire to die to one that is dominated by a desire to live, the young men become more emotionally and cognitively aware and available, and are more open to see, think and feel in new ways. This allows them to challenge their pessimistic thinking and profound sense of hopelessness (Beck et al., 1975), to notice previously unrecognised positive aspects of their selves and their lives and to identify life enhancing possibilities and resources. They gradually come to see that life is challenging but nevertheless rewarding, and that their fears and concerns, while valid, can be managed less painfully. Thus they move from perfectionism and rumination (O.Connor & Sheehy, 2001) to acceptance and reflection. However, the past does not disappear; rather, orienting toward life means managing a death oriented past and the negativity that this represents. While remembering the past is frightening and confusing for the young men, as it is a stark reminder of their darkest moments, it also serves to alert them to the fact that they do not want to return to that place of intolerable pain, thereby providing an impetus for staying alive.

…the way I was feeling before was by far the worst thing that I have ever felt in my whole life, like it is just the fear of going back to that to be honest with you…

With awareness that the past does not necessarily determine the future, the young men are able to generate and sustain hope and a sense of control in living. Others also inspire hope and confidence by demonstrating belief in their personal value, encouraging them to take on new challenges. Receiving expressions of genuine belief in one.s personal value by others is deemed central to recovering one.s mental health (Helm, 2009).

My friends would have had a nice sense of me and would have felt there was a huge amount of potential in me, in a very broad sense, in a very human sense, that was being inhibited…

Challenging their victim saturated selves means that the young men relinquish passivity and become more actively involved in directing their lives in purposeful ways. This reinforces a sense of personal value that allows them to become visible and connected with the world, consistent with the view that reconnecting with humanity is essential to overcoming suicidality (Cutcliffe & Stevenson, 2007). Re-engagement with life and the world also enables them to express thoughts and emotions previously withheld, which consolidates their connections with those in their lives, including social and professional relationships.

…she [partner] said ‘What’s going on in your head?’, and I said ‘Basically, I am hurting’…

Vigilance for imperfections in self and others is replaced with an openness to seeing positive opportunities for connecting, shifting them from being victims to being authors of their lives and inter-subjective selves, and from isolation to belongingness. Rather than seeking out others to blame or loath, the young men seek out those with whom they can have rewarding experiences, enhancing their personal worth and interpersonal connectedness and consolidating their sense of self. However, disconnecting from sources of torment is important in sustaining control and a positive direction in life.

I just decided that I had to cut myself off completely from her [mother]…

Renewal of self-trust is necessary so that the young men are no longer at the mercy of chance, fate or others, and this is enhanced by a deep knowing about themselves and death acquired in their suicidal crises and close encounters with death. It has been proposed that an acute awareness of death allows one to accept the inevitability and close proximity of death, thereby challenging illusory assumptions about the predictability and safety of life and one.s value in the world (Janoff-Bulman, 1985). The young men reshape such assumptions to go on living and can then reframe life events as learning opportunities rather than confirmation of their unworthiness. This gives them the strength to deal with life challenges, allowing their new identities to take shape.

…I kind of know I could deal with most things now because I know I have come through the other side of pretty serious stuff…

Enacting a new worthy identity

As the young men re-engage with their selves, others and life again, they become ready to establish and enact their new sense of identity in their daily lives. This requires commitment and hard work so that old patterns of thinking and behavior do not re-emerge and regain control. Resolution of the pull between life and death and the integration of the worthy and unworthy selves is a dichotomous synthesis whereby the young men bring union and harmony to previously contradictory aspects of their selves and their worlds. Such synthesis can emerge in the aftermath of a sense of disintegration (Fisher, 1999). Following their suicidal crisis, life for these young men does not reach the heights of reward that they had previously imagined and had scolded themselves for failing to achieve. However, they do have the opportunity to be ordinary people, living ordinary lives, and they accept this with enthusiasm.

…okay, so I can.t change the world, but I can do something that has meaning, that fits with my values…

Part of the integrating process involves the young men making sense of their selves and their lives and gaining a sense of power in relation to their suicidality. This can be described as power with rather than power over suicidality, as some aspects remain a mystery to them. They find resources to go on living despite questions about their pasts and uncertainty about their futures. Sometimes this involves putting the suicidal episode aside and focusing on their daily routines while at other times it means engaging in deep searching of the self. Such moments of internal reflection are frequently triggered by external encounters that revalidate the young men.s worthiness, resonating with the literature that views resilience as a relational phenomenon (Wexler et al., 2009).

With new insight into and awareness of their strengths and vulnerabilities, the young men free themselves from the chains of convention so that their uniqueness can be appreciated and performed in their daily living, which has been deemed an important aspect of regaining an acceptable sense of self (Fisher, 1999). This new state of being replaces ambivalence with certainty, hopelessness with hope, chaos with direction, and a sense of being lost to one of being found. Living a satisfactory life promotes a sense of responsibility for and commitment to their selves and their lives, enhancing worthiness in a circular fashion.

All of a sudden I began to think of about how I could create a place for myself in the world, a place where I could be comfortable…

The young men appreciate that others in their situation might not have the resources to move forward in the same way; hence they are grateful for opportunities that confirm their efforts and achievements. They develop new interests and activities that reflect their sense of caring about themselves and their lives, replacing old self-destructive patterns with more life-enhancing routines. In addition, they formulate new and enabling self-descriptions, having previously been labelled and labelling themselves in derogatory ways.

I am after putting effort myself just to do it like. For some people they might be weaker. I don’t know how I done it myself, but there are a lot of people who mightn’t be able to…

The young men acknowledge the influence of contact with a health professional and they clearly distinguish between helpful and unhelpful encounters. They identify positive practices as those that enhance worthiness, such as a collaborative, respectful and individualised treatment approaches, belief in their value as people, and genuine caring and concern on the part of the practitioner.

…I just thought that this transparency, this openness, this sense of collaboration whereby not only do I have a voice but this person is even willing to say .Well this is how I work, and if it is something you are interested in I will share even the mode of work I do with you…I think that is extraordinary…

In terms of unhelpful responses the young men highlighted practices reflective of a “risk society” (Roberts, 2005) that seek to eliminate risk through control, overshadowing care and connection. Discourses underpinning the desire for predictability and control also give rise to contradictory pulls within the professional, such as competing beliefs about the person.s value as an individual (Joyce et al., 2007) and deservedness of care (Bergmans et al., 2007), which can serve to reinforce young men.s sense of difference and powerlessness.

When you are a service user of psychiatric services it tends to be that you are given the terms, I think it is defined for you. There is very little sense of you being able to name or construct what is going on for you with professionals…

The study highlights the unpredictability and complexity of the suicide trajectory and recovery path. For professionals this brings into sharp focus the importance of making and taking opportunities for engaging in validation and in life-enhancing interactions with suicidal young men. At the very least this involves engaging in “simple acts of human kindness” (Helm, 2009, p. 59).

Summary

Re-vitalizing worthiness captures the central psychosocial process that young men go through to attempt to answer their profound existential question about the meaning and nature of their relationships with living and dying. Having succeeded in confronting and addressing their worst fears about themselves, their lives and their fates, they emerge as stronger and more integrated young men who proudly establish their place in the world. They overcome suicidality and repair their sense of fragmentation in the world by shedding their unworthy identities and claiming significance as persons of worth who are deserving of life.

Discussion

This study explores the phenomena of suicide and suicidality among 17 young men who experienced suicidality and were involved with mental health services. The substantive theory that emerged suggests that overcoming suicidality is possible, that re-vitalizing worthiness is central to this transition and that this complex process is influenced by a range of internal and external factors. Hence, the study raises a number of issues in terms of understanding and responding to a suicidal young man at professional and social levels and highlights areas for further research, as elaborated briefly below.

Implications for professional practice

It is important to identify how the substantive theory can inform mental health practice, given the prominent role professionals have in responding to the suicidal person. Participants ranged the span of suicidality presentations that are typical of those that attend mental health and other services. Hence, the transitioning processes described are highly relevant to mental health practice.

The literature suggests that overcoming adversity is largely influenced by contextual factors, such as support and encouragement received from key others and opportunities provided for reflection and growth (Clarke, 2001), a view supported by this study. Hence, the mental health practitioner has a vital role to play in the dynamic re-vitalizing worthiness process. Any interaction with a young man, regardless of his level of suicidality and the nature of the contact, can potentially impact his life journey. Worthiness can be facilitated through establishing a safe context for reflection and disclosure of inner turmoil, and engagement in worth-enhancing encounters. While such processes may not directly impact a young men.s mental pain, it can influence his suicidal urge at a moment in time, serving as a deterrent against suicide (Shneidman, 2001). It can also trigger or create momentary space for reconsideration of his life, which may serve as a catalyst for reorientation toward life and reorganization of self-destructive patterns (Orbach, 2001).

A number of key practices and processes are identified as significantly impacting the re-vitalizing worthiness process. The mental health professionals that make the most positive difference in the lives of young men are those who work with rather than on them, tolerate and work with the mystery of their experiences, engage with them in relation to their dark side, sustain a supportive role throughout their unpredictable journeys of self-discovery, and demonstrate belief in their potential to recover and renew their lives. Practices that are identified as unhelpful include those that perpetuate young men.s sense of difference and powerlessness. Such practices are experienced as controlling, confining, coercive and stigmatising, for example pejorative labelling and exclusion from their own care and treatment. These views and experiences are consistent with the recovery literature in general (Watkins, 2007), although prior to this study they have not been succinctly elaborated in relation to suicidality.

The emphasis on risk containment leading to restrictive practices may reflect the profound fear (Becker, 1973), social stigma (Sommer-Rothenberg, 1998) and professional discomfort (Gibbs, 1990) associated with death in general and suicide in particular. Given the documented negative consequences for professionals (Ting et al., 2006) and consequently clients (Samuelsson et al., 1997) of such restrictive practices, it is important that institutions providing training and education for professionals working with suicidal young men recognise the complexity of practice in this area and reflect this in course curricula. Some possible areas for consideration in training include incorporation of the multiplicity of theoretical, moral, social, gender and personal perspectives that can influence practice, so that practitioners can critically examine their decision-making and its foundations (Gordon, 2010). If practitioners are to sustain emotional tolerance, psychological awareness and an ethos of critical enquiry in the face of conflicting discourses and demands, they need support and opportunities for personal and professional reflection and integration, such as clinical supervision and continual professional development opportunities. In addition to enhancing job satisfaction and practitioner morale, such activities promote and nurture holistic, safety enhancing practices and therapeutic engagement. This means embracing a preventative approach while also shifting professional beliefs from cure to care and actions from control to connection.

Social implications

This study has social implications at micro and macro levels that stretch beyond the mental health arena. It is worthwhile noting that many suicidal people, particularly young men, do not engage with mental health services, which reflects well established help-seeking attitudes and behaviors (Burke et al., 2008). Furthermore, those who do engage have already had multiple encounters with others in their social networks and local communities. Therefore, promoting rather than diminishing social ownership for suicide and suicidality holds open the possibility of empowering others such as family, friends, peers, colleagues and other members of social and community networks to respond in more proactive ways to validate young men in their daily lives, or at the very least not to condone invalidating social practices. An opportunity also exists for community based professionals, such as school or college staff and family health practitioners, to respond in ways that facilitate young men in becoming visible, without the fear of further stigmatization and social rejection. This is important given that initial contact with the suicidal person influences the course of their help-seeking path (Hemmings, 1999) and can challenge stigma and reduce marginalization. Furthermore, young men frequently continue to have such contact following professional health care, hence expanding the network of care can be helpful (Stevenson & Gordon, 2009).

Implications for research

The study draws attention to some areas that require further exploration in relation to and beyond the substantive area. The theory provides an in-depth understanding of the process of re-vitalizing worthiness, however, it was beyond the scope of this study to examine specific aspects of this process in greater depth. For example, exploring how personal and interpersonal processes converge at a moment in time to enhance worthiness, which might also provide some insight into why some young men remain suicidal or complete suicide.

Research examining the relevance of the theory beyond the substantive area, for example, in relation to young men in other cultures, older men, and / or women would strengthen and expand the theory. Synthesizing studies that have focused on recovery from other life adversities would move the theory beyond the substantive area and form a sound basis for the development of a formal theory (Glaser & Strauss, 1967) of recovery. This demonstrates modifiability of the substantive theory, which is an important measure of rigor.

The GT Learning Curve: Challenges and Rewards

“By far the most exciting use of grounded theory over the last ten years is its legitimating of concept generation. The researcher is empowered to discover and generate new categories and properties, instead of being forced to use received concepts…It is academic freedom to the max.”(Glaser, 1998, p.133)

Some of the key challenges and rewards that the first author and main researcher (EG) experienced in this study include remaining open-minded, trusting the study process and defending the robustness of the theory which ironically mirrored aspects of the participants transitioning process.

Open-mindedness

Remaining open-minded throughout the study process required me to reflect upon my personal and professional biases about the topic, and study context, process and outcomes. However, it was important to ensure that I did not become embroiled in my own reflective process, privileging this above the data. I was assisted in striking this balance by consulting with the other authors about data conceptualization and by seeking variation in data through adherence to the Constant Comparative Analytic Method. This facilitated discovery of unknown biases, management of the known as this emerged and promoted a more curious posture in relation to emerging concepts. This process mirrored how the young men were able to emerge from the confinement of their dark realities as they opened their minds to alternative ways of thinking about themselves and their lives.

Trusting the process

Another associated challenge was to trust in the study process and believe that the theory would emerge in time. Anxiety about coming up with a product within the study timeframe pushed me to sometimes want to settle for a poorly saturated and partial theory. Again managing this was facilitated by consultation with the other authors and importantly patience. This mirrored the young men.s impatience with their unsatisfactory lives, which pushed them to seek immediate solutions, and finally abated as they began to trust in themselves and the world.

Robustness of theory

Finally, another related challenge centred on believing in and defending the robustness of the substantive theory that emerged. Knowing when a point of theoretical saturation had been reached required me to play with emerging concepts until the core variable felt whole and complete also requiring patience and trust in the process. This was similar to how the young men who were feeling invisible for much of their lives were enabled to become anew as they gained confidence in themselves and their ability to sustain their new lives.

Trusting the process and defending the robustness of the theory became easier towards the end of the study when I began to talk about the theory to people who were suicidal and to colleagues who reinforced its relevance and grab. This mirrored the experience of the young men as their new identities emerged and were validated by positive feedback and support from others in their lives.

Conclusion

This CGT study developed a substantive theory for understanding the process of overcoming suicidality among young men in Ireland. It highlights that overcoming suicidality is possible and identifies that re-vitalizing worthiness, which means regaining a sense of value as an individual deserving of life, is central to this process. The study adds to the fields of suicidology and mental health by offering a systematically developed, new and coherent theory of overcoming suicidality. It explains in detail the processes involved in this transition providing practitioners with a new and exciting way to understand recovery in suicidality. It outlines social and professional practices that enhance and impede this process. Hence, practitioners in the field of mental health and beyond can draw upon the substantive theory to work sensitively and therapeutically with suicidal young men at different points on their suicide trajectories. The challenges experienced in conducting this CGT study were outweighed by the rewards of acquiring a PhD for the first author and by the achievement of developing a substantive theory that is unique and makes a significant social and professional contribution in the area of suicide.

Acknowledgements

This study was funded by the Health Research Board (Ireland). It was carried out by a research team at the School of Nursing, Dublin City University (DCU) and formed the basis of the first authors PhD thesis.

Authors:

Evelyn Gordon, RPN, Reg. Fam. Ther. & Sup. (FTAI), MSc, PhD
Lecturer, Faculty of Science & Health
Dublin City University
Dublin, Ireland
Email: evelyn.gordon@dcu.ie

John R. Cutcliffe, RMN, RGN, BSc (Hon), PhD
Acadia Professor of Psychiatric and Mental Health Nursing
University of Maine, USA.

Chris Stevenson, RMN, CPsyc., BA (Hons), MSc, PhD.
Chartered Psychologist / Family Therapist
ParSons Dowd Psychological
Cuthbert House, Newcastle, UK NE12ET.

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