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A Study of Young Adults w h o A t t e m p t e d
Suicide in Turkey

KAMIL ALPTEKIN AND VELI DUYEN
This study was conducted with the aim of gaining an integrated and comprehensive
psychosocial understanding of the behaviours of young adults, who were brought to
the emergency service unit of a hospital after they had attempted suicide. Semi-
structured interviews were used to gather data from 21 individuals. Most studies
conducted earlier have attributed suicide attempts to problems encountered in
relationships with the opposite sex. However, the findings of this study indicate that
suicide attempts are largely a result of the individual’s inability to face or cope with
difficult situations and the ability to solve his/her problems.
Kamil Alptekin is Assistant Professor, Duzce University, Turkey, and Veli Duyan is
President, Faculty of Health Sciences, Department of Social Work, Ankara University,
Turkey.

INTRODUCTION
The act of attempting or committing suicide transcends all population
groups. It is a peculiar, individual and social act; a self-destructive behav-
iour terminating in death. Various biological/physiological and psycho-so-
cial factors play an important role in determining the attempt to commit
suicide. Studies suggest that suicide is a global problem and it appears to be
rapidly increasing among the younger population (Beautrais, 1998;
Bille-Brahe, 2001; Goldsmith, Pellmar, Kleinman and Bunney, 2002).
The statistical data published by the State Institute of Statistics, Turkey,
reveals the fact that the number of suicides has increased to a level requir-
ing critical examination. However, in spite of the alarming figures, suicide
is not considered to be a major problem yet (Sayýl, 1994; Sayýl, 2000;
Eskin, 2003). The available data reported 2829 suicides in 2006 and the
suicide rate is estimated to be 388 in a thousand. Very little preventive ac-
tion has been taken by the Turkish government. So far, no national level
IJSW, 72(3), 419–440, July 2011

420 Kamil Alptekin and Veli Duyan
preventive programmes have been prepared. Barring the Ankara Univer-
sity Psychiatric Crisis Research and Practice Centre, no other institution
has or is conducting suicide preventive studies at the primary level. There
are, however, several studies undertaken at the secondary and tertiary
level. These studies are largely disorganised and mainly conducted as psy-
chological counselling and guidance units of educational institutions, psy-
chiatry clinics, polyclinics and emergency services of hospitals (Alptekin,
Duyan, and Uçan, 2008).
Various early historical writings, philosophical and religious contribu-
tions, and art forms have documented suicide as a basic human existential
phenomenon. Existing sociological theories on suicide are largely influ-
encedby Durkheim (1897). Durkheim’s theory was based upon the evalua-
tion of statistics of western European countries during the second half of
the nineteenth century. He distinguished between four sub-types of sui-
cide: fatalistic, altruistic, anomic and egoistic. Psychological models in-
clude psychodynamic, attachment, and cognitive-behavioural theories that
are only partially substantiated by empirical research. The main theories
are concerning aggression directed inward, rather than outward, the loss of
a symbiotic relationship, and a severe personal insult resulting in severe
loss of self-esteem (Bronisch, 2004).
Research studies conducted on suicidal behaviour have not produced
any reliable data. Suicide has been conceptualised and studied as a problem
related to depression for the last two decades. A majority of studies under-
taken to understand the relationship between suicide and disease have also
viewed suicide as an illness (Odað, 2002). In the light of the above, re-
search studies could be framed within the parameters of social, cultural,
personal and psychological parameters that seek to gain a better under-
standing of depression and chronic physical illnesses. In this context, pov-
erty, political, and social chaos and violence, substance abuse, and the
dynamics of family and professional life could be connected to the globally
increasing suicide rates (Kleinman, 2003).
There is no doubt that the source of inspiration for the quantitative stud-
ies on suicide is the empirical mind set stemming from positivist philoso-
phy. In such studies, it is common practice to examine socio-demographic
variables, psychiatric illnesses and risk factors, as well as reporting on the
type, incidence and prevalence of behaviour. However, the researchers
have not adequately focussed on examining the interplay of the
psychosocial dynamic forces underlying the development and complexity
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A Study of Young Adults who Attempted Suicide in Turkey 421
of suicide such as loneliness, despair and deadlocks (Alptekin, 2008). Such
an examination would provide more detailed and qualitative information
on suicide.
METHODOLOGY
The purpose of this study was to arrive at an integrated and comprehensive
understanding of suicide. The sample comprised 21 young adults, who
were admitted to the Emergency Service of Ankara Numune Training and
Research Hospital in Ankara, Turkey. The researchers examined the
psychosocial factors leading to attempted suicide within a qualitative her-
meneutic methodological framework.
Hermeneutics is one of the basic approaches in social sciences that seeks
to understand the reasons for any action. It takes “content” and “context”
into account, while employing “interpretation” in order to understand the
“meaning” that resides in all human actions and interrelationships. Ac-
cordingly, human existence is determined by a network of meanings that
surrounds people (Göka, 1993). The researcher interprets the tacit mean-
ings while adding his/her own experiences to the text of this meaning, and
reaches a “profound” view (Neuman, 2003). Hence, the hermeneutic ap-
proach is lodged within the broader framework of qualitative research
(Neuman, 2003; Padgett, 1998).
Suicide Attempters
For this study, the suicide attempters (SA) were chosen by using “standard
sampling” within the “intentional sampling techniques” suitable for quali-
tative research. Thus, inclusion/exclusion criteria were developed at the
beginning of the study by choosing the subjects for the sample.
The selected inclusion criteria were:
1. The intervention for the SA should be completed.
2. This should be the first attempt of the SA.
3. The SA should be 18–35 years.
4. The SA should not have been previously diagnosed with ’schizo-
phrenia or other psychotic disorders’ which are listed in Axis I of the
DSM-IV-TR (2000). He/she should also not be under the influence
of ‘substance abuse’ or any situation caused by a general medical condi-
tion.
5. The SA should sign the informed consent form.
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422 Kamil Alptekin and Veli Duyan
The exclusion criteria included the following:
1. The suicide attempt was a result of an accident.
2. The SA claimed that his/her act was not a suicide attempt.
3. The SA’s cognitive and emotional condition is weakened and is un-
able to continue the interview (for example, not able to think clearly, is
too exhausted, depressed or angry to talk, is in a constantly aggressive
state, and so on).
Initially. twenty five individuals brought to the Hospital for attempted
suicide between June 1, 2006 and July 18, 2006 were selected for the sam-
ple. Among these, four individuals refused to take part in the study. There-
fore, the remaining 21 individuals (16 females and five males) comprised
the study sample. The hospital staff psychiatrist was consulted for finalis-
ing the criteria for selecting the SAs.
The average age of the study sample was 23 years. Of these, 12 were sin-
gle, 6 were married, 2 were divorced and 1 was a divorcee. While among
these, 3 were still in school, 6 were primary school graduates and 7 were
high school graduates. Except for one female SA, who lived with her
friends, the rest lived with their families (12 in nuclear families, 4 in ex-
tended families and 4 in single-parent or fractured families). Among these,
12 were not actively employed. The remaining were employed in the pri-
vate sector and included a sales clerk, secretary, salesperson, casual la-
bourer, doorkeeper, and gas station attendant.
Finally, none of the SAs had any physical disabilities. However, six of
the female SAs had received ambulatory psychiatric treatment and three
SAs were still under medication. None of the participants were under the
influence of any substance abuse. Only 3 male participants consumed alco-
hol. During the course of the previous year, seven female SAs had visited a
physician for physiological complaints, while two (one male and one fe-
male) consulted a physician for psychological complaints. Lastly, 6 SAs
had relatives with a history of suicide and 4 had family members who had
attempted suicide in the past.
Data Collection Process
The study was carried out in conjunction with the first Psychiatric Clinic of
the Ankara Numune Training and Research Hospital, which is an ’adjudi-
cator hospital’. This hospital is one of the biggest and easily accessible
general hospitals located centrally in Ankara, Turkey. Moreover, it is also
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A Study of Young Adults who Attempted Suicide in Turkey 423
one of the hospitals to which suicide attempters are generally brought to for
treatment and recovery.
Study procedures were patterned after, and followed the guidelines es-
tablished by the basic operations of the Emergency Service.
Following procedures were thus applied to each SA:
Every morning at 09:15 a.m., the attending physician and the
researcher met in the Emergency Service section and together visited
the Observation Room.
The Emergency Internal Medicine Polyclinic physician and the
attending nurses provided preliminary information on the condition of
the patient on admission, his/her treatment, and other details including
his/her medical chart and file to the concerned medical personnel. The
physician and the researcher continue to wait in the Observation
Room.
The SA visited the attending physician in the Observation Room.
During this visit, the physician conducted an interview with the
SA to determine whether he/she could be included in the sample.
Once the attending physician had certified that the SA could be
included in the study, the researcher informed him/her about the aim
and procedures of the study.
The SA was then asked if he/she was willing to participate in the
study. If the SA agreed to participate in the study agreed, he/she was
asked to read and sign the ‘informed consent form’.
The participant SA was also asked to fill the ‘Socio-demographic and
Medical Information Form’.
The method of interview and recording the information were
determined in accordance with the participant SA’s wishes.
The Interviews
The interviews with the SAs were carried out in the Emergency Service
Observation Room at the time of discharge. The interviews were based on
a structure that included directive approaches, within the framework of the
‘Semi-Structured Interview Form’. Suitable measures were adopted by the
researchers to maintain a flexible approach while engaging the respondents
in a conversation for at least a minimum of 32 minutes. Care was also taken
to keep the environment free of all distractions.
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424 Kamil Alptekin and Veli Duyan
The discussion during the interviews were focussed on the
themes/thoughts related to the period around the suicide attempts. Questions
were asked in the order listed in the Interview Schedule so as to protect their
content and to enable the comprehension of the SAs. Each word and re-
sponse of the respondent was observed and noted. Careful and detailed ob-
servations were made of the behaviour, sincerity of expressions expressed
and emoted, their intonation and gestures. If a question triggered any appar-
ent nervousness or stress, the researcher would quickly skip to the next ques-
tion. If the answers were vague, further probing questions were asked for
clarification. Depending on the SAs’ preference, 15 of the interviews were
recorded, and notes were made on paper for the remaining six.
Analysis
The content analysis of the interviews revealed the central and related themes
leading to the suicide attempt. As per Creswell’s (2003) guidelines, the data
was analysed in 6 phases. During the first phase extensive literature review
was undertaken with a view to understanding the structural features and mean-
ingful elements of the phenomenon of suicide attempts. The base information
from each interview was collated to fit in with the aim and the conceptual
framework developed for the study. The incidence of the attempted suicide
was studied in three parts for a better functional understanding:
Pre-attempt (the period before the suicide was attempted and the
developmental process).
The attempt.
Post-attempt.
During the second stage the Case Process and Evaluation Form for each
individual was filled out. These were based on the daily interviews and each
suicide attempt was studied as a separate unit. The chapters of the report
comprised the following: (a) The base information: Socio-demographic and
medical data, (b) Aim of the study, (c) Process of the study, (d) Case brief
and (e) Evaluation and Conclusion.
In the third stage, interviews were transcribed and the data were coded with
respect to the general categories and themes previously determined. Special
care was taken to ensure that all interview notes were reorganised and all audio
recordings transcribed verbatim within a month of the interviews.
In the fourth stage, the data were gathered into one frame for
defragmentation and qualitative analysis. Further sub themes were created
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A Study of Young Adults who Attempted Suicide in Turkey 425
and those not compatible with the categories listed in the pre-attempt pe-
riod were relocated to other periods. The conceptual frame developed for
the study is presented in Table1.
In the fifth stage supported by the SAs’ expressions the contents of the
themes and subthemes were explained.
In the sixth stage specific aspects of the suicide attempt and the factors
responsible for the individual attempting suicide were evaluated.
TABLE 1 : Thematic Frame
Category Theme
Category
Sub
Theme
Sub theme
Personality trait
y
s wit
s
h positiv
h
e element
e
s
_ . , ,. Personalit
Personality trait
y
s wit
s
h negativ
h
e element
e
s
Perceived
Perceive personalit
d
y
personalit trait
y
s
traits
Personality traits including both positive
Personality traits including both positive
an
and negativ
d negative element
e elements
s
Characteristic o
c
f famil
f
y relation
y
s
Attitude o
e
f parent
f
s
Family lif
y
e
lif
Troubled membe
d
r o
r
f th
f
e famil
e
y
Extensive marriag
e
e problem
e
s
Opportunity t
y o hav
o
e friend
e
s
Relations wit
s
h socia
h
l
socia circl
l
e
circl Relation
e Relations with the opposite sex
Preventive an
e
d saviou
d
r rol
r
e o
e f friend
f
s
Absenteeism a
m t schoo
t
l
Lif
Life prio
e
r
prio Schoo
r
l
Schoo lif
l
e
lif Positio
e
Position o
n
f bein
f
g a
g trouble
a
d studen
d
t
to suicide
Attitude o
e
f schoo
f
l administrator
l
s
attempt
attempt
Stressful wor
l
k environmen
k
t
Work lif
k
e
Difficult
Difficulty i
y in balancin
n balancing differen
g different area
t areas o
s of lif
f life
e
Insufficient source
t
s o
s
f suppor
f
t
Coping wit
g
h
wit an
h
d
an solvin
d
g
solvin .
g
.
Palliative measure
e
s t
s o solv
o
e problem
e
s
problems
Existenc
Existence o
e of childre
f children i
n if marrie
f married
d
Anger
Anxiety
Emotional stat
l
e
Hopelessness
Shame an
e
d guil
d
t
Mentioning suicid
g
e
suicid Direc
e
Direct mention o
n
f suicide attempt
attemp
attempt Indirec
t
Indirect mentio
t
n o
n f suicid
f
e attemp
e
t
No mentio
o
n o
n
f suicid
f
e attemp
e
t
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426 Kamil Alptekin and Veli Duyan
Category Theme
Category
Sub
Theme
Sub theme
Quarrel
Being abandone
g
d
Triggering factor
g
s
Revealing a
g secre
a
t relationshi
t
p
Failing th
g
e clas
e
s
Had thought
d
s o
s f suicid
f
e 5
e minute
5
s befor
s
e
the attemp
e
t
Had thought
d
s o
s
f suicid
f
e 1-3hour
e
s
1-3hour befor
s
e th
e
e
attempt
Thoughts o
s f
o suicid
f
e
suicid .
e
Ha
Had thought
d thoughts o
s f
o suicid
f suicid ee mor
moree tha
thann 3
3 hour
hours
s
before th
e
e attemp
e
t
Thinking o
g f lif
f
e
lif an
e
d deat
d
h togethe
h
r
Problem solvin
m
g
Purpose o
e f
o suicid
f
e
suicid Punishin
e
Punishing
g
attempt Easin
t
Easing menta
g
l pain/burde
l
n
Expressing hur
g
t feeling
t
s
Life prio
e
r
prio ,
r
. f
Took action after making a plan
. Took action alter making a plan
to suicide
Planning suicide attempt
to suicide Planning suicide attempt
Took action without making a plan
attempt
attemp Too
t
k action without making a plan
Own hous
n
e
Time an
e
d plac
d
e o
e f
. . IIn
n a
a relative s
relative’s hous
house
e
suicide attempt
suicide attempt
In a place outside the house
In a place outside the house
Had knowledg
d
e abou
e
t th
t
e metho
e
d
Choice o
e
f th
f
e metho
e
d
, . . . Wa
Was able to estimate the fatality of the
and it
d s
it ratin
s
g
ratin i
g n
i term
n
s
term o
s f
o
„ ,. metho
metho d
d
fatality
Had n
d o knowledg
o
e abou
e
t th
t
e metho
e
d
Active hel
e
p seekin
p
g
Seeking hel
g
p t
p o
t surviv
o
e
surviv Passiv
e
Passive help seeking
Active an
e
d passiv
d
e hel
e
p seekin
p
g
Felt regre
t
t
Reactions t
s o havin
o
g
. . Ha
Hadd n
noo regre
regret
t
attempted suicide
attempted suicide
Had complicated thoughts and feelings
Had complicated thoughts and feelings
Reaction o
n of f th
the e famil
family y Protectiv
Protective and supportive attitude
and environmen
d
t
environmen Repudiativ
t
Repudiative attitude
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A Study of Young Adults who Attempted Suicide in Turkey 427
Ethical Considerations
The approval for the research study was taken from the Ethics Committee.
Informed written consent for participation in the study was taken from all
the SAs. The SAs were free to refuse or quit an interview at any time. They
were also not obliged to answer all the questions. The SAs were also as-
sured of strict confidentiality and privacy. The researchers also ensured
that a female physician was present as an observer.
FINDINGS
The findings are derived from the analysis of the discussions of the period
before and after the attempted suicide. Information was gathered from the
participants in the following manner: six months before the attempted sui-
cide, the duration of six hours before the attempted suicide and two hours
after the attempt.
I. SAs’ Lives Before the Suicide Attempt
Perceived Personality Traits: Almost half of the SAs defined themselves
as positive individuals. The statements made by them included adjectives
and phrases like “well-intentioned”, “benevolent”, “cheerful-merry”,
“lively”, “hardworking” and “competent.” Nevertheless, a few other SAs
indicated that they exhibited some negative personality traits which eluded
to suicidal behaviour. They used terminology like “inability to control my-
self”, “introversive”, “self-destructive”, “nervousness”, “shyness”, “con-
tradiction-mental alienation”, “sentimentality”, and “being useless”. In
addition, some SAs indicated that they had both positive and negative per-
sonality traits.
Family Life: All the SAs narrated their life-stories and the unfolding of
events that lead to the suicide attempts. Barring four participants, all the re-
maining SAs indicated problems in interaction with family members. They
expressed in detail the characteristics of family relationships, attitudes of
parents towards them, the perception of family members towards them and
also how family members have been the source of discontent in their mar-
riages and personal lives.
An interesting aspect that came up in this study is the nature of family
dynamics experienced varied according to the type of family one belonged
to. SAs living in nuclear families had tense and confrontational relation-
ships with their spouses and/or parents. Four SAs, who lived in ex-
tended/joint families, experienced distinctive hierarchy related problems
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428 Kamil Alptekin and Veli Duyan
that jeopardised relationships. While, extended families are generally pro-
tective and supportive, they can also be very restrictive as family members
exert undue pressure to conform to behaviour that limits freedom of ex-
pression and movement.
Additionally, four SAs lived in fractured families, considered to be a
risk factor for those contemplating suicide (Retterstol, 1993; Odað, 2002;
Haley, 2004). These families are characterized by degeneration in the fam-
ily order due to the absence of a spouse or parent. The absence of the per-
son who may have played a pivotal role in providing stability to the family
has led to lack of cohesiveness and bonding among individual members. In
such families, a simple problem could lead to a major crisis.
SAs between the ages of 18–22 years revealed that they were disturbed
by their parents’ over-indulgence or indifference, restrictive or authoritar-
ian behaviour, discrimination among siblings, and verbal assaults. The
SAs, who were disturbed by their parents’ negative attitudes, were ob-
served as being distant and aloof with their fathers and confrontational and
contentious with their mothers. Some SAs were considered to be the most
problematic persons in the family and were often scapegoated. Very often,
family members withdrew all emotional support and strict control was ex-
ercised over the movements and activities of these individuals. This led to
further alienation of the SAs from their families.
Furthermore, most SAs had relatively more constructive, sincere, and
stronger relationships with their siblings than with their parents. The SAs
bonded better with their siblings; this aspect of togetherness was mani-
fested during family quarrels or periods of crisis and transition. Depend-
ence on, and affiliation among siblings were an impressive finding of this
study. For this reason, positive relationships with siblings could be evalu-
ated as a factor to prevent suicide within the context of this study.
Finally, four of the six married SAs faced verbal abuse. The narratives
also revealed that lack of interest, trust and happiness between the spouses
contributed to marital problems. Rather than attempting to resolve their
problems among themselves first, the SAs sought the intervention of family
members. Sometimes, the SAs used their children as pawns to prove a point
or get even with each other. This led to further escalation of problems.
Relationships with Social and Peer Environment
The nature of relationships maintained by the participants can be categor-
ised into two types — advantageous (first group) and disadvantageous
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A Study of Young Adults who Attempted Suicide in Turkey 429
(second group). These groups emerged on the basis of personality traits,
parental attitudes and the status of the SA within the family (daughter or
wife, unemployed member of the family and so on). The SAs in the first
group expressed loneliness while those in the second group experienced
disempowerment and disorganised network of relationships.
During the interviews, a majority of SAs emphasised “relationships
with the opposite sex” as the precipitating factor in attempting suicide. Of
the 12 single SAs, 8 were involved in romantic relationships. The SAs
communicated that they found it difficult to keep their relationships and
feelings under control. A 18 year old high school male graduate SA stated
that he experienced many hurdles in his relationships.
Failed relationships with the opposite sex was emotionally taxing as the
SAs were unable to share their feelings of pain and dejection with friends
or family members. Helpless in the face of disappointment, anger and de-
spair, the SAs were drawn into an emotional crisis and further loneliness.
The SAs with a strong network of peers found emotional support in sin-
cere and concerned friends. Here, the friends played two distinct roles. Be-
fore the suicide was attempted, the friends played the role of “protectors”
and after the attempt as “saviours”. Although the friends could not prevent
the attempt to commit suicide, they were seen as instrumental in imparting
correct advise and offering moral support.
After the suicide attempt, some of the SAs sought help from friends,
rather than their families. In some cases, the friends immediately came to
their rescue. The role of the “saviour” was essayed by good friends in pre-
serving the lives of these SAs.
School Life: “Absenteeism”, “being a troubled student”, and “attitude of
school administration” were significant areas of discontent expressed by
SAs in school life. Familial problems resulted in poor attendance for some
SAs. A few had trouble adapting to school life and were considered as “trou-
bled students”. Some SAs opined that school administrators were unable to
recognise symptoms of emotional distress and crisis situations. On the con-
trary, instead of providing the already disturbed SAs with emotional and
moral support, the school administrators were antagonistic and reproachful.
Work Life: Employed SAs were under additional stress as they had to
deal with work pressure, leaving little time for family and romantic rela-
tionships. Trying to establish a balance between work and relationships put
the SAs under severe strain leading to a complete emotional breakdown.
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430 Kamil Alptekin and Veli Duyan
Resolving Problems: Encountering various problems, limited coping
strategies, weak network of friends and support systems left the SAs vul-
nerable to attempting suicide. Their loneliness was further compounded
with strained relationships with family members and practically non-exis-
tent relationships with neighbours.
Most of the SAs preferred to solve their problems by procrastinating or
isolating themselves from the environment. Many adopted temporary cop-
ing measures such as returning home late from work, not answering phones,
ending friendships suddenly, focussing on a different subject, leaving home
for a while during troubled times, hoping “that time will heal it all”, remain-
ing passive, or having a second baby. The researchers observed that married
SAs attempted to resolve marital problems by opting for more children. In-
terviews revealed that this was a strong motivating factor towards preserving
their marriage and fighting for survival. On the basis of this information, this
research strongly recommends further study into the area of “having chil-
dren” as a preventive measure for attempting suicide.
Emotional State: Chronic problems and accumulation of negative experi-
ences were the predominant factors leading to depression. Feelings of anger, ag-
itation, hopelessness, shame and guilt were experienced intensely by the SAs.
The researchers also observed that the past experiences further stimu-
lated and escalated their predominant emotion of suppressed anger to pre-
cipitating the suicide attempt .
Some of the SAs were nervous. The nervousness stemmed from the
problems generally related to relationships with their spouses, parents or
partners. As observed in all suicide studies, hopelessness was one of the
most frequently experienced feelings articulated in this study. Cognitive
beliefs such as failure to resolve problems alone, inability to foresee a
bright future or a way out, losing trust in people and perceiving self as a
“loser”, led to feelings of hopelessness. Besides, some of the SAs were
subjected to feelings of “shame”, stemming from “being humiliated”, “suf-
fering from affront” and “being condemned” while undergoing personal
feelings of guilt as they “held themselves responsible”.
Disclosing the Intention to Commit Suicide: Twelve of the SAs had not
disclosed their intention of attempting suicide to anyone. The others who
stated their intention, did it directly or indirectly. Those who did declare
their intention to commit suicide directly also implied that they wanted to
take precautionary measures and were hesitant to take the drastic step.
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A Study of Young Adults who Attempted Suicide in Turkey 431
II. The Lives of the SAs during the Period of the Suicide Attempt
Triggering Factors: Data gathered from the interviews helped determine
the triggering factors for attempting suicide. Except for two individuals, all
the other SAs stated that “quarreling”, “being abandoned”, “exposure of a
clandestine relationship” and “failing the class”, were the predominant
triggering factors.
Thoughts of Suicide: The researchers also found that that thoughts of
suicide differed in terms of frequency, intensity and duration. Analysis of
the statements made by the SAs showed that thoughts of suicide occurred
in the period between the onset of the triggering factor and the moment of
attempt. The duration of the period was usually less than three hours. Some
of the SAs had also seriously contemplated suicide earlier. It was observed
that they were caught at the crossroads of the desire to survive and the wish
to die. A study conducted earlier had established that the period between
individual’s thought of suicide and moment of suicide attempt is less than
five minutes. Based on this finding, only three attempts in this study could
be termed as typical impulsive behaviour. Four of the five SAs, who had
thoughts of suicide in the past, have had ambulatory psychiatric treatment.
This finding shows that if a psychiatric disorder is not treated effectively,
thoughts of suicide can recur.
Motivation for Attempting Suicide: The researchers also found that the
inability to deal with problems drove the SAs to choose death over life.
Suicide seemed to be the only solution available to them.
Some of the SAs attributed their source of discontent to other individu-
als, while some acknowledged the problem was within them. In both cases,
the SAs wanted to punish themselves and the other concerned people.
Planning the Suicide Attempt: While six of the SAs stated that they had
planned the suicide attempt in advance, 11 of them had not done any plan-
ning. Due to the contradictory information provided by the remaining four
SAs, the researchers were unable to understand their thought patterns. Data
from the interviews also revealed that advanced planning included collect-
ing the requisite medicines, scouting the location of various individuals
living in the house, arranging a room in a hotel and also waiting for all
members and residents of the house to fall asleep. It was also noted that the
the SAs attempted suicide when suicidal ideations were at their peak.
The Time and Place of the Suicide Attempt: Most of the attempts took
place in the SAs’ houses when at least one of the household members was
IJSW, 72(3), 419–440, July 2011

432 Kamil Alptekin and Veli Duyan
in the vicinity or was about to get home (between 18:00-20:00 hours). The
preference for choosing the home as the venue for suicide suggests that the
SAs must have considered the possibility of being rescued, by design and
not by coincidence. Very few of SAs who attempted suicide chose places
like the “boiler room (heating plant)” or a “hotel room”. This data indicates
lack of intention and commitment to end life.
Choice of the Method Employed and its Rating in Terms of Fatality: All
SAs chose to “overdose” on medication. One female and two males cut
their wrists slightly, one female left the gas valve open and two males
drank excessive amounts of beer. These six SAs also had felt the need to in-
form people around them that they were in a difficult situation and needed
help. They also expressed the wish to be considered more seriously by the
people around them.
On the basis of the methods employed, the SAs could be categorised
into three groups. The first group included the SAs who consumed an over-
dose of medicines and were knowledgeable about their effects. The second
group took an overdose of medicines on the basis of estimated knowledge.
The third group included those who had no knowledge about the medicine
or the amount to be taken.
III. The SAs’ Lives after the Suicide Attempt
Seeking Help to Survive: Except for three SAs, all the others sought help im-
mediately after the suicide attempt. More than half of the SAs either sent text
messages to family members and friends to “say goodbye” or called some-
one shortly after the attempt or quickly went to the emergency service by
themselves. Some SAs sought the attention and help from family members
indirectly by making veiled threats of imminent danger or the possibility of
an untoward event/accident that was about to take place. Care was also taken
by the SAs to attempt suicide in a visible place. Alternatively, empty medi-
cine boxes were intentionally thrown around to ensure detection.
Responses of the SAs: The researchers observed that most of the SAs re-
gretted the suicide attempt. These SAs considered their actions irresponsi-
ble. Some of the SAs had no regrets and implied that they would try it
again. Another group of SAs, who were obviously very distraught after the
event, were unable to comprehend what they had done. These SAs felt
hopeless and were observed to have confused feelings and ideas.
Reaction of the Family and Environment: One or two family members
of the SAs were aware of the suicide attempt as the incident had taken place
IJSW, 72(3), 419–440, July 2011

A Study of Young Adults who Attempted Suicide in Turkey 433
at home. The family member, who made the initial contact with the SAs
was initially frightened and nervous. However, after the initial anxiety, the
family member was protective and supportive towards the SA.
Some SAs disclosed that they did not receive much support or empathy
from family members. On the contrary, they were exposed to harsh verbal
abuse and insults. This harsh attitude from family members only resulted in
further aggravating their despair and prolonging the SAs’ existing feelings
of helplessness, fear and nervousness.
DISCUSSION
This study tried to understand why individuals attempted suicide as a solu-
tion to end all problems. The researchers found that a combination of vari-
ous factors played a role in the final decision.
Suicide attempts can be understood within their own psychosocial con-
texts and provide a framework for understanding the formation/develop-
ment process. Given these common points, the researchers developed a
formation/development framework for suicide attempts (Figure 1).
The SAs generally lack social support and have poor problem solving and
coping skills. They also experience interpersonal relationship problems as
manifested in their interactions with friends, family members or school ad-
ministration. Unresolved problems give rise to feelings of anger, anxiety,
hopelessness, shame, and guilt leading to depression. In the face of such feel-
ings, the SAs are thrown into a vortex of helplessness and unbearable mental
agony, which eventually triggers the decision to attempt suicide.
Although the arrows located in the framework show the interaction and
flow direction of factors triggering the attempts, they usually overlap and
proceed in a cyclical way. When the framework is examined, “interper-
sonal relations” come to the fore as the major determinant factor in the
SAs’ tendency towards attempting suicide.
“Relations with the opposite sex” is located at the centre of interpersonal
relations. Erickson’s Psychosocial Development Theory places the devel-
opmental stage (young adulthood) at the centre of interpersonal relations.
When developmental functions are not fulfilled as stated in Erickson’s the-
ory, young adults experience isolation and also wish to be alone. Feelings
of isolation is a potential risk factor for suicide behaviour (Haley, 2004).
Findings show that imbalanced and unhealthy relations with the opposite
sex can lead to feelings of isolation.
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434 Kamil Alptekin and Veli Duyan
FIGURE 1: Family Life
IJSW, 72(3), 419–440, July 2011

A Study of Young Adults who Attempted Suicide in Turkey 435
Data gathered for this study has revealed that most of the SAs have weak
social support. Interpersonal relationships with relatives is very poor and
practically non-existent with neighbours . Strained relationships lead to in-
adequacy and low self-worth and detrimental to resolution of problems.
Hence, SAs are unable to find effective/permanent solutions to their prob-
lems. In fact, establishing relations with the people in the immediate vicin-
ity is very important to gain social support and enlarge social network. As
Haley (2004) points out, enlargement of social network increases the pos-
sibility of preventing suicide behaviour.
Another interesting finding in the study is the emotional state of the
SAs. Their emotional state reflected the nature of problems experienced by
them. Many of them had been through long periods of low mood and de-
pression. An important point to be highlighted here is that a continuous
negative emotional state, is a significant factor during and after the suicide
attempt.
Harrera, Dahlblom, Dahlgren and Kullgren (2006) determined the emo-
tional state as an important factor in the SAs’ inclination to attempt suicide.
They categorised these feelings into seven groups — shame, guilt, feeling
of being on the edge, being refused, lack of relatives, transformed love and
lack of confidence. Gair and Camilleri (2000), in another study, deter-
mined that the SAs experienced feelings of hopelessness, exhaustion, guilt,
depression and being lost . The most frequent feelings expressed in this
study were anger, anxiety, hopelessness, low self-esteem, shame and guilt
respectively.
Various studies have shown that when individuals undergo a crisis,
any one factor may trigger the attempt to commit suicide. Ertemir and
Ertemir (2003), in their study on the characteristics of youth’s suicide at-
tempts, determined that a trigger factor had an influence on 26 cases out
of 3 1 . In this study, the primary triggering factors were quarrels with sig-
nificant others (65.38%) and quarrels with parents (30.76%). Özgüven,
Soykan and Haran (2003) determined that the most frequent trigger fac-
tor in the cases of suicide attempts are “quarrels.” The results of this study
also corroborate data available in existing literature. More than half the
suicide attempts were triggered after a quarrel with either parents or part-
ners.
Odag (2002), stated that all suicide attempts have a single purpose of
ending life. Although suicide attempts seem to be about self-harming and
destroying one’s own life, they also have corollary effects on expansive,
IJSW, 72(3), 419–440, July 2011

436 Kamil Alptekin and Veli Duyan
complicated and numerous factor networks, which surround them. Other
studies have also supported Odað’s views. For example, Harrera and others
(2006) determined that female SAs attempt suicide not only to bring an end
to their own lives but also to solve or escape from their problems. Suicide is
seen as a solution to all problems when SAs are unable to cope with diffi-
culties in school or work place and health, inadequacy in communication
and social integration, inability to achieve goals in life, and so on. Wyder’s
study (2004) focussed on causes and events triggering suicide attempts.
The reasons include: 1) inability to cope with a problem or stressor, 2) in-
ability to deal with rejection or refusal, 3) as a means to putting an end to
mental agony, 4) mental illness, 5) under the influence of alcohol or other
substances.
The findings of this study also highlighted “solving a problem”, “pun-
ishment” or “easing mental agony” as reasons for attempting suicide. Their
actions can be evaluated as: a) need to demonstrate their helplessness in
finding a way out of their problems/social environment in a radical and
striking way or b) need to express uncontrollable/unbearable feelings of
anger and anxiety with a risky action.
The study has also focussed on the efforts of the SAs to “seek help to
survive” after the suicide attempt. Gülec and Aksaray’s (2006) study
showed that half of the SAs (32 cases out of 63, 50.8%) sought help after
their attempts. Seeking help after the attempt can be seen as an indication
of SAs not being completely disconnected from life and a declaration of
their willingness to communicate.
Findings from this study also suggest that having a dependable friend, soli-
darity among siblings and existence of children below the age of three could
be considered as preventive factors. Gair and Camilleri (2000) proposed that
friends play an important role in preventing suicides. Quin, Agerbo,
Westergard-Nielsen, Eriksson and Mortersen (2000) added that being parents
of children of the age of two years and below decreases the risk of attempting
suicide. It is important to keep these aspects in mind to prevent suicides.
IMPLICATIONS FOR INTERVENTION
This research study focussed solely on interviews of SAs brought to the
emergency services for medical aid. Although, the researchers did not con-
duct the interviews for the purpose of counselling or treatment, it was
found that the interaction had a positive impact on the SAs. These inter-
views were conducted in a non-threatening, empathetic, supportive,
IJSW, 72(3), 419–440, July 2011

A Study of Young Adults who Attempted Suicide in Turkey 437
trusting and respectful atmosphere. Observations were made on the impor-
tance of the psycho-social dimension in treatment, once the medical condi-
tions were taken care of. It is important to thoroughly understand the
psycho-social dimensions of each individual case, before initiating any
form of psychotherapy.
Emphasis should be on the inclusion of family members in the treatment
plan. Special care should be taken of SAs who are not in a position of con-
trolling or wielding power in the family hierarchy. These include house-
wives, daughters and unemployed individuals.
Suicide prevention programmes in Turkey are limited to interventions at
the secondary and tertiary level. However, it is clear that interventions
based on secondary and tertiary studies, cannot prevent or reduce suicide
behaviour. The problem should be addressed at the community level. In
this respect the findings of the research show that difficulties experienced
at school including continuity of education, failure or repeating the same
class, listening to verbal insults from teachers and managers, and inability
to fit within the class environment can have severe psychological repercus-
sions on the mental health of individuals, thus pushing them towards con-
templating suicide. In such a scenario, more school-based studies
focussing on young people should be conducted for preventing or reducing
suicidal behaviour at the primary level.
LIMITATIONS
1. Since the sample of the study has been established according to the in-
clusion/exclusion criteria, the findings are valid only for the sample
group.
2. There are various biological, psychiatric and psychosocial dimensions
to attempted suicide. This study focussed on the psychosocial rather
than the biological and psychiatric context of suicide behaviour.
3. This study is limited to the time determined for “suicide attempt periods.”
4. During the course of this study, the researchers realised that it was im-
possible to conduct more than one interview with the sample group.
Therefore, data is restricted to information gathered from single inter-
views with the subjects in the Emergency Service Observation Room.
Limitations in this study bring forward the need for new qualitative
studies on this subject. In future studies, a more homogeneous (for in-
stance, single unemployed women between the ages 18–24) and a smaller
IJSW, 72(3), 419–440, July 2011

438 Kamil Alptekin and Veli Duyan
sample should be studied with in-depth interviews. Moreover, every op-
portunity should be seized to carry out more than one interview with the
subject. These studies should also focus on the social sources of stress/bur-
den that people face in their daily life. The relationship between suicide at-
tempts and the socio-cultural structure/reality should be evaluated
simultaneously. This will pave the way for understanding how living in
difficult circumstances merge with private/subjective realities at the indi-
vidual and societal level, and trigger suicidal behaviour (Alptekin and oth-
ers 2006).
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