Linking life- and suicide-related goal directed processes: a qualitative study.

Note: A shorter version of this article was presented at the Conference of the European Society for Suicide Prevention, Copenhagen, 2004.

Previous analyses of the narratives of 40 persons hospitalized in a general hospital after suicide attempt found that they described their suicide attempts as goal-directed processes, sometimes planned in advance, sometimes executed spontaneously. They also described short-term actions, mid-term projects, and long-term careers reflecting goal-directed processes related to maintaining and developing their lives. In this qualitative study that reports on a re-analysis of these data, the research participants' narratives were examined for links between life-related and suicide-related goal-directed processes. The analysis followed a distinction between a goal-directed view of suicide processes and a dynamic systems view. The findings indicated that some links were goal-directed and consistent with the reasoning of life-maintaining projects. These "top-down" links between life-related and the suicide-related goal-directed processes reflected the goal-directed view of suicide processes. Other links indicated a substantially limited capacity for goal-directedness, reflecting the "bottom-up" dynamic systems view. Finally, it third group of links reflected a mix of "top-down" and "bottom-up" processes. Implications are offered for mental health counselors working with suicidal clients.

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Suicide acts, despite their high rates and repeated occurrence, are extraordinary events. Some authors (e.g., Maltsberger, 2004) indicate that suicide involves a complete break down of any order in the person's life. Others (e.g., Maris, 1981) suggest that suicide is part of long-term, orderly processes. We need to unpack this apparent dichotomy in terms of both breakdown and orderly processes as they are experienced in clients who have attempted suicide.

The present study uses an action theoretical view of suicide acts and the processes that precede suicide. This view is premised on an understanding of suicide as goal-directed action (Michel & Valach, 1997). Like other everyday human actions, suicide attempts and other self-destructive behaviors involve the intentional and goal-directed actions of the person both in the short-term, self-destructive act itself, and in longer-term projects and careers of which the self-destructive acts are a part. Michel and Valach (2001) showed that self-destructive and suicidal processes could be seen in terms of joint goal-directed action. The "processes" we refer to in this article include actions, projects, and careers and their associated verbal and non-verbal behaviors, cognitions, feelings, and social interactions. This term applies equally to processes that are life-affirming or life-destroying. In as much as these processes are related to each other, we can also refer to them as a goal-directed system.

In the reports of research participants after a non-lethal suicidal act, we were able to identify short-term suicide actions, mid-term suicide projects, and a long-term suicide career, all of which the participants constructed as goal-directed processes (Valach, Michel, Young, & Dey, 2002). These narratives referred to both suicide-related and life-related processes (that is actions, projects, and careers related to life instead of to suicide).

The specific question addressed in this article is how persons, after a suicide attempt, link suicide-related and life-related processes, that is, how they switch between their life goal-directed system and their suicide goal-directed system. The linking of these processes is a segment in the stream of actions that allows a quick switch from being engaged in one system to pursuing another. This phenomenon has not been investigated extensively. Specifically, in terms of the narrative of a suicide attempt, we identify this link in the case when an action of an everyday project is suddenly followed by an action related to an existing suicide project.

It is hypothesized that the links between suicide-related and life-related processes may occur in one of two ways. First, the link may be organized as "top-down" steering and control in which both sets of processes are linked within the explicit goal-directed system (see Figure 1). Here, the person may have decided at some previous time to attempt suicide. The link is clear to the person at the time of the attempt and seemingly rational. This type of link is anchored conceptually in the goal-directed perspective described above.

[FIGURE 1 OMITTED]

Second, suicidal processes can also reflect bottom-up steering or control of a suicide action by the person who is attempting suicide. In this case, the suicide action is described as starting with smaller component parts and gradually building up to the larger units and is contrasted to top-down processes that begin with larger units and then proceed to smaller units. In bottom-up processes, the links are suggested to occur in processes of a lower order in goal-directed action, that is, words, phrases, movements, images, perception of environmental features, or sudden feelings rather than goals or long-term plans. This perspective captures the unconscious processes or responds to a momentary pull or impulse that is critical in the suicide attempt. However, this bottom-up process still occurs in the context of life-maintaining processes, which are expected to contextualize the person's narrative. Thus, the term "bottom-up" steering indicates a process in which the specific behavioral elements appear first and the higher order processes such as goals are developed later. Bottom-up steering is reflected in the terms "affective," "emotional" or "impulsive" suicide (Simon, Swarm, Powell, Potter, Kresnow, & O'Carroll, 2001; Williams, Davidson, & Montgomery, 1980) as distinct from the term "rational" suicide that is often used in everyday language and in law for a suicide action that was not planned in advance and was executed under strong emotion in a specific stressful situation. This perspective is captured in dynamic systems theory (Vallacher & Nowak, 1997).

The purpose of this research is to unpack the link between life processes and suicide processes using the notions of "top-down" and "bottom-up" steering we have described. The bottom-up launching of a suicide-related process may be one particular way of getting involved in a suicidal attempt, but not the general rule. Even more, we suggest that suicide- and life-related processes are both goal-directed processes. The link between suicide- and life-related processes reflects either the goal-directed system or the dynamic system, described above. If suicide-related and life related processes co-exist, it would represent a substantial challenge to the conception of suicide as disengagement (e.g., Carver & Scheier, 1998). These explications will be illustrated with the patients' narratives following a non-fatal suicide act.

METHOD

In this study we were interested in eliciting a narrative of the suicide attempt and related actions in the context of a psychotherapeutic interview. This narrative gave us access to the construction of the suicide act and related projects and careers and to their associated goal-directed processes.

Participants

A consecutive sample of 40 persons, hospitalized because of the health consequences of their suicide attempts comprised the participants in this study. As they were hospitalized in a general hospital in a Swiss city, they represented a non-random sample of the general population of suicide attempters in the area. Their education spanned from compulsory schooling to university degree, and their occupations from university student, home keeper to unemployed labourer. Citizens of foreign countries were underrepresented (instead of the expected value N=8 (20% inhabitants in Switzerland are of foreign nationality), there were only 4 foreigners in the sample). A few days after their attempt, a psychotherapist invited them to participate in this study. Their participation was explained as consisting of talking to a psychotherapist about their suicide attempt. The participation rate for the study was reasonable (40 recruited clients out of 162 treated in the hospital after a suicide act in that year), although we did not attempt to obtain a representative sample. The only systematic selection bias occurred when some of the persons who had been admitted to the inpatient general hospital where they would have been recruited for the study were relocated to a psychiatric hospital prior our request, and thus not available to be interviewed. Consequently, we did not have any persons diagnosed with an acute psychotic disorder. The sample consisted of 25 women, 15 men (mean age = 42 years, range 17 to 80 years). The interviews were conducted by psychotherapists, eight of whom were medical doctors and one a psychologist. The narratives of two research participants could not be analyzed in regard to the target issues for various reasons and thus were not included in this report, leaving a final sample size of 38.

Setting

The interviews were conducted in a psychiatric outpatient clinic, a building about 100 meters away from the hospital emergency ward where the research participants were in care. In the interview room, the research participants were exposed to two video cameras, two video recorders, and two large TV monitors. Nevertheless, the setting was private and calm.

Procedure

The interview, in which the clients were asked to describe how it came about that they had attempted suicide, lasted 30 to 60 minutes and was video recorded. The research participants were encouraged to talk about everything they considered relevant to their suicide attempt. The interviewers prompted them for details, asked them to clarify unclear points, and were emphatic, non-evaluative, and emotionally supportive.

Ethical Considerations

This project was supported by the Swiss National Research Foundation. It was approved by the relevant hospital departments, and by the ethics committee of the Swiss National Research Foundation. Following recruitment, the research participants were again informed about the procedure in every detail and asked to sign a permission to videotape the interviews. They were informed that these videotapes would be seen by project collaborators, transcribed and analysed for research purposes. They were also asked for permission to allow us to quote substantial parts of these interviews in an anonymous form in scientific professional publications.

Assumptions

In this study, we asked for the participants' narratives in an ecologically valid way. In effect, this interview was part of the participant's risk assessment for suicide. We believed that these participants could provide competent stories of their suicide attempt given the time and opportunity to do so. We also believed that these stories would contain the information the participants found important. We considered the present sample satisfactory for this method and for the evaluation procedure (i.e., risk assessment).

Analysis

Forty interviews were translated from Swiss-German to German, transcribed, and 38 were submitted to a content analysis. The quotations used in this report were then translated into English and subsequently "smoothed" to capture colloquial English expression. In this analysis, we identified descriptions of processes related to the suicide behaviour of the research participants and distinguished between long-term, medium-term and short-term processes which we labelled respectively as careers, projects and actions (Valach, Young, & Lynam, 2002). Actions were identified as short-term processes, mostly several minutes long during which the actual poisoning, jumping, cutting or shooting occurred. Projects covered a middle ground between these short-term actions and the nearly lifelong processes we refer to as careers. For example, when a research participant described processes in which she was trying to determine, over a period of time, whether an existing relationship was really beneficial for her, it was labelled as a "project." The time span in which all the relationships to a boyfriend occurred or, rather, the social-action systems of relationships would be understood as a relationship career.

Within each of these goal-directed systems (career, project, action), we identified goals, functional steps, and elements of these processes. Goals could be long-term, midterm, or short-term. The analysis then identified the series of steps that the research participant used to accomplish these goals. Finally, we identified a number of features of these action steps, that is, action elements, which could be defined in physical terms, for example, time, and physical objects involved. As we identified the person's suicide related actions, projects and career as well as those related to his or her everyday life, we also identified the links between these life-related and suicide-related processes by searching for statements describing how the person switched between their ongoing life-related processes to their suicide-related processes. If this switch was informed by a goal consideration, we labelled it "top-down," if the suicide action was launched by more momentary processes, for example, by the availability of the means of attempt in a moment of despair, we registered these as "bottom-up" processes.

FINDINGS

In the narratives generated in response to the question of how it came about that the person had attempted suicide, the research participants described their non-fatal suicide attempts as actions and related these attempts to mid-term projects and long-term careers. They also described a series of actions that were part of life-maintaining projects and careers, but which suddenly became part of both a suicide-related project and career. Most of the research participants described mid-term suicide-related projects that they constructed as part of a suicide-related career in their lives. However, we also found that there was a link between, or switch from, life-maintaining actions and projects to suicide actions and projects (see the clients' narratives below).

We observed these links in the narratives of suicide processes where an action describing an everyday project was suddenly followed by an action related to an existing suicide project. For example, a middle-aged woman and mother of two school-aged children, while feeling more and more disoriented that day, ate yoghurt at one moment and then jumped from her balcony at another. A young woman, after being deserted by her boyfriend, was visited by her worried mother. She expressed hostile feelings toward her mother's protective attitude and after her mother left, she cut her wrists. Another young woman came home from work she hated, observed her female friend having a good time with her boyfriend, went to her bedroom and swallowed a large number of pills. A middle-aged woman took a taxi to a cliff behind her village, sat there, and after seeing her husband's car, "let go" and fell into the gorge. A young woman after a number of arguments with her boyfriend, who repeatedly left her only to come back a few days later to tell her that their relationship was over, saw pain pills on the table and took a large quantity of them.

In this analysis, the research participants' narratives addressed the actions prior to the suicide behavior, the link to a suicide action and project, and finally, the suicide action itself. Analyzing the descriptions of the links, that is, how the clients changed the course of their actions from life-oriented to death oriented, we were able to distinguish three types of links following the "top-down" and "bottom-up" typology described earlier. First, some links reflected a "top-down" steering and control, characteristic for goal directed processes (n = 17 of 38 cases). These research participants reported a conscious decision to attempt a suicide, including having the goal to attempt suicide and the choice of means. Second, bottom-up links occurred in 9 of 38 cases. These narratives reflected unspecified goals that the research participants were not fully aware of. For example, one research participant described cutting herself without wanting to kill herself and then, in the course of cutting, she suddenly cut herself in a manner that endangered her life. In these cases, the persons often launched the suicide action by utilizing behavior that is exhibited by persons with disordered executive functions. For example, persons with disordered executive functions may take and use a toothbrush if it were placed in front of them, even if there is no need to brush one's teeth. However, the bottom up launching of suicide action could be triggered either by contextual external or by behavioral and internal features. Finally, in some cases the suicide action seemed to be launched by a mixture of "top-down" and "bottom-up" processes (n = 12 of 38 cases). In these cases, the person used goal considerations that led to an action step (as in top down processes) as well as engaged in the suicide process without a clear goal, including what the end state of the action was (as in bottom-up processes). In our sample we found that more women (7 of 23; 30%) than men (2 of 15; 14%) reported bottom-up links and more men (8 of 15; 53%) than women (9 of 23; 39%) reported top-down links. The distribution of mixed links across gender was about equal (7 of 15 women or 31%; 5 of 15 men or 33%). The following examples illustrate this typology of links.

Top-Down Links Between Ongoing Life Processes and Suicide Actions

Demonstrating the top-down link between ongoing life processes and suicide actions is this case of a middle-aged women.

Suicide preceding life-related actions. On Friday, [my husband] said he has to go to the office and he would be late.... I waited till 11 o'clock and then went to bed. On Saturday morning he was not there. I was worried. The roads" were icy and I thought that he had an accident. I went to have a look whether the car was there. It was not there. I opened the letterbox and found a message that he was going to come tomorrow when he would tell me more.... I left a message on his answering machine that he should call me. He rang and said that he needed this day [to himself]. He also wrote a letter. He spent the night in a hotel and promised that he was going to come Sunday night to have a look. I did the housework as [I do] every Saturday. I went to do the shopping.

The description of the husband's disengagement can be seen as a part of the ongoing partnership and, therefore, as a life-related action even though the research participant's further narrative shows that, for her, it was a prelude to a transition to her suicide related processes.

The link. I [had] made the decision to commit suicide a long time ago. Only the last straw was missing that broke the camel's back. I thought about it very often but I never had the courage.

Because of my illness (eating disorder) my husband was not able to go on like this any more. It was an unsolvable dilemma, a vicious circle, and he wanted to move out. That was decisive. I couldn't have imagined life without him.

His informing me that he couldn't stand it any longer and that is why he was leaving was the last straw. I was expecting this.

Suicide action. By this time everything was prepared. I went to have a look to see whether the material (the medication she overdosed with) that I prepared long time ago, perhaps half a year ago, was there or whether I would have to go to the pharmacist. I saw that everything was there. I was just checking whether there was enough.

It was in the morning before shopping. Then I did the shopping, cleaned the parrot's cage, and then I became frightened that he might not come [home] on Sunday night. I had to make sure that he is going to come; otherwise the parrot would die without food the whole week long. So I told him on the answering machine that I was starting therapy on Sunday morning. He should come in the afternoon to feed the parrot. So I was sure that he would come.

Then I covered the cage so that he would be quiet in the morning ... Then I switched the light off. Next morning he would see the food ... I wanted to lie down. I put two hot water bottles into the bed. He phoned to ask whether I really was going to therapy. He promised to come the next afternoon.

I went downstairs, took a glass and put the rolls of pills in the water. It was shortly after 11 because he phoned at 11.... I was ready ... I was sure that he was not going to come [home] before lunchtime.

The moment [of] getting into a warm bed was always the best part of a day. But I was not able to fall asleep. Normally, I could go to bed and fall asleep like a stone. I realized that my heart was beating fast.

... I started with the sleeping pills. There was a whole box. There were also some painkillers, some allergy pills. I simply took everything.

I had the feeling that there were about 20 sleeping pills and 30 painkillers. I know that I had a sudden thought after taking the sleeping pills, asking myself about the meaning of what I was doing.... I thought that I would have to get up and call the emergency physician to empty my stomach. But it was only a passing thought and it was quickly over.

I went on until everything was gone. I know that with the last box I was asking myself whether I had to take that as well.... I had the feeling that I needed it as well because it might not be enough.... I did not have any other thought. I just had had enough of this life, in this vicious circle.

It was clear to me that he was leaving me. There was so much damage done in the course of my illness and I was sure it was going to get worse. I felt that he was at the end of his power. He could not go on like this any longer.

I was not prepared to go to the hospital, which was the reason why my husband gave up.

He had arranged a hospital stay for me several times and I cancelled them, so he was disappointed.

The vicious circle meant that the course of the day was exactly planned and I had to vomit (because of an eating disorder) after every meal. It was three times a day following a special routine. Both of us could not stand it any more.... I wanted to end my existence.... That is what I wished and was waiting for. I understood that death was a possible consequence of me not eating for the last two years.

Once I had told my husband that I want to be buried at home.

I woke up during the night and realized that I had thrown up. Terrible, I thought, you are vomiting on the blanket. Then I couldn't remember anything. Then I remember that they were trying to insert a stomach probe.

Summary. The action that preceded the suicide attempt was the woman's husband leaving her. The link was that she indicated that she had decided a long time ago to die by suicide. She also prepared the necessary means for her suicide act and was only waiting for a situation to arise, which would give her the "last push." This situation occurred when her husband wanted to leave her. Then she proceeded in a rational way, took precautions, made sure that the details would not get out of hand after her death, and took pills. In her narrative, the link between her life-maintaining processes and the suicide goal-directed system was a goal-directed, top-down process. This woman had on-going processes in her life that were related to suicide, including thoughts, feelings, expectations, and plans. She was able to differentiate these processes as a distinct part of her life and ultimately they facilitated the suicide attempt. When these processes were consciously implemented, the suicide action followed. The processes involved were cognitively controlled and goal directed. The control and steering were top-down.

Bottom-Up Link Between Ongoing Life Processes and Suicide Actions Example 1

Demonstrating the bottom-up link between ongoing life processes and suicide actions is this case of a middle-aged woman.

Life-related and suicide preceding actions. There was an internal restlessness.... I asked my sister if I could come [to visit her] because I was not able to go to work because I was frightened that I might faint in the garden. I was afraid of fainting and never waking up again. My thoughts were too much for me. I was challenged by my thoughts. Even if I was playing with the children I was drifting away, following my thoughts; thoughts about reincarnation again and again. I dealt with death and asked myself what it means to die, where would I go ill died or one of my children [died]?

In the morning when I went to my sister's, I was afraid of going into water. It was pulling me. I am also attracted by [the] water at T. (the town the client lives in which lies on a large lake). Water calls me.

There was a ray [of sunshine] on the water that lulled me into the water. God was occupying my mind and [the thought] that coming out of water [was that] one could be created anew, perhaps as an animal.... My son had to go to school and so we went together He was on his bike and I went by car.

He took a short cut but I did not see it. It was very bad for me because I did not know when he would come back, whether I was going to see him and that I had not said good-bye. I don't know why. I wanted to see him again. I was afraid of parting.

I had difficulties parting in the morning with my daughter.... Children mean a lot to me. And if I don't know whether I am going to see them again after they have gone somewhere it is very difficult for me. I have this terrible feeling even if they only leave for school.

I drove slowly because I could not see my son any more. And this preoccupied me a lot.

I was also thinking about the end of the world. Then I thought that I could be seeing my son for the last time. It was very intensive. Then I went to my sister's and did not realize what was happening.

I was frightened that I would do something to myself without being able to control it.

My daughter said she did not understand something and I said I couldn't help her either She was upset, complaining that she couldn't manage because she had gym over lunch and the school was too much for her and she had to go to her piano lesson. Then I realized that it was too much for her. Perhaps it was too much for me as well.

I realized that it was too much for all of us, getting from appointment to appointment.

There were very many thoughts that put me under pressure so that I felt I was going to get muddled.

Then I said that I don't want my children to have a disordered mother whom they have to visit in psychiatry. Rather no mother at all. That was strong. Then there was the thought that I wanted to tell my sister that if I was not in control of my senses and health, she should switch off the life supporting machines. I don't want anybody to suffer because I was mentally and physically gone. I felt that strongly.

I was not courageous enough to tell her that I was thinking about what should happen to me. I know that I talked to my stepmother and she said something about suicide and I said I promised her that I was not going to do anything, but somehow it did not get through. I wasn't able to concentrate. My daughter said something as well that I didn't understand and I thought that I would be glad if no one said anything, as I wouldn't understand it.

I was restless and disorganized mentally. I knew that I would have to occupy myself otherwise I would be restless. So I was sorting bills and thought, I know that all, why am I doing it. And as it was finished and I was still restless I didn't know what to do. My sister asked me whether I wanted to eat something, whether I wanted yoghurt. I was eating yoghurt and then I can't remember anything.

The yoghurt was bilberry yoghurt and I ate it with distaste, as I don't like it. I did it just to keep occupied.

[For the first time] in the evening I realized that I was very restless. My sister had a terrace and the door was opened. I had the feeling that it should be closed because ...

Link. I felt being driven outside, that someone wanted me to jump or [I] myself [wanted to jump].

Suicide action. And then I didn't know anything. I was told that I got up after the yoghurt and walked to the terrace and jumped ..., as if this was the clearest thing. She [my sister] saw it at the last moment, asked what I was doing, but I had already jumped. It is about 10 to 15 meters down.

Summary. The actions that preceded the attempt involved the research participant trying to gain control over her thoughts. In the link, she was challenged by thoughts, feeling muddled and disorganized, and losing control. She felt she was being driven outside and that someone wanted her to jump. Her actions were automatic. The internal process that directed her actions was the experience of mental disorganization. Both of these represent bottom-up processes.

The research participant described a series of thoughts and situations in which she felt under pressure. To deal with these disturbing thoughts, she introduced a sequence of measures--such as visiting her sister, trying to distract herself by keeping occupied, asking others to keep quiet, eating to achieve distraction, even wanting to close the door to the terrace. Then she felt like she was being driven to the terrace and subsequently she jumped. The link between her life-related actions and her suicide action was a bottom-up process she was not even aware of. However, this suicide process was integrated into a suicide project, which she described in her narrative, for example, dealing with the issue that "better no mother than a mother in a psychiatric clinic."

Example 2

Demonstrating the bottom-up link between ongoing life processes and suicide actions is this case of a 22 year-old woman.

Life-related and suicide preceding actions. I came home from work, was frustrated as I felt terrorized there. My boyfriend, who decided three weeks ago that he wanted to leave me and then came back in order to leave me again the next day was at home and made me feel even worse. We argued, shouted at each other, threw chairs and cushions. We argued about his not being able to make up his mind. We argued and then a moment came when I had [had] enough. I went to my room to cry.

Link. There were pills in my room that I simply took.

Suicide action. I could not go on any further. I did not want to live. I wanted to be dead. I wanted my peace and quiet. I had not had [any] peace for quite long time. We were constantly arguing. But peace is something important. I was unable to find it. It was probably a solution for my problem. I wanted to have peace so that I would not be here, that I didn't want to be here. I wanted to find my peace.

I simply took the pills. I was not frightened.... Ten minutes later my girl friend came, she knew that I hadn't been feeling well recently, realized the situation, and they both took me to the hospital.

Summary. The situation that preceded the suicide attempt involved the research participant's argument with her boyfriend, followed by her going to her room to cry. The link was that there were pills available, so she took them. The processes involved losing cognitive control through an affective outburst and facilitated by the availability of pills. The control and steering were bottom-up that catered to her strong affect.

Later in her narrative, this woman reported that although she had not seriously attempted suicide before, she thought about it often. She already had gone to catch a tram to take her to a high terrace in front of a church from which people with suicidal ideation occasionally leaped. However, she did not entertain the idea of suicide as a definitive part of her agenda. While crying and feeling unhappy, the availability of pills facilitated her suicide action. The link between her life-related action and her suicide career was achieved in a bottom-up manner, while the suicide itself proceeded in a goal-directed way.

Mixed (Top-Down and Bottom-Up) Links Between Ongoing Life Processes and Suicide Actions

Demonstrating the mixed top-down and bottom-up link between ongoing life processes and suicide actions is this case of a middle-aged woman.

Preceding, life-related action. My husband was very tense because of his work and I could not speak to him very often. I had the feeling that I was creating problems for him, because I was always telling him that I was in pain. I was very sad. I was afraid of the future because of my pain. I knew that I had to accept it but I did not always manage to. One morning I felt really not well and had pain and there were tensions in the family with my son.

I wrote a note to my husband. I had had enough. My husband suspected that I had gone to a place where a suicide recently occurred. I decided that it was the moment to do something. I was aware of the fact that suicides [were] committed there.

I was afraid to die but nevertheless I went there ... I took a taxi and went there, high up near my flat.... I did not intend to die. When I left [my flat] I was not clear about my intentions.

I thought that I might jump and that would be the best for him. I had the feeling that I was boring him with my problems, pains and being depressed.

Once I got out of the taxi I did not know what to do. I did not feel well.... I walked a bit. There is a high bridge next to the motorway over the gorge. It really is high. I was frightened because of its height. There were no trees.

Links. The bridge was on the other side and I did not go there. It is a couple of minutes away.... I saw the bridge from the stone I went to sit on.... The bridge frightened me. The bridge was out of the question for me (to use for suicide, because it was too frightening) ... I was afraid of dying even though I was ill.... I was thinking continually about it but i hoped not to have to die.... I did not understand ... I don't know what was going on in me. I sat down on a big stone and saw that there was a steep drop. I lay down because I was in pain. I did not feel well. Then I saw my husband driving by.

There was a gorge near the stone. There were some small trees.... Then I saw my husband and became frightened.... It was like watching a film. I was frightened that he might come and be mad with me. I would have understood [his being mad with me] but I would prefer if he said a few nice words to me.

Suicide action. He saw me but was not able to turn around on the motorway. He turned later and came but I could not see him anymore because I was already down the gorge. I had fallen. I made a movement in order to try to stop and I was not able to, it was too late.... I was very afraid and it happened very quickly. Just for a moment when I was able to hold onto a bush and then it was over. I did not have any time, it was too late.

I moved. I wanted to hold on and then was not able to do anything. I slid and let go. I was afraid before I wanted to fall. But I could not do anything. I was not able to hold on. It was all over.

I was frightened when I came to a stop, but beforehand while sliding I was not frightened. When I stopped with all the small injuries, for the first time I realized what happened. It was hard. I could not understand.

I'd fallen down 40 to 50 meters and then stopped. I was sitting on several small trees. I was full of cuts and bruises and I was frightened. I started to scream--I called because my husband was very near. Then he called the police.

Summary. The situation preceding the suicide attempt involved the research participant not feeling well and experiencing tension at home. The link occurs when she went to a place where suicides were often attempted and accomplished. She wrote a note that indicated she couldn't go on, but she was not clear about her intentions. She sat on the edge of a gorge, saw her husband, was frightened and let go. The processes involved purposefully getting herself into the situation where a suicide attempt was possible, but then let it happen (top-down, but last step is bottom-up). The steering and control is mixed: bottom-up and top-down.

The research participant reported an intentional link to a situation suitable for suicide and an automatic response resulting in "letting go." This could be described as a mixed way of linking her life related processes and her goal directed system of suicide processes.

DISCUSSION

In this study, we attempted to demonstrate how "break downs" often described in suicide processes are well-organized processes of goal-directed actions. Specifically, persons who have attempted suicide construct their life-endangering actions (suicide actions) as goal-directed. We suggested that there are links between life-related and suicide-related processes. In our view the links between life-related and suicide related processes could be seen either as goal-directed (that is "top-down") or as "bottom-up," which are often called stimulus-driven processes. Our findings indicate that that while suicide processes are goal directed (are steered in a "top-down" manner), the links between life- and suicide-related processes can also be seen as "bottom-up" processes. These two classes of control in action and attention have already been suggested and supported by neurological findings (Corbetta & Shulman, 2002).

We also illustrated the link between life-promoting and suicide-related goal-directed processes at the lower level of action organization, which accommodates movements and processes we are not highly conscious of. Under "action organization" we understand the systemic order of an action process at three basic levels. The highest level contains conscious goal, the middle level consists of action steps and sub-goals and the lowest level accommodates action elements. This link can be understood in terms of dynamic systems theory (Vallacher & Novak, 1994, 1997). In general, dynamic systems theory attempts to show how even in the nonhuman world many processes are organized in a goal-directed-like manner (natural processes enfold as if they were goal directed). This conceptualization is adequate when bottom-up launching of a suicide action is concerned.

Counseling Implications for Assessment of Suicidality

These findings have substantial implications for the practice of mental health counseling. We can assume that conventional suicidality assessment is mostly suitable for those who link their life processes to suicidal processes by a top-down link. Those who use bottom-up steering links might be incorrectly assessed because their eminent suicidality cannot be identified in this way. They are not aware of the urgency of their long-term suicidal intentions and their suicide attempt arises in a way, which used to be called "spontaneous."

Mental health counselors often question whether a client's denial of suicidal intention is trustworthy. However, asking about denial of suicidal intentions may not be very helpful in clients who will apply bottom-up steering in their launching of suicide actions. Consequently, assessing suicidality after a suicide attempt would imply assessing the type of link used, and, if a bottom-up link were found, then it would be important to clarify in which processes it is embedded. For example, if it were a part of an impulsive action organization, it could be a part of a flashback based on traumatic experience; or it could be an emotionally anchored link; or it could be accompanied by reduced executive faculties as the quotations above indicate. These aspects would obviously have to be considered and addressed when suicide prevention is considered. Suicide prevention, informed by this suggestion, would have to relate to more than to the question of suicide intention. It would have to address suicide processes in their long, middle and short-term organization. We would have to ask about a suicide career, suicide projects and suicide actions. We would have to make sure that neither the goals of the suicide career nor the goals of the suicide project or of the suicide action are eminent. Further, in all three types of processes we would have to ask not only about the suicide goals (the level of socially meaningful processes), but also about their functional order. Questions like "is there anything in this life-related project that could be functionally served by a suicide action?" or "is there anything in this life-related action which could be facilitated by a suicide action step?" would have to be answered. Further, we would have to deal with the issue of whether some of the physically defined features of the life-related career, life-related projects and life-related actions which are described at the lowest level of the action organization could be used for suicide actions or suicide actions steps. At the same time, we would always have to keep in mind that individual as well as joint processes are considered as actions and other processes could be individual or joint processes. Equally, the life-oriented system processes, individual and joint, would have to be targeted intensively in the above-mentioned forms and at each level with the aim of assessing their strength. In addition, as presented in this paper, the links would have to be identified and addressed. While attending to the top-down steered links would follow the steps suitable for monitoring goal-directed processes, the bottom-up steered links would have to be identified as described above and dealt with according to their roots which could consist of traumatic experiences.

Further Research

We have shown in this study that suicide-related processes and the links between them and life-directed processes can be distinct and separate systems. Future research can clarify the nature of these links. The conception of top-down links and the goal-directed organization of suicide might call for a different research paradigm. The identification of bottom-up links can help to radically improve the strength of many correlation or regression studies designed to analyze some specific conditions of suicide, because such designs are particularly suited for identifying the conditions of bottom-up links.

Limitations

This qualitative study is far from providing an authoritative and conclusive statement on suicide processes. It deals with one aspect of these processes. We have addressed other aspects of suicide processes in a series of publications (Valach, Scheidegger, Michel, Young, & Dey, in press, Valach, Young, & Michel, 2004, Michel, Dey, Stadler, & Valach, 2004, Valach, Michel, Dey, & Young, 2002, Valach, Michel, Young, & Dey, 2002, Young & Valach, 2002, Michel, Maltsberger, Jobes, Leenaars, Orbach, Stadler, Dey, Young, & Valach, 2002, Michel & Valach, 2001, Michel & Valach, 1997) in order to develop a more comprehensive picture. The findings in this study are based on a limited number of research participants and the sample may not be representative. For example, one would expect more women and immigrants to be represented in this group based on the demographic characteristics of the area where the research was conducted. Our group reflected the population treated in a hospital setting for the medical consequences of their suicide attempt. In addition, although we did ask in detail about the suicide process as part of the clients' narratives, we did not attempt to clarify in the interview whether the indicated link was bottom-up or top-down. Rather, we relied on the research participants' reports. Thus, it is possible to argue that a different way of questioning may have led to slightly different distribution of the results.

CONCLUSION

We described suicide processes as goal directed processes comparable to the organization of life related processes in short-terms actions, midterm projects and long-term career. Further, we argued that the links between life-related processes and suicide processes can often be understood as goal-directed processes. They sometimes are organized in the way as it is described by dynamic system theory which addresses the bottom-up steering in contrast to top-down steering outlined in the theory of goal directed action. There also is a mixed form containing both forms of steering.

The way we conceptualized the links between suicide related and life related systems is fairly simplified to suit the format of this brief report. The merging of bottom-up and top-down processes in any human action and behavior is more complex than could be specified in this empirical study. Finally making sense of one's own and others' behavior in terms of goal processes is a highly culturally specific feature anchored to some degree in social representations. Thus, the questions examined here should be re-examined in other socially and culturally defined groups.

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Correspondence may be addressed to: Valach, Ladislav, PhD, Psychopathology, Faculty of Philosophy, University of Zurich, Clinic Schloessli, 8618 Oetwil am See, Switzerland, Tel.: ++41 1 929 85 06, Fax: ++4 11 929 85 20. E-mail [e-mail]