Lancet Psychiatry has recently run an editorial on suicide prevention. In this blog I want to write a response.
Let me say that, perhaps surprisingly, I actually agree with the editor. It all makes sense, particularly in this sentence:
Meanwhile, we need to go beyond platitudes, such as stating that it is good to talk, and provide professionals with evidence-based, personalised treatments for their patients.
To be honest, I even hope that I have had some small and insignificant role in getting the “OK to talk” appeal to be called a platitude. Though, I would prefer to call it nonsense. In any case, Lancet is right insisting on personalised treatments, taking into account the here-and-now relationship between the person who is to help and one who is to be helped. But something is missing here, isn’t it? And this is why I am disappointed with the editorial.
If it is the ‘small details’ that are needed, how do you get them, if suicidology is by and large focusing on the quantitative, top-down research which is not designed to focus on the ‘small details’? Let’s put it differently. Will I ever read in a medical journal an appeal for qualitative research into suicide? The research which focuses on the individual and their experience.
It’s perhaps worth reminding ourselves of the work of Birthe Loa Knizek and Heidi Hjelmeland, whose research (a number of places) suggests that quantitative research accounts for 97 per cent of articles published in three leading journals in suicidology: Archives of Suicide Research, Crisis and Suicide and Life-threatening Behavior. Moreover, the only suicidological book-length study which reports qualitative research is the recently published volume by Justyna Ziółkowska (Samobójstwo. Analiza narracji osób po próbach samobójczych ‘Suicide. An Analysis of Narratives of Persons after Suicide Attempts’). The only other book based on qualitative research, presenting a number of studies though, is Understanding Suicide by Fincham and colleagues.
Now, what I say here is not exactly earth-shattering. For quite some time there have been calls within suicidology to extend it beyond the quantitative frame. Some even say that suicidology has reached its limits and cannot go further without dropping its insistence on number crunching. Narratively constructed experience is said to be crucial for extending suicidological knowledge onto meanings of suicide in its social context.
Of course, mainstream suicidology is more than happy to lend its rhetorical support to qualitative studies. Yet, apart from rhetoric, not much more is offered apart from the suicidological margins. And this is exactly why it’s disappointing that an editorial calling for insights that for all intents and purposes can only be delivered by qualitative research, blanks this kind of research. And so, the questions of meaning, experience, context will remain to be unanswered.
Let me offer one tiny example of what I mean – this is one of the points I make in my forthcoming book on suicide notes. Consider a suicide note, quoted here in its entirety:
See you later.
What does it mean? The note suggests, after all, that suicide is not final, that there is something afterwards, also for the person taking her or his life. Moreover, there were many such notes in the corpus of more than 400 notes I have. From promises of unending love to promises of future contact, many notes suggested that somehow life continues. No, there is no evidence that note authors ‘lost it’ or that the notes can be explained by references to spirituality.
In my view, a more fruitful way to consider them is to ask the question what suicide meant to the people who wrote those notes. No simple and clear answers are likely, to be honest, but the problem is that mainstream suicidology doesn’t even ask such questions. And it is only through qualitative research, taking the bottom-up perspective, that we can start finding the answers, perhaps beginning to unpick the homogenised category of suicide.
Qualitative research is not a threat or competition to the suicidological mainstream. After all, it asks different questions, but these questions can offer new and potentially important insight into suicide. And as I welcome the understanding that the small perspective matters, I also hope that the time for drawing the qualitative perspective into the mainstream will come soon.