Adolescent suicide is a public health crisis. According to the World Health Organization (WHO), suicide is the third-most common cause of death among adolescents aged 15 to 19 years globally. Youth Month is a pertinent time to reflect on the mental and physical health of our young people. Although South African statistics fluctuate widely due to a lack of systematic data collection, it has been estimated that 17.8% of South African high school students attempted suicide during the preceding six months. While it is impossible to ask those who have died about their experience, research has shown that suicide attempts are strong predictors of future suicide attempts and suicide.
As part of my recent doctoral study at Stellenbosch University, I interviewed adolescents who had attempted suicide, their caregivers and healthcare providers, hoping to better understand the phenomenon of adolescent suicide attempts. At the time of recruitment, all adolescents were attending a psychiatric hospital on the Cape Flats. In addition to being interviewed, the adolescents took photographs illustrating what had led to their suicide attempts and what kept them alive.
Considering their perspectives allowed for a multiperspectival understanding of adolescent suicide attempts. Although there are many quantitative studies exploring risk factors, only a few focus on the lived experience of adolescents who have attempted suicide, especially in South Africa. By eliciting the nuances of lived experience within a particular socioeconomic and historical context, we hoped to enhance understanding of adolescent suicide attempts, which could help inform prevention strategies.
What did we find?
Adolescent suicide attempts are complex and cannot be reduced to simple cause-and-effect explanations. All participants emphasised the importance of relationships, especially those with parents, as both contributing to the adolescent’s attempt and as a factor that could have potentially prevented the attempt. The adolescents spoke about feeling misunderstood, alone and unheard. They desperately desired a close connection with their parents and caregivers. Many were being cared for by extended family or lived in single-parent households.
Financial strain, trauma, sexual abuse
Many households experienced extreme financial strain. The adolescents lived in a context of trauma. Some described a sense of betrayal by caregivers that they directly attributed to their attempt. They spoke about having their experience of sexual abuse, often at the hands of relatives or people known to the family, denied or minimised. For example, one of the adolescents described how the lack of protection contributed to her suicidal state: “And then she caught him do it also. But yet she still did nothing, so that is when I started feeling hopeless, like nobody is going to do anything about this. She sees it happening and yet she does nothing about it.” The adolescents’ experience was supported by the accounts of caregivers, some of whom acknowledged the minimisation of abuse by family, while others questioned the adolescents’ version of events.
Relationships with siblings and peers also featured prominently in the adolescents’ accounts. Some spoke about staying alive to take care of and protect their younger siblings. Talking about a sibling, one adolescent said, “She’s the only one that makes me be who I am, still alive … I don’t want to hurt her.”
Parentification
Their accounts illustrate the parentification taken on by those who are still children themselves. Yet, this responsibility was described as preventing a repeat of the attempt. The protective aspect may reflect our desire, as human beings, to feel important and useful. One adolescent described being regarded as a valued member of society as critical for suicide prevention: “Just give them the right amount of support, make them feel like they are still needed in the world. They still have to be here. They, give them tasks to do that only they can do. Like make them feel special. That would basically help. Because that worked for me, so it might work for others.”
Adolescents related how close relationships with friends protected them against further suicide attempts because they reduced feelings of isolation. Yet, they also spoke about bonding over suicidal behaviour and admitted to learning about suicidal behaviour from their peers. Bullying and exclusion from a peer group were also described as contributing to suicidal behaviour. In the words of one adolescent: “I am tired of feeling left out, rejected, not accepted, and if I am dead, I won’t feel that anymore.”
None of the participants endorsed a purely psychiatric understanding of the adolescents’ suicide attempts. Research has demonstrated that psychiatric diagnoses, such as major depressive disorder, strongly associate with suicide attempts and suicide. Yet, equating suicide attempts with a psychiatric diagnosis is an oversimplification that negates the sociocultural context. Most people with a psychiatric diagnosis do not attempt suicide, while others without a diagnosis may do so.
The adolescents, caregivers and health care providers described the adolescents’ suicide attempts as a desperate bid to escape emotional pain. In the words of one adolescent, “I just wanted everything to stop”. Some perceived themselves as an economic burden to their families, hoping that their death would alleviate their financial woes. As one adolescent explained: “My suicide was going to help people. There would be one less person to worry about, one less person to pay for, and that money that was spent on me could be spent on the others in the house.”
It appears that at the time of their suicide attempt, the adolescents’ perception of their choices was narrowed, so that suicide was regarded as the singular solution to alleviating their problems and pain.
Suicide attempts are not solely an individual phenomenon. They occur in a relational, socioeconomic, cultural, and historical context intertwined with the individual’s experience. The complexity implies that prevention efforts cannot solely be the responsibility of the mental health sector, nor that the sole focus should be on the individual adolescent who has attempted suicide. The relational nature of suicidal behaviour suggests that families need to be considered in both prevention efforts and recovery following an attempted suicide. Broader social factors such as bullying, the high rates of adolescent abuse in South Africa, and caregivers’ emotional and financial well-being should be considered in any policies addressing adolescent suicide.
What can you do to assist an adolescent who may be at risk of attempting suicide?
Adolescents emphasised how they wanted to have their experiences validated and to feel less invisible to the adults in their lives. A caring adult, who allows the adolescent to feel listened to and seen, may be the catalyst that allows them to consider an alternative to suicide. The adolescents requested that adults “just sit and listen” and that they should “get the teenager to open up to you; relate to how they’re feeling”. According to one adolescent, suicide attempts could be prevented if “we found a person that really understood us, and how we like really feel and stuff like that … yes, and someone that could deal with our emotions.”