- Case Report
- Summary
- Introduction
- Long-Term and Mid-Term Pursuits and Short-Term Actions
- Midterm Pursuits “Projects”
- Short-Term Actions in A Conflict Project
- Problems of the Action Organization
- Consciously Prepared or Spontaneously Undertaken?
- The Young Woman’s Talk with the Psychiatrist
- Problems of the Action Monitoring Processes
- Problems of the Action Energizing
- Suicide and the Interactive and Joint Action
- Self-Confrontation-Interview
- Conclusion
- Disclosures
- References
Suicide attempt: Action theory informed case study
Ladislav Valach*
Private practice, formally at University Zurich, Switzerland
Submission: March 22, 2021; Published: April 29, 2021
*Corresponding author: Ladislav Valach, Ph.D., Private practice, University Zurich, Switzerland Email ID: ladislav.valach@swissonline.ch
How to cite this article: Valach. L. Suicide attempt: Action theory informed case study. Psychol Behav Sci Int J .2021; 16(5): 555948. DOI: 10.19080/PBSIJ.2019.10.555948.
- Case Report
- Summary
- Introduction
- Long-Term and Mid-Term Pursuits and Short-Term Actions
- Midterm Pursuits “Projects”
- Short-Term Actions in A Conflict Project
- Problems of the Action Organization
- Consciously Prepared or Spontaneously Undertaken?
- The Young Woman’s Talk with the Psychiatrist
- Problems of the Action Monitoring Processes
- Problems of the Action Energizing
- Suicide and the Interactive and Joint Action
- Self-Confrontation-Interview
- Conclusion
- Disclosures
- References
Summary
It is proposed that suicide should be seen as a goal-directed process. This approach, developed and presented in regard to singular propositions of the theory of goal-directed action in a number of between cases analyses is used here in a single case study. In this analysis the main issues of a suicide action are discussed. These specific issues are then illustrated, such as the embeddedness of the short term goal-directed action of suicide in various mid-term and long-term pursuits, the problems of action organization, the issue of top-down and bottom up steering, the action monitoring problems, the action energizing problems, the joint and interactive processes in suicide, the joint actions within a psychiatrist’s interview of a person after a suicide attempt and the contribution of the self-confrontation interview to the knowledge of the suicide attempt. This is closed with some suggestions how this conceptualization and the provided knowledge can be and are used in the suicide prevention treatment.
Keywords:Suicide; Emotions; Dyspraxia; Psychologist; Cognition; Emotional desire; Cognitive monitoring; Joint action
- Case Report
- Summary
- Introduction
- Long-Term and Mid-Term Pursuits and Short-Term Actions
- Midterm Pursuits “Projects”
- Short-Term Actions in A Conflict Project
- Problems of the Action Organization
- Consciously Prepared or Spontaneously Undertaken?
- The Young Woman’s Talk with the Psychiatrist
- Problems of the Action Monitoring Processes
- Problems of the Action Energizing
- Suicide and the Interactive and Joint Action
- Self-Confrontation-Interview
- Conclusion
- Disclosures
- References
Introduction
The most relevant event for a suicide is a suicide attempt [1,2]. Consequently, a patient surviving a suicide attempt does not present a reason to relax with an “everything is fine now” feeling but an urgent and alert thought that “it is five to twelve”. Thus, patients after a suicide attempt require systematic professional attention. The first step is to recognize that meeting a patient after a suicide attempt is not about finding whether the patient is suicidal but realizing that such a patient is in imminent danger of suicide. However, suicide is not something which comes upon a person “out of the blue”, but, as we indicated, is a goal-directed action [3] within a midrange project and long-term suicide career [4]. Such an action is not only wrong ethically, as a protection and preservation of a human life merit a high value in our culture, but the whole action system is faulty in many aspects [5]. Consequently, we do not have to exclusively study and deal with the underlying mental health issue of a suicide but address the actual suicidal processes in order to understand it and provide help and suicide prevention. In this article an analysis of a specific suicide process of one person is presented addressing the critical issues of suicide articulated, conceptualized and studied in a series of previous publications of qualitative between-cases analyses. In these publications we argued and illustrated the theses that suicide is an action process [6], that it is joint social process [7], and that it is distorted action process [5], to such a degree that one could ask, whether it could be called a certain type of dyspraxia [8]. Further, we addressed the issue of top-down and bottom-up steering in suicide [9], maintained that there are problems in action monitoring systems [10], as well as some problems in action energizing [11]. For obtaining information on suicide attempts we not only suggested a different attitude of professionals to a suicidal person [12], but also a use of narrative interview [13] and a self-confrontation interview which is form of video supported recall [14-16].
In this article a within case analysis is presented addressing the problems in suicide attempted supported in outlined findings. The analyzed case of a suicide attempt stems from a larger research project (supported by the Swiss National Research Foundation assuring that all ethical standards were upheld) in which patients were interviewed a few days after their suicide attempt by a psychotherapist followed by a self-confrontation interview. The information used was derived from the video recording of the interview and of the self-confrontation interview.
The case of a suicide attempt is presented in the long-term and mid-term suicide relevant processes and in the actions, cognitions and emotions described by the patient. Then the problems of action organization is discussed as well as the question of top-down and bottom-up steering, the problems of action monitoring, action energizing, and the issue of joint and interactive actions relevant for the suicide. This is followed by a summary of the joint actions of the psychiatrist and the patient in the narrative interview and of the self-confrontation interview in each segment. Case 5: Female, 18 years: ”It was too much for me that evening… I wasn’t thinking properly when I took the pills”.
The young woman fell in love with a young man from another town. When her mother forbade to see him because of her bad school grades, she cut herself with a knife on her lower arm and, because of the pain, she stopped and overdosed instead. Asked by a psychiatrist about this event (“If you could tell me what actually happened”) she replies, “actually it all started much earlier on”. She describes then some long-term pursuits and goals as well as middle term processes (“projects”) that she finds important for understanding her suicide attempt. These are the processes in which she integrates her suicide actions.
- Case Report
- Summary
- Introduction
- Long-Term and Mid-Term Pursuits and Short-Term Actions
- Midterm Pursuits “Projects”
- Short-Term Actions in A Conflict Project
- Problems of the Action Organization
- Consciously Prepared or Spontaneously Undertaken?
- The Young Woman’s Talk with the Psychiatrist
- Problems of the Action Monitoring Processes
- Problems of the Action Energizing
- Suicide and the Interactive and Joint Action
- Self-Confrontation-Interview
- Conclusion
- Disclosures
- References
Long-Term and Mid-Term Pursuits and Short-Term Actions
Sample
The young woman describes her stay in a boarding school and her “yearning for relationships” “…when I was in the boarding school, I felt deported by my parents. Then I got a little rat, which I had for three years. The rat was more than a good friend to me and at that time it was more important to me than my mother”. She met her best girlfriend there “in this boarding school there was a girl who was my best friend” (“relationship with a friend”). Another pursuit in which she is engaged with a varying degree of success is her school. “They told my mother that I was not doing my homework and that I have low grades in French (“school attendance”). Another pursuit that she follows with some difficulties is her “relationship with her father”. “My father left home when I was three years old and promised things, such as that he would pick me up and take me to the cinema and he never came… He came back a year ago and lives with us now… When he has problems, he drinks and when he is drunk, he comes home and tries to explain to me that he loves me and that is too much for me, because I don’t see him as a father”. Her “relation to mother” is, despite all the arguments, an important support for her and when she becomes anxious after overdosing, she goes to her mother. “Relationships with young men from the cultural circle of her father” are other pursuits of the young woman that have been marked by several disappointments. First is her father who left her and who did not cope well with his immigration. He lived in Switzerland, went back to Algeria, and then returned to Switzerland to live with his wife and child. He tries to coerce his daughter into following Muslim behavioral rules, but he gets drunk frequently. The young woman describes her relationship with a young man. “I had a relationship with him for a year and everything was fine, but one day he came to me with a photo album full of women’s pictures and said that I should choose one for him, as he had to get married… As a Muslim he had to get married in a certain age. He said he was going on holiday for a week, and I have not seen him since then as he disappeared. He still owes my mother 3000 Fr that she lent him for his car”.
She was also disappointed in another relationship. “About a half a year later I met another man. We went together for three months and then we had an argument and he hit me”. She summarized her problems with her most important desires and goals in a call to her best friend before her suicide attempt “I said that I didn’t want to live anymore, and that nothing makes any sense. I asked, what sense does it make when I have troubles at home, my boyfriend has left me, and I have problems at school”.
- Case Report
- Summary
- Introduction
- Long-Term and Mid-Term Pursuits and Short-Term Actions
- Midterm Pursuits “Projects”
- Short-Term Actions in A Conflict Project
- Problems of the Action Organization
- Consciously Prepared or Spontaneously Undertaken?
- The Young Woman’s Talk with the Psychiatrist
- Problems of the Action Monitoring Processes
- Problems of the Action Energizing
- Suicide and the Interactive and Joint Action
- Self-Confrontation-Interview
- Conclusion
- Disclosures
- References
Midterm Pursuits “Projects”
The most important midterm pursuit or striving of the young woman at the time of her suicide attempt was her “relationship with her boyfriend”. She met him in another town where he lives, which limited their time to spend together. Nevertheless, they tried their best. “He called me every day and then we would talk for four to five hours. Then I went to his town and it was deliriously beautiful”. They both fell in love and the patient recounts “We understood each other well from the very beginning and had a lot of fun together… I went to my girlfriend and told her that I wasn’t sure if I had fallen in love. He did not know that I had said that and five minute later he told her the same. We got together during the weekend and I told him that I am from another town and asked if he could imagine having a relationship over the distance, because it could sometimes take two weeks to meet again. He said he did not know, and I told him to take his time, think it over and let me know. Then he rang every evening, asked me how I was, and we talked. A week later he said that he was ready for this relationship and could do it. I asked him whether he was sure, otherwise we did not have to start, because it would be less painful than breaking up later. He said he could do it. During all this time I realized that he was someone who cared for me. I told my mother that it was the first time I had fallen in love. On Sunday, he accompanied me to the train and said that he would miss me”.
- Case Report
- Summary
- Introduction
- Long-Term and Mid-Term Pursuits and Short-Term Actions
- Midterm Pursuits “Projects”
- Short-Term Actions in A Conflict Project
- Problems of the Action Organization
- Consciously Prepared or Spontaneously Undertaken?
- The Young Woman’s Talk with the Psychiatrist
- Problems of the Action Monitoring Processes
- Problems of the Action Energizing
- Suicide and the Interactive and Joint Action
- Self-Confrontation-Interview
- Conclusion
- Disclosures
- References
Short-Term Actions in A Conflict Project
Suicide action
Patient (P) meets a boy and falls in love
Cognition P: Actually, it begins much earlier.
Action P: I was in a boarding school and
Cognition P: there was a girl there who was my best friend.
Action friend: She then left and went home to her mother.
Action P: I went couple of times to her town to see her.
Action P: and met a boy there.
Cognition P: He was my age....
Joint action P, boyfriend: On one weekend we got together.
Action P: Afterwards, I went home.
Action mother: My mother said that a relationship cannot work with such a distance and that I cannot always go and see him.
Cognition: The following weekend when I wanted to see him
Action mother: my mother said that it is out of question and that I could go next weekend.
Action P: I said OK and
Action P: went the following weekend.
Joint action P, boyfriend: We met again and
Joint action P, boyfriend: we talked on the phone quite often beforehand.
Action boyfriend: He called every day and then we talked for four to five hours.
Action P: I went to his town and it was deliriously beautiful.
Action P: I went home on Sunday,
Joint action P, boyfriend: after we talked about our relationship and the distance.
Action boyfriend: He said, we are going to manage and that our relationship is going to be a long one.
Mother forbids her to visit her boyfriend until her school grades are better
Action mother: On Thursday before I went to see him my mother went to parent-teacher meeting in my school.
Action teacher: and was told that I am not doing my homework.
Cognition P: I don’t know exactly what she was told,
Action mother: but she came home and ignored me.
Cognition P: Then I thought that something went wrong.
Cognition P: But then I was allowed to go and see my boyfriend.
Action mother: She just said that we have to talk on Monday about the worse things I can imagine.
Action P: Then I came home on Sunday and
Joint action mother, P: everything was normal.
Action P: When I came home on Monday,
Action mother: she said we have to talk.
Action mother: She mentioned my bad grade in French, the last one was 1 (very bad) and
Action mother: she wanted to forbid everything, the telephone calls, my journeys to see my boyfriend until I get a grade 6 (very good).
Cognition P: It seemed impossible to me to get such a grade in such a short time.
Cognition P: This left me puzzled,
Action mother: that she said I can go and see my boyfriend when a get a grade 6 and even then, I can go only once a month.
Boyfriend terminates their relationship.
Action boyfriend: Then my boyfriend rang.
Action P: and I told him everything.
Action boyfriend: He said that once a month is a bit seldom.
Action P: Then I suggested that he could visit me and sleep at our place.
Action boyfriend: He then said that he is not going to come as he hates my town.
Action P: Following that I told him that now I can see how little I meant to him as he would not even come to my place.
Action boyfriend: After that he said that we had better end our relationship.
Cognition P: I thought that I had fallen in love the first time and that I would be well behaved so that I could see him more often and
Action boyfriend: he terminates our relationship.
Problems with parents (father)
Cognition P: During this time, I had terrible problems at home with my parents.
Action father: My father left home when I was three,
Action father: he promised things such as that he was going to pick me up and take me to the cinema, but he never came.
Action father: He came back a year ago and lives with us now.
Cognition father: He is a Muslim and for him a girl of my age should not have a boyfriend and should not go out.
Cognition father: He thinks that he can bring me up on his terms.
Action father: When he has problems, he drinks.
Action father: and when he has drunk, he comes home.
Action father: and tries to explain to me how much he loves me.
Cognition P: That is then too much for me, because I don’t see him as a father.
Action P: I saw him occasionally (after he left) but not as a father.
Cognition P: Later on, it became too much for me.
Action mother: My mother says every time, that she is going to throw him out if he drinks Action mother: and that he has to behave himself if he wants to live with us
Action mother -: and then she does not do it.
Problems with parents (mother)
Joint action mother, father: And when they have troubles together
Action mother: then my mother gets at me saying that it is my fault.
Cognition mother: For a last half a year she has been ill.
Action mother: She had her stomach reduced.
Cognition mother: Now she is somehow depressed.
Cognition P: I have the feeling that she is short tempered and takes it out on me.
Suicide action: Pill overdosing
Cognition P: On this Monday morning it all became too much for me. I was not really thinking when I took the pills.
Cognition P: After that I thought that is not getting me anywhere and wanted to go to bed and
Cognition P: than I felt very dizzy, and everything began to turn and
Emotion P: I was frightened.
Action P: than I called my mother.
Seeking help in a hospital
Joint action mother, P: She went to the hospital with me.
Cognition P: When I thought about it later on
Feeling P: I had the feeling that what I had done was very
stupid.Cognition P: I am thinking it now as well.
Cognition P -: I just had a black out. I was not thinking at all.
The source of the pills
Action mother: My mother went to a physician in another town because of her being overweight and
Action others: I was always being told in the boarding school whenever I had eaten anything sweet such as chocolate that I am too fat, that I have to lose weight.
Joint action mother, P: My mother took me with her to this physician in another town andAction physician: he also gave me appetite suppressant.
Action P: Then I took it for a month and
Feeling P: I felt miserable.
Action P: At the same time, I was taking the contraceptive pill and
Cognition P: I thought that these two things were not compatible.
Action P: Then I stopped taking the appetite suppressant and that is why I still had 20 of them in the bathroom cabinet.
Action physician: I also received painkillers from this physician because I was suffering from strong period pains.Cognition P: I also had some coughing pills that I obtained three years ago.
The last call with a friend before the suicide attempt
Action P: … I called my friend in another town because my boyfriend was a good acquaintance of hers.
Action P: I told her everything as I was completely out of my mind.
Action P: I said that I did not want to live anymore and that nothing makes any sense and
Action friend: she said I should not do anything stupid.
Action P: Then I asked what a sense is there as I have troubles at home, my boyfriend left me and I have problems at school.
Action friend: Then she said I should calm down and
Action P: I said no, I do not want to go on like this
.Action friend: She said I should go to bed and that she was going to call me tomorrow evening.
Action P: Than I put the phone down.
The last talk with mother before the suicide action
Action P: I prepared my stuff for school the next day and
Action P: then went to say good night to my mother.
Emotion P: I was crying and
Action mother: she asked “what’s the matter”.
Action P: I replied «nothing» and
Action mother: she said we have to talk but
Action P: I told her that it is none of her business.
Preparation for suicide
Action P: Then I lit all my candles in my room and played a song that I always listened to with my boyfriend.
Action P: Then I collected all pills in the bathroom.
Suicide action step
Action P: then I took them all.
Thoughts and emotions during the suicide attempt
Cognition P: I don’t know exactly what I wanted to get out of it.
Cognition P: I think sometimes that I wanted to get some
attention, becauseCognition P: when I think about it, I actually did not want to die.
Action P: I did call my mother afterwards and told her that I do not want to die.
Suicide attempt by cutting the lower arm
Action P: … I also tried to cut my veins.
Cognition P: But I thought that it might hurt too much.
Action P: … I did try it
Action P: … before I took the pills.
Action P: … I searched for my knife and then I tried it but
Pain P: it hurt too much.
Cognition P: I was bleeding a lot.
Thoughts and emotion during the suicide attempt by overdosing
Cognition P: Then I thought that I am going to feel less when I take the pills.
Action P: People say that one just falls asleep.
Cognition P: In that moment I thought that I don’t want to live any longer.
Emotion P: … when I was in the boarding school, I felt deported away from my parents.
Action P: Then I obtained a small rat, that I had for three years.
Cognition P: She was more than a good friend to me. At that time, she was more important to me than my mother.
Action P: I talked to her and she was always with me.
Action P: Then she died. Well, I had to put her down because she developed cancer.
Emotion P: I must say, it was a terrible time for me.
Cognition P: I thought that it would be nice if I could die with her, then I would be together with her.
Cognition P: But it was not like I wanted to die, in order to be with her or to kill myself. Cognition P: … It was only that time with the rat and now, well not now, but at the time when I wanted to die on that Monday.
Action P: … with the friends I was with until now...,
First terminated relationship with a boyfriend
Action P: with one boyfriend we were together one year and
Cognition P: he was a part of my family, accepted by my mother.
Action father: my father was in Algeria for a year at that time.
Cognition father: He did not know anything about it.
Joint action P, boyfriend: I was with him for one year and everything was fine,Action boyfriend: until one day he came with a photo album full of pictures of women and asked me to choose one for him, because he had to get married.
Cognition P - : …I did not know anything about the fact that he had to get married.
Cognition P: He was also Muslim and from a certain age on a Muslim has to get married.
Action uncle of boyfriend: His uncle was asking him all the time what the matter is, whether he was gay and why was he not getting married.
Cognition P: It was going fine for one year and I did not know anything about it and
Action boyfriend: … then he came with a thick album full of women and
Action boyfriend: said that he wanted to marry the one I chose.
Cognition P: I thought I was going mad…
Emotion P: later on, I was very angry with him, but
Emotion P: at first, I laughed and
Cognition P: thought I must be mad.
Emotion P: Later on, I was very upset, as he did not say anything.
Action boyfriend: He said that he thought that it would take a different course.
Joint action P, friend - : We did not really terminate the relationship.
Action friend: he said that he was going on holiday and he would be back in a week and he disappeared since then. He owes my mother 3000 francs, that.
Action mother: she lent him to buy a car.
Action friend: So, he owes us some money and he disappeared.
Second terminated relationship with a boyfriend
Action P: About half a year later I met another man.
Joint action P, friend: After about three months we had an
argument and Action friend: he hit me.Cognition P: So, I thought “that’s over”.
Action P: (I terminated the relationship) as he does not have to say anything.
Action P: I told him that now he has had it and left.
Meeting a new boyfriend
Emotion P: At that time, I was afraid to go to town.
Action P - : So, I did not go out much and did not socialize.
Action P: Then I said I have had enough of men.
Action P: I said in such times that I would go to a convent.
Action P: Then I concentrated on my friends, the school and home.
Action P: Less than four months later I went to another town and met the current boyfriend.
Falling on love with the new boyfriend
Joint action P, boyfriend: We understood each other very well from the beginning and
Joint emotion P, boyfriend: had fun together …
Action P: I went to my girlfriend and
Action P: said I was not sure if I had fallen in love.
Cognition boyfriend - : He did not know that I said it and
Action boyfriend: five minutes later he told her the same.
Joint action P, boyfriend: We got together during the weekend and
Action P: I told him that I am from another town and asked if he could imagine having a relationship over this distance, because it could sometimes take two weeks before we could meet again.
Action boyfriend: He said then that he did not know.
Action P: I told him that he should take his time, think about it, and tell me then.
Action friend: He called me every evening and asked how I was doing and
Joint action P, boyfriend: we discussed.
Action boyfriend: One week later he said that he was ready to engage in a relationship and that he could do it.Action P: I asked him whether he was sure about it, then otherwise we don’t have to start with it at all, because it would be easier that way than if it ended.
Action boyfriend: He said he could do it.
Cognition P: During those weekends together and when we talked on the phone, I realized that he was someone who cared for me.
Action P: I also said to my mother that I believed that I’d fallen in love for the first time.
Action boyfriend: On Sunday he brought me to the train and said he was going to miss me.
Breaking up with the boyfriend
Cognition P: And then, one day later, everything is over.
Emotion P: I was very angry at my mother, because it was her fault that it was over as
Action mother: she forbade me to see him.
After the suicide attempt
Mother talking to patient’s boyfriend
Cognition P: I also learned that
Action mother: my mother called my boyfriend after my suicide attempt.
Action mother: She asked him what he had said to me.
Action boyfriend: He asked her why she wanted to know and
Action mother: she said that she wants to know.
Action boyfriend: Then he said that he ended the relationship and
Action mother: she told him that I was in the hospital because I wanted to kill myself.
Action boyfriend - : After that he was unable to say a word. Girlfriend informs patient about her talk to patient’s boyfriend
Cognition P: I’ve heard later from my girlfriend that he ended the relationship because he thought that it was better for both of us that way.
Cognition boyfriend: If it were according to his feelings, we still would be together.
Cognition boyfriend: It was apparently very hard for him as well, but he thought it wiser to end the relationship, because seeing each other only once a month is not enough. Boyfriend calls patient
Action boyfriend: He called me then on Wednesday, Thursday and Saturday.
An acquaintance intervenes in her relationshipAction acquittance: An acquaintance came to see me on Wednesday after
Action P: I was able to go home on Tuesday and
Action acquittance: she said that she was going to the bathroom, while I was watching tv and I have my boyfriend’s telephone number on my pin-board and
Cognition P: I’ve since learned, that
Action acquittance: she called him and said that I am not well and asked whether he would want to give me another chance.
Action acquittance: She called him twice
Cognition P: which I did not know and
Emotion boyfriend: he was very upset, because of that, because it is a thing between him and me and nobody else’s business.
Cognition P - : I have not heard anything since then and
Action P: I’ve told him that I am not going to call any more but he can, if he wants to, because I don’t want to get on his nerves.
Cognition boyfriend: He thinks that I sent my acquaintance to call him and
Emotion P: that upset me. I am still very angry at her.
Cognition P: I thought «I’ve had enough, I am pissed, and you can all kiss my backside». That is what I thought.
Meaning of the suicide action
Cognition P: … In a certain way I wanted to die, but in another way, I hoped that my mother would find me before it was too late.
Action P: I am seeing a psychologist and
Joint action psychologist, P: we talked about it and
Action psychologist: she said that it was a call for help.
Suicide action
Action P: I pressed the pills out of the packaging and then I ate them out of my hand.
Action P: … I picked up the boxes of pills from the bathroom and went to bed.
Action P: Then I pressed the pills out and put the empty cases under the carpet and ate them from my hand
Action P: … with apple juice.
Cognition P: Then I thought that this is not getting me anywhere.
Action P: Then I got up and looked into my mother’s bathroom cabinet and
Cognition P: thought “you don’t know what you are taking” because with my pills I knew more or less what they were.
Action P: Then I went back to bed and waited.
Cognition P: Then I thought, “it is not getting me anywhere” and
Sensation P: then it started to burn and itch under my skin.
Action P: I scratched myself and
Feeling P: became nervous
Sensation P: then everything started to spin.
Cognition P: Then the people on my posters started to move towards me, which I did not understand and my room felt like a helter-skelter.
Emotion P: Then I became frightened.
Patient seeks help from her mother
Action P: I called my mother, told her that I am frightened and
Action mother: she asked why. She said… I don’t know any
more whatAction P: the first thing that I said was that she should not hate me or something like that.
Action mother: She asked why and
Action P: I said that I’ve eaten pills.
Cognition P: She did not want to believe it at first, until
Action P: I showed her the empty pill packaging.
Action mother: The first thing she did was to call the toxcenter and
Action mother: … ask what there was to do.
Action mother: Then she gave me a glass of salty water to make me vomit,
Action P - : which I was unable to do.
Patient and her mother go to the hospital
Joint action mother, P: then we came here into the hospital.
Action father: My father was at home as well.
Action father: He came back from his drinking tour.
Action mother: My mother went to him and said he should
help.Action father: He asked why and
Action mother: she answered that I’d taken an overdose of pills, and
Action father: he answered, “I see, that is good” and stayed sitting in the kitchen.
Emotion P: … I started to panic.
Emotion P - : (when I cut myself, I did not panic at all.) Pain P: It was only painful.
Considerations and action after the suicide action
Cognition P: I thought that I was stupid to do something like this for a man.
Action P: When I told this to my psychotherapist, I had to laugh that someone would do it because of something like that.
Cognition P: (something like this should not happen again). I don’t know if I can say this about my whole life, but at the moment I am feeling well, even at home.
Joint action P, mother: I had a good talk with my mother yesterday.
Cognition P: The only problem I have is that I feel very stressed.
Cognition P: At the moment, I believe, it is good, because in all this stress I cannot think about my boyfriend.
Cognition P: Only when I am alone do I think about him and it is a total emptiness.
- Case Report
- Summary
- Introduction
- Long-Term and Mid-Term Pursuits and Short-Term Actions
- Midterm Pursuits “Projects”
- Short-Term Actions in A Conflict Project
- Problems of the Action Organization
- Consciously Prepared or Spontaneously Undertaken?
- The Young Woman’s Talk with the Psychiatrist
- Problems of the Action Monitoring Processes
- Problems of the Action Energizing
- Suicide and the Interactive and Joint Action
- Self-Confrontation-Interview
- Conclusion
- Disclosures
- References
Problems of the Action Organization
The life enhancing hierarchy of the long-term goals, projects that are in these long-term pursuits goal relevant, and actions, that serve in these middle- and long-term pursuits, would provide an orderly action organization of actions, projects and life goals among each other. Equally, an order within action, in which goals, action steps and action elements unfold in a synchronized way, and the steering, control and regulation together with other action processes are meaningfully and functionally tuned in with each other, could be seen as optimal. Is this the case in this young woman in her suicide story? She informs us that already in the boarding school she found “not being alone” more important than her life. This repeated when her boyfriend ended their relationship, because her mother did not allow her to see her boyfriend in another town more often than once a month. In this case these were not only thoughts, such as “life is meaningless without this relationship”, or “I don’t want to be alone” that she found more important than “her life”, but she acted upon them and tried to kill herself by cutting her arm and then, because that hurt, taking an overdose of pills. How far she managed to order meaningful actions within other important projects and long-term strivings is less important for the understanding of her suicide action even if she fights again and again with similar problems. Her long-term goals seem to be dictated by her emotional desire for a relationship and love in such a way that she subordinates everything to this. The life goals do not play any significant role in her story. She is not particularly interested in her school, does not talk about any hobbies or joint ventures, then her friendships are mainly aimed at satisfying of emotional needs. They are more emergency anchors than future oriented joint projects.
How does she present her action organization at the moment of her suicide attempt? She describes her mental state on the evening before her suicide attempt as being completely overtaxed and says that she could not think clearly: “It was too much for me on that Monday evening, I did not think properly when I took the pills”. The synchrony of setting a goal, of action steps and the flow of movements towards a meaningful life enhancing goal was not given because the steering and the action regulation of the taking the pills happened without action control, without questioning her doing in regard to other goals. When her control thought returned “Afterwards I thought that it would not get me anywhere and wanted to go to sleep” it was too late “…then I became dizzy and everything began to spin”. While acting from being overtaxed beforehand, she became frightened now. This generated her security seeking action and she called her mother. Further, she says how her suicide action was steered by contrary goals «In one way I wished that I would die, in another I hoped that my mother would find me beforehand”. A day later she was able to assess her action properly “…I had the feeling that what I had done was very stupid”. But also, here it was not assessing goals against each other or means and goals, but it was an emotional assessment which could have functioned in a neutral situation only. Later on, she adds some reasons for her suicide action to the assessment of her action “I thought that it was very silly to do something like this because of a man”. But even here she has to use an emotional denigration. In a similar situation of being overtaxed she finds a suicide action suitable “I am fed up of it and you can all kiss my a..” . The patient shows a similar problem of action organization in her suicide action by cutting. When she felt pain, she was able to change the means of suicide but not the goal. Her action was determined by regulation processes only (monitored by pain), but not by the flexible handling of goals “…I also tried to cut my veins… then I thought that it would hurt too much… I tried it before I took the pills… I searched for a knife and then tried it and it hurt too much… It bled heavily… then I thought that I would feel it less if I took pills instead… At that moment I thought that I didn’t want to live anymore”.
- Case Report
- Summary
- Introduction
- Long-Term and Mid-Term Pursuits and Short-Term Actions
- Midterm Pursuits “Projects”
- Short-Term Actions in A Conflict Project
- Problems of the Action Organization
- Consciously Prepared or Spontaneously Undertaken?
- The Young Woman’s Talk with the Psychiatrist
- Problems of the Action Monitoring Processes
- Problems of the Action Energizing
- Suicide and the Interactive and Joint Action
- Self-Confrontation-Interview
- Conclusion
- Disclosures
- References
Consciously Prepared or Spontaneously Undertaken?
The patient announced her suicide action in advance and did not get inspired or triggered to do it in the last moment when facing appropriate suicide means. In addition, the preparation of her suicide action consists of an “emotional tuning in” “Afterwards I lit all the candles in my room and played a song that I listened to with my boyfriend”. Then she overdosed. After she took her pills, she examined her mother’s medicines, but rejected them, because she did not know what was there “…then I got up and searched my mother’s bathroom cabinet and thought “you don’t know what you are taking”, because with my pills I knew what was there”.
For preparing a suicide action there are certain emotions, suicide intentions and wishes to die. The patient describes how she felt disposed of in the boarding school, obtained a rat and when she had to put her down the patient did not want to live any more “I talked to her and she was with me all the time… she died then. Well, I had to put her down, because she had cancer… and I have to say that it was a very difficult time… I thought that it would be nice if I could die with her then I would be together with her”. These emotions of “feeling being disposed of”, “deserted”, “left on her own”, “hurt in her trust” developed and strengthened with new experiences of the patient. She reports how her father left her when she was three and frustrated her repeatedly with unfulfilled promises, how she was “disposed of” to a boarding school, how she met young men who disappointed her and, finally, how she responded with a suicide action when her boyfriend ended their relationship, because she could not visit him as often as they would like to. Based on that she formed an emotion, an action pattern, that she was able to respond to with giving up her life.
- Case Report
- Summary
- Introduction
- Long-Term and Mid-Term Pursuits and Short-Term Actions
- Midterm Pursuits “Projects”
- Short-Term Actions in A Conflict Project
- Problems of the Action Organization
- Consciously Prepared or Spontaneously Undertaken?
- The Young Woman’s Talk with the Psychiatrist
- Problems of the Action Monitoring Processes
- Problems of the Action Energizing
- Suicide and the Interactive and Joint Action
- Self-Confrontation-Interview
- Conclusion
- Disclosures
- References
Problems of the Action Monitoring Processes
The patient does not describe extreme gaps in monitoring functions, that is in attention or consciousness, emotion and pain. She felt pain when she cut herself and decided for a less painful suicide means. She does not describe “not feeling anything” during her suicide, “not having any feelings”, or “feeling cold as a stone”. Nor was her attention extremely altered. She did not observe herself from the outside, nor did she feel like another person. However, her cognitive monitoring of the extremely dangerous situation, in which her life was at stake, must be seen as very faulty. In a such a dangerous situation we wish not only to mobilize superhuman powers but also a clarity in thinking that would take us away from the threat. This was not the case in this patient, as she indicated repeatedly that she “did not think properly”.
- Case Report
- Summary
- Introduction
- Long-Term and Mid-Term Pursuits and Short-Term Actions
- Midterm Pursuits “Projects”
- Short-Term Actions in A Conflict Project
- Problems of the Action Organization
- Consciously Prepared or Spontaneously Undertaken?
- The Young Woman’s Talk with the Psychiatrist
- Problems of the Action Monitoring Processes
- Problems of the Action Energizing
- Suicide and the Interactive and Joint Action
- Self-Confrontation-Interview
- Conclusion
- Disclosures
- References
Problems of the Action Energizing
The patient felt exposed to threats which she was, in her eyes, not able to influence and, could not, therefore, generate any energy for life and for dealing with these problems. Problems in her family, school and with her boyfriend, of which solutions she thought are accessible only to other people. This view consumes a lot of energy. It could be argued that she uses this view with other issues as well. She reports that she fought being overweight and this problem was addressed by appetite suppressant pills prescribed by a physician. Equally, she addressed her other problems by overdosing.
- Case Report
- Summary
- Introduction
- Long-Term and Mid-Term Pursuits and Short-Term Actions
- Midterm Pursuits “Projects”
- Short-Term Actions in A Conflict Project
- Problems of the Action Organization
- Consciously Prepared or Spontaneously Undertaken?
- The Young Woman’s Talk with the Psychiatrist
- Problems of the Action Monitoring Processes
- Problems of the Action Energizing
- Suicide and the Interactive and Joint Action
- Self-Confrontation-Interview
- Conclusion
- Disclosures
- References
Suicide and the Interactive and Joint Action
The patient lived, at the time of her suicide attempt, at home and had a close contact to her parents. That, however, she did not always find helpful. Her suicide action occurred in a social context in contact with others. Her boyfriend ended their relationship and the patient talked about her feelings and her suicide intentions to a girlfriend. She went, crying, to her mother to say good night and probably good bye, before she started her suicide action in her room. When she did not feel well after overdosing, she again called her mother. Also, other experiences which she relates to her understanding of her suicide are meeting other people and relationships with others. The difficult relationship with her father, feeling disposed of by her family, the hurtful meetings with her boyfriends and other friends and, finally, the being deserted by her last boyfriend, with whom she fell in love for the first time in her life, complete this picture of her embeddedness in joint social actions and projects. The order by her mother not to visit her boyfriend because of her school grades was the decisive impact other people had on the life of this young woman.
- Case Report
- Summary
- Introduction
- Long-Term and Mid-Term Pursuits and Short-Term Actions
- Midterm Pursuits “Projects”
- Short-Term Actions in A Conflict Project
- Problems of the Action Organization
- Consciously Prepared or Spontaneously Undertaken?
- The Young Woman’s Talk with the Psychiatrist
- Problems of the Action Monitoring Processes
- Problems of the Action Energizing
- Suicide and the Interactive and Joint Action
- Self-Confrontation-Interview
- Conclusion
- Disclosures
- References
The Young Woman’s Talk with the Psychiatrist
The psychiatrist attentively follows in a goal-directed manner his topics of his concept of a suicide in this talk and the patient fluidly and extensively reports about the events. Consequently, the talk appears as a compact unit, an encompassing action. Nevertheless, individual parts can be segmented from the stream of the talk.
i. In the 1st joint action, the psychiatrist suggests a joint task “Perhaps it would be most simple to talk about what actually happened…” and the patient accepts the task after a clarifying question. She describes in nearly 700 words how she met a girl in a boarding school and through her a young man whom she fell in love with and visited in another town until her mother forbade her to see him because of her school grades. The young man declined visiting her in her town and conveyed that, under such circumstances, they should terminate their relationship. At the same time the young woman experienced some troubles at home, as her father, who had left the family when she was three, returned home and attempted to control her in a very strict manner. The psychiatrist interrupts her asking about her contacts with her father during his absence and the patient finishes her suicide story in another 240 words.
ii. In the 2nd joint action, which the psychiatrist starts with an unfortunate double question (what happened during the overdosing and where did she get her tablets from?) and the patient concentrates on answering the second question.
iii. In the 3rd joint action, the psychiatrist suggests looking at the events around her suicide step by step and the patient describes the steps, how she spoke with her mother, how when her girlfriend rang and she told her about her suicide intention, prepared her things for the school next day, wished, while crying, good night to her mother, lit her candles, put the music on, picked up the pills from the bathroom cabinet and took them.
iv. The 4th joint action is initiated by the psychiatrist’s question about the eating of the pills, and it is followed by a series of questions and short answers. The young woman discloses in these answers that she cut her lower arm with a suicide intention before taking the pills instead, as cutting hurt her too much.
v. Also, in the 5th joint action the psychiatrist explores her suicide thoughts in the decisive suicide action step and she maintains that she did not want to live at that time.
vi. In the 6th joint action, the psychiatrist askes about past suicide actions and thoughts. The patient speaks about her time in the boarding school, about her rat, how she talked a lot to this animal and how, when the rat died, the young woman also wished to be dead.
vii. The psychiatrist asks in the 7th joint action about the meaning of the relationship the young woman had with her boyfriend. She talks about her previous friendships with young men who treated her badly. She continues then talking (700 words) about the relationship with her last boyfriend.
viii. The psychiatrist tries to find out in the 8th joint action, whether the patient considered other options in the moment of her suicide, which she denies. Afterwards they go through the event step by step, in order to recall all thoughts and emotions. The patient mentions her ambivalent feeling towards death. On the one hand, she wished not to live any more, but hoped secretly that her mother would find her beforehand. She speaks about her fear and anxiety when she told her mother what she had done and about her panic attack on the way to the hospital.
ix. The psychiatrist opens the 9th and last joint action with a question whether the patient believes that she could repeat her suicide action. She thinks that at the moment the danger is not there, but “…only when I am travelling on train, being alone, do I think of him and there is a total emptiness”.
- Case Report
- Summary
- Introduction
- Long-Term and Mid-Term Pursuits and Short-Term Actions
- Midterm Pursuits “Projects”
- Short-Term Actions in A Conflict Project
- Problems of the Action Organization
- Consciously Prepared or Spontaneously Undertaken?
- The Young Woman’s Talk with the Psychiatrist
- Problems of the Action Monitoring Processes
- Problems of the Action Energizing
- Suicide and the Interactive and Joint Action
- Self-Confrontation-Interview
- Conclusion
- Disclosures
- References
Self-Confrontation-Interview
The self-confrontation-interview was conducted by a psychologist shortly after the talk to the psychiatrists. The video recording of the talk with the psychiatrist was presented in short but meaningful segment of a few (about 3) minutes. This interview was also video recorded.
The young woman completes, after viewing the 1st segment, her experiences from the boarding school and when she came home how she wished to go back to the boarding school “I said that in the boarding school I thought this is the worst it can get and wanted to go home, back to my mother. This summer I came home. It was good for one month, but afterwards troubles started. I felt that she was blaming me for everything. Then I started to say that I wanted to go back to the boarding school if this continues like that”.
The patient adds after the 2nd segment more about her relationship with her father by whom she felt abandoned and whom she cannot forgive “When I was told in the boarding school that I could go home I did not know that my father would be living with us. I heard it only about two to three months before I was able to go home. My father never cared for me earlier, made empty promises and I did not forgive him for that. My mother always says that if I try - always me - then it would be good with my father. I think that it depends on me, because I don’t want to accept him as my father, because for me he is not my father. In the time when I could have needed him, he was not there for me and now he thinks that he can change all these things on me he missed during the fourteen, fifteen years. That is very difficult for me. There were times when he put down all the telephone calls for me if it was a man calling. He put the telephone down on all my male friends. Recently, I’ve told my mother that I want to leave home again. She said that to my father and, as he knows that I have problems with him, he said that I should not go, but that he is going to. I had a good talk yesterday with my mother. We agreed that I should stay at home and that I should consider all the decisions about me as a matter only between me and her. And I’ve told her that I am going to try hard to get along with my father. It does not mean that I accept him, but I am going to be decent and polite to him. We said that we are going to try that”. Asked about her feeling she maintains that “The feelings towards my father are more like hate than love…When I talk about him it is more “denigration””.
The patient describes her feelings towards the psychiatrist during the talk after the 3rd segment when he asked her about getting the pills out from the packaging “When I was describing how I ate the pills I thought in that moment, that when I think about it, it was absolutely stupid, and I asked myself how I could have done it”. She adds “Actually, I find it ridiculous. To do something like this because of a young man. But in that moment, I did not think at all”.
She describes after the 4th segment the grief she felt when talking about her boyfriend’s phone call “In that moment, when I was talking about it, I felt grief, because after the call, it hurt me a lot how he said that he was going to end the relationship”.
After the 5th segment the patient adds some more information about her experience with her rat “I thought that it was a very bad time when my rat died. I thought this is the end. She was gone and I could not talk to anyone for quite a long time and was crying a lot. The teacher in the boarding school told me that it was only an animal, and I should not make such theatrics. That made it worse and hurt a lot. That was the time when I thought that I want to die, but I felt like this is the end and there was such emptiness. I did not have many friends at that time as I did not know anyone. That is why I had the rat, and I could talk to her and knew that she was not going to tell anyone. It felt like she was listening to me and she sat there, looked at me and when she realized that I am sad she came to me to snuggle and when I was happy, she wanted to play. I do not know if I just imagined that or if she really sensed how I felt. It felt as if someone from the family had died”. She also adds some thoughts she had during her overdosing “I was simply finished with my nerves. I was terribly sad. I was mad at my mother. I blamed her for my relationship finishing because she forbade me to visit him in another town. Then I was confused. I thought that it cannot go on like this and that it does not make any sense to live. Instead of stressing the good I dwelt on the bad. The troubles at home, the thing with my boyfriend, that at school. I thought “it does not make any sense anymore””.
Also, after the 6th segment the young woman adds many details, she thought of during the talk with the psychiatrist, but did not verbalize. She talks about her previous relationship and her boyfriend. She was 16 or 17 and he was 6 years older. They went out together for a year until he disappeared without saying goodbye to get married, owing some money to her mother. She maintains “When I think about it, I have to laugh. It would not occur to me in a dream that my boyfriend would come to me suddenly saying I should choose him a wife. I had to laugh when I was talking about it. There is no anger about it”.
After seeing the 7th segment, the patient reiterates “There is nothing to add. Only sadness, grief. It still hurts a lot. If I had the chance, I would use it and do it again”. Addressing her feelings, she had in the 8th segment, she says “I can describe my feelings well. It was anger, because it is completely wrong that my girlfriend would call and try to persuade my boyfriend. I did not know anything about it and now he is mad at me, because he thinks that I told her to call and help. I am angry with her and have not talked to him since. He does not call anymore, and I am mad at her. I could smack her face because it is so wrong what she did. I would never have done that. Do I have to follow her so that she does not rummage in my things? I was very disappointed because I thought that she was a good friend”.
The patient describes after the 9th segment the feelings she had while talking to the psychiatrist “Sadness, grief…I felt it the day before yesterday, I feel it now and I felt it during the whole talk. I would say, it is always there, at the moment. It was also very embarrassing”.
In the 10th segment she felt the same as before, perhaps also a “bit nervous”.
After the 11th and the last segment, in which she talks about the time after her suicide attempt, she says “It is like a feeling of happiness… I am just glad, because of the talk with my mother, which went very well… because of stress. I am stressed in the morning when I have to catch a train, then I have school and a lot of homework. I come home and do my homework. I have so much stress that I can’t think and contemplate. Only sometimes, when I am on the train after the school, a time comes up that I could cry or in the evening before going to bed. Otherwise, I have to say that I am fine. Let’s say, if I could cut out the topic of my boyfriend, I would be ecstatically happy”. The patient finds the talk with the psychiatrist helpful “…it was a bit strange and funny to talk about it. First of all, to talk to someone I don’t know, whom I saw for the first time. But I think it was good to talk about it”.
- Case Report
- Summary
- Introduction
- Long-Term and Mid-Term Pursuits and Short-Term Actions
- Midterm Pursuits “Projects”
- Short-Term Actions in A Conflict Project
- Problems of the Action Organization
- Consciously Prepared or Spontaneously Undertaken?
- The Young Woman’s Talk with the Psychiatrist
- Problems of the Action Monitoring Processes
- Problems of the Action Energizing
- Suicide and the Interactive and Joint Action
- Self-Confrontation-Interview
- Conclusion
- Disclosures
- References
Conclusion
A conception of suicide was discussed relying less on psychiatric diagnoses but seeing the suicidal processes in terms of systems of goal-directed actions, projects and long-term striving. Then an interview or a talk with a patient after a suicide attempt was presented in the proposed frame of reference. First, the long-term strivings the patient considered relevant for her suicide attempt were outlined. Then the important mid-term processes the patient thought important for understanding her suicide action were described. In the subsequent section the individual actions and cognitions/emotions the patient mentioned in her talk about her suicide were listed. Discussing her suicide attempts in terms of the proposed conceptual reference we dealt, firstly, with the disclosed problems of action organization. Some of the issues are in suicide research studied as cognitive fallacy problems. We addressed the problems of properly ordering the action, projects and long-terms strivings to each other and also the problems in the organization of action concerning its order of steering, control and regulation. An adequate suicide prevention should target these issues. Relating short-term actions to mid-term projects and long-term striving is an obvious topic in many suicide preventive strategies. Addressing the systems order within an action requires additional psychotherapy techniques. One issue concerning the relation of the systems of goal-directed processes to each other represents the consideration of top-down and bottom up steering. In suicide action this refers to linking an action to a particular project and switching from a life enhancing project with the appropriate action to a suicide project with a suicide action. The reference to ongoing project in everyday action is also an important topic to reflect upon and to work on in a suicide preventive intervention. However, the best researched are the issues of action monitoring in suicide often addressed as amnesia, alexithymia, dissociation, numbness and other. We stressed that they should not be studied and conceptualized as personality dispositions, but as processes of goal-directed systems be it in an action, project or in long-term strivings. The issues with action energizing were often formulated within the depression approach to suicide. However, it has to be understood that the question of action energizing could be studied related to suicide action. Nevertheless, treating problems within this topic could be inspired by the current approaches to depressive phenomena. We pointed out that suicide is a socially embedded process best seen and dealt with as a joint goal-directed process. This is not just a conceptual statement stressing the social and collective against the individual, but it supports the suicide preventive intervention as a joint action and a joint project often described as a collaborative approach [17]. Obviously, in the suicide preventive psychotherapy sessions the social experience, social embedding and the way how the patient relates to others must be revised and the destructive processes changed. The immediate way of unfolding the suicide narrative as well as the way the patient relates and engages in social encounter is the talk to a psychiatrist, also summarized in this paper. The way how such a talk is informed by psychotherapy skills impacts the future suicidal projects and, better still, life enhancing projects of the patient. We maintain that this impact is even stronger in the video-supported self-confrontation interview. This is an interview on the internal processes the patient had during the talk to the psychiatrist. In presenting short segments of the video (1-3 minutes) the patient reports actual thoughts, emotions and sensation instead of making summarizing and explanatory statements. Informing on each presented segment we can point out new information about the suicide action not disclosed in the interview, the internal processes experienced and also the impact of the self-confrontation on the patient’s understanding of the suicide action. Consequently, the self-confrontation interview is an important part of the suicide prevention. The ASSIP (Attempted Suicide Short Intervention Program) is a joint project of the psychotherapist and the patient containing narrative interview and the self-confrontation interview among other and provided 80% probability reduction of suicide attempts in 2 years in patients after a suicide attempt [18,19].
- Case Report
- Summary
- Introduction
- Long-Term and Mid-Term Pursuits and Short-Term Actions
- Midterm Pursuits “Projects”
- Short-Term Actions in A Conflict Project
- Problems of the Action Organization
- Consciously Prepared or Spontaneously Undertaken?
- The Young Woman’s Talk with the Psychiatrist
- Problems of the Action Monitoring Processes
- Problems of the Action Energizing
- Suicide and the Interactive and Joint Action
- Self-Confrontation-Interview
- Conclusion
- Disclosures
- References
Disclosures
The author declares no conflicts of interest.
- Case Report
- Summary
- Introduction
- Long-Term and Mid-Term Pursuits and Short-Term Actions
- Midterm Pursuits “Projects”
- Short-Term Actions in A Conflict Project
- Problems of the Action Organization
- Consciously Prepared or Spontaneously Undertaken?
- The Young Woman’s Talk with the Psychiatrist
- Problems of the Action Monitoring Processes
- Problems of the Action Energizing
- Suicide and the Interactive and Joint Action
- Self-Confrontation-Interview
- Conclusion
- Disclosures
- References
References
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- Branley-Bell D, O'Connor DB, Green JA, Ferguson E, O'Carroll RE, et al. (2019) Distinguishing suicide ideation from suicide attempts: Further test of the Integrated Motivational-Volitional Model of suicidal behavior. Journal of Psychiatric Research 117: 100–107.
- Michel K, Valach L (2002) Suicide as goal-directed action. In: Ed K van Heeringen (Ed.), Understanding Suicidal Behaviour: The Suicidal Process Approach to Research and Treatment. Wiley & Sons, Chichester, England, pp.230-254.
- Valach L, Michel K, Young RA, Dey P (2002) Stories of attempted suicide: Suicide career, suicide project, and suicide action. In: L Valach, RA Young, MJ Lynam (2002) Action theory. A primer for applied research in the social sciences. Praeger, Westport, CT, United States, pp.153-171.
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