Annelie Werbart Törnblom - Exploring paths to youth suicide and sudden violent death: A multimethod case-control investigation

Hello and congratulations to your PhD,
People at the Department of Women’s and Children’s Health and others are interested to know a little more about your work.

Annelie Törnblom
Annelie Törnblom

What is your thesis about?

Suicide and other forms of sudden violent death are the most common causes of death among young people worldwide. Both suicide and other forms of sudden violent death are more frequent among males than females. Risk factors, suicidal behavior, and help-seeking patterns differ between young women and men. The aim of my thesis was to explore the hypothesis that there are similar backgrounds to both death by suicide and to other forms of sudden violent death among youths. The aims of the quantitative studies were: (1) to compare risk factors for youth suicide and for other forms of sudden violent death with matched living controls; (2) to examine associations between life events and coping strategies common in these three groups of young people. The aims of the qualitative studies were: (3) to build a generic conceptual model of the processes underlying youth suicide, grounded in the parents’ perspective; (4) to compare boys’ and girls’ suicidal processes. In the prospective longitudinal case-control design, 63 consecutive cases of youth suicide and 62 cases of other forms of sudden violent death were compared with 104 matched control cases. Data were collected in 196 psychological autopsy interviews with parents and other relatives and 240 equivalent interviews in the control group. The interview data were analyzed both qualitatively and quantitatively in distinct steps.

Which is the most important key result? 

(1) The number of stressful life events in the previous year was the only common risk factor for suicide and other forms of sudden violent death. Specific risk factors for suicide were any form of addiction and being an inpatient in adult psychiatric care, whereas for other forms of sudden violent death, risk factors were poorer elementary school results, lower educational level, and abuse of psychoactive drugs. (2) Four coping strategies, two more adaptive and two less adaptive, were identified. Distinctive of the suicide and the sudden violent death group was significantly less Planful Problem-Solving, and more Escape-Avoidance and Confrontive Coping than among the controls. Distinctive for the suicide group was the highest level of Escape-Avoidance, corresponding to internalizing ways of coping, whereas the sudden violent death group had the highest level of Confrontive Coping, corresponding to externalizing ways of coping. Surprisingly, no significant between-group differences in Seeking Social Support were found. Between-group differences were partly mediated by differences in adverse childhood experiences and in negative life events in the previous year. Furthermore, distinctive for the sudden violent death group was a stronger association between adverse childhood experiences and Escape-Avoidant Coping than among the controls. (3) Family alliances, coalitions and secrets were intertwined with the young person concealing problems and “hiding behind a mask,” whereas the professionals did not understand the emergency. Parallel processes within the parental relationship, the parents’ relationship with the young person, and the family’s contacts with professionals transmitted and disseminated destructive forces in negative feedback loops. Finding no way out, from their perception of double shame; their own and in the eyes of others, the young persons looked for an “emergency exit.” Signs and preparations could be observed at different times but were recognized only in retrospect. Typically, the young persons and their parents asked for professional help but did not receive the help they needed. (4) Different forms of shame were hidden behind gender-specific masks, or personas shown to other people. Common for both young men and women, even if expressed in a gender-specific manner, were the prototypical personalities of the clown and the lark, the warrior and the invisible girl, and the prince and the princess. Other prototypical personalities were unique to young women: the mother’s friend and confidante, the girl who did not want to grow up, the wandering Saint, and the Nobel Prize winner. Both the young men and women were struggling with issues of their gender identity. Five interwoven paths to suicide were found: being hunted and haunted, being addicted, being depressed, being psychotic, or—for the girls—having an eating disorder.

Is there something else you would like to add? Maybe something that surprised you during your PhD student journey?

I remember walking up the hill with the person I was going to interview about his son’s suicide and he suddenly reflected and said “I don’t know why I have decided to be interviewed by a total stranger about the most precious things in my life.” I think I answered something like “I do not know why either,” and I said it was courageous. In retrospect, I understand we both had one thing in common: we were curious to find an answer to “Why did this death happen?” Later on, I learned that all parents had their own private theories trying to explain how this could had happened, containing everything from self-blame, genetic inheritance, bad luck, destiny, to blaming others. Still, I was convinced they all were telling the truth. Almost all parents admitted they had heard their child saying something astonishing at some point during the year prior to the death, which they did not understand at that time, but which now took on new meaning.

How can this new knowledge contribute to improve women’s and children’s health?

The suicide group seems to have been more vulnerable and exposed to different kinds of stressors, whereas the sudden violent death group seems to have been more prone to acting out and risk-taking. Improved recognition and understanding of the interplay between life events, both in the far past and present, and coping styles, may facilitate the identification of young people at risk of suicide and other forms of violent death. Both groups must be the subject of prevention and intervention programs. Future preventive programs need to address barriers to communication among all parties involved: the young people, parents, and community support agencies. Understanding and making use of the parents’ tacit knowledge can contribute to better prevention and treatment.

My studies demonstrate that it is a matter of life and death who receives the suicidal message, how it is interpreted, and what actions they take. The preconceptions and beliefs among friends, siblings, parents and professionals will be decisive. In my studies, most young persons communicated their suicidal thoughts and plans not only to siblings or friends but also to a parent or professionals. Thus, they were not blind to his cues, they simply misinterpreted them. A further problem was the lack of communication between parents, parents and professionals, parents and friends or siblings. My studies indicated that parents could report unambiguous, suicidal communication but not take the threat seriously. Only in retrospect they could recognize signs and preparations. Thus, there is an urgent need for more knowledge of warning signs observable in other arenas, such as school, the workplace, other places where youth activities take place, and medical and social services.

One conclusion from the quantitative studies was that not only suicide, but also other forms of sudden violent death in youths must be the subject of prevention and intervention programs. Given that the two groups share the same risk factors, adverse life experiences and coping strategies to some degree, large scale suicide prevention programs may contribute to reduced rates of other forms of sudden violent death in youths.

One of the findings from the qualitative studies was the lack of communication among parents, parents and friends or siblings, as well as parents and professionals. This furthers the discrepancies between the perspectives of all involved protagonists. Thus, fostering communication between all parties involved might be decisive for the success of preventive measures and interventions. In professional meetings with suicidal people, one of the main tasks may be to take an interest in and arouse the young person’s curiosity about their own explanations for their dilemma. For the professionals, it may be helpful to recognize and reflect on their own private theories about the young person’s difficulties and the potential solutions. Furthermore, addressing barriers to help for youths, their parents and friends, and healthcare professionals might be the most important ingredient in preventive programs.

Thank you very much Annelie and good luck in the future.

Exploring paths to youth suicide and sudden violent death: A multimethod case-control investigation