Archives of Psychiatric Nursing 28 (2014) 5561

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Archives of Psychiatric Nursing

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The Healing Process Following a Suicide Attempt: Context and Intervening Conditions
Fan-Ko Sun a, b,, Ann Long c, Lee-Ing Tsao d, Hui-Man Huang a, e
a
University of Ulster
b
Department of Nursing, I-Shou University, Kaohsiung City, Taiwan, R.O.C.
c
School of Nursing, University of Ulster, Belfast, Northern Ireland, UK
d
Nursing Department & Graduate school, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan ROC
e
Department of Nursing, Chang Jung Christian University, Tainan City, Taiwan R.O.C.

a b s t r a c t

The purpose of this study was to explore the context and the intervening conditions that impacted on
individuals' healing from a suicide attempt. Patients who had survived a suicide attempt (n = 14) and their
caregivers (n = 6) were interviewed in this study. Findings revealed that the suicidal individuals who lived in
a sheltered, friendly environment, and had support systems helped their suicidal healing process. Conversely,
suicidal individuals who experienced negative aspects of self, family predicaments, environmental difculties,
and the re-emergence of stressors impeded their suicidal healing process. Consequently, health professionals
need to promote healthy internal and external environments for suicidal individuals.
2014 Elsevier Inc. All rights reserved.

The World Health Organization (2013) reported that approxi- BACKGROUND

mately one million people die from suicide every year and that the
known global mortality rate for suicide is 16 per 100,000 individuals.
The suicide rate in many countries exceeds 16 per 100,000 in-
dividuals, for example: the Republic of Korea (31.0/100,000 in 2009);
Japan (24.4/100,000 in 2009); France (16.3/100,000 in 2007) and in
Taiwan (16.2/100,000 in 2012) (World Health Organization, 2013). In
Taiwan, the suicide rate reached a peak of 19.3 per 100,000 in 2006
(Department of Health, Executive Yuan, Taiwan, ROC, 2013). Hence,
suicide prevention centres were created, and a suicide report format
was established in 2006 for helping to reduce the high suicide rate in
Taiwan (Suicide Prevention Centre, 2007). Ofcial records in 2011
showed that the suicide rate in Taiwan has decreased to 15.1 per
100,000 (Department of Health, Executive Yuan, Taiwan, ROC, 2013).
However, the report also shows that the number of suicide attempts
has gradually increased since 2006 (Lee, 2013). It is well documented
that both culture and environment have an impact on peoples' healing
following a suicide attempt (Sun, Long, Huang, & Huang, 2008; Tzeng,
Su, Chiang, Kuan, & Lee, 2010). It is paramount that health pro-
fessionals recognize and take steps to improve both the internal and
external environment that impacts on peoples' healing process after
their suicide attempt.
Suicide: The Chinese Culture
Many countries in both eastern and western cultures consider
suicide being morally wrong and as a weak or foolish behaviour (Sun
et al., 2008; Tzeng et al., 2010). In Chinese culture, the term bu-hsiao
refers to suicide, which means non-lial piety, because the basic
hsiao, or lial piety, means to protect the life and the body that your
parents donated to you. Thus, parents are extremely saddened when
their children attempt to destroy, by way of suicide, the life and body
they have bestowed on them. This belief, based on the philosophy of
Confucius, posits that hsiao is inuenced strongly in Taiwanese
culture and thinking (Sun et al., 2008; Tzeng et al., 2010). Many
studies have reported that suicide still carries a tremendous stigma
(Dyregrov, 2011; Keyvanara & Haghshenas, 2010; Sun et al., 2008;
Tzeng & Lipson, 2004). Moreover, individuals who attempt suicide as
well as their families feel tremendous shame and fear that their
friends and society will reject them. Social stigma can be diminished if
people become willing to enter into dialogue about suicide, and
perhaps a more open debate about the topic might help people feel
more comfortable seeking help (Dyregrov, 2011).

Suicide: Protective, Resilient and At-Risk Environments

There are some protective or resilience factors that can help

Corresponding Author: Fan-Ko Sun, RN, University of Ulster, Associate Professor,
Department of Nursing, I-Shou University, No.8, Yida Rd., Jiaosu Village, Yanchao
District, Kaohsiung City 82445, Taiwan, ROC.
E-mail addresses: sunfanko@isu.edu.tw.com (F.-K. Sun), ma.long@talktalk.net
(A. Long), leeing@ntunhs.edu.tw (L.-I. Tsao), x2156@mail.cjcu.edu.tw (H.-M. Huang).
prevent suicide and people who are recovering following an attempt.
These protective resilience factors include (1) developing positive
coping strategies could prevent re-attempts, (2) participating in
sporting activities, (3) developing healthy family relationships, (4)
providing supportive school environments, (5) accessing social

0883-9417/1801-0005$34.00/0 see front matter 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.apnu.2013.10.004
56 F.-K. Sun et al. / Archives of Psychiatric Nursing 28 (2014) 5561
support networks in the general population, (6) promoting healthy
cultural and religious beliefs, (7) engaging in employment, (8)
educating and training healthcare professionals to provide holistic
health interventions and care services to meet the needs of
individuals and families (Fang, Lu, Liu, & Sun, 2011; Ke, 2008; McLean,
Maxwell, Platt, Harris, & Jepson, 2008; Sun, Long, Boore, & Tsao, 2006;
Sun et al., 2008).
Conversely, there are factors that slow down or negate the healing
process. These factors include (1) the reappearance of stressors
especially those they feel they cannot cope with, which reawaken
their suicidal ideations, (2) psychiatric symptom interference usually
due to a failure to take their medication, (3) lack of support systems
from family, friends, professionals, and/or society, (4) negative
thinking about everything and everybody leading to suicidal idea-
tions, (5) loss of problem solving skills leading to thoughts that
suicide is the only way to deal with their problems (Chi, 2011; Ke,
2008; McLean et al., 2008).
Recovering From a Suicide Attempt: Chinese Research
With respect to the Taiwanese culture, a literature search
demonstrates that only two studies have focused on patients
recovering from suicide attempts. In the rst, Ke (2008) used
interviews to explore the resilience of suicide survivors (n = 6) and
found that three major domains were required for recovery: (1)
external support and resources, (2) inner power and personal
strength, and (3) social and interpersonal skills. The external support
and resources domain includes six concepts: (1) a good role model, (2)
religious support, (3) positive family support, (4) healthy and
appropriate teaching strategies for children, (5) effective courses
and programmes that facilitate positive change, and (6) supportive
social networks.
In the second study, Chi (2011) adopted grounded theory (GT) to
understand the healing process of individuals who attempted suicide
(n = 14). Findings show that the healing process comprises ve
stages: (1) self-awareness, (2) help-seeking, (3) repetitiveness, (4)
adjustment, and (5) acceptance. In the help-seeking stage, individuals
accessed help from medical professionals or community social
supports during the recovery process. However, the above two
studies offered only a broad outline of the process of peoples' healing
after their suicide attempt. They did not explore, in depth, the GT
context and intervening conditions of the healing process in Chinese
culture. Thus, the aim of this paper was to understand the internal and
external environments (the context) and the protective/resilient and
impeding circumstances (intervening conditions) affecting the ac-
tion/interactions of individuals when navigating the healing process
after their suicide attempt in Chinese culture.
METHODS
This paper is a portion of a larger research area whose aim was to
develop a theory to guide suicidal individuals to aid in healing after
their suicide attempt (Sun & Long, 2013). In this study, Strauss and
Corbin's method of grounded theory was used because Denzin and
Lincoln (2011) found that it is the most appropriate method to use
when the aim of the research is to develop a theory.
Participants
Theoretical sampling was used because it helped to integrate the
concepts and to clarify the relationship between one concept and
another. Accordingly, each interview guide was modied before the
next interview in harmony with concepts that emerged during the
previous interview; for instance, when the patient participants
expressed that psychiatric consultants had helped cure them from
their depression and prevented suicide attempts, an additional four
psychiatric professionals were selected for interview to reach
saturation of the data. Moreover, when this study achieved data
saturation, the researcher added three more participants to conrm
that this study had really achieved saturation. That is, no new
concept was elicited in the three participants. The total number of
participants in this study was 20 participants including patients who
were healing from suicide attempts (n = 14) and their caregivers
(n = 6). The inclusion criteria for the patient sample included
having a diagnosis of depression and a suicide attempt that
happened more than 1 year ago. The inclusion criterion for the
caregiver was people who were suicidal individuals' family or curer
who helped them heal from their suicide attempts.
The demographic details of patients were as follows: women
(n = 10), men (n = 4); ages between 22 and 83 years; religion
(n = 9), non-religion (n = 5); university education (n = 6), senior
high (n = 4), junior high (n = 2), 5-year junior college (n = 2);
married (n = 7), divorced (n = 3), widowed (n = 3), single (n =1);
employed (n = 11), unemployed (n = 3); and previous suicide
attempts: 1 to 3 times (n = 12), 4 to 6 times (n = 1), 7 to 9 times
(n = 1). The demographic details of caregivers were as follows:
women (n = 3), men (n = 3); ages between 22 and 46 years;
university education (n = 5), 5-year junior college (n = 1); married
(n = 5), single (n = 1); patients' psychiatrists (n = 3), patients'
daughters (n = 2), patient's psychiatric nurse (n = 1).
Data Collection
Data were collected from the out-patient clinic of one medical
centre's hospital in Taiwan during 2011 and 2012. Before collecting
data, this study was approved by one medical centre's hospital
institutional review board (no. 100-111) and the university ethics
committee (no. 99-013). Each participant received oral and written
information regarding the purpose of the research; were informed of
their rights and signed the consent form. The researcher notied the
participants that they had the right to refuse to participate. Even
though, they had signed the informed consent, they could withdraw
from the study without any excuse and they were free to refuse to
answer any of the questions. The researcher guaranteed the
participants that all interview data would keep in condence and
that their responses would be anonymously coded. They were also
informed that a paper would be submitted for publication.
Subsequently, participants were interviewed once, in a conversa-
tion room in the hospital, for approximately 60 minutes, using a
semi-structured interview guide. The initial interview guide com-
prised four themes namely: (1) the internal and external resources
that enabled individuals to heal from their suicide attempt, (2) the
environment or circumstances that helped individuals stop their
suicide attempt, (3) positive thoughts or happenings that prohibited
individuals from re-attempting suicide in the past year, and (4)
negative thoughts or happening that postponed the restorative
process after their suicide attempt.
Data Analysis
The researcher used bracketing skill to make sure that the
researcher had minimal impact on the data analysis and the results
(Morse, 1994). Grounded theory emphasises that data collection,
coding and analysis are conducted simultaneously (Corbin & Strauss,
2007). Therefore, a research assistant typed each interview transcript
within 2 days following the interview. Concurrently, the lead
researcher listened carefully to the tape-recorded version to conrm
the accuracy of the typed transcript. Subsequently, data were
analysed line-by-line to uncover important, repeated and highlighted
information. These important data were then coded into signicant
statements (meaning units), and emergent concepts were created.
Next, constant comparative analysis was used to group similar
 F.-K. Sun et al. / Archives of Psychiatric Nursing 28 (2014) 5561
A sheltered environment
A protective environment
Feeling accepted in the environment
A friendly environment
Fig. 1. The environmental context for people healing from a suicide attempt.
concepts together to create four subcategories within the contextual
conditions component of the paradigm (Corbin & Strauss, 2007) and
nine subcategories within the intervening conditions of the paradigm.
Finally, constant comparative analysis was used to identify similar
subcategories, which were clustered together to create two categories
within the contextual conditions component of the paradigm and two
categories within the intervening conditions of the paradigm.
The research used four methods to set up the credibility of this
qualitative research study (Lincolin & Guba, 1985). (1) Prolonged
involvement: empathic communication was used during each inter-
view process, which took place following their 6 month consultation at
the out-patient clinic. (2) Continuous observations: the interviewer has
worked in psychiatric wards for 14 years and has competent skills of
observation to assess participants' verbal (observe participant's verbal
volume, speed, intensity, style, and word meaning) and non-verbal
communication (observe participant's appearance, behaviour, gestures,
emotional reactions, and expression in their eyes and face) during and
after interviews in case any of the participants needed to return to the
out-patient clinic for follow-up. (3) Member checks: four participants
(two patient participants and two caregiver participants), whose typed
transcripts resulted in more emergent concepts than the others, were
invited to review all created concepts, categories and subcategories to
ensure that they were accurate representations of their experiences. (4)
Expert review: two nursing professors who are procient in GT research
reviewed all the created concepts, categories and subcategories to verify
that they corresponded with those of the researchers. In addition, the
researcher used an audit trail to set up the dependability of this
qualitative research study (Lincolin & Guba, 1985). A nursing professor
with experience in grounded theory acted as an auditor for purposes of
establishing levels of dependability and conformability. She checked all
research data including the transcripts, the concepts and categories of
data analysis, narrative exemplars, interview guide and nal product.
FINDINGS
The researcher created ten categories from the interview data and
used the Corbin and Strauss's (2007) paradigm to link the relationships
between the 10 categories. The ve components of the paradigm are (1)
causal conditions, (2) contextual conditions, (3) intervening conditions,
(4) action/interactions, and (5) consequences. By linking the ve
components of the paradigm, a substantive theory to direct the healing
and restorative process of people who have recently attempted suicide
was created. Each of the components within the paradigm interacts
with all other components. Therefore, the contextual conditions and
intervening conditions affected the individuals' action/interactions
strategies by either nurturing healing conditions or impeding condi-
tions during the healing process. This paper concentrates on the
contextual conditions (the internal and external environment) and the
57
A secure environment
Feeling needed in the environment
intervening conditions (the protective and impeding circumstances)
from which four categories were created.
The Context
In the component of the paradigm (Corbin & Strauss, 2007),
contextual conditions, participants expressed that suicide is seen as a
dishonourable act in Chinese culture and therefore other people make
derogatory judgments about those who attempt. While participants
perceived that these historical beliefs had a positive effect on their
recovery. However, they also perceived that it would be more helpful
if Taiwanese society could modify their beliefs and accept that suicide
does happen and that individuals who attempt need to be accepted
and cared for in a sheltered and friendly environment. Therefore, two
categories were created in the contextual conditions (see Fig. 1).
A sheltered Environment
All participants expressed that people who attempt suicide need a
sheltered environment to aid them to heal and recover from their
suicide attempt. They perceived that a sheltered environment
provided protection and security. Thus, it was important that no-
one would hurt them while they still felt fragile. Consequently, this
category was composed of two sub-categories.
1. A protective environment: In this sub-category, most of the
participants perceived that living in a protective environment
nurtured the healing process following their suicide attempt.
They described a protective environment as one in which there
is no stress (P1). I need it to be stable (P2). One patient who
had healed from her suicide attempt had this to say:
P1 (Participant 1): When I was so sad and full of anguish, I was
glad I was in the hospital so I could hide myself from the world.
The hospital environment protected me. I could temporarily
escape from my stress and this prevented me re-attempting a
suicide attempt.
2. A secure environment: The participants felt comfortable (P2)
when they are living in a secure environment. They perceived
this as being related to trust (P1), feeling safe inside myself
(P10), and a calm environment. They felt at ease (P16) and
were able to carry out the activities of daily living including
talking with friends. This made them feel secure inside and
outside of self. One caregiver had this to say:
P18: My father moved came to live with me after his suicide
attempt. However, he wanted to live in his own home because he
said he felt more comfortable and secure there. He felt secure
there cooking and buying his own food. I asked him to promise
58 F.-K. Sun et al. / Archives of Psychiatric Nursing 28 (2014) 5561
Intervening conditions
Caring by family
and friends
Treatment by mental
health professionals
Healing
Support from members circumstances
of society
Religious support
Stress decrement
Fig. 2. Intervening conditions for people healing from a suicide attempt.
me that he would never attempt suicide again. He has kept his
word for the past ve years.
A Friendly Environment
The participants felt the society still adopted negative attitudes
towards people who attempted suicide. Participants perceived the
need for living in a friendly environment where people and society
accepted them and even one person (P16) needed them. Conse-
quently, this category was composed of two sub-categories.
1. Feeling accepted in the environment: In this sub-category, a
number of participants expressed that it helped them to heal
following a suicide attempt when their family, friends, and
society accepted them and did not judge (P12) them harshly
(P9) for attempting suicide. Further, they realised that they
needed to accept myself (P18) rst and accept the suicide
attempt as a careless action (P8). One patient said:
P12: Ive an old friend whos a school-teacher. He and his wife
always seemed to accept me when I was often depressed. I felt
their acceptance inside of me. When I was admitted to the
hospital they came to visit me. This meant a lot to me.
2. Feeling needed in the environment: Most of the participants
disclosed that they felt like a valuable and worthwhile person
when they felt someone needed them in the environment (P 10).
They wanted to feel needed by (1) their children who required
their love and guidance; (2) their parents, who expected them to
show lial piety; (3) society, who needs them to be of service
and contribute to the community. One psychiatrist said:
P16: My patient (P2) needs to make money so that her two sons
can study at university. She now knows that her sons need her to
be there for them, stay with them and support them. She has not
re-attempted since these realisations.
Intervening Conditions
In this component of the paradigm (Corbin & Strauss, 2007),
intervening conditions, participants expressed that they had received
Received negative
aspects of self
Family
predicaments
Impeding
circumstances
Environmental
difficulties
Escalation of
stress
a lot of help (P1) to assist healing and to prevent them re-
attempting. However, they also experienced some set-backs (P5)
that delayed the healing process. Therefore, two categories were
created in the intervening conditions (see Fig. 2).
Healing Circumstances
In this category, participants expressed that their healing
circumstances included their family and friends' caring, the mental
health professionals' treatment, support from members of society,
and religion. These people helped in different ways to reduce
their stress.
1. Caring by family and friends: In this sub-category, most of the
participants who had attempted suicide received care from
their family and friends during the healing process. This meant
a lot to me (P13). I never knew so many of my family cared for
me (P11). They were also aware that their family were
Concerned (P4) and forgave (P10) them. They realised that
this support helped them to overcome their difculties. One
participant said:
P13: My daughter helped me a lot. She always listened to me
when all I did was grumble. Once, I was very sad and I couldnt
sleep. I called her at two oclock in the morning and talked to her
for over an hour. She told me I can call her at any-time when Im
in a bad mood.
2. Treatment by mental health professionals: Most of the partic-
ipants expressed that the support provided by the mental health
professionals was extremely powerful and valuable because the
doctors and nurses were always there (P7) when the patients
needed them. Whilst they perceived that the greatest help they
received was from psychiatrists who prescribed their medica-
tions (P1), they were also grateful for the care and support they
received from the psychiatric nurses (P10), the social workers
who listened (P11) to them and the psychologists for their
psychotherapy (P12). One participant expressed:
P7: After taking my medication, I felt relaxed and I stopped myself
from going into a blind alley. The medicine can really help me to
control my moods. I know how important it is to take the
medicine when Im trying to heal from a suicide attempt.
 F.-K. Sun et al. / Archives of Psychiatric Nursing 28 (2014) 5561
3. Support from members of society: some participants
explained that they received support from members of
society. For example, communicating with other patients
and discovering that they were not alone in their experience
encouraged them and validated their desperation and the
difculties they experienced. Further, they perceived that
their superiors forgave them, and this helped them phase
back into where their colleagues encouraged them and gave
them positive reinforcement. Those who were unemployed
received money from social subsidies. One participant
explained:
P8: My superior always supported me and understood me. He
found out my strengths and changed me to a new job that I am
good at. He was very patient in teaching me, supporting me,
encouraging me, and giving me approval. I feel condent now.
4. Religious support: Some participants felt that their religious
beliefs and their faith helped them to reduce their suicidal
thinking. Most of the participants in this study were either
Buddhist or Christian. These religions do not sanction suicide
however these participants felt that they received help through
prayer. Moreover, their religious afliations provided opportu-
nities for them to seek support among the congregation. The
following citation illustrates these ndings:
P19: Religion seemed to help my patient (Participant 5). Her
religion perceives it as a mortal sin, and that people who commit
suicide go to hell. She believes that.
5. Stress decrement: In this sub-category, some participants
expressed that they attempted suicide because they were
suffering from enormous stress, and now that the stressors
have been eliminated, they no longer have suicidal ideation.
They resolved or reduced their stress in some cases by changing
jobs, or by sharing their nancial difculties with an advisor.
One family member explained:
P15: My father died when I was a child. My mother had a lot of
nancial difculties so we lived in a stressful environment. Now,
my younger sister and I have grown up so we have part-time jobs
to make some money. Lack of nancial stress helps my mother
and she has no thoughts of suicide now.
Impeding Circumstances
In this category, the participants perceived that it was challenging
to make the transition from wanting to die to wanting to live because
they met some internal obstacles as well as complications from family
members and in the environment during the healing process
following their suicide attempt. These impeding circumstances
made them feel stressed again and, for some, re-awakened their
thoughts of suicide.
1. Perceived negative aspects of self: Many of the participants felt
that their negative behaviours delayed their transition from
desiring to live. For example, some stopped taking, or self-
reduced their medication. Many were unable to express their
emotions, and some said they were stubborn (P1) and
refused to listen (P6) to others' guidance or suggestions.
Some said they led unhealthy and irregular lifestyles (P12),
while many still focused on sad or depressing experiences. One
participant stated:
P7: When my condition got better, I began reducing my
medication. Then my mood deteriorated, and I become intro-
59
verted. Thankfully, I went to see a doctor and he told me that I
couldnt adjust the dose myself.
2. Family predicaments: In this sub-category, many participants
mentioned that family problems delayed the healing process.
For example, most of the participants stated they had suicidal
thoughts (P10) when they had a quarrel with a family member.
Further, some stated that their moods plummeted and their
thoughts became morbid when they worried about their
children, or when their parents became ill or died. One
participant expressed:
P7: When my husband had a quarrel with me or my son he didnt
listen to me. I sunk into very negative emotions and thought that
my life was worthless. When my husband couldnt understand
me, I felt that my life was meaningless.
3. Environmental difculties: Some of the participants expressed
that certain environmental difculties impeded their healing
process and they complained that their illness had undergone
many ups and downs (P6) during their healing. Moreover, they
could not tolerate any type of environmental obstacle because
of their sensitive characteristics (P8). For example, if they had a
conict with others, or lacked a support system, they had
difculty coping with life. One participant explained:
P7: Ive been diagnosed with depression for six years. Sometimes I
feel good and sometimes bad. My depression became serious
when I had a life-changing crisis- my girlfriend left me.
4. Escalation of stress: Some participants complained that they
plunged into depression when past stressors were re-awak-
ened. The re-emergence of stressors included: stress at work,
nancial stress, or additional stress in a relationship. The more
re-emergent stressors they experienced, the more serious their
condition became. One participant said:
P10: I couldnt sleep when Id enormous stress at work. The
insomnia affected my emotions at work and resulted in me being
unable to complete projects. My mood sunk and I began feeling
life was meaningless.
DISCUSSION
This paper explored two components of the paradigm (Corbin &
Strauss, 2007), the environmental factors (the context) and the
intervening factors (intervening conditions) that impacted on patient
participants' healing after their suicide attempt. In relation to the
environment factors, ndings demonstrated that patients who have
attempted suicide need to feel sheltered and safe with their internal
and external environment. These ndings support those of Maslow
(1954), who discovered that human beings function using ve
hierarchies of needs and that the need for safety is the second of the
ve hierarchies. Therefore, the importance of creating a protective
and secure environment was highlighted in this study by high risk
suicidal individuals because they are hyper-sensitive and vulnerable
to the attitudes and behaviours of others. These ndings agree with
those of Wiklander, Samuelsson, and Asberg (2003) and Holm and
Severinsson (2011). Findings from the current study revealed that
suicidal individuals need to feel, protected and comfortable in the
environment during their healing process. A protective environment
not only meant that the external environment was safe (no dangerous
objects, a secure room) but also that the internal environment felt safe
(stress free, stable and calm) corresponding with the ndings of
Brock, Gurekas, Gelinas, and Rollin (2009) and Chi (2011).
60 F.-K. Sun et al. / Archives of Psychiatric Nursing 28 (2014) 5561
The need for a friendly environment emerged in the ndings of the
current study. Participants stated that they felt people were friendly
when others accepted them. Further, they expressed that they had
attempted suicide because they thought they had failed in life, that
life was meaningless and they could not accept themselves at this
period of time. Consequently, when they felt accepted by others, this
helped them to accept themselves. These ndings corroborate those
of Wiklander et al. (2003), who reported that the suicide patients in
their study who experienced hospital personnel as being kind,
nonjudgmental, and respectful seemed more able to transform their
feelings of shame and were more able to accept themselves. However,
some earlier studies noted that some health professionals adopt
judgmental attitudes towards people who repeat suicide attempts or
who used non-lethal methods to attempt suicide, such as drug
overdosing or wrist cutting (Bailey, 1994; Ramon, 1980; Suokas &
Lonnqvist, 1989). Health professionals play an important role in
caring for people who are at risk of suicide. Therefore, it is
fundamental for all health professionals to espouse caring and
empathic attitudes towards individuals who attempt and re-attempt
regardless of method chosen. More education is needed on suicide,
suicide prevention and care (Brunero, Smith, Bates, & Fairbrother,
2008; Chan, Chien, & Tso, 2008; Sun, Long, Huang, & Chiang, 2011).
The participants in this study stated that their recovery was a long
and difcult journey and that, at times, they wanted to give up when
they suffered painful life experiences, or when their mental disorder
became unstable. Therefore, people who attempted suicide need
support networks from a range of people who can help them
overcome, or cope with their situation and reduce their stress. The
evidence in the current study demonstrated that healthy support
systems facilitate the healing process. Most of participants in this
study received support from their family and friends and from mental
health professionals. However, people who want to recover from their
suicide attempts should also seek support from social groups because
increased social support has been found to reduce suicide attempts
(McLean et al., 2008; You, Van Orden, & Conner, 2010). Moreover, in
the current study, participants explained that they received support
from their religion because their religious beliefs generally discour-
aged suicide and because they received support from the congrega-
tion. These ndings support those of McLean et al. (2008); Molock,
Puri, Matlin, and Barksdale (2006) and Robins and Fiske (2009).
Conversely, some participants complained that they experienced
some painful experiences that impeded the healing process. Examples
were inner psyche-problems, family problems and environmental
problems such as nancial problems. Another major problem that
impeded the healing process was that some of the participants
reduced, or stopped taking their medication especially when their
condition improved. They wanted to prove to themselves that they
had completely recovered from their depression and their suicide
attempt. However, their conditions deteriorated when they took these
actions with their medications. These ndings corroborate those of
Simon and Savarino (2007), who explored the time patterns of suicide
attempts among outpatients starting depression treatment with
medication or psychotherapy. Findings demonstrated that the
incidence of suicide attempts was highest in the month before
starting treatment and next highest in the month after starting
treatment. Thereafter, the incidence levels declined. The importance
of patients being educated about their medication ramications is
paramount. Further, following discharge from hospital patient should
be followed-up in the community to ensure that they are taking their
medications as prescribed.
Implications for Practice
It is fundamental that society itself accepts that suicide does
happen. Suicide is everybody's responsibility, and society should
create and maintain a sheltered and friendly environment for people
who are healing following a suicide attempts. For example, the
government could have policies on material that are considered
dangerous, such as the burning of charcoal, which is the second most
popular suicide method in Taiwan (Department of Health, Executive
Yuan, Taiwan, ROC, 2013). Moreover, all health professionals should
demonstrate caring, non-judgemental and supportive attitudes
towards suicidal patients and those who are recovering following a
suicide attempts. Health professionals must also strive to identify
factors that either facilitate or impede on people during the healing
process. Further, health professionals could provide more guidance on
the ups-and-downs of the healing process as well as the impeding
conditions to help reduce the risk-factors during the healing process.
Limitations
This study is limited because only participants who attended the
psychiatric outpatient department of a hospital in Taiwan were
accessed. Suicide remains a stigma in Taiwanese society. Consequent-
ly it is difcult to enlist people in such studies. Future studies could try
to access people via the Internet.
CONCLUSION
Recovery from a suicide attempt is a complex and dynamic process
(Ke, 2008). In GT research, this complex process includes the causal
conditions, contextual conditions, intervening conditions, action/
interactions and consequences. This paper presented and discussed
the internal and external environments (the context) and the
protective and impeding circumstances (intervening conditions)
that participants perceived helped people heal from a suicide attempt
or impede the journey. Suicide prevention centres can apply these
ndings from this paper to direct and aid suicidal patients heal and
recover from a suicide attempt by creating a sheltered and friendly
environment, by helping them nd support systems, and by
facilitating them to cope with their challenging situations.
Acknowledgment
We would like to thank the participants of this study, and we are
grateful for the research funding received from the National Science
Council, Research Grant No. NSC 100-2314-B-214-004.
References
Bailey, S. R. (1994). Critical care nurses' and doctors' attitudes to parasuicide patients.
The Australian Journal of Advanced Nursing, 11(3), 1117.
Brock, G., Gurekas, V., Gelinas, A. F., & Rollin, K. (2009). Use of a secure room and a
security guard in the management of the violent, aggressive or suicidal patient in a
rural hospital: A 3-year audit. Canadian Journal of Rural Medicine, 14(1), 1620.
Brunero, S., Smith, J., Bates, E., & Fairbrother, G. (2008). Health professionals attitudes
towards suicide prevention initiatives. Journal of Psychiatric and Mental Health
Nursing, 15(7), 588594, http://dx.doi.org/10.1111/j.1365-2850.2008.01278.x.
Chan, S. W. C., Chien, W. T., & Tso, S. (2008). The qualitative evaluation of a suicide
prevention and management programme by general nurses. Journal of Clinical
Nursing, 17(21), 28842894, http://dx.doi.org/10.1111/j.1365-2702.2008.02424.x.
Chi, M. T. (2011). Recovery process of attempted suicide patients. Unpublished
dissertation, I-Shou University, Kaohsiung, Taiwan.
Corbin, J., & Strauss, A. (2007). Basics of qualitative research: Techniques and procedures
for developing grounded theory (3rd ed.)Thousand Oaks, CA: Sage.
Denzin, N. K., & Lincoln, Y. S. (2011). Handbook of qualitative research (4nd ed.)
Thousand Oaks: Sage.
Department of Health, Executive Yuan, Taiwan, ROC (2013). The cause of death in 2011.
Retrieved from: http://www.doh.gov.tw/CHT2006/DM/DM2_2.aspx?
now_fod_list_no=12336&class_no=440&level_no=4.
Dyregrov, K. (2011). What do we know about needs for help after suicide in different
parts of the world. Crisis, 32(6), 310318, http://dx.doi.org/10.1027/0227-
5910/a000098.
Fang, C. K., Lu, H. C., Liu, S. I., & Sun, Y. W. (2011). Religious beliefs along the suicidal
path in northern Taiwan. OMEGA, 63(3), 255269.
Holm, A. L., & Severinsson, E. (2011). Struggling to recover by changing suicidal
behaviour: Narratives from women with borderline personality disorder. Interna-
tional Journal of Mental Health Nursing, 20(3), 165173, http://dx.doi.org/
10.1111/j.1447-0349.2010.00713.x.
 F.-K. Sun et al. / Archives of Psychiatric Nursing 28 (2014) 5561
Ke, Y. J. (2008). Suicide attempts by the resilience of explanatory style and the course of
the study, Unpublished dissertation, National Changhua University, Changhua,
Taiwan.
Keyvanara, M., & Haghshenas, A. (2010). The sociocultural contexts of attempting
suicide among women in Iran. Health Care for Women International, 31(9),
771783.
Lee, M. B. (2013). 2012 informed case statistics from the Suicide Prevention Centre.
Newlsetter for Suicide Prevention Network, 8(1), 56.
Lincolin, Y., & Guba, E. (1985). Naturalistic inquiry. Newbury Park CA: Sage.
Maslow, A. H. (1954). Motivation and personality. New York: Harper & Row.
McLean, J., Maxwell, M., Platt, S., Harris, F., & Jepson, R. (2008). Risk and protective factors
for suicide and suicidal behavior: A literature review. Edinburgh: Scottish Govern-
ment, Social Research (www.scotland.gov.uk).
Molock, S. D., Puri, R., Matlin, S., & Barksdale, C. (2006). Relationship between religious
coping and suicidal behaviors among African American adolescents. Journal of Black
Psychology, 32(3), 366389.
Morse, J. M. (1994). Critical issues in qualitative research methods. Thousand Oaks: Sage.
Ramon, S. (1980). Attitudes of doctors and nurses to self-poisoning patients. Social
Science and Medicine, 14, 317324.
Robins, A., & Fiske, A. (2009). Explaining the relation between religiousness and
reduced suicidal behavior: Social support rather than specic beliefs. Suicide & Life-
Threatening Behavior, 39(4), 386395, http://dx.doi.org/10.1521/suli.
2009.39.4.386.
Simon, G. E., & Savarino, J. (2007). Suicide attempts among patients starting depression
treatment with medications or psychotherapy. American Journal of Psychiatry,
164(7), 10291034.
Suicide Prevention Centre (2007). Objectives. Retrieved from: http://www.tspc.doh.
gov.tw/tspc/portal/center/index.jsp.
61
Sun, F. K., & Long, A. (2013). A suicidal recovery theory to guide individuals on their
healing and recovering process following a suicide attempt. Journal of Advanced
Nursing, 69(9), 20302040, http://dx.doi.org/10.1111/jan.12070.
Sun, F. K., Long, A., Boore, J., & Tsao, L. I. (2006). Patients and nurses perceptions of ward
environmental factors and support systems in the care of suicidal patients. Journal
of Clinical Nursing, 15(1), 8392.
Sun, F. K., Long, A., Huang, X. Y., & Chiang, C. Y. (2011). A quasi-experimental
investigation into the efcacy of a suicide education programme for second-year
student nurses in Taiwan. Journal of Clinical Nursing, 20(56), 837846, http:
//dx.doi.org/10.1111/j.1365-2702.2010.03503.x.
Sun, F. K., Long, A., Huang, X. Y., & Huang, H. M. (2008). Family care of Taiwanese
patients who had attempted suicide: A grounded theory study. Journal of Advanced
Nursing, 62(1), 5361, http://dx.doi.org/10.1111/j.1365-2648.2007.04578.x.
Suokas, J., & Lonnqvist, J. (1989). Work stress has negative effects on the attitudes of
emergency personnel towards patients who attempt suicide. Acta Psychiatrica
Scandinavica, 79(5), 474480.
Tzeng, W. C., & Lipson, J. G. (2004). The cultural context of suicide stigma in Taiwan.
Qualitative Health Research, 14(3), 345358.
Tzeng, W. C., Su, P. Y., Chiang, H. H., Kuan, P. Y., & Lee, J. F. (2010). The invisible family: A
qualitative study of suicide survivors in Taiwan. Western Journal of Nursing
Research, 32, 185198, http://dx.doi.org/10.1177/0193945909350630.
Wiklander, M., Samuelsson, M., & Asberg, M. (2003). Shame reactions after suicide
attempt. Scandinavian Journal of Caring Sciences, 17, 293300.
World Health Organization (2013). Suicide prevention. Retrieved from. http://www.
who.int/mental_health/prevention/suicide/suicideprevent/en/.
You, S., Van Orden, K. A., & Conner, K. R. (2010). Social connections and suicidal
thoughts and behavior. Psychology of Addictive Behaviors, 25(1), 180184, http:
//dx.doi.org/10.1037/a0020936.