6 DISCUSSION
6.3 Bridging Quantitative and Qualitative Investigations
for the young men could be to admit that they had a problem. For example, they could admit having sleeping problems but did not want to reveal the underlying circumstances, so nobody could understand their dilemma. For both males and females, the conclusion was that there was no help to get.
greater extent among females than among males. Looking at the moderating effects of life events on the ways of coping, stressful life events in the previous year were more strongly associated with Confrontive Coping among females in the suicide group and among males in the sudden violent death groups compared to the controls.
Leipold, Munz, and Michéle-Malkowsky (2019) studied coping in adolescence and emerging adulthood. The use of problem-focused coping and seeking social support increased at the threshold between adolescence and early adulthood.
Young women perceived more stress and tended to use more socioemotional support. The negative correlation between perceived stress and well-being was moderated by seeking social support and meaning-focused coping (the ability to see the problem from a different point of view). That means that individuals who are more prone to using these two coping styles could experience higher levels of well-being despite stress.
In a previous study, Orbach, Mikulincer, Sirota, and Gilboa‐Schechtman, (2003a) investigated correlations between nine mental pain factors and four coping styles (Problem-Focused Coping, Emotion-Focused Coping, Seeking Social Support, and Distancing). The hypothesis that mental pain is inversely related to Problem-Focused Coping (taking actions to change the stressor) could be confirmed, whereas the associations between mental pain and Emotion-Focused Coping (trying to regulate emotional reactions to the stressor) displayed a paradoxical pattern. Elevation of mental pain might demand Emotion-Focused Coping, but at the same time such coping can reinforce mental pain (Orbach et al., 2003a). In the qualitative studies III and IV, the young persons experienced unbearable mental pain, while feeling entrapped in an unsolvable dilemma and crushed between the cogwheels of pow-erlessness. Unable to change the stressors or to regulate their emotions, they saw the suicidal “emergency exit” as the only way out of the shameful scene. Even if the sudden violent group was not studied by applying qualitative methods, we can assume the presence of unbearable mental pain in these cases. Quantitative study I showed that risk factors for sudden violent death included adverse child-hood experiences, stressful life events in the year preceding the death, addiction, lack of meaningful occupation, CAP and admission to an adult inpatient psychi-atric ward, being admitted to a compulsory treatment unit for young people with substance abuse or criminality, being investigated or sentenced for criminal acts, and having borderline and antisocial personality disorder. Furthermore, study II indicated high levels of Confrontive Coping in this group. Taken together, these results indicate the use of externalizing coping to escape mental pain.
Furthermore, the quantitative results from studies I and II can be compared to the qualitative typology of prototypical personalities in the suicide group, presented in study IV. Some of the personas, or masks shown to the outside world, were
common for both young men and women, even if expressed in a gender-specific manner: the clown and the lark, the warrior and the invisible girl, and the prince and the princess. Other personas 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. Furthermore, even if the four paths to suicide (being hunted and haunted, addicted, depressed or psychotic) were common for both genders, distinct and typical subcategories for the young women were being scared and having an eating disorder but hiding it from friends and professionals, whereas misuse of anabolic steroids was present only among young men. Even if acting out was typical despite gender, females displayed more self-destructive behavior, thus turning their aggression inward, while males were more often involved in outward aggression. Additionally, more males than females had no psychiatric contact, thus suggesting there were gender-specific help-seeking patterns not only among the young people but perhaps also among their parents.
In the present investigation, every second young person who died in suicide had made no previous suicide attempt. The qualitative studies indicated that parents could report unambiguous, suicidal communication but not take the threat seri-ously. 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. The relatively high percentage of multiple suicide attempts in the suicide group can be interpreted in terms of Joiner’s (2005) interpersonal-psychological theory of suicide, suggesting that repeated suicide attempts may familiarize individuals with the fear and pain connected with lethal self-harm. Furthermore, violent physical methods were more common than use of medication or drugs, hanging being the most common suicide method among both sexes (Table 4). This is also the most prevalent method despite gender in Europe (Värnik et al., 2008). Previous Swedish register studies showed a highly increased risk of death by suicide after earlier violent suicide attempts (Runeson, Haglund, Lichtenstein, & Tidemalm, 2016; Runeson, Tidemalm, Dahlin, Lichtenstein, &
Långström, 2010).
In the sudden violent death group, none of the females and only one tenth of the males attempted suicide. The qualitative studies of suicide suggested a vicious circle of powerlessness and destructive processes among the three protagonists:
the young person, the parents and the professionals, ending with the young per-son’s conclusion that the only way out was the lethal “emergency exit” from the shameful scene. We can only speculate that this vicious circle could be broken in cases of attempted suicide not ending with later death by suicide. No qualitative analysis of interview data in cases of other forms of sudden violent death has been hitherto conducted. However, we can presume that similar vicious circles were
active in these cases, resulting in risk-taking behavior. Traffic accidents were the most common cause of sudden violent death for both sexes, followed by medication (abuse of psychoactive drugs) and overdose among boys (cf., Cunningham et al., 2018; Kinner et al., 2015; Repo-Tiihonen et al., 2001; Stattin & Romelsjö, 1995;
Stenbacka & Jansson, 2014). The quantitative study II suggested a vicious circle of stressful life events and maladaptive coping with lethal outcomes in both groups.
The importance of stressful life events and inability to cope with them was also found in the qualitative studies III and IV. All studies, taken together, strengthen the idea of aggression and violence turned against oneself in cases of suicide and turned outwards in cases of other forms of sudden violent death.
The research program started from an empirically anchored hypothetical model (presented in the Introduction), based on the assumption that children and ado-lescents growing up in insecure environments show symptoms of acting out as a reaction to their difficult life situation, and are at risk of both suicide and sudden violent death. An accumulation of adversities in life and an inability to cope with them was depicted as a “stepladder” ending with suicide or other forms of sudden violent death (Figure 1). The quantitative studies I and II allowed exploration of linear associations between risk factors, life events and coping strategies, and belong-ing to the suicide group or to the sudden violent death group, in comparison with the control group. The qualitative studies of the parents’ perspective on their sons’
and daughters’ suicide resulted in replacing the linear “stepladder” with a generic conceptual model of processes behind youth suicide, depicted as the cogwheels of powerlessness. A similar analysis of qualitative data in the sudden violent death group is still to be done. However, the researcher’s intimate knowledge of the interviews in cases of other forms of sudden violent death suggests the existence of similar cogwheels of powerlessness among all the involved protagonists, the main difference being that there were more externalizing ways of coping in this group.
Furthermore, looking from a more encompassing societal perspective, a compre-hensive generic model of the processes behind youth suicide and sudden violent death has to be supplemented by the background cogwheel of social conditions, contributing to the feeling of powerlessness in all involved protagonists. For exam-ple, having a meaningful occupation (studies or work) was 87% less likely in the suicide group and 84% less likely in the sudden violent death group than in the control group. In the suicide group, 24%, and in the sudden violent death group 27% of the young people were unemployed, as compared to 6% in the control group (Table 3). Furthermore, several of the young people in both target groups were involved in undeclared, illegal work. The narratives of the informants con-veyed the young person’s lack of feeling of community, in strong contrast to the narratives in the control group. However, there were no notable between-group differences in the parents’ occupation. Still, in both groups the parents could express
lack of adequate social support. In the suicide group, the parents’ experiences of the professionals as unavailable, disorganized, replacing each other, having differ-ent opinions and communicating poorly with the family as well as other services mirrors the politically governed organization of social and health care services.
Taken together, the paths to suicide and to sudden violent death have some common characteristics but also noticeable differences regarding both adverse life experi-ences and ways of coping. The working hypothesis for the research program was only partially supported. Still, the findings presented here indicate that death by suicide, and other forms of sudden violent death might, both but to different extents, result from elements of self-destructive behavior (Menninger, 1938; Richardson et al., 2013; Stanistreet, 2001; Teplin et al., 2005).