Introduction
Suicide among elderly people is a global problem (Shah, Reference Shah2007). To a large extent the research field has been dominated by quantitative methods and has concentrated on factors associated with increased suicide risk (Heisel, Reference Heisel2006). Several risk factors have been shown in the elderly, particularly depression, somatic illness, functional decline and social isolation (Beautrais, Reference Beautrais2002; Conwell et al., Reference Conwell2000; Harwood et al., Reference Harwood, Hawton, Hope and Jacoby2001; Waern et al., Reference Waern, Rubenowitz, Runeson, Skoog, Wilhelmson and Allebeck2002). Personality traits that demonstrate little aptitude to face change increase the risk of suicide (Duberstein, Reference Duberstein1995). In a clinical context the problem is that the risk factors occur frequently in a normal population segment of elderly people and will therefore be of limited value for identifying those who are susceptible to suicide.
Psychological autopsy allows the circumstances around the suicide to be reconstructed, for instance through interviews with informants who knew the deceased (Pouliot and De Leo, Reference Pouliot and Leo2006). With a qualitative research approach, this method can give a different type of knowledge – an understanding of the process that led up to the individual suicide. Suicidologists have claimed that qualitative methods are important as they can elucidate research issues that cannot be quantified (Harwood and Jacoby, Reference Harwood, Jacoby, Hawton and van Heeringen2000).
Nonetheless, few qualitative studies on suicidal behavior among elderly people have been published (Crocker et al., Reference Crocker, Clare and Evans2006; Kjølseth and Ekeberg, Reference Kjølseth and Ekeberg1997; Moore, Reference Moore1997). Crocker and colleagues investigated the actual understanding of the process among elderly people who had attempted suicide. They found that it was not the risk factors that were of greatest importance but the extent to which these people saw them as a “turning point” – a warning of functional decline, dependence and isolation. The elderly talked about loss of control and a feeling of being “invisible”, of being disconnected from others. Among elderly Norwegians who had attempted suicide, self-esteem was strongly associated with the ability to achieve (Kjølseth and Ekeberg, Reference Kjølseth and Ekeberg1997). When aging involved the loss of this ability, they perceived themselves to be of no value. As far as we know, no qualitative psychological autopsy studies have been published on elderly people who have committed suicide.
An understanding based on theoretical knowledge and clinical experience leads us to view the suicide of an elderly person as the conclusion of a complex process in which biological, psychological, social and existential aspects are of significance for the decision. We no longer have access to the personal experience, thoughts and motives of the suicide victim. Through the narratives of people who knew them, however, knowledge is conveyed of how these people were perceived and experienced by others. Although this approach gives an “external perspective”, the accounts can help to elucidate the suicidal process of the individual.
This article describes a partial study in a large-scale research project on elderly people in Norway who committed suicide. Qualitative research methodology has been applied in interviews with those who knew the suicide victims. The focus of the study is on identifying what characterized these elderly people as persons. In a future study the main theme will be the circumstances around the suicides, including aspects of communication, depression and physical functioning.
The objective of this study is to investigate whether the descriptions of elderly people who committed suicide, given by those who knew them, provide common features that create recognizable patterns. How were they perceived by those around them? What special features did they possess? What characterized their conduct and relationships? Can any such features/patterns help to shed light on the suicidal process?
Methods
Design
The study is a psychological autopsy study based on qualitative interviews. Psychological autopsy enables the suicide to be reconstructed through interviews with informants who knew the deceased person well (Beskow et al., Reference Beskow, Runeson and Asgard1990).
Sampling
A total of 172 municipal medical officers in ten counties in southern Norway were asked to report regularly to the project manager all definite suicides among those aged over 65 in their region. The medical officer acquired information on the deceased's closest relatives, his/her family doctor, and the home-based care nurse, if any. Written information on the project and a request to take part in the interview were sent to potential informants. On receipt of written informed consent to participate, the project manager contacted the informants and arranged the interview.
Twenty-nine suicides were reported to the project over a period of approximately eighteen months (2006/2007). In two cases the relatives did not want to take part in the interview, in three cases it was impossible to obtain information about the relatives, and in one case the cause of death was uncertain. The study therefore comprises 23 suicides: four women and 19 men aged between 65 and 90. Four of them were under 70, seven were between 70 and 80, and 12 were over 80. The average age was 78.
Informants
The aim was to have two or three informants for each suicide: close relatives, their family doctor, and the home-based nurse/home help (if relevant). Eleven had not had a home-based care nurse, and six had not had any contact with their family doctor. The relatives interviewed were four spouses, 19 children, three siblings, and eight daughters- or sons-in-law/close friends. The prerequisite for participating in the interview was that the informants had had close contact with the elderly person – as relatives or as his/her family doctor for a long period (years) – or had had regular contact during the last year of life as a home-based care nurse or home help. In this context the term “close contact” implies that such persons knew the deceased well. A total of 63 interviews were conducted for the 23 suicides with 34 relatives, 17 family doctors and 12 home-based care nurses.
Interviews
Most of the interviews with relatives were held in their homes. Doctors and healthcare staff were interviewed at their workplaces.
The objective of the interviewer was “to get to know the elderly person” from the informants’ narratives, as far as this was possible. The first question was worded as follows: “Can you tell me how you experienced him/her?” The interviewer structured the conversations to cover the topics of major lifetime events, health, aging, personality traits and the social context, including relationships. The open structure of the interviews also encouraged the informants to take up topics they viewed as important in their account of the deceased. The interviews usually lasted approximately two hours and were tape-recorded in their entirety. They took place two to six months after the suicide, as recommended by Beskow et al. (Reference Beskow, Runeson and Asgard1990). All the interviews were conducted by the first author, who is a specialist in internal medicine/geriatrics and has long clinical experience. She also has a particular interest in the problem of suicide among elderly people, as well as experience from previous qualitative interviews.
Ethics
The study was approved by the regional ethical research committee. The informants were guaranteed anonymity in the published results.
Data analysis
All the interviews were transcribed almost verbatim by the author. In general, the analysis follows the systematic text condensation method (Malterud, Reference Malterud2001; Reference Malterud2002), a method based on elements from both phenomenological analysis and grounded theory (Smith, Reference Smith2003) and modified by Malterud. Malterud states that the method is suitable for descriptive transverse analysis of material from many different informants for developing new descriptions and concepts.
The analysis has four stages: first, all the interviews are read through several times to acquire an overall picture and to capture the essence of what is recounted in each suicide case. The first author had already gained a good insight into the material during the process of interviewing and transcribing. In the next stage the meaning units in the text are identified, extracts that give information about the topics defined in the approach to the problem. These text elements are systemized and coded so that they can then be read in connection with other related text elements across informants. In the third phase, the content is abstracted and condensed into main topics and sub-topics, and finally the results are recontextualized, i.e. the descriptions of the contents are validated against the original material.
The analysis constantly alternates between the abstracted result categories/topics and the original text. Many of the interviews were also read by the co-authors and then discussed with the first author. Co-author SS also participated in the analysis work.
Results
There were three main topics in the informants’ descriptions of the elderly: life history as the elderly person had recounted it and as the informants had observed it, personality traits as the informants had seen and understood them, and the relationship as the informants had experienced it.
Life histories
The life histories of the elderly people contained two sub-topics that were common to a large proportion of them. The first can be described as “the ability to survive” since it concerns difficulty – in childhood and adolescence, in particular, but also later in life. The second topic is entitled “action-oriented achievers” and describes how the informants observed the lives of the elderly people.
“The ability to survive”
More than half had told stories of childhood/adolescence characterized by considerable difficulty: illness, loss of close relatives and poverty. “They had to manage on their own,” the informants said about several of them.
Six of the 23 subjects lost one of their parents at an early age (four as infants), three also lost siblings (one through suicide) in their youth. Several had felt rejected by step-parents, and talked of a lack of care after one of the parents died. Many grew up under poor conditions in large families: “Those who were going to school had to have the clothes without holes.” Illness marked two of them early in life: one had to spend two years in infancy at a tuberculosis sanatorium far away from home. Many of the elderly had acquired education for themselves despite limited financial resources. Three enlisted for active service at a young age.
They experienced, and seemed to cope with, severe loss also later in life. Seven of them had lost their spouse relatively early, and three had experienced losing children, one losing two sons in accidents. One who suffered from a serious chronic illness throughout his life looked after four children, two of whom were handicapped, when he found himself alone with them.
In the interviews many of the elderly emerged as “survivors”. Poverty and emotional deprivation on the part of caregivers in childhood did not prevent them from functioning well as adults. They also coped with stress later in adulthood.
“Action-oriented achievers in life”
One son said the following of his father: “He was a man who took action, there's no doubt about that”, and this applies to at least three out of four of the elderly in the material.
With few exceptions work was the main arena for self-realization throughout their adult lives. A few took higher education, but most were industrial workers in trades, transport or other parts of the service sector. The informants’ descriptions of the elderly as industrious and conscientious concurred throughout. Another recurring feature was that they were described as people with great stamina who often offered practical help to others, and several were portrayed as particularly skilled in their various occupations. They were always called on when “tricky problems” arose: “He always had an answer. He was the one who got to grips with things,” one daughter told us.
With few exceptions they had stable relationships with their employers, several holding leadership posts at work. One became “boss” at the sawmill in a rural area. His doctor described him as being “of the good old sort, conscientious and a real hard worker”. They were action-oriented at transitions in life, whether these involved illness or other loss. A doctor told us about one of the elderly who had had a stroke: “He came to me after the stroke, and he'd cycled two thousand kilometers during the summer. He didn't seem like a patient who had just sat down and given up!”
One daughter also described her father's behavior after his wife died: “When she passed on he had to cook, iron, wash clothes – everything. But he didn't just sit down. He got on with it straightaway!”
They also confronted age by being active. They worked, and they did not give up even though age gradually made them weaker. A son told us about when his father retired: “He was well-prepared for retirement – it was all planned. He just carried on working. He'd built a big office at home, so in actual fact he still went to work!” If their lives are viewed in an overall perspective, the term “life's achievers” will describe most of them.
Personality traits
A great majority of the elderly were perceived as having a “strong” personality. Strong will was the main topic, and according to the informants was a distinguishing feature of more than three-quarters of them. This is described in two sub-topics: obstinacy and controlling others.
Obstinacy
Great obstinacy was what characterized the elderly most. “Strong-willed and obstinate” was a characteristic often applied. They knew what they wanted and did not easily let themselves be influenced by others. “He was stubborn, and he'd seldom accept useful advice and correction,” one son said. They did what they wanted. One son said of his mother: “She was stubborn! If she had decided to do something, there was no stopping her.”
The portrayals of stubbornness and the will to make their own decisions constantly recurred and were extremely evident for most of them. The descriptions could concur on every point, and it was often these traits that were spontaneously recounted first as a characteristic of the person concerned. The following quote from a son is typical: “Nobody could force him to do anything. Nobody was to meddle in his affairs. He was the one who decided! He was quite clear on this!”
This obstinacy could be problematic when the elderly needed help. They would rather manage by themselves without others becoming involved, and they could make it very clear what type of help they wanted. One of them was dependent on home-based care but was selective about who she accepted. “She wanted to know who was coming. Sometimes she wouldn't open the door if she didn't want visitors or if it wasn't the right person.”
Controlling others
They were strong-willed with regard to making their own decisions, but (as was said about 14 of them) they frequently also had a strong desire to control others. The relatives experienced that the elderly people set the terms and “took all the decisions”. In a family context, and particularly where children were concerned, this was viewed as causing conflicts. The elderly were perceived as strong, and some of them could not stand being contradicted. According to one son, his father's fixed expression was “Either you're with me or you're against me.” The informants told us that the elderly “had to” decide in all situations. They could have authority externally, so that people respected them, but this could also lead to people “turning away from them”. The authority was often associated with the fact that they were skilled at their jobs. They could impress those around them by their vigor and their eagerness to find the right answer, but they did not often accept others’ solutions.
One daughter described this with a typical quote from her father: “If it's going to be done that way then I don't want anything to do with it. And you can fix it yourselves afterwards because I know it won't work!” Several family doctors said they had also experienced this desire to control: “He knew what he wanted, and I think it was difficult for me to oppose him. I always had to do what he wanted.”
A strong will, in the form of obstinacy and a need to control those around them, had affected the relationships. Some people among both the relatives and the healthcare staff described how they had experienced the elderly as self-centered and self-absorbed, and as having an exhausting effect on their surroundings. Others expressed respect for the strength of the elderly, as one daughter who said: “Yes, he didn't only control those around him but also himself. Mostly himself, I would think.”
The descriptions above are relevant to the majority of those in the material. Six people emerged in a different light. They demonstrated the will to make their own decisions, but were not externally dominant in the same way. Common to some of them was that special life circumstances had imposed social and relational limitations: they lived alone, or with a sick spouse.
Relationships
The third main topic in the interviews was that of the informants’ experiences of their relationships with the elderly people, in which distance is frequently described. Some of the elderly had good contacts within their family, and some were portrayed as caring parents and grandparents, but most of the accounts characterize the relationships as distant. Many informants also expressed the relationship as difficult. The main impression was that the elderly had shown strong self-control and reserve on an emotional level. This affected how the informants viewed the elderly and how they felt the elderly regarded them. These aspects of the informants’ relationships with the elderly can be described in two sub-topics, the titles of which are quotes from the informants: “I didn't know him” and “He showed no ability to meet us halfway”.
“I didn't know him”
The informants described the elderly as having little ability to open up or to convey their feelings to those around them. With few exceptions this was a clear and recurrent finding in the material, and was obvious where their own problems were concerned. They could not, or would not, tell those around them about what they actually felt. The informants’ opinions on the elderly were almost identical in this aspect. A typical description was: “I'd say he was closed. When it came to thoughts and feelings about things he didn't say much. He kept such things to himself. The whole time!” Many used expressions like: “He never opened himself to us, never showed his feelings!”
One daughter described her father as “disciplined” – her father was of the opinion that one should keep one's troubles to oneself. “He never mentioned his problems,” she said.
The informants said that these traits had made it difficult to help the elderly. One daughter said, “Nobody realized he was ill. He's always been like that – gritted his teeth, pulled himself together.”
Nor did the elderly complain to their doctors. A doctor said the following about one of his patients: “I think it would've been inconceivable for him to ring and ask for an appointment and say he was frightened and anxious – completely inconceivable!” Several of their children described how this non-expression of feelings had made them feel that they “didn't know” their father/mother. They could have a social network, but descriptions of close friendships among the elderly people were rare.
“He showed no ability to meet us halfway”
The elderly person's lack of ability to show his/her feelings can also have contributed to many informants not experiencing closeness in the relationship. Not talking about feelings was perceived by some as a lack of empathy. One family member described how it had been difficult to establish a close relationship: “There was something basically missing. Responsiveness perhaps.” The informants described the experience of distance, also in close relationships. This could be significant when the elderly person needed help. One spouse felt powerless when her husband fell ill: “He wasn't good at expressing himself, so I sort of couldn't give anything back.”
Several children talked about there being lack of warmth in the relationship with their father/mother. The informants were also able to express their understanding of this: “Behind the mask he wore I think we meant quite a lot to him, but he just couldn't tell us.” Some of the children had had complicated and somewhat difficult relationships with their elderly parent, and they could use strong words in their descriptions: “He was egoistical, introverted and lonely, and he almost claimed to like it. He was not really a good father!”
One daughter expressed the essence of the informant's experience in her portrayal of her mother: “She never cried. And I can't remember her ever giving me a hug.”
Discussion
The descriptions of a large number of the elderly in this study have clear similarities. They were experienced as strong-willed people. An explicit obstinacy is portrayed as their most characteristic trait. They wanted control over themselves, their lives and their surroundings. They did not convey their feelings to those around them, and were therefore perceived as “closed” individuals. This non-expression of feelings created distance between them and their surroundings, and it characterized close relationships as well as other social contacts.
Childhood and adolescence had been difficult for many of them, involving poverty and the loss of those who looked after them. Nonetheless the majority became well-established as adults and emerged as vigorous and “achieving” people – many also in later life. They had been markedly action-oriented, even when loss and crises had occurred earlier in life. They seemed to maintain their pressing need to control into old age, and showed little ability to develop new strategies for adapting.
The descriptions reveal a “pattern” of how these elderly people appeared in some key contexts, and we see this pattern as an expression of their personality traits. Research into the personality traits of elderly people who commit suicide is limited, but it is interesting to compare the descriptions of the people in our material with findings made in studies with a quantitative design. By applying the NEO Personality Inventory, Duberstein discovered that elderly people who committed suicide had a lower score for the dimension of openness to experience (OTE) than both younger suicide cases and the control group (Duberstein et al., Reference Duberstein, Conwell and Caine1994). Cognition, affect and behavior are included in the OTE dimension. Duberstein (Reference Duberstein1995) describes persons with a low OTE as rigid and needing few new experiences and changes. They experience both positive and negative feelings less intensely than open persons, they allow themselves to enjoy “pleasurable experiences” to a lower degree, and they find it more difficult to show their feelings. The behavioral pattern is also affected: those with low OTE are less active and take less responsibility. According to Duberstein, although these people will be satisfied with delimited work tasks, their self image is strongly associated with being productive and useful. They can develop problems with adapting in the aging phase since activity can no longer be maintained and their lack of flexibility hinders them from finding new roles.
Like Duberstein, Clark also finds a type of behavioral rigidity in elderly suicide cases (Clark, Reference Clark1993). Clark's model describes a “lifelong character fault” in these people, which leads to inadequate coping strategies when their functions fail them. Harwood and colleagues studied the personality traits of elderly suicide cases in a more recent psychological autopsy study (Harwood et al., Reference Harwood, Hawton, Hope and Jacoby2001). They found a connection between anankastic personality traits, which can to some extent be defined as overlapping with OTE, and suicide among the elderly.
We recognize some of the traits described in these studies in our own material, but there are also significant differences and the descriptions provide a more nuanced picture of the elderly people. Work had undoubtedly been important for them as a positive force in their lives. They were not afraid of responsibility, and many of them had shown creativity, competence, and considerable work capacity in their field. For many of them the work arena was also a social setting where they could make their contribution to others. The impression from the descriptions was that for them work was exactly that “pleasurable experience” where they found “fulfillment”. They put demands on themselves and were very conscientious, but without this appearing forced.
Obstinacy and stubbornness, which are clear characteristics among the elderly, are anankastic traits (WHO, 1992). These characteristics made these elderly people capable of taking control over their lives. The fact that they also tended towards controlling the lives of those around them was perhaps more a result of their own need for control than of a wish to dominate. They also seemed to have a high degree of control over their own feelings, and they would not, or could not, show weakness. This does not necessarily mean that they did not experience strong feelings – maybe the opposite was the case.
“Control” was of key significance for the elderly. Those around them viewed them as strong-willed individuals capable of taking action and with a considerable ability to exert control, thus gaining confirmation of themselves and their own self image.
Countless studies have shown that the experience of control is significant for mental health and well-being and is associated with elements such as motivation, coping and self-esteem (Skinner, Reference Skinner1996). Rothbaum and Weisz (Reference Rothbaum and Weisz1982) saw control as a bilateral process, and introduced the terms “primary” and “secondary” control. Primary control involves trying to change the surroundings so that they satisfy one's own wishes and needs. Secondary control entails adaptation to the surroundings and to one's own limitations.
Heckhausen and Schulz (Reference Heckhausen and Schulz1995) use the terms in their “life span theory of control”. They describe how control mechanisms change through the course of life. They are particularly concerned about control strategies associated with age-related loss. When a person ages, and biological and social resources are limited, the maintenance of primary control will be increasingly dependent on secondary control processes. Finding a balance between primary and secondary control strategies is important for the individual's development potential in each phase of life, and, according to Heckhausen and Schulz, it is crucial toward the end of life for a good aging process. While primary control is active, action-oriented, outward-looking and targeted at changing the external surroundings, secondary control – as described by Heckhausen and Schulz – is a cognitive process that seeks to achieve changes in the individual himself. This means that the individual can tolerate the various losses while still experiencing control. Heckhausen and Schulz view secondary control as the individual's ability to create motivation and to change one's opinion of oneself and one's surroundings – for example, through accepting limitations and adjusting goals. Other authors have described how such a necessary adjustment process in old age entails a devaluation of and/or disengagement from activities that are limited by age (Rothermund and Brandtstadter, Reference Rothermund and Brandtstadter2003).
If we relate our findings to these control concepts, the informants tell us about people who had been capable of exercising strong primary control throughout their lives, and the experience of having control was important for their self-esteem. They also coped with loss earlier in life through primary control strategies. Whether they experienced loss of relationships or health at an early or a late age, work and activity was their remedy. These coping strategies were also clear in elderly Norwegians who had attempted suicide (Kjølseth and Ekeberg, Reference Kjølseth and Ekeberg1997).
Heckhauser and Schulz are of the opinion that secondary control mechanisms are crucial for maintaining self-esteem when an individual is confronted by loss and functional decline in the aging phase (Heckhausen and Schulz, Reference Heckhausen and Schulz1999). The informants’ accounts of the elderly people contained almost no descriptions of the ability to adjust and to accept one's limitations – adaptations that are prerequisites for secondary control strategies. Other authors claim that the adjustment process on loss of functional capacity in old age is made more difficult and is delayed when the person has previously experienced strong control (Brandtstadter and Renner, Reference Brandtstadter and Renner1990). This is confirmed in our study. Stubbornness and obstinacy in these elderly people made them somewhat inaccessible for dialogues with others on alternative solutions. The practice of secondary control requires flexibility as well as willingness to change one's focus and one's view of the values of life. Many of the elderly did not seem to possess these qualities.
Their emotional pattern also prevented closeness with those around them, which could have promoted secondary control strategies. Secondary control mechanisms are important for relationships since adjustment is necessary to attain closeness and trust. These mechanisms thus acquire importance for the feeling of belonging (Morling and Evered, Reference Morling and Evered2006). What Crocker's informants described as “invisibility” – the feeling of being disconnected from others – can therefore be considered descriptive for many of the elderly people in our material.
These theoretical control perspectives can serve to give us an understanding of why elderly people with such “patterns” as those described by the informants will be particularly vulnerable when irreversible loss of functional capacity occurs in old age. Their self-image and self-esteem is associated with and dependent on the experience of control, exercised through strength and action. To be able to accept help they must let this control go, which they cannot do. For the same reason they are also unable to develop secondary control strategies. Closed-off feelings and relationships involving distance contribute to this. The overall result may be great loneliness, which further reinforces the pain of the loss of self-esteem. In his theory of “suicide as escape from self”, Baumeister describes how loss of self-esteem can cause reactions that lead to the risk of suicide. He claims the starting-point may be that a person no longer manages to live up to his or her own expectations (Baumeister, Reference Baumeister1990).
The qualitative approach means that we can see the described personality traits in the light of the life-time of the elderly person. There is little knowledge of the importance childhood experiences may have for their mental health and suicide risk, but there is a proven connection between childhood abuse (about which we have no information in our material) and reduced physical and mental health in elderly people (Draper et al., Reference Draper2008). Furthermore, early loss/separation is associated with the risk of suicide among elderly people (Duberstein et al., Reference Duberstein, Conwell and Cox1998). Among those in our study, genetic prerequisites – together with environmental factors during childhood and adolescence – may have fostered the development of certain personality traits. Emotional deprivation on the part of the caregivers while they were growing up may thus have encouraged the development of coping strategies based on a considerable capacity for control. Cohler and Jenuwine (Reference Cohler and Jenuwine1995) describe how personality traits can have different significance in different phases of life. The traits seen in the elderly had developed, and were perhaps necessary, to cope with difficulties in early life. To some extent they were also appropriate and promoted coping strategies throughout their adult lives. In old age the same traits constitute a risk since they prevent the necessary development of new coping strategies. What is particularly important is that it is difficult to maintain a good self-image when the ability to achieve is reduced and it becomes necessary to accept help.
The patterns described will be recognizable in a clinical context in encounters with elderly patients, and knowledge of them can provide a better understanding of the situation of elderly people and thereby also increase the awareness of a potential risk of suicide. In the discussion we have given theoretical grounds for why these elderly people became susceptible to suicide. This also has implications for therapy: a therapeutic goal is to ensure that elderly people are given confirmation of their personal value when their functional capacities and ability to take action diminish.
Choice of methodology/validity
We chose to use a qualitative methodology since the complexity of the problem and the lack of knowledge in general about suicidal behavior in elderly people indicate the benefits of a qualitative research approach. Using qualitative interviews differs from using a questionnaire: the interview enables the researcher to study the information given by the informants more deeply and to find more shades of meaning. Problem areas that are difficult to investigate through standardized questionnaires can be elucidated when informants are able to express themselves in an interview. They can take up topics that the informants themselves find meaningful, and they are not bound by the standardized question format.
Our approach proved to be appropriate. The history of each elderly person emerged through the narratives of the informants. Suicide is the conclusion of a process that can be illuminated through their history: history reveals connections that can provide a broader understanding of the suicidal process than that acquired through quantitative methods.
Whether the approach is qualitative or quantitative, a psychological autopsy will elicit information from secondary sources. The informants’ attitudes, their relationship with the deceased, and their reactions to the suicide affect the information they give in both questionnaires and interviews. In qualitative interviews the researcher can gain an impression of such contexts: they can be discussed as problems in the conversation and can enrich the interviews. The interviewer could experience that the actual reactions to the suicide from the informants and their relationship with the deceased could add important information. It was important to find out more about the relationship between the informants and the elderly since it showed how the elderly were perceived by others. When assessing personality traits, it can also be an advantage if the information is given by observers rather than by the person involved.
With two exceptions there were several informants for the suicides, and their descriptions corresponded well. The informants’ varying relationships with the deceased contributed to making the description more detailed and nuanced. It was clear to the interviewer that the informants were describing the “same person”, but the descriptions complemented each other. “Conflicting” information from different informants did not appear to be a problem in the study. The validity of the information was reinforced during the interviews through follow-up questions designed to clarify the informants’ statements. The informants were close relatives and healthcare staff who had had contact with the elderly, most often over a long period. The interviews were held relatively soon after the suicides to ensure that the healthcare staff also remembered their elderly patients well.
A qualitative interview on a sensitive topic such as the suicide of a relative/patient requires considerable confidence and trust to be established in the conversation. The interviewer's background as a clinician/specialist in geriatrics was of great significance for the interview situation. The fact that the same person conducted all the interviews is therefore regarded as an advantage since her competence was enhanced through this experience in the course of the study. However, this may also undermine the study since the researcher's pre-understanding will affect the interviews. The collaboration between the researchers in the analysis process was important: it extended the framework of understanding without consensus being the goal.
Ethics
The informants had a positive attitude to being interviewed (only two suicides had to be excluded because the relatives did not want to take part). Many said that participating had been a positive experience. The interview gave them the opportunity to express thoughts and feelings about the suicide that they would not otherwise have been able to impart.
Transferability
For a study using qualitative methodology, the material comprises a relatively high number of suicides from a geographically large region in Norway constituting both urban and rural areas. The suicides were reported regularly by the registration body in the municipalities with no selection other than absolute certainty that the cause of death was suicide.
The entire age range from 65 to 90 is represented. The low proportion of women reflects the fact that suicide in the oldest age groups is gender-related: there is a much higher incidence of suicides among men (Heisel, Reference Heisel2006). In 2006 in Norway the suicide rate for men over the age of 70 was 25 per 100,000 of the population, while for women in the same age group it was 3 (Statistics Norway, 2008). According to the suicide figures from the region in question in 2006, almost half the suicides were reported to the project (Statistics Norway, personal communication). The inadequate registration routines of some municipal medical officers may be the cause of the shortfall. Another reason is that death from uncertain causes may be classified as suicide at a later date, and these deaths were therefore not reported to the project. Such deaths are not individually registered, but we presume that they will often be deaths from poisoning with medicines. The methods applied in the material correspond approximately to the distribution in the entire country in the survey year, which opposes any suggestion of distortion. Norwegian women more often choose methods that provide a higher chance of survival (poisoning), while men use those that are more certain to lead to death (Kjølseth et al., Reference Kjølseth, Ekeberg and Teige2002).
However, our findings also concur with regard to the women in the study. The patterns can be recognized among elderly women who were interviewed after serious attempts at suicide using medicines (Kjølseth and Ekeberg, Reference Kjølseth and Ekeberg1997). This can indicate that the results apply to elderly people of both sexes who show suicidal behavior.
In this study there were a total of 16 suicides by firearms/hanging/jumping and four drownings, while only three were due to poisoning with medicines. It is possible that not only gender but also personality traits are decisive for choice of method. This may thus restrict the transferability of our findings to elderly people who choose violent methods of suicide.
The findings in terms of the described patterns are unambiguous and recur in a large portion of the material. We are therefore of the view that it is probable that our results also apply to other suicides among elderly people in Norway.
Conflict of interest
None.
Description of authors’ roles
Ildri Kjølseth designed the study, conducted the interviews, analyzed the interviews and wrote the article. Øivind Ekeberg was main supervisor throughout the project. He took part in designing the study, the analysis and the writing process. Sissel Steihaug was second supervisor in the project. She participated in the analysis and in the writing process.
