THE CATHOLIC UNIVERSITY OF AMERICA
A Cross-Cultural Examination of Suicide Status Form Responses
A DISSERTATION
Submitted to the Faculty of the
Department of Psychology
School of Arts and Sciences
Of The Catholic University of America
In Partial Fulfillment of the Requirements
For the Degree
Doctor of Philosophy
By
Blaire C. Schembari
Washington, D.C.
2017
A Cross-Cultural Examination of Suicide Status Form Responses
Blaire C. Schembari, Ph.D.
Director: David A. Jobes, Ph.D.
Globally, an estimated 800,000 people die by suicide each year (World Health
Organization [WHO], 2014). The epidemiological variations in suicide rates across the world point to the potential role culture plays in the experience of suicidality. Although suicide is widely regarded as a potentially preventable death, meaningfully reducing suicide rates has proven to be a challenge. In direct response to the need to clinically treat suicidal risk, Jobes
(2012; 2016) developed a suicide-specific therapeutic framework called the “Collaborative
Assessment and Management of Suicidality” (CAMS). Central to CAMS-guided care is the
“Suicide Status Form” (SSF), which is a multipurpose assessment, treatment planning, tracking, and outcome-oriented clinical tool (Jobes, 2016). The SSF is among the few suicide risk assessment instruments that applies both quantitative and qualitative methods. This exploratory cross-sectional and descriptive study investigated potential differences and similarities of the experience of suicidality between suicidal patients from six different nations (China, Denmark,
Ireland, Norway, Switzerland, and the USA). First session quantitative and qualitative responses to Section A of the SSF completed by N= 362 suicidal patients engaged by CAMS-guided care were examined. Results evidenced significant differences across various quantitative and qualitative variables. Specifically, differences were observed between patients’ ratings of the
SSF Core Assessment constructs and their wish to live/wish to die ratings. Qualitative differences were also observed, specifically among the SSF Core Assessment constructs, reasons
for living/reasons for dying, suicidal motivation, and One-Thing Response. Several similarities were also observed across both quantitative and qualitative assessments. Specifically, patients did not differ in terms of ranking the SSF Core Assessment constructs in order of importance and no differences were found between patients’ suicidal orientation. Various factors (e.g., sample, setting, severity of risk), along with culturally-driven differences and similarities of the suicidal experience were explored. This was the first-ever study to explore detailed psychological differences of the suicidal experience across this many nations.
This dissertation by Blaire C. Schembari fulfills the dissertation requirements for the doctoral degree in Clinical Psychology approved by David A. Jobes, Ph.D., as Director, and by Sandra
Barrueco, Ph.D., and Peter M. Gutierrez, Ph.D. as Readers.
______David A. Jobes, Ph.D., Director
______Sandra Barrueco, Ph.D., Reader
______Peter M. Gutierrez, Ph.D., Reader
ii
Dedication Page
To those who are struggling with thoughts of suicide, and to the memory of those we have lost to suicide.
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Table of Contents
DOCTORAL DISSERTATION APPROVAL PAGE.……………………………………..….ii
TABLE OF CONTENTS……………………….………………………………………………iv
LIST OF TABLES………………………………………………………………………...…….xi
LIST OF ABBREVIATIONS…………………………………………………………..……...xii
ACKNOWLEDGEMENTS…………………...……………………………………………....xiii
INTRODUCTION………………………………………………………………………….……1
SSF Assessment Data…..…………………………………………………………………6
Quantitative SSF Research………………………………………………....……………..7
Ratings of SSF core assessment constructs…………………………….….……...7
Rankings of SSF core assessment constructs……………….……………………..8
Self versus other rating……………………………………………………………9
WTL/WTD assessment…………………………………………………………..10
Qualitative SSF Research…………………………………………………..……………11
SSF incomplete sentence prompts….……………………….….…………….….11
SSF reasons for living/reasons for dying………………..……………………….12
SSF one-thing response…………………………………….……………………13
SSF “Micro-Coding”…………………………………………………………….14
SSF “Macro-Coding”…………………………………………………………….14
Suicidal orientation (self vs. relational)………………………………….15
Suicidal motivation (RFL vs. RFD)………………………….…………..17
Limitations of Coding Systems………………………………………………….……….18
Culture and Suicide...... 19
iv
Nations of Comparison...... 22
China...... 22
Denmark...... 24
Ireland...... 26
Norway...... 27
Switzerland...... 28
The United States of America...... 28
Study Rationale and Hypotheses...... 29
Rationale...... 29
Hypotheses...... 30
METHOD...... 31
Sample and Participant Selection...... 31
China...... 31
Denmark...... 31
Ireland...... 32
Norway...... 32
Switzerland...... 32
The USA...... 32
Procedures...... 32
SSF Translation Methods...... 33
China...... 33
Denmark...... 33
Norway...... 33
v
Switzerland...... 33
Translation methods of qualitative responses from the SSF...... 34
China...... 34
Denmark...... 34
Norway...... 34
Switzerland...... 34
Measures...... 34
Quantitative Methods...... 36
Index ratings of SSF core assessment constructs...... 36
Index rankings of SSF core assessment constructs...... 36
WTL/WTD assessment……...... 36
Qualitative Coding Procedures...... 37
General coding procedures...... 37
SSF micro-coding...... 38
SSF core assessment incomplete sentence prompts...... 38
RFL/RFD...... 39
One-thing response...... 40
SSF macro-coding...... 41
Suicidal orientation ...... 41
Suicidal motivation...... 42
RESULTS...... 43
Index ratings of SSF core assessment constructs...... 43
Psychological pain...... 43
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Stress...... 44
Agitation...... 44
Hopelessness...... 44
Self-Hate...... 44
Overall risk of suicide...... 45
Mean comparisons controlling for overall suicide risk...... 45
Index rankings of SSF core assessment constructs...... 47
Psychological pain...... 47
Stress...... 47
Agitation...... 47
Hopelessness...... 47
Self-Hate...... 47
Mean comparisons controlling for overall suicide risk...... 47
WTL/WTD assessment...... 48
Qualitative Results...... 48
Micro-coding of SSF core assessment incomplete sentence prompts...... 50
Psychological pain...... 50
Stress...... 50
Agitation...... 50
Hopelessness...... 51
Self-Hate...... 51
Micro-coding of SSF reasons for living……..…...... 51
Family...... 51
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Friends...... 51
Responsibility to others...... 52
Burdening others...... 52
Plans and goals...... 52
Hopefulness for the future...... 53
Enjoyable things...... 53
Beliefs...... 53
Self...... 53
Micro-coding of SSF reasons for dying...... 54
Others (relationships)...... 54
Unburdening others...... 54
Loneliness...... 54
Hopelessness...... 54
General descriptors of self...... 54
Escape-in general...... 55
Escape-the past...... 55
Escape-responsibilities...... 55
Micro-coding of One-thing response...... 56
Orientation...... 56
Reality testing...... 56
Clinical utility...... 57
Macro-Coding...... 57
Suicidal orientation...... 57
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Suicidal motivation...... 57
DISCUSSION...... 58
Hypothesis 1: Quantitative Assessments...... 58
China...... 60
Denmark...... 62
Ireland ...... 63
Norway...... 65
Switzerland...... 66
The USA...... 67
Hypothesis 2: Qualitative Assessments...... 68
China...... 72
Denmark...... 74
Ireland...... 77
Norway...... 79
Switzerland...... 83
The USA...... 85
General Discussion and Integration of Findings…………………………………………………88
Clinical Implications…………………………………………..…………………………89
Study Limitations...... 91
Future Directions...... 92
REFERENCES...... 94
TABLES...... 111
APPENDIX A...... 127
ix
APPENDIX B...... 128
APPENDIX C...... 129
APPENDIX D...... 130
APPENDIX E...... 131
APPENDIX F...... 132
APPENDIX G...... 133
x
List of Tables
TABLE 1: Sample Demographics...... 100
TABLE 2: Means and Post-hoc Tests of Ratings of Core SSF Assessment by Country...... 101
TABLE 3: Means and Post-hoc Tests of Rankings of Core SSF Assessment by Country...... 102
TABLE 4: Percentages and Frequencies of WTL/WTD: SIS by Country...... 103
TABLE 5: SSF Core Assessment Sentence Blanks Percentages and Frequencies within Country:
Psychological Pain...... 104
TABLE 6: SSF Core Assessment Sentence Blanks Percentages and Frequencies within Country:
Stress...... 105
TABLE 7: SSF Core Assessment Sentence Blanks Percentages and Frequencies within Country:
Agitation...... 106
TABLE 8: SSF Core Assessment Sentence Blanks Percentages and Frequencies within Country:
Hopelessness...... 107
TABLE 9: SSF Core Assessment Sentence Blanks Percentages and Frequencies within Country:
Self-Hate...... 108
TABLE 10: Means and Post-hoc Tests of RFL by Country...... 109
TABLE 11: Means and Post-hoc Tests of RFD by Country...... 110
TABLE 12: One-Thing Response Percentages and Frequencies within Country: Orientation...111
TABLE 13: One-Thing Response Percentages and Frequencies within Country: Reality Testing ...... 112
TABLE 14: One-Thing Response Percentages and Frequencies within Country: Clinical Utility ...... 113
TABLE 15: Suicidal Orientation: Percentages and Frequencies of within Country...... 114
TABLE 16: Suicidal Motivation: Percentages and Frequencies within Country...... 115
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List of Abbreviations
Analysis of Covariance (ANCOVA)
Analysis of Variance (ANOVA)
Attempted Suicide Short Intervention Program (ASSIP)
Centers for Disease Control and Prevention (CDC)
Collaborative Assessment and Management of Suicidality (CAMS)
The Catholic University of America Suicide Prevention Laboratory (CUA-SPL)
Next-Day Appointment (NDA)
Randomized Clinical Trial (RCT)
Reasons for Dying (RFD)
Reasons for Living (RFL)
National Office for Suicide Prevention (NOSP)
Suicide Index Scale (SIS)
Suicide Status Form (SSF)
United States of America (USA)
Wish to Live (WTL)
Wish to Die (WTD)
World Health Organization (WHO)
xii
Acknowledgements
I would like to acknowledge the following individuals for their instrumental contributions. I would like to start by acknowledging Dave Jobes, my mentor and the director of my committee, for his unwavering support throughout my entire graduate career. I owe a significant debt of gratitude to my committee members, Sandra Barrueco and Pete Gutierrez, for their expertise and guidance. I would also like to acknowledge Marc Sebrechts, department chair, for his support.
The incredible members of The Catholic University of America Suicide Prevention
Laboratory (CUA-SPL) made one of largest contributions. Without the tireless hard work of these graduate and undergraduate students, I would not have been able to complete this project. I would specifically like to thank, Lisa Petersen, my data manager/coordinator/team leader, my coding team leaders, Allie Bond, Katie Broshek, Madi Bell, and their team members, Amanda
McCleary, Arghavan Hamedi, Conor Sullivan, Cynthia Fioriti, Katie Lenguadoro, Liam
Frieswick, Melvin Walker, Paul El-Meouchy, and Thomas Ingram. I would also like to thank the doctoral CUA-SPL students Molly Bowers, Abby Ridge Anderson, Brian Piehl, Samantha
Chalker, Josephine Au, and Asher Siegelman.
In addition, without the support from my international collaborators, this project would not exist. I would like to acknowledge the significant efforts of Eoin Galavan, Arjan Gjonaj,
Anja Gysin-Maillart, Konrad Michel, Wenche Ryberg, Roar Fosse, Kate Comtois, Christen
Pedersen, and Jianing You.
Lastly, I would like to acknowledge my fiancé, Phil Ehret, for being my biggest cheerleader, stats consultant, and editor. Thank you for being patient, loving, and always willing to help.
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CHAPTER 1
Introduction
Suicide is a significant worldwide problem. Globally, approximately 2,192 people die each day (WHO, 2014). These statistics are alarming and compel appropriate public health and clinical responses. Although suicide is widely regarded as a potentially preventable death, meaningfully reducing it has proven to be a difficult challenge for researchers, public health professionals, and mental health clinicians alike. Various public health and clinical suicide prevention efforts have been underway for well over 50 years, yet global suicide rates have remained relatively constant and have actually continued to increase (Stack & Kposowa, 2011;
Värnik, 2012). While public health approaches to preventing suicide show some promise (Yip et al., 2012), in many ways, clinical methods of assessing and treating suicide are remarkably un- evolved (Jobes, 2012). From a purely clinical mental health perspective, there have been numerous efforts to find effective treatments to reduce suicide (Comtois & Linehan, 2006; Jobes,
Au, & Siegelman, 2015). In the present study we considered one particular suicide-specific treatment approach developed by Jobes (2006; 2016) called the “Collaborative Assessment and
Management of Suicidality” (CAMS).
CAMS is an evidence-based clinical framework that can be used to guide a thorough clinical assessment and suicide-specific/problem-focused treatment for suicidal patients across a range of clinical settings. The CAMS approach fundamentally relies on a non-judgmental, empathetic collaboration between the patient and clinician, which is distinctly different than other clinical approaches that can convey a sense of moral judgment about and a coercive (even shaming) approach to managing suicidal risk (Jobes, 2012). Over the past 15 years, there has been an increasing body of empirical support in the form of non-randomized and randomized
1
2 clinical trials for the feasibility and effectiveness of CAMS for suicidal patients in different clinical settings (Andreasson et al., 2016; Comtois et al., 2011; Ellis et al., 2015; Jobes, Wong,
Conrad, Drozd, & Neal-Walden, 2005; Jobes, 2012; Jobes, Comtois, Brenner, Gutierrez, &
O’Connor, 2016). Beyond the treatment-research aspects of CAMS, the intervention has also been broadly trained and disseminated both domestically and internationally. Indeed, the main source text for the approach has been previously translated into Chinese and Korean and additional translations are now pending (Jobes, 2016). Recently, a randomized controlled trial
(RCT) of CAMS vs. Dialectical Behavior Therapy (DBT) was completed in Denmark
(Andreasson et al., 2016) and an additional RCT of CAMS was completed in Norway (Ryberg et al., 2016). Additional clinical trials of CAMS are being planned in mainland China, Australia, and Germany.
The “Suicide Status Form” (SSF) is a multipurpose assessment, treatment planning, tracking, and outcome-oriented clinical tool (Jobes, 2016) that is central to the CAMS approach to managing suicidal risk. The SSF is a unique assessment tool in that, conceptualized as the clinical “roadmap,” it consistently guides the process of CAMS from beginning, through the course of care, and to treatment completion. The SSF is made up of eight documents that are employed across the full course of CAMS-guided clinical care. The SSF provides various opportunities for suicide-specific assessment and treatment planning. The first session, which includes sections A-D of the SSF and the CAMS Stabilization Plan is made up of four pages.
The interim tracking forms consist of two SSF documents and are utilized for on-going assessment and treatment planning of suicidal risk. Lastly, the final documentation of all clinical outcomes, which consists of two SSF documents, is utilized at the conclusion of care. In terms of assessment aspects, the first session SSF is a rich data source, as it utilizes both quantitative and
3 qualitative assessment methods, which provide the clinician and patient a deeper look into the patient’s suicidal wish.
In the first index session of CAMS, a mixed methods approach is employed across several empirically and theoretically supported quantitative constructs (i.e., Psychological Pain,
Stress, Agitation, Self-Hate, Hopelessness, Overall Risk for Suicide, Reasons for Living (RFL) and Reasons for Dying (RFD), and Wish to Live (WTL) and Wish to Die (WTD)) to better understand the patient’s unique psychological experience of suicidality. These quantitative variables include patients’ rating and rankings of Psychological Pain, Stress, Agitation, Self-
Hate, Hopelessness and Overall Risk for Suicide, as well as the ranking of patients’ hand-written
RFL and RFD, and rating of their WTL and WTD. Overall Risk for Suicide is only rated; it is not ranked, as patients’ risk for suicide is the main treatment focus and therefore ranking its level of importance is not applicable.
Over the past 25 years, the SSF has undergone several modifications and is now in its fourth version (Jobes, 2016). The central quantitative assessment, referred to as the “SSF Core
Assessment,” has been shown to have robust psychometric properties in terms of validity and reliability (Conrad et al., 2009; Jobes, Jacoby, Cimbolic, & Hustead, 1997).
Beyond the quantitative SSF constructs there are also various qualitative assessments that are used in the index session of CAMS. These include open-ended questions that specifically flesh out patients’ experiences with Psychological Pain, Stress, Agitation, Self-Hate, and
Hopelessness. These open-ended questions also ask patients to pen in their RFL and RFD, as well as to identify the one thing that would make them no longer feel suicidal (the One-Thing
Response).
4
The SSF qualitative assessments have several highly reliable coding systems to analyze qualitatively written patient responses (Jobes, 2016). Up to the present time, these coding systems have only been validated in samples of patients from the United States of America
(USA) and Denmark (see Corona et al., 2013). But use of the SSF is growing both domestically and abroad and to our knowledge the tool has been translated into Spanish (Bamatter, Barrueco,
Oquendo, & Jobes, 2015), Chinese, Korean, Danish, Norwegian, Ukrainian, German, and Farsi, and additional translations are currently underway (D. Jobes, personal communication, January
16, 2017).
As the SSF continues to grow as an internationally recognized tool for suicide-specific clinical use and research, further empirical investigation of the SSF on international samples is needed. Given its use across different nations around the world, we sought to study potential cross-cultural similarities and differences to help discern what is common and exceptional about the suicidal experience from culture to culture (Colucci, 2013). The known epidemiological variations in suicide rates across the world suggest the valuable role culture might play (Colucci,
2013). In addition to the possible role that culture may play in understanding the suicidal mind, appreciating potential cultural influences may further help to better assess and treat suicidal risk cross-culturally (Chu, Goldblum, Floyd, & Bongar, 2010).
As the SSF continues to be translated for global clinical use, there is a need to further understand the utility of the SSF cross-culturally, in particular, how suicidal patients from different nations relate (or not) to an American/English-based tool, which is made up of the various SSF constructs. This understanding is important for three reasons. First, on a large scale, furthering the understanding of patients’ responses to suicide-specific constructs can help enhance what is currently known about suicide and the possible impact of culture. Second, the
5
SSF has undergone numerous studies examining patient responses as they relate to overall suicide risk and treatment outcomes. By examining if there are any differences or similarities between international samples we may gain insight into important aspects (e.g., for risk assessment and treatment outcomes) pertaining to international samples. Third, because the SSF constructs are largely derived from American theorists, these constructs may--or may not--be tapping into important, universal aspects of the suicidal experience that other studies from different cross-cultural samples have not previously investigated. For example, self-hate may not have been historically assessed in Denmark, as the notion of self-hate may not be culturally relevant to the Danish culture (D. Jobes, personal communication, January 16, 2017). However, assessing self-hate may ultimately prove to be an important aspect to the suicidal experience among Danes (or not).
In an effort to better understand the potential impact culture may have on individuals’ experience and expression of suicidality within the CAMS framework, Schembari and Jobes
(2015) examined baseline ratings of SSF Core Assessment variables from patients from
Denmark, Ireland, the USA, and Switzerland. When controlling for overall risk of suicide, the findings indicated significant differences between suicidal patients from these nations across these constructs, which may perhaps reflect, to some extent, a possible role that culture may play in relation to the suicidal experience. This was the first study to directly compare index session
SSF responses across patients in different countries with potential implications for the cultural impact on suicidal phenomenology. These intriguing results prompt the need for further investigation of potential cross-cultural differences of the suicidal experience, with implications for clinical assessment and treatment around the world. However, this preliminary investigation
6 had distinct limitations in the form of a small sample size and a rather narrow focus on the six
SSF Core Assessment constructs.
The present study was thus conducted to further advance the current state of knowledge regarding potential difference and similarities among suicidal patients from different countries, which may reflect in part the potential impact of culture on the human experience of self- destruction. In other words, is there a transcendental experience of being suicidal that is universal around the globe? Or are there aspects of the experience of suicidality that are unique to culture, context, and the psychosocial influences of nation states? The present study aspires to begin to explore these important questions by cross-sectionally comparing index session SSF quantitative and qualitative responses of suicidal patients obtained from clinical samples of CAMS patients seen in six different countries—China (specifically Hong Kong as a relatively new province of mainland China), Denmark, Ireland, Norway, Switzerland, and the United States of America.
SSF Assessment Data
As previously noted a valuable aspect of CAMS is the use of the first session SSF that employs a combination of both quantitative and qualitative suicide risk assessments. The utilization of both quantitative and qualitative assessments allows for a much deeper phenomenological and idiosyncratic understanding of a patient’s suicidal state. To date, several methodologies have been developed to organize and understand different SSF-generated assessment data. These methodologies provide a valuable opportunity to analyze suicidal patient responses that help shed light on important information about patients’ subjective suicidal experience. Currently, much of the SSF-based assessment research has been conducted using
American samples. The present study endeavored to extend these methodologies to clinical
7 samples obtained from several countries, which may meaningfully enhance the generalizability of using the SSF across different cultures.
To achieve this, the present study focused exclusively on the initial SSF assessment that is used in the index session of CAMS (specifically, the first session SSF “Section A”). Thus, various first session SSF Section A quantitative and qualitative responses were the focus of the present study. What follows is a detailed description of the methodologies that have been used to organize and understand index session SSF Section A responses, including the theoretical underpinnings of the constructs and empirical research of these data to date.
Quantitative SSF Research
As previously described the SSF Section A assessment provides both quantitative and qualitative assessments, which will now be described in more detail.
Ratings of SSF Core Assessment constructs. The SSF Core Assessment is the main quantitative assessment that is first introduced in the index session of CAMS (and is continually re-visited over the course of subsequent CAMS-guided care). As noted earlier, the SSF Core
Assessment includes the constructs of Psychological Pain, Stress, Agitation, Hopelessness, Self-
Hate, and Overall Risk of Suicide. Each of these constructs has corresponding rating scales that range from 1 (low) to 5 (high). The SSF Core Assessment was derived from suicidology theory and research. For example, Psychological Pain, Stress, and Agitation are based on the work of
Shneidman (1988), and his “Cubic Model of Suicide.” The SSF construct Hopelessness is based on the theoretical work of Beck, Rush, Shaw, and Emery (1979). Beck’s theory of depression, as illustrated by this concept of the cognitive triad, is organized around hopelessness pertaining to self, others, and the future. There is extensive empirical support between hopelessness and suicidal risk (see Beck, 1986; Brown, Beck, Steer, & Grishman, 2000; Nademin, Jobes,
8
Downing, & Mann, 2005). The SSF construct Self-Hate was derived from the work of
Baumeister (1990) and his escape from self theory of suicide. According to Baumeister (1990), when one’s self-hatred becomes too unbearable, suicide can become a viable option to escape that experience. Research indicates a strong connection between the desire to escape and suicidal risk (see Jobes, 2005; Jobes & Mann, 1999). Finally, the SSF construct Overall Risk of Suicide is considered a bottom-line behavioral assessment— are you going to take your life or not?
Although this construct is not based on any specific theory, its clinical/methodological utility and its predictive validity are noteworthy (Jobes, Kahn-Green, Green, & Goeke-Morey, 2009).
The SSF Core Assessment has undergone two rigorous psychometric evaluations (see
Conrad et al., 2009; Jobes, et al., 1997). Both studies demonstrated strong validity and reliability.
In addition to evaluating the psychometric properties of the SSF Core Assessment scales, several studies have examined first session ratings of these scales to describe and predict treatment outcomes and reductions of suicidal ideation over the course of treatment (see Jobes, 1995; Jobes et al., 1997). Another study using hierarchical linear modeling observed four distinctly different treatment trajectories based only on baseline SSF Core Assessment ratings reported in the first session of CAMS (see Jobes et al., 2009).
Rankings of SSF Core Assessment constructs. Following the rating of each SSF Core
Assessment construct, patients are directed to rank order the first five theoretical constructs (i.e.,
Psychological Pain, Stress, Agitation, Self-Hate, and Hopelessness) from 1 (most important) to 5
(least important). Overall Risk of Suicide is not ranked. Recently, Martin, Lento, and Jobes
(2014) conducted an exploratory study that systematically reviewed patients’ rankings of the SSF
Core Assessment constructs across four different samples of suicidal patients within the USA
(i.e., inpatient adults, active duty soldiers, outpatient adults, and justice-involved adolescents).
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Results revealed significant differences between the four samples, indicating variations in construct importance. This was the first study to examine the rank order of the SSF Core
Assessment constructs. Results indicated significant differences in rankings across sites. Stress was observed to be the highest ranked (i.e., most important), while both Agitation and
Hopelessness were ranked the lowest (i.e., least important).
Self vs. other rating. Following the SSF Core Assessment section there are two quantitative assessment items that were based on a theoretical model of suicide developed by
Jobes (1995) that reflects an extensive psychological literature on agency vs. communion. This assessment thus asks the suicidal patient to rate the degree to which their suicidality is related to self or others (i.e., Self-oriented vs. Relationally-oriented). A recent study by Lento, Ellis, and
Jobes (2013) examined baseline responses to these prompts and compared them to outcome measures among suicidal inpatients. Responses were categorized into seven different categories--
Completely Self, Mostly Self, More Self, Equally Self & Relational, More Relational, Mostly
Relational, and Completely Relational—based on the numerical ratings of each prompt. Results indicated that at the start of CAMS treatment, self-oriented patients had higher suicidal ideation, hopelessness, and depression compared to relationally-oriented patients. Both Self- and
Relationally-oriented patients were equally responsive to treatment; however, results indicated a significant moderation effect for suicidal ideation, such that among patients with higher degrees of Self-orientation, index suicidal ideation was highest for patients with no relational focus, and lowest for patients with greater degrees of relational focus. These findings indicate that Self- oriented patients with higher degrees of self-focus may need extended treatment to reduce suicidal ideation. Moreover, higher degrees of relational focus may serve as a protective factor.
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WTL/WTD assessment. The SSF “WTL/WTD” assessment consists of two prompts that ask patients to indicate how much they “wish to live to the following extent” and “wish to die to the following extent.” Each prompt has a corresponding nine-point Likert scale, with 0 indicating
“not at all” and 8 indicating “very much.” The WTL/WTD assessment is based on the theoretical work of Kovacs and Beck’s (1977) “internal struggle hypothesis,” which posits that suicidal persons deal with conflicting feelings of wanting to live and wanting to die. Kovacs and Beck’s
(1977) initial research on the WTL/WTD self-rating scales revealed that among a sample of suicide attempters, patients with high ratings for both WTL and WTD had the highest average suicide lethality, as measured by the Suicidal Intent Scale (Beck, Schuyler, & Herman, 1974).
These results indicate the utility of the WTL/WTD self-ratings as a valuable tool to predict suicide risk and treatment outcomes of suicidal patients (Beck, Kovacs, & Weissman, 1979;
Kovacs & Beck, 1977). Moreover, Brown, Steer, Henriques, and Beck (2005) developed a 3- point WTL/WTD interval-scale index score based on the Scale for Suicide Ideation (SSI; Beck,
Brown, & Steer, 1997). When examining the association between this index score and suicidal risk, Brown and colleagues (2005) found a significant relationship, such that individuals with higher scores (indicating a stronger WTD) were at significantly higher risk for dying by suicide.
In recent years, O’Connor and colleagues (2011; 2012), Lento, Ellis, Hinnant, and Jobes
(2013), and Corona and colleagues (2013) have expanded on the above-mentioned research by systematically examining the SSF based WTL/WTD self-rating scales. O’Connor et al. (2011) expanded on the work of Brown and colleagues (2005) by using a modified version of the
WTL/WTD interval-scale score, called the Suicide Index Score (SIS) for categorizing patients’ ratings of the SSF WTL/WTD Assessment into three categories—WTL, Ambivalent, and WTD.
The SIS is calculated by converting the WTL and WTD rating scales into a 3-point ordinal scale,
11 such that ratings that range from 0-2 are converted to a 1 (low), ratings that range from 3-5
(middle) are converted to a 2, and ratings that range from 6-8 (high) are converted to a 3 (see
Corona et al., 2013; Lento et al., 2013). The SIS score is then calculated by subtracting the adjusted WTD score from the adjusted WTL score. The SIS ranges from -2 to 2 with lower scores indicating a greater wish to die. Additionally, the SIS score can then be further grouped into three categories—WTL (SIS = 1 or 2), Ambivalent (SIS = 0), and WTD (SIS = -1 or -2).
Qualitative SSF Research
As noted there are various qualitative opportunities embedded in Section A of the first session SSF, which are worth considering in more depth.
SSF incomplete sentence prompts. The first qualitative response opportunity is found within the SSF Core Assessment. In this section, there are five open-ended prompts that correspond with five constructs of the SSF Core Assessment—Psychological Pain, Stress,
Agitation, Hopelessness, and Self-Hate. The qualitative prompts found in this section are based on Rotter and Rafferty’s (1950) Incomplete Sentence Blank methodology. These sentence prompts provide patients with the opportunity to express their suicidal experiences according to the aforementioned constructs in their own hand-written words (Jobes, 2012).
Following the first construct, Psychological Pain, the incomplete sentence blank states,
“What I find most painful is: ______.” Following the second construct, Stress, the sentence prompt reads, “What I find most stressful is: ______.” The sentence prompt following the third construct, Agitation, reads, “I most need to take action when: ______.” Following the fourth construct, Hopelessness, the prompt states, “I am most hopeless about: ______.” Lastly, the sentence prompt following the fifth construct, Self-Hate, reads, “What I hate most about myself is: ______.”
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In order to meaningfully organize patients’ responses, a reliable coding system (K > .80) was developed based on a modified version of Hill, Thompson, and Williams’ (1997)
“Consensual Validation” methodology (see Jobes et al., 2004). This coding system was developed using SSF responses from American suicidal college students and active-duty Air
Force personnel. Interrater reliability for the five constructs were as follows: Psychological Pain
(K = .85), Stress (K = .88), Agitation (K = .88), Hopelessness (K = .90) and Self-Hate (K = .86).
Results revealed 12 themes: Self, Relational, Role Responsibilities, Global/General, Helpless,
Unpleasant Internal States, Unsure/Unable to Articulate, Situation-Specific, Compelled to Act,
Future, Internal Descriptors, and External Descriptors (Jobes et al., 2004). These themes differ across the five core constructs, such that not every construct can be coded using all 12 themes.
For example, responses to Psychological Pain can be coded into the following seven categories:
Self, Relational, Role/Responsibilities, Global/General, Helpless, Unpleasant Internal States, and
Unsure/Unable to Articulate. A coding manual was developed detailing general and specific guidelines for coding responses to these sentence prompts (Jobes et al., 2004; Jobes, 2016).
SSF reasons for living/reasons for dying. The second qualitative assessment opportunity in Section A of the SSF is called the “RFL/RFD Assessment” (Jobes, 2012; Jobes,
2016). This assessment provides patients with space to write out their respective RFL and RFD responses and rank order each construct in relation to importance. The RFL/RFD assessment was inspired by the work of Linehan, Goodstein, Nielsen, and Chiles’ (1983) Reasons for Living
Inventory and Kovacs and Beck’s (1977) theoretical notion of the internal struggle hypothesis
(Jobes & Mann, 2000).
Jobes and Mann (1999) developed a reliable coding system for this assessment based on suicidal university college counseling center patients. Results yielded nine reliable themes for
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RFL responses (K = .81): Family, Friends, Responsibility to Others, Burdening Others, Plans and Goals, Hopefulness for the Future, Enjoyable Things, Beliefs, and Self. Results also revealed nine reliable themes for RFD responses (K = .80): Others (Relationships),Unburdening Others,
Loneliness, Hopelessness, General Descriptors of Self, Escape- In General, Escape- The Past,
Escape- The Pain, and Escape- Responsibilities. In 2005, Nademin and colleagues conducted an exploratory study comparing RFL responses of suicidal college counseling center patients from three different universities to non-suicidal college student sample. This coding system was applied. Results indicated observable differences between the suicidal students’ response themes and the non-suicidal students’ response themes, such that, in total, the non-suicidal students had more RFL responses compared to the suicidal students, and the non-suicidal students reported significantly more future-oriented responses (e.g., hope, plans, goals) compared to the suicidal students.
SSF one-thing response. The third and final qualitative assessment found at the bottom of Section A is the SSF “One-Thing” response. This prompt provides patients with the opportunity to complete the sentence, “The one thing that would help me no longer feel suicidal would be: ______.” Like the SSF incomplete sentence prompts, this final qualitative assessment is based on the work of Rotter and Rafferty (1950). Fratto, Jobes, Pentiuc, Rice and Tendick
(2004) developed a reliable coding system for the SSF One Thing response (K > .80). Based on this system, responses can be organized into three dimensions: 1) Orientation of the one thing response, 2) Reality Testing of the response, and 3) Clinical Utility of the response. Each of these dimensions can be organized into the following categories: Orientation (Self, Relational, Not
Codable), Reality Testing (Realistic, Not Realistic, Not Codable), and Clinical Utility (Clinically
Relevant, Not Clinically Relevant, Not Codable).
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Reliable coding of the SSF One-Thing response has the potential to enhance clinicians’ insight into patients’ suicidal experience, possibly impacting treatment and clinical outcomes
(Jobes, 2016). For step-by-step instructions on how to code responses to the SSF One-Thing prompt, see Jobes (2016).
SSF “Micro-Coding”
A major qualitative methodology employed by SSF researchers has been the use of two different coding systems— “micro-coding” and “macro-coding,” which can be applied to various
SSF written responses. SSF micro-coding has involved organizing and coding specific qualitative content responses across the first page of the SSF. Over the years, this has been a valuable line of research to help reveal the nature and key considerations of suicidal thinking and related behaviors directly from the written words of actively suicidal patients (Jobes, 2012).
Under Section A of the SSF, the three different opportunities for qualitative responding, just described, can be micro-coded according to methods developed by the Catholic University of
America Suicide Prevention Laboratory (CUA-SPL). Those include, the SSF Core Assessment
Constructs, RFL and RFD, and the One-Thing Response.
SSF “Macro-Coding”
In contrast to SSF micro-coding, macro-coding examines a suicidal patient’s responses from a broader/gestalt perspective incorporating multiple SSF responses at once. In other words, an entire set of SSF responses are taken into account when coding the gestalt of certain response styles from a “10,000 foot perspective,” so to speak. There are two different opportunities for macro-coding, which include suicidal orientation and suicidal motivation.
Suicidal orientation (self vs. relational). Jobes, Stone, Wagner, Conrad, and Lineberry
(2010) developed a reliable coding system that takes into account all the previously described
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SSF qualitative responses in Section A. This coding system broadly organizes patients’ SSF responses into two categories of “Suicidal Orientation”: Self-oriented or Relationally-oriented.
Stone (2011) first used this coding system to reliably (K = .98) categorize self and relational suicidal orientations among N = 108 suicidal inpatients. These typologies were then analyzed according to established measures of suicide risk. Results revealed that patients who were Self-oriented had significantly higher suicide risk compared to those whose response style was Relationally-oriented.
Jennings, Jobes, O’Connor, and Comtois (2012) used this coding system to compare self and relational orientations among low-income suicidal outpatients seen within a CAMS clinical trial. There were no observed differences in psychological distress at baseline; however, compared to Self-oriented patients, those that were Relationally-oriented yielded better overall responses to treatment (i.e., they reported less psychological distress at 12-month follow-up).
Jennings and colleagues (2012) also found that Self-oriented patients were significantly less hopeful and optimistic at both the start of treatment and at the 12-month follow-up.
As discussed by Jobes (1995; Jobes et al., 2004), the identification of potential clinical typologies of suicidal patients has long been an interest within the field of suicidology as a means of enhancing clinical care. Among the various typology models, “Self” and “Relational” typologies have received the greatest amount of empirical attention. There are two major theories that serve to explain the Self-oriented suicidal typology, Blatt’s (1974) “introjective depression” and Baumeister’s (1990) “escape from self.” The second major suicidal typology is Relational.
Durkheim (1951) proposed that suicide is caused by a dysregulation of social forces. In addition to his theory of introjective depression, Blatt (1974) proposed another variant of depression,
“anaclitic depression.” This form of depression is characterized by external interpersonal issues.
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An individual experiencing anaclitic depression experiences intense fear of rejection and a deep need to belong (Reis & Grenyer, 2002). Moreover, Joiner (2005) and Van Orden et al. (2010) suggest an “Interpersonal Theory of Suicidal Behavior.” This theory proposes suicidal behavior is produced when both suicidal desire and capability are active. Suicidal desire consists of two constructs, thwarted belongingness and perceived burdensomeness, and both focus heavily on relational factors. Finally, Shneidman (1987) suggested that social connectedness plays an integral role in understanding suicidal behavior.
The integration of Self and Relational typologies has also been observed. Bakan (1966) conceptualized two overarching typologies of existence—Agency, which are self-oriented goals, and Communion, which are relationally-oriented goals (Buss, 1990). Moreover, Jobes (1995) conceptualized a continuum on which all suicidal persons exist. At one end of the spectrum is intrapsychic, characterized by internal focus and a private experience of pain; at the other end is interpsychic, described as externally derived experiences of interpersonal pain.
The identification of suicidal orientation has the potential to provide clinicians with important insight into their patients’ suicidal experience. For instance, Stone (2011) and Jennings et al. (2012) found higher suicidal risk for Self-oriented patients at baseline, and Jennings et al.
(2012) observed poorer clinical outcomes for Self-oriented patients compared to Relationally- oriented. This is highly valuable information for clinicians to have at the outset of treatment in order to more accurately assess suicidal risk and possibly shape treatment to meet patients’ individual needs and experiences (Jobes, 2016).
Suicidal motivation (RFL vs. RFD). Another reliable macro-coding system developed by the CUA-SPL uses the frequencies of patients’ RFL and RFD responses to reliably categorize patients into one of three groups of “Suicidal Motivation”: Life-Motivated, Ambivalent and
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Death-Motivated. Suicidal Motivation macro-coding is determined as follows: Life-Motivated patients provide more RLF responses than RFD responses, Ambivalent patients provide an equal number of RFL and RFD responses, and Death-Motivated patients provide more RFD responses than RFL responses (Stone, 2011).
Jennings and colleagues (2012) also applied this macro-coding system to a sample of suicidal outpatients at treatment onset. This study revealed different longitudinal treatment outcomes for each Suicidal Motivation group, indicating Suicidal Motivation at baseline might provide important predictions for mental health care outcomes. Recently, Corona and colleagues
(2013) examined Suicidal Motivation within two Danish outpatient samples. Suicidal Motivation was reliably coded. This study found significant differences among motivation groups when comparing SSF Core Assessment ratings at treatment completion. Specifically, there was an observed increase in intensity (1-5) of patient-rated Overall Risk of Suicide across the motivation groups, such that Life-Motivated persons had lower rating of Overall Suicide Risk at treatment completion, followed by Ambivalent, and Death-Motivated, who had the highest risk ratings.
Moreover, at treatment completion, patients in the Ambivalent group provided the lowest ratings of the other five SSF Core Assessment constructs, and patients in the Death-Motivated group endorsed the highest ratings. These findings suggest patients’ degree of emotional turmoil is not completely indicative of their subjective ratings of risk for suicide. These results also underscore the protective nature of RFL.
Moreover, suicidal motivation refers to individuals’ psychological attachment to living verses dying. The methodology for determining an individual’s Suicidal Motivation relies on identifying the difference between individuals’ self-reported RFL compared to their self-reported
RFD. Originally derived by Linehan and colleagues (1983), the Reasons for Living Inventory
18 was developed to assess the various reasons individuals might have for not wanting to die by suicide. There is strong empirical evidence that suggests RFL serve as a protective factor against suicide (Flowers, Walker, Thompson, & Kaslow, 2014; Jobes & Mann, 1999; Malone et al.,
2000). Variability in the frequency of reported RFL and RFD indicate a potential increase in suicide risk, specifically for individuals with fewer RFL (see Jobes & Mann, 1999).
Limitations of Coding Systems
Among the aforementioned studies of the SSF qualitative coding systems, there has only been one to date that has examined suicidal patients’ responses from an international sample (see
Corona et al., 2013). Corona and colleagues (2013) examined 52 Danish outpatients receiving
CAMS. The study investigated self-report ratings of the SSF Core Assessment constructs across different Suicidal Motivation groups over the course of treatment. Significant differences between groups were observed, suggesting that grouping patients by Suicidal Motivation may be beneficial to understanding suicide risk. Research on culture and suicide indicate that the expression and experience of suicide varies across cultures (Chu et al., 2013). In order to further explore the important potential differences and similarities between cultures within the context of suicide, a cross-sectional comparison of the SSF constructs is needed. For example, questions this comparison may answer include: What are some common aspects of the suicidal experience across cultures? What are the major differences of the suicidal experience? What can these differences/similarities potentially tell us about suicide risk/ and treatment outcomes? Examining suicidal patients’ SSF responses from different nations may also meaningfully advance the use of
CAMS by further supporting the SSF as a useful clinical tool across different countries and cultures.
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Culture and Suicide
Risk for suicide varies across gender, ethnicity, sexual orientation, and age (Chu et al.,
2013; Colucci, 2013). For example, within the USA, rates of suicide are highest among older adults; however, in Japan suicide rates are higher among younger persons (Colucci, 2013).
Moreover, a decade ago suicide rates in China, particularly young females in rural China, were higher than males (Vijayakumar, 2015), whereas in Ireland suicide is more common among males compared to females (WHO, 2014), which is typical across most other parts of the world.
Sociocultural variations have also been observed to influence precipitating factors of suicide. For instance, commonly cited reasons for suicide among samples in the USA are often focused on escape from the self, relationships, and feelings of hopelessness (Jobes & Mann, 1999), whereas in Japan and India commonly reported precipitants of suicide include physical illness or disease, disagreements with in-laws, school, and job stress (Lester, Agarwal, & Natarajan, 1999; Lester &
Saito, 1999).
The role of acceptability of suicide in relation to suicide risk also varies across cultures, such that higher acceptability of suicide is associated with increased risk for suicide (Gunnell &
Lewis, 2005). Stack and Kposowa (2008) examined the acceptability of suicide among 31 nations and found a positive correlation between nations’ degree of acceptability of suicide and national suicide rates. An example of this can also be seen in European nations where physician- assisted suicide is legally permitted. For instance, in Belgium, Germany, and Switzerland, where physician-assisted suicide is legal, suicide rates are 19.4, 11.9, and 18.0 per 100,000, respectively
(WHO, 2014). Nations such as Italy, Spain, and the United Kingdom, where physician-assisted suicide is illegal, reported suicide rates are 6.3, 7.6, and 6.9 per 100,000, respectively (WHO,
2014).
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Increased suicide risk has also been found in the USA among persons from minority cultures, particularly immigrants and Native Americans, due to environmental and social stressors, especially acculturative stress (Goldston, Weller, & Otima, 2014). For example, racial and ethnic minorities are disproportionately affected by discrimination and have reduced educational, health, and occupational opportunities, which may be indirectly related to increased risk for suicide (Compton, Thompson, & Kaslow, 2005; Walls, Chapple, & Johnson, 2007;
Yoder, Whitbeck, Hoyt, & LaFromboise, 2006). Moreover, cultural minorities in the USA have also been found to experience more barriers to mental health services, such as mistrust of providers due to past negative/exploitive experiences (Breland-Noble, 2004), limited transportation to services, lack of culturally sensitive interventions, and limited availability of translation services (Goldsmith, Pellmar, Kleinman, & Bunney, 2002). Additionally, stigma associated with help seeking further increases cultural minorities’ risk for suicide (Choi, Rogers,
& Werth, 2009). Interestingly, among Latinos, immigrants tend to have fewer reported suicide attempts and less ideation compared to USA-born Latinos (Sorenson & Shen, 1996), and Latino youth born from immigrant parents also reported less suicidal ideation and fewer attempts compared to USA-born Latino children of immigrant parents (Peña et al., 2008).
Moreover, cultural literature suggests another major contributor to suicide risk is acculturation and acculturative stress (Goldston et al., 2014). For example, research has demonstrated increased risk for suicide among Caribbean immigrants (Joe, Baser, Breeden,
Neighbors, & Jackson, 2006), as well as Asian American immigrants (Lau, Jernewall, Zane, &
Myers, 2002), as evidenced by higher rates of suicide attempts and ideation in both immigrant populations. Acculturative stress can often result from perceived pressure to acculturate to the dominant culture. This pressure can also contribute to increased risk for suicide, particularly
21 among young immigrants. Indeed, research shows that adolescent Latinas may experience stress due to societal pressures to acculturate and adopt majority values, which may conflict with their family’s traditions and beliefs, leading to increased distress and potential suicidal behavior
(Zayas & Pilat, 2008). Research also suggests that African Americans may experience increased risk for suicide when they receive pressure to acculturate from the dominant culture and pressure to maintain their own culture (Willis, Coombs, Cockerham, & Frison, 2002).
Acculturation and the stress associated with acculturation is unique in that not only does the process of adapting to a dominant culture, while attempting to maintain one’s own cultural identity, place an individual at an increased risk for suicide, but during the immigration process one may lose important protective factors that buffer against suicide risk, such as connectedness with family and/or community (Goldston et al., 2013). Research indicates, for some cultures, low levels of acculturation or assimilation may serve as a protective factor against risk for suicide.
For example, suicide rates among Native American tribes suggest that low acculturation or assimilation, along with moderate social integration were associated with lower rates of suicide, compared to high levels of acculturation or assimilation and low levels of social integration (Van
Winkle & May, 1986). This finding is also consistent among Hispanics, suggesting that holding onto one’s native culture may enhance unity by increasing cultural connectedness among similar ethnic communities (Wadsworth & Kubrin, 2007).
There are many other cultural factors, beyond the aforementioned aspects, that should be considered as potential risk factors for suicide (e.g., religion and sexual orientation). However, this study’s data were limited to investigating culture, as determined by the patient’s nation of residence. We suggest future research consider cultural factors beyond the aforementioned aspects, as they may be important to take into consideration when assessing and determining risk
22 for suicide.
Nations of Comparison
In the present study, we compared SSF responses from six different countries. Therefore, the following sections will explore what is known about suicide in each of these nations.
China
Although this section is labeled “China,” its contents will focus on the people of Hong
Kong. Even though Hong Kong is currently an entity of the Chinese government and is considered to be a special administrative region, their cultural and political values are quite westernized compared to mainland China. However, since most residents of Hong Kong are ethnically Chinese and they did not undergo a Cultural Revolution like mainland China did, many Chinese traditions and cultures have been preserved. In terms of similarities, both cultures value collectivism, filial piety (i.e., respect for elders), and "face" (i.e., dignity, honor, respect, status). With historical British influence, the lifestyle, values, infrastructure, and education system of Hong Kong are quite modernized compared to mainland China. Moreover, the main language spoken in Hong Kong is Cantonese and people write in Traditional Chinese, while most people in mainland China speak Mandarin and write in Simplified Chinese (J. Au, personal communication, January 21, 2017). Therefore, it may not be appropriate to generalize from research on suicide from mainland China and other Asian nations to the people of Hong Kong.
In 2015, there were 12.6 per 100,000 recorded suicides in Hong Kong. Men were observed to have higher suicide rates (17.4 per 100,000) compared to women (8.5 per 100,000)
(The Hong Kong Jockey Club Centre for Suicide Research and Prevention, 2016). Suicide rates by age group from 1981-2015 indicated individuals 65 years old and above had the highest suicide rates. Rates of youth suicide are on the rise; indeed, suicide is the leading cause of death
23 for youths 15-24 years of age (Yip & Chak, 2011). Methods used in completed suicides from
1999-2015 revealed the most common was jumping, followed by hanging, charcoal burning, poisoning, and other (e.g., cutting). Within recent years, poisoning by gas, particularly charcoal gas inhalation, has become a prominent method among persons aged 35-44 years (Yip & Chak,
2011).
There are several sociocultural factors that impact suicide among Asian countries (see
Chen, Wu, Yousuf, & Yip, 2012). Traditionally, the family system is considered to be of primary importance and individual needs are considered secondary (Slote & De Vos, 1998). This is particularly true for suicidal adolescents, as many family-related factors have been found to contribute to suicide risk, including problematic family dynamics, parental rejection, and stressful life events, including divorce of parents (Chen et al., 2012; Yip & Chak, 2011). In addition, research suggests Chinese adolescents who have poor problem solving skills, as well as poor interpersonal and social problems, along with academic stress are at an increased risk for suicide (Yip & Chak, 2011).
In contrast to Western cultures, being married is not necessarily a strong protective factor against suicide among Eastern cultures. For example, research indicates that martial relationships may influence Asian female suicides, and statistics reveal that unmarried young Asian women have the lowest suicide rates (Gururaj, Issac, Subbakrishna, & Ranjani, 2004; Zhang et al.,
2010).
Moreover, economic distress, including unemployment has been found to strongly influence suicide, particularly among males, who are viewed as providers for the family. For example, Rehkopf and Buka (2006) conducted a meta-analysis examining the association between suicide and socioeconomic characteristics between Asian countries and Western
24 countries. Results found that suicide rates of Asian countries were more likely to be significantly adversely impacted by socioeconomic conditions compared to Western countries.
In fact, familicide-suicide, which is a form of murder-suicide involving a parent and child and/or other family members or, in some instances, all members of the family, rates have been observed to increase when the male head of the household loses his job (Yip et al., 2012). In addition, rates of familicide-suicide have risen within the last 10 years, due to the prominent use of charcoal burning as a method of suicide, as this method more easily facilitates multiple deaths
(Yip et al., 2012).
Denmark
In 2012, the crude suicide rate per 100,000 in Denmark was 11.2 (WHO, 2012). The age- standardized suicide rate per 100,000 for males was 13.6, with hanging being the most common method for suicide. The most common age range for male death by suicide is 49-59 years of age; whereas, for female deaths by suicide (6.2 per 100,000) the most common age range is 60-70+ years (Centre for Suicide Research, 2014). In 2007, Denmark reportedly had the higher suicide rates compared to Norway and Sweden; however, 2011 statistics reveal Denmark had the lowest suicide rates compared to the other Nordic countries, which include Greenland, Iceland, Finland,
Sweden, Norway, and Denmark (Haagensen, 2014).
Danish culture possesses strong supportive attitudes towards the acceptability of suicide
(Cutright & Fernquist, 2000, 2001; Fernquist, 2003). In fact, Denmark ranks fourth in the world for pro-suicide attitudes, following China, the Netherlands, and Finland (Stack, 2000). In combination with pro-suicide values, Denmark has historically low levels of social integration, which may, in part, account for Denmark’s suicide rates (Agerbo, Stack, & Petersen, 2011). In a study by Bille-Brahe (1987), Denmark’s national registry was used to assess social integration,
25 which consisted of levels of integration across three areas— immediate environment, work environment, and community life. Overall, low social integration was significantly correlated with rates of suicide, particularly among Danish middle-aged women.
Suicide research indicates there is a strong emphasis on social isolation – particularly divorce, as a common risk factor of suicide among Danish men and women (see Agerbo, Sterne,
& Gunnell, 2007). According to the European Commission, in 2014 Denmark’s crude divorce rate was 3.4 per 1,000 inhabitants (Eurostat Statistics Explained, 2016). Stack (1990) examined the effect of divorce on suicide among Danish men and women from 1951 to 1980. Results indicated a strong positive correlation between divorce and suicide. Indeed, results from a more recent study that examined Danish data from 1970 to 2006 confirmed the strong relationship between divorce and suicide, particularly among Danish males (Andrés & Halicioglu, 2010).
Moreover, according to an older qualitative investigation of the dynamics of suicide within the Danish culture, a common form of discipline used by parents had been to provoke guilt within their children, leading to strong feelings of dependency (Hendin, 1965). Following loss or separation from their parents, Danish adults may become depressed and/or suicidal.
Therefore an observed reason for suicide, at the time, among Danish adults was to be reunited with lost loved ones (e.g., reunion fantasies) (Hendin, 1965). Overall, social factors appear to be important within the Danish culture. The loss of an intimate relationship (e.g., parent-child, husband-wife) appears to be a potential contributor to suicide risk.
Ireland
In 2015, the crude suicide rate in Ireland was 9.7 per 100,000 (National Suicide Research
Foundation, 2015). Out of the total number of deaths by suicide in 2015, 83% were male
(National Suicide Research Foundation, 2015). Male deaths by suicide are particularly high in
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Ireland (17.4 per 100,000) compared to females (3.4 per 100,000) (Central Statistics Office,
2014). Over the last decade, this large gender discrepancy has been a consistent feature of the deaths by suicide in Ireland (National Office for Suicide Prevention [NOSP], 2013). The peak age range for suicide among males is 20-24 years old, at 31.9 per 100,000 and almost half of the men that died by suicide in 2010 were under the age of 40 (NOSP, 2013). The peak age ranges for female suicide are 45-49 and 60-64 years (NOSP, 2013). The most commonly observed methods of suicide are hanging and drowning (NOSP, 2013).
Research indicates that alcohol and unemployment both play important roles in influencing suicide risk, particularly among Irish males (NOSP, 2013; Walsh & Walsh, 2011).
Additionally, Dooley and Fitzgerald (2012) conducted a large-scale survey of mental health among youth in Ireland and found several important issues leading to mental health problems and suicide, specifically excessive consumption of alcohol and poor financial stability.
According to Wyllie and colleagues (2012), major cultural factors such as social and economic inequality contribute to suicide, particularly among men. The authors noted that Irish society values power and control and Irish men especially compare themselves against an unattainable ‘gold standard.’ Moreover, when Irish males believe they are not able to reach the
‘gold standard’ they feel an overwhelming sense of shame and guilt – which may lead to suicidal thoughts/behaviors. Lastly, the Wyllie and colleagues noted that high unemployment rates have greatly impacted working class men, and the reduction of traditional male industries in Ireland has not only affected the unemployment rates, but also Irish men’s source of masculine pride and identity.
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Norway
In 2012, 10.2 per 100,000 persons reportedly died by suicide in Norway (WHO, 2012).
The rate for suicide among Norwegian males is 13.0 per 100,000 and 5.2 per 100,000 among females. The peak age-range for male suicides is 25-44 and 45-64 for females (Colicci, 2013).
Similarly to Denmark, the Norwegian culture also possesses liberal views of suicide (Stack,
1998). Moreover, alcohol abuse is particularly common among Norwegians. According to the
WHO (2014), prevalence of alcohol use disorders for Norwegian males was reported to be
12.0%, and 4.2% for females. Such high prevalence rates may contribute to rates of self-harm and suicide (Rossow & Amundsen, 1995). Similarly to Denmark, other prominent risk factors for suicide among the Norwegian culture include unemployment, divorce, and low social integration
(Barstad, 2008; Dieserud, Loeb, & Ekeberg, 2000). Social relationships are also highly valued among the Norwegian culture; therefore, martial dissolution or other forms of relationship loss are also considered strong risk factors for suicide (Barstad, 2008; Dieserud et al., 2000).
Regarding the experience of suicidal behavior among Norwegians, Biong and Ravndal
(2007) noted suicide is considered to be “a movement between different positions of wanting death as an escape from pain and hope for a better life” (p. 246). Moreover, research also indicates that it is common within Norwegian culture to blame others for personal failures
(Colucci, 2013). Therefore, external issues may be a prominent theme for Norwegian’s motives for suicide.
Switzerland
In 2012, Switzerland’s national suicide rate was 12.2 per 100,000 (WHO, 2012). The rate for suicide among Swiss males is 13.6 per 100,000, and females is 5.1 per 100,000. Moreover, in
2012, 972 persons reportedly died by non-assisted suicide in Switzerland (WHO, 2014). Of this
28 total number, approximately 68% were men (WHO, 2014). The peak age-ranges for male suicide are 30 to 34 years and 20 to 24 years, and the peak-age ranges for female suicide are 20 to 24 years and 25 to 29 years (Flavio et al., 2013). The most common method for suicide among men is using firearms and among women is poisoning via overdose (WHO, 2014).
Culturally, the Swiss have a liberal view of suicide. Indeed, in Switzerland assisted suicide, without selfish motives, meaning, physicians who are motivated by compassion to assist their patients to die by suicide, is legal (Hurst & Mauron, 2003). In recent years, tourists have visited Switzerland to die via assisted suicide. A recent pilot study reported that assisted suicides of non-Swiss citizens in Switzerland have doubled between 2009-2012 (Gauthier, Mausbaoh,
Reisch, & Bartsch, 2015). Research indicates the most commonly cited reasons for attempting suicide in Switzerland include mental anguish, feelings of lost control, a wish to die, desire to escape an impossible situation, and inability to bear the current situation (Schnyder, Valach,
Bichsel, & Michel, 1999). The most commonly reported feelings associated with attempting suicide include emptiness, anxiety/panic, despair, disappointment/insult, and powerlessness/hopelessness (Schnyder et al., 1999).
The United States of America
Suicide is the tenth leading cause of death in the USA, (13.26 per 100,000) (Centers for
Disease Control and Prevention [CDC], 2015). Indeed, in 2015, approximately 44,193 persons in the USA died by suicide (CDC, 2015). Suicide is more prevalent among men (21 per 100,000) compared to females (6.04 per 100,000); however, females are 3-4 times more likely to attempt suicide (CDC, 2015). For males, the age group with the highest rate of suicide is 85 years and older (48.20 per 100,000), whereas for females, the age group with the highest rate of suicide is
50-54 years old (11.15 per 100,000). The most common means of suicide in the USA include
29 firearms, non-pesticide poisoning, and hanging (CDC, 2010). Recent research investigating patients’ reasons for suicide among a USA population reported internally-focused issues (such as dislike for oneself), externally-focused issues (such as unemployment), interpersonal issues, pain and stress, and feelings of hopelessness (Schembari, Martin, & Jobes, 2013).
Study Rationale and Hypotheses
Rationale
This study aimed to advance the current state of knowledge regarding suicide from an international perspective and examine the potential impact of cultural influences on suicidality in order to cultivate insight about universal and culture-specific aspects of the suicidal patient’s psychological experience of suicidality. Possible between-country differences and/or similarities for suicidal patients’ index responses to Section A of the SSF administered in the first session of
CAMS care were examined. Given the increased use of CAMS internationally, this study also aimed to further understand the utility of the SSF as an international tool for the assessment of
(and treatment) of suicidal risk. This study may enhance clinicians’ and researchers’ understanding of the international differences between suicidal persons of six different countries with possible implications for the development of more precise and culturally-informed assessments for suicide risk, as well as enhanced treatment outcomes and enriched use of CAMS as an internationally used suicide-specific clinical intervention.
Hypotheses
This cross-sectional study is among the first to systematically explore detailed clinical constructs obtained from samples of actively suicidal patients in treatment from six different countries. To date, we are not aware of any similar study that has systematically examined such detailed first-hand self-report of suicide-related thoughts, feelings, and behavior across six
30 different nationalities. Given the dearth of any detailed cross-cultural clinically-focused knowledge of this international public health issue, a cross-sectional, exploratory, and descriptive investigation was clearly warranted. As an exploratory study, this investigation maintains two broad hypotheses: (1) The SSF Core Assessment constructs are based on major theories of suicide and research, and are considered to be universally relatable across suicidal patients. It is hypothesized that the SSF Core Assessment constructs and the WTL/WTD Assessment will be quantitatively rated and ranked in a comparable fashion across self-report SSF responses from suicidal patients seen in the six nations of interest, indicating cross-cultural universality of these constructs. (2) Formulated by limited cross-cultural research and anecdotes from previous clinical trials, we further hypothesize that there will be significant differences obtained from qualitative SSF coding systems that may reveal some culture-specific responses.
CHAPTER 2
Method
This study examined the two broadly stated exploratory hypotheses by using various
SSF-specific quantitative methodologies and qualitative coding systems, respectively. Because there is variability in the clinical use of CAMS and the administration of the SSF therein, this investigation endeavored to standardize the available clinical data to help ensure that respective samples of data were as comparable as possible.
Sample and Participant Selection
This cross-sectional study examined index session SSF responses obtained from Section
A, of actively suicidal outpatients who were undergoing CAMS-guided clinical care in six different countries— China, Denmark, Ireland, Norway, Switzerland, and the USA, creating a total sample of 362 suicidal patients. Please see below for details regarding each nation’s sample and participation selection. For additional demographic information, please see Table 1.
China. These data were derived from a relatively small sample of university students who were currently receiving CAMS-guided care at a university counseling center (n = 12)1.
Denmark. These data were derived from a research study aimed at evaluating the usefulness and feasibility of CAMS on a sample of Danish outpatients, who were seen at one of two community mental health centers in Aarhus and Copenhagen (n = 56). Participants who were already receiving CAMS-guided care were included in this study (for more information see
Perdersen & Nelson, 2011 and Corona et al., 2013).
1 Due to the small sample size, the name of the university was not included in order to protect the anonymity of the student-patients. 31
32
Ireland. These data were derived from suicidal outpatients, who were receiving CAMS- guided outpatient care at Coolock Health Centre in Dublin, Ireland (n = 49). Note that gender data were provided for the overall sample but were not matched to participant responses.
Norway. These data were collected as part of a RCT of CAMS for suicidal outpatients and inpatients across four treatment sites (n = 97). For details on recruitment procedures, see
Ryberg et al. (2016).
Switzerland. These data were collected as part of a RCT of the Attempted Suicide Short
Intervention Program (ASSIP) using a sample of inpatients who had recently attempted suicide
(n = 120). For details on recruitment procedures, see Gysin-Maillart, Schwab, Soravia, Megert, and Michel (2016).
The USA. Finally, these data were derived from a feasibility study aimed at evaluating the use CAMS-guided care with a Next-Day Appointment (NDA), which is a follow-up appointment scheduled for the next day, within an outpatient treatment setting (n = 28). For more information, see Comtois et al., (2011).
Procedures
This is an archival cross-sectional study of de-identified SSF responses obtained from international collaborators who are providing CAMS-based treatment and conducting clinical research ranging from quality assurance/correlational research to rigorous randomized controlled clinical trials of CAMS or using the SSF within a RCT. While there is indisputable variability in the use of the SSF and adherence to CAMS, we nevertheless have a rich international database of a well-researched assessments (i.e., the variables that are included under Section A of the first session use of the SSF) completed by hundreds of actively suicidal patients from six different countries. In our efforts to eliminate error variance, we have done everything possible to
33 standardize and make data from the various clinical settings as comparable as possible. When limits of the data may impact our findings, we have endeavored to be as transparent and forthright about those limits as possible for the optimal interpretation of our research results.
Procedurally, the first consideration, along these lines, is the translations of SSF responses across the four non-English speaking data sets.
SSF Translation Methods.
China. Two postgraduate psychology students of the primary clinician at the university counseling center translated the SSF-IV from English into Chinese. A back translation process was subsequently employed.
Denmark. The primary investigator of the Danish study, Christian Pedersen, M.A, conducted the initial translation of the SSF-II-R. The back-translation of the SSF-II-Rs from
Danish into English was done by a professional translator and approved by Dr. Jobes.
Norway. The primary investigator of the Norwegian study, Roar Fosse, led the initial translation of the SSF-IV. First, three individuals from Oslo’s Research and Development
Department independently translated the SSF-IV from English into Norwegian. Second, meetings were held to decide upon Norwegian consensus versions. Third, a fourth person from the Research and Development Department back-translated the Norwegian consensus versions into English. Fourth, the English back-translations were sent to Dr. Jobes for evaluation of whether they expressed the same content and meaning as the English originals. Slight modifications to the English back-translation were made as per Dr. Jobes’ recommendations, and the Norwegian translation was modified appropriately.
Switzerland. A co-investigator of the Swiss study, Konrad Michel, M.D, conducted the initial translation of the SSF-III from English to German. A subsequent back-translation of the
34
SSF-III from German to English was done by a co-investigator, Dr. Walther Gekle and subsequently approved by Dr. Jobes.
Translation Methods of Qualitative Responses from the SSF
China. Responses were translated into English by one of the university counseling center’s primary clinician’s students, and another student back-translated the responses from
English into Chinese. The two translators then discussed and resolved any discrepancies.
Denmark. A professional translator translated patient responses into English. Responses were translated word-for-word, as closely as possible.
Norway. A co-investigator of the Norwegian study, Dr. Wenche Ryberg, translated responses from Norwegian into English. Patient responses were translated based on the core meaning of the responses.
Switzerland. Patient responses were translated into English by the Swiss study’s primary investigator, Dr. Anja Gysin-Maillart. Responses were forward translated and translated word- for-word, as closely as possible.
Measures
The Suicide Status Form (SSF; Jobes et al., 1997) is a clinical assessment, tracking, and outcome tool used within CAMS as a suicide-specific clinical framework. The first session version of the SSF employs both quantitative and qualitative prompts, in order to help clinicians elicit an in-depth understanding of suicidal patients’ experiences of their suicidality. Since its inception, the SSF has undergone multiple revisions to enhance its usability (Conrad et al., 2009) and is currently in its fourth iteration (SSF-IV—Jobes, 2016). For the present study, multiple versions of the SSF were used. Specifically, data collected in China used the SSF-IV, data collected in Denmark was completed using the SSF-II-R, data collected in Ireland was done
35 using the SSF-IV, data collected in Norway was completed using the SSF-IV, data collected in
Switzerland was done using the SSF-III, and data collected in the USA was completed using the
SSF-IV. Section A of the SSF has mostly not changed from version to version, although the
WTL/WTD was modified from 5-point scales in the SSF-II to 9-point scales in the SSF-II-R, and have remained the same in the SSF-III, SSF-III-R and SSF-IV.
This study examined baseline patient-generated written responses obtained from Section
A of the first session SSF (only). Responses from Section A of initial CAMS sessions were focused on because section A includes all SSF constructs, which allows for a deeper exploration of patient-generated content. As previously described, the first component of Section A of the
SSF is the SSF Core Assessment, which is followed by the Self vs. Others rating scales, the
RFL/RFD assessment, the WTL/WTD rating scales, and the One-Thing response. The SSF Core
Assessment demonstrates strong psychometric properties with American samples, including good to excellent validity – Cronbach alphas ranging from .78 to .98 (Conrad et al., 2009). There is also predictive validity data about the utility of the SSF Core Assessment related to overall symptom distress and differential reductions of suicidal ideation over the course of clinical care
(Jobes et al., 2009). In addition, Section A of the first session SSF has various qualitative assessments that provide valuable clinical information relevant to risk and treatment and these data have been systematically studied (Jobes, 2012; Jobes et al., 2004; Jobes & Mann, 1999). As used within CAMS, the completion of the SSF has proven to be a therapeutic assessment within a large meta-analysis of 17 assessment approaches (Poston & Hanson, 2010). Please refer to
Appendix A for a copy of Section A of the initial session SSF.
36
Quantitative Methods
As previously described, the quantitative portions of the SSF include the index ratings and rankings of the SSF Core Assessment constructs, the Self vs. Others rating scales, the
RFL/RFD rankings, and the WTL/WTD rating scales. For the purpose of this study, the Self vs.
Others rating scales and the RFL/RFD rankings were not included in our analyses.
Index ratings of SSF Core Assessment constructs. Patients across all six countries of comparison completed this component of Section A of the SSF.
Index rankings of SSF Core Assessment constructs. Ireland, Norway, and the USA were the only countries of comparison to rank the SSF Core Assessment components of Section
A (i.e., patients in the Chinese, Danish, and Swiss samples did not complete these rankings).
WTL/WTD assessment. The coding of the SSF WTL/WTD assessment followed the coding procedures developed by O’Connor and colleagues (2011). In order to determine patients’ SIS, which allows for patients’ ratings on the SSF WTL/WTD Assessment to be categorized into three categories—WTL, Ambivalent, and WTD; WTL and WTD rating scales were converted into 3-point ordinal scales. As mentioned above, two different scale ranges, 5- and 9-point response scales were used in this study. Responses using the 5-point rating scale were recoded such that scores that ranged from 1-2 were converted to 0 (low), ratings that were 3 were converted to 1 (middle), and ratings that ranged from 4-5 were converted to 3 (high).
Responses using the 9-point rating scale were recoded such that scores that ranged from 0 to 2 were converted to 0 (low), ratings that ranged from 3 to 5 were converted to 1 (middle), and ratings that ranged from 6 to 8 were converted to 2 (high). The SIS score was then calculated by subtracting the adjusted WTD score from the adjusted WTL score. The SIS ranges from -2 to 2 with lower scores indicating a greater wish to die. Additionally, the SIS scores were then further
37 grouped into three categories: WTL (SIS = 1 or 2), Ambivalent (SIS = 0), and WTD (SIS = -1 or
-2). For additional information see Corona et al. (2013) and Lento et al. (2013).
China, Ireland, Norway, Switzerland, the USA were the only countries of comparison to complete this component of Section A of the SSF (i.e., the Danish did not).
Qualitative Coding Procedures
General coding procedures. Four teams, consisting of graduate and undergraduate students, were developed to code data for each of the four coding systems (SSF Core Assessment
Incomplete Sentence Blanks, RFL/RFD, One-Thing Response, and Suicidal Orientation). Over the course of three meetings, teams were provided training on their respective coding systems by
Dr. Jobes. Teams were also instructed on how to use their respective coding manuals. Each manual was derived from Jobes (2016). Following this training, each team leader was sent a password-protected file containing practice SSF data for their respective coding systems derived from a combination of three samples (active duty soldiers, college students, and justice-involved youths). Once the teams coded their practice data, interrater reliability was calculated. The minimum cut off for reliability was (K >.60) and this needed to be achieved by at least two coders. After reliability was calculated, a resolution meeting was held to address any discrepancies. This was done regardless of meeting the reliability threshold. If the minimum reliability was not achieved, teams received a second training by Dr. Jobes, at which point, for some coding systems, specific decision criteria were developed. Following this, a second round of practice coding was then done, using a different set of responses from a combination of the same three data sets. Following the second round of coding, the abovementioned steps were repeated. Once reliability was achieved, the two coders with the highest reliability from each team coded this project’s data.
38
All coding teams were able to achieve acceptable reliability within two practice rounds, with the exception of two constructs from the SSF Core Assessment sentence blanks—
Psychological Pain and Self-Hate, and one dimension of the One Thing response— Clinical
Utility. For details on how the low interrater reliability for these respective coding systems was addressed, please see below.
SSF Micro-coding.
SSF Core Assessment incomplete sentence prompts. The coding of the SSF Core
Assessment sentence blanks followed the coding methodology set forth by Jobes and colleagues
(2004). All responses were coded using the coding manual for the SSF Core Assessment sentence blanks (see Jobes, 2016). The coding of these data followed the above general coding procedures. In addition, the team, in collaboration with Dr. Jobes, developed specific decision criteria. The decision criteria for this coding system were as follows: In general, responses that were not clearly written by the clinician or by the patient were coded as Not Codable. Statements such as “I feel worthless” were considered to be Self, not Unpleasant Internal States. When coding Psychological Pain, responses that truly did not fit into any other category were coded as
Not Codable. An example of a Not Codable response would be, “falling off my bike.” In addition, any reference to being detained, such as “current detainment,” “being in detention,”
“being here,” “I’m still locked up,” etc., were coded as Helpless. When coding Stress, general statements about the future were coded as Helpless and any statements about moving or living arrangements were considered to be Situation Specific. When coding Hopelessness, any references to a fear of not getting better or life not becoming good again were coded as Self.
When coding Self-Hate, statements related to failure were coded as Helpless. Responses unless otherwise more specific, for example, “I am a failure,” were coded as Self. There were no
39 decision rules developed for coding Agitation.
As previously mentioned, three of the five SSF Core Assessment sentence blanks achieved sufficient reliability (K = .60-.80) within two rounds of practice coding. In order to address low interrater reliability on the reaming two constructs— Psychological Pain and Self-
Hate, this coding system’s team leader instructed the primary investigator of this study on how to use the coding manual to code these responses, as well as explained the aforementioned decision criteria. The primary investigator then followed the abovementioned general coding procedures, comparing her coding to the team leader’s coding to determine interrater reliability.
The final interrater reliability coefficients for each SSF Core Assessment sentence blank were as follows: Psychological Pain (K = .74), Stress (K = .69), Agitation (K = .69),
Hopelessness (K = .69), and Self-Hate (K = .72). Ireland, Norway, and the USA were the only countries of comparison to complete this assessment of Section A of the SSF.
RFL/RFD. The coding of the RFL/RFD assessment followed the methodology set forth by Jobes and Mann (1999). All responses were coded using the coding manual for the SSF
RFL/RFD assessment (see Jobes, 2016). The coding of these data followed the above general coding procedures. In addition, the team, in collaboration with Dr. Jobes, developed specific decision criteria. The decision criteria for this coding system were as follows: For RFL, references to families or friends alone were coded into their respective categories (i.e., Family and Friends), but contextual information was considered when the patient provided it. For example, if a patient stated, "my family" it was coded as Family, whereas a response of "I can't leave my family without a provider" was coded as Burdening Others. In addition, the category,
Beliefs, was considered to extend beyond religious beliefs and it also included non-religious, philosophical beliefs or life principles. For example, "Life is too precious."
40
Moreover, for RFD, when one or more type of escape reference could be inferred, it was coded as Escape - In General. References to mental illness (e.g., depression, anxiety) were considered psychological pain and therefore coded as Escape - The Pain. References to desiring death or language that seemingly fantasied about death (e.g., "to be at peace"), were coded as
Escape - In General. A small portion of data were too difficult to be resolved by the team, so Dr.
Jobes was consulted in these instances to provide a final code. As previously mentioned, the
RFL/RFD assessment achieved sufficient reliability (K > .60) within two rounds of practice coding. The final interrater reliability for RFL was K = .73 and RFD was K = .65. All six nations of comparison completed this component of Section A of the SSF.
One-thing response. The coding of the SSF One-Thing response followed the coding methodology set forth by Jobes (2016). All responses were coded using the coding manual for the SSF One-Thing response (see Jobes, 2016). The coding of these data followed the above general coding procedures. As previously mentioned, two of the three One-Thing response dimensions (Orientation and Reality Testing) achieved sufficient reliability (K = .60-.80) within two rounds of practice coding. Interrater reliability was unable to be achieved on the Clinical
Utility dimension after two rounds of practice coding. This is likely attributed to the undergraduate student coding team’s unfamiliarity with what would be clinically feasible or unfeasible to address in therapy, as the coding team members consisted of non-clinician undergraduate students. As a result, a decision was made to have two clinicians, the primary investigator and Dr. Jobes, code this dimension. Therefore, the coding system’s team leader instructed the primary investigator on how to use the coding manual to code these responses. The primary investigator communicated these instructions to Dr. Jobes. Both then followed the abovementioned general coding procedures. In addition, the primary investigator and Dr. Jobes
41 developed specific decision criteria. The decision criteria for this dimension are as follows: In general, responses that were unrealistic, but provided clinical direction were coded as Clinically
Relevant (e.g., “Living a stress free life”). Responses that were broad, but provided clinical utility were coded as Clinically Relevant (e.g., “Happiness”). Responses that contained information that could be addressed via adjunctive therapies, such as family therapy, were coded as Clinically Relevant. Lastly, responses that contained information that could be addressed via case management, such as “to find a job,” were coded as Clinically Relevant.
The final interrater reliability coefficients for each of the SSF One-Thing response dimensions were as follows: Orientation (K = .79), Reality Testing (K = .62), and Clinical Utility
(K = .64). China, Ireland, Norway, and the USA were the only nations of comparison to complete this component of Section A of the SSF.
SSF macro-coding.
Suicidal orientation. Suicidal orientation (i.e., Self vs. Relational) was determined based on a systematic coding process following the work of Jennings et al. (2012) and Stone (2011). In order to preserve standardization of coding, the coders followed the decision criteria set forth by
Jennings et al. (2012). According to these criteria, all responses are considered Self-oriented by default and responses are only coded as Relationally-oriented if they are found to meet specific conditions. Those conditions include responses that explicitly referenced another person (e.g.,
“my son”), group of people (e.g., “my co-workers”), animal (e.g., “my dog”), and an external being (e.g., “God”). Additionally, responses were coded as Relationally-oriented if they reflected emotions of aloneness or isolation, such as “I’m all alone” or “I have no one.”
In addition, in order to address any discrepancies, the coding team followed Jennings et al.’s (2012) decision rule, which states, coding teams are to examine the two quantitative
42 questions— “How much is being suicidal related to thoughts and feelings about yourself?” and
“How much is being suicidal related to thoughts and feeling about others?” to determine which category the responses fit best. Responses that are high on the “yourself” question warrant the participant be coded as Self-oriented, and responses that are high on the “others” question necessitate the participant be coded as Relationally-oriented. As previously mentioned, sufficient reliability was achieved (K > .60) within two rounds of practice coding. The final interrater reliability coefficient was K = .78. Suicidal orientation was able to be determined for all six nations of comparison.
Suicidal motivation. Suicidal Motivation was derived using the coding system developed by Jobes and colleagues (2010). Suicidal motivation was determined by the primary investigator based strictly on the frequencies of responses, such that RFL > RFD = Life-Motivated, RFL <
RFD = Death-Motivated, and RFL = RFD = Ambivalent. Suicidal motivation was able to be determined for all six countries of comparison.
CHAPTER 3
Results
Given the number and complexity of the results, a particular systematic analytic plan was employed. First, descriptive statistics were calculated for the quantitative variables of interest: the six SSF Core Assessment ratings, the five SSF Core Assessment rankings, and SIS derived from the WTL/WTD ratings. Next, a series of one-way analyses of variance (ANOVAs) were used to test mean differences between countries on these variables of interest. If there was an overall significant difference between countries on a given variable, a series of Tukey HSD post- hoc tests were conducted to examine specific mean differences between countries. Further, exploratory analyses of covariance (ANCOVAs) were calculated for each of the SSF Core
Assessment ratings, except Overall Risk of Suicide, and the SSF Core Assessment rankings, where between-country differences were tested while controlling for Overall Risk of Suicide.
Finally, because SIS was an ordinal variable, an independent-samples non-parametric Kruskal-
Wallis test was conducted to examine median differences between countries on the SIS.
Index Ratings of SSF Core Assessment Constructs
Psychological pain. A one-way ANOVA was calculated to compare average ratings of
Psychological Pain by country. Overall, there was a significant difference of ratings of
Psychological Pain between countries, F(5, 356) = 37.92, p < .001. Means for all constructs are presented in Table 2. Post-hoc tests showed China had significantly lower ratings of
Psychological Pain compared to Denmark, Ireland, Norway, and the USA. Comparisons also indicated Switzerland had significantly lower ratings of Psychological Pain compared to
Denmark, Ireland, Norway, and the USA. These results suggest China and Switzerland reported
43 44 lower levels of Psychological Pain, compared to Denmark, Ireland, Norway, and the USA who reported higher levels. No other significant differences between countries were found.
Stress. A one-way ANOVA was calculated to compare ratings of Stress by country.
Overall, there was a significant difference of ratings of Stress between countries, F(5, 356) =
13.07, p < .001. Post-hoc tests showed Switzerland had significantly lower ratings of Stress compared to China, Denmark, Ireland, Norway, and the USA. No other significant differences between countries were found.
Agitation. A one-way ANOVA was calculated to compare ratings of Agitation by country. The analysis was significant, F(5, 354) = 11.12, p < .001. Post-hoc tests showed that
Switzerland had significantly lower ratings of Agitation compared to Denmark, Ireland, Norway, and the USA. No other significant differences between countries were found.
Hopelessness. A one-way ANOVA was calculated to compare ratings of Hopelessness by country. The analysis was significant, F(5, 356) = 22.41, p < .001. Post-hoc tests indicated
China had significantly lower ratings of Hopelessness compared to Denmark, Ireland, and
Norway. Switzerland also had significantly lower ratings of Hopelessness compared to Denmark,
Ireland, and Norway. The USA’s mean ratings were also significantly lower than the mean ratings of Denmark, Ireland, and Norway. No other significant differences between countries were found.
Self-Hate. A one-way ANOVA was calculated to compare ratings of Self-Hate by country. The analysis was significant, F(5, 355) = 12.84, p < .001. Means comparisons indicated significant differences between ratings from China and Ireland, such that China had significantly lower ratings of Self-Hate than Ireland. Post-hoc tests also revealed Switzerland had significantly lower ratings of Self-Hate compared to Denmark, Ireland, and Norway. Ratings were also
45 significantly different between the USA and Ireland, such that the USA had significantly lower ratings of Self-Hate compared to Ireland. No other significant differences between countries were found.
Overall risk of suicide. A one-way ANOVA was calculated to compare ratings of
Overall Risk of Suicide by country. The analysis was significant, F(5, 349) = 12.31, p < .001.
Post-hoc tests indicated Switzerland had significantly lower ratings of Overall Risk of Suicide compared to Denmark, Ireland, and Norway. Significant differences were also found between
Ireland and China, Norway, and the USA, such that Ireland had significantly higher ratings of
Overall Risk of Suicide compared to China, Norway, and the USA. No other significant differences between countries were found.
Mean comparisons controlling for overall risk of suicide. Overall Risk of Suicide was significantly associated with Psychological Pain, F(1, 348) = 61.42, p < .001. Even when controlling for Overall Risk of Suicide, country still had a significant relationship with
Psychological Pain, F(5, 348) = 29.53, p < .001. When controlling for Overall Risk of Suicide, the estimated marginal ratings of Psychological Pain by country followed the same pattern as the
ANOVA.
Moreover, Overall Risk of Suicide was significantly associated with Stress, F(1, 348) =
51.96, p < .001. Even when controlling for Overall Risk of Suicide, country still had a significant relationship with Stress, F(5, 348) = 7.61, p < .001. When controlling for Overall Risk of
Suicide, the estimated marginal ratings of Stress by country did not follow the same pattern of the ANOVA. Specifically, the relationship between Switzerland and China was no longer significant, p = .085, such that Switzerland no longer had significantly lower ratings of Stress
46 compared to China. However, when controlling for Overall Risk of Suicide, Switzerland still had significantly lower ratings of Stress compared to Demark, Ireland, Norway, and the USA.
Overall Risk of Suicide was significantly associated with Agitation, F(1, 346) = 39.67, p
< .001. Even when controlling for Overall Risk of Suicide, country still had a significant relationship with Agitation, F(5, 346) = 6.87, p < .001. When controlling for Overall Risk of
Suicide, the estimated marginal ratings of Agitation by country did not follow the same pattern of the ANOVA. Specifically, the relationship between Switzerland and Ireland was no longer significant, p = .564, such that Switzerland no longer had significantly lower ratings of Agitation compared to Ireland. However, when controlling for Overall Risk of Suicide, Switzerland still had significantly lower ratings of Agitation compared to Denmark, Norway, and the USA.
Overall Risk of Suicide was significantly associated with Hopelessness, F(1, 348) =
54.83, p < .001. Even when controlling for Overall Risk of Suicide, country still had a significant relationship with Hopelessness, F(5, 348) = 13.11, p < .001. When controlling for Overall Risk of Suicide, the estimated marginal ratings of Hopelessness by country followed the same pattern as the ANOVA.
Overall Risk of Suicide was significantly associated with Self-Hate, F(1, 347) = 19.79, p
< .001. Even when controlling for Overall Risk of Suicide, country still had a significant relationship with Self-Hate, F(5, 347) = 6.40, p < .001. When controlling for Overall Risk of
Suicide, the estimated marginal ratings of Self-Hate by country did not follow the same pattern of the ANOVA. Specifically, the relationship between China and Ireland was no longer significant, p = .217, such that China no longer had significantly lower ratings of Self-Hate compared to Ireland. Moreover, the relationship between the USA and Ireland was no longer
47 significant (p = .296), such that the USA no longer had significantly lower ratings of Self-Hate compared to Ireland.
Index Rankings of SSF Core Assessment Constructs
Psychological pain. A one-way ANOVA was calculated to compare average rankings of
Psychological Pain by country (Ireland, Norway, and the USA). There was no significant difference in rankings of Psychological Pain between countries, F(2, 106) = 0.62, p = .538.
Means for all constructs are presented in Table 3.
Stress. A one-way ANOVA was calculated to compare average rankings of Stress by country (Ireland, Norway, and the USA). There was no significant difference in rankings of
Stress between countries, F(2, 100) = 1.78, p = .174.
Agitation. A one-way ANOVA was calculated to compare average rankings of Agitation by country (Ireland, Norway, and the USA). There was no significant difference in rankings of
Agitation between countries, F(2, 100) = 2.87, p = .061.
Hopelessness. A one-way ANOVA was calculated to compare average rankings of
Hopelessness by country (Ireland, Norway, and the USA). There was no significant difference in rankings of Hopelessness between countries, F(2, 100) = 1.22, p = .330.
Self-Hate. A one-way ANOVA was calculated to compare average rankings of Self-Hate by country (Ireland, Norway, and the USA). There was no significant difference in rankings of
Self-Hate between countries, F(2, 94) = 0.15, p = .860.
Mean comparisons controlling for overall risk of suicide. Overall Risk of Suicide was not significantly associated with index rankings of SSF Core Assessment constructs (ps > .05).
When controlling for Overall Risk of Suicide, there were still no significant relationships between country (Ireland, Norway, and the USA) and index rankings of SSF Core Assessment
48 constructs (ps > .050), except for Agitation, F(2, 100) = 3.77, p = .027, where there was a significant difference between Norway and the USA. Post-hoc tests revealed Norway and the
USA had significantly different rankings on the construct, Agitation, p = .023, such that Norway ranked Agitation as more important than the USA.
WTL/WTD Assessment
An independent-samples Kruskal-Wallis test was conducted to examine SIS differences in medians between countries (China, Ireland, Norway, Switzerland, and the USA) on the SIS.
There was a significant difference of SIS between countries, H(4) = 47.98, p < .001. For observed percentages and frequencies of SIS by country, please see Table 4.
Post-hoc tests showed Ireland (median = 0, Ambivalent) had significantly lower SIS ratings compared to Switzerland (median = 1, WTL; p < .001) and the USA (median = 1, WTL; p = .008). There were also significant differences between Ireland and China (median = 1, WTL; p = .018), such that Ireland had significantly lower SIS ratings compared to China. In addition,
Norway (median = 0, Ambivalent) had significantly lower SIS ratings compared to Switzerland
(median = 1, WTL; p < .001). These results suggest that Ireland and Norway reported an SIS rating indicative of Ambivalence, compared to China, Switzerland, and the USA, who reported an SIS rating indicative of a WTL.
Qualitative Results
To organize the various SSF-related qualitative assessments, a systematic analytic plan was employed. First, descriptive statistics were calculated for our variables of interest: SSF
Micro-coding (SSF Core Assessment Incomplete Sentence Blanks, RFL/RFD, and One-Thing
Response) and SSF Macro-coding (Suicidal Orientation and Suicidal Motivation). Next, a series of Pearson’s Chi-Square Tests of Independence (Fisher, 1922; Pearson, 1900) were performed to
49 compare observed and expected frequencies of our categorical variables of interest, except for the RFL/RFD Assessment (please see below for more information). If a variable yielded fewer than five observations for more than 20% of their cells, violating the assumption of expected frequencies, the maximum likelihood ratio, which is well suited for small sample sizes, was used to determine significance instead of the chi-square test statistic (Field, 2013; McHugh, 2013).
Fisher’s exact tests were not performed, as all contingency tables were larger than 2x2 and performing Fisher’s exact tests on larger contingency tables would have been too computationally intensive (Field, 2013). If there was an overall significant association, a series of z-tests for independent proportions were conducted to compare the percent of responses in each respective coding category between countries. Bonferroni adjustments were applied (Field,
2013). Moreover, in an effort to reduce the number of times the assumption of expected frequencies was violated, variables with categories that indicated responses could not be categorized (i.e., Not Codable and Unsure/Unable to Articulate) were excluded from the analyses. The percentages and frequencies are, however, reported in each coding system’s table.
The RFL/RFD Assessment was not analyzed using the aforementioned plan, as the nature of the data violates the chi-square assumption of independence. This assumption states, “each subject may contribute data to one and only one cell” in the chi-square (McHugh, 2013, p. 144).
Because respondents can write multiple RFL and RFD, an alternative analytical plan was devised to compare RFL and RFD between nations. Therefore, a series of one-way ANOVAs were conducted to compare the mean number of responses for each coding category of RFL and RFD per individual respondent between countries. Significant ANOVAs were followed up with Tukey
HSD post-hoc tests.
50
Micro-coding of SSF Core Assessment incomplete sentence prompts.
Psychological pain. A Pearson’s Chi-Square Test of Independence was calculated to compare Psychological Pain responses by country. The overall analysis was not significant, likelihood ratio (10, n = 157) = 9.47, p = .489. This indicates there is no association between
Psychological Pain and country. Percentages and frequencies for all constructs are reported in
Table 5.
Stress. A Pearson’s Chi-Square Test of Independence was calculated to compare
Stress responses by country. The overall analysis was significant, likelihood ratio (12, n = 147) =
26.07, p = .011. Please see Table 6 for reported percentages and frequencies within country. A series of z-tests for independent proportions were conducted for post-hoc comparisons between proportions of Stress responses coded according to response category between countries. Post- hoc comparisons revealed the proportion of responses coded as Role/Responsibilities were significantly higher in the USA compared to Norway. Please see Appendix B for all post-hoc comparison coefficients.
Agitation. A Pearson’s Chi-Square Test of Independence was calculated to compare
Agitation responses by country. The overall analysis was significant, likelihood ratio (14, n =
130) = 32.14, p = .004. Please see Table 7 for reported percentages and frequencies within each country. A series of z-tests for independent proportions were conducted for post-hoc comparisons between proportions of Agitation responses coded according to response category between countries. Post-hoc comparisons revealed the proportion of responses coded as
Role/Responsibilities were significantly higher in the USA compared to Ireland and Norway.
Please see Appendix C for all post-hoc comparison coefficients.
51
Hopelessness. A Pearson’s Chi-Square Test of Independence was calculated to compare
Hopelessness responses by country. The overall analysis was significant, likelihood ratio (10, n =
155) = 19.26, p = .037. Please see Table 8 for reported percentages and frequencies within country. A series of z-tests for independent proportions were conducted for post-hoc comparisons between proportions of Hopelessness responses coded according to response category between countries. No post-hoc comparisons met the level of significance after the
Bonferroni correction. Please see Appendix D for all post-hoc comparison coefficients.
Self-Hate. A Pearson’s Chi-Square Test of Independence was calculated to compare Self-
Hate responses by country. The overall analysis was significant, likelihood ratio (10, n = 144) =
19.36, p = .036. Please see Table 9 for reported percentages and frequencies within country. A series of z-tests for independent proportions were conducted for post-hoc comparisons between proportions of Self-Hate responses coded according to response category between countries.
Post-hoc comparisons revealed the proportion of responses coded as Internal Descriptors were significantly higher in the USA compared to Norway. Please see Appendix E for all post-hoc comparison coefficients.
Micro-coding of SSF reasons for living.
Family. A one-way ANOVA was calculated to compare the average number of
RFL coded as Family by country. Overall, there was a significant difference between countries,
F(5, 349) = 3.51, p = .004. Means for all coding categories are presented in Table 10. Post-hoc tests showed China had significantly fewer RFL coded as Family compared with Switzerland,
Ireland, and Norway. These results suggest Family is not as frequently identified as a RFL among Chinese respondents. No other significant differences between countries were found.
Friends. A one-way ANOVA was calculated to compare the average number of
52
RFL coded as Friends by country. Overall, there was a significant difference between countries,
F(5, 349) = 4.18, p = .001. Post-hoc tests showed Denmark had significantly more RFL coded as
Friends compared with Ireland and Norway. These results suggest Friends are frequently identified as a RFL among Danish respondents. No other significant differences between countries were found.
Responsibility to others. A one-way ANOVA was calculated to compare the average number of RFL coded as Responsibility to Others by country. Overall, there was a significant difference between countries, F(5, 349) = 5.60, p < .001. Post-hoc tests showed China had significantly more RFL coded as Responsibility to Others compared to Ireland, Norway, and the
USA. Comparisons also indicated Norway had significantly fewer RFL coded as Responsibility to Others compared to Switzerland. These results suggest Responsibility to Others is frequently identified as a RFL among Chinese respondents and it is not a frequently identified RFL among
Norwegian respondents. No other significant differences between countries were found.
Burdening others. A one-way ANOVA was calculated to compare the average number of RFL coded as Burdening Others by country. Overall, there was a significant difference between countries, F(5, 349) = 3.38, p = .005. Post-hoc tests showed Denmark had significantly more RFL coded as Burdening Others compared to Switzerland. This finding suggests not wanting to burden others by their death is a frequently identified RFL among Danish respondents. No other significant differences between countries were found.
Plans and goals. A one-way ANOVA was calculated to compare the average number of
RFL coded as Plans and Goals by country. There was no significant difference between countries, F(5, 349) = 1.32, p = .255.
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Hopefulness for the future. A one-way ANOVA was calculated to compare the average number of RFL coded as Hopefulness for the Future by country. There was a significant difference between countries, F(5, 349) = 7.01, p < .001. Post-hoc tests showed Norway had significantly fewer RFL coded as Hopefulness for the Future compared to China, Denmark,
Switzerland, and the USA. These results suggest having a sense of hope for the future is less of a frequently identified RFL among Norwegian respondents. No other significant differences between countries were found.
Enjoyable things. A one-way ANOVA was calculated to compare the average number of
RFL coded as Enjoyable Things by country. There was a significant difference between countries, F(5, 349) = 6.23, p < .001. Post-hoc tests showed Norway had significantly fewer
RFLs coded as Enjoyable Things compared to Ireland and Switzerland. These results suggest
Norwegians do not identify enjoyable activities or objects as a RFL as frequently as the Irish or
Swiss. No other significant differences between countries were found.
Beliefs. A one-way ANOVA was calculated to compare the average number of
RFL coded as Beliefs by country. There was a significant difference between countries, F(5,
349) = 5.43, p < .001. Post-hoc tests showed the USA had significantly more RFL coded as
Beliefs compared to Denmark, Ireland, Norway, and Switzerland. These results suggest
Americans more frequently identify religious, personal, or ethical beliefs as RFL than Danes,
Irish, Norwegian, or Swiss respondents do. No other significant differences between countries were found.
Self. A one-way ANOVA was calculated to compare the average number of RFL coded as Self by country. There was no significant difference between countries, F(5, 349) = 2.07, p =
.068.
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Micro-coding of SSF reasons for dying.
Others (relationships). A one-way ANOVA was calculated to compare the average number of RFD coded as Others (Relationships) by country. There was no significant difference between countries, F(5, 302) = 1.82, p = .109. Means for all coding categories are presented in
Table 11.
Unburdening others. A one-way ANOVA was calculated to compare the average number of RFD coded as Unburdening Others by country. There was no significant difference between countries, F(5, 302) = 2.18, p = .056.
Loneliness. A one-way ANOVA was calculated to compare the average number of RFD coded as Loneliness by country. There was a significant difference between countries,
F(5, 302) = 3.54, p = .004. Post-hoc tests showed Switzerland had significantly more RFD coded as Loneliness compared to Ireland and Norway. These results suggest the Swiss identify loneliness as a RFD more frequently than Irish or Norwegian respondents. No other significant differences between countries were found.
Hopelessness. A one-way ANOVA was calculated to compare the average number of
RFD coded as Hopelessness by country. There was a significant difference between countries,
F(5, 302) = 2.88, p = .015. Post-hoc tests showed the USA had significantly more RFD coded as
Hopelessness compared to Denmark and Norway. These results suggest Americans more frequently identify feelings of hopelessness as a RFD than Danish and Norwegian respondents.
No other significant differences between countries were found.
General descriptors of self. A one-way ANOVA was calculated to compare the average number of RFD coded as General Descriptors of Self by country. There was a significant
55 difference between countries, F(5, 302) = 3.15, p = .009. Due to multiple post-hoc comparisons, no significant differences between countries were found.
Escape-in general. A one-way ANOVA was calculated to compare the average number of RFD coded as Escape- In General by country. There was no significant difference between countries, F(5, 302) = 1.67, p = .142.
Escape-the past. A one-way ANOVA was calculated to compare the average number of
RFD coded as Escape- The Past by country. There was no significant difference between countries, F(5, 302) = 0.21, p = .957.
Escape-the pain. A one-way ANOVA was calculated to compare the average number of
RFD coded as Escape- The Pain by country. There was a significant difference between countries, F(5, 302) = 5.61, p < .000. Post-hoc tests showed Ireland had significantly more RFD coded as Escape- The Pain compared with Denmark and Switzerland. Comparisons also indicated Denmark had significantly fewer RFD coded as Escape- The Pain compared to Norway and the USA. These results suggest Irish identify the desire to stop psychological pain as a RFD more frequently than Danish and Swiss respondents. Moreover, these findings also suggest the
Danish do not identify a desire to escape mental anguish as frequently as Norwegian and
American respondents. No other significant differences between countries were found.
Escape-responsibilities. A one-way ANOVA was calculated to compare the average number of RFDs coded as Escape- Responsibilities by country. There was a significant difference between countries, F(5, 302) = 3.27, p = .007. Due to multiple post-hoc comparisons, no significant differences between countries were found.
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Micro-coding of one-thing response.
Orientation. A Pearson’s Chi-Square Test of Independence was calculated to compare
One-Thing responses coded on the dimension of Orientation (Self vs. Relational) by country.
The overall analysis was significant, 2(4, n = 158) = 14.14, p = .007. Please see Table 12 for reported percentages and frequencies within country. A series of z-tests for independent proportions were conducted for post-hoc comparisons between proportions of Self and
Relationally oriented responses between countries. Post-hoc comparisons revealed the proportion of Self responses in the USA were significantly higher than the proportion of Self responses in
Denmark and Norway. Compared to Denmark, Ireland had a significantly higher proportion of
Self responses. Moreover, the proportion of Relationally oriented responses in the USA were significantly higher than the proportion of Relationally oriented responses in Denmark and
China. Please see Appendix F for all post-hoc comparison coefficients.
Reality testing. A Pearson’s Chi-Square Test of Independence was calculated to compare
One-Thing responses coded on the dimension of Reality Testing (Realistic vs. Unrealistic) by country. The overall analysis was not significant, likelihood ratio (4, n = 158) = 1.90, p = .754.
This indicates there is no association between Reality Testing and country. Please see Table 13 for reported percentages and frequencies within country.
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Clinical utility. A Pearson’s Chi-Square Test of Independence was calculated to compare
One-Thing responses coded on the dimension of Clinical Utility (Clinically Relevant vs. No
Clinically Relevant Information) by country. The overall analysis was not significant, likelihood ratio (4, n = 160) = 4.86, p = .303. This indicates there is no association between Reality Testing and country. Please see Table 14 for reported percentages and frequencies within country.
Macro-coding.
Suicidal orientation. A Pearson’s Chi-Square Test of Independence was calculated to compare Suicidal Orientation (Self vs. Relational) by country. The overall analysis was not significant, 2(5, n = 359) = 10.90, p = .054. This indicates there is no association between
Suicidal Orientation and country. Please see Table 15 for reported percentages and frequencies within country.
Suicidal motivation. A Pearson’s Chi-Square Test of Independence was calculated to compare Suicidal Motivation (Life-Motivated, Ambivalent, Death-Motivated) by country. The overall analysis was significant, 2(10, n = 362) = 44.17, p < .001. Please see Table 16 for reported percentages and frequencies within country. A series of z-tests for independent proportions were conducted for post-hoc comparisons between proportions of Life-Motivated,
Ambivalent, and Death-Motivated individuals between countries. Post-hoc comparisons revealed the proportion of Life-Motivated individuals in Norway were significantly lower than the proportion of Life-Motivated individuals in Denmark and Switzerland. Compared to
Switzerland, Norway had a significantly higher proportion of Ambivalent individuals. Please see
Appendix G for all post-hoc comparison coefficients.
CHAPTER 4
Discussion
This study is the first detailed examination of suicide-specific clinical content obtained from actively suicidal patients engaged in a suicide-specific treatment in six different countries from around the world. An exploratory, descriptive, cross-sectional study was deemed necessary as there are virtually no published studies that have systematically examined detailed first-person self-reports of suicide-related thoughts, feelings, and behaviors that cut across national boundaries and cultural influences therein. Indeed, much of the cross-cultural research in suicidology is largely epidemiological or general in the form of non-methodologically-based risk factors that provide little about the nature of the intra-subjective experience of “being suicidal” particularly within the context of different cultural influences. Thus as an exploratory study, this investigation had two broad hypotheses. First, because the SSF Core Assessment constructs are based on theories of suicide and are considered to be universally relevant across suicidal patients, it was generally hypothesized that the SSF Core Assessment constructs, and the WTL/WTD
Assessment would be quantitatively comparable across all six countries of interest, thereby reflecting some measure of the cross-cultural universality of these constructs. Second, formulated by the extant limited cross-cultural research and various anecdotes obtained from clinical trials, it was generally hypothesized that there would be significant differences between the qualitative responses across the six countries of interest, perhaps reflecting culture-specific influences.
Hypothesis 1: Quantitative Assessments
Contrary to broad hypothesis, analyses of the SSF Core Assessment ratings revealed a number of significant differences between countries, even when controlling for Overall Risk of
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Suicide, indicating these constructs were not rated in a comparable fashion across all six nations of interest. Specifically, China and Switzerland reported lower levels across all constructs (i.e.,
Psychological Pain, Stress, Agitation, Hopelessness, and Self-Hate) compared to the other nations of comparison. Ratings across all constructs were comparable between Denmark, Ireland,
Norway, and the USA, with the exception of Overall Risk of Suicide, in which Ireland was rated higher than the other nations of comparison. These observed differences potentially suggest that some relevant cultural aspects may perhaps influence individual experiences of suicidality, or how these experiences are described depending on their country of origin. These preliminary findings warrant a deeper exploration as to why and how these differences may exist.
Analyses of the rankings of the SSF Core Assessment did not reveal significant differences between countries, except when controlling for Overall Risk for Suicide, there was a significant difference of the rankings of Agitation between Norway and the USA, such that
Norway ranked Agitation higher (indicating more importance) compared to the USA. It is unclear as to why this difference was observed. However, provided all other comparisons of the
SSF Core Assessment rankings were non-significant, this pattern of responses indicate these constructs were rated in a comparable fashion across three nations of interest (Ireland, Norway, and the USA). These results may suggest that although individuals may experience suicidality in significantly different ways, the degree of relative importance pertaining to these constructs may be consistent across country of origin. It is important to note, only three out of the six nations of interest were included in these analyses. If data from China, Denmark, and Switzerland were able to be included, it is possible significant differences may have been detected.
Analyses of the Wish to Live/Wish to Die (WTL/WTD) Assessment revealed significant differences in Suicide Index Scale (SIS) ratings between countries, indicating these constructs
60 were not rated in a comparable fashion across five nations of interest (China, Ireland, Norway,
Switzerland, and the USA). Specifically, Ireland and Norway yielded scores that indicated
Ambivalence, whereas the scores of China, Switzerland, and the USA indicated a WTL. These observed differences potentially suggest relevant cultural aspects may influence the extent of individuals’ suicidal wish. Again, these findings warrant a deeper exploration as to why and how these differences exist. It is important to note, only five out of the six nations of interest were included in these analyses; data from Denmark was missing.
Provided the cross-country variability among the SSF quantitative assessments, the original hypothesis— the SSF Core Assessment constructs, as well as the WTL/WTD
Assessment was generally not supported. With some exceptions, various quantitative SSF ratings were not especially similar, which may bring into question the validity and reliability of the SSF constructs across different international clinical settings.
What follows is more discussion of the aforementioned results as they specifically relate and apply to each nation of interest in this study.
China. Overall, analyses from the SSF quantitative assessments indicated, when controlling for Overall Risk of Suicide, respondents from China reported lower levels of
Psychological Pain compared to respondents from Denmark, Ireland, Norway, and the USA.
Their reported levels of Psychological Pain did not differ from Switzerland’s. Moreover, Chinese respondents reported lower levels of Hopelessness compared to Denmark, Ireland, and Norway.
Their reported levels of Hopelessness did not differ from Switzerland’s and the USA’s. Chinese respondents reported lower levels of Self-Hate compared to Ireland; however, this relationship was not observed after controlling for self-rated Overall Risk of Suicide, indicating Overall Risk of Suicide likely influenced this initially observed relationship. Lastly, Chinese respondents’ SIS
61 scores were higher compared to Ireland and Norway, which indicated a WTL. This difference was not observed between Switzerland and the USA, who had comparable SIS scores. When examining average ratings within China, respondents reported high levels of Stress and
Agitation.
As described above, pairwise comparisons revealed specific inter-country differences, which may be challenging to interpret given limitations of the current data (i.e., only data from the SSF was collected, no other psychological constructs were measured, and lack of existing cross-cultural research on suicidality). However, an overall factor that may account for some of the observed differences may be related to the Chinese culture’s lesser emphasis on (internal) mental states. Specifically, Wang (2017) noted, “Chinese parents and children do not frequently talk about mental states and instead talk more about other people’s behaviors, actions, and roles”
(p. 23). This focus on external versus internal experiences may correspond with the collectivistic nature of the Chinese culture. Meaning, the Chinese culture is less focused on individual (often internally driven) needs and is more focused on relational (often externally driven) needs.
Moreover, research indicates among Chinese men and women, psychological problems, such as symptoms of anxiety and depression, are often experienced somatically (externally) (Yeung,
Chang, Gresham, Nierenberg, & Fava, 2004; Zhu et al., 2012), again, emphasizing external versus internal experiences. It is possible this focus on external rather than internal experiences may have influenced the Chinese respondents’ low ratings of Psychological Pain, Hopelessness, and Self-Hate, as these are primarily internal mental states compared with the other two constructs— Stress and Agitation, which may include both internal and external experiences.
Overall, the Chinese respondents indicated low levels of reported Overall Risk of
Suicide, particularly compared to Ireland, which may have influenced their higher reported SIS
62 score, which indicated a stronger WTL compared to Ireland. Taken together, these results may, or may not, reflect important cultural differences between China and the other nations of comparison and warrant further investigation to understand the nature of these differences.
Denmark. Overall, analyses from the SSF quantitative assessments indicated, when controlling for Overall Risk of Suicide, respondents from Denmark reported higher levels of
Agitation compared to Switzerland. Their reported levels of Agitation did not differ from the other nations of comparison. Moreover, Danish respondents reported higher levels of
Hopelessness compared to China, Switzerland, and the USA. Their reported levels of
Hopelessness did not differ from Ireland’s and Norway’s. Lastly, when examining average ratings within Denmark, respondents tended to report high levels of Psychological Pain and
Hopelessness and low levels of Self-Hate. They also tended to report high levels of Overall Risk of Suicide.
In general, the difference observed between Denmark’s ratings of Agitation compared to the other nations of interest only differed when compared to Switzerland, potentially indicating this result may be best explained by factors specifically related to the Swiss, rather than Danish culture. For further discussion, please see the section on Switzerland below.
Denmark’s ratings of Hopelessness differed significantly from China, Switzerland, and the USA, but not Ireland and Norway. This may potentially reflect shared cultural influences between Denmark, Ireland, and Norway. Although the Nordic cultures share many similarities, it is unclear as to why or how Irish culture may relate. It is possible Denmark and Ireland share problems with social integration, which may contribute to similar experiences of Hopelessness.
For example, low social integration due to divorce and/or unemployment may contribute to social isolation and increased hopelessness. Research indicates low levels of social integration
63 contribute to suicidality among the Danish (Agerbo, Stack, & Petersen, 2011). Moreover, high unemployment rates in Ireland, which also leads to low social integration, contribute to suicidality among the Irish (Wyllie et al., 2012). Future research should further examine
Hopelessness as a potentially important shared risk factor for suicide between the Nordic and
Irish cultures. This may help shape suicide-specific interventions aimed at building hope among these cultures.
Furthermore, Denmark’s high report of Psychological Pain and Hopelessness in conjunction with high self-ratings of Overall Risk of Suicide may underscore the importance of
Psychological Pain and Hopelessness on suicide risk among Danes, specifically. Lastly, their low report of Self-Hate may reflect a lack of familiarity with this concept within their culture.
Anecdotal evidence suggests Self-Hate is an unfamiliar concept among the Danish culture.
Future research should investigate if this concept is not relatable to Danish culture specifically, or if it is also not relatable across all Nordic cultures.
Ireland. Overall, analyses from the SSF quantitative assessments indicated when controlling for Overall Risk of Suicide, respondents from Ireland reported higher levels of
Hopelessness compared to China, Switzerland, and the USA. Their reported levels of
Hopelessness did not differ from Denmark’s and Norway’s. Moreover, Irish respondents reported higher levels of Overall Risk of Suicide compared to China, Norway, Switzerland, and the USA, but not Denmark. As mentioned above, there was a significant relationship between
Ireland and China on Self-Hate, such that Ireland has significantly higher ratings compared to
China. However, when controlling for self-rated Overall Risk of Suicide this relationship was no longer significant. In addition, Irish respondents’ SIS scores were lower compared to China,
Switzerland, and the USA, which indicated Ambivalence. This difference was not observed
64 between Norway, who had comparable SIS scores. When examining average ratings within
Ireland, respondents reported high levels of Self-Hate and Hopelessness. They tended to report low levels of Agitation.
As previously mentioned, Ireland’s ratings of Hopelessness differed significantly from
China, Switzerland, and the USA, but not Denmark and Norway. This may potentially reflect shared cultural influences between Denmark, Ireland, and Norway.
Furthermore, Ireland’s high self-report of Overall Risk of Suicide in conjunction with their tendency to have high ratings of Self-Hate and Hopelessness may highlight the importance of these constructs as notable suicide risk factors among the Irish. Provided the values of Irish society, especially for men, for power, control, and success, individuals may experience intense shame and guilt if they are not able attain these (Wyllie et al., 2012). This may lead to suicidal thoughts and behaviors, which may potentially be experienced as feelings of self-loathing (Self-
Hate) and feelings of little or no control over the future/a sense that things will not improve
(Hopelessness). More than half of this study’s Irish sample was male, possibly indicating that
Self-Hate and Hopelessness may be specific risk factors for Irish men. Future research is needed to further examine Self-Hate and Hopelessness as potentially important risk factors for suicide within the Irish culture, as well as how these risk factors may differ between Irish men and women. This may help shape suicide-specific interventions to focus on self-compassion and hope building.
Overall, the Irish respondents indicated high levels of reported Overall Risk of Suicide, particularly compared to China, Norway, Switzerland, and the USA, which may have influenced their lower reported SIS score, which indicated Ambivalence.
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Norway. Overall, analyses from the SSF quantitative assessments indicated when controlling for Overall Risk of Suicide, respondents from Norway reported higher levels of
Hopelessness compared to China, Switzerland, and the USA. Their reported levels of
Hopelessness did not differ from Denmark and Ireland. Moreover, Norwegian respondents’ SIS scores were lower compared to China, Switzerland, and the USA, which indicated Ambivalence.
This difference was not observed in comparison to Ireland, who had comparable SIS scores.
When examining average ratings within Norway, respondents tended to report high levels of
Psychological Pain and low levels of Agitation.
Moreover, there were no significant findings when comparing the rankings of the SSF
Core Assessment by country; however, when controlling for Overall Risk of Suicide, there was a significant difference between Norwegian respondents’ ranking of Agitation compared to
American respondents’, such that Norwegian respondents ranked Agitation as more important.
Interestingly, this higher rank of importance does not follow with Norway’s tendency to rate
Agitation low. Future research should be done to clarify this finding.
As previously discussed, Norway’s ratings of Hopelessness, which differed significantly from China, Switzerland, and the USA, but not Denmark and Ireland, may potentially suggest shared cultural influences between Denmark, Ireland, and Norway. Future research should further examine Hopelessness as a potentially important shared risk factor for suicide between
Denmark, Ireland, and Norway.
Norway’s SIS score, which reflected Ambivalence, may be specifically related to the experience of suicidal behavior among Norwegians. As previously noted, Biong and Ravndal
(2007) described suicide in the Norwegian culture as “a movement between different positions of wanting death as an escape from pain and hope for a better life,” illustrating ambivalence
66 between living and dying (p. 246). Moreover, this description may also explain the Norwegian respondents’ high ratings of Psychological Pain. Future research should be conducted to further understand the experience of Psychological Pain and how this may relate to ambivalence to the suicidal wish among Norwegians, as this may provide insight into specific interventions that may reduce psychological pain and increase hope, moving the suicidal individual from Ambivalence to WTL.
Switzerland. Overall, analyses from the SSF quantitative assessments indicated when controlling for Overall Risk of Suicide, respondents from Switzerland reported lower levels of
Psychological Pain compared to Denmark, Ireland, Norway, and the USA. Their reported levels of Psychological Pain did not differ from China. Moreover, Swiss respondents reported lower levels of Stress compared to all other nations of comparison. Swiss respondents also reported lower levels of Hopelessness, Self-Hate, and Overall Risk of Suicide compared to Denmark,
Ireland, and Norway, but not China and the USA. They also reported lower levels of Agitation compared to Denmark, Ireland, Norway, and the USA; however, this relationship was no longer observed after controlling for Overall Risk of Suicide, indicating Overall Risk of Suicide likely influenced this initially observed relationship. Lastly, Swiss respondents’ SIS scores were higher compared to Ireland and Norway, which indicated a WTL. This difference was not observed between China and the USA, who had comparable SIS scores. When examining average ratings within Switzerland, respondents tended to report high levels of Self-Hate and Stress. They tended to report low levels of Psychological Pain.
Findings from research on the experience of suicide among the Swiss are in contrast with the above-mentioned findings, specifically low ratings of Psychological Pain and SIS scores that indicate a WTL. As previously described, the most commonly cited reasons for attempting
67 suicide in Switzerland include mental anguish, feelings of lost control, a wish to die, desire to escape an impossible situation, and inability to bear the current situation (Schnyder et al., 1999).
A potentially important factor that may have influenced the above findings is that this study’s sample of Swiss respondents consisted of patients who had been hospitalized for a recent suicide attempt. Many of the patients in this sample were involuntarily hospitalized. Therefore, it is possible they had a strong desire to leave the hospital, which may have influenced them to answer questions pertaining to the severity of their suicidality in a dishonest manner. Patients may have believed if they reported the intensity of their suicidality honestly, they may have been forced to stay in the hospital longer. Future research should be done to examine the potential differences in SSF Core Assessment ratings between Swiss outpatients who are suicidal and have no history of suicide attempt(s) verses those who do, as well as Swiss inpatients with a history of suicide attempt(s) who are voluntarily hospitalized, versus those who are involuntarily hospitalized.
The USA. Overall, analyses from the SSF quantitative assessments indicated, when controlling for Overall Risk of Suicide, respondents from the USA reported lower levels of
Hopelessness compared to Denmark, Ireland, and Norway. Their reported levels of Hopelessness did not differ from China and Switzerland. Moreover, American respondents reported lower levels of Self-Hate compared to Ireland; however, when controlling for Overall Risk of Suicide, this relationship was no longer observed.
In general, there were no significant findings when comparing the rankings of the SSF
Core Assessment by country; however, when controlling for Overall Risk of Suicide, there was a significant difference between American respondents’ ranking of Agitation compared to
Norwegian respondents’, such that American respondents ranked Agitation as less important.
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Lastly, American respondents’ SIS scores were higher compared to Ireland and Norway, which indicated a WTL. This difference was not observed between China and Switzerland, who had comparable SIS scores. When examining average ratings within the USA, respondents tended to report high levels of Stress and Psychological Pain. They tended to report low levels of
Hopelessness.
Specific aspects of American culture may explain these results. For instance, American respondents’ report of low levels of Hopelessness may reflect the common sentiment of being able to “live the American dream.” Meaning, central to American culture is the belief that individuals have the opportunity and freedom to make their lives whatever they want them to be, which is a fundamentally hope-instilling message (Lee & Seligman, 1997). Regarding American respondents’ ranking of Agitation as being less important, specifically when compared to
Norway’s, warrants further empirical study to understand why and how this difference exists.
Lastly, American respondents’ tendency to report high levels of Stress and Psychological
Pain may reflect commonly cited reasons for suicide among Americans (see Schembari et al.,
2013). These higher ratings may also be influenced by American culture’s emphasis on individualistic goals, which often promotes the experience of stress, and attention on the self, which is inherently internally focused. Therefore, Americans may have greater familiarity with internally focused concepts such as Psychological Pain and may be more easily able to identify when they are experiencing such pain.
Hypothesis 2: Qualitative Assessments
Analyses of the SSF Core Assessment sentence blanks revealed significant differences between countries on the constructs of Stress, Agitation, Hopelessness, and Self-Hate, indicating these constructs were not identified in a comparable fashion across Ireland, Norway, and the
69
USA (data were unavailable for China, Denmark, and Switzerland). For example, for the constructs Stress and Agitation, the USA generated significantly more responses categorized as
Role/Responsibility compared to the other nations of comparisons. These observed differences potentially suggest relevant cultural aspects may influence individuals’ experience of suicidality.
These findings warrant a deeper exploration as to why and how these differences exist. As previously described, there was an overall significant difference between countries on the construct of Hopelessness; however, some of the pairwise comparisons were no longer significant at the significance level prescribed by the Bonferroni correction. Lastly, there were no significant differences found between counties on the construct of Psychological Pain.
Analyses of the Reasons for Living/Reasons for Dying (RFL/RFD) Assessment revealed significant differences between countries, indicating these constructs were not identified in a comparable fashion across all six nations of comparison. Specifically, Danish respondents’ RFL were more frequently categorized as Friends and Burdening Others compared to the other nations of comparisons. Chinese respondents’ RFL were most frequently categorized as
Responsibility to Others compared to the other nations, and American respondents’ RFL were more frequently categorized as Beliefs compared to the other nations. Regarding RFD, Swiss respondents had significantly more responses categorized as Loneliness compared to the other nations. American respondents’ RFD were more frequently categorized as Hopelessness, and
Irish respondents’ RFD were more frequently categorized as Escape- The Pain compared to the other nations.
These observed findings may indicate cultural differences between what suicidal persons identify as RFL and RFD. Interestingly, there were more observed differences between country’s reported RFL compared to their reported RFD. This potentially indicates that culture may have
70 more of an influence on what individuals identify as their RFL compared to RFD. In addition, fewer observed differences between country’s reported RFD might indicate similarities across cultures regarding identified RFD. Further exploration is needed to better understand the nature of these differences and potential similarities.
Analyses of the One-Thing response revealed significant differences between countries on the dimension of Orientation (Self vs. Relational), indicating responses to the prompt, “The one thing that would help me no longer feel suicidal would be: ______” were not identified in a comparable fashion across countries (data were unavailable for Switzerland). Specifically, the
USA reported higher amounts of Self oriented One-Thing Responses compared to the other nations of comparisons. This observed difference potentially suggest that relevant cultural aspects may influence individuals’ identification of what would help them to no longer feel suicidal, specifically if what would help them is related to the self or others. This finding may be related to the USA’s individualistic culture in which people strive towards independence by focusing on the self (Markus & Kitayama, 1991).
There were no significant differences found between countries on the dimension of
Reality Testing (Realistic vs. Unrealistic), indicating responses were identified in a comparable fashion across countries. These results suggest there may be shared cultural aspects that influence individuals’ identification of what would realistically or unrealistically help them to no longer feel suicidal.
Finally, there were no significant differences found between countries on the dimension of Clinical Utility (Clinically Relevant vs. No Clinically Relevant Information), indicating responses were identified in a comparable fashion across countries. These results suggest there may be shared cultural aspects that influence individuals’ identification of what would help them
71 to no longer feel suicidal, specifically responses that are clinically useful for guiding psychotherapy or not clinically useful.
Analyses of macro-coded Suicidal Orientation (Self vs. Relational) revealed no significant differences between countries, indicating overall responses to the entirety of Section
A of the SSF were comparably categorized into Self and Relational orientations across all six nations of interest. These results suggest these factors (self and relational) may be shared, universal cultural aspects that influence individuals’ overall experience of suicidality.
Analyses of macro-coded Suicidal Motivation (Life-Motivated, Ambivalent, Death-
Motivated) revealed significant differences between countries, indicating the total number of reported RFL and RFD were not comparable across all six nations of interest. Specifically, there was a significant difference between Norway and the other nations of comparison, such that
Norway’s motivation was categorized as Ambivalent, whereas the other nations were categorized as Life-Motivated. This observed difference potentially suggests that Norwegian respondents are at a greater level of distress compared to the other nations. Indeed, previous research suggests ambivalence toward suicide may indicate a greater risk for suicide (Brown et al., 2005; Jobes &
Mann, 1999).
One potential explanation of this finding may be related to the design and implementation of
Norway’s universal healthcare system. This system provides greater access to health services and primary care physicians and community healthcare centers are mainly responsible for caring for patients with psychiatric illnesses (Amble et al., 2014). Therefore, before patients are admitted to inpatient services, several healthcare professionals have strictly screened them (Amble et al.,
2014). Thus, when patients are hospitalized they are often in extreme distress. Previous research has observed higher levels of reported distress among Norwegian clinical samples compared to
72 other international clinical samples (i.e., China, Germany, Italy, The Netherlands, Sweden, and the USA) (Amble et al., 2014). The authors also suggested this finding is related to the structure of the Norwegian healthcare system (Amble et al., 2014). Moreover, Norwegian inpatients are frequently involuntarily admitted. Indeed, approximately 40% of the Norwegian sample used in this study was involuntarily hospitalized (W. Ryberg, personal communication, February 19,
2017). Thus, potentially indicating higher levels of distress.
Provided the variability among the SSF qualitative coding systems between nations, the original hypothesis— significant differences between the qualitative coding systems, based on cultural content responses will be observed— is supported.
The following sections discuss the aforementioned results as they relate to each nation of interest.
China. Overall, Chinese respondents had significantly fewer RFL coded as Family compared to Ireland, Norway, and Switzerland. These findings may suggest for Chinese respondents, their family is not a commonly identified reason to stay alive compared to Ireland,
Norway, and Switzerland. Additional research should explore potential reasons why family is not as frequently endorsed among Chinese respondents compared to other nations. It is possible one reason is culturally-driven (e.g., pressure from family to succeed may be more prominent in the
Chinese culture, which may make family less of a reason for living compared to countries in which families may not pressure individuals to succeed and, therefore, may be considered more of a reason for living). In addition, Chinese respondents had significantly more RFL coded as
Responsibility to Others compared to Ireland, Norway, and the USA. Taken together with the aforementioned findings, these results suggest that although Chinese respondents do not specifically identify family as a RFL as often as the other nations (Ireland, Norway, and
73
Switzerland) do, they frequently identify having a responsibility to other people as a RFL, which is in line with the collectivistic nature of the Chinese culture.
Moreover, Chinese respondents reported significantly more RFL coded as Hopefulness for the Future compared to Norway. This finding is in line with and may be influenced by the previous finding that on the SSF Core Assessment constructs Chinese respondents reported lower levels of Hopelessness compared to Norway. Although Family may not be specifically identified as a RFL among Chinese respondents, its value as a RFL may be assumed by other
RFL (i.e., Responsibility to Others and Hopefulness for the Future), such that Chinese respondents may not want to disappoint their families by dying prematurely (Responsibility to
Others) and therefore not reaching their full potential (Hopefulness for the Future).
Finally, there were no significant differences found between China and other nations across the following RFL coding categories, Friends, Burdening Others, Planning and Goals,
Enjoyable Things, Beliefs, and Self, which possibly suggests China, Denmark, Ireland, Norway,
Switzerland, and the USA may comparably identify RFL that fall into these categories.
When examining RFD, Chinese respondents did not differ significantly compared to the other nations of comparison across all nine coding categories. This may suggest Chinese persons’ RFD are similar to individuals from other nations. It is also possible because of the small sample size of Chinese participants, significant differences could not be detected.
Additional research is needed to further explore if any differences do exist among Chinese respondents’ RFD compared to other nations.
On the One-Thing response, Orientation dimension, China had significantly more
Relationally oriented responses compared to the USA. Taken together, this finding may reflect core differences between collectivistic and individualistic cultures, such that China, a
74 collectivistic culture, may tend to identify relationally-oriented things/experiences that would help them to no longer feel suicidal more so than self-oriented, whereas the USA, an individualistic culture, may tend to identify self-oriented things/experiences more so than relationally-oriented. With a larger sample size, it is likely these differences would be even more pronounced.
Regarding Suicidal Orientation (Self vs. Relational), although no significant cross- country differences were observed, interestingly, when examining the proportion of Chinese SSF profiles coded as either Self or Relational, results indicated more than half of the Chinese profiles were coded as Self-oriented. Meaning, taken as a whole, these SSF profiles suggest suicidality is related to the self rather than others. It is possible, due to the small sample size that these trends would not be sustained if a large sample was used and results may reflect more relationally-oriented profiles.
Finally, regarding Suicidal Motivation (Life-Motivated, Ambivalent, and Death-
Motivated), although no significant differences were found between China and the other nations of comparison, among Chinese respondents, they tended to be more Life-Motivated. This finding is in line with Chinese respondents reporting a stronger WTL, as well as rating low levels of
Overall Risk of Suicide.
Denmark. Overall, Danish respondents had significantly more RFL coded as Friends compared to Ireland and Norway. These findings may suggest for the Danish, their friends are a more commonly identified reason to stay alive compared to Ireland and Norway. This finding is in line with Danish culture, which emphasizes the importance of social relationships (Hendin,
1965). In addition, Danish respondents had significantly more RFL coded as Burdening Others
75 compared to Switzerland. Again, this finding is in line with the Danish culture’s focus on social factors.
Moreover, Danish respondents reported significantly more RFL coded as Hopefulness for the Future compared to Norway. Danish responded also reported significantly fewer RFL coded
Beliefs compared to the USA. This finding may highlight cultural differences regarding the emphasis placed on religious, personal, or ethical beliefs as a reason to stay alive. Finally, there were no significant differences found between Denmark and other nations across the following
RFL coding categories, Family, Responsibility to Others, Planning and Goals, Enjoyable Things, and Self, which possibly suggests Denmark, China, Ireland, Norway, Switzerland, and the USA may comparably identify RFL that fall into these categories.
When examining RFD, Danish respondents had significantly fewer RFD coded as
Hopelessness compared to the USA, suggesting feelings of hopelessness are not as commonly identified as RFD among Danes compared to Americans. In addition, Danish respondents reported significantly fewer RFD coded as Escape- The Pain compared to Ireland, Norway, and the USA, indicating Danes do not identify a desire to escape mental anguish as frequently as
Norwegian and American respondents. This finding differs from the previous finding that
Denmark has high ratings of Psychological Pain. It may be such that, although, the Danish experience of Psychological Pain is elevated, the desire to escape this pain is not a frequently identified RFD.
Moreover, Danish respondents did not differ significantly compared to the other nations of comparison across the following coding categories, Other (Relationships), Unburdening
Others, Loneliness, General Descriptors of Self, Escape- In General, Escape- The Past, and
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Escape- Responsibilities. This may suggest, Danes’ identified RFD that fall into these categories are comparable to individuals from China, Ireland, Norway, Switzerland, and the USA.
On the One-Thing response, Orientation dimension, Denmark had significantly fewer
Self oriented responses compared to Ireland and the USA. Moreover, Denmark had significantly more Relationally oriented responses than the USA. Taken together, these findings may reflect important cultural differences between Denmark, and Ireland and the USA regarding the identification of things/experiences that would help one to no longer feel suicidal. It is possible that among Danes, they may look to others and relationships to help them cope with and overcome psychological difficulties, particularly suicidal ideation. Indeed, evidence suggests social factors possess a great deal of importance among the Danish culture and the loss of an intimate relationship (e.g., parent-child, husband-wife), social isolation, and low social integration all contribute to suicide risk (Hendin, 1965).
Regarding Suicidal Orientation (Self vs. Relational) although, no significant cross- country differences were observed, interestingly, when examining the proportion of Danish SSF profiles coded as either Self or Relational, results indicate more than half of the Danish profiles were coded as Self-oriented. Meaning, taken as a whole, these SSF profiles suggest suicidality is related to the self rather than others. Although social factors play an important role in Danish culture, it is possible Danes may tend to attribute their suicidality to themselves, but seek relationally-oriented solutions.
Finally, regarding Suicidal Motivation (Life-Motivated, Ambivalent, and Death-
Motivated), Denmark had a significantly higher proportion of Life-Motivated respondents compared to Norway. This finding is in line with Denmark’s reported RFL, specifically their more frequent identification of friendships as a RFL compared to Norway. This may indicate the
77 presence of social supports, which may serve as a buffer against suicide, thus influencing higher proportions of Life-Motivated responses.
Ireland. Overall, analyses of the SSF Core Assessment sentence blanks revealed significant difference between Ireland and the other nations of comparison (Norway and the
USA) on Agitation. Although overall significant differences were observed for Hopelessness, post-hoc comparisons revealed no significant differences. The construct of Psychological Pain did not yield any significant differences.
On the construct of Agitation, the proportion of responses coded as Role/Responsibilities were significantly less among Irish respondents compared to American. This may indicate for the
Irish, the experience of Agitation, or urge to take action, as it relates to suicidality, is not driven by responsibilities related to occupational, financial, academic, or family roles. Indeed, among
Irish respondents the majority of responses for Agitation were coded as Unpleasant Internal
States. These findings may shed light on important differences and similarities between nations.
In order to more fully understand the nature of these differences and similarities, and how they may relate to culture, additional research is needed.
Regarding RFL, Irish respondents had significantly more RFL coded as Family compared to China. These findings may suggest for the Irish, their family is a more commonly identified reason to stay alive compared to China. It is possible this finding is in line with Irish culture, which may emphasize the importance of family. In addition, Irish respondents had significantly fewer RFL coded as Friends compared to Denmark, suggesting social factors may not be as much of a buffer against suicide for the Irish as they are for the Danish.
Moreover, Irish respondents reported significantly fewer RFL coded as Responsibility to
Others compared to China. Irish respondents identified significantly more RFL coded as
78
Enjoyable Things compared to Norway, and they also reported significantly fewer RFL coded as
Beliefs compared to the USA. This finding may highlight cultural differences regarding the emphasis placed on religious, personal, or ethical beliefs as a reason to stay alive. Finally, there were no significant differences found between Ireland and other nations across the following
RFL coding categories, Burdening Others, Planning and Goals, Hopefulness for the Future, and
Self, which possibly suggests Ireland, China, Denmark, Norway, Switzerland, and the USA may comparably identify RFL that fall into these categories.
When examining RFD, Irish respondents had significantly fewer RFD coded as
Loneliness compared to Switzerland, suggesting feelings of loneliness are not as commonly identified as RFD among the Irish compared to the Swiss. In addition, Irish respondents reported significantly more RFD coded as Escape-The Pain compared to Denmark and Switzerland, indicating the Irish identify a desire to escape mental anguish more frequently than Danish and
Swiss respondents. This finding is in line with Ireland’s elevated average rating for
Psychological Pain. It may be such that the Irish experience high levels of Psychological Pain, which fuels their desire to escape this pain.
Furthermore, Irish respondents did not differ significantly compared to the other nations of comparison across the following coding categories, Other (Relationships), Unburdening
Others, Hopelessness, General Descriptors of Self, Escape- In General, and Escape-The Past.
This may suggest the Irish’s identified RFD that fall into these categories are comparable to individuals from China, Denmark, Norway, Switzerland, and the USA.
On the One-Thing response, Orientation dimension, Ireland had significantly more Self oriented responses compared to Denmark. This may reflect important cultural differences between Ireland and Denmark, and shared cultural similarities with the USA regarding the
79 identification of things/experiences that would help one to no longer feel suicidal. It is possible that among the Irish, similarly to Americans, they may believe it is their own responsibility to cope with and overcome psychological difficulties, particularly suicidal ideation. Additional research on the Irish’s experience of suicide is needed to provide support for this notion.
Regarding Suicidal Orientation (Self vs. Relational), no significant cross-country differences were observed. When examining the proportion of Irish SSF profiles coded as either
Self or Relational, results indicate more than half of the Irish profiles were coded as Self- oriented. Meaning, taken as a whole, these SSF profiles suggest suicidality is related to the self rather than others. As observed, Irish may tend to attribute their suicidality to themselves, and seek self-focused solutions.
Finally, regarding Suicidal Motivation (Life-Motivated, Ambivalent, and Death-
Motivated), Ireland did not differ, significantly, from the other nations of comparison. However, when examining inter-country responses, less than half of Ireland’s responses were coded as
Life-Motivated. This likely aligns with Ireland’s higher report of Overall Risk of Suicide and lower reported SIS score, which indicated Ambivalence.
Norway. Overall, analyses of the SSF Core Assessment sentence blanks revealed significant difference between Norway and the other nations of comparison (Ireland and the
USA) on the constructs Stress, Agitation, and Self-Hate. Although Hopelessness yielded significant differences, post-hoc comparisons did not reveal any significant difference. The construct of Psychological Pain did not yield any significant differences.
The proportion of responses coded as Role/Responsibilities for the construct of Stress were significantly lower among Norwegian respondents compared to American respondents.
This may suggest for Norwegians, the experience of Stress, as it relates to suicidality, is not
80 driven by responsibilities related to occupational, financial, academic, or family roles. Similar to this finding, on the construct of Agitation, the proportion of responses coded as
Role/Responsibilities were significantly lower among Norwegian respondents compared to
American respondents. This finding again suggests the notion of roles and responsibilities may not drive suicidal Norwegians to take action as much as it does suicidal Americans. It is possible within the Norwegian culture there is less of an emphasis on the importance or value of individual roles and responsibilities as there may be in American culture.
Analyses on the construct of Self-Hate indicated Norway had significantly fewer responses coded as Internal Descriptors compared to the USA. This finding may indicate
Norwegians do not identify the lack of having positive qualities, or the experience of having negative qualities as what they hate most about themselves, as much as do American respondents. Lastly, on the construct of Hopelessness, no significant differences were observed.
Overall, these results may highlight important differences and similarities between nations. In order to more fully understand the nature of these differences and similarities, and how they may relate to culture, additional research is needed.
Regarding RFL, Norwegian respondents had significantly more RFL coded as Family compared to China. These findings may suggest for Norwegians, their family is a more commonly identified reason to stay alive compared to China. It is possible this finding is in line with Norwegian culture, which may emphasize the importance of family. In addition, Norwegian respondents had significantly fewer RFL coded as Friends compared to Denmark, suggesting social factors may not be as much of a buffer against suicide for Norwegians as they are for the
Danes.
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Moreover, Norwegian respondents reported fewer RFL coded as Responsibility to Others compared to China and Switzerland. Norwegian respondents also identified fewer RFL coded as
Hopefulness for the Future compared to China, Denmark, Switzerland, and the USA. They also reported fewer RFL coded as Enjoyable compared to Ireland and Switzerland. These cross- cultural differences may be driven by important cultural factors. Additional research is needed to understand these factors and their potential influence on Norwegians’ RFL. Furthermore,
Norwegians identified fewer RFL coded as Beliefs compared to the USA. This finding may highlight cultural differences regarding the emphasis on religious, personal, or ethical beliefs as a reason to stay alive. Finally, there were no significant differences found between Norway and other nations across the following RFL coding categories, Burdening Others, Planning and
Goals, and Self, which possibly suggests Norway, China, Denmark, Norway, Switzerland, and the USA may comparably identify RFL that fall into these categories.
When examining RFD, Norway had significantly fewer RFD coded as Loneliness compared to Switzerland, suggesting feelings of loneliness are not as commonly identified as
RFD among the Norwegians compared to the Swiss. In addition, Norwegian respondents reported significantly fewer RFD coded as Hopelessness compared to the USA. Interestingly, this finding differs from previous results that observed Norway having high ratings of
Hopelessness on the SSF Core Assessment constructs. It may be that although Norwegians have high levels of Hopelessness, they do not report Hopelessness as a RFD as much as do
Americans.
Post-hoc comparisons also revealed that Norway reported significantly more RFD coded as Escape- The Pain compared to Denmark, indicating Norwegian respondents identify a desire to escape mental anguish more frequently than Danish respondents. This finding is in line with
82
Norway’s high rating for Psychological Pain. It may be that Norwegians experience high levels of Psychological Pain, which drives their desire to escape this pain.
Moreover, Norway did not differ significantly compared to the other nations of comparison across the following coding categories, Other (Relationships), Unburdening Others,
Escape- In General, and Escape- The Past. This may suggest Norway’s identified RFD that fall into these categories are comparable to individuals from China, Denmark, Ireland, Switzerland, and the USA.
On the One-Thing response, Orientation dimension, Norway had significantly fewer Self oriented responses compared to the USA. This may reflect important cultural differences between Norway and the USA, and shared cultural similarities with Denmark regarding the identification of things/experiences that would help one to no longer feel suicidal. It is possible that among the Norwegians, similarly to the Danish, they may believe it is not their responsibility to cope with and overcome psychological difficulties, particularly suicidal ideation. Additional research on the Norwegian’s experience of suicide is needed to provide support for this notion.
Regarding Suicidal Orientation (Self vs. Relational) macro-coding, although no significant cross-country differences were observed, when examining the proportion of
Norwegian SSF profiles coded as either Self or Relational, results indicate more than half were coded as Self-oriented. Meaning, taken as a whole, these SSF profiles suggest suicidality is related to the self rather than others.
Finally, regarding Suicidal Motivation (Life-Motivated, Ambivalent, and Death-
Motivated), Norway had significantly fewer Life-Motivated respondents compared to Denmark and Switzerland. Moreover, Norway had significantly more Ambivalent respondents when
83 compared with Switzerland. When examining inter-country responses, the majority of Norway’s responses were coded as Ambivalent. This aligns with their lower reported SIS score, which indicated Ambivalence.
Switzerland. Regarding RFL, Switzerland had significantly more RFL coded as Family compared to China. These findings may suggest for the Swiss their family is a more commonly identified reason to stay alive compared to China. In addition, Swiss respondents reported significantly more RFL coded as Responsibility to Others compared to Norway. It is possible these findings are in line with Swiss culture, which may emphasize the importance of family and other relational factors.
Furthermore, Swiss respondents identified significantly fewer RFL coded as Burdening
Others compared to Denmark. This finding may relate to Switzerland’s high acceptability of suicide, such that because suicide is more acceptable, the Swiss may not view suicide as a burden to others and therefore not as a RFL. The Swiss also reported significantly more RFL coded as
Hopefulness for the Future compared to Norway suggesting for the Swiss having a sense of hope for the future is more frequently identified as a RFL than it is for Norwegians. Furthermore,
Switzerland identified significantly more RFL coded as Enjoyable Things compared to Norway, which may indicate pleasurable activities or things are more commonly identified motivators for living among the Swiss compared to Norwegians. In addition, the Swiss reported significantly fewer RFL coded as Beliefs compared to the USA. This finding may highlight cultural differences regarding the emphasis on religious, personal, or ethical beliefs as a reason to stay alive.
Finally, there were no significant differences found between Switzerland and other nations across the following RFL coding categories, Friends, Planning and Goals, and Self,
84 which possibly suggests Switzerland, China, Denmark, Ireland, Norway, and the USA may comparably identify RFL that fall into these categories.
When examining RFD, Switzerland had significantly more RFD coded as Loneliness compared to Ireland and Norway, suggesting feelings of loneliness are commonly identified as
RFD among the Swiss compared to the Irish and Norwegians. In addition, Swiss respondents reported significantly fewer RFD coded as Escape- The Pain compared to Ireland, indicating
Swiss do not identify a desire to escape mental anguish as frequently as do Irish respondents.
This finding is in line with Switzerland’s low average rating of Psychological Pain.
Moreover, Switzerland did not differ significantly compared to the other nations of comparison across the following coding categories, Other (Relationships), Unburdening Others,
Hopelessness, General Descriptors of Self, Escape- In General, and Escape- The Past, and
Escape- Responsibilities. This may suggest Switzerland’s identified RFD that fall into these categories are comparable to individuals from China, Denmark, Ireland, Norway, and the USA.
Regarding Suicidal Orientation (Self vs. Relational), although no significant cross- country differences were observed, when examining the proportion of Swiss SSF profiles coded as either Self or Relational, results indicate more than half were coded as Self-oriented. Meaning, taken as a whole, these SSF profiles suggest suicidality is related to the self rather than others.
Lastly, regarding Suicidal Motivation (Life-Motivated, Ambivalent, and Death-
Motivated), Switzerland had a significantly higher proportion of Life-Motivated respondents and a significantly lower proportion coded as Ambivalent compared to Norway. This finding is in line with Switzerland’s higher SIS score, inducting a WTL, as well as their low levels of Overall
Risk of Suicide.
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The USA. Overall, analyses of the SSF Core Assessment sentence blanks revealed significant difference between the USA and the other nations of comparison (Ireland and
Norway) on the constructs Stress, Agitation, and Self-Hate. Although Hopelessness yielded significant differences, post-hoc comparisons only revealed no significant differences. The construct of Psychological Pain did not yield any significant differences.
Analyses of responses to the construct Stress indicated the USA had significantly more responses coded as Role/Responsibilities compared to Norway. This may suggest for Americans the experience of Stress, as it relates to suicidality, is driven by responsibilities related to occupational, financial, academic, or family roles more so than it is for Norwegians. Moreover, on the construct of Agitation, the USA also had significantly more responses coded as
Role/Responsibilities compared to Ireland and Norway, again suggesting that the notion of roles and responsibilities likely drives suicidal Americans to take action more so than it does for suicidal Irish and Norwegians.
Analyses on the construct of Self-Hate indicated the USA had significantly more responses coded as Internal Descriptors compared to the Norway. This finding may indicate
Americans identify the lack of having positive qualities, or the experience of having negative qualities, as what they hate most about themselves more so than do Norwegian respondents.
Moreover, for Self-Hate, American respondents tended to provide fewer responses that were coded as Global/General compared to Ireland. This might suggest American respondents are more likely to identify specific reasons for self-hate compared to Irish respondents. Finally, post- hoc analyses on the construct Hopelessness found no significant differences. Taken together, these results may highlight important differences between nations. In order to more fully
86 understand the nature of these differences and how they may relate to culture, additional research is needed.
Regarding RFL, the USA had significantly fewer RFL coded as Responsibility to Others compared to China. This finding is perhaps consistent with America’s predominately individual- focused culture—“rugged individualism.” In addition, American respondents reported significantly more RFL coded as Hopefulness for the Future compared to Norway. This finding is in line with Americans’ low ratings of Hopelessness on the SSF Core Assessment.
Furthermore, American respondents identified significantly more RFL coded as Beliefs compared to Denmark, Ireland, Norway, and Switzerland. This finding may highlight cultural differences regarding the emphasis on religious, personal, or ethical beliefs as a reason to stay alive.
Finally, there were no significant differences found between the USA and other nations across the following RFL coding categories, Family, Friends, Burdening Others, Planning and
Goals, Enjoyable Things, and Self, which possibly suggests the USA, China, Denmark, Ireland,
Norway, and Switzerland may comparably identify RFL that fall into these categories.
When examining RFD, the USA had significantly more RFD coded as Hopelessness compared to Denmark and Norway. This finding is interesting, as it contrasts the finding that
Americans reported low ratings of Hopelessness and had significantly more RFL coded as
Hopefulness for the Future. Taken together, these findings may simply suggest that the experience of hope in general (having, or not having it) is important for Americans as it relates their experience of suicidality.
Comparisons also revealed significant differences between American respondents’ identification of more RFD coded as Escape- The Pain compared to Denmark. This finding may
87 indicate that Americans identify a desire to escape mental anguish more frequently than do
Danish respondents.
Finally, the USA and the other nations of comparisons did not differ significantly across the following coding categories, Other (Relationships), Unburdening Others, Loneliness, Escape-
In General, and Escape- The Past. This may suggest the USA’s identified RFD that fall into these categories are comparable to individuals from China, Denmark, Ireland, Norway, and
Switzerland.
On the One-Thing response, Orientation dimension, the USA had significantly fewer responses coded as Relationally oriented compared to Denmark and China. Moreover, the USA had significantly more Self oriented responses compared to Denmark and Norway. These findings may reflect important cultural differences between China, Denmark, and Norway, and shared cultural similarities with the Irish regarding the identification of things/experiences that would help one to no longer feel suicidal. It is possible Americans believe it is their own responsibility to cope with and overcome psychological difficulties, particularly suicidal ideation.
Regarding Suicidal Orientation (Self vs. Relational), no significant cross-country differences were observed. However, when examining the proportion of American SSF profiles coded as either Self or Relational, results indicate more than half were coded as Self-oriented.
Meaning, taken as a whole, these SSF profiles suggest suicidality is related to the self rather than others. As observed, Americans may tend to attribute their suicidality to themselves, and seek self-focused solutions.
Finally, regarding Suicidal Motivation (Life-Motivated, Ambivalent, and Death-
Motivated), the USA did not significantly differ from the other nations of comparison. When
88 examining inter-country responses, the majority of the USA’s responses were coded as Life-
Motivated. This finding is in line with the USA’s higher SIS score, indicating a WTL.
General Discussion and Integration of Findings
The overall results of this study indicated variability in suicidal experiences, as measured by patient-generated responses on the SSF, across suicidal persons in six different nations. This variability may, or may not, be a reflection of cultural differences. Nevertheless, these results highlight potentially important cultural factors that necessitate further investigation.
Across this study’s findings (quantitative and qualitative), several themes emerged. First, persons from the USA generated more responses that highlighted the importance of roles/responsibilities and the self compared to the other nations of interest. As previously noted, no direct conclusions can be drawn between these results and culture; however, these findings are consistently in line with dominant American culture, as well as the emphasis on personal and professional responsibilities, and individualism (Markus, & Kitayama, 1991).
Second, Norwegian respondents indicated higher levels of ambivalence toward the suicidal wish compared with other nations. This finding is challenging to interpret given limitations of the current data. However, one potential explanation may be related to the design and implementation of Norway’s healthcare system, which allows for greater access to health services. Having greater access may help prevent suicide risk and unnecessary psychiatric hospitalizations. Therefore, individuals who are admitted to inpatient hospitals are only done so when they are in extreme distress and at a high risk for harm to self or others. As previously noted, this finding may have important clinical implications, as previous research suggests ambivalence toward suicide may indicate a greater risk for suicide than those who are life- motivated (Brown et al., 2005; Jobes & Mann, 1999).
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Third, compared to other nations, Ireland reported the highest level of suicide risk and generated more responses that underscored the importance of escaping the pain as a reason to die. It may be possible these findings are related to the majority of our sample being male. As previously discussed, Irish males have a particularly elevated risk for suicide. These results may have important implications for clinical intervention, such as cultivating coping skills to effectively address the desire to escape pain.
Fourth, overall, China and Switzerland had lower ratings across most constructs and a stronger desire to live compared to other nations. These findings may highlight important protective or other factors, which merit further exploration in order to determine their nature.
Finally, there was significant comparability between Denmark, Ireland, Norway, and the USA across several constructs, indicating shared factors that, once again, warrant further investigation in order to determine to what these shared factors can be attributed.
Overall, this study accomplished three important goals— 1) advancing the current state of knowledge of the suicidal experience from an international perspective; 2) furthering the utility of the SSF as an international tool for the assessment and treatment of suicidal risk; 3) enhancing clinicians’ and researchers’ understanding of the differences and similarities of the suicidal experience.
Clinical Implications
The principal result of this study is that the suicidal experience is variable from person to person (nation to nation). The cause of this diversity is unclear; however, this variability suggests clinical approaches to treating suicide should also vary. Clinicians should adopt a flexible approach and tailor their interventions to address the specific needs of their patients/clients.
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For example, according to this study’s results, clinicians treating individuals from China may focus on strengthening their experience of having a responsibility to others as a protective factor against suicide, as this was the most commonly identified reason for living among our Chinese sample. Clinicians working with individuals from Denmark may use interventions that strengthen their friendships, as this was one of their most commonly identified reasons for living.
This may take the form of behavioral activation, such as going out with friends, calling a friend, or writing a letter to a friend. Clinicians working with individuals from Ireland may emphasize enhancing reasons for living, identifying and strengthening protective factors, and collaboratively developing coping skills focused on helping patients effectively manage their desire to escape the pain, such as learning distress tolerance derived from DBT (Linehan, 2014).
Moreover, clinicians treating Norwegian patients/clients may consider using strategies from Motivational Interviewing (Miller & Rollnick, 2013) to help them move from ambivalence toward a wish to live/motivation for living. Clinicians working with Swiss patients may choose to focus on reducing feelings of loneliness (the most commonly endorsed reason for dying among the Swiss) by encouraging their patients to engage in social activities. Finally, clinicians working with Americans may want to focus on helping their patients develop effective coping strategies to reduce feelings of stress and agitation as they relate to personal or professional roles/responsibilities, such as values-based work derived from Acceptance and Commitment
Therapy (Hayes, Strosahl, & Wilson, 1999).
Taken together, this study’s findings provide several clinical implications that we hope will facilitate clinicians’ ability to address diverse suicidal experiences.
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Study Limitations
This study was the first ever to investigate detailed accounts of the suicidal experience across suicidal persons in six different nations. Therefore, this study was exploratory. Unlike larger, epidemiological, or experimental endeavors, which aim to address different research questions, this exploratory study had a limited sample size and minimal covariates. All significant observations in this study are, therefore, unable to be directly attributed to culture.
However, although no causality can be inferred, this study’s findings may help increase awareness of potentially important risk factors that may, or may not be influenced by culture.
There were several limitations to this study. First, the sample size was small, which may have limited the ability to detect differences of small effect sizes between countries. Moreover, this study’s small sample size reduces the generalizability of its findings. Second, the samples between countries may be qualitatively different. For example, Chinese college students may be distinctly different from Swiss inpatients; thus, observed differences between those two samples and others may be due to such qualitative differences. Confounding variables such as this may make it difficult to know with certainty if observed differences are due to culture/country versus other factors (e.g., treatment setting, adherence using the SSF). Third, limited data collected was derived from the SSF, which restricts the ability to investigate the influence of other covariates
(e.g., education level, occupational status) on the outcome variables. Fourth, because American students coded the qualitative responses, there is the potential for bias and misinterpretations of responses that were translated into English from different languages. In addition, specific cultural meaning of responses may have been diluted or lost when translating responses from their language of origin into English.
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Lastly, the interrater reliability coefficients of the qualitative variables were lower compared to previous studies that have utilized the same coding systems. Although the coefficients in the present study were all considered to be acceptable (K = .60-.80), past studies have observed coefficients of .80. Lower interrater reliability may have influenced the consistency by which this study’s qualitative variables were coded into their respective categories. Despite the aforementioned limitations, this study’s findings shed light on potentially important cultural factors that warrant future exploration.
Future Directions
The observed differences and similarities across SSF variables between countries could be accounted for by many factors. However, they obviously implicate the potential importance of cultural factors that may impact individuals’ experience of suicidality. Understanding why and how these cultural differences and similarities exist, as well as the way in which these factors influence individuals’ experience of suicide may be important to the development of culturally- relevant suicide risk assessment measures and interventions. In order to examine these differences and similarities further, additional research is needed.
Future studies should aim to address the limitations of the current study by recruiting larger samples, reducing the number of confounding variables by collecting data from comparable samples, and standardizing methods of translating and coding patient-generated responses. To enhance the generalizability of the SSF to non-American cultures, future research should examine non-American patients’ experiences using the SSF, for example, asking patients how the SSF constructs relate to their cultures.
In addition, future studies should examine additional factors that may influence this study’s findings, such as age, gender, religion, sexual orientation/identity, occupational status,
93 socioeconomic status, education level, marital status, previous suicide attempts, and acculturation/assimilation. Finally, replication of the current study would be valuable to determine if this study’s results are replicable.
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Tables
Table 1
Sample Demographics
Marital Status Sex Age (% yes) (% female) M (SD) % (n) % (n) China 75.0% (9) Denmark 28.54 (11.31) 28.6% (16) 75.0% (42) Ireland 40.0% (19) Norway 34.18 (12.30) 57.7% (56) Switzerland 37.83 (14.42) 28.3% (34) 55.0% (66) USA 33.75 (9.67) 46.4% (13) Note. Age was unavailable for China and Ireland. Marital status was unavailable for China, Ireland, Norway, and the USA. Ireland had significantly more males than females compared to each of the other samples, ps < .001.
111
Table 2
Means and Post-hoc Tests of Ratings of Core SSF Assessment by Country
Psychological Pain Stress Agitation M (SD) M (SD) M (SD) China 2.17 (1.12)a 3.67 (1.07)a 2.92 (1.31)a, b Denmark 3.85 (0.93)b 3.55 (1.45)a 3.57 (1.04)b Ireland 3.80 (1.12)b 3.69 (1.20)a 3.14 (1.34)b Norway 3.94 (1.09)b 3.55 (1.31)a 3.12 (1.42)b Switzerland 2.19 (1.16)a 2.43 (1.33) 2.20 (1.21)a USA 3.64 (1.25)b 3.71 (1.27)a 3.15 (1.49)b
Overall Risk of Hopelessness Self-Hate Suicide M (SD) M (SD) M (SD) China 2.17 (1.34)a 2.50 (1.17)a, c, e 1.64 (0.81)b, e, f, g Denmark 3.80 (1.07)b 3.48 (1.27)b, c 2.37 (1.17)c, d, f Ireland 3.88 (0.99)b 3.96 (1.24)b 2.98 (1.30)c Norway 3.71 (1.23)b 3.49 (1.38)b, d, e 2.23 (1.28)d, g Switzerland 2.38 (1.30)a 2.47 (1.27)a 1.57 (0.95)a, b USA 2.93 (1.36)a 3.00 (1.52)a, c, d 2.04 (1.07)a, d, e
Note . Means for each scale that share a superscript are not significantly different (ps > .05, Tukey HSD post-hoc tests).
112
Table 3
Means and Post-hoc Tests of Rankings of Core SSF Assessment by Country
Psychological Pain Stress Agitation Hopelessness Self-Hate
M (SD) M (SD) M (SD) M (SD) M (SD) Ireland 4.44 (14.48) 3.19 (1.26) 3.59 (1.32) 2.74 (1.35) 3.00 (1.53) Norway 2.37 (1.34) 3.09 (1.09) 3.33 (1.49) 2.79 (1.32) 3.19 (1.57) USA 2.46 (1.33) 2.64 (1.31) 4.15 (1.08) 2.33 (1.14) 3.15 (1.49)
113
Table 4
Percentages and Frequencies of WTL/WTD: SIS by Country
WTL Ambivalent WTD % (f) % (f) % (f) China 83.4% (5) 16.7% (1) 0.0% (0) Ireland 26.5% (13) 26.5% (13) 47.0% (23) Norway 46.0% (41) 20.2% (18) 21.9% (30) Switzerland 75.0% (90) 18.3% (22) 6.7% (8) USA 57.2% (16) 32.1% (9) 10.7% (3)
114
Table 5
SSF Core Assessment Sentence Blanks Percentages and Frequencies within Country: Psychological Pain
Role/ Global/ Self Relational Responsibilities General % (f) % (f) % (f) % (f) Ireland 21.3% (10) 31.9% (15) 0.0% (0) 2.1% (1) Norway 15.6% (14) 32.2% (29) 2.2% (2) 3.3% (3) USA 30.8% (8) 19.2% (5) 0.0% (0) 11.5% (38)
Unpleasant Unsure/Unable to Helpless Internal States Articulate Not Codable % (f) % (f) % (f) % (f) Ireland 12.8% (6) 31.9% (15) 0/0% (0) 0.0% (0) Norway 12.2% (11) 27.8% (25) 1.1% (1) 5.6% (5) USA 15.4% (4) 23.1% (6) 0.0% (0) 0.0% (0)
115
Table 6
SSF Core Assessment Sentence Blanks Percentages and Frequencies within Country: Stress
Role/ Relational Self Responsibilities % (f) % (f) % (f) Ireland 20.4% (10) 12.2% (6) 18.4% (9) Norway 17.5% (14) 6.3% (5) 10.0% (8) USA 14.8% (4) 11.1% (3) 44.4% (12)
Global/ Situation- General Specific Helpless % (f) % (f) % (f) Ireland 10.2% (5) 18.4% (9) 10.2% (5) Norway 7.5% (6) 16.3% (13) 16.3% (13) USA 0.0% (0) 18.5% (5) 7.4% (2)
Unpleasant Unsure/ Internal States Unable to Articulate Not Codable % (f) % (f) % (f) Ireland 10.2% (5) 0.0% (0) 0.0% (0) Norway 0.0% (0) 2.5% (2) 7.5% (6) USA 16.3% (13) 3.7% (1) 0.0% (0)
116
Table 7
SSF Core Assessment Sentence Blanks Percentages and Frequencies within Country: Agitation
Compelled to Global/ Act General Helpless % (f) % (f) % (f) Ireland 2.1% (1) 6.3% (3) 4.2% (2) Norway 8.6% (6) 2.9% (2) 5.7% (4) USA 0.0% (0) 8.7% (2) 0.0% (0)
Role/ Self Relational Responsibilities % (f) % (f) % (f) Ireland 10.4% (5) 25.0% (12) 0.0% (0) Norway 8.6% (6) 8.6% (6) 0.0% (0) USA 13.0% (3) 26.1% (6) 13.0% (3)
Situation- Unpleasant Unsure/ Not Specific Internal States Unable to Articulate Codable % (f) % (f) % (f) % (f) Ireland 10.4% (5) 41.7% (20) 0.0% (0) 0.0% (0) Norway 21.4% (15) 31.4% (22) 2.9% (2) 10.0% (7) USA 17.4% (4) 13.0% (3) 0.0% (0) 8.7% (2)
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Table 8
SSF Core Assessment Sentence Blanks Percentages and Frequencies within Country: Hopelessness
General/ Role/ Global Future Relational Responsibilities % (f) % (f) % (f) % (f) Ireland 24.5% (12) 26.5% (13) 8.2% (4) 14.3% (7) Norway 14.0% (12) 17.4% (15) 20.9% (18) 11.6% (10) USA 3.8% (1) 11.5% (3) 7.7% (2) 23.1% (6)
Unpleasant Unsure/Unable Self Internal States to Articulate Not Codable % (f) % (f) % (f) % (f) Ireland 22.4% (11) 4.1% (2) 4.1% (2) 0.0% (0) Norway 23.3% (20) 5.8% (5) 5.8% (5) 7.0% (6) USA 50.0% (13) 3.8% (1) 3.8% (1) 0.0% (0)
118
Table 9
SSF Core Assessment Sentence Blanks Percentages and Frequencies within Country: Self-Hate
Internal External Helpless Descriptors Descriptors Relational % (f) % (f) % (f) % (f) Ireland 20.4% (10) 32.7% (16) 18.4% (9) 6.1% (3) Norway 16.0% (13) 22.2% (18) 19.8% (16) 8.6% (7) USA 8.3% (2) 29.2% (14) 16.7% (4) 4.2% (1)
Global/ Role/ Unsure/Unable to General Responsibilities Articulate Not Codable % (f) % (f) % (f) % (f) Ireland 16.3% (8) 2.0% (1) 0.0% (0) 4.1% (2) Norway 23.5% (19) 2.5% (2) 2.5% (2) 4.9% (4) USA 0.0% (0) 4.3% (1) 4.2% (1) 4.2% (1)
119
Table 10
Means and Post-hoc Tests of RFL by Country
Responsibility to Family Friends Others M (SD) M (SD) M (SD) China 0.25 (0.45)a, b 0.17 (0.39)a, b, c 0.58 (0.67)a Denmark 0.80 (0.79)a, b 0.67 (0.75)a, c 0.13 (0.39)b, c, d Ireland 1.17 (0.88)b 0.29 (0.50)a, b, c 0.21 (0.46)c, g, h Norway 1.03 (0.76)b 0.33 (0.52)a, b 0.04 (0.21)d, f, g Switzerland 1.06 (.90)b 0.53 (0.59)a, b, c 0.25 (0.43)a, b, e, h USA 0.79 (0.79)a, b 0.61 (0.69)a, b, c 0.18 (0.39)c, e, f
Burdening Hopefulness for Others Plans and Goals the Future M (SD) M (SD) M (SD) China 0.17 (0.39)a, b, c 0.17 (0.39) a 0.92 (0.90)a, c Denmark 0.17 (0.42)b 0.30 (0.50) a 0.59 (0.63)a, c Ireland 0.10 (0.37)a, b, c 0.23 (0.52) a 0.48 (0.68)a, b Norway 0.03 (0.18)a, b, c 0.14 (0.38) a 0.22 (0.44)b Switzerland 0.02 (0.13)c 0.19 (0.45) a 0.74 (0.82)a, c USA 0.14 (0.36)a, b, c 0.07 (0.26) a 0.75 (0.80)a, c
Enjoyable Things Beliefs Self M (SD) M (SD) M (SD) China 0.17 (0.58)a, b, c 0.17 (0.39)b, c 0.42 (0.51) a Denmark 0.26 (0.44)a, b, c 0.02 (0.14)a, c 0.17 (0.47) a Ireland 0.48 (0.85)a, c 0.02 (0.14)a, c 0.29 (0.50) a Norway 0.10 (0.29)b 0.04 (0.21)a, c 0.11 (0.41) a Switzerland 0.55 (0.73)a, c 0.08 (0.30)a, c 0.30 (0.57) a USA 0.39 (0.88)a, b, c 0.32 (0.61)b 0.29 (0.60) a
Note. Means for each scale that share a superscript are not significantly different (ps > .05, Tukey HSD post-hoc tests).
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Table 11
Means and Post-hoc Tests of RFD by Country
Others (Relationships) Unburdening Others Loneliness M (SD) M (SD) M (SD) China 0.17 (0.41) a 0.17 (0.41)a, b, c 0.00 (0.00)a, b, c, d, e Denmark 0.40 (0.74) a 0.11 (0.31)a, b, c 0.15 (0.36)a, f, g, h, i Ireland 0.39 (0.70) a 0.22 (0.51)a, b, c 0.02 (0.14)b, g, j, k, l Norway 0.22 (0.54) a 0.26 (0.56)b 0.02 (0.15)c, i, l, m Switzerland 0.16 (.42) a 0.07 (0.25)c 0.19 (0.45)d, f, j, n USA 0.27 (0.45) a 0.19 (0.40)a, b, c 0.08 (0.27)e, h, k, m, n
General Descriptors Hopelessness of Self Escape- In General M (SD) M (SD) M (SD) China 0.17 (0.41)a, b, c, d, e 1.17 (0.98) a 0.17 (0.41) a Denmark 0.21 (0.41)a, f, g, h 0.43 (0.65) a 0.47 (0.55) a Ireland 0.29 (0.58)b, g, i, j, k 0.43 (0.82) a 0.82 (0.99) a Norway 0.18 (0.38)c, h, k, m 0.38 (0.64) a 0.55 (0.79) a Switzerland 0.34 (0.56)d, f, i, l, m 0.64 (0.84) a 0.73 (0.90) a USA 0.58 (0.76)e, j, l 0.85 (0.92) a 0.58 (0.86) a
Escape- Escape- The Past Escape- The Pain Responsibilities M (SD) M (SD) M (SD) China 0.00 (0.00) a 0.00 (0.00)a, b, c, d, e 0.00 (0.00) a Denmark 0.02 (0.15) a 0.09 (0.28)a, f 0.21 (0.59) a Ireland 0.06 (0.24) a 0.61 (0.73)b, g, h 0.04 (0.20) a Norway 0.05 (0.21) a 0.39 (0.58)c, h, i 0.06 (0.24) a Switzerland 0.04 (0.26) a 0.32 (0.52)d, f, i, j 0.22 (0.49) a USA 0.04 (0.20) a 0.54 (0.58)e, g, j 0.31 (0.47) a
Note. Means for each scale that share a superscript are not significantly different (ps > .05, Tukey HSD post-hoc tests).
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Table 12
One-Thing Response Percentages and Frequencies within Country: Orientation
Self Relationally Not Codable % (f) % (f) % (f) China 40.0% (2) 60.0% (3) 0.0% (0) Denmark 42.1% (8) 52.6% (10) 5.3% (1) Ireland 68.1% (32) 25.5% (12) 6.4% (3) Norway 58.4% (45) 26.0% (20) 15.6% (12) USA 88.9% (24) 7.4% (2) 3.7% (1)
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Table 13
One-Thing Response Percentages and Frequencies within Country: Reality Testing
Realistic Unrealistic Not Codable % (f) % (f) % (f) China 80.0% (4) 20.0% (1) 0.0% (0) Denmark 89.5% (17) 5.3% (1) 5.3% (1) Ireland 83.0% (39) 12.8% (6) 4.3% (2) Norway 76.6% (59) 6.5% (5) 16.9% (13) USA 88.9% (24) 7.4% (2) 3.7% (1)
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Table 14
One-Thing Response Percentages and Frequencies within Country: Clinical Utility
Clinically No Clinically Relevant Not Relevant Information Codable % (f) % (f) % (f) China 40.0% (2) 60.0% (3) 0.0% (0) Denmark 68.4% (13) 31.6% (6) 0.0% (0) Ireland 70.2% (33) 25.5% (12) 4.3% (2) Norway 68.8% (53) 15.6% (12) 15.6% (12) USA 70.4% (19) 25.9% (7) 3.7% (1)
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Table 15
Suicidal Orientation: Percentages and Frequencies of within Country
Self Relational % (f) % (f) China 75.0% (9) 25.0% (3) Denmark 64.8% (35) 35.2% (19) Ireland 83.7% (41) 16.3% (8) Norway 81.3% (78) 18.8% (18) Switzerland 79.2% (95) 20.8% (25) USA 92.9% (26) 7.1% (2)
125
Table 16
Suicidal Motivation: Percentages and Frequencies within Country
Life-Motivated Ambivalent Death-Motivated % (f) % (f) % (f) China 75.0% (9) 16.7% (2) 8.3% (1) Denmark 67.9% (38) 17.9% (10) 14.3% (8) Ireland 42.9% (21) 30.6% (15) 26.5% (13) Norway 30.9% (30) 42.3% (41) 26.8% (26) Switzerland 69.2% (83) 15.0% (18) 15.8% (19) USA 42.9% (12) 28.6% (8) 28.6% (8)
126
AppendixAppendix A CAMS Suicide Status Form—SSF IV (Initial Session)
Patient: ______Clinician: ______Date: Time: ______
Section A (Patient):
Rate and fill out each item according to how you feel right now. Rank Then rank in order of importance 1 to 5 (1=most important to 5=least important). 1) RATE PSYCHOLOGICAL PAIN (hurt, anguish, or misery in your mind, not stress, not physical pain): Low pain: 1 2 3 4 5 :High pain _____ What I find most painful is: ______
2) RATE STRESS (your general feeling of being pressured or overwhelmed): Low stress: 1 2 3 4 5 :High stress _____ What I find most stressful is: ______3) RATE AGITATION (emotional urgency; feeling that you need to take action; not irritation; not annoyance): Low agitation: 1 2 3 4 5 :High agitation _____ I most need to take action when: ______
4) RATE HOPELESSNESS (your expectation that things will not get better no matter what you do): Low hopelessness: 1 2 3 4 5 :High hopelessness _____ I am most hopeless about: ______
5) RATE SELF-HATE (your general feeling of disliking yourself; having no self-esteem; having no self-respect): Low self-hate: 1 2 3 4 5 :High self-hate _____ What I hate most about myself is: ______
6) RATE OVERALL RISK OF Extremely low risk: 1 2 3 4 5 :Extremely high risk N/A SUICIDE: (will not kill self) ( will kill self)
1) How much is being suicidal related to thoughts and feelings about yourself? Not at all: 1 2 3 4 5 : completely 2) How much is being suicidal related to thoughts and feelings about others? Not at all: 1 2 3 4 5 : completely
Please list your reasons for wanting to live and your reasons for wanting to die. Then rank in order of importance 1 to 5. Rank REASONS FOR LIVING Rank REASONS FOR DYING
I wish to live to the following extent: Not at all: 0 1 2 3 4 5 6 7 8 : Very much I wish to die to the following extent: Not at all: 0 1 2 3 4 5 6 7 8 : Very much The one thing that would help me no longer feel suicidal w ould be: ______
CAMS Suicide Status Form—SSF IV (Copyright David A. Jobes, Ph.D. All Rights Reserved) 127
Appendix B
SSF Core Assessment Sentence Blanks: Stress z-test for independent proportions Post-hoc comparisons
Role/Responsibilities
USA + Ireland; z = 2.55, p = .011 USA + Norway; z = 3.80, p < .001*
Ireland + Norway; z = 1.13, p = .258
Unpleasant Internal States
USA + Ireland; z = -1.69, p = .091 USA + Norway; z = -2.33, p = .020
Ireland + Norway; z = -1.19, p = .234
* Indicates statistical significance at Bonferroni corrected p-value = .008
128
Appendix C
SSF Core Assessment Sentence Blanks: Agitation z-test for independent proportions Post-hoc comparisons
Role/Responsibilities
USA + Ireland; z = -2.68, p = .007* USA + Norway; z = -3.01, p = .003*
The comparison between Ireland and Norway could not be computed due to a count of 0 responses coded as Role/Responsibilities for each country.
* Indicates statistical significance at Bonferroni corrected p-value = .025
129
Appendix D
SSF Core Assessment Sentence Blanks: Hopelessness z-test for independent proportions Post-hoc comparisons
Relational
USA + Ireland; z = 0.07, p = .944 USA + Norway; z = 1.68, p = .093
Ireland + Norway; z = 2.10 p = .036
Self
USA + Ireland; z = -2.43, p = .015 USA + Norway; z = -2.39, p = .017
Ireland + Norway; z = 0.33, p = .741
* Indicates statistical significance at Bonferroni corrected p-value = .008
130
Appendix E
SSF Core Assessment Sentence Blanks: Self-Hate z-test of independent proportions Post-hoc comparisons
Internal Descriptors
USA + Ireland; z = -2.31, p = .021 USA + Norway; z = -3.48, p < .001*
Ireland + Norway; z = -1.20, p = .230
Global/General
USA + Ireland; z = 2.06, p = .040 USA + Norway; z = 2.68, p = .009
Ireland + Norway; z = 1.08, p = .280
* Indicates statistical significance at Bonferroni corrected p-value = .008
131
Appendix F
“One-Thing” Response: Orientation z-test for independent proportions Post-hoc comparisons
Self Relationally
USA + Ireland; z = 2.01, p = .044 USA + Ireland; z = -1.92, p = .055 USA + Denmark; z = 3.40, p < .001* USA + Denmark; z = -3.44, p < .001* USA + China; z = 2.57, p = .011 USA + China; z = -2.98, p = .003* USA + Norway; z = 2.88 p = .004* USA + Norway; z = -2.03 p = .042
Ireland + Denmark; z = 6.67, p = < .001* Ireland + Denmark; z = -2.11, p = .035 Ireland + China; z = 1.26, p = .211 Ireland + China; z = -1.62, p = .105 Ireland + Norway; z = 1.07, p = .285 Ireland + Norway; z = -0.05, p = .960
Denmark + China; z = 0.09, p = .936 Denmark + China; z = -0.29, p = .772 Denmark + Norway; z = -1.28, p = .201 Denmark + Norway; z = 2.25, p = .024
China + Norway; z = -0.81, p = .418 China + Norway; z = 1.64, p = .101
* Indicates statistical significance at Bonferroni corrected p-value = .005
132
Appendix G
Suicidal Motivation z-test for independent proportions Post-hoc comparisons
Life-Motivated Ambivalent
USA + Ireland; z = 0.00, p = 1.00 USA + Ireland; z = -0.19, p = .849 USA + Denmark; z = -2.20, p = .028 USA + Denmark; z = 1.13, p = .258 USA + China; z = -1.87, p = .062 USA + China; z = 0.80, p = .424 USA + Norway; z = 1.18, p = .238 USA + Norway; z = -1.31, p = .190 USA + Switzerland; z = -2.61, p = .009 USA + Switzerland; z = 1.70, p = .089
Ireland + Denmark; z = -2.58, p = .010 Ireland + Denmark; z = 1.53, p = .126 Ireland + China; z = -1.20, p = .046 Ireland + China; z = 0.97, p = .332 Ireland + Norway; z = 1.43, p = .153 Ireland + Norway; z = -1.37, p = .171 Ireland + Switzerland; z = -3.19, p = .002 Ireland + Switzerland; z = 2.32, p = .020
Denmark + China; z = -0.49, p = .624 Denmark + China; z = 0.10, p = .920 Denmark + Norway; z = 4.43, p < .001* Denmark + Norway; z = -3.09, p = .002 Denmark + Switzerland; z = -0.17, p = .865 Denmark + Switzerland; z = 0.48, p = .631
China + Norway; z = 3.00, p = .003 China + Norway; z = -1.71, p = .087 China + Switzerland; z = 0.42, p = .674 China + Switzerland; z = 0.15, p = .881
Norway + Switzerland; z = -5.61, p < .001* Norway + Switzerland; z = 4.49, p < .001*
Death-Motivated
USA + Ireland; z = 0.19, p = .849 Denmark + China; z = 0.55, p = .582 USA + Denmark; z = 1.57, p = .116 Denmark + Norway; z = -1.79, p = .073 USA + China; z = 1.40, p = .162 Denmark + Switzerland; z = -0.27, p = .787 USA + Norway; z = 0.19 p = .850 USA + Switzerland; z = 1.57, p = .116 China + Norway; z = -1.40, p = .162 China + Switzerland; z = -0.69, p = .490 Ireland + Denmark; z = 1.56, p = .119 Ireland + China; z = 1.34, p = .180 Norway + Switzerland; z = 1.98, p = .048 Ireland + Norway; z = -0.04, p = .970 Ireland + Switzerland; z = 1.61 p = .107
* Indicates statistical significance at Bonferroni corrected p-value = .001
133