Exploration of factors associated with social worker attitudes toward suicide

Abstract

Background:

Social workers are expected to play important roles in suicide intervention. Caregiving behaviours of medical personnel to suicidal individuals have been reported to be influenced by their own attitudes toward suicide. In this context, only a limited number of studies have examined social workers’ attitudes toward suicide.

Aim:

The purpose of this study was to explore associations between personal or occupational factors of social workers and their attitudes toward suicide.

Methods:

A self-administered questionnaire was mailed to 2,999 study participants registered with the Tokyo chapter of the Japanese Association of Certified Social Workers. We adopted the Attitudes Toward Suicide Scale (ATTS) to measure attitudes toward suicide. MANCOVA was used to test for the effects of demographic, personal and occupational factors on ATTS sub-scale scores.

Results:

Participants with a history of suicidal thoughts had stronger attitudes regarding the right to suicide than those with no history; these attitudes were not affected by a history of participating in suicide-prevention training.

Conclusions:

Our findings suggest that suicide education should incorporate programmes directed at altering permissive attitudes toward suicide.

Keywords

Attitudes toward suicide social worker suicide-prevention training

Introduction

Suicide is a serious social problem worldwide. Since 1998, more than 30,000 individuals have died by suicide each year in Japan (Cabinet Office, 2010). Japan’s annual suicide rate is approximately 25 per 100,000 people, which is the highest among the seven major industrialized nations (World Health Organization, 2010).

As the major social service providers, social workers are likely to encounter suicidal individuals across all fields of practice (Feldman & Freedenthal, 2006). In fact, more than 90% of social workers have worked with at least one client at risk for suicide (Feldman & Freedenthal, 2006) and 33% of mental health social workers have lost a client to suicide completion (Jacobson, Ting, Sanders & Harrington, 2004). Due to the high frequency of encounters with client suicidal behaviours, social workers are required to receive adequate professional training in suicide prevention.

Previous studies reported that caregiving behaviours of medical personnel to suicidal individuals could be affected by their own attitudes toward suicide (Bagley & Ramsay, 1989). Very few studies, however, aim to reveal social worker attitudes toward suicide. The belief that suicide is a personal right has been associated with ineffective counselling of potentially suicidal clients (Neimeyer, Fortner, & Melby, 2001). Therapeutic reactions of nurses and doctors to suicidal clients are associated with the belief that people should communicate suicidal problems and have sympathy toward those who attempted suicide, while anger toward such patients emerged as a predictor of non-therapeutic reactions (Demirkiran & Eskin, 2006).

Attitudes toward suicide could be affected by various factors such as age, gender, personal or professional experience or contacts with suicidal individuals, as well as one’s own suicidal behaviours. Among nurses, for example, older nurses tended to be more empathetic toward suicidal patients (Samuelsson, Sunbring, Winell & Åsberg, 1997), more condemnatory toward the right to suicide (Botega et al., 2005) and more accepting of the right-to-die under certain circumstances (Alston & Robinson, 1992). Among medical students, general practitioners, teachers and police officers, older participants found suicide more comprehensible than the younger participants did (Öncü, Soykan, İhan, & Sayıl, 2008). Among laywomen, the oldest group expressed the least understanding toward suicide (Renberg & Jacobsson, 2003). In terms of gender, women were more likely to disapprove of one’s right to suicide (Hjelmeland et al., 2008). Meanwhile, women agreed more strongly that people had a right to die (Domino & Groth, 1997). Compared to male physicians, female physicians tended to believe that rational suicide should be allowed under certain conditions (Duberstein et al., 1995). Nurses who frequently contacted suicidal patients were more empathetic toward patients who had attempted suicide than those with fewer contacts (Samuelsson et al., 1997). In contrast, nurses who had never cared for suicidal patients, or who had a family history of suicide, expressed more condemnatory attitudes (Botega et al., 2005). Several studies revealed associations between permissive attitudes toward suicide and suicidality (Renberg & Jacobsson, 2003); for instance, undergraduate students with a history of suicide crisis were more accepting of the idea of suicide than those with no history (Lester, Guerriero & Wachter, 1991; Limbacher & Domino, 1986; McAuliffe, Corcoran, Keeley, & Perry, 2003). Some studies reported significant correlations between suicide permissiveness and adolescent suicide risk (Stein, Brom, Elizur & Witztum, 1998; Stein, Witztum, Brom, DeNour & Elizur, 1992; Zemaitiene & Zaborskis, 2005).

Social work researchers have contributed little to our understanding of suicide (Joe & Niedermeier, 2008), despite the fact that many social workers are in positions of possible intervention with suicidal clients (Feldman & Freedenthal, 2006; Jacobson et al., 2004). Although social worker attitudes toward voluntary euthanasia and assisted suicide have been explored (Csikai, 1999a, 1999b; Erlbaum-Zur, 2005; Ogden & Young, 2003), their attitudes toward suicide remain unknown.

To this end, the present study explores demographic, occupational and personal factors associated with attitudes of social workers toward suicide.

Methods

Procedure

We enrolled 2,999 individuals registered in the Tokyo chapter of the Japanese Association of Certified Social Workers (JACSW), which had 47 local chapters and 33,793 members as of July 2011. The study protocol was approved by the Ethics Committee of the National Centre of Neurology and Psychiatry in Japan. All participants received a self-administered questionnaire, a written explanation of the study, and a self-addressed and stamped return envelope by mail along with a monthly newsletter published by the chapter in September 2009. A reminder notice was sent out to participants along with a monthly newsletter in October 2009. The last completed questionnaire was received in December 2009. Of the 2,999 participants, 842 completed and returned the questionnaire (28% response rate). The questionnaire contained no information regarding the identity of individuals, and participants were asked to complete and return the questionnaire without indicating their names on the questionnaire or envelope to preserve anonymity.

We adopted the Attitudes Toward Suicide Scale (ATTS) originally developed in Sweden (Renberg & Jacobsson, 2003) to assess study participant attitudes toward suicide. The ATTS can be utilized in a large survey study and is considered the most feasible among other relevant scales used to assess attitudes toward suicide (Kodaka, Poštuvan, Inagaki & Yamada, 2010). The ATTS will make it possible to examine similarities and differences of attitudes among social workers in different countries in the future.

The ATTS was developed through two survey studies conducted in 1986 and 1996 (Renberg & Jacobsson, 2003). The first version of ATTS was developed in 1986 based on the Suicide Opinion Questionnaire (SOQ; Domino, Moore, Westlake & Gibson, 1982) and was expanded in the second 1996 study to reflect related attitudinal studies, especially the one introducing the theoretical concept. This concept was first presented by Diekstra and Kerkhof (1989) regarding attitudes toward suicide. Exploratory factor analysis yielded 10 interpretable factors, accounting for 60% of the total variance (Renberg & Jacobsson, 2003). Cronbach α coefficients for those factors ranged from 0.38 to 0.86. The 1996 version contained a total of 40 items, 37 of which were scored on a five-point Likert scale ranging from strongly agree to strongly disagree. The remaining three items were scored by a different scoring method and were designed to assess the probability of one’s own suicidality, preferable manners of one’s own death and one’s ideas about the extent of suicide prevention. The present study employed the former 37 attitudinal items.

A preliminary version of the adapted ATTS was created by translation of the original ATTS from Swedish into Japanese by a professional bilingual translator, and then through paraphrasing it by the Japanese authors of the present study. Following this, 11 mental health professionals and four lay people were asked to complete the preliminary questionnaire and give feedback on the terminology. Based on their feedback, the questionnaire was modified and back-translated from Japanese to Swedish by a professional bilingual translator (different from the one involved in the first translation). The appropriateness of the back-translated version was evaluated by one of the original developers of the ATTS before it was finalized.

We also collected information on gender, age, practice field, number of years working as a social worker, experience with clients or someone close who had committed or attempted suicide or had suicidal ideation, history of participation in suicide-prevention training and participant history of suicidal ideation.

Data analysis

A confirmatory factor analysis was performed to examine whether ATTS data collected in the present study would fit the original Swedish 10-factor model of the ATTS obtained in 1996 (Renberg & Jacobsson, 2003); however, our data did not converge. According to Mofidi, Ghazinour, Renberg and Richter (2008), their data did not replicate the original 10-factor structure either. Therefore, we performed exploratory factor analyses to extract factors using the principal factor method with a promax rotation, where items with loadings < 0.35 and those with loadings > 0.35 over two or more factors were discarded. Cronbach’s α was calculated for each factor. To obtain sub-scale scores, item scores were summed up for each sub-scale and divided by the number of items. In this calculation, items with negative loadings were scored in reverse order.

Multivariate analysis of covariance (MANCOVA) was used to test how scores of ATTS sub-scales were affected by gender, age, number of years working as a social worker, experience with suicidal behaviour of clients or significant others, history of participation in suicide-prevention training and participant history of suicidal thoughts.

We considered p < .05 as a statistically significant level for a two-tailed test. All data analyses were performed using SPSS version 16.0 (SPSS Inc., Chicago, IL, USA) and M-plus version 6 (Muthen & Muthen) statistical packages.

Results

Demographics and other characteristics

Table 1 presents participant demographics and characteristics, and demographics of the 33,793 individuals registered in the JACSW. We were unable to obtain information on those who failed to return the questionnaire and demographic data for the 2,999 social workers who registered in the Tokyo chapter and received the questionnaire. Regarding contacts with suicidal clients, 36.9% (n = 311) had worked with clients who died by suicide, 47.7% (n = 402) with those who attempted suicide and 46.0% (n = 387) with those who had suicidal thoughts. In their private lives, 39.5% (n = 333) of participants knew someone close who had died of suicide, 24.0% (n = 202) knew individuals who had attempted suicide and 23.6% (n = 199) knew individuals who had had suicidal ideation.

Table 1.

Demographics and other characteristics.

	Study participants (N = 842)		JACSW members
	%	n	%
Gender: female	70.3	592	58.4
Practice field
Elderly	15.7	132	25.9
Health care	7.2	61	10.5
Psychiatric care	1.4	12	1.0
Disability	13.1	110	10.9
Community-general support centre	16.6	140	7.2
Children	7.6	64	3.2
Low income/homeless	3.7	31	2.4
Public administration/Council of social welfare	16.2	136	12.2
Education	3.4	29	4.6
Others	13.7	115	19.1
Missing	1.4	12	2.9
Experiences of contacts with suicidal people
Occupationally: yes	73.8	621
Personally: yes	60.2	507
History of participation in suicide-prevention programmes: yes	30.8	259
History of suicidal ideation: yes	21.7	183
	M (SD)		M
Age (years)	44.1 (11.4)	838	42.9
Number of years working as a social worker	8.6 (7.5)	809

JACSW: Japanese Association of Certified Social Workers

Factor analysis of the ATTS

Exploratory factor analyses revealed the following six interpretable factors: (1) ‘Right to suicide’; (2) ‘Common occurrence’; (3) ‘Suicidal expression as mere threat’; (4) ‘Unjustified behaviour’; (5) ‘Preventability/Readiness to help’; and (6) ‘Impulsiveness’ (Table 2). Lower ‘Right to suicide’ sub-scale scores indicate a stronger agreement with the right to suicide; lower ‘Common occurrence’ sub-scale scores indicate a stronger view of suicide as common and normal; lower ‘Suicidal expression as mere threat’ sub-scale scores indicate a firmer belief that people who talk about suicide do not actually take their lives; lower ‘Unjustified behaviour’ sub-scale scores indicate a stronger belief that suicide is a bad and unjustified action; lower ‘Preventability/Readiness to help’ sub-scale scores indicate a more positive attitude toward suicide prevention and readiness to help individuals at risk of suicide; and lower ‘Impulsiveness’ sub-scale scores indicate a stronger tendency to regard suicide as an impulsive act.

Table 2.

Factors obtained from exploratory factor analyses and internal consistency for the ATTS.

Factors and items	Factor loading	Internal consistency (Cronbach’s α)
I Right to suicide		0.75
Should get help to die if people suffer from severe, incurable disease	0.81
Suicide is an acceptable way to end incurable disease	0.65
Have a right to commit suicide	0.58
Want to get help to die if I suffer from severe, incurable disease	0.55
Situations in which the only solution is suicide	0.38
Can understand why people suffering from severe, incurable disease take their own lives	0.35
II Common occurrence		0.63
Most people have thought about suicide	0.64
Anyone can commit suicide	0.58
Could kill myself out of loneliness	0.51
Could talk about my suicide wish without meaning it	0.50
Do not understand others’ wishes to commit suicide	-0.40
III Suicidal expression as mere threat		0.65
People who talk about suicide do not actually take their lives	0.75
People who make suicide threats rarely complete suicide	0.67
IV Unjustified behaviour		0.61
Suicide is the worst thing to do to relatives	0.73
Suicide is never justified	0.65
V Preventability/Readiness to help		0.44
Can always help those who are suicidal	0.59
Suicide is preventable	0.44
I am ready to help suicidal people	0.42
VI Impulsiveness		0.34
Suicide attempts are impulsive	0.48
Suicide is carried out after long-term consideration	-0.41
Suicide occurs without prior warning	0.40

Items are abbreviated

Factors associated with attitudes of social workers toward suicide

MANCOVA found that experience with suicidal behaviours of clients or significant others, history of participation in suicide-related training and participant history of suicidal ideation significantly affected the attitudes sub-scale scores (Table 3). Gender, age and number of years working as a social worker on the attitudes sub-scales scores were not significant.

Table 3.

Main effects of demographic, occupational and personal factors on attitudes toward suicide.

	Gender Pillai’s trace: F = 1.22; p = .30				d.f	F
	Male		Female
	M	SD	M	SD
Right to suicide	3.43	0.78	3.54	0.67	1	5.41
Common occurrence	2.65	0.72	2.67	0.71	1	0.71
Suicidal expression as mere threat	3.47	0.81	3.41	0.83	1	0.52
Unjustified behaviour	2.46	0.96	2.44	0.91	1	0.21
Preventability/Readiness to help	2.56	0.67	2.59	0.62	1	0.15
Impulsiveness	3.37	0.57	3.34	0.60	1	0.70
	Age Pillai’s trace: F = 1.31; p = .25
Right to suicide					1	0.00
Common occurrence					1	3.28
Suicidal expression as mere threat					1	0.36
Unjustified behaviour					1	1.34
Preventability/Readiness to help					1	0.47
Impulsiveness					1	1.52
	Number of years working as a social worker Pillai’s trace: F = 1.27; p = .27
Right to suicide					1	1.20
Common occurrence					1	0.82
Suicidal expression as mere threat					1	0.01
Unjustified behavior					1	1.74
Preventability/Readiness to help					1	4.26
Impulsiveness					1	0.76
	Participation in a suicide prevention programme Pillai’s trace: F = 6.56; p < .001				d.f	F
	Yes		No
	M	SD	M	SD
Right to suicide	3.52	0.67	3.51	0.72	1	1.19
Common occurrence	2.55	0.69	2.74	0.72	1	6.54*
Suicidal expression as mere threat	3.65	0.88	3.35	0.79	1	18.87***
Unjustified behaviour	2.55	0.93	2.40	0.92	1	1.20
Preventability/Readiness to help	2.45	0.63	2.64	0.63	1	9.68**
Impulsiveness	3.44	0.63	3.31	0.57	1	8.11**
	Experiences in occupational involvement with suicidal ones Pillai’s trace: F = 2.61; p < .05
	Yes		No
	M	SD	M	SD
Right to suicide	3.49	0.71	3.60	0.68	1	1.64
Common occurrence	2.61	0.71	2.90	0.70	1	6.73*
Suicidal expression as mere threat	3.48	0.84	3.30	0.77	1	1.11
Unjustified behaviour	2.51	0.92	2.26	0.92	1	6.60*
Preventability/Readiness to help	2.56	0.65	2.67	0.57	1	2.02
Impulsiveness	3.36	0.60	3.32	0.58	1	0.12
	Experiences in personal contacts with suicidal ones Pillai’s trace: F = 3.99; p < .01
	Yes		No
	M	SD	M	SD
Right to suicide	3.45	0.72	3.63	0.66	1	3.71
Common occurrence	2.55	0.69	2.89	0.72	1	16.86***
Suicidal expression as mere threat	3.51	0.84	3.31	0.79	1	4.78*
Unjustified behaviour	2.54	0.96	2.28	0.84	1	6.18*
Preventability/Readiness to help	2.57	0.65	2.60	0.59	1	0.01
Impulsiveness	3.37	0.61	3.32	0.56	1	0.06
	History of suicidal ideation Pillai’s trace: F = 21.71; p < .001
	Yes		No
	M	SD	M	SD
Right to suicide	3.25	0.69	3.59	0.69	1	28.69***
Common occurrence	2.16	0.57	2.83	0.68	1	118.24***
Suicidal expression as mere threat	3.49	0.89	3.42	0.81	1	0.12
Unjustified behavior	2.59	0.97	2.40	0.91	1	2.27
Preventability/Readiness to help	2.61	0.65	2.58	0.63	1	0.26
Impulsiveness	3.39	0.61	3.33	0.59	1	0.79

MANCOVA (Box’s M test: p = .109); * p<.05, ** p<.01, *** p<.001

Study participants who encountered client death by suicide and those who worked with clients who attempted suicide and/or had suicidal thoughts were more likely to consider suicide as a common behaviour, and disagree that suicide was an unjustified behaviour. Those who knew someone close with suicidal behaviours were more inclined to agree that suicide was rather common, and disagree that suicide was unjustified and that individuals talking about suicide would not complete suicide. Those who had participated in suicide-prevention training were more likely to consider suicide as a common and non-impulsive action. These participants were also more strongly opposed to the idea that a person who makes suicide threats does not actually take their own life and were ready to help suicidal individuals, with the belief that suicide can be prevented. Finally, those who had a history of suicidal thoughts were more inclined to perceive suicide as a common act. They also held a stronger right-to-suicide attitude compared to those without such a history.

Discussion

To the best of our knowledge, this is the first study to examine relationships between personal and professional factors and attitudes of social workers toward suicide.

Clinical practices performed by social workers that have not received adequate suicide education could have adverse effects not only on clients but also on practitioners themselves (Feldman & Freedenthal, 2006). Inappropriate caregiver attitudes toward suicide could lead to low competency in suicide intervention (Demirkiran & Eskin, 2006; Neimeyer et al., 2001). In this context, social workers should receive suicide-related training to effectively alter attitudes that could possibly be detrimental during interventions with suicidal clients.

The present study demonstrated that participation in suicide-prevention education in addition to daily job training was associated with increased awareness toward suicide, including cognitive evaluation of suicide issues, attitudes toward suicide prevention and preparedness for helping suicidal individuals. These findings suggest the importance of introducing suicide-training programmes for social workers with varying levels of expertise.

While the majority of participants in the present study had contacts with clients who had died by suicide, attempted suicide and/or had suicidal thoughts, less than one-third of the participants had received any kind of suicide-related education in accordance with the US study (Feldman & Freedenthal, 2006). This result, combined with findings regarding positive effects of participation in suicide-prevention training on the attitudes toward suicide as mentioned above, suggests that educational and professional organizations should seriously consider introduction of suicide education to school curricula and postgraduate training.

Our finding was consistent with previous reports (Lester et al., 1991; Limbacher & Domino, 1986; McAuliffe et al., 2003; Renberg & Jacobsson, 2003; Stein et al., 1992; Stein et al., 1998; Zemaitiene & Zaborskis, 2005) in that participants who had a history of suicidal thoughts were more likely to approve the right to suicide than those without such a history. Neimeyer et al. (2001) suggested that considering suicide as one’s own right may lead to poorer suicide counselling skills. We did not observe a significant effect of history of participation in a suicide-prevention training programme on the ‘Right to suicide’ sub-scale score, which was consistent with another study (Botega et al., 2007). Accordingly, current suicide education may not effectively change one’s attitude toward viewing suicide as a personal right. Thus, future suicide education programmes may need to focus on altering permissive attitudes toward suicide, while emphasizing the necessity of knowledge and skill acquisition in suicide management within a conventional curriculum. In addition, supervision or consultation in clinical practices would likely be helpful for social workers with a history of suicidal crisis.

Social workers who have had contact with suicidal individuals, both professionally and personally, tended to disagree that suicide is an unjustified choice. This result was somewhat consistent with that of a Brazilian study (Botega et al., 2005). According to this study, nursing professionals who had provided care for patients in suicidal crisis were less condemnatory toward suicide than those who had never provided care for such patients. Within the same study, however, was the finding that those with a family history of suicide were more condemnatory, which contrasted with our findings. The present study asked participants if they had a significant other or personal acquaintances, which included not only family members but also partners, friends or co-workers, who had completed suicide, attempted suicide and/or had suicidal ideation. In contrast, Botega et al. (2005) focused only on a family history of suicide. Professional background may have also contributed to the variability in attitude, judging by study results showing that social workers expressed stronger suicide acceptability compared with other mental health professionals (Swain & Domino, 1985).

We did not find significant correlations between demographic factors and attitudes toward suicide. As described above, previous studies (Alston & Robinson, 1992; Botega et al., 2005; Domino & Groth, 1997; Duberstein et al., 1995; Hjelmeland et al., 2008; Öncü et al., 2008; Renberg & Jacobsson, 2003; Samuelsson et al., 1997) reported mixed results regarding the influence of age and gender on attitudes toward suicide. One reason for the inconsistencies might be differences in both professional and sociocultural backgrounds, as these could play important roles in defining the relationship between demographic factors and attitudes.

Limitations

The low response rate is one notable limitation of this study. This may reflect the possibility that only those who were interested in the study theme completed and returned the questionnaire. There was essentially no difference in the demographic data of participants compared to that of the JACSW regarding gender, age and practice field. In this study, 21.7% of participants reported a history of suicidal ideation, which is similar to the 19.1% reported among lay people in the Japanese national survey (Cabinet Office, 2008). Given the relatively low response rate, the results should be interpreted with caution.

This study adopted the ATTS originally developed in Sweden to measure attitudes toward suicide in order to allow for future cross-cultural studies. Yet, given the low Cronbach’s α for some ATTS sub-scales, further studies will be needed to examine their psychometric properties. Moreover, we examined only a limited set of variables to explore their associations with attitudes toward suicide. Future studies will be needed to identify other factors relevant to such attitudes. Finally, intervention studies will be needed to explore the cause-and-effect relationships between attitudes and their relevant factors, which a cross-sectional study does not address.

Conclusions

The present study identified personal and occupational factors associated with attitudes of social workers toward suicide. Our findings imply that suicide-prevention education in addition to daily clinical training should aim to alter attitudes toward approving the right to suicide.

Footnotes

Acknowledgements

We thank Dr Ellinor Salander Renberg (Umeå University, Sweden) for her assistance in developing the Japanese version of the ATTS. We also thank Mr Ichiro Uehara (former office manager, the Tokyo chapter of the Japanese Association of Certified Social Workers) and Ms Yasue Watanabe (National Institute of Mental Health, National Centre of Neurology and Psychiatry) for their assistance in coordinating the process of survey distribution. Funding for this study was provided by the Japan Society for the Promotion of Science Grant-in-Aid for Young Scientists (B) (20730399 and 22730469).

Notes

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