Men’s Reflections on Postsuicide Attempt Episode in Bangladesh

Abstract

This is the first ever research in Bangladesh that provides understanding about men’s postsuicide attempt reflections from a district called Jhenaidah which is assumed to be a high suicide-prone area in the country. Employing qualitative semistructured interviews with 17 men who have attempted suicide, aged 18 years and older, this research finds the survivors encountered several immediate reactions from others specifically targeting toward demeaning their masculinity. Nonetheless, they adopted several means to cope with the postsuicide episode that are thematically arranged as self-deprecation, rebuilding oneself, revenge vis-à-vis forgiveness, and impulses to escape vis-à-vis nonreactive. The postattempt episodes of the survivors are likely to be moved toward further risk factors. Therefore, it is important to take protective measures for the survivors. Specific to this district, developing a context-specific suicide prevention model, targeting the risk population could be a possible solution to the problems associated with the postattempt episodes.

Keywords

suicide-attempt men masculinity postattempt experiences coping strategies Jhenaidah Bangladesh

Introduction

Globally, it is estimated that for every suicide incident there are 20 to 30 times more attempts (Bachmann, 2018; World Health Organization [WHO], 2014). While women are more vulnerable to suicide attempts, men die up to four times the rate (Player et al., 2015; Rivers, 2014; Vijayakumar, 2015), thus reinforcing the gender paradox in suicidal behavior (Canetto & Shakinofsky, 1998). Suicide attempt is equally as burdensome as suicide (Sivertsen et al., 2019) as a history of failed suicide attempt(s) is a risk predictor for eventual suicide (Chan et al., 2016; Liu, Huang, & Liu, 2018). Due to the nature of the phenomenon, it is noteworthy that the risk factors associated with suicide and its attempt are similar (Tsai & Cao, 2018). Suicide attempt is recognized as a kind of self-injurious behavior directed with some intention to kill oneself (Nock et al., 2008; Turecki & Brent, 2016). It is an excruciating event not only for the individuals who attempt but also for family members and society (Pavulans, Bolmsjö, Edberg, & Jehagen, 2012).

Suicide attempters are often stigmatized and marginalized by the public community (Lester & Walker, 2006). Moreover, the distress brought to the families of the survivors following the attempt is also miserable as the relatives’ experience shame from the stigma of such behavior (Asare-Doku, Osafo, & Akotia, 2017). Subsequently, not only do family members have to deal with the long-term stigmatization and shame but they also need to extend care and support to the suicide attempter who caused social injury to the family (Osafo, Hjelmeland, Akotia, & Knizek, 2011). Furthermore, suicide attempters also fear harsh reactions from their family and friends which further enhances their silent pain and experiences (Olson, 2016). The aftermath of suicide attempt is commonly characterized by feelings of shame, impulses to hide, or fear of seeking help (Asare-Doku et al., 2017; Wiklander, Samuelsson, & Asberg, 2003). In general, the postsuicide attempt complexities and troubles could likely create higher risks for further attempts in the near future (Osafo, Akotia, Andoh-Arthur, & Quarshie, 2015). Studies show that gender complexities may also invite negative impacts for attempters, with males deemed more at risk due to the embedded social expectations that they must be action-oriented or accomplishers. Men attempting suicide are viewed as failures due to their fragile mental health and their inability to kill themselves (Gold, 2012).

Studies on suicide survivors present an influential means to understand the victims’ characteristics, details of the suicidal process, and the specific risk factors (Pandey, 2005). Moreover, identification of this high-risk population will pave an opportunity to assist them and further support the development of comprehensive and effective suicide prevention strategies (Lester & Walker, 2006; WHO, 2014). Regrettably, suicide attempters are often a neglected part to the suicide prevention discourse, and their perspectives considered less useful than those who have lost their loved ones (Alexander, Haugland, Ashenden, Knight, & Brown, 2009; Litts, 2008). Very little is known about the coping practices of the attempt survivors with the subsequent episodes of their life or the ways they dealt with or overcome difficulties (Alexander et al., 2009; Bazrafshan, Jahangir, Mansouri, & Kashf, 2014).

This research is premised in Bangladesh, a country in South Asia where suicide is considered a serious social and public health burden (Arafat, Mali, & Akter, 2018; Shahnaz, Bagley, Simkhada, & Kadri, 2017). In this study, effort has been made to specifically present the lived experiences or reflexivity of men surviving suicide, and how they coped with varied postsuicide attempt episodes. No study has ever been conducted in Bangladesh to examine the aftermath experiences of suicidal persons, although subsequent experiences are significant in terms of both risk and protective factors.

Research Process

Setting

This study was conducted in Jhenaidah district, Bangladesh which is a high suicide-prone area (Arafat, 2019; Khan, Ratele, Najuwa, Islam, & Dery, 2019). The fieldwork took place between December 2018 and February 2019.

Participants

Seventeen participants were purposively selected using the referrals from the Society for Voluntary Activities, a nonprofit organization in Jhenaidah district, Bangladesh working to minimize suicidal behavior in this district. Participants comprised men with an age range of 18 to 55 years (M = 30), with 11 men between 18 and 30 years old, 5 men between 31 and 50 years old, and 1 man was older than 50 years old. In total, 16 participants attempted suicide once in their lifetime, whereas 1 attempted twice. Only 1 participant left a suicide note before the attempt. Methods used in suicide attempts were pesticide ingestion (17) and hanging (1).

Procedure

The purpose of the study was clearly explained to prospective participants at a preferred time and place. Those who agreed to participate were requested to give written consent for individual interviews. A semistructured in-depth interview schedule was used to prompt participants to recollect the circumstances surrounding their postsuicide attempts and their lived experience following the attempt. Interviews were conducted in the participants’ local language, Bangla, and lasted between 35 and 120 minutes. All interviews were digitally recorded following permission. In addition to interview data, relevant demographic information was also collected from the participants.

Data Analysis

The interviews were transcribed verbatim and translated into English. All authors read the entire interview transcripts several times in order to internalize the meaning of the data. Thematic analysis was employed using Braun and Clarke’s (2006) guidelines. This method required researchers to undertake a close reading of the transcriptions to obtain a firm grip of the data and carefully identify the regular-recurring experiences and feelings of the participants. Final themes associated with the life experiences after the suicide attempts were developed through a process of consensus within the research team.

Ethics

The study received ethics approval from the University of South Africa (Ethical Clearance Code: 2018-CHS-0114). This article is a partial outcome of a broader academic research on men’s suicidal behavior and masculinity in Bangladesh. Participants were briefed about the risks and benefits of participating in the study and assured to maintain confidentiality and anonymity. They were also informed about their rights to refuse to participate and withdraw at any moment. All participants individually signed the consent form written in Bangla. Considering the sensitiveness of this study, a trained counselor accompanied the research team during the field work to extend immediate psychological support if necessary. In addition, provision was also available to transport the participants to a nearby public hospital in the event of an emergency.

Findings

Five major themes were identified, namely, (a) suicide attempt is an unmasculine act, (b) self-deprecation, (c) rebuilding oneself, (d) revenge vis-à-vis forgiveness, and (e) impulses to escape vis-à-vis nonreactive.

Suicide Attempt Is an Unmasculine Act

This was the most recurring theme that surfaced during the interviews. Most of the participants reported that they had encountered serious taunting from the community immediately after the incident. People viewed suicide as a cowardly and feminine act; a weakness which cannot be a resolution to men’s problems. The following narratives illustrate how a suicide attempt was labeled as an unmanly act.

People were saying, “Is it right to do such a thing?” Can a man do such things? They insulted me in many different ways, using demeaning language. (Participant 1)

I experienced difficulties for some time. Immediately after the incident, I felt like a circus animal. Friends and family members used to visit me, and passed many comments. They said as a man I should not have done it. This is a cowardly act. (Participant 2)

Even though I got support from family, but society criticised (me). My critics said a man’s anger does not demand to commit suicide. It is rather something feminine. (Participant 3)

Everyone in the community was telling me, “could a man do such a thing?” Suicide is something that girls do. (Participant 4)

Few of the participants received support from their families following the aftermath. All of the participants reported that the society or community stigmatized their suicide attempt as they associated this behavioral response as more likely to occur among women. As per the perception of the community, men must adhere to the masculine norms and be prepared to encounter the challenges and adversities in life. They must not escape by attempting suicide. Men who attempted suicide compromised the ideals of masculinity and demeaned their masculine status.

Self-Deprecation

Several survivors reflected on their decision to commit suicide. They perceived their behavior as a serious mistake, expressed regret, self-blame, and criticized themselves for the distress brought by their wrong doings. They indicated it was never justified for men to be involved in such activities since men need to bear a lot of responsibilities in life, and a self-induced death cannot be a solution to their problems. Survivors also acknowledged the burden suicide attempts cause for the family. A few pertinent examples are stated below:

I couldn’t understand all this back then. But now I will not do it. This isn’t the work of a man. Hardships and sorrows will be there. A man has to have the ability to understand these. Moreover, if a man commits suicide then another ten lives are ruined. (Participant 5)

I think I should not have done that. This is not right. To ingest poison or to hang oneself is not right. If something had happened to me what value would that life have had. I had my whole life ahead of me. I had a lot of responsibilities. What I did was really cowardly. Life means war, to live is to fight. This didn’t come to mind then. Now I understand what I did was wrong. Moreover, after poison ingestion I also face many physical problems. I couldn’t find the strength to work. (Participant 6)

The excerpts indicate that participants had developed a kind of sensitivity after their attempts. Their sensitivity centered on the social expectations placed on them as men. Such self-deprecation helped some of the survivors to rebuild their own identity as men.

Rebuilding Oneself

Several responses indicate that after having survived a suicide attempt, participants developed enough courage to fight back against the negative suicide aftermath. A few participants demonstrated how they reenergized themselves after the incident. Participant 7 attempted suicide because of his inability to pay the hospital bills after his wife’s caesarean delivery of their son. No relatives supported him during that critical moment, mocking his inability instead. Thereafter, he overcame the prevailing crisis of his life without looking for support from others. He said he developed strength and energy and eventually succeeded in life through hard work and persistence.

After I managed to survive, the look at my son’s face gave me the strength to carry on. Slowly, but surely, I managed to pull myself out of that mind frame and be where I am today. I did not wait around for help from anyone. I did not care what people said behind me. I felt like I have to stay alive for my family and son’s future. It was at that time that I got the opportunity to buy this vehicle. By taking a loan through various ways and means I managed to buy this car. A worked day and night driving the car. I invested in my own poultry farm and bought my own land. (Participant 7)

Participant 4 attempted suicide due to his failure to repay the debts made so as to maintain his family’s livelihood. He said he was not supported financially by his close relatives, and even his own son did not extend support. Nevertheless, after the incident, he rejuvenated himself pushing past the mistakes he had made and involved himself in farming and other activities.

I was very well aware of the fact that committing suicide is a wrong thing for me to do. I don’t even know how I ended up doing this thing myself. Since I am a man, I feel more embarrassed to recall the event. After the incident, I started paying more attention to ensure prosperity to my family. Even after that incident, I bought over 100 decimal lands, worked hard and became financially capable. I need nobody’s support now. (Participant 4)

Other examples also indicate that men succeeded in managing the felt despairs that influenced their decision to commit suicide. But they appear to have moved past the dismay and apparent failures by regaining energy required to rebuild their lives.

Revenge Vis-à-Vis Forgiveness

There were a few examples where suicide attempt was caused due to relationship problems with intimate partners such as a wife or girlfriend. Survivors were so intensely attached to their relationships that they could not cope with the troubles that arose in those relationships. Interestingly, some of them fought back by adopting a revengeful attitude, while others demonstrated forgiveness after the suicide attempt. Both categories of the survivors normalized their life after the attempts. Two contractionary examples are presented below.

Participant 8’s wife had an affair with a local man whom she could not marry due to family pressure. According to Participant 8, she spoke to others that she does not want to continue the marriage. She falsely accused him of sexual impotence and left him. He suffered social humiliation and attempted suicide. As a means to cope, he remarried to prove that he is not impotent.

I had spent six months in a lot of pain. I started hating myself and thought as a man I shouldn’t have done that. Anyway, I decided to get married again to show her that I am not sexually impotent. A real man is not sexually impotent. That’s why I got married again. [—] I have no pain now. Why should you die for your wife?

Participant 9 had ongoing conflict with his wife over their financial constraints. At one stage, his wife left him and found a factory job elsewhere. Presumably, she developed a relationship with another person in her workplace which caused Participant 9 to attempt suicide. After sometime, his wife returned home and sought forgiveness. He forgave and continued to live life.

My wife pleaded for forgiveness, touching my feet. [—] When a man has a woman by his side, he feels strong. But when she is out of sight, the strength within disappears. I was yearning to see her. It felt like ages since I had last seen her face. [—] She swore by the Holy Koran that she hadn’t done wrong to me by having an extramarital affair. Then, I forgave her. I forgave because I am a true man.

These examples portray how men coped with their issues related to masculinity, which appear to be associated with suicide. Men used two important means to get past their crises of masculinity. In one case, they demonstrated a fight back attitude and in other case, it demonstrated a reconciliatory attitude. Understandably, both seem to have their own merits in the wake of their responses after the attempt.

Impulses to Escape Vis-à- Vis Nonreactive/Avoidance

Struggling with the harsh reactions of the community and family members, some of the survivors wanted to escape from their reality. They wanted to get away from the pains, anxiety, humiliation, and multiple exigencies surrounding the incidents. In one extreme case, such an impulse resulted in a further attempt. For example, Participant 10’s first attempt was due to ongoing relationship problems with his wife whom he married without informing his parents. His family only came to know about this marriage once he had attempted suicide. Knowing that, they scolded him harshly, and badmouthed his wife and her family. Falling into a state of dilemma, he attempted further to escape from both his wife and family members.

A number of other examples illustrate that some of the participants developed a nonreactive or avoidant attitude toward the remarks and criticisms made by others about the suicide attempts. They claimed to have learnt to bear their suffering via their own ways and means without allowing things to get worse. The following narratives exemplify the nonreactive stance adopted by some of the participants:

Even now a few people tell me the same thing (criticising the attempt). But I don’t let my anger get the best of me. I remain calm. I would, perhaps, say the same thing to other people. But who understands the bitterness of reality? (Participant 9)

Everyone who came to know about the event reacted to it in many different ways—I did not react but had to bear all those remarks. [—] I did not blame anyone; rather I blamed my own fate. You see, who is there to blame. I created my own problems. (Participant 11)

What is noted from these response is that in order to avoid further emotional pain, at least one participant considered escaping from the existing troubles by attempting to kill himself would be the best options. On the other hand, most participants thought keeping themselves nonreactive or passive in the face of criticisms should be the option to deal with their troubles. For them, nonreaction is the best strategy to normalize the situation.

Discussion

This study provides some important insights into men’s subjective experiences of their postsuicide attempt in Jhenaidah district, Bangladesh. Findings suggest that one of the important postattempt risk factors concerns the way survivors are treated by family, friends, and the community. Society’s attitude conveys critical messages to men about their suicide attempts and constructions of masculinity. In this study, suicide survivors encountered severe cultural stigma for their failed masculinity as suicidal behaviors. When social and cultural context forces men to believe that they are not meeting the masculine standard, they may feel a sense of shame and defeat (Platt, 2017). This finding is corroborated by Brohan, Slade, Clement, and Thornicroft (2010) in contending that self-stigma is constructed through experience and perception of public stigma. Furthermore, suicidal stigma in interpersonal and social relationships may have detrimental effects on recovery (Rimkeviciene, Hawgood, O’Gorman, & De Leo, 2015), as can be seen in the case of one participant who made his second suicide attempt due to the intense emotional pressure by his immediate family.

Escaping from the struggle in life by killing oneself is considered as a masculine defeat, a symbolic understanding of the crisis in masculinity (Morgan, 2006). In this sense, attempting suicide is an unmasculine act since suicide is regarded as something women do. A key feature of masculinity is being self-reliant (Pirkis, Spittal, Keogh, Mousaferiadis, & Currier, 2017). Within the study context, the participants were unable to manage their issues by themselves and sought suicide as a form of escape. It is interesting to note that the very societally- prescribed masculine qualities that the participants could not fulfill are reflected in the ways they criticized themselves following the aftermath. In this instance, the coping mechanisms include the rebuilding of oneself and becoming of self-sustaining.

Disturbingly, an inability to deal pressures associated with masculinity constructions could motivate future suicide attempt (Canetto, 1995). In contrast to the finding in this study in which suicide was seen as a feminine act, an analysis of suicide in United States confirm that accomplishment of suicide by men is a powerful and permissible act, and a symbol of courage and determination against the adversities (Canetto, 2004). Importantly, the myth or narrative associated with suicide attempt as a cowardly or unmasculine act or even a brave act does not offer insights into the lives of the attempters as men suffering from social expectations placed upon them (Barrero, 2008). In this critical juncture, if the family or community does not behave empathetically with the survivors, further risks may continue since social support and positive interaction from family, friends, and community are reported to be an important protective factor against suicide—an Indian study confirms the positive implications of this fact (Kumar & George, 2013). A Ghanaian study, conversely, confirms negative consequences for the survivors, including further trauma when the community stigmatizes attempters (Osafo et al., 2015).

Apart from the broad stigmatization of suicide attempt as a cowardly or unmasculine act, survivors of suicide attempters used multiple means to cope with or face up to their postattempt episode which were thematically arranged as self-deprecation, rebuilding oneself, revenge vis-à-vis forgiveness, and impulses to escape vis-à-vis nonreactive/avoidance. Studies confirm that attempters use multiple coping strategies during postattempt period (e.g., Bazrafshan et al., 2014; Kumar & George, 2013), and the broader categories of coping strategies include adaptive and maladaptive (Ong & Thompson, 2018), action-based, emotion-based, and avoidant (Bazrafshan et al., 2014), and problem-focused, emotion-based, and dysfunctional (Marty, Segal, & Coolidge, 2010). It is important to note that if suicidal individuals are helped with adaptive coping mechanisms to minimize the severity of the problems, they find alternative solutions and make best use of the existing situation; in other words, the risks associated with further suicide may be reduced (Horesh et al., 1996). Conversely, if the survivors adopt maladaptive coping mechanism, further risk will likely occur. For example, one survivor in this study made a further attempt because they wanted to escape their troubles—a feature of maladaptive coping mechanism. It is assumed that, some of the strategies adopted by the survivors were healthy and some of unhealthy. As the purpose of this study was not to assess the effectiveness of the postattempt coping strategies but to know the contextual perspective embedded in postattempt experiences, this study cannot make a broad scale generalization of the strategies. It rather leaves a message to future studies to work on making an assessment of postattempt coping strategies.

Limitation

The study has several limitations. Being a qualitative study conducted in a specific location with a small number of participants, findings cannot be a true representation of all male suicide survivors in Bangladesh. The likelihood of report bias is also a limitation caused by the time-lapse between the incident of suicide attempts and the dates of interview. Also, some of the participants may not have received postsuicide therapy which could have limited their ability to articulate or cope with some of the experiences and perceptions.

Conclusion

Given the elevated risk for suicide in men, the need for an improved understanding of postsuicide attempt phenomenon is important. It is understandable that participants’ postsuicide reflexivity is associated with a lot of complexities and stigmatizations, and they adopted number of mechanisms to cope with the situations. Findings of the study suggest adopting measures to bring normalcy to the life of the attempters and release their burden. In this case, specific measures can be adopted for this district as a model intervention, including different stakeholders and experts keeping in mind the importance of the contexts of suicide. If the model becomes successful, it may be replicated in rest of the country. This research on postsuicide episode In Bangaladesh can be considered as a revelation to significant first. However, more research is needed on postsuicide incidents ranging from epidemiological to social-psychological.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Anisur Rahman Khan is an assistant professor in the Department of Sociology at East West University, Bangladesh. His research and teaching focus on men and masculinity, sociology of suicide and social policy analysis. He worked as a postdoctoral research fellow at the Institute for Social and Health Sciences, University of South Africa (UNISA), and the South African Medical Research Council (SAMRC)-UNISA Violence, Injury and Peace Research Unit, Cape Town, South Africa.

Kopano Ratele is the director of the South African Medical Research Council (SAMRC) Masculinity & Health Research Unit and professor at the University of South Africa where he runs the Transdisciplinary African Psychologies Programme. His research, teaching, social-political activism, and community mobilization work focuses on men, boys and masculinity, violence, class, fatherhood, race and decolonial psychology.

Najuwa Arendse works as a scientist at the South African Medical Research Council (SAMRC) – University of South Africa (UNISA) Violence, Injury and Peace Research Unit, Cape Town, South Africa. Her research interest and current works include the development and implementation of injury surveillance systems; formative evaluations; and, health promotion and injury prevention interventions.

ORCID iD

Anisur Rahman Khan

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