Men in despair: A qualitative psychological autopsy study of suicide in Northern Uganda

Abstract

The psychosocial circumstances surrounding men’s suicide in postconflict Central Northern Uganda were investigated using qualitative psychological autopsy interviews. Records of 17 men who died by suicide were identified through police and local leaders in Internally Displaced Peoples’ camps of Amuru and Gulu Districts. Two to five significant others were interviewed around each case. Data were analyzed by interpretative phenomenological analysis (IPA). Lost dignity and social value, lack of hope for the family’s future, overwhelming family responsibility, and mental illness were circumstances found to have preceded the suicides. The protracted war in the Northern region of Uganda left men in rural communities feeling disempowered and disenfranchised. This may have contributed to suicidal behavior in some of them. Suicide prevention in this area needs to be multidisciplinary with an emphasis on helping both men and women understand and deal with the many social changes that have evolved over time and affected their traditional roles and responsibilities.

Keywords

men’s suicide postconflict Northern Uganda psychological autopsy

Suicide is underresearched in sub-Saharan Africa, particularly in Uganda. There are no official statistics on suicide prevalence in most of these countries (Lester, 2008) because of unreliable mortality records (Meel, 2003; Ndosi, Mbonde, & Lyamuya, 2004). Although limited information is available regarding suicide in sub-Saharan Africa, there are indicators that suicide is increasing and more common among men in South Africa (Burrows & Laflamme, 2006; Meel, 2003), Uganda (Kinyanda, Nakku, et al., 2009) and Tanzania (Ndosi et al., 2004). A baseline survey on mental health by the Support to the Health Sector Plan Project (SHSSP) in 11 districts found an average crude suicide rate of 1.02/100,000, with the highest rate of 4.96/100,000 reported in Adjumani, a postconflict district in the Northern region of Uganda (Kinyanda, 2004). Ovuga and Boardman (2009) reported similar rates in the same district. These rates are probably an underestimate. In their study in four subcounties in a war-ravaged area in Central Northern Uganda, Kinyanda and colleagues (2009) reported an annual suicide rate of 12.5/100,000 to 20/100,000 in the period 2005–2007. This study was undertaken in Internally Displaced Persons’ camps (IDPs). The male to female ratio was 4.4:1. Interpersonal conflict, excessive alcohol use, financial problems, mental illness, loneliness, poverty, and unemployment were some of the reasons reported for suicide.

Suicide is a multifarious event (Leenaars, 2002). Thus, a single method cannot be relied upon to understand suicidal behavior (Hjelmeland & Knizek, 2010). The studies cited above were basically quantitative and focused mainly on epidemiological aspects of the phenomenon. To better understand suicide, there is a need to complement quantitative studies with qualitative research (Hjelmeland & Knizek, 2010). Furthermore, any effective prevention strategy needs both nomothetic and idiographic understanding of the phenomenon (Leenaars, 2002). As well, a person’s actions are always goal directed and in relation to the sociocultural world in which they occur (MacCleave, James, & Stairs, 2002). Therefore, suicidal acts must be understood within the context they occur, since human motivations are grounded in cultural meaning systems (Heine, 2007). Cultural differences have been reported in risk factors for suicide (Vijayakumar, John, Pirkis, & Whiteford, 2005) and culture is an important contributor to the meaning and patterns of suicidal acts, including methods and precipitating factors (Hjelmeland, 2010; Lester, 2008; Samaraweera, Sumathipala, Siribaddana, & Bhugra, 2008).

In the Northern region of Uganda, information from media and from personal communications with elders and health professionals indicated a high incidence of suicidal behavior, especially among men and young adults following a protracted period of armed conflict (Kizza, Hjelmeland, Kinyanda, & Knizek, 2011). The purpose of the present study, therefore, was to get an in-depth understanding of the psychosocial circumstances contributing to suicide among men in this region by means of a qualitative psychological autopsy. Such an understanding may pave the way for culture- and gender-sensitive suicide prevention strategies in this region.

Method

Design

Our goal was to understand the dynamics and circumstances surrounding suicide. Thus, we used a qualitative psychological autopsy approach because it is capable of yielding rich data about the lives of suicidal individuals (Owen, Lambert, Lloyd, & Donovan, 2008). Psychological autopsy methods use interviews with relatives and significant others to generate a detailed picture of the deceased individuals’ lives and events leading to their death (Hawton et al., 1998; Owen et al., 2008). The interviews included both narrative- and problem-focused elements. The basis for the narrative part of the interview was one broad question: Can you please describe the circumstances that surrounded the suicidal death of your [relation to deceased mentioned here]? The problem-focused part of the interview ensured that those areas that were considered important were explored if not already covered by the informants in their narrative. The questions in the problem-focused section were guided by the 16 themes for psychological autopsy studies developed by Shneidman (1993). In order to capture the specific context more clearly, two additional themes were also included: how significant others were coping with the loss; and participants’ opinions about the magnitude of the suicide problem before and after the war in the region.

Setting

The study was conducted in the Acholi subregion in Northern Uganda. For two decades (1986–2006) this region was severely affected by civil conflict between Uganda government armed forces and rebel groups (Harlacher, Okot, Obonyo, Balthazard, & Atkinson, 2006). This was a period characterized by atrocities and torture in all forms (El-Bushra & Sahl, 2005; Harlacher et al., 2006). As a result, two million people were forced to live in IDPs (Roberts, Ocaka, Browne, Oyok, & Sondrop, 2008). The camps were densely populated and people lived under dreadful and very risky conditions (Liebling-Kalifani et al., 2008). People were mainly dependent on humanitarian aid for survival because arable land was inaccessible (Harlacher et al., 2006; Liebling-Kalifani et al., 2008). The conflict led to a breakdown of cultural values¹ (El-Bushra & Sahl, 2005) and people lived in a permanent state of trauma and depression (Ovuga, Oyok, & Moro, 2008; Roberts et al., 2008). There were limited opportunities for income, especially for men, who were grossly disempowered due to restricted access to the factors of production, that is, land and cattle, the source of their wealth and power (El-Bushra & Sahl, 2005). Consequently, most men in the camps resorted to excessive consumption of alcohol (Harlacher et al., 2006; Liu Institute for Global Issues, Gulu District NGO Forum, & Ker Kwaro Acholi, 2005). Women assumed a greater number of responsibilities in the camp and became the breadwinners, though this was normally a man’s responsibility. Brewing alcohol was one of the women’s sources of income (Olaa, 2001). The long-lasting conflict, which dramatically changed the psychosocial environment, also considerably changed the traditional power relations between men and women (Dolan, 2009; El-Bushra & Sahl, 2005).

Subjects and informants

Study subjects

Of the 17 male deceased, 12 were between 18–39 years and five were between 60–85 years. All had an elementary level or no formal education. Thirteen were married while four were separated or widowed at the time of death. Eleven used “Sibaco” (a local name for organophosphate pesticide) to kill themselves, whereas five hanged themselves, three used a mixture of substances, and one took a drug overdose. Ten suicides occurred inside the huts. Six of the deceased had a history of previous suicide attempt, with two involving attempted homicide. Twelve had a family history of suicide, the majority of whom died during the last years of the war or immediately after. The majority had lost two or more close relatives to suicide.

Informants

For each suicide case, two to five informants aged 18 years and above, whom were close to the deceased (including spouses, parents, siblings, children, grandparents, cousins, nephews, in-laws and/or friends) were interviewed for a total of 62 informants.

Procedure

Data were collected between November 2007 and September 2008, mainly from IDP camps of two districts (Amuru and Gulu) in Central Northern Uganda. The two districts were selected out of convenience in terms of accessibility. In order to observe confidentiality and anonymity of the decedents and informants, the specific camps remain anonymous. Suicide is still criminalized in Uganda (Kinyanda, 2006) and therefore all suicidal deaths should be reported to the police. In addition, all deaths must be reported to local authorities. Hence, suicide subjects were identified mainly through police records and local leaders. Prior to the interview the local leaders together with the study coordinator/interpreter identified the bereaved families or a family member, informed them about our study and invited them to participate. Other informants within a particular family were located through a snowball sampling technique in which one interviewee would lead us to another. Interviewing several informants for each suicide case is one way to triangulate the information and increase the reliability and validity of the data gathered (Batt, Bellivier, Delatte, & Spreux-Varoquaux, 2004). The time period between the suicide and the interview ranged from 5.5 to 19 months, which is in keeping with other psychological autopsy studies (e.g., Dyregrov, 2004; Hawton et al., 1998; Henry & Greenfield, 2009; Owen et al., 2008).

The first author, a senior clinical psychologist, was responsible for data collection. Though Ugandan, she is from a different ethnic group than the informants and therefore she had to use English, the official language of Uganda (Ministry of Gender, Labour and Social Development, 2006), for the interviews, which were conducted with interpreters (male and female) because almost all of the participants could only speak Luo. Potential interpreters were first interviewed to make certain they did not have negative attitudes towards people bereaved by suicide. The interpreters were taken through the study objective, interview guide, how to conduct interviews and their role during the data collection process. Interpreters were mental health workers and therefore already accustomed to therapeutic interviews, which are similar to the qualitative research interviews (Batt et al., 2004). To maintain a smooth flow of the narration, the interpreter simply summarized the responses to the interviewer during the interview. The interviews were tape-recorded with the informed consent of the informants.

Data analysis

A complete English written transcription of the texts was done. The first author transcribed the few English recordings and the interpreters concurrently translated and transcribed the Luo recordings. Thereafter, a reconstruction of the lived experiences of the deceased as narrated by each informant was made under the following topics: life history (childhood and adulthood); circumstances surrounding the death, personality/character, previous suicidal attempt(s); family history of suicide; and the perceived contribution of the war and camp life to the suicidal act. The reconstructed stories from the informants of a particular case were assessed for similarities, differences, and contradictions and then integrated into one coherent story depicting the lived experiences of that particular deceased person. A modified form of interpretative phenomenological analysis (IPA) in which we focused on the decedents’ experiences and the psychosocial circumstances prior to suicide was used to analyze the data under significant emerging themes (Smith, Flowers, & Larkin, 2009; Smith & Osborn, 2003). Through IPA, we tried to explore in detail the lived experiences of our study subjects and to come up with an interpretative stance to explain their suicide (Smith & Eatough, 2007; Smith & Osborn, 2003). The first author read and reread the transcripts several times and then generated the initial textual analyses with emerging themes that were substantiated with relevant quotes. During the whole analytical process the research team met frequently to review and discuss the interpretations and clustering of the themes. The validity in the research was thus addressed in three ways. First, the psychological autopsy study is based on the assumption that through the interview of several bereaved, it is possible to construct a valid picture of the deceased. Second, through a critical screening of the interpreters, who would be the actual interviewers, it was attempted to reduce interviewer bias. Third, repeated discussions of emerging themes and clustering of themes triangulation at the researcher level aimed to reduce the investigator bias (Yardley, 2008).

Ethical consideration

Ethical clearance was obtained from the Regional Research Ethics Committee in Central Norway and from the Uganda National Council of Science and Technology (UNCST). A clearance letter from the UNCST was presented to the Resident District Commissioner (RDC) of Gulu District in Northern Uganda. The endorsed copies of that letter were distributed to the District Security Officer (DSO), officer in charge at Gulu Central Police Station and local council officers in the camps. A letter explaining the study and requesting them to participate was read to each of the informants. Thereafter, each informant gave written consent by signing or thumb-printing the consent form. Freedom to refuse to be interviewed and to withdraw from the interview at any point was also emphasized. None of the informants we approached declined to participate. In addition, the interviewer continuously monitored the effect of the interview on the participants as recommended by Smith and Osborn (2003), and thus sought process consent as described by Kavanaugh and Ayres (1998) for the participants that appeared distressed. At the end of each interview, debriefing was done and arrangements put in place for crisis management in case of need (Kizza et al., 2011). In this paper, any potentially identifying information has been removed; pseudonyms are used for the decedents in the illustrative quotes and informants are identified only by labels to ensure their anonymity.

Findings and discussion

The findings are grouped in four broad themes; lost dignity and social value; no hope in the family’s future; overwhelming family responsibility; and mental illness. To preserve anonymity we have not given the number of decedents per given theme or subthemes, but the themes are presented in order of frequency.

Lost dignity and social value

For a significant number of the deceased, their suicide seemed to have followed loss of dignity and social value, either due to loss of self-worth and respect from others, lost control over the wife, inability to meet the sanctions imposed following the violation of social norms or abuse of trust.

Lost self-worth and respect from others

Struggles between parents and their children are common manifestations of family life and rarely result in death, except when they involve extremely high levels of humiliation and embarrassment. This seemed to have been the case for some of the study subjects. For example, an elderly deceased never took care of his children in their childhood. This embittered his children and one of them ended up mistreating him as described below:

He [the son] could tell him that: “You did not take care of us; you left us to keep on moving in people’s homes for protection. You never educated us, now you want us to take care of you and yet you should be the one to take care of us.” Such things of the past always hurt and when one constantly reminds you, they arouse a lot of thoughts and cause you to regret every bit of life. (Case 8: Informant 2)

In Africa, it is the duty of children to look after their parents when they are old and frail (Mbiti, 1991; Nwoye, 2007). However, it may not be easy for the children to take on this responsibility if the parent(s) never met their own responsibilities in their children’s early lives, as filial responsibility is ideally supposed to be a form of reciprocation (Nwoye, 2007). The previous extract seems to allude to this fact. Although the son seemingly accepted the responsibility of taking care of his father, he ended up constantly blaming him for neglecting his children during childhood. The informant suggested that the constant reminder of the past made the old man feel uncomfortable and regretful. Being an Acholi man, the deceased’s legacy was mainly in being able to take care of his household and to command respect from the family and community. The son’s criticism may have undermined his integrity, self-esteem, and credibility among his peers and within the general community. In addition to the constant reproaches from the son, the old man also suffered social isolation. The son was feared by the community because of his violent past and therefore no community member dared assist the old man in any way. Humiliation and social isolation are known driving forces to suicidal behavior (Williams & Pollock, 2001) and thus might have been important in our cases.

Lost dignity was not only a factor in the elderly male suicides, but also appeared to have been a key issue for the young men as well. Some young men decided to rely on risky behaviors like stealing and/or gambling to be able to earn a living and, as a result, they clashed with their parents. One example is the story of Awot:

When Awot failed to get the money and after realizing that he may not be able to clear the debts he had accumulated from his friends, he resorted to breaking into my house and stealing my money and using it to play cards. Still he never regained the money. As a result he decided to commit suicide because he knew if I return and find my money was not there I would kill him. (Case 13: Informant 1)

This deceased had no income but survived on stealing, gambling, and debts. The quote seems to suggest that the deceased was already aware that the father could not stand his behaviors and therefore serious consequences were likely to ensue. But with increasing pressure from peers and debtors, he had to take a risk, possibly with the hope that he might recover what he had lost and clear his debts. He ended up trapped in debt, fear of facing his father, and having to maintain his young family. In the camps, young men tended to abandon school and opt for early marriages, possibly as a means of being regarded as “men.” To achieve positive social status in Acholi culture, a man must provide for a family; otherwise, he may not be recognized as a “man” (Dolan, 2002, 2009). Thus, it seems like the young men in our sample were struggling to maintain their “good face” but were let down by lack of income. They were trapped in an identity vacuum in which they were neither men nor children—a dilemma they tried to solve through risk-taking behavior.

Lost control over the wife

Another virtue of an ideal Acholi man is to have control in his home, including of his wife and children (El-Bushra & Sahl, 2005). Our findings seem to indicate that failure to have control of the spouse was crucial in the suicide of some of our study subjects. As stated earlier, because of limited opportunities for income due to conflict the majority of the men were unemployed. This situation drove many to excessive alcohol use, gambling, and womanizing. However, they had to finance these activities by selling food crops produced and controlled by their wives. While some men were able to retain power and control over resources in their homes (El-Bushra & Sahl, 2005), for some of the men in our sample who died by suicide, their spouses had managed to deny them access to the crops by hiding them, as illustrated below:

Since he could not stop selling the produce after harvesting, I would be forced to hide the produce at his sister’s place where he could not have access to them. Maybe that is what annoyed him to commit suicide because that was the very month I hid the produce. (Case 6: Informant 1)

The previous quote seems to allude to a heightened and intolerable frustration for the deceased. It also implies that the deceased had lost control over the family resources as well as of his spouse. According to El-Bushra and Sahl (2005), among the Acholi, the husband has control over all resources, including children and women in a household. “A man’s honor, reputation, ego and masculinity are severely affected if he cannot control his wife” (Silberschmidt, 2001, p. 665). It is an insult for an Acholi man to be humiliated by a woman/wife, especially before his fellow men; in an “ideal” Acholi home the husband’s authority is unquestionable. And, if the woman happens to overpower the man, that man is despised and regarded as the “woman” in the home. Given the crowded nature of the camp life, such disagreement could hardly go unnoticed by others. The deceased may have found this damage to his social identity to be unbearable. To deal with or escape from such humiliation and disgrace, the young men in our example might go on a drinking spree: “the very week he died, he had been drinking alcohol heavily for the previous four days without resting even a single day” (Case 6: Informant 1). This may have driven the young man further toward suicide since alcohol is known to lower the individual’s threshold to suicide or promote impulsive behaviors, a common precursor to suicide (Möller-Leimkühler, 2003; Stack & Wasserman, 1993).

Inability to meet the sanctions for violating sociocultural norms

The institution of marriage is very important in Acholi culture and specific norms and values dictate when and who to marry, or not. For example, as in other African cultures, incestuous marriage is a taboo among the Acholi. When someone violates these norms and values, he/she is sanctioned and usually fined in cash or kind. Our findings indicate that sanctions related to violation of marital sociocultural norms predated some of the young men’s suicide. One of the deceased was (unknowingly) involved in an incestuous marriage and another was cohabiting with an underage girl. In the case of incest, the couple was forced to separate and the deceased had to pay a fine. In the case of the marriage of a minor the deceased had either to pay the fine or go to prison. In addition to the punishment, cleansing rituals must be performed to dissipate the misfortune strongly believed to affect not only the individual concerned, but the whole family and entire clan (Mbiti, 1991; Njoh, 2006). Similarly, marrying a girl younger than 18 years of age is unlawful in Uganda. It is punishable with six or more years of imprisonment and it is very costly to settle it out of court (Dolan, 2009). Culturally, it is a social transgression and therefore the man has to pay an “elopement fee” (Olaa, 2001). Such situations may have led to feelings of sadness, despair, and loss of hope within the deceased since they could not raise the expected fines and no one could come to their rescue. Failure to be cleansed meant remaining with that curse for the rest of their lives and would make it very difficult to find another stable marriage:

“My friend, things are sour, these people have refused to refund back my money and the woman has even left now. I do not have any other way of generating money again and if rituals are not performed whatever I will do to get another woman will be a failure … ” he started crying bitterly that “where will I get salvation … from whom will I get support to help me out of all these misfortunes?” (Case 4: Informant 2)

This quote depicts a person in severe emotional pain who was desperate and had lost hope of being rescued from the situation. Remaining unmarried meant never to be regarded as a responsible “adult man” in Acholi culture, with the dignity of being a family head (Dolan, 2009). With their life goals profoundly compromised, life may have lost meaning, and the resultant feelings of helplessness and despondency may have contributed to the suicide.

Shame because of the abuse of trust

Pressures for having abused the trust invested in them by others seemed to have generated remorseful feelings within some deceased, which in turn may have contributed to the suicide, as implied in the voice below:

He had worked in that position [clan treasurer] for quite a long time, the other clans felt he could be a go-between, and therefore entrusted him with the money … the issue of the money might have been a heavy burden … because when he died … we never found any single coin, and remember he would drink every day and did not have any income, so it means he was spending that money on drinking [alcohol]. (Case 9: Informant 2)

In this example, an elderly man was entrusted with money based on his previous record. As an elder who ideally commanded a lot of respect in Acholi culture (Liu Institute for Global Issues et al., 2005), failing to live up to the trust invested in him could have been a source of shame and embarrassment. Studies done some decades ago found shame to be one motive for men’s suicide in East and Central Africa (Stengel, 1964) and for the Basoga² in Uganda (Fallers & Fallers, 1967). According to Hastings, Northman, and Tangney (2000), a feeling of shame is likely to result in suicidality. They argue that ashamed people tend to be filled with thoughts about others’ negative evaluations and as a result feel an intense desire to escape or hide themselves from further disgrace and condemnation.

Loss of dignity and social value in life seemed to contribute to the suicide of some men both young and elderly. However, they differed in what underlay these feelings. For the young men, finding themselves in an identity vacuum where they were neither “children” nor “adult men,” and the threat of remaining “boys” seemed to have been a key issue behind this lost of dignity, self-esteem, and social value. Their goals of becoming respectable married men capable of tending to their families appeared unachievable and they may have felt they had no future to look forward to. For the elderly men, their lost dignity and social value centered on what meaning life still held for them. There was no one left for them to rely on to live out the remainder of their lives as respectable Acholi men and they faced misery, shame, and social isolation. It is noteworthy that our findings are consistent with Fallers and Fallers’ (1967) observation that loss of status played a role among the Basoga men who died by suicide.

No hope for the family’s future

Like in many African families, the future of the Acholi family lies in having children and land. Acholi is a patrilineal society and, for a man, having no child signifies an end to his lineage (Mbiti, 1991). As well, in rural communities of Uganda, land is a symbol of the family’s or clan’s identity. Families depend on land for survival and it is a source of both livelihood and well-being (Rugadya, 2009). Therefore, having no children and no land means no hope for the family’s future. This state of affairs seemed to have predated the suicide of some of the men in the study. This is elaborated under the following subthemes: “perceived end of one’s lineage” and “constrained survival means.”

Perceived end of one’s lineage

Acholi is a patrilineal society and male children are highly valued, as they are relied on for lineage continuity as well as for crucial social and economic support in old age. Unlike girls, who get married and leave the homestead, adult male children tend to set up their household around that of their parents (Harlacher et al., 2006). Here they continue to share most of the socioeconomic activities of the family, thus providing social insurance for their parents (Dyer, 2007). Hence, having no male child may be equated with “extinction” of the family, and in some cases may have led to suicide. This is illustrated in the following example where an old man had lost his only son:

My brother, the only male child he had, was also abducted. Two months prior to his death [decedent] news came that he [son] was shot dead and we never buried him. So all those problems made my father to think so much as to how he will survive if all his daughters get married, who will keep him? (Case 5: Informant 4)

The decedent had an accumulation of problems which had heavily impacted on his future prospects for survival. Prior to the son’s death, this man had lost all his siblings and close relatives. At the time of his suicide, the only person he could depend on was the daughter, who was expected to be married off.

Apart from being a source of social security in old age, children in Africa also ensure marital stability, gender identity, and parenthood (Dyer, 2007). Marrying and begetting legitimate children is part of the Acholi masculine ideal (El-Bushra & Sahl, 2005; Dolan, 2009). A man who is married but has no children is still regarded as a boy (Barker & Ricardo, 2005). Implicitly, therefore, one cannot be regarded as an “adult man” when impotent. Impotence was a factor that preceded some of our suicides. Impotence was also noted in earlier studies to have played a role in men’s suicide (Fallers & Fallers, 1967). Kinyanda, Hjelmeland, Musisi, Kigozi, and Walugembe (2005) also found impotence to be significantly associated with repeated deliberate self-harm (DSH) in Uganda, DSH being a known precursor to suicide. The suicide victims in our study for whom impotence seemed to have played a role were also reported to have had previous suicide attempts. Sexual intercourse is seen as an act of authority by men, especially if their position is threatened (Fallers & Fallers, 1967). In contemporary Uganda, sexual impotence still carries a lot of stigma and is deeply humiliating (Kinyanda et al., 2005). Impotence tends to be kept a secret among the Acholi, as in other African cultures. However, the family will do anything possible to save the marriage of an impotent member. For example, a brother or a trusted close relative or friend might secretly take on the sexual duties to help the couple have children (Mbiti, 1989, 1991). Keeping such a problem secret was difficult in the congested camp environment as described by one of the informants:

Because we are in public, packed together with many people from different villages [who are] not even relatives, a very sensitive issue like this one [impotence] we could not keep it a secret. And once it leaked outside the family, other people could use it to insult … they would use it to insult him. But if we were in our village the whole clan [the whole village was made up mainly of clan members] would understand the condition and how to handle him. (Case 17: Informant 2)

This informant seems to suggest that the social milieu of the camp complicated the deceased’s predicament. Thus, in addition to the lost hope of continuity of his lineage, he may also have experienced unbearable humiliation and embarrassment, with devastating impact on his perceived self-efficacy and self-esteem.

Constrained survival means

Loss of land, inability to freely engage in income-generating activities and HIV/AIDS infection constrained the survival of some of the decedents. The following quotes signify how crucial and meaningful the land was to one of the deceased: “he lost his land, the center of his life—food, clothing and medical care were coming from that piece of land he lost” (Case 15: Informant 3), or “the land was where he was born, brought up from there, he had nowhere to put his children and to feed them” (Case 15: Informant 2). Ideally, an adult man in Acholi culture is expected to provide for his wife/wives and children materially, and land used to be one of the major sources of wealth and power (El-Bushra & Sahl, 2005). Land ownership in Africa means wealth, honor, and dignity (Ojaide, 1992; Rugadya, 2009). Land was the only capital that was possessed by the majority of the individuals in the IDP camps and therefore it was “highly prized and fiercely defended” (Oxfam, 2007, p. 21). Thus, loss of land to an Acholi rural man means not only lost livelihood but also lost honor and dignity because he cannot provide for his household. The envisaged failure to live up to the normative expectations may give rise to negative self-evaluation, along with feelings of inadequacy and incompetence.

Lack of freedom to engage in income-generating activities was another factor that constrained survival means. For example, unofficial retirement from work made a decedent unable to freely engage in any profitable activities for fear of being arrested. Thus, he was forced to lead an undesirable lifestyle, and living in hiding may have become too heavy for him to bear. Constrained survival means was also related to illness. Learning that the spouse suffered from HIV/AIDS, and concluding that he might also be HIV positive evoked a high level of fear in one deceased man:

He had another wife with whom he also had one child. Initially he was not aware that she was HIV positive but when he learnt of it, his lifestyle changed completely. He started drinking heavily … He started disassociating himself from his work mates … become friendlier to his cousin, who was impotent and together they planned to die on the same day. (Case 4: Informant 3)

Because he expected that he was also HIV positive, he may have dreaded a future with AIDS. The associated stigma and/or thought of being unable to fulfill his obligations toward the rest of the family may have made him socially impotent and unable to see a future.

Loss of hope in the family’s future was a critical issue in both the young and old men. In both cases concern about the continuity of the family lineage, legacy, or livelihood seemed to underlie the loss of hope in the family’s future. However, for the young decedents, their concern for continuity was related more to how to survive in the contemporary world, whereas for the old, it was possibly about how they would be remembered in the future.

Overwhelming family responsibility

In Northern Uganda, a significant number of children were orphaned because of the war (Ntozi, Ahimbisibwe, Odwee, Ayiga, & Okurut, 1999). Thus, it was a moral obligation of the surviving aunts/uncles to take up the responsibility of the orphans. In this regard some individuals ended up inheriting many orphans, which in turn drained them not only financially, but also emotionally or psychologically. This appeared to have been the case with some of our decedents as indicated in the following excerpt:

He had to take on too much responsibility … something that stressed him so much to balance his children’s needs and those of the orphans. He was under pressure until a period came when he could not accommodate it anymore and he decided to kill himself. (Case 20: Informant 1)

In an extended family system where the children of your siblings are your children (Olaa, 2001), it was a moral and cultural obligation for the relatives of the deceased to care for the siblings’ offspring and to accord them the same privileges as his own biological children. However, given the socioeconomic hardships in the camps (Dolan, 2009), it was challenging to provide for their needs thus undermining a key masculine role.

Mental illness

Mental illness was reported to have preceded suicide in only one of the deceased. One of the informants said “[he] had a mental problem… He began isolating himself… He was a very talkative person, but at that period, he was quiet… He would sit in one position alone…” This went on for the last six months of his life. A few days before disappearing and hanging himself he complained of soldiers following him and wanting to kill him: “That very evening… he continued to another relative of ours… and talked the same thing that soldiers wanted to shoot him…. The lady looked around but there was nothing…” (Case 19: Informant 3). This person seemed to have had hallucinations that were threatening and distressing, and that may contribute to suicidal behavior (Boltin, Gooding, Kapur, Barrowclough, & Tarrier, 2007).

General discussion

Loss of dignity and social value, no hope for the family’s future, overwhelming pressures, and mental illness appear to have been important contributors to men’s suicides. Of note, however, mental illness was only described explicitly by informants in one of the 17 suicides. This is in keeping with Kinyanda, Wamala, Musisi, and Hjelmeland (2011) who found that mental illness was a factor in only two (5.2%) of the 38 suicides reported in the same region. This rate is considerably lower than the 90% reported in Western cultures (Cavanagh, Carson, Sharpe, & Lawrie, 2003). One explanation for this difference may be that such studies have tended to depend on clinical samples whereas the two studies in Northern Uganda were basically community samples.

On the whole, the analysis found that decedents had experienced a sense of loss of control or defeat, rejection or isolation, and humiliation, with no perceived possibility of changing the situation. Suicide was probably viewed as the only escape route under such unendurable circumstances. These findings are consistent with several psychological theories of suicide including escape theory (Baumeister, 1990), Shneidman’s theory of psychache (1998), the interpersonal theory of suicide (Joiner, 2005; van Orden et al., 2010), the strain theory of suicide (Zhang & Lester, 2008), and the cry of pain model of suicidality (Williams, 2001; Williams & Pollock, 2001). However, we found the “cry of pain” model and entrapment model of suicide, to encompass many elements in our study. According to this model, suicidal behavior can be seen as a reaction or a response to a situation that involves defeat, rejection, or humiliation, in whcih there is no escape and no possibility of rescue. All of these characteristics were found in this study of men’s suicide in postconflict Northern Uganda.

For example, having a great deal of social “face” is a key value in traditionally collectivist cultures like the Acholi (Heine, 2007). Through an informal school known as “wang oo” (an evening fireplace where traditional knowledge is passed on to young generations), Acholi men are socialized into being an “ideal Acholi man,” one who is strong and capable of providing for and defending his household as well as his community. He is in control and able to exercise power over others (El-Bushra & Sahl, 2005). In keeping with Shneidman (1998), for Acholi men, these characteristics probably signify what Schneidman (1998) has termed “vital needs,” the source of their self-esteem and social value. Unfortunately, the war destabilized rural Acholi families, interfering with traditional processes of socialization and social transformation of young men into socially valued adults who are able to live up to the cultural expectations. Hopelessness and despair at the failures to achieve the status of an adult was common among the young men who died by suicide. This may have been intensified by adherence to traditional gender role ideals. According to Möller-Leimkühler, (2003), men who choose to behave according to traditional masculine values are intolerant to loss of mastery and control and are most likely to use suicide as a stress response.

Acholi is an interdependent society and thus continuity of the family lineage is vital to men’s survival. Uganda, like other low-income countries, lacks resources to adequately care for and support the elderly who are therefore dependent on their children. Thus, the absence of children, especially male children, threatens not only the continuity of the lineage but also the social security of parents in their old age. Because of the mass killings and abductions, which mainly targeted men, some individuals found themselves as the only male survivors of their homestead. This raised serious concern for their future survival and well-being and may have threatened their sense of belonging, a core motive for human behavior that enables people to survive and thrive (Fiske & Fiske, 2007). In turn, this may have given rise to intolerable feelings of loneliness, hopelessness, abandonment, and possibly anger or guilt for having survived the turmoil.

Similarly, Acholi is a traditional patrilineal culture with an extended family system. Child rearing is a responsibility of all the adults in the family. Again, because of the conflict that claimed the lives of many, it was imperative for any surviving adult in a household, even in abject poverty, to shoulder the responsibility of looking after the children left behind. It was common to find an elderly man or woman caring for over 20 orphans whose parents had been brutally murdered, with such memories still vivid in their minds. In addition to such overwhelming responsibilities, the caretakers might also be struggling with their own traumatic bereavement (Worden, 2009). They were then trapped between a horrific past and a dim and uncertain future.

The findings seem to indicate that failure to live up to social expectations as Acholi men was an overarching factor in the suicides. Similar observations were made by Dolan (2009) in Northern Uganda, who found that the majority of male suicides were related to an inability to live up to the gendered social expectations, that is, to a loss of masculinity (Dolan, 2009). The effects and after-effects of war challenged the men’s ability to be “men,” causing identity or existential crises for many. They felt trapped in unbearably stressful circumstances which were (or were perceived to be) inescapable, and for which suicide was probably the only escape route. And, since the means of inflicting harm were readily available, one could easily end up taking one’s life. For example, an organophosphate pesticide (locally known as “Sibaco”), is openly sold in the local shops. Although selling it to women was restricted because they were increasingly using it to attempt suicide, men could readily buy it (personal communication from the elders and informants).

Conclusion

This study has illuminated psychosocial factors that may have played a significant role in men’s suicides in postconflict Northern Uganda. The study revealed that men’s suicide was basically associated with the failure to adjust to the changed and challenging socioeconomic and cultural environment brought about by the two decades of armed conflict in the area. This made men feel disempowered and disenfranchised and in turn led to loss of self-worth and social value.

When people are settled back in their former villages it would be ideal to monitor the occurrence of suicide and note whether the mentioned factors still count in the Acholi’s settled life. Furthermore, this study should be replicated in other communities in Uganda that have been relatively peaceful to clarify what role the predicaments created by the conflict play. Although a number of theories developed in the West seem to be applicable to the findings of this study, there is a need for studies aimed at theory development in Ugandan cultural contexts.

Psychological autopsy studies have the inherent limitation of potential reporting biases by the informants. We tried to reduce this by triangulation in data collection and analysis. Another major challenge was the use of interpreters. Because the majority of the informants could only speak the local language, the interview had to be held through an intermediary who only summarized the information for the researcher during the interviews. Thus, it was sometimes not possible for the interviewer to probe some crucial areas. Nevertheless, the translated transcripts still yielded very rich descriptions with implications for suicide prevention.

Any suicide prevention strategy should aim at rebuilding men’s confidence and positive self-evaluation. This requires a public health and a multidisciplinary approach for suicide prevention, involving not only the health sector but also other social sectors like gender and community development in addition to the cultural institutions. Through vigorous sensitization of the public, men and women in this region have to be helped to appreciate how the traditional gender roles (productive for men and reproductive for women) have evolved over time due to the protracted war and the prevailing socioeconomic changes. However, such changes have not affected the patriarchy system of Acholi, where the man continues to be the head of the family. The current economic and political empowerment of women should be viewed as helping to supplement the household’s income (Olaa, 2001).

Furthermore, the Acholi people need to be helped to initiate or to strengthen the existing community-based psychosocial support groups geared toward identifying and responding to the psychosocial needs of men and community members in general (Kizza et al., 2011). Apart from helping to supplement the scarce financial and human mental health resources (WHO & Ministry of Health, Uganda, 2006), such community initiatives are sustainable because the communities get to own them. Such community-based initiatives have been successful in Adjumani, a district that also had a high incidence of suicide (Ovuga, Boardman, & Wasserman, 2007). In this district, a community voluntary organization was initiated to respond to the high level of suicide and alcohol use problems. One important resource the Acholi have is the spirit of togetherness and readiness to participate in suicide prevention in their communities (Kizza et al., 2011), and this can be mobilized in future efforts.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1

Acholi cultural values include among others those aspects that pertain to manhood and womanhood. An ideal Acholi man was one who was a strong fighter and protector, who was never defeated and never gave up, a provider and controller, a figure of authority and a leader. In contrast, an ideal Acholi woman was described as humble, gentle, and submissive to authority (El-Bushra & Sahl, 2005)

3

Basoga is one of the major ethnic groups in Eastern Uganda.

Dorothy Kizza is a PhD student at the Department of Social Work and Health Science, Norwegian University of Science and Technology, Trondheim, Norway, and a Principal Clinical Psychologist at Butabika National Referral and Teaching Hospital Kampala, Uganda.

Birthe Loa Knizek holds a PhD from The Qualitative Methods Center, Psychology, Aarhus University, Denmark. She has a position in the Faculty of Nursing, Sør-Trøndelag University College, Trondheim, Norway. Her current interests in suicidology include theory development, attitudes towards suicidal behaviour and suicide prevention, cultural aspects of suicidal behaviour, methodological (qualitative) challenges as well as the intersection between morality/spirituality in suicidology. She also works clinically with children and adolescents.

Eugene Kinyanda is a Consultant Psychiatrist working as a Research Manager with the MRC/UVRI Uganda Research Unit on AIDS. He obtained a PhD in Suicidology at the Norwegian University of Science and Technology in 2006 and has since then undertaken considerable research and publications in the area of suicide in the African sociocultural context.

Heidi Hjelmeland is Professor of Health Science at the Norwegian University of Science and Technology, Trondheim, as well as Senior Researcher at the Norwegian Institute of Public Health, Oslo, Norway. She is currently Vice President of the International Association for Suicide Prevention, Coeditor of the journal Suicidology Online as well as member of the Editorial Boards of the journals Crisis and Suicide and Life-Threatening Behavior.

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