“I didn’t do it!”: Lived experiences of suicide attempts made without perceived intent or volition

Introduction

Suicide is widely accepted as a willful intentional act to end one’s own life. However, suicide intention cannot be conceptualized as binary “intending to die” versus “not intending to die,” as suicide intent is more effectively understood across a spectrum. Some individuals attempt suicide as a cry for help with no intention to end their life (Freedenthal, 2007), while others may attempt suicide based on a poorly defined, vague, impulsive, or partially constructed intent, with a less than clear understanding of the results of their actions (Ledewitz, 2001). For others, their intentions are based on feeling trapped in current circumstances or not wanting to live, rather than an aim to end their existence. Researchers contend that suicidal intent is difficult to assess and individuals attempting suicide do not always know what their intentions are at the time of the attempt (Hjelmeland, 1996). Although death can accidently occur as a result of one’s own actions (e.g., unintentional overdose, autoerotic asphyxiation, etc.), these actions are not defined as a suicide attempt (Rockett & Caine, 2020). A suicide attempt, however, as per its definition does require some degree of intent, whether a fully intentional act or a less defined thought. This research focuses on a rare phenomenon where some individuals attempted suicide without any discernible intention or self-agency in their identifiable suicidal action, but where the action is in no way defined or understood as an accident.

This study is based on prior qualitative grounded theory research in Central Asia (Savani, 2020) investigating 12 individuals who self-identified as having made a suicide attempt. Four participants interviewed identified their suicide attempts as having occurred without perceived ideation, intention, agency, or volition. To fully examine this phenomenon, a thematic secondary analysis was conducted on the described lived experiences of these individuals. This research will further describe the differences between the four individuals attempting suicide without agency and those eight individuals who knowingly attempted suicide.

Suicide is a serious and complex problem experienced in every region across the world. Although 79% of all suicides occur in the low- and middle-income countries around the world (WHO, 2019), most research on suicide is conducted in richer countries. Across the world, suicide appears to have different epidemiology, with causes ranging from biology, genetics, and mental health, to religious, spiritual, familial, social, and economic. In many Asian countries, risk factors for suicide relate to social problems like family disputes, unemployment, and gender-based violence rather than individual, mental health issues (Goldsmith et al., 2002; Vijayakumar, 2015). The current study was conducted in Central Asia, where suicide is poorly researched despite high rates in the region (Savani et al., 2020).

This study is a secondary analysis of the interview data collected for a prior grounded theory project. The study aims to explore the particular phenomenon of suicide attempts without intention, volition, or agency. Initial data collection revealed one-third of participants experienced an unusual, out of the ordinary, trance-like state during their suicide attempt, which they described as unusual, uncharacteristic, and novel. Of the 12 (seven female and five male) participants who made a suicide attempt, four participants (one female and three male) reported no ideation, no plan, no volition, and no agency in the attempt. Nonetheless, each of these participants clearly described becoming aware of their suicide attempt after the act; this history was often supported by family members. These participants reported making their attempt in a state where they were not conscious nor had any awareness of making the attempt, nor any pre- or post-suicide intention. This study is guided by the following research questions:

What are the lived experiences of individuals who made a suicide attempt without perceived intention, ideation, volition, or agency?

Methods

Findings

Of the 12 participants interviewed, seven were female and five were male, with an average age of 34 years. Most participants resided in rural areas (n = 9), were married (n = 7), were of low socioeconomic status (SES), and self-identified as religious based on their participation in prayers and other religious activities (see Table 1 for further demographic data). Religiosity was coded from transcripts. Participants who were coded as using more religious terms (five words or more) were categorized as “very religious,” whereas participants who used fewer terms (fewer than five words) were categorized as “religious.” Specifically, all 12 participants identified as being practicing Muslims. Eight of the 12 participants reported knowing someone else who had either attempted or died by suicide. All 12 participants were from different villages in the province and had no geographical proximity to each other.

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Table 1.

Participant demographic information.

Sex	Age	Rural/urban	Marital status	Education	Employment status	SES	Religiosity*	Family support	Method	Impulsive attempt
F	23	Rural	Single	Bachelors	Employed	Poor	Religious	Low, living alone	Poison	Yes
F	22	Rural	Single	Bachelors	Unemployed	Poor	Religious	Low, living alone	Poison	No
M	42	Rural	Married	High School	Self-employed	Poor	Very religious	Strong	Drowning	Yes
F	20	Rural	Single	Some college	Unemployed	Poor	Religious	Low, living with father	Poison	Yes
F	20	Urban	Married	Some college	Self-employed	Poor	Religious	Low, joint family situation	Poison	Yes
F	38	Rural	Married	Some college	Business owner	Poor	Very religious	Low, unsupportive husband	Drowning	No
F	36	Urban	Married	Masters	Employed	Not poor	Very religious	Strong	Drowning	No
M	40	Rural	Married	Some college	Self-employed	Poor	Religious	Strong	Hanging	Yes
F	40	Urban	Married	Some college	Unemployed	Poor	Religious	Low, abusive husband	Poison, drowning	No
M	20	Rural	Single	Some college	Student	Poor	Religious	Yes	Hanging	Yes
M	46	Rural	Married	High school	Employed	Poor	Religious	Strong	Hanging, poison	Yes
M	62	Rural	Divorced	Some college	Partially employed	Very poor	Religious	None	Hanging	Yes

Four of the 12 participants in this study made a suicide attempt without any reported intent, ideation, plan, or agency. Each of these four participants self-identified as being religious. Further, none of these participants reported to have any mental illness, including psychotic disorders, mood disorders, substance use disorders, or personality disorders, and were very functional in their daily lives. Each of these four individuals reported that they did not have any significant reason to kill themselves. They also reported having no prior intent to end their lives. These participants described that the suicide attempt happened to them and that the action of making the suicide attempt was not of their own doing. Three of these four participants attributed their attempt to an altered state of mind, akin to being in a trance. They described their experience as related to the metaphysical realm and made sense of their attempt in religious and spiritual terms. Further, each of these participants stated that they did not want to ever attempt suicide again and were afraid that this would happen to them in the future. Table 1 presents the demographic characteristics of these four individuals shaded in grey.

Describing the trance-like state

Four of the 12 participants who made a suicide attempt reported having no ideation, plan, agency, or awareness of the attempt, as if the attempt occurred while each was in an altered state of mind. Participants described the experience of the suicide attempt as being in an out-of-reality, almost trance-like state. They each described themselves as though they had no control over what was happening to them. Participants talked about being possessed by the spirits, an idea that is not uncommon in this region of the world. One participant used the word wahm, a Shughni word used to describe a state in which one feels attacked by the spirits, not in control of one’s own thoughts and behavior, and experiences a choking sensation with liquid coming out of the nose and mouth.

None of the participants used the word “trance”; the researchers used the term as it reflected the similarly described experiences. All these four suicide attempts were described as a sudden occurrence, made on impulse. According to the participants, the attempt was a sudden event that happened in their life. One participant said while describing the event that “it came suddenly.” They described their experience as an abrupt and swift episode, which they later came to know as a suicide attempt. These were remarkable findings in the data and were a significant factor associated with suicide in this geographical and cultural context. Participants attributed their attempt to an experience that was difficult to explain with logic. This experience was reported as frightening, confusing, illogical, and bothersome. However, the other eight participants who knowingly made their suicide attempt did not report any such experiences, even though some of their attempts were impulsive.

Common themes in trance-like suicide attempts

In comparing the participant interview data for the four individuals who had no perceived agency in their suicide attempt with the data for the eight participants who were aware, intended to attempt, and acknowledged their attempt, there were unique differences. In closely examining the textual data from the four participants in the trance-like suicide attempts, some common themes emerged which were not found in the data on the other eight participants.

Discussion

Four out of the 12 people interviewed for this study reported making a suicide attempt without perceived intent, or otherwise acknowledging agency in the attempt. For these participants, something unusual in their suicide attempt reportedly occurred. One participant described their suicide attempt as something “I did not do.” This was a unique phenomenon reported by some individuals, which we were unable to clearly identify elsewhere in the literature. While a number of medical, psychiatric, cultural, and environmental possibilities may exist for these rarely presented experiences, which are explored below, an unexpected phenomenon emerged in this study. While not identified, reported, or examined in the literature, some participants clearly reported that it is possible to experience such occurrences.

This rare phenomenon of suicide attempts where participants claim to not have intention, ideation, or agency has some unique features. These attempts were highly impulsive actions, described as sudden occurrences. Individuals stated never thinking about suicide prior to the attempt and having no reason to consider suicide, yet they experienced a suicide attempt. These phenomena were also events where participants claimed to not know what happened and questioned why such an event had occurred. Moreover, participants stated that the action of the suicide attempt was not carried out by them and that it was not of their own doing, as if someone or something had taken over and they were left with only a partial memory of the event. In addition, participants ascribed spiritual or transcendental meanings to these occurrences, but it remains unclear if this was done because these phenomena were hard to explain in any other way.

The occurrence of suicide attempts occurring without perceived intent, ideation, plan, volition, or agency raises a number of possibilities. First, that such a phenomenon may have been proxies for other conditions relating to medical, mental health, or substance use issues, cultural or religious factors, environmental or community factors, or individual coping mechanisms, as discussed below. Second, that such a phenomenon reflects experiences that truly exist, that may be specific to some cultures across the world, and that the research and clinical communities need to explore and examine further.

Suicide attempts without ideation, intention, or agency may be related to medical, psychiatric, substance use, cultural or environmental factors. There is some evidence for such attempts being related to certain medical conditions. Studies have found unusual and dramatic self-injurious behavior related to Acute and Transient Psychotic Disorder (Harish et al., 2012), where there is often no cognition or memory of the suicide attempt. Research indicates that suicide attempts that are associated with substance use and depression may limit the cognitive abilities of the attempters (Mean, et al., 2005; Suominen et al., 1996). In addition, there is evidence of such suicide attempts occurring in an altered state of mind where individuals deny having agency in or memory of the act that seemed like a suicide attempt (Waltzer, 1968). Occurrences like such suicide attempts where there is a sudden, fleeting occurrence of unusual behavior where intent or memory is lacking are reported to be more common in low- and middle-income countries (Pillmann et al., 2003).

In our findings from the participants who spoke of such suicide attempts, no prevalence of such medical conditions or mental health / substance use issues was identified, but full assessments were not conducted. While there is a possibility that these participants may have suffered from a psychotic disorder during the time of their suicide attempt that led to the lack of intent or awareness about the attempt, when interviewed these participants presented as oriented, coherent, and lucid; they spoke clearly and understandably and did not demonstrate any unusual or abnormal behavior. Also, these participants went about their normal life and were demonstrably functional as a teacher, a store owner in retail business, a farmer, and a student. None reported impairments in their social and occupational functioning.

Another possibility for these unusual suicide attempts could be related to religious and cultural beliefs. Research has posited that suicidal behaviors and meanings are influenced by culture (Chu et al., 2010; Lester, 2009). In the aftermath of their attempt, three out of the four participants ascribed religious meaning to their attempts. Participants spoke of being possessed by the spirits, communicating with the dead, and being asked to carry out an action by a mystical figure all dressed in white. In many Asian countries, the color white is associated with piety, religiosity, wisdom, and religious leadership. Conversely, participants may have intentionally or unintentionally borrowed local religious and cultural norms and symbolism to rationalize their suicide attempt. Researchers have found that notions of being possessed by the spirits are associated with mental disturbances and out-of-the-ordinary behavior in many parts of the world (Arieli & Aychen, 1994). In addition, the idea of being possessed has been posited in low-resource contexts as an explanation for behavior that is unknown and cannot be explained (Ventriglio et al., 2018). Further, attributing mental illness or other out-of-the-ordinary behavior to supernatural forces is not uncommon (Dein & Illaiee, 2013). Specifically, the concept of jinn possession among Muslim communities has references in the Quran and has historically been used to explain serious mental illness (Islam & Campbell, 2014). Scholars have researched the idea of jinn possession in relation to mental illness, epilepsy, and other illnesses within Muslim communities (Obeid et al., 2012). In our findings, one participant spoke of having wahm, which refers to being attacked by the spirits and not in control of one’s own thoughts and behavior. The concept of wahm, although prevalent in the Central Asian context, has unfortunately not received much attention in the literature. The meaning of the suicide attempt event within this study highlights the cultural importance of understanding suicide attempts. In Chu et al.’s (2010) cultural model of suicide, three theoretical principles are identified within minority groups, specifically how culture affects: the types of stressors that lead to suicide, meanings associated with stressors, and how suicidal thoughts and attempts are expressed. Although this study examined the dominant culture rather than minority cultures, findings may lend support to the third principle that culture affects how suicidal attempts are expressed. Future research exploring the cultural model and theories of suicide are recommended.

One participant spoke of having a conversation with her deceased father, another spoke of seeing someone who appeared to him as a religious authority and took him to hang himself, and another spoke of experiencing wahm. Three of the four participants spoke of being in a space where something happened related to the supernatural. Each of the participants were open and engaging during the interview. They presented as oriented, with normal attention and concentration, cognitively lucid, readily able to recall past events, and demonstrated an appropriate range of affect during the interview.

Also, these experiences could be related to the societal, community, and religious pressure on their behavior. Some scholars have reported that individuals who hurt themselves may deny suicidal intent or pretend to have intent for other gains (Freedenthal, 2007). In the local religious and legal context, suicide is forbidden. Study participants identified as Muslim, reflecting the dominant religion in their larger community and regional population. The Quran has explicit prohibitions around suicide, as does the country’s legal code that decrees aiding and abetting suicide a punishable offense (Mishara, 2020). With clear negative proscriptions against suicide, community responses to suicide are often highly stigmatized, with categorical condemnation of suicide the norm. Individuals who attempt suicide risk tarnishing their public image as a good Muslim and a good citizen, should it be discovered that they have attempted suicide. Although these individuals may not be intentionally hiding evidence of their actions, they may be under extreme pressure to provide alternative explanations for such taboo action such as supernatural or spiritual attributions. Such responses may be tacit and a consequence of living in a society that condemns suicide and may also be a way for some people to save face and family honor, and avoid stigma of mental illness, as has been identified in other Muslim contexts (Khan and Reza, 2000). Consequently, these suicide attempts without agency could be a response to negative social and community judgement frequently ascribed to individuals engaging in suicidal behavior.

The religious and moral code in this context bans suicide. The Quran is more explicit and harsher about prohibiting suicide than the Bible (Alonzo & Gearing, 2018). Two specific verses of the Quran that condemn suicide are: “And do not kill yourselves. Surely God is Most Merciful to you” (Q 4:29) and “And do not throw yourselves in destruction” (Q 2:195) (Ibrahim, 2020). Further, several prophetic traditions continue to maintain the prohibition of suicide and the value and sanctity of human life (Shah & Chandia, 2010). The socio-cultural-religious context of Tajikistan, the rural, traditional environment, local suicide beliefs and taboos, and the Quranic prohibitions of suicide create a backdrop where acknowledging a suicide attempt may be perceived as shameful and there may be significant public pressure to “conform” to the religious code as a Muslim. In doing so, there may be internal pressure to deny thinking about, planning, or engaging in any suicidal behavior. In the aftermath of a suicide attempt, belief that there was no suicidal intent or agency may provide a way that a “good” Muslim may avoid ongoing negative stigma. Consciously acknowledging the attempt and/or internalizing the belief that they made the attempt may be going against a negative ingrained dogma of suicide prohibition for some individuals. Stigma and/or cultural norms pressuring some to observe and follow the moral code may have been a defining feature of how these individuals conceptualized their suicide attempt.

The spiritual or transcendental meaning ascribed to the suicide attempt may have provided an effective defense structure designed to reconcile with what was forbidden in Islam, such as a suicide attempt. All four participants were Muslim, and as a faith, Islam prohibits suicide. The faith of all four participants may have been a barrier in confronting or acknowledging what really happened, and the spiritual/transcendental meaning ascribed to the attempt may have been an interpretation of the event that these participants were able to live with. For instance, one of the four participants said that suicide was wrong for Muslims, and it was the worst behavior that a Muslim could engage in. She said: “It [suicide] is worst for Muslims, God gave to us soul, a clean soul, and we have to give it back clean—but not this way, not with suicide—only if God wants.” While other participants did not say this specifically about suicide, all of them acknowledged being Muslim and practicing the faith. In addition, talking about the suicidal behavior as an action where they did not make the attempt or have agency in their suicidal behavior may have lessened the perceived community stigma or burden that came with having made a suicide attempt in this religious context. Suicide attempts where survivors deny intent, ideation, or agency, or attribute it to supernatural causes remain hard to explain given the insufficient knowledge, insight, or tools available to examine such behavior. Specifically, the concept of wahm or jinn possession as it relates to mental illness and suicide attempts in Muslim communities needs to be investigated further. Research that relates to individuals identifying as Muslim and representing mental illness or suicide attempts being influenced by wahm needs further attention.

Notwithstanding the cause of these non-agency suicide attempts, there are implications for assessment and treatment across cultural groups. The phenomenon of non-agency suicide attempts may pose potential clinical implications. Standard assessments as they are currently constructed to assess and identify risk for clients may not capture this phenomenon. If clinicians are unaware that such phenomena could exist, they may not be asking questions to identify these experiences. The Columbia-Suicide Severity Rating Scale (Posner, 2011) and other established instruments are not built to capture the described experiences and may not be able to assess suicide risk accurately when used.

It is recommended that suicide assessments in contexts where such rare suicide attempts do occur may have to be modified. For example, questions like “Have you ever had an experience where you put your life in danger without wanting to do so or without realizing that you are doing so?” need to be considered as potential additions to clinical assessments. Clinical suicide assessments and research on lived experiences of suicide need to capture such phenomena that may not seem like clear suicide attempts. If these occurrences do exist and may be experienced by some individuals, further understanding and investigation is warranted on this phenomenon.

Limitations

This is the first study to investigate suicide among the population in Badakhshan, Tajikistan; a remote Muslim province of Central Asia. This study set out to explore the lived experiences of suicide in this limited geographical location. A major limitation of this study is its small sample size. The original grounded theory study included data from 12 participant interviews. Of these, only four participants had suicide attempt experiences without ideation, intent, volition, or agency. This is a relatively small number of participants, limiting the inferences that can be made with this research. Another limitation of the study was an entirely female research team (resulting in more female participants) and the author’s inability to speak the local languages. Further, data collected by the research assistants in the local languages were directly transcribed into English and not translated back into the original language. Given that there is a paucity of prior research on suicide in Tajikistan, and there are no studies in the province of Badakhshan, the present study is limited.

Conclusion

Studies show that 48% of suicide attempts occur within 10 min of thought (Deisenhammer et al., 2009; Hawton, 2007; Simon et al., 2005), and some of these may take place much more quickly and impulsively. This study examined rare occurrences of suicide attempts in which individuals seemed to not have intention, awareness, or agency of action, but attempted to end their lives to their own surprise and that of family and friends. The study explored these suicide attempts through the lived experience of four suicide attempters. Results indicate that these attempts were impulsive, participants had no control over what happened to them, and most participants attributed their attempts to a spiritual experience. Unintended suicide attempts represent a rare, yet real, phenomenon that is embedded in local cultural and family context and demands greater attention from psychiatric clinicians and researchers. In geographical contexts where such suicide attempts do occur, suicide prevention and intervention efforts need to identify and address these phenomena.