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Khatami M, Khodabakhshi-Koolaee A. An Analysis of Meaningless and Absurd Experiences in Unsuccessful Suicide Attempts in Iran. PCP 2021; 9 (1) :61-70
URL: http://jpcp.uswr.ac.ir/article-1-730-en.html
1- Department of Psychology and Educational Science, Faculty of Humanities, Khatam University, Tehran, Iran.
2- Department of Psychology and Educational Science, Faculty of Humanities, Khatam University, Tehran, Iran. , a.khodabakhshid@khatam.ac.ir
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1. Introduction
Suicide is a bitter, permanent, irreversible, and irreparable solution to a problem(s) that are usually temporary (Soreff, Basit, & Attia, 2017). In its 2020 report on Suicide Prevention Day, September 10, the World Health Organization (2020) stated that suicide kills 800000 people worldwide each year, or one in every 40 seconds in the world. For every successful suicide, there are 20 unsuccessful suicides. Suicide is the second leading cause of death for people aged 15 to 29. The highest suicide rate (79%) is seen in poor or middle-income countries. The highest suicide rates are in Lithuania with a suicide rate of 31.9 per 100000 people, Russia with 31, the Republic of Guyana in Latin America with 29.2, and South Korea with a suicide rate of 26.9, accounting for the four highest suicide rates in the world. In the meantime, Iran, with 5.3 per 100000 people, is ranked third in terms of the suicide rate among Islamic countries; that is, more than 13 people commit suicide daily in Iran, most of whom are between the ages of 15 and 35 (World Health Organization, 2020). In 2019, The Centers for Disease Control and Prevention reported that the suicide rate in the United States increased by 30% from 2000 to 2017 (Miron, Yu, Wilf-Miron, & Kohane, 2019).
Suicide bereavement can continue and have devastating effects on individuals and communities. Studies have shown that, on average, five immediate family members and more than 135 other individuals can be harmed by the suicide committed by a person (Andriessen, Krysinska, Kõlves, & Reavley, 2019). Since ancient times, human rights have always been the subject of controversy over the rights of society, and the question has been raised as to whether individuals have the right to end their lives or killing themselves is morally wrong (Douglas, 2015).
It should be noted that at some point in history and in some cultures or for some philosophers, suicide has not been considered as an abnormal, disturbing, and destructive phenomenon. For example, among the ancient Greeks or Romans, death was not considered a significant and unfortunate issue. In their philosophy, art was how to die, or in ancient Japan (before the Meiji Revolution and the formation of modern Japan), suicide (Hara-kiri) somehow brought honor to the discredited dignity of man. Even some contemporary philosophers, like David Hume, considered suicide to be a human right (Liubov, 2014). Another contemporary example is the acceptance of the right to suicide in Switzerland. In Switzerland, since 1941, suicide has been declared legal and free for people suffering from incurable diseases. Of course, committing assisted suicide is considered legal if it meets two conditions: First, the assistant is not a physician. Second, he/she does not gain any benefit from the death of the person who wants to commit suicide (Gaignard & Hurst, 2019). The existentialist view looks at the phenomenon of suicide more rationally than pathologically. 
In this view, meaninglessness and existential isolation may lead one to commit suicide in response to environmental stressors and existential sufferings and worries about the meaning of life; the meaninglessness and emptiness of life are at the heart of suicidal ideation (Orbach, 2008). In the same study, Gamondi, Pott, Preston, and Payne (2020) considered the suicide of a family member to be a personal matter and believed that it was outside the physician’s jurisdiction except in certain circumstances. There are many reasons for suicide, some of which are as old as human life. Previous studies have examined some of the causes of suicide. Bryan, Rudd, and Wertenberger (2013), for example, stated soldiers commit suicide to reduce psychological distress. Other researchers have considered economic crises as one of the causes of suicide (Economou et al., 2013; Simou & Koutsogerogou, 2014; Antunes et al., 2015). Mohammadi et al. reported suicide attempts in Iran. They indicated that based on 25180 subjects interviewed, face-to-face, at home, the lifetime prevalence was 1.4% (0.9% males and 2% females). The majority of attempters were 26-55 years of age, married, more highly educated, female, retired, and lived in urban areas. Many of the attempters (45.3%) reported at least one psychiatric disorder during their lifetime. Major depressive disorder (22%), panic disorder (6.3%), and obsessive-compulsive disorder (6%) were the most common disorders (Mohammadi et al., 2005).
Suicide is treated differently from country to country depending on cultural, religious, and contextual circumstances. This study deals with the meaninglessness and absurdity of life in the stories and experiences of Iranian participants. Since the concept of suicide is a complex, multi-layered and deep pathological issue, and it is not possible to have a deep understanding of it except with a full understanding of the life story and lived experience of the person committing suicide, this study employed a phenomenological approach to explore the experiences of people attempting suicide. Descriptive phenomenology has a more flexible structure in exploring and explaining a subject (Rezaei, Khodabakhshi-Koolaee, Falsafinejad, & Sanagoo, 2020). 
It is a suitable method for understanding the lived experiences of individuals. Besides, it is a scientific method that summarizes the topics with a subjective approach. This method can be implemented through face-to-face semi-structured interviews to establish a deep and empathetic relationship with the participant. As a result, it enables the researcher to have a better understanding of the lived experience of the individual and finally to come up with a deeper interpretation and explanation of the subject. This study can provide useful insights for psychologists, counselors, and researchers about why people commit suicide and help them have a deeper understanding of the link between real external shortcomings and internal sufferings of the suicidal person. Accordingly, the main purpose of this study is to answer the following question: What are the meaningless and absurd experiences of people making unsuccessful suicide attempts? 

2. Methods
The present study employed a qualitative approach and a descriptive phenomenology to explore the structure of various types of experience such as perception, thought, memory, imagination, emotion, desire and will, physical awareness, physical action, and social activity (Smith, 2013; Rezaei et al., 2020). In this study, the people who attempted suicide described their stories, experiences, or feelings to the researcher. Afterward, the researcher recorded and interpreted their statements to determine the lived experience of the person by analyzing the feelings of absurdity and meaninglessness in unsuccessful suicide attempters. The participants in this study were unsuccessful suicide attempters hospitalized in the intensive care unit of Loghman-e Hakim Hospital in Tehran during summer 2020. The inclusion criteria include being a man, attempting suicide, being admitted to a hospital by a psychiatrist, and 18 to 40 years old. The exclusion criteria were reluctance to continue the interview or having an acute physical illness at the discretion of the hospital physician. 
The participants were selected using the purposive sampling method, and sampling was continued until data saturation, i.e., when the interview with new participants did not reveal new information or themes in the data (Cresweel & Baez, 2020). Accordingly, the collected data were saturated after interviews with 15 individuals who had attempted suicide up to 30 days before the interview date. Each interview lasted 30 to 60 minutes, for a total of 540 minutes. To avoid bias and errors in determining data saturation, three professors of Psychology, Psychiatry, and Nursing reviewed the collected data and the interviews continued until they confirmed the adequacy of the data.
The data were collected using semi-structured interviews with the participants. Before starting the interview, the researcher provided the participants with some explanations about the research procedure and how the interviews are conducted. Then, the researcher recorded the participants’ demographic characteristics. The psychologist (researcher) was responsible for the semi-structured interviews. He had a Master’s degree in Clinical Psychology. The main questions asked in the interviews were: 
What life experiences did you have that led you to commit suicide? 
What was the reaction of those around you to your suicide? 
What emotions and thoughts did you experience in the minutes and hours before the suicide attempt? 
What is your general attitude towards life?
Does life have a special meaning for you? 
All interviews were conducted face-to-face. At the end of each interview, the recorded interviews were transcribed for subsequent coding and analysis. Data analysis was performed using Colaizzi’s seven-step method (Shosha, 2012).
In the first step, at the end of each interview and taking field notes, the recorded statements of the participants were listened carefully and transcribed word for word. The transcripts were then reviewed several times to uncover the participants’ feelings and experiences. In the second step, significant statements related to the phenomenon in question were underlined and extracted. In the third step, the related themes were extracted and categorized. Besides, each significant statement recognized previously was reviewed, and the underlying theme reflecting the participant’s main idea was identified. Afterward, the relevance of the identified themes with the original statements was checked and confirmed. In the fourth step, the researcher carefully reviewed the themes developed and placed them into thematic clusters based on their similarities. In the fifth step, the themes describing the phenomenon under study were merged into more general categories. In the sixth step, an exhaustive description of the phenomenon under study was presented. In the final step, the coded data were verified by presenting them to the participants and confirming the findings.
The robustness of the data was further checked using the credibility criteria proposed by Guba and Lincoln (Lincoln & Guba, 1990; Cope, 2014). Accordingly, the researcher focused on selecting the appropriate context, triangulation of the data obtained from the interviews with the previous studies in the literature on failed suicide attempts and their underlying causes, exploring the participants’ experiences, and involving them in the interpretation of the data, asking the participants to review the data, and providing a detailed description of the procedures taken to conduct the study. Besides, the professors working in the Nursing and Psychiatric Research Center of Golestan University of Medical Sciences were asked to peer check the data. Written consent was obtained from the participants for the interviews and for recording them. The participants were told that their participation in the study was voluntary and they could leave the study at any stage they wished. They were also assured that their names, addresses, and phone numbers would be kept confidential. Besides, after transcribing the interviews, the participants’ recorded voices were deleted. This research was registered at Khatam University of Tehran under the code of ethics IR.KHATAMU.REC.1399/3.

3. Results
Table 1 presents the descriptive statistics for the participants’ demographic data. 

The analysis of the lived experiences of the participants who attempted unsuccessful suicide revealed four main themes and 22 subthemes, as shown in Table 2. 

The main themes and subthemes extracted in this study are discussed based on the participants’ experiences and statements. 
Underlying and revealing causes of suicide
Failed love experiences: “Honestly, I’m in love with a girl I met at university, and we have been friends for about a year, but our parents are against our marriage, so I committed suicide” (Participant #12).
Parental separation experience during childhood or adolescence: “The separation of my parents at the age of 15 had a nasty effect on me. I felt I was lonely and sad. Of course, my mother was living with me, but my father left us. I just started enjoying life when my parents separated” (Participant #2).
Deception, lies, or violence committed by other people: “I hate lies. Everyone lies to each other. My friend once told me to go out of town by car, I went with him, but he and two other people took me out of town and beat me severely because I started seeing his girlfriend” (Participant #12).
Poverty: “Yeah, no money. When you go out with your friend, but you do not have money to buy something and let him buy you something for you. What about the next time? Or when your friend says, let’s go out to the park and buy some food, I have to reject his offer as I have no money. I’m feeling bad when I have no money; why you should live in this world when you have no money” (Participant #6).
Lack of autonomy and the need for self-esteem: “Money makes everyone happy. It induces your self-esteem, but when you do not have it, you are nothing. Nobody talks to you. Even your parents do not count on you” (Participant #15).
Constant conflict with the spouse: “I feel the home is like a barracks, and she is my commander, not my wife, a bullying superior. I get angry when she orders me to do this and not to do that. I don’t respond. She always likes to give orders, especially in the presence of others, even about small things. She always tells me what to do and what not to do. My wife has made me tired of life; I took pills not to feel anything anymore. I wanted to get rid of this woman” (Participant #4).
Not being understood and emotionally supported by the parents: “I have studied at the University of Tehran, and am relatively economically prosperous, smart, and physically healthy, but I wanted to kill myself because I was tired of my parents. My family does not care about me. They do not understand me. We are always arguing, and they humiliate me before others” (Participant #8).
Parental strictness and control: “No, it’s not good at all. My parents always get on my nerves and are very strict. They even blame me for the way I talk and pick on me for why I did this, talked like that, and why I’m wearing these clothes, why I got tired of them. I do not know where to flee, and I wanted to kill myself to get rid of them, but I couldn’t” (Participant #11).

Outburst of feelings and thoughts before suicide
Feeling lonely: “I always felt lonely as if I had no one in the world” (Participant # 1). 
Feeling sad: “I am sad and unhappy. Who am I? Nobody. I have nothing valuable in my life to be proud of. I felt I’m fragile. I used to compare myself with others who had money and many other things” (Participant # 2).
Feeling comfortable and relaxed with indifference: “I felt terrific before I killed myself and thought that I was getting rid of this damn life: That everything just ends and I get rid of this boring life and that tonight is the last night. I was even somehow happy” (Participant # 9).
Feeling bored and impatient: “I was upset, I was tired of all this repetition, I was saying things are repeated every day, a job every day, saying the same things every day, a kind of boring life every day” (Participant # 2). 
Feeling of despair and hopelessness: “The keyword I use for such situations is to feel miserable, that is, you are forced to do things, and there is no way out. I call this situation a real misery” (Participant #12). 
Feeling meaningless, empty, and worthless: “I told myself that nothing is worth it, everyone wants to hurt you. Everyone is a liar; I was in a bad mood and cared about nothing. Everything was meaningless and ridiculous to me” (Participant # 3). 
Feeling angry and annoyed: “I was angry with myself, this life, and this country that I do not like. I was angry with poverty and misery that will not end unless you kill yourself and get rid of it” (Participant # 11).

Reaction of those around to suicide
Intense fear: “My parents just learned about my suicide and were very scared” (Participant #2).
Impatience and crying: “I do not remember much except my mother crying” (Participant #11).
Anger: “Yeah, one of my friends who took me to the hospital was very angry, and he said I should not have done this and I must not give up fighting for life” (Participant #1). 
Taking care not to repeat suicide: “My parents treated me well and were kind to me for seven or eight months. They were badly scarred. My father was always standing at my bedside. He said he was wrong. He told that to my mother, not I, but he heartened me” (Participant #13).

The overall meaning of life and a looking at life after suicide
Life is still meaningless: “Life is absurd, meaningless, and boring. It is not a special thing, we come to life, and we leave it. I will be OK if we do not mess with it, but if we did, we would die with suffering” (Participant # 5).
A transient feeling of regret: “It is not worth killing myself for that girl. My parents were right, she was a pervert girl, and it is not worth it” (Participant #14).
No plan to continue life: “When I leave here, I have no specific plans for the future. There is no future for miserable people like us” (Participant #13).
The probability of recommitting suicide: “I have no hope for life. No, I do not want to live. I was thinking the same before suicide. Maybe I should say that the next time I will not bother myself so much and make it easier [I will kill myself more easily]” (Participant #8).

4. Discussion
The present study explored meaningless and absurd experiences in failed suicide attempts and revealed that among the 22 subthemes extracted from the interviews with single people attempting suicides, poverty and lack of financial independence, love failure, and not being understood by parents were the most fundamental and effective factors underlying attempted suicides. 
Poverty was pointed out by the suicide attempters in two cases as the most important factor and in three cases as a complementary factor in their suicide attempts. Similarly, a study by Economou et al. (2013) in Greece during the economic crisis showed that the economic crisis was a driving factor for suicide among depressed people or those who suffered from interpersonal mistrust (Economou et al., 2013). The present study showed that poverty and financial failure were two essential factors promoting suicide attempts. Poverty induces various feelings, including hopelessness, lack of motivation, feeling powerless, and lack of social acceptance, not being accepted by the opposite sex due to financial inability, constant anxiety, regret, or anger that can lead people to suicide.
Another factor increasing the possibility of suicide, as pointed out by two participants, was the lack of financial autonomy (even despite the average economic well-being of the family), resulting in low self-esteem. Such people are just looking for independence from their parents. In a similar vein, Safiri and Rezaeinasab (2016) studied the self-immolation of women in Ilam Province, Iran. They showed one of the important factors leading to suicide is not having financial independence. Besides, Mohammadi et al. revealed the demographics characterized by the attempted suicide in Iran, such as young age, being married, retired, and living in urban areas (Mohammadi et al. 2005).
Unsuccessful love experiences were pointed out by 10 out of 15 participants (67%) as the main revealing factor and, at the same time, the final element in the decision to commit suicide. The main obstacle in all of these love failures was the opposition of parents to their son’s friendship and marriage with a girl whom they loved. Azizpour indicated that opposition to marriage and problems with family traditions were themes extracted from the life experiences of women attempting suicide in Iran (Azizpour, 2018).
Three participants pointed out conflict with the spouse as the underlying factor for attempted suicides. The conflicts were caused by humiliation, disregard for the spouse’s views and opinions, control, using offensive words, anger, mood instability, and physical conflict. This finding is consistent with a study by Kouchakian and Kaldi (2016), who examined the unknown causes and motives of suicide in married people. According to existential psychology, one of the defense mechanisms used by people is nihilism, which is to doubt any activity that provides meaning. When a person falls into the void of meaninglessness and emptiness, the possibility of suicide is increased.
Another factor mentioned by four participants was not being understood and emotionally supported by the parents. This made them lacking a good relationship with their parents resulting in mental fatigue and ultimately the decision to commit suicide. The participants also stated that they felt anger, sadness, and loneliness due to a lack of parental attention and support, as was evident in previous studies (Kiani, Fatehizadeh, & Ghasemi, 2013). From the existential perspective, a person’s defense mechanism can be in the form of fusion with something or a person (here the beloved) and taking refuge. Besides, if the person is deprived of the beloved, his fusion defense fails, and the person can end up in a psychological impasse and find suicide as the only solution. Besides, Comiford, Sanderson, Chesnut and Brown (2016). revealed that of the 4754 suicides, approximately 17% had intimate partner problems before suicide. They concluded that conducting suicide interventions for individuals with intimate partner problems by targeting risk factors prevalent among this population is so essential. Moreover, Lane et al. indicated that intimate partner problems increase suicide risk. They concluded that problems in the relationship with an intimate partner could be a risk factor for suicide (Lane et al., 2020).
This study was conducted with some limitations. First, the participants in the study were only men. They were inpatients in Loghman-e-Hakim Hospital in Tehran. Second, due to the special conditions of participants, it was not possible to conduct face-to-face interviews with the family members, and thus we did not know about their perspectives. In further studies, the interview with the family members and examining the other psychological components would be useful. 

5. Conclusion
Given this study’s findings, a single person may suffer from a lack of empathy and emotional support in life due to the lack of a close relationship with his parents. Therefore, his needs for love, care, attention, and intimacy are not satisfied. At the same time, a person may taste poverty and economic deprivation, not allowing him to satisfy his basic need for progress and autonomy. Therefore, when he reaches the age of puberty, the need for love and attachment that was deprived of him in the past is sought with a craving for the opposite sex. As a result, he seeks to compensate for all his deprivations by marrying a girl he loves. Consequently, if he cannot marry her for any reason, he will find no way out of his psychological suffering, and thus the life becomes meaningless and absurd for him. Because he has lost his last emotional refuge, he commits suicide out of desperation.

Ethical Considerations
Compliance with ethical guidelines

The study was approved by Khatam University Ethics Committee (IR.KHATAMU.REC.1399/3). Informed written consent was taken from all participants. Signed permission was given for information gathered in this project, including direct quotes, to be used in publications and reports, provided that participants were not personally identified nor their community directly named or identified.

Funding
This article is an excerpt from the MA. thesis of the first author at the Department of Psychology and Educational Science, Faculty of Humanities, Khatam University, Tehran.

Authors' contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to express our sincere thanks to the managers of Loghman-e Hakim Hospital in Tehran and all the participants who contributed to this study.


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Type of Study: Research | Subject: Rehabilitation
Received: 2020/05/24 | Accepted: 2020/10/26 | Published: 2021/01/1

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