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Metasynthesis of Youth Suicidal Behaviours: Perspectives of Youth, Parents, and Health Care Professionals

  • Jonathan Lachal ,

    Affiliations AP-HP, Hôpital Cochin, Maison de Solenn, Paris, France, Université Paris Descartes, Sorbonne Paris Cité, Paris, France, INSERM, U1178, Paris, France

  • Massimiliano Orri,

    Affiliations INSERM, U1178, Paris, France, Université Paris Sud-Paris 11, Paris, France

  • Jordan Sibeoni,

    Affiliations AP-HP, Hôpital Cochin, Maison de Solenn, Paris, France, Université Paris Descartes, Sorbonne Paris Cité, Paris, France, INSERM, U1178, Paris, France

  • Marie Rose Moro,

    Affiliations AP-HP, Hôpital Cochin, Maison de Solenn, Paris, France, Université Paris Descartes, Sorbonne Paris Cité, Paris, France, INSERM, U1178, Paris, France

  • Anne Revah-Levy

    Affiliations INSERM, U1178, Paris, France, Argenteuil Hospital Centre, Centre de Soins Psychothérapeutiques de Transition pour Adolescents, Argenteuil, France



Youth suicide is a major public health issue throughout the world. Numerous theoretical models have been proposed to improve our understanding of suicidal behaviours, but medical science has struggled to integrate all the complex aspects of this question. The aim of this review is to synthesise the views of suicidal adolescents and young adults, their parents, and their healthcare professionals on the topics of suicidal behaviour and management of those who have attempted suicide, in order to propose new pathways of care, closer to the issues and expectations of each group.

Methods and Findings

This systematic review of qualitative studies — Medline, PsycInfo, Embase, CINAHL, and SSCI from 1990 to 2014 — concerning suicide attempts by young people used thematic synthesis to develop categories inductively from the themes identified in the studies. The synthesis included 44 studies from 16 countries: 31 interviewed the youth, 7 their parents, and 6 the healthcare professionals. The results are organised around three superordinate themes: the individual experience, that is, the individual burden and suffering related to suicide attempts in all three groups; the relational experience, which describes the importance of relationships with others at all stages of the process of suicidal behaviour; and the social and cultural experience, or how the group and society accept or reject young people in distress and their families and how that affects the suicidal process and its management.


The violence of the message of a suicidal act and the fears associated with death lead to incomprehension and interfere with the capacity for empathy of both family members and professionals. The issue in treatment is to be able to witness this violence so that the patient feels understood and heard, and thus to limit recurrences.


Suicide and attempted suicide are a major public health issue in Europe and throughout the world [1]. Youth—that is, adolescents and young adults, aged 15 to 29 years, and also referred to here as young people—are particularly at risk of suicidal behaviours: suicide is the second leading cause of death among this age group [1], and the rate of suicide attempts is estimated to be 10 to 20 times higher than that of completed suicides [2,3]. Worldwide, there are officially around 164 000 deaths by suicide annually among those younger than 25 years [4] and the sex ratio ranges from about 2 to 6 young men for every young woman. Distribution at the international level is heterogeneous, with prevalence higher in Eastern Europe, lower in Central and South America, and intermediate in the USA, Western Europe, and Asia. The rates in Africa are generally unknown [57].

In numerous Western countries, the incidence of suicidal behaviours among young people increased considerably from the beginning of the 20th century into the 1990s [7,8], when large-scale campaigns of prevention and the introduction of antidepressant treatments resulted in a significant reduction in deaths from suicide [912]. Although these prevention campaigns are ongoing [13], recent trends in many countries show that the prevalence rates of suicidal attempts have stopped falling; they are either becoming stable or starting to rise again [5,14,15].

Numerous theoretical models have been proposed to improve our understanding of suicide [3,5,10,1619], but medical science has struggled to integrate all the complex aspects of this question at the interface of medical, sociological, anthropological, cultural, psychological, and philosophical issues [20]. Explanatory models are necessary, to allow us to think about suicide in a new and different way. Meta-synthesis is a useful and recognised tool that can help to understand complex medical questions [2124]. It appears to be a tool of choice for apprehending questions about suicide and allows in-depth access to the perspectives of the different groups involved with young people who have attempted suicide.

We conducted a systematic review of the qualitative studies about suicidal behaviours in the medical literature and a meta-synthesis (through a thematic analysis) of 44 studies that interviewed youthful suicide attempters, their parents, and the healthcare professionals providing care to them [25,26]. We decided to include these three groups of participants because they are the main protagonists of the therapeutic relationship in this context. Our objective in conducting this review was to describe the experience of attempted suicide and its management as closely as possible from the perspective of each of these three groups, covering the issues and expectations of each, so that we can propose new pathways for thinking about and improving care.



We used thematic synthesis [27]. Our procedure took place in four stages: designing the research, that is, defining the question, subjects, types of studies to include, and the protocol; the search for and selection of articles; and the analysis itself, in two separate stages, first a descriptive portion in which we determined and compared themes, and then an interpretive stage in which we constructed a descriptive schema of the phenomenon, original proposals that we then examined from the perspectives of theory, the literature, clinical practice, and care [25,27]. These steps increase both the possibilities for generalisation and the strength of these generalisations.[28] Our method is consistent with the ENTREQ statements [29]. (S1 Table)

Here are the six steps of our method:

  1. Definition of the research question (summarised in the aims and objectives);
  2. Identification and selection of studies;
  3. Quality assessment of the selected studies;
  4. Analysis of the papers, identification of themes, and translation of the themes across studies;
  5. Generating analytical themes and structuring the synthesis
  6. Writing the synthesis.

Selection of Studies

We conducted a systematic search for qualitative studies specifically devoted to suicidal behaviours in young people (step 2). The QUALIGRAMH working group (Qualitative Group for Research in Adolescent Mental Health, INSERM U 669, Maison des Adolescents, Hôpital Cochin, Paris), composed of specialists in qualitative research and disorders of young people, defined the study criteria.

The papers were selected only if they met the following criteria:

  • Used solely qualitative methodology.
  • Specifically concerned suicidal behaviours in adolescents and young adults (referred to hereafter as youth or young people).
  • Interviewed:
    1. - Young people who were suicidal, or who had attempted suicide in their youth, or
    2. - Parents of these youth, or
    3. - Medical professionals who provide care to suicidal youth.
  • Were published in English or French between 1990 and May, 2014 (the period covering most of the qualitative articles about suicide).

Finally the following studies were excluded:

  • Studies using quantitative or mixed methodologies;
  • Studies in the general population exploring prevention of suicide or social representations of suicide in adolescents and young adults;
  • Studies concerning solely deliberate self-harm or non-suicidal self-injury.

The study was conducted from January to May 2014. An initial search identified a selection of papers, from which we collected keywords. Based on this selection as well as on existing literature reviews about suicide [3032], the research group drew up a list of keywords, a mix of free-text terms and thesaurus terms related to suicidal behaviours, youth, and qualitative research [33,34] and compiled a list of databases indexing qualitative studies in the fields of medicine, sociology, and psychology [25,35]. We performed our search on July 1, 2013 (and updated it on May 31, 2014) (Table 1 and S2 Table).

Table 1. Web searches—January 1, 1990 to July 1, 2013 (updated on May 31, 2014).

In all, we obtained 1804 references, 1403 of which remained after removal of duplicates (Fig 1). Two authors (JL and MO) screened all titles and abstracts, according to the relevance of their theme and methodology. If the abstract was not sufficient, the full text was read. Disagreements were resolved during working group meetings. For example, we initially included all studies concerning deliberate self-harm or non-suicidal self-injury in our selection. After discussions and literature review [3], we decided to exclude all these papers because we do not think that the issues of suicide and self-harm are identical: the question of death is posed differently for these two groups of subjects. Another issue was whether or not to include mixed studies, given that the best way of dealing with mixed methods remains unclear [25]. After consulting these papers, we concluded that they did not contribute to our thematic framework and decided to exclude them from the analysis. Full texts of potentially relevant papers were then examined, and a second selection was performed (the papers excluded at this point and the reasons for their exclusion are listed in S1 File). After removal of studies that did not meet the criteria defined above, 42 papers remained. Scanning the reference lists for more potentially relevant papers provided 2 more papers. In all, the review finally included 44 studies, around 2.5% of the papers screened. This rate is consistent with the findings of other such meta-syntheses [25,33,34].

Assessment of Paper Quality

The evaluation of quality (step 3) is necessary to enable discussion of the studies and to ascertain the value and integrity of the data used. The working group chose a tool widely used for medical meta-syntheses, the Critical Appraisal Skills Programme (CASP) [32,36]. Two researchers (JL and MO) independently performed the evaluation, and the working group reached a consensus about it. Table 2 summarises the quality evaluation criteria.

Table 2. Evaluation of the quality of the studies according to the Critical Appraisal Skill Programme (CASP).

Data Analysis

We followed the procedure described by Thomas and Harden (2008) to analyse the data [27]. The analysis (step 4) included a careful reading of the titles, abstracts, and complete papers as well as repeated rereadings. One researcher (JL) extracted the formal characteristics of the studies, while he and two others (ARL and MO) independently extracted and analysed the data, which were then compared during meetings. We used thematic analysis to develop categories inductively from the first-order themes identified in these studies. Afterwards, the translation work involved comparing themes across papers to match themes from one paper with those from another and ensure that each key theme captured similar themes from different papers. Finally, we ordered these translation results into a framework containing three superordinate themes (step 5). This step is more interpretive, since the group decided to organize the themes through a more conceptual line of argument. The last step consisted in expressing the synthesis in a useful form (step 6). This process led not to a summary of the different studies included, but to an interpretation of the papers, described in the discussion. Research meetings were held regularly to discuss the results obtained. The triangulation of sources—meta-synthesis does this by definition—and the triangulation of reviewers made possible a high level of rigour in the results [37,38].

Results: Description of the Studies

Presentation of the Included Studies

In all, we examined 31 studies that questioned young suicide attempters, by semi-structured interviews, free interviews, focus groups, internet forums or chat rooms, or questionnaires. Six studies questioned healthcare professionals who provide care to suicidal youth; these used semi-structured interviews and focus groups to collect date from doctors, nurses, psychiatrists, psychology students, social workers, and counsellors. Finally, seven studies questioned the parents of suicidal youth, in structured, semi-structured, or unstructured interviews. Studies come from 16 different countries: 16 from North and Central America (Canada, Nicaragua, and the USA), 13 from Europe (Italy, Norway, Sweden, and the United Kingdom), 3 from Africa (Ghana and South Africa), 6 from Asia (Hong Kong, Israel, Iran, Vietnam and the Republic of Korea), and 6 from Oceania (Australia and New Zealand). Tables 3, 4 and 5 detail the characteristics of each study.

Table 3. Main characteristics of the studies (Studies interviewing young people who have attempted suicide).

Table 4. Main characteristics of the studies (Studies interviewing parents).

Table 5. Main characteristics of the studies (Studies interviewing health professionals).

Quality Assessment

Our evaluation found that on the whole the quality of the studies was good (Table 2 and S3 Table). The ethical considerations were sometimes insufficient, and the description of the analytical method sometimes inadequately detailed. This flaw was most often explained by editorial constraints (maximum word lengths that were more appropriate for the presentation of quantitative than qualitative research).

No study was excluded from the analysis on the basis of this evaluation. The original authors of the meta-ethnographic approach report that poorer quality studies tend to contribute less to the synthesis [25,3941]. Further, there is no consensus on the role of quality criteria and how they should be applied, in particular for systematic reviews (see also [25,38]).

Results: Thematic Synthesis

The thematic analysis clearly showed three superordinate themes of experience. The first is individual experience, comprising three subthemes: the experience of distress, self-control, and the parents’ impotence in the face of the suicide attempter’s distress. The second superordinate theme is the relationship with others, including the subthemes: changes in the relational distance, feelings of difference and rejection, and the experience of incomprehension. The third main theme concerns the social and cultural aspects of the suicidal act. The themes that compose it are: failure to fit in the group, and sociocultural facilitators and barriers to suicide and its management (Tables 6, 7, 8 and 9).

Table 7. Quotations from participants and authors of primary studies to illustrate each theme of superordinate theme 1 (Individual experience).

Table 8. Quotations from participants and authors of primary studies to illustrate each theme of superordinate theme 2 (Relational experience).

Table 9. Quotations from participants and authors of primary studies to illustrate each theme of superordinate theme 3 (The social and cultural experience).

Individual Experience

The three themes belonging to this superordinate theme describe the individual burden and suffering that suicide brings about, albeit in different forms, in all three groups.

The experience of distress.

The experiences of sadness and of mental or emotional distress are at the heart of the accounts provided by both the youth and the professionals [4261].

Most of the participants describing their suicidal experience mentioned feelings of depression: sadness [45,50,54,60], sorrow [54], mental pain [49,53,54,56], despair [49,50,54,56,60], detachment [45,56], anger, and irritability [45,49,50,54,60]. The professionals may diagnose depression [44,47,50,55,57,61], but certainly not on a routine basis [42].

The experience of failure is at the heart of this distress [43,44,4654,56,58,59]: decreased self-esteem [46,49,56], feelings of uselessness [50,5254,58], incompetence [49], and worthlessness [50,53,54]. Participants sometimes even mentioned self-hatred [48].

Improvement corresponds to exit from the downward spiral of failure [43,46,47,51,59]. The youth interviewed reported the reappearance of positive thoughts [43,47] and restoration of their self-esteem [46,51,59].


The second subtheme concerns self-control: simultaneously, loss of self-control, impossibility of coping, leading to despair and suicidal action, but also to an attempt to regain control by expressing distress [4451,53,56,59,6170].

Many suicidal youth have the impression that they have lost control of their existence [45,49,50,56,63,70], that they can no longer take part in decisions that concern them, no longer influence the course of their own lives [45]. Dealing with their problems, doubts, and fears [44,48,50,61,64,67] or with their painful experiences or strong emotions [44,48,61,68] seems impossible to them. They no longer understand themselves [44,45,56]. Life becomes both hopeless and senseless [50]. Suicide might then appear as a means of regaining self-control [49,56,64].

By talking about themselves, by understanding themselves, changing their point of view, giving a meaning to their existence, these young suicide attempters regain control over their lives [44,4648,51,53,59,61,62,6466,68,69]. The therapeutic space [44,46,48,59,64,65,68,69], but also the spaces for individual [51,53] and community [62] expression are settings that enable the young to cope [47,61], where they can rediscover themselves, learn to understand themselves and one another [46,47,61,64,68], change their perspective about things [46,64], give a new meaning to their existence [47,48,61,66], and imagine a positive future [47].

Parents’ impotence in the face of the suicide attempters' distress.

The family and the treatment teams both reported similar experiences of the distress of these youth, dominated by feelings of helplessness, guilt, anger, and the impression that they are losing control of these young people [7180].

The family experiences their child’s first suicide attempt in a way resembling the youth’s experience: loss of hope, blame, guilt, self-recrimination, a sense of total failure; rejection, isolation, and incomprehension; powerlessness and helplessness, loss of control [7176]. The realisation is often sudden, which destabilises the parents still further [71,74]. Whether they were drowning in guilt [71,74,75] or rejecting the responsibility for their child's suffering [77], parents confided their difficulties in rallying round. Their impression of the healthcare system as useless, futile, or rejecting [75,76] reinforces their experience of helplessness.

Healthcare professionals too can feel impotent in the face of the young people's individual feelings of distress: they have the impression that the interventions that they can suggest are not appropriate [78]; those who provide care for these youth wish they had specialised interventions and specific training available [78,79]. They are also helpless in dealing with the parents, whom it might be difficult to help to respond usefully when their attitudes show resistance or shock or when they minimise the risk [80].

Relational Experience

The three subthemes here describe the importance of the relationship with others at all stages of the suicidal process: i) during the phase when suicidal ideation develops, ii) during the events precipitating the act itself, iii) during the phase of crisis resolution.

Changes in the relational distance.

At each stage of the suicidal process and its care, the youths, their parents, and the healthcare professionals described movements of rapprochement and of distancing from one another [42,43,4558,60,61,63,6572,76,7884].

The stability of the relationship is important for the youth, as it is for their parents [45,4850,5255,57,58,60,61,63,65,67,71,72,76,84]. All of them reported that relational difficulties, separations, mourning, and feelings of insecurity are elements that engender suicidal ideation [45,48,50,5255,57,58,60,61,63,65,67,84]. Breaches and break-ups, conflicts, separations, losses, and absence can all explain the decision to act [50,5257,61,63,65,67,72,76,84]. Communication is difficult, and suicide attempts can serve to express one’s distress to the others [45,4850,52,5558,60,61,72,76], or to take vengeance on one or more family members or friends [56]. Many professionals also consider that attempted suicide is a mode of communication [42,79,80,82]: according to them, youth use suicide as a powerful form of communication, a way to say something important [82]. The challenge is thus to help the family hear this complex message so that they can work together effectively with the young person [80].

After the suicide attempt, the parents move closer to their child, who becomes a constant preoccupation and sometimes requires constant monitoring.[71,72,76] For the youth, the rapprochement with their families, the reconnection, the improvement of relationships and communication are simultaneously conditions for and consequences of getting better [43,46,47,49,52,56,58,61,66,67,70,81,84]. Relationships with the healthcare provider are central to treatment: the professional must be an unconditional source of love and support [46,51,68,69,83]. Professionals noted that the need for attention is at the heart of treatment: attention from family and friends, but also and especially from healthcare providers, who must commit themselves strongly to the relationship and give of themselves. This type of commitment embarrasses some, who underline the need for particular skills, but also the risk of wasting time, for the result is never certain [42,7880].

Feelings of difference and rejection.

Feelings of difference and rejection are present throughout the suicidal process: rejection by peers, family, friends, but also sometimes professionals [45,4961,65,67,70,71,74,76,77,84].

The feeling of being different from others is very present in the young people’s discourse, shared by the parents [45,4961,65,67,70,71,76,77,84]. The youth find themselves singular, cannot succeed in resembling their peers, feel isolated and rejected [49,51,5456,58,59,67,84]. The rejection is based most often on elements of reality: harassment at school, bullying, or discrimination based on sexual orientation [45,50,51,58,61,65]. The youth also say that they find it hard to fit into their family, which is often broken, or in conflict [50,52,55,57,60]. The fear of being judged by others—because of their differences and their inability to adopt the group's common values—amplifies the feeling of solitude and the real isolation [49,52,53,55,57,70]. In some contexts, boys are more vulnerable to isolation than girls [67]. Many parents, reporting what their child has confided in them, confirm these feelings of difference and rejection [71,76,77]. The parents also sometimes feel rejected by their children [71,74,74,76,77].

The experience of incomprehension.

The experience of incomprehension and of feeling unheard is central to the suicidal process for all the participants: before the suicide attempt, in the precipitating factors, and while in care [42,43,46,47,4953,5560,62,65,66,6872,74,7680,82,83,85].

The youth do not feel understood [43,4952,55,57,58,62,66,68,70,83]. The family’s or peer group’s failure to hear leads to the suicidal behaviour [43,4952,5558,60,62,66,68,70,83].

The parents, for their part, do not understand [71,72,74,76,77,80]. Faced with the violence of the act, their immediate reaction is denial, distancing from what frightens them [71,74,80], or shock or stupefaction that prevents any reaction [71,80]. Later, they ask themselves numerous questions that remain unanswered [72,74,76,77].

Getting better requires that the youth be understood by those around him or her [43,49,56,58,65], including by empathetic professionals [62,65,66,68], supported by family or a therapeutic setting [46,47,49,51,53,58,59,62,65,66,6870,83]. Professionals underlined the difficulties of empathy and the contradictory positions, which are a barrier to care [42,78,79,82,85].

The Social and Cultural Experience

The two subthemes of this superordinate theme describe the socio-cultural dimension of suicide. The peer group, the cultural group, and the society, by the ways they accept or reject youth in distress and their families, play a role in the process of suicidal behaviour and in its management.

Failure to fit into the group.

Both the youth and their parents underlined the difficulties of belonging to the peer group, to the cultural group, or more broadly, to the social group. Young people associate this failure to fit in with shame, guilt, and anger—and parents often corroborate these feelings [4345,4861,63,6567,70,72,76,77,84].

The self-esteem of young people is based on numerous standards and values—religious, cultural, or of the ideal family structure, school success, beauty, health, or sexuality [4345,49,50,5254,5761,6567,70,84]. Inability to meet these standards provokes different reactions: shame about the inability to cope and the experience of stigmatisation [44,5254,56,61,65,67,84], guilt [48,49,52,56,61,67] or anger against others [45,49,50,54]. These emotions can be so strong that young people can consider suicide a conceivable response [50]. Some situations—those of LGBT youth, as well as cultural or religious minorities—are examples of these difficulties [51,55,61,63,65,84].

Parents repeat what their children have said and report this feeling of failure. The shame of what they did or did not do, of their performance in school, of what has happened, of what they cannot accept, of their physical appearance, of who they are or cannot succeed in being [72,76]—all these play a role in the escalation of their distress [77].

Sociocultural facilitators and barriers to suicide and its management.

The sociocultural environment, religious beliefs, representations of death, community groups: all of these are levers that facilitate or obstacles that block effective care [42,49,5154,6063,6567,69,7173,7780,82,83,85].

Religious beliefs are often a protective factor: the principal religions preach that suicide is forbidden, an offense to God, for humans have a duty to take care of themselves [42,52,53,85]. But this ban can also lead to the exclusion of those who are suffering [42,52], and the absence of any consideration of their suffering in their religious beliefs can be "a reason for engaging in suicidal behaviour" [42]. In some contexts, this difference in the influence of religion may be more marked according to gender and may protect girls more than boys [67].

Media representations of self-harm behaviour play an important role in suicidal actions [77,82]. According to some healthcare professionals, the media may promote an idealised image of rebellious youth, including those who rebel by suicide [82].

Each group of participants raised the question of the right to die or of whether it is forbidden, an issue underlain by ethical, philosophical, and cultural considerations [42,49,5254,61,63,6567,7880,82,85].

Stigmatisation of distress and of suicidal ideas block access to care for young people and their families [60,67,7173]. Families that have experienced a child's suicide—attempted or completed—do not allow themselves to talk about it. In particular, in some cultures, suicide is a trauma that affects the entire family and is transmitted from generation to generation [85].

But there are organisations and structures in society that promote care: religious and organisational support for the parents [72] and peer networks for youth [51,53,62,69,83].


This qualitative synthesis of 44 studies questioning youthful suicide attempters, their parents, and their healthcare providers enabled us to identify three superordinate themes which describe their experience: individual experience, relational experience, and social and cultural experience. One result is transversal at the heart of each group’s experience: incomprehension is a barrier to effective care. The violence of the message of a suicidal act and the fears associated with death lead to incomprehension on all sides and interfere with the capacity of both family members and professionals to empathize with the young person.

This incomprehension is present in most of the themes: difficulty in understanding oneself and in coping with one’s individual experience; difference, incomprehension, and rejection in relational experiences; and shame, guilt, and inability to fit into the social or cultural group. The suicidal act, frightening and shocking, reinforces this incomprehension. The family expresses doubts, calls itself into question, but also blames the youth: how could he have done this to us? Professionals cannot make sense of the act. The will to die is unthinkable.

When youth behave suicidally, they impose the violence of their act on others, on family, friends, and on the healthcare providers who support them. The suicide attempt acts out feelings of anger, hatred, and vengeance toward the other: others who are not sufficiently present, did not listen enough, did not understand enough. It is then very hard to be empathetic toward a youth who treats you so aggressively. It is difficult to empathize, identify, with distress that is expressed as violence—violence directed at the family, friends, and professionals. This is the primary observation of this meta-synthesis: everyone experienced and expressed great difficulty in identifying with the distress of these youths. Family members reacted by denial, by distancing themselves from what frightens them. Healthcare providers described their difficulties in being empathetic and asked for assistance, usually framed as a desire for specialised training. The violence addressed to them as the other stupefies their capacity to understand, listen, and empathize.

The response of the sociocultural group to suicidal behaviour is also most often a response to this violence: criminal prosecution for suicidal behaviour, allowed in some countries, is intended to protect the group. The moral condemnation that some participants report, sometimes transmitted between generations, is also intended to limit these actions perceived as aggressive. The results show this to be particularly true in Asia, Africa, and among men in South America [52,54,57,67,84,85]. Religion, when it condemns suicide, protects the group from violence to the detriment of any consideration of the individual's distress. The group is thus protected from the distress linked to loss and mourning, but also and especially from the violence driven by the suicidal behaviour. In the West, finally, the medicalization of suicidal behaviour seeks to give a meaning, labelled in terms of pathology, to this violence [7,43,61].

How can we support a family member whose distress is unthinkable? How can we treat someone when our capacity of empathy is dumbfounded? How can we escape this relation impasse? This is the primary issue in caring for these youths and their families.

Implications for Practice

It is important to rethink the relationships between doctors, parents, and young patients in the context of attempted suicide. The difficulties of empathy toward these young people interfere both with care and support by their families. The issue in treatment is to witness this violence so that the patient feels understood and heard. The objective of course is to prevent recurrence: when the violence of the message is not heard in treatment, the suicidal potential remains present.

One pathway for envisioning the therapeutic relationship with these patients may be in the concept of intersubjectivity and in the conceptualisation of a "third space" [8691]. The concept of intersubjectivity envisions the construction of self through the experience of a relationship with another and of interactions with another. The therapeutic relationship can thus be thought of as a place of exchange and construction, as “two autopoietic human beings with embedded nervous systems that are engaged within a shared environment, the intersubjective third space, from which new therapeutic possibilities can arise”[91]. The model of the third space has been envisioned in the care of chronically suicidal patients [87]. It suggests treatment ideas borrowed from the treatment of patients with chronic pain. These situations may promote the appearance of negative empathy based on experiences of hostility, prejudice, and stigmatization [90]. The third space restarts communication in different ways, by sharing the experiences of patients and professionals and makes it possible to combat the professionals' rejection and negative feelings, thus promoting care.

From a relational perspective, the creation of a third space gives the parties the opportunity to create a respectful interpersonal relationship [87]. Professionals must make a commitment to share their representations of patients’ suicide behaviour. The objective here is to establish relative equity within the relationship, so that patients feel understood and able to share their experience [90]. The third space is a staging of the active rapprochement of patients and professionals. The latter share with the patients important representations of the suicidal behaviour and also of the loss of their ability to contain the patient's experience. This rapprochement allows patients to let themselves share this experience.

From social and cultural perspectives, work is necessary on the representations of suicidal behaviour conveyed in the medical world. Numerous disciplines, especially the social sciences, consider suicide, which can thus be envisioned in a collective dimension, as a social fact or as influenced by cultural phenomena [9296]. The current trend is towards the medicalization of our understanding of suicidal behaviours [7]. Nonetheless, these behaviours are not solely related to medicine and pathology: the psychiatric comorbidities of suicide vary greatly as a function of social, cultural, and educational contexts [7]. Treatment of adolescents with suicidal behaviour and their families should always include multidisciplinary management, including social workers and people with training in education [7,97]. A better understanding and management of suicidal behaviour requires apprehending it in all its psychological, social, and cultural complexity [20].

Implications for Research

This synthesis has enabled us to examine the perspectives of the principal protagonists of care for young people who take suicidal actions. The parents' perspective has principally focused on the study of families in which those acts were successful. It appears important to develop research about the parents of youth whose attempts failed: what changes does this failed act induce in a family?

The media's fascination with suicide has been studied widely, and youth are particularly exposed.[3,98100] But media are also powerful tools that enable the circulation of representations. Research must also examine how to use the media as a tool to share representations around suicide.

Finally, more in-depth study is needed of the representations of both the death of a young person and a self-inflicted death, by the integration of the social, anthropological, and philosophical dimensions. The sociological literature on this question (see [95,101,102]) has difficulty associating the individual and societal levels. It is essential to integrate these different perspectives to be able to propose an explanatory model of suicide among the young on which proposals for care can be based.

Strengths and Limitations of This Review

This review integrates the experience of distress and care of the principal stakeholders participating in the care of youth suicide: suicidal young people, their families, and healthcare professionals. It is based on a rigorous method, tested in medical research [2527,103106] and meets the criteria of the principal protocol used in qualitative research (ENTREQ). A systematic review of the principal search engines in this domain enabled us to select a large body of articles. The synthesis is based on the analysis of 44 studies, globally of good quality, published in peer-reviewed journals. The themes proposed here are widely found in the literature. They describe the experience of nearly 900 participants, providing a perspective much larger than any of the initial studies.

The data from the qualitative meta-synthesis includes participants for whom only partial data are available, as well as the interpretations of the researchers whose studies we included. Any generalisation should be cautious. Nonetheless the triangulation of numerous points of view, different methods, and different cultural areas, is a strength that promotes the emergence of theoretical explanatory proposals.

Although the synthesis includes articles from diverse cultural areas, the restriction to articles in either English or French limits the cultural perspectives. For the future of this method, it would be useful to develop methods that would allow the inclusion of data from cultural areas that publish only rarely or even never in English.

The articles included provide only a limited look at the influence of gender on the experience of suicidal behaviour. Nonetheless, other types of studies have explored the role of gender with important results (see for example [107110]). In the future, qualitative studies on suicidal behaviour should consider its role.

The results of the studies are particularly homogeneous, which in qualitative research is a limitation, for this field seeks to shed light on the question through new perspectives. This observation has already been noted in some meta-syntheses of adult suicide attempters [30,32]. The difficulties related to thinking about death and the message of the suicide may explain this homogeneity. Qualitative research involves the subjective participation of researchers. The question of suicide seems to be difficult for researchers to envision, just as it is for participants to think about.

Supporting Information

S1 File. List of articles excluded in the last step of the review.


S2 Table. Complete search strategy.

Performed on July 1, 2013 (updated on May 31, 2014).


S3 Table. CASP (Critical Appraisal Skill Program) results.

T: Totally met; P: Partially met; N: Not met;?: Unclear.



We would like to thank all QUALIGRAMH researchers and JA Cahn for the translation work.

Author Contributions

Conceived and designed the experiments: JL MO JS MRM ARL. Performed the experiments: JL MO ARL. Analyzed the data: JL MO JS MRM ARL. Wrote the paper: JL MO JS MRM ARL.


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