The students’ perspective on suicide approach during Occupational Therapy training¹

Abstract

This article aims to analyze the occupational therapy students’ perception of a Public higher education Institution on suicide approach during training. This is a qualitative study with descriptive-analytical approach, with transverse temporal cut, performed in Rio de Janeiro. Suicide is still a complex theme and requires greater visibility. Most students interviewed expressed the view that suicide can be a result of mental disorder or associated with intense suffering. They also reported not having taken the approach on the suicide in the undergraduate disciplines, only indirectly, especially in Ethics and Oncology disciplines. Despite this, they reported about the relevant and consistent topic that the literature demonstrates. Rethink the approach of this theme in the formation of occupational therapists is an important issue to be treated in Brazilian universities.

Keywords:
Occupational Therapy; Suicide; Professional Training; Public Health

Resumo

Este artigo objetiva analisar a percepção dos estudantes de Terapia Ocupacional de uma Instituição de Ensino Superior (IES) pública sobre a abordagem do suicídio durante a formação. Trata-se de um estudo do tipo qualitativo, com abordagem descritivo-analítica e recorte temporal transversal realizado na cidade do Rio de Janeiro. O suicídio ainda é um tema complexo e que necessita de maior visibilidade. A maioria dos estudantes entrevistados manifestou a concepção de que o suicídio pode ser consequência de transtorno mental ou associado a sofrimento intenso. Relataram não terem tido a abordagem sobre o suicídio nas disciplinas de graduação, apenas de forma indireta, especialmente nas disciplinas de Ética e Oncologia. Apesar disso, fazem colocações pertinentes sobre o tema, e em consonância com o que demonstra a literatura. Repensar a abordagem desse tema na formação de terapeutas ocupacionais é uma questão importante a ser tratada nas universidades brasileiras.

Palavras-chave:
Terapia Ocupacional; Suicídio; Capacitação Profissional; Saúde Pública

1 Introduction

The World Health Organization (WHO) estimates that one million people committed suicide in 2000 worldwide. Each suicide has a serious impact on at least six other people. It is impossible to measure the psychological, social and financial impact that the suicide causes in a family and in the community (ORGANIZAÇÃO..., 2000).

In Brazil, about 10,000 suicides are registered every year. Between 1980 and 2012, suicide rates had grown 62.5% and the largest increase occurred since 2000 (WAISELFISZ, 2014). Souza (2010) says that suicide is not only related to a cause, encompassing several biological, psychological and social factors. The WHO also adds genetic and environmental factors. Psychiatric disorders, social and cultural issues are among these causes (WORLD..., 2014).

Suicide is addressed in several contexts with different definitions, both in health, education, sociology and in the social sciences. WHO understands that suicide is the act of deliberately of killing oneself (WORLD..., 2014). The Federal Council of Medicine (CFM) says that it is an act performed by the individual himself whose intention is death, in a conscious and intentional way (ASSOCIAÇÃO..., 2014). In the perspective of sociology, Emile Durkheim (2000) states that the attempt and the act are carried out by the victim himself and that he knows that he will produce a positive or negative result. Also, it shows how the variation in suicide rates depends on strictly social factors.

The suicidal behavior is also included in this definition, which includes thoughts, plans and suicide attempts (WORLD..., 2014). Unfortunately, health professionals know only part of the dimension of suicidal behavior (BRASIL, 2006).

Thus, professionals working in the different sectors (health, education, social assistance) need to have this issue worked during their graduation, such as the occupational therapist.

This article aims to analyze the perception of undergraduate students of the Occupational Therapy course of a Public Higher Education Institution (HEI) on the approach to the subject of suicide during training.

2 Method

A qualitative research was developed with descriptive-analytical approach and transverse temporal cut-off. The research was carried out in a Public Higher Education Institution (HEI) of the city of Rio de Janeiro, with students of the graduation in Occupational Therapy.

Semi-structured interviews were the technique used for the research, carried out individually with the students. The interview followed a script created by the author according to the objectives of the research and was recorded and transcribed by the researcher. There were 13 students interviewed, who were contacted by the researcher through an active search and who met the following inclusion criteria:

Availability;

Be regularly enrolled in the 7^th or 8^th periods;

Have attended the following subjects: Occupational Therapy and Mental Health; Anthropology and Sociology; Philosophy; Occupational Social Therapy; Collective Health and Public Health.

The choice of the subjects considered for the inclusion criterion was based on those with an focus on the different theoretical approaches on suicide, although it is understood that there are several others subjects in the training that approach the theme from different perspectives: age, gender, care.

The project was submitted and approved by the Ethics and Research Committee opinion number 57264116.3.0000.5257, and all ethical procedures determined by Resolution 466, 2012, of the Ministry of Health were carried out.

3 Results and Discussion

The results were grouped into two categories of analysis: (1) what students understand by suicide; and (2) approaching suicide during training.

3.1 What students understand by suicide

Suicide is a complex subject because it is influenced by many factors. It does not exist a single cause or a single reason and so it is approached in different conceptions, such as by Philosophy, Sociology, Anthropology, Psychology, Moral, Religion, Biology, History, Economics, Law, Psychoanalysis, Statistics, among others (CASSORLA, 1984; ORGANIZAÇÃO..., 2000). In this way, there are several perceptions of the students on this theme.

Some students define it as an intentional act of taking one’s own life, as observed in the lines that follow:

I think suicide is the act of the individual mowing their own life (Student E).

It is the act of voluntarily taking one’s life (Student F).

It is important to realize that one of the students highlights the fact that suicide is a voluntary, premeditated, intentional act. Minayo (2005) already emphasized that intentionality is the key element in the definition of suicide. The World Health Organization (2012) understands that suicide is the act of deliberately killing oneself. The CFM understands it as an act performed by the individual, whose intention is death, consciously and intentionally, even if ambivalent, using a medium that he believes to be lethal (ASSOCIAÇÃO..., 2014). The literature on the topic shows these characteristics quite clearly.

For Durkheim (2000),

suicide is every case of death that directly or indirectly results in an act, whether positive or negative, carried out by the victim himself and that he or she knows would produce this result (DURKHEIM, 2000, p. 11).

For Minayo (2005),

suicide, also technically called as “fatal suicidal behavior”, is the result of an act deliberately undertaken and executed with full knowledge or prediction of its outcome (MINAYO, 2005, p. 207).

Another speech highlights the attempt, which is also important to emphasize when studying suicide.

Suicide is when a person causes an attack on one’s life (Student A).

The attempt is also part of this definition. Attempted suicide is all suicidal behavior that does not cause death and refers to self-inflicted intoxications, injuries and intentional self-harm that may or may not have death as its purpose (WORLD..., 2014). Minayo (2005) says that the

suicide attempt or non-fatal suicidal behavior are the acts committed by individuals who intend to kill themselves, but whose outcome does not result in death (MINAYO, 2005, p. 207).

Durkheim (2000) adds that the attempt is the act as defined before, but interrupted before it results in death.

The official records on suicide attempts are scarcer and less reliable than those of suicide (CENTRO..., 2006). It is estimated that there are at least 10 attempts of seriousness for each suicide case that demand medical care and follow-up in a specialized care network. These behaviors can be up to 40 times more frequent than accomplished suicides. It is also considered that for each documented attempt there are four other unregistered ones (BRASIL, 2006). According to Vidal and Gontijo (2013):

It is likely that many of these attempts do not reach the hospital because they are of a small severity. Even when patients arrive at care units, the records at emergency services often point only to injury or trauma resulting from attempts that require medical care (VIDAL; GONTIJO, 2013, p. 109).

The occurrence of a suicide attempt is the main risk factor, which should be considered a warning sign by all the health professionals who monitor the patient. Thus, such attempts will be considered as one of the main foci of surveillance, prevention, and control actions (RIO GRANDE DO SUL, 2011).

Thus, it was relevant to note that the students considered suicide attempts an important issue to be studied and clarified.

Students also linked suicide to suffering and/or the consequence of a mental disorder:

I believe it to be an extreme psychic injury (Student J).

Due to mental distress, it is often related to depression (Student G).

These students’ statements are consistent, since studies of suicide and attempts often relate them to the presence of mental disorders, and this is the most common approach in the training of professionals within the area of health sciences.

Research in both developed and developing countries reveals two important factors related to suicide. First,

[...] most people who commit suicide have a diagnosable mental disorder. Second, suicide and suicidal behavior are more frequent in psychiatric patients (ORGANIZAÇÃO..., 2000, p. 5).

During 2002, the World Health Organization (2014) reports that in almost all suicides occurring in the world, individuals were suffering from a mental disorder. The main mental disorders associated with cases of suicide and suicide attempts are mood disorders; mental and behavioral disorders due to the use of psychoactive substances; personality disorders; schizophrenia; anxiety disorders; comorbidity that increases risks (BRASIL, 2006; ORGANIZAÇÃO..., 2000).

Unfortunately, most individuals who have some type of disorder do not seek a specialized professional. Depression, for example, is the most common diagnosis of suicides cause. It affects, throughout the life, between 10% and 25% of the women and between 5% and 12% of the men. Among the severely depressed, 15% commit suicide (ORGANIZAÇÃO..., 2000).

Suicide can often be the consequence of intense suffering not associated with mental disorder. A significant number of respondents expressed this view:

It is a moment of total suffering, tension, anguish, and despair, and the individual finds no other solution than to commit an action against one’s own life (Student A).

[...] it is a phase or a situation that the person is suffering a lot (Student D).

In my opinion, suicide is related to the large-scale suffering of an individual due to their inability to deal with situations that cause a mental disturbance (Student I).

In an attempt to alleviate pain and sorrow, death interpreted as a last resource (Student G).

A suicide never has a single or isolated cause. The cause of a suicide is usually the final expression of a crisis process experienced by the person. There are several situations of vulnerability to suicide that deserve attention. Among the most frequent, there may be mentioned: serious diseases; social isolation; hopelessness; marital and family crisis; mourning; loss or problems in employment. These situations are not determining for suicide but may interact and contribute to their occurrence when there is intense suffering (RIO GRANDE DO SUL, 2011; SILVA, 2015).

According to the manual of suicide prevention directed to the professionals of the Basic Care (ORGANIZAÇÃO..., 2000), an expressive part of the people communicate their thoughts and suicidal intentions. They often give signs and make comments about “wanting to die,” “feeling of worthlessness,” and more. All these requests for help cannot be ignored. Whatever the problems, feelings, and thoughts of the suicidal person, they tend to be the same all over the world.

It is possible to realize that intense suffering is not necessarily related to mental disorders. That is, not all suffering is an illness. Dalgalorrondo (2008) says that during life, it is normal for people to experience suffering, such as sadness, discouragement, fear, fatigue, anger, among others. However, these moments do not mean that there is mental suffering, but rather phases of everyday life.

Nevertheless, such feelings can lead to suicide, demonstrating the need to observe and understand the signs presented by people around them.

3.2 Approaching suicide during training

When the students were asked if the subject of suicide was addressed during graduation, most of them reported that there was no such approach during graduation:

I do not remember, I know it was quoted, but not specifically worked on (Student B).

It was not mentioned by the subjects, much less studied (Student C).

The topic of suicide, alone, I did not study it. What I saw was a shallow approach (Student E).

No, the subject is not discussed in the graduation (Student L).

The above statements are consistent with the invisibility of the theme, especially when there are taboos to be faced and myths that must be demystified. D’Oliveira (2006) in his study reports on the prejudices faced in the implementation of the Nucleus of Care to Suicide at Phillipe Pinel Hospital, in Rio de Janeiro. For the author, the great obstacle faced by all who deal with this issue is the prejudices accumulated for decades by laymen and health professionals. This obstacle, for example, has influenced the installation of the service in a psychiatric hospital.

Besides the imaginary about the impropriety of the place, another challenge to be faced is to convince health professionals and managers of the need for specialized care to those who attempt suicide (D’OLIVEIRA, 2006, p. 181).

Suicide was and remains a taboo among most people. It is a topic that confronts several religious beliefs and also is sustained because many see the suicidal as a failure (BRASIL, 2008; CENTRO..., 2006). This stigma, which includes little knowledge, prejudice, discrimination, and negative labeling, is one of the biggest obstacles for people who have attempted suicide, for survivors (friends or relatives of someone who commits suicide), and for individuals who commit suicide. Thus, it causes obstacles to the request for help and compromises the intervention of the suicide prevention services (PORTUGAL, 2013). The Center for Valorization of Life (CVL) says it is necessary to stop being afraid to talk about it, overturn taboos and share information related to the topic. This action of education should be the first preventive measure, being essential to leave the prejudices aside and to check some basic data about the subject (CENTRO..., 2006). The effect of this process of stigma also influences the media, which deprives itself of divulging issues related to the subject, through the fear of the “Werther Effect” - waves of suicides by imitation or induction.

The stigma can prevent people from seeking help and can become a barrier to accessing suicide prevention services, including post-event counseling and support; this deserves special attention in countries where suicide acts are illegal. Also, high levels of stigma can negatively affect appropriate information and record suicidal behaviors, with their consequences for public health. Together with greater awareness and knowledge of mental health among the general population, governments and other stakeholders should also clog stigma from the outset and during the process (ORGANIZAÇÃO..., 2012).

This stigma also falls on the training of health professionals. Surveys indicate that about 40% of people who committed suicide sought health centers and found professionals who made judgments and criticisms (KOVÁCS, 2013). According to Kovacs (2013), “health workers take the aggressive side of suicide and may feel it as an attack because they have been trained to save lives” (KOVÁCS, 2013, p. 74). When the person does not want to live, the professionals feel confused, because the premises of their vocation are confronted.

In this way, breaking these prejudices since the training is relevant to reflect and build new strategies of care. The students acknowledge that this topic is a taboo:

To also enable the approach to suicide [...] reflecting on the taboos that this theme brings (Student C).

However, some students remember the indirect approach of the topic in different subjects, As observed in the following statements:

What I saw was a superficial approach on the subjects of assisted suicide, euthanasia, dysthanasia and orthatanasia, in the subjects of Health and Society, Ethics and Oncology (Student E).

We did not talk about suicide exactly, but about euthanasia; in mourning, the stages of mourning that can lead to depression and consequently to suicide (Student D).

It is natural for the topic to be discussed in the subject of Oncology, for its proximity to assisted suicide and euthanasia. Some authors propose more current definitions on these themes. Euthanasia can be understood as the abstention of procedures that allow to rush or to cause the death of an incurable patient to free him of extreme sufferings. Euthanasia is given by the patient’s consent and can be classified as non-voluntary and voluntary:

[...] the first one happens without knowing the will of the patient and the second, in response to the expressed will of the patient. In assisted suicide, the patient performs the final action (CASTRO et al., 2016, p. 356).

Orthostatic or passive euthanasia is ensured by the Constitution, as it aims to guarantee dignified death to the terminally ill patient, who has the autonomy to refuse inhuman and degrading treatment (CASTRO et al., 2016).

In Brazil, euthanasia is considered a murder crime, according to article 121 of the Criminal Code (BRASIL, 1940). Although not regulated, the issue in Brazil has been widely discussed among doctors, philosophers, religious and lawyers, who seek to insert it into our legal system. However, in the Code of Medical Ethics it is forbidden for the doctor to shorten the life of the patient, even if at his request or his legal representative; and in cases of incurable and terminal illness, the doctor should offer all available palliative care (CONSELHO..., 2006).

The discussion of suicide as an ethical issue is quite relevant, as we have previously stated, assisted suicide and euthanasia in the world are still not consensus. However, the right to a dignified death is constitutionally admissible, and euthanasia may be allowed depending on local law.

This may be a result of more clinical training, as most students still relate suicide to medical and health issues, possibly because they are enrolled in a medical school and have the vast majority of health-related subjects.

It is also noticed that the issue was not addressed in the collective health subjects, which shows a worrying fact regarding the training since suicide is a great public health issue in all countries. Between 2002 and 2012, the total number of suicides in the country increased from 7,726 to 10,321, an increase of 33.6%.

Of the three violent causes cited, it was the one with the highest ten-year growth, far exceeding homicides (2.1%) and mortality in transportation accidents (24.5%) (WAISELFISZ, 2014, p. 111).

There were no reports of this approach in subjects related to gender discussion, such as Women’s Health and Men’s Health. There is evidence showing that the prevalent pattern in suicides is three to four times higher mortality rates for men.

The suicide attempt is more frequent among women, but men achieve a higher death rate because they use more aggressive methods (SOUZA, 2010, p. 7).

The male rates grew 84.9%, well above the female rates, which increased only 15.8%. Among young people, the process was different: male rates increased 54.1% while female rates declined 27.7% (WAISELFISZ, 2014).

Regarding to the life cycles, the course shows two specific subjects: Occupational Therapy in Children’s Health and Occupational Therapy in Gerontology.

In none of these subjects the students interviewed discuss suicide; although they point out that they believe it would be important:

It is a subject that should be addressed within some subjects such as mental health, child health, women’s health, ethics, gerontology, so it could be studied broadly in each context (Student F).

The age cut has also been highlighted in several surveys. WHO (ORGANIZAÇÃO..., 2012) notes that this number is increasing. According to Souza (2010):

In Brazil, 43 children aged 0-9 between 2000 and 2008 died of suicide [...]. In the same period, 6,574 adolescents aged 10-19 years old died from suicide. On average, 730 adolescents die each year from suicide. The impact of mortality rises with increasing age: 24% of suicide deaths occurred in the younger age group and 52.6% in people aged 30-59 years old (SOUZA, 2010, p. 6).

The suicide rate worldwide is higher in older individuals than in younger people, compared to other age groups, and accounts for 14.3% of all deaths (WAISELFISZ, 2014; WORLD..., 2014). Between 2000 and 2008, 10,434 elderly people committed suicide in Brazil, and the suicide rate for this population is 7/100 thousand inhabitants (SOUZA, 2010).

It is worth mentioning that when analyzing the Brazilian data on suicide, the high underreporting rates should be considered, that is, suicide mortality in Brazil may be higher than the data show (BOTEGA et al., 2006).

As previously discussed, mental disorders are a major risk factor for suicide. Even so, no student reported that the subject was discussed in the subject Occupational Therapy in Mental Health, nor in the fields and internship supervision. This absence does not go unnoticed in the students’ speech:

[...] I think, mainly because we have a specific area that is mental health, surely we have to study the subject of suicide at graduation. Even because we live in a society that is going through a process of emotional illness, there is a social charge (Student D).

Durkheim (2000) treats suicide as an issue related to social and cultural factors. In this perspective, the subject could have been discussed in other subjects, such as Occupational Social Therapy, Anthropology or Sociology, and Philosophy, which was not pointed out by the students.

This insufficiency of discussion about suicide in its different theoretical approaches does not go unnoticed by the students, as shown in the following speech:

Situations related to suicide may arise in practice and deficiency in the training of O. T. interfering directly with the quality of the intervention in the face of a potentially serious situation (Student D).

It is possible to understand how this issue affects several people and the urgency of developing coping and prevention strategies related to suicide. However, we need this content to be offered before practice, that is, in different subjects, with different approaches, since the approach of suicide must cross the theoretical contents in the training of the occupational therapist.

During the interviews, students were also asked about their conception on the relevance of the suicide approach in the graduation of Occupational Therapy. The first question to be pointed out is that the students recognize the importance of having this theme worked during their professionalization process:

It is very important that the subject is approached during the graduation, so the students can know and deepen their knowledge on the subject, allowing a reflection (Student A).

[...] certainly, this is a very pertinent subject for the undergraduate course in Occupational Therapy (Student J).

It is important to talk about suicide during graduation so when professionals, during practice we can recognize characteristics of this suffering and make a good intervention to help the patient to face their difficulties (Student G).

The increase in cases and suicide attempts and their impact on health and social issues around the world mean that the issue needs to be addressed and points out the urgency of preventing them and therefore is a contemporary demand and needs to be discussed and their policies enforced.

Thus, addressing the issue of suicide during undergraduate training and health practices, but discussing the subject in all its complexity, with reference to the human and social sciences, is also of great relevance for the implementation of the guidelines of public policies on health, education and social assistance, educational and preventive actions related to suicide.

The students explain several reasons that justify the importance of studying this theme during training. Among them:

[...] based on the premise that people who commit suicide generally use the justification that they committed such an act because of issues related to their daily life, their social, family, emotional relationships, their work, and so on (Student I).

These people can be our co-workers, family, friends, and patients, and even not to be heard. So I think it is important to address this issue, to stimulate the eyes of those who are around, suffering and asking for help - even if quietly (Student E).

[...] for students to learn how to act if they encounter a patient who wants to commit suicide (Student D).

[...] they would leave the university better able to identify the signs and know how to deal with the patients who present tendencies to suicide, being able to carry out a more specific work to meet the need of each one (Student K).

There is a foundation and sensitivity in the speeches of these students since any professional can find such situations, in different places of action, not only in health services but in schools, work environments, territorial practices. Still, about how this approach should be given, students make some suggestions:

It would be interesting if in undergraduate study we first learned theoretical aspects of suicide and the emotional, cognitive, and social processes involved (Student B).

I think that suicide should be approached in two ways: one, diffused in all other subjects in a certain way when speaking of the integral care of the subject; and I think it would be worth elective subject to address the issue of suicide other related topics such as euthanasia, grief and about that suffering and emotional illness (Student G).

I think a link must be created between aspects of the occupational therapy area, that is occupations, client factors, performance skills, performance standards, contexts and environments, and cinematographic films or bibliographies, reports or articles that point out the relation between the failure in one or more aspects cited with the option for suicide (Student L).

There are several perspectives for changes in the training of occupational therapists and, considering that the learning scenarios are of potential importance as a locus of training, it is extremely relevant that the students propose reflections and transformations for the incorporation of integrality into the teaching-learning process, allowing an interdisciplinary and extended approach (ALBUQUERQUE et al., 2008).

4 Final Considerations

It is noticed that suicide is still a complex subject and needs a greater visibility. It is a phenomenon influenced by many factors and there is no a single cause. When interviewing the Occupational Therapy students of an HEI, it was interesting to note that they considered suicide attempts an important issue to be studied and clarified. They also expressed the view that suicide can be a consequence of intense suffering, not associated with mental disorder, that is, not all suffering means being sick.

The training of the occupational therapist is the object of study in several areas of graduation and topic of discussion between students and professors to reformulate theory and practice. Even today, researchers and educators focus on discussions and concerns about quality education (PAN, 2014). Quality training includes following the National Curricular Guidelines, instituted by resolution CNE/CES 6, of February 19, 2002, updating it in the discussions with the new demands that arise in the practical field.

Thinking about training means a process of constant reflection. Thus, it is necessary for occupational therapists involved in professional training to attend to current demands and reflect on ways to incorporate them into the curriculum. Unfortunately, most of the students interviewed at this HEI reported that there was no suicide approach during graduation. However, the research may provide students with a reflection on this subject, making it a subject within the training of occupational therapists. From this perspective, this research sought to point out some possibilities regarding the subject of suicide. The need for continuity of studies on the subject in other HEI and greater appropriation of the discussion by occupational therapists is highlighted, so this content can effectively enter as a guideline in professional training.

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Notes

• 1
  The article is part of the research developed in the Department of Occupational Therapy of the Federal University of Rio de Janeiro entitled “The approach of suicide in the training of the occupational therapist: what the students say”, whose results were presented as work of conclusion of course of the first author. The research was submitted to the Research Ethics Committee of the Hospital Clementino Fraga Filho of UFRJ, and it was approved through opinion number 1,636,174.

Publication Dates

• Publication in this collection
  Dec 2018

History

• Received
  28 Dec 2017
• Reviewed
  27 Sept 2018
• Accepted
  30 Sept 2018