Experience of pre-suicidal suffering: insights from suicide attempt survivors

ABSTRACT

Purpose

Psychache significantly contributes to the suicidal process. However, the transition from pre-suicidal suffering to a suicide crisis remains one of the least explored stages in suicidology.

Methods

We retrospectively explored experience of pre-suicidal suffering through semi-structured, in-depth interviews with 12 individuals recruited from the Vilnius City Mental Health Center, Lithuania. Interpretative phenomenological analysis was employed to identify recurring patterns.

Results

Nine primary group experiential themes emerged: Certain adverse life events occurring during the suicidal process were not immediately perceived as connected; Complex traumatic events laid the groundwork for a profound sense of lack; A compensatory mechanism balanced the experience of profound lack; Exhaustion ensued from efforts to sustain the compensatory mechanism; The main trigger directly challenged the compensatory mechanism; The affective state followed the experience of the main triggering event; Dissociation served to isolate psychache; Thoughts of suicide experienced as automatic; Suicide was perceived as a means to end suffering.

Conclusion

The findings suggest that the suicidal process unfolds over an extended period of suffering, culminating in a crisis to alleviate unbearable psychological pain. In clinical practice, identifying the main triggering event discussed in this study can be pivotal in understanding the essence of suffering characterized by profound lacking and developed compensatory mechanisms.

KEYWORDS:

• Pre-suicidal suffering
• psychache
• suicidal process
• suicidal crisis
• compensatory mechanism
• suicide attempt
• IPA

Introduction

Psychache has been recognized as a significant contributor to the suicidal process for many years (Cheng et al., 2021; Shneidman, 1993). Shneidman (1993) initially introduced the concept of unbearable psychological pain—psychache—as a crucial variable in the suicidal process. He presented a three-dimensional Cubic Model of Suicide, demonstrating that increased unmet needs (perturbation), real and imagined stressful events (press), and feelings of psychological pain (psychache) heighten the likelihood of an individual facing a suicide crisis. At the core of this model is the premise that the more intense the psychache, the stronger the individual’s desire to escape it, resulting in an increased unwillingness to live and a higher probability of developing a suicidal process. It is clearly stated that unresolved psychache invariably leads to suicidal behaviour and, in nearly all cases, is the cause of a suicide crisis.

Numerous researchers have built upon Shneidman’s work (1993) expanding knowledge about psychache (Baumeister & Leary, 1995; Cacioppo & Patrick, 2008; R. C. O’Connor & Kirtley, 2018; Van Orden, 2014). Turning to the latest theories about the suicidal process, it is evident that the model first described by Joiner and further elaborated by Van Orden (2014), The Interpersonal Theory of Suicide, questions how individuals who contemplate suicide differ from those who attempt it. The authors discuss how adverse life events impede basic human needs, leading to feelings of low belongingness and perceived burdensomeness, which in turn trigger the desire to die by suicide. Additionally, for the capability to attempt suicide, attributes such as fearlessness about death and a tolerance for physical pain are necessary. The assumption is made that psychache arises because certain life events are labelled as adversities, blocking basic human needs and causing psychological pain. Studies corroborate the significance of the meanings assigned to life events in the trajectory of the suicidal process (Hjelmeland & Knizek, 2010; Mcmanama O’Brien et al., 2019). Thus, it is crucial to investigate the specific meanings people attribute to life events and how these meanings influence the suicidal process.

Furthermore, R. C. O’Connor and Kirtley (2018) introduced The Integrated Motivational—Volitional Model of suicidal behaviour, which aligns with the aforementioned perspective—a culmination of adverse life events initiates suicidal ideation by inducing feelings of defeat, humiliation, and entrapment. This theory further details how adversities interact with the process. The authors categorize triggering events into a triad: diathesis, environmental context, and adverse life events at any stage of life, emphasizing that these events accumulate and intensify the motivation for suicidal thoughts. Other research supports the idea of a cumulative effect (Fergusson et al., 2000). Consequently, not only is it important to understand the meanings attributed to adverse life events in comprehending the suicidal process, but also the experience of exposure to a series of such events, or the cumulative effect.

Given the models discussed above, psychache plays a significant role in the suicide process, stemming from cumulated experiences of life events that were meaningfully labelled as adversities and blocked the availability of desired needs.

Many years of studies have revealed a variety of adverse life events significantly linked to the suicidal process: health issues (mental and physical), relationship problems, bereavement following a loss, occupational and financial problems, environmental conditions, and more (Carrasco-Barrios et al., 2020; Fergusson et al., 2000; Milner et al., 2017; R. C. O’Connor & Kirtley, 2018; Serafini et al., 2015). Closer examination of these groups shows that no area of human life is immune to becoming an adversity. In a comprehensive analysis of suicide risk factors identified over the past 50 years, Franklin et al. (2017) concluded that new data do not yield new findings nor improve predictions for suicidal behaviour. On the other hand, research indicates that in the 6 months before an attempt, individuals report experiencing four times more life events than the general population and five and a half times as many as individuals with depression (De Vanna et al., 1990; Paykel et al., 1975). These data demonstrate that in the months leading up to a suicide attempt, individuals encounter an increased number of adverse life events that they must confront and navigate, necessitating a deeper comprehension of the formation and perception of such risks.

Moreover, adverse life events are not solely associated with the suicidal process but also with other clinical and psychological conditions such as psychiatric disorders, acute psychological stress, cardiovascular disease, cancer, resilience, growth, among others (Kelly-Irving et al., 2013; Schneider et al., 2021; Su et al., 2015; Tiet et al., 1998, 2001; Vollhardt, 2009). This suggests that the accumulation of adverse life events causing suffering can lead to various trajectories. In this study, the focus lies on suffering indirectly related to suicidality by triggering the suicidal process, otherwise termed pre-suicidal suffering. The transition from the pre-suicidal stage to suicidal ideation is one of the least researched stages in suicidology (R. C. O’Connor & Kirtley, 2018). Understanding the transition is vitally important for understanding individuals in a suicidal crisis and developing suicide prevention strategies.

An intriguing study examining the transition from ideation to action in adolescent suicide (Mcmanama O’Brien et al., 2019) states that historical, sociocultural, and interpersonal factors alone are insufficient for an adolescent to result in a suicide attempt. Moreover, researchers conclude that existing psychological pain (or suffering) may interact with interpersonal factors, distort cognitions, and elevate emotional experiences to the point where they become overwhelming. These findings suggest cyclic dynamics—not only do adverse life events cumulate and increase suffering, but the experience of suffering may also intensify the adverseness experienced.

Some studies examining suicidal motivation (Orri et al., 2014; Pavulans et al., 2012) identify the motif of a desire to regain control when entering a suicidal crisis. Thus, a suicide attempt or even the broader suicide process might serve as a means to regain control amid cumulated adversities. This aligns with theoretical models which suggest that during the motivational phase, individuals experience feelings of defeat and entrapment (R. C. O’Connor & Kirtley, 2018). Additionally, motifs of a desire to communicate pain or enact revenge have been identified in other studies (Heesen et al., 2024; Orri et al., 2014). To enhance our understanding of how pre-suicidal suffering motivates the suicidal process, these studies suggest that the process is a search for a solution to alleviate the pain. These and further research indicates a connection between psychache and suicidality (Lakeman & Fitzgerald, 2008; Shamsaei et al., 2020). Currently, in suicidology, there is a scarcity of research analysing the phenomenon of pre-suicidal suffering, its connection to the suicide process, and how it differs from suffering that does not develop into a suicide process.

Hence, to better understand individuals in a suicide crisis, the present research aims to gain deeper insight into how people experience pre-suicidal suffering and how it develops into a suicidal process and suicide attempt.

Materials & methods

Sample

A sample of 12 people (4 men, 1 non-binary individual, and 7 women) who had attempted suicide in the past year was recruited through the Vilnius City Mental Health Center (Lithuania). Attempted suicide was defined as engaging in non-fatal, self-directed, harmful actions with evidence of intent to end life (R. C. O’Connor et al., 2013). The inclusion criteria were being 18+ years old, having attempted suicide no more than one year ago, voluntary agreement to participate in the research, proficiency in the Lithuanian language, and participants on medical treatment agreed that medications would not significantly influence our conversations. Exclusion criteria were met if an individual was suicidal at the moment of recruitment or interview, experiencing a psychotic episode, or the suicide attempt was more than one year ago. The participants, aged between 18 and 63 years (M = 29.83; SD = 14.6), were all residents of Lithuania. Interviews were conducted between July and December 2022. For three participants, it was their first attempt; for five, the second; for two, the third; for one, the fourth; and for one, the sixth. Further demographic data are provided in Appendix A, Table AI.

Procedures and measures

Ethical approval for the study was obtained by the Vilnius University Psychological Research Ethics Committee (Reference Nr. 35/(1.13E)250000-KT-5). Permission to proceed with the research at The Vilnius City Mental Health Center was consented to by institution representatives (Reference Nr. RG-093). Two departments—the Department of Crisis Intervention and the Department of Acute Psychiatric Conditions—consented to the collaboration. Staff members of the departments were provided with instructions on how to present the research to potential participants and answer frequently asked questions.

Potential participants, throughout the recruitment period (April to December 2022), were invited to participate in the research. If they expressed willingness, in-person meetings with the researcher were scheduled at their convenience. The response rate to the invitation (number of completed interviews out of the number of invitations to participate in the research) was 65.22%.

At the meeting, the researcher once again outlined the aim of the research, the interview procedures, the participant’s right not to answer questions, stop the interview at any moment, and the researcher’s commitment to confidentiality. If participants agreed to proceed, informed consent was signed, and the interview was conducted as planned.

A semi-structured interview was designed by the authors at the Centre for Suicidology, Vilnius University. The interviews were initially tested in an experimental trial and adjusted to better elicit the experience of pre-suicidal suffering and guide participants through a smoother interview experience. Topics included in the interview were: a brief description of the circumstances surrounding the suicide attempt, reflections on adverse life events prior to the attempt, reactions to current adverse events, the importance of others during these events, possible needs during these times, and additional information that might aid the researchers.

The interviews, which were audio-recorded, lasted between 14 and 114 minutes (M = 43.58 min; SD = 31.91), allowing participants to choose the time they needed to share their story. Interviews began with demographic data collection and were followed by semi-structured, in-depth discussions. At the end of each session, emerging feelings were discussed, flyers with helpline contacts were provided, and participants were thanked for their contribution. Interview records were transcribed, personal information was anonymized, and the names of research participants were changed. To ensure the quality of the research and an ethical approach to handling the participants, we adhered to guidelines for both qualitative research conduction and publication (Elliott et al., 1999) and requirements for clinical psychology research (Barker et al., 2015).

Analysis

Interpretative phenomenological analysis (IPA, Smith et al., 2022) was employed to analyse the interview data using an inductive approach. IPA is an optimal strategy for collecting and analysing rich, detailed data from personal narratives. This method facilitates the exploration of in-depth circumstances and the connections between life events and experiences, thereby identifying repetitive patterns within a group. It offers a flexible approach for investigating unfamiliar phenomena and is particularly suitable for sensitive topics such as pre-suicidal suffering and suicide attempt experiences. The analytical strategy is well-documented, structured, and accessible to researchers (Braun & Clarke, 2013; Smith et al., 2022). In this research, we followed the steps described by the authors (Smith et al., 2022).

Research team and reflexivity

This research adopts a phenomenological approach, which posits a gap between reality itself and personal experience, leading to varied structural views on life among individuals. Over time, each person’s subjective reality intersects with other subjective realities and reality itself, necessitating psychological flexibility to adapt and progress. Rigid patterns hinder adaptation and can lead to psychological conflicts or suffering. This perspective guided our structuring of the research, aiming to determine if individuals facing a suicidal crisis exhibit repetitive patterns in their pre-suicidal suffering experiences.

Lithuania, the location of this study, consistently records one of the highest suicide rates in Europe. The prevalence suggests that the extent of suffering in Lithuania exceeds that in other countries, underscoring the need for focused research attention and the development of a national suicide prevention system. We believe that every individual confronting a suicidal crisis deserves support and assistance, which should be provided by the national health system.

The interviews were conducted by the first co-author (M.M.), a PhD candidate with a master’s degree in clinical psychology, trained in qualitative methods, including IPA, at the Institute of Phenomenological Research in Vilnius, Lithuania. M.M. has six years of experience working with qualitative data across various projects. The second co-author (L.V.), a graduate psychology student pursuing a master’s degree, has three years of experience in qualitative research. The third co-author (D.G.), a professor and seasoned researcher in suicidology with more than 36 years of experience, supervised this study. IPA was facilitated by the first co-author (M.M.), and the coding system was refined through discussions with the other co-author (L.V., D.G.).

Results

All 12 research participants experienced a series of adverse life events prior to attempting suicide, enhancing our understanding of how the accumulation of meaningful adverse life events can evolve into pre-suicidal suffering and the suicidal process. The application of IPA to the 12 interviews yielded 726 experiential statements, from which 119 experiential themes and 9 main group experiential themes (GETs) were derived. The themes identified are as follows:

1. Certain adverse life events occurring during the suicidal process were not immediately perceived as connected;

2. Complex traumatic events laid the groundwork for a profound sense of lack;

3. A compensatory mechanism balanced the experience of profound lack;

4. Exhaustion ensued from efforts to sustain the compensatory mechanism;

5. The main trigger directly challenged the compensatory mechanism;

6. The affective state followed the experience of the main triggering event;

7. In the current affective state, dissociation served to isolate psychache;

8. Thoughts of suicide, emerging in the affective state, were experienced as automatic;

9. Suicide was perceived as a means to end suffering.

Each of the nine GETs is further elaborated below.

Certain adverse life events occurring during the suicidal process were not immediately perceived as connected

Seven out of twelve research participants indicated a disconnection between certain adverse life events and the present suicidal process, even though other concurrent adverse events were perceived as connected. For instance, participant Laimonas articulated a distinct contrast between two experiences—the diagnosis of cancer and his subsequent dismissal from work—where only the latter significantly influenced his desire to continue living:

Cancer-related issues actually didn’t affect me much… Noooooo … . I dealt with the cancer, we accepted it, and everything was fine. (Laimonas)

Another participant, Lėja, commented on her financial challenges:

You always have financial problems when you have many children, but you learn to navigate through them; they are not really connected. [to my other issues] (Lėja)

This specific GET is crucial for understanding that not only while some individuals facing a cumulation of adverse life events develop suicidal thoughts, others do not, but also not all adverse events contribute to the overwhelmingness that leads to suicidal ideation. This observation raises a critical question: How can adversities that are connected to and disconnected from suicidality be distinguished?

Complex traumatic events laid the groundwork for a profound sense of lack

Seven out of twelve participants described recurring life experiences, often from early life, that left enduring “wounds” still sensitive or easily provoked by subsequent events. These experiences led to a persistent feeling of profound lacking in various aspects such as acceptance, love, control, grace, kindness, calmness, and completeness. The experience of Juliana vividly illustrates a deep-seated lack of acceptance:

… and my father told me, “I don’t have a daughter, I only have a son, you and your mother mean nothing to me.”For me it was like … I don’t know … It crushed me. I vividly remember the room where he said it, my brother’s presence, and his activities at that moment… < … > I never felt a fatherly hand or love. (Juliana)

Further analysis of Juliana’s narrative revealed additional experiential statements of rejection from both parents and her subsequent lifelong quest for acceptance. A crucial incident that triggered her suicidal crisis was another person reminding her of her right to leave a room, which she interpreted as being unnecessary and uncared for in that space. Following this event, she began actively planning a suicide attempt.

This GET recurs in the narratives of various participants, indicating that pre-suicidal suffering often starts long before an actual suicide attempt, typically originating in childhood. It demonstrates how historical emotional wounds contribute significantly to the suicidal process.

A compensatory mechanism balanced the experience of profound lack

Seven out of twelve research participants demonstrated the reactive development of compensatory mechanisms to manage the experience of profound lacking noted in the previous GET. For instance, to compensate for the lack of family love, participant Lėja discussed her social support network:

Sometimes I feel inferior… But I also have very good friends. I am content with what I have ((laughing)) < … > Even though I don’t have a stable family, my friends are so supportive that I don’t feel I need one. (Lėja)

Lėja’s narrative revealed numerous experiential statements about rejection and abuse from family members, as well as the significance of having a supportive and substantial circle of friends. The triggering event for her suicidal crisis was the betrayal by a close friend, despite her belief that true friends would not betray.

This GET illustrates the complex interplay between profound lacking and compensatory strategies, which are often rigid by nature, usually in conflict with reality, and energy-intensive to maintain.

Exhaustion ensued from efforts to sustain the compensatory mechanism

Many interviews began with participants expressing, “I was just so exhausted … ”. Six out of twelve described feeling physically and/or emotionally drained from sustaining their compensatory mechanisms. For example, participant Brigita discussed her primary life goal during a period of crisis:

When I had my son, I was already struggling with depression for eight years. Raising my son I had no support, my mother was uninvolved, and my husband was always at work. Frankly speaking, I was overwhelmed by the exhaustion. < … > I felt like a failure because my role as a mother demanded that I devote myself entirely to my child. (Brigita)

Years earlier, Brigita had suffered greatly from the loss of a relative she cared for, a loss she felt deeply responsible for. Her narrative included numerous experiential statements emphasizing the importance she placed on supporting her child and her certainty that she had done all she could. However, the constant and intense effort required for such compensation led to exhaustion. The critical event triggering Brigita’s suicidal crisis was criticism that she was not an adequate wife and mother.

This GET highlights that individuals who are actively managing profound lacking with compensatory mechanisms may deplete their energy and become increasingly vulnerable to external pressures.

The main trigger directly challenged the compensatory mechanism

Eight out of twelve research participants identified a specific triggering event prior to their suicide attempt as a critical turning point. The common characteristic of these main triggers is that they directly challenged the participants’ compensatory mechanisms. For example, participant Robertas, who was regaining control over his life, experienced a setback due to illness:

I already had a plan. Not only were the dates set, but I also knew the steps… At this time in December, I was supposed to be working. It seemed like it was my last chance to try. (Robertas)

Another participant, Asa, who was seeking acceptance from others, was devastated by a friend’s rejection:

… recently, I went through a tough breakup with a partner, and then a friend I had known for twelve years told me, “I don’t know, maybe it’s your depression or something, but you’ve changed a lot, I don’t want to be friends with you anymore.” I felt so much rejection … It might have pushed me over the edge. (Asa)

Participant Lėja insightfully noted that the main trigger is often a culmination of complex traumatic experiences and the breakdown of compensatory mechanisms:

It wasn’t just the last straw. It felt like both the beginning and the end of everything … (Lėja)

This GET indicates that triggering events are not random but are significant incidents that challenge a person’s coping mechanisms, often the natural responses to painful experiences.

The affective state followed the experience of the main triggering event

Nine out of twelve research participants described experiencing a distinct emotionally charged state following the main trigger. Six reported that this affective state ensued directly after the main trigger, while four noted that their current feelings were intensified by memories of past experiences.

… and what is important, when they betrayed me, I started to think how my father left me, how I am not needed to my mother, how she was forgetting me, that my grandparents are not alive anymore and every- everything that was in the past just came back and added together to what they have done to me. (Ona)

Another depiction of this affective state was shared by Alfredas:

I was at home and it was like seizure, the seizure of hatred towards everything. I mean towards environment, items, furniture, myself … That kind of thing. It’s like you lose all sense of what you’re doing. Sometimes you might hurt yourself or slam a fist into the wall. (Alfredas)

This GET underscores the presence of an intense emotional response where past grievances resurface and amplify the distress experienced just before a suicide attempt.

In the current affective state, dissociation served to isolate psychache

Six out of twelve participants reported experiencing dissociation during their present affective state. This detachment involved feeling alienated from their bodies, observing themselves from a distance, lacking control over their actions, or having selective memory. Participant Lėja described this state vividly:

I tried to explain it to my doctor last time - just an affective state ((pause)). When you are stuck in yourself. This feeling when you … you see everything but your hands are doing what they want. Because it … it looks like this hemisphere is working and this one too – this is a healthy mind, and this is a stupid mind. And this stupid mind is taking over. And you just … just like … are sitting in your head and thinking, ‘hm, and what is coming next?’ Just like ((pause)). I don’t know how to explain. (Lėja)

This GET details the intensity of the affective episodes participants experienced shortly after the triggering event, highlighting their attempts to mentally distance themselves from the pain.

Thoughts of suicide, emerging in the affective state, were experienced as automatic

Five out of twelve participants reported that during their intense emotional states, suicidal thoughts emerged automatically, and they struggled to control these thoughts. Vanda explained:

And I don’t want to die, I want to live but the thoughts persist—self-harm and a compulsion to end my life, various visions. Plans start forming, and… I can’t control it … (Vanda)

The origins of these narratives of suicidal thoughts were scarcely traced in this study. One participant noted that she adopted a narrative from a beloved relative and attempted to emulate it. Another recounted that narratives suggesting suicide were imparted to her at a young age by her family:

When I was growing up… I was raised by my mother’s relatives and my sister with father’s. They kept saying that I would end up like my mother or die by suicide like my father. It’s as if it’s ingrained in me—to be a loser always trying to kill oneself … ((long pause)) ((trembling voice)) … and everyone keeps saying that I have children, meaning I shouldn’t end my life. But they don’t understand that it’s not up to me ((crying)). (Lėja)

This GET suggests that thoughts of suicide can arise as deeply ingrained, automatic responses during an affective state.

Suicide was perceived as a means to end suffering

Seven out of twelve participants indicated that their decision to attempt suicide was driven by a desire to cease the unbearable psychache and achieve peace.

I don’t know if someone will agree, but for me, it is quite logical … If I experience things that are worse than death, I think … We don’t know what happens after death. But I believe there’s just emptiness, nothingness. Like sleeping without dreaming. You simply… cease to exist. That would be so peaceful. That’s why I want it when this state begins. (Robertas)

This GET contributes to the understanding of the complexity of the suicidal process. When individuals face profound, prolonged pain, leaving them vulnerable, and when an idea on how to alleviate these painful feelings emerges clearly, the challenge is in resisting the impulse.

Discussion

In this study, we aimed to delve deeply into personal narratives of suicide attempts to identify repetitive patterns that reveal how individuals experience pre-suicidal suffering leading to a suicidal crisis. The emerging results yielded group experiential themes (GETs) that were organized into a coherent pattern (Figure 1). This pattern demonstrates how complex traumatic experiences can instigate feelings of profound lacking that persist throughout an individual’s life. To cope, individuals may develop compensatory mechanisms to counterbalance these feelings. These mechanisms often require significant energy to maintain throughout one’s life and can lead to exhaustion. A compensatory mechanism, typically a rigid belief structure or thought pattern, often conflicts with reality, which is why external life events can trigger and challenge them. Many individuals recall a main triggering event in the suicidal process that challenged their beliefs and led to an overwhelming affective state, where past traumas and current situations amalgamated, intensifying the psychache to unbearable levels. In response, some individuals reported dissociation, while others experienced automatic suicidal thoughts, suggesting an end to their pain.

Figure 1. Diagram illustrating the pathway from the experience of profound lacking to the automatic emergence of suicidal thoughts.

This pattern aligns with several theoretical models that rely on concepts such as accumulated adverse life events, feelings of defeat, entrapment, burdensomeness, thwarted belongingness, psychache, a desire to escape, and acquired capacity for suicide (Baumeister, 1990; R. C. O’Connor & Kirtley, 2018; Shneidman, 2004; Van Orden, 2014). This congruence indicates that our research taps into the core aspects of the suicidal process as discussed in contemporary academic discourse. While it is possible to engage in an extensive discussion on how each step of the pattern supports and expands upon these theoretical aspects, we will focus on the most critical elements.

Numerous studies have linked adversities in childhood and adulthood with the suicidal process (Carrasco-Barrios et al., 2020; Foster, 2011; Krysinska & Lester, 2010; D. B. O’Connor et al., 2018), illustrating that an accumulation of stressful events can correlate with increased suicidal ideation and behaviour (Howarth et al., 2020). This understanding suggests a natural inclination to associate every adverse life event with the potential for a suicidal crisis. However, the findings of our study caution against this assumption, reminding us that not every adverse event during a suicidal crisis is connected to suicidality. Moreover, distinguishing between adversities that are related to the suicidal process and those that are not may provide insights into why only some individuals develop a suicidal crisis. Our results propose that adversities perceived as related to suicidality might trigger compensatory mechanisms, indicating that these events do not allow individuals to suppress unwanted feelings. Nonetheless, this hypothesis necessitates further investigation.

Complex traumatic experiences are commonly associated with suicidality (Jannini et al., 2023; Nepon et al., 2010; Sareen, 2014), particularly highlighting symptoms of re-experiencing and avoidance (Selaman et al., 2014). However, some researchers argue that the link between traumatic experiences and suicidality is often overstated (Hjelmeland & Knizek, 2010). Our findings indicate that complex traumatic experiences contribute to pre-suicidal suffering and play a crucial role in the development of compensatory mechanisms. Yet, our research also suggests that numerous factors following traumatic experiences contribute to the development of a suicidal process, indicating that trauma alone does not fully explain suicidality.

A unique aspect of this study is the exploration of why certain events accumulate and become overwhelming, leading to pre-suicidal suffering. Our results suggest that the key factor in this accumulation might be an attempt to maintain a compensatory mechanism, which involves suppressing intrusive traumatic memories and emotions. The sense of overwhelmingness arises when an individual’s capacity to withstand external provocations, confrontations, and intrusions targeting their compensatory mechanisms is exhausted. Intriguing research by Mary et al. (2020) suggests that intrusive memories are essential for integrating new information into autobiographical memory. However, suppressing these intrusions can overtax the memory control system, ultimately leading to post-traumatic symptoms. Other studies support the notion that suppression can cause a rebound effect and lead to exhaustion (Gold & Wegner, 1995; Mommersteeg et al., 2006; Pettit et al., 2009; Secosan et al., 2020).

Our study reinforces that episodes of affective states are common in narratives of suicide attempts. Research links these affective states with suicidal crises, noting that affectivity is a trait more commonly observed in individuals at risk of suicide, with an increase in the frequency of affective states near the time of the suicidal process (Hendin et al., 2007; Rogers et al., 2022; Schuck et al., 2019). Klonsky (2007) posited that self-harm often occurs in response to acute negative emotional affect. Our findings reveal that many individuals experience active suicidality in a similar manner, particularly after the breakdown of their protective compensatory mechanisms.

Years ago, Orbach (2003) hypothesized that in the face of intense physical pain, individuals might dissociate, distancing themselves from the painful experience. A comprehensive meta-analysis by Calati et al. (2017) confirmed that dissociation is significantly linked with suicide attempts and non-suicidal self-injury. Our study extends the understanding of dissociation in the suicidal process, illustrating that it may be employed as a strategy to distance oneself from psychache during affective states.

Furthermore, our findings expand the understanding of how suicidal thoughts might initiate at a very fundamental, perhaps unconscious level of the psyche, acting intrusively with increasing difficulty to resist. Additional research supports the presence of intrusive imagery about suicide (Holmes et al., 2007; Van Bentum et al., 2017, 2023). While such images are typically discussed as occurring before a suicidal crisis, our findings suggest that during an affective state of overwhelming suffering, thoughts might activate as a learned pattern, surfacing into consciousness automatically as a method to cope with emotional pain. This study did not successfully trace the origins of individuals’ initial encounters with the idea of suicide or the contexts in which they occurred, which remains a promising direction for future research.

Clinical implications

This study underscores that individuals facing a suicide attempt often experience substantial suffering prior to the onset of a suicidal crisis. The findings could enhance theoretical models of the suicidal process, particularly those detailing the transition from pre-suicidal suffering to the actual suicidal crisis. However, further research with larger samples is necessary.

For practitioners working within a therapeutic framework, it may be beneficial to inform patients that suicidal thoughts can appear to arise automatically in the affective state, but it is not imperative to act on these thoughts. Implementing a safety plan is crucial in such instances.

Furthermore, in psychological counselling or therapy, using the main triggering event as a focal point could help identify the core of pre-suicidal suffering. By examining the triggering event and its significance to the individual, therapists can work with their patients to uncover the underlying compensatory mechanism and the core wounds. This approach is based on the understanding that the main trigger directly challenges the compensatory mechanism that shields the individual from traumatic experiences.

As a result, safely addressing feelings of profound lacking and suppressed traumatic experiences could prevent exhaustion, reduce the frequency of affective states, and mitigate the risk of a suicidal crisis.

Conclusion

In conclusion, the findings suggest that the suicidal process can be viewed as an extended period of suffering, where a suicidal crisis emerges only in the final stages as a means to confront the most intense experiences of psychological pain. Secondly, our research reminds us that not all adverse life events occurring during the crisis are directly linked to the suicidal process, particularly those that do not challenge a compensatory mechanism. Thirdly, while complex traumatic experiences contribute to the suicidal process, they alone cannot fully explain it due to the presence of multiple factors influencing suicidality. Fourthly, the overwhelming nature of accumulated adverse life events is often connected with efforts to sustain a compensatory mechanism, which conflicts with reality and leads to exhaustion. Fifthly, the main trigger in the suicidal process is typically seen as directly opposing the compensatory mechanism. Therefore, it is valuable for practitioners to trace the relationship between the main triggering event and the compensatory mechanism in an individual’s narrative. Sixthly, the presence of an affective state characterized by automatically emerging suicidal thoughts and attempts to alleviate pain is a common theme in many narratives. Our study indicates that individuals often struggle to resist these automatic thoughts due to a desire to end their pain.

Author contributions

Conceptualization, M.M. and D.G.; data curation, M.M.; investigation, M.M.; methodology, M.M. and D.G.; supervision, D.G.; validation, M.M., L.V. and D.G.; visualization, L.V.; writing—original draft preparation, M.M., L.V., D.G.; writing—review and editing, M.M., L.V., D.G. All authors have read and agreed to the published version of the manuscript.

Clinical trial registration

No trial registration is required for the article.

Ethics approval statement

This study was conducted at The Vilnius City Mental Health Center, Vilnius, Lithuania, between April and December 2022. Ethical approval was granted by the Vilnius University Psychological Research Ethics Committee (Reference Nr.35/(1.13E)250000-KT-5).

Patient consent statement

Informed consent was obtained from all participants in the study.

Permission to reproduce material from other sources

No permissions are required for the article.

Acknowledgments

We extend our gratitude to our colleagues at the Vilnius City Mental Health Center for facilitating our access to research participants and ensuring a seamless data collection process. We also wish to express our heartfelt thanks to all the individuals who courageously shared their personal experiences with us, demonstrating trust in and support for the field of suicidology research.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The authors elect to not share data.

Additional information

Funding

This research did not receive any financial support for its conduct or authorship.

Notes on contributors

Miglė Marcinkevičiūtė

Miglė Marcinkevičiūtė is a PhD candidate at Vilnius University and a practicing psychologist. Her interest in suicidology began in 2018 during her Master’s studies with a focus on male suicidality. She has contributed to numerous scientific projects that deepen the understanding of suicidality both in Lithuania and internationally. Her doctoral thesis extends this research, exploring suicide prevention through the study of how individuals ascribe meaning to adverse life events during a suicidal crisis.

Lauryna Vilutytė

Lauryna Vilutytė is a first-year Master’s student in Organizational Psychology. For seven years, she has been an active member of the “Jaunimo linija” community, an emotional support hotline in Lithuania, and for three years, she has served as a trainer in suicide intervention programmes. Lauryna is continuously involved in various projects related to suicide prevention and is proficient in qualitative research methods.

Danutė Gailienė

Prof. Dr. habil. Danutė Gailienė is a Professor of Clinical Psychology at Vilnius University and a practicing psychotherapist. She initiated research into suicidal behaviour and suicide prevention at Vilnius University. She is the author of the books “They Should Not Have Died. Suicide in Lithuania” (1998) and “Ideas of Suicide Prevention” (2001), along with numerous scientific articles. Prof. Gailienė is a member of the International Association for Suicide Prevention (IASP) and the International Academy for Suicide Research, and she played a key role in launching the national suicide prevention strategy.

Appendix

A

Table A1. Participant Characteristics.

Name*	Sex	Age	Living place (at the moment of last attempt)	Living situation (at the moment of last attempt)	Education level	Occupational status	Mental health diagnosis
Alfredas	Man	53	City	Living alone	Post-secondary non-tertiary education	Unemployed/Has a disability	Schizophrenia
Lėja	Woman	30	City	Living with partner and children	Post-secondary non-tertiary education	Unemployed	Bipolar Type I disorder
Juliana	Woman	20	Town	Living with parents	Secondary education	Student	Personality disorder and depressive disorder
Marija	Woman	21	City	Living with friends	Secondary education	Student	Depressive disorder
Brigita	Woman	39	City	Living with partner and children	Tertiary education	Employee/On maternity leave	Depressive disorder and schizophrenia
Vanda	Woman	21	Town	Living with other relatives	Secondary education	Employee	Depressive disorder
Elzė	Woman	29	City	Living with parents	Tertiary education	Employee	Depressive disorder and schizophrenia
Deividas	Man	18	Suburb	Living with other relatives	Secondary education	Student	–
Ona	Woman	21	City	Other: moving to live with other relatives	Secondary education	Student/Employee	Depressive disorder
Asa	Non-binary	19	Suburb	Living with parents and other relatives	Secondary education	Employee	Personality disorder and depressive disorder
Robertas	Man	24	Town	Living with other relatives	Primary education	Unemployed/Has a disability	Schizophrenia
Laimonas	Man	63	City	Living with partner	Lower secondary education	Unemployed	Depressive disorder

*Names of research participants have been changed.