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Expert and Lay Explanations of Suicidal Behaviour: Comparison of the General Population's, Suicide Attempters', General Practitioners' and Psychiatrists' Views
Tina Zadravec, Onja Grad and Gregor Socan Int J Soc Psychiatry 2006 52: 535 DOI: 10.1177/00207640060668408 The online version of this article can be found at: http://isp.sagepub.com/content/52/6/535

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EXPERT AND LAY EXPLANATIONS OF SUICIDAL BEHAVIOUR: COMPARISON OF THE GENERAL POPULATIONS, SUICIDE ATTEMPTERS, GENERAL PRACTITIONERS AND PSYCHIATRISTS VIEWS

TINA ZADRAVEC, ONJA GRAD & GREGOR SOCAN

ABSTRACT Background: Different explanations of suicidal behaviour coexist today. The incompatibility of the beliefs among experts and (potential) users of medical services can inuence the implementation of prevention programmes, helpseeking behaviour and adherence to treatment. Aims: The aims of the study were to identify explanatory models of suicidal behaviour and to determine possible incompatibilities between lay (the general population and suicide attempters) and expert (the general practitioners and psychiatrists) views. Methods: The Questionnaire on Attitudes towards Suicide was revised on the basis of semi-structured interviews with the general population, suicide attempters, general practitioners and psychiatrists. The revised version was then applied to each of these four groups. Results: Five explanatory models were identied: namely, personality, sociological, medical, crisis and genetic models. Signicant group differences on the explanatory models were found. The lay people favoured crisis, sociological and medical models whereas the experts shared the belief in the medical, genetic and crisis models. Conclusions: The crisis model gained considerable support and was generally accepted as correct. This could be the common ground between lay people and experts and the starting point of both treatment and prevention programmes. Key words: attitudes of health personnel, public opinion, suicide

INTRODUCTION
Suicidal behaviour has been recognised as a mental health problem, and many nations have already implemented national programmes for its prevention. Nevertheless, no single theory of suicide can explain the phenomenon entirely. A variety of dierent theories and explanations of suicidality have emerged throughout history. They have been modied and complemented with evidence-based knowledge acquired in recent decades. Despite the diversity,
International Journal of Social Psychiatry. Copyright & 2006 Sage Publications (London, Los Angeles, New Delhi and Singapore) www.sagepublications.com Vol 52(6): 535551. DOI: 10.1177/00207640060668408

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these coexisting theories have some underlying assumptions in common and could be categorised in broader perspectives (Lester, 1994; Shneidman, 1989; Stillon & McDowell, 1996). Although many contemporary theories promote the multidimensionality of suicidal behaviour and the interplay of biological, sociological and psychological factors, they dier in the factors they nd crucial in explaining, treating and preventing suicidal behaviour. For the purpose of this study three broader perspectives are described briey in the following section. Only the main ideas of each perspective are mentioned. Medical or biological explanations of suicidal behaviour claim that suicide is generally a complication of a psychiatric disorder (Mann, 2002). Psychiatric disorder has been diagnosed in more than 90% of suicide victims and in most persons who attempt suicide (Bertolote et al., 2004; Tanney, 2000). Familial and genetic factors contribute to the risk of suicidal behaviour (Roy et al., 2000). The stress-diathesis model proposed by Mann et al. (1999) suggests that diathesis to suicidal behaviour exists in the form of a lifelong stable trait of aggression/impulsivity that may be related to a specic impairment of serotonergic activity. Interaction of diathesis with stressors like mental disorders or adverse life-events can lead to suicide (Amsel & Mann, 2001). The treatment of psychiatric disorders is recommended to reduce suicidal behaviour (Mann, 2002). Social theories of mental illness and suicidality emerged in the 19th century when industrialisation, urbanisation and secularisation had begun weakening the ties between the individual and society (Stack, 2000b). Durkheim (1897/1951) proposed that the level of social integration (attachment of the individual to social networks) and the level of social regulation (stable values and norms of the society) determine the suicide rate in a given society. Overly high or extremely low levels increase suicide rates. Empirical evidence supports relations between suicide rates and indicators of social integration/regulation such as divorce, marriage, birth rate and unemployment (Stack, 2000a; 2000b). Social theories claim that wider social forces are more important in suicidality than individuals characteristics. Large-scale social changes are needed to reduce the suicide rates. Psychological explanations of suicidal behaviour focus on the way that inner cognitive processes and aective states inuence suicidal behaviour. In the theory of psychache Shneidman (1985) argues that unfullled psychological needs increase psychological pain or psychache from which people try to escape by suicidal behaviour. Psychoanalytic theories assume that suicide is an expression of unconscious conict, the failure in the task of separation-individualisation or the consequence of the self pathology (Maris et al., 2000). They stress the importance of intense aective states like experiences of aloneness, worthlessness, guilt and despair (Buie & Maltsberger, 1989; Hendin et al., 2004). Cognitive theories emphasise relations between cognitive factors and suicidal behaviour, e.g. decits in problemsolving skills (McLeavey et al., 1987; Pollock & Williams, 1998), hopelessness (Beck et al., 1974; Beevers & Miller, 2004), or low self-esteem (Dieserud et al., 2001; Hawton, 2001). The psychotherapeutic approach focusing on psychological mechanisms that trigger intense aective states and lead to the constriction of the cognitive processes is recommended (Maris et al., 2000; Shneidman, 1985; Williams & Pollock, 2001). Regardless of the existing theoretical perspectives, people do tend to develop their own explanations of mental illness or suicidality based on a variety of dierent factors; for example, their experiences with the phenomenon, wider cultural inuences, knowledge and so on. The importance of such explanatory models was stressed by Kleinman (Kleinman,

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1980). Explanatory models concern the ways in which an illness episode is interpreted and understood by patients, healers and other members of the social world. It includes opinions about aetiology, expected course, outcome and ideas about the appropriate treatment of an illness (Kleinman & Seeman, 2003). The explanatory models are dynamic and negotiable. An expert who understands his patients explanatory model can better empathise with him and better negotiate a shared understanding of the causes and treatment of the current illness, which results in a better outcome of the treatment (Kleinman, 1980).

AIMS
The aims of the study were to identify the explanatory1 models on suicidal behaviour in chosen social groups and to determine possible incompatibilities between the lay (the general population and suicide attempters) and the expert (the general practitioners and psychiatrists) views. The eect of gender, age, religiosity and contact with suicidal behaviour in the family or in the surroundings on explanatory models was investigated as well.

METHODS Questionnaire development

A questionnaire was developed on the basis of a qualitative analysis conducted on a series of individual semi-structured interviews (14 people from the general population, 10 suicide attempters, 11 general practitioners and 10 psychiatrists). The inclusion criteria for the people from the general population in the interviews were: (1) no suicide attempts in the past; (2) no suicide attempts or suicide in the immediate family; (3) no formal education on the subject of suicidality; and (4) no professional or voluntary work with people at risk of suicide. People of dierent genders, ages, education, employment status, household composition and civil state were recruited from acquaintances of the researchers or their friends. In the sample of suicide attempters the rst ve female and ve male suicide attempters, hospitalised at the crisis intervention unit or psychiatric intensive care unit of the University Psychiatric Hospital Ljubljana at the time of the research, were included. The heterogeneity of the sample of the general practitioners, invited to participate in the interview part of the research, was ensured by dierences in gender, age, private or public practice, urban or rural areas and the users of the medical services (children and adolescents or adult population). All of the participating psychiatrists worked at the University Psychiatric Hospital Ljubljana, which is the teaching hospital for mental health personnel. Psychiatrists worked either on an inpatient or outpatient basis with patients of dierent age, gender and psychopathology. Only three patients and one psychiatrist declined to participate in the interviews. The main topics of the interviews were origins, treatment, prevention and stigmatisation of suicidal behaviour. No attempt was made to standardise the wording or the sequence of the questions in order to allow as free an expression of opinions as possible. The interviews were audiotaped and transcribed. Then the thematic analysis was carried out, since this

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procedure allows comparison of the dierent groups views (Flick, 2002). The thematic structure developed from the rst case was modied and elaborated continuously for all further cases. The transcripts were reread and recoded during the process until no new themes and subthemes emerged. Each theme and subtheme that emerged was then converted into the form of an item. The 55 items that the authors agreed summarised most adequately the opinions of the participants on the subject were then added to the Questionnaire on Attitudes Towards Suicide (ATTS) developed by Swedish authors Salander Renberg and Jacobsson (2003). The ATTS was constructed on the basis of two large-scale population studies on attitudes towards suicide in Sweden and consists of three main sections: (i) 39 items covering multidimensional attitude areas; (ii) contact with suicide problems; and (iii) own life-satisfaction and suicidal behaviour. Basic demographic variables were also included. Most of the attitude items were scored on ve-point Likert scale from strongly disagree, with a score of 1, disagree (2), undecided (3), agree (4), to strongly agree (5). The instrument measures a very broad area of attitudes towards suicide and has a satisfactory face and construct validity. The factor analysis of the attitude items resulted in a 10-factor model with the internal consistencies of the factors (Cronbachs alphas) varying from 0.38 to 0.86 (Salander Renberg & Jacobsson, 2003). The Norwegian version of the questionnaire yielded similar results: an 11-factor structure model with the internal consistencies of the factors (Cronbachs alphas) between 0.28 and 0.84 (Hjelmeland et al., 2006). For a more detailed description of the instrument, see Salander Renberg and Jacobsson (2003). In order to use the questionnaire on the Slovenian population the ATTS was rst translated into Slovenian from English and then backtranslated into English, as is a standard procedure in cross-cultural studies. The pilot study of the questionnaire on the Slovenian population showed similar factor structure and reliability scores as the Swedish version (Salander Renberg & Jacobsson, 2003), but the Slovenian version of the questionnaire is still in the process of validation. For the purpose of this study, the 55 additional items were scored on the ve-point Likert scale as well. The added items did not overlap with the original ATTS items. The revised version of the ATTS, namely the original ATTS with the added 55 items from the interviews, was sent to the four samples described below.

Procedure The questionnaires were sent by mail to a representative sample of the general population aged 1874 (N 1092), general practitioners (N 250) and all psychiatrists in Slovenia (N 221). One reminder was sent two weeks later. The representativeness of the sample of the general population according to gender, age and regional distribution was ensured by the Statistical Oce of the Republic of Slovenia. Suicide attempters were approached at the crisis intervention unit and psychiatric intensive care unit of the University Psychiatric Hospital Ljubljana. The diagnosis of parasuicide according to World Health Organization (1986) denition2 was made by a psychiatrist. The psychiatrists also examined the mental state of the patient but did not exclude any of the patients. The questionnaire was administered individually by an experienced researcher. The lling out of the questionnaire took on average 45 minutes. All of the participants were informed about the purpose and risks of the research. Suicide attempters provided written consent for their participation. The research was approved by the National committee of ethics.

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Statistical analysis In the revised version of the questionnaire 24 items describing causes and treatment of suicidal behaviour were selected in advance on the basis of the content. Factor analysis (principal components, varimax rotation) was used to examine the underlying structure of the selected attitudes. On the basis of the correlations between items this psychometric procedure generates a smaller number of latent factors or dimensions that can explain the correlations between the items on the higher, more general level. The results of all four groups were combined before carrying out factor analysis with a larger sample, ensuring more stable factor solution. For each factor, scores on the items with loadings higher than 0.40 were summed to derive a sum score for the respective factor. Means and standard deviations were computed. Due to slight skewness of some distributions the procedure of the normalisation of the scores was used but did not change the results signicantly so further analysis was carried out on the raw data. The one-way ANOVA and Schees post-hoc test were used to examine the dierences between the groups and eta squared was calculated to evaluate the contribution of the group membership to the explanation of the variability in the scores. Pearsons bivariate correlation was used to investigate the eect of age and the one-way ANOVA to determine the eect of gender, religiosity and contact with suicide problems. Religiosity was not specied according to the type of religious aliation. Only the dichotomous option of being or not being religious was oered. The variable contact with suicide problems included any contact with the suicide or suicide attempts in the immediate family (parents, siblings, children and partner) or surroundings (other relatives, friends, co-workers, patients). The variable was dichotomised.

RESULTS Description of the sample

The socio-demographic characteristics of the samples are presented in Table 1. According to the latest census (Statistical Oce of the Republic of Slovenia, 2002), the responding sample of the general population did not dier in age, employment status and civil state from the Slovenian population, but was overrepresented by females and people with higher education. Also fewer people in the sample lived alone. Six of the approached suicide attempters refused to cooperate or did not manage to ll in the entire questionnaire. At the time of the study another 32 suicide attempters were hospitalised but were not included, either due to absence of the researcher during weekends and holidays or due to the patients being quickly discharged. In terms of gender and age the included suicide attempters did not dier from the 38 not participating. Other sociodemographic characteristics of the non-participating suicide attempters were not available. According to the census (Statistical Oce of the Republic of Slovenia, 2002), the sample of the participants was overrepresented by divorced and unemployed individuals. The questionnaire was administered on average 4.5 days after the suicide attempt (median). The most frequently chosen methods for suicide attempt were self-poisoning (48%), cutting (21%) and hanging (18%). Two methods were used by 16% of the participants. For half of the sample this was their rst attempt. Thirty-seven (59%) participants had already undergone or were

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Table 1 Socio-demographic characteristics of the samples P Response rate Gender Male Female Age Census comparison Gender Age Education Household composition Employment status Civil state Non-responders comparison Gender Age Suicide attempt (N) Last year Previous N 331 N 134 195 M 43.0 2 9.23 3.16 122.34 43.74 3.45 6.96 / / 4 11 % 30 % 41 59  16.0 p 0.001 0.789 0.000 0.000 0.178 0.073 N 63 N 32 31 M 41.6 2 .006 6.94 6.49 1.22 11.7 26.7 2 0.72 3.72 11 27 SA % 91 % 49 51  13.0 p 0.936 0.139 0.090 0.749 0.003 0.000 p 0.397 0.446 2 1.74 / 1 0 N 144 N 43 101 M 45.0 / / / / / / p 0.187 2 0.21 / 0 3 GP % 60 % 30 70  8.1 N 81 N 34 45 M 47.5 / / / / / / p 0.647 PS % 37 % 43 57  9.9

Note. P general population; SA suicide attempters; GP general practitioners; PS psychiatrists; census comparison comparison of the responding sample with the census 2002; non-responders comparison comparison of the responding sample with the non-responders; N number; M mean;  standard deviation; 2 chi square; p signicance level.

currently involved in psychiatric treatment and 28 (44%) had received inpatient treatment at some point in their lives. The responding sample of the general practitioners and psychiatrists did not dier from the representative sample in gender distribution. The general practitioners have worked in this eld on average for 18 years (median) and the psychiatrists on average for 15 years (median).

Factor analysis Of the 24 items two items were excluded due to low factor loadings on all factors (Suicide attempters should learn how to solve problems and Suicide attempters should change the way of their thinking). Only one item (Suicide is a consequence of adverse life-events) showed two factor loadings higher than 0.40, but was kept in the analysis because of the importance of its content. The factor solution did not change if the item was excluded. The higher factor loading was taken into account when summing the item scores. Factor analysis of the 22 items yielded ve factors with an eigenvalue of > 1:00, which accounted for 47.42% of the total variance (Table 2). The rst factor was labelled personality model, describing personality traits related to suicidal behaviour that were developed in

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the family of origin by improper upbringing. Spoiled, overly ambitious or weak people overreact to everyday problems and should change their personality. The second factor was named sociological model, corresponding to sociological theories on suicide. Contemporary society is responsible for putting extensive pressure on its members. The pressure should be reduced and concrete help provided to suicide attempters. The third factor was called medical model. It emphasised a changed mental state in suicide attempters and the necessity of the psychiatric or psychological treatment of the mental disorder. The fourth factor was labelled crisis model, arguing that suicidal behaviour is a reaction to severe distress and that psychotherapeutic help is needed. The fth factor was named genetic model and promoted a genetic basis and proneness to suicide. Besides factor loadings, coecients  for the ve scale scores are additionally presented in Table 2.

Group comparison The average scores obtained on dierent explanatory models showed that the personality model was the least favoured by all groups since it received the lowest mean scores in relation to the possible maximum score on this model, which was 35 (Table 3). The general population, suicide attempters and general practitioners promoted the crisis model as the best explanation of suicidal behaviour (17.1019.58 out of 30) whereas psychiatrists promoted the medical model (15.06 out of 20). The general population and suicide attempters also scored highly on the sociological and medical models. The general practitioners agreed with the medical and genetic models as well, while the psychiatrists rst choice was followed by the genetic and crisis models. In fact, on almost all explanatory models, except personality model in all groups and sociological model among the medical sta, two-thirds or more of the possible score was obtained. The eta squared coecients showed that the group membership did not contribute much to the variability in the explanatory models. Signicant group dierences were found on all explanatory models. Schees post-hoc tests showed that the general population and suicide attempters did not dier on any of the explanatory models. The general population diered signicantly from psychiatrists and general practitioners on all models, with the exception of an insignicant dierence on the crisis model p 0:975 in comparison with the general practitioners. The suicide attempters shared the belief in the medical p 0:487 and genetic models p 0:062 with psychiatrists, and belief in the crisis p 1:000 and medical models p 0:451 with the general practitioners. The general practitioners and psychiatrists had the medical p 1:000 and genetic models p 0:977 in common, but diered on the others. On the whole, the results indicate that the explanations on suicidal behaviour change towards acceptance of the medical model through experience of ones own suicidality and through education and professional contact with suicidal people. Demographic variables Age Almost all correlations between the age of the participants and explanatory models within the groups are insignicant or show low signicant correlations. Of interest is the moderate positive correlation between the age of the psychiatrists and the personality model, indicating that older psychiatrists were more in favour of the personality model.

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Table 2 Factor analysis of the attitude items F1 0.65 0.05 0.28 0.11 0.04
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F3

F4

F5

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0.64 0.61 0.54 0.53 0.49 0.45 0.06 0.15 0.17 0.24 0.02 0.27 0.10 0.09 0.09 0.12 0.12 0.04 0.38 0.06 0.06 18.72 0.70 0.04 0.19 0.06 0.04 0.01 0.04 9.79 0.72 0.53 0.08 0.11 0.19 0.03 0.22 7.64 0.62 0.23 0.63 0.58 0.53 0.25 0.09 5.96 0.43

0.19 0.06 0.25 0.06 0.22 0.37 0.72 0.72 0.70 0.56 0.46 0.42 0.08 0.04 0.03

0.02 0.04 0.17 0.16 0.03 0.10 0.03 0.06 0.15 0.02 0.00 0.09 0.71 0.70 0.70

0.07 0.37 0.15 0.11 0.00 0.06 0.21 0.06 0.10 0.01 0.41 0.20 0.10 0.32 0.24

0.15 0.11 0.00 0.17 0.25 0.17 0.02 0.09 0.04 0.13 0.09 0.07 0.05 0.14 0.05 0.04 0.08 0.12 0.11 0.77 0.76 5.57 0.52

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Spoiled people engage into suicidal behaviour when they do not get what they want. Suicide is an exaggerated reaction to unimportant everyday problems. Suicide is a result of a weak and overly sensitive personality. Suicide is a consequence of improper upbringing. People who attempt suicide should change their personality. Suicide occurs when people try to surpass their capabilities. The family is responsible for the suicidal behaviour of its member. Suicide is a consequence of a stressful life in contemporary society. The best cure for suicidal behaviour is lowering of social pressures. Suicidal behaviour is a sign of a sick society. All responsibility for suicidal behaviour lies in the hands of society. Suicide is a consequence of adverse life-events. Suicide attempters need concrete help and actions (e.g. employment). Suicidal behaviour diminishes with the treatment of mental disorder. Suicidal behaviour is treatable with medication. Suicidal behaviour is a reection of mental problems, so psychological or psychiatric help is necessary. Suicidal behaviour occurs as a consequence of a changed mental state. Suicidal behaviour is a response to severe distress. Even though the decision to commit suicide may be impulsive, the individual must have been in long-lasting distress. Suicide attempters can be helped only by (long-term) psychotherapy. Some people are prone to suicide. Suicidal behaviour is genetically based.

% explained variance Cronbachs 

Note: F factor

Table 3 The average scores and group dierences in explanatory models P r M 19.58 20.70 14.43 11.84 6.57 (4.83) (4.20) (2.84) (1.92) (1.92) 17.10 18.74 15.02 11.85 7.34 (3.63) (3.47) (2.24) (1.74) (1.23) 15.30 16.92 15.06 10.85 7.24 (3.46) (3.29) (2.13) (1.67) (1.47) M M (3.91) (3.47) (2.46) (1.59) (1.49) r r r SA GP PS Range 735 630 420 315 210 0.111 0.126 0.062 0.044 0.054 24.92 *** 29.49 *** 13.58 *** 9.24 *** 11.58 *** g2 F

Personality Sociological Medical Crisis Genetic

18.95 20.63 13.71 11.93 6.58

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Note: Range the possible range of the mean scores on the given models; 2 eta squared; *** p < :000; other abbreviations as in Table 1.

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Table 4 Relationship (Pearsons bivariate correlation) between the age of the participants and the mean scores on the explanatory models within the groups and for all participants combined Personality Age Age Age Age Age (P) (SA) (GP) (PS) (ALL) **0.24** 0.01 0.13 **0.48** **0.15** Sociological *0.14* 0.21 0.04 *0.24* 0.07 Medical **0.21** 0.08 0.10 0.08 **0.16** Crisis 0.07 0.22 0.04 0.12 0.06 Genetic *0.13* 0.17 0.10 0.17 **0.13**

Note: * p < 0:05; ** p < 0:01; ALL all the groups combined; other abbreviations as in Table 1.

Gender The eect of gender was not signicant, except for the crisis model (F 16:107, p 0:000), which was favoured by females in all groups. Interaction between group and gender was signicant for the personality (F 3:292, p 0:020) and crisis models (F 3:203, p 0:023), both due to female suicide attempters emphasising the two models more than male suicide attempters. Religiosity The eect of the religiosity was insignicant except for marginal signicance in the personality model. Religious people in all groups scored slightly higher on the personality model than non-religious people (F 4:162, p 0:042). None of the interactions between religiosity and group was signicant. Contact with suicide problems The eect of contact was marginally signicant for the medical model (F 3:917, p 0:048), meaning that people without contact with suicide problems believed more in the medical model. In contrast, the genetic model was favoured by people who had contact with suicide problems (F 7:513, p 0:006). The interaction between contact and group was signicant for the sociological model (F 4:085, p 0:007), which was promoted by the general practitioners and suicide attempters who had contact with the problem of suicide. The signicant interaction with the genetic model (F 3:085, p 0:027) revealed that suicide attempters with contact argued for genetic origins of suicidality.

DISCUSSION
The questionnaire, developed on the basis of the qualitative analysis, giving interviewees the possibility to freely express their opinion, showed that people explained suicidal behaviour according to ve dierent models or dimensions; personality, sociological, medical, crisis and genetic. These explanatory models partly corresponded to the main theoretical perspectives in suicidology. Four models laid causes and treatment of suicidal behaviour mostly on the individual. Even the personality model that emphasised the role of the family put the responsibility for treatment on the individual once the suicidal behaviour had occurred.

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Only the sociological model stressed the wider environment and the role of society over the individual and his or her characteristics. The general population and suicide attempters did not dier signicantly on any of the models. They favoured the crisis, sociological and medical models. The general practitioners and psychiatrists shared similar opinions, emphasising the medical, genetic and crisis models. The personality model was the least accepted by all groups. On the whole, the groups showed the most agreement with the crisis model, with the exception that psychiatrists gave a slight priority to the medical model. Although we expected that lay people and experts explained the suicidal behaviour roughly in line with the three major perspectives, namely medical, sociological and psychological as mentioned in the introduction, we did not want to impose the three perspectives on the participants by developing items only on the basis of these theories. The items, generated from the interviews, actually revealed ve explanatory models that we labelled personality, sociological, medical, crisis and genetic models. It must be emphasised that explanatory models in lay people are often incoherent, vague and lled with multiple meanings (Kleinman, 1980). That is why in our research we allowed people to simultaneously agree with dierent explanatory models and did not force them to choose between dierent explanations. The personality model was the most unexpected explanatory model. This model could not have occurred if the questionnaire was based on the theoretical perspectives. The contribution of personality factors to suicidal behaviour has been mostly neglected in the mainstream suicidology literature (Johnson et al., 1999), although personality traits are mentioned as part of the assessment of suicide risk (Packman et al., 2004). Even though none of the groups lling out the questionnaire agreed with the personality explanations of suicidal behaviour, personality as a mediator between adverse life-events and suicidal crisis was stressed by the general population and suicide attempters in the interviews. The personality model related suicidal behaviour to weak, spoiled or overly ambitious people who overreact to everyday problems. In other studies on public opinion about causes of mental disorders the participants agreed that weak mental constitution, unstable personality or weakness of character was one of the causes of mental disorder (Jorm et al., 1997; Matschinger & Angermeyer, 1996). Strength of character is of clinical importance predominantly in psychodynamic theories of suicidality (Maltsberger, 1992), but the relationship between personality disorders and suicidal behaviour is becoming more acknowledged. People with personality disorders are at higher risk for suicidal behaviour than the general population or psychiatric patients without personality disorders. Also the repetition of the suicidal behaviour is higher in suicide attempters with personality disorders (Cheng et al., 2000; Haw et al., 2001; Suominen et al., 2000). However, personality traits like being overly ambitious or spoiled indicated that the moral dimension might be added to suicidal behaviour in the personality model, which is not unusual in lay explanatory models (Kleinman, 1980). Perhaps ascribing people at risk for suicide with some kind of bad personality gives an opportunity to distance oneself from suicidal behaviour. Dividing people into them and us is one of the elements of stigmatisation (Link & Phelan, 2001). In this explanatory model the development of personality was believed to depend on the upbringing in childhood, which is promoted in psychodynamic theories (Maris et al., 2000). The role of the primary family had been proven to be related to suicidal behaviour in various ways, e.g. sexual and physical abuse, child maltreatment, neglect, family instability

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(Van der Kolk et al., 1991; Yang & Clum, 1996). The responsibility of the family for the suicidal behaviour of its member is stressed also in the sociological theories. The social learning theories claim that suicidal behaviour is acquired through socialisation. The family or friends transmit both the motives for suicidal behaviour and the expectations about the outcome of suicidal behaviour. So the suicidal behaviour is a learned method of coping with crisis that could be modelled or shaped (Lester, 1987). The family is also a source of social support, which is an important stress buer (Hart et al., 1988; Heikkinen et al., 1993). Perhaps the responsibility of the family might be seen in the recognition of distress and suicide risk of its member as well. Even though the personality model stressed the responsibility of the family and the need for a dierent upbringing, the proposed treatment of suicidality in this model was to change suicide attempters personality structure. These gave a sense of permanent proneness to suicide once the suicidal behaviour occurs because personality is a rather stable and unchangeable phenomenon. This explanatory model is a mixture of two models, e.g. moral or behaviour model and psychoanalytical or psychodynamic model, described by other authors in the eld of mental illness (Furnham & Bower, 1992; Siegler & Osmond, 1966; Tyrer & Steinberg, 1987). According to the perspectives mentioned in the introduction, it combines the elements of psychological and sociological perspective and colours them with slight moral judgement. The sociological model tted best the theoretical and evidence-based sociological perspective (Durkheim, 1897/1951; Stack, 2000a, 2000b) by emphasising the inuence of wider social factors on the individual. The responsibility for suicidal behaviour was placed on the society, which should provide the individual with basic living conditions (e.g. employment) and release him from the social pressures. Suicidal behaviour was treated as a sign of a sick society and society was therefore responsible for undertaking concrete help and actions that would lower social pressures on the individual. This was the only model that put the source of suicidal behaviour entirely outside the individual. Unfortunately the social model did not oer any tangible treatment possibilities for the individuals at risk, since no expert help focused on the individual was seen as necessary while large-scale social changes are vague and dicult to implement. The medical perspective as described in the introduction was represented in our research surprisingly by two separate models the medical and the genetic models. Both medical and genetic explanations are evidence-based and have gained great support in recent decades (Mann, 2002; Van Heeringen, 2001). The medical and the genetic explanations belong to the same theoretical perspective but are not necessarily related in the minds of the people, as seen in this study. The medical model stressed the relationship between mental illness and suicidal behaviour. For the treatment of mental illness or changed mental state, psychiatric or psychological help was recommended, with medication being a strong option. No items describing aggression and/or impulsivity as a diathesis for suicidal behaviour were included in the questionnaire, so this part of the medical perspective was missing in the medical model. The second part of the medical perspective was described in the genetic model, which proposed that some people are genetically prone to suicide. In this model no treatment possibility was oered. This dissociation of the medical and genetic models might be due to the views on treatment possibilities. Perhaps saying that mental illness has a genetic component that could not be changed gives a sense of hopelessness in the treatment of suicidal behaviour.

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It might be easier to claim that most suicidal behaviour is treatable by curing mental illness while some unpreventable suicides are the unfortunate consequence of genetic proneness. The crisis model oered more hope as suicidality was thought to be treatable by psychotherapy. As the concept of distress in this model was not particularly specied we can only hypothesise that distress could be parallel to the concept of crisis as rst described by Ringel (1976). In theory the suicide crisis is not an illness but a time-limited phenomenon of cognitive, aective and behavioural constriction that occurs usually after a traumatic event and is a signal of immediate danger of suicide. Shneidmans (1985) concept of psychache is somewhat similar, though the psychache is caused by unfullled psychological needs and not a precipitating (external) event. This model actually stressed the importance of the inner, subjective experiences of the suering person and the need to communicate and share this experience (Michel et al., 2002). It combined elements of psychological perspective and crisis theory. All the models, except the personality model, gained considerable support from participants. This might either indicate the lack of proper elaboration of opinion on suicidal behaviour or be an acknowledgement of the multidimensionality of suicidality since all the models that emerged more or less corresponded to theoretical ndings. Even though suicidality is an acknowledged mental health problem, very little evidence is available today on its eective treatment (Hawton et al., 1998). The psychiatrists views were the most homogeneous. They agreed only with the medical, genetic and crisis models, showing that they follow the evidence-based medical doctrine. Besides the three mentioned models the general practitioners partly agreed also with the sociological model. Perhaps the suicide attempters with more pronounced psychopathology are referred to psychiatrists whereas in general practice suicide attempters with more heterogeneous (life) problems seek help. The general population and suicide attempters believed most rmly in the crisis, sociological and medical models. The lack of signicant dierences between the two groups in all of the models might indicate the strength of public opinion or socialisation process over the experience of ones own suicidal behaviour. The suicide attempters had the most heterogeneous opinions within their own group. This nding might indicate multicausality of suicidal behaviour. Even though suicide attempters did nd the medical model as acceptable as the medical sta, they still believed in the other models as much as the general population as if only one new explanation was added to the previous views, which is one of the possible outcomes in the process of negotiating the explanatory models through communication between patient and the expert (Kleinman, 1980). Perhaps suicide attempters that rejected psychiatric treatment disagree more with the medical model. Goldney et al. (2002) noticed that the subgroup of the general population that had professional contact because of depression and suicidal ideation did not show increased knowledge. However, Jorm et al. (2000) had discovered that having sought help for depression was associated with beliefs closer to those of professionals. The age, gender and religiosity of the participants and the possible contact with suicide problems did not inuence greatly the explanatory models. This could be another proof of the stability of the models. On the whole, the four groups agreed the most with the crisis model, even though the psychiatrists were marginally more in favour of the medical model. The most accepted individual treatment of suicidal behaviour was psychotherapy followed by medication or treatment of mental disorder. The general population, suicide

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attempters and to a lesser degree also general practitioners, promoted wider social changes and concrete help to people in distress. The results indicated that the explanations of suicidal behaviour changed towards accepting the medical model and rejecting the personality and sociological models through experience of ones own suicidality and through education and professional contact with suicidal people. The greatest weakness of this study stemmed from the low response rate of the general population and psychiatrists, although this was not surprising. The Slovenian general public is not used to lling in research questionnaires, which is why the questionnaires were sent to such a relatively large sample in the rst place. According to the sociodemographic characteristics, the responding sample was similar to the representative sample. Typically more females lled in the questionnaire. Since the responding sample was overrepresented with more educated people the results could not be generalised to the entire population. In addition, people that lled in the questionnaire may well be more interested in this issue. On the other hand, due to the small number of psychiatrists in Slovenia, psychiatrists are burdened with lling in all sorts of questionnaires. It is possible, or even likely, that they are sceptical about the anonymity of their responses. The solid response rate of the general practitioners might indicate their greater interest in and need for help with this issue. Also, in the future the eort should be made to attract the suicide attempters that refused psychiatric care. The best way to explore explanatory models are illness narratives, e.g. stories about illness and healing from those who live through illness episodes, because they relate more broadly to the interpersonal context and eects of illness (Kleinman & Seeman, 2003). Explanatory models, generated from a relatively narrow set of questions in an abstract form, are necessarily more constrained and articial compared with the illness narratives. In our study we tried to combine both approaches with rst applying semi-structured interviews and the later questionnaire, based on the outcomes of the interviews. The qualitative studies are usually conducted on smaller samples with limited possibilities of generalising the results. Also the qualitative analysis is to a certain degree subjective and it is always possible that other researchers would come to somewhat dierent conclusions or choice of items for the questionnaire. Even though the factor-analytical approach on more representative samples seems more objective, the question remains whether the application of items, produced on small samples, on dierent groups and with a dierent procedure (postal questionnaires) is justied. We would like to emphasise as well that factor analysis is only a tool to get an insight into some of the possible relations and concepts, which by their nature are too complex to be captured in their true dimensions. The application of the questionnaire has some disadvantages as well. As dierent explanations and possible treatments were oered in advance this could also inuence the results, giving people ideas that they might not come up with themselves. Diculties were also encountered when trying to construct a questionnaire that would be suitable for both the lay population and the experts. The nal version of the questionnaire turned out to be a bit too demanding for the lay population. Perhaps this is why people with a higher education were overrepresented. To the best of our knowledge no such studies on suicidal behaviour exist so the results could not be directly compared to those of the previous studies. The majority of the studies on attitudes towards suicide focus on normative evaluation of suicidal behaviour, with only single items or factors referring to opinions about possible causes and treatment of suicidal

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behaviour (Diekstra & Kerkhof, 1989; Domino et al. 1982; Salander Renberg & Jacobsson, 2003). Due to the lack of previous studies the results of this study should be replicated before any generalisation can be made.

CONCLUSIONS
The questionnaire, based on the interviews with lay people and experts, revealed that people explained suicidal behaviour according to ve explanatory models, namely the crisis, medical, sociological, genetic and personality models. Even though the four groups of participants agreed more or less with all the models, signicant dierences between the groups were found. The lay people (the general population and suicide attempters) favoured the crisis, sociological and medical models, whereas the experts (the general practitioners and psychiatrists) shared a belief in the medical, genetic and crisis models. This discrepancy could negatively inuence help-seeking behaviour, adherence to treatment as well as implementation of prevention programmes. The crisis model gained considerable support and was generally accepted as correct. This could be the common ground between lay people and experts and the starting point of treatment and prevention. It is advisable to identify the beliefs of the suicidal people and to adjust the treatment to their beliefs if possible. Any introduction of the less accepted treatment from the expert position should be applied with caution.

ACKNOWLEDGEMENTS
The study was supported by Ministry of Science, project number V50577061801, Samomorilnost in rodnost na Slovenskem (Suicide and fertility in Slovenia).

NOTES 1. In the research we used the term explanatory model for the general views of the dierent social groups on suicidal behaviour while in practice an expert should assess an explanatory model for every patient and for each illness episode separately (Kleinman, 1980). 2. Parasuicide is dened as: An act with nonfatal outcome, in which an individual deliberately initiates a nonhabitual behaviour that, without intervention from others, will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognised therapeutic dosage, and which is aimed at realising changes which the subject desired via the actual or expected physical consequences.

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Tina Zadravec PhD, University Psychiatric Hospital Ljubljana, Slovenia. Onja Grad PhD, Professor, University Psychiatric Hospital Ljubljana, Slovenia. Gregor Socan, PhD, Assistant Professor, University of Ljubljana, Slovenia. Correspondence to Tina Zadravec, University Psychiatric Hospital Ljubljana, Centre for Mental Health, Zaloska 29, 1000 Ljubljana, Slovenia. Email: tina.zadravec@guest.arnes.si

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