Edited by:
Reviewed by:
Vasundharaa S. Nair, O. P. Jindal Global University, India
*Correspondence: Mette Palm,
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One of the key issues in the current knowledge base on persistent or chronic suicidality is the discrepancy between the extensive experiential knowledge embedded in clinical practice and its limited representation in the scientific literature. Both individuals living with persistent suicidality and the professionals who support them develop beliefs about its underlying causes and what is needed for effective management or treatment. Studying these subjective understandings may provide valuable insights into the contextual, relational and psychological factors related to persistent suicidality and help inform appropriate care strategies.
This study aims to identify the perceived causes of persistent suicidality and the needs of those affected, from both the perspectives of individuals with lived experience of persistent suicidality and professionals providing support.
Semi-structured interviews were conducted with 12 individuals with lived experience of persistent suicidality and 10 occupational experts. Data were analyzed using reflexive thematic analysis.
Although individual experiences vary, persistent suicidality is perceived to be linked to childhood trauma and psychopathology. It may persist due to its perceived functionality or as a result of unsuccessful treatment and resulting feelings of demoralization. Key needs include continuity in care relationships, feeling genuinely heard, and openly discussing suicidal thoughts. This involves acceptance of these thoughts and exploring their meaning. Some individuals with persistent suicidality perceive aspects of care as ineffective or, in some cases, as contributing to further distress.
Care for individuals with persistent suicidality should not focus solely on recovery but also on the acceptance and managing of suicidal thoughts. Effective care strategies may include teaching alternative coping and communication methods. The findings underscore the need for continuity of care and emphasize the importance of addressing non-disclosure and transference-countertransference dynamics in therapy.
Suicide ranks among the leading causes of death worldwide, accounting for more than one in every 100 deaths (1.1%) in 2021 (
In recent years, a growing body of scientific literature has turned its attention to the phenomenon of long-term forms of suicidality, also known as chronic or
Despite the early stage of research on persistent suicidality, research findings indicate that 28-43% of people who consider suicide at some point still do so years later (
One of the key issues in the current knowledge base on persistent suicidality is the discrepancy between the considerable amount of knowledge held by care professionals and the limited representation of this knowledge in the scientific literature. There is limited understanding of how persistent suicidality is perceived by both care providers and individuals with lived experience. Most existing studies on persistent suicidality rely on quantitative methods, with insights predominantly shaped by external observers who typically lack the lived experience (
This study aimed to identify perceived causes of persistent suicidality and the needs of those enduring it, from the perspective of both individuals living with persistent suicidality and those providing care and support. In doing so, it sought to complement the limited scientific literature with knowledge derived from clinical practice. Perceived causes and needs can be deeply interconnected, with specific causes directly influencing individual needs. Studying them together provides a broad understanding of the scope of challenges related to persistent suicidality. Findings may inform recommendations for appropriate responses in the prevention or treatment of persistent suicidality, as well as inform future research directions.
Semi-structured interviews were used to gather insights into the perceived causes of persistent suicidality and the needs of individuals with persistent suicidality, from the perspective of both experts by occupation (EbyO) and experts with lived experience (EbyE). This study adopts a social constructivist interpretive framework, assuming that social reality is multiple, processual, and constructed (
A total of 22 participants from different disciplines were included in this study: 10 EbyO and 12 EbyE.
Initially, a list of 12 leading Dutch participants with knowledge of persistent suicidality was compiled by the authors, containing 10 EbyO and 2 EbyE. However, during the data collection phase, the interviews with EbyE provided unique valuable insights, prompting the inclusion of an additional 10 individuals with lived experience.
The EbyO were purposefully sampled from the authors’ extended networks to hold a broad variety of positions, with some also having held or currently holding dual positions: professor, researcher, psychologist, psychiatrist, medical director, ethicist, spiritual caregiver, philosopher, theologian, and an end-of-life counselor. On average, they had 20 years of work experience.
EbyE were people who self-identified as expert by experience in persistent suicidality. Convenience sampling was used to include participants from this hard-to-reach population. Recruitment took place through the social media channels of various foundations that support people with death wishes and suicidality namely, 113 Suicide Prevention, ‘PsychoseNet,’ and Suicide Prevention Center. Inclusion criteria were good command of Dutch, being older than 18 years, and self-identified as having persistent suicidality. Participants were excluded if they were non-Dutch speaking or if, during the preparticipation telephone interview with psychiatrist SvV, a shared decision was made that participation posed too much of a burden on the participant. In one instance, an individual with lived experience was excluded from participating in the study due to psychological distress.
Participation involved no direct benefits other than contribution to the science.
The topic guide for the semi-structured interviews was prepared by the authors, originating from the disciplines of (care) ethics, psychiatry, psychology, and health sciences, and all actively engaged in (research on) suicide prevention and mental healthcare. One of the authors brought lived experience with persistent suicidality in the past. The topic guide included open-ended questions designed to align with the research objectives (Appendix 1). Following the interviews with the initial 12 participants, the topic guide was slightly revised for 10 additional EbyE. The focus was shifted from an observed understanding of persistent suicidality to a greater emphasis on firsthand experiences and needs (Appendix 2).
As data collection took place during the COVID-19 pandemic, the interviews were conducted either online via Microsoft-Teams or in person at a mutually agreed location, based on the participant’s preference. Five of the 22 interviews were conducted in person and the remainder were online. Data collection occurred between May 2021 and April 2022. During the interviews, only the participant and the interviewers (EE or MP, both women and affiliated with 113 Suicide Prevention at the time) were present. EE and MP are trained qualitative researchers and conducted the first two interviews together to ensure a consistent approach. Interviews were conducted in Dutch and fieldnotes were taken. With the participant’s permission, an audio or video recording was made and later manually transcribed verbatim. To minimize their own influence on participants’ answers during the interview, the interviewer posed open-ended and non-directive questions. Additionally, the interviewer adopted the terminology used by the participants to better align with their experiences. Participants were interviewed for the duration of approximately one hour.
Data analysis was conducted by means of reflexive thematic analysis, as described by Braun and Clarke. This approach was first described in 2006 (
Perceived causes of persistent suicidality*.
| Themes | Sub-themes |
|---|---|
| Adverse (childhood) experiences | Abuse as a child (emotional, physical and/or sexual) |
| (Temporarily) out-of-home placement or adoption as a child | |
| Parental neglect or unsafe home situation | |
| Being the victim of bullying | |
| Death of loved one | |
| Being involved in a fatal accident | |
| Psychopathology | (Co-occurrence of) various forms of (long-term) psychopathology |
| Suicidality as a function | Perceiving the option of suicide as a way to regain control |
| Suicidality as a way to express pain and ask for help | |
| Suicidality as a coping mechanism to reduce emotional suffering | |
| Suicidality as a means of communication | |
| Demoralization | Feeling that treatment is and will remain ineffective |
| Having had adverse experiences with past treatment | |
| Feeling misunderstood and lacking trust in care | |
| Disengagement from care | |
| Non-disclosure | |
| Having a long history of psychiatric care | |
| Treatment options are perceived as exhausted |
*The prevailing view among experts was that persistent suicidality emerged and persisted due to a complex interplay of multiple factors, rather than stemming from a single cause.
Needs of individuals with persistent suicidality.
| Themes | Sub-themes |
|---|---|
| (Inter)personal | Acceptance of persistent suicidal thoughts (both for the individual and their loved ones) |
| Discussing suicidal thoughts with loved ones | |
| Therapeutical | Discussing suicidal thoughts within therapy |
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| Addressing underlying psychopathology | |
| Reducing ignorance and stigma among caregivers | |
| Continuity of care and a safe therapeutic relationship | |
| Multi-disciplinary care and involvement of family | |
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| Discussing the possibility of medical assistance in dying | |
| Societal | Participation and inclusion |
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| Financial support |
In line with the reflexive thematic analysis approach and given the exploratory nature of this study, data saturation was not pursued as an objective (
ATLAS.ti Web (version 7.6.1) was used for data analysis.
The Medical Ethical Review Committee of Amsterdam University Medical Center issued a non-WMO statement for this study (METC number 2021-0225). Prior to the interview, participants received an information letter and written informed consent was obtained. For the EbyE specifically, apart from the preparticipation interview with psychiatrist SvV, the possibility of receiving aftercare was provided. One participant made use of this aftercare. Approximately three days after the interview, narrative interview reports were sent to the participants for comments and/or correction by email. Most found the report complete, with a few suggesting minor corrections or preferred phrasing changes. Additionally, immediately following the interviews, participants explicitly stated that their participation was a positive experience. In particular, different EbyE indicated that they valued being able to openly speak about their death wishes.
Given the relatively small sample size and considerable demographic variation, demographic information was omitted from the verbatims to mitigate the risk of participant identification.
This project was preregistered on the Open Science Framework on October 7, 2022. Identifier: DOI 10.17605/OSF.IO/DMHRV. This study adhered to the guidelines outlined in the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist for its reporting (
The characteristics of the EbyO and the EbyE can be found in
Characteristics of experts by occupation (n=10).
| Gender | Participants (n) |
|---|---|
| Women | 4 |
| Men | 6 |
| Age (average 54 years) | Participants (n) |
| 25-34 | 2 |
| 35-44 | 1 |
| 45-54 | 1 |
| 55-64 | 2 |
| 65+ | 4 |
| (Former) occupation * | Participants (n) |
| End-of-Life Counselor | 1 |
| Ethicist | 1 |
| Medical-Director | 2 |
| Philosopher | 2 |
| Psychologist | 5 |
| Psychiatrist | 2 |
| Professor | 1 |
| Researcher | 2 |
| Spiritual Counselor | 1 |
| Theologist | 1 |
| Work experience (average 20 years, range 5–40 years) | Participants (n) |
| 0-9 | 2 |
| 10-19 | 3 |
| 20-29 | 2 |
| 30-39 | 1 |
| 40+ | 2 |
*Most experts held more than one occupation.
Characteristics of the experts by experience (n=12).
| Gender | Participants (n) |
|---|---|
| Women | 9 |
| Men | 3 |
| Age (average 46 years) | Participants (n) |
| 18-24 | 1 |
| 25-34 | 2 |
| 35-44 | 1 |
| 45-54 | 5 |
| 55-64 | 2 |
| 65+ | 1 |
| Age of realization of having a death wish * | Participants (n) |
| Before adulthood | 9 |
| During adulthood | 3 |
| Current partner status | Participants (n) |
| Partner | 5 |
| Divorced | 3 |
| No partner | 4 |
| (Step)Children | Participants (n) |
| (Step)children | 5 |
| Childless | 7 |
| Working status | Participants (n) |
| Working | 6 |
| Studying | 5 |
| Not working or studying | 1 |
| Lifetime psychiatric disorders mentioned by participants (average 2.7 disorders, range 0–6 disorders) ** ˟ | Participants (n) |
| Addictive Disorder | 1 |
| Autism Spectrum Disorder (ASD) | 2 |
| Attachment Disorder | 2 |
| Attention Deficit Hyperactivity Disorder (ADHD) | 1 |
| Anxiety Disorders | 1 |
| Bipolar Disorder | 4 |
| Borderline Personality Disorder (BPD) | 3 |
| Dissociative Identity Disorder (DID) | 1 |
| Dysthymia | 1 |
| Eating Disorder | 1 |
| Major Depressive Disorder (MDD) | 4 |
| Narcissistic Personality Disorder (NPD) | 1 |
| (Complex) Post Traumatic Stress Disorder (PTSD) | 9 |
| Psychotic Disorder | 1 |
| Sleep-Wake Disorder | 1 |
In the first part of the results section the insights regarding the perceived causes of persistent suicidality are given. The second part presents themes related to the needs of individuals with persistent suicidality. Quotations from the interviews are included to illustrate how findings are grounded in the data. For each quotation, the number of participant and expert group are given (e.g. EbyE1 for expert by experience, participant 1).
Participants expressed that the persistent suicidality arises from and is sustained by a complex interplay of numerous factors, including biological, psychological, and social influences. These factors differ from person to person and influence an individual’s ability to cope with distress and the weight of the burden they have to bear (i.e. their suffering). EbyO explained that the degree to which people can tolerate suffering varies, and that as long as hope for improvement of their situation exists, people can endure a lot. However, when the experienced burden surpasses one’s capacity to bear it, this can result in a loss of perspective and a sense of despair, leading to thoughts of death.
A frequently mentioned psychosocial factor at the root of persistent suicidality was adverse (childhood) experiences, often resulting in trauma. This was evident in interviews with EbyE, where all but one participant recalled negative events and experiences from their early youth or adolescence as cause of their persistent suicidality. These events included abuse (emotional, physical, and/or sexual), death of a loved one, and (temporary) out-of-home placements. Reported experiences were having a “narcissistic parent,” neglect, being adopted, and having been bullied. EbyO suggested that as a result of these experiences during development, individuals may lack the foundation upon which to build a meaningful and fulfilling life, leaving them without a sense of purpose and consequently developing persistent suicidality. This was evident in the account provided by one of the EbyE regarding the origin of her persistent suicidality:
I believe this is part of why I do not have that joy of living. From childhood, I was told that I am not wanted, that [my mother] would also rather I die by suicide, that I was a burden to others, and that I could not do anything right. That I do not live up to the ideal for her, what she thought it would entail to have a child. [ … ] You grow up with that, and while I can rationally reason that they might be all wrong, I do not know any better than I have been told [these things] every day (EbyE9).
According to the EbyE, childhood experiences have shaped her self-perception, and this has resulted in an inability to relate appropriately to the reality in which she finds herself today. This experience is echoed by the other EbyE who all reported to struggle with low self-esteem or a poor sense of self, leading to a lack of direction, feelings of being a burden to others, and (overly) critical thinking, ultimately contributing to persistent suicidality.
Psychopathology was often listed as a factor substantially increasing the risk of persistent suicidality. All but one EbyE had a history of psychopathology (see
For multiple EbyE, their suicidality appeared, whether consciously or unconsciously, to have taken on a specific meaning or function in their lives. EbyE reported experiencing significant distress due to negative emotions, self-defeating thoughts, and ongoing external stressors, such as financial debts, relationship breakdowns, or the loss of loved ones. They frequently expressed a sense of needing to escape when confronted with these thoughts or stressors. In this context, both EbyE and EbyO have outlined how persistent suicidality can exist as a “coping mechanism,” viewing it as strategy to evade the hardships of life by altering thoughts and feelings. By perceiving the ability to end their lives as a means to escape and avoid facing inner pain, individuals made their existence more bearable and experience a sense of control. Though counterintuitive, one EbyE even referred to her persistent suicidality as a “survival mechanism” (EbyE10). Another EbyE further clarifies this by stating:
I actually envision this suicidality as sort of similar to addiction. It is a way to escape. To not have to feel. To just want to get away from the pain underneath [ … ]. And it is also a sort of protective mechanism almost, not to have to face the deep pain of abandonment, of not belonging, of not being good enough (EbyE4).
Additionally, several EbyE expressed wanting to communicate their pain and thoughts but not knowing how to do so. This is prevalent in the narrative of one of the EbyE who referred to his first suicide attempt as “a cry for attention, a cry out of desperation” (EbyE11). Some EbyO believed that suicidality can (unconsciously) function as a form of communication, which then becomes a factor contributing to its persistence. This was particularly noted in relation to individuals with BPD. In their view, thoughts of suicide begin because individuals find something deeply painful. Following this, the way their environment reacts to their suicidality can reinforce it, eventually turning it into something that can be used consciously or unconsciously. Therefore, displaying suicidality may become a way for individuals to express themselves, with an underlying plea for help. Although numerous EbyE described expressing their suicidality as a plea for help, they did not particularly link it to the persistence of their suicidality. The functionality of suicidality was understood as a factor bolstering and sustaining it.
Interviews with EbyE revealed that most have long treatment histories, but many reported that these treatments did not yield their preferred results. Feeling that their condition persisted despite their efforts, or following negative experiences with health care professionals regarding suicidality, individuals often reported treatment fatigue. Relatedly, EbyO noted that caregivers may feel powerless when unsure how to proceed with care. Several EbyE shared that their caregivers expressed an inability to find additional ways to treat them, leaving them with the feeling that improvement was no longer attainable. In line with this, participants opposed the use of the term ‘chronic suicidality’, arguing that it conveys a sense of permanence that undermines hope for recovery. Additionally, some EbyO shared that, in their view, treatments are sometimes poorly delivered. This may result in poor treatment outcomes and, consequently, the persistence of suicidality.
Due to demoralization and treatment fatigue, some EbyE had chosen to disengage from the conventional mental health care. Others continued to receive care but chose not to fully disclose their experiences, believing that sharing would not lead to meaningful improvement or due to disagreements with physicians’ past actions and fear of those actions being repeated, as illustrated in the following quotation:
EbyE12: [There] are also a lot of topics that I deliberately do not discuss with [mental health caregivers], because I know that could lead to another admission, or whatever. While it is not necessary, at that moment [ … ]
Interviewer: What are some other topics that you feel you cannot discuss?
EbyE12: [ … ] past traumas or whatever. So, you leave that out, too. Because, oh yes, that can affect me a lot, so if I am affected, they can see that it is going badly, so then, that … Constantly that little thing so of what can I tell, what can I not tell. [ … ] I think the death wish is the number one thing in that, that you just absolutely do not discuss that, because you do not know what the next steps will be.
Interviewer: Do you believe that [the care] offered to you right now is helpful then?
EbyE12: No, I think they intervene too late every time. The ability to recognize the signals seems to be lost these days.
By not being fully open about their experiences, individuals may not receive the care they truly need. This may prevent them from addressing the underlying issues they face, allowing their suicidality and other mental health problems to persist.
Needs of individuals with persistent suicidality were identified across (inter)personal, therapeutic, and societal levels.
A common need highlighted by almost all participants was the acceptance that their suicidality might not disappear over time. Several EbyE reported feeling as if they were not allowed to have these thoughts and were puzzled by their presence, given that they experience thoughts of death alongside feelings of belonging, falling in love, and finding joy in life. One participant explained: “I have a girlfriend, I have my parents, I have my job. I work at [organization]. I have everything … Am I even allowed to be suicidal, I wonder?” (EbyE11). In addition to personally accepting their persistent suicidality, they expressed a need for recognition of it from others.
Numerous EbyE indicated that personal attention and the ability to discuss their wish to not be alive play a crucial role in the acceptance of these thoughts. Conversations with family members and friends often helped them through tough times. They explained that talking about the desire to die reduced feelings of loneliness and fostered a greater sense of connection to life. The following quote explains why participants place such value on this:
The fact that you can finally talk about it. That is the most important thing. It is mainly a lot of pain. Then you can share it. That it does not matter for a moment that you do not want to be here, that someone understands that. That you do not have to pretend that you do want to be here (EbyE9).
In some accounts, EbyE expressed a fear of losing relationships or burdening others as a result of being open about their suicidal thoughts, with some reporting that this had indeed happened. As a result, some individuals chose to withhold their thoughts and isolate themselves, believing that this action protects both themselves and others.
Besides the need to openly talk about their persistent suicidality with loved ones, EbyE stressed the importance of discussing persistent suicidality in a therapeutic relationship. They emphasized that discussing their suicidality not only entails acknowledgment of its existence but also in-depth explorations of its origin, characteristics, and one’s personal needs. They seek greater emphasis on learning how to manage suicidal thoughts, with a focus on the meaning and acceptance of these thoughts, rather than solely focusing on recovery. Despite this need, several EbyE reported refraining from disclosing their persistent suicidality to caregivers, fearing immediate crisis interventions, such as hospitalization, which they perceived as overly reactive and as undermining their personal autonomy. EbyO noted that openly discussing the desire to die and the underlying reasons can paradoxically encourage individuals to consider living.
Participants also emphasized the importance of addressing any underlying conditions and suffering, if present. EbyO shared that this can be achieved through psychotherapeutic treatments and/or medication. Introducing less harmful coping strategies to manage stress and negative emotions, or focusing on alternative forms of communication, can be beneficial. Several participants emphasized the need to focus on identifying and treating problems in early childhood to help prevent more severe psychopathology and persistent suicidality. Some EbyO shared that, in their view, treatments are sometimes not properly carried out because not all necessary steps are followed. This can result in poor treatment outcomes and, consequently, the persistence of suicidality. Besides, the impact of psychopathology on the suicidal process should be considered in treatment. One EbyE noted that, as suicidality can be seen as a contra-indication for certain types of therapy, persistent suicidality hindered her from receiving the care she sought (EbyE9).
Several EbyE reported feeling misunderstood in the care system with regard to their persistent suicidality. One shared: “[I was] always told by institutions that my problems were too complex, and yes, that they could not help me. So, I was basically always filled with medication. But not really heard, seen, or actually helped” (EbyE5). Another participant echoed this experience: “I feel that caregivers often … They know the protocol, they hear something that fits the protocol, so they follow the protocol. And they do not look at ‘Well, what is behind this, why is this happening?’” (EbyE12). Both experiences highlight participants’ feelings that their problems must fit certain frameworks to be addressed by caregivers, and their desire for a more personalized approach. EbyO noted significant ignorance and stigma among caregivers regarding persistent suicidality, suggesting that better training could greatly improve care.
Given the long-term nature of their suicidality, participants emphasized the importance of continuity in care. Individuals experiencing persistent suicidality often had an extensive treatment history, and frequent changes in caregivers were perceived to disrupt the development of safe and trusting therapeutic relationships, which they often longed for in care. Other needs related to building a strong and safe therapeutic relationship. EbyE felt that knowing more about caregivers would make discussing intimate experiences easier and create a safer environment. They also suggested addressing transference and countertransference. A lack of attention to these dynamics could threaten the therapeutic relationship and lead to negative treatment outcomes.
Some EbyE reported having positive experiences with body-oriented therapy, spiritual counseling, or expressed a desire to engage in discussions with professionals who have lived experience. Several EbyE shared how focusing on bodily sensations has helped them to access and process their emotions and memories, which had been difficult to reach through traditional talk therapy alone. Conversations with spiritual counselors and professionals with lived experience were perceived as open and without judgment, offering an existential focus that fostered deeper self-understanding. One of the EbyO highlighted the importance of including family members or friends in therapy, particularly when individuals express feeling like a burden to their loved ones.
A couple of EbyE indicated that they might request medical assistance in dying (MAiD) in the future, which is legal under strict conditions for psychiatric suffering in the Netherlands (
On a societal level, participants expressed the importance of participation and inclusion. EbyE shared that their mental health problems excluded them from activities, like attending college or working, which their peers were engaged in and they too aspired to participate in. They indicated that it can be challenging that their persistent suicidality is often invisible to the outside world, highlighting the need for greater awareness of their suffering. EbyE shared that people often underestimate their problems, which only increases the burden of their suffering.
Do you know how complicated it is to get benefits? [ … ] The [organization that provides benefits to people who are unemployed or unable to work] is always pushing you. You know. There is just no understanding for people who feel this way. And I look perfectly fine on the outside. You know. People also think, ‘Oh, it cannot be that bad.’ And that is really complicated. I am not lying in the gutter, and I am not doing foolish things. I am actually … I am really trying my best (EbyE4).
Relatedly, several EbyE expressed a need for financial support. They reported being unable to maintain steady employment or continue their studies due to their condition, leading to a need for benefits.
Thematic analysis of the data revealed that persistent suicidality is a complex and multifaceted phenomenon, with underlying causes that can vary between individuals. The findings indicate that adverse (childhood) experiences and psychopathology are perceived as root causes of persistent suicidality. Additionally, suicidality was believed to persist as a result of its function in individuals’ lives, such as acting as a coping mechanism or a form of communication (as noted by EbyO). Other perceived contributing factors include treatment fatigue, non-disclosure of problems, and the experience of reaching the limits of available treatment options. Needs related to persistent suicidality primarily involved individuals’ desire to be genuinely heard and to openly discuss their wish to die. This can help foster acceptance of their desire to cease living.
Although the research base on persistent suicidality is still limited, constraining far-reaching comparisons with prior studies, our findings nonetheless reveal some notable points of overlap with the existing literature. Both our findings and prior studies’ findings indicate that persistent suicidality may be linked to feelings of hopelessness, a loss of future perspective, and early life adversity (
Feelings of hopelessness and the belief that persistent suicidal thoughts would not subside were particularly prevalent among EbyE whose mental health counselor had stated that the treatment options were exhausted. This relates to the finding that the EbyE opposed the phrasing ‘chronic suicidality,’ as it implies the expectation that the wish to no longer be alive will not fade. This is an important finding in the ongoing debate surrounding the definition and classification of suicidality (
The finding that suicidality may persist because it becomes a form of coping aligns with a previous study of Hennings (
A similar psychological mechanism may help explain the finding that some EbyO believe acute suicidality can become persistent as a means of communication as a result of environmental reactions. Earlier research on suicidality in patients with BPD also highlights its role as a means of communication, suggesting that it is often a way of expressing distress (
Across the various identified themes, both those concerning the perceived causes of persistent suicidality and those related to care needs, it becomes apparent that care for individuals with persistent suicidality is at times perceived as ineffective or even harmful. Several EbyE reported feeling misunderstood in the care system, perceiving that caregivers are primarily focused on adhering the protocols rather than truly seeing and understanding them. EbyO similarly indicated that caregivers may lack sufficient awareness and may hold stigmatizing attitudes regarding persistent suicidality. Various caring theorists have warned that (unintentional) deficiencies in caregiving, as experienced by patients, can be harmful for the patients (
An important factor to consider in relation to persistent suicidality, though difficult to observe due to its unconscious nature, is transference in therapy. Transference can unconsciously hinder the therapeutic process, contributing to persistence of suicidality. Research underscores the harmful effects of unawareness of transference in suicidal patients (
A key need for individuals with persistent suicidality is the ability to openly discuss their suicidal thoughts, yet some hesitate to do so due to fears of ineffective treatment or (coercive) crisis intervention. This aligns with previous findings that 70% of psychotherapy clients conceal suicidal ideation to avoid unwanted consequences like involuntary hospitalization (
Continuity in care relationships was another need, with previous studies supporting its potential positive impact. A meta-synthesis of 25 qualitative studies on patients’ perceptions of care continuity found that patients viewed relational continuity as contributing to higher quality consultations, characterized by improved mutual understanding and greater comfort (
One way to address the need to focus on the meaning and acceptance of persistent suicidality, rather than primarily on recovery, is through a palliative care approach. Researchers have highlighted the significance of palliative care for psychiatric patients (
This study has several strengths and limitations. As one of the first studies to center on persistent suicidality, this research uniquely contributes to the field by qualitatively examining the phenomenon through interviews both experts with occupational and lived experience. It therefore combines holistic clinical understandings of the phenomenon with firsthand knowledge from lived experience, leading to rich, contextualized data. Besides, this combination of participants ensures that the findings of the research can be generalized to a wider population as multiple viewpoints have been included, reducing information bias. However, this study also has some limitations. Because EbyE participants were recruited through convenience sampling, a substantial proportion originated from the same network, which may have introduced selection bias. Moreover, recruiting EbyE participants through convenience sampling may have introduced a bias toward those more willing or able to articulate their experiences, potentially excluding less vocal perspectives Although the participants were experts on the topic and came from diverse backgrounds, this study is based on the views and experiences of a relatively small group of individuals that were willing to participate. Finally, because the data analysis process involved constant comparison and interpretation, relying heavily on the researchers’ interpretations, some subjective bias is inevitable. Efforts were made to minimize these effects by discussing the findings within the research group, stating positionality, and remaining closely tied to the data. This study was conducted in The Netherlands, where suicide and MAiD (only when strict criteria are met) are legally permitted. As a result, researcher’s interpretations and participants’ experiences may have been shaped by this relatively distinctive context, which should be considered when extrapolating these findings to other countries.
This study enhances the understanding of persistent suicidality as a complex and multifaceted phenomenon. While the specific perceived causes of persistent suicidality vary among individuals, the findings suggest that it is linked to adverse experiences and psychopathology. It may persist as a coping mechanism, a form of communication, or due to unsuccessful treatment. Key needs include feeling genuinely heard and openly discussing suicidal thoughts. Attention should be given to reasons for non-disclosure and transference-countertransference dynamics in therapy. Findings underscore a need for psychiatric palliative care initiatives and continuity in care relationships. Care should not focus solely on recovery but also emphasize managing and acceptance of suicidal thoughts.
Data cannot be shared publicly because of to potentially identifying information and lack of participant consent for sharing the anonymized data. The transcripts are archived on a secured server of Amsterdam UMC. Anonymized excerpts of transcripts are available upon request for researchers who meet the criteria for access to confidential data. Requests to access the datasets should be directed to m.m.palm@amsterdamumc.nl.
According to the Dutch Medical Research Involving Human Subjects Act this study was exempted from ethical review as decided by the Medical Ethical Review Committee of Amsterdam University Medical Center. The study was conducted in accordance with the national legislation and institutional requirements. The participants provided their written informed consent to participate in this study.
MP: Formal analysis, Investigation, Validation, Writing – original draft, Writing – review & editing. SV: Conceptualization, Funding acquisition, Supervision, Validation, Writing – review & editing. LS: Conceptualization, Methodology, Validation, Writing – review & editing. AB: Supervision, Validation, Writing – review & editing. EW: Conceptualization, Validation, Writing – review & editing. EE: Conceptualization, Formal analysis, Investigation, Methodology, Supervision, Validation, Writing – review & editing.
The author(s) declare financial support was received for the research and/or publication of this article. This work was supported by the NVVE (Right to Die Society) (grant number NA). The funder had no role in the design, conduct, or reporting of the research.
The authors extend their gratitude to all participants for sharing their stories.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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