You are on page 1of 10

See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/253332909

Why self-immolation? A qualitative exploration of the motives for attempting


suicide by self-immolation

Article  in  Burns: journal of the International Society for Burn Injuries · July 2013
DOI: 10.1016/j.burns.2013.06.016 · Source: PubMed

CITATIONS READS

18 183

6 authors, including:

Leeba Rezaie seyed ali Hosseini


Kermanshah University of Medical Sciences (KUMS) University of Social Welfare and Rehabilitation Sciences
34 PUBLICATIONS   199 CITATIONS    93 PUBLICATIONS   358 CITATIONS   

SEE PROFILE SEE PROFILE

Mehdi Rassafiani Farid Najafi


Kuwait University Kermanshah University of Medical Sciences
139 PUBLICATIONS   576 CITATIONS    145 PUBLICATIONS   1,002 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Personal factors affecting ethical performance in healthcare workers during disasters and mass casualty incidents in Iran: a qualitative study View project

Emergency Operation Plan View project

All content following this page was uploaded by Leeba Rezaie on 10 September 2018.

The user has requested enhancement of the downloaded file.


burns 40 (2014) 319–327

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/burns

Why self-immolation? A qualitative exploration


of the motives for attempting suicide by
self-immolation

Leeba Rezaie a, Seyed Ali Hosseini a,*, Mehdi Rassafiani a, Farid Najafi b,
Jalal Shakeri c, Hamid Reza Khankeh d
a
Department of Occupational therapy, University of Social Welfare and Rehabilitation Science (USWR), Tehran, Iran
b
Kermanshah Health Research Center (KHRC), School of Population Health, Kermanshah University of Medical
Sciences (KUMS), Kermanshah, Iran
c
Department of Psychiatry, Farabi Hospital, Kermanshah University of Medical Sciences (KUMS), Kermanshah, Iran
d
Department of Nursing, University of Social Welfare and Rehabilitation Science (USWR), Tehran, Iran

article info abstract

Article history: Introduction: Suicide by self-immolation is one of the great health concerns in developing
Accepted 23 June 2013 countries such as Iran. Exploration of motives for attempting suicide by self-immolation in
different point of view of people with experience and information on can be considered as a
Keywords: crucial aspect in self-immolation prevention. The study aimed to explore motives for suicide
Self-immolation by self-immolation in Kermanshah, Iran.
Motives Methods: A qualitative approach using semi-structure interview was employed to explore
Qualitative study motives for attempting suicide by self-immolation in Kermanshah, Iran (2012). 15 partici-
Content analysis pants including 9 self-immolated patients, a patient’s husband, and 5 members of medical
Prevention staff of these patients were interviewed. The interviews were taped and transcribed. A
Iran content analysis using constant comparison was performed for transcribed interviews.
Results: Five main categories were emerged that explore motives for suicide by self-immo-
lation including mental health problems, family problems, cultural context, self-immola-
tion as a threat, and the distinct characteristics of the method. All categories had their
specific subcategories which had been integrated based on distinct properties in a given
category. More than one motive might be addressed by study participants, which listed in
the appropriate categories.
Conclusion: There are several reasons for suicide by self-immolation that should be consid-
ered in prevention programs. There may be an interactional pattern among the motives.
Further study to explore process of the interactional pattern is recommended.
# 2013 Elsevier Ltd and ISBIElsevier Ltd and ISBI. All rights reserved.

1. Introduction research in the global world. High rate of mortality (70–90%)


and morbidity caused by self-immolation is noticeable in
Self-immolation or act of intentional burns is one of the Middle East countries and India in which self-immolation is a
horrific methods for suicide which has been a focus of common method for suicide [1–4]. Beside, more complicated

* Corresponding author. Tel.: +21 22180123; fax: +21 22180123.


E-mail addresses: la_rezaie@yahoo.com (L. Rezaie), alihosse@gmail.com (S.A. Hosseini), mrassafiani@yahoo.com (M. Rassafiani),
farid_n32@yahoo.com (F. Najafi), jshakerimd@yahoo.com (J. Shakeri), hrkhankeh@hotmail.com (H.R. Khankeh).
0305-4179/$36.00 # 2013 Elsevier Ltd and ISBIElsevier Ltd and ISBI. All rights reserved.
http://dx.doi.org/10.1016/j.burns.2013.06.016
320 burns 40 (2014) 319–327

recovery process, and disabling impairments which required aspect of the phenomenon in these studies, the real nature of
to a longer term process of rehabilitation for survived self- self-immolation remain unclear and needs a holistic approach
immolated patients [2,5–7] caused that self-immolation is to study of all aspects of self-immolation [14,15]. Obviously,
considered as a major public health concern and a large successful prevention programs need to recognize all aspects
growing body of research devoted to it. of self-immolation clearly. As recommended by Rezaie and
Previous studies have revealed several important aspects Schwebel [16] a qualitative approach to study of self-immola-
of self-immolation worldwide. Reportedly, there is a different tion would be helpful to explore all aspects of the phenome-
pattern of suicide by self-immolation between developed and non holistically. Qualitative approaches are useful methods
developing countries. While low suicide rate by self-immola- for an in depth study of a phenomenon which is not well
tion (1% of all of suicide) is reported in developed countries, in known, and one with socio-cultural aspect. They have a good
some part of developing countries such as Iran, 27% all of potential for exploring the symbolic meaning of social
suicides and more than 70% of committed suicides is phenomena [17–19]. We believe self-immolation can be
conducted by self-immolation [7–10]. considered as a social phenomenon with symbolic meaning
These studies also reported that some significant differ- that has not been explored deeply. Therefore we designed a
ence between motives for self-immolation and other methods qualitative study using content analysis to explore motives for
for suicide. In this regard more documented role of socio suicide by self-immolation in Kermanshah, Iran.
cultural context for women in developing countries including
living in husbands’ extended family, to be undervalued, and
cultural rituals such as Sati (burning of the Hindu widow) in 2. Methods
India [2,3,5,11] is reported. In fact, in comparison with other
methods for suicide, socio cultural factors have a more 2.1. Study design
powerful role for attempting suicide by self-immolation.
The issue has been reported in several studies. Rezaie et al. A qualitative approach using latent content analysis was
compared demographic characteristics, risk factor, and considered appropriate for our study. In this method,
warning signs for suicide by self-immolation with suicide by information from participants is gathered directly without
self-poisoning. They reported that older age, lower level of any pervious hypothesis. Produced knowledge is based on
education, female gender, and married status were more unique point of views of participants. Codes and categories are
prevalent in the self-immolation group [12]. Smaller frequency derived by the inductive process, and conceptually ordered
of warning signs for suicide in self-immolation group was considering properties and dimensions are developed [17,18].
another important difference. The authors believed it can be
attributed to smaller frequency of psychiatric disorders and 2.2. Setting and participants
more powerful influence of sociocultural context which made
it difficult to prevent self-immolation [13]. Therefore, there is a After establishing a consensus between University of Social
tendency toward differentiation between self-immolation and Welfare and rehabilitation science (USWR) and Kermanshah
other method for suicide in literature and prevention program University of Medical Science (KUMS) formal permission for
with emphasis on socio cultural context is recommended. conducting of the study in Kermanshah Imam Khomeini
In Iran, such as other developing countries, self-immola- hospital was provided. It is an educational hospital under
tion is one of the health concerns. As reported, there is high supervision of KUMS and the main center for admission of
rate of self-immolation in some province including Kerman- suicidal patients. A well trained member of our research team
shah, target of this study, Ilam, and Kurdistan, so that 27% of who had a good ability for data gathering in qualitative research,
all of suicide has been carried out via self-immolation [10]. especially interview, was responsible to attend in Kermanshah
Also a relatively regular pattern of young married women with Imam Khomeini hospital. In addition to course of qualitative
lower education as the main victims, family quarrel as the research in post graduating education, participating in several
precursor of self-immolation, and the importance of sociocul- workshops of qualitative research in USWR enabled her to
tural context, especially in rural areas have been reported in collect data appropriately. She was in contact with the head
Iran [8–10]. Therefore, self-immolation is a focus of research in nurse of burn unit who provided a list of admitted self-
recent decades and some interventions for prevention has immolated patients. Therefore, access to participants, espe-
been recommended. cially self-immolated patients and their relatives, was possible
As stated above, previous studies have revealed several risk for her. It should remember that there were different profes-
factors which can influence the process of attempting suicide sions in our research team such as a qualitative researcher, a
by self-immolation. Personal risk factors (such as age, and psychiatrist, an epidemiologist, which provided us with the
sex), psychiatric disorders (especially adjustment disorders), opportunity for investigators triangulation.
and sociocultural context (such as living in husbands, We used purposeful sampling as our approach to gather
extended family) are among them, however; the exact data. Open sampling with maximum diversity for selection of
mechanism of their influence has not been explained [8–10]. our participants has been used. In this type of sampling,
In fact, self-immolation is considered as a multidimensional instead of a representative sample, there is a maximum
phenomenon with a great emphasis on sociocultural context. variation in the selection of the sample. It is an appropriate
But, due to some limitations including lack of an integrative sampling method when the phenomenon of interest is broad
approach to examine all probable motives for self-immolation, and multidimensional. Also it can be helpful for gathering data
and applying quantitative approaches which emphasis one from different point of view of informants on the researched
burns 40 (2014) 319–327 321

phenomenon [19]. Having experience about self-immolation, about the motive or motives for attempting suicide by self-
and willingness to participate in the study were our general immolation and followed by more detailed questions to probe
inclusion criteria. Therefore, patients who attempted suicide the interview. All our participants could speak Farsi and we
by self-immolation, their relatives, and medical staff including were confronted with any problem for translating of inter-
psychiatrist, psychologist, and nurses were our participants in views. All interviews were taped and lasted 20–60 min. In
this study. For patients who attempted suicide, being in an addition to the tape records of the interview, field notes were
appropriate mental and physical health status for interview written. They were used as complementary data and for
was another inclusion criterion. The criterion was assessed in trustworthiness as well.
cooperation with a physician who undertakes patient treat-
ment and supervisory team as well. Considering the inclusion 2.4. Data analysis
criteria, 15 participants were interviewed. 9 patients (7 females
and 2 males) who attempted suicide by self-immolation and As recommended by Strauss and Corbin [17] data collection
were admitted to Kermanshah Imam Khomeini hospital, and a and data analysis were performed simultaneously and data
patient’s husband were interviewed. Other participants were were analyzed using constant comparative method which is
medical staff including 2 psychiatrists, 2 nurses, and a Grounded Theory data analysis method. Data analysis
psychologist who had experience in working with patients included several steps. First, taped interviews were tran-
who attempted suicide by self-immolation. Except for psy- scribed verbatim and prepared for content analysis. In the
chiatrists who were interviewed in their offices, other second stage, before the beginning of coding, the transcribed
participants were interviewed in the burn unit of Kermanshah text was read several times for familiarization. A design for
Imam Khomeini hospital over a 6 month period (June to generating of codes and categories was considered in the third
November, 2012). In general the time and the venue of stage. Codes and categories were extracted by the inductive
interview has been determined by the study participants. process as open coding through, line by line reading the text
and relevant code devoted to it and differentiation of
2.3. Data collection categories was provided by constant comparison in the fourth
stage open coding. Peer check and member check and
We used semi-structure interview for data collection. Semi- constant comparison were performed to reach a consensus
structure could provide a good opportunity for patients to talk in coding in the fifth stage. After completing coding and
about their attempts without any restriction caused by the assuring from accuracy of coding, conclusion was performed
closed questions of questionnaires. Other participants also in sixth stage and concepts were identified. All concepts were
perceived themselves with a comfortable atmosphere of retrieved after the 13th interview, and the last two interviews
conveying their experience about patients who attempted were performed to ensure saturation. We listed some
suicide. Every interview started with some open questions examples of data analysis in Table 1.

Table 1 – Examples of extracting of codes, sub categories, and categories from raw data.
Meaning unit Code Subcategory Category
Psychiatric disorders such as depression Psychiatric disorders as a motive Primary psychiatric Mental health
can be a motive for self-immolation. (p4) for self-immolation disorders problems
It seems psychosocial stress has a more Role of psychosocial stress Adjustment Mental health
powerful role in self-immolation. (p13) in self-immolation psychiatric disorders problems
6 month after marriage, I attempted to Self-immolation due to Wives–husbands Family problems
self-immolation due to my husband annoyance of husband problems
annoyance. (p2)
I and my father cannot speak together Relationship problem Parent–children Family problems
peacefully. (p3) between father and son problems
I did not want to get divorce, it is not Divorce as an un acceptable act Cultural customs Cultural context
acceptable act in our culture. (p12) and values
Self-immolation means failure against Self-immolation as failure Cultural meanings Cultural context
problems (p11) of self-immolation
When my cousin burnt herself, I thought Self-immolation due to imitation Cultural identification Cultural context
I should also burn myself. (p9)
In family quarrels, women usually threat Self-immolation as a threat Threat to modify Self-immolation
to self-immolation to frighten their in a family quarrel environment as threat
husbands. (p15)
Another point is easy access to kerosene Easy access to flammable Self-immolation as Distinct characteristics
and other flammable liquids. (p1) liquids as a motive for a more accessible method of the method
self-immolation
Self-immolation was the best choice Self-immolation due to severe Self-immolation as Distinct characteristics
for dying. (p5) desire to dying a lethal method of the method
When a person has a deep protest, she Self-immolation as a way to express Self-immolation as a Distinct characteristics
attempts to self-immolation. (p4) a deep protest more expressive method of the method
322 burns 40 (2014) 319–327

2.5. Trustworthiness ‘‘My several years of experience in burn wards, especially


with women who constitute most of our patients, tells me
We used the strategies recommended by Lincoln and Guba for the major motive for self-immolation is psychiatric
trustworthiness of our data. According to this recommenda- disorders. i.e., a person should have an acute psychiatric
tion, 4 criteria of creditability, dependency, conformability, disorder or unstable mind that decides to attempt to self-
and transferability are necessary for trustworthiness [20]. immolation in an immediate moment. Sometimes, some of
Creditability of data gathering was provided by triangulation our patients’ tell us that a voice told them burn themselves.
strategy, i.e., in addition to semi structure interview, filed It means that she attempted to self-immolation as a result
notes, and prolonged engagement in subject matter were used of a hallucination.’’ (p6)
for the creditability of data [21]. Dependency of data was
assessed by peer check and member check strategies [22]. In Adjustment psychiatric disorders or disorders with no
member check strategy, participants were provided with a previous history of hereditary causes were another mentioned
summary of analyzed interview to know whether emerged motive for self-immolation. Some participants stated that
categories from interview were correct. Peer check was because of irresolvable problems such as family problems they
performed on a weekly basis, so that the research team had experienced several negative feelings including tension,
a thorough discussion about emerged data. The personal sadness, hopelessness, and tiredness so they thought that
interest of researcher on the subject, search for the idea of suicide is a reasonable solution for them. They believe they
other researchers and maintaining documents of study could could not tolerate additional stress and their attempt to self-
provide confirmability of data [20]. Offering a comprehensive immolation was a reaction to express tiredness from the
description of the subject, participants, data gathering, data stressful situation. Feeling of loss of control on self was one of
analysis, and study limitations could provide transferability of the most important symptoms that they had experienced
the study, so that other researchers could continue the study when attempting self-immolation. They stated that they did
[21,22]. not understand what they do and their attempt was very
suddenly and unplanned. In fact, they expressed the psychi-
2.6. Ethical considerations atric symptoms including attempting self-immolation in
reaction to chronic or sever stress. Two examples of this
The study was approved by the ethical committee of subcategory are:
University of Social Welfare and Rehabilitation Science
(USWR) Tehran, Iran. According to the protocol of the study, ‘‘The second category of mental health problems is reactive
all participants were informed about confidentiality of their mental health problems in which a person has suffered
names in any report of the study and recording of the from a psychiatric disorder in reaction to life problems. For
interviews. Then, informed consent was provided for all of example a person who has lived in the family with poverty,
them. economic problems, unemployment, and addiction. In fact,
psychiatric disorder has been a reaction to this situation for
this person. This type of psychiatric disorders may not
3. Results present as a psychotic disorder, but may lead to an
impulsive act to self-immolation during a family quarrel.’’
Study participants were 9 self-immolated patients in range of (p4)
22–50 years old with mean age of 26.8  8.9, (including 5 ‘‘When quarreling with my father, I went to kitchen and
married, and 2 single women, and 2 men), their relatives (1 took a bottle of ethanol. Then I poured it on myself
participant) and medical staff (5 participants). Five main suddenly. Really, I do not know how I did it, how pass to
categories were extracted from our data including mental mind. I did not want to burn myself.’’ (p3)
health problems, family problems, cultural context, self-
immolation as a threat, and distinct characteristics of the
method. These main categories with their subcategories have 3.2. Family problems
been explained as below.
All of our participants addressed family problems as a main
3.1. Mental health problems motive for suicide by self-immolation. The problems mostly
were related to emotional relationship between family’s
Mental health problems were one of the motives for suicide by members. Lack of warmth and empathy, to be emotionally
self-immolation based on experiences and perceptions of ignored, and finally domestic violence were among mentioned
study participants. This category had two subcategories of family’s problems in self-immolated patients. Our analysis
primary psychiatric disorders and adjustment psychiatric showed that there were two subcategories for family problems
disorders. The sub categories have been described below. including wives–husbands’ problems and parent–children
Primary psychiatric disorders such as depression, and problems.
schizophrenia were mentioned as a motive for suicide by self- Wives–husbands’ problems which presented as marital
immolation. Participants believe that this problem is common dissatisfaction was the first mentioned motive by our married
in all types of suicide. Psychiatric disorders can provide self-immolated participants. They expressed a variety of
appropriate conditions to raise this problem. For example one problems from verbal dispute upon to be exposed to physical
participant said: violence in relationship with their husbands. The problems
burns 40 (2014) 319–327 323

had been started at a short period after marriage and worsen were rejected. They told me to get a divorce, but I was sure
over time. They also believed that their husbands did not that if I had a divorce, my situation would have been worse
understand their emotional demands. Having to tolerate due than what it was. In our family, girls are not valued.
to cultural custom of being of indecent of divorce made Everyone advised me tolerance of any hardships in my
difficult dealing with this situation, therefore suicide by self- husband’s house is better than divorce. So I had to come
immolation was considered as the best solution for them. One back. My husband promised not to annoy me anymore but
participant stated as below: he did not keep his words’’.)p8)

‘‘My husband is the motive for my self-immolation. He was The second subcategory was cultural meaning of self-
angry, moody, addict, suspicious and a mentally ill. He hit immolation. Some of our participants believed that, cultural-
me. He said I ‘‘love you but at first’’, I married with you ly, there are meanings for self-immolation which may
because of money. He was good at first, he said ‘‘go to your influence attempting self-immolation. Based on our data
parents and bring me money’’. I was doing it. He bought cultural meanings are attitudes and believes of people about
nothings for me, even clothes. He did not take me to a self-immolation and who attempted it. Culturally, the self-
wedding, to a funeral, nowhere. He said you are not a immolation word associated with pain and suffering, and it is
human. I have tolerated this situation for a long time. (p12)’’ thought that self-immolation always occurs when a person
has been exposed to harassment of others. Sever desire to die
Parents–children problems or Lack of a warm relationship for escaping from the situation is considered as rational
between parents and their children was another subcategory motive for attempting self-immolation. Therefore self-im-
for family problems among patients who attempted self- molation may be encouraged unconsciously, and there is
immolation, so that there was a mutual dissatisfaction from cultural meaning for it as a means of relief of suffering and
part of both parents and children. Children complained that pain and serious desire to die. One examples of this
the parents could not understand their emotional needs, and subcategory is:
parents believed that they have dedicated their lives to them,
but they do not appreciate. In some cases, the dissatisfaction ‘‘Of course, it is necessary to study about this. Actually
led to an emotional detachment feeling flowed by attempting what I’m saying is based on my clinical experience. For
self-immolation. One participant said: example, when a woman takes 10 pills and is taken to
hospital for gastric lavage, her family may say she wants to
‘‘My mother died eight years ago in a car accident. I have a make a scene. It may suggest that they think there is no
younger sister. My father got married again. Now he loves strong desire to die and it is her way to modify the
his new wife and does not care about us. I was bored, home environment. While in self-immolation, all people think
was not a good place for me, my stepmother bothered me there is a strong desire to die and it will be an important
she was insulting me all the time. I had to work for her. My issue which can influences on cognitive structure. Actually,
father was supporting her. I decided to kill myself’’.(p9) there is a special belief in some cultures that a self
immolated person wants to establish that she or he is
sinless, i.e. she/he wants to tell others that I am innocent.
3.3. Cultural context Perhaps, we should consider the opposite point of view in
other methods of suicide’’. (p13)
Cultural context is another extracted category in our analysis.
It included three subcategories of cultural customs and values, Cultural identification was the last subcategory which was
cultural meaning of self-immolation, and cultural identifica- extracted from the analysis of the cultural context category.
tion. The subcategories are described below. Some of our participants mentioned that culturally, self-
Study participants addressed to the role of cultural immolation may be imitated and cultural identification can be
customs and values in self-immolation. Marriage and divorce considered as a probable motive for self-immolation. Study
related customs are among important ones in the under- participants have mentioned these:
studied culture. Accordingly, girls have to marry in younger
age and decision of girls’ marriage is made under authority of ‘‘One of the motives for self-immolation is the culture of
their fathers so that they do not have an active participation in the west region of Iran, culture of the people, which is
this important decision making. On the other hand, divorce is unavoidable. The environment they live. It seems that self-
considered as an indecent act; therefore they cannot get immolation has found its position. When we asked them,
divorce easily, if they have irresolvable problems with their they said their sister, or another person in their family has
husbands. Obviously, the situation may result in sadness and already attempted self-immolation. It looks like a chain,
dissatisfaction. Some participants emphasized on these they are following each other. Of course, there are also
customs a motive for attempting self-immolation. For exam- other motives such as family problems.’’ (p7)
ple one participant said: ‘‘I chose it because I think it finished me up, of course there
was something like poison and pills. One of my relatives
‘‘Four month after marriage, I left my home, after 11 who was my close friend and was a married woman had
months, I came back because I had to. When I went to my attempted self-immolation. She was survived for 1 day
father’s home, I saw nothing had changed, nobody did after her attempt and then died. I thought, maybe, I will die
respect me. Even, they reproached me you married but you and join her. She was married, and had a baby. She
324 burns 40 (2014) 319–327

celebrated the birthday of her baby, her husband’s family usually occurs in patients with severe intent to die. In fact they
had quarreled with her and she burnt herself’’. (p5) attempt self-immolation as a successful way of dying. One
example of these statements is:

3.4. Self-immolation as a threat ‘‘Really, I made a decision to die. If I wanted to seek


attention, or liked getting advice, I would choose an easier
Self-immolation as a threat was another extracted category way. I think, self-immolation is not a good choice for
with a subcategory of threat to modify of environment. suicide show off. When a person attempts to self-immola-
Some of our participants addressed threat to self-immola- tion, he/she already made his/her decision. It is a very
tion to modify or to control of the environment as a motive for horrific act. It bears a severe damage. That moment, he/she
attempting self-immolation. Accordingly, in some cases, there is waiting for death. He/she knows that its outcome is
might be no real intent to commit suicide and self-immolation disability. Dying is better than disability’’.(p14).
was been only a threat in a stressful situation. Actually this is a
strategy to change something but some time it does not work. Self-immolation as a more expressive method or choosing
We included two examples of these statements: self-immolation as a more dramatic method for suicide is
another mentioned motive by our participants. Participants
‘‘One more point is when a person wants to impress others. stated that self-immolation has the more dramatic influence
The ways of impression in different cultures are various. than other methods for suicide. In fact, they believe that the
Most of the times, a person says ‘‘I wanted to impress horrific and lethal nature of self-immolation make it as a
others and got their help’’. So, she threats to attempt self- better way to convey the severity of experienced pain.
immolation and most of the times, actualizes her threat. Accordingly, self-immolation is considered as a way to express
Unfortunately, when it flares up it causes at least in 50% a deep protest and a person wants to show her problems very
burns with no achieving her wish.’’ (p4) dramatically. One example for the subcategory is:
In our environment, threat to self burn is very common. It is
a powerful weapon for women. When women want to ‘‘Severe stress in the family environment is another
frighten their husbands, to stop their bother, they threat to important factor and under pressure of this situation a
suicide by pills or self burn. So when my wife threatened person wants to cry for help and shows her protest. The
me to self burn, I did not believe her threat, I thought she more dramatic and aggressive method, the better way for
also wants to frighten me and gains my attention. But she protest. Self-immolation is a dramatic method for suicide.
carried out her threat. It was unbelievable for me (p 15).’’ It can draw attention to pressure. In fact, self-immolation is
a way to express severe relational problems’’.(p1)

3.5. Distinct characteristics of the method

Our participants believed that there are some distinct 4. Discussion


characteristics for self-immolation that can be considered
as a motive for attempting suicide by itself. Self-immolation as Our results show that there are several different motives for
a more accessible, lethal, and more expressive method for attempting suicide by self-immolation. Based on experiences
suicide were the mentioned characteristics which has been and perceptions of study participants (including self-immo-
inserted in three subcategories. lated patients, their relatives, and medical staff) five categories
The first subcategory was self-immolation as a more of mental health problems, family problems, cultural context,
accessible method. Easy access to kerosene or other flamma- self-immolation as a threat, and distinct characteristics of the
ble liquids which facilitates attempting suicide was another method were explored as motives for attempting suicide by
mentioned motive for self-immolation. For example two self-immolation. Previous reports [9,10,12–16] have also
participants said: emphasized the role of different factors on attempting self-
immolation; however, because of the nature of these studies
‘‘Easy access to flammable liquids is another motive for (quantitative studies) the exploration of motives has not been
self-immolation, i.e., in areas in where there is the device performed. On the other hand, usually all aspects have not
for self-immolation, people attempt suicide by self-immo- been studied in these reports. Below the results are discussed
lation. For example, kerosene is used for self-immolation in in more details.
the areas where people used this thermal device.’’ (p1) In consistent with previous studies [3,23] mental health
‘‘When quarreling with my husband, I told I kill myself. problems including primary psychiatric disorders and adjust-
There is no poison and tablet (drug) at home and I could not ment psychiatric disorders were among the motives for
go buy them. I poured alcohol on myself while I anticipated attempting suicide by self-immolation. The role of mental
that he would stop me. But he did not stop me and I fired the health problems in attempting suicide by self-immolation is
match. I wish I died and were relieved. But I did not think I an important aspect of self-immolation which should be
would suffer like this’’. (p8) considered in the prevention program. With regards to
primary psychiatric disorders, as other methods for suicide,
According to subcategory of self-immolation as a lethal self-immolation may be considered as a sign of a psychiatric
method, some of our participants believed that self-immolation disorder such as depression. But, the second sub category or
burns 40 (2014) 319–327 325

adjustment psychiatric disorders in which psychiatric symp- with regards to respect to women. Perhaps, cultural customs
toms such as an impulsive act to self-immolation were and values should be considered as a spectrum that self-
reported as a reaction to chronic or severe stress seems more immolated patients may live at the end of spectrum with a
important. Impulsive act to suicide is not associated with a restricted one. We do not know exactly whether the rigid
previous plan and may take place very suddenly; therefore, it customs and values are the main problem for these patients,
is more difficult to prevent it. Zarghami reported that 62% of or other problems such as family problems may be exaggerat-
patients who attempted to self-immolation had an impulsive ed in this context. However, further research to explore the
intention [24]. We do not exactly whether impulsive act in self- cultural context of self-immolated patients, for example an
immolated patients should be considered as a sign of a ethnography, study is recommended.
psychiatric disorder or may be a reaction to severe or chronic Cultural meanings of self-immolation were another aspect
stresses in their life. Therefore, further research in this area is of the role of culture in self-immolation. Accordingly, the
recommended. meanings suggest that, typically, self-immolated patients who
Results also show that existed conflicts between the family are being in a stressful situation and their attempt is a more
members of self-immolated patients, especially wives–hus- expressive way for getting rid of it. In fact, instead of
bands, and parents–children problems was a mentioned devaluating of the act, the meaning can provoke an empa-
motive for attempting self-immolation. The extended spec- thetic or even sympathetic feeling in turns can lead to
trum of family problems from verbal dispute to physical encourage attempting self-immolation. Lester emphasized
violence was reported close to self-immolation. As described the different meanings of suicide in different cultures [24]. He
by the study participants, self-immolation occurs during a cited examples from different cultures and addressed to the
family quarrel. Typically, as reported in previous studies [8– meaning of suicide in these culture which can encourage
10,15], family quarrel is considered as a precursor for self- attempting suicide. However, since there is no reported study
immolation. Family is a scared institution in Iranian culture on cultural meaning of self-immolation in Iran, further
based on peace and respect between family’s members. The research in this area is recommended.
exact pathological mechanism of relationship in these The last aspect of cultural problems discussed here is
families is unknown. Whether, as described by women, their cultural identification. Our results show that there may be an
husbands are too aggressive to have a warm relationship, or imitative pattern for self-immolation. Accordingly, self-im-
there may be a mutual lack of necessary skills in both man and molation can be imitated, i.e., in the culture in which self-
woman for a warm relationship is not clear. On the other immolation is a more prevalent method, there is a more
hand, parents–children problems is another aspect of family probability that further attempts will occur by an identifica-
problems in self-immolated patients. It seems that there is a tion pattern. Ahmadi and Rezaie et al. reported that imitation
failure in the pattern of relationship in these families. should be considered as an influential factor in attempting
Obviously, parents–children relationship may be affected by suicide by self-immolation [10,12]. However, we do not know
parent–parent relationship. Nevertheless, there is no evidence exactly whether as reported by Rezaie and Schwebel the
to support that both type and severity of family problems in similarity between self-immolated patients may facilitate the
self-immolated patients may be different in patients who process of cultural identification [15], or there may be other
attempted to other methods of suicide, because it was not the contributing factors; therefore, further research to explore
focus of this qualitative study, therefore further research in cultural identification is recommended.
this area is recommended. On the other hand, considering the In general, there is no documented evidence for a well
importance of family problems as a precursor for self- designed culturally oriented intervention for self-immolation
immolation, psychoeducational programs such as life skills in literature, but considering the importance of socio cultural
training to improve relationship between family members is context in self-immolation, specific intervention in this area is
recommended. necessary. Cultural oriented intervention such as participa-
As reported by our participants, cultural context with the tion of religious leaders in prevention programs and women
three subcategories were another mentioned motive for empowerment which recommended by Wu et al. can be useful
attempting suicide by self-immolation. The role of culture a prevention strategy [11]. Accordingly, it seems religious
in suicide by self-immolation has been emphasized in leaders’ advice about being sinfulness of attempting self-
previous studies [3,8–10,12–16] so that self-immolation is immolation and establishing a peaceful atmosphere in family
considered as a method with more documented history of by respecting to women is a more effective way for providing
cultural meanings than other methods [2]. Cultural customs change in positive cultural attitude toward self-immolation.
and values, especially those related to marriage and divorce On the other hand, psycho education programs focused on
among cultural problems which could influence deciding to rethinking about marriage customs including age of marriage
attempt self-immolation. Forced marriage, and overvaluation and how to decide to marry can be another useful culturally
of early marriage of girls, and negative attitude toward divorce oriented intervention [15]. However, the importance of
as an indecent act were examples of these customs. It seems cultural sensitivity should be considered in this intervention.
that these customs can play a role to create negative feelings As already mentioned, threat to self-immolation to modify
toward themselves and unhappiness in women who have to environment was a motive for attempting suicide. In this case,
live in this cultural context. Other previous studies [14,15] also threat to self-immolation is usually applied as a coping
addressed to these customs and traditions as factors influ- mechanism, when a person is confronted with a stressful
encing on self-immolation. However, Iranian culture is a rich situation. By this way, h/she wants to seize control of the
culture with a long history of positive traditions, especially environment, but s/he may actualize her/his threat. Previous
326 burns 40 (2014) 319–327

studies [10,12,13] have also reported that treat to self- suicide prevention strategies including programs such as early
immolation should be considered as an influential factor in diagnosis and treatment of psychiatric disorders can be useful
self-immolation, but the authors believe that there may be in self-immolation prevention. In this view, despite the
no strong relationship between severe suicide intent and distinct nature of self-immolation, considering it as a method
threat to self-immolation. It should be remembered that for suicide and similar motives with other methods of suicide
verbal threat is considered as a warning sign for all types of should not be overlooked. The second type or specific strategy
suicide [25] but it seems it has a more powerful role in self- should focus on the different aspects of self-immolation such
immolation. Considering the role of threat in self-immola- as cultural context, and so its adverse consequences. In this
tion, further study to explore probable cultural, and or regard, suicide prevention programs with emphasis the
psychological background and contributing factors to cultural context is recommended. Obviously, these programs
actualize threat to self-immolation is recommended. may lasted longer than other programs which require a more
Self-immolation as a more accessible, more expressive careful planning, implementation, and assessment process.
and lethal method were mentioned as motives for attempt- On the other hand, with regards to adverse consequences as
ing suicide by this method. Easy access to means has been reported by Ahmadi and Ytterstad showing the history of self-
reported as a facilitator factor for suicide by self-immolation immolated patients including post attempt consequences can
[8,10,12–14]. However, it should be remembered that be a useful community based intervention [26]. However, a
only easy access to means cannot justify attempt self- scientific and procedural coordination between two types of
immolation. prevention strategies is necessary.
Lethal nature of self-immolation is one of the most Finally, several different motives for self-immolation
important and concerning aspects of self-immolation which should be considered in an interactional pattern, although,
discriminate it from other methods. However, we believe that according to the type of study (latent content analysis) we
the contributing factors to produce sever intent to suicide by could not perform the analysis for providing the pattern.
self-immolation should be explored. Self-immolation as a However, based on previous reports and so the current data it
way to dramatic expression of problems was the last seems there are some interactions between them. In this
characteristic which may distinguish it from other methods. regards, attitude toward psychiatric disorders, and mental
Accordingly, there is a relationship between the tendency health, the pattern of relationships in the family, and the
toward to express problems and self-immolation as a method coping mechanisms can be influenced by the cultural context
for suicide. Whether, only lethal nature of self-immolation [27]. On the other hand, as included in the results section,
make it as a more expressive method, or there may be a there may be a mutual relationship between family problems
cultural identification to express problem by self-immolation and psychiatric disorders especially adjustment type. Also,
is not clear. On the other hand, considering adverse threat to self-immolation may be considered as a culturally
consequences of attempting suicide by self-immolation as learned behavior when a family quarrel occurs [12]. Therefore,
a more expressive, and successful lethal method can be to explore the interactional pattern among the motives and to
concerning. Providing information about adverse conse- provide a provisional model further qualitative research, using
quences of self-immolation in prevention programs is a grounded theory, is recommended
recommended.
5.1. Strengths and limitations

5. Conclusion and implications The study should be seen in light of some strengths and
limitations. It is the first qualitative study on self-immolation
Although, the results cannot be generalized to self-immola- in Kermanshah, Iran that could provide the valuable
tion in worldwide and only can be applied in similar cultures information about motives for attempting self-immolation.
and situations, there are several conclusions and implications Since, the data were gathered through semi-structure
for this study. First, the study showed that there may be interview, more precise and comprehensive information
several motives for attempting suicide by self-immolation. was extracted. On the other hand, data gathering from the
Confirming previous studies which emphasized the role of point of view of both informants and who had experience
several contributing factors in self-immolation, we believe about self-immolation could increase the richness of data. In
that all of motives are important and a comprehensive fact, a relatively clear picture of self-immolation was
prevention program should pay attention to all of them. provided by a combination of the experience of self-
Secondly, as discussed above, the motives for self-immolation immolated patients, their relatives, and medical staff (using
are various. Some of them such as mental health problems, triangulation strategies for data gathering).
and family problems are similar with other suicide. It seems We also mention the limitations of the study. First, we
other motives including cultural context, self-immolation as a confronted with the limited access to knowledge of self-
threat, and distinct characteristics of the method are specific immolated patients’ husbands about attempting self-immo-
to self-immolation. In fact, self-immolation should be consid- lation. Their knowledge may be helpful to better understand-
ered as a suicide method with two different types of motives. ing of the problems, especially family problems. Secondly, the
We believe that with regards to these types, prevention process of self-immolation was not explored, and the study
programs can also be divided into two types of general suicide can be considered as a preliminary stage of exploration of self-
prevention strategies, and specific suicide prevention strate- immolation process. Therefore, further research to overcome
gies with a focus on self-immolation. The first type or general the limitations, is recommended.
burns 40 (2014) 319–327 327

[12] Rezaie L, Khazaie H, Soleimani A, Schwebel DC. Is self-


Conflict of interest statement immolation a distinct method for suicide? A comparison of
Iranian patients attempting suicide by self-immolation and
by poisoning. Burns 2011;37(1):159–63.
The authors have no financial and personal relationships with
[13] Rezaie L, Khazaie H, Soleimani A, Schwebel DC. Self-
other people or organizations that could inappropriately immolation a predictable method of suicide: a comparison
influence (bias) their work. study of warning signs for suicide by self-immolation and
by self-poisoning. Burns 2011;37:1419–26.
[14] Ahmadi A, Mohammadi M, Schwebel DC, Hassanzadeh
Acknowledgment M, Yari M. Classic philosophy lessons and prevented
self inflicted burns: a call for action. Burns
2009;35(1):154–5.
The authors wish to express their gratitude to all who [15] Rezaie L, Schwebel DC. An ecological approach to explain
participated in this study. suicide by self-immolation among women in rural Iran.
Neurosciences (Riyadh) 2012;17(October (4)):309–13.
[16] Rezaie L, Schwebel DC. Research priorities for suicide by
references self-immolation: beyond quantitative approaches. Burns
)2012;(July) [Epub ahead of print].
[17] Strauss A, Corbin J. Basics of qualitative research:
[1] Rashid A, Gowar JP. A review of trends of self-inflicted techniques and procedures for developing grounded
burns. Burns 2004;30(6):573–6. theory, 2nd ed., Thousand Oaks, USA: Sage Publications;
[2] Thombs BD, Bresnick MG, Magyar-Russell G. Who attempts 1998.
suicide by burning? An analysis of age patterns of mortality [18] Streubert H, Carpenter D. Qualitative research in nursing:
by self-inflicted burning in the United States. Gen Hosp advancing the humanistic imperative, 4th ed.,
Psychiatry 2007;29(3):224–50. Philadelphia: Lippincott Williams & Wilkins; 2007.
[3] Laloë V. Patterns of deliberate self-burning in various parts [19] Sandelowski M. Focus on qualitative methods: Using
of the world: a review. Burns 2004;30(3):207–15. qualitative methods in intervention studies. Res Nurs
[4] Saadat M. Epidemiology and mortality of hospitalized burn Health 1996;19:359–64.
patients in Kohkiluye Va Boyerahmad province (Iran): 2002– [20] Guba EG. ERIC/ECTJ annual review paper: criteria for
2004. Burns 2005;31:306–9. assessing the trustworthiness of naturalistic inquiries.
[5] Peck MD, Kruger GE, van der Merwe AE, Godakumbura W, Educ Commun Technol 1981;29(2):75–91.
Oen IM, Swart D, et al. Burns and injuries from non- [21] Beck C. Qualitative research: the evaluation of its
electric-appliance fires in low- and middle-income credibility, fittingness, and auditability. West J Nurs Res
countries Part II: a strategy for intervention using the 1993;15(2):263–6.
Haddon matrix. Burns 2008;34(3):312–9. [22] Linoln Y. Emerging criteria for quality in qualitative and
[6] Fardiazar Z, Sadeghi-Bazargani H, Mohammadi R. Domestic interpretive research. Qual Inq 1995;1(3):275–89.
injuries and suicide among women of reproductive age in [23] Ahmadi A, Mohammadi R, Schwebel DC, Yeganeh N,
Iran. Int J Gen Med 2012;5:547–52. Epub 2012 June 20. Hassanzadeh M, Bazargan-Hejazi S. Psychiatric disorders
[7] Theodorou P, Phan VT, Weinand C, Maegele M, Maurer CA, (Axis I and Axis II) and self-immolation: a case–control
Perbix W, et al. Suicide by burning: epidemiological and study from Iran. J Forensic Sci 2010;55(2):447–50 [Epub 2010
clinical profiles. Ann Plast Surg 2011;66(April (4)):339–43. January 11].
[8] Poeschla B, Combs H, Livingstone S, Romm S, Klein MB. [24] Lester D. Suicide and culture. World Cult Psychiatry Res Rev
Self-immolation: socioeconomic, cultural and psychiatric 2008;3:51–68.
patterns. Burns 2011;37(6):1049–57. [25] Rudd D, Berman A, Joiner Th, Nock M, Silverman M,
[9] Ahmadi A, Mohammadi R, Stavrinos D, Almasi A, Schwebel Mandrusiak M, et al. Warning signs for suicide: theory,
DC. Self immolation in Iran. Burn Care Res 2008;29(3):451–60. research, and clinical applications. Suicide Life Threat
[10] Ahmadi A. Suicide by self-immolation: comprehensive Behav 2006;36(3):255–62.
overview, experiences and suggestions. J Burn Care Res [26] Ahmadi A, Ytterstad B. prevention of self-immolation by
2007;28(1):30. community based intervention. Burns 2007;33:1032–47.
[11] Wu KCC, Chen YY, Yip PSF. Suicide methods in Asia: [27] Soltani A, Moayyeri A, Raza M. Impediments to
implications in suicide prevention. Int J Environ Res Public implementing evidence-based mental health in developing
Health 2012;9(4):1135–58. countries. Evid Based Ment Health 2004;7:64–6.

View publication stats