Confessions : Suicidal ideation on a Ghanaian radio program

On July 17, 2013, listeners to a Ghanaian radio program were invited to telephone in and describe their personal experiences of suicidal ideation on air. Those who called the studio were asked four pointed questions by the program’s host: (1) Have you ever formed a suicidal intention? (2) What precipitated the formation of the suicidal ideation? (3) What suicide method did you plan to use? (4) Why did you refrain from carrying out the act? The program was digitally recorded, transcribed, translated into English and then subjected to a rigorous analysis of the main thematic issues. This article presents results from the analysis of the data that accrued from the program and discusses the implications of such data for suicide research and prevention in Ghana. Findings indicate that all the suicide ideators were female, young and affected by traumatic life events or family conflict. All four ideators experienced suicidal thoughts but had not attempted suicide. Overall, the results are consistent with extant findings in the suicidology literature. Given the paucity of information on fatal and nonfatal suicidal behavior in Ghana, the information contained herein potentially advances current knowledge and understandings of the nature and patterns of suicidal behavior in this geographic and cultural region of the world.


INTRODUCTION
Suicidal ideation is a term employed to describe thoughts about, or an obsession or fixation with suicide (Gliatto and Rai, 1999;Sokero, 2006).Sometimes referred to as "suicidal thinking" or "suicidal thoughts," the assortment of behaviors deemed suicidal ideation varies immensely, ranging from brief or momentary thoughts about suicide to comprehensive or meticulous planning, role playing, self-harm and unsuccessful attempts of suicide, which may be purposely designed to fail or be noticed, or may be fully intended to result in death.Although the majority of suicide ideators do not attempt to commit suicide, a large proportion of such persons do (Gliatto and Rai, 1999).Suicidal ideation is more common than attempted suicide and completed suicide (Gliatto and Rai, 1999;Sokero, 2006).Existing research indicates that suicidal ideation is generally associated with depression; however, suicide ideation is also connected with many other psychiatric disorders (Gliatto and Rai, 1999).Traumatic life events such as miscarriage and stillbirths, major medical health problems, abduction and sexual abuse also are known to increase the risk of suicidal ideation.Research also demonstrates that family conflicts such as divorce, separation and domestic violence contribute to suicide ideation.

Suicide in Ghana
According to Act 29, Section 57 of Ghana's Penal Code (1960), "whoever attempts to commit suicide shall be guilty of a misdemeanor."It should be stressed that this manifestly anti-suicide law is stringently enforced by the Ghanaian authorities.Thus, persons who make abortive attempts to kill themselves are immediately apprehended by police, summarily arraigned in criminal courts and swiftly prosecuted, after receiving any necessary medical treatment.If convicted, they are sentenced to custodial sentences, face hefty financial penalties, or are subjected to both sanctions.The stringent legal penalties for nonfatal suicidal behavior are reinforced by a strong cultural proscription of, and social stigma towards suicidal behavior.Among all ethnic groups in Ghana, suicidal behavior is denounced as a malefaction, a taboo and an abomination of the highest order (Greene, 2002;Nukunya, 2004).While ethnic group differences exist concerning the specific nature of mortuary beliefs and practices associated with suicidal deaths, there is universal condemnation of suicidal behavior in Ghana.Among all ethnic groups, self-inflicted death by suicide is regarded as a form of "bad death."Social reproach towards suicidal behavior is manifested in the brevity of the grieving period, discouragement of public mourning, the enactment of perfunctory burial rites, as well as the prohibition of funeral obsequies.In addition, following a suicide death, elaborate decontamination rituals are performed to purge the community of the taboo of suicide (Adinkrah, 2012).

Significance of Study
Suicide is a major and growing public health problem worldwide, claiming over one million lives annually across the globe.It is estimated that worldwide, some additional twenty to thirty million people make abortive attempts to terminate their lives each year (World Health Organization (WHO), 2012).Extant research and data indicate that Ghana is not exempted from suicide mortality and morbidity or the sequelae of nonfatal suicidal behavior (Adinkrah, 2010;Kokutse, 2012;Osafo et al., 2011).However, in Ghana, as in several African countries, the full scope and patterns of fatal and nonfatal suicidal behavior are significantly unknown (Adinkrah, 2010).The reasons for this are myriad.First, at present, many African countries do not collect, collate or disseminate their data regarding suicide mortality and morbidity (Windfuhr and Kapur, 2011).In Ghana, for example, no governmental agency is currently charged with responsibility for the collection and collation of statistics concerning fatal and nonfatal suicidal behavior.Second, suicide is both socially tabooed and legally proscribed behavior and discourse on the topic is shunned.Third, very few systematic studies currently exist on suicide and suicidal behavior in Ghana (Adinkrah, 2010).Thus, current understanding of suicide and suicidality in Ghana is still fragmented and limited.
Given the paucity of information on suicidal behavior in Ghana, suicidologists and other stakeholders exploit opportunities to garner information about suicidal behavior, motivated by the premise that additional knowledge about the nature and patterns of suicidal behavior will advance understanding of the issue and lead to the design and implementation of culturallyappropriate and effective prevention programs.The purpose of this article then was to contribute to the understanding of suicidal behavior and suicidality by systematically examining information on suicidal ideation obtained from a Ghanaian radio program.Recently a number of suicidologists (Colucci, 2013;Hjelmeland, 2013, Hjelmeland andKnizek, 2011;Lester, 2013;Windfuhr and Kapur, 2011) have forcefully argued for the incorporation of cultural analysis into the study and prevention of suicidal behavior.They urge suicidologists and suicide researchers to broaden the geographical scope of suicide research to include non-western, nonindustrialized societies, as well as encourage the exploration of cultural contexts and perspectives in their analyses.In a similar vein, recently, a number of suicidologists have advocated a change in methodological approaches for the study of suicide phenomena, arguing that increased use of qualitative research approaches in suicide research will advance current understandings of suicide and suicidality (Hjemeland and Knizek, 2011).
The current research, with its focus on a content analysis of cases of suicidal ideation expressed on a Ghanaian radio program, potentially improves current understanding of suicidal determinants and identification of suicide risk factors while simultaneously contributing to a cultural understanding of suicidal behavior.Specifically, it provides some answers to two major questions: what makes people form suicidal intentions in Ghana?Are these intentions and their triggers different from findings contained in the international suicidological literature?METHODOLOGY On July 17, 2013, Peace FM 104.3, a leading Ghanaian radio station, featured a half-hour program focusing on suicidal ideation.Established in May, 1999, Peace FM is a popular commercial radio station based in Ghana.It is currently the most listened to commercial radio station in Accra, Ghana's capital.The station has extensive coverage throughout the country, reaching about 90% of Ghana's entire population.In 2009, The World Geographical Media adjudged Peace FM station "one of the top 50 most talked about radio stations in the World" (Nyaba, 2009).Today, live broadcasts and recorded programs from Peace FM can be accessed through the internet.The Confessions program is broadcast every Wednesday.The featured topic for each program is different and is announced several hours in advance of the actual broadcast.During the particular program of Confessions which is the focus of this research, listeners were invited to call in to recount personal instances in their lives when they considered committing suicide.Callers were also asked to provide details about the events that triggered the formation of the suicidal thoughts and what method they intended to use to commit the act.Finally, they were asked to indicate what kept them from enacting the suicidal act.At the beginning of the show, potential callers were promised complete anonymity; telephone numbers, names and other identifiable information were not solicited.The program was broadcast in a combination of English and the local Akan language.This author, who is a native Akan speaker, recorded the entire radio program on a digital audio recorder, then transcribed it for this research.The transcribed data were then subjected to rigorous and systematic analysis.A summary of each case is provided for illustrative purposes and to illuminate the study.

RESULTS
The data revealed that all four suicide ideators who called in were female.Another important finding was that in all four cases, suicidal ideation was precipitated by a traumatic life event or family conflict.In one case, the caller felt distressed over the fact that she and her daughter had been physically neglected and psychologically abandoned by her husband, following the birth of her daughter.In another case, a woman felt melancholic after learning about her adoptee status, withheld from her since she was a child.In the two other cases, the women were intensely distressed by the life-altering injuries that they sustained from automobile accidents.
Two of the suicide ideators who revealed that they were parents indicated that they had thought about committing suicide but had been restrained from carrying out the act because of their children.One of the women had a newly-born infant at the time she formed the suicidal intention; the other had three older children.
Regarding suicide method, one suicide ideator had contemplated using a knife to kill herself while another thought about using poison.The other women provided no information on the method they considered using to commit suicide.The data show that two of the suicide ideators had not totally abandoned the idea of committing suicide and were in need of urgent medical and material assistance as well as counseling at the time that they Adinkrah 231 called in.The host of the program used elements of Christian religion, including scripture, prayers and sermonizing about God-the creator, as the maker and owner of life and the only one who should take life-to appeal to the suicide ideators to refrain from harboring suicidal thoughts and pursuing such intentions ever again.

Case histories
In this first case, the suicidal ideation occurred about a year prior to the call-in program.At that time, the subject had just given birth to an infant daughter and was residingwith her husband.She indicated that prior to the birth of her daughter, she was enjoying life with her husband.Things changed drastically following the birth of her baby.Her husband started neglecting her and her baby, leaving them alone in the house from morning, only returning home late in the evening hours.She said she did not have a job at the time and felt she and her daughter were being financially, materially and emotionally neglected by the husband.Frustrated and betrayed, she contemplated suicide.She recollected telling herself: "If I can't walk out of this marriage, then what is the point of me living."She told the host of the program that she had several recurrent thoughts of killing her daughter and then herself.She thought about finding and drinking a poisonous chemical to end her life.She did not reveal her suicidal ideation to her husband.Neither did she reveal her suicidal thoughts to her mother or friends.What prevented her from carrying out her suicidal thoughts?She thought more deeply about her mother and her daughter.She felt concerned that upon her death, her mother would miss her immensely.She also thought about her daughter who she realized was an innocent victim in her crisis.Each time she looked at her daughter, she would reconsider her decision.Regarding the morality of suicide, the caller indicated that at the time she was experiencing suicidal ideation, she did not consider suicide as an immoral mode of death.Neither was she afraid of the act of taking her life.The caller stated: "when you get into certain life situations, you don't even consider the wrongfulness of suicide as an act."She further intimated that when one encounters emotionally debilitating family events and one is not truly "God-fearing," it becomes easy for one to carry out suicidal intentions.She currently looks with regret upon a time that she ever thought about killing herself at all.She indicated that at the time of the call to the radio station, she had been separated from her husband and was now content with her life.The host thanked her for changing her mind about committing suicide and advised her to continue praying.She agreed with the host of the program that the life that we are given never really belongs to us.Concluding, the host also told her: "I hope that you keep praying for such thoughts not to recur.Find happiness in God and not happiness in man." In Case 2, a female caller telephoned to say that she once thought about killing herself.She sighed very heavily when her phone call was answered.This prompted the host to ask her if she was filled with pain.She responded that "nsɛmwɔhɔpaa" (There is a lot going on).She said there was so much going on in her life that she had almost lost her mind (abɔ me dam).She said talking was even difficult for her.She said she cried a lot because of her situation which she described as hopeless.She described herself as a mother of three children.She said she was physically deformed and that her level of disfigurement was extensive.She indicated that her face and "everything was ruined" (biribiaraasɛe) which made her feel less than human.She feels that when they count human beings, she is not counted as one (yɛkannipaayɛnkan me nka ho).The physical deformity arose from an automobile accident that occurred three years prior to her call into the program.She said that when she compared her prior physical looks with her current looks, she feels utterly depressed, distressed and melancholic.She indicated that if it were not for the children, she would have killed herself a long time ago.After hearing her story, the host played the song: "I will praise my maker while I have breath."The host asked her: "Do you think where you are, God can't do anything about it?"She was reminded that even though things are bad, she still has life within her.The call terminated abruptly.The host expressed disappointment, telling the caller who still sounded suicidal that "something is going to happen, keep listening." The 24-year-old woman in the third case telephoned in with a hoarse voice.This prompted the host of the program to ask the caller whether this was her normal voice or if she had been crying.She responded that she was very sad (me werɛahow) before recounting her story.She shared that prior to her formation of the suicidal ideation, she lived with an older woman whom she regarded as a mother.She emphasized that the woman had treated her very well, in the same manner that someone would treat his or her biological child.Indeed, she had no reason to doubt that this was her biological mother.Her suicidal ideation developed after she overheard this woman telling another person, that she was not her real child.The older woman revealed to the other person that the caller lost both of her parents in infancy and that the older woman took her into her care and raised her as her own child.The caller said she was shocked to hear the story of her adoptee status.She later confronted the woman about the authenticity of the story.After several attempts at evading the issue, the older woman confirmed the account that the caller had overheard.According to her when she first heard the story, "me yɛɛbasaa" (I felt despondent).She stated that if both of her parents were deceased, there was no point in continuing to live and if it were not for her belief in God, she would not be living.She was especially distressed by the fact that she did not know any of her biological family members.She revealed these suicidal thoughts to her Christian pastor who talked to her at length and dissuaded her from acting on her suicidal ideation.The host of the program told her: "You don't have parents, but you have God."The caller stated that "when I see somebody with his parents, I feel basaa (downhearted).The presenter replied."If you don't have parents on this earth, it is painful but you have God.You don't know what plan God has for you." The caller in Case 4 was a 23-year-old woman who began the interview with the statement, "Ewiaseyɛya, Ewiasennyɛdɛ.Sɛwonniobiara a, w'asɛmyɛmmɔbɔ (Life is painful; Life is not fun; If you don't have a helper, you are miserable).She however agreed with the host when he responded that "Nyametease" (God lives).According to the caller, she had migrated from her village into the city to make a living.She was knocked down by a moving motor vehicle and sustained injuries to her legs and her spine.While in the hospital, the driver responsible for causing the accident took care of her financially and materially but stopped offering assistance as soon as she was discharged from the hospital.She was also experiencing ongoing health problems including pains in her leg and waist caused by injuries sustained from the accident and was unable to walk properly.She has no money to go to the hospital for any additional treatment for her injuries and pain.Without employment, she also lacks the means to feed herself and meet other basic needs of sustenance.She laments the fact that at her young age, she is unmarried, has no children but is saddled with unbearable problems.She thought about using a knife to kill herself.The caller maintained that she still harbored suicidal intentions but that the knife she planned to use to commit suicide was not sharp enough.On numerous occasions, she has asked her mother to sharpen the knife without telling her the reason why she wanted it sharpened but her mother had never acted on her requests.She indicated that the physical pain she suffered was particularly unbearable at night, so much so that she had difficulty sleeping (me brɛanadwo; mentuminna).She described extensive swelling in one of her legs.She believes she will be able to find peaceful rest upon her death."Mɛku me ho namakɔ home; me ku me ho a,na ne nyinaa to atwa" (I'll kill myself in order to gain respite; when I kill myself, all my suffering will end).The host of the program concluded the interview with her with a request that she talk to him off air after the program.

DISCUSSION
The results of this research are generally consistent with findings from the suicide literature.Certain facts that emerged from the analysis merit further discussion.As noted, all suicide ideators who called in were female.This is worth noting given the fact that the vast majority of persons who commit both fatal and nonfatal suicidal acts in Ghana are male (Adinkrah, 2010).The cultural basis for this finding is also worth noting.In Ghana, males are less likely than females to discuss their problems with others.It is considered unmasculine to seek social support through sharing one's difficulties.A man is expected to face his problems stoically and alone.If he cannot find solutions, it is better to die than live a shameful life in perpetuity (Adinkrah, 2012).In general, Ghanaian masculinity ideals promote independence and discourage help-seeking behavior in men.Thus, men are less likely to seek help from their family, friends, neighbors or a talk show host.
Another important finding that emerged from the analysis of data is that in all four cases examined, the suicidal ideation was precipitated by a traumatic life event or family crisis.This finding is consistent with findings from the suicidology literature which indicates that suffering a major adverse family or life event is a significant contributing factor for suicide risk (Rihmer, 2011).In two of the cases, the callers experienced chronic or disabling medical disorders while in the two other cases, the callers had experienced unfortunate family events.It is notable that two of the suicide ideators contemplated suicide but were restrained from committing the act because of their children.One of the women had a newborn baby; the other had three children.Both said they were restrained from killing themselves because of their children.This coincides with extant findings from the suicide literature which indicates that having children is a protective factor against suicide (Windfuhr and Kapur, 2011).
Regarding the preferred methods of suicide in these cases of suicide ideation, one woman thought about using a knife to kill herself while another thought about using poison.This is consistent with gender-based findings in epidemiological studies of suicidal behavior in Ghana and globally.In Ghana, and globally, males are more likely to use the more immediately-lethal methods such as self-inflicted gun shots and hanging while females are apt to use less violent methods like ingestion of poison, drug overdose and cutting (Windfuhr and Kapur, 2011).It is remarkable that four persons called within the program's thirty minute time-frame to share their suicidal intentions with the program host.As previously noted, in Ghana, suicide is highly stigmatized behavior, with serious implications for the suicide ideator, the suicide attempter, and survivors bereaved by suicide.Thus, disclosing suicidal thoughts to a stranger requires fortitude.Although callers were promised anonymity and confidentiality, it is certainly possible that listeners who were suicide ideators but did not call in were not convinced by the claims of confidentiality promised.They may have feared the possibility of being exposed and were therefore inhibited about calling in to share their suicidal ideation.

RECOMMENDATIONS AND LIMITATIONS
The findings of this study have implications for suicide prevention strategies in Ghana.Persons or individuals who suffer negative family events such as familial abandonment or neglect, need counseling while persons who suffer traumatic life events such as automobile accidents need medical and material assistance such as medical care and supplemental material care (money, food, clothing etc.).The study is not without its limitations.One limitation is the small number of cases examined.Second, the research focused exclusively on suicidal ideation expressed by callers to a radio program.Thus, it is limited in its capacity to tell us about suicide ideation in Ghana more generally.Thus, the conclusions presented here are tentative.Additional research is recommended to explore some of the issues examined in this study in greater depth.Despite these shortcomings, the study has something to offer to the study of suicide and suicidality in Ghana.In conclusion, the analysis of information from myriad sources, including the print and electronic media, has the potential to contribute to existing knowledge on suicidal behavior in Ghana.This is necessary, given the current paucity of information on the phenomenon.