Print version ISSN 1413-8123
Ciênc. saúde coletiva vol.17 n.8 Rio de Janeiro Aug. 2012
Watching, listening and sharing: field work for psychosocial autopsies
Observar, ouvir, compartilhar: trabalho de campo para autópsias psicossociais
Maria Cecília de Souza MinayoI; Sonia GrubitsII; Fátima Gonçalves CavalcanteIII
I Centro Latino Americano de Estudos de Violência e Saúde Jorge Carelli, Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz. Avenida Brasil
4036/700, Manguinhos. 21040-361 Rio de Janeiro RJ. firstname.lastname@example.org
II Programa de Mestrado Pós Graduação em Psicologia, Universidade Católica Dom Bosco
III Laboratório de Práticas Sociais Integradas, Mestrado Profissional em Psicanálise, Saúde e Sociedade, Universidade Veiga de Almeida.
The article describes the research realization phases of field work in ten municipalities in five regions entitled "Is it possible to prevent the anticipation of the end? Suicide among the elderly in Brazil and the possibilities for action by the Health Sector." The sample comprises 51 psychosocial autopsies of 5 elderly people who committed suicide in 9 locations and 6 in another. 84 family members were interviewed. Semi-structured psychosocial autopsies and contextual observations were used. Each interview lasted 60 minutes on average and in the majority of the cases there was more than one encounter with family members. The study consisted of a collective process that involved bibliographic review, discussion of the samples, approach strategies, field results and empirical analysis. This article highlights the theoretical, conceptual and practical preparation of researchers and production and standardization of instruments; information about existing data sources and those that are actually used; introduction of institutional credentials; assessment of the family context, difficulties and strategies for empirical study; entrance to and exit from the field; and the impact of the research on the investigators.
Key words: Psychological autopsy, Psychosocial autopsy, Suicide, The elderly.
O artigo descreve as etapas de realização do trabalho de campo da pesquisa. É possível prevenir a antecipação do fim? Suicídio de Idosos no Brasil e possibilidades de Atuação do Setor de Saúde, realizada em 10 municípios das cinco regiões do país. A amostra composta por 51 autópsias psicossociais abrangeu cinco idosos que faleceram por suicídio em nove municípios e seis em um deles. Oitenta e quatro familiares foram entrevistados. Trabalhou-se com um roteiro denominado autópsia psicossocial e com observação do contexto. Cada entrevista durou 60 minutos em média, e na maioria dos casos, houve mais de um encontro com os familiares. O estudo foi construído por meio de um processo coletivo que abrangeu compartilhamento da revisão bibliográfica, discussão do universo, das amostras, das estratégias de abordagem, dos resultados de campo e das análises empíricas. Este artigo destaca a preparação teórica, conceitual e prática dos pesquisadores; o processo de elaboração dos instrumentos para o trabalho de campo; informações sobre as fontes de dados existentes e sobre as efetivamente acessadas; apresentação de credencial institucional; entrada no contexto das famílias, dificuldades e estratégias para realização do estudo empírico; entrada e saída do campo; e impacto da pesquisa sobre os investigadores.
Palavras-chave: Autópsia psicológica, Autópsia psicossocial, Suicídio, Idosos.
This text deals with fieldwork in suicide research. Its goal is to reflect upon the difficulties and possibilities that this type of in situ presence can add for a better understanding of the phenomenon. In the case at hand, the fieldwork discussed here concerns the suicide of elderly people, based on the study: "Is it possible to prevent the anticipation of the end? Suicide Amongst the Elderly in Brazil and Possibilities of Action by the Health Sector"1.
In qualitative research the term field, used in the context of psychosocial autopsy, is understood as the spatial cutoff that encompasses, in empirical terms, the theoretical perspective of the object of the investigation. Qualitative research deals with people and groups, seeing them as social actors in a relationship, whether in a face-to-face encounter or through the exposing of one's ideas and actions, in the case of document analysis. In the field, the objects of study are part of a relation of inter-subjectivity between researcher and researched, which results in a comprehensive product that is not concrete reality, but rather a discovery constructed with all that is available to the investigator: his or her hypotheses and theoretical premises, conceptual and methodological framework, interactions, observations and inter-relations with the interviewees and workmates, and previous experiences2.
Fieldwork allows the approximation between the researcher and the reality in which one asked questions, seeking to test and deepen one's hypothetical knowledge. Thus, every researcher that goes to the field, in addition to being a curious person, an observer and an inquirer, also needs to exercise what Gadamer3 calls hermeneutic capability or the art of placing oneself in the place of the other, promoting the understanding prior to any interpretation3,4. These skills should be practiced with no interruption, as the research will be as more fruitful as the scholar is able to confront ones theories and hypotheses with empirical reality, in a open, intense and flexible way.
Though there are many ways and techniques to do field work, there were two main instruments used in this research: participating observation and interview. While the former dealt with what goes unsaid but can be seen and perceived, the latter was based on the speech the interviewees.
Apart from several meanings, the activity of observing has a practical sense: it allows the researcher to stand freer from pre-judgment, as that does not necessarily make one a prisoner of an instrument that collects data or of previously-tested hypotheses. As one lives with the group, the observer can remove from the script of the interview questions one deems irrelevant from the point-of-view of the interlocutors and also understand aspects that rise little by little. Participating observation helps to link the facts to their representations and to uncover the contradictions between norms, rules and practices in the daily routine of the group or of the institution observed2.
The interview should be conceived as an interactional work (that is, of researcher-researched relation), as privileged instrument to collect data, where the words of an interviewee reveal the living conditions and the expression of value and belief systems. At the same time, the interview works its magic to transmit, via a spokesperson, what the group thinks in the same conditions and situations2. As a result of that, in qualitative research, all efforts should be undertaken to make sure that "the body and the blood from real life form the framework of abstract constructions" as Malinowski says, using this biological metaphor5.
Fieldwork is, therefore, the gate to the new, although the latter does not present itself clearly. It is the questions that produce the reality, from the theory and concepts transformed into topics of research that allow the construction of a perspective of observation and understanding. For all that, apart from being a very important stage in the research, the immersion in empirical reality is the dialectic counterpoint to social theory.
Field work can be broken down into several aspects that will be dealt with here, already tackling the object at issue: the preparation of the activity and of the instruments; access to secondary data sources; presentation of institutional credentials; access to the families according to the locations; approximation with the families, interviews and observation of the context of the suicide; and finally, entering and exiting the field and its unfolding events.
The relevance of presenting the expertise and experiences that occur in the empirical investigation on suicide amongst the elderly would be due, especially, to the difficulties found in getting reliable information as well as in approaching the relatives, generally, painfully marked by what they see as a tragedy in their social system6. In all the work reports, the researchers1 pointed to some difficulties, such as: location of the houses, mapped by several means accessed; episodes of denial or of doubts of the relatives regarding the veracity of the suicidal act; refusals to comment on the fact or failure to show at the scheduled interviews. These factors highlight how complicated the theme is and how difficult it is to treat it.
The empirical research took place in 10 cities of the five regions of the country, where the rates of suicide amongst the elderly are above the national average: in the North it was done in Manaus; in the Northeast, in Fortaleza, Teresina, and Tauá; in the Mid-West, in Campo Grande, and Dourados; in the Southeast, in Campos dos Goytacazes; and in the South, the research took place in São Lourenço, Candelária and Venâncio Aires. In the North, only Manaus was chosen, as there are no other places above the national average. And in the Southeast, the empirical study was done only in Campos, as a large work of research on psycho-social autopsy had just been completed by people of this same group in Rio de Janeiro7,8. Emphasis was placed on the research in the south of the country where the phenomenon is more relevant and in the Northeast, in places where the rates are also very high.
The study was done by five duos consisting of 10 senior researchers but doing the entire work also involved 32 students from the doctorate, Masters and scientific initiation. Five cases were researched in each location and 84 relatives were interviewed, 62 women and 22 men and, when possible, we sought to interview more than a person per case. The interviews were made with relatives of elderly people who had died after suicide at least two years before fieldwork and, retrospectively, up to four years before, as the studies on the subject recommend. Context observation was also part of the study. This article attempts to summarize this empirical experience.
Stages of empirical execution in psychosocial autopsy
Preparation for field work and of the instruments for interview and observation - The first criterion in preparing the sample for the qualitative study was the incidence of the phenomenon, as per regions and cities, found after an epidemiological survey; the second, saving the relevance of the phenomenon at the location, entailed the aspects of convenience such as distance to the location and the possibility of getting logistic or institutional support. As it is a type of investigation that demands sizeable investment in the field and in the analysis of the results, the researchers made a joint decision to work with five interviews in each one of the chosen locations, although they were free to individually do a more extensive study. Why five and not six, or ten? This was an agreed number as, in any case, the type of research would not produce that which is called, in qualitative approaches, information saturation, given the complexity of the motives given by the relatives of those who committed suicide2.
In order for the stories, both personal and those of relatives, to be understood in the context of the personal, social, and cultural life of elderly people who died after committing suicide, a brief description was made of the cities selected, based on a survey of the following data: (1) main urban or rural characteristics; (2) availability of social, economic and cultural organization; (3) existence or lack thereof of public and social services such as meeting places for elderly people, or programs for the prevention of suicide; (4) dynamics of the daily routine for the population, that is, if at the location social life is intense or otherwise; if there are social resources, such as leisure clubs, religious associations, handcraft activities, tourist activities; (5) means of work and of entertainment, and finally, (6) a characterization of life for the elderly population.
The instrument adopted for interview and observation, named "psychological autopsy" by Shneidman9, and others such as Conwell et al.10,11, Hawton et al.12, Beeston13, Werlang e Botega14, was adapted for this study by Minayo et al.15, who started to use the term "psycho-social autopsy", understanding that this expression better integrates the anthropological and social aspects in the analysis of the emotional states of an individual.
This instrument, which can be considered a script for a semi-structured interview14 - and will be detailed in a specific article allowed for the psycho-social characterization of the elderly that died after committing suicide and of their relatives based on data about their story and way of life; on the evaluation of their background and of the environment at the time of death; on the impact suffered by the family; the lethality of the method; the intention, already manifested by the elderly person to commit suicide; the state of mind of the person prior to the fatal act; the image and the reactions of the family (type of communication, relations between the people, rules and expression of affection) and of the community; and the existence or lack of sources of support amongst the relatives, neighbors, social and health services, or those provided by an NGO that would deal with this issue.
The discussion for doing the research was a reflection process in which all the researchers took part, via the socialization of a bibliographical database with classical studies that inaugurated the field and articles, updated to 2010. After that, a workshop was held to socialize the understanding of the phenomenon and to streamline the instruments. All this preparation material was compiled in a manual that standardized procedures and recommendations. Fieldwork took approximately four months. One month after its completion, and with all the material pre-analyzed as per location, a second workshop was held for critical reflection and discussion of the results from the interviews and observations and geared to optimizing the data collection instruments.
Secondary data sources accessed in the field This stage consisted of the use of strategies to locate and access the data and the suicide cases. Some official institutions that hold records for the occurrence of the self-inflicted death were identified and contacted. Access to information, however, was not always provided.
There were five main institutions to which requests for information were sent:
The Instituto Médico Legal (IML) [Legal Medicine Institute], which has criminal experts and produces the reports that describe the cause of death and the evidence that corroborate the diagnosis of suicide.
The Military Police, which issues a Police Occurrence Report (BO), which records the circumstances of the death and the verdict on the suicide.
The City Notary Registrar Office where is it possible to check the cases, examining the Death Certificates (DOs), although they do not always have a verdict for suicide in their final report.
The Mortality Information System (SIM) which has as source the Death Certificates from the data provided by the City Health Department which, in its turn, in suicide cases, are based on the reports from the Instituto Médico Legal.
The City Health Department when giving access to records from hospitals and emergency units and to the professionals who work in the Family Health Strategy. Generally, the latter ones know the families and have the advantage of being in touch with the place population.
Charts 1 and 2 show where the teams sought information and support to select the families for interview. The first one lists those that were contacted and the second one lists those that responded to the request and collaborated.
The difficulties to obtain information on the subject are part of the context, of the myths and beliefs that surround self-inflicted death. As a result of that, the articulation with institutional information agents took place by taking into account their availability and open-mindedness to the research, their speed to provide the data and even their support to the execution of fieldwork, in some cases.
The first contacts already pointed at the importance of choosing the institutions that would embrace the project and offer the data more quickly and in a clearer way, after receiving the clarifications due on the proposal and on the support of the Ethics Committee of Fundação Oswaldo Cruz. In some situations it was necessary to make some sort of agreement to start the work. According to the field logs from different teams, we found support in the institutions that form Chart 2.
The reception by some entities and their professionals was fundamental for the success of the research, as one of the basic principles of field work is that the investigator obtains the support of the people his possible interviews will rely on, to facilitate interlocution. However, researcher often had to seek the families and interact with them, based only on the secondary data they had, relying on their experience and ability to approach. This took place especially at the locations where the issue of suicide amongst the elderly is not considered socially relevant, as is the case in large cities.
The presentation of institutional credentials and interview scheduling - as done in research made by several teams, simultaneously and in many places in the country - and in the case of this study on suicide, was fundamental care was taken to create a standardized credential for the researchers, directed at the mediating institutions and the families.
The coordinators wrote a letter on official Fundação Oswaldo Cruz letterhead paper, describing all the main aspects of the study and attached a release to be signed by the interlocutor. This term of consent became a requirement since Ordinance 96/1996 of the Brazilian Department of Health that regulates research in Brazil with human subjects. The credential in the hands of each researcher is yet another instrument in the precautions required in all the steps of the study.
Each group in their location used different means to schedule the interviews. Many, based on the secondary data, visited their relatives, personally dealing with a possible meeting; others sent letters and waited for the replies that in some cases came but did not in others; others used the phone and made it several times. In most of the cases, the many procedures were used simultaneously, aiming at guaranteeing the meetings. There were several manners of reaction: immediate acceptance, reluctance to schedule a date, which frequently led to a refusal, or immediate refusals. The researchers have a list of families up to 10 times larger than that necessary to meet the number planned in the research.
One of the difficulties found in the field was the demand for the signature of the release, free and knowingly, by the participants. Many relatives were afraid of exposing themselves and refused to sign, and therefore could not be included in the survey. Some feared their words might have legal implications or be publicized. This took place even with the assurance of anonymity and confidentiality, set in document and verbally. Researchers had to frequently assure the relatives that it was neither an interview nor Police or media business. As in all survey processes, reactions at this point were also not unanimous. Some interlocutors said they would even consent with the publication of their real names in the interviews, if necessary.
We found a diversity of behaviors between the interviewees that corresponded somewhat as to how the family group has been reacting to the problems that took place, from the post-death moment of the elderly people. For example, in some cases of refusal, it was seen that the relatives had suffered a great deal of prejudice in the community environment or they had themselves retreated, after the death of the elderly person. The researchers also mentioned cases of families that accepted taking part in the research but in a first contact were also fearful of opening themselves because of the prejudice they had been suffering since the death of the relative. They only felt at ease when perceived the welcoming attitude and the solidarity of the researchers. The way to face the fatal event, therefore, is usually influenced by social, moral, and even financial repercussions, for many years to come.
Access to the families, as per locations - each field log described specific details, as per researcher, interlocutors and culture of the place. In nine out of the ten locations the testimonies of the relatives were recorded. Only in Campos dos Goytacazes the researchers decided not to use a recorder in the interviews, after two families refused this type of record of their accounts, although they did not object to note-taking. The recordings were replaced by notes in the conversation and by immediate supplementing of the entire story heard in comparison with the writings of the duo of researchers.
In the cities of Candelária, São Lourenço and Venâncio Aires in the Southern Region, one of the biggest problems was the access to the homes. Most of the families of the elderly people who died after committing suicide live in the rural area, in small and mid-sized belonging to German origin settlers. Many contacts with the relatives and with the communities were facilitated by professionals of the Psycho-Social Care Centre for Alcohol and Drugs (CAPSad) and the Program for the Protection Against Violence (PPV).
The team in Mato Grosso do Sul experienced two different realities, which influenced the actions of the researchers and the access to the interviewees. Campo Grande, capital of the State, is a typical business and service economy city, with a high quality of life index and is 90% developed. There were no difficulties to move and access the homes, also favoring a return to deepen and clarify some data. It was frequent that friends and relatives of the elderly person deceased would refer other people to be interviewed.
In Dourados, second largest city in Mato Grosso do Sul for its economic potential and population, the development index does not match its population growth, the infrastructure and life conditions are precarious, especially in boroughs that are distant from the city center. An Indian reservation and a landless people settlement are part of the urban fringe. In the place where the landless settlement is, the suicide rate is high, according to the health agent who helped the survey group. Two cases were found there, of elderly people who died after committing suicide. The health professionals cooperated with the access and the referral of families.
Researchers in Fortaleza thought the interviews took place in an atmosphere of peace and with the support of the relatives of the elderly people. However, they met with several refusals or barriers in the first contacts, such as, for example, allegations of lack of time by the person invite to give a testimony, fear of compromising or same cases where the relatives still felt very fragile to talk about their loss. The researchers found that some had completely gone into isolation. The presence and support of the groups of family health professionals were fundamental and we should point the participation of community agents and, in some cases, of neighbors.
In Tauá, the location of the cases and homes was very fast, with the support of the CAPS team. The city is small, as in the case of the cities researched in the Southern Region. The health professionals contributed a great deal for the access to the families and the fieldwork progressed with ease, allowing a later reflection on the phenomenon, with these professionals, giving them feedback on the people that would need to be monitored.
In Teresina, contacts were initially made through the Post. The reception of the relatives was rated as good, but approaching them was very difficult. Generally, the researchers started a meeting with a free conversation about the family and the elderly person. In the sequence, the interview about the person who had died after committing suicide occurred in an atmosphere of safety and trust, but with moments of emotion, tears and sadness, lamenting and even mutual blaming between the relatives.
In their field logs, researchers in Fortaleza, Tauá and Teresina pointed that their behavior was calm, trying to harmonize the people, respecting their religious beliefs, their insecurities, without judging the facts and contexts observed.
In Manaus, there was satisfactory reception to the proposal after clarifications made in the initial contact with the participants. Only one of the five families interviewed displayed caution and distrust at first to, later overcome that.
In Campos dos Goytacazes we gave preference to the cases that had full data, that is, expert's report, occurrence record and record book annotations. There were several kinds of difficulties to access the cases away from the city center, with scheduling that would later fail, but in the five interviews made, the researchers considered that there was an atmosphere of trust and mutual understanding.
Approaching the families and the context of suicide - In nine out of the ten cities, the interviews took place in the homes, which facilitated the observation of this micro-universe. In one of the places, due to the difficulties for physical access to the houses, the interviews were made either at home of some relative or in their places of work. Institutional support, which had been important in choosing the cases, played a fundamental role in the communication with the families, especially in making the first psychosocial autopsy.
Since the meetings held at the start of the survey, researchers knew the hurdles they would have to overcome in field work2,8-14. All of those who study the phenomenon of suicide highlight the difficulty both of institutions as of the people to discuss the subject due to the high social and emotional contents and of the civil disablements, beliefs, fears and emotions that surround it. This is a difficult theme to be discussed by the relatives, but also by friends and neighbors who, even knowing the facts, many times refused to take part in the survey, claiming that the occurrence was a family problem for no one to intrude upon.
Upon arrival, the researchers would rapidly discuss the sense and goal of the study, using common sense language and showing the interlocutors how their testimony would help, directly and indirectly, for the research as a whole, for the community and for the very family. Some named this conversation "warm-up", that is, it was an introduction aimed at perceiving whether the possible interviewees had emotional availability for the conversation and to create the most understanding and respectful an atmosphere as possible.
As it is known, theoretically and in practice, from the first moments of contact, the interviewees start to build an identity to the researcher and, as a result of that, all the guidance was for them to present themselves in an accessible manner and transmit trust. The mention to the institution responsible for the research, in this case, Fundação Oswaldo Cruz, allied to the University supporting each researcher in each location, was very important to give the families security.
As the goals of the work became clearer for the relatives who accepted to give the interview, the conversations would generally flow. Given the sensitivity of the situations, even when the researchers managed to breach the barriers, the caution and careful way to approach continued. The fact that the researchers were highly skilled in field research favored the articulation and the approach. Many managed the privilege of interviewing the relatives who were with the elderly people in their last moments.
During the interviews, many relatives showed the house, photographs and belongings of the elderly person and the place where the suicidal act occurred. For example, in the Southern Region, where most of the deaths took place by hanging and in sheds that store food and tools, many relatives made a point of taking the researchers there. There was a case where a son showed the tree branch he had cut, indignant with the act of his father, who had tied the rope he used to kill himself on that trunk.
As it happens in any field work, all remarked that there were relatives who told the stories with so much detail that it rendered the script almost useless, whereas other were economical with their words, with communication being very difficult. Care was taken to seek several points-of-view on the same fact, as recommended in the literature6,8-15 as its tragic dimension can stir manifestations of feelings and multiple experiences (pain, anger, sadness, introspection, depression, for example) and diverging interpretations.
Even when listening to several testimonies on the same case, however, authors such as Hawton et al.12 point that there is a limit for the credibility of the accounts, as the relatives tend to conceal the aspects they would not like to come out to the light. A this point, it is important to point that, in any study of a qualitative nature, the investigators know they will never find the truth, as the testimonies are always a reflection on past events and from a certain point-of-view2. If this is what happens in any theme of research, and especially in approaching such a controversial subject, always taboo, as the suicide. As a result of that, the analysis of the interviews made at the time of, and after, the fieldwork took into account not the idea of true discourse but the version of the interviewees in inter-subjectivity with the investigators.
Despite the fact that the project planned one single interview, in most of the cases more than one took place as the researchers thought that going back to those homes would not only be a way to deepen the understanding of the fact but also to show compassion and collaborate in relieving the suffering of the relatives. After each interview, the duo of researchers would make a comprehensive and critical analysis of the case, of the procedures adopted, of the points that should have been dealt with and that were not and of which would deserve more emphasis. In the same manner, they produced annotations on the aspects observed regarding the context.
As already said, the feelings that accompanied the making of the psychosocial autopsy are unpredictable. For example, in Fortaleza, there was the case of the brother of an elderly person who volunteered to tell the story and the circumstances, but the family decided to interrupt the interview as another sister, who took part in the meeting was moved and distraught. In Manaus, on the other hand, the daughter of a man who had died after committing suicide remarked on her grateful surprise of power, as she, for the first time, was able to talk about the death of the father. And at the end, she remarked she was feeling well after this unexpected meeting. Similar and varied situations tool place during all the empirical study.
Two crucial moments: entering and exiting the field All field researchers were mature people, experienced in the areas of Psychology, Anthropology, Nursing, Social Service, and Public Health. Even then, suicide as a theme of study and listening to real stories generally caused them great impact and emotion. In the preparation for the investigation doubts and fears were raised regarding the personal conditions of exposing themselves to such a strong emotionally laden theme. However, and generally, the very reception of the relatives of those elderly people favored the contacts. Many of them were eager to be heard and tell of their drama, to someone who would not recriminate them but offer them understanding. The emotional involvement, the interest and motivation of the research team favored the execution of the tasks and meeting of the deadlines. As the work was concluded, all the investigators pointed that the experience of visiting and listening to the families - even with all the difficulties faced in doing so - was important as a personal challenge, for mobilizing affections and experiences, as it was for professional maturing. However, the field logs record a general feeling of how difficult and exhaustive it was to deal with the theme.
In exiting the field, the strategies of the group or individuals varied according to the experiences they took part in and of the expectations the families placed on them. Eventually, some people, apart from receiving informal support of the researchers during the time spent in the homes, were promptly forwarded to institutions that offer psychological counseling, because of the degree of disturbance displayed by them, associated to the consequences of suicide or to the narrative of the fact occurred. Thus, the more common in the farewell was the offering of guidance, to see the relatives deal with the situations of suffering and their referral to Psycho-Social Support Centers (CAPS) or to Family Health Strategy (ESF) units, for the cases that warranted care, on one hand. And, on the other hand, the articulation with local services, seeking to involve them in the situations of the relatives that displayed problems or health disorders associated to the death of an elderly person. In several cases, there were other elderly people such as widowers, widows or brothers of the deceased, who needed support.
In this sense, the commitment of the researchers with their interviewees was going on as from the moment of the fieldwork and has been extending after its completion. For example, those working in the Northeast region said that, after the formal interviews, they talked to the relatives, guiding them on the possibilities of support provided by specialist professionals, by the health services, social or religious groups, always seeking to adjust to the values and customs of the families and their social reality. In Manaus, the researchers gave priority to the monitoring of the families. In a more immediate way, they are encouraging those who need support to seek the Clinic at the School of Psychology at the Federal University of the State of Amazonas, where specialized services exist. Similarly, in the other locations, several ways for the return of the return of the research have already been started even before the end of the academic activities.
We should mention the effort of the researchers in the Southern region to immediately return the findings of the survey and to discuss proposals for prevention with professionals from the three cities studied. Using the technique of conversation circle with the professionals of the CAPS or of the Family Health Strategy, they show the situation they found the families in and discuss they work that was done, the perception of the researchers and the perspectives for action, based on some successful local experiences. This way, they have established a connection for continuity with the local health institutions.
All the field researchers reported in their logs how many families, especially those who live in the countryside and in small cities, are not provided by public funding to help them care for their elderly people in a situation of suicide risk and also to support in the period following the suicide, when some members enter a depressive state. In some cases, the researchers were afraid of not realizing the emotional load and vulnerability of the people interviewed.
Many families seek strength in religion as a support to live on. Contrary to what is more conventional - as the Catholic religion excludes from its middle those who die after committing suicide - there are some accounts of priests who are friends of the families who provided their solidarity when they lost an elderly person and continue to give vital help to the relatives after the suicide.
The investigators reported, especially, their concern with the meager or inexistent proposals of the Health Sector that generally ignores the factors that surround the suicidal act, in god part preventable, as say the WHO16 and the Brazilian Department of Health17 or present bureaucratic and standardized solutions that do not meet the actual situations, or are tied to the `medicalization' of the fact and to the association between depression and suicide. A researcher noted that, in a particular location, the health professionals advised the relatives not to give attention to the complaints of the elderly, making some situations banal, situations that already pointed to the suicidal intent, a procedure that is totally mistaken. 8-14
This article sought to describe, on a step-by-step basis, the stages of execution in fieldwork for the survey "Is it possible to prevent the anticipation of the end? Suicide Amongst the Elderly in Brazil and Possibilities for Action by the Sector"1, This empirical undertaking attained its goals, allowed the construction of a situation that favors the carrying out of the psycho-social autopsy and facilitated the understanding and analysis of the context where the facts took place. The purpose of detailing the strategies for the field aimed at other investigators, so that they can learn both the difficulties as the means that allow to empirically attain the goals of the study.
This work was a first step towards deepening the meanings of the Death by Suicide Amongst the Elderly in Brazil. The methods, techniques, questions and the hypotheses are always open to criticism and no field of work has the final say on empirical reality, much richer than any incursion one might take into it. As a result of that, even if standardized instruments were used, the researchers at each location had to adapt them to their needs and pointed gaps in their work.
The empirical work also tested the emotional and social capability of the researchers, when dealing with a subject as painful as self-inflicted death is, of an elderly person, and of its consequences for the relatives. Each step taken to manage listening to the stories about a person who died after committing suicide and of its core of primary relations, corresponded to a large quantity of previous investments. And for each successful contact, several failed. As it was hard work and at the same time done with the support of a group of research colleagues that we in communication with one another and in a virtual network during all the process, each story heard and the participation in the investigation in itself made for an experience that will mark everyone's life.
It is relevant to say that all fieldwork demands a unique, comprehensive investment. But this effort is much greater when it is about a theme so loaded with social-cultural and emotional significance as suicide amongst the elderly. A study as this demands experience, maturity and resources, to allow decision-making here and now, and cannot be done by inexperienced people or those without some psychosocial background qualification, as the narrative of the cases can emotionally destabilize not only the relatives but also the researchers.
In spite of the limitations, the researchers thought they succeeded in the execution of the fieldwork, which was facilitated by a type of research organization that required collective involvement in all the stages. There was a preparation of the people who included themselves in the work. However, there is awareness in the group that this study is only a first step and that more investment is needed to follow on this path.
Finally, we should point that, with rare exceptions, the health professionals at the locations studied saw a sizeable lack of knowledge both of the magnitude of the phenomenon of suicide amongst the elderly as of the orientations that the WHO and the Brazilian Department of Health offer to counter self-inflicted deaths. Therefore, it is necessary to go beyond the written text and invest in the qualification of agents capable of understanding and acting with greater efficiency in the support of the people in subjected to the risk of suicide and of the relatives who suffer the loss of their loved ones, given the consequences these losses produce.
S Grubits, MCS Minayo, and FG Cavalcante contributed equally for the production of the article.
1. Minayo MCS, Cavalcante FG. É possível prevenir a antecipação do fim? Suicídio de Idosos no Brasil e possibilidades de Atuação do Setor Saúde. [ Links ] [Projeto de Pesquisa]. Rio de Janeiro: Claves/Fiocruz; 2010.
2. Minayo MCS. O desafio do conhecimento. 12ª ed. São Paulo: Editora Hucitec; 2010. [ Links ]
3. Gadamer HG. Verdade e método. 3ª ed. Petrópolis: Editora Vozes; 1999. [ Links ]
4. Heidegger M. Ser e tempo. Petrópolis: Editora Vozes; 1988. [ Links ]
5. Malinowski B. Os Argonautas do Pacífico Ocidental. São Paulo: Abril Cultural; 1978. (Coleção Os Pensadores). [ Links ]
6. Cassorla R. Do suicídio: estudos brasileiros. Campinas: Editora Papirus; 1991. [ Links ]
7. Minayo MCS, Pinto LW, Assis SG, Cavalcante FG, Mangas RM. Trends in suicide mortality among Brazilian adults and elderly, 1980-2006. Rev Saude Publica 2012; 46(2):300-309. [ Links ]
8. Minayo MCS, Cavalcante FG, Mangas, RM, Souza JRA. Motivos associados ao suicídio de pessoas idosas em autópsias psicológicas. Trivium 2011; 3(1):109-117. [ Links ]
9. Shneidman ES. Comprehending suicide: landmarks in 20th century suicidology. Washington DC: American Psychological Association; 2001. [ Links ]
10. Conwell Y, Van Orden K, Caine E. Suicide in older adults. Psichiatr Clin N Am 2011; 34(2):451-468. [ Links ]
11. Conwell Y, Olsen K, Caine ED, Flannery C. Suicide in late life: psychological autopsy findings. Int Psychogeriatr 1991; 3(1):59-66. [ Links ]
12. Hawton K, Appleby L, Platt S, Foster T, Cooper J, Malmberg A, Simkin S. The psychological autopsy approach to studying suicide: a review of methodological issues. Journal of Affective Disorders 1998; 50(2-3):269-276. [ Links ]
13. Beeston D. Older people and suicide. Centre for Ageing and Mental Health. Stanfordshire: Stanfordshire University; 2006. [ Links ]
14. Werlang BSG, Botega NJ. A semi-structured interview for psychological autopsy in suicide cases. Rev Bras de Psiquiatria 2003; 25(4):212-219. [ Links ]
15. Minayo MCS, Cavalcante FG, Souza ER. Methodological proposal for studying suicide as a complex phenomenon. Cad Saude Publica 2006; 22(8):1587-1596. [ Links ]
16. World Health Organization (WHO). Multisite intervention study on suicidal behaviours - SUPRE-MISS: Protocol of SUPRE-MISS. Genève: WHO; 2002. [ Links ]
17. Brasil. Ministério da Saúde (MS). Prevenção do Suicídio: manual dirigido a profissionais das equipes de saúde mental. Brasília: MS, OPAS, Unicamp; 2006. [ Links ]