A Multifactorial Interpretation of a Teenager's Suicide: Based on Krystal's Death in Casual Vacancy.

OBJECTIVES: It is hard to accumulate research data on adolescents' suicide, because friends and family of the suicide completers might be reluctant to share the experience. To overcome the lack of information on adolescent suicide victims, the authors examined the risk and protective factors for adolescents' suicide from a character in a novel.
METHODS: Krystal, an adolescent female in the novel The Casual Vacancy by Joanne Rowling, failed to overcome her unfortunate cir-cumstances and committed suicide. The authors analysed Krystal's case based on the guideline for patients with suicidal behaviours to address the complicated situation of her death.
RESULTS: Krystal grew up in a poor and dangerous environment. Despite the environmental hardships, she developed ego maturation with affectionate help from Mr Fairbrother, an assistant coach of the Girls' Rowing Team and a parish councillor. The sudden passing away of Mr Fairbrother brought on a crisis of identity for Krystal. In addition, a villainous character raped her and her brother drowned to death, which brought her great sorrow. She felt helpless and committed suicide.
CONCLUSION: In spite of many risk factors for suicide, Krystal was able to keep her life with a few protective factors, a younger brother in the home, and a sense of responsibility for the family. After the loss of her brother, however, she collapsed in a moment. Krystal's suicide might not only be a personal choice but a breakdown of the social protection system for the youth.

INTRODUCTION

While the most common cause of death in the population aged 15 to 29 years is unintentional injury, mostly by traffic accidents, suicide is the second leading cause globally [1]. In Korea, the most frequent cause of death in the population aged 10 to 19 years was road accident, followed by suicide, in 2002. By 2009, things had turned around and suicide became the number one cause of adolescent death, as it still remains today [2]. Though an increase in adolescent suicide is a serious social issue, there are various reasons associated with suicide that prevent a sociocultural or psychological approach to understand it [3]. Throughout the history of suicidology one can identify obstacles to these approaches. In 1910, a psychoanalytic symposium regarding suicide was held in Vienna [4]. The symposium, which was led by the psychoanalyst Alfred Adler, was an unprecedented event at the time. It was 58 years later that the first Annual Conference of the American Association of Suicidology was held in Chicago, U.S., in 1968 [4].

As suicide is a unique behaviour that poses a challenge to sociocultural examination, researchers have been systematically compiling data of the suicide completer’s family background, behavioural patterns, status of change, and history of psychiatric treatment, through interviewing their known associates and examining their diary or suicide note, to identify the cause of suicide. Such data serve in reconstructing the way of life of the deceased and analysing the factors that led to suicide. This method of investigation has been termed as psychological autopsy [3]. The study of adolescent suicide is difficult compared to adult suicide due to relatively low incidence, but in Korea, studies based on psychological autopsy have recently been conducted with a focus on adolescent suicide [5].

Adolescence is a difficult period of time as teenagers undergo role transitions and identity changes [6]. More frequent exposure to adversity during childhood could be the cause of a teenager having difficulty in dealing with more serious challenges, increasing the risk of self-injury or suicidal behaviour. Experts investigating suicide claim that adolescent suicide prevention programs should focus on screening individuals for exposure to the risk factors of suicide in order to guide them to receive appropriate treatment [7]. However, a social atmosphere in which talking about suicide cases is avoided, makes it difficult to investigate suicide [7]. When it comes to adolescent suicide, it is even more challenging to acquire cooperation such that the predictors of suicide can rarely be identified, and it is virtually impossible to predict the risk or the time of repeated suicidal attempts even in high-risk groups.

To overcome such limitations in practice, the authors of this study had previously conducted an investigation on a literary work to analyse the characters and form hypotheses to excavate the necessary data [8]. In the present study, the case of the suicide of the character Krystal in the novel The Casual Vacancy by Joanne Rowling [9] was analysed in lieu of an actual adolescent suicide case, so as to determine the factors associated with increased risk and protective effect for adolescent suicide. This study takes a novel approach, as psychological autopsy of a fictional character has not previously been conducted to identify the risk and protective factors of suicide in adolescents.

METHODS

Subjects

The story of the novel The Casual Vacancy unfolds as the sudden death of a respectable parish councillor Barry Fair-brother in an imaginary, idyllic village of Pagford Town, is followed by various conflicts among the local residents. This study investigated a 16-year-old female student Krystal Weedon, a character who tries to rise above the hardships of living with a drug addict mother, but who commits suicide in the end. The plot of the story is as follows.

Terri grew up with a father who abused his children. As an adolescent, she became addicted to drugs, and gave birth. Krystal, as Terri’s third child, did not receive proper nurturance since childhood, and grew up in dangerous and dirty environments. When Krystal was in elementary school, she ignored school rules and even imitated sexual behaviour in the classroom. By the time she reaches high school, she develops conduct problems such as stealing, lying, being violent with other students, and remaining absent from classes. While she indiscriminately has sex with boys, she is bossy and full of confidence. City Council member Barry Fairbrother treated Krystal without prejudice despite her rebellious behaviour. In addition, he recognized her athletic talents, and convinced her to join the Girls’ Rowing Team. She develops empathy, friendship, and emotional attachment through the team sport and also learns the meaning of happiness. However, as Mr Fair-brother suddenly dies of subarachnoid haemorrhage, she loses a solid support base. In the meantime, she is in a state of chaos due to the death of her great-grandmother Nana Cath, who had provided her with the only safe upbringing throughout her life. To make matters worse, Obbo, a dealer who sells drugs to Terri, rapes Krystal. Krystal wanted to be a “young Nana Cath” for her own baby and her younger brother Robbie. However, Robbie, who was left alone for a while, drowns while Krystal was having sex with Fats (school teacher’s son) with the intention of becoming pregnant. Overcome by guilt and grief, Krystal commits suicide by overdosing on heroin.

Methods

From Krystal’s case, the factors associated with increased risk and those associated with protective effect for adolescent suicide were identified based on the guideline for the examination and treatment of patients with suicidal behaviours, published by the American Psychiatric Association [10]. As Krystal is a fictional character, it was not possible to conduct a post-death interview of her family, friends, or other known associates. This study thus aimed to present as much data about Krystal as could possibly be gleaned from the novel. The discussion is embedded within the context of adolescent suicide. This study was conducted with the approval of the Institutional Review Board of Kyung Hee University Hospital (KHUH 2018-06-079).

RESULTS

Factors associated with increased risk for suicide

For Krystal, the suicide risk factors included various environmental factors in addition to personal vulnerability (Table 1). First, regarding the age, race, and gender of the suicide, Krystal was an adolescent, which is an age group vulnerable to suicide. Her being Caucasian was another risk factor.

Table 1

Factors associated with the increased risk for suicide in the case of Krystal based on practice guideline from the American Psychiatric Association*

Risk factors	Episodes or details	Availability
Demographic features
Adolescent and young adult age group	Adolescent (16 years old)
Race	Caucasian
Psychiatric disorders
Cluster B personality disorder	Antisocial personality trait
Other substance use disorders	Cigarette and marijuana
Physical illness		Not available
Psychosocial features
Recent lack of social support	Death of Mr Fairbrother
Poor relationship with family	Conflicts with mother
Recent stressful life event	Rape by mother’s boyfriend
	Drowning of brother
Childhood trauma
Physical abuse	Exposure to adverse experiences
Genetic and familial effects
Family history of mental illness	Mother’s substance use disorder
	Trans-generational antisocial traits
Psychological features
Hopelessness	Poverty, no shelter
Shame	Guilt of her brother’s drowning
Decreased self-esteem	Turning against self
Impulsiveness	Aggressive and violent behaviours
Cognitive features		Not available
Suicidal thoughts/behaviors
Lethality of suicidal plans or attempts	Critical heroin overdose
Additional features
Unstable or poor therapeutic relationship	Insufficient rapport with the social worker

American Psychiatric Association. Practice guideline for the assessment and treatment of patients with suicidal behaviors. November 2003 [10].

Second, although Krystal did not have a physical illness, she had begun smoking at an early age and frequently smoked marijuana, indicating potential substance abuse. She also displayed behavioural characteristics related to cluster B personality disorders: fight and knock out teeth of a classmate, multiple sexual relationships with boys, and unauthorized school absence.

Third, Krystal had been exposed to various psychosocial stressors since infancy. Her only social support system vanished with Mr Fairbrother’s sudden death. The imminent closing down of Bellchapel, the Methadone Rehabilitation Clinic necessary for the treatment of her drug addict mother, following Mr Fairbrother’s death, became an additional threat to Krystal.

Fourth, Krystal had undergone countless traumatic events in childhood. Aside from the possibility that she had been physical abused, her childhood environment was highly unsuitable for childcare.

Fifth, in addition to the drug addict mother, it is assumed that there had been other factors related to family history: domestic violence, runaway mother, and incest.

Sixth, emotional conflict and psychological loss served as another risk factor. The death of Krystal’s great grandmother Nana Cath, who had always been a secure base for her even amidst the inappropriate care by her mother Terri, meant not only an emotional endpoint but also the loss of the secure base she could return to in the face of a hardship.

Krystal used to be a confident leader among her peers, acting on impulses without much contemplation or guilt. It was after she met Mr Fairbrother upon joining the Girl’s Rowing Team that she experienced feelings of guilt or shame as she started a journey of self-reflection and growth, and began to place responsibility on herself before blaming others.

Seventh, Krystal had not previously shown any suicidal accident or self-injury, but the one suicidal behaviour was fatal with the overdose injection of heroin. Krystal had never used the drug before, however, she knew well how to inject heroin from watching her mother using it.

Factors associated with protective effects for suicide

In the case of Krystal, identifying the protective factors for suicide was much difficult as compared to identifying the risk factors (Table 2). First, the presence of a child at home and the responsibility for family acted as two very important protective factors. Although Robbie was her little brother and not her own child, she felt sorry for him that he could not receive proper care from their mother. The responsibility she felt towards Robbie, preventing him from being sent to a child-care facility or foster home, became Krystal’s reason to live on.

Table 2

Factors associated with the protective effects for suicide in the case of Krystal based on practice guideline from the American Psychiatric Association*

Protective factors	Episodes or details	Availability
Children in the home	Younger brother, till he was alive	Brother’s death triggered her suicide
Sense of responsibility to family	Younger brother, till he was alive
Life satisfaction	Captain of the rowing team
Positive problem-solving skills	Violent, but self-confident and bossy
Positive social support	Nana Cath as a safe base Mr Fairbrother	Nana Cath’s and Mr Fairbrother’s death triggered her suicide

American Psychiatric Association. Practice guideline for the assessment and treatment of patients with suicidal behaviors. November 2003 [10].

Second, the satisfaction or compensation experienced in everyday life could also be a reason for living. After she joined the Girl’s Rowing Team, Krystal experienced such feelings as empathy, affection, consideration, and respect for the first time, which facilitated a healthy ego development in her.

Third, although Krystal used to have behavioural problems, after joining the Girl’s Rowing Team, she learned to apply a healthy and positive approach to solving problems.

Fourth, although Krystal was raised in an extremely poor environment without sufficient social support system, Nana Cath, her great grandmother, cared for her with love, and Mr Fairbrother helped her to find a positive support system. Kay, a social worker, also helped by encouraging Terri to keep attending the drug addiction treatment programme, though the result was unsuccessful.

DISCUSSION

To predict adolescent suicide is an extremely challenging task even for experts due to the lack of sufficient psychopatho-logical data on adolescent suicide as well as the numerous, complex risk factors. Among many explanatory and predictive models of suicidal behaviour, a typical stressor is the acute worsening of a psychiatric disorder from the stress-diathesis model [11], but often an acute psychosocial crisis, such as in Krystal’s case, seems to be the most proximal stressor. Aggression and impulsivity are components of the diathesis for suicidal behaviour [11]. A few decades ago, identification of particular persons who were likely to commit suicide was not feasible because of the low sensitivity and specificity of available identification procedures, and the low base rate of this behaviour [12]. In a large-scale investigation involving 60 behavioural assessment tools for the data for suicide in childhood and adolescence, as commissioned by the National Institute of Mental Health in the U.S., only a small number of tools were shown to have predicted suicidal attempts, with an even smaller number of tools predicting completed suicide [13]. While such tools may assist clinicians, so far there is no tool that can replace a sophisticated clinical approach.

Psychological autopsy should go beyond the scope of general autopsy to describe what the individual lived for and what kind of life they would have lived [3]. This includes the life values and goals as well as the issues they had tried to resolve. The most significant advantage of a study using psychological autopsy is the possibility of establishing specific and comprehensive measures of prevention through the study’s findings. An analysis of 154 studies based on psychological autopsy showed that mental disorder was the variable displaying the highest correlation with suicide [14]. Especially, comorbid mental disorder and substance abuse preceded suicide in more cases than controls. An analysis of the multivariate effects of the potential risk factors found that the common risk factors for suicide were addiction, inpatient adult psychiatric care, and the number of stressful life events [15]. The available research data in the present study were not sufficient to draw a conclusion regarding the influence of a certain disease or sociological variable on suicide. Nevertheless, one of the risk factors in Krystal’s case was the abusive use of cigarettes and marijuana.

If psychological autopsy is conducted for Krystal, a higher weighted value should be given to the various events in her life as the risk factors before the suicidal attempt. In a previous study that analysed 173 cases of suicide in elementary, middle, and high schools during 2018–2019, the presence and level of the risk factors of adolescent suicide including mental disorder, previous suicidal attempt, depression, anxiety, broken family, and deviant behaviour, were used to divide the subjects into three groups; silent type, environmental risk type, and depressive type [5]. The silent type displayed none of the examined risk factors. The environmental risk type showed higher percentages of broken family and deviant behaviour. The depressive type showed a higher percentage of diagnosis of mental disorder compared to the other two groups, as well as a history of suicidal attempts. However, interestingly, a Swedish study that performed psychological autopsy of 63 cases of suicides aged 10–25 years found that 49.2% had never made a previous suicidal attempt [15]. The warning signs (verbal, behavioural, and emotional) before suicide were observed in the depressive type to a significantly higher degree than in the other groups. Krystal might belong to the environmental risk type, with serious risk factors including family dissolution and deviant behaviour. This underscores the need and importance of establishing policies towards social consensus and reduced environmental risk factors related to adolescent suicide in addition to individual psychopathological analysis.

While the correlations of suicide risk factors have been abundantly reported, the data on suicide protective factors are not sufficient. In this respect, to identify the psychodynamics, such as the reason for living among the protective factors of suicide, is crucial [16]. One of the reasons Krystal could see value in her life despite the poor environment and incompetent mother, was her little brother Robbie. Although he was not her own child and they had different fathers, Krystal felt a sense of responsibility towards Robbie as a family, which had a protective effect for suicide. As the author of The Casual Vacancy, Joanne Rowling, has also said in the context of her own life that the thing that made her seek help when she was depressed and had suicidal ideation, was probably her daughter [17].

Had Krystal been able to pursue a healthy ego development in an appropriate way, it would have been her shield of protection against suicide. In a study that followed the individual defence maturity for 70 years beginning from the late adolescence, the children who received less emotional warmth were more likely to develop adaptive defences during the middlescence and senescence [18]. Although this study was limited because all 72 participants were males and Harvard sophomores at the onset of the study, the results suggested the possibility that, even if an individual had undergone a difficult childhood like Krystal’s, how they spent their adolescence and adulthood could determine and enhance their quality of life and their social life to a significant degree. Krystal was a teenager with conduct problems, who frequently resorted to immature defence mechanisms, such as acting-out, projection, or denial before meeting Mr Fairbrother. For Krystal, more mature ego development could progress as she received genuine support from Mr Fairbrother and experienced empathy and affection through group activities. Krystal used to tease Sukhvinder, but as Mr Fairbrother appropriately pointed out the problems of such behaviour, she could finally see the consequences of her actions for others and experience the painful but precious emotions to help her reflect on herself [8]. However, the gradual development of Krystal’s identity was disturbed abruptly by the sudden death of Mr Fairbrother. She had advanced into the state where the sense of guilt and conscience judgment take priority, but her decision based on a yet inadequate internal working model led the situation in an undesirable direction. The defence mechanism of identification, by which Krystal felt responsible to care for her little brother as Nana Cath, is an excellent sign of maturity [19]. However, because of the guilt she experienced when she realised that she could not properly care for Robbie, Krystal felt overly responsible and ultimately made an inappropriate choice to conceive a baby with Stuart Wall, aka Fats, as a means to find a place to live. When Robbie died by drowning while she was having sex with Fats, Krystal felt a deep sense of guilt. In the past, Krystal would have dealt with such guilt using an immature defence mechanism such as projection to avoid her responsibility, but with higher maturity, Krystal turned to a higher-order defence mechanism of turning-against-the-self [20]. Similarly, the sexual assault by her mother’s boyfriend and drug dealer Obbo, led Krystal to self-criticism and self-destruction that exceeded the limit of her coping capacity [21]. Krystal’s suicide process could be reconstructed into a triad of motivation for suicide [22]: escape from reality (the wish to die); anger or revenge against people who hurt her (the wish to kill); and guilt about her younger brother who drowned (the wish to be killed) [10].

Social support system is a crucial protective factor of adolescence suicide [23]. Krystal had made significant efforts to adapt to and survive her poor environment, but most of her efforts were unsuccessful because the social support system that could have helped her did not function properly. The hopelessness and helplessness Krystal felt were increased when the social worker Kay Bawden failed to get a rehabilitation centre for Krystal’s mother Terri, and when she failed to find an institution that would look after her brother Robbie. The society that failed to protect a teenager Krystal from the sexual assault by an adult Obbo is another factor showing the connection between Krystal’s suicide and the problems inherent in the social system. In another words, when the society and the government do not satisfy the role of organising and managing the overall resources and efforts on the national level, what appears as suicide could actually be viewed as a social homicide [24].

The factors contributing to adolescent suicide include psychiatric, psychological, social, and cultural factors in addition to personal factors. The influence of the media including the Internet should also be taken into account [25]. A mini-series based on the novel 13 Reasons Why [26] aired with the same title is a representative case. The protagonist of the novel, Hannah Baker, is devastated after she is raped by a boy from her school. Although she seeks help from the school counsellor, Mr Porter, just before committing suicide, she does not receive it and her belief that nobody cares for her is reinforced. The helplessness may have driven her to commit suicide [26]. On March 31, 2017, as Netflix released the entire series 13 Reasons Why, allowing for unlimited viewing of the episodes over a short-period of time (i.e., binge-watching) [27], it may have had a powerful influence on adolescents, whose brains are still developing the ability to inhibit risky behaviours and emotions [25]. From an analysis of Internet searches for suicide following the release of 13 Reasons Why by Netflix, suicide queries were cumulatively 19% higher for 19 days following the release [28]. While it was not clear whether any query preceded an actual suicide attempt, this report suggests that while the series may have increased suicide awareness, it may also have unintentionally increased suicidal ideation [28]. Interestingly, however, there has been no significant change in suicide/homicide rate between the groups aged 18–29 years and 30–64 years in the U.S. after the release of the mini-series. [27]. The suicide of the teenager protagonist had raised a concern that the suicide rate by girls in the same age group might increase, but there has been no significant change, whereas the suicide rate by boys aged 10–17 years significantly increased. The reason for these findings is not clear. As the book, 13 Reasons Why, is listed as one of the New York Times best sellers during the past decade, given the likely preponderance of female readership, there may have been some degree of desensitisation among girls prior to the release of the Netflix series [27]. Imitation may have contributed to the increase in the male youth suicide rate after the release of the series, given that a male adolescent character made a serious suicide attempt by firearm at the end of the series [27]. The Casual Vacancy was also broadcasted based on the novel of the same title as a British miniseries on 15 February 2015 [29]. We searched for any reports on changes in suicide rates after the release of this miniseries, but to the best of our knowledge, there were no related reports. Perhaps the reason is that Sarah Phelps, screenwriter of the miniseries, obtained the consent of the original author Joanne Rowling to change the story of Krystal being raped by Obbo and her death to something other than suicide [30].

In sum, Krystal, a girl raised as a juvenile delinquent in a poor environment, is given an opportunity to discover her merits through sports, thus facing a turning point for healthy ego development. However, the sudden fall of her fragile support system results in the higher-order defence mechanism being turned into a suicide risk factor towards a tragic end. ‘Could we have prevented Krystal’s death?’ reflected Sukhvinder, Krystal’s best friend, as she prepared for Krystal’s funeral. Krystal might have been saved, if she or those in her life had been able to think that ‘The light of God shines from every soul’ [9, p.329] before the suicidal episode.

The limitations in this study are as follows. First, the investigation focused on a single work of literature, and Krystal was only one of the supporting characters in the novel, so sufficient information about her was not available. Therefore, the personal history and collateral information are not sufficient to explain the steps through Krystal’s suicide. Second, Krystal had not shown any previous suicidal attempt or suicidal thoughts, and her death was due to a single fatal attempt. Despite the authors’ efforts to find any signs prior to suicide, no indicative sign or specific symptom could be found.

This study is the first to analyse the risk and protective factors of adolescent suicide by adopting psychological autopsy of a fictional character in literature. It is our hope that the data obtained through such literary analysis would provide valuable insights for the experts in practice, the adolescents who have suicidal ideation, and the family of the deceased.

CONCLUSION

Suicide is not just a tragedy for the person who commits suicide, but it has a tremendous impact on the people in their life. Not all individuals who are exposed to the risk factors choose to end their lives. The personal vulnerability must be inter-twined in a complicated interplay with the environmental factors. Krystal lived in an extremely poor environment with respect to livelihood and the psychopathological status of the family members, but the level of her personal vulnerability to suicide could not be identified. The various risk factors, which already existed on a serious level, continued to deteriorate, whereas the protective factors of suicide were being either lost or weakened. The reason Krystal chose suicide could be because she was in an incomplete stage of healthy ego development, or because she could not handle the weight of self-punishment while in a state of hopelessness, helplessness, and experiencing feelings of guilt. Had Krystal been able to recognise that a relatable support system was within her reach, the result could have been different. Suicide is a personal choice, as in this case, but as the life of an individual is built within a society, suicide is inevitably a part of social pathology. This highlights the need for a social protective system against suicide apart from the personal protective factors. For teenagers, in particular, as they are yet in a state of developing their personal identity and financial independence, care and protection from the family as well as the society are essential.