For ten years, South Korea has ranked either first or second in suicide rates among the Organization for Economic Cooperation and Development (OECD) countries [1]. Specifically, the suicide mortality rate among late adolescents has increased. The 20~24 years age group showed the sharpest increase in suicide rates, per 100,000 between 2015 (13.2) and 2019 (17.2) in Korea [2]. This is higher than the most recent suicide rate of 10 per 100,000 in the 20~24 years age group, as reported by the OECD [1]. This trend has also been observed in other studies. Comparing the average number of suicides among college students in the United Kingdom between 2000 and 2002, and 2014 and 2016, the increase in the number was higher in the 21~24 years age group (approximately 2.78 times), when compared to other age groups [3]. This indicates the need for greater focus on suicide risks and mental health in these age groups.

We considered the recent changes in biological growth, as well as major social roles during adolescence [4, 5], and defined adolescence as age ranging from 10 to 24 years, with late adolescence including the ages 18~24. During late adolescence, rapid environmental and role changes often occur in various aspects, such as school, society, profession, and family [4, 5]. These changes lead to various economic and psychosocial conflicts, thereby increasing mental health crises. The biggest mental health crises have been reported to occur during late adolescence [6]. Upon entering college, one has to leave existing familiar relationships and adapt to an unfamiliar environment as well as forge new relationships. Late adolescents often experience emotional maladjustments or distress due to transitioning to higher academic demands and employment pressures [7]. Such complex sociopsychological factors could lead to suicide attempts in late adolescence [8, 9]. Further, depression, anger, despair, and financial problems have been reported as suicide factors [7, 8, 9]. Despite high suicide risk, there are insufficient studies on experiences of overcoming suicide among adolescents and late adolescents, as compared with studies on adults [9, 10]. Moreover, studies on suicide in South Korea have mainly concentrated on its relationship with specific risk factors [11, 12]. Although such suicide risk factor studies help screen susceptible people, they are limited to direct interventions for prevention [11, 13]. More studies are, therefore, needed on suicide-related protective factors [11].

A protective factor allows someone to overcome a suicide crisis without death by suicide in the face of adversity [11]. Considering that suicide must be approached from a multifaceted perspective within the socio-cultural context [9], the process of overcoming suicide crises is complex and requires a deep and broad understanding of the act as a multidimensional phenomenon. From the perspective of case managers, this study used a qualitative research method to identify the factors and processes that can help late adolescents overcome suicide.

Case managers are professionals who closely observe late adolescents' process of overcoming crises through counseling. In Korea, under the supervision of the Ministry of Health and Welfare, emergency room-based suicide attempter follow-up management program are being conducted at emergency medical institutions across the county [14, 15]. This program is connected to the Community Mental Health Welfare Center, and case managers provide active interventions, such as continuous counseling, monitoring, crisis interventions, and referrals for psychiatric or other professional treatment [14, 15, 16]. Due to this program, the number of suicide reattempts are reported to be decreasing [14]. In the community, case managers play the role of companions, based on their rapport with late adolescent suicide attempters [17, 18], and thereby, they indirectly gain experience on various methods for late adolescent suicide attempters to overcome suicide crises. Because the process of overcoming suicidal crisis is dynamic and complex, in this study, it was conducted a focus group interview as a qualitative research method, which enables exploration and discovery, deep contextual understanding of objects or events, and collecting data based on the participants' rich experiences for specific topics [19]. Therefore, this study explored case managers' experiences with late adolescent suicide attempters in the community, and identified the reinforcing factors and processes that can help overcome the crisis. Focus group interviews were conducted with case managers at mental health welfare centers in the P, G, and B areas in South Korea, as well as by performing a qualitative content analysis [20] on the collected data.

As a result of analyzing the case managers' experience pertaining to case management of late adolescent suicide attempters, the main theme of the reinforcing factors for overcoming suicide crisis in this population was derived as "a step in a new direction". The categories were classified into "inner changes", "another possibility opened up by the interest of significant others", and "connecting with community resources to help overcome". The subcategories for each category are described as follows.

1. Inner Changes

The case managers mentioned that late adolescents were prepared to overcome their suicide crises by accepting and taking an objective view of the problems that led to their suicide attempts. They made various efforts to overcome these problems and started showing an active attitude toward overcoming their crisis. Although a difficult situation, the adolescents showed inner changes in attitude, and motivated themselves to overcome their suicide crisis by describing the future in detail, or making efforts to achieve their dreams, and not attempting suicide (Figure 1).

Figure 1 Diagram for the reinforcing factors of overcoming suicide crisis in late adolescent suicide attempters. Click for larger image

1) Self-recognition of problems and acceptance

The case managers also stated that late adolescents were able to overcome their suicide crises once they started thinking about their problems, stress, or the nature of their pain, and began accepting them. As late adolescents talked about their suicide-related problems, stress, and hardships to case managers, they gradually started looking at these objectively; this was an important reinforcing factor in overcoming suicide crises.

Ever since she learned to accept and take an objective view of herself, and recheck what her problems were, it has gotten better and better. (FG 1, Participant 1)

She talked a lot about what had happened to her and all the stress. I felt that accepting the problems and opening up to others is important for overcoming a crisis. (FG 1, Participant 2)

2) Willingness to overcome on one's own

According to the interviews with the case managers, some late adolescents attempted suicide to escape from unchanging situations or with the intention of punishing someone. However, to overcome their difficulties, they visited counseling centers and attempted different methods, such as exercise and psychiatric treatments. The case managers stated that these small attempts among late adolescents were the start of shaping an active attitude toward overcoming their crisis.

When I asked them, 'if you can neither change your surroundings nor escape the situation, what do you think you can do to survive?' Some said, 'I need to see a psychiatrist', whereas others said, 'I will try to exercise or do something else. I will also try something more and get through this'. (FG 1, Participant 1)

Looking for a job was stressful for her. She eventually tried to commit suicide. She visited the community center on her own and asked for a consultation to overcome it. (FG 3, Participant 2)

3) The embodiment of the future and dream

The case managers further mentioned that some late adolescents overcame their suicide crises by setting life goals and gradually attempting to achieve their dreams, as they described their future in detail.

Imaging a more concrete future rather than a vague one. A client described her future as having two children and leading an easy life, in which she could read during her free time. She said, 'To achieve this goal, I am going to study diligently, work hard to get a job, and make money. Now I have goals in life'. She has fully recovered and returned to society. (FG 1, Participant 2).

She had a dream of writing and was trying to submit a piece for a competition. She said that even if she had to quit school or things got worse, she would still try to overcome suicide crisis, so as to realize her dream. (FG 1, Participant 1).

By examining the experiences of case managers, this qualitative study investigated various factors and their dynamics that can help adolescents overcome suicidal ideation. Its results revealed that as adolescents begin to receive external help and promote internal changes, they start taking their first steps toward overcoming the suicidal crisis. In the first category, "inner changes", late adolescents were trying to make a positive change in their attitudes toward overcoming suicide through acceptance and objectification of suicide-related situations, a determination to overcome on their own, and the embodiment of a future. Previous studies have shown that objective awareness, hope, optimism, and future-oriented attitudes in late adolescents, which appeared in the subcategories, play important roles in overcoming and significantly reducing suicide crises [23, 24]. In particular, the interaction between hope and optimism shows a significant positive effect, not only on the reduction of suicidal ideation, but also on depressive symptoms [23]. As shown in this study, the process through which case managers assisted the adolescents in setting concrete life goals and dreaming about becoming members of society, based on awareness of their problems, provides valuable information for developing problem solving approaches. Therefore, on the basis of this study's results, if counseling, relevant information, programs, clinical approaches, and activities are provided, it will greatly help in overcoming suicides among late adolescents.

In the second category, "another possibility opened up by the interest of significant others", people surrounding them helped promote the intention to overcome the suicide crisis by understanding and accepting the problems they faced and participating in a joint effort to solve them. This is consistent with previous studies conducted in Korea and abroad, in which the feeling that the adolescents are well understood by "significant others" and recognizing that they are connected, acts as protective factors against suicides and suicide crises [12, 23, 25, 26]. Conversely, some studies have reported that the problems with meaningful others, including family members, may also be risk factors [9, 12]. Therefore, educational institutions and mental health welfare centers should employ a multifaceted approach, promoting the intention to overcome suicide crises in late adolescents through positive understanding and support from significant others. Above all, as family members have a decisive influence in a suicide crisis [9, 26], interventions should take place at the family level, using resources, such as family education and group counseling, to form desirable relationships between family members and teach therapeutic roles.

In the third category, an awareness of coping resources led to a connection with community resources and provided actual help during the process of overcoming suicide. Many studies have reported that "realistic difficulties" due to socioeconomic problems have a significant effect on repeated suicide attempts in late adolescents [12, 27]; providing expert therapies and social support are closely related to overcoming it [25, 28]. Through the results of this study, it can be confirmed that existing resources in the community available to late adolescents causes positive changes in their lives. These results suggest that the collaboration between related organizations and a multidisciplinary approach to help late adolescents overcome suicidal crises can assist in solving suicide problems and encourage late adolescents to continue overcoming these behaviors. However, domestic support is limited by various factors, such as social prejudice, a lack of professional workforce and support, and insufficient information and research [9, 12]. Therefore, it is necessary to provide local community resources to assist late adolescents during a suicide crisis, especially institutional support, for more effective collaboration and communication between public, private, and academic resources.

Late adolescence is an important turning point, in which a person prepares for independence [12, 29]. Late adolescents in South Korea, particularly those who are used to tightly mapped out schedules with a tremendous study load until high school, tend to experience great burden, stress, and psychosocial problems during their first years of "independence" at college or the workplace [9]. For this situation, a specific approach is required, as socioeconomic conditions, family factors, and values shared by similar age groups can interact and lead to serious suicide crises [30]. Hence, the reinforcing factors and specific details for overcoming suicide crises proposed in this study can provide important pathways for establishing a specific plan for the high suicide risk group in local communities.

By interviewing case managers, this study identified factors implicit in the experiences of overcoming suicide among late adolescents, and suggested a process that affects the intention and behaviors to overcome suicide. Specifically, information on the specific protective factors and their dynamics leading to overcoming suicide can provide meaningful data that can help the adolescents based on their characteristics in the clinical field or community-based institutions. In terms of nursing education and research, the results of this study will promote an in-depth understanding of the adolescents' suicide problems and provide useful data for nursing planning to prevent and overcome their suicide crises.

Despite its contributions, our study had several limitations. First, due to domestic conditions, interviews could not be conducted directly with late adolescents. Consequently, an extended application of our results to late adolescents in the process of overcoming suicide in South Korea may have limitations. Thus, we suggest that future studies attempt to explore detailed experiences pertaining to overcoming suicide, through interviews with a larger number of late adolescents, with or without case managers. Second, our study mainly addressed the positive factors implied in experiences of overcoming suicide in late adolescents. To offer more effective help to late adolescents, future studies should attempt an in-depth exploration of elements that can exacerbate suicide crises, integrating them with the results from existing literature.

As a result of analyzing the contents of focus group interviews with case managers, this study found that late adolescents tried to move forward in a new direction by continuing their own efforts to overcome suicide crisis, with the support of meaningful people and using various resources. The results of this study, that identified the reinforcing factors and the overcoming process, can provide useful information for planning and developing policies and intervention programs for overcoming suicide crises, considering the situation and growth characteristics of late adolescents.