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Culture and suicide : perspectives of first-generation Korean-Canadian immigrants Han, So Eun 2013

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     CULTURE AND SUICIDE: PERSPECTIVES OF FIRST-GENERATION KOREAN-CANADIAN IMMIGRANTS   by   So Eun Han  B.A., University of British Columbia, 2003    A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE DEGREE OF   MASTER OF ARTS   in   The Faculty of Graduate Studies  (Interdisciplinary Studies Graduate Program)    THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)   April 2013    © So Eun Han, 2013  ii Abstract  Background: Suicide is a serious health concern worldwide. In 2007, almost 4,000 Canadians took their own lives and among older and middle-age groups, suicide is one of the leading causes of death for both men and women. Given the far-reaching impact on families and societies, suicide has been widely studied; yet, accounts about the connections between suicide and culture in the context of immigrant populations are still poorly understood. Objective: To better understand the connections between suicide and culture, and to provide a foundation on which to build targeted culturally-sensitive suicide prevention programs, this research used qualitative research method to describe the perception and experiences of suicide of fifteen Korean-Canadian immigrants. Results: Three inductively derived themes were identified to detail the study findings: 1) perceptions of and attitudes toward suicide among Korean-Canadian immigrants; 2) narratives around the causes and triggers of their suicidal thoughts and behaviours; and 3) manifestations of and strategies to manage their suicidal thoughts and behaviours. Within these three themes, there are a total of nine sub-themes which are intricately connected. Discussion: While recognising and embodying stigma around suicide, participants understood the hopelessness and despair that could drive immigrants toward suicide. Causes and triggers for suicidal thoughts most often emerged from academic pressures, estranged family, and dis- identities – all of which were intricately connected to participants’ immigration experiences. Noteworthy were deeply embedded Confucian values, which could exert an array of influences on Korean-Canadians. In addition, extensively discussed were dis-identity experiences whereby a sense of self and as well as collectivist familial bonds were challenged, and suicidal ideation  iii could flow toward and/or from these changes. Many participants were unaware of mental health services and programs amid being challenged by language barriers when they did access mental health services. While, it is critical for healthcare providers to understand immigrant patients’ cultural background to fully assess their risk for suicide, also urgently needed are targeted efforts to raise public awareness about suicide and educate immigrants about professional and self-help options to manage their mental health and well-being.      iv Preface The research in this thesis was conducted according to the guidelines of the University of British Columbia’s Behavioural Research Ethics Board (BREB). Approval to conduct interviews with human subjects was obtained from UBC BREB – H11-03418. Data is drawn from fifteen individual in-depth interviews conducted in Vancouver, British Columbia by Han, who also completed the following research activities: 1. Data collection: Han conducted 15 qualitative, in-depth individual interviews with Korean-Canadian immigrants – all of which inform the findings shared in this thesis. 2. Data analysis: Data analysis with ongoing supervisory committee consultation. Feedback from Drs Oliffe, Ogrodniczuk and Baker were subsequently incorporated into the thesis. 3. Thesis preparation: This thesis was written with theory-based feedback from Drs Oliffe, Ogrodniczuk and Baker. Two publications were drawn from the literature review conducted for this thesis:  Han, C.S., Oliffe, J.L., & Ogrodniczuk, J.S. (Accepted on August 1st, 2012, In press). Suicide among East Asians in North America: A scoping review. Journal of Mental Health. [Available online: http://informahealthcare.com/doi/abs/10.3109/09638237.2012.734651]   Han, C.S., Ogrodniczuk, J.S., Oliffe, J.L. (In review). Qualitative research on suicide in East Asia: A scoping review. Journal of Mental Health.          v Table of Contents Abstract ........................................................................................................................................... ii  Preface ........................................................................................................................................... iv  Table of Contents .............................................................................................................................v  List of Tables ................................................................................................................................ vii  Acknowledgments ....................................................................................................................... viii  Dedication ...................................................................................................................................... ix  Chapter 1 Introduction .....................................................................................................................1  1.1  Introduction: Suicide ......................................................................................................1  1.2  Culture and Suicide ........................................................................................................1  1.3  Why Study Suicide among Korean-Canadian Immigrants? ...........................................3  1.4  Thesis Objectives ............................................................................................................5  1.5  Thesis Outline .................................................................................................................6  Chapter 2 Literature Review ............................................................................................................7  2.1  Introduction ....................................................................................................................7  2.2  Historical Perspectives of Suicide in Western Culture ...................................................8  2.3  The History of Suicide in East Asian Culture ..............................................................13  2.4  Suicide among East Asian Populations in North America ...........................................18  2.4.1  Rates of suicidal ideation and behaviour ...............................................................19  2.4.2  Acculturation and suicide ......................................................................................20  2.4.3  Family support and suicide ....................................................................................22  2.4.4  Manifestations of suicide .......................................................................................24  2.5  Conclusion ....................................................................................................................27  Chapter 3 Methods .........................................................................................................................28  3.1.  Introduction ..................................................................................................................28  3.1.1  Ethnography as methodology ................................................................................28  3.1.2  In-depth interviews ................................................................................................30  3.1.3  Participant observations.........................................................................................31  3.1.4  Ethics .....................................................................................................................32  3.2.  Methods ........................................................................................................................32  3.2.1  Participant recruitment ..........................................................................................32  3.2.2  Study participants ..................................................................................................33  3.2.4  Data collection .......................................................................................................36  3.2.5  Instruments used in data collection .......................................................................37  3.3.  Analysis ........................................................................................................................38  3.3.1  Data analysis ..........................................................................................................38  3.3.2  Reflexivity .............................................................................................................40  Chapter 4 Findings .........................................................................................................................43  4.1  Perceptions of and Attitudes Toward Suicide ..............................................................43  4.1.1  Stigmatizing suicide ..............................................................................................43  4.1.2  Understanding suicide ...........................................................................................47  4.1.3  Modern Korea and suicide.....................................................................................49  4.2  Culture-Specific Suicide Risk Factors ..........................................................................52  4.2.1  Academic pressure.................................................................................................53  4.2.2  Estranged family and beyond ................................................................................55   vi 4.2.3  Altered identities ...................................................................................................59  4.3  Suicidal Experiences and Management Strategies .......................................................62  4.3.1  Manifestations .......................................................................................................63  4.3.2  Self-management and help seeking .......................................................................65  4.3.3  Advice for other Korean-Canadian immigrants who have suicidal thoughts ........70  Chapter 5 Discussion .....................................................................................................................73  5.1  Discussion .....................................................................................................................73  5.1.1  Confucianism and suicidality among Korean-Canadian immigrants ....................73  5.1.2  Immigrating to Canada ..........................................................................................76  5.1.3  Korean-Canadian immigrants and suicidality .......................................................78  5.1.4  Korean-Canadian immigrants and help-seeking ...................................................80  5.2  Conclusion ....................................................................................................................82  5.3  Study strengths and limitations ....................................................................................82  5.4  Implications for practice and recommendations for future research ............................84  References ......................................................................................................................................89  Appendices ...................................................................................................................................100  Appendix A: Recruitment flyer in English ...........................................................................100  Appendix B: Recruitment flyer in Korean ............................................................................101  Appendix C: Participant screening form ..............................................................................102  Appendix E: Interview guide in Korean ...............................................................................105  Appendix F: Fieldnotes [P101 to P115] ...............................................................................108  Appendix G: Mental health service resources information sheet in English ........................123  Appendix H: Mental health service resources information sheet in Korean ........................124  Appendix I: Demographic survey in English .......................................................................125  Appendix J: Demographic survey in Korean ........................................................................128  Appendix K: Beck’s Scale of Suicidal Ideation (SSI) ..........................................................131                     vii List of Tables  Table 1. Baechler’s typology of suicides ...................................................................................... 11  Table 2. Participant demographics ................................................................................................ 34  Table 3. Guba’s (1981) Criteria for assessing the trustworthiness of naturalistic inquiry ........... 83       viii Acknowledgments  First, I would like to extend sincere thanks to Drs Oliffe, Ogrodniczuk and Baker for sharing their knowledge and expertise, and for their professional guidance and support throughout the entire process. In particular, I would like to take this opportunity to thank Dr Oliffe for his patience, excellent guidance and both academic and moral/emotional support he has given me for the last five years. I am most certain that without his endless encouragement and guidance, I would have never found interest in research or believed in myself that I could actually take on a role of social science researcher and be involved in other people’s lives. Simply, thank you for helping me to find my path in life.  Also, I would like to express my gratitude to my family for their unconditional support, patience and encouragement for me to successfully complete this research study.  Finally but most importantly, I would like to thank the fifteen Korean-Canadians who participated in this research study. I am so grateful for their honesty and courage in sharing their thoughts and experiences with me. Without doubt their stories became a part of me. As they all wished, I hope their shared stories and valuable insights will be utilised to help others in need and make this world a better place.  진심으로감사합니다!      ix Dedication  To 엄마 and Gen. T.       1 Chapter 1 Introduction  1.1 Introduction: Suicide Recently, suicide has surfaced as a global problem, ranking amongst the leading causes of death in many countries across the world, including Canada (Public Health Agency of Canada, 2005; World Health Organization, 2011a). The global rates of suicide have increased by 60% in the last 45 years and according to the World Health Organization [WHO], there is one suicide death every 40 seconds (World Health Organization, 2011a). Indeed, suicide represented 1.8% of the total global burden of disease in 1998, a figure that is expected to increase to 2.4% by the year 2020 (World Health Organization, 2011a). In Canada, nearly 4,000 people took their own lives in 2009 (Statistics Canada, 2012a), and among middle-aged and older men, suicide is one of the persistent and prominent causes of death (Minino, Xu, Kochanek, & Tejada-Vera, 2009; Statistics Canada, 2012b).  1.2 Culture and Suicide Culture encompasses several definitions across different disciplines including social sciences, art, music, literature, medicine and science, making it one of the most complicated words in the English language (Williams, 1988). Culture has a transgenerational quality since it continues beyond the lifetime of individuals (Rosman & Rubel, 1995); yet, it has no clear boundaries because it is fluid and subject to change over time (Oliffe, 2005; Wright, 1998). In this thesis, the term ‘culture’ is used to represent the assumptions, values, and patterns of behaviour distinctive to a specific community (i.e., Korean-Canadian immigrants) that define members of that community and show them how they should behave and relate to one another.  2 Simply put, the term ‘culture’ used in this thesis means shared set of meanings or a cognitive map of meaning (Spradley, 1980) that guides Korean-Canadian immigrants’ behaviours. Hence, suicide is closely connected to and defined by culture, as Hjelmeland (2010) asserts: [S]uicidal behaviour always occurs and is embedded within a cultural context and no suicidal act is conducted without reference to the prevailing normative standards and attitudes of a cultural community (p. 34).  Said another way, suicide is a universal behaviour; yet, the meaning and implications of suicide vary from a culture to another (Lester, 2011). For example, the Western theories of suicide are largely based on the individualistic framework that when a person commits suicide, he or she is responsible for his or her action (Leach, 2006, p. 132). Inversely, in Asian culture, where a strong collectivist orientation exists, suicide is viewed more as an interpersonal, community act (Leach, 2006, p. 132). As such, culture exerts strong influences to shape individual’s perceptions of and attitudes toward suicide which in turn impact the onset, development, patterns and rationalisation of suicidal ideation and behaviours (Hjelmeland, 2010). Accordingly, patterns, trends and norms, along with perceptions and attitudes around suicide within a particular culture should be investigated and understood through a lens of cultural relativism and social constructivism. In other words, individuals’ perceptions of and attitudes toward suicide and their suicidal behaviours should be understood in terms of their own cultural and sociological alignments. However, as Colucci (2006) asserts, one of the greatest shortcomings in suicidology is that the role of culture is often downplayed or neglected entirely.   3 1.3 Why Study Suicide among Korean-Canadian Immigrants? Given the far-reaching impact on families and societies, suicide has been widely studied, and various epidemiological profiles and risk factors have been proposed. Yet, most of these research studies aggregate population data and lack cultural and contextual insights. This trend limits understandings about suicide – and suicide prevention and intervention efforts – especially in multi-cultural nations such as Canada. Canada is a multi-cultural nation wherein 20% of the total population is foreign-born and/or visible minorities (Statistics Canada, 2009a; U.S. Census Bureau, 2010); and immigration has been highlighted as the key contributor to population growth. For example, immigrants from Asian countries account for almost 60% of the recent Canadian immigrant populations (Statistics Canada, 2009a; U.S. Census Bureau, 2010) and nearly 50% in the metropolitan Vancouver region (Statistics Canada, 2009a). According to Sainsbury and Barraclough (1968) and Malenfant (2004), suicide rates among immigrants may more likely reflect the rates of their native countries than those of the host countries. In that sense, it is critical to examine suicide and suicidal behaviours among Asian-born populations in Canada, as currently there are strikingly high suicide rates in Asia. In fact, China, alone, is estimated to account for 30% to 44% of the world’s suicides (Beautrais, 2006; Värnik, 2012). Furthermore, high rates of suicide, exceeding 15 per 100,000 people, are seen in Hong Kong, while even higher rates, more than 20 per 100,000 people, are recorded in China, Japan, and Korea (World Health Organization, 2011b). In particular, the suicide rates in Korea had a threefold increase over the past two decades (World Health Organization, 2011b; Yip, 2008), emerging as the highest in the world in 2012 (World Health Organization, 2012).  4 Amid the ever-present importance of immigrants’ health – both physical and mental, it is clear that suicide among immigrants and other foreign-born populations has significant social, economic and political implications in Canada. Yet, connections between immigration and suicide are still poorly understood and lack empirical and theory-based research to account for the diversity within sub-groups of Canadian immigrants (Han, Oliffe., & Ogrodniczuk., In press). This means that immigrants are examined as one group, largely overlooking racial, ethnic, religious and/or cultural differences within and across different sub-groups of immigrants. Moreover, within the small body of North American research work on suicide among immigrants as a whole, there are mixed and inconsistent findings in terms of suicide prevalence, aetiology, as well as risk and protective factors (Han et al., In press). Furthermore, the vast majority of these research studies were conducted in the U.S. Korean-Canadian immigrant communities, which are relatively new compared to other immigrant communities such as Chinese and South Asian groups, are growing at an exceptionally rapid rate (Baker, 2008; Lindsay, 2007). Indeed, the Korean-Canadian community has been steadily growing for the last two decades, becoming the 4th largest visible minority group in British Columbia, and the 9th largest in Canada (Statistics Canada, 2009b). Most Koreans residing in Canada are foreign-born and live in the provinces of Ontario and British Columbia (Lindsay, 2007). For example, in British Columbia, the Korean-Canadian community started with less than 1,700 Koreans in 1975 (Yoo, n.d.) but the number increased to 50,000 in 2006 (Census Canada, 2006). Though, this number is claimed to be underreported according to the local Consulate General of Korea, who estimate the number to be closer to 70,000 (including Canadian citizens of Korean descent and landed immigrants, but also Korean international  5 students and their parents who chose to stay with them during the study, as well as other types of sojourners) (Baker, 2008). Amid recent growing interest in the mental health of immigrants, examining perceptions of suicide as well as suicidal ideation and behaviours of Korean-Canadian populations will contribute significantly to better understanding the connections between suicide and culture in the context of Canadian immigrants. In addition, this will provide a foundation on which to build targeted culturally-sensitive suicide prevention and intervention programs.  1.4 Thesis Objectives The objective of this research study is to describe connections between suicide and culture among first-generation Korean-Canadian immigrants. Primarily grounded in the interpretive traditions of qualitative research (Thorne, 2008), fifteen participants’ perspective of and attitudes toward suicide were explored through individual, in-depth interviews. In addition, the participants’ experiences as an immigrant were examined to further understand how it intersects with suicidal ideation and behaviours. Finally, to better capture deeply-rooted cultural and philosophical values and beliefs as well as the cultural meanings of suicide, the participants’ perspectives on life and death were investigated. The research questions below were addressed to achieve the study objectives: 1. What are the experiences of and attitudes towards suicide among first generation Korean- Canadian immigrants? 2. What are the culture-specific suicide risks and protective factors among Korean-Canadian immigrants?  6 3. How does immigration inform and influence suicidal ideation and/or behaviours among Korean-Canadian immigrants?  1.5 Thesis Outline This thesis is organised as follows. Chapter 1 begins with an introduction to why we need to examine culture in suicidology while stating the thesis objectives and research questions. Chapter 2 includes a three-part literature review; 1) Suicide in Western culture; 2) Suicide in East Asian culture; and, 3) a synthesis of studies addressing suicide among East Asian populations living in North America, including Korean immigrants. Chapter 3 details the methodology and methods employed in this research study along with its rationale. Also included in Chapter 3 is a section on reflexivity to address some of the personal and ethical issues that emerged during the course of the research study. Highlighted in Chapter 4 are the research findings drawn from qualitative interviews with fifteen Korean-Canadian immigrants. These are presented in three sections: 1) perceptions of and attitudes toward suicide; 2) culture- specific suicide risk factors; and 3) suicidal experiences and management strategies. Finally, this thesis ends with discussion of the research findings in Chapter 5, followed by the conclusion including the study limitations and some directions for future research.        7 Chapter 2 Literature Review  2.1 Introduction  A literature search to locate research studies pertaining to suicide among Korean populations in Canada returned no published articles. A subsequent search using a broader geographic area to include the United States (U.S.) yielded only one article (i.e., Cho & Haslam, 2010). Hence, a search encompassing a broader geographic area as well as larger population was necessary. Therefore, this literature review was based on studies of East Asian populations (i.e., Korean, Chinese and Japanese) in North America (i.e., Canada and the U.S.). Given the tremendous geographic, cultural and ethnic variations within Asia, in the literature, Asian populations are often categorised into four sub-groups: East Asian (e.g., Chinese, Japanese, Korean), Southeast Asian (e.g., Filipino, Thai, Vietnamese), South Asian (e.g., Indian, Pakistani), and Pacific Islander (e.g., Hawaiian, Samoan) (Baruth & Manning, 2003). Amid diversity within East Asia, Holcombe (2001) identified three commonalities among East Asian countries: Confucianism, Buddhism, and Chinese script. In particular, Confucianism and Buddhism are prevailing philosophies in all three countries, which are deeply embedded in many East Asian traditions and cultural and social values to guide people’s everyday lives. In addition, while Japan and Korea have their own distinct languages, both countries still use Chinese characters (i.e., Hanja in Korea and Kanji in Japan). Bearing in mind these shared philosophical and religious beliefs and written language, an argument can be mounted to categorise Chinese, Japanese and Korean populations as a single East Asian group (Holcombe, 2001)when discussing the topic of suicide.  8 This chapter is divided into six sections. Followed by this introduction (section 2.1) is a summary of how suicide has been viewed in Western culture (section 2.2) and in East Asian culture (section 2.3). Then an extensive review in section 2.4 explores suicide in East Asian populations in Canada and the U.S. The section 2.5 includes a review of mental illness-related research conducted in the specific context of Korean-Canadian populations. Finally, this chapter concludes with the section 2.6, locating the knowledge gaps in this area of research as well as the urgency for examining suicide among Korean immigrants in Canada.  2.2 Historical Perspectives of Suicide in Western Culture Suicide has a long history. Documented as early as in ancient Egypt,1 suicide has long been present in human history. Due to the significant stigma, and religious and legal sanction against it, not until 1651, was the term ‘suicide’ listed in the English dictionary, unifying other spoken words such as  ‘self-murder’, ‘self-killing’, and ‘self-slaughter’, which all denote the wrongful act of murder onto oneself (Paterson, 2001, p.10). In fact, the negative attitude toward suicide reigned supreme in Europe until the early Renaissance, and when the question, ‘to be or not to be?’2 was posed, it stirred up a private, ongoing debate, bringing us into deeper questions about the meaning of life and death (Minois, 1999, p.3). This negative view of suicide has been challenged by many philosophical arguments such as idealism and liberalism  11The Dispute between a Man and His Ba – an ancient Egyptian text about an unhappy man who accused his ‘soul’ of dragging him towards death before his time. This single manuscript on a hieratic papyrus [Berlin Papyrus No. 3024] is also known as “A dispute over suicide”, “Debate between a man tired of life and his soul”, “The man who was tired of life”. The text is divided into seven sections – a dialogue between the man and his Ba (i.e., his soul) about the man’s wish to end his life where his Ba tries to dissuade him. The resources were primarily based on Wim van den Dungen’s text (available at http://www.maat.sofiatopia.org/ba.htm) and W. K. Simpson’s The Literature of Ancient Egypt, translated by R. O. Faulkner (available at http://www.reshafim.org.il/ad/egypt/texts/man_tired_of_life.htm) 2The opening phrase of a soliloquy in Shakespeare’s play Hamlet in 1623.   9 which position suicide as one’s basic right [and freedom]. According to these views, voluntary death is not a crime – rather it is an ultimate behaviour that distinguishes humans from other animals (Baechler, 1979; Schopenhauer, 1962). Yet, still Christian Churches maintains its view of suicide as an act of sin which is decidedly intolerable and inexcusable – except for death by voluntary martyrdom.3 Intriguing here is that the voluntary death of a martyr is not only excusable but much honored by people. Martyrdom can elude from a Christian’s rigid stand toward suicide because its intention is considered altruistic and religious (e.g., to glorify God or to choose to suffer death rather than renounce religious principles). As such, in the Western societies, a voluntary death is interpreted differently contingent on one’s motivation for committing suicide. Simply put, there are predominantly two types of suicide: egoistic suicide and altruistic suicide. For example, altruistic suicide such as martyrdom was considered an act of courage and honour, and was praised after the death. Contrarily, a commoner’s suicide to escape his/her sufferings is considered an egoistic suicide which bears significant stigma. It is viewed as a cowardly act to avoid responsibilities or escape from the reality. Until recently, this kind of suicide was severely punished by torturing the corpse and the proper burial ceremony was not offered.4 For example, in France, suicide was declared as a crime and fortified by the criminal ordinance issued in 1670. The deceased person’s body was severely punished by being drawn through the streets amid civil legislation confiscating the person’s property (Minois, 1999).  3 A martyr is somebody who suffers persecution and death for refusing to renounce, or accept, a belief or cause, usually religious. Martyrdom is the suffering of death on account of adherence to a cause and especially to one’s religious faith. For more complete definition, please see http://en.wikipedia.org/wiki/Martyr. 4Various information on the Western views and legislature on suicide presented here is mainly based on Emile Durkheim’s Le Suicide published in 1951, Minois’ 1999 book, History of suicide: Voluntary death in Western culture, and finallya BBC article written by Gerry Holt, When suicide was illegal – available at http://www.bbc.co.uk/news/magazine-14374296.   10 By the 19th century, many European countries formally decriminalised suicide; and since then a number of different definitions and major theories (Baechler, 1979; Durkheim, 1951; Freud, 1920; Menninger, 1938), and philosophical positions (e.g., moralist, libertarian, and relativist) have been proposed (Mishara & Weisstub, 2005) to better understand the behaviour. Until recently, suicide was discussed only from a moral point of view and considered as an insult to God and society (Douglas, 1967; Minois, 1999, p.3). Therefore, it was largely neglected in academic work, and not systematically studied or researched until the late 19th century, and this work strictly focused on the causes (not the moral implications) of suicide. Indeed, the empirical work of Durkheim in 1897, Le Suicide was the first academic, sociological evaluation of suicide, reporting different risk factors in European countries during the 19th century. In this work, Durkheim (1951) sought out scientific evidence on how social factors can be used to explain different suicide rates across different societies.  Here, he introduced two distinct social forces: social integration which is individual’s commitment to norms, values and beliefs (i.e., family, religion and status integration) and moral regulation which is the societal control (i.e., ethics and values) over individual’s desires. Durkheim asserted that any imbalance of these two social forces would increase the probability of suicide as defined in four categories: fatalistic, egoistic, anomic and altruistic suicide. Simply put, egoistic suicide is caused by a lack of integration; whereas, altruistic suicide is caused by too much of integration. Similarly, lack of regulation results in anomic suicide, while excess of regulation resulted in fatalistic suicide. In 1920s, Freud (1921) developed a theory of aggression where he proposed a death instinct as an internalised aggression. This Freudian concept of internalised aggression was integrated into and further expanded by Menninger. In his book, Man against himself (1938) Menninger discussed three components in the suicidal act: murder, murderer and murdered – the  11 wish to kill and to be killed. Menninger then discussed the transition of a wish to kill that turns into a wish to be killed through the process of denial which further developed into the wish to die. He also defined two categories for suicidal behaviours– chronic suicide and focal suicide. According to Menninger (1938), behaviours such as asceticism and martyrdom, alcohol addiction and psychosis were chronic suicide since the behaviours could shorten and critically hinder an individual’s life. Focal suicide included self-mutilations, purposive accidents, and poly surgery. It was considered as a type of suicide because it involves killing or destroying a part of an individual’s body. More recently, grounded in the interpretivist principles, Jean Baechler (1979), a French historian and sociologist described four types of suicide primarily based on personal reasons for choosing suicide death: escapist, aggressive, oblative, and ludic suicide. Specifically, drawing on historical accounts and cross-cultural descriptions of suicide, Baechler (1979) identified 11 types of suicidal meanings, which he allocated to four categories (see Table 1).  Table 1. Baechler’s typology of suicides5  Escapist Aggressive Oblative Ludic Flight  Vengeance  Sacrifice  Ordeal Grief  Criminal suicide  transfiguration Game Punishment  Blackmail  Appeal  The aim of the escapist suicide is to escape an unbearable situation. This category of suicide includes four sub-types that a flight suicide is the escape from a general situation; a grief suicide is followed by the loss of a central element of the individual’s personality or life; and, a  5 From Suicides (p. 63) by Jean Baechler, 1979 (B. Cooper, Trans.), New York: Basic Books (original work published 1975).  12 punishment suicide is a way for an individual to atone for a real or imagined fault. In the aggressive suicide, the primary aim of the suicide is to hurt or harm somebody else. This includes a vengeance suicide to provoke remorse in someone or make the community turn away from someone; a criminal suicide – a murder-suicide; a blackmail suicide which puts pressure on another person by depriving him or her of something valued; and an appeal suicide, whereby an individual tries to signal that he or she is in danger. The third category of suicide, the oblative suicide is to gain something by sacrificing the individual’s life in order to save or gain a greater value, or transfiguring to attain a state considered by the individual to be infinitely more delightful than life. Finally, the ludic suicide is to seek the risk and excitement that suicide brings about. For instance, through an ordeal suicide, an individual risks his or her life in order to prove him or herself or to solicit the judgment of others; whereas, the sole purpose of a game suicide is to play with one’s own life. Amid a number of theories to explain these behaviours, suicide is still not fully understood. This is due in large part, to its complex nature while new theoretical, methodological, political and ethical issues are continuously raised as the research field of suicidology evolves (Diaconu, 2010; Hjelmeland, 2010). For example, heavily grounded in the biomedical model, researchers in the 20thcentury primarily concentrated on connecting suicide with mental illnesses (Cutcliffe & Links, 2008). However, recently consensus among academics and researchers prevails that automatic association between suicide and mental illnesses is not epistemologically appropriate (Cutcliffe & Links, 2008; Maris, Berman, & Silverman, 2000; Shneidman, 2000). This is because suicide embeds not only biomedical and genetic factors but also significant philosophical, social, religious, moral and cultural aspects (Minois, 1999, p. 1),  13 which are constantly shifting. For this reason, as Minois (1999) states, suicide cannot be studied in the same way we examine a physical disease such as cancer or other somatic illnesses.  2.3 The History of Suicide in East Asian Culture Unlike Western culture’s clear positioning on suicide through religion and social institutions, there are no explicit guidelines around suicide in East Asian cultures. For example, the positioning of Buddhism and Confucianism, two central philosophies/religions that constitute the essence of the traditional East Asian culture, are ambivalent when it comes to the topic of suicide.  While Buddhist precepts advocate not to kill, there are no precise guidelines that forbids suicide. Unlike Christianity, in the sophisticated philosophical Buddhism, there is no notion of Heaven and Hell. Instead, Buddhist philosophy is fundamentally grounded in the notion of ‘temporary ego substitute’ and ‘temporary world’, prescribing that anything that can change is not ultimately real. Therefore there is no reality to one’s self, including suffering (Baker, 2008; Choi, 1996). In addition, Buddhist philosophy teaches the principle of Samsara, a cycle of birth, death, and rebirth until you reach enlightenment (i.e., Nirvana) to escape from the continuous cycle (Baker, 2008). Therefore, in philosophical Buddhism, suicide is not discussed in the context of right or wrong. Rather, according to its core principle of the denial of self and reality, suicide is an act of absolute absurdity as the reason for suicide – whichever it might be – is not real, after all. However, some forms of suicide are accepted and even striven in different sects of Buddhism such as monks’ self-immolation (Benn, 2007; Jun, 1965) and self-mummification (Hori, 1962; Sharf, 1992). Self-immolation refers to setting oneself on fire, often as a form of protest or for the purposes of martyrdom. Between the 4th and 20th centuries, Buddhist monks’  14 self-immolations were practiced in China and Tibet for religious as well as political purposes (Benn, 2007). In addition, self-mummifications among ascetic Buddhist monks by starving themselves to death, practiced in Tibet and Japan, bear more religious implications (Hori, 1962; Sharf, 1992). This ritualised suicide through self-denial is to realise the enlightenment of the Buddha (Hori, 1962). Similar to Christian acceptance of martyrdom as an honorable act, voluntary death by self-mummification and self-immolation among Buddhist monks to achieve enlightenment was honored by followers. Yet, it is important to understand that the notion of Samsara and temporary substitute ego, as well as these Buddhist monks’ religiously and politically motivated voluntary death have limited impact on commoners. In fact, as Choi (1996) suggested, only a small percentage of Buddhists believe in the theory of Samsara. Therefore, regardless of Buddhist’s ambivalent position on voluntary death, suicide still bears stigma and is taboo in Buddhist societies among commoners. For example, while there is no notion of heaven and hell in philosophical Buddhism, people took some part of the notion of samsara and reinterpreted that the person who commits suicide will reincarnate into a being such as a worm in his/her next life (Baker, 2008). Compared to Buddhist principles, Confucian ethics take less ambiguous position on suicide. Foremost, Confucian societies forbid voluntary death because one’s body is not a property of one’s own but of one’s parents – which spells that one has no right to harm it (Yao, 2000). A good example of how this concept manifests itself would be the tale of Xiahou Dun, a prominent military general during the late Han Dynasty. According to legend, when an enemies’ arrow was shot in Xiahou Dun’s left eye, he pulled out the arrow with his eye still attached to the arrow’s point, cried, “The essence of my parents cannot be thrown away” and swallowed his  15 damaged eye.6 This story vividly illustrates how Confucian ethics – in this case, filial piety – played a fundamental role and influenced people in ancient East Asia. To fully grasp how Confucian ethics affect the way of life among East Asians, we must understand that Confucianism is primarily about the role in the society, which is defined by one’s relationships to others within the hierarchy. Also, it is noteworthy to acknowledge the critical role that Confucian values played in providing the basic ethical guidelines for the commoners. Indeed, at least for lay people, Confucianism built the basics of East Asians’ moral principles while Buddhism provided additional ethical guidelines building on the base laid by Confucianism. Of the numerous virtues promoted in Confucianism [e.g., Humaneness, Loyalty, Etiquettes, Righteousness], the virtue of Filial Piety is considered among the core values that mandates respect for one’s parents and ancestors. This obligation is not limited to the living parents by respecting them and attending their daily needs but extends to the deceased parents and ancestors by performing ancestral rites. Therefore, one’s suicide is definitely immoral as it involves not only destroying others’ (i.e., parents) property, but also, not being able to fulfill one’s important duty to keep their ancestors immortal through ancestral rites. Hence, suicide is regarded as the most non-filial act in Confucian societies and this belief still exerts great influences in the modern East Asia. However, there are always exceptions. If the virtue of filial piety is out weighted by the virtues of Humaneness and Righteousness, suicide is not only accepted but in fact expected. Since the Han Dynasty, the principles of Humaneness and Righteousness became the utmost  6This famous anecdote is from Luo Guanzhong’s Romance of the three Kingdoms translated to Korean by Lee Mun- Yeol in 2002. The book is a historical novel set amid the turbulent years near the end of the Han Dynasty and the three kingdoms era of Chinese history during 169-280.      16 important virtues. In particular, when combined together, it was the supreme morality – the quintessence of the ideal life [and death] that will be remembered, respected and honoured in history (Lo, 2002). Therefore, it is important to understand that these two virtues are considered more important than one’s life itself, whereby choosing death to preserve these two virtues was deemed praiseworthy and even obligatory. Said another way, preserving life through accepting humiliation is worse than death (Kim Hogarth, 1996; Lo, 2002; Yao, 2000). It is important to understand that these virtues do not only exist in abstract concepts. Since the Han Dynasty, the Humaneness and Righteousness were reinforced and practiced through human relationships and interpersonal commitments (e.g., familial, social and political relationships). Therefore suicide to preserve the virtues within these relationships and commitments are acceptable. These includes suicide for the sake of the country; of the husband; of the master; of the benefactor, as a token of gratitude; of a friend – brotherhood; of keeping a secret for somebody; of saving other lives; and, of avenging one’s parents, husband or master (Lo, 2002). Aside from suicide to protect the virtues of Humaneness and Righteousness,  there was a similar morally positive view on death with dignity – an  honour-suicide, committed to avoid humiliation and disgrace. A good example for this is a voluntary death by noblemen during the Joseon Dynasty who were offered to choose between suicide and paeng-hyung.7 The convicts who got paeng-hyung were mostly noblemen and once paeng-hyung was executed where the convict went into the cauldron filled with tepid water, all of his social and political roles, identities and privileges were stripped. When he came out of the cauldron, people needed to  7 Paeng-hyung is a form of capital punishment – a death by boiling during the Joseon Dynasty. Unlike the original form of paeng-hyung in Mongolia, where the convicts were literally boiled to death, during the Joseon dynasty, it became an honorary execution.  17 behave as he was dead. Therefore, even though he was physically alive, he was socially and politically condemned – a social death penalty.8 Therefore, when they were offered to commit suicide or get paeng-hyung, most of noblemen during the Joseon Dynasty opted suicide to keep their – as well as their family’s – status and honour after death. Amid ambivalent positioning of philosophical Buddhism and Confucianism on the topic of suicide, evident are different stances towards suicide in East Asian culture particularly among the commoners: 1) suicide committed for self-regarding reasons (equivalent of Western ‘egoistic suicide’); and 2) suicides committed for other-regarding reasons (equivalent of Western ‘altruistic suicide’).  Yet, there are apparent two-fold differences between East Asian and Western dual positions on suicide. First, while egoistic suicides bear tremendous stigma and are unjustifiable in Western culture, in the East Asian context, some self-regarding suicide can be condoned, by securing sympathy from other people such as honour-suicide. It seems that if the motive of a voluntary death is to avoid disgrace to oneself or one’s family, or to accept one’s mistake, honour-saving suicide death is not only accepted but viewed as appropriate. Secondly, other-regarding suicide in East Asian culture encompasses a broader sense than altruistic suicide in Western culture as Lo (2002) further explains: First, in other-regarding suicides, the reference of “other” can range from one individual to the entire country. Second, the meaning of “other-regarding suicide” is wider than that of “altruistic suicide” because altruism is consequences-oriented, viz., the promotion of others’ interest. Other-regarding suicide can be consequence-  8 Various information on the paeng-hyung presented here is based on Online Korean Culture encyclopedia available at http://terms.naver.com/entry.nhn?cid=1595&docId=527879&mobile&categoryId=1595. There were also a number of passages on paeng-hyung in the Daily Records of the Royal Secretariat of the Joseon Dynasty – particularly during the Injo, Yeongjo, and Gojong’s reign - for more information visit http://db.itkc.or.kr.   18 oriented, but not necessarily so; it can be a suicide for the sake of manifesting one’s total dedication to another person or persons. (p.625)   Yet, evident across Western and East Asian cultures is that the type of suicide that bears stigma and taboo belongs to the category of egoistic self-regarding suicide; while the altruistic other- regarding suicide has not only been accepted but sometimes glorified.  2.4 Suicide among East Asian Populations in North America  Recent research and media coverage has called attention to the alarming suicide rates among East Asians in North America, particularly women and adolescents (Cho & Haslam, 2010; The New York Times, 2009; Time Health, 2008). This has compelled researchers to consider the role that culture might have in influencing one’s decision to take his/her own life. Specifically, understanding the context behind differing suicide risks and protective factors for a group of people belonging to a particular culture [or sub-culture] is crucial to develop targeted suicide prevention and intervention strategies. Yet, suicide among these sub-populations is poorly understood. For example, there are no clear patterns established regarding the rates of suicidal ideation and behaviours among East Asian populations in North America (Han et al., In press). Indeed, literature reveals mixed and inconsistent findings regarding suicidal ideation and behaviours, and risk and protective factors among East Asian populations. In a synthesis of the literature review of suicide among East Asian populations in North America, four key findings are shared; 1) rates of suicidal ideation and behaviour; 2) acculturation; 3) family support; and, 4) different manifestation of suicide among East Asian populations.   19 2.4.1 Rates of suicidal ideation and behaviour  Some studies indicated that East Asians exhibited higher suicidal ideation and behaviour compared to the general North American populations (Aubert, Daigle & Daigle, 2004; Choi, Rogers, & Werth, 2010; Duldulao, Takeuchi, & Hong, 2009), while other studies reported the opposite results (Cheng et al., 2010; Cho & Haslam, 2010) or no evidence of difference between these sub-populations (Kennedy, Parhar, Samra, & Gorzalkla, 2005). For example, Kennedy et al. (2005) examined first, second, and third generation immigrants of Chinese, Indo- Asian, and European descent in Canada and did not find any differences in terms of suicidal ideation, plans, or behaviours across these sub-groups. However, Choi et al.’s (2010) findings reported that East Asian American college students showed a greater degree of suicidal behaviour (M=5.98; SD=2.84) compared to European American students (M=4.82; SD=2.41) in other studies (see Muehlenkamp, Gutierrez, Osman, & Barrios, 2005). In addition, a Canadian- based study by Aubert et al. (2004) compared suicide risk and hostility between Chinese Canadian students (N=89) and Canadian students in general (N=81), and showed that the Chinese Canadian students scored higher on suicidal ideation, as well as the Hostility and Direction of Hostility Questionnaire (HDHQ). In contrast, Cho and Haslam (2010) and Cheng et al. (2010) reported less suicidal ideation and behaviours among East Asian sub-groups in North America. In a U.S.-based comparative study, Cho and Haslam (2010) found that Korean immigrant students exhibited lower suicidal ideation than mainstream American students. In line with this finding, Cheng et al. (2010) demonstrated that, of the 191 East Asian participants, 2.5% reported suicide attempts and 8.8% reported suicidal ideation in their lifetime, which were lower than the national averages of 4.6% and 13.5%, respectively. When these participants were disaggregated by birthplace, Cheng  20 et al. (2010) noted that those who were foreign born reported lower rates of suicide attempt (2.2%) and ideation (7.6%) than the U.S.-born East Asian participants (3.5% and 12.4%). The statistical significance of these rates was not explicitly discussed in these studies; nonetheless, the differing rates are suggestive of a possible correlation between birthplace and the prevalence of suicidal ideation and attempts.  2.4.2 Acculturation and suicide In the literature, acculturation – a process of cultural and psychological changes among minority groups to adapt to new conditions of life (Berry, 1997; Sam & Oppedal, 2003) – was often discussed, and connections between acculturation [and stress thereof] and suicide described. Yet, despite efforts to connect suicide to distress levels associated with acculturation, the literature failed to reach consensus. Han et al. (In press) suggested that perhaps acculturation (e.g., language proficiency, friendships, social behaviours and attitudes) itself is not only difficult to define and measure, but varies significantly in predicting suicidal ideation and behaviour. Some studies did not find any significant associations between acculturation and suicidal ideation and behaviour (Choi et al., 2010; Kennedy et al., 2005); whereas, other studies underscored some potential connections (Aubert et al., 2004; Cho & Haslam, 2010; Duldulao et al., 2009). In Choi et al.’s study (2010), the association between suicide and acculturation of 314 Asian American college students was explored using the College Student Reasons for Living Inventory (CSRLI) and found no connection. Similarly, in a Canadian-based study conducted in Vancouver, B.C., Canada, Kennedy et al. (2005) revealed no significant differences in suicidal ideation among Chinese, Indo-Asian, and European immigrants across diverse generations. To  21 explain this result, Kennedy et al. (2005) suggested the rich and diverse ethnic and cultural community in Vancouver, Canada wherein large Chinese and Indo-Asian communities reside reduced the stress that can emerge from immigration and acculturation. They posited that this may be an important protective factor for recent Chinese and Indo-Asian immigrants that reduced the potential for acculturation induced stress. In fact, many previous studies support the enormous benefits of having communal and community based social support from the individual’s own culture or ethnicity (Donnelly, Hwang, Este, Ewashen, Adair, & Clinton, 2011; Noh, Speechley, Kaspar, & Zheng, 1992). On the other hand, Cho and Haslam (2010) argued that although acculturation was not directly associated with suicidal ideation, longer durations of stay in the U.S. were associated with greater distress in Korean adolescents, implying that distress can increase over time as Korean immigrants or international students adapt (or not) to their new environments. In line with this finding, Duldulao et al. (2009) reported that U.S.-born East Asian American women had much higher suicidal ideation (15.93%), plans (7.14%), and attempts (6.29%) compared to the  U.S. national estimates (8.58%, 3.31%, and 2.54%, respectively), and to East Asian immigrant women who came to the U.S. more recently (7.92%, 2.45%, and 2.69%, respectively). Explaining this result, Duldulao et al. speculated that U.S.-born East Asian women may be exposed to greater socio-political risk factors such as sexism and racism as they are more integrated into the dominant society; whereas recent immigrant East Asian women are less acculturated and therefore less exposed to such risks. Similarly, Aubert et al. (2004) argued that even though their research findings were difficult to interpret, it provided some potential connections between acculturation and suicide. They compared three sub-group of: 1) Chinese- Canadian students who immigrated to Canada at the age of 10 years or older; 2) Chinese-  22 Canadian students who immigrated to Canada when they were younger than 10 years old; and, 3) Chinese-Canadian students who were born in Canada. The study findings revealed that Chinese- Canadian students who came to Canada at the age of 10 years or older showed higher suicide risk than those students who immigrated before age 10. Therefore, they hypothesised that the Chinese-Canadian students who were born in Canada would have even lower suicide risk. However, the results demonstrated that this group exhibited higher suicide risk than the Chinese- Canadian students who immigrated to Canada at a younger age; yet, lower than those who came to Canada at the age of 10 or older.  2.4.3 Family support and suicide Many research studies suggested that family support and conflict play a critical role in East Asians’ suicidal ideation and behaviours, whereby high levels of family conflict and low support directly increase suicide risks within this sub-population (Cheng et al., 2010; Cho & Haslam, 2010; Chung, 2003; Lau, Zane, & Myers, 2002; Noh, Kaspar, & Wickrame, 2007; Wong, Brownson, & Schwing, 2011a; Wong, Tran, Koo, Chiu, & Mok, 2011b). For example, Lau et al.’s (2002) study of East Asian American youth and suicide risk factors highlighted that family conflict, especially the intergenerational parent-child conflict, played a significant role in suicidal ideation and behaviour among East Asian American youth, particularly for less acculturated East Asian youth.  Lau et al. (2002) suggested this may be due to their limited social support network outside of their family and holding more collectivist values which stress the importance of family and relationship harmony, filial piety, and avoiding confrontation and conflict.  This finding is consistent with the sense that East Asian’s collectivist and interdependent cultural orientations that stress the centrality of the family can increase suicidal  23 ideation and behaviours. Furthermore, as part of a U.S. multi-campus national study, Wong et al. (2011a) conducted a descriptive analysis of the types of events that occurred prior to the onset of suicidal ideation in East Asian American students. They identified the three most frequently reported events as family problems (47.7%), academic problems (43.1%), and financial problems (24.6%), adding further empirical weight to underline the interconnectedness of family conflict and East Asian American’s suicidal ideation. Perhaps, in the context of collectivist and interdependent cultural orientations, both conflict within and alienation from one’s family could lead to suicidal ideation and behaviour in East Asian populations. A U.S-based study examining cultural validity in the College Student Reasons for Living Inventory (CSRLI), revealed utility across cultural sub-groups of Asian American college students with the exception of the subscale Fear of Social Disapproval (Choi et al., 2010). Here, Choi et al. (2010) acknowledged the potential insensitivity of their social disapproval survey question items to East Asian American students as well as diverse cultural understandings of what ‘social disapproval’ means within this sub-group. For example, in the CSRLI, social disapproval is directed toward the individual (e.g., “killing myself would show a lack of character”); whereas, East Asian Americans may attribute social disapproval directly to their family instead (Choi et al., 2010). Said another way, East Asian students may interpret social disapproval as a consequence that their negative action would bring to their family, rather than themselves. The family support and conflict can also connect to the notion of ‘model minority’ discussed in several studies (Chung, 2003; Noh et al., 2007; Wong et al., 2011a; 2011b) as there was consensus that performing well academically was an important family obligation for East Asian students. The notion of model minority refers to a stereotype or image of East Asian  24 Americans, portrayed as hard working and high-achieving (Wong, Lai, Nagasawa, & Lin, 1998), which can have negative impacts on individuals who belong to a model minority group and align to their expectations (e.g., exam anxiety; alienation from other students etc.) (Qin, Way, & Mukherjee, 2008; Wong et al., 1998). They argued that this as a prime example of model minority in that parental and societal expectations about academic performance had to be met to bring honour to and approval from the family. Therefore, many East Asian American college students perceived these expectations as a major cause for their suicidal ideation (Noh et al., 2007; Wong et al., 2011a; 2011b). For example, poor academic performance (e.g., low GPA) was an especially salient risk factor among East Asian American college students (Wong et al., 2011a).  2.4.4 Manifestations of suicide Some studies found that East Asians manifested psychological distress and suicidal ideation differently than the general population. East Asians tend to internalise rather than externalise thoughts about suicide (Lau et al., 2002), exhibit fewer depressive or anxiety symptoms (Cheng et al., 2010), resist reporting suicidal ideation (Aubert et al., 2004) and/or deny illness amid self-blame and embodying destructive risk-taking behaviours (Noh et al., 2007). Although depression is a strong correlate of suicide in the general population, connections between depression and suicide among East Asian Americans are less evident. In a U.S.-based study (Cheng et al., 2010), 50% of the East Asian American is who reported suicidal ideation, and 34% of the attempters did not meet DSM-IV criteria for any depressive or anxiety disorders. While speculating that East Asian Americans are more likely to express psychological distress through somatic complaints, it was suggested that the DSM-IV might not be culturally sensitive  25 or tailored to capture the unique expressions and manifestations of depressive and/or suicide symptoms among East Asian Americans (Cheng et al., 2010). In a study of 285 East Asian American youth who had received outpatient mental health services, Lau et al. (2002) revealed that suicidal East Asian American youth displayed more internalizing symptoms (e.g., withdrawing from others, being anxious and worried) than externalizing symptoms (e.g., being disobedient, antisocial, impulsive). Other studies concurred, including a qualitative interview study that examined suicidal ideation and behaviour of 26 East Asian American women (Noh et al., 2007). Noh et al. (2007) stressed that East Asian American women’s specific ways of manifesting suicidal ideation and psychological distress (e.g., self- blame, self-destruction, and risk taking behaviours), or inability to express their psychological pain (i.e., self-denial, silence) needs to be taken into consideration while acknowledging their specific cultural and social contexts (e.g., the importance of family cohesion) to develop effective healing therapies. In addition, the tendencies to conceal personal issues in attempting to maintain family cohesion among the study participants (Noh et al., 2007) can be explained in the context of collectivist and interdependent cultural orientations. Given that East Asians may manifest suicidal ideation and behaviours differently than the mainstream population in North America (e.g., internalizing, risk-taking behaviours and denial), it seems unlikely that generic suicide measurement scales are sensitive to individuals of EA ancestry. Perhaps, specific manifestations such as somatisation and/or denial of suicidal ideation and behaviours among East Asians might be culturally adapted ways of carefully avoiding the stigma of suicide. These findings are in line with some studies conducted in East Asian that highlight how Chinese families tend to focus on suicidal patients’ somatic symptoms and needs (Tzeng & Lipson, 2004). In a Taiwanese-based study, Tzeng and Lipson (2004)  26 investigated stigma among Taiwanese suicidal patients and their families following non-fatal suicidal attempt. They found that in conjunction with the common cultural belief in East Asian that suicide is hereditary, the Confucian and Buddhist moral mandates significantly contributed to form a serious post-suicide attempt stigma. Stigma marginalised patients and their families and further inhibited them from expressing their distress and/or seeking help. In effort to alleviate or reduce pain and stigma, the patients and their families reinterpreted suicide attempts as bad luck, hot/bad energy, or not a true suicide. Accordingly, bereaved East Asian family members also tended to internalise the pain and shock, along with the shame and guilt flowing from a family member’s suicide. For example, regardless of the Chinese culture’s emphasis on the burial ceremony, the suicide survivors kept the victims’ funeral private, hid it, or expelled the deceased from the family in effort to conceal the suicide to protect the family from stigma and dishonour (Tzeng, Su, Chiang, Kuan, & Lee, 2010a). In that process, they made both the deceased and family survivors ‘invisible’ (Tzeng, Su, Tzeng, Yeh, Chen, & Chen, 2010b). While it is usual for Western suicide survivors to seek support from outside the family, Taiwanese suicide survivors deliberately avoided  seeking help or comfort from other people in order to preserve the family’s honour and evade the stigma of suicide (Tzeng and Lipson, 2004; Tzeng et al., 2010a; Tzeng et al., 2010b). Tzeng et al. (2010a; 2010b) concluded that the stigma experienced by suicide survivors may be universal; yet, suicide survivors’ responses to the aftermath of suicide are strongly influenced by their sociocultural contexts. It is within this context that studies examining suicide among East Asians in North America reveal important methodological and empirical insights. Within the limited empirical literature addressing suicide in the context of East Asian populations in North America, there  27 was consensus that denotes the importance of taking cultural and social contexts into consideration. There were strong assertions that many risk and protective factors for suicide are culturally salient and dependent on cultural values, beliefs and norms such as relational harmony, conformity to norms, and filial piety. While East Asian collectivist and interdependent orientations can underscore bringing honour and protecting family from shame and dishonour, evident also was the possibility that these cultural alignments might shift within and across generations to influence what factors reside as risky or protective for suicide.  2.5 Conclusion  Throughout the literature on suicide among East Asian populations in North America (section 2.4), the importance of examining and understanding social positions and conditions, and cultural context of immigrants prevailed. Importantly, the patterns as well as inconsistent findings in the literature revealed the urgent need for research investigating suicide among immigrants. Suicide is a complex issue – dealing with the macro-level social and cultural influences which interplay with micro-level individual and interpersonal factors. To address this knowledge gap, this research study explored the connections between culture and suicide among Korean-Canadian populations. Specifically, through individual qualitative interviews, delineated are descriptive and in-depth understandings about East-Asians-Canadians’ perspectives of and attitudes toward suicide as well as their experiences as an immigrant.      28 Chapter 3 Methods   3.1. Introduction  3.1.1 Ethnography as methodology  The key points of interest in this study are participants’ experiences, attitudes, perceptions, interpretations, beliefs and understandings of suicide. These view points are solicited to understand and describe the ‘what’, ‘how’, and ‘why’ of a phenomenon (i.e., suicidal ideation and behaviour) which confirms the appropriateness of a qualitative approach for this study (Green & Thorogood, 2009). However, the specific research method to employ in the study was not readily apparent in the beginning of the research process. When first suggested by my principal supervisor to consider ethnography for this research study, I was not entirely convinced. The notion of ethnography as a research practice that social science researchers use to understand human groups by fully immersing themselves into the same social space as the participants in the study (Madden, 2010, p. 17) seemed foreign and overwhelming to me. In particular, labour-intensive and time-consuming conventional classic anthropological ethnography (e.g., a long-term commitment to a research study, collecting multiple forms of data, etc.) seemed challenging  for a masters-level student due to cost and time constraints as well as lack of research expertise. However, after a few hours of intensive reading on ethnography, these concerns and presumptions that made me wonder ‘why ethnography’? were soon replaced by ‘why not ethnography?”9 As Wolcott (1988) summarized, Ethnography means:  … literally a picture of the way of life of some identifiable group of people. Conceivably, those people could be any culture-bearing group, in any time and place. (…) Particular  9 A title of a journal article: Oliffe, J. L. (2005). Why not Ethnography? Urology Nursing Journal, 25(5), 395-399.  29 individuals, customs, institutions, or events are of anthropological interest as they relate to a generalised description of the life-way of socially interacting group. Yet culture itself is always an abstraction, regardless of whether one is refereeing to culture in general or to the culture of a specific social group. (p. 188).  As such, ethnography as a research method fits my study with its mandate on cultural interpretation and analyses (Wolcott, 1990, p. 69). Also, the ontological and epistemological underpinnings of ethnography which emphasise social processes and participants’ realities to understand a particular situation (De Laine, 1997, p.163) suit the philosophical and theoretical grounds of the research study.  Moreover, while maintaining traditional holistic approaches, new hybrid forms such as focused ethnography, permit a narrowed focus and more manageable research objective to describe particular behaviours in specific contexts rather than attempting to portray a whole cultural system (de Laine, 1997, p. 17). This is especially beneficial for new, different or unknown research topics because ethnography seeks to build theories of human behaviours and attitudes to understand what it means to be human in particular social and cultural contexts (Madden, 2010, p 17; Oliffe, 2005;).  In that sense, this theory-generating characteristic of ethnography is decidedly attractive and needed for the current research arena where both theory based and empirical work is lacking. However, there is also an ongoing debate on the scientific status of ethnography where the focus is upon relatively small samples and unstructured method of data collection, which leads to the issues around generalisability of the research findings. Yet, as Oliffe (2005) argues, ‘the aim of ethnography is in fact, to describe particular cultures in specific contexts rather than claiming research findings as representative of, or generalisable to, other groups’. Therefore, the choice of small samples and semi- or un-structured ways of data collection  30 represent a trade-off between studying cases in depth or breadth where ethnography focuses on the former (Hammersley, 1990, p. 9).  3.1.2 In-depth interviews Even though a shared set of meanings (e.g., cultural rules and norms) can exist in a given society or sub-group, it is in fact individuals who interpret them in a variety of ways. Semi-structured individual interviews were chosen as the research method because they offer access to people’s ideas, thoughts and memories that guide behaviours in their own words rather than in the words of the researcher (De Laine, 1997). Also, this method gave participants more freedom in and control of the interview situation than with structured approaches (Kirsch, 1999), inviting them to discuss what was most important and relevant to them in regards to suicide. This was especially important to the current research study because to investigate a deeply stigmatised topic such as suicide, it is crucial to minimise the researcher-researched power dynamic and create an environment where participants can talk freely and comfortably about suicide. In addition, in-depth interviews have potential benefits for participants as Stein, Brom, Elizur and Witztum (1998) argue, just talking about suicide helps to demystify and de-stigmatise it which can increase help-seeking behaviours in participants. In sum, semi-structured individual in-depth interviews provided a rich contextual knowledge by focusing on each participant’s relevant issues pertaining to suicide while emphasising depth, nuance, complexity and roundedness in their narratives (De Laine, 1997; Mason, 2002). Despite its numerous advantages, in-depth interviews also have limitations. While in- depth interviews can generate rich data because it allows for expansions and clarifications, it can also easily get sidetracked (Madden, 2010). In addition, it is important to recognise that all  31 participants did not find it easy to express themselves verbally and be equally credible (Mason, 2002). These problems are directly linked to the expertise of the researcher in facilitating in interactive and reflexive ways while closely monitoring and carefully steering the interview using the interview guide (Kirsch, 1999). In fact, often the apparently irrelevant information in the interview turned out to be closely related to the research questions in the larger scheme which can also be followed by using probing questions.  3.1.3 Participant observations As Mason (2002) argues, it is important not to over-estimate the representational or reflexive qualities of interview transcripts as they are always partial, an incomplete record of non-verbal aspects of the interaction. Therefore, in addition to the in-depth interviews, a participant observation method in a form of systematic fieldnotes was used in the current study. This approach was used to add context to the participants’ interview data paying attention to their non-verbal communication. Guided by Spadley’s (1980) checklist for fieldnotes including space, actor, activity, object, act, event, time, goal and feeling, I paid close attention to visual elements (e.g., appearance, attire, affect, body language, facial mannerism, gestures, eye contact, etc.); speech elements (e.g., voice quality, speaking style, intonation, stress, etc.); and environmental elements (e.g., where interview took place, layouts and spatial characteristics, etc.) (Mason, 2002, p. 89; Punch, 2005, p. 181). Furthermore, I included a reflexive analysis, recording my reactions and emotions to analyse how I influenced, and was influenced by the interviews (e.g., power dynamics, emotions).    32  3.1.4 Ethics Ethics approval of the research study [H11-03418] was obtained from the University of British Columbia in April 2012.  3.2. Methods 3.2.1 Participant recruitment Using the purposive sampling technique, fifteen Korean immigrants were recruited May through November 2012 from the Greater Vancouver, Canada. Recruitment strategies included print and online media advertisement in weekly Korean newspapers (e.g., Gyocharo; VanChosun) and English online site (e.g., Craiglist), and recruitment flyers available in both English and Korean (see Appendix A and B) posted at various sites including large Korean supermarkets and restaurants (e.g., H-mart, Hanam), and college and university campuses in Vancouver (e.g., UBC, Langara college). Recruitment flyers described the study objectives and invited potential participants to contact me for more information.The participant inclusion criteria were as follow: a) First-generation Korean immigrants– defined as Korean born; b) 19 years or older; c) Reside in the Greater Vancouver area; d) Speak English and/or Korean; and, e) Have previously experienced suicidal thoughts and/or attempted suicide.  When contacted by potential research participants, the study was further explained and the inclusion criteria questions were asked to confirm their eligibility to participate in the  33 study (see Appendix C). Eligible participants were provided with an opportunity to ask any questions about the project and an interview meeting was scheduled to take place at a time and location convenient for participants.  3.2.2 Study participants A total of 15 Korean immigrants – 4 male and 11 female – between the ages of 20 and 62 years old (M= 32.6) who self-identified as first-generation Korean immigrants participated in this study. The term first-generation immigrant is used to define a generation status which includes persons who are foreign born, immigrated to Canada for the purpose of permanent residence (Statistics Canada, 2006). Participants lived in Canada for 1 to 25 years (M=10.7 years; SD = 7.8). All 15 participants previously had experienced suicidal ideation and 2 (1.3%) disclosed that they had experienced non-fatal suicidal behaviours in the past. Four participants sought professional help for their suicidal thoughts and behaviours. Using the Beck’s Scale of Suicidal Ideation (BSS; Beck & Steer, 1991), the severity of participants’ suicidal intent was assessed retrospectively when it was at its worst point. Here, participants were asked to cast their minds back to the time of greatest suicidal thoughts and fill out the BSS based on that experience. The results from two participants were not included in the analysis because the scales were not completed properly or completed using the current perspective – not retrospectively. Of thirteen BSS results, ranging 9 to 28, most of the participants (n=9) scored 10 or higher for their suicidal intention at the worst point. Table 2 provides more details on the participant demographic characteristics.    34  Table 2. Participant demographics Demographics Age 20-29 30-39 40-49 50-59 60-69 Mean Range   8 4 1 1 1 32.6 20-62 Gender Male Female   4 11 Religion Atheist Buddhist Catholic Christian Protestant Spiritual None   1 2 6 2 2 1 1 Marital Status Single/never married Married Common-law Separated Divorced   7 5 1 2 Living Status Alone Roommates Parents Spouse/partner Spouse/partner and children Spouse/partner, children and other extended family  1 5 2 2 4 1 Years in Canada 0-5 years  5 6-11 years More than 11 years  3 7  Highest Education College University – Undergraduate Currently in university - Undergraduate University – Graduate Not specified   1 6 5  2 1 Current Occupation Students IT industry Service Industry Homemaker Employed – but not specified Not specified    7 2 2 1 1 2 Previously sought treatment(s) Yes No  If yes, type(s) of treatment Psychiatrist Psychologist Medication Other counseling   4 11   1 1 1 2 BSS Score [of 13] At the worst point 0-9 10 or above Not specified Mean Range    4 10 1 13.2 0-28         36 3.2.4 Data collection  Prior to interviews, the research study and objectives were explained, and participants were provided with an opportunity to ask questions. The written informed consent was reviewed verbally to ensure that the consent was given based on a complete understanding of the scope and voluntariness of participation. Upon completion of written consent form, participants provided demographic details. Individual semi-structured interviews lasting 30 to 90 minutes were conducted in the participants’ preferred language (i.e., English or Korean), seeking an in-depth understanding of the participants’ experiences, attitudes, perceptions, interpretations, beliefs, and understanding around suicide. Interviews were conducted May through December, 2012, and were directed by the interview guide (see Appendix D and E) which was derived from three overarching research questions. Specifically, questions such as “in your opinion, how do people view suicide?”, “what do you believe led you to consider suicide?”, “how did you manage your suicidal thoughts and/or behaviours?”, “what is life? What is death?” were included. Yet, participants also discussed what was most important and relevant to them in regards to suicide. The interview questions were open and not worded or nuanced to support any particular theoretical perspective. During and after each interview, participant observation fieldnotes were completed to document the overall impression and details of the interview (e.g., participant affect, body language, power dynamics and so on) as well as my own reactions and emotions towards the participants’ narratives (see Appendix F). In addition, at the end of the interview, I asked participants to complete the 19-item Beck’s Scale of Suicide Ideation (BSS; Beck & Steer, 1991), and also solicited their feedback about the interview in general. These participant observation fieldnotes were used in the analysis process to provide more detailed context. Participants received a  37 nominal honorarium of CDN $30 to acknowledge the time spent and their contribution to the study. Also they were provided with a printed list of mental health service resources available in both English and Korean (see Appendix G and H).  3.2.5 Instruments used in data collection Participants were asked to complete a demographic survey to obtain information pertaining to their age, gender, religion, marital status, living situation (e.g., living alone, with roommates, parents or spouse/partner etc.), the length of residence in Canada, education and employment background as well health information (see Appendix I and J). In addition to the demographic survey, the Beck’s Scale of Suicidal Ideation (BSS; Beck & Steer, 1991 – see Appendix K) was administered to systematically assess participants’ degree of suicidal intention at its worst point. The BSS is a 19-item scale to measure severity of individual’s suicidal intent by scaling various dimensions of self-destructive thoughts, plans and expectations (Beck & Steer, 1991). This self-reported scale is one of the most widely used measures of suicidal ideation which can be completed in 5-10 minutes. The BSS has moderately high average of internal reliability with Cronback alpha coefficient of 0.87 to 0.90, and test-retest reliability of 0.54 (Beck & Steer, 1991; Steer, Kumar, & Beck, 1993). These items are rated on a three-point scale (0 to 2); therefore, total scores could range from 0 to 38 – increasing scores reflect greater suicide risk. There is no formal cutoff score for serious suicidal ideation; yet, Holi et al. (2005) reported that in some previous studies, a score of 6 or higher has been used as a cutoff threshold for clinically significant suicidal ideation in adults while suggesting a cutoff threshold score of 4 for adolescents. The BSS is one of the few suicide assessment instruments to have documented the predictive validity for completed suicide (Beck & Steer, 1991; Steer et al.,  38 1993). However, the inclusion of the BSS in this research study was not intended to predict suicide; rather it was primarily used to describe the degree of the participants’ previous suicidal intention at its worst point. Specifically, participants were instructed to recall their experience of most intense desire to commit suicide. The rationale of this retrospective assessment is to better understand and describe the participants’ history of suicidal ideation and attempts, as well as their perceived severity of their previous suicidal intention.  3.3. Analysis 3.3.1 Data analysis Data analysis was concurrent with data collection and continued through the writing up of the results. Interviews were digitally recorded, translated to English where necessary, transcribed verbatim excluding identifying information. Each transcript was checked for accuracy and imported to QSR NVivo 8TMqualitative data analysis software, for coding and data management. This research study was based on the three research questions as key concepts, and using constant comparison analysis methods, recurrent, prevailing themes were identified. Constant comparison analysis is synonymous with grounded theory and it was used as an analytic method in clarifying the meaning of each theme and exploring their relation to one another (De Laine, 1997, p. 241). This method is used to accommodate the fluid and dynamic nature of data collection and analysis to explore and describe social situations and to understand social phenomena (Corbin, 2009). It worked in the cyclical process of collecting data, analysing it, developing provisional codes and using this to suggest further sampling and analysis, and checking out emerging theory until a point of theoretical saturation was reached (Green & Thorougood, 2009, p. 203; Punch, 2005, p. 158). Specifically, the first few interviews entailed  39 open coding to identify as many potential codes as possible. As data collection progressed, interview questions were further refined to address and test the emergent findings derived from the early analyses. Then, to detail more descriptive summaries as well as core concepts of the data (Strauss & Corbin, 1998), these codes were reassembled into tentative themes including– perceived normative perceptions and attitudes toward suicide; participants’ own perceptions and attitudes; causes and triggers; protective factors; manifestations; cultural and immigration-related experiences; experiences in Korea; world view; management strategies; and views of life and death.  In the process, each transcript was read multiple times in three distinct ways – literal (e.g., literal dialogue), interpretive (e.g., my interpretation) and reflexive (my role in the interview) (Mason, 2002) – to ensure the consistency and roundedness in my interpretation and representation of the data. As additional interviews were completed, these codes were then condensed into a more sophisticated and concrete theoretical theme by gathering together those that were relevant. As a result, three emergent themes were identified for the current research study: 1) the perceptions of and attitudes toward suicide among Korean-Canadian immigrants; 2) the participants’ narratives around the causes and triggers of their suicidal thoughts and behaviours; and 3) the participants’ manifestations of and strategies to manage their suicidal thoughts and behaviours. Initially, a separate theme to describe participants’ immigration experiences was to be included in the findings. Yet, after numerous readings of the first ten interview transcripts, it was evident that most of narratives around immigration (e.g., the reasons for immigration, experiences as an immigrant in Canada) were deeply embedded in, thus should be reflected in the three aforementioned sections. Given that the primary study aim was to understand the  40 culture-specific experiences of suicide among Korean-Canadian immigrants, immigration experiences were relevant and integrated with participants’ suicidal thoughts and behaviours. Overall, the key focus in the data analysis was to provide a detailed, context-rich account by paying particular attention to the ways in which culture influenced the participants’ experiences, attitudes and beliefs around suicide. Throughout the data analysis process, participant observation fieldnotes taken during and after interviews were referred to for further context and analysis.  3.3.2 Reflexivity Ethnographers do not have an undisputed warrant to study others; this right has been lost. Self-reflection is no longer an option, nor can it be presumed that objective accounts of another’s situation can be easily given. Truth is also always personal and subjective. An evocative and not a representational epistemology is sought. (Denzin, 1997, p. 265-266)  In conducting the research study, I have critically reflected on my positionality in the research – particularly my shifting position along the insider-outsider spectrum. I self-identify as a first-generation working-class Korean-Canadian female graduate researcher, examining suicide among other Korean-Canadian immigrants. Through various community involvements and social networks, I am much integrated into, thus have access to, the Korean community in Vancouver. This is important because it provided some assurance about the feasibility of conducting the research study and aided participant recruitment. Likewise, my proficiency in Korean played a pivotal role in conducting interviews with 10 participants who preferred to be interviewed in Korean.  Thus, I can confidently present myself as a culturally literate insider researcher, gifted  41 with the ‘double perspective’ (Kirsch, 1999, p. 14) and ‘double consciousness’ (Du Bois, 1903). However, as a graduate researcher, I also assumed the role of an outsider – asking questions, analysing and defining the participants’ realities in my own words largely based on my interpretations. Yet, as the research progressed, I soon realised my ambiguous and multiple positionality as an insider, outsider and beyond. In fact, the sub-population that I am interested in is a somewhat invisible group within the Korean-Canadian community (i.e., a group of Korean immigrants who had suicidal ideation and/or attempted suicide). That said, the membership to the Korean-Canadian community confirmed my position as an insider whilst the same membership had the potential to cast me as a pseudo-insider or pseudo-outsider for the participants. For instance, due to my identity as an insider to Korean-Canadian society who can potentially start and spread gossip about them, some tensions and struggles around revealing experiences and thoughts especially in the beginning of interview were evident among some participants. It was understandable because in a close knit community such as the Korean- Canadian society, bad news or rumors can easily and viciously spread, ostracising and stigmatising some individuals and their families within the community. Hence, my multiple and ever-changing identities (i.e., insider, outsider and beyond) had to be constantly re-located and negotiated to find the most appropriate position throughout the research, contingent on each participant and his/her specific context. As a researcher, I actively participated in the interviews by being reflexive and interactive as well as sensitive to the participants’ narratives (Kirsch, 1999). Mostly, I asked questions; yet, I also answered questions and shared my thoughts and story with the participants which helped to build stronger relationship with them. Yet, at times, this created a rather tricky  42 situation where I felt pressured to take on a role of a counselor. Due to the tremendous social stigma and taboo, suicide is seldom openly discussed. Moreover, many participants seemed reluctant to seek professional help for their mental health issues due to various reasons including fear of stigma, language barrier and lack of resources. Hence, some participants seemed to consider the interview for this research study as an opportunity to seek advice and/or guidance. This had the potential to take a great toll on me as a graduate student researcher without intensive training on how to counsel suicidal individuals. Therefore, I made it clear to the participants of my position as a graduate student researcher and that the interview was not intended as a form of counseling therapy but rather an opportunity for me to learn about their experiences, attitudes and perceptions around suicide. However, I also discussed the benefits of narrative therapy of demystifying and de-stigmatising suicide just by talking about it (Stein et al., 1998). Finally, as Denzin (1989) argues, ‘interpretive research begins and ends with the biography and self of the researcher’ (p. 12) and this can pose an ethical concern around researcher bias, particularly insider bias. As an insider researcher, I can be overly influenced by my pre-conception and cultural knowledge, overlooking issues that I cannot perceive because I’m too immersed in the culture. An effort to reduce such limitations, I was constantly asking and challenging myself with the questions such as ‘what extend should I involve my cultural knowledge in the analysis?’, ‘how reliable is this cultural knowledge that I presume to have?’, and ‘am I really culturally literate in the Korean-Canadian immigrant culture or is it simply my own account and sense-making?’ In addition, during and after each interview, I rigorously documented and monitored my reactions and emotions to critically analyse how I influenced the interviews and interpreted data.  43 Chapter 4 Findings  Responding to the three overarching research questions, the study findings are presented in three sections. Section 4.1 describes the perceptions of, and attitudes toward suicide among Korean-Canadian immigrants. Section 4.2 details the participants’ insights about the causes and triggers of their suicidal thoughts and behaviours. Finally, participants’ manifestations of, and strategies to manage their suicidal thoughts and behaviours are presented in section 4.3. Within each section, inductively derived themes along with illustrative participant quotes are provided. For additional specific participant demographic data and details about the interview settings, please see Table 2 – participant demographics and Appendix G – participant fieldnotes.  4.1 Perceptions of and Attitudes Toward Suicide In general, Korean-Canadian participants recognised dominant negative attitudes and views of suicide in our society, and many discussed and shared the negative perceptions of suicide. However, most of the participants also acknowledged that after experiencing suicidal thoughts themselves, they became more accepting and empathetic toward people who are suicidal or committed suicide.  4.1.1 Stigmatizing suicide Most participants recognised and reported prevailing negative views of suicide in our societies. They stated that most people regard suicide as a ‘cowardly, irresponsible act,’ an effort to escape from their problems, as a 37-year-old male manufacturing technician described:  44 They would rather think of it as giving up. Just taking an easy way out. Well, I kinda think so as well. It’s an easy way out. Your life is pretty much over but the people who’s left are not gonna feel the same way. So, it’s like neglecting your responsibility. Even though I thought about it myself, I still think it’s a little bit of coward way. Pretty sure most people think so as well.  Vividly illustrated in this commentary is the stigmatizing nature of suicide, which is understood as transgressing cultural  norms and morals that value life above all else. Noteworthy also is how suicide was discussed in ways that align to these norms and ideals – despite some participant’s struggles with suicidal thoughts. As such, participants’ narratives were largely based on the relational aspects of suicide, and the stigmatizing after-effects of a suicide on the surviving families and friends. In line with this, many participants acknowledged that suicide was rarely talked about or discussed openly, particularly in the presence of family and friends of suicide victims. A 20-year-old woman posited that this strategy was in part, to protect the family’s honour and privacy: I think, a lot of people, when they hear, like when my family members hear about somebody committing suicide, then it’s more hush-hush, kind of taboo, but um, it’s not a surprise (…) Like, if somebody does that, I think it’s more like a, you know, keep the family’s privacy.  While acknowledging widespread reticence around discussing suicide, this woman discursively positioned the silence, in this instance, as socially and culturally normative, and, to some extent, a mandated way to signal respect for the surviving family. That said, a few  45 participants countered this, suggesting their silence further stigmatised suicide whilst, ironically muting the self-disclosures of their own suicidal ideation. For example, evident in many participants’ narratives was how common it was to have suicidal thoughts at different points in one’s life, as a 20-year-old female university student commented, ‘no way suicidal thoughts are wrong. Everybody has them. But to actually act upon it is a very bad failing…’ Interestingly, some participants  pointed out that  discourses round  the normalcy of having suicidal thoughts was often used as an excuse to avoid or shorten conversations about suicide in general. Regardless of whether suicidal ideations were fully normed, it remained a private matter and some participants remarked that the lack of communication and public awareness about suicide played a critical role in sustaining silences and indifferent attitudes. A 26-year-old man also suggested that media reports about suicide did not disrupt those silences: In the media, suicide has recently become a controversial and serious issue but before whenever there is news on suicide death, people tend to say, again? Why? And then move on with their everyday life.  Participants also discussed perceptions and cultural attitudes – both Korean and Korean-Canadian – toward suicide contingent on the gender of the deceased. Many participants recognised that men’s suicide was closely linked to financial challenges while women’s suicide was most often considered a by-product of uncontrollable emotional and interpersonal distress. Suggested also was that men’s [money-related] suicide was honourable and somewhat acceptable, while women’s [emotional and relationship-related] suicide drew greater stigma, as a 20-year-old female participant summarised:  46 I think when a woman does it, it’s more shameful. Like, more blame placed on her, like why are you leaving your family behind? Now your family is all torn to pieces. But um, I think if a man does it, it’s more like an honour thing, like you’re providing for your family. It’s a sacrifice you make for your family, kind of perception, I think.  In addition, some participants pointed to men’s and women’s dissimilar abilities to express their emotions. For example, a 48-year-old woman explained men’s high suicide rates: I guess men can’t express their emotions and feelings, leaving it unattended until it reaches the limit. Whereas women, they can express themselves quite comfortably. I think women feel less shameful in expressing their feelings. But men they perceive it as being weak which transgresses the ideal masculinity. When I see on the newspapers, most often it’s men who commit suicide.  Discussed in this narrative was how men’s reluctance to express their emotions can lead men to suicide. Here, she suggested that culturally informed masculine ideals that prescribe men to be strong and stoic can dislocate help-seeking efforts, and ultimately lead men toward suicide. Concurrently, this participant attributed women’s low suicide rates to their ability to communicate and dissipate their negative emotions. However, a 37-year-old male participant disagreed and positioned women’s emotionality as an agent that can lead to suicide among women: Actually, I read the newspapers that I see more girls killing themselves and personally, I think it is because girls are more emotional. Guys… they are kinda immune to it. They are not as emotional as girls especially because girls mature  47 faster than boys. So the level of thinking is different and I guess that the level of stress is different. So, I could imagine that girls have higher suicide rates.   In this commentary, the male participant positioned men’s lack of emotion as protective against suicide amid contrasting women’s high emotionality as a risk factor heightening their vulnerability for suicide. In sum, it was interesting to see how participants suggested that women’s emotionality and expression of feelings attracted less stigma; while their suicide bore a significant amount of shame and blame. Conversely, participants acknowledged that men’s ideal masculinities of self-reliance and stoicism could shame men who expressed their feelings. Yet, they also acknowledged that men’s suicide was viewed more leniently, or was accepted as honourable – if it was connected to their failure to measure up as a provider for their family.  4.1.2 Understanding suicide In line with these prevailing negative views about suicide, participants expressed the deepest remorse and shame about their suicidal thoughts. Yet, also evident were empathetic attitudes toward suicide victims, as a 20-year-old female university student described: Until grade 10, I thought suicide was wrong, too extreme. Back then, I just couldn’t understand why people would do that to themselves. But, as I grew older and experienced the reality, I began to understand how hopeless and desperate that person must have felt to actually choose to die. Yeah, I became more understanding now.   48 Similar to this woman, many participants broadened their perspectives about suicide through an intimate awareness of the helplessness and hopelessness they themselves experienced. In that sense, when asked specifically about their suicidal thoughts and experiences, some participants expressed positive views about suicide as described by another 20-year-old female university student: I think if there is a person who really wishes to die, I think it’s not right to stop him or her without knowing their story (…) I can’t say it’s okay to do it but… if there are absolutely no reasons to live for while continuously having this idea and suffering, then I think… suicide could be a remedy.  In this commentary, the participant positioned suicide as an individual right and a plausible solution – when all else had failed – a view drawing on similar arguments around the ‘right-to- die’ (for example, Schopenhauer)10. While this viewpoint may be too extreme for some people, in consonance with their understanding and empathy for suicide victims, some participants urged not to take a suicide at face value. They emphasised that in order to fully comprehend suicide, individual characteristics (e.g., personality, resilience etc.) as well as the context in which the suicide occurred needed to be understood. A 30-year-old married woman explained: You have to know the person’s life and what they’ve gone through but also you have to consider how much this person, well, you have to know the person’s personality and the way they perceive things. So, there is the same problem and you put 10 people and then they go through the same experience, it will lead, the outcomes would be all different.  10Schopenhauer’s The World as Will and Representation.   49  Discussed here was how important it is to go beyond a simple cause-and-effect model (e.g., severely depression  suicide) to better understand suicide, by considering the multiple layers that include individual characteristics as well as macro level influences. This participant was cognizant that people’s diverse backgrounds and internal and external resources critically impacted their ability to overcome a specific problem, including those leading toward suicide. Prevailing across many participants’ narratives was acknowledgment that establishing linkages between diverse risk and protective factors, and causes and effects were undoubtedly important. However, emphasised was the crucial need to understand the surrounding environments in addition to individual characteristics and resources to fully understand and unravel the contexts in which a suicide occurred. These insights seemed to be afforded in large part by participants’ lived experiences with suicidal ideation and attempts.  4.1.3 Modern Korea and suicide Participants were asked to share their perspectives about the current high suicide rates in Korea. The current competitiveness of Korean society was most often cited as a key issue. In addition, participants attributed the high suicide rates to an insufficient social security system, which garnered unbridgeable gaps between rich and poor. Specifically, many participants, including a 62-year-old woman considered the recent increase in suicide rates as ‘one of the side effects of the rapid economic growth in Korea’. A brief overview of the modern history of Korea, provided by a 48-year-old woman, a former high school teacher, also helped to contextualise the current challenges: Perhaps it is closely linked to our history, the Korean War especially. It was all about  50 survival back then. Everything was about staying alive, making a living, money, money, money, so other people’s welfare were none of our concerns. We may be successful economically and financially. We got to this stage in such a short time but the right level of mentality and psychological foundation has never been re- established or developed along with the financial growth. So, like financially and economically, we are all the way up here but psychologically, we are sitting in the bottom. I think this gap perhaps led to high suicides in Korea.  In her extensive narrative, the participant criticised the current materialistic and money-focused Korean society while recognizing the critical lack of infrastructure to guard and guide people’s sense of security. Evident was that this ‘staying alive’ attitude had penetrated most, if not all, aspects of Korean society. Foremost, many participants discussed the failing Korean education system. A 26-year-old male student who went to high school in Korea remembered, ‘at least 3-4 students kill themselves every year’ the day before the university entrance exam. By way of explaining these phenomena, a 37-year-old male technician who went to high school in Korea as well described the ever-present pressure to succeed in school regardless of the individual’s own dreams and outlook on life: Even if you don’t care – well I don’t care if I go… I don’t need to go to university to make myself better. But you see people around you studying, studying and you see them pushing themselves to study then you get peer pressure. And, it’s the environment that makes you think that you have to do that.  Despite the participant’s firm belief that university education had little to offer him in achieving  51 his life goals, he experienced a great deal of pressure and stress to keep up with his peers. Perhaps this can be partly explained by normative social influences which pressure individuals to conform in order to be accepted by others because deviation from the script is considered a failure (Aronson, Wilson., & Akert, 2005). Amid prevailing focus on competition and success in Korean society, pressure to excel at school can have fatal ramifications as well as wrongfully leading young Korean students to have a vicious reasoning and morality among. A 48-year-old former high school teacher shared a discussion she had with her students about a suicide death of a high school student: Korea is becoming soul-less. That high school girl was always the first in her class and she committed suicide because on the last test, she was second. It’s not even a valid reason you think but still, the grade was everything to her and the society that made the school grade this girl’s sole purpose of life is the problem. [and] I was talking to my students about [the] high school girl who committed suicide to make sure they don’t do that. And one of them said something that completely blew my mind. She said it’s all good because now there is one less person to compete with.  Evident here is the extent to which social environments and statements can garner cultural norms that young people are especially susceptive to buying into. In this particular example, the mentality of survival of the fittest is understood as the cultural norm. Some participants were able to see that the competition in school was a mere starting point in a lifetime of endless pressures, as a 28-year-old male website developer portrayed: And, kids are pretty much forced to study because if they don’t have a good university education, they can’t get a good job, and if they don’t get a good job, they  52 don’t earn good money. And currently, which is really sad, that if you don’t make good money, you don’t get, how do I say, good treatment from the society as well, so… let’s say they got in a good company, but starting at that point, you are in another competition in that work one more time. It’s a never ending story.  Demonstrated in this participant’s narrative are two key points. First, the cultural alignment that places university qualifications as the catalyst for achieving other ‘real life’ goals. Second, how people’s level of success – which garners proportionate levels of respect – is primarily gauged by the individual’s financial accomplishments and economic power. Here, the participant recognised competition as cyclic wherein the visibility of success (e.g., economic power, level of respects received) pressures individuals to conform to the cultural ideals – in this case, admission to a good university, a good career, and handsome remuneration. Implicit in this commentary is how such cultural and societal pressure can set and define Koreans’ individual ego and philosophy of life, heavily grounded on the materialistic values. Therefore, when perceived that they failed to be on the right track toward achieving and advertising materialistic success, individuals’ sense of identity can be critically compromised. Said another way, with perceived failure to meet cultural and societal expectations, Koreans can feel a sense of failure in life, filled with self-doubt, guilt, shame and loss of purpose, which  can lead to suicide.  4.2 Culture-Specific Suicide Risk Factors Overall, participants considered suicide when they felt desperate, hopeless and helpless. There were various combinations of causes and triggers that influenced the participants’ suicidal ideation and behaviours, and three emergent themes were identified: academic pressure;  53 estranged family and beyond; and altered identities. It is important to note that even though these themes were presented as distinct, many participants discussed different issues relevant to two or all three themes.  4.2.1 Academic pressure Perhaps because among the 15 participants, eight were students or recent graduates, many of them recalled that they had the most severe suicidal thoughts when they were in school. A 20-year-old female student remembered a time when she seriously considered killing herself: Actually, I contemplated a few times when I was not doing well in school, letting my parents down and being a burden to them financially… So I was depressed when I was in university (…) School and studying was everything to me, in my life. You know it’s a big deal in Korean-Canadian society. Especially it is so for my parents because I’m the only child.  Similarly, a 26-year-old male student described how he felt lost when he received a bad grade in school: I thought to myself, ‘why should I live with this kind of grade? What do I tell mom?’ (…) Before, I was happy to get my grades back because I was always the first and proud to show them to mom. But since high school, I’ve never shown them to mom. I was ashamed of myself, felt sorry for mom…  Apparent in their narratives is the pervasive over-emphasis on academic excellence among Korean-Canadians which is premised on the attitudes embedded in the Korean education and  54 societal systems, founded in large part on the competitive ideal that privileges the survival of the fittest. Also revealed in their commentaries was how participants over-represented their school life as the sole purpose of their existence, as well as how they linked their unsuccessful academic endeavors to a failure to meet their parents’ expectations. Implicitly depicted here was the sense of obligation as well as their desire to be a ‘model’ daughter or son, by bringing honour and joy to their parents – in this case through their outstanding school performances. Perhaps this can be explained by the notion of filial piety, which is considered among the greatest Confucian virtues among Koreans. Entwined is the pressure flowing from filial piety to make the parents proud and bring honour to and approval from the family, a situation which can derail students whose academic shortcomings can disgrace their family’s name, in addition to signaling their own profound failure (Noh et al., 2007; Wong et al., 2011b). Rather than trying to meet parental expectations and dealing with the emotional sequalae of perceived failure, some of participants confessed their desire to escape the unbearable pressures. They described that the stress they felt to realise their parents’ expectations led them to consider suicide, as a 27-year-old student remembered: R: So, that’s the main reason why you thought about suicide? P: Yes, because it was really hard. I was young then and all these tutoring and attention from mom didn’t feel like love and positive attention. I just wondered why the hell are you doing this to me?  Likewise, a 37-year-old male participant expressed how his parents and other people’s attention and expectations yielded unbearable tension:  55 Everybody is pushing you and you get so stressed out that it gets top of your head and don’t know what to do. And, for me, the easy way out was killing myself… didn’t even care about what my parents would go through … And, it seems like killing myself would be a way out and also at the same time, I could punish the people who pushed me around. So it could be also my way out and also be my pay- back to them for forcing me around and telling me what to do.  In contrast to the former interpretation about poor grades leading to the consideration of  suicide out of shame, these two participants indicated that the pressure and expectations from their parents were the main reason for them to consider suicide. In particular, the 37-year-old man positioned suicide as a means to punish his parents and other people who decided his life and forced him to live a life he didn’t want to. These disparate perspectives demonstrate how similar stressors, though leading toward the same outcome (suicide), can be taken and processed differently contingent on the individual context and traits.  4.2.2 Estranged family and beyond Diverse issues concerning family relationships connected to suicidal thoughts were evident in many interviews. In particular, parent-child conflicts predominated. For example, a 28-year-old male website developer explained how stressful it was for him to live up to his parents’ expectations: And got into fight with my parents a lot. So, I was going through that but my grades weren’t really dropping much. So, I wasn’t in the stress of studying but I was rather under stress of getting along with my family. Yeah, and the expectations… Meeting  56 their expectations. [R: What kinds of expectation?] P: Well, my parents are both university professors and they were good guys, and how do I say, good students throughout their student life. And they would never expect me going from such a good kid to all the way to wild. So they were surprised and didn’t know what to do [about my rebellious acts against them]. They would not convince me not to do it but rather they panicked and yelled about it, which they are regretting right now.  It seems that this participant felt constant pressure, being brought up in an upper middle class, well-educated family where he had to ‘behave’ – perhaps, to complete the picture of an honorable family. At one point, he refused to live by his parents’ standards which created tensions and conflict between the participant and his parents, and eventually ruptured their relationship. Yet, implicit in his narrative is his wish to be heard by his parents and talk through problems, which he regretted did not happen. Similarly a 20-year-old female participant detailed the conflicts she had with her parents which led her to run away from home and consider suicide when she was in her teens: Like, I was kind of like the delinquent child, black sheep of the family. And they just kind of wanted to hide me away and reject me from the rest of the family, but they’d go on (…) Even for family outings and stuff, even when they would meet with their friends, they’d take my other siblings and then I’d be left at home, and I mean, that’s partly my decision too. But then, also I know they want to hide me and they’re ashamed of me, kind of thing.   57 Clearly portrayed in this commentary is how the participant felt rejected by her family. Perhaps, estrangement from her parents minimised or avoided additional tensions and fights. Yet, regardless of the initial intention, evident was that ostracisms and a lack of communication created a sense of marginalisation within her own family. These circumstances were in turn directly linked to the onset of the participant’s suicidal ideation. Parent-child conflicts can stem from an array of reasons; yet, to resolve the conflict, it requires one common element, the participation of both parties. However, present in the two participant commentaries was a lack of, or absence of effective communication and participation between parents and child in effort to resolve the issues they had. Perhaps this is in large part due to conflicting communication styles between the parents and the child where the parents adhered to traditional Korean authoritative ways of communication; while the child attempted more egalitarian ‘Canadian’ parent-child relationships. Also discussed were marital problems described by three married female participants who shared details about their suicidal thoughts, and attempts.  A 54-year-old beauty therapist, who had been suffering intimate partner violence throughout her married life, explained: My main issue was my husband’s abuse and his extra-marital affairs and the in-law’s abuse. My husband had five sisters and I am 12 years younger than my husband (…) To them, a daughter-in-law was not a member of family as I am totally replaceable – just get a new one! To them, I was an object that can be replaced at any time.  Revealed is the participant’s multiple sources of marginalization, conditions that led to her suicidal thoughts and attempts. Indeed, in East Asia including Korea, women’s depression and suicide has been attributed to the conflicts with and marginalisation inflicted by their in-laws (Ji,  58 Kleinman, & Becker, 2001; Yip, Liu, Hu, & Song, 2005; Lee, Um, & Kim, 2004 ). Korea has gone through significant changes in the last few decades, including the major advancement of gender equality and in fact, Korea just elected its first female president, Geun-Hye Park (Time World, 2012). However, still remaining strong in modern Korean society are the Confucian hierarchy and patriarchal values which fuel conflicts between women and their in-laws (especially with their mother-in-law) fighting to get accepted and treated as a family member. Finally, in another instance, suicidal thoughts were experienced following a loss of relationships (e.g., divorce, break-up, bereavement). A 28-year-old male participant explained that he thought about suicide to punish his former partner for leaving him: I guess at that point of me committing suicide was more of a getting back at someone who dumped me. Somewhat it would make it [R: as a vengeance?] yeah, I guess I was angry and disappointed. I just wanted to make her feel bad as well in what would be the most extreme way...  Also discussed were suicidal thoughts as a result of bereavement, as described by a 31-year-old female participant who lost her father and her baby daughter within a month. She explained how devastated her entire family was: So within a month, my dad and my baby passed away, so my whole family was just... We all thought about dying together. Well, after my dad passed away we talked about it…  My dad did everything for us and there was no one who could take care of us… so what now? But the conclusion was that we have the baby, our miracle… so we must go on and survive… But, when the baby died… (crying)   59 Undoubtedly, the loss of her father and her baby exerted a great toll on the participant and her family. However, evident was that the grief and loss were not dealt with effectively. The participant described that she did not know where to go to seek help and get emotional support as: Mom always says not to tell anyone about it because it is embarrassing. She thinks talking about her pain and her family issues to someone is a disgrace. But the funny thing is that yeah, they [the participant’s mother and sister] don’t want to talk about it with no one, not just with other people but like they wouldn’t speak to me about it either. Actually, they get mad at me when I bring up the topic. They just want to bury it but I can’t.  In addition, to their obvious effort to keep the family’s privacy – and avoid any potential gossip – the reluctance to disclose their sadness to other people is perhaps linked to Confucian belief that emphasises emotional and behavioural control (Rhi, 1986) and the common East Asian belief that excessive expression of emotion (especially negative ones) can upset emotional harmony, thus creating and brining more negative energy (Donnelly, 2007; Tzeng et al., 2010a; 2010b).  4.2.3 Altered identities  Many participants pointed to inner struggles around their identities as a reason for considering suicide. Specifically posed were existential questions about the purpose of their life and identities. A 20-year-old female student, who had always been a ‘good’ daughter to her parents, described the different world she experimented with in her first year of university: I lived in a dorm during the first year and then home stayed for another year. It was my first time living away from home. I have always been living under my parents’  60 roof and their surveillance but now that I got my freedom, I became depraved, a bad girl and I felt so sorry for myself that I just wished to reset my life altogether.  When specifically asked how she became ‘depraved’, the participant responded that she started smoking, drinking and skipping classes – which sounded like activities synonymous with many young freshmen’s. She appreciated the freedom that she had for the first time in her life, and explored different elements of life (e.g., smoking and drinking) which were contraband under her parents’ direct surveillance. Yet, because she was still identified with these cultural restrictions, she became disappointed and concluded that her new life was no longer worth living. Some participants’ suicidal thoughts related more to existential inquest and finding the meaning of their life. A 28-year-old website developer shared some thoughts he often had when he was younger, which started with a simple question ‘what is the purpose of the life? ’ in weighing the benefits of suicide: After you’ve achieved everything that you wanted, what’s there for you? Then, all goes back to why am I living? So, I tried this hard to get here and there is nothing left to do… that would suck! I’m sorry for my language but that’s really gonna be disappointing… So after thinking about that, what if I don’t go through all these stressful situations and just die now?  It is rather interesting for a 28-year-old young man to have this perspective because often similar dialogues are discussed among older persons with depression in recognition of their older age and mortality. For example, Oliffe et al’s (2011) qualitative study of older  men with depression reported  many participants expressed such skeptic and nihilistic insights about their life.  61 Similarly, a 48-year-old female recent immigrant shared her perspectives about her suicidal thoughts: On surface, failing business and martial issues were the problem but underneath, the core issue was that I became more skeptical about my life (…) I feel as though my life has been a waste. I thought I was smart, capable and made an accomplished life but I realised that it was not. I lack in social skills so now that I have to start a new life in Vancouver, I need to do everything to survive. But I have no guts to do that, to go low per se. So now I feel like I’m a worthless person. There is absolutely nothing I can do in this world (cry)…my life seemed so empty. Why do I live? So I wanted to die.  This participant is in her late 40’s and perhaps she was experiencing what is commonly referred to as a midlife crisis Yet, her particular context needs to be taken into consideration to understand how immigrating to Canada stripped away her previous identity and rocked the foundation of who she had been in Korea. This participant, an upper middle class high-school teacher in Korea, who had earned respect and wealth, came to Canada to start fresh. The reality however hit her after a couple of years in Canada when she realised that her previous skills and success, and social connections in Korea were not transferrable, thus creating great discrepancies between her former and current social roles and identities. Similarly, a 62-year-old female detailed the typical life of Korean immigrants in Canada: Yes, those people immigrating to Canada used to enjoy a pretty high standard of living back in Korea. But when they come to Canada, their high level education, and previous work experiences and background are not recognised at all thus they have  62 only a relatively narrow set of occupation opportunities such as simple labour. So at first, people find it really hard to swallow their pride and face the reality.  Evident here is that many Korean immigrants coming to Canada lose their former identities because credentials and experience (e.g., high education, social roles and status, work experience) are not acknowledged in Canada. Transitioning from smart, capable, accomplished people to feeling worthless can negatively impact mental health. In essence, the aforementioned 48-year- old female participant experienced a culture shock and new immigrant identity crisis giving rise to what might be mistakenly explained away as a midlife crisis. Throughout the participants’ narratives, evident was the greater the discrepancy between the participants’ ideal (or former) and perceived (or current) identities and roles, the greater the identity crisis they suffered. In particular, many participants who immigrated to Canada as an adult with family shared that they were hoping to have a peaceful and relaxing life in Canada. Some confessed that they believed that the well-structured Canadian social welfare and health system was going to make their new life in Canada relatively easy and manageable. However, the reality proved different for some participants. Due to factors including language barriers, cultural differences and being unfamiliar with Canadian systems and ways of life, they realised that they could never completely integrate into the mainstream Canadian culture.  4.3 Suicidal Experiences and Management Strategies Korean-Canadian participants detailed their suicidal experiences that encompass a variety of psychological (e.g., paranoia), behavioural (e.g., binge eating) as well as somatic symptoms (e.g., abdominal pain). Participants also illustrated how they managed their suicidal  63 thoughts and impulses, and based on their experiences, they shared advice and recommendations for others who have suicidal thoughts.  4.3.1 Manifestations  Many participants detailed the symptoms they experienced while they were suicidal. These ranged from being obsessed with thoughts of suicide to feelings that they were already dead. As a 20-year-old female student confessed, some participants described how they couldn’t stop thinking about suicide and that everything reminded them of suicide: … it’s like if there was any ways or things that I could use to kill myself, for instance a knife, I would just stare at it …  It’s really weird but I would stare at it thinking how I would use it to kill myself without inflicting too much pain. Furthermore, another 20-year-old woman noted that her distress levels as well as suicidal thoughts manifested in a variety of ways. She explained how she was unable to control her emotions and subsequently became paranoid: I mean, there was a period of time where I felt  like I was being watched by somebody, like, I, I mean, now that I think about it, it’s totally crazy but I thought there were cameras in my room. So I think, I had some kind of psychosis or something. And um, [R: paranoia?] yeah. So, I was always crying and I couldn’t control myself and my mom was so worried like she said, “what’s wrong with you? Do we need to take you to the mental hospital?” things like that.  In addition to the psychological and emotional challenges she experienced, this woman, and some other participants, also noticed changes in their behaviours during the time they were  64 suicidal. Often, these behaviours were understood as strategies to manage their suicidal thoughts and impulses.  The aforementioned 20-year-old women who experienced paranoia when she was suicidal reported that in order to control her irrepressible emotions, she used to inhale nail remover (i.e., acetone) that ‘would make [her] feel better and helped [her] calm down a lot’. Similarly, a 31-year-old female participant confessed that she used alcohol to quell her suicidal thoughts: So, whenever I feel bad, I drink. My whole family drink a lot especially recently. It’s almost like I can’t live without alcohol and when you are drunk you get relaxed and say, c’est la vie.  In addition to alcohol and substance use to dissipate their suicidal thoughts, some participants remarked on changes in their appetite and eating behaviours when they had suicidal thoughts. For instance, a 20-year-old female student who admitted to being obsessed with the idea of killing herself , noticed how she started binge eating to manage her suicidal thoughts: Ah, overeating was one of the ways I managed the thoughts. I binge ate so much that I’d gain almost 20 kg. It was a way to relieve the stress and pressure from the suicidal thoughts. I would go grocery shopping and get stuff enough for a week and I would eat them all in one single day. And I would throw up from overeating.  Furthermore, some participants reported that they suffered different somatic symptoms when they were suicidal including headache, shortness of breath, abdominal pain, arthritis and so on. However, when they sought medical help for their physical ailments, often they were reassured that there was nothing physically wrong with them. A 54-year-old female beauty therapist who  65 suffered from intimate partner violence explained that following her first suicide attempt, the stress and tensions manifested as major physical symptoms: So everything manifested physically. [R: How so?] P: So, first, I got an unknown illness. Doctors ran different test and exams on me to find the reason but they couldn’t find exactly what was wrong with me. For the 24 years of marriage, I had these symptoms. My overall body condition is still really bad. I can say the whole body except for my hair was in pain. I can probably list more than 20 different physical symptoms that I had.  Clearly shown in participants’ accounts are how Korean-Canadian participants’ suicidal ideation can be manifested in an array of ways, and how some of these behaviours were taken as specific tactics to subdue their emotional pain and control their suicidal thoughts. In fact, it is well documented in the literature that self-medicating behaviours are often seen among people who experience depression in effort to quell their negative emotions (Oliffe, Galdas, Han, & Kelly, 2013; Weiss, Griffin, & Mirin, 1992; Bolton, Robinson, & Sareen, 2009). Yet, also confirmed by the participants was that these behaviours were not effective in helping them to recuperate their psychological and emotional well-being but instead, they recursively intensified their suicidal thoughts.  4.3.2 Self-management and help seeking  In terms of self-managing suicidal thoughts and behaviours, many participants recalled significant challenges. As a 48-year-old woman eloquently explained, ‘when you are at  66 that stage, you don’t have a coping skill. You can’t think through anything.’ Many participants agreed that they didn’t or couldn’t seek help or talk to anyone about what they were experiencing. ‘The fear of the social stigma of suicide and mental illnesses’, ‘not wanting to disappoint their families and friends or cause others trouble’, ‘fearing not being taken seriously or ridiculed’, ‘not finding others’ support beneficial’, ‘preferring to deal with the issues alone’, ‘lack of knowledge in support system and available resources’ – all featured as reasons why participants resisted telling others of their woes or seeking professional help. Nonetheless, and perhaps as a by-product of these factors, participants found ways to self-manage their suicidal ideations and behaviours. The most recurrent theme embedded in their narratives was their concern for their family and friends as a stimulus for trying to stay alive. For example, a 20-year-old female student explained: I thought if I killed myself my mom would not manage. Like I was the only one good thing going on in her life. Yeah.I think during those times, just back then, if it wasn’t for my mom, I would have probably done something…  The participant valued her life based on the relationship she had with her mom, which reminded her how her death would impact her mother. Such reflective thoughts were consistently evident across most participants’ interviews. Some participants proposed more tangible ways of dealing with their suicidal thoughts as a 38-year-old female participant suggested: I tried to minimise the time spent alone. And I thought about who I can get help from. I realised that I didn’t have enough energy and resources to get away from this situation by myself. This means that I needed to get other people’s help.   67 Evident in her commentary was how she carefully assessed her situation and came to the realisation that she was not capable of managing it alone; therefore, she sought help. By reaching out for help, she secured the supports she needed to successfully manage her suicidal thoughts. In addition, religion and spirituality played a big role for some participants. In particular, the Christian doctrine of heaven and hell, and decidedly negative views of suicide inhibited some participants’ suicidal ideations. A 31-year-old participant who self-identified as Catholic further explained how she quelled her suicidal thoughts after the death of her father and her daughter. Here, she used the term ‘a perilous sea’ to describe her life in general: Yeah, it’s a perilous sea but there must be somewhere we can disembark somewhere out there. It’s like we need to cross this sea to get there, for perpetual peace and happiness? [R: Would that be death?] Yes, I think we can get there through death. So it might be my religious side talking but I think if I commit suicide… If I jump off of this boat, then I will never get there and see my dad and my baby (crying) so I have no other choice but to keep on riding on this boat so I can meet them one day.  Most participants reported that they did not or could not seek professional support, as a 26-year-old participant illustrated, ‘Koreans think counseling and seeking help from a psychologist or psychiatrist is for psychos’. Indeed, Yoo and Skovholt (2001) found that Korean students reported more negative attitudes toward seeking professional help and taking up counseling treatments than American students. Also, some participants didn’t seek professional help because they thought their problems were not serious enough, or it never occurred to them because they were unaware of the available resources. However, the few participants who sought  68 professional help acknowledged treatment benefits. A 48-year-old female participant described how she felt relieved after talking to her counselor about her problems: So I met him once a week and it was so helpful because at that time I couldn’t talk to anyone about it. So during the one-and-a-half-an-hour counseling session, I spent more than half of the session crying. I cried so much but after I cried, I felt better. Also because he was an immigrant himself, he understood what I was going through.  Evident in this participant’s narrative is how beneficial therapeutic counseling can be just by creating an environment where the participant could let out her emotions and talk about her problems that led her to suicidal thoughts. Noteworthy here was the importance of the rapport built between the counselor and the participant. As indicated in her comment, the participant was able to connect with the counselor because they shared a commonality (i.e., immigrant status) that led her to conclude that he would understand what she was going through as an immigrant. Similar to professional counseling services, social support can also be cathartic when expressed with authentic concern and care for the individual who is at risk. For example, a 20-year-old woman described the support and guidance received from her grade 7th teacher: She said these words to me that changed my life and I still think about it a lot, almost every day. She said to me, “(P name) find your truth”. So, yeah, you know, what she was saying is don’t care about what anyone else thinks and if you know you’re right then you do what you got to do. Believe in yourself. So that really meant a lot to me, that really helped me. It helped me feel like I don’t need to leave this world, like people have the kindness to acknowledge me and you know, I’m not just gonna go off and die.  69 Demonstrated was her teacher’s guidance to break with cultural norms and find her own truth (i.e., be her true self), empowering the participant to map her course to find inner peace. That said, also expressed were concerns about the limitations of both professional and social supports. The aforementioned participant was reluctance to talk about the family conflict and abuse underpinning her distress because she wanted to protect her family. Likewise, several participants highlighted limitations associated with professional help and service providers including suggestions that theory-based advice was not always practical or applicable in the real world, especially amid experiencing language barriers and cultural differences. A 62-year-old female participant highlighted the need for more psychiatrists and counselors who can speak both Korean and English: I think many Korean immigrants are suffering from depression and suicidal thoughts but they just don’t know where to go to get help. I’m sure that there are many great doctors and counselors in Canada but because many of the first generation Korean immigrants speak limited English, they can’t effectively communicate and express their states in English so it’s really almost impossible to seek help from Canadian counselors.  While acknowledging and appreciating resources and services available in the Canadian public health care system, participants highlighted how ethnic matching of healthcare providers would provide more culturally-sensitive and accessible healthcare and counseling services.   70 4.3.3 Advice for other Korean-Canadian immigrants who have suicidal thoughts  When asked to provide advice or recommendations on how to manage suicidal thoughts and behaviours, participants’ responses tended to reiterate their self-management strategies. Consistently suggested was to think of all the relationships in one’s life and how suicide would affect others. A 26-year-old male student who had served in the Korean military reflected on the advice he had for junior servicemen: if you die, you will hurt your parents and people around you ...So, if you can die without causing any of these, then go ahead but it won’t work out like that. Then, why don’t you just go on and try to live a good life.  Included here are ideals about how a person is intricately interconnected with others through an array of relationships and interactions, as well as, how that person’s life [and death] always impacts others. The participant emphasized the negative impact one’s suicide death can have on others, especially their parents, in arguing that living was an  obligation  as a means to protecting and fulfilling their responsibilities for others. Many participants also wanted to remind people that life has good moments as well as bad; therefore, avoid reacting recklessly to the bad moments. A 38-year-old woman explained: Life is like waves. There are ups and there are downs. Some get hit in the face and complain but some surf them as they come and go.  In line with this philosophical viewpoint, a 30-year-old female participant described how suicidal thoughts can be prompted by a bad moment or transient phase that will ultimately pass by:  71 Everyone have that thought of suicide in their mind – everybody does, I think, but actually initiate in action, you need help from drugs or alcohol so some people, not all but, it could have been a mistake. Like you wake up in the morning and realise that you were so silly last night right?  This narrative is based on the participant’s own non fatal suicidal behaviours in which she attempted to drown herself in the bathtub while drunk, and how glad she was that it didn’t work out. Advised in this narrative was to avoid – or at least minimise - alcohol and drug influences as they can amplify suicidal thoughts, and potentiate an irrational state of mind and actions. Furthermore, a 37-year-old manufacturing technician articulated that suicide is not an easy way out: There is no easy way out. It [suicide] looks like an easy way out but I think killing yourself is one of the hardest things you can do. Yeah, you need a lot of courage and if you had that much of courage, you can go through whatever problem that you might have in your life.  This participant pointed to the tremendous amount of courage and effort required to act on the suicidal thoughts and cleverly suggested that such energy and potential could solve the actual problems underpinning the suicidal thoughts. Prevailing advice also included recommendations for seeking help.  A 28-year-old male participant promoted the benefits of talking to someone about suicide by locating a suicidal thought as “just a stupid thought but when you share it with other people, it kinda dissipates but if you keep it to yourself, it’s not going anywhere.” Another 28-year-old male participant warned  72 to be cautious to find the right person to speak to because talking to someone who is not sincerely caring for you or can’t really identify or empathise with your situation would not be much help: So my advice is that if you have this kind of thought, don’t keep it to yourself. Let it out. But not to anyone but find someone who really can understand you or someone who had similar experiences. Otherwise, talking to those who cannot really understand, mindlessly saying ‘aww’, ‘I’m sorry’, won’t help much.  Conversely, some participants positioned suicidal thoughts and behaviours as an individual’s private ordeal that need to be dealt with and managed alone as people need to search for and find their own answer. A 62-year-old participant advised that one needs to focus on self-management: Well, it’s easier said than done but if you can, you have to take care of yourself. You are the only one who can do something about it. Don’t expect other people or things that are making you feel depressed and consider committing suicide to change. So, try to think positively and manage yourself. Don’t be impulsive. Try to talk to people around you and survive the moment.  This participant suggested that orienting oneself away from suicidal thoughts was the ultimate solution. Appealing to characteristics of self-reliance and strength, participants’ recommendations challenged others to seek help as the conduit to effective self-management in converting their negativity to muster positive outcomes.     73 Chapter 5 Discussion  5.1 Discussion  This study highlighted connections between suicide and culture among first-generation Korean- Canadian immigrants. Using in-depth semi-structured interviews and constant comparative methods, this study yielded three themes and nine sub-themes that illuminate Korean-Canadian participants’ perceptions of suicide as well as their experiences with suicidal ideation. In this chapter, the research findings are further discussed to explore how Korean-Canadian immigrants' Korean cultural alignments (e.g., Confucianism) and immigrating to Canada (e.g., altered identities) were intricately connected to their suicidality.  5.1.1 Confucianism and suicidality among Korean-Canadian immigrants  The findings in the current study support Sudak, Maxim and Carpenter’s (2008) assertion that in spite of  trends toward diminishing stigma associated with mental illnesses in the past few decades, suicide  remains highly stigmatised, bearing  tremendous negativity and imposing widespread silences. While a few participants adopted counter-arguments of a relativist or even a libertarian point of view positioning suicide as one's right and freedom, it is likely that dominant cultural discourses prevailed to mute widespread expression of such radical viewpoints. Indeed, most participants recognised and aligned with normative negative stances toward suicide, even though their personal experiences led them to disapprove of generalisations that suicide was an act of selfishness and failure (Lester, 1998). In this regard participants understood the hopelessness and despair that could drive others toward suicide while countering their own ideations by focussing on how suicide would devastate their significant others. This may be in  74 part premised by the Confucian ethics which place the utmost value on the collective purpose and harmony where an individual is defined and identified largely by his/her roles and position within the society (Yao, 2000). Nonetheless it is ironic that such cultural norms also tend to silence and stigmatise those who are known to be interiorly challenged to find contentment. Specifically, the Confucian principle of filial piety can exert great cultural influence, essentially outlawing suicidal ideation and suicide behaviours, both fatal and non-fatal. One strictly enforced core principle of Confucian philosophy is to respect one’s parents by being obedient and bringing honour to them (Yao, 2000). In modern times, this mandate is embodied by performing well academically and making a career in a respected profession. Similar to Korean participants in Jo, An and Sohn. (2011)’s study, participants in the current study most often identified their parents as the reason they did not act on their suicidal thoughts. However, paradoxically, many participants also suggested their parents were strong contributors to their psychological distress, which in turn led to suicidal ideation. For example, drawing from Baechler’s (1979) eleven types of suicidal meanings, most participants’ accounts revealed escapist suicide tendencies in their desire to flee from pressures – which in many cases were related to academic underperformance. In fact, similar to Wong et al.’s (2011a) description of the types of events that occurred prior to the onset of suicidal ideation in East Asian American students, a majority of the current study participants cited  academic and family issues as the chief causes of their suicidal thoughts. The results of this study are also in line with previous research reporting how East Asian college students perceived parental and social expectations (e.g., model minority) as the major cause for their suicidal ideation (Noh et al., 2007; Wong et al., 2011b). Findings from the current study confirm that the identities of participants in the student sub-group were heavily tied to their academic performance, a situation in large part driven by  75 cultural filial piety obligations. Accordingly, failure to perform and substandard results were understood as eroding the individual’s self-esteem and bringing into disrepute their purchase on being the model son or daughter. In the extreme, this also extended to the point of individuals questioning the value of their existence. Perceptions about suicide were also deeply gendered, and the findings presented herewith incorporate Griffith (2012) and Lohan’s (2010) analytic frames which purposely integrated other social determinants of health including culture, race and age. Therefore, gender can be understood as a multi-dimensional concept that refers to social and cultural expectations about identities, roles and relations that are ascribed to the sexes (Johnson & Repta, 2012). In the context of Korean-Canadian society, Confucian philosophy can be highly influential in prescribing specific practices as legitimately residing with Korean men and women. For example, participants believed that emotional and interpersonal issues drove Korean-Canadian women toward suicidal ideations while men were more likely to suicide in the wake of financial failures. This finding supports Qin, Mortensen and Agerbo’s (2000) and Jack’s (1992) research that highlighted gender differences in the nature and cause of suicidal ideation, as well as specific responses. Moreover, parallel with  assertions by Canetto (1997) and Deluty (1988-1989) that women who suicide are usually judged more harshly than men, participants in the current study recognised this gender-based discrepancy when discussing and differentiating  men’s and women’s suicide. Central to these narratives were participants’ understandings about the pressures that can accompany men’s traditional ‘provider’ roles, and how suicide can be, as a last resort, an attempt to provide for their family by bequeathing their life insurance money. Until recently, men were most often the sole or main breadwinner in Korean families, and principally identified  76 themselves and functioned within the roles of provider and protector of the family (Kim & Chung, 2011). Perhaps, due to this rigid mandate for men to acquire wealth and provide financial family security, unsuspected suicide could leave the legacy of financial aid through life insurance payouts.  Likewise, there was tacit consensus among participants that men’s suicide was excusable and even honourable when the motive was firmly-centered on men’s attempt to fulfill such selfless provider roles. Said another way, men’s suicide was not viewed as a selfish act of escaping but rather, as an act of sacrifice in some contexts. In addition, this finding was influenced by participants aligning to the Confucian acceptance and respect for honour-suicide as a way to avoid disgrace or to accept one’s failure (Lo, 2002). These beliefs could be argued as by-products of adhering to traditional gender roles and relations. Interesting also are feminine discourses round women’s honour-suicide (e.g., to follow their husband’s death or to preserve their chastity) (Kim-Hogarth, 1996). This traditional feminine ideal was  absent from the current study findings, and this may indicate that Korean women’s roles and identities have transitioned over time and in specific contexts (i.e., immigration) , while men’s alignments to traditional masculine provider and protector identities have remained relatively unchanged.  5.1.2 Immigrating to Canada  Emile Durkheim (1951) asserted that suicide is not a result of an individual’s decision but it takes place within a social context. In line with Durkheim’s analysis, studies have focused on the effect of social contexts, largely socio-economic factors on suicide (Yamamura, 2010; Milner, McClure, & De Leo, 2012; Kõlves, Milner & Värnik, 2013). Although debates continue about the relative influence of social, culture and individual factors on suicide, it is  77 clear that these macro- and micro-level elements are key considerations in fully understanding suicide. For example, participants recognised locale and context specific social issues as fueling the current high rates of suicide in Korea, and many of these can be explained by Durkheim’s theory of suicide. In brief, as described by Durkheim, Korean society’s low levels of two social forces – social integration and moral regulation – most often manifests as a) egoistic or b) anomic suicide. Specifically, Durkheim argued that egoistic suicide is a consequence of ‘excessive individuation’ – being detached from other members of society and family, and the resultant low levels of social integration (Durkheim, 1951). This kind of detachment is evident in modern Korea where high rates of divorce (United Nation, 2011) amid low birth rates (Lim, 2011; United Nations, 2011) have emerged in the past few decades. Durkheim’s (1951) second social force, moral regulation, refers to society’s principal ethics and orders. As Park and Lester (2006) proposed, suicide rates in Korea have skyrocketed in the past few decades because the society lacks moral regulation leading to  what Durkheim called ‘anomic’, a condition that weakens the bonds between the individual and the society. Korean society has been experiencing intensive globalisation and modernisation in the last few decades, transforming traditional collective moral values toward individualistic and materialistic cultures synonymous with the West. These processes can debase traditional social order and bonds, unfairly invoking a sense of failure among many who reside or resonate with those longstanding values. Evident in the current study findings was recognition of a lack of moral regulation in modern Korean society wherein rapid social changes and expansion of capitalism in the past few decades ‘changed’ Korean society as a whole. In particular, Korean-Canadian participants who chose to immigrate to Canada – not as a result of their parents’ decision – fully recognised the  78 recent dramatic social and cultural changes in modern Korea. They pointed to the deterioration of social and familial bonds, and lack of stable social order and infrastructure in Korean society as the principal factors for high suicide rates in Korea. Furthermore, these Korean-Canadian participants explicitly indicated that they decided to immigrate to Canada largely due to the same aforementioned social issues in Korea, in search of security and a less competitive life in which to raise a strong and happy family. Yet, ironically, indicative in many Korean-Canadian immigrants’ accounts was deterioration of familial bonds, which led some to suicidal ideation. In line with Berry et al.’s (2006) assertion, the current study findings showed that due to the different rates and receptivity of acculturation between first-generation immigrant parents and second-generation children, language and communication difficulties and other cultural conflicts among family members can emerge (Luo & Wiseman, 2000). Accordingly, this ineffective (lack of) communication in turn can negatively affect family bonding processes (Santisteban & Mitrani, 2003), which led some participants to contemplate suicide amid missing the family support needed to quell their suicidal ideations. In addition, culture shock and a sense of lost identity, as well as the pressures that families and individuals take up in making transitions to secure some sense of belonging to Canada can exert a great toll on Korean-Canadian immigrants.  5.1.3 Korean-Canadian immigrants and suicidality  For the most part, participants’ direct experiences with suicidal ideation and behaviours neatly fit within the existing body of research on suicidality. There were no significant differences or unique behaviours apparent in the study participants compared to other populations reported on in the literature. That said, the current study findings did not fully  79 correspond to some previous work emphasising East Asian’s tendencies to manifest their internal distress somatically (Donnelly, 2007; Lee et al., 2004). Instead, the current study found that behavioural (e.g., binge eating), and psychological (e.g., hopelessness) impacts of suicidal ideation reported in their broader literature on suicide were strongly endorsed by the Korean- Canadian immigrants. However, evident and unique to the current study findings was how participants’ suicidal ideations can connect directly to their immigration experiences, especially those that erode people’s identities and their cherished markers. Some research suggests that immigration increases the risk for suicide because it severs bonds to family, friends, and country which may result in feelings of loss, loneliness, and uprootedness, and reduced coping resources (Hovey & Magana, 2002; Ponizovsky, Ritsner, & Modai, 2000). Conversely, some research reports that new immigrants tend to be healthier than age matched cohorts in the host country due to the healthy immigrant effect (McDonald & Kennedy, 2004; Wu  & Schimmele, 2005). In the current study, much of the cultural and psychological changes that participants experienced (e.g., cultural shock, uprootedness, language barriers etc.) when they arrived in Canada might be reasonably explained as by-products of acculturation processes (Wu & Schimmele, 2005; Kaplan & Marks, 1990) rather than directly related to suicidal ideation. However, findings reflecting hardships linked to altered identity and social roles, which were most prominent among participants who had high levels of education and professional careers ahead of coming to Canada, suggest otherwise.  Similarly, Kim & Chen’s (2011) Canadian-based study revealed that higher education levels were a risk factor for psychological distress and depression among older Korean–Canadian immigrants. Perhaps, this was due to their struggles to relinquish their previous expectations and roles in adapting to their new environment.  80 Linkage between Korean-Canadian immigrants’ altered identities and suicidality were most evident among immigrants who immigrated as an adult. Moreover, it was especially prominent among those who came to Canada in search of securing a better life for their children. Here, it is important to understand Korean cultures that emphasise family interdependence and obligations, along with the family hierarchies and role expectations that flow from those norms (Lam, 1997; Uba, 1994). For example, children need to fulfill the filial piety discussed earlier by being obedient and working hard in school. Yet, this relationship is bi-directional. Parents are also expected to fulfill their roles by sacrificing their own interests to provide discipline, care and support (both emotional and financial) to their children for their entire life (e.g., educational and career development, marriage, housing etc.). The fulfillment of family obligations is perceived as the most significant emotional tie that bonds Korean family members. This means that while study participants  suffered psychological stresses in trying to live up to their parents’ expectations, it is also feasible that their  parents were challenged by experiencing their own altered identities and social roles, a conundrum eroding  self-respect and self-esteem.  5.1.4 Korean-Canadian immigrants and help-seeking The current study findings suggest that, in managing their suicidal thoughts, most participants preferred and opted for self-management approaches – rather than seeking professional or social supports. Some participants [un]intentionally dismissed their psychological pain and distress, and considered their suicidal ideations as not warranting professional help. This trend can be explained by Noh and Avison (1996) suggestion that Korean-Canadian immigrants’ cultural tendency is toward the underutilisation of mental health services amid fears of stigma associated with mental illnesses. Indeed the current study also revealed some  81 participants’ criticisms of the practicability and value in seeking professional help. Calls for ethnic matching detailed in the current study support Donnelly et al. (2011)’s assertion that limited English language skills and a lack of professional interpreter services in the healthcare system disables many immigrants from accessing or benefitting from  mental health counselling services. Perhaps, as Lau et al. (2002) suggested, Korean-Canadian immigrants’ limited social support networks and language skills lead them to self-manage their psychological distress. This issue is especially serious because, as shown in the current study, most of the underlying causes of suicidal ideation emerge from familial and identity issues, alienation from one’s family, situations that in and of themselves can reduce social support networks. In addition, this study is also in line with Noh et al.’s (1992) findings suggesting that support received from members of the Korean-Canadian social network, directly and positively influenced the mental health of the participants; while the protective effects of social supports from non-Korean social networks was negligible. These accounts illuminate Thoits’ (1986) hypothesis of sociocultural similarity which stresses the importance of empathic understanding of stressful situations by providers of support. In other words, Thoits (1986) posited that sociocultural similarity increases the affinity between the provider and receiver of support, which is the key to effective health care. As such, social and cultural understandings are indeed essential for an individual (as a therapist, family member or friend) to fully empathise and understand another person, which denote the power of genuine social connection and narrative healing. Perhaps, that is why support from family members – who reside within the same social and cultural milieu – can be so therapeutic. Therefore, in the context of immigrants, who tend to have limited social support networks, when family  82 disconnects emerge (through culture clash, language barriers, being divided by distance) suicidal ideations can emerge in response to breaking with as well as aligning to cultural norms.  5.2 Conclusion  The current study focused on describing the suicide related perceptions and experiences among an understudied and underserved sub-population. While most of the existing suicide literature is grounded in quantitative methods, this qualitative study provides important contextual information to better understand suicide in general (Green & Thorougood, 2009) and, more specifically among Korean-Canadian immigrants.  5.3 Study strengths and limitations  A major strength of the study was the richness of the data, and the contextual experiences within a particular cultural milieu of Canadian immigrants. In addition, the therapeutic benefits to participants of qualitative interviews reported elsewhere (Murray, 2003; DeCou, Skewes, Lopez, & Skanis, 2013) were especially evident in the current study. Similar to participants in DeCou et al.’s (2013) qualitative interview study about the benefits of discussing suicide, the 15 Korean-Canadians in the current study acknowledged the benefits of talking in- depth about an ordinarily taboo subject – suicide. As a 20-year-old female university student summarised, ‘Very cathartic, Yeah, it was good to have someone who’s interested [in my story].’ To ensure the trustworthiness of research interpretation and conclusion in the current study, several steps were undertaken, informed by Guba’s (1981) four criteria for assessing the trustworthiness of naturalistic inquiry – please see Table 4. Transparency throughout the entire research project (Guba, 1981), comprising reviews of detailed fieldnotes and verbatim interview  83 transcripts in selecting representative participant quotes, was systematically undertaken. In addition, the research findings and interpretations were discussed with members of the supervisory committee as well as the study participants. Saturation was also achieved in that no additional themes were derived from the last few interviews (Strauss & Corbin, 1998).  Table 3. Guba’s (1981) Criteria for assessing the trustworthiness of naturalistic inquiry  Criteria Strategies Credibility Prolonged and varied field experience, time sampling, reflexivity, triangulation, member checking, peer examination, interview technique, established authority of researcher, structural coherence, referential adequacy Transferability Nominated sample, comparison of sample to demographic data, time sample, dense description Dependability Dependability audit, dense description of research methods, stepwise replication, triangulation, peer examination, code- recode procedure Confirmability Confirmability audit, triangulation, reflexivity  A number of literature searches in relevant research areas (i.e., suicide among East Asians in North America; qualitative research on suicide in East Asia; research on mental health of Korean immigrants in North America) were conducted to introduce, as well as compare with the current study findings. Much of the current study findings corroborate with these previous research, confirming the plausibility and dependability of the current study findings. Yet, this study also has several limitations. First, by focussing on first-generation Korean-Canadian immigrants the results are limited in what they can reasonably say about other Canadian sub-groups. Second, the small sample size (N=15) may also be argued as affording only preliminary insights about many intersections of gender, class and other social factors. For example, only four of the fifteen participants were male. Although efforts were made to recruit more male participants, this proved especially challenging. This may reflect men’s reluctance to  84 participate in qualitative research or uncertainty about expressing their feelings (Oliffe & Mroz, 2005; Courtenay, 2000) in addition to social stigma associated with suicide and mental illness. In sum, the convenience sampling employed in this study limited the scope for comparative analyses across a range of variables including gender, age and socio-economic status. While there are several limitations, this study significantly contributes to the literature by augmenting what we know about Korean-Canadian immigrants’ suicidality and help-seeking behaviours. Specifically, inductively derived from participants’ in-depth narratives were the core issues that underpinned their suicidal ideation and behaviours, as well as their general life philosophy. This not only adds empirical weight to the literature connecting culture and suicidality, it also demonstrates the clear need for a more culture-specific research as a means to developing culture-sensitive counselling and healing strategies. In view of that, the current study findings provide a preliminary knowledge to guide the development of culture- sensitive suicide prevention programs targeting Korean-Canadians, some aspects of which might guide targeted interventions with other Canadian immigrant groups.  5.4 Implications for practice and recommendations for future research  In light of the current research findings, Canadian mental healthcare providers must be cognisant of immigrant patients’ cultural backgrounds as a means to understanding what underpins their risk for suicide. Particularly, healthcare providers must understand that immigration is a time of great change and potential distress. Immigrants, especially the new comers, can suffer from the severing of bonds to family, friends, and country which may result in feelings of loss, loneliness, and uprootedness (Hovey & Magana, 2002; Pnizovsky et al., 2000). This negative stress can be further exacerbated by experiences such as discrimination, language  85 barrier, the lack of financial and social resources, and identity issues. Therefore, gaining insights into how immigrants’ preferences and cultural backgrounds shape their values, beliefs, attitudes and communication styles, in addition to their new identity as an immigrant in Canada will strengthen the patient-provider liaison. However, perhaps as Donnelly et al. (2011) has argued, the Canadian public healthcare system’s under-developed responsiveness to the unique cultural needs of immigrants serve to further isolate immigrant populations. Likewise, the current study findings illuminate the need for Canadian healthcare providers to meaningfully engage immigrant populations who experience suicidal ideation and/or behaviours. Moreover, the explicit permission to talk about their cultural backgrounds and life circumstances in the context of their mental distresses is key to providers’ treatment efforts. For instance, knowing how Confucian morals can influence Korean-Canadian immigrants (both positively and negatively) in the context of suicidal ideation and behaviours, will help healthcare providers to better understand and empathise with at-risk Korean-Canadians and their families. In this way, healthcare providers will also be better equipped to treat mental illness by recognising the most culturally acceptable treatment modalities. Furthermore, premised on Thoits (1986) and Noh et al.’s (1992) assertion, emphasizing the importance of ethnic matching is the need to educate and credential healthcare providers from a variety of cultural and ethnic backgrounds. However, also important to recognise is that regardless of the ethnic match or mismatch between patients and healthcare providers, genuine effort on the part of healthcare providers to understand immigrant patients produces the most beneficial outcomes (Carter, 1995; Chang & Berk, 2009). Debates around the benefits and efficiencies of ethnic matching in healthcare services continues with some  86 researchers arguing for it (Flicker, Waldron, Turner, Brody, & Hops, 2008; Wintersteen, Mensinger, & Diamond, 2005; Farsimadan, Draghi-Lorenz, & Ellis, 2007). In contrast other researchers and clinicians assert, language apart, ethnic match makes virtually no difference in terms of the benefits and effectiveness of the treatment (Carter, 1995, Chang & Berk, 2009; Horst et al., 2012; Karlsson, 2005; Shin et al., 2005). Ahead of discussing the efficiencies of ethnic matching, two issues should be thoughtfully considered. First, it is crucial to understand that Korean-Canadians are reluctant to seek professional help for their suicidal ideation and other mental health issues (Noh & Avison, 1996; Jang, Kim, Hansen, & Chiriboga, 2007; Shin, 2002). Second, frequently addressed in Korean-Canadian participants’ narratives were their lack of awareness of programs and help available for their mental distress. Likewise, the tendency toward underutilisation of mental health services seems to intersect with language barrier, unawareness and inaccessibility of available help programs and services amid stern negative perceptions of mental health service use and fear of the stigma associated with mental illnesses. While it is critical for primary healthcare providers to connect with immigrants, perhaps even more urgent is the need to raise awareness of mental health issues among Korean- Canadians. A key challenge to this is shifting cultural norms garnering fear and reluctance to talk about and seek help for mental health issues. Overcoming Korean-Canadians’ tendency to conceal emotional distress because it contravenes Confucianism might be achieved through raising awareness about the biological underpinnings of mental illnesses. In this way, mental illness can be understood and addressed as a disease in similar ways to the professional treatment of physical illnesses (Karasz, 2005).  87 In the same vein, it is important to provide educational services to immigrants who are at high risk of suffering mental illnesses. Perhaps, policy makers who deal with immigrant populations could use the current study findings as a resource in designing care pathways or counselling strategies and programs that help raise understandings about how culture can intersect with suicidality among immigrant minorities in Canada. For example, in addition to the aforementioned strategy, perhaps, highlighting success stories about Korean celebrities who have experienced depression and recovered by getting help would be another viable tactic. Also, more written resources in different languages and making them available on the Internet in public places would be beneficial. This will ensure the effectiveness of promoting mental health among immigrants, as well as reducing social stigma and shame particularly in the context of Canadian immigrant communities. Bill C-300, an Act respecting a Federal Framework for Suicide Prevention, has been passed in the House of Commons and became law as of February 15, 2013; and, promoting public awareness about suicide in effort to reduce death and injury due to suicide is now mandated. This was a key step to acknowledge suicide as a serious public health issue, and the importance of providing guidelines to improve public awareness of suicide and to define and promote effective evidence-based practices for the prevention of suicide (Harold Albrecht MP, 2012). In order to achieve these aims, it is vital to carefully look at diverse immigrant sub-groups to explore the commonalities as well as the diversities of suicidality – across and within pockets of Canadian culture. Acknowledging the importance and implications of immigrants’ health in Canada, growing interest in the mental health of immigrants has emerged. However, as mentioned earlier, there is a dearth of research addressing suicide among immigrants in Canada. Hence, further  88 cross-cultural research examining diverse sub-groups is urgently needed. 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Retrieved from http://www.multiculturalcanada.ca/Encyclopedia/A-Z/k1             100 Appendices  Appendix A: Recruitment flyer in English            101 Appendix B: Recruitment flyer in Korean                102 Appendix C: Participant screening form      Outcome:  Deemed eligible and consent obtained  Deemed eligible but not willing to participate (no consent)  Deemed ineligible   MEETING DATES INTERVIEW DATE:       TYPE OF CONTACT:  PHONE          EMAIL         SMS DATE: NAME: CONTACT (e.g., email, phone): SCREENING YES NO  Are you first-generation Korean-Canadian? (Defined as born in Korea)?  Are you 19 years or older?  Do you speak and read English and/or Korean?  Have you had experience with suicidal thoughts or behaviours?    I, _________________________________ (Print name), confirm that I have received $30 for participating in the Korean-Canadian immigrant’s perspective on suicide project.  Signature of participant: ____________________________________________________  ------------------------------------------------------------------------------------------------------------ Date: _____________________________  Research staff:  _______________________   103 Appendix D: Interview guide in English  Interview Guide Culture and suicide: Perspectives of first-generation Korean-Canadian immigrants   Introduction  Explain the study purpose and digital recording.  Offer to answer any questions (repeat this offer at the end of the interview as well).  Complete consent form and give one copy to participant.  Explain the purpose of the survey and scales (i.e., demographic form, suicide assessment scale).  Complete demographics survey.  Complete suicide assessment scale.  Research objective Describe the connections between suicide, culture and immigration among first generation (defined as Korean born) Korean-Canadian immigrants through the following research questions: 1. What are the perceptions and attitudes toward suicide among Korean-Canadian immigrants? 2. What culture-specific risks and protective factors influence suicide among Korean-Canadian immigrants? 3. What is the role of immigration and suicidal ideation and/or behaviour among Korean-Canadian immigrants?  Interview Questions Note: Each interview question corresponds to one or more of the aforementioned research questions as indicated in the parentheses next to the interview question.   What prompted you to participate in this study? (Introductory question) Probe: what did you hope the outcome would be?  Tell me a little bit about yourself (e.g., where you grew up, went to school, your career history) and your family and cultural background. (Introductory question) Probe: general demographic probing. Role/impact of mother, father, siblings, children and other close relatives.  Tell me a little bit about your immigration to Canada. (Question #3) Probe: when did you come to Canada? Why did you decide to immigrate to Canada? Or how did you receive when you found out your parents decided to immigrate to Canada. What were your expectations? Are these expectations met? Describe your experience as immigrant in Canada.  Currently, Korea scores the second highest suicide rates in the world. Why do you think it is so? (Question #2 & #3) Probe: perceived problems in Korea – financial, political, cultural, sociological etc.  In your opinion, how people view suicide? For example, people around you. Different views like stigma or any other views associated with suicide. So, what are the norms in your opinion? Are there any differences between Korean and Canadian societies? Is there any gender differences? For  104 instance, how people perceive a woman committing or thinking about suicide as opposed to a man committing or thinking about suicide. (Question #1 ) Probe: perceived norms of perceptions and attitudes toward suicide.  So, perhaps, then we can now talk about what’s your view on suicide? (e.g., Stigma, libertarian or moralist view etc.) (Question #1) Probe: participant’s perception and attitude – more explicitly.  Tell me about any personal experiences you have had with suicide. When did you first suspect that you were suicidal? What do you believe led you to consider suicide? How did it impact you and your family/friends? (Question #2). Probe: what was your initial reaction? What were the symptoms, changes that you noticed? Can you describe your ideation and behaviour and /or attempt?   How did immigrating to Canada influence your mental health? (Question # 3) Probe: Any influence from immigration? Did participant position immigration to Canada as protective or risk factor? Are suicidal thoughts common among immigrants in Canada?   How did you manage your suicidal ideation and behaviour? Have you ever sought professional help? (Question # 1 & 2) Probe: describe some of the most effective ways to manage your suicidal ideation and behaviours? What specific self-treatments did you use? If sought professional help: Specifically which professional help did you seek help from? What led you to seek help? What were your expectations? Did it help? What do you find most helpful? What was not helpful? What were the challenges to seek help? If not, why not? What inhibits you to seek professional help? What were the challenges to seek help?   Did you communicate with your family or friends about your suicidal thoughts or behaviours? (Question # 1 & 2) Probe: Specifically who did you communicate with? What was their initial reaction? Did it help? What were the consequences of revealing? If not, why not? What inhibits you to communicate with anyone about it? What do you think would happen if you reveal it to your family or friends?   Tell me about what prevented you… or how did you manage your suicidal thoughts… that stopped you… inhibit you from committing suicide? (Question # 2)   Almost final questions… What is life? What is death? (Question #1) Probe: General philosophical stance around life and death.  Do you have any recommendations for other people in general or Koreans specifically who are experiencing suicidal thoughts in terms of managing their thoughts? (Question #2 & 3) Probe: for you, what is the key to recovery from suicidal ideation and behaviours? Protective factors?   How did you find this interview?  (Closing question) Probe: did it meet your expectations? Do you feel better or worse after the interview?   Is there anything else you would like to share with me or ask me?     105 Appendix E: Interview guide in Korean  Interview Guide Culture and suicide: Perspectives of first-generation Korean-Canadian immigrants   도입  현연구프로젝트에대한보충설명과인터뷰내용을녹음하는이유에대한설명.  (지속적인) 질의응답시간.  참가자가서명한동의서의복사본을내어준다.  그외설문조사에대한설명 (i.e., 데모그래픽, 자살심각성스케일).  데모그래픽설문조사.  자살심각성의평가.   연구의목적 본연구프로젝트는자살과문화그리고이민생활의연관성을분석하기위해이민 1세와 1.5세한인들을상대로아래의세문항을중심으로인터뷰를하고저합니다. 1. 자살에대한인식과개념. 2. 문화적요소가자살에미치는영향. 3. 이민생활이자살에미치는영향.  인터뷰질문 질문들은위에제시한세문항을중심으로만들어졌으며각질문옆에따르는문항을기록해놓았다.   이연구에참여하시게된동기가무엇입니까? (도입질문) 고려사항: 어떤결과를기대하십니까?   당신과당신의가족에대해좀더말해주시겠습니까? (예: 고향, 자란환경, 출신학교, 직업). (도입질문) 고려사항: 일반데모크래픽사항, 가족 (부모, 형제, 배우자, 자녀, 친지등)에게받았던영향.   이민을하게된이유와이민생활에대해조금말씀해주시겠습니까?(#3문항) 고려사항: 언제캐나다에오셨습니까? 왜캐나다이민을결심하시게되었습니까? 혹은, 부모님이캐나다로이민을결정하셨을때어떻게받아드리셨습니까?  어떤기대를하고오셨나요? 그기대에미쳤나요? 참가자가생각하는이민생활.   현재, 한국자살률은세계에서두번째로높습니다. 왜그렇다고생각하십니까? (#2 & #3문항) 고려사항: 한국내에서문제 (정치적, 경제적, 문화적, 사회적등외).   106  당신이보기엔사람들은왜자살이란선택을택할까요? (예: 오명, 자유의지론, 도덕주의, 윤리기타등). 남녀차이가있다고생각하십니까? 한국사회와캐네디언사회의차의점이있다고생각하십니까? (#1문항) 고려사항: 참가자가생각하는자살에대한대중의인식과개념.   당신은자살에대해어떻게생각하나요? (예: 오명, 자유의지론, 도덕주의, 윤리기타등).(#1문항) 고려사항: 참가자의자살에대한인색과개념.   당신이느꼈던혹은겪었던자살생각이나충동, 그리고행동에대해조금말해주시겠습니까? 언제처음으로알게되었죠? 왜아니면무엇이당신에게자살이란선택에대해생각하게끔했다고생각하십니까? 이런생각과충동들이당신의가족과주변사람들에게어떤영향을끼쳤습니까? (#2문항). 고려사항: 처음이런생각이들었을때어떻게대응했습니까? 어떤증상이나달라짐이있었나요? 자세히어떤생각과충동이들었습니까? 실제로행동으로옮긴적이있으십니까?   이민생활이당신의정신적건강에어떤영향을미쳤나요?(# 3문항) 고려사항: 이민생활이주는영향? 참가자는이민을좋은영향아님나쁜영향으로생각하나? 자살사고가이민자들에겐빈번한일인가?   그런생각과충동, 혹은행동들을어떻게감당하셨나요? 전문의에게상담을받아보신적이있나요? (# 1 & 2문항) 고려사항: 가장효과적이고실질적인방법이뭐가있을까요? 참가자는어떻게 (좀더구체적으로) 자살사고과충동을억제했는지?  전문의에게상담을했을경우: 어떤전문의에게상담을받으셨나요? 어떤계기로상담을받게되었나요? 어떤기대로상담을받게되었나요? 상담이도움이되었나요? 어떤부분이가장도움이되었나요? 어떤부분이도움이되지않았나요? 전문의의상담을받기가어려운이유가무엇이있을까요? 전문의에게상담을받지않았을경우: 왜상담을받지않으셨지요? 무엇이참가자를전문의에게상담을받지않게하는가? 상담을받기에무엇이힘든가요?   당신은자신이겪고있는자살생각이나충동, 그리고행동에대해가족이나주위사람에게말한적이있습니까? (# 1 & 2문항) 고려사항: 좀더구체적으로누구에게표현했는지? 그들의처음반응은? 표현함으로도움이됬는지? 표현함으로어떤결과를맞았는지? 표현하지않은경우: 왜표현하지않았는가? 무엇이표현하지못하게만드는가? 만약표현할경우어떤상황이초래될것이라고생각하는가?   당신의자살생각이나충동그리고그에따른행동들을어떻게억제하고방지했나요? (# 2문항)   인생은무엇이라고생각하십니까? 죽음은무엇이라고생각하십니까?(#1문항) 고려사항: 인생과죽음에대한철학적인관점에대해.   107  자살을생각하거나충동을느끼는한인이민자들이나다른일반인들에게해주실충고가있나요? 자살생각이나충동을억제하고방지할수있는방법등.  (#2 & 3문항) 고려사항: 참가자에게가장중요한회복의비결이무엇이었는지. 보호적인요소는?   이인터뷰소감?  (마무리질문) 고려사항: 기대에미쳤나요? 이인터뷰가어떤영향을끼쳤나요?   이밖에질문이나더하고싶은이야기가있으신가요?                                       108 Appendix F: Fieldnotes [P101 to P115]    109     110    111     112     113     114     115     116     117     118     119     120     121     122     123 Appendix G: Mental health service resources information sheet in English     Participant Resource Sheet  Should you require further opportunities to discuss any related issues please contact your health care provider (e.g., family doctor, counsellor, psychiatrist) or one of the following resources:  Changeways Clinic 2525 Willow Street — Ste 509            Tel: 604.871.0490 http://www.changeways.com/  Crisis Centre Tel: 604-872-3311            www.crisiscentre.bc.ca  Mood Disorders Association of BC 604.873.0103                                       http://mdabc.net/  Canadian Mental Health Association (CMHA) Tel: 604.688.3234                               http://cmha.bc.ca/  SAFER  (For those in suicidal crisis and family and friends) 300-2425 Quebec Street                      Tel: 604.879.9251  Any Hospital Outpatient Psychiatric Clinic, including:  VancouverGeneralHospital, Outpatient Psychiatry 715 West 12th Avenue                         Tel: 604.875.4794  St. Paul’s Hospital Outpatient Psychiatry Service 1081 Burrard Street                              Tel: 604.806.8004   If you require immediate assistance, the following resources might be of use:  Distress Line (24hr):    604.872.3311 or 1.800.784.2433 Mental Health Emergency Services (24hr):    604.874.7307  You can also go to an Emergency Department nearest to you.       124 Appendix H: Mental health service resources information sheet in Korean     참여자 정보 자료   전문적인상담이필요하신분들은아래의정보를참고하십시오.   Changeways Clinic 2525 Willow Street — Ste 509            Tel: 604.871.0490 http://www.changeways.com/  Crisis Centre(위기보호 센터) Tel: 604-872-3311            www.crisiscentre.bc.ca  Mood Disorders Association of BC(BC 기분장애 협회) 604.873.0103                                       http://mdabc.net/  Canadian Mental Health Association (CMHA) (캐나다 정신건강 협회) Tel: 604.688.3234                               http://cmha.bc.ca/  SAFER  (For those in suicidal crisis and family and friends) 300-2425 Quebec Street                      Tel: 604.879.9251   Any Hospital Outpatient Psychiatric Clinic, including:  VancouverGeneralHospital, Outpatient Psychiatry 715 West 12th Avenue                         Tel: 604.875.4794  St. Paul’s Hospital Outpatient Psychiatry Service 1081 Burrard Street                              Tel: 604.806.8004  If you require immediate assistance, the following resources might be of use:  Distress Line (24hr):    604.872.3311 or 1.800.784.2433 Mental Health Emergency Services (24hr):    604.874.7307  이외 가까운 응급병원에서도 도움을 받을 수 있습니다.    125   Appendix I: Demographic survey in English  Demographic Form Culture and suicide: Perspectives of first-generation Korean-Canadian immigrants   Participant Code:   This demographic form is being used to collect some basic background information about the people in this research study. Please be assured that details such as your real name or other information that might identify you to others will not be used in any write up, reports or papers that come out of this project.  * Please remember that you can alwayschoose not to answer any of these questions.  A. BACKGROUND & PERSONAL INFORMATION Date   Name   Age   Sex   Religion    Marital status: (Please circle the most appropriate answer) 1. Single/never married 2. Married 3. Common-law 4. Separated 5. Divorced 6. Widowed 7. Prefer not to answer  Live with:(Please circle the most appropriate answer) 1. Alone 2. Roommates 3. Parents 4. Spouse/partner 5. Spouse/partner + children  126 6. Spouse/partner + children + other extended family (Please describe) ______________________________ 7. Prefer not to answer  In what year did you immigrate to Canada? ________________  B. EDUCATION & EMPLOYMENT BACKGROUND  What is your highest education? ______________________________________  What was your occupation before coming to Canada?  __________________________________________________________________  What is your current occupation in Canada?  __________________________________________________________________    C. HEALTH INFORMATION  How would you rate your overall level of physical health at this point in time?  Extremely poor    Excellent 1 2 3 4 5    How would you rate your overall level of mental health at this point in time?  Extremely poor    Excellent 1 2 3 4 5    Do you currently have any other health concerns? (If yes, please describe)   ___________________________________________________________________     127 Have you sought or received treatment(s) for suicidal thoughts or behaviours? 1. Yes 2. No  If yes, what type(s) of treatment? (Please circle all that apply) 1. Psychiatrist 2. Psychologist 3. Family doctor 4. Medication 5. Other counseling 6. Group therapy 7. Others        __________________________________    Thank you!                                  128   Appendix J: Demographic survey in Korean  Demographic Form Culture and suicide: Perspectives of first-generation Korean-Canadian immigrants  Participant Code:   본연구데모그래픽설문은연구참가자에대한기본적인통계자료를위한것입니다. 연구참가자의실명이나그외특별한정보는연구논문이나리포트에쓰이지않을것을알려드립 니다.  *연구참가자들은아래의질문에대답하지않을권리가있습니다.   D. 개인정보  날짜   이름   나이   성별   종교    캐나다이민연도________________  결혼여부: (가장근접한답에동그라미를치시오) 8. 미혼/한번도결혼한적이없음 9. 기혼 10. 동거 11. 별거  129 12. 이혼 13. 사별 14. 밝히고싶지않음  지금누구와살고계십니까: (가장근접한답에동그라미를치시오) 8. 독거 9. 룸메이트 10. 부모님 11. 배우자/동거인 12. 배우자/동거인+ 자녀(들) 13. 배우자/동거인+ 자녀(들) + 그외다른식구들 (부과설명) ______________________________ 15. 밝히고싶지않음   E. 교육&직업배경  최종학력 ______________________________________  캐나다에오기전직업 __________________________________________________________________  현재의직업 __________________________________________________________________   F. 건강상태  당신의현재전반적인건강상태  매우나쁘다    매우좋다 1 2 3 4 5  당신의현재정신건강상태  130  매우나쁘다    매우좋다 1 2 3 4 5  이밖에다른건강사항이있읍니까? 만약에있다면말씀해주십시오.   __________________________________________________________________   자살생각과행동에대해전문치료를받은적이있습니까? 3. 예 4. 아니오  만약받으적이있다면, 어떤종류의치료를받았습니까? (해당되는모든것에동그라미를치시오) 1. 신경정신과 2. 정신과 3. 주치의 4. 약물치료 5. 상담치료 6. 그룹치료 7. 그외        __________________________________    감사합니다!                 131  Appendix K: Beck’s Scale of Suicidal Ideation (SSI)      132        133      

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