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Committed and attempted suicides : sex-related differences in self-destructive behavior McNicoll, Paule 1979

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COMMITTED AND ATTEMPTED SUICIDES: SEX-RELATED DIFFERENCES IN SELF-DESTRUCTIVE BEHAVIOR MAJOR PAPER SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SOCIAL WORK i Q / SUBMITTED BY: PAULE McNICOLL DATE: DECEMBER 1979 TABLE OF CONTENTS INTRODUCTION 1 Part I: DEFINITIONS AND DIFFERENTIATIONS 3 Part II: THEORIES AND PERSPECTIVES A. Anthropological perspective.. . . ».. . 14 B. Historical perspective. 17 C . Sociological perspective 21 Do Psychological pG2rsp©c~biv©»ooaooooooooo»«oooooo 0 2*7 E. Philosophical perspective«. . <, 0 ° » .o .„ . - . . .„.. o <>.36 F. Social-Psychological poi* Sp 0 C "fcl V© OOOOQOOOOttDOOa 39 G r • D l S C T J - S S l O T l a o o o o ^ t o 0 0 0 0 0 0 0 0 0 0 * 0 0 0 0 0 0 0 0 0 0 0 o f ^ o ^ o a ^ ^ ' / ' Part III: INTERVENTION ... 49 A. Exploration of the particular circumstances...,50 B. Intervention on c ommi Lmsn ~t oo*ooo*o*ooo o»oooooo»3^-10 over-commitment to success. 0 . 0 . . . . » . . . . • . . . .52 2. over-commitment to affiliation...000.00 a....5^ 3" vacillation between success and affiliative goals,o.....56 C . Intervention on communication „ ........M.......58 PSL2r~fc XV • PREVENTION • • • 0 * * 0 0 0 0 0 0 0 0 0 « 0 0 0 0 0 0 0 » 0 0 0 0 0 « 0 0 0 0 0 0 62 A. Demands for exercising of competence 0. .. <,.... 0 063 Bo Demands for interpersonal giving,.....00.......65 Co Degree of toleration of suicide.........,,.....66 D. Availability of succorance...0...........».....67 E. Hope in the future time perspective...........-70 F. Production of personalities with a strong sense of competence 72 1. androgynous upbringing 72 2. adequate handling of aggression .7^ 3. learning of communication skills.... -.76 CONCLUSION FOOTNOTES 8 1 BIBLIOGRAPHY . . . 90 COMMITTED AND ATTEMPTED SUICIDES: SEX-RELATED DIFFERENCES IN SELF-DESTRUCTIVE BEHAVIOR INTRODUCTION Seven out of ten suicides are committed "by males; 1 seven out of ten suicide attempts are made by females . The statistical data seem to hold for "both adults and 2 adolescents, for people of different races , and m all countries. What are the factors responsible for such an impressive contrast? The current "wisdom" poses that, while most men make up their minds and proceed accordingly, women's attempts tend to be hysterical gestures intended to attract attention and/or manipulate people in their environment. Such an explanation has a strong impact on suicide care. Men, who have more likely used lethal means, are treated with dignity and empathy. Women are often faced with irritated reactions and punitive atti-tudes-. It is also expected that they will probably make a further attempt. Even the authoritative Los 3 Angeles Suicide Prevention Center adopted^ an actu-arial stance: its Training Manual recommended that a call from a male be considered more serious . This paper challenges the common understanding of the sex-differences in self-destructive behavior. After having specifically defined the term suicide and clarified the differences between committed and attempted suicides, we will discuss the major theories and perspectives on the subject: anthropological, historical, sociological (Durkheim), psychological (Freud) and psychiatric, philosophical and social-psychological (D.H. Miller). Suicide is not a simple matter, nor is the matter of sex-differences in suicide attempts. This paper will address the knowledge acquired through the multi-ple approaches and outline the consequences for inter-vention and prevention. 3-Part 1; DEFINITIONS AND DIFFERENTIATIONS Suicide is not as easy to define as it seems at first sight. Durkheim's description of suicide as "all cases of death resulting directly or indirectly from a positive or negative act of the victim himself, which he knows will produce this result"-*, still one of the "best in theory, does not correspond with the availa-ble official statistics. The universal death-classi-fication instrument is the N.A.S.H. method^ which registers the death of the over-indulgent diabetic as natural, the head-on car collision of the depressed as accidental, and some crimes against highly provocative victims as homocidal. Therefore, the data is more incomplete than incorrect. It underestimates the number of suicidal events. In absence of a better alternative, we have to accept the discrepancy between the theoretical and practical definitions. Many scientists have adapted their formulations in a way that correspond to the data they analyze. In a literature search, Shneidman sorts . . 7 out nine elements of definition'. In approaching the different theories, we must be flexible and aware of the fact that the definition is not constant. Another source of confusion is the objective manner in which a self-destructive gesture is qualified g as a suicide or as a suicide attempt. Farber suggests a more accurate way to categorize suicidal behavior. He uses a simple formal construction to cross-tabulate intention and outcome: to die INTENTION not to die Intention is quite a subjective criterion but it can be evaluated by hard data as the potential threat to life and the chances of external intervention. As long as we keep considering the outcome only, we lack the clarity indispensable to theory and action. Consider the two following examples: Judy has been left by her lover who previously had forced her into leaving her job, breaking contact with her family and having an abortion. She decided it was the end of everything and shot herself in the mouth. The bullet went through the head, but miraculously did not injure the brain. She was saved, and stunned. She is said to have made a suicide attempt (rather than a missed suicide act). OUTCOME death survival true suicide missed suicide missed sui-cide attempt true suicide attempt Jerome had always been depressed, as far as his acquaintances can recall. He invariably failed to keep any job, or friends, or a girlfriend. Many times, he had taken barbiturate overdoses, but always called someone just in time to be saved and hospitalized. Last month, he was found dead in his car of carbon-monoxide poisoning. He had parked near a telephone "booth, and a paper with the name and telephone number of his last therapist was crumpled in his hand. Officially, Jerome committed suicide (although it appeared his intention was not to die). Stengel^ isolates three features of suicide attempts 1. uncertainty of outcome; 2. appeal effect; and J. a urge for self-punishment that is also associated with committed suicide. The first feature, uncertainty of outcome, has been deduced from the fact that carefully planned suicidal acts are rare. Many are carried out on sudden impulse, but suicidal thoughts were always present. Both suicides and suicide attempts are performed in places where inter-vention is possible, even probable. Whether or not there will be intervention is usually left to chance. The methods used by true committers, though, are far more lethal and in case of attempts, the attempters themselves 10 often initiate the rescue by asking for help 6. "The various features of the suicidal act as a behavior pattern indicate that it is not only directed toward destruction and death but also toward human contact and life. This is why it has been described as Janus-H11 faced", or as a gamble with death. Here is an example: Frequently in the past year, Gerald, Jean's husband, had not come home from work until eleven o'clock at night. He had given no notice, no apologies. When questioned, he always answered with a vague, but decent excuse. Jean suspected he had a mistress and did not care about her anymore. She took a hot bath and deeply slashed her wrists about thirty minutes before his earliest time of arrival. Gerald came just in time to save her. Sometimes an attempt is a dangerous test to obtain 12 the judgement of fate. Moran , in a study made with members of Gamblers Anonymous,found that their proportion of attempters was about eight times greater than the general population rate. These results were not con-13 firmed by Kennedy ^who duplicated the study. A very promising approach to the understanding of the gambling tendency would be a comparative study of suicide and suicide attempt versus internality and externality of locus of control. Internally oriented individuals think their fate is contingent on their 7. behavior and competence; externally oriented individuals believe their future is determined by chance, environ-ment, fatality, and so on. A literature search in this area has already correlated externality and low self-14 . 1 < esteem , externality and suicide proneness , and these three factors together with a negative evaluation of a 16 personal future . It could be postulated that attempter are even more externally oriented than committers, and that women,having a lower sense of competence and less means to make their way out of the domestic world,so they rely more on external influences than men. Alas, sex differences of locus of control seem to follow quite complex and variable routes, and nowhere is there data to substantiate this thesis. Appeal effect is the second characteristic different iating suicide and suicide attempt. An attempt aims, consciously or not, at making other humans show concern and love and act accordingly. Kathleen, thirteen-years old, had a violent fight with her mother who "treated her like a baby". Still angry and feeling powerless, she took her mother's bottle of sleeping pills and swallowed all of .them. She then took a bus for a distant city. She was found sound a-sleep at the bus depot, five hours later, and transferred to a nearby drug crisis centre. What happens to family members and friends after the suicidal gesture is similar to grief reactions. There is a resurgence of love, a sense of guilt of not having cared enough, especially in cases where there were unconscious death wishes toward the attempter and finally, an -urge for compensation and reparation. It is sometimes short-lived, but always there. It is a universal reaction, present in all cultures. Punitive reactions toward the attempter seldom occur. When they do, it is usually because family and friends interpret the gesture as an act against them or as a manipulation. Stengel1'7 sees women attempting suicide more often than men because they utilize it as a means of manipulating relationships and environment, and because other means of pressure, like physical threat or financial blackmail, are not available to them to the same extent they are to men. The theory of manipulation is a very dangerous one that presently prevails in psychiatric practice. Manipu-lation means "the act of operating upon or managing persons or things with dexterity; esp. with disparaging impli-ii 18 cation, unfair management or treatment" . It is es-sentially pejorative. Certainly, some women use attempts as a way of manipulating; some men do it too. When present, manipulation covers an inability to cry for help in a direct and efficient manner. It is a secondary trait of suicide attempts which demonstrates the need for the attempter to improve his(her) communication skills 1 9 In a very different fashion, Jourard y proposes that both suicides and attempters are responding to clues by some significant others that invite them to die. What the significant others really want sometimes is only a change in behavior or in some aspect of character. The person for whom these changes necessitate a basic reorganization of their self-concept may overreact and interpret other's demands as a wish that they disappear. The message is generally conveyed covertly, through meta-communication, so its existence can be at all times safely negated. Women would be more likely to perceive these clues and be influenced by them, if the universal assumption that women have a greater sensitivity in interpersonal relationships than men is true. After all, they are brought up as nurturers and most of them spend their lives attending other people's needs (mothers, waitresses, nurses, clerks, social workers, wives, doctors,etc..). Dublin corroborates this idea when he writes:"The problems of successful suicides are largely centered in themselves; 20 the unsuccessful are concerned chiefly with other people. 21 Yap also found that interpersonal conflicts precipitated more suicide attempts than suicides. 10. Urge for self-punishment is the third and the last feature of suicide attempt that differentiates it from committed suicide. Aggression turned inwards is found to a larger extent in committed rather than in attempted suicide. After his divorce and the accidental death of his daughter who drowned in his presence, Brian, twenty-nine-years old, joined a very strict religious sect. He eventually became a minister of this order, but had to leave because of some interpersonal conflicts. He was quite withdrawn for a while, but then found a construction job as a crane operator. A few hours after an altercation with his boss, he, by mishap, almost hit the man's head with a heavy load he was operating. He was immediately fired. Three days later, he had delusions that Satan took possession of him. As he interpreted the Scriptures, he could not be in God's grace again with the hand that had sinned. He chopped off his right arm with an ax as a means of proving repentance and of facing the life-death judgement. Such acts, fortunately not often so bloody and dramatic, have a cathartic affect; they bring an instant 22 release of emotional tension . This may contribute to the improvement that generally follows an attempt. Men have more opportunities than women to express their 11. surplus of aggressiveness: violent sports, physical fights, verbal clashes. Women, socialized to be nice and understanding are more likely to keep aggression inside. They would not completely turn it against themselves, however, since aggression against others is more manifest 2 3 2 4 in an attempt than in a suicide . Clifton and Lee noted some results indicating that even if women are less likely than men to commit suicide, they are more self-destructive. They identify physical suicide and social-psychological self-destruction as two different phenomena. i It underlines the necessity for women to learn to express anger without guilt and to be able to assert themselves. It.seems to be a better alternative than life-threatening behavior. The etiologies of fatal and non-fatal suicidal behaviors are quite distinct, and European experts consider them to be two completely different phenomena. Many factors seem in favor of this hypothesis: already mentioned are the different sex-ratios, methods and motivations, different directions of aggression. Another indication would be the frequency of suicide notes. Of those who committed suicide, thirty-five to thirty-nine percent left a note. In suicide attempts, a note is left in one to two percent of the cases. It can be argued that attempters themselves, friends and family are more likely to hide the notes when the suicide is not complete. The discrepancy of the results, however, leaves room for some discussion. There is also an American thesis posing, on the contrary, that suicidal "behavior may be seen as a con-tinuum. We present Farber's25hope spectrum as a guideline for this particular opinion. HOPE AND SUICIDAL BEHAVIOR SPECTRUM High - uncontrolled elation with unrealistically high hopes, as in manic psychoses - good moods, within normal range - normal, realistic,"healthy" people HOPE - mild depressions, within normal range - suicidal gesture, without lethal intent - the gamble with death, true attempt - true suicide, with full lethal intent Low - deep depression It is interesting to remark that committed suicide is not placed at the extreme pole. Having this model in mind, we understand.why an improvement in the mood of a depressed patient can coincide with an increased suicide risks there is still some hope in suicide, hope that death can be a solution, hope that one can perform a meaningful act and, as discussed later, hope of a magical denouement. -Absent -Mild SUICIDAL BEHAVIOR -Highly ambivalent -Serious -Latent 13-9f Dorothy Miller presents a third perspective. Her concept of "suicidal career" implies that self-destructive "behavior does not sprout from nothing and that it is possible to identify some precursor signs long before the final gesture. Men's and women's careers are manifestly different. Feminine behavior becomes obviously self-destructive sooner and the evo-lution toward death is slower for women than for men. ; A suicide attempt is considered cowardice: it is tolerated for females, but men cannot afford this kind of labeling. They would rather discharge their anger and frustration in a "manly" way: delinquency, alcoholism, fights, and so on. Men's suicidal careers are also shorter because they rely less than women on other people's interventions. They are the bosses at home and at work. They are the ones who decide where to live, when to take holidays. Their successes are generally "one-man shows", disregarding the fact that women have often aided their achievements.1 This paper subscribes to Miller's perspective because it encompasses both differences and similarities of suicidal behavior and highlights the sex-related tendencies of self-destruction. 14. Part II: THEORIES AND PERSPECTIVES A. Anthropological perspective A brief look at suicide within different cultures shows variances in functions and meanings. In Japan, suicide is traditionally considered a very honorable act and there is a whole ritual attached to it. In the 27 Trobriand society , suicide is used a^ a legal mechanism. If someone commits a major infraction, like incest or homicide, public disapproval induces the offender to take pQ his(her) own life. In some African communities , self-destruction is a means of revenge against enemies because of the belief in the ghostly powers of the dead. The Yuit 29 esquimo , on the contrary, may choose to die to save the life of a friend or to acquire prestige; for these purposes, the committer has to be a male in the prime of his life. The anthropological perspective demonstrates that suicide and life-threatening behavior are completely integrated in some cultures. In terms of his own culture, the old Yuit who ends his life in order to pass honorably into the other world is not pathological: he obeys the self-regulating traditions of his society. Suicide is therefore not necessarily a sickness. 15. According to anthropological analysis, the difference in men-women ratios, motivations, and methods of suicide depends directly on specific social structures. A good example is the differing suicide patterns of the Gisu and 30 the Soga, two African tribes-' . Soga women have an extremely high rate of suicide and they commit it more 31 often than the males . It has been found that the main cause of strife is marital relationship. Women are often in a double-bind position, having to please their husbands, who generally act like tyrants, and their own father and brothers at the same time. Life seems easier for the Gisu 32 women^ . They also have their share of conjugal conflicts but public opinion gives them support. One of their popu-lar sayings is " A woman can always find a husband but a O "3 man who cannot keep a wife is indeed unfortunate". The causes of suicide are also socially determined. In Asia, the sutee, or custom for the wife to commit sui-cide on the body of her dead husband is directly related to the fact that she is considered his possession. A sui-cide for any other reason would be severely punished as an attempt to steal from her "master". As for the means of suicide, they often are prescribed by tradition. A double standard for men and women is present m the Tikopia society^ . Unmarried young women are expected to swim in the sea where they are usually eaten "by sharks. When there are too many young men, some take a canoe for a sea voyage, a hazardous adventure in this part of the world. A "rescue service", however, is sent in pursuit of them and many are saved. From this discussion, it can be concluded that there is no simple way to approach the suicide phenomenon. In all cases a thorough examination of the social-cultural context is necessary. 17. B. Historical perspective History presents suicide within the frame of the changing social conditions, value systems, institutions, and ideologies. The following is a brief account of our western history of self-destruction. The Bible relates only five instances of suicide, mostly committed to avoid the consequences of military and political defeats. Nowhere is there any indication of disapproval. There is not even a specific word for suicide. After the fall of Jerusalem, Jewish religious leaders, confronted with a sudden epidemic of fanatic voluntary martyrdom, dictated some loose definitions of unnecessary suicide. In the Greco-Roman civilisation, suicide to avoid humiliation and the suicide of the soldier, the slave or the widow following his(her) master were approved. With the advent of Christianity and Christian persecutions, voluntary martyrdom and suicide became social diseases. Some legal measures were taken primarily based on religious and political grounds. The penalties included mutilation of the dead body and/or refusal of honorable sepulture. Suicide of mentally disordered persons was recognized as such, but the general phenomenon was viewed more as a moral matter than as a medical one. 1 8 . During the Middle Ages, the antagonism against suicide became condemnation. The Christian Church equated suicide with homicide and started refusing burial in consecrated cemeteries. The only exception was the insane. On the secular level, the sin of sui-cide was punished by confiscation of property and degradation of the corpse. The situation remained unchanged until the Eighteenth Century, when the suicide rate increased and attitudes toward suicidal behavior became less 3 "5 hostile. The Christian Humanists"^ underlined the mitigating circumstances surrounding a suicide. In the Nineteenth Century, the Enlightenment movement stressed the environmental factors and viewed suicide as a consequence of mental and emotional disorders. Suicide emerged as a subject for statistical-sociological and medical-psychiatric inquiry. After two hundred years, this latter formulation is still the prevalent view of suicide. It is interesting to note the relationship between suicide and religion. Religious crises seem to trigger suicide epidemics. Therefore, religious leaders are the strongest opponents of self-destruction. Davis-^postulated that women were protected from suicide by their greater religiosity and obedience to Churches' edicts. His 37 thesis was promptly discarded by Lester and Lester^' under the assumption that, if it were true, women would also be protected from suicide attempts, which actually they perform more often than males. The belief that the majority of suicide attempters do not want to die invalidates their refutation. Durkheim^® and Dublin-^ have already correlated suicide and religious beliefs. Kranitz and other researchers have been unable, however, to find any association between suicide attempts and religion. It seems as if religion has some influence on completed suicides, but not on attempts. Davis' theory is- still unabated. Before accepting it, women's greater religiosity and conformity should be scientifically tested. Because religion was the only non-domestic area open to women for many centuries, strong affiliative needs may have been invested in this domain, which could favor the causation of religious influences. There is also a history of the daily life which gives equal attention to men and women. Throughout the ages, women "cared for the children, the sick, the aging, the injured, and from this came to learn about death differ-ently from their male counterparts. For men, death was related to food for the tribe or a victory over an „ki adversary, m short, something to be carried out 20. Even now, similar sex-role definitions are valid and have an impact on one's basic attitudes: women are more oriented toward the preservation of life and men accept ho facing death more readily. Carole Light Selvey , in a study of the symbolism attached to death, found that men associated it with ideas of mutilation; for women, death was related to loss of love. Both males and females could imagine a man's death more easily. Women reported more fear of death than men. This suggests that the hidden forces of tradition can positively affect the present suicide ratios in dictating to women that death is to be feared, avoided and prevented, and to men that death is to be challenged. . 21 . C. Sociological perspective . i 43 Durkheim s ^ work is the cornerstone of modern knowledge about suicide. He did not believe in the utility of individual data in the understanding of sui-cide. Startled by the fact that the number of suicides in a given society is quite stable and that there is obviously no communication whatsoever between the persons who commit suicide, Durkheim concludes that it "can only be due to the permanent action of some impersonal cause n 4 4 which transcends all individual cases . He concen-trates on the collective conscience, and its vital influ-ence on individual behavior. This conscience, or culture, includes social precepts, avenues of communication, definite formulae of faith and even material things such as monuments and architectural forms, that play an es-sential role in the common life. When this conscience functions coherently, soli-darity results. Inversely, a lack of common bonds leads to "egoistic" suicide. The individual is disconnected from his(her) collectivity. What is left is personal ambition and when this seems to fail, there is no larger frame of reference and support to take "over. 22. Social control can replace solidarity when it is lacking. The individual interests are organized in a way that facilitates the common interest. Society is still an integer and the suicide rate remains low. "Anomic" suicide is the result of a lack of social constraint. In order to be satisfied, the individual has to measure and adapt his(her) aspiration level to reality. When reality is in constant movement, one cannot get any sense of efficiency, the aspiration level having no constraint, nor bounce. This happens with rapid change, particularly economic change. The di-rection of the transformation, positive or negative, is irrelevant. According to Durkheim and most scientists, "egoistic" and "anomic" would be the two most common types of sui-cide in modern society. Each form has its antithesis. "Altruistic" suicide derives from a lack of individual differentiation and reminds us of the Japanese kamikaze. An "altruistic" society " considers individual life secondary, to be sacrificed to the larger goal of social good"^5. "Fatal istic" suicide, contrary to "anomic" sui-cide, is the result of too strict regulations that com-pletely negate freedom. Oppressive discipline blocks people's ambitions and passions. "Altruistic" and "fatal-istic" suicides are thought to be practically non-existent in the post-industrial world. 23. To summarize Durkheim's general theory: "suicide varies inversely with the degree of integration" (re-ligious, domestic and politic) "of the social groups of which the individual forms a part"^. Commenting on the more frequent completion of sui-cide by males, Durkheim assumed that women were more directly influenced by their organism and therefore bene-fitted from a "natural" immunity against self-destruction. Based on the presumption that women have a more rudi-mentary sensibility, the theory deduces that they have less need for socialization, are less interested and involved in collective existence, and consequently are less prone to react to social influences by committing sui-cide or in any other way. Durkheim's Le Suicide was written in 1891, and time has proven its premises to be wrong. A now-and-then comparison suggests that one's gender deeply affects one's social experience. Durkheimian topology of suicide provides us with four interesting axes for a discussion of men-women sui-cidal differences. "Anomie", or lack of external restraint, is certainly the most reputed of Durkheim's concepts. The majority of women have been and still are entrusted with the responsibility of interpersonal harmony and of domestic affairs. Their main tasks are concerned with 24. the well-being of their significant others and with the perpetuation of the basic organizational chores. Their roles are less vulnerable to fluctuations than men's roles and social change only affects them in an indirect manner. In short, women do not suffer much from anomie, because they inhabit a restrained world. There are exceptions to this statement: professional women experience the difficulties in self-definition brought about by rapid change and their suicide/suicide . . i 47 attempt ratio is similar to men s "Egoism", or the disconnection of the individual from his(her) society, is another condition generating many suicides. The amount and the importance of inter-actions in women's lives lessen the probability of their feeling alienated from their environment. What women may face, on the contrary, is that most of their energies are drained by nurturing others and that there is almost no energy available for working out a meaningful con-nection with society. This is called "altruism", or a weak sense of individuation, and is said to exist only in primitive civilizations. The same thing happens with "fatalism", conformity resulting from too strict regu-lations. Women have a long-time "vocation" as child-bearing housewives and alternatives have only recently appeared. Still, Durkheim claimed that "fatalism" has "little contemporary importance". 25. IlR K.K. Johnson challenges this assertion and divides the collective life into two spheres: the public, "manly" one, characterized by anomie/egoism and the private sphere to which women are relegated. With no specialization that would give them specific goals, a sense of achievement, and the possibility of economic independence; with no pre-paration or encouragement to compete, struggle and defy; with an ingurgitated philosophy of dedication to others, women do not have many alternatives other than devoting their lives to a "home". This upbringing and the resulting situation lead to "impersonalism" where "the ego is not its own property, where it is blended with something not itself, where the goal of conduct is exterior to itself Women's private world is characterized by fatalism/altruism, even if the main stream of society does not show such features„ Would fatalism and altruism be more conducive to sui-cide attempt than to suicide? Not necessarily. The case of the protesting Buddhist who sets fire to his clothes is an example of altruism that leads to fatality„ But in the case of Western women, the fact that they are devoted to people and not to a cause seems to make the difference. At least, one can hope for a reaction from people. 26. Cantor50 has found that women attempters were more likely than others to be nurturant persons frustrated by the lack of reciprocity of care when they are in need. The testimony of this depressed woman is an example:51 "I felt that I trusted and they - they took advantage of i I am very sincere, but I wasn't wise. I loved, and loved strongly and trusted, but I wasn't wise. I - I deserved something, hut. T thought if I give to others, they'll give to me". 27. D. Psychological perspective Freud has made the most influential contribution to the psychology of suicide, although his views on the subject, scattered over his entire work, have never been presented in a synthesized theory. In 1910, at a symposium on suicide held by the Vienna Psychoanalytic Society, Stekel enunciated that "No one kills himself who did not want to kill another, or, at least, wish death to Cn another"-^ . The statement had such an enormous impact on Freud's work that it has been wrongly attributed to him. In 1917, in Mourning and Melancholia-^. Freud postulated his concepts of sadism and masochism and explained their interrelation: 1. self-destruction means destructive tendency against self and implies that the self is treated as if it were an external object; 2. suicidal persons are often highly ambivalent in their object attachments and tend to "introject" some close relations into their own self; 3 . therefore, when conflict and separation occurs, they tend to direct their unconscious sadism against them-selves . In 1920, Freud complemented his perspective on sui-cide by introducing his concept of Thanatos, or instinctual drive toward death, aggression and destruction, the active antithesis of Eros, or life instinct. When Thanatos is winning, the stage is set for the suicidal process to 28. happen. "Even a conscious intention of committing sui-cide chooses its time, means,and opportunity; and it is quite in keeping with this that an unconscious intention should wait for a precipitating occasion, which can take over a part of the causation and by engaging the subject's defensive forces, can liberate the intention from their pressure . For Freud, each suicide is multiply determined by the interaction of several motives. The specific suicide mechanisms are loss of love object, narcissistic injury, overwhelming affect, splitting of the ego and the famous inversed aggression, which has been wrongly singled out as the only freudian explanation of suicidal inducement. Freud commented briefly on suicide attempt: he saw it as a compromise between death and life instincts. As for the difference in men and women's suicidal behavior, nowhere has any mention been found. Although it provided a basis for Freud's approach on self-destruction, the concept of death instinct had little impact, even among psychoanalists5-5. This is probably due to its vagueness and the difficulty in finding confirmation for it in everyday life. It can be advanced that, because of the traditional sex-role division, women relate more to Eros, the instinct of unification, preservation and life. 29. Even in the presence of suicide precursors, women remain obstinately ambivalent. A scientist, Pierre Shneider^, proposes a similar thesis when he relates the higher incidence of suicide among men to their greater vulner-57 ability-" , which he believes is also manifest in diseases and accidents. He thinks it is a biological law that men are less resistant and cling to life less than women. All these are intuitions, and in order to be pursued, need to be confirmed by substantial data, which are not available at this time. Taking one by one the suicide mechanisms presented by Freud, we see that the first one, loss of love object, may have special relevance for women. Lovers partly identify themselves with the object of their passion. There is nothing pathological in this process, the self-concept being made up in large part of identifications. However, identification can be over—emphasized in some dangerous ways of loving: for instance, the symbiotic love where the self and object are so fused that the presence of the object is considered a necessity for one's existence. Fusion is the ideal of romantic love which affects all of North-American society, but more so the feminine world in which total love is seen as the ultimate experience. There is also no other goal in women's upbringing that competes with it and diversifies women's energies. The suicide of 30. some widows would "be triggered by such a mechanism. Their reaction is not only mourning, or the vision of loss, of a deserted world, but also melancholia, or the sensation that the ego itself is depleted. Narcissistic injury is another frequent precipitating evento For the narcissist, no object of love or attain-ment exists but him(her)self. Therefore, (s)he is very vulnerable to any frustration. The cause of hurt is experi-enced as coming from inside; the anger is therefore directed against oneself. It is hard to determine which gender, if any, is more affected by narcissism. On one hand, it seems the contrary of altruism, but altruism can also serve to obtain self-gratification and omnipotence„ Sappenfield-5 establishes the possibility of loving one's CJO own love. The only research available on the subject^7 finds that narcissistic attitudes are more frequently found in female than in male students. More evidence has to be gathered before it can be thoroughly discussed. Narcissism is an attitude, not a behavior, and direct observation does not provide much useful information. Overwhelming affect of rage, guilt, anxiety, or any combination of these and others can also lead to suicideo The ego then loses its sense of perspective and its control of the situation is jeopardized. Generally such turmoil is of short duration. It can generate impulsive 31. acts which are often aborted due to lack of preparation or containment "by bystanders. Exceptionnally, with this mechanism, the direction of the aggressiveness is outwards It is suggested that overwhelming affect induces more attempted than completed suicides. It is now a cliche for men to brag about the emotionality of women. There may be a basis for this assumption. Andrieux^ reports that, out of a population of eight hundred and seventy students, women showed more excitability and were also less objective than men in dealing with affective data. One has to consider that a woman's world is often limited and unidimensional: any disruption of it is perceived 6l as affecting the whole world» Cumming , in a research performed in British Columbia, has found that married employed women were less suicidal than unemployed house-wives. The contact with the public sphere brings new alternatives, possibilities and information and, as a consequence, an increase of objectivity. It is believed that overwhelming affect plays a major role in the precipi tation of women's suicide attempts. The concept of ego-splitting is a strategic one for under standing suicidal behavior, flow can over-coming the instinct of conservation be explained other-wise? The splitting of the ego means that different parts of the psyche specialize in opposite functions. 32. In the case of suicide, one of the poles is self-destruction. As an example, Freud writes: "The melan-cholic' s erotic cathexis of his object thus undergoes a two-fold fate: a part of it regresses to identification, but the other part, under the influence of the conflict m 62 of ambivalence, is reduced to the stage of sadism.." Women are familiar with the splitting experience: most of them are deeply divided between the conflicting goals of motherhood and career. The latter is tempting if someone wants to attain self-fulfillment, or at least self-confidence. But guilt arises when these plans interfere with home, spouse and child-care duties. According to Sederer and Seidenberg this conflict would not be a superficial one and would generate a lot of tension within the ego. Men, by contrast, would not suffer from such an ego/ego-ideal incompatibility. Double-bind situations seem to favor and force the splitting of the ego and women have more than their fair share of them. Whether or not all forms of ego-splitting are conducive to suicidal behavior is still to be determi-ned. The result, however, is always a state of anxiety and instability which may eventually be transformed into more dangerous forms of splitting,, 33. The last precursor of suicide is inversed aggression, which was discussed earlier. The interventionists at the Vancouver Crisis Centre and at Safer are unanimous when talking about women who attempt suicide. They exclaim: "These women are angry!" They explain women's large reserves of anger by the fact that they have fewer occasions to release their violent energy , as in sports, or to sublimate it, as in creative work. A contradiction emerges at this point. Because of their lower rate of completed suicide, women seem to turn their aggression inwards to a smaller extent than men. However, suicide is not the only outcome of inversed anger. It appears that women direct their aggression toward themselves, indeed, but they prefer the depressive mode to the sui-cidal one. Freud's life-instinct hypothesis comes to mind: their life-preserving orientations may give women an abhorrence of death. Suicide and depression are very often linked in research and literature. They coincide in many, but not i, in all cases, as shown by the following results: 34. Suicide rates per 100,000 persons per year for different diagnostic categories. Alcohol disorders Organic disorders Schizophrenia Depressive psychoses Neuroses - psychosomatic disorders Personality disorders 119 130 78 133 167 566 The parallel suicide-depression tends to limit the field to psychiatry. The question is: "is suicide an illness?" It is very hard to find an operational definition of pathology. Mainly, we have to rely on the presence of symptoms. Two ways of measurements are utilized in suicidology. The first one deals with subjective data collected through psychological autopsies and interviews of friends and relatives of the suicides. Depending on the researcher's evaluation, the percentage of suicides who presented psychiatric problems varies from five percent to ninety-four percent^5. If objective data (hospitalization, persons followed by psychiatrists,etc..) only are compiled, the results vary from five percent to twenty-two percent^,, In Poland, only four percent out of fourteen percent of attempters in the clientele of an ambulance service were found to be mentally ill^„ 35. Since definition and scientific evaluation do not give a satisfactory answer, let us weigh the advantages and disadvantages of the prevalent illness thesis on research and intervention. The psychiatric researchers have identi-fied psychotic patients as more likely to commit suicide /o and neurotic persons more likely to attempt it . Simi-69 larly, Roth and Luton 7 have found that proportionally more males were psychotic and more females were neurotic. The question is now to investigate if the female attempters are neurotic, and the males who commit suicide are psychotic The psychiatric stance provides some interesting guidelines for suicide research. However, it is a partial approach that needs to be complemented by other sciences' perspectiveso 36. E. Philosophical perspective Gabriel Marcel has written: "...the fact that sui-cide is always possible is the essential starting point of any genuine metaphysical thought"^0. For the ex-istentialists, attitude toward life and responses to problems are shaped by this ever present concept of sui-cide-as-a-possibility. Most philosophers disapprove of the act as a solution. Sartre poses that suicide is not a way out, that death "removes all meaning from life"''^, and Camus sees it as a repudiation. He writes: "Suicide settles the absurdo.olt is essential to die unreconciled and not of one's own free will"''72. Heidegger"^, on the contrary, claims that in suicide, the human being finds his(her) most authentic expression. If one sees ex-istentialism as an attempt to grasp control over one's own existence, one understands Nietzche's celebration of "a different death: free, conscious, without accident, without ambush"^. In fact, it sounds as if people would choose suicide very lightly. This is not the case. People kill them-selves when their lives are threatened with losing all sense. Often the thought of death is enough to re-discover or re-orient toward a new meaning in life. When they decide to encounter death in a suicidal gesture, men 37. and women have a different experience. Males, more inclined toward achievement, challenge and are tried by the universe. Females, for whom a significant relation-ship may be a valid enough reason to live, probe their human peers, who have at least some power of intervention. Through suicide, the person re-asserts mastery over 7 5 his (her) fate. Segerberg'-^ states medical authorities believe the terminal cancer patients most likely to commit suicide are the ones who are used to exerting control over themselves and others. If it is true, it comes as no surprise that the male rate of completed suicide is higher than the female rate. As has been discussed before, women are often alienated from their own personal existence, from social life and, needless to mention, from social power. "Female suicide attempts (and antecedent behavior) are most appropriately conceived of as partial self-destruction to the end of making life possible, not ending it. The majority of self-destructive women are engaging in forms of ego-defensive risk-taking, which may prove fatal, but are intended to be problem-solving"' . Males do not resort as much to suicide attempt because it is socially considered "hysteric", or feminine. Different expressions of deviance are tolerated for men and women. It is considered virile to have accident and road mishaps, to fight and brawl, to drink heavily, and even to indulge 38. 77 in crime. Whitlock and Broadhurst''have found that sui-cides have committed more of these infractions than averageo Therefore, more attention should be given to these behaviors in assessing a suicide risk. Women's tolerated deviances are promiscuity, drug abuse (usually tranquilizers) and mental illness. These deviant conducts, along with suicide attempts, would be, in last analysis, coping, adaptive mechanisms in order to avoid the last outrage: suicide. The existential approach exposes suicidal behavior in all its complexity. It destroys the myth of the "balance sheet suicide" where a person looks at his(her) own life, "draws the balance sheet of gains and losses, finds him-self bankrupt and commits suicide"''7^. No one in his (her) right mind would behave so rationally. If so, the wonder would be why there are so few suicides. The person should be envisioned with all the richness of his(her) body and mind, with all the details of his(her) environment and with the dynamic interaction that proceeds between the inner and outer components..In a word, we need a theory grounded in real life, a psycho-social perspective. 39. F. Social-psychological perspective i 7 9 Dorothy Miller s'7 symbolic interaction theory seems the best suited for a comprehensive analysis of self-destructive phenomena. It contains, under a different formulation, the essential elements of the major theories of suicide: for instance, Farber's "threat to acceptable life conditions" becomes "crisis"; Freud's mechanisms of loss of love, narcissistic injury, overwhelming affect can be recognized in the concept of commitment; Durkheim's notions of anomie, fatalism and egoism are diffused under "commitment" and "communication". Miller goes beyond the purely objective approach and really takes into account the imaginary dimension of the person. Also, she offers more than static definitions; she organizes the suicidal process in a sequence of events which furnishes valuable insights for prevention and intervention. For these reasons, Miller's perspective appears the most advan-tageous of all. There is one reserve: the theory does not relate well to suicide attempt and needs to be complemented in this respect. This difficulty, however, can be overcome. The basic structure on which the suicidal process develops is commitment, or the dedication of oneself to a certain social status. Miller suggests that our society presents two major script-statuses to people: the "rags to riches", and the "one-and-only-true-love" myths. Most 40. adults are committed to a certain degree to both of these, and probably to a few others. Problems may occur when there is an exaggeration, a total commitment, or em-bracement to one status. The person over-identifies with his(her) "hero-image", and in case of failure, experiences ego loss. As in Freud's theory, the aggression is then turned inwards. "Commitment" is a "social psychological stance that proposes what is worth living for is worth dying for"^°. The passage from commitment to suicide is played in six acts. The first condition concerns a threat to a very basic need: one's positive self-evaluation. It happens when the person notices a discrepancy between his(her) self image and a negative vision (s)he perceives others have of him(her)selfo The individual then reacts by evaluating his(her) future predicament. The situation may be judged temporary, in which case the person would stop worrying. But if the self is over-committed to a status that is un-realistic considering the person's strengths and talents, an outlook on the future would only show a worse portrait. The person would rehearse in imagination the possibilities at his(her) disposal. Most people would correct their self view to adapt to the situation; the persons who embraced a status would not do so. They would experience a major crisis: in losing their embraced status, they sense they lose their "honor". In fact, they probably have already 41. retreated from interaction with other people in order to avoid being confronted with their limitations. In refusing to adjust, they restrain considerably the field of alter-natives and skew the balance toward suicide. Through self-destruction, suicides hope to leave a symbolic statue, a testimony showing they stood up to their convictions and that their whole life was not in vain. Finally, there is a hope for a magic solution that liberates the courage to take one's own life and persists until the very end. Sui-cide is an essentially human act. No other animal possesses the symbolic means and the manipulation of language neces-sary for time-binding evaluation, suicidal rehearsal and such a complex making of choices„ Miller tested her theory in a case study of twenty-five former psychiatric patients who eventually committed sui-81 cide „ She found they were over-committed to an un-realistic and invalidated view of themselves and, in order to protect this ideal from rectifying feedback, became isolated from all meaningful communication with significant others. These persons wanted to be appreciated and loved, but they were too self-centered to make themselves availa-ble to others and provoked rejection. When a crisis occured to threaten the only perspective they would have accepted, they could not make the necessary adjustment. 42. It seems from this scenario that the commitment of suicides is directed toward personal ambition, that is their "hero-image". Affiliative needs exist, but there is no investment in satisfying them. Recognizing the kind of hero a person strives to be may enable us to predict the type of suicidal behavior this person will demonstrate. Ideas of grandeur lead to completed suicide; the ones who attempt suicide are generally harmonizers. A rapid look at the literature shows that women are not likely to harbor a strong "hero-image"„ Even before birth, their parents were more probably hoping to have a boy than 82 83 a girl . Lewis and Rubin D confirmed the difference in anticipation and found there was a difference in treatment, starting from birth, that gives advantage to the boy. Most people, men and women, definitely prefer masculine charac-84 teristics over feminine ones . In such a context, it takes women longer than men to like their self-identity®-'. 86 Some researchers found women still have an ambivalent self-concept. Finally, Clifton and Lee learned that women scored significantly lower than men in self-confidence®^. In their daily interactions, they also show a tendency to "extrovert" their positive feelings about compliments and turn inwards negative feelings from unpleasant situations. In a word, not only do they have a lower sense of compe-tence, but have integrated a mechanism to stabilize it at 00 a low level. The "fear of success" reaction frequent 43. among women is another indication of this fact. Their low self-esteem seems to prevent women from making any 89 clear-cut decision on a vital issue. Teicher 'writes that a person indulging in non-fatal suicidal behavior is so basically insecure that (s)he cannot direct his(her) aggression either completely inwards or act it out on the person at whom the feeling is directed. Another dimension of this script that does not corre-spond to most women's lives is the idea of "retreatism" from all significant others. For a person infatuated with him(her)self, relating to peers would lower his(her) expectations to a realistic level. Women need contacts with the public sphere in order to increase their self-view to a realistic level. They suffer from a constant put-down of their self-concept because they have integrated the habit of putting other people's needs before their own. Miller's original contribution is the concept of rehearsal. This idea is more important than it first suggests. Through the imaginary process, the diverse influences exerted on the person mingle in a highly complex and unique fashion. All the gender-related differences we discussed earlier, in the upbringing, in the historical and cultural background, in anatomy, in social circumstances, ..etc.,. are combined and transformed into one single motivation to live, to die, or to gamble. Women's suicide attempts can be conceived as suicide re-hearsals in which participation of the significant others is requested because they are of prime importance. It is also a definite attempt at communication. Suicides differ from the general population, and even from suicide attempters, by their rigid stance in . . 9 0 front of crisis' . Women as a group have the advantage of being more flexible, which explains their lower rate of sui-cide. Because of their upbringing as nurturers, they are 9 1 more concerned about relating to other people than men are7. They take more into account other people's needs and, partly due to their lack of power, are accustomed to adapt to major external decisive interventions in their lives. 9 2 The following quotation from Jean Baker Miller suggests that women are also more emotionally adaptable than men: "There is no question that most women have a much greater sense of emotional components of all human activities than most men. This is, in part, a result of their training as subordinates; for anyone in a subordinate position must learn to be attuned7^ to the vicissitudes of mood, pleasure and displeasure of the dominant group'.' Carole Light i 9 4 Selvey s study7 on sex-differentiated responses in front of powerlessness support the assumption of men's greater rigidity. While men cope by becoming more assertive in 45. front of adversity and persist in their stance until the end, women generally seek a love object and tend to abandon the struggle. If frontal combativity is advantageous most of the times, it has also its pitfalls. When people kill themselves, it is with the intention of at least giving sense to their deaths, and doing so, validate their lives. As Miller puts it: they want to leave a symbolic statue of themselves. Men and women have very different ideal images, and this fact influences their ways of seeking death. Males want to be remembered as strong and efficient. Fast, dramatic and highly destructive methods are best suited for this purpose. Women want to leave an image of beauty and emotion. They are very a< concerned with what happens to their bodies after death' . Consequently, they use less disfiguring and less dangerous methods, which also require more time and increase the probability of rescue. The recourse to soft methods has also received an anatomical explanation. Women are smaller and less strong than men. It is relatively more strenuous for them to use the most lethal means of suicide as pulling the trigger of some guns, hanging, or seriously wounding themselves. The hypothesis is rather weak. It is true, though, that a woman is less likely to know how to use arms and where to obtain one surreptitiously. This may account, in part, for women's preference for gas and barbiturates. The use of 46. drugs should not be considered an indication the person 9 6 does not want to die. Marks7 found that women, who are the main users of drugs as a method of suicide, associated this use with efficiency. Medical authorities must therefore re-assess the current ratings of suicide methods in order to stop underestimating women's serious-ness of intent. The projected image may also have its importance in true suicide attempts. An interventionist from Safer commented that women attempters were "particularly beautiful". When an attempt is seen as a means to "move" significant others, it is not surprising that other methods of communication, and particularly "body language" have been tried previously. It would be interesting to find out what is the power of beauty, and to investigate to what extent, if any, reliance on charm prevents someone from taking direct charge of his(her) life. One can be caught up easily by the saying: "Charm is the strength of woman. Strength is the charm of man". Finally, Miller writes that, until the last minute and in most instances, there is hope of a magic solution„ Women seem more practical in their hope. It may be less magic, but it is more efficient to expect salvation from other people than to count on a miracle of nature. Women demand less from life: a significant relationship is for many a valid enough reason to live. Hope, therefore, is easier for them. 4 7 . G. Discussion 97 Dorothy Miller7' explains the occurence of suicide by the loss of "honor", self-esteem someone acquires by being committed to a realistic view of oneself. This paper poses that the only non-acceptable life circumstance is the loss 98 . . of meaning7 . It is a necessary and sufficient condition to cause a suicidal gesture. One may argue that loss of honor and loss of meaning coincide very often; the question is that loss of meaning precedes the other and is less prone to pejorative interpretations. Another divergence from Miller's theory is the ad-junction of a slightly different script distinguishing suicide attempts from committed suicides. In the case of partial destruction, there is an ambivalence between two script-statuses rather than an over-commitment to only one cause. There is also no phase of "retreatism" from sig-nificant others. On the contrary, suicide attempters seek consolation in a rapproachement with people they love. Thus, "since women...develop stronger affiliative needs, the combination of expressing aggression through self-destructive behavior, and needing contact with people may account for the high rate of suicide a'ttempts among women. Completion of suicide would, of course, satisfy only the * »99 expression of anger ' . 48. Apart from a nuance between loss of honor and loss of meaning and a modification of the suicide scenario in the case of suicide attempts, this essay completely follows Miller's analysis of self-destructive behavior. 4-9. Part IIIi INTERVENTION It is with suicide as it is with everything else: a better understanding leads to more accurate and efficient attitudes. The present situation is deplorable: sui-cidal behavior, and especially feminine suicidal behavior, is interpreted as merely manipulative and suicidal persons are actually mistreated. Often a patient-at-tempter is rejected or alienated by interventionists. Bloom 1^ reports that each of thirty-two suicides he has analyzed were preceeded by rejecting behavior from their therapists. These data do not pose a cause-effect relation ship between rejection and suicide but one may question the helpfullness of the succor provided by an exasperated interventionist. Interventionists adopt a more compassion-ate and respectful attitude when they perceive self-destructive people as persons who labor to keep or gain some meaning in life against and through the conflicting demands of their environment. Manipulation may be present in suicidal behavior; it is not, however, the essential feature. An understanding of the specialized patterns of social ization of males and females is indispensable to appreciate the differences in suicidal behaviors. These patterns are responsible for engendering specific vulnerabilities in men and women by encouraging individuals to develop 50. masculine and feminine strengths at the expense of their complement. For intervention purposes, the recognition that men and women go through divergent formative processes is an essential background knowledge. It is important, however, to not perpetuate the polarization of men's and women's characteristics. If men and women were to be treated differently, the tendency of rigid categorization would survive. The accent of intervention and prevention needs to be put on completeness„ The last parts of this essay will consider men and women as persons-in-a-process-of-completion, not as members of a sexual denomination. A. Exploration of the particular circumstances The first therapeutic step is a thorough examination of the situation in the emotional, physical, cultural, circumstantial and interpersonal contexts of the person. No one is the "typical male or female attempter". Applied to any individual case, the gender characteristics presented in this essay are gross simplifications. They are valid guideposts, but there is a limit to their use. Temper-amental differences exist. Cultures have various impacts: 101 for•instance, Hendin suggests that a Norwegian male is less likely to be competitive than a Swedish female. Social and individual circumstances are to be taken into account: the forty-five years old male bachelor who takes 51. care of his parents has a more "feminine" situation than the rich and young female scientist who has agreed with her husband to not have children, and whose primary goal in life is clearly her career. When this essential exploration of the particular circumstances of the sui-cidal person is over, the therapeutic intervention can be adapted and organized around two poles of Miller's 102 theory : commitment and communication. B. Intervention on commitment In both cases of missed suicides and suicide attempts, the objective of the therapeutic intervention is the emerging of a new self-concept. This search for identity can be a temporary life-goal for the suicidal person. As i 103 « in Steppenwolf' s magic circus , therapists must "demon-strate to anyone whose soul has fallen to pieces that he can rearrange these pieces of a previous self in what order he pleases, and so attain to an endless multiplicity of moves in the game of life . However, suicides and sui-cide attempters, depending on their commitment configu-ration, have different needs and are to be treated according-ly. The identified problem of suicide committers is over-commitment to a single meaning in life. If their ideal becomes impossible to attain, there is no other motivation 52. for living. Over-committed persons are dependent on the object of their dedication and are therefore highly vulnerable. Men are more likely to be found in this category; but many women, for example the widow who kills herself after the death of her beloved husband, are also over-committed. People devoted to personal success and people devoted to interpersonal relationships present different difficulties and so, will be treated separately. 1. Over-commitment to success Over-commitment to success affects men more than women because they were taught and are expected to direct their energies toward wealth and fame. Whether they are males or females, all suicide committers have to learn "role distance" or the necessary "separatedness between an individual and his putative role" They need to acknowledge the emotional dimension of their life. They may be afraid of their emotions and they are generally ashamed of asking for help. The approach should respect their need for emotional distance. Therapy should begin in a way they understand: logical and direct. These persons need confirmation of their sense of mastery and it is a good procedure to give them choices whenever possible, and emphasize the fact 53. that they have some control over the therapeutic inter-vention. Their main task is to recognize, express and control their emotions instead of negating them. The therapist needs to first ensure an atmosphere of trust and security, then point out emotions when they surface and guide the person in choosing and mastering ways to deal with them. When this process is well under way, the next step is for the suicidal individual to "become realistic about his(her) goals„ It is a precarious part of therapy, but it can be achieved by fusion of new emotional abilities with his(her) aspirations, that is, learning to enjoy achievements and permit him(her)self some relaxation time between challenges. An essential part of the therapy is the opening of new or renewed channels of communication which will be discussed later. It is good practice to see the suicidal person on a one-to-one basis at first, but the end of the process can favorably take place in a group. The correct therapeutic attitude has been described by 1 0 6 Leonard . She writes: "It is not a case of how to break a strong man down but how to help a little boy grow under the burden of an enormous coat of armour until he can put it aside for a more adequate coping mechanism"^0''. Women's suicidal behavior generally derives from these two determinants: over-commitment to affiliation or vacillation between success and affiliative goals. 54. 2. over-commitment to affiliation Not all over-committed persons are ambitious. Some people invest their energies in affiliation. Women tend to do so much more than men, but some male workers, for instance, are more-than-loyal to their "company" and experience retirement as a loss of significance. Lovers, too, may become completely dependent on one another. Romantic love is such an integral part of the western culture that symbiotically enamored people stir up envy and not concern. They certainly do not seek help for 108 their "bliss". Calista Leonard differentiates two types of dependence: the passive and aggressive forms. The passive dependent is rarely suicidal: when a source of satisfaction disappears, (s)he looks for another one and adapts generally without much trauma. The symbiotic suicidal person is fundamentally aggressive dependent: his (her) devotion is a way of control, a way of paying for the security of the relationship. When there is a break, (s)he reacts by outraged emotional distress. This person will probably ask for help only in a seriously sui-cidal crisis. When the symbiotic relationship is threatened instead of definitively terminated as in a lovers' conflict, the person may attempt suicide rather than commit it, hoping to move his (her) partner and solve the conflict. 55. The interventionist first becomes a substitute for the lost love object and provides the necessary attention and reassurance to the person. There are two specific dangers to avoid with such clients: an emotionally charged therapist-client relationship that could lead to another symbiotic situation and early termination because of his(her) misleading improvement in the beginning of therapy; the latter could be interpreted as rejection. The interventionist helps the person define an ideal of independence that is possible, safe and pleasurable. Going then to the roots of the problem, work concentrates on the identification and the release of "hidden" impulses that provoke shame, fear of isolation and need to pay compen-sation to affiliates. These impulses are very often what prevents a person from conforming to his(her) ideal. A woman's aggression, for instance, can be conveniently disguised by generosity and subservience. The next step is therefore to accept and learn how to control and utilize the aggressive energy, so it is safe and useful. At this stage, the person could benefit from group intervention. The termination of one-to-one therapy, however, should not be immediate, but should be done progressively. The field will then be clear for the person to engage in more in-dependent relationships. 56. 3. vacillation between success and affiliative goals It could be deduced that persons with dual or multiple commitments have a sane attitude. In the case of crisis, they may interchange one aim for another, which gives them more flexibility. There are two conditions for this dual commitment to function harmoniously: clear priorities and realistic expectations have to be de-termined and the commitments have to be pursued within coherent social norms. Women's situation is the best example possible. Female suicide attempters are often ambivalent between their needs for perfection and their needs for affiliation. In the present social structure, these commitments are conflicting. Few men experience a similar dilemna, so we concentrate on women's case. There is a myth of the total woman, successful wife, successful mother, successful professional and successful person that poisons the existence of the struggling majority of imperfect life-size females. The magazines are full of these ideal specimens who desinterestedly give tips and secrets to their untalented and stubbornly unsuccessful sisters. The message is: "Women, if you want to have personal goals, make sure first that yo'ur husband, your children and your house will still receive the best of your care". The whole thing is a fraud and the only 57. reward one can expect from obeying such advice is a decrease in self-esteem and despair. The problem being mainly social, so must be the cure. A group approach is recommended, but it must be clarified with the client that group participation is not second-class treatment as it is sometimes experienced in thera-peutic milieux. The reasons must be made explicit. Women suffer from contradictory social demands. As long as they endure this condition alone, they are powerless; they cannot •understand the external nature of their troubles and enjoy the strength of peer support. Members of the group are considered free and responsible indi-viduals. Each member's competence and uniqueness is to be reinforced, and no real pressure or condemnation is to be exerted. Some behaviors that seem undesirable may well 109 be temporary but important coping mechanisms. Maris 7 proposes that promiscuous women or drug-addicts often commit suicide in reaction to society's rejection of their coping habits. There must be tolerance and a selective support of all life-enhancing behaviors„ The group gives women an opportunity to complement their socialization by learning to make decisions for themselves, to risk, to confront others and to become assertive, that is, direct and efficient. The group leader may foresee a crisis when a woman who does well in group begins to transfer her 58. newly acquired skills to her daily encounters and does not receive the positive response she is expecting. Participation in the group should go "beyond this point and only cease, if it must, after the woman has decided on clear and realistic commitments to satisfy both her self-achieving and affiliative needs and has started to implement her new life projects successfully. A complete recovery would lead to feminist and/or social action to eradicate the contradictions that double-bind women. C. Intervention on communication Commitment, the first axis of intervention, identified three categories of suicidal behavior and three appropriate modes of intervention. Communication is more universal: all suicidal persons need to improve their communication skills and open new communication networks. "A change in the self can occur with a change in reference groups or in the course of interaction between the self and the sig-nificant others"110. 1. intervention with family and friends Generally, relatives, friends and colleagues are shocked and touched by a suicide gesture and become more amenable to change: this is a favorable factor that has to be fully exploited. A healthy communication pattern with one's significant others is the key to achieving and 59. maintaining a realistic balance in one's multiple aspi-rations. Family and friends need always be seen by the interventionist; the state of communication between sig-nificant others and the client needs to be assessed and, ideally, they would be included in therapy. The goals of the interventionist are to clarify the pre-suicidal and present situations (state of relation-ships, ambiguities, expectations, and so on), to initiate good habits of communication, and to help the persons involved to confront their reality and to deal with it. To achieve these aims, the therapist has to create an atmosphere of trust and security. First, (s)he would be an example of an adequate communicator. Also, (s)he would structure the sessions in such a way that the attendants would be very clear about what to expect and what is expected from them, and be confident of receiving the therapist's support for their participation. The therapist would help the sender to enunciate a complete and clear message. (S)He would underline and clarify the non-verbal communication, especially when it is incongruent with the verbal expression, and help the receiver to listen and understand the message. For instance, the listener may listen selectively or interpret the message too soon, before it is complete. A good way of measuring and assuring good communication is counter-2354. checking, meaning having "both partners agree on what has just been said before letting the discussion proceed further. All interferences have to be stopped and their absence has to be experienced as a good thing. Sometimes the und erstanding of the message is immediately helpful. It may also be a disturbing factor. The therapist then helps the individuals to deal with their reality, whether they want to change it or adapt to it. 2. group intervention An improvement in the person's communication with significant others would definitely be a major step in an overall development of communication skills. It is helpful that a parallel effort be done in group therapy, especially in cases where the significant others are hostile toward the suicidal person and/or are unwilling to participate in therapy. To the individuals already involved in working with their family and friends, group participation gives an opportunity to rehearse adequate communicative behavior in a less emotionally charged atmosphere. Group work provides a safe milieu for the apprentice ship of direct and efficient communication and a good opportunity at self-knowledge. The same techniques of message clarification are used in group and family work. Two major differences with family therapy are 1. that 61. participants share similar situations and therefore establish very early a base of equality, understanding and support, and 2. that the work is mainly focused on the "here and now". It is also harder for the indi-viduals to transpose their new knowledge to their close relationships rather than perpetuate it, as when sig-nificant others are involved in the change process. In all cases, the recovery is well-advanced when the person perceives his(her) situation considerably changed, and for the better. 62. Part IV: PREVENTION "The frequency of suicide in a population is a function of the frequency of individuals possessing a certain vulnerability in that population and the extent of certain deprivations in that population" . Prevention measures, therefore, need to be organized around personal and societal axes, Farber presents the following 112 equation: e • d -p PIC. DEC, DIG, Suicide Rate = i S U j H F T TS where PIC = frequency of production of personalities injured in their sense of competence, DEC = demands for exercising of competence, DIG = demands for interpersonal giving, TS = tolerance of suicide in a given society Su = availability of succorance, HFT = degree of hope in the future time perspective. Abbiati113, after a study in Maine, corroborated the validity of the five social criteria,, He left out the production of personalities injured in their sense of competence because it required different measures. This factor will therefore be the last to be discussed. 63. A. Demands for exercising of competence Demands for exercising of competence refers to the degree of competition in a society. The more pressure there is for achievement, the more suicidal is a society. By itself, competition is not a destructive force; it becomes so when it is the major social dynamism. Men are directly affected by it: the value of their existence is often gauged by their work performance. They are then denied their primordial human worth. The same phenomenon is starting to affect women noticeably. The difference in men/women suicide ratios is rapidly diminishing. Women now commit suicide more than ever, especially in areas where they are the most involved in the job market. It does not mean that women should stay at home; they need the validation of the public sphere. Going to work, however, is not the ultimate solution, especially if it means adding the burden of outside performance to their domestic responsibilities. Two things happen. First, they integrate the dominant competitive ideology which they extend to their private world, making a contest out of kitchen chores and child rearing. Secondly, they undertake more work than any human being can handle, which can only lead to failure and loss of sense of competence. 64. When one has accepted success as the sole criterion of meaning, there is no significance left after a failure arid suicide becomes an alternative to life. First, women should not bear the tasks of domesticity-alone; these should be divided equally between life partners. Also, it is time that society accepted the responsibility of providing services to children and families such as universal day care and parental leaves for maternity, sickness, or care of a child„ The struggle for these demands is still going on. The most decisive change, however, which will affect the suicide rate is more subtle and harder to obtain: it concerns the revival of emotion and affiliation as important social values. Striving for achievement will be harmoniously balanced with the striving for affection and sociability. Music, theatre, arts in general are vehicles that promote human connectedness. It remains to individuals to create around them an atmosphere of open communication. Child-rearing practices could be changed in order to fill the gaps of the present socialization as will be seen later. 65. B. Demands for interpersonal giving Demands for interpersonal giving can put strenuous pressure on people and be conducive to suicide. The high suicide rate among professional nurturers (psychiatrists, nurses, and so on) is an illustration. These data are hard to reconcile with the satisfaction of the need for succorj because for someone to receive help, there must be someone to provide it. Who would do such a thing if giving is conducive to suicide? The problem is not about providing support and understanding, which can be rewarding; it is one of specialization. It is believed, for instance, that women's altruistic orientations drain their forces and are responsible for their high level of self-destruction. As long as there are people-who-give and people-who-achieve, these two groups will self-destroy, each one victim of its particular imbalance. All human beings, males and females, need to enjoy both the giving and the receiving of support and affection. On a professional level, there will always be a need for care services. The concept of team approach, where many individuals share tasks and responsibilities and support one another, is indispensable to avoid the "burning-out" of professionals. Administrators of helping services 66. should "be sensitized to the special needs of their staff. Colleagues should also adopt a supporting attitude toward one another. The person him(her)self should be aware of his(her) limits and needs, learn to ask for assistance and be permitted to retreat for a while, when needed, without penalty or shame. C. Degree of toleration of suicide The degree of toleration of suicide in a country directly influences the national rate of suicidal be-havior. Italy, where suicide is still considered a sin by many and an insult to life and civilization by all, has a much lower rate of suicide than atheist and freedom-seeking Nordic countries like Sweden and Denmark. Tole-ration of suicide is the object of hot debate right now. The Voluntary Euthanasia Society in England just released 114 an advice booklet to help determined people to commit suicide in a proper way,'without unfortunate consequences for their significant others. Of course, this raises a violent polemic in the whole country. An increase in the suicide rate is feared. Most people seem to sub-scribe to the idea that "a firmly structured and rigid so-ciety has good rescue procedures and a low suicide rate although the number of attempted suicides might be high. 67. That kind of society" would "not readily permit one of its members to detach himself from it, by suicide or any other 11 < way" D . We do not believe in avoiding suicide at all costso There are two dimensions of life: quantity and quality. It is the indefeasable right of the individual to determine under which circumstances his(her) life has irreversably ceased to bear meaning. Prevention measures should concentrate on the quality of living. Life is to be enhanced, not coerced„ D. Availability of succorance Availability of succorance is an effective detractor of suicide. The help may come from family, friends, neighbors, colleagues and from social agencies. The most effective and legitimate support is provided by intimates and significant others. Social agencies are always a palliative. During the suicidal crisis, they fill the gaps in the persons' helping networks. Their real impact comes in the post-crisis period, when they assist their clients in creating or rest o ring natural supporting relationships. An on-going campaign that would inform the population on the precursors of a suicidal crisis, on the attitude to take and on some practical means of inter-vention would most probably lower the rate of suicide. 68. In Vancouver, there are two community agencies specializing in suicide prevention. The Crisis Inter-vention and Suicide Prevention Centre is a telephone-based service operated by trained volunteers under professional supervision. It is complemented by a mobile squad that goes to the site of a call when necessary and by a room facility where someone in distress can stay for the night. The service is modelled after The Samaritans and other suicide prevention centres in all major cities of the western world. These centres have been the object of criticism lately. The main reproaches were that they did not reach the male population and the 116 true committers and that many of them lacked proper 11 7 planning and organization The Vancouver Crisis Centre is impressive in the way it has achieved the essential requirements for a service of quality: accessibility and availability, maintenance of responsibility by an efficient referral procedure, integration into the network of community agencies by multiplying contacts and avoiding duplication of services, ll8 and up-to-date crisis intervention principles„ Motto evaluated the impact of suicide prevention centres by evaluating the population at risk. He corroborated that the centres did not reach high-risk individuals. His conclusions, however, was that the existence of suicide prevention centres was well-validated by their response to 69. low-lethality callers and their handling of everyday criseso In fact, the major difference between low- and high-lethality suicidal persons seems to be in their a-bility to rely on succor. It is therefore a very important feature to take into account in upbringing, especially for young boys, seeing as they are generally prevented to rely on others. The other Vancouver-based prevention agency is Safer, or Suicide Attempt Counselling Service. It is unique in the world. The nine-staff team work with four major city hospitals and follow all cases of attempted suicides on a regular basis. Since many attempters repeat their act and one out of eight attempters eventually commits suicide, Safer works with a high-risk population. It is important that its service be evaluated soon, first, to be perfected, and secondly, to consider the possibility of duplicating similar services in other areas. The professionals from Safer also engage in educational activities, visiting schools, parents' groups, policemen, and so on. A popular knowledge of the suicide phenomenon permits earlier de-tection of suicidal intent and more appropriate help. It also increases the pool of potential helping persons. A very important group has not been re-ached yet: the general practitioners. Most suicides have seen their doctors within the month preceeding their gesture, gener-7 0 . ally presenting vague signs of anxiety and depression. A trained doctor would hopefully notice more of these covert demands for help. Finally, it is indispensable that all helping agents work together. Each one has a partial view of the situation and under no circumstance should they be unaware of the others or opponents. E. Hope in the future time perspective The last social situation that triggers suicide is the lack of hope in the future time perspective. This 119 is true for the personal future as found by Ganzler who compared three groups of individuals: group I, going through a serious suicidal crisis, group II, being in a non-suicidal crisis and group III, experiencing no crisis. When the latter group had a positive view toward the present and the future, group II described the present in negative terms, but showed a positive attitude toward the future. Persons in suicidal crisis saw both present and future in negative terms and showed noticeably less change toward hope. People are social beings and their particular circumstances, like their reference groups, have a strong impact on their view of the future. Gender and nation-ality are two reference groups with special importance. 7 1 . Fewer German women than men committed suicide after the fall of the Third Reich, in 1945. For them, life after the defeat promised less hardship and reprisal than for men. Another example is the high rate of suicide among North-American Indians. Dispossessed of their land and of their customs, future prospects are not as good for them as for the Whites who show a lower incidence of self-destruction. A stagnant and sinking economy has disastrous effects. Every measure that carries promises of brighter days may be considered to prevent suicide to a certain extento Within a society, access to wealth and recognition is very unequal. Social class, geo-graphic situation and gender are factors that have an influence on the level of hope for the good life. Therapists know about the tremendous motivation that arises in suicidal persons when they discover new strengths and opportunities. This is one of the key-vehicles toward recovery. It is essential that society proves to be flexible and facilitates the re-integration of individuals who have temporarily lost purpose. The i960 years have brought some measures of social mobility, as upgrading education, transition courses for women going back to work after a long absence, and' so on. Some problems exist: many of these programs are temporary 7 2 . and part of their staff's energies are spent on the re-newal of their contracts. Many more programs are needed. If the present institutions were not overwhelmed, they hopefully would not need such complicated access to contain the demand. The potential users have often to face rigid bureaucratic requirements. There is place for more flexibility in the administration of these programs, which should also be implemented in larger number and on a more permanent basis, that means, until the unequality ceases. F. Production of personalities with a strong sense of competence. 1. androgynous upbringing The major preventive impact on suicide will come from an androgynous upbringing. Boys and girls have to be considered according to their full potential and not as future specialists in achieving or nurturing. When children are taught to conform to a mold, there is a limit imposed on their self-definition and subsequent flexibility. Dependence and aggression are some areas of special importance. 7 3 . Women tend to rely on others' opinions, support and resources. In return, they assume nurturing and basic life-preserving tasks. Such behavior is neutral: it is good or bad according to its appropriateness to the circumstances. When it becomes a rigid model, as in contemporary feminine child-rearing, it has some positive effects like a sense of security and provides partial protection against committed suicide. It also handicaps in that it prevents the formation of a sense of competence, limits the field of creativity, and completely hinders the excitement of challenge and mastery. Men do not rely so much on others' • opinions and are more autonomous than women in the public sphere. They are, however, also dependent. They have learnt to re-press their emotions and concentrate on achievement. Thus, they are at a loss to express pain and despair. Fortunately for them, they are very often cared for and nurtured by women without having to ask specifically for it. They also often vicariously take advantage of the female emotional expressiveness. However, when a major crisis occurs, they seldom are able to cry for help. Both girls and boys should be brought up taking risks, making efforts, experiencing failure and success. They should be encouraged to express their emotions and directly ask for the satisfaction of their needs. Because 7 4 . of tradition, systems tend to self-perpetuate and a special effort is needed to change the situation. Sexist fairy tales should "be banned and replaced by new sagas involving male and female figures as equal partners. Boys' toys and games and girls' toys and games could be replaced by children's toys and games. Here too there is a need for innovation. It has been seen that both male and female suicidal persons were unable to ask for help effectively. There is a need for communication games that cover all aspects of life, particularly the direct asking for help, which should not be perceived as shame-ful, but as another common and pleasurable experience. The subsequent years of socialization should follow the same principles. Sex-segregating schools, "masculine" and "feminine" labels on professions, differential eti-quette for dating, and other forms of sex polarization should disappear. The idea is to prepare children for life, not for a limiting type of marriage. 2. adequate handling of aggression Another important aspect in need of change is the handling of aggression. Aggression is repressed in little girls„ They learn to express anger in covert ways which are not adequate. The balance of angry energy is often turned against themselves, contributing to their 75. very high level of self-destructiveness. Boys, on the contrary, must become outwardly aggressive. The ideal image presented to them is the strong man fighting for his rights. They learn that they need a reserve of ag-gression, but should liberate the surplus in violent exercises such as football, army training, and so on. Sometimes this elimination is not complete and aggression gets out of hand: it is then directed outward or inward, but almost always in violent and destructive forms. Aggression is a fact and a necessity of life. The aim of formation should be the utilization of ag-gressive energy in a useful way, such as reaching one's goal in life. A pre-requisite to a proper handling of aggression is the integration of a social code of ethics. For instance, a bandit who performs hold-ups to make a fortune may reach his goal, indeed, but at the expense of society. Aggression should be, first, acknowledged, and then mastered to become assertion, that is, the ability to live the life one wants without imposing on the rights of others or having one's own rights imposed upon. 7 6 . 3. learning of communication skills The ability to directly express one's needs and demand one's rights is a skill which has to be learned. Appropriate models should be presented in tales and in television programs, and hopefully provided by parents and adults working with children. Communication games could be introduced early in life and maintained in later school years. Since sports and exercises have a ca-thartic effect, they could be encouraged in both girls and boys. The correct expression of strong emotions like love, anger, desire, frustration, pain, and so on, is also ca-thartic and brings a sense of reality. It needs to be permitted to all individuals. Children who would have integrated such a comfortable and competent self-concept would be likely to become adults relatively immune to self-destruction. To summarize this chapter on prevention, a sane society would produce individuals with a solid sense of competence and self-love and, in times of adversity, would exert less pressure and provide more support to its members. 7 7 . CONCLUSION This dissertation poses that people kill themselves when they lose their meaning in life. Because of their different psychological and sociological experiences, men and women do not adopt the same meanings. Thus, they find themselves in different circumstances and their sui-cidal behavior varies accordingly. There are two goals in the contemporary world that affect everybody: achievement and affiliation. There are two unhealthy ways to devote oneself to their pursuit: over-commitment to any of these goals, which leads to completed suicide, and indecision between the two goals, which is more conducive to suicide attempt. The sound attitude is a double commitment with clear priorities and realistic expectations. In that way, the individual is independent and flexible and is less inclined toward suicidal behavior. It is the purpose of therapeutic intervention to remedy to the gaps of social-ization: women learn to forthrightly accept and make place for their striving for achievement and men get re-ac-quainted with their need for affiliation. The emphasis of our approach is on the critical situation the person has to face rather than on his(her) behavior. This is the main factor that determines our resolution not to consider suicidal behavior as pathology, 7 8 . but to choose an existential perspective. Campbell 1 2 0 has given a clear description of existential analysis as the act of "looking behind the symptoms for the specific 1P 1 modes of existence which determine these symptoms.." This viewpoint also has practical advantages. It relates to all forms of suicidal behavior, not only to the self-destruction of the depressed or the mentally ill, but also to the terminal cancer patient who wants to avoid pain and disfiguration, to the kamikaze and to the sutee. Secondly, in a period of confusion about professional roles, it provides an ideal model for social work practice: identification and re-organization, if possible, of the environmental factors that have a threatening impact on one's existence, be it interpersonal (problems of com-munication), situational (isolation of the single mother, for instance), financial, societal (sutee custom, or different and confining expectations for men and women that affect their attitude toward life), and treatment of the intra-personal consequences of these factors. The therapeutic attitude corresponding to this view is "guiding the patient from an uncharted existence into new roads wich u 1 2 2 allow existence to proceed in an orderly sequence" 79. On a preventive level, the current process of social-ization has to be modified in order to eradicate the problem as much as possible. The proposed model is andro-gyny, or the formation of children toward completeness and not toward complementarity. Individuals and their so-cieties change together„ In order for the future gener-ation to become androgynous, efforts have to be concerted to create an androgynous world. It is not exactly what is happening now. Society seems in a process of "masculini-zation". Even mental health professionals, from whom one would expect some impartiality, do not consider a "healthy mature female" quite as healthy as a "healthy mature 1 23 male" . A definite starting point is a change of men-tality of the interventionists, including social workers. They first must abandon their double-standard evaluation of men and women. Achievement, freedom, scientific objec-tivity axe the contemporary prominent values. It is appropriate for women to welcome these new values, but it is important that they do not negate or despise their "feminine" heritage. Both privately and through feminist organizations, they will have to impose it on society until words like emotivity, passivity, dependence will not bring forth any negative connotation., That will be the day 80. when the whole range of actions and reactions will be permitted to all and their appropriatedness will depend solely on the context. Society will allow then more creativity and flexibility and people will seldom have to resort to self-destruction. 81. FOOTNOTES 1 On 768 suicides: 540 males (71 percent), 228 females (29 percent); on 2 , 6 5 2 attempts: 828 males (31 percent), 1,824 females (69 percent). G. Lester and D. Lester, Suicide: the Gamble with Death, Englewood Cliffs, N.J., Prentice-Hall, 1971, P-88 2 Except North-American Blacks. 3 The L.A.S.P.C. was dismantled in March 1979, victim of Proposition 1 3 . 4 E. Shneidman and N. Farberow, The Cry for Help, New York, McGraw-Hill, 1961, p.49. 5 E. Durkheim, Suicide.New York, Free Press, 1951. p. 144. 6 N for natural, H for homicidal, A for accidental. Each death that does not belong to these categories is S for suicidal. E.S. Shneidman, N.L. Farberow and R.E. Litman, The Psycho logy of Suicide, New York, Science House, 1970, p. 556. 7 Nine elements that can be found in various degrees or combination in a definition: 1. the initiation of an act that leads to the death of the initiator, 2. the willing of an act that leads to self-extermination 3 . the willing to die, 4. the loss of will, . . 5. the wish to die that influences a person to initiate an act that leads to this person's death, 6. the awareness of someone concerning his(her) long-term self-destruction, 7. the degree of central integration of the decisions to commit a self-exterminating gesture, 8. the degree of firmness and persistence in the decision to act, 9 . the degree of lethality of the act. E.S. Shneidman, "Suicide", International Encyclopedia of the Social Sciences, New York, MacMillan and Free Press, 1968, VolT 15, P- 377-8 M. Farber, Theory of Suicide, New"York, Funk and Wagnalls, 1868, p. 8. 82. 9 E. Stengel, Suicide and Attempted Suicide, Bristol, Penguin Books, 1964, pp. 100-103. 10 In one study, Stengel found that 19/66 male and 24/101 female attempters were the agents intervening in their own salvation. Stengel, op. cit., p. 90. 11 Stengel, op. cit., p. 90. 12 E. Moran, "Varieties of Pathological Gambling", British Journal of Psychiatry, Vol. 116, 1970, pp. 593-597. 13 P. Kennedy, A. Phanjoo and W. Shekim, "Risk-Taking in the Lives of Parasuicides", British Journal of Psy-chiatry, Vol. 119, 1971, pp. 281-286. 14 J.D. Teicher, "A Study in Attempted Suicide", Journal of Nervous and Mental Disease, Vol. 105, no. 4, (April 1947), p. 283-15 C.B. Williams and J.B. Nickels, "Internal-External Control Dimension as Related to Accident and Suicide Prone-ness", Journal of Consulting and Clinical Psychology, Vol. 33, no. 4, 1969, PP- 485-494. 16 Ibidem, passim. 17 Stengel, op. cit., p. 120. 18 The Oxford English Dictionary, Compact Edition, Oxford University Press, 1971, Vol. 6, p. 125-19 S.M. Jourard, "The Invitation to Die", On the Nature of Suicide, ed. E. Shneidman, San Francisco, Jossey Bass, 1969, PP- 129-141. 20 L. Dublin, Suicide: a Sociological and Statistical Study, New York, Ronald Press, 1963, p. 164. 21 P. Yap, Suicide in Hong Kong, London, Oxford University Press, 1958, p. 74. 83. 22 J.M. Sendbuehler, "Attempted Suicide: a Description of the Pre and Post-Suicidal States", Canadian Psychiatric Association Journal. Vol. 18, no. 2 (March 1973), pp. 113-116. 23 Stengel, op. cit.. p. 100. 24 K. Clifton and D. Lee, "Self-Destructive Conse-quences of Sex-Role Socialization", Suicide and Life-Threatening Behavior. Vol. 6, no. 1 (Spring 1976), pp. 11-25 M. Farber, Theory of Suicide, p. 24. 26 D.H. Miller, "Suicidal Careers: Case Analysis of Suicidal Mental Patients", Social Work. Vol. 15, no. 1 (January 1970), pp. 2 7 - 3 6 . 27 B. Malinowski, Crime and Custom in Savage Society, London, Kegan Paul, 1926, passim. 28 J. LaFontaine, "Anthropology", A Handbook for the Study of Suicide, ed. S. Perlin, New York, Oxford Universi-ty Press, 1975. pp. 77-91. passim. 29 Ibidem, passim. 30 L.A. Fallers and M.C. Fallers, "Homicide and Sui-cide in Busoga", African Homicide and Suicide, ed. P. Bohannan, Princeton, Princeton University Press, i960, pp. 65-93. passim. 31 Sixty-nine males for one hundred females. Ibidem, p. 114. 32 Thirty-two males for twelve females. Ibidem, p.114. '33 Ibidem, p. 115. 34 R. Firth, Tikopia Ritual and Belief, London, Allen and Unwin, 1967, pp. 116-140. 35 Montaigne, Erasmus, Donne, Burton. 36 J.C. Davis, "Suicide and Some-Illustrative Cases", JAMA. 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Andrieux, "Structure des reactions emotionelles chez des etudiants des deux sexes", Psychologie Francaise, Vol. 3, 1958, pp. 137-150. 60 Ibidem, passim. 61 E. Cummings, C. Lazar and L. Chisholm, "Suicide as an Index of Role Strain among Employed and Not Employed Married Women in British Columbia", Canadian Review of Sociology and Anthropology, Vol. 12, no. 4, 1975, PP. 463-469. 62 S. Freud, "Mourning and Melancholia", A General Selection from the Works of Sigmund Freud, J. Rickman ed., New York, Liveright Publishing, 1957. P* 133* 63 L. Sederer and R. Seidenberg, "Heiress to an Empty Throne: Ego-Ideal Problems of Contemporary Women", Contemporary Psychoanalysis, Vol. 12, no. 2 (April 1976) , pp. 240-251. 64 A. Pokorny, "Suicide Rates in Various Psychiatric Disorders", Journal of Nervous and Mental Disease, Vol.139. 1964, p. 503. 65 A. Temoche, T. Pugh and B. MacMahon, "Suicide Rates Among Current and Former Institution Patients", Journal of Nervous and Mental Disease, Vol. 138, no.6 (December 1964), pp. 124-130. 66 Ibidem, passim. 67 H. Cetner, J. Gromska, T. Litwinska and M. Tyszkie-wicz, "Suicide: a Social or a Psychiatric Problem?", Psvchiatria Polska, Vol. 7, no. 4 (August 1973), pp. 403-407. 68 T. Dorpat and J. Boswellj "An Evaluation of Sui-cidal Intent in Suicide Attempts', Comprehensive Psy-chiatry, Vol. 4, 1963. pp.117-125. 86. 69 W. Roth and F. Luton, "The Mental Health Program in Tennessee", American Journal of Psychiatry, Vol. 38, no. 2 (March 1976), pp. 399-402. 70 L.H. Farber, Lying, Despair, Jealousy, Envy, Sex, Suicide, Drugs and the Good Life, New York, Basic Books, 1976, p. 64. 71 W. Kauffman, Existentialism, Religion and Death, New York, New American Library, 1976, p. 204. 72 Ibidem, p. 207. 73 Ibidem, p. 201. 74 Ibidem, p. 207. 75 0. Segerberg, Living with Death, New York, Dutton, 1976, p. 108. 76 R.W. Maris, "Deviance as Therapy: the Paradox of the Self-Destructive Female", Journal of Health and Social Behavior. Vol. 12, 1971, p. 123-77 F. Whitlock and A. Broadhurst, "Attempted Suicide and the Experience of Violence", Journal of Bio-Social Science, Vol. 1, no. 4 (October 1969), pp. 353-368" 78 E. Stengel, Suicide and Attempted Suicide, Bristol, Penguin Books, 1964, p. 112. 79 D.H. Miller, "Suicide: Toward a Symbolic Inter-action Theory of Self-Destruction", Omega, Vol. 1, no. 2, 1970, pp. 145-153-80 Ibidem, p. 152. 81 D.H. Miller, "Suicidal Careers: Case Analysis of Suicidal Mental Patients", Social Work, Vol. 15. no. 1 (January 1970), pp. 27-36. 82 C. Westoff and R.R. Rindfuss, "Sex Preselection in the United States: Some Implications", Science, Vol. 184, no. 4137 (10 May 1974), pp. 633-636. 83 M. Lewis."State as an Infant-Environment Inter-actions: an Analysis of Mother-Infant Interaction as a Function of Sex", Merrill-Palmer Quarterly, Vol. 18, no. 2 (April 1972), pp. 95-121. 87. J. Rubin, F. Provenzano and Z. Luria, "The Eye of the Beholder: Parents' View on the Sex of Newborns", American Journal of Orthopsychiatry, Vol. no. 4 (July 1974), pp.512-519. 84 I.K. Broverman, S.R. Vogel, D.M. Broverman, F.E. Clarkson and P.S. Rosenkrantz, "Sex-Stereotypes: a Current Appraisal", Women and Achievement, ed. M.S. Mednick, S.S. Tangri and L.W. Hoffman, Washington, Hemisphere Publishing, 1975, p.36. 85 K. Clifton and D. Lee, "Self-Destructive Conse-quences of Sex-Role Socialization", Suicide and Life-Threatening Behavior, Vol. 6, no. 1, Spring 1976, p. 12. 86 Ibidem, p.12. 87 Ibidem, passim. 88 M.S. Mednick, S.S. Tangri and L.W. Hoffman, Women and Achievement, Washington, Hemisphere Publishing, 1975. p. 208. 89 J.D. Teicher, "A Study in Attempted Suicide", Journal of Nervous and Mental Disease, Vol. 105, no. 4 (April 1947), p. 283 90 C. Neuringer, "Dichotomous Evaluation in Suicidal Individuals", Journal of Consulting Psychology, Vol. 25, no. 5, 1 9 6 1 , pp. 445-449. 91 A. Anastasi, Differential Psychology, New York, MacMillan, 1958, pp. 478-481. 92 J. Baker Miller, Toward a New Psychology of Women, Boston, Beacon Press, 1976, p. 38. 93 We underlined. 94 C. Light Selvey, "Concerns about Death in relation to Sex, Dependence, Guilt about Hostility and Feeling of Power 1 essnessOmega, Vol. 4, no. 3, 1973, PP- 209-219. 95 J.C. Diggory and Rothman, "Values Destroyed by Death", Journal of Abnormal and Social Psychology, Vol. 63, 1961, pp. 205-210. 96 A. Marks, "Sex-Differences and their Effects upon Cultural Evaluation of Methods of Self-Destruction',' Omega, Vol. 8, no. 1, 1977, PP- 65-70. 88. 97 D.H. Miller, "Suicide: Toward a Symbolic Inter-action Theory of Self-Destruction", Omega, Vol. 1, no. 4, 1970, pp. 145-153-98 "A person lives as long as he experiences his life as having meaning and value, and as long as he has some-thing to live for - meaningful projects that will animate him and invite him in the future or entice him to pull him-self into the future. He will continue to live as long as he has hope of fulfilling meanings and values. As soon as meaning, value and hope vanish from a person's experience, he begins to stop living; that is, he begins to die". S.M. Jourard, "The Invitation to Die", On the Nature of Suicide, ed. E. Shneidman, San Francisco, Jossey-Bass, 1969, P- 132. 99 B. Suter, "Suicide and Women", Between Survival and Suicide, ed. Wolman, New York, Gardner, 1976, p. 138 100 V. Bloom, "An Analysis of Suicide at a Training Center", American Journal of Psychiatry, Vol. 123, no. 8 (February 1 9 6 7 ) , pp. 918-925-101 H. Hendin, Suicide in Scandinavia, Garden City, N.Y., Doubleday Anchor Books, 1965, passim. 102 D.H. Miller, "Suicide: Toward a Symbolic Interaction Theory of Self-Destruction", Omega, Vol. 1, no. 4, 1970, pp. 145-153. 103 H. Hesse, Steppenwolf, New York, Holt, Rinehart and Winston, 19&3-104 Ibidem, p. 192. 105 D.H. Miller, op. cit., p. 151. 106 C. Leonard, Understanding and Preventing Suicide, Springfield, Illinois, Charles C. Thomas, 1 9 6 7 . 107 Ibidem, p. 177-108 Ibidem, p. 116-118. 109 R. Maris, "Deviance as Therapy: the Paradox of the Self-Destructive Female", Journal of Health and Social Behavior, Vol. 12, 1971. pp. 113-124. 110 D.H. Miller and D.J. Goleman, "Predicting Post-Release Risk among Hospitalized Suicide Attempters", Omega, Vol. 1, no. 1, 1970, p. 76 . 89. 111 M. Farber, Theory of Suicide. New York, Funk and Wagnalls, 1968, p. 10. 112 Ibidem, p. 7 5 . 113 D. 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