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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: DATE:  PAULE McNICOLL  DECEMBER 1979  TABLE OF CONTENTS  INTRODUCTION  1  Part I:  3  DEFINITIONS AND DIFFERENTIATIONS  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 Gr •  D l S C T J - S S l O T l a o o o o ^ t o  Part III:  0 0 0 0 0 0 0  0 0 0 * 0 0 0 0 0  INTERVENTION  0 0  0 0  0 0  o f ^ o ^ o a ^ ^ ' / '  ... 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... 0 00.00 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 1. androgynous upbringing 2. adequate handling of aggression 3. learning of communication skills....  72 72 .7^ -.76  CONCLUSION 81  FOOTNOTES 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 countries.  , and m  all  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 attitudes-.  It is also expected that they will probably  make a further attempt.  Even the authoritative Los 3  Angeles Suicide Prevention Center adopted^ an actuarial 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 and perspectives on the subject:  theories  anthropological,  historical, sociological (Durkheim), psychological (Freud) and psychiatric, philosophical and socialpsychological  (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 multiple approaches and outline the consequences for intervention 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 available 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: OUTCOME death  survival  to die  true suicide  missed  not to die  missed suicide attempt  true suicide attempt  INTENTION  suicide  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).  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 carbonmonoxide 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 acts are rare.  suicidal  Many are carried out on sudden impulse,  but suicidal thoughts were always present.  Both suicides  and suicide attempts are performed in places where intervention 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 12 dangerous test to obtain 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 population13rate.  These results were not con-  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  believe their future is determined by chance, ment, fatality, and so on.  individuals environ-  A literature search in this  area has already correlated externality and low selfesteem  14  . 1 < , 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 iating suicide and suicide attempt.  different  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. took a bus for a distant city.  She then  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 impliii 18  cation, unfair management or treatment" sentially pejorative.  .  It is es-  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  In a very different fashion, Jourard  1y 9 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 metacommunication, 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; the unsuccessful are concerned chiefly with other people.  20  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-nineyears 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. fired.  He was immediately  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; 22 release of emotional tension  .  they bring an instant  This may contribute to  the improvement that generally follows an attempt. have more opportunities than women to express their  Men  11.  surplus of aggressiveness: fights, verbal clashes.  violent sports, physical  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 in an attempt than in a suicide  23  .  Clifton and Lee  24  noted some results indicating that even if women are less likely than men to commit suicide, they are more selfdestructive.  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 continuum.  We present Farber's 2 5 hope spectrum as a guideline  for this particular  opinion.  HOPE AND SUICIDAL BEHAVIOR SPECTRUM -Absent 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  SUICIDAL -Mild  BEHAVIOR  -Highly ambivalent -Serious -Latent  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.  139f Dorothy Miller  presents a third perspective.  Her concept of "suicidal career" implies that selfdestructive "behavior does not sprout from nothing and that it is possible to identify some precursor long before the final gesture.  signs  Men's and women's  careers are manifestly different.  Feminine behavior  becomes obviously self-destructive sooner and the evolution 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: fights, and so on.  delinquency,  alcoholism,  Men's suicidal careers are also  shorter because they rely less than women on other people's interventions. at work.  They are the bosses at home and  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 pQ to take his(her) own life. In some African communities , selfdestruction 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: self-regulating traditions of his society. therefore not necessarily a sickness.  he obeys the Suicide is  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 husbandO "3but a 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 suicide 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. present m  A double standard for men and women is  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. of disapproval. suicide.  Nowhere is there any indication  There is not even a specific word for  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.  18.  During the Middle Ages, the antagonism against suicide became condemnation.  The Christian Church  equated suicide with homicide and started refusing burial in consecrated cemeteries. was the insane.  The only exception  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. suicide epidemics.  Religious crises seem to trigger  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. is- still unabated.  Davis' theory  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 differently 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; was related to loss of love.  Both males and females  could imagine a man's death more easily. more fear of death than men.  for women, death  Women reported  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 suicide.  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 somen 4 4impersonal cause which transcends all individual cases  .  He concen-  trates on the collective conscience, and its vital influence 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 essential role in the common life. When this conscience functions coherently, solidarity 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 suicide 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" suicide, is the result of too strict regulations that completely 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 p a r t " ^ . Commenting on the more frequent completion of suicide by males, Durkheim assumed that women were more directly influenced by their organism and therefore benefitted from a "natural" immunity against  self-destruction.  Based on the presumption that women have a more rudimentary 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 suicide or in any other way.  Durkheim's Le Suicide was written  in 1 8 9 1 , 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 suicidal 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 connection 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 regulations.  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  the collective life into two spheres:  and divides  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 suicide 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.  Cantor 5 0 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: 5 1 "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 themselves . In 1920, Freud complemented his perspective on suicide 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 psychoanalists 5 - 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 vulner57  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. vulnerable to any frustration. enced as coming from inside; directed against oneself.  Therefore,  (s)he is very  The cause of hurt is experithe anger is therefore  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. turmoil is of short duration.  Generally such  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. may be a basis for this assumption.  There  A n d r i e u x ^ 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 housewives.  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 wise?  other-  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 selfdestruction.  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 determined.  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 which was discussed earlier.  aggression,  The interventionists at the  Vancouver Crisis Centre and at Safer are unanimous when talking about women who attempt suicide. "These women are angry!"  They exclaim:  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. emerges at this point. completed suicide,  A contradiction  Because of their lower rate of  women seem to turn their aggression  inwards to a smaller extent than men.  However, suicide  is not the only outcome of inversed anger. that women direct their aggression toward  It appears themselves,  indeed, but they prefer the depressive mode to the suicidal one. mind:  Freud's life-instinct hypothesis comes to  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  in all cases, as shown by the following results:  i,  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  78 133  167 566 119 130  The parallel suicide-depression tends to limit the field to psychiatry. illness?"  The question is:  "is suicide an  It is very hard to find an operational  definition of pathology. presence of symptoms.  Mainly, we have to rely on the  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 i l l ^ „  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 . Simi69 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 suicide-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 a m b u s h " ^ . 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 selfdestruction 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.  in crime.  77 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 tranquilizers) and mental illness.  (usually  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 himself bankrupt and commits suicide"''7^. right mind would behave so rationally. would be why there are so few suicides.  No one in his (her) If so, the wonder 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  79  Dorothy Miller s' 7 symbolic interaction theory seems the best suited for a comprehensive analysis of selfdestructive 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. offers more than static definitions;  Also, she  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 advantageous 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 embracement 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 unrealistic 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; a status would not do so. crisis:  the persons who embraced  They would experience a major  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 alternatives 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. cide is an essentially human act.  Sui-  No other animal possesses  the symbolic means and the manipulation of language necessary 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 available 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 a girl  82  .  Lewis and Rubin  83 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 characteristics over feminine ones  84  .  In such a context, it  takes women longer than men to like their self-identity®-'.  86 Some researchers self-concept.  found women still have an ambivalent  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 competence, but have integrated a mechanism 00 to stabilize it at 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 correspond 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 selfview 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. suggests.  This idea is more important than it first 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 rehearsals 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 .  .  90  front of crisis' .  Women as a group have the advantage of  being more flexible, which explains their lower rate of suicide.  Because of their upbringing as nurturers, they are  91  more concerned about relating to other people than men are 7 . 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 9 2lives. 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 attuned 7 ^ to the vicissitudes of mood, pleasure and displeasure of the dominant group'.' i  Carole Light  94  Selvey s study 7  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:  leave a symbolic statue of themselves.  they want to  Men and women have  very different ideal images, and this fact influences their ways of seeking death. strong and efficient.  Males want to be remembered as Fast, dramatic and highly destructive  methods are best suited for this purpose. leave an image of beauty and emotion.  Women want to  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. than men.  Women are smaller and less strong  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. hypothesis is rather weak.  The  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 96  does not want to die.  Marks  7  found that women, who are  the main users of drugs as a method of suicide, associated this use with efficiency. therefore re-assess the  Medical authorities must current ratings of suicide  methods in order to stop underestimating women's seriousness of intent. The projected image may also have its importance in true suicide attempts.  An interventionist from Safer  commented that women attempters were beautiful".  "particularly  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. demand less from life:  a significant relationship is for  many a valid enough reason to live. easier for them.  Women  Hope, therefore, is  47.  G. Discussion  97 Dorothy Miller 7 ' 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 meaning  7  . .  .  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 adjunction 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 selfdestructive 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 * anger »99 expression of ' .  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. B l o o m 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 selfdestructive people as persons who labor to keep or gain some meaning in life against and through the conflicting demands of their environment. in suicidal behavior;  Manipulation may be present  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 would survive.  categorization  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-processof-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. amental differences exist.  Temper-  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 suicidal 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. i  103  in Steppenwolf' s magic circus  As  « , 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 configuration, have different needs and are to be treated accordingly. The identified problem of suicide committers is overcommitment 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. category;  Men are more likely to be found in this 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 intervention.  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 06 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. people invest their energies in affiliation.  Some  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  types of dependence:  differentiates two  the passive and aggressive forms.  The passive dependent is rarely suicidal: of satisfaction disappears,  when a source  (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 suicidal 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 compensation 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 independent 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 determined and the commitments have to be pursued within coherent social norms. example possible.  Women's situation is the best  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 secondclass treatment as it is sometimes experienced in therapeutic 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 individuals.  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 significant  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 aspirations.  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 relationships, 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 significant 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  equation: 112  e  d  •  -p  Suicide Rate = i  PIC.  TS  DEC, DIG, HFT  S U j  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. A b b i a t i 1 1 3 , 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. factor will therefore be the last to be discussed.  This  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; becomes so when it is the major social dynamism. directly affected by it:  it Men are  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. in men/women suicide ratios is rapidly  The difference 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; need the validation of the public sphere.  they  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 domesticityalone;  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„ for these demands is still going on.  The struggle  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. suicide rate among professional nurturers nurses, and so on)  is an illustration.  The high  (psychiatrists, 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 "burningout" 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 behavior.  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 freedomseeking Nordic countries like Sweden and Denmark. Toleration 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. the suicide rate is feared. scribe to the idea  An increase in  Most people seem to sub-  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  .  costso quality.  We do not believe in avoiding suicide at all There are two dimensions of life:  quantity and  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. palliative.  Social agencies are always a  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 intervention 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 telephonebased 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. been the object of criticism lately.  These centres have The main reproaches  were that they did not reach the male population and the true committers  116  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 ability 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. the world.  It is unique in  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 detection 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: general practitioners.  the  Most suicides have seen their  doctors within the month preceeding their gesture, gener-  70.  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.  71.  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. vehicles toward recovery.  This is one of the key-  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. problems exist:  Some  many of these programs are temporary  72.  and part of their staff's energies are spent on the renewal 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.  73.  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. are, however, also dependent.  They  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  74.  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. a need for innovation.  Here too there is  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 shameful, 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 etiquette 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. little girls„  Aggression is repressed in  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 aggressive 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.  76.  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 cathartic and brings a sense of reality. permitted to all individuals.  It needs to be  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.  77.  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 suicidal behavior varies accordingly.  There are two goals in  the contemporary world that affect everybody: and affiliation.  achievement  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 socialization:  women learn to forthrightly accept and make place  for their striving for achievement and men get re-acquainted 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,  78.  but to choose an existential perspective.  Campbell120  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 selfdestruction 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 12 2 allow existence to proceed in an orderly sequence"  79.  On a preventive level, the current process of socialization 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. cieties change together„  Individuals and their so-  In order for the future gener-  ation to become androgynous, efforts have to be concerted to create an androgynous world. happening now. zation".  It is not exactly what is  Society seems in a process of "masculini-  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 of men and women.  evaluation  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) longterm 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, degree of lethality of the act. 9 . the E.S. Shneidman, "Suicide", International Encyclopedia of the Social Sciences, New York, MacMillan and Free Press, 1968, VolT 15, P- 3778 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 Psychiatry, 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. 28315 C.B. Williams and J.B. Nickels, "Internal-External Control Dimension as Related to Accident and Suicide Proneness", 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. 12519 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. 113116. 23 Stengel, op. cit.. p. 100. 24 K. Clifton and D. Lee, "Self-Destructive Consequences of Sex-Role Socialization", Suicide and LifeThreatening Behavior. Vol. 6, no. 1 (Spring 1976), pp. 1125 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 University Press, 1975. pp. 77-91. passim. 29 Ibidem, passim. 30 L.A. Fallers and M.C. Fallers, "Homicide and Suicide 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. Vol. 43, 1904, pp. 121-123. 37 G. Lester and D. Lester, Suicide: the Gamble with Death, p. 91• 38 Durkheim, ot>. cit., pp. 353-354.  84.  39 Dublin, op. cit., pp. 75-79. 40 L. Kranitz, J. Abrahams, D. Spiegel and P. KeithSpiegel, "Religious Beliefs of Suicidal Patients", Psychological Reports, Vol. 22, no. 3 (June 1968), p. 936. 41 A. Maurer, Death, Women and History", Omega, Vol, 6, no. 2, 1975, p. 131. 42 C. Light Selvey, "Concerns about Death in relation to Sex, Dependency, Guilt about Hostility and Feeling of Powerlessness", Omega, Vol. 4, no. 3, 1975, P- 131. 43 Durkheim, op. cit., passim. 44 Ibidem, p. 309. 45 K.K. Johnson, "Durkheim Revisited: Why Women Kill Themselves?", Suicide and Life-Threatening Behavior, Vol.9> no. 3 (Autumn, 1979) , P- 14746 Durkheim, op. cit., p. 209. 47 F.B. Davis, "The Relationship Between Suicide and Attempted Suicide: a Review of the Literature", Psychiatric Quarterly, Vol. 4l, no.4 (October 1 9 6 7 ) , p. 7 6 2 . 48  K.K. Johnson, op. cit., pp. 145-153-  49 P. Cantor, "Personality Characteristics Among Youthful Female Suicide Attempters", Journal of Abnormal Psychology, Vol. 8 5 , no. 3 , 1976, pp. 324-32951 P. Bart, "Depression Among Middle-Aged Women", Readings in the Psychology of Women, ed. J. Bardwick, New York, Harper and Row, 1972, p. 142. 52 P. Friedman, On Suicide, New York, International University Press, 1967, P- 22. 53 S. Freud, Psychopathology of Everyday Life, New York, Norton, 196554 Ibidem, p. 181. 55 E. Jones, The Life and Work of Sigmung Freud, New York, Basic Books, 1957. passim. 56 P. Schneider, La Tentative de Suicide, Paris, Delachaux and Niestle, 1954.  85.  57 Even when the method is the same, men succeed to kill themselves more than women. G. Lester and D. Lester, The Gamble with Death, p. 90. 58 B. Sappenfield, "Beliefs in the Omnipotence of Love", Psychological Re-ports. Vol. 38, no. 2 (April 1976), pp. 399-402. 59 C. 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. 1 2 , 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. Tyszkiewicz, "Suicide: a Social or a Psychiatric Problem?", Psvchiatria Polska, Vol. 7, no. 4 (August 1973), pp. 403407. 68 T. Dorpat and J. Boswellj "An Evaluation of Suicidal Intent in Suicide Attempts', Comprehensive Psychiatry, 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. 12377 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 Interaction Theory of Self-Destruction", Omega, Vol. 1, no. 2, 1970, pp. 145-15380 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. 6 3 3 - 6 3 6 . 83 M. Lewis."State as an Infant-Environment Interactions: 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 Consequences of Sex-Role Socialization", Suicide and LifeThreatening 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 e s s n e s s O m e g a , 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. 6 3 , 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 Interaction Theory of Self-Destruction", Omega, Vol. 1, no. 4, 1970, pp. 145-15398 "A person lives as long as he experiences his life as having meaning and value, and as long as he has something to live for - meaningful projects that will animate him and invite him in the future or entice him to pull himself 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. 918-925101 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&3104 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. 177108 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 PostRelease Risk among Hospitalized Suicide Attempters", Omega, Vol. 1, no. 1, 1970, p. 7 6 .  89.  111 M. Farber, Theory of Suicide. New York, Funk and Wagnalls, 1968, p. 10. 112 Ibidem, p. 7 5 . 113 D. Abbiati, "Suicide in Maine: a Social Psychological Approach", Suicide and Life-Threatening Behavior, Vol. 7, no. 2 (Summer 1977), pp. 80-91. 114 The Province. October, 28, 1979, p. A3. 115 M. Farber, op. cit., p. 110. 116 R. McGee, "The Delivery of Suicide and Crisis Intervention Services", Suicide Prevention in the 70's, Washington, DHEW Publication, 1973, pp. 8 1 - 8 9 . 117 Ibidem, passim. 118 J. Motto, "Evaluation of a Suicide Prevention Center by Sampling the Population at Risk", Suicide and Life-Threatening Behavior, Vol. 1, no.1, 1971, pp. 18-21. 119 S. Ganzler, "Some Interpersonal and Social Dimensions of Suicidal Behavior", Dissertation Abstracts, Vol. 28 (B), July 1967, pp. 1192-1193120 R. Campbell, "The Schizophrenias: a Report on the Current Views', Psychiatric Quarterly, Vol. 32, no. 2 (April 1958), pp. 318-334. 121 Ibidem, p. 333122 Ibidem, p. 333123 I.K. Broverman, D.M. Broverman, F.E. Clarkson, P.S. Rosenkrantz and S.R. 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