Suicide, assisted suicide and euthanasia: international perspectives.

Suicide, assisted suicide and euthanasia are elusive and controversial issues worldwide. To discuss such issues from only one perspective may be limiting. Therefore, this paper was written by authors from various regions, each of whom has been asked to reflect on the issues. The countries/cultures are: Australia, China, Cuba, Ireland, India, Japan, Russia, South Africa, The Netherlands, North America (Turtle Island) and United States. Historically and today, suicide is viewed differently. Assisted suicide and euthanasia are equally seen from multifarious perspectives. Highlighting development in the Netherlands, Australia's Northern Territory and Japan (ie. the famous Yamanouchi Case), the review shows growing re-examination of the right to die. There appear, however, to be no uniform legal and ethical positions. Further debate and discussion globally is needed to avoid myopic perspectives.

Controlling the environment to prevent suicide: international perspectives.

BACKGROUND: Suicide and suicidal behaviour are multifaceted events requiring complex solutions. Controlling the environment is a neglected solution, despite strong support for this approach from the World Health Organization (WHO). METHOD: To discuss this approach from a global view, this review is written by authors from various cultures: American, Australian, Canadian, Chinese, Cuban, Dutch, Indian, Irish, Japanese, Lithuanian, Native North American, Russian, and South African. RESULTS: We examine gun control to illustrate the environmental control approach; however, the worldwide diversity of suicide methods calls for diverse responses. Further, controlling the environment encompasses more than restricting the means of suicide, which we illustrate with examples of toned-down media reports and restricted medicine availability. CONCLUSIONS: Controlling the environment may be a viable strategy for preventing suicide, although research shows that few clinicians implement such approaches.

Suicide prevention in Canada: a history of a community approach.

Suicide is a major mental health and public health problem in Canada. Canada's suicide rate ranks above average in comparison to countries around the world. The prevention of suicide predates the European presence in Canada and much can be learned from these endeavours. Current efforts grew largely from the grass roots, with little government support or initiative (with a few provincial/territorial exceptions). Canada's community efforts have been diverse and inclusive. Among such efforts have been: (a) traditional approaches among Native peoples, (b) the establishment of the first crisis centre in Sudbury in the 1960s, (c) the development of a comprehensive model in Alberta, (d) the beginning of a survivor movement in the 1980s, and (e) the national prevention efforts of the Canadian Association for Suicide Prevention. There are, however, striking lacks--most notable among them the paucity of support for research in Canada. Future efforts will call for even greater community response to prevent suicide and to promote wellness.

Suicide notes in alcoholism.

Alcoholism is associated with a vast number of suicides. The most systematic study of suicide among alcoholics is the work of Eli Robins and George Murphy. The suicide notes in these studies have remained unanalyzed to date. The present analysis suggested that these suicide notes of alcoholics did not differ from those of nonalcoholics; core themes in their deaths are unbearable psychological pain, cognitive constriction, indirect expressions, rejection-aggression, and identification-aggression. Although caution is in order in accepting the null hypothesis, we can at least suggest that further study is needed.

Suicide prevention in schools: the art, the issues, and the pitfalls.

Suicide is a major mental health problem and public health problem worldwide. Schools and their communities must respond in a comprehensive fashion. Caplan's model of primary, secondary, and tertiary prevention--or prevention, intervention, and postvention--is proposed as a comprehensive response to suicide in youths. Current myths and facts about these fabrications are discussed for each mode of response. Research, clinical suggestions, and a call for further discussion are presented.

Domestic integration and suicide in the provinces of Canada.

Canada's rate of suicide varies from province to province. The classical theory of suicide, which attempts to explain the social suicide rate, stems from Durkheim, who argued that low levels of social integration and regulation are associated with high rates of suicide. The present study explored whether social factors (divorce, marriage, and birth rates) do in fact predict suicide rates over time for each province (period studied: 1950-1990). The results showed a positive association between divorce rates and suicide rates, and a negative association between birth rates and suicide rates. Marriage rates showed no consistent association, an anomaly as compared to research from other nations.

Suicide notes in the courtroom.

The suicide note is of particular interest and importance to the forensic scientist/clinician. In those cases dealing with wrongful death and suicide, the note can shed significant light on other forensic data, just as the other forensic data can shed significant light on the note. This paper presents two forensic cases to illustrate the prima facie (nomothetic) relevance of the suicide note in the courtroom and to address some of its limitations (idiograpic).

Is there a regional subculture of firearm violence in Canada?

A study in Canada of the accidental death rate from firearms, and of suicide and homicide rates by firearms and by all other methods, for the period 1975-85, indicated that the rates were positively associated with one another. The results were interpreted using a subcultural theory of violence, and the social policy implications of the results were discussed.

Social factors and mortality from NASH in Canada.

The NASH categories (Natural, Accident, Suicide, Homicide) used on death certificates are known to obscure many of the psychological dimensions of death. Although there are many studies of death certificates of the extent to which suicide may be misclassified as accidental or natural deaths, and a few studies comparing individuals who commit suicides to accidental death victims, this topic is often neglected at a sociological level. This analysis of the NASH modes of death examines if these deaths differ from a sociological perspective. Specifically, rates of divorce, marriage, birth, and unemployment were correlated with deaths of natural causes (stomach cancer, cirrhosis of the liver), accidents (motor vehicle accident), suicide, and homicide. The results suggest that the sociological associations with some causes of death (i.e., cirrhosis of the liver, suicide and, homicide) have a similar social pattern but are different from others (i.e., motor vehicle accidents and stomach cancer). Although there are problems of interpretation at a sociological level, it is suggested that the social epidemiology of death may be obscured by the NASH classification. Recent suggestions on terminology and taxonomy by the International Academy for Suicide Research (IASR) are offered as one step towards addressing this issue.

Sylvia Plath: a protocol analysis of her last poems.

Personal documents have a significant place in psychological research. Suicide notes, diaries, novels, poems, and so on allow us to better understand the suicidal mind. The works of Sylvia Plath--a poet who killed herself at age 30--are prime examples for such protocol study. This article examines the last 6 months of Plath's poetry, revealing a suicidal malaise. Associating the results to the lives of Cesare Pavese and the case study of Natalie, a Terman-Shneidman subject of the intellectually gifted, the study shows a unit thema that facilitates the process of death. The poems reveal such themes as unbearable pain, loss, and abandonment that likely contributed significantly to death becoming the only solution.

Rick: a suicide of a young adult.

A small but concerning percentage of completed suicides are seen as having left no clues. The classical case, albeit a literary one, is Robinson's Richard Cory. These people often dissemble, even about their suicide risk. An even smaller group of these individuals present themselves in therapy without communicating a sign of suicide risk. Utilizing an idiographic approach, the case of a young adult male (Rick) is presented. The narrative reconstruction gives voice behind the man's mask. The autopsy reveals a young man who was in deep pain and unable to adjust to life's demands. Rick lacked ego strength, being overly narcissistic and having deeply troubled, symbiotic attachments to his family in a world of interpersonal isolation. In the end, even the help of his therapist, who tried to reach through the mask, was not enough and Rick killed himself. The pain had become unbearable. A few guiding remarks for such cases are offered, noting that therapists must constantly address the dissembling in some suicidal patients.

Suicide in the United kingdom and ireland.

The purpose of this study was to compare epidemiological trends in suicide for the three regions of the United Kingdom (England and Wales, Northern Ireland, and Scotland) and for Ireland from 1960 to 1990. The data on suicide rates were obtained from the World Health Organization statistical base, supplemented by data from the statistical offices of the four regions. While the suicide rates in Ireland, Northern Ireland and Scotland increased during the period under study, English/Welsh suicide rates first declined and then held steady. In Ireland, both male and female suicide rates increased, whereas in the other regions only male suicide rates rose. According to age, in England and Wales, suicide rates rose for male teenagers and young males, while for the other regions male suicide rates increased in general for all age groups. Social indicators (unemployment, marriage and birth rates) were quite successful in predicting male suicide rates in all four regions and in predicting female suicide rates in England and Wales and in Ireland. The results emphasize the importance of studying several regions in epidemiological studies in order to identify which trends are general and which are unique to one nation. In the present study, the epidemiological trends for suicide in England and Wales were quite different from those in the other three regions. In particular, the steady overall suicide rate in England and Wales and the rising suicide rate for young males alone differ from the trends observed in the other regions and raise importante questions about the causes of the social suicide rate in these four regions.

Suicide trends in eight predominantly English-speaking countries 1960-1989.

Suicide rates between 1960 and 1989 were explored for eight predominantly English speaking countries with similar national characteristics. New World countries showed significant similarities but differed from Old World countries. The two North American (NA) New World countries showed more similarity to each other than the two Australasian New World countries. The NA countries showed an unique plateau in the 1980s for males aged 15-29 years. Old World males of all ages showed common rises, suggesting a partial sex-specific influence in the young. However, trends among the 15- to 19-year-olds were significantly different to trends among the 20- to 29-year-olds in both sexes suggesting a substantial youth-related contribution to the rises. Rates among 15- to 19-year-old females rose in the early 1960s, ahead of males but in parallel with rises among older females, suggesting part of the rise was sex- as opposed to age-related. Although rates among the 15- to 19-year-old females showed little change since 1970, this may be partly a function of sex-related improvements-observable in older females disguising unfavourable youth-related influences. Possible aetiological factors are suggested but remain speculative. Studies of other nations with common cultural characteristics may clarify trends and aetiological issues. Care should be taken to differentiate sex- from age-related influences.

Suicide notes at symbolic ages.

Symbolic ages, like 40, 65, or 70, are often stocktaking occasions. Phillips and Smith in 1991 showed that suicides peak at such ages for married males and suggested that suicide notes may be an avenue to analyzing such stocktaking in people's lives. 40 notes from symbolic and nonsymbolic ages were compared based on a multidimensional clinical perspective. No differences were noted. Although caution is in order in accepting the null hypothesis, it is speculated that macrosocial phenomena may not be easily translatable into psychological ones.

The ethics of suicide and suicide prevention.

Is suicide ever a defensible choice, particularly for the terminally ill? The present article debates this difficult question, examining the relevance of such issues as the morality, rationality, and dynamics of the suicidal act, and the legitimacy of physician-assisted suicide. Contrasting perspectives on these issues are articulated by two prominent suicidologists, as a spur to the reader's deeper reconsideration of the ethics of suicide and suicide prevention.

Suicide: a multidimensional malaise.

No one really knows why human beings commit suicide. The goal of this paper is to provide a psychological point of view on the topic, among the many other perspectives that are needed. It addresses the question by providing a theory of suicide, arguing that it is theory that allows us to sort out the booming buzzing mess of experience (Wm. James). Suicide is a multi-dimensional malaise. Metaphorically speaking, it is an intrapsychic drama on an interpersonal stage. As sound theory must be empirically observable, the theory is next applied to research of suicide notes, studying such factors as age, sex, and method of suicide, cross-culture and cross-time. Next, because all theory must have clinical applicability, a clinical case study of Goethe's Werther is provided. Overall, it is concluded that we need to continue to develop models to understand the suicidal mind.

Clinical evaluation of suicide risk.

Suicide risk assessment may well be the most complex clinical task that mental health professionals face. Tests have shown to be of little use. To confront this complexity, assessment and prediction are best seen as interwoven with understanding suicide, a multi-dimensional malaise. With the essential concepts of lethality and perturbation, a clinical theory of suicide is presented. Intrapsychic aspects (i.e., unbearable psychological pain, cognitive constriction, indirect expressions, inability to adjust, and ego) as well as interpersonal aspects (i.e., interpersonal relations, rejection-aggression, identification-egression), are outlined to aid in assessment. Transference and countertransference issues in assessment are noted. A case illustration to aid in clinical insight is provided. It is concluded that all assessment and prediction of suicide risk ultimately depends on the skill of the clinician.